From fairytale to clinical practice: A response to commentaries

Opioid overdose remains one of the most urgent public health crises in the United States, and for many individuals, the first and sometimes only encounter with health care comes through emergency medical services (EMS). As a result, the role of EMS has evolved far beyond reversing overdoses in the moment. Opioid use disorder (OUD) is a treatable medical disease with effective treatment, and EMS agencies are uniquely positioned to partner with local community resources and hospitals to combine efforts in implementing harm-reduction and treatment strategies. This document provides specific guidance for EMS agencies seeking to build or expand comprehensive programs addressing OUD through a variety of evidence-based approaches. The National Association of EMS Physicians recommends: State and local EMS oversight entities should ensure that EMS clinician scope of practice allows for administration of medications for opioid use disorder (MOUD), specifically buprenorphine. EMS Systems should establish low-barrier program and protocols for prehospital administration of medications for opioid use disorder (MOUD), specifically buprenorphine, and integrate the program with available community resources. EMS Medical Directors should collaborate with other system leaders to implement validated protocols for the treatment and safe disposition of patients including navigation of patients to alternate destinations or treatment in place. EMS Systems should collaborate with other system leaders on harm reduction strategies, including opioid education and naloxone distribution. EMS Systems should consider community engagement and input into the design, implementation, and quality improvement efforts for programs to address opioid use disorder, and EMS clinicians should receive comprehensive and adaptive education programs that address the pharmacological and biopsychosocial aspects of OUD and reducing stigma.

FOR MORE THAN A DECADE, CARDIOPULMONARY RESUScitation (CPR) using only chest compressions, forgoing ventilations by rescue breathing, has been described as an option in the out-of-hospital management of sudden cardiac arrest when bystanders are unwilling or unable to provide standard CPR that combines chest compressions with rescue breathing. The “Guidelines 2005” CPR standards promulgated by the American Heart Association (AHA) and the International Liaison Committee on Resuscitation (ILCOR) indicate that “the best method of CPR is compressions coordinated with ventilations.” However, the guidelines also note that laypersons who are unable or unwilling to provide rescue breaths should be encouraged to provide compressiononly CPR to individuals experiencing out-of-hospital cardiac arrest. This recommendation followed a 1997 AHA science statement that was the first document to propose compression-only CPR as a reasonable alternative to standard CPR by bystanders. Several fairly compelling theoretical arguments support the concept of compression-only CPR. First, it seems likely that compression-only CPR is easier to teach and remember than standard CPR, particularly for those who do not work in health care professions. Second, it has been postulated that bystanders may prefer to avoid mouth-to-mouth contact with persons who sustain cardiac arrest, particularly when those persons are strangers. However, in a study of actual bystanders of out-ofhospital cardiac arrest, very few (1.1%) mentioned reluctance to perform rescue breathing, and none reported fear of contracting infection. Third, and perhaps most compelling, an increasing body of evidence suggests that interruptions in chest compressions, even for such seemingly important interventions as providing artificial ventilation, are detrimental. Forward flow of blood ceases very soon after chest compressions are halted, and several compressions are needed to reestablish perfusion when compressions are resumed. The “push hard, push fast, don’t stop” mantra of current CPR teaching is designed to reinforce the need for minimal interruptions in chest compressions to maintain some degree of perfusion to the vital organs until more definitive therapy (such as defibrillation) can be delivered. Despite these theoretical advantages, most animal studies and human trials comparing standard CPR and compression-only CPR have reported similar outcomes for the 2 techniques; data showing a convincing survival advantage to the compression-only technique are lacking. Additionally, most of the existing human data are from observational studies, with few experimental trials in the published literature. Randomization is one of several significant barriers to performing these trials, particularly when examining CPR provided by bystanders who witness the collapse and provide immediate intervention while emergency medical services (EMS) personnel are summoned. Although it is possible to randomize the type of CPR provided by EMS personnel responding to an out-of-hospital cardiac arrest, or by a team responding to an in-hospital cardiac arrest, it is nearly impossible to randomize the type of CPR provided by a bystander at the scene of an out-of-hospital cardiac arrest. One elegant solution to this problem was used in a 2000 study by Hallstrom et al and in 2 recently published studies. Randomization was performed by 9-1-1 dispatchers for callers who were willing to perform CPR but did not know how to do so. In each study, the survival rate for patients who experienced out-of-hospital cardiac arrest and received dispatcher-assisted standard CPR was similar to that for those with cardiac arrest who received dispatcherassisted compression-only CPR, despite data showing that chest compressions are delivered sooner when the dispatcher omits the ventilation instructions, providing another theoretical benefit to compression-only CPR. However, in these 3 studies, no CPR was delivered from the time the patient collapsed until the time the caller recognized the emergency, reached 9-1-1, completed the questions in the dispatcher’s algorithm, was randomized by the dispatcher, and received CPR instructions. This no-perfusion time, typically longer than 2 minutes, may have contributed to the findings.

