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Racial/Ethnic, Social, and Geographic Trends in Overdose-Associated Cardiac Arrests Observed by US Emergency Medical Services During the COVID-19 Pandemic

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Can a national emergency medical services (EMS) database be used to rapidly surveil geographic, social, and overall trends in US overdose mortality?

Findings  In this cohort study of 83.7 million EMS patient encounters, overdose-associated cardiac arrests rose about 40% nationally in 2020, with the largest increases among racial/ethnic minorities, in areas of socioeconomic disadvantage, and in Western states. High concordance was observed with provisional total overdose death figures through July 2020.

Meaning  In this analysis, overdose deaths reached unprecedented levels during the pandemic, highlighting the need for investments in overdose prevention as an essential element of the COVID-19 response and postpandemic recovery, particularly for communities with greater vulnerability.


Importance  Provisional records from the US Centers for Disease Control and Prevention (CDC) through July 2020 indicate that overdose deaths spiked during the early months of the COVID-19 pandemic, yet more recent trends are not available, and the data are not disaggregated by month of occurrence, race/ethnicity, or other social categories. In contrast, data from emergency medical services (EMS) provide a source of information nearly in real time that may be useful for rapid and more granular surveillance of overdose mortality.

Objective  To describe racial/ethnic, social, and geographic trends in EMS-observed overdose-associated cardiac arrests during the COVID-19 pandemic through December 2020 and assess the concordance with CDC-reported provisional total overdose mortality through May 2020.

Design, Setting, and Participants  This cohort study included more than 11 000 EMS agencies in 49 US states that participate in the National EMS Information System and 83.7 million EMS activations in which patient contact was made.

Exposures  Year and month of occurrence of overdose-associated cardiac arrest; patient race/ethnicity; census region and division; county-level urbanicity; and zip code–level racial/ethnic composition, poverty, and educational attainment.

Main Outcomes and Measures  Overdose-associated cardiac arrests per 100 000 EMS activations with patient contact in 2020 were compared with a baseline of values from 2018 and 2019. Aggregate numbers of overdose-associated cardiac arrests and percentage increases were compared with provisional total mortality in CDC records from rolling 12-month windows with end months spanning January 2018 through July 2020.

Results  Among 33.4 million EMS activations in 2020, 16.8 million (50.2%) involved female patients and 16.3 million (48.8%) involved non-Hispanic White individuals. Overdose-associated cardiac arrests were elevated by 42.1% nationally in 2020 (42.3 per 100 000 EMS activations at baseline vs 60.1 per 100 000 EMS activations in 2020). The highest percentage increases were seen among Latinx individuals (49.7%; 38.8 per 100 000 activations at baseline vs 58.1 per 100 000 activations in 2020) and Black or African American individuals (50.3%; 21.5 per 100 000 activations at baseline vs 32.3 per 100 000 activations in 2020), people living in more impoverished neighborhoods (46.4%; 42.0 per 100 000 activations at baseline vs 61.5 per 100 000 activations in 2020), and the Pacific states (63.8%; 33.1 per 100 000 activations at baseline vs 54.2 per 100 000 activations in 2020), despite lower rates at baseline for these groups. The EMS records were available 6 to 12 months ahead of CDC mortality figures and showed a high concordance (r = 0.98) for months in which both data sets were available. If the historical association between EMS-observed and total overdose mortality holds true, an expected total of approximately 90 632 (95% CI, 85 737-95 525) overdose deaths may eventually be reported by the CDC for 2020.

Conclusions and Relevance  In this cohort study, records from EMS agencies provided an effective manner to rapidly surveil shifts in US overdose mortality. Unprecedented overdose deaths during the pandemic necessitate investments in overdose prevention as an essential aspect of the COVID-19 response and postpandemic recovery. This is particularly urgent for more socioeconomically disadvantaged and racial/ethnic minority communities subjected to the compounded burden of disproportionate COVID-19 mortality and rising overdose deaths.

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Article Information

Accepted for Publication: March 30, 2021.

Published Online: May 26, 2021. doi:10.1001/jamapsychiatry.2021.0967

Corresponding Author: Joseph Friedman, MPH, Center for Social Medicine and Humanities, B7-435, PO Box 951759, Los Angeles, CA 90095 (josephfriedman@mednet.ucla.edu).

Author Contributions: Mr Friedman had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Friedman, Beletsky, Schriger.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Friedman, Braslow, Beletsky.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Friedman, Mann, Schriger.

Obtained funding: Braslow.

Administrative, technical, or material support: Friedman, Hansen, Bourgois, Schriger.

Supervision: Friedman, Bourgois, Braslow, Bui, Beletsky, Schriger.

Conflict of Interest Disclosures: None reported.

Funding/Support: Mr Friedman received support from the UCLA Medical Scientist Training Program (National Institute of General Medical Sciences training grant GM008042). Dr. Schriger’s time on this project was supported by an unrestricted grant from the Korein Foundation.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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