Risk Factors for Opioid Overdose


Purpose of Review

Opioid overdoses have risen starkly over the last two decades in the USA and are now among the leading causes of overall mortality. This review summarizes the current literature on risk factors for overdose as well as public health solutions.

Recent Findings

Although opioid overdose mortality is highest among men and non-Hispanic whites, the rate of death is rising more rapidly now among women and non-Hispanic blacks. Incarceration remains a significant risk factor for overdose death, especially in the first weeks upon reentry reflecting the absence of treatment in prisons and jails despite strong evidence for the benefits of pharmacotherapy integration into these settings. Pharmacotherapy with either methadone or buprenorphine greatly reduces the risk of overdose; however, treatment discontinuation leads to an increase risk of death.


Naloxone distribution both through co-prescribing and community-based opioid overdose prevention programs remains the fundament of the public health response. Both are effective and cost-effective in reducing overdose; however, uptake is hampered due to variance in state naloxone access and Good Samaritan laws. Supervised injection facilities are a promising innovation to address overdose, especially in communities with high overdose rates.

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References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.

    O’Donnell JK, Gladden RM, Seth P. Trends in deaths involving heroin and synthetic opioids excluding methadone, and law enforcement drug product reports, by census region—United States, 2006–2015. MMWR Morb Mortal Wkly Rep. 2017;66(34):897–903.

    Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Seth P, Scholl L, Rudd RA, Bacon S. Overdose deaths involving opioids, cocaine, and psychostimulants—United States, 2015–2016. MMWR Morb Mortal Wkly Rep. 2018;67(12):349–58.

    Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    HIV surveillance—United States, 1981-2008. MMWR Morb Mortal Wkly Rep. 2011;60(21):689–93.

  4. 4.

    Vietnam War U.S. military fatal casualty statistics. [cited 2018 June 2]; Available from: https://www.archives.gov/research/military/vietnam-war/casualty-statistics#date.

  5. 5.

    •• Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci U S A. 2015;112(49):15078–83. Demonstrated how the opioid crisis has shifted mortality for middle-aged non-Hispanic whites in the USA, primarily due to overdose.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  6. 6.

    Case A, Deaton A. Mortality and morbidity in the 21st century. Brook Pap Econ Act. 2017;2017:397–476.

    Article  Google Scholar 

  7. 7.

    Slavova S, O’Brien DB, Creppage K, Dao D, Fondario A, Haile E, et al. Drug overdose deaths: let’s get specific. Public Health Rep. 2015;130(4):339–42.

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Ruhm CJ. Geographic variation in opioid and heroin involved drug poisoning mortality rates. Am J Prev Med. 2017;53(6):745–53.

    Article  PubMed  Google Scholar 

  9. 9.

    Horon IL, Singal P, Fowler DR, Sharfstein JM. Standard death certificates versus enhanced surveillance to identify heroin overdose-related deaths. Am J Public Health. 2018;108(6):777–81.

    Article  PubMed  Google Scholar 

  10. 10.

    • Brady JE, et al. Risk markers for fatal and non-fatal prescription drug overdose: a meta-analysis. Inj Epidemiol. 2017;4(1):24. A systematic review of 29 studies which identified substance use disorder, psychiatric disorders, white race, age and male sex as risk factors for overdose.

  11. 11.

    Schiavon S, Hodgin K, Sellers A, Word M, Galbraith JW, Dantzler J, et al. Medical, psychosocial, and treatment predictors of opioid overdose among high risk opioid users. Addict Behav. 2018. https://doi.org/10.1016/j.addbeh.2018.05.029.

  12. 12.

    Mitra G, Wood E, Nguyen P, Kerr T, DeBeck K. Drug use patterns predict risk of non-fatal overdose among street-involved youth in a Canadian setting. Drug Alcohol Depend. 2015;153:135–9.

    Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Lake S, Hayashi K, Buxton J, Milloy MJ, Dong H, Wood E, et al. The effect of prescription opioid injection on the risk of non-fatal overdose among people who inject drugs. Drug Alcohol Depend. 2015;156:297–303.

    Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Shah NG, Lathrop SL, Reichard RR, Landen MG. Unintentional drug overdose death trends in New Mexico, USA, 1990–2005: combinations of heroin, cocaine, prescription opioids and alcohol. Addiction. 2008;103(1):126–36.

    Article  PubMed  Google Scholar 

  15. 15.

    Coffin PO, Galea S, Ahern J, Leon AC, Vlahov D, Tardiff K. Opiates, cocaine and alcohol combinations in accidental drug overdose deaths in New York City, 1990–98. Addiction. 2003;98(6):739–47.

    Article  PubMed  Google Scholar 

  16. 16.

    Bohnert ASB, Walton MA, Cunningham RM, Ilgen MA, Barry K, Chermack ST, et al. Overdose and adverse drug event experiences among adult patients in the emergency department. Addict Behav. 2017. https://doi.org/10.1016/j.addbeh.2017.11.030.

  17. 17.

    Walton GR, et al. The impact of benzodiazepine use on mortality among polysubstance users in Vancouver, Canada. Public Health Rep. 2016;131(3):491–9.

    Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Bohnert AS, Valenstein M, Bair MJ, Ganoczy D, McCarthy J, Ilgen MA, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. Jama. 2011;305(13):1315–21.

    Article  PubMed  CAS  Google Scholar 

  19. 19.

    Caudarella A, Dong H, Milloy MJ, Kerr T, Wood E, Hayashi K. Non-fatal overdose as a risk factor for subsequent fatal overdose among people who inject drugs. Drug Alcohol Depend. 2016;162:51–5.

    Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Stoove MA, Dietze PM, Jolley D. Overdose deaths following previous non-fatal heroin overdose: record linkage of ambulance attendance and death registry data. Drug Alcohol Rev. 2009;28(4):347–52.

    Article  PubMed  Google Scholar 

  21. 21.

    Frenk SM, Porter KS, Paulozzi LJ. Prescription opioid analgesic use among adults: United States, 1999–2012. NCHS Data Brief. 2015;(189):1–8. https://www.cdc.gov/nchs/data/databriefs/db189.pdf.

  22. 22.

    • Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in drug and opioid overdose deaths—United States, 2000–2014. MMWR Morb Mortal Wkly Rep. 2016;64(50–51):1378–82. CDC report highlighting the sharp increase in fentanyl and other synthetic opioids in overdose deaths.

  23. 23.

    Liang Y, Goros MW, Turner BJ. Drug overdose: differing risk models for women and men among opioid users with non-cancer pain. Pain Med. 2016;17(12):2268–79.

    Article  PubMed  Google Scholar 

  24. 24.

    •• Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. Jama. 2016;315(15):1624–45. Opioid prescribing guidelines which include summary evidence of the lack of benefit of chronic opioid therapy for chronic pain.

    Article  PubMed  CAS  Google Scholar 

  25. 25.

    U.S. Food and Drug Administration. FDA Drug Safety Communication: FDA approves new label changes and dosing for zolpidem products and a recommendation to avoid driving the day after using Ambien CR. 2017 December 11; Available from: https://www.fda.gov/drugs/drugsafety/ucm352085.htm.

  26. 26.

    Huang X, Keyes KM, Li G. Increasing prescription opioid and heroin overdose mortality in the United States, 1999–2014: an age-period-cohort analysis. Am J Public Health. 2018;108(1):131–6.

    Article  PubMed  Google Scholar 

  27. 27.

    Pletcher MJ, Kertesz SG, Kohn MA, Gonzales R. Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. Jama. 2008;299(1):70–8.

    Article  PubMed  CAS  Google Scholar 

  28. 28.

    Singhal A, Tien YY, Hsia RY. Racial-ethnic disparities in opioid prescriptions at emergency department visits for conditions commonly associated with prescription drug abuse. PLoS One. 2016;11(8):e0159224.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  29. 29.

