Spatiotemporal Analysis Exploring the Effect of Law Enforcement Drug Market Disruptions on Overdose, Indianapolis, Indiana, 2020-2021.

Objectives. To test the hypothesis that law enforcement efforts to disrupt local drug markets by seizing opioids or stimulants are associated with increased spatiotemporal clustering of overdose events in the surrounding geographic area. Methods. We performed a retrospective (January 1, 2020 to December 31, 2021), population-based cohort study using administrative data from Marion County, Indiana. We compared frequency and characteristics of drug (i.e., opioids and stimulants) seizures with changes in fatal overdose, emergency medical services nonfatal overdose calls for service, and naloxone administration in the geographic area and time following the seizures. Results. Within 7, 14, and 21 days, opioid-related law enforcement drug seizures were significantly associated with increased spatiotemporal clustering of overdoses within radii of 100, 250, and 500 meters. For example, the observed number of fatal overdoses was two-fold higher than expected under the null distribution within 7 days and 500 meters following opioid-related seizures. To a lesser extent, stimulant-related drug seizures were associated with increased spatiotemporal clustering overdose. Conclusions. Supply-side enforcement interventions and drug policies should be further explored to determine whether they exacerbate an ongoing overdose epidemic and negatively affect the nation's life expectancy. (Am J Public Health. 2023;113(7):750-758. https://doi.org/10.2105/AJPH.2023.307291).

Buprenorphine and opioid analgesics: Dispensation and discontinuity among accidental overdose fatalities in the Indianapolis metropolitan area, 2016-2021.

BACKGROUND: This study describes overall trends and sociodemographic disparities in buprenorphine and opioid analgesic uptake and prescribing patterns prior to fatal overdose events. METHODS: We examined toxicology data from all accidental overdose deaths from 2016 to 2021 (N = 2682) in a large metropolitan area. These data were linked at the individual-level with a prescription drug monitoring program (PDMP). RESULTS: Fewer than half of all deaths had any kind of PDMP record (39.9 %, n = 1070). Among those with a buprenorphine prescription, 10.6 % (n = 35) of decedents had a buprenorphine dispensation within 7 days of their death, while the majority (64.7 %, n = 214) were dispensed buprenorphine more than 30 days prior to death. Evidence existed of racial disparities among those with any buprenorphine uptake, whereby Black individuals (7.3 %, n = 24) had significantly fewer any dispensations compared to White individuals (92.7 %, n = 307). Among those with an opioid analgesic prescription, about 12.2 % (n = 90) were dispensed within 7 days of death, with the majority (68.5 %, n = 506) occurring more than 30 days prior to death. Like buprenorphine dispensations, Black individuals were prescribed a significantly smaller proportion of opioid analgesics (21.9 %, n = 162) versus White individuals (77.7 %, n = 574). Buprenorphine was detected in 78.5 % of deaths where fentanyl was present in the toxicology record, significantly greater when compared to opioid analgesics (57.5 %). CONCLUSION: Consistent with prior research, our findings suggest prescription opioid analgesics may protect against fatal overdoses. Access to buprenorphine treatment did not keep pace with the rising lethality of the overdose crisis, and in recent years, a smaller percentage of the people at risk of fatal overdose availed themselves of MOUD preceding their death.

Community overdose surveillance: Fentanyl involvement in overdose deaths in rural Michigan.

