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Objective: To help understand whether decreased emergency medical services (EMS) utilization due to the COVID-19 pandemic contributed to increased accidental fatal drug overdoses, we characterized recent EMS utilization history among people who had an accidental opioid-involved fatal drug overdose in Rhode Island., Methods: We identified accidental opioid-involved fatal drug overdoses among Rhode Island residents that occurred from January 1, 2018, through December 31, 2020. We linked decedents by name and date of birth to the Rhode Island EMS Information System to obtain EMS utilization history., Results: Among 763 people who had an accidental opioid-involved fatal overdose, 51% had any EMS run and 16% had any opioid overdose-related EMS run in the 2 years before death. Non-Hispanic White decedents were significantly more likely than decedents of other races and ethnicities to have any EMS run ( P < .001) and any opioid overdose-related EMS run ( P = .05) in the 2 years before death. Despite a 31% increase in fatal overdoses from 2019 through 2020, corresponding with the onset of the COVID-19 pandemic, EMS utilization in the prior 2 years, prior 180 days, or prior 90 days did not vary by time frame of death., Conclusion: In Rhode Island, decreased EMS utilization because of the COVID-19 pandemic was not a driving force behind the increase in overdose fatalities observed in 2020. However, with half of people who had an accidental opioid-involved fatal drug overdose having an EMS run in the 2 years before death, emergency care is a potential opportunity to link people to health care and social services., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Importance: Health departments have used a variety of methods for overdose surveillance, and the Centers for Disease Control and Prevention (CDC) is implementing a standardized case definition to improve overdose surveillance nationally. The comparative accuracy of the CDC opioid overdose case definition vs existing state opioid overdose surveillance systems is unknown., Objective: To evaluate the accuracy of the CDC opioid overdose case definition and existing Rhode Island Department of Health (RIDOH) state opioid overdose surveillance system., Design, Setting, and Participants: This cross-sectional study of ED opioid overdose visits was conducted at 2 EDs in Providence, Rhode Island, at the state's largest health system from January to May 2021. Electronic health records (EHRs) were reviewed for opioid overdoses identified by the CDC case definition and opioid overdoses reported to the RIDOH state surveillance system. Included patients were those at study EDs whose visit met the CDC case definition, was reported to the state surveillance system, or both. True overdose cases were confirmed by EHR review using a standard case definition; 61 of 460 EHRs (13.3%) were double reviewed to estimate classification accuracy. Data were analyzed from January through May 2021., Main Outcome and Measure: Accurate identification of an opioid overdose was assessed by estimating the positive predictive value of the CDC case definition and state surveillance system using results from the EHR review., Results: Among 460 ED visits that met the CDC opioid overdose case definition, were reported to the RIDOH opioid overdose surveillance system, or both (mean [SD] age, 39.7 [13.5] years; 313 males [68.0%]; 61 Black [13.3%], 308 White [67.0%], and 91 other race [19.8%]; and 97 Hispanic or Latinx [21.1%] among each patient visit), 359 visits (78.0%) were true opioid overdoses. For these visits, the CDC case definition and RIDOH surveillance system agreed that 169 visits (36.7%) were opioid overdoses. Of 318 visits meeting the CDC opioid overdose case definition, 289 visits (90.8%; 95% CI, 87.2%-93.8%) were true opioid overdoses. Of 311 visits reported to the RIDOH surveillance system, 235 visits (75.6%; 95% CI, 70.4%-80.2%) were true opioid overdoses., Conclusions and Relevance: This cross-sectional study found that the CDC opioid overdose case definition more often identified true opioid overdoses compared with the Rhode Island overdose surveillance system. This finding suggests that using the CDC case definition for opioid overdose surveillance may be associated with improved data efficiency and uniformity.

In 2017, Rhode Island responded to rising overdose deaths by establishing statewide emergency department (ED) treatment standards for opioid overdose and opioid use disorder. One requirement of the policy is that providers prescribe or provide take-home naloxone to anyone presenting to EDs with opioid overdose. Among adults presenting to EDs with opioid overdose from 2018 to 2019, approximately half received take-home naloxone. Receipt of naloxone was associated with administration of naloxone before ED presentation, ED policy certification level, and regional overdose frequency. ( Am J Public Health . 2023;113(4):372-377. https://doi.org/10.2105/AJPH.2022.307213).

