Police-mental health co-response versus police-as-usual response to behavioral health emergencies: A pragmatic randomized effectiveness trial.

BACKGROUND: People with mental illness are overrepresented in United States (US) criminal legal systems. In response, alternatives to traditional police response to behavioral health emergencies have become more common, despite limited evidence for their effectiveness. We conducted the first randomized controlled trial of a police-mental health co-response team to determine program effectiveness relative to a police-as-usual response on key outcomes identified by community stakeholders. METHODS: Between January 2020 and March 2021, we randomized behavioral health emergency calls for service in one of six police districts in Indianapolis, Indiana to receive a co-response or police-as-usual response during operational hours between 10 a.m. and 5 p.m. Mondays - Fridays. Eligible calls for service were determined via pre-specified phrases indicating a behavioral health incident over the police dispatch radio. Researchers then communicated random assignment with the co-response team to indicate whether they should respond or withhold. Logistic and negative binomial regression were used to assess group differences in emergency medical services (EMS) events within 12 months of the randomized incident along with jail booking, outpatient encounters, and emergency department visits. FINDINGS: We randomized 686 calls for service with co-response completed in 264 cases and police-as-usual response in 267 cases. The overall rate of attrition was similar across conditions and the final sample included 211 co-responses and 224 police-as-usual responses. We found no significant differences in any EMS event (odds ratio [OR]: 1.26; 95% confidence interval [CI]: 0.85-1.88, p = .246) or event counts (incidence rate ratio [IRR]: 0.85; 95% CI: 0.52-1.37, p = .504). We also found no differences in secondary outcomes (jail booking, outpatient encounters, and emergency department visits). DISCUSSION: A police-mental health co-response team model was not more effective than traditional police response on key outcomes. Co-response team models, such as the one reported here, may unintentionally foster emergency services utilization among persons with behavioral health needs. Without a functioning national mental health system, communities in the US will continue to struggle to identify solutions to meet the needs of community members with complex behavioral health issues.

The role of co-occurring disorders in criminal recidivism and psychiatric recovery among adults with opioid use disorder and criminal-legal involvement: A statewide retrospective cohort study.

INTRODUCTION: Individuals with opioid use disorder (OUD) in the criminal-legal system commonly present co-occurring mental health disorders. However, evidence-based treatment for high-risk populations such as those with co-occurring disorders is often unavailable within jails and prisons. Coordination of timely and affordable access to behavioral health treatment following incarceration is critical to address the multidimensional needs of people with co-occurring needs. However, the role of co-occurring disorders among adults with OUD and criminal-legal involvement who are accessing community-based treatment is understudied. METHODS: This retrospective cohort study investigated community and recovery outcomes among 2039 adults with OUD and criminal-legal involvement enrolled in a statewide forensic treatment initiative between October 2015 to March 2018. Using court records and clinical data, we assessed the impact of co-occurring OUD and mental health disorders on criminal recidivism and psychiatric recovery and the moderating role of co-occurring disorders on the relationship between community-based treatment and these outcomes. RESULTS: We found that 47 % of those with OUD also had an underlying mental health disorder. Co-occurring OUD and mental health disorders predicted higher rates of recidivism during the early stages of treatment. Furthermore, group and individual therapy services were associated with lower odds of recidivism. A co-occurring disorder was an important predictor of more severe behavioral health needs when exiting community-based services and did moderate the relationship between service utilization-specifically group therapy and substance use outpatient services-and psychiatric recovery (i.e., behavioral health needs at exit). CONCLUSIONS: Co-occurring mental health disorders are highly prevalent among adults with OUD who have criminal-legal involvement, but it appears that they can benefit from social support services in the community. Given the multidimensional needs of this high-risk population, criminal-legal stakeholders and community-based clinicians must work in tandem to develop tailored treatment plans that give individuals with co-occurring OUD and mental health disorders the best chance for success post-incarceration rather than a siloed approach to overlapping disorders.

Antecedents of fatal overdose in an adult cohort identified through administrative record linkage in Indiana, 2015-2022.