Purpose: Examine fatal overdose toxicology trends to contribute toward understanding the outreach and treatment needs of people who use drugs in rural areas. Methods: We describe toxicology results from overdose deaths that occurred between January 1, 2018, and December 31, 2020, in 11 rural counties in Michigan, a state with relatively high rates of overdose mortality. One-way ANOVA with Tukey's HSD posthoc tests were used to test statistically significant differences in the frequency of substances detected between years. Findings: Decedents (N = 107) were male (72.9%), White (96.3%), non-military (96.3%), unemployed (71.0%), married (73.9%), and had a mean age of 47 years old. The number of observed overdose deaths increased considerably from 2019 to 2020, with an increase of 72.4%. Fentanyl was the most common substance detected and had a 94% increase during the three-year period to present in 70% of all the deaths in these counties in 2020. Among the deaths we examined where cocaine was detected, 69% also contained fentanyl, and in deaths where methamphetamine was detected, 77% also contained fentanyl. Conclusion: Findings could inform rural health and outreach initiatives aimed at reducing overdose risks by providing education on the risks of stimulant and opioid couse but also the widespread saturation of illicit drugs that contain fentanyl. Lowthreshold harm reduction interventions are discussed amid limited prevention and treatment resources in rural communities.

Buprenorphine involvement in opioid overdose deaths: A retrospective analysis of postmortem toxicology in Marion County, Indiana, 2015-2021.

Background: Amidst an unprecedented overdose epidemic, the opioid partial agonist buprenorphine is a medication for opioid use disorder associated with reductions in overdose. Despite its efficacy, buprenorphine prescribing remains closely regulated, owing to concerns about misuse, and its possible role in overdoses. Methods: A retrospective analysis of the Marion County, Indiana coroner's postmortem toxicology data for unintentional opioid-involved overdose deaths from 2015 through 2021. The county was chosen as a novel setting whose corner provided comprehensive overdose data. It contains Indianapolis, a large city in the US Midwest The 2,369 opioid-involved overdoses were analyzed for the presence of buprenorphine and its metabolite, as wel as potent substances associated with illicit drug use and overdose. Results: Of the 2,369 postmortem toxicology records analyzed, 55 (2.3%) indicated presence of buprenorphine. Of buprenorphine-involved cases, 51 (92.7%) involved other potent substances such as fentanyl, heroin, cocaine, methadone, and amphetamines; 4 (7.3%) were attributed to buprenorphine and liver failure, diabetic ketoacidosis, or relatively less potent substances. Fentanyl was present in 28 cases (50.9%), benzodiazepines were present in 24 (43.6%). Black opioid decedents were considerably less likely to have buprenorphine in their toxicology than White decedents. Conclusions: Buprenorphine was rarely detected in the postmortem toxicology of unintentional opioid overdoses in a major US city in the Midwest. In nearly all cases it was accompanied by other potent substances that more frequently cause fatal overdoses on their own. This study confirms findings from other geographic settings that the overdose mortality risks associated with buprenorphine are low.

Dual public health crises: the overlap of drug overdose and firearm injury in Indianapolis, Indiana, 2018-2020.

BACKGROUND: Drug overdose and firearm injury are two of the United States (US) most unrelenting public health crises, both of which have been compounded by the COVID-19 pandemic. Programs and policies typically focus on each epidemic, alone, which may produce less efficient interventions if overlap does exist. The objective is to examine whether drug overdose correlates with and is associated with firearm injury at the census tract level while controlling for neighborhood characteristics. METHODS: An ecological study of census tracts in Indianapolis, Indiana from 2018 to 2020. Population rates per 100,000 and census tracts with the highest overlap of overdose and firearm injury were identified based on spatial clusters. Bivariate association between census tract characteristic and drug overdose and firearm violence rate within spatial clusters. Zero-inflated negative binominal regression was used to estimate if the drug overdose activity is associated with higher future firearm injury. RESULTS: In high overdose-high firearm injury census tracts, rates of firearm injury and drug overdose are two times higher compared to city wide rates. Indicators of structural disadvantage and structural racism are higher in high overdose-high firearm injury census tracts compared to city-wide averages. Drug overdoses are associated with higher rates of firearm injury in the following year (IRR: 1.004, 95% CI 1.001, 1.007, p < 0.05), adjusting for census tract characteristics and spatial dependence. CONCLUSIONS: Drug overdose and firearm injury co-spatially concentrate within census tracts. Moreover, drug overdoses are associated with future firearm injury. Interventions to reduce firearm injuries and drug overdoses should be a co-response in high drug overdose-high firearm injury communities.

