A new front against fatal overdoses

As Monroe County grapples with an opioid crisis, an Overdose Fatality Review initiative is in its early stages of finding ways to solve the serious problem of fatal drug overdoses.

“This is not just a health problem, or a public safety problem, or a government problem—it is a community crisis, and it will take a comprehensive, sustained, systematic effort to address it,” said Monroe County Executive Adam Bello said in January when he announced the creation of the OFR. “The OFR is a step toward making this happen.”

The initiative, led by the county’s Research Strategy and Development division, will carefully examine the conditions that lead to fatal overdoses that occur or have occurred in the county. With the data it obtains, OFR will try to determine how local governmental agencies, nonprofits, substance use disorder treatment providers and other organizations can work together to prevent them. Funding for the program comes from a three-year, $1.6 million Justice Department grant.

So far, the OFR has appointed members to its governing board, which will guide its efforts. It is currently seeking individuals to join its case review team, which is responsible for researching fatalities and recommending measures to prevent them.

Deadly combinations

The OFR has its work cut out for it. According to a report from the Monroe County Office of the Medical Examiner, in 2023 alone 512 people suffered fatal overdoses attributed to opioid and/or cocaine use, almost 19 percent of the 2,746 overdoses that occurred that year. The number of fatal overdoses was up 26 percent from the year before and 48 percent compared with 2021. The number of drug-involved deaths that occurred in 2024 is not yet available.

This year, just one class of drugs, opioids, was involved in 248 overdoses by March 20, according to the county’s Opioid Overdose Dashboard. Of that total, 20 were fatal.

The medical examiner’s report lists 15 different substances that contributed to at least some of the 2023 fatalities, including alcohol, amphetamines, and the veterinary tranquilizer xylazine, but opioids or cocaine were present in all cases. Illicit fentanyl, a synthetic opioid, and slightly altered forms of the drug called fentanyl analogs were most frequently present, appearing in slightly more than 83 percent of the cases. Cocaine ranked second at nearly 65 percent. Prescription opioids such as oxycodone were present in just under 7 percent of the cases. The Black community was overrepresented; it makes up 16.5 percent of the county’s population but almost 40 percent of the drug-involved fatalities.

“Speedballing,” the simultaneous use of fentanyl analogs and cocaine, appears to have been particularly deadly due to their combined effects on users. Fentanyl, a depressant that can be smoked, injected, taken in pill form and consumed in other ways, is 50 times more potent than heroin. In addition to the euphoria and other effects that a user might want to experience, the drug causes respiratory depression, a condition in which the person breathes more slowly and shallowly.

Cocaine, a stimulant that’s typically swallowed, inhaled through the nose or injected, can make the user more energetic and alert while causing such conditions as vasoconstriction, a narrowing of the blood vessels that increases the need for oxygen. Put the two drugs together and the user becomes more prone to overdose. Of the fatalities that occurred in 2023, 335, or just over 65 percent, involved the combination. That’s a 32 percent increase compared with 2022.

Many of the fatalities might have resulted from drug dealers’ greed and their customers’ ignorance, experts observe. Dealers often mix their products with other drugs or substances to boost their bulk and profits. The heroin that was found in five of 2023’s fatal overdoses could have been cut with sugar or milk powder. Cocaine and other stimulants might be cut with small amounts of highly potent fentanyl and sold to users.

“What we will find is that the cocaine and the fentanyl are already mixed together in the same glassine bag,” says Frank Tarentino, New York special agent in charge with the Drug Enforcement Agency.

Buyers ignorant of the adulteration can be in danger.

“They think they’re buying cocaine, but they’re really buying cocaine mixed with fentanyl, and that’s what’s killing people often,” Tarentino says.

Drug users might also mix opioids and stimulants on their own, seeking to gain the effects of both. Opioid-stimulant combinations have grown more common and deadly across the country. A UCLA-led research team reported that the proportion of U.S. overdose deaths involving fentanyl and stimulants jumped from 0.6 percent in 2010 to 32.3 percent in 2021, 50-fold increase. Stimulants like cocaine and methamphetamine were the most common class of drugs found in fentanyl-involved overdoses in every U.S. state examined in the last year.

Tackling the problem

Monroe County officials believe the fatality review board is best positioned to tackle the problem here. Multiple agencies and nonprofits will work together when the OFR initiative is fully up and running.

“It is highly focused on two goals: enhanced, multidisciplinary collaboration and data sharing and innovative, community-specific overdose prevention,” says Rachel McGinnis, the assistant director of the RSD division and OFR coordinator.

The OFR, which is patterned after a national model, has already enlisted various local leaders to serve on its governing committee, which provides leadership, support and accountability for the program as it goes about its tasks.

“The diversity of the team assists in ensuring that we have members at the table who bring information, experiences and knowledge in relationship to substance use within our local community,” McGinnis says.

