Impact of Bystander Naloxone on Emergency Medical Transport Refusal After Opioid Overdose: A Statewide Retrospective Analysis.

introductionThe opioid epidemic remains a public health crisis in the United States. Naloxone is a cornerstone of overdose reversal, and its increasing availability to bystanders has improved immediate survival. However, little is known about how bystander naloxone administration influences use of emergency medical services (EMS), particularly patient refusal of transport. Understanding these dynamics is critical for development of EMS protocol and harm reduction strategies.

methodsWe performed a retrospective cohort study of suspected opioid overdoses reported to the Connecticut Statewide Opioid Reporting Directive (SWORD) between November 1, 2019-June 30, 2024. The primary outcome was EMS transport refusal, defined as non-transport after naloxone administration. The primary exposure was initial naloxone administrator (bystander vs first responder). Secondary variables included naloxone dose frequency, patient demographics, and time. Bivariate tests compared group differences. We used multivariable logistic regression to assess the association between bystander naloxone and refusal, adjusting for covariates. To evaluate temporal trends, we performed separate logistic regression models with calendar quarter (Q) modeled as a continuous variable (Q1 2020-Q2 2024).

resultsAmong 15,025 nonfatal suspected overdoses involving naloxone in Connecticut, bystanders were initial administrators in 18%. Transport refusal occurred more often after bystander administration compared to first responder administration (16.1% vs 6.2%). In adjusted analyses, bystander administration was associated with nearly threefold higher odds of refusal (adjusted odds ratio [aOR] 2.90; 95% CI, 2.53-3.31). Multiple-dose incidents were associated with decreased refusal (aOR 0.83; 0.72-0.93). During the study period, bystander administration increased from 15% in Q4 2019 to 24% in Q2 2024, corresponding to a 3.8% increase in odds per quarter (OR 1.04; 95% CI 1.03-1.05, P < .001). Refusal more than doubled from 4% to 12%, with odds increasing 4.5% per quarter (OR 1.05; 1.04-1.06, P < .001).

conclusionBystander-administered naloxone is increasingly common and strongly associated with higher odds of EMS transport refusal. While refusal does not always equate to unsafe outcomes, it represents missed opportunities for initiation of medications for opioid use disorder, harm reduction counseling, and linkage to care. Emergency medical services agencies should consider strategies such as leave-behind naloxone, peer recovery coach deployment, and EMS-initiated buprenorphine to capitalize on these encounters.