EMS and the Opioid Crisis
Emergency medical services have been at the forefront of overdose response for decades. While recent CDC data reports a 24% decline in drug overdose deaths from October 2023 to September 2024, nearly 650,000 cases of nonfatal overdoses were recorded nationwide in 2023, rising from previous years, according to National Emergency Medical Services Information System (NEMSIS) data. A study analyzing data from 491 U.S. counties reported that the rate of nonfatal opioid-involved overdose EMS encounters rose on average 4% per quarter from January 2018 to March 2022, increasing from 98 to 179 per 10,000 EMS encounters.
Despite their frontline role, EMS systems face several significant challenges, including workforce challenges, funding instability and ambulance deserts—or gaps in the provision of ambulance services. The American Ambulance Association reports an annual turnover rate of around 30% among EMTs and part-time paramedics. According to the 2022 National EMS Management Association’s EMS Trends Report, 97% of the participating EMS agencies indicated difficulty recruiting and retaining personnel, and over 2 million people live in areas where emergency services are limited.
To address these issues, state lawmakers are leveraging policies to enhance EMS’ role in overdose response. Increasingly, states are strengthening coordination between EMS and crisis response systems like 911 public safety access points and the 988 Suicide and Crisis Lifeline to ensure timely and appropriate care for individuals experiencing an overdose.
Key Roles Within EMS
EMS is a coordinated system designed to respond to emergencies—including overdoses—with trained pre-hospital clinicians and essential support personnel. While EMS clinicians are the most visible part of the system, the system includes roles in dispatch, communication and leadership that ensure timely and effective emergency response.
| Dispatch and Communication |
EMS Clinicians
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Leadership and Oversight |
- 911 Telecommunicators: Answer emergency calls, assess the nature of the situations, dispatch the appropriate first responders and provide critical instructions to callers until help arrives.
- 988 Crisis Counselors: Answer mental health-related emergency calls, provide immediate support, connect individuals to resources, and facilitate connections to professional care.
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- Emergency Medical Responders: Initiate immediate, lifesaving care and assist EMTs and paramedics during emergencies and transport.
- Emergency Medical Technicians: Provide basic emergency medical care and transportation for critically ill or injured patients.
- Advanced EMTs: Provide both basic and limited advanced medical care, including some medications and procedures.
- Paramedics: Provide advanced emergency medical care, including medication administration, advanced airway management, and other critical interventions.
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- EMS leadership—including supervisors, managers and medical directors—ensure the quality and consistency of care, support team operations and uphold professional standards.
- Oversight occurs at multiple levels, including state, county and municipal levels.
- Every state has a state EMS office, which designates an EMS director and medical director who regulate and coordinate EMS licensing, training and operational protocols.
- EMS leaders at the county and municipal levels oversee operations, implement policies, and collaborate with state officials to support emergency response services in their communities.
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EMS’ Role in Overdose Prevention and Response
EMS systems include dispatch, first responders, fire departments, ambulance agencies, hospital emergency departments and state EMS offices. EMS systems operate at the crossroads of health care, public health and public safety, placing them in a unique intersection of other services and systems intended to enhance the community’s health and safety. For example, EMS can connect patients to treatment centers and collect public health data, especially in situations when patients are not transported to an emergency department, contributing to more accurate case reporting. Coordination across EMS system and ecosystem stakeholders, like state and local governments and health care facilities, may support overdose prevention and response efforts.
EMS clinicians are trained to assess and manage overdose response, administer medications to reverse opioid overdose like naloxone and transport patients to appropriate health care facilities. In instances where transport services are refused, EMS may be a patient’s only clinical service encounter post overdose.
State Actions to Strengthen EMS in Overdose Prevention and Response
State lawmakers may consider policies to expand EMS involvement in overdose prevention, equip EMS clinicians with the necessary tools, training and authority to administer life-saving interventions and strengthen EMS systems. Policies may include:
- Modifying EMS clinician training and scope of practice to improve care delivery.
- Updating state and local EMS plans to enhance coordination and service delivery.
- Establishing data-sharing systems to track overdose trends and guide response efforts.
- Supporting alternative response models, including transport to non-emergency health care facilities.
- Coordinating cross agency communications with 911 and 988.
- Allocating funds to ensure stability for EMS systems.
Modifying EMS Clinician Training and Scope of Practice
States are modifying EMS authority to administer medications for opioid use disorder (OUD), such as buprenorphine and naloxone.
Buprenorphine is a medication used to treat OUD by reducing cravings and withdrawal symptoms. Research suggests that initiating buprenorphine treatment immediately after an overdose can improve patient stabilization and long-term recovery outcomes. New Jersey allows paramedics in mobile intensive care units to administer buprenorphine after naloxone has been given to reverse an overdose.
Naloxone is a medication used to reverse overdose from OUD. Some states allow EMS to distribute naloxone kits to at-risk individuals or their families, ensuring access to the overdose reversal drug even after EMS personnel leave the scene. Arizona authorizes health professionals, including EMS, to provide naloxone to at-risk individuals and to community organizations serving those with substance use disorders.
Ensuring Access through Local EMS Plan
State legislatures help shape EMS operations by establishing standards of care, funding allocations, and regulatory oversight. EMS plans—developed at state and local levels—are adaptable, allowing for flexibility in overdose response efforts. These plans may define service delivery requirements, clinician certification standards and regional coordination efforts to ensure timely and effective emergency response.
Oregon requires each county to develop a plan for the coordination of ambulance services and establish one or more ambulance service areas. Texas created a pilot program for EMS to provide emergency telemedicine medical services in rural areas. Illinois allows EMS medical directors in rural communities (populations under 7,500) to credential registered nurses, physician assistants, and advanced practice registered nurses as EMTs to expand the workforce.