BACKGROUND: The United States continues to experience unprecedented rates of overdose mortality and need to identify effective policies or practices that can be implemented. This study aims to measure the prevalence, frequency, timing, and rate of touchpoints that occurred prior to a fatal overdose where communities might intervene. METHODS: In collaboration with Indiana state government, we conducted record-linkage of statewide administrative datasets to vital records (January 1, 2015, through August 26, 2022) to identify touchpoints (jail booking, prison release, prescription medication dispensation, emergency department visits, and emergency medical services). We examined touchpoints within 12-months prior to a fatal overdose among an adult cohort and explored variation over time and by demographic characteristics. RESULTS: Over the 92-month study period there were 13,882 overdose deaths (89.3% accidental poisonings, X40-X44) in our adult cohort that were record-linked to multiple administrative datasets and revealed nearly two-thirds (64.7%; n=8980) experienced an emergency department visit, the most prevalent touchpoint followed by prescription medication dispensation, emergency medical services responses, jail booking, and prison release. However, with approximately 1 out of every 100 returning citizens dying from drug overdose within 12-months of release, prison release had the highest touchpoint rate followed by emergency medical services responses, jail booking, emergency department visits, and prescription medication dispensation. CONCLUSION: Record-linking administrative data from routine practice to vital records from overdose mortality is a viable means of identifying where resources should be situated to reduce fatal overdose, with potential to evaluate the effectiveness of overdose prevention efforts.

Supply-side predictors of fatal drug overdose in the Washington/Baltimore HIDTA region: 2016-2020.

BACKGROUND: Rising rates of fentanyl- and polydrug-involved drug overdose deaths have prompted inquiry into the role of drug supply in fatal overdose outcomes in the United States. To date, however, there have been few empirical investigations of drug enforcement strategies on fatal overdose rates, despite knowledge that both drug use and supply are often geographically distributed. To address this limitation, we examined measures of drug enforcement as predictors of next-year fatal overdose rates in the Washington/Baltimore High Intensity Drug Trafficking Area (W/B HIDTA). METHODS: We conducted mixed-effects models to examine the role of drug seizures and disruption in drug trafficking organizations (DTOs) and money laundering organizations (MLOs) on fatal overdose rates over a 5-year period (2016-2020) across 45 local jurisdictions in the W/B HIDTA region. Outcomes included any, opioid-involved, and fentanyl-involved fatal overdose. RESULTS: Adjusting for covariates, both the total number of drug seizures and amount of cocaine seized (in dosage units per capita) positively predicted next-year opioid- and fentanyl-involved fatal overdose rates. Disruption to DTO and MLO operations did not significantly predict next-year fatal overdose rates for any outcome. CONCLUSION: Supply-side enforcement activities alone may have limited impact on reducing fatal overdose rates, but may serve as important markers to identify communities at high risk of fatal overdose and facilitate targeted intervention. Our findings underscore the importance of comprehensive law enforcement approaches that extend beyond drug enforcement to integrate prevention, linkage to treatment, and harm reduction strategies as needed to address the overdose epidemic.

Correlates of suicide risk among Black and White adults with behavioral health disorders in criminal-legal systems.

BACKGROUND: Adults with behavioral health disorders in criminal-legal systems are at heightened risk of suicide relative to the general population. Despite documented racial disparities in criminal processing and behavioral health treatment, few studies have examined racial differences in suicide risk in this already high-risk population. This study examined 1) the correlates of suicide risk in this population overall and by race and 2) the moderating role of race in these associations. METHODS: We investigated correlates of clinician-rated suicide risk at baseline in a statewide sample of 2,827 Black and 14,022 White adults with criminal-legal involvement who engaged in community-based behavioral health treatment. Regression-based approaches were used to model suicide risk and test for evidence of interaction effects. RESULTS: Findings showed the strongest correlates of suicide risk were greater behavioral health needs, evidence of self-harm, and a primary mental health diagnosis or co-occurring diagnosis. In race-specific analyses, correlates of suicide risk were mostly similar for both Black and White clients, with a couple exceptions. Interaction terms testing between-group effects on correlates of suicide risk were non-significant. CONCLUSIONS: Adults with behavioral health disorders in criminal-legal systems experience similar risk factors for suicide as the general population. Similar to prior research, we found that Black adults, in particular, are at lower risk for suicide overall. Contrary to expectations, we found similarities in correlates of suicide risk across race in our sample of felony-level adults with behavioral health disorders in the criminal-legal system. Prior research shows that behavioral health professionals should be cognizant of cultural factors when developing a comprehensive approach to suicide care and treatment. Our findings show correlates of suicide risk are largely stable in Black and White adults involved in criminal-legal systems, suggesting culturally responsive treatment for suicide risk should target shared risk factors.

