Intended and Unintended Outcomes of Building Comprehensive Multidisciplinary Overdose Fatality Review Teams

The Michigan Public Health Institute (MPHI) began establishing overdose fatality review (OFR) teams in Michigan in 2021. Following case reviews, MPHI sought feedback, surveyed teams, and followed up on information gaps. This resulted in several community-based, often team member-led presentations that have provided unexpected learning opportunities. The review of the case of a veteran who died because of an overdose left team members with unanswered questions, especially regarding the services and resources available to this particular population. As a result, a review team member connected MPHI with a representative from the Michigan Veterans Affairs Agency, who presented to the team about these issues and ended up joining the team. Michigan’s Children’s Protective Services representatives presented information to teams regarding what happens when children experience the loss of their parents due to overdose. In addition, the largest harm reduction agency in the region provided training on Narcan access and administration, as well as the services that the agency provides. Finally, MPHI asked emergency medical services (EMS) to share its criteria for naloxone administration, post-overdose substance use disorder treatment resources provided by EMS and any changes MPHI should recommend where those resources do not exist, treatment for non-opioid overdoses, and whether the need for naloxone reversal is increasing from previous years. MPHI has invited additional groups to educate its teams regarding information from their respective disciplines in order to enhance team capacity and efficacy. Increasing teams’ awareness of the various resources available in their communities is crucial to ensuring a robust review process that produces better-informed recommendations to prevent overdoses in Michigan communities.