The 15-seat committee includes Bello, Rochester Mayor Malik Evans; Monroe County Sheriff Todd Baxter; University of Rochester Medical Center CEO David Linehan M.D.; Holly Sienkiewicz, director of research at Common Ground; and McGinnis. RSD research specialist Carlos Ortiz-Bonilla is the group’s lead researcher.

In addition to seating the governing committee, the OFR has invited people to join its case review team, which will have the job of determining the circumstances that led to fatal overdoses. McGinnis says the team’s 24 members will include a substance use disorder prevention specialist, a pharmacist or toxicologist, a social worker, representatives of local law enforcement agencies and community organizations, and a specially trained “next-of-kin interviewer” who will interview people who were close to the victims of fatal overdoses. Finally, the team will have places for people with lived experiences who have been directly affected by substance use or overdoses.

“That is important to have at the table, because we are not able to see things through that lens if we haven’t had those experiences ourselves,” McGinnis says.

Once the case review team is ready, it will prepare for its mission by forming necessary subcommittees, conducting mock case reviews and performing other tasks. The team will research fatal overdoses and meet once a month to review the cases and offer suggestions or recommendations as to what might be done to prevent the fatalities. With those in hand, the governing committee can provide some leadership and support needed to implement those suggestions and recommendations.

Oneida County’s first set of recommendations in 2022 by its Opioid Task Force suggests peer support services, including home visits, to help addicts cope and manage recovery. Recommendations also included increasing awareness of resources, stepped-up harm reduction efforts, a family loss program, and educational programs for families, and a coordinated and user-friendly centralized care system.

A report on Maryland’s local OFR teams’ recommendations shows that a focus on data quality and the case review process allowed these teams to use a person-centric approach to improve gaps in the system and support people at risk. These teams’ recommendations inform local and state policies and activities by identifying unmet needs and finding opportunities for new initiatives.

Some parts of Monroe County’s case review team’s job might be harder than others. Genesee and Orleans counties have experienced the same kinds of problems with drug overdoses as Monroe, though on a much smaller scale. Since 2019, Genesee has experienced 79 and Orleans 35 fatal overdoses. Half of the fatalities the two counties experienced in 2023 involved fentanyl, which was sometimes mixed with other drugs.

“We have seen an increase of accelerant recreational drugs like cocaine also being involved in some of the deaths in the last couple years,” says Paul Pettit, public health director for GO Health, a shared services arrangement between the two counties’ health departments.

The problem prompted GO Health to launch the Genesee County Fatality Review Board last May. The FRB functions much as Monroe County’s OFR, though it lacks a governing committee. Though the board’s next-of-kin interviewers are mental health therapists who are specially trained for the job, it has been tough to get the relatives and friends of those lost to open up.

“Some of them have responded back that it’s still too raw, it’s just something that they’re not wanting to participate in at this time,” Pettit says.

The FRB has reviewed four cases of fatal drug overdoses so far. Though the reviews haven’t led to changes in the way the county responds to overdoses, they have helped improve communications between local law enforcement officers and the county’s mental health department.

“Anytime we can improve our system and improve our response is a win for everybody, and may ultimately have a positive impact down the road,” Pettit says.

In addition to creating the OFR, Monroe County has taken more direct steps to try to decrease fatal drug overdoses, particularly those involving opioids. The Department of Public Health’s Project IMPACT (Improving Addiction Coordination Team) sends outreach workers into areas where overdoses are frequent to offer free Naloxone, a drug that quickly reverses overdoses, and try to connect those involved with drugs with options for substance use disorder treatment and other community resources.

IMPACT has installed about 601 Naloxone boxes around the county that dispense the drug free, and provides on-site training in its use and in harm-reduction techniques that can help save the lives of those who use drugs. The department also offers free fentanyl and xylazine test strips that can be used to detect the presence of the drugs.

Data on the success of OFRs is hard to come by. A 2022 study published in the Journal of Public Health Management and Practice examined the measurement of OFR practices. It found that while a data manager is a key component of the OFR model, the review groups studied (30 county-level overdose fatality review teams from six states) did not have such a role. According to the study’s authors, this role tracks and presents trends in overdose data at OFR meetings and manages the storage and analysis of case review information and recommendations. Additionally, these teams need training and practice in overdose prevention options. While having people with lived experiences is a step in the right direction, their impact on policy recommendations might be limited.

The study notes that “case review models are a sound public health strategy,” and over time OFRs could become as successful as the Fetal Infant Mortality Review. Protocols developed in the 1980s in response to a spike in infant mortality were the foundation for the “Back to Sleep” campaigns, which resulted in significant, multistate changes in infant sleep positions and, ultimately, in reductions in infant deaths. Hospital mortality review committees that identify gaps in care and develop strategies to reduce inpatient mortality are another example.

When it comes to long-term outcomes, the effectiveness of OFRs in Monroe County and elsewhere remains to be seen.

Mike Costanza is a Rochester Beacon contributing writer. Jacob Schermerhorn created the data visualizations for this article. 

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