Evaluation of a Police-Mental Health Co-response Team Relative to Traditional Police Response in Indianapolis.

OBJECTIVE: Criminal justice and emergency medical service (EMS) outcomes were compared for individuals experiencing a behavioral health crisis who received a response from a co-response team (CRT) or a usual response from the police after a 911 call. METHODS: A prospective, quasi-experimental design was used to examine outcomes of a CRT pilot tested in Indianapolis (August-December 2017). Weighted multivariable models examined effects of study condition (CRT group, N=313; usual-response group, N=315) on immediate booking, emergency detention, and subsequent jail bookings and EMS encounters. Sensitivity of outcomes to follow-up by a behavioral health unit (BHU) was also examined. RESULTS: Individuals in the CRT group were less likely than those in the usual-police-response group to be arrested immediately following the 911 incident (odds ratio [OR]=0.48, 95% confidence interval [CI]=0.25-0.92) and were more likely to experience any EMS encounter at 6- and 12-month follow-up (OR range=1.71-1.85, p≤0.015 for all). Response type was not associated with jail bookings at 6 or 12 months. Follow-up BHU services did not reduce bookings or EMS encounters. CRT recipients with BHU follow-up were more likely than those without BHU follow-up to have a subsequent EMS contact (OR range=2.35-3.12, p≤0.001 for all). These findings differed by racial group. CONCLUSIONS: CRT responses may reduce short-term incarceration risk but not long-term EMS demand or risk of justice involvement. Future research should consider the extent to which CRT and follow-up services improve engagement with stabilizing treatment services, which may reduce the likelihood of future crises.

Social support among people with mental illnesses on probation.

OBJECTIVE: Justice-involved people with mental illnesses, in general, experience poor criminal justice outcomes (i.e., high rates of recidivism and probation revocations) and are at increased risk of homelessness, unemployment, stigma, trauma, and poor physical health. Low social support is repeatedly associated with worse mental health outcomes in the general population but little is known about social support among probationers with serious mental illnesses. METHOD: To address these gaps in the literature, we used an observational cross-sectional study design and data from a large, randomized controlled trial of specialty mental health probation to examine self-reported social support and its relationships with mental health functioning and other outcomes for individuals with serious mental illnesses on supervised probation. RESULTS: Probationers who self-reported lower levels of social support also reported greater mental health symptomatology and reported lower quality relationships with their probation officers. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Low social support among probationers with mental illnesses has important implications for mental health and criminal justice practice and policy. Coordinating services between the criminal justice and mental health systems to offer opportunities for social support and meaningful community engagement for those with mental illnesses who are on probation could improve a number of mental health and criminal justice outcomes for this population. Peer support and supported employment services, for example, in addition to outpatient mental health services, could be two strategies that could address social isolation and help individuals living with mental illnesses optimize their recovery and rehabilitation. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Barriers and facilitators to the use of the SSI/SSDI Outreach, Access, and Recovery (SOAR) model with justice-involved adults.