Objective: To evaluate the impact of a statewide treatment standards policy for post-overdose emergency department (ED) care on services provided and subsequent treatment engagement., Methods: This pre-/post-study used electronic health record data and surveillance data from Rhode Island. Outcomes were compared for patients attending EDs for opioid overdose before (03/1/2015-02/28/2017) and after (04/01/2017-03/31/2021) policy release., Results: Overall, 2,134 patients attended 2,891 ED visits for opioid overdose. Compared to pre-policy, visits post-policy more often included initiation of buprenorphine in or from the ED (<1% vs. 3%, p<0.01), provision of a take-home naloxone kit or prescription (41% vs. 58%, p<0.01), and referral to treatment (0% vs. 34%, p<0.01). Provision of behavioral counseling in the ED and initiation of treatment within 30 days of the visit were similar during the two periods., Conclusions: Statewide post-overdose treatment standards may improve provision of some ED services. Additional strategies are needed to improve subsequent treatment engagement.

Background: Rates of psychostimulant use, misuse, and hospitalization have increased markedly over the past decade. The objective of this study was to estimate the association between receipt of a psychostimulant prescription in the past year and fatal, unintentional psychostimulant-involved overdose. Methods: We conducted a population-based case-control study using linked, state-level databases from the Rhode Island Department of Health. Cases were defined as Rhode Island residents who experienced a fatal, unintentional drug overdose involving a psychostimulant, and controls included non-psychostimulant involved fatal overdoses occurring between May 1, 2017 and May 31, 2020 The primary exposure of interest was receipt of a psychostimulant prescription within 12 months prior to death, ascertained through linkage to the state's prescription drug monitoring program. Conditional logistic regression was used to estimate unadjusted and adjusted odds ratios. Results: Of 894 eligible overdose fatalities, the majority were white/non-Hispanic (72%), mean age was 43 years, and most resided in Providence County (69%). A total of 39 (4%) involved a psychostimulant. After adjusting for year of death and matching by sex, age, and county of residence, cases had 4.1 (95% confidence interval: 1.6, 10.6) times the odds of receiving a prescription stimulant in the past year compared to controls. Conclusions: Our findings suggest that there is a strong, positive association between prescription psychostimulant receipt and psychostimulant-involved fatal overdose. In response to an evolving polysubstance use landscape, current harm reductions measures, including naloxone training, fentanyl test strip distribution, and overdose education, should be expanded to include patients who receive psychostimulant prescriptions.

