• Are there certain characteristics or circumstances that increase risk of overdose in this event?

The State Unintentional Drug Overdose Reporting System (SUDORS) captures variables that identify key risk factors of overdose deaths.

• Which specific drug(s) have been involved in the overdose incident?

This may not be reliably available from death certificates because ME/C may list only one contributing drug, all drugs that are noted on toxicology reports, or no specific drug at all (e.g., “multi-drug toxicity”). Post-mortem toxicology testing results provide the most in-depth information about substances involved in an overdose.

• Do prescription drug histories of decedents indicate if prescription drugs were being misused prior to death?

Useful resource: Contributions of prescribed and non-prescribed opioids to opioid related deaths: population-based cohort study in Ontario, Canada

• What level of awareness do persons who use drugs have about this overdose event, and what precautionary actions have they taken in response?

Useful resource: Characteristics of Fentanyl Overdose — Massachusetts, 2014–2016

• What drugs are being used in combination and how frequently?

Useful resources: Polysubstance combinations involving prescription opioids and rationales for combining among people who use internet drug discussion forums and NDEWS – Atlanta Metro Sentinel Community Site

Clinical Characteristics

• What are the clinical characteristics of affected individuals?

Consider: Characteristics of Fentanyl Overdose — Massachusetts, 2014–2016.  Is repeated naloxone dosing required? Is there a difference in the number of naloxone administrations by laypersons versus EMS? 

• What drugs did the person think they were using versus what does toxicology show?

Recently, there have been large discrepancies between what people may think they are using and what the illicit drug contains (e.g., a person bought counterfeit prescription pills, cocaine, or heroin adulterated with fentanyl). Useful resources: Expected and actual fentanyl exposure among persons seeking opioid withdrawal management, Multiple Fentanyl Overdoses — New Haven, Connecticut, June 23, 2016 , and CDC – Health Alert Network on synthetic opioids.

Multi-Jurisdictional Coordination

• Is there a potential for cases to occur in other states? Is the jurisdiction near the border with another state?

If so, engage neighboring states and communities as needed.