Examining the spatial risk environment tied to the opioid crisis through a unique public health, EMS, and academic research collaborative: Lowell, Massachusetts, 2008–2018

Abstract

Between 2015 and 2018, Lowell Massachusetts experienced outbreaks in opioid overdoses, HIV, and hepatitis C virus infections (HCV) among people who inject drugs. Through an innovative collaboration between emergency medical services (EMS), public health, and academic partners, we assessed the geographic distribution of opioid-related risks to inform intervention efforts. We analyzed data from three unique data sources for publicly discarded syringes, opioid-related incidents (ORIs), and fatal opioid overdoses in Lowell between 2008 and 2018. We assessed the risk environment over time using a geographic information system to identify and characterize hotspots and noted parallel trends within the syringe discard and ORI data. We identified two notable increases in ORIs per day: the first occurring between 2008 and 2010 (from 0.3 to 0.5), and the second between 2011 and 2014 (from 0.9 to 1.3), following the introduction of fentanyl within local drug markets. We also identified seasonal patterns in the syringe discard, ORI, and overdose data. Through our spatial analyses, we identified significant clusters of discarded syringes, ORIs, and fatal overdoses (p < 0.05), and neighborhoods where high densities of these outcomes overlapped. We found that areas with the highest densities shifted over time, expanding beyond the epicenter of the Downtown neighborhood. Data sharing and analyses among EMS, public health, and academic partners can foster better assessments of local risk environments. Our work, along with new public health efforts in Lowell, led to a city-funded position to improve pick-up and proper disposal of publicly discarded syringes, and better targeted harm reduction services.

Risk factors for pediatric intoxications in the prehospital setting. A geospatial survey

“…Chalfin and colleagues showed that higher parental education, which often correlates with income, resulted in less underage binge drinking but had no influence on cannabis consumption ( 29 ). Regarding the clustering around urban areas, our results are consistent with the work of Stopka et al from Massachusetts ( 30 ). Additionally, Bearnot et al ( 31 ) found hotspots of drug use in areas facing socioeconomic hardships and around hospitals.…”

Risk factors for pediatric intoxications in the prehospital setting. A geospatial survey

“…Chalfin and colleagues showed that higher parental education, which often correlates with income, resulted in less underage binge drinking but had no influence on cannabis consumption ( 29 ). Regarding the clustering around urban areas, our results are consistent with the work of Stopka et al from Massachusetts ( 30 ). Additionally, Bearnot et al ( 31 ) found hotspots of drug use in areas facing socioeconomic hardships and around hospitals.…”

Assessing Spatial and Temporal Variation in Opioid-Related Incidents and Risk Factors in Lowell, Massachusetts, from 2011 to 2022: A Bayesian Spatial-Temporal Approach

“…The estimated elevated risk of ORI in summer aligns with previous research, and it is well documented that opioid overdoses tend to increase during the summer, validating the incorporation of seasonality into our statistical models. 13,14,26 The increased risk of ORI seen during 2016 to 2018 is consistent with prior work on ORI in Lowell during this period 14 and is associated with increasing opioid overdose rates with the rise of fentanyl in the opioid drug supply. 27 The sustained decreased risk of ORI observed in Lowell during 2020 and 2021 is in contrast to other work showing increases in EMS calls for opioid overdose during COVID-19 compared with prior years, even despite brief decreases following stay-at-home orders, both at the national level 28–31 and for Massachusetts.…”

“…Before 2013, suspected ORIs were defined as incidents where opioid use was witnessed, reported, or suspected by EMS personnel. 14 Beginning in 2013, electronic Patient Care Reports (ePCR) generated from each Trinity EMS interaction with a patient were fed through FirstWatch, a firm specializing in emergency response data management. FirstWatch scans ePCR for keywords including heroin, opioid, opium, Narcan, naloxone, needle, syringe, overdose-heroin, and overdose-opioid.…”

“…FirstWatch scans ePCR for keywords including heroin, opioid, opium, Narcan, naloxone, needle, syringe, overdose-heroin, and overdose-opioid. 14 When FirstWatch identifies opioid overdose-related keywords in an ePCR, the cases are flagged as potential ORI. Furthermore, the quality assurance team at PrideStar Trinity EMS reviews the flagged cases for confirmation as an ORI on a weekly basis.…”

Methods for jurisdictional vulnerability assessment of opioid-related outcomes

“…The combination of exploratory spatial data analysis, spatial analysis of the vulnerability, and integration of accessibility models were critical to the development of a strong and holistic understanding of the underlying socioeconomic, cultural, political, and geographic context that affected opioid use, misuse, treatment, and harm reduction environment in study areas. ( Shrestha et al, 2022 ; Stopka et al, 2021 ) GIS analyses utilizing a variety of mapping techniques were used to depict the spatial distribution of core indicators and covariates, analyze accessibility to service providers, and vulnerability scores at varying geographic levels, including the census tract, ZCTA, and county, depending on data availability, with a preference for maximum spatial granularity. However, the effects of many policy decisions or interventions were observed at a much larger spatial scale (county-level or even state-level differences) when a larger spatial scale for analysis might be sufficient.…”

Risk factors for pediatric intoxications in the prehospital setting. A geospatial survey

“…Chalfin and colleagues showed that higher parental education, which often correlates with income, resulted in less underage binge drinking but had no influence on cannabis consumption ( 29 ). Regarding the clustering around urban areas, our results are consistent with the work of Stopka et al from Massachusetts ( 30 ). Additionally, Bearnot et al ( 31 ) found hotspots of drug use in areas facing socioeconomic hardships and around hospitals.…”