Client attitudes toward virtual treatment court.

INTRODUCTION: As a response to the COVID-19 pandemic, many treatment courts shifted to offering teleservices. We sought to examine the barriers that clients faced when transitioning to virtual court and treatment, and how this transition impacted their perceptions of the treatment court experience. METHODS: The National Center for State Courts administered an online survey between January 1, 2021, and July 31, 2021, deployed to state and local court administrators, which resulted in 1356 unique client responses from 121 courts. The survey measured attitudes about the treatment court process, including interactions with the judge, the behavioral health treatment staff, and treatment groups, as well as barriers to virtual and in-person court. We hypothesized that clients with fewer technological barriers to virtual service, who shifted to virtual court or treatment, would report more positive attitudes to this service delivery. RESULTS: Clients felt more comfortable participating in virtual court sessions than in-person sessions but were less likely to feel like the judge was familiar with their case during virtual court sessions. From the treatment perspective, clients felt more connected with other group members and reported greater benefit from treatment staff when treatment services were delivered in-person, but clients felt less anxious when treatment groups were virtual. CONCLUSIONS: Even though virtual experiences were more comfortable than in-person experiences for clients, the results are nuanced and show preference for some in-person connections as they transitioned to virtual connections. Future research should examine how to improve client connections with staff/group members during virtual court or treatment sessions, particularly as courts and treatment providers are likely to continue some services virtually into the future.

Jail and overdose: assessing the community impact of incarceration on overdose.

BACKGROUND AND AIMS: Incarceration produces a specific public health threat for drug overdose, and correctional settings do not offer medication for opioid use disorder. This study examined the overall impact of jail incarceration on overdose, the specific hazard for those booked on a syringe-related charge and the proportion of all overdose decedents in the community who were in the jail prior to death. DESIGN AND SETTING: A cohort study of fatal overdose outcomes among a sample of individuals booked into and released from jail between 1 January 2017 and 31 December 2019. Marion County, IN, USA. PARTICIPANTS: All individuals released from one county jail between 1 January 2017 and 31 December 2017 and decedents who died within the county from an accidental fatal overdose between January 2017 and December 2019. MEASUREMENTS AND FINDINGS: Using information on all jail booking events, including charge type, during a 5-year period (January 2015-December 2019), we looked at the hazard of accidental fatal overdose post-release, controlling for age, sex and race. Of all overdose deaths in the county, 21% (n = 237) had been in the county jail within 2 years prior to their death. Each prior booking increased the hazard of mortality by approximately 20% [hazard ratio (HR) = 1.21, 95% confidence interval (CI) = 1.15, 1.28], while the presence of a syringe charge at most recent booking prior to release more than tripled the hazard of mortality (HR = 3.55, 95% CI = 2.55, 4.93). CONCLUSIONS: In Marion County, IN, USA, there appears to be an association between increased risk of fatal drug overdose and both syringe-related arrests and repeat jail bookings.

Community overdose surveillance: Comparing substances collected from the death scene investigation to toxicology results.

BACKGROUND: Recent overdose trends are characterized by increased toxicological detection of stimulants with opioids, yet it is unclear whether these substances are mixed prior to consumption or purposefully used simultaneously. METHODS: Postmortem toxicology data were collected in Marion County, Indiana, from 45 fatal overdose cases involving heroin, fentanyl, methamphetamine, or cocaine. Substances found by death scene investigators at the scene of the fatal overdose (57 samples) were tested using high-pressure liquid chromatography mass-spectrometry (LC-MS) technology. We compared toxicology and LC-MS results to understand whether substances contributing to overdose were found in combination or separately at the scene of the overdose. RESULTS: Comparing toxicology reports with LC-MS results from substances found at the scene of overdose deaths involving opioids and stimulants reveal that deaths are largely the result of the co-use of opioids and stimulants, rather than use of stimulants combined with opioids. CONCLUSIONS: Collecting and testing physical samples from fatal overdose scenes and comparing these to post-mortem toxicology results is a new way to examine polydrug use patterns. This community overdose surveillance method can be used to improve overdose prevention and response efforts.

