1 in 10 EMS Naloxone Recipients Survive OD, Die Within Year

[cduggles]

Naloxone reverses 93% of overdoses, but many recipients don't survive a year

A review of emergency medical services data from Massachusetts found that when given naloxone, 93.5% of people survived their overdose. The research looked at more than 12,000 dosages administered between July 1, 2013 and December 31, 2015. A year after their overdose, 84.3% of those who had been given the reversal drug were still alive.

"With this reversal agent, we're saving the vast majority of people," said Dr. Scott Weiner, lead author of the study and an emergency physician at Brigham and Women's Hospital. "These are people who got naloxone by ambulance. So we saved them. The lesson learned is not that naloxone is failing; it's working."

But it also means that once saved from an overdose by EMS, a patient had about a 1 in 10 chance of not surviving a year. About 35% of those who were dead a year later died of an opioid overdose. And that should be a concern, Weiner said: "It doesn't treat the underlying problem.".

 

[cj]

Only 35 Percent of the 1 in 10 is dead of opiate overdose. That's a surprising statistic.

 

[Jabberwocky]

Yeah 8/10 people do... kinda a misleading article. But OD issues have never been reported with much accuracy or precision...

 

[S.J.B.]

Only 35 Percent of the 1 in 10 is dead of opiate overdose. That's a surprising statistic.

That is astounding. It's too bad the study isn't linked in the article, as it would be interesting to see what is causing the majority of these deaths. I think it's a clear indicator that the people being administered naloxone tend to be living very precarious lives, which isn't surprising. There are probably HIV, tuberculosis, HCV, etc. related deaths in there.

 

[Foreigner]

So it should actually be 0.35 out of 10 people died of overdose a year later. Great writing.

That's still a lot of people though.

 

[Jabberwocky]

That is astounding. It's too bad the study isn't linked in the article, as it would be interesting to see what is causing the majority of these deaths. I think it's a clear indicator that the people being administered naloxone tend to be living very precarious lives, which isn't surprising. There are probably HIV, tuberculosis, HCV, etc. related deaths in there.

I would also imagine alcohol and poverty related illnesses also play a huge role in OD deaths.

 

[cduggles]

Hi!
I looked on the ACEP website for information about the data presentation.

The article is likely in the peer review or publication but I did find this additional article:

Most Patients Survive One Year After Naloxone Rescue

After resuscitation, 15% dead within a year

by Ryan Basen, Contributing Writer, MedPage Today
November 02, 2017

WASHINGTON -- Almost 85% of patients administered naloxone by emergency services in Massachusetts lived for at least another year, according to a study presented here.

But that still meant 1-year mortality of 15%, and about 40% of those fatalities occurred later on the day they were resuscitated.

Emergency medicine physician Scott Weiner, MD, and colleagues at Brigham and Women's Hospital in Boston analyzed state-level data on 12,192 administrations of naloxone by emergency medical services. They found 6.5% died the same day they received the opioid reversal agent and 9.3% within the following 12 months -- many though not all from opioid overdoses.

Also, of the 1,132 dying within 1 year (excluding same-day deaths), 37.9% died outside a hospital, the researchers found. "That's a huge cohort that's dying before medical attention can get to them," Weiner said.

"These patients should be considered extremely high risk, and should receive interventions such as offering buprenorphine, counseling and referral to treatment prior to ED discharge," he said during his presentation at the American College of Emergency Physicians annual meeting.

Opioid overdose was listed as the cause of death for 49.8% of patients who died the same day and 35.4% of those who died within one year.

About one-half of the documented deaths (again excluding same-day fatalities) occurred within one month of initial rescue. "That first month is very, very dangerous," Weiner said, noting that his team did not determine why.

Weiner's team conducted a retrospective observational analysis of data collected from July 2013-December 2015 from three public state sources, including emergency medical services, death records and payer claims. Patients were excluded if they had received naloxone during January-June 2013.

"Naloxone is working," Weiner said, citing the "quite high" one-day survival rate. "Naloxone is fundamental, but it's a Band-Aid, not a treatment."

Opioid users need better treatment overall, he said, suggesting more community access to naloxone, and education on how to administer naloxone for family and other potential caregivers.

These patients struggle to care for themselves, let alone make it to their medical appointments: "Their brain is taken over by this disease. It's all-consuming," Weiner said. "We have to be able to match that need."