OBJECTIVE: The purpose of this study was to identify barriers and facilitators to use of the SSI/SSDI Outreach, Access, and Recovery (SOAR) model with justice-involved adults. METHOD: Using a modified snowball sampling strategy, we distributed an online mixed-methods survey to SOAR providers with known criminal justice collaborations. Participants were 58 providers who completed or supervised completion of SOAR applications for justice-involved adults and who represented unique agencies across 29 states. Content analysis identified conceptual categories in qualitative data. Descriptive statistics were produced for all study variables. RESULTS: Although most agencies currently completed applications for justice-involved adults (n = 50, 86.2%), few reported collaborations with justice agencies (n = 19, 32.8%). Commonly cited barriers to successful applications included gaps in care for justice-involved populations and incomplete or unavailable medical records. Facilitators included strong leadership, agency communication and relationship building, and access to medical-especially psychiatric-staff. Most participants rated the SOAR model as successful in facilitating benefits access (n = 37 of 57, 64.9%). CONCLUSION AND IMPLICATIONS FOR PRACTICE: Despite obstacles to serving this high-risk population, practitioners have developed strategies to facilitate use of the SOAR model with justice-involved adults. These strategies offer promise for the implementation of SOAR in other criminal justice settings. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Individual and county-level variation in outcomes following non-fatal opioid-involved overdose.

BACKGROUND: A lack of large-scale, individually linked data often has impeded efforts to disentangle individual-level variability in outcomes from area-level variability in studies of many diseases and conditions. This study investigated individual and county-level variability in outcomes following non-fatal overdose in a state-wide cohort of opioid overdose patients. METHODS: Participants were 24 031 patients treated by emergency medical services or an emergency department for opioid-involved overdose in Indiana between 2014 and 2017. Outcomes included repeat non-fatal overdose, fatal overdose and death. County-level predictors included sociodemographic, socioeconomic and treatment availability indicators. Individual-level predictors included age, race, sex and repeat non-fatal opioid-involved overdose. Multilevel models examined outcomes following non-fatal overdose as a function of patient and county characteristics. RESULTS: 10.9% (n=2612) of patients had a repeat non-fatal overdose, 2.4% (n=580) died of drug overdose and 9.2% (n=2217) died overall. Patients with a repeat overdose were over three times more likely to die of drug-related causes (OR=3.68, 99.9% CI 2.62 to 5.17, p<0.001). County-level effects were limited primarily to treatment availability indicators. Higher rates of buprenorphine treatment providers were associated with lower rates of mortality (OR=0.82, 95% CI 0.68 to 0.97, p=0.024), but the opposite trend was found for naltrexone treatment providers (OR=1.20, 95% CI 1.03 to 1.39, p=0.021). Cross-level interactions showed higher rates of Black deaths relative to White deaths in counties with high rates of naltrexone providers (OR=1.73, 95% CI 1.09 to 2.73, p=0.019). CONCLUSION: Although patient-level differences account for most variability in opioid-related outcomes, treatment availability may contribute to county-level differences, necessitating multifaceted approaches for the treatment and prevention of opioid abuse.

A Principled Approach to the Construction of Risk Assessment Categories: The Council of State Governments Justice Center Five-Level System.

Consistent risk category placement of criminal justice clients across instruments will improve the communication of risk. Efforts coordinated by the Council of State Governments (CSG) Justice Center led to the development of a principled (i.e., a system based on a given set of procedures) method of developing risk assessment levels. An established risk assessment instrument (Level of Service Inventory-Revised [LSI-R]) was used to assess the risk-level concordance of the CSG Justice Center Five-Level system. Specifically, concordance was assessed by matching the defining characteristics of the data set with its distribution qualities and by the level/category similarity between the observed reoffending base rate and the statistical probability of reoffending. Support for the CSG Justice Center Five-Level system was found through a probation data set (N = 24,936) having a greater proportion of offenders in the lower risk levels than a parole/community data set (N = 36,303). The statistical probabilities of reoffending in each CSG Justice Center system risk level had greater concordance to the observed Five-Level base rates than the base rates from the LSI-R original categories. The concordance evidence for the CSG Justice Center Five-Level system demonstrates the ability of this system to place clients in appropriate risk levels.

Validating Imputation Procedures to Calculate Corrected Opioid-Involved Overdose Deaths, Marion County, Indiana, 2011-2016.