    Joynt M, Train MK, Robbins BW, Halterman JS, Caiola E, Fortuna RJ. The impact of neighborhood socioeconomic status and race on the prescribing of opioids in emergency departments throughout the United States. J Gen Intern Med. 2013;28(12):1604–10.

    Article  PubMed  PubMed Central  Google Scholar 

  30. 30.

    Groenewald CB, Rabbitts JA, Hansen E, Palermo TM. Racial differences in opioid prescribing for children in the United States. Pain. 2018:1. https://doi.org/10.1097/j.pain.0000000000001290.

  31. 31.

    Shiels MS, Freedman ND, Thomas D, Berrington de Gonzalez A. Trends in U.S. drug overdose deaths in non-Hispanic Black, Hispanic, and non-Hispanic White persons, 2000–2015. Ann Intern Med. 2018;168(6):453–5.

    Article  PubMed  Google Scholar 

  32. 32.

    Hsu DJ, McCarthy EP, Stevens JP, Mukamal KJ. Hospitalizations, costs and outcomes associated with heroin and prescription opioid overdoses in the United States 2001–12. Addiction. 2017;112(9):1558–64.

    Article  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Golembeski C, Fullilove R. Criminal (in)justice in the city and its associated health consequences. Am J Public Health. 2005;95(10):1701–6.

    Article  PubMed  PubMed Central  Google Scholar 

  34. 34.

    Nellis A. The color of justice: racial and ethnic disparity in state prisons. 2016; Available from: http://www.sentencingproject.org/wp-content/uploads/2016/06/The-Color-of-Justice-Racial-and-Ethnic-Disparity-in-State-Prisons.pdf.

  35. 35.

    Ojmarrh M. A meta-analysis of race and sentencing research: explaining the inconsistencies. J Quant Criminol. 2005;21(4):439–66.

    Article  Google Scholar 

  36. 36.

    Csete J, Kamarulzaman A, Kazatchkine M, Altice F, Balicki M, Buxton J, et al. Public health and international drug policy. Lancet. 2016;387(10026):1427–80.

    Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    MacDonald J, Arkes J, Nicosia N, Pacula RL. Decomposing racial disparities in prison and drug treatment commitments for criminal offenders in California. J Leg Stud. 2014;43(1):155–87.

    Article  Google Scholar 

  38. 38.

    Kanato M. Drug use and health among prison inmates. Curr Opin Psychiatry. 2008;21(3):252–4.

    Article  PubMed  Google Scholar 

  39. 39.

    • Fazel S, Bains P, Doll H. Substance abuse and dependence in prisoners: a systematic review. Addiction. 2006;101(2):181–91. Systematic review of 14 studies detailing high rate of addiction among prisoners, specifically among female prisoners.

  40. 40.

    Rounds-Bryant JL, Baker L Jr. Substance dependence and level of treatment need among recently-incarcerated prisoners. Am J Drug Alcohol Abuse. 2007;33(4):557–61.

    Article  PubMed  Google Scholar 

  41. 41.

    Belenko S, Hiller M, Hamilton L. Treating substance use disorders in the criminal justice system. Curr Psychiatry Rep. 2013;15(11):414.

    Article  PubMed  Google Scholar 

  42. 42.

    Fiscella K, Pless N, Meldrum S, Fiscella P. Alcohol and opiate withdrawal in US jails. Am J Public Health. 2004;94(9):1522–4.

    Article  PubMed  PubMed Central  Google Scholar 

  43. 43.

    • Nunn A, et al. Methadone and buprenorphine prescribing and referral practices in US prison systems: results from a nationwide survey. Drug Alcohol Depend. 2009;105(1–2):83–8. Survey of pharmacotherapy in prisons revealed that many systems do not offer medication or treatment referrals upon release.

  44. 44.

    • Hedrich D, et al. The effectiveness of opioid maintenance treatment in prison settings: a systematic review. Addiction. 2012;107(3):501–17. Systematic review of 21 studies detailing benefits of pharmacotherapy in prisons including, decrease in risky behaviors while incarcerated and possible decrease in overdose death upon release.