Introduction/Background Individuals who accidentally overdose (OD) with opioids, especially those recently released from prison, are at significant risk for death. Investigators initiated a program to assess, educate, equip and reassess at-risk, volunteering prison inmates in opiate OD prevention, recognition and naloxone administration for post-release exposure to OD situations. Methods Inmates expressing an interest in study participation after recruitment announcements, mailings and posters were approached for consent. Those agreeing to participate underwent a baseline assessment of OD-related knowledge, including recognition of opioid OD and awareness of naloxone. The study intervention was an educational DVD with standardized didactics; skills practice was not feasible during incarceration. Subjects were provided with an intra-nasal naloxone kit at time of release and scheduled for followup assessment. In order to evaluate subjects perception, acquisition, retention and delivery of layperson resuscitative skills for opioid OD at post-release followup, emergency medicine, simulation and substance abuse investigators developed an OD simulation script with accompanying 24 item assessment checklist for a low-fidelity full-body manikin. The scenario was designed to elicit, record and positively reinforce subjects performance of basic airway maneuvers, rescue breathing, naloxone administration, accessing of emergency services, avoidance of harmful actions and continued monitoring. Drug use props, distractor decoys (for common OD treatment errors) and ambient noise were provided. Investigators designed the simulation scenario for administration with video-recording as part of an assessment battery* that evaluated each subject soon after release. Pre-pilot sessions tested the scenario for feasibility and research utility. The study was IRB approved. *Assessments include the validated Brief Overdose Recognition and Response Assessment [BORR],1 questionnaires on OD risks, naloxone risks and perceptions of self-efficacy/confidence in pertinent knowledge and skills. Results One hundred sixty six inmates expressed an interest in study participation, of whom 99 (60%) consented to participate and completed the baseline assessment; 94 completed the study intervention training while incarcerated. Subject demographics were representative of the target population: average age 34.2 years; male 85%; race: white 81%, African American 7%, American Indian 5%, Hispanic/Latino 11%. 88 subjects received a naloxone kit. Six-month interim follow-up data were available for 40 subjects (43% of trained recruits) out of a projected cohort of 100 subjects. None of the follow-up subjects reported OD’s after release; 60% reported engaging in OD protective behaviors since release, including 3 naloxone administrations. At followup, subjects exhibited significant gains in OD recognition and response (naloxone administration) knowledge and self-efficacy scores as recorded by BORRA and questionnaires. Subjects scores on critical action checklists during simulation scenario at followup averaged 11.4±4.0 (range 3–22, out of 24 total correct actions). Average time to assemble the kit and administer intranasal naloxone was 55 seconds. Naloxone was administered IV, IM and without intra-nasal atomizer to the manikin by one participant each. Five participants incorrectly administered the naloxone (e.g., one nostril only or half the dose). Three participants stated they did not know how to put the naloxone together during the simulation; 5 individuals (12%) self-corrected themselves during the simulation. Additionally, potentially harmful interventions such as slapping, kicking or hitting the manikin were observed during 17 (46%) simulation sessions and unnecessary chest compressions were often performed. Conclusion Investigators developed and initiated an opioid OD prevention program for at-risk prison inmates, with a simulation component for hands-on demonstration of knowledge and assessment of skills at follow-up. The variation in in-simulation performance across subjects and relative to traditional assessment tools appears to support the utility of simulation as an evaluative methodology to assess layperson OD management skills. Reference 1. Green TC, Heimer R, Grau LE. Distinguishing signs of opioid overdose and indication for naloxone: an evaluation of six overdose training and naloxone distribution programs in the United States. Addiction, 2008; 103(6): 979–89. Disclosures Part-time employee of Inflexxion Inc. University Emergency Medicine Foundation (research grant 2009) intellectual property (copyrights; patent pending) on GLIDEPATH system.

