An Examination of Statewide Protocols for Emergency Medical Services Administration of Naloxone
DOI:
https://doi.org/10.47265/cjim.v3i1.5196Keywords:
Opioid, Overdose, Emergency Medicine, Naloxone, Prehospital, opioidAbstract
Introduction: Death due to opioid overdoses are on the rise in the United States. Naloxone is a potentially life-saving treatment that has been proven to be safe and effective in treating an opioid overdose. Emergency Medical Services (EMS) are often the first on the scene for medical emergencies and may play a key role in early interventions to reverse opioid overdose. We examined publicly available EMS protocols for opioid overdose for all 50 states in the U.S. to determine EMS scope of practice regarding naloxone administration and available routes of administration.
Methods: Publicly available statewide EMS protocols and supplemental documents were identified from state and municipality official websites. These protocols and supplementary documents were reviewed independently by two abstractors who collected data regarding the routes of administration and scope of practice by provider level. Any inconsistencies between abstractors were remediated by the research team.
Results: Naloxone-specific EMS protocols were available for 35 out of 50 (70%) states with an additional 5 (10%) states having documents pertinent to the route of administration by provider level. Among them, 28 states (70%) permitted Emergency Medical Responders (EMRs) to administer naloxone whereas 9 (22.5%) states only allowed EMT administration, and 3 (7.5%) states allowed Paramedic administration respectively. The Intranasal (IN) route of administration was available in all 40 (100%) states, Intravenous (IV) route available in 37 (92.5%), and Intramuscular (IM) route available in 32 (80%) states. Less common routes of administration including auto-injection was available for 23 (57.5%) states while subcutaneous route was only used by 8 (20%) of states.
Conclusion: Our analysis of publicly available EMS protocols in the United States showed that most states allowed EMRs to administer naloxone for presumed opioid overdoses aligned with the current EMS Scope of Practice Model recommendations. However, the minimum level of training required for administration varied between states with several states still requiring minimal EMT-level training. Our findings suggest the need for greater consistency between EMS naloxone protocols between states to reduce mortality associated with the opioid epidemic.
KEYWORDS
Opioid overdose, naloxone, prehospital care, EMS protocols, EMS scope of practice
References
Understanding the Opioid Overdose Epidemic | Opioids | CDC. Published October 7, 2022. Accessed December 1, 2022. https://www.cdc.gov/opioids/basics/epidemic.html
HAN Archive - 00438 | Health Alert Network (HAN). Published September 21, 2021. Accessed December 1, 2022. https://emergency.cdc.gov/han/2020/han00438.asp#print
Analysis of Drug Test Results Before and After the US Declaration of a National Emergency Concerning the COVID-19 Outbreak | Emergency Medicine | JAMA | JAMA Network. Accessed December 1, 2022. https://jamanetwork.com/journals/jama/fullarticle/2770987
Strang J, McDonald R, Campbell G, et al. Take-Home Naloxone for the Emergency Interim Management of Opioid Overdose: The Public Health Application of an Emergency Medicine. Drugs. 2019;79(13):1395-1418. doi:10.1007/s40265-019-01154-5
Karamouzian M, Kuo M, Crabtree A, Buxton JA. Correlates of seeking emergency medical help in the event of an overdose in British Columbia, Canada: Findings from the Take Home Naloxone program. International Journal of Drug Policy. 2019;71:157-163. doi:10.1016/j.drugpo.2019.01.006
Keseg DP, Augustine JJ, Fowler RL, Scheppke KA, Farcy DA, Pepe PE. Annotated Guidance and Recommendations for the Role and Actions of Emergency Medical Services Systems in the Current Opioid and Drug-Related Epidemics. The Journal of Emergency Medicine. 2019;57(2):187-194.e1. doi:10.1016/j.jemermed.2019.04.017