  45. 45.

    Stallwitz A, Stover H. The impact of substitution treatment in prisons—a literature review. Int J Drug Policy. 2007;18(6):464–74.

    Article  PubMed  Google Scholar 

  46. 46.

    Leach D, Oliver P. Drug-related death following release from prison: a brief review of the literature with recommendations for practice. Curr Drug Abuse Rev. 2011;4(4):292–7.

    Article  PubMed  CAS  Google Scholar 

  47. 47.

    Binswanger IA, Blatchford PJ, Mueller SR, Stern MF. Mortality after prison release: opioid overdose and other causes of death, risk factors, and time trends from 1999 to 2009. Ann Intern Med. 2013;159(9):592–600.

    Article  PubMed  PubMed Central  Google Scholar 

  48. 48.

    Binswanger IA, Stern MF, Deyo RA, Heagerty PJ, Cheadle A, Elmore JG, et al. Release from prison—a high risk of death for former inmates. N Engl J Med. 2007;356(2):157–65.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  49. 49.

    Krinsky CS, Lathrop SL, Brown P, Nolte KB. Drugs, detention, and death: a study of the mortality of recently released prisoners. Am J Forensic Med Pathol. 2009;30(1):6–9.

    Article  PubMed  Google Scholar 

  50. 50.

    Kouyoumdjian FG, Kiefer L, Wobeser W, Gonzalez A, Hwang SW. Mortality over 12 years of follow-up in people admitted to provincial custody in Ontario: a retrospective cohort study. CMAJ Open. 2016;4(2):E153–61.

    Article  PubMed  PubMed Central  Google Scholar 

  51. 51.

    • Merrall EL, et al. Meta-analysis of drug-related deaths soon after release from prison. Addiction. 2010;105(9):1545–54. Meta-analysis of 6 studies demonstrating increased risk of overdose death in first month following release.

  52. 52.

    Forsyth SJ, Carroll M, Lennox N, Kinner SA. Incidence and risk factors for mortality after release from prison in Australia: a prospective cohort study. Addiction. 2018;113(5):937–45.

    Article  PubMed  Google Scholar 

  53. 53.

    Bird SM, Hutchinson SJ. Male drugs-related deaths in the fortnight after release from prison: Scotland, 1996–99. Addiction. 2003;98(2):185–90.

    Article  PubMed  Google Scholar 

  54. 54.

    Farrell M, Marsden J. Acute risk of drug-related death among newly released prisoners in England and Wales. Addiction. 2008;103(2):251–5.

    Article  PubMed  Google Scholar 

  55. 55.

    Bukten A, Stavseth MR, Skurtveit S, Tverdal A, Strang J, Clausen T. High risk of overdose death following release from prison: variations in mortality during a 15-year observation period. Addiction. 2017;112(8):1432–9.

    Article  PubMed  Google Scholar 

  56. 56.

    Binswanger IA, Nowels C, Corsi KF, Glanz J, Long J, Booth RE, et al. Return to drug use and overdose after release from prison: a qualitative study of risk and protective factors. Addict Sci Clin Pract. 2012;7:3.

    Article  PubMed  PubMed Central  Google Scholar 

  57. 57.

    Farahmand P, Modesto-Lowe V, Chaplin MM. Prescribing opioid replacement therapy in U.S. correctional settings. J Am Acad Psychiatry Law. 2017;45(4):472–7.

    PubMed  Google Scholar 

  58. 58.

    Wakeman SE. Why it’s inappropriate not to treat incarcerated patients with opioid agonist therapy. AMA J Ethics. 2017;19(9):922–30.

    Article  PubMed  Google Scholar 

  59. 59.

    Fox AD, Maradiaga J, Weiss L, Sanchez J, Starrels JL, Cunningham CO. Release from incarceration, relapse to opioid use and the potential for buprenorphine maintenance treatment: a qualitative study of the perceptions of former inmates with opioid use disorder. Addict Sci Clin Pract. 2015;10:2.