Aims: To determine the impact of naloxone training on knowledge of opiate overdose and confidence and willingness to take appropriate action and to examine the use of naloxone and other harm-reduction actions at the time of overdose events. Methods: The evaluation was based on a repeated-measure design, whereby clients were tested before and after training. In total, 521 opiate users and four non-opiate users, drawn from five community sites (362) and three prison locations (163), completed pre- and post-test self-completed questionnaires. Actions taken at the time of overdose events by the naloxone group and a comparison group were compared using forms completed by agency staff. Findings: Knowledge about how to recognise and respond to overdose events increased among trainees across all measures. So too did perceived confidence in responding to them and willingness to carry out the recommended procedures. Over the course of the evaluation, there were 28 recorded uses of naloxone, resulting in 27 recoveries and one fatality. Conclusions: The study has shown that training in overdose management and the use of naloxone can bring about significant improvements in knowledge and willingness to take action. THN trainees also demonstrated that they were able to use naloxone successfully in overdose events.

The recommendations for electrical therapies described in this section are designed to improve survival from SCA and life-threatening arrhythmias. Whenever defibrillation is attempted, rescuers must coordinate high-quality CPR with defibrillation to minimize interruptions in chest compressions and to ensure immediate resumption of chest compressions after shock delivery. The high first-shock efficacy of newer biphasic defibrillators led to the recommendation of single shocks plus immediate CPR instead of 3-shock sequences that were recommended prior to 2005 to treat VF. Further data are needed to refine recommendations for energy levels for defibrillation and cardioversion using biphasic waveforms.

Drug-related deaths in Italy, especially from opioid overdoses, increased by 6% among individuals aged 15-34 from 2014 to 2018. Opioid-related deaths rose by 6.6% in the 15-24 age group and by 5.4% in the 25-34 age group during this period. There is limited data on the effectiveness of different naloxone administration routes—intranasal (IN), intramuscular (IM), and intravenous (IV)—and no established guidelines for prehospital overdose management. Timely intervention is crucial to reduce overdose mortality. This review aims to assess the effectiveness of naloxone administration methods in opioid overdoses, focusing on prehospital settings and comparing IN, IM, and IV routes. A narrative review was conducted in accordance with PRISMA guidelines. The search included terms such as “naloxone,” “opioid overdose,” “intranasal administration,” and “prehospital emergency care,” with Boolean operators to refine the scope. The study selection was guided by the PICO framework (population, intervention, comparison, outcome). Studies were assessed for quality using the Dixon-Woods tool, and inclusion/exclusion criteria were applied. Studies will be selected based on populations treated with naloxone administered via intranasal, intramuscular, or intravenous routes, focusing on comparisons between these formulations in terms of onset time and intervention effectiveness. Out of 111 studies, five met the eligibility criteria. These studies showed that intranasal naloxone achieves higher plasma concentrations than intramuscular doses but with slower absorption and longer peak times. Additionally, intramuscular naloxone results in faster respiratory recovery and requires fewer doses. Intranasal naloxone has a bioavailability of 46.8% to 50.8% compared to intravenous naloxone, with efficacy outcomes varying by administration route. The review shows that intranasal naloxone, especially at a 2 mg dose, achieves plasma levels similar to intramuscular formulations and has linear pharmacokinetics across dosages. While its bioavailability is lower (46% to 50%) compared to intravenous administration, it is a safer and more practical option for non-clinical settings. Although intramuscular and intravenous routes work faster, the slower absorption of intranasal naloxone may help reduce withdrawal symptoms, supporting gradual dosing strategies. These findings emphasize the need for further research on optimizing naloxone dosing for synthetic opioid emergencies. This review highlights intravenous naloxone as the most effective route for opioid overdose treatment, with intramuscular and intranasal routes offering practical alternatives in prehospital settings. Intranasal naloxone, despite its lower bioavailability, provides a non-invasive option suitable for lay responders. Gradual dose escalation is recommended to minimize withdrawal symptoms. The increasing prevalence of synthetic opioids underscores the need for updated clinical guidelines on naloxone dosing and administration routes.

