摘要：Objectives. We determined the factors that affect naloxone (Narcan) administration in drug overdoses, including the certification level of emergency medical technicians (EMTs). Methods. In 2012, 42 states contributed all or a portion of their ambulatory data to the National Emergency Medical Services Information System. We used a logistic regression model to measure the association between naloxone administration and emergency medical services certification level, age, gender, geographic location, and patient primary symptom. Results. The odds of naloxone administration were much higher among EMT-intermediates than among EMT-basics (adjusted odds ratio [AOR] = 5.4; 95% confidence interval [CI] = 4.5, 6.5). Naloxone use was higher in suburban areas than in urban areas (AOR = 1.41; 95% CI = 1.3, 1.5), followed by rural areas (AOR = 1.23; 95% CI = 1.1, 1.3). Although the odds of naloxone administration were 23% higher in rural areas than in urban areas, the opioid drug overdose rate is 45% higher in rural communities. Conclusions. Naloxone is less often administered by EMT-basics, who are more common in rural areas. In most states, the scope-of-practice model prohibits naloxone administration by basic EMTs. Reducing this barrier could help prevent drug overdose death. Drug overdose is a major cause of injury-related death in the United States. 1 In 2011, the number of deaths associated with opioid prescription pain relievers was 16 917, 2 and an additional 4397 deaths were heroin-related. 3 In addition to death, the burden of lost productivity and medical costs associated with opioid-related poisoning is $20.4 billion annually (in 2009 dollars). 4 The growing number of overdose deaths suggests that primary prevention efforts need to be strengthened and augmented. In an effort to reduce deaths through any means available, recent attention has focused on the ability of emergency medical services (EMS) providers to save lives at the scene of an opioid drug overdose. In addition to life support measures to ensure adequate airway support, breathing, and circulation, many EMS providers are equipped with an opioid antagonist medication, naloxone, that can be used to treat respiratory depression in suspected opioid overdose patients. According to 1 study, naloxone is the drug most commonly administered to adolescents in the prehospital setting. 5 Prehospital use of this drug is routine, 6 serious adverse effects are rare, and it has no abuse potential. 7 The drug overdose mortality rate rose 159% in nonmetropolitan rural counties between 1999 and 2004, compared with 54% in metropolitan counties. 8 Rural EMS, covering about 20% of the population and 80% of the land mass of the United States, 9 are starkly different from urban and suburban EMS. In addition to longer response times, 10 major challenges in rural EMS include, but are not limited to, personnel shortages, inadequate advanced training opportunities for EMS response staff, antiquated equipment (e.g., communications equipment), poor public access to EMS, and an absence of regionalized systems of specialized EMS care, such as trauma systems. 11 Guidance on EMS administration of pharmaceuticals is contained in the national EMS scope-of-practice model. 12 States are free to create their own guidance and protocols; however, most states follow this model. This guidance limits basic life support personnel, including people certified as emergency medical technician–basic (EMT-basic), to assisting patients in taking their own prescribed medications and glucose and aspirin orally. Only advanced life support personnel are permitted to administer naloxone. However, basic life support providers can often be the first responders on the scene in cases of opioid overdose, particularly in rural communities. The availability and dispatch of EMS resources to the scene of an injury or illness is multifactorial and depends on the details of the emergency and anticipated resource requirements, available personnel and equipment, and location of the event. In adherence to the national scope-of-practice policy guidance, 38 states prohibit EMT-basics from administering parenteral pharmacotherapies. 13 In the 12 states that allow EMT-basics to administer naloxone, it is frequently administered intranasally and not by injection. In all states, only advanced life support providers are permitted to initiate intravenous access and administer intravenous medications, including naloxone. In cases of opioid overdose, if EMS providers do not have someone authorized to administer naloxone, the patient may be at a higher risk of death. Recognizing this barrier to naloxone administration, some authors have suggested more widespread use of intranasal naloxone by non–advanced life support providers. 13,14 Other researchers have reported that dispatching of EMT-basics results in underuse of naloxone. 15 EMS providers operate by following protocols for medical care and administration of medications. These protocols are approved by a local, regional, or state medical director. These clinical protocols direct the actions and interventions of EMS providers on scene and in transport, and they include the collection and use of physiological data (low respiration rate, decreased responsiveness, pupil dilatation, and other signs, including cardiac arrest) 16 along with other information (i.e., drug paraphernalia at scene and bystander-provided information) to make a determination of suspected opioid overdose. Although 29 states have established statewide protocols for naloxone administration, only 12 states allow EMT-basic personnel to administer naloxone. In many cases, variability occurs at the regional or local level. 17 Standard uniform guidance on naloxone administration does not exist, and published guidance varies across localities and states. Smaller rural communities have a much higher proportion of EMT-basic personnel. 18 Authorizing these EMS personnel to administer naloxone to patients thought to have an opioid overdose will result in fewer deaths. However, the magnitude of this certification barrier to naloxone administration is largely unknown. Whether certification issues among EMS providers have a disproportionate impact on rural areas is also unclear. In addition, major signs or symptoms that contribute to a preliminary diagnosis of overdose by EMS personnel at the injury scene are generally unknown. In this study, we examined the factors that were associated with naloxone administration and that may assist states in reviewing policy on naloxone administration and reduce mortality at the scene of injury in the case of a suspected opioid drug overdose.