    Article  PubMed  PubMed Central  Google Scholar 

  60. 60.

    Rich JD, McKenzie M, Larney S, Wong JB, Tran L, Clarke J, et al. Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: a randomised, open-label trial. Lancet. 2015;386(9991):350–9.

    Article  PubMed  PubMed Central  Google Scholar 

  61. 61.

    Degenhardt L, Larney S, Kimber J, Gisev N, Farrell M, Dobbins T, et al. The impact of opioid substitution therapy on mortality post-release from prison: retrospective data linkage study. Addiction. 2014;109(8):1306–17.

    Article  PubMed  Google Scholar 

  62. 62.

    Marsden J, Stillwell G, Jones H, Cooper A, Eastwood B, Farrell M, et al. Does exposure to opioid substitution treatment in prison reduce the risk of death after release? A national prospective observational study in England. Addiction. 2017;112(8):1408–18.

    Article  PubMed  Google Scholar 

  63. 63.

    •• Sordo L, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. Bmj. 2017;357:j1550. Meta-analysis quantifying the benefit of pharmacotherapy for the prevention of overdose among individuals with opioid use disorder.

    Article  PubMed  PubMed Central  Google Scholar 

  64. 64.

    Degenhardt L, Randall D, Hall W, Law M, Butler T, Burns L. Mortality among clients of a state-wide opioid pharmacotherapy program over 20 years: risk factors and lives saved. Drug Alcohol Depend. 2009;105(1–2):9–15.

    Article  PubMed  Google Scholar 

  65. 65.

    Bell JR, Butler B, Lawrance A, Batey R, Salmelainen P. Comparing overdose mortality associated with methadone and buprenorphine treatment. Drug Alcohol Depend. 2009;104(1–2):73–7.

    Article  PubMed  CAS  Google Scholar 

  66. 66.

    Clausen T, Anchersen K, Waal H. Mortality prior to, during and after opioid maintenance treatment (OMT): a national prospective cross-registry study. Drug Alcohol Depend. 2008;94(1–3):151–7.

    Article  PubMed  Google Scholar 

  67. 67.

    Clausen T, Waal H, Thoresen M, Gossop M. Mortality among opiate users: opioid maintenance therapy, age and causes of death. Addiction. 2009;104(8):1356–62.

    Article  PubMed  Google Scholar 

  68. 68.

    Gibson A, Degenhardt L, Mattick RP, Ali R, White J, O’Brien S. Exposure to opioid maintenance treatment reduces long-term mortality. Addiction. 2008;103(3):462–8.

    Article  PubMed  Google Scholar 

  69. 69.

    • Mattick RP, et al. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;(2):Cd002207. https://doi.org/10.1002/14651858.CD002207.Cochrane review demonstrating equivalence of both buprenorphine and methadone in suppressing illicit opioid use; methadone is superior in treatment retention.

  70. 70.

    Bentzley BS, Barth KS, Back SE, Book SW. Discontinuation of buprenorphine maintenance therapy: perspectives and outcomes. J Subst Abus Treat. 2015;52:48–57.

    Article  Google Scholar 

  71. 71.

    Bogdanowicz KM, Stewart R, Chang CK, Shetty H, Khondoker M, Day E, et al. Excess overdose mortality immediately following transfer of patients and their care as well as after cessation of opioid substitution therapy. Addiction. 2018;113(5):946–51.

    Article  PubMed  Google Scholar 

  72. 72.

    Miller M, Barber CW, Leatherman S, Fonda J, Hermos JA, Cho K, et al. Prescription opioid duration of action and the risk of unintentional overdose among patients receiving opioid therapy. JAMA Intern Med. 2015;175(4):608–15.

    Article  PubMed  Google Scholar 

  73. 73.