Search Strategy and Review Methods A structured literature search was conducted to identify publications addressing the early post-resuscitation phase following return of spontaneous circulation (ROSC) in patients with out-of-hospital cardiac arrest (OHCA), with particular focus on prehospital management and the interval preceding hospital handover. The search strategy was structured around four conceptual domains: (1) population – out-of-hospital cardiac arrest; (2) physiological state – return of spontaneous circulation; (3) setting – emergency medical services and prehospital care; and (4) processes of interest – early post-ROSC management, recurrent cardiac arrest (rearrest), monitoring, transport and hospital handover. Electronic searches were performed in PubMed/MEDLINE, Scopus and Web of Science Core Collection. Search queries combined controlled vocabulary (e.g. MeSH terms) and free-text terms related to OHCA, ROSC, emergency medical services and post-resuscitation processes including rearrest, monitoring, transport and hospital handover. Search strategies were iteratively refined to improve specificity for literature addressing early post-ROSC prehospital care and transport-related decision making. Searches were limited to publications in English published between 1990 and 2025. Detailed database queries are provided in the associated search strings document. Studies were eligible if they addressed adult patients with out-of-hospital cardiac arrest who achieved ROSC and described clinical, physiological or operational aspects of the prehospital phase preceding hospital handover. Publications examining rearrest, post-ROSC physiological instability, monitoring strategies, transport preparation, destination decisions, pre-notification or early post-resuscitation management in the EMS setting were considered relevant. Observational studies, registry analyses, clinical reviews, guideline documents and relevant methodological publications were eligible for inclusion. Studies focused exclusively on in-hospital cardiac arrest, paediatric populations or purely in-hospital post-resuscitation care without relevance to the prehospital phase were excluded. Titles and abstracts were screened independently by two reviewers to assess relevance to the research question. Full texts of potentially relevant publications were subsequently reviewed for eligibility. Disagreements were resolved by discussion and consensus. Included studies were synthesised using a structured narrative approach designed to integrate heterogeneous evidence relevant to the early post-ROSC phase in the prehospital environment. Studies were grouped according to thematic domains reflecting key aspects of care during the ROSC-to-handover interval, including physiological instability after ROSC, mechanisms and recognition of rearrest, monitoring and stabilisation strategies, operational traps during the post-resuscitation phase, preparation for transport, transport environment and destination decisions, and communication with receiving hospitals. Because the objective of the review was conceptual and integrative, the synthesis focused on identifying recurring physiological mechanisms, operational challenges and system-level considerations rather than performing quantitative pooling of results. Evidence was interpreted with attention to study design, EMS system characteristics and methodological limitations. This narrative synthesis aimed to develop an integrated conceptual framework describing the ROSC-to-handover interval as a distinct clinical–operational phase linking resuscitation and definitive post-cardiac arrest care. PubMed / MEDLINE search strategy (("Heart Arrest"[Mesh] OR "cardiac arrest"[tiab] OR "out-of-hospital cardiac arrest"[tiab] OR OHCA[tiab]) AND ("Return of Spontaneous Circulation"[Mesh] OR "return of spontaneous circulation"[tiab] OR ROSC[tiab]) AND ("Emergency Medical Services"[Mesh] OR prehospital[tiab] OR "pre-hospital"[tiab] OR EMS[tiab] OR "prehospital care"[tiab]) AND ("post-resuscitation"[tiab] OR "post cardiac arrest"[tiab] OR rearrest[tiab] OR "re-arrest"[tiab] OR transport[tiab] OR handover[tiab] OR destination[tiab] OR bypass[tiab])) Filters: English Scopus search strategy TITLE-ABS-KEY ( ( "out-of-hospital cardiac arrest" OR OHCA OR "cardiac arrest" ) AND ( "return of spontaneous circulation" OR ROSC ) AND ( prehospital OR "pre-hospital" OR "emergency medical services" OR EMS ) AND ( "post-resuscitation care" OR "post cardiac arrest care" OR rearrest OR "re-arrest" OR transport OR handover OR destination OR bypass ) ) AND ( LIMIT-TO ( LANGUAGE , "English" ) ) Web of Science search strategy TS=(("out-of-hospital cardiac arrest" OR OHCA OR "cardiac arrest") AND ("return of spontaneous circulation" OR ROSC) AND (prehospital OR "pre-hospital" OR "emergency medical services" OR EMS) AND ("post-resuscitation care" OR "post cardiac arrest care" OR rearrest OR "re-arrest" OR transport OR handover OR destination OR bypass)) Literature identification and screening The database search performed on xxxx XX, 2026 identified the following records: PubMed/MEDLINE (n = xxx ) Scopus (n = xxx ) Web of Science Core Collection (n = xxx) A total of xxxx records were identified across the three databases. After removal of duplicates, the remaining records were screened based on titles and abstracts to assess relevance to the research question. Potentially relevant articles were retrieved for full-text assessment. Publications were excluded if they focused exclusively on in-hospital post-resuscitation care, paediatric populations, or topics unrelated to the early post-ROSC phase in the prehospital environment. Studies addressing physiological stabilisation after ROSC, monitoring strategies, mechanisms of rearrest, transport preparation, destination decisions and hospital pre-notification were considered eligible for qualitative synthesis. The final set of included studies was used to inform the narrative synthesis and conceptual framework describing the ROSC-to-handover interval presented in the main manuscript.

