Safer Solutions: Non-Fatal Opioid Overdoses

Current data shows that the rate of opioid overdose fatalities in the U.S. population has been decreasing since 2023. This is excellent news, but it doesn’t necessarily mean that fewer overdoses are occurring; it just means fewer people are dying from overdoses. Based on surveillance conducted by the Centers for Disease Control and data from the National Highway Traffic Safety Administration, non-fatal opioid overdoses are decreasing more slowly than fatal opioid overdoses, suggesting that the improved survivability of an opioid overdose is a large contributor to the decreasing rate of opioid overdose deaths.

Although non-fatal overdoses don’t get a lot of press coverage, they are more common than fatal ones. In fact, one study estimated that in 2020, there were four non-fatal opioid overdoses for every one fatal opioid overdose. Non-fatal opioid overdoses garner little attention even though they can have severe consequences. A drop in fatal opioid overdoses is worth celebrating; however, this is only part of the story. 

Two ways to decrease opioid overdose deaths

There are two ways to bring down the rate of opioid overdose deaths in the population: 

• Prevent overdoses from happening altogether.
  Helping people get into treatment can help them reduce or discontinue their drug use, thereby reducing overdoses and overdose deaths. Accessible drug checking equipment (e.g. fentanyl test strips) can lower the chances of an opioid overdose by helping people who use drugs do so more safely. 
• Improve the survivability of an opioid overdose.
  There are a number of strategies for this, including broad distribution of the opioid overdose-reversal medication naloxone and educating the public about responding to an overdose.

Sorting out how much each of these two scenarios contributes to the declining rates of opioid overdose deaths is complicated. There’s no way to directly count an overdose that never occurred, so it’s hard to know how averted opioid overdoses contribute to the decline in overdose deaths. Counting non-fatal overdoses is easier, but still not straightforward. If emergency medical services are called for a person who is overdosing and/or they are cared for at a hospital, there’s a record that allows public health authorities and researchers to identify the overdose as fatal or non-fatal. However, not every person who overdoses receives formal medical care, so counts of non-fatal overdoses are likely lower than the actual number that occur. 

Non-fatal opioid overdoses can still cause harm

Typically, an opioid overdose causes respiratory depression, characterized by slow and shallow breathing that can progress to full respiratory arrest. Decreased respiration stresses the body by depriving it of oxygen. If a person’s breathing becomes too depressed or stops completely, this can lead their heart to stop, often causing a fatal overdose.

Another outcome of respiratory depression is loss of consciousness, which occurs as the brain is deprived of oxygen. Brain injuries from oxygen deprivation can occur after as few as four minutes. People who survive an opioid overdose but acquire a brain injury may experience motor function challenges, mood disturbances, vision problems, and/or cognitive impairment. The risk of long-term brain injury increases with repeated non-fatal overdoses.

Brain injury is not the only potentially life-changing outcome of a non-fatal overdose. Other physical side effects can include pneumonia, seizures, and irregular heartbeat. Non-fatal overdose is also associated with a higher risk of experiencing a subsequent fatal overdose or death by suicide. 

Post-non-fatal opioid overdose interventions are needed

Many people receive medical care during or after a non-fatal opioid overdose, making it a prime opportunity to offer harm reduction and treatment resources. Non-fatal opioid overdoses are associated with an initial (yet unsustained) increase in treatment engagement. One study found that only 16.6 percent of people who experienced a non-fatal overdose received any treatment in the following 90 days. Another study found that only 6.2 percent of people who survived an opioid overdose filled naloxone prescriptions, while only 4.1 percent received medications for opioid use disorder (MOUD) in the 12 months after their overdose. This is unfortunate because both using MOUD (i.e., methadone, buprenorphine, extended release naltrexone) and filling a naloxone prescription are associated with decreased odds of subsequent fatal overdose.  

The reasons for the low uptake of treatment after a non-fatal opioid overdose range from the personal to the systemic. Not everyone who experiences an opioid overdose is ready to engage with treatment or views their drug use as a problem. A study of people in Baltimore, Maryland who inject drugs and who survived an overdose found that only a quarter sought treatment within 30 days after their overdose; 70 percent of those who did not seek treatment were not ready for treatment; and 30 percent did not view their drug use as a problem. Researchers in Houston, Texas attempted to offer treatment to people who experienced a non-fatal opioid overdose via a mobile outreach team, finding that two-thirds of people contacted chose not to engage with treatment—primarily because they weren’t ready. But even when treatment engagement is unlikely, providing people with take-home naloxone kits after an overdose and educating them about harm reduction strategies like not using alone can help prevent future overdoses among this population. There is also value in medical providers sharing information about treatment resources, even if a person isn’t ready to enter treatment.

People who are ready to enter treatment might encounter systemic barriers that prevent engagement. The United States does not have sufficient MOUD treatment capacity, and being placed on a waitlist is often cited as a reason for not enrolling in treatment. Two approaches can increase treatment enrollment by helping people navigate challenges. First, “warm hand-off” programs through emergency medical providers who facilitate the first contact with a treatment program rather than simply providing a referral are associated with higher enrollment. Second, emergency medical responders in some jurisdictions can initiate buprenorphine when interacting with a patient after an opioid overdose. They can either administer it on the spot or provide a prescription and a referral or warm hand-off to a provider who can continue their care. One assessment of an emergency department-initiated buprenorphine program in California found that 85.8 percent of patients diagnosed with opioid use disorder elected to receive buprenorphine in the emergency department. Patients who received buprenorphine were also almost twice as likely to be engaged in treatment after 30 days as those who did not receive buprenorphine. 

Non-fatal opioid overdoses are a public health challenge as well as an opportunity. While the long-term effects of non-fatal opioid overdoses can be severe, they often allow a touchpoint with the healthcare system that can facilitate treatment access and provide harm reduction resources—two strategies that often work hand in hand. Fewer deaths from opioid overdoses is cause for celebration, but this shouldn’t overshadow the need for attention and intervention following a non-fatal overdose.