Evaluation of an emergency department-based opioid overdose survivor intervention: Difference-in-difference analysis of electronic health record data to assess key outcomes.

BACKGROUND: In recent years, a number of emergency department (ED)-based interventions have been developed to provide supports and/or treatment linkage for people who use opioids. However, there is limited research supporting the effectiveness of the majority of these interventions. Project POINT is an ED-based intervention aimed at providing opioid overdose survivors with naloxone and recovery supports and connecting them to evidence-based medications for opioid use disorder (MOUD). An evaluation of POINT was conducted. METHODS: A difference-in-difference analysis of electronic health record data was completed to understand the difference in outcomes for patients admitted to the ED when a POINT staff member was working versus times when they were not. The observation window was January 1, 2012 to July 6, 2019, which included N = 1462 unique individuals, of which 802 were in the POINT arm. Outcomes of focus include MOUD opioid prescriptions dispensed, active non-MOUD opioid prescriptions dispensed, naloxone access, and drug poisonings. RESULTS: The POINT arm had a significant increase in MOUD prescriptions dispensed, non-MOUD prescriptions dispensed, and naloxone access (all p-values < 0.001). There was no significant effect related to subsequent drug poisoning-related hospital admissions. CONCLUSIONS: The results support the assertion that POINT is meeting its two primary goals related to increasing naloxone access and connecting patients to MOUD. Generalization of these results is limited; however, the evaluation contributes to a nascent area of research and can serve a foundation for future work.

Arrest and emergency medical services events among participants from one of the first mental health courts.

OBJECTIVE: This study looked at, in addition to subsequent arrest, emergency medical services (EMS) events as an outcome of participation in mental health court (MHC). METHODS: We linked information from participants of a MHC in Marion County, Indiana with jail booking and EMS services data. To understand programmatic impact, we looked at differences in jail bookings and EMS events within one year prior to and one year after MHC participation. We ran paired t-tests to understand whether correlations were significant. We also considered differences in outcomes between those who successfully completed MHC versus those who did not. RESULTS: MHC participation was significantly associated with a reduction in jail bookings and EMS events in the 12 months after program participation compared to the 12 months before. When comparing MHC participant groups, a significant reduction in jail bookings is found consistently whereas a significant reduction in EMS events was found in only some participant groups: the entire MHC group and the misdemeanor-level court (PAIR) participants when they successfully completed the program. CONCLUSIONS: EMS utilization should be an outcome of consideration in evaluating the success and cost savings of MHCs. Where MHCs do not result in significantly reduced EMS events, communities should consider what individual-level and community-level factors contribute to this and adjust accordingly.

Impact of COVID-19 Pandemic on Drug Overdoses in Indianapolis.

We described the change in drug overdoses during the COVID-19 pandemic in one urban emergency medical services (EMS) system. Data was collected from Marion County, Indiana (Indianapolis), including EMS calls for service (CFS) for suspected overdose, CFS in which naloxone was administered, and fatal overdose data from the County Coroner's Office. With two sample t tests and ARIMA time series forecasting, we showed changes in the daily rates of calls (all EMS CFS, overdose CFS, and CFS in which naloxone was administered) before and after the stay-at-home order in Indianapolis. We further showed differences in the weekly rate of overdose deaths. Overdose CFS and EMS naloxone administration showed an increase with the social isolation of the Indiana stay-at-home order, but a continued increase after the stay-at-home order was terminated. Despite a mild 4% increase in all EMS CFS, overdose CFS increased 43% and CFS with naloxone administration increased 61% after the stay-at-home order. Deaths from drug overdoses increased by 47%. There was no change in distribution of age, race/ethnicity, or zip code of those who overdosed after the stay-at-home order was issued. We hope this data informs policy-makers preparing for future COVID-19 responses and other disaster responses.