If it hasn’t failed, does it work? On ‘the worst we can expect’ from observational trial results, with reference to airway management devices

The Substance Abuse and Mental Health Services Administration’s (SAMHSA) Harm Reduction grant program expanded access to several harm reduction strategies to mitigate opioid overdose fatalities, including expanding access to naloxone. Interviews with first responders in a frontier and remote (FAR) state were conducted to understand their job responsibilities in relation to overdose response and prevention and their perceptions of training laypersons to administer naloxone. This study includes 22 interviews with law enforcement, EMS and/or fire personnel, and members of harm reduction-focused community organizations. The study finds widespread support for increasing access to naloxone and training laypersons in naloxone administration throughout Montana, due to rural first responders’ inability to meet the needs of residents and an overall lack of resources to address addiction and the effects of fentanyl. Participants from harm reduction-focused community organizations convey support for training lay persons, but also illuminate that real and perceived cultural opposition to harm reduction strategies could reduce the likelihood that laypeople enroll in naloxone training. This study adds to the literature because it focuses on first responders in a FAR area that would benefit from layperson naloxone education and administration training due to its geographic expansiveness and the area’s overall lack of access to medications for opioid use disorder or other treatment services. Expanding harm reduction approaches, like increasing access and training laypersons to administer naloxone, might be FAR residents’ best chance for surviving an opioid overdose.