The researchers recommend buprenorphine, counseling, and referral prior to discharging patients from the ED based on their clinical experience, Weiner said. He recommended expanding access to recovery coaches (sometimes called "angels") and for providers to "start patients on buprenorphine right away."
EMS recorded a mean 406.4 naloxone administrations per month. Median age of the deceased was 54 (IQR 38-68) and 61% were male.

Study limitations included analysis of data from only one state via a database with limited and potentially erroneous information. It's also possible naloxone was administered to patients who did not overdose on opioids specifically; researchers had no access to data on comorbidities.

Weiner reported naloxone-related financial relationships with General Emergency Medical Supplies Corp. and Epidemic Solutions Inc.

Article Link

Primary Source
American College of Emergency Physicians
Source Reference: Weiner S, et al "One-year mortality of opioid overdose victims who received naloxone by emergency medical services" ACEP 2017; Abstract 402.
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I was surprised at the % of same-day deaths.

The one-year survival rate is likely lower than the one presented here, but I felt that this large-scale study represents a tremendous effort and will inform the referral process and hopefully other types of help for patients admitted to the ER after overdosing.

 

[S.J.B.]

Thanks Cduggles, that's interesting. It seems that the relatively low percentage of these people dying ostensibly from opioid overdoses may simply have to do with what's written on the death certificate. If only half of the people who died on the very same day ostensibly died from overdose, I have no doubt that a good portion of the other half died from complications of overdose that simply were attributed to something else.

 

[cj]

Thanks Cduggles, that's interesting. It seems that the relatively low percentage of these people dying ostensibly from opioid overdoses may simply have to do with what's written on the death certificate. If only half of the people who died on the very same day ostensibly died from overdose, I have no doubt that a good portion of the other half died from complications of overdose that simply were attributed to something else.

Ate you saying if the naloxone brought back a pulse but they never woke up and died a week later when the vent was pulled they wouldn't be counted as an OD?

 

[spacejunk]

naloxone isn't very long lasting, and sometimes wears off before the opiates (and/or other downers) do - which i believe can lead to a second "overdose".
i wonder if that plays any kind of role here; insufficient post-naloxone observation?

 

[CFC]

Interesting cduggles. The issue of what's written on death certificates and coroners reports is pretty salient here I think. We have similar problem among bodybuilders using steroids and a massive under-reporting of deaths as a consequence.

 

[S.J.B.]

Ate you saying if the naloxone brought back a pulse but they never woke up and died a week later when the vent was pulled they wouldn't be counted as an OD?

That seems unlikely.

 

[JessFR]

Let's face it. Being a junkie is very hazardous to your health.

It's sad, but im not sure what can be done. Ok that's not true, there's lots of things I'm sure could be done. But for political reasons they won't be. So what I mean is I'm not sure what can be done within the plausible policy changes that the system and status quo will tolerate.

Very sad. I'd be curious what makes up most of the 65% who died within a year but not from another overdose.

Regardless. That is still a lot of lives saved. We will never save everyone all the time. Obviously that doesn't justify doing nothing, I just mean people are sometimes unrealistic in their commitment to saving everyone.

 

[cduggles]

^^Great comments and questions!

As many of you have noted, using the cause of death on a death certificate to determine if a relationship exists to OD or health complications associated with IV drug use or addiction is challenging.

I'm hoping the study will have many more details than the abstract presented at the meeting, as well as the effects of data limitations.

These jumped out at me:

Also, of the 1,132 dying within 1 year (excluding same-day deaths), 37.9% died outside a hospital, the researchers found. "That's a huge cohort that's dying before medical attention can get to them," Weiner said.
....
About one-half of the documented deaths (again excluding same-day fatalities) occurred within one month of initial rescue. "That first month is very, very dangerous," Weiner said, noting that his team did not determine why.

I wonder what the cause of death (at least on death certificate) and time frame was in the 37.9% of deaths that occurred outside the hospital, excluding first-day deaths.

Although I was unfortunately not shocked that ~50% of deaths (excluding first-day deaths) occurred within one month, I do wonder if a large % were attributed to ODs.

Also, what % of patients who received naloxone were lost to follow-up in this large study?

I'm keeping two eyes out for similar publications or a paper from this abstract. Keep you posted!