OBJECTIVES: Understanding the scope of the current opioid epidemic requires accurate counts of the number of opioid-involved drug overdose deaths. Given known errors and limitations in the reporting of these deaths, several studies have used statistical methods to develop estimates of the true number of opioid-involved overdose deaths. This study validates these procedures using a detailed county-level database of linked toxicology and vital records data. METHODS: We extracted and linked toxicology and vital records data from Marion County, Indiana (Indianapolis), during a 6-year period (2011-2016). Using toxicology data as a criterion measure, we tested the validity of multiple imputation procedures, including the Ruhm regression-based imputation approach for correcting the number of opioid-involved overdose deaths. RESULTS: Estimates deviated from true opioid-involved overdose deaths by 3% and increased in accuracy during the study period (2011-2016). For example, in 2016, 231 opioid-involved overdose deaths were noted in the toxicology data, whereas the corresponding imputed estimate was 233 opioid-involved overdose deaths. A simple imputation approach, based on the share of opioid-involved overdose deaths among all drug overdose deaths for which the death certificate specified ≥1 drug, deviated from true opioid-involved overdose deaths by ±5%. CONCLUSIONS: Commonly used imputation procedures produced estimates of the number of opioid-involved overdose deaths that are similar to the true number of opioid-involved overdose deaths obtained from toxicology data. Although future studies should examine whether these results extend beyond the geographic area covered in our data set, our findings support the continued use of these imputation procedures to quantify the extent of the opioid epidemic.

Racial differences in overdose events and polydrug detection in Indianapolis, Indiana.

BACKGROUND: We examine racial disparities in drug overdose death rates by analyzing trends in fatal and nonfatal overdose outcomes in a large metropolitan area (Indianapolis, Indiana). METHODS: Death certificate and toxicology records for accidental drug overdose deaths from 2011 to 2018 were linked with emergency medical services (EMS) data. Bivariate comparisons examined differences in toxicology findings at the time of death as well as prior EMS events both overall and by indicator of non-fatal overdose. RESULTS: From 2011-2018, 2204 residents (29.4 per 100,000) died of drug overdose, 18.6% were Black (N = 410, 19.5 per 100,000) and 78.5% White (N = 1730, 35.2 per 100,000). In the year prior to death, 33.5% (N = 656) of decedents had an EMS event, 12.1% (N = 237) had an overdose event, and 9.4% (N = 185) had naloxone administered. Overdose complaint and naloxone administration were more likely to occur among White than Black patients. White decedents were more likely than Black decedents to have had naloxone administered in the year prior to death (10.1% vs. 6.8%, χ2 = 4.0, p < .05, Cramer's V=.05). Toxicology data illustrate changing polydrug combinations, with Black decedents more likely to test positive for fentanyl-cocaine polydrug use in recent years. CONCLUSIONS: Recent racial disparities in overdose deaths are driven by a combination of fentanyl and cocaine, which disproportionally impacts African American drug users, but may be addressed through expanded harm reduction and community outreach services. Additionally, there is a need to assess the role of differing practices in overdose emergency service provision as a contributing factor to disparities.

Principles and practices of risk assessment in mental health jail diversion programs.

Eligibility criteria for participation in mental health jail diversion programs often specify that, to be diverted, a candidate must not pose a level of threat to public safety that cannot be managed in the community. Risk assessment tools were developed to increase consistency and accuracy in estimates of threat to public safety. Consequently, risk assessment tools are being used in many jurisdictions to inform decisions regarding an individual's appropriateness and eligibility for mental health jail diversion and the strategies that may be successful in mitigating risk in this context. However, their use is not without controversy. Questions have been raised regarding the validity and equity of their estimates, as well as the impact of their use on criminal justice outcomes. The purpose of this review is to provide an overview of the science and practice of risk assessment to inform decisions and case planning in the context of mental health jail diversion programs. Our specific aims include: (1) to describe the process and components of risk assessment, including differentiating between different approaches to risk assessment, and (2) to consider the use of risk assessment tools in mental health jail diversion programs. We anchor this review in relevant theory and extant research, noting current controversies or debates and areas for future research. Overall, there is strong theoretical justification and empirical evidence from other criminal justice contexts; however, the body of research on the use of risk assessment tools in mental health jail diversion programs, although promising, is relatively nascent.