Background: The increasing rates of highly potent, illicit synthetic opioids (i.e., fentanyl) in the US is exacerbating the ongoing opioid epidemic. Multiple naloxone administrations (MNA) may be required to successfully reverse opioid overdoses. We conducted a real-world study to assess the rate of MNA for opioid overdose and identify factors associated with MNA. Methods: Data from the 2015–2020 National Emergency Medical Services Information System was examined to determine trends in events requiring MNA. Logistic regression analysis was performed to determine factors associated with MNA. Results: The percentage of individuals receiving MNA increased from 18.4% in 2015 to 28.4% in 2020. The odds of an event requiring MNA significantly increased by 11% annually. The adjusted odds ratio (aOR) for MNA were greatest among males, when advanced life support (ALS) was provided, and when the dispatch complaint indicated there was a drug poisoning event. Conclusions: The 54% increase in MNA since 2015 parallels the rise in overdose deaths attributable to synthetic opioids. This growth is visible in all regions of the country, including the West, where the prevalence of illicitly manufactured synthetic opioids is intensifying. Given this phenomenon, higher naloxone formulations may fulfill an unmet need in addressing the opioid overdose crisis.

Introduction: EMS time factors such as total prehospital, activation, response, scene and transport intervals have been used as a measure of EMS system quality with the assumption that shorter EMS time factors save lives. The objective was to assess in adults and children accessing ground EMS (population), whether operational time factors (intervention and control) were associated with survival at hospital discharge (outcome). Methods: Medline, EMBASE, and CINAHL were searched up to January 2015 for articles reporting original data that associated EMS operational time factors and survival. Conference abstracts and non-English language articles were excluded. Two investigators independently assessed the candidate titles, abstracts, and full text with discrepant reviews resolved by consensus. Risk of bias was assessed using GRADE. Results: A total of 10,151 abstracts were screened for potential inclusion, 199 articles were reviewed in full-text, and 73 met inclusion criteria. Amongst included studies, 49 investigated response time, while 24 investigated other time factors. All articles were observational studies. Amongst the 14 (28.6%) studies where response time was the primary analysis, statistically significant associations between shorter response time and increased survival were found in 5 of 7 cardiac arrest, 1 of 5 general EMS population, and 0 of 2 trauma studies. Other time factors were reported in the primary analysis in 10 (41.7%) studies. One study reported shorter combined scene and transport intervals associated with increased survival in acute heart failure patients. Two studies in trauma patients had somewhat conflicting results with one study reporting shorter prehospital interval associated with increased survival whereas the other reported increased survival associated with longer scene and transport intervals. Study design, analysis, and methodological quality were of considerable variability, and thus, meta-analyses were not possible. Conclusion: There is a substantial body of literature describing the association between EMS time factors and survival, but evidence informing these relationships are heterogeneous and complex. Important details such as patient population, EMS system characteristics, and analytical approach must be taken into consideration to appropriately translate these findings to practice. These results will be important for EMS leaders wishing to create evidence-based time policies.