    Manchikanti L, Kaye AM, Knezevic NN, McAnally H, Slavin K, Trescot AM, et al. Responsible, safe, and effective prescription of opioids for chronic non-cancer pain: American Society of Interventional Pain Physicians (ASIPP) guidelines. Pain Physician. 2017;20(2s):S3–s92.

    PubMed  Google Scholar 

  74. 74.

    Behar E, Rowe C, Santos GM, Coffa D, Turner C, Santos NC, et al. Acceptability of naloxone co-prescription among primary care providers treating patients on long-term opioid therapy for pain. J Gen Intern Med. 2017;32(3):291–5.

    Article  PubMed  Google Scholar 

  75. 75.

    Takeda MY, Katzman JG, Dole E, Bennett MH, Alchbli A, Duhigg D, et al. Co-prescription of naloxone as a universal precautions model for patients on chronic opioid therapy—observational study. Subst Abus. 2016;37(4):591–6.

    Article  PubMed  Google Scholar 

  76. 76.

    Mueller SR, Koester S, Glanz JM, Gardner EM, Binswanger IA. Attitudes toward naloxone prescribing in clinical settings: a qualitative study of patients prescribed high dose opioids for chronic non-cancer pain. J Gen Intern Med. 2017;32(3):277–83.

    Article  PubMed  Google Scholar 

  77. 77.

    Boyer EW. Management of opioid analgesic overdose. N Engl J Med. 2012;367(2):146–55.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  78. 78.

    Alcorn T. America embraces treatment for opioid drug overdose. Lancet. 2014;383(9933):1957–8.

    Article  PubMed  Google Scholar 

  79. 79.

    Clark AK, Wilder CM, Winstanley EL. A systematic review of community opioid overdose prevention and naloxone distribution programs. J Addict Med. 2014;8(3):153–63.

    Article  PubMed  CAS  Google Scholar 

  80. 80.

    Mueller SR, Walley AY, Calcaterra SL, Glanz JM, Binswanger IA. A review of opioid overdose prevention and naloxone prescribing: implications for translating community programming into clinical practice. Subst Abus. 2015;36(2):240–53.

    Article  PubMed  PubMed Central  Google Scholar 

  81. 81.

    Langham S, Wright A, Kenworthy J, Grieve R, Dunlop WCN. Cost-effectiveness of take-home naloxone for the prevention of overdose fatalities among heroin users in the United Kingdom. Value Health. 2018;21(4):407–15.

    Article  PubMed  Google Scholar 

  82. 82.

    Coffin PO, Sullivan SD. Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. Ann Intern Med. 2013;158(1):1–9.

    Article  PubMed  Google Scholar 

  83. 83.

    Lambdin BH, Davis CS, Wheeler E, Tueller S, Kral AH. Naloxone laws facilitate the establishment of overdose education and naloxone distribution programs in the United States. Drug Alcohol Depend. 2018;188:370–6.

    Article  PubMed  Google Scholar 

  84. 84.

    McClellan C, Lambdin BH, Ali MM, Mutter R, Davis CS, Wheeler E, et al. Opioid-overdose laws association with opioid use and overdose mortality. Addict Behav. 2018. https://doi.org/10.1016/j.addbeh.2018.03.014

  85. 85.

    Winograd RP, Davis CS, Niculete M, Oliva E, Martielli RP. Medical providers’ knowledge and concerns about opioid overdose education and take-home naloxone rescue kits within Veterans Affairs health care medical treatment settings. Subst Abus. 2017;38(2):135–40.

    Article  PubMed  Google Scholar 

  86. 86.

    Pauly JB, Vartan CM, Brooks AT. Implementation and evaluation of an opioid overdose education and naloxone distribution (OEND) program at a Veterans Affairs Medical Center. Subst Abus. 2018:1–17. https://doi.org/10.1080/08897077.2018.1449174.

  87. 87.

    Bixler D, Corby-Lee G, Proescholdbell S, Ramirez T, Kilkenny ME, LaRocco M, et al. Access to Syringe Services Programs—Kentucky, North Carolina, and West Virginia, 2013–2017. MMWR Morb Mortal Wkly Rep. 2018;67(18):529–32.