Background: Overdose deaths have increased dramatically in the United States, including in Rhode Island. In July 2021, the Rhode Island government passed legislation supporting a two-year pilot program authorizing supervised consumption sites (SCSs) in response to this crisis. We estimated the costs and benefits of a hypothetical SCS in Providence, Rhode Island., Methods: We utilized a decision analytic mathematical model to compare costs and outcomes for people who inject drugs under two scenarios: (1) a SCS that includes syringe services provision, and (2) a syringe service program only (i.e., status quo). We assumed 0.95% of injections result in overdose, the SCS would serve 400 clients monthly and have a net cost of $783,899 annually, 46% of overdoses occurring outside of the SCS result in an ambulance run and 43% result in an emergency department (ED) visit, 0.79% of overdoses occurring within the SCS result in an ambulance run and ED visit, and the SCS would lead to a 25.7% reduction in fatal overdoses near the site. The model was developed from a modified societal perspective with a one-year time horizon., Results: A hypothetical SCS in Providence would prevent approximately 2 overdose deaths, 261 ambulance runs, 244 ED visits, and 117 inpatient hospitalizations for emergency overdose care annually compared to a scenario that includes a syringe service program only. The SCS would save $1,104,454 annually compared to the syringe service program only, accounting only for facility costs and short-term costs of emergency overdose care and ignoring savings associated with averted deaths. Influential parameters included the percentage of injections resulting in overdose, the total annual injections at the SCS, and the percentage of overdoses outside of the SCS that result in an ED visit., Conclusion: A SCS in would result in substantial cost savings due to prevention of costly emergency overdose care., Competing Interests: Declarations of Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Potential conflicts of interest: LCC conducts research unrelated to this work funded by the Hassenfeld Family Foundation. All other authors declare that they have no potential conflicts of interest., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Accidental opioid-involved overdose deaths are increasing nationally in the wake of the COVID-19 pandemic, but it is unclear if this reflects a change in populations most at risk. Objective: To determine whether the demographic characteristics and controlled substance prescription history of accidental opioid-involved drug overdose decedents in 2020 differed from prior years. Methods: We identified accidental opioid-involved overdose decedents using Rhode Island (RI) State Medical Examiner's Office data. Decedents were linked to the RI Prescription Drug Monitoring Program database. We compared demographic characteristics and prescription history by year of death. Results: From 2018 to 2020, 763 RI residents died from accidental opioid-involved overdose in RI. From 2018 to 2019, deaths decreased by 7%, but then increased by 31% from 2019 to 2020. Demographic characteristics were similar by year of death (all p  > 0.05). The percentage of decedents with a prior opioid prescription and a prior benzodiazepine prescription declined from 2018 to 2020 ( p  < 0.01 and p  = 0.03). Conclusions: We found that opioid-involved overdose deaths in RI are increasing overall, but without significant changes in demographics. While prior exposure to some controlled substances did decline over time, it is not clear if these changes reflect more responsible prescribing practices, or a more concerning pattern such as patient abandonment or decreased healthcare access. More studies are needed to better describe the current trend of increasing opioid-involved deaths while also pursuing current evidence-based interventions.

The Rhode Island Department of Health (RIDOH) uses emergency department data to monitor nonfatal opioid overdoses in Rhode Island. In April 2019, RIDOH detected an increase in nonfatal opioid overdoses in Woonsocket, Rhode Island, and sent an alert to state and local partners (eg, fire departments, emergency departments, faith leaders) with guidance on how to respond. To guide community-level, strategic response efforts, RIDOH analyzed surveillance data to identify overdose patterns, populations, and geographic areas most affected. During April-June 2019, nonfatal opioid overdoses in Woonsocket increased 463% (from 13 to 73) when compared with the previous 3 months. Because of the sustained increase in nonfatal opioid overdoses, RIDOH brought together community partners at a meeting in June 2019 to discuss RIDOH opioid overdose data and coordinate next steps. Data analyses were essential to framing the discussion and allowed community partners at the event to identify an unexpected increase in cocaine-involved nonfatal opioid overdoses in Woonsocket. Many patients with cocaine-involved nonfatal overdoses also had fentanyl in their system, and input from community partners suggested that many patients were unaware of using fentanyl. Community response actions included targeting harm reduction services (eg, distribution of naloxone, mobile needle exchange); deploying peer recovery support specialists to overdose hotspots to connect people to treatment and recovery resources; placing harm reduction messaging in high-traffic areas; and targeted social media messaging. After the meeting, nonfatal opioid overdoses returned to pre-outbreak levels. This case study provides an example of how timely opioid overdose data can be effectively used to detect a spike in nonfatal opioid overdoses and inform a strategic, community-level response.

Objective: To estimate the prevalence of concurrent prescription opioid and non-opioid controlled substance use in Rhode Island (RI)., Methods: We conducted a cross sectional observational study using data from the RI Prescription Drug Monitoring Program on controlled substance prescriptions dispensed in 2018. We estimated the prevalence of concurrent use of other prescribed controlled substances among adults who received at least one opioid prescription., Results: In 2018, 142,692 RI adult residents received at least one opioid prescription, of whom 25.1% (99% confidence interval [CI]: 24.8-25.4) were concurrently prescribed at least one other controlled substance, including benzodiazepines (17.0%, 99% CI: 16.8-17.3), medications for insomnia (4.0%, 99% CI: 3.9-4.2), and stimulants (3.8%, 99% CI: 3.6-3.9)., Conclusion: The concurrent use of prescription opioids and other prescribed controlled substances is common. Our findings suggest an urgent need to implement focused initiatives to address controlled substance polypharmacy to reduce the risk of overdose.