Using prescribing and toxicology data to determine non-medical prescription drug overdose.

BACKGROUND: Overdose deaths have increased dramatically in the United States and are often attributed to prescription opioids. This study presents a framework for "overdose typologies", including non-medical prescription drug use, to more accurately describe drug use patterns. METHODS: This study examined linked prescription drug monitoring program (PDMP) and toxicology data (2016-2018) from accidental overdose deaths from a large metropolitan coroner's office in the Midwest (Indianapolis, Indiana). RESULTS: In total, 1,112 accidental overdose deaths occurred and over two-thirds (68.0%; n = 756) were coded as an illicit drug user with no prescription opioid present in the toxicology. The most infrequent categories were prescription opioid users 5.5% (n = 61). CONCLUSION: Linked PDMP and toxicology reports are useful in identifying drug use patterns that contribute to mortality.

Racial differences in overdose events and polydrug detection in Indianapolis, Indiana.

BACKGROUND: We examine racial disparities in drug overdose death rates by analyzing trends in fatal and nonfatal overdose outcomes in a large metropolitan area (Indianapolis, Indiana). METHODS: Death certificate and toxicology records for accidental drug overdose deaths from 2011 to 2018 were linked with emergency medical services (EMS) data. Bivariate comparisons examined differences in toxicology findings at the time of death as well as prior EMS events both overall and by indicator of non-fatal overdose. RESULTS: From 2011-2018, 2204 residents (29.4 per 100,000) died of drug overdose, 18.6% were Black (N = 410, 19.5 per 100,000) and 78.5% White (N = 1730, 35.2 per 100,000). In the year prior to death, 33.5% (N = 656) of decedents had an EMS event, 12.1% (N = 237) had an overdose event, and 9.4% (N = 185) had naloxone administered. Overdose complaint and naloxone administration were more likely to occur among White than Black patients. White decedents were more likely than Black decedents to have had naloxone administered in the year prior to death (10.1% vs. 6.8%, χ2 = 4.0, p < .05, Cramer's V=.05). Toxicology data illustrate changing polydrug combinations, with Black decedents more likely to test positive for fentanyl-cocaine polydrug use in recent years. CONCLUSIONS: Recent racial disparities in overdose deaths are driven by a combination of fentanyl and cocaine, which disproportionally impacts African American drug users, but may be addressed through expanded harm reduction and community outreach services. Additionally, there is a need to assess the role of differing practices in overdose emergency service provision as a contributing factor to disparities.

Police officer attitudes towards syringe services programming.

BACKGROUND: As the United States experiences a drug overdose epidemic, syringe services programs (SSPs) have been utilized to reduce rates of infectious disease and improve treatment outcomes for people who inject drugs (PWID). Police officer support of SSPs is crucial to program success. One way to improve officer support and collaboration is to develop officer training presentations about SSP services and procedures as well as information on officers' roles in program implementation. METHODS: Researchers accompanied staff from the Marion County Safe Syringe Access and Support Program as they provided SSP training presentations to Indianapolis Metropolitan Police Department officers at district roll calls. Immediately following each presentation, officers completed a survey measuring attitudes toward SSPs, PWID, and the information presented. RESULTS: Of the 339 completed surveys returned, most officers expressed support for the SSP and a desire to help PWID. However, those with experience of a needle stick injury were more critical of the program, reporting it enables drug use. Approximately half of respondents reported limited knowledge of SSPs, even after the training. Qualitative data indicate about half of officers reported they could use discretion in deciding whether to arrest for illegal possession of a syringe. CONCLUSIONS: Overall findings indicate positive attitudes towards SSPs; however, officer feedback identifies several concerns and areas for improvement. Public health agencies must develop comprehensive, tailored presentations that address common officer concerns and misconceptions regarding SSPs, PWIDs, and harm reduction strategies to improve officer support.

Identifying Unreported Opioid Deaths Through Toxicology Data and Vital Records Linkage: Case Study in Marion County, Indiana, 2011-2016.