Assessing Spatial and Temporal Variation in Opioid-Related Incidents and Risk Factors in Lowell, Massachusetts, from 2011 to 2022: A Bayesian Spatial-Temporal Approach

“…The estimated elevated risk of ORI in summer aligns with previous research, and it is well documented that opioid overdoses tend to increase during the summer, validating the incorporation of seasonality into our statistical models. 13,14,26 The increased risk of ORI seen during 2016 to 2018 is consistent with prior work on ORI in Lowell during this period 14 and is associated with increasing opioid overdose rates with the rise of fentanyl in the opioid drug supply. 27 The sustained decreased risk of ORI observed in Lowell during 2020 and 2021 is in contrast to other work showing increases in EMS calls for opioid overdose during COVID-19 compared with prior years, even despite brief decreases following stay-at-home orders, both at the national level 28–31 and for Massachusetts.…”

“…Before 2013, suspected ORIs were defined as incidents where opioid use was witnessed, reported, or suspected by EMS personnel. 14 Beginning in 2013, electronic Patient Care Reports (ePCR) generated from each Trinity EMS interaction with a patient were fed through FirstWatch, a firm specializing in emergency response data management. FirstWatch scans ePCR for keywords including heroin, opioid, opium, Narcan, naloxone, needle, syringe, overdose-heroin, and overdose-opioid.…”

“…FirstWatch scans ePCR for keywords including heroin, opioid, opium, Narcan, naloxone, needle, syringe, overdose-heroin, and overdose-opioid. 14 When FirstWatch identifies opioid overdose-related keywords in an ePCR, the cases are flagged as potential ORI. Furthermore, the quality assurance team at PrideStar Trinity EMS reviews the flagged cases for confirmation as an ORI on a weekly basis.…”

Methods for jurisdictional vulnerability assessment of opioid-related outcomes

“…The combination of exploratory spatial data analysis, spatial analysis of the vulnerability, and integration of accessibility models were critical to the development of a strong and holistic understanding of the underlying socioeconomic, cultural, political, and geographic context that affected opioid use, misuse, treatment, and harm reduction environment in study areas. ( Shrestha et al, 2022 ; Stopka et al, 2021 ) GIS analyses utilizing a variety of mapping techniques were used to depict the spatial distribution of core indicators and covariates, analyze accessibility to service providers, and vulnerability scores at varying geographic levels, including the census tract, ZCTA, and county, depending on data availability, with a preference for maximum spatial granularity. However, the effects of many policy decisions or interventions were observed at a much larger spatial scale (county-level or even state-level differences) when a larger spatial scale for analysis might be sufficient.…”

Risk factors for pediatric intoxications in the prehospital setting. A geospatial survey

“…Chalfin and colleagues showed that higher parental education, which often correlates with income, resulted in less underage binge drinking but had no influence on cannabis consumption ( 29 ). Regarding the clustering around urban areas, our results are consistent with the work of Stopka et al from Massachusetts ( 30 ). Additionally, Bearnot et al ( 31 ) found hotspots of drug use in areas facing socioeconomic hardships and around hospitals.…”

Assessing Spatial and Temporal Variation in Opioid-Related Incidents and Risk Factors in Lowell, Massachusetts, from 2011 to 2022: A Bayesian Spatial-Temporal Approach

“…The estimated elevated risk of ORI in summer aligns with previous research, and it is well documented that opioid overdoses tend to increase during the summer, validating the incorporation of seasonality into our statistical models. 13,14,26 The increased risk of ORI seen during 2016 to 2018 is consistent with prior work on ORI in Lowell during this period 14 and is associated with increasing opioid overdose rates with the rise of fentanyl in the opioid drug supply. 27 The sustained decreased risk of ORI observed in Lowell during 2020 and 2021 is in contrast to other work showing increases in EMS calls for opioid overdose during COVID-19 compared with prior years, even despite brief decreases following stay-at-home orders, both at the national level 28–31 and for Massachusetts.…”

“…Before 2013, suspected ORIs were defined as incidents where opioid use was witnessed, reported, or suspected by EMS personnel. 14 Beginning in 2013, electronic Patient Care Reports (ePCR) generated from each Trinity EMS interaction with a patient were fed through FirstWatch, a firm specializing in emergency response data management. FirstWatch scans ePCR for keywords including heroin, opioid, opium, Narcan, naloxone, needle, syringe, overdose-heroin, and overdose-opioid.…”

“…FirstWatch scans ePCR for keywords including heroin, opioid, opium, Narcan, naloxone, needle, syringe, overdose-heroin, and overdose-opioid. 14 When FirstWatch identifies opioid overdose-related keywords in an ePCR, the cases are flagged as potential ORI. Furthermore, the quality assurance team at PrideStar Trinity EMS reviews the flagged cases for confirmation as an ORI on a weekly basis.…”

Methods for jurisdictional vulnerability assessment of opioid-related outcomes

“…The combination of exploratory spatial data analysis, spatial analysis of the vulnerability, and integration of accessibility models were critical to the development of a strong and holistic understanding of the underlying socioeconomic, cultural, political, and geographic context that affected opioid use, misuse, treatment, and harm reduction environment in study areas. ( Shrestha et al, 2022 ; Stopka et al, 2021 ) GIS analyses utilizing a variety of mapping techniques were used to depict the spatial distribution of core indicators and covariates, analyze accessibility to service providers, and vulnerability scores at varying geographic levels, including the census tract, ZCTA, and county, depending on data availability, with a preference for maximum spatial granularity. However, the effects of many policy decisions or interventions were observed at a much larger spatial scale (county-level or even state-level differences) when a larger spatial scale for analysis might be sufficient.…”