Bystander Presence and Naloxone Administration During Fatal Opioid-involved Overdoses in Rhode Island: Implications for Naloxone Coverage Among Families and Peers

Abstract

Objective: This study investigated community bystander presence and naloxone administrations by location type during accidental fatal opioid-involved overdoses in Rhode Island. Methods: We analyzed accidental opioid-involved overdose fatalities among adults in Rhode Island between 2020 and 2022, obtained from the State's Unintentional Drug Overdose Reporting System (SUDORS). Variables of interest included location of death, community bystander presence, and naloxone administration. We calculated the proportion of overdose deaths where community bystanders were present and naloxone was administered. Using multivariable Poisson regression with robust standard errors, we identified statistically significant (P<0.05) correlates of naloxone administration by any responder during fatal overdose events. Results: Of 1084 opioid-involved overdose fatalities analyzed, bystanders were present in 44.7% of cases. Most fatal overdoses occurred in housing environments (84.5%), where the widest disparity between bystander presence (61.1%) and naloxone administration (29.0%) was observed. In multivariable analysis, naloxone was more likely to be administered in overdoses occurring in outdoor spaces (adjusted prevalence ratio [adjPR] = 1.50, 95% CI: 1.07-2.02), hotels/motels (adjPR=1.57, CI: 1.12-2.21), businesses (adjPR=1.89, CI: 1.14-3.12), and motor vehicles (adjPR=2.00, CI: 1.18-3.38), relative to overdoses in housing environments. Naloxone administration clustered in younger decedents (10-year decrements: adjPR=1.10, CI: 1.01-1.20) and persons experiencing homelessness (adjPR=1.67, CI: 1.23-2.26). Conclusion: Fatal opioid-involved overdoses in housing environments were more likely to have community bystanders present but less likely to have responders intervene with naloxone. Equipping families and cohabitants with the tools, resources, and self-efficacy for earlier, timelier naloxone intervention may address overdose fatalities in Rhode Island.