Assessing the Population-level and Equity Impact of the Emergency Medical Services Overdose Prevention Project (EMS-OPP) Using Critical Race Theory - The public health crisis of overdose continues unabated in King County, WA, with over 500 deaths in 2020, 700 in 2021, and rates continuing to rise with vast disparities in those affected. Emergency Medical System providers (EMS) are first to arrive at the scene of an overdose and are critical partners in care for people who use drugs. We partnered with people who use drugs, EMS leadership, and community partners to collect pilot data and then co-design EMS-delivered interventions tailored to reduce stigma and increase access to care for people who use drugs. These interventions are being rolled out as the EMS Overdose Prevention Project (EMS-OPP), and hold great potential to reduce racial disparities in access to evidence-based medical services and to improve long-term outcomes. EMS-OPP includes training for all EMS providers on stigma reduction and trauma-informed care, an EMS naloxone leave-behind program, and warm hand-off to a follow-up team for connecting to care. King County EMS teams will adopt these programs iteratively, and plan to have 90% of teams participating by 2026. Although this provides an excellent opportunity to assess the effectiveness of EMS-OPP, currently no investigation of patient-level, population-level, or equity impacts is planned. Thus, we will capitalize on the natural experimental conditions using a concurrent triangulation mixed methods design to examine the impact of EMS- OPP on racial disparities in health outcomes. Specifically, guided by Public Health Critical Race Praxis, we will partner with people who use drugs and Public Health Seattle & King County to: 1) evaluate the effect of EMS- OPP on racial disparities in patient-level experiences (e.g., discrimination in EMS interactions) and outcomes (e.g., linkage to buprenorphine treatment) (Aim 1); 2) further evaluate EMS-OPP from the perspectives of Black, Hispanic/Latinx, and American Indian/Alaska Native non-fatal overdose survivors using in-depth interviews (Aim 2); and 3) examine the impact of the EMS-OPP on racial disparities in population-level outcomes (e.g., connections to follow-up care) (Aim 3). Aims 1 involves the creation of a cohort of non-fatal overdose survivors with recent EMS interactions, linking multiple data systems. Aim 2 uses a qualitative study design involving semi- structured interviews with Black, Hispanic/Latinx, and American Indian/Alaska Native survivors from Aim 1. Aim 3 uses data from the EMS Records Management System data using an interrupted time series design comparing disparities in overdose outcomes for patients treated EMS-OPP-trained teams vs. not. In response to the escalating overdose crisis, and racial disparities in outcomes, state governments have expanded EMS funding, training, and scope of practice. Our proposed study capitalizes on this key moment in the opioid crisis to assess the population-level and equity impact of a structural community-level intervention with real-world complexities that has the potential for spread and scale. Findings will be shared in community venues (e.g. posters, community zine), policy briefs, conference presentations, and academic journal articles. 1