Results of the Brief Jail Mental Health Screen Across Repeated Jail Bookings.

OBJECTIVE: The Brief Jail Mental Health Screen (BJMHS) is widely used at intake in county jails to identify detainees who may have serious mental illness and who should be referred for further mental health evaluation. The BJMHS may be administered multiple times across repeated jail bookings; however, the extent to which results may change over time is unclear. To that end, the authors examined the odds of screening positive on the BJMHS across repeated jail bookings. METHODS: Data were drawn from the administrative and medical records of a large, urban county jail that used the BJMHS at jail booking. The study sample comprised BJMHS results for the 12,531 jail detainees who were booked at least twice during the 3.5-year period (N=41,965 bookings). Multilevel logistic modeling was used to examine changes over time overall and within the four decision rules (current psychiatric medication, prior hospitalization, two or more current symptoms, and referral for any other reason). RESULTS: Results show that the odds of a positive screen overall increased with each jail booking, as did the odds of referral for any other reason. In contrast, the odds of screening positive for two or more current symptoms and prior hospitalization decreased. There was no change in the odds of screening positive for current psychiatric medication across bookings. CONCLUSIONS: Findings show that BJMHS results changed across bookings. Further research is needed to determine whether changes reflect true changes in mental health status, issues with fidelity, the repeated nature of the screening process, or other factors.

Criminal Justice Professionals' Attitudes Toward Mental Illness and Substance Use.

Despite the high prevalence of behavioral health disorders in justice settings and prior research on the importance of attitudes in successful treatment outcomes for behavioral health populations, few studies have examined criminal justice professionals' attitudes toward mental illness and substance use. We conducted a state-wide survey of 610 criminal justice professionals using items adapted from the Drug and Drug Problems Perceptions Questionnaire (Albery et al. 2003) to examine attitudes toward mental illness and substance use as a function of criminal justice position and personal contact. For attitudes toward both mental illness and substance use, defense attorneys and community corrections officers reported more positive attitudes relative to jail correctional staff and prosecutors. For attitudes toward substance use, personal contact moderated the effect of position on attitudes. Findings underscore the importance of targeted training and other contact-based interventions to improve criminal justice professionals' attitudes toward behavioral health populations.

Reliability and Validity of START and LSI-R Assessments in Mental Health Jail Diversion Clients.

Risk assessment instruments are increasingly used in mental health jail diversion programs. This study examined the reliability and validity of Short-Term Assessment of Risk and Treatability (START) and Level of Service Inventory-Revised (LSI-R) assessments overall and by client race. Research assistants completed START and LSI-R assessments for 95 diversion clients. Arrests and jail days were collected via official records and self-report 3, 6, 9, 12, and 18 months after baseline. Assessments demonstrated good interrater reliability and convergent validity. START strength total scores and LSI-R risk estimates were the strongest predictors of recidivism. Total scores and risk estimates did not differ as a function of client race, but there were some differences in accuracy of START vulnerability and LSI-R total scores and risk estimates in predicting jail days (but not arrests), over shorter follow-ups. No such differences were found for START strength total scores across any follow-up period or recidivism measure.

Barriers and facilitators to implementing an urban co-responding police-mental health team.