Dowling J, Isbister GK, Kirkpatrick CMJ, Naidoo D, Graudins A. Population Pharmacokinetics of Intravenous, Intramuscular, and Intranasal Naloxone in Human Volunteers. Therapeutic Drug Monitoring. 2008;30(4):490. doi:10.1097/FTD.0b013e3181816214
Strang J, McDonald R, Alqurshi A, Royall P, Taylor D, Forbes B. Naloxone without the needle − systematic review of candidate routes for non-injectable naloxone for opioid overdose reversal. Drug and Alcohol Dependence. 2016;163:16-23. doi:10.1016/j.drugalcdep.2016.02.042
Williams K, Lang ES, Panchal AR, et al. Evidence-Based Guidelines for EMS Administration of Naloxone. Prehospital Emergency Care. 2019;23(6):749-763. doi:10.1080/10903127.2019.1597955
Faul M, Dailey MW, Sugerman DE, Sasser SM, Levy B, Paulozzi LJ. Disparity in Naloxone Administration by Emergency Medical Service Providers and the Burden of Drug Overdose in US Rural Communities. Am J Public Health. 2015;105(Suppl 3):e26-e32. doi:10.2105/AJPH.2014.302520
Grover JM, Alabdrabalnabi T, Patel MD, et al. Measuring a Crisis: Questioning the Use of Naloxone Administrations as a Marker for Opioid Overdoses in a Large U.S. EMS System. Prehospital Emergency Care. 2018;22(3):281-289. doi:10.1080/10903127.2017.1387628
National Association of State EMS Officials. National EMS Scope of Practice Model 2019. National Highway Traffic Safety Administration. https://www.ems.gov/pdf/National_EMS_Scope_of_Practice_Model_2019.pdf
O’Connor RE, Cone DC. If You’ve Seen One EMS System, You’ve Seen One EMS System…. Academic Emergency Medicine. 2009;16(12):1331-1332. doi:10.1111/j.1553-2712.2009.00607.x
Smart R, Haffajee RL, Davis CS. Legal review of state emergency medical services policies and protocols for naloxone administration. Drug and Alcohol Dependence. 2022;238:109589. doi:10.1016/j.drugalcdep.2022.109589
Namboodri BL, Rosen T, Dayaa JA, et al. Elder Abuse Identification in the Prehospital Setting: An Examination of State EMS Protocols. J Am Geriatr Soc. 2018;66(5):962-968. doi:10.1111/jgs.15329
Dadoo S, Grover JM, Keil LG, Hwang KS, Brice JH, Platts-Mills TF. Prehospital Fluid Administration in Trauma Patients: A Survey of State Protocols. Prehospital Emergency Care. 2017;21(5):605-609. doi:10.1080/10903127.2017.1315202
(PDF) Evolution of United States Legislation to Facilitate Bystander Response to Opioid Overdose. Accessed December 1, 2022. https://www.researchgate.net/publication/332907723_Evolution_of_United_States_Legislation_to_Facilitate_Bystander_Response_to_Opioid_Overdose
Keane C, Egan JE, Hawk M. Effects of naloxone distribution to likely bystanders: Results of an agent-based model. International Journal of Drug Policy. 2018;55:61-69. doi:10.1016/j.drugpo.2018.02.008
Nugent K, Matthews P, Gissendaner J, et al. A Comparison of Efficacy of Treatment and Time to Administration of Naloxone by BLS and ALS Providers. Prehospital and Disaster Medicine. 2019;34(4):350-355. doi:10.1017/S1049023X19004527
Gupta R, Shah ND, Ross JS. The Rising Price of Naloxone — Risks to Efforts to Stem Overdose Deaths. New England Journal of Medicine. 2016;375(23):2213-2215. doi:10.1056/NEJMp16095782
Dietze P, Jauncey M, Salmon A, et al. Effect of Intranasal vs Intramuscular Naloxone on Opioid Overdose: A Randomized Clinical Trial. JAMA Network Open. 2019;2(11):e1914977. doi:10.1001/jamanetworkopen.2019.14977
Randomised trial of intranasal versus intramuscular naloxone in prehospital treatment for suspected opioid overdose - Kelly - 2005 - Medical Journal of Australia - Wiley Online Library. Accessed May 18, 2023. https://onlinelibrary.wiley.com/doi/abs/10.5694/j.1326-5377.2005.tb06550.x
Additional Files
Published
How to Cite
Issue
Section
Categories
License
Copyright (c) 2023 Rayad Shams, Haylie Fehl, Ishani Kapoor, Dr. Joseph M. Grover, MD, Dr. Mehul D. Patel, PhD
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