OBJECTIVES: To demonstrate the severity of undercounting opioid-involved deaths in a local jurisdiction with a high proportion of unspecified accidental poisoning deaths. METHODS: We matched toxicology data to vital records for all accidental poisoning deaths (n = 1238) in Marion County, Indiana, from January 2011 to December 2016. From vital records, we coded cases as opioid involved, specified other substance, or unspecified. We extracted toxicology data on opioid substances for unspecified cases, and we have reported corrected estimates of opioid-involved deaths after accounting for toxicology findings. RESULTS: Over a 6-year period, 57.7% of accidental overdose deaths were unspecified and 34.2% involved opioids. Toxicology data showed that 86.8% of unspecified cases tested positive for an opioid. Inclusion of toxicology results more than doubled the proportion of opioid-involved deaths, from 34.2% to 86.0%. CONCLUSIONS: Local jurisdictions may be undercounting opioid-involved overdose deaths to a considerable degree. Toxicology data can improve accuracy in identifying opioid-involved overdose deaths. Public Health Implications. Mandatory toxicology testing and enhanced training for local coroners on standards for death certificate reporting are needed to improve the accuracy of local monitoring of opioid-involved accidental overdose deaths.

The housing first technical assistance and training (HFTAT) implementation strategy: outcomes from a mixed methods study of three programs.

BACKGROUND: This paper discusses the initial testing of the Housing First Training and Technical Assistance (HFTAT) Program, a multifaceted, distance-based strategy for the implementation of the Housing First (HF) supportive housing model. HF is a complex housing intervention for serving people living with serious mental illness and a substance use disorder that requires significant individual- and structural-level changes to implement. As such, the HFTAT employs a combined training and consultation approach to target different levels of the organization. Training delivered to all organizational staff focuses on building individual knowledge and uses narrative storytelling to overcome attitudinal implementation barriers. Consultation seeks to build skills through technical assistance and fidelity audit and feedback. METHOD: We employed a mixed method design to understand both individual-level (e.g., satisfaction with the HFTAT, HF knowledge acquisition and retention, and HF acceptability and appropriateness) and structural-level (e.g., fidelity) outcomes. Quantitative data were collected at various time points, and qualitative data were collected at the end of HFTAT activities. Staff and administrators (n = 113) from three programs across three states participated in the study. RESULTS: Satisfaction with both training and consultation was high, and discussions demonstrated both activities were necessary. Flexibility of training modality and narrative storytelling were particular strengths, while digital badging and the community of practice were perceived as less valuable because of incompatibilities with the work context. HF knowledge was high post training and retained after 3-month follow-up. Participants reported training helped them better understand the model. Attitudes toward evidence-based interventions improved over 6 months, with qualitative data supporting this but demonstrating some minor concerns related to acceptability and appropriateness. Fidelity scores for all programs improved over 9 months. CONCLUSION: The HFTAT was a well-liked and generally useful implementation strategy. Results support prior research pointing to the value of both (a) multifaceted strategies and (b) combined training and consultation approaches. The study also provides evidence for narrative storytelling as an approach for changing attitudinal implementation barriers. The need for compatibility between specific elements of an implementation strategy and the work environment was also observed.

Fentanyl related overdose in Indianapolis: Estimating trends using multilevel Bayesian models.