BACKGROUND: In an effort to reduce the increasing number of persons with mental illness (PMI) experiencing incarceration, co-responding police-mental health teams are being utilized as a way to divert PMI from the criminal justice system. Co-response teams are typically an inter-agency collaboration between police and mental health professionals, and in some cases include emergency medical personnel. These teams are intended to facilitate emergency response by linking patients to mental health resources rather than the criminal justice system, thus reducing burdens on both the criminal justice systems as well as local healthcare systems. The current study examines the barriers and facilitators of successfully implementing the Mobile Crisis Assistance Team model, a first-responder co-response team consisting of police officers, mental health professionals, and paramedics. Through content analysis of qualitative focus groups with team members and interviews with program stakeholders, this study expands previous findings by identifying additional professional cultural barriers and facilitators to program implementation while also exploring the role of clear, systematic policies and guidelines in program success. RESULTS: Findings demonstrate the value of having both flexible and formal policies and procedures to help guide program implementation; ample community resources and treatment services in order to successfully refer clients to needed services; and streamlined communication among participating agencies and the local healthcare community. A significant barrier to successful program implementation is that of role conflict and stigma. Indeed, members of the co-response teams experienced difficulty transitioning into their new roles and reported negative feedback from other first responders as well as from within their own agency. Initial agency collaboration, information sharing between agencies, and team building were also identified as facilitators to program implementation. CONCLUSION: The current study provides a critical foundation for the implementation of first-responder police-mental health co-response teams. Cultural and systematic barriers to co-response team success should be understood prior to program creation and used to guide implementation. Furthermore, attention must be directed to cultivating community and professional support for co-response teams. Findings from this study can be used to guide future efforts to implement first-response co-response teams in order to positively engage PMI and divert PMI from the criminal justice system.

Identifying Unreported Opioid Deaths Through Toxicology Data and Vital Records Linkage: Case Study in Marion County, Indiana, 2011-2016.

OBJECTIVES: To demonstrate the severity of undercounting opioid-involved deaths in a local jurisdiction with a high proportion of unspecified accidental poisoning deaths. METHODS: We matched toxicology data to vital records for all accidental poisoning deaths (n = 1238) in Marion County, Indiana, from January 2011 to December 2016. From vital records, we coded cases as opioid involved, specified other substance, or unspecified. We extracted toxicology data on opioid substances for unspecified cases, and we have reported corrected estimates of opioid-involved deaths after accounting for toxicology findings. RESULTS: Over a 6-year period, 57.7% of accidental overdose deaths were unspecified and 34.2% involved opioids. Toxicology data showed that 86.8% of unspecified cases tested positive for an opioid. Inclusion of toxicology results more than doubled the proportion of opioid-involved deaths, from 34.2% to 86.0%. CONCLUSIONS: Local jurisdictions may be undercounting opioid-involved overdose deaths to a considerable degree. Toxicology data can improve accuracy in identifying opioid-involved overdose deaths. Public Health Implications. Mandatory toxicology testing and enhanced training for local coroners on standards for death certificate reporting are needed to improve the accuracy of local monitoring of opioid-involved accidental overdose deaths.

EMS naloxone administration as non-fatal opioid overdose surveillance: 6-year outcomes in Marion County, Indiana.

BACKGROUND AND AIMS: Despite rising rates of opioid overdose in the United States, few studies have examined the frequency of non-fatal overdose events or mortality outcomes following resuscitation. Given the widespread use of naloxone to respond to overdose-related deaths, naloxone administration may provide a useful marker of overdose events to identify high-risk users at heightened risk of mortality. We used naloxone administration by emergency medical services as a proxy measure of non-fatal overdose to examine repeat events and mortality outcomes during a 6-year period. METHODS: We conducted a retrospective investigation of all cases in Marion County, Indiana between January 2011 and December 2016 where emergency medical services used naloxone to resuscitate a patient. Cases were linked to vital records to assess mortality and cause of death during the same time-period. We used Cox regression survival analysis to assess whether repeat non-fatal overdose events during the study period were associated with the hazard of mortality, both overall and by cause of death. RESULTS: Of 4726 patients administered naloxone, 9.4% (n = 444) died an average of 354 days [standard deviation (SD) = 412.09, range = 1-1980] following resuscitation. Decedents who died of drug-related causes (34.7%, n = 154) were younger and more likely to have had repeat non-fatal overdose events. Patients with repeat non-fatal overdose events (13.4%, n = 632) had a ×2.07 [95% confidence interval (CI) = 1.59, 2.71] higher hazard of all-cause mortality and a ×3.06 (95% CI = 2.13, 4.40) higher hazard of drug-related mortality. CONCLUSIONS: Among US emergency medical service patients administered naloxone for opioid overdose, those with repeat non-fatal opioid overdose events are at a much higher risk of mortality, particularly drug-related mortality, than those without repeat events.