2025 National Forum on Overdose Fatality Review

Over the past 4 years, the Jay County, Indiana, rural suicide overdose fatality review (SOFR) team has reviewed 58 cases and identified 438 data-driven recommendations. These recommendations—categorized into immediate, intermediate, and longer-term actions—address gaps in services across the community. Immediate actions, such as educating emergency room patients about their prescribed medications, have helped sustain momentum among SOFR members. 

A major success was securing a recovery home; though it is not yet accepting individuals, its establishment has already addressed several key gaps identified in the recommendations. This home provides a foundation for future recovery support by creating a safe and supportive space, and its presence has already fostered stronger community collaboration. The consistent theme of safe and supportive housing remains the SOFR team’s top priority, and this presentation will showcase how addressing this need is helping turn the tide in the fight and in stigma reduction regarding substance use disorder. 

The last 4 years Lackawanna County OFR team has conducted case reviews in which next-of-kin (NOK) interviews were completed. Conducting an NOK interview is a significant and often underestimated task, especially for the participant. These interviews are valuable tools for OFRs to gain deeper insights into the decedents’ lives, identify nontraditional touchpoints or systems that may not be represented by the OFRs, and provide essential grief support to loss survivors. To better understand the demands and impact of these interviews on participants, Lackawanna County contracted with the University of Pittsburgh’s Program Evaluation and Research Unit (PERU) for assistance. PERU was tasked with gathering feedback from participants who completed an NOK interview, analyzing that data, and authoring a comprehensive report on the outcomes. 

This presentation describes three recommendations put forth by the Cuyahoga County, Ohio, Overdose Fatality Review. The first recommendation led to the installation of 100-plus NaloxBoxes throughout the county, including outdoor locations, to increase the accessibility of harm reduction resources. A virtual training on naloxone administration was also implemented widely in the county. The second recommendation resulted in over 11,000 fentanyl test strips (FTS) distributed within local communities and targeted hot spots. The third recommendation was a cross-sector collaboration that led to the creation of an infographic for the county jail to share information regarding risk of overdose upon release from jail. The infographic communicated key messages that were displayed in the jail. These recommendations spanned three major groups: (1) professionals, (2) the general public, and (3) community service agencies.  

The King County, Washington, Overdose Fatality Review (OFR) Team, in collaboration with the Seattle-King County Public Health Overdose Prevention and Response Team, implemented a training at the Seattle, Washington, Police Department to educate officers about buprenorphine and the local resources available for patients to access it. Officers were trained on the role of buprenorphine in treating opioid use disorder (OUD) and provided with business card-sized handouts containing information about King County’s 24/7 buprenorphine hotline and the Washington Recovery Helpline. These handouts can be distributed during law enforcement interactions with individuals at risk of overdose, offering a direct connection to substance use treatment and recovery resources. By leveraging the frequent touchpoints between police officers and individuals with OUD, this initiative transforms routine police encounters into opportunities for intervention, fostering connections to recovery services and ultimately increasing the utilization of lifesaving resources. 

This session promises practical guidance, shared learning, and valuable tools for building an infrastructure to support overdose fatality review (OFR). Attendees will leave prepared to develop actionable strategies for implementing a state infrastructure to support local OFRs. State agency personnel at any level of expertise and engagement in the OFR process are encouraged to attend.  

Attendees will join their state agency peers for an interactive session tailored exclusively for state leads. In this session, Institute for Intergovernmental Research (IIR) facilitators will introduce the enhanced OFR State Checklist, a tool designed to equip state agencies with planning how best to support state and local OFR initiatives. Attendees will hear directly from states using the checklist to help build, strengthen, and sustain their support for state OFR infrastructure. This session offers an opportunity to connect with peers from other state agencies, discuss relevant issues and trends, share resources, exchange ideas, and acquire new skills to strengthen OFR programs. Participants will update their own assessments during the session with their plans and current activities. States completing their assessments in this session will have the opportunity to highlight key components of their state infrastructure efforts on the OFRTools website state profiles. 

Salem County is the smallest county in the state of New Jersey but is maximizing its impact by using overdose fatality review team (OFRT) recommendations to tackle stigma. With only roughly 65,000 residents, Salem County faces unique obstacles associated with its network of rural municipalities. To leverage local barriers like secluded populations, lack of transportation, deeply rooted stigma, and limited access to overdose prevention supplies, Salem County is utilizing the data from its OFRT to pinpoint opportunities for enhanced public health. Since its formation in 2020, implemented recommendations from the county’s OFRT have contributed to the average 34 percent decrease in fatal overdoses from its 2019 peak. Stigma reduction has been identified as a recommendation from the team’s first case review and has been addressed through community education and outreach across all county municipalities, distribution of diverse overdose prevention supplies, increased linkages to care, and more! 

Turning the tide looks different in every state and county, with each community starting from a unique point. Hardin County, Kentucky, is navigating the waves of the current overdose crisis while embracing the transformations emerging from the overdose fatality review (OFR) team.  

The Hardin County OFR Team has played a vital role in fostering collaboration among community partners, allowing the team to identify and address critical gaps in response efforts. One example is the OFR teams review of the overdose deaths of two individuals needing medical clearance prior to incarceration. As a result of the review, OFR team members from the involved agencies have begun the process to improve communication and reevaluate procedures that were identified as contributing to these avoidable deaths.