Establishing Data-Sharing Systems
Collaboration between EMS and state public health agencies can enhance overdose prevention efforts through real-time data collection and analysis. Key benefits of EMS data integration include:
- Up-to-Date Overdose Monitoring: EMS data can help public health agencies identify overdose hotspots and trends in real-time, allowing for targeted interventions such as outreach programs.
- Forecasting and Early Intervention: By analyzing EMS overdose response data, public health officials can detect emerging drug trends, such as fentanyl-laced substances and issue timely public health advisories.
- Resource Allocation: Data-sharing agreements can help agencies allocate resources effectively, such as deploying harm reduction services or mobile crisis teams in high-risk areas.
- Policy Evaluation: EMS data can be used to measure the impact of public health and legislative initiatives.
Various data collection and analytical tools are available to lawmakers that may provide valuable information on their state EMS system, including NEMSIS and Overdose Detection Mapping Application Program (ODMAP).
After each call, EMS clinicians document treatment provided, including transportation, and suspected cause of emergency such as drug overdose or substance misuse using the Electronic Patient Care Reports. These data are later aggregated within NEMSIS and used for trend analysis and comparison. Collecting information can assist state officials, providing insight used to determine budgets and operational needs.
The ODMAP is a free, web-based tool that provides near real-time suspected overdose surveillance data across jurisdictions to support public safety and public health efforts to mobilize an immediate response to a sudden increase, or spike in overdose events. As of July 2024, approximately 5,200 agencies across all 50 states, the District of Columbia, and Puerto Rico are using the ODMAP platform. Florida requires suspected overdose data collected from EMS clinicians, hospitals and urgent care centers to be reported to ODMAP. Maryland asks law enforcement officers to submit any suspected overdose incidents on ODMAP.
Supporting Alternative Response Models
Traditionally, EMS transports patients to emergency departments (EDs) after stabilization. However, alternative response models, including community paramedicine and alternate destination transport, allow transport to non-emergency medical facilities, such as urgent care centers, behavioral health clinics and primary care clinics. Studies show diverting non-emergent patients to alternative medical treatment centers other than hospitals may help with ED crowding, improved patient outcomes and cost savings.
Reimbursement for EMS services has typically been linked to transports to emergency departments. When patients are transported to other medical facilities, coverage gaps may arise, or the service may not qualify for reimbursement. In a 2021 survey conducted by the Association of State and Territorial Health Officials, only 5% of EMS respondents reported receiving reimbursement for transporting patients who overdosed to alternative destinations.
State legislatures may support alternative destination transport by authorizing EMS to transport patients to non-hospital facilities and ensuring reimbursement of such services. The map below includes the states that allow alternative destination transport as of 2023. Arkansas permits an ambulance service provider to transport Medicaid beneficiaries to a mental or behavioral health facility. EMS clinicians are to coordinate by telemedicine with a physician or a behavioral health specialist. Hawaii established the Crisis Intervention and Diversion Services Program to direct individuals experiencing a mental health crisis or suffering from substance abuse to an appropriate health care clinic.
Improving Coordination of 988 and 911
The 911 system is designed for immediate response (e.g., EMS, fire, law enforcement) while the 988 Suicide and Crisis Lifeline serves as a crisis resource for mental health or substance use emergencies. Improved coordination between these systems can reduce unnecessary emergency room visits and improve patient outcomes. States like Oregon and Arizona report that the majority of 988 calls end in non-medical intervention and are resolved by phone. Still, many Americans facing a behavioral health emergency rely on 911 for help.
States are improving coordination of 988 and 911 in various ways. Virgina established the Marcus Alert System, which provides emergency behavioral health response via coordination among 988 and 911 call centers and law enforcement. As of July 2024, 10 cities and counties are using the system; statewide implementation is required by July 2028. California enacted the Miles Hall Lifeline and Suicide Prevention Act, directing the Office of Emergency Services to ensure seamless transfers between 911 and 988 centers and to appoint a 988 system director to oversee interoperability. West Virginia tasked the Secretary of the Department of Health and Human Resources with developing a coordination plan between 911 hotline centers, the state mental health authority and the National Suicide Prevention Lifeline to improve crisis response.
Ensuring EMS Sustainability
EMS systems rely on various funding sources including local taxes, grants, state government allocations and reimbursement from health insurance providers. A 2021 survey conducted by the National Association of Emergency Medical Technicians estimated $4.5 billion in unpaid EMS services nationwide. Additionally, EMS agencies are often only reimbursed for patient transport, not for prehospital care provided at the scene, leaving EMS agencies to foot the bill for the cost of readiness, including supplies, staffing and other resources. Funding shortages can cause long response times and staffing shortages and may affect care levels.
Oklahoma allows county-level sales tax votes to fund EMS operations. West Virginia mandates insurance coverage for non-hospital emergency transport. New Hampshire is seeking approval to use Medicaid funds to cover ambulance services when care is provided without transport.
EMS plays an instrumental role in overdose response and prevention. Addressing workforce shortages, improving funding stability and strengthening interagency collaboration can enhance EMS response capabilities, improve patient outcomes and save lives.
This resource is supported by the Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $650,000 with 100% funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, CDC/HHS or the U.S. government.
Please note that NCSL takes no position on state legislation or laws mentioned in linked material, nor does NCSL endorse any third-party publications; resources are cited for informational purposes only.
Aneesa Turbovsky is a policy analyst with the NCSL Health Program.