Naloxone Use, 911 Calls, and Emergency Visits After Nonfatal Overdose.

Importance: People may not call 911 or visit the emergency department (ED) after a nonfatal overdose (NFOD), particularly when a layperson has already administered naloxone. Understanding service-engagement patterns can improve postoverdose care. Objective: To examine service use following an NFOD. Design, Setting, and Participants: This cross-sectional study of a telephone survey included adults who used cocaine, opioids, or methamphetamines in the prior 12 months. Respondents were recruited from harm-reduction, treatment, and social services organizations in New Jersey, Wisconsin, Michigan, and New Mexico from January 2023 to August 2024. Exposure: Experience with an NFOD in the prior 12 months. Main Outcomes and Measures: The main outcomes were use of naloxone, calls to 911, and ED visits following an NFOD and self-reported reasons for not calling 911. Adjusted odds ratios (AORs) were calculated to examine factors associated with each outcome and categorized free-response reasons if not engaging in care. Results: Among the 2097 participants (median [IQR] age, 42 years [34-52 years]; 1165 males [55.6%]), 538 (25.7%) had experienced at least 1 NFOD in the prior year. During the most recent NFOD, use of naloxone was reported by 430 of 524 survivors (82.1%), calls to 911 were reported by 328 of 535 survivors (61.3%), and visits to the ED were reported by 253 of 538 survivors (47.0%). In multivariable regressions of survivors of overdose, 911 was more likely to have been called at the most recent overdose event by people who resided in New Jersey (vs Wisconsin) (AOR, 3.24 [95% CI, 1.40-7.47]; P = .01), by non-Hispanic Black people (compared with non-Hispanic White people) (AOR, 1.79 [95% CI, 1.08-2.97]; P = .02), and by people who used drugs a few times a month at the time of the interview (vs no drug use) (AOR, 3.83 [95% CI, 1.23-12.00]; P = .02). The most commonly reported reasons for not calling 911 were that the person regained consciousness without naloxone (n = 61 [28.6%]) or that a bystander administered naloxone (n = 57 [26.8%]). Among those with a 911 call, visits to the ED were more common among Black individuals (AOR, 2.89 [95% CI, 1.11-7.54]; P = .03). Most people (n = 150 [61.5%]) received take-home naloxone in the hospital, and approximately one-fifth or fewer reported receiving buprenorphine (n = 57 [21.9%]) or methadone (n = 42 [16.2%]) before discharge. Conclusions and Relevance: In this cross-sectional study of survivors of drug overdose, fewer than half of recent overdose events did not culminate in a visit to the ED. These results suggest that policies to improve postoverdose outcomes must simultaneously focus on people who engage with emergency medical services and on those who do not seek formal medical care.