From Q4 2020 through mid-2023, rates of fentanyl-involved nonfatal overdose ED visits increased. Rates subsequently declined through Q1 2024; the declines were observed overall and across a majority of demographic groups. These findings are consistent with recent mortality data, which indicate that overdose deaths with illegally manufactured fentanyl and fentanyl analogs detected peaked in mid-2023 and started to decline thereafter (2). The overall declines in both nonfatal and fatal overdoses involving fentanyl are encouraging; however, more time is needed to determine whether these observed decreases will be sustained and to identify factors responsible for the observed declines.

EDs are critical locations for implementing strategies that might prevent future or repeat fentanyl-involved overdoses among patients with substance use disorder, with a history of drug use, or who experienced a recent nonfatal overdose, particularly among those persons for whom an ED is the primary contact with the health care system. EDs can introduce overdose prevention strategies, initiate treatment, and link persons who have opioid use disorder to care. Initiating buprenorphine and other medications for opioid use disorder in EDs can offer a pathway to recovery by quickly stabilizing withdrawal symptoms and connecting patients to ongoing treatment.^†† Other ED-based response strategies include providing naloxone to persons who recently experienced an overdose or to their families; naloxone reverses opioid overdose and can be used at home (5). Some recent data suggest that patient refusals of transport to an ED via emergency medical service (EMS) are increasing (6); training first responders (e.g., EMS personnel) and equipping them with naloxone and methods to link persons who experience overdoses to health care resources might also be important. Administration of naloxone can mean the difference between a nonfatal and fatal fentanyl-involved overdose. This dataset does not include information about the proportion of fentanyl-involved nonfatal overdose ED visits for which naloxone was administered or what proportion of visits were by persons who experienced a previous overdose. However, recent mortality data from 38 U.S. jurisdictions demonstrate that approximately two thirds (65.9%) of fatal overdoses (from any drug) in 2023 had at least one opportunity for intervention, such as having a potential bystander present (42.6%), a mental health diagnosis (28.7%), or a previous overdose (13.5%), whereas fewer than one quarter (23.7%) of fatal overdoses had documentation that naloxone was administered.^§§

These findings highlight an urgent need to expand interventions, including naloxone distribution and training, as well as linkage to treatment services, which have the potential to not only reduce the likelihood of fatal overdoses but also to help prevent recurrent overdoses among those who survive. In addition, screening, treating, or referring patients for co-occurring mental health conditions can be done in an ED or any other setting, aligning with the Substance Abuse and Mental Health Services Administration’s “No Wrong Door” policy for treatment access, which states that effective systems must ensure that persons needing treatment will be identified, evaluated, and receive treatment, either directly or through appropriate referral, no matter where they seek services.^¶¶ ED-based recovery support programs can include peer recovery specialists who share similar lived experience, such as treatment for addiction, to help facilitate linkage to care and recovery support services.***

This study found that the highest rates of fentanyl-involved nonfatal overdose ED visits were among younger adults aged 25–34 years, males, and AI/AN persons. Although information on fentanyl-involved nonfatal overdoses by demographic categories is limited, other drug overdose data such as EMS or mortality data can provide useful context. In a recent analysis using EMS encounter data, the highest rates of opioid-involved nonfatal EMS encounters were among males and adults aged 25–34 years (6). Moreover, in 2021 and 2022, the highest age-adjusted rates of all drug overdose mortality were among males (45.1 and 45.6 per 100,000 population, respectively) and AI/AN persons (56.6 and 65.2, respectively) (1). In the current study, the sharpest increase in rates of fentanyl-involved nonfatal overdoses was among AI/AN persons, similar to recent trends among all drug overdose deaths from 2021 to 2022, which increased 15.0% among this group (1). AI/AN communities are at increased risk for substance use related injury and harm (7). Tailored prevention measures might help reduce exposure to substance use.

Limitations

The findings in this report are subject to at least six limitations. First, fentanyl-involved nonfatal overdoses might be underreported or misclassified because of hospital drug testing practices (8); however, some jurisdictions recently mandated testing for fentanyl as part of ED urine toxicology screens, which might improve ascertainment.^††† Second, the syndrome definition used in this study cannot distinguish between illegally manufactured fentanyl (or fentanyl analogs) and prescription fentanyl; however, a majority of fentanyl-involved overdose deaths are caused by illegally manufactured fentanyl (2). Third, ED data quality and completeness, including demographic data, vary by facility. Fourth, this dataset only captures nonfatal overdoses treated in EDs and might not represent persons who overdose in community settings and are not transported to an ED. Fifth, there could be a small number of fatal overdoses in this study; approximately 1% of fentanyl-involved overdose ED visits in this study were marked as ending in death. Finally, rates of fentanyl-involved nonfatal overdoses among AI/AN persons could be underestimated because of racial misclassification of AI/AN persons (9); further, data from a majority of tribal-specific health facilities are not included in NSSP.

Implications for Public Health Practice

ED interventions to increase access to and availability of naloxone and to expand linkage to and retention in evidence-based care, including medications for opioid use disorder, are important. Focusing activities in communities with high or rising rates of fentanyl overdose, such as AI/AN communities, might help decrease both nonfatal and fatal overdoses. Ongoing monitoring of trends in fentanyl-involved nonfatal overdoses by state and local jurisdictions can identify areas in need of evidence-based prevention, treatment, and recovery support services.