Opioid overdose is the leading cause of death for Americans 25 to 64 years of age, and opioid use disorder affects >2 million Americans. The epidemiology of opioid-associated out-of-hospital cardiac arrest in the United States is changing rapidly, with exponential increases in death resulting from synthetic opioids and linear increases in heroin deaths more than offsetting modest reductions in deaths from prescription opioids. The pathophysiology of polysubstance toxidromes involving opioids, asphyxial death, and prolonged hypoxemia leading to global ischemia (cardiac arrest) differs from that of sudden cardiac arrest. People who use opioids may also develop bacteremia, central nervous system vasculitis and leukoencephalopathy, torsades de pointes, pulmonary vasculopathy, and pulmonary edema. Emergency management of opioid poisoning requires recognition by the lay public or emergency dispatchers, prompt emergency response, and effective ventilation coupled to compressions in the setting of opioid-associated out-of-hospital cardiac arrest. Effective ventilation is challenging to teach, whereas naloxone, an opioid antagonist, can be administered by emergency medical personnel, trained laypeople, and the general public with dispatcher instruction to prevent cardiac arrest. Opioid education and naloxone distributions programs have been developed to teach people who are likely to encounter a person with opioid poisoning how to administer naloxone, deliver high-quality compressions, and perform rescue breathing. Current American Heart Association recommendations call for laypeople and others who cannot reliably establish the presence of a pulse to initiate cardiopulmonary resuscitation in any individual who is unconscious and not breathing normally; if opioid overdose is suspected, naloxone should also be administered. Secondary prevention, including counseling, opioid overdose education with take-home naloxone, and medication for opioid use disorder, is important to prevent recurrent opioid overdose.

The first description of modern cardiopulmonary resuscitation (CPR) included the instruction to compress the chest “about 60 times per minute”1; however, the optimal compression rate was unknown. Franz Koenig is credited with describing the original technique for external cardiac massage, which included a compression rate of 30 to 40 per minute.2 But in the first published description of external cardiac massage in 1892, Friedrich Maass documented a better clinical response with a rate of 120 per minute.2 To this day, the optimal compression rate is the subject of controversy. Animal data indicate that cardiac output increases with compression rates up to as high as 150 per minute.3 In a canine model of prolonged cardiac arrest, compression rates of 120 per minute compared with 60 per minute increased mean aortic (systolic and diastolic) and coronary perfusion pressures, and 24-hour survival (61% versus 15%, P =0.03).4 In a study of 9 patients undergoing CPR, a compression rate of 120 per minute generated higher aortic peak pressures and coronary perfusion pressures compared with a compression rate of 60 per minute (the rate recommended by the 1980 American Heart Association [AHA] guidelines). This evidence is supported by another study of 23 patients in cardiac arrest in which compressions at 120 per minute resulted in significantly higher end-tidal carbon dioxide values compared with compressions at 80 per minute.5 Article see p 3004 The first large, prospective, observational study of the influence of chest compression rate on patient survival was published in this journal in 2005.6 The number of delivered chest compressions was recorded by trained observers during in-hospital resuscitation attempts. A higher chest compression rate was associated with a higher rate of return of spontaneous circulation (ROSC). The mean chest compression rate for initial survivors was 90 …

Extracorporeal Cardiopulmonary Resuscitation: Prehospital or In-Hospital Cannulation?

The contamination of non-opioid drugs with fentanyl presents a risk at US music festivals, where environmental factors exacerbate overdose-related risks. Naloxone is an opioid antagonist medication that can be used by festival attendees to reverse opioid overdose. We conducted a field survey at a 4-day Colorado music festival (N=227) to characterize attendees' prior experience with naloxone and to investigate whether attendees carry naloxone with them in both festival and non-festival settings. We also assessed attendees' level of confidence in responding to an overdose with naloxone and asked attendees to report any barriers they experienced to carrying naloxone at festivals. Prevalence of carrying naloxone in any context was 55.5% (N=126). Festival carriage was more common than carriage in non-festival settings, with 55.1% reporting at least "sometimes" carrying at festivals compared with 32.7% outside festival settings. In addition, 8.4% had used naloxone to respond to an overdose, and 4.4% had personally been administered naloxone. Among participants who reported carrying naloxone, 65.3% had never received training. Regarding confidence in overdose response, 29.9% of naloxone carriers reported being only "slightly confident" or "not at all confident." Barriers included access, festival restrictions and legal concerns, lack of education, training, and awareness, convenience factors, and perceived responsibility of carrying naloxone. Findings highlight the need for increased naloxone access, training, and awareness among festival attendees. Actionable recommendations include free or low-cost naloxone distribution, on-site training, and transparent entry policies to reduce barriers and promote overdose response as a community responsibility.