OVERDOSE FATALITY REVIEW


In practice, Overdose Fatality Reviews involve a series of confidential individual death reviews by a multidisciplinary team to effectively identify system gaps and innovative community-specific overdose prevention and intervention strategies.

Overdose Fatality Review (OFR)

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The purpose of an OFR is to effectively identify system gaps and innovative community-specific overdose prevention and intervention strategies.

In practice, OFRs involve a series of confidential individual death reviews by a multidisciplinary team. A death review (also referred to as a “case review”) examines a decedent’s life cycle in terms of drug use history, comorbidity, major health events, social-emotional trauma (including adverse childhood experiences), encounters with law enforcement and the criminal justice system, treatment history, and other factors, including local conditions to facilitate a deeper understanding of the missed opportunities for prevention and intervention that may have prevented an overdose death.

By conducting a series of OFRs, jurisdictions begin to see patterns of need and opportunity, not only within specific agencies, but across systems.

Blending input from public health, public safety, providers, and the community, OFR teams develop program and policy recommendations to improve coordination and collaboration between agencies and community conditions to prevent future overdose deaths.

These recommendations are presented to a governing committee that supports and provides resources for implementation and a framework for accountability for action. Examples of successful recommendations include the integration of peer recovery specialists into new settings, targeted naloxone distribution, and improved coordination of public safety and public health.

Guide Design

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This guide is a companion document to the CDC Foundation’s Public Health and Safety Team (PHAST) Toolkit and was created to help communities plan, implement, and evaluate OFRs. It is designed for multiple audiences including public health, public safety, criminal justice, drug treatment, and social services.

The goal of the guide is to provide the reader with the needed information to build a successful OFR process with a strong foundation in coalition, data collection, and prevention. The guide content draws on other fatality reviews and the authors’ practice-based knowledge. It is organized into five modules:

Are Overdose deaths preventable?

Overdose Deaths Are Preventable

Yes. Overdose deaths can be prevented with coordinated prevention strategies, timely implementation of evidence-based interventions, community mobilization, and supportive families and friends.

The shared understanding that overdose deaths are preventable guides the entire overdose fatality review (OFR) process. Federal agencies, such as the Bureau of Justice Assistance (BJA) and the Centers for Disease Control and Prevention (CDC), are strategically coordinating to mobilize local communities to develop and implement OFRs.

OFR Resources

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