INTRODUCTION: The opioid epidemic has been largely attributed to changes in prescribing practices over the past 20 years. Although current overdose trends appear driven by the opioid fentanyl, heroin has remained the focus of overdose fatality assessments. We obtained full toxicology screens on lethal overdose cases in a major US city, allowing more accurate assessment of the time-course of fentanyl-related deaths. METHODS: We used coroner data from Marion County, Indiana comprising 1583 overdose deaths recorded between January 1, 2010 and April 30, 2017. Bayesian multilevel models were fitted to predict likelihood of lethal fentanyl-related overdose using information about the victim's age, race, sex, zip code, and date of death. RESULTS: Three hundred and seventy-seven (23.8%) overdose deaths contained fentanyl across the seven-year period. Rates rose exponentially over time, beginning well below 15% from 2010 through 2013 before rising to approximately 50% by 2017. At the beginning of the study period, rates of fentanyl overdose were lowest among Black persons but increased more rapidly, eventually surpassing Whites. Currently, White females are at particularly low risk of fentanyl overdose whereas Black females are at high risk. Rates were highest for younger and middle-aged groups. Over time, fentanyl was more likely detected without the presence of other opioids. CONCLUSIONS: Fentanyl has increasingly been detected in fatal overdose deaths in Marion County. Policy and program responses must focus on education for those at highest risk of fentanyl exposure and death. These responses should also be tailored to meet the unique needs of high-risk demographics.

Lay responder naloxone access and Good Samaritan law compliance: postcard survey results from 20 Indiana counties.

BACKGROUND: To reduce fatal drug overdoses, two approaches many states have followed is to pass laws expanding naloxone access and Good Samaritan protections for lay persons with high likelihood to respond to an opioid overdose. Most prior research has examined attitudes and knowledge among lay responders in large metropolitan areas who actively use illicit substances. The present study addresses current gaps in knowledge related to this issue through an analysis of data collected from a broader group of lay responders who received naloxone kits from 20 local health departments across Indiana. METHODS: Postcard surveys were included inside naloxone kits distributed in 20 Indiana counties, for which 217 returned cards indicated the person completing it was a lay responder. The survey captured demographic information and experiences with overdose, including the use of 911 and knowledge about Good Samaritan protections. RESULTS: Few respondents had administered naloxone before, but approximately one third had witnessed a prior overdose and the majority knew someone who had died from one. Those who knew someone who had overdosed were more likely to have obtained naloxone for someone other than themselves. Also, persons with knowledge of Good Samaritan protections or who had previously used naloxone were significantly more likely to have indicated calling 911 at the scene of a previously witnessed overdose. Primary reasons for not calling 911 included fear of the police and the person who overdosed waking up on their own. CONCLUSIONS: Knowing someone who has had a fatal or non-fatal overdose appears to be a strong motivating factor for obtaining naloxone. Clarifying and strengthening Good Samaritan protections, educating lay persons about these protections, and working to improve police interactions with the public when they are called to an overdose scene are likely to improve implementation and outcomes of naloxone distribution and opioid-related Good Samaritan laws.

Who is Overdosing? An Updated Picture of Overdose Deaths From 2008 to 2015.

PURPOSE: To determine the role of opioids in drug overdose deaths in Allen County, Indiana between January 1, 2008, and December 31, 2015. METHODS: File review of 418 overdose deaths was performed using Indiana State Department of Health death certificates available through the Allen County Coroner's Office. Data from autopsy and toxicology reports and coroner-requested prescribing data from Indiana's Prescription Monitoring Program were reviewed. Cause of death and available data were analyzed to identify patterns and trends related to overdose deaths. RESULTS: Four hundred eighteen drug overdose deaths were identified (336 accidental, 66 intentional, and 16 undetermined). Mean age was 42.5 years, 88.5% were Caucasian, and 68.7% were employed. The majority of deaths occurred at a place of residence (71.4%) and with other people present (57.5% of the time). Depression was the most common comorbidity identified. The most common drug classes identified by toxicology were opioids, followed by benzodiazepines. Significant increases in both heroin (35% of deaths in 2015 versus 8.2% in 2013) and fentanyl (30% of deaths in 2015 versus 2.2% in 2011) were observed. CONCLUSIONS: Drug overdose continues to be a significant cause of death in Allen County. The majority of deaths were accidental and in relatively young, employed individuals. Prevention and awareness strategies should be encouraged, given that the majority of overdose deaths occurred at a place of residence with other people frequently present. Additional concerns about patterns of drug use were confirmed with marked increases in both heroin and fentanyl contributing to overdose deaths in the latter part of the study.