    Article  PubMed  PubMed Central  Google Scholar 

  88. 88.

    McGowan CR, Harris M, Platt L, Hope V, Rhodes T. Fentanyl self-testing outside supervised injection settings to prevent opioid overdose: do we know enough to promote it? Int J Drug Policy. 2018;58:31–6.

    Article  PubMed  Google Scholar 

  89. 89.

    Kerr T, Mitra S, Kennedy MC, McNeil R. Supervised injection facilities in Canada: past, present, and future. Harm Reduct J. 2017;14(1):28.

    Article  PubMed  PubMed Central  Google Scholar 

  90. 90.

    Gaeta JM, Racine M. New strategies are needed to stop overdose fatalities: the case for supervised injection facilities. Ann Intern Med. 2018. https://doi.org/10.7326/M18-0258.

  91. 91.

    •• Marshall BD, et al. Reduction in overdose mortality after the opening of North America’s first medically supervised safer injecting facility: a retrospective population-based study. Lancet. 2011;377(9775):1429–37. Demonstrates local reduction in overdose death following the establishment of a supervised injection facility.

    Article  PubMed  Google Scholar 

  92. 92.

    Davidson PJ, Lopez AM, Kral AH. Using drugs in un/safe spaces: impact of perceived illegality on an underground supervised injecting facility in the United States. Int J Drug Policy. 2018;53:37–44.

    Article  PubMed  Google Scholar 

  93. 93.

    Harris RE, Richardson J, Frasso R, Anderson ED. Perceptions about supervised injection facilities among people who inject drugs in Philadelphia. Int J Drug Policy. 2018;52:56–61.

    Article  PubMed  Google Scholar 

  94. 94.

    Bradford AC, Bradford WD. Medical marijuana laws may be associated with a decline in the number of prescriptions for Medicaid enrollees. Health Aff (Millwood). 2017;36(5):945–51.

    Article  Google Scholar 

  95. 95.

    Bradford AC, Bradford WD. Medical marijuana laws reduce prescription medication use in Medicare part D. Health Aff (Millwood). 2016;35(7):1230–6.

    Article  Google Scholar 

  96. 96.

    Nielsen S, Sabioni P, Trigo JM, Ware MA, Betz-Stablein BD, Murnion B, et al. Opioid-sparing effect of cannabinoids: a systematic review and meta-analysis. Neuropsychopharmacology. 2017;42(9):1752–65.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  97. 97.

    Bachhuber MA, Saloner B, Cunningham CO, Barry CL. Medical cannabis laws and opioid analgesic overdose mortality in the United States, 1999–2010. JAMA Intern Med. 2014;174(10):1668–73.

    Article  PubMed  PubMed Central  Google Scholar 

  98. 98.

    Powell D, Pacula RL, Jacobson M. Do medical marijuana laws reduce addictions and deaths related to pain killers? J Health Econ. 2018;58:29–42.

    Article  PubMed  Google Scholar 

  99. 99.

    Phillips E, Gazmararian J. Implications of prescription drug monitoring and medical cannabis legislation on opioid overdose mortality. J Opioid Manag. 2017;13(4):229–39.

    Article  PubMed  Google Scholar 

  100. 100.

    Darke S, Farrell M. Would legalizing illicit opioids reduce overdose fatalities? Implications from a natural experiment. Addiction. 2014;109(8):1237–42.

    Article  PubMed  Google Scholar 

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Correspondence to Mishka Terplan MD MPH.

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Thokozeni Lipato declares that he has no conflict of interest. Mishka Terplan declares that he has no conflict of interest.

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This article is part of the Topical Collection on Substance Use Disorders

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Lipato, T., Terplan, M. Risk Factors for Opioid Overdose. Curr Treat Options Psych 5, 323–333 (2018). https://doi.org/10.1007/s40501-018-0153-1

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  • Opioids
  • Overdose
  • Mortality
  • Risk factors