 

[cduggles]

naloxone isn't very long lasting, and sometimes wears off before the opiates (and/or other downers) do - which i believe can lead to a second "overdose".
i wonder if that plays any kind of role here; insufficient post-naloxone observation?

Yes SJ! It never ceases to amaze me how little most clinicians know about treating patients who OD or are in withdrawal, not to mention addiction.

I've also heard that patients are immediately thrown into complete withdrawal and they want the WDs to stop immediately. Not an easy situation for anyone.

Interesting cduggles. The issue of what's written on death certificates and coroners reports is pretty salient here I think. We have similar problem among bodybuilders using steroids and a massive under-reporting of deaths as a consequence.

CFC, are steroids something coroners test for routinely? I'm very interested to know.

 

[CFC]

CFC, are steroids something coroners test for routinely? I'm very interested to know.

Very rarely. You can't really acutely OD on them, and the harms tend to develop over many years. It would take a specific reason for a coroner to investigate (or speculate) whether, say, a heart attack was caused by long-term steroid abuse or other causes. But then the same is true for other drugs like stimulants which can also cause lasting internal physical harm when abused long-term.

In other words, we only ever see the tip of the iceberg.

 

[JessFR]

I suppose I can't say it's too surprising to me since I probably would have thought this once too but at some point learned how it really worked, but it's amazing the disparity between stuff like blood tests in reality vs what people imagine. Probably in part due to the CSI effect people tend to think blood and similar tests will pick up anything of interest.

When in reality testing for EVERYRHING EVERY time would be prohibitively expensive and time consuming. But of course as a result, all sorts of interesting stuff is missed.

Generally unless it's either common or already suspected, it's not tested for.

 

[cj]

I suppose I can't say it's too surprising to me since I probably would have thought this once too but at some point learned how it really worked, but it's amazing the disparity between stuff like blood tests in reality vs what people imagine. Probably in part due to the CSI effect people tend to think blood and similar tests will pick up anything of interest.

When in reality testing for EVERYRHING EVERY time would be prohibitively expensive and time consuming. But of course as a result, all sorts of interesting stuff is missed.

Generally unless it's either common or already suspected, it's not tested for.

Yeah if foul play isn't suspected there really isn't much point in digging too deep. The person is dead so why is kinda a moot point. But I think the amount of suicides that are recorded as accidental overdose makes up for any missed overdoses in the statistics.

 

[JessFR]

Indeed. I'd bet there are a lot of suicides written off as overdoses. But it's bullshit.

In my experience, if you're say, a heavy heroin user, using several times every day and have been for years as I was, your odds of accidental overdose drop down to almost nothing. Eventually your tolerance simply makes it highly unlikely that you could accidentally experience a fatal overdose. But people living like that tend to be depressed and prone to suicide. But say you did OD and kill your self on purpose. Most people will assume ignorantly that it was an inevitable accident, when in fact suicide is actually much more likely.

Again, this is just in my experience, but id strongly suspect that nearly all actual accidental overdose deaths happen with someone who has only recently started using and thus has a low tolerance. Either because it's their first time or they've started again after a period of abstinence.

But most people don't have a realistic idea of overdose risks in one respect or another, and most people assume that most people aren't suicidal unless they have reason to suspect. Though I've found amount IV heroin addicts, while I wouldn't say most I've known have been suicidal, most have definitely been depressed and at risk of suicide.

 

[cj]

Indeed. I'd bet there are a lot of suicides written off as overdoses. But it's bullshit.

In my experience, if you're say, a heavy heroin user, using several times every day and have been for years as I was, your odds of accidental overdose drop down to almost nothing. Eventually your tolerance simply makes it highly unlikely that you could accidentally experience a fatal overdose. But people living like that tend to be depressed and prone to suicide. But say you did OD and kill your self on purpose. Most people will assume ignorantly that it was an inevitable accident, when in fact suicide is actually much more likely.

Again, this is just in my experience, but id strongly suspect that nearly all actual accidental overdose deaths happen with someone who has only recently started using and thus has a low tolerance. Either because it's their first time or they've started again after a period of abstinence.

But most people don't have a realistic idea of overdose risks in one respect or another, and most people assume that most people aren't suicidal unless they have reason to suspect. Though I've found amount IV heroin addicts, while I wouldn't say most I've known have been suicidal, most have definitely been depressed and at risk of suicide.

Absolutely. I tried to overdose three times while addicted and couldn't get it done even with large doses of Xanax in the mix.