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United Way of Lancaster County


County’s first overdose fatality review finds gaps, ‘missed opportunities’

Jodi O’Reilly, executive director of The Gate House, gives a presentation at a forum on the Lancaster County Overdose Fatality Review Team’s 2023 report at St. Joseph University on Thursday, Feb. 8, 2024. (Photo: Tim Stuhldreher)

“We’re trying to think about root causes,” Brenda Buescher told her audience of medical and social service professionals Thursday morning.

She was presenting the first annual report of the Lancaster County Overdose Fatality Review Team. Penn Medicine Lancaster General Health, which leads the team, hosted the forum at St. Joseph’s University, formerly the Pennsylvania College of Health Sciences.

Click to download PDF.

Joining Forces, the local coalition created to combat the opioid crisis, announced the plan for a fatality review team in 2022. Its task: To take a deep dive into the specifics of a select subset of overdose deaths, incorporating case reviews, interviews with family members, data from public records and more. The goal is to develop a thorough qualitative picture of the totality of circumstances leading to a death.

That provides context for quantitative statistics, Buescher said, and helps researchers understand the causes of substance abuse deaths and develop strategies for prevention.

In 2023, the team reviewed 10 overdose deaths of Lancaster County residents that took place here between May 2021 and December 2022. All 10 deaths were caused by fentanyl, either alone or in combination with another drug. (Overall, fentanyl was a factor in 90% of 2022 Lancaster County overdose deaths.)

Click to enlarge. (Source: Lancaster County Opioid Fatality Review)

The team tried to pick cases that reflected the overall demographics of local overdose deaths. Buescher said the findings “very much align” with what other local and national data indicate.

Among the findings:

  • 8 of the 10 had a documented history of mental health problems, and 4 had expressed suicidal thoughts or attemqted suicide. Only 2 had received treatment in the year prior to death.
  • All 10 had at least one arrest and 8 had been incarcerated at least once and 3 were on probation at time of death. The number of arrests ranged from 1 to 15.
  • 9 had received treatment for substance use disorder at some point. Only one had documentation of medication-assisted treatment.
  • For 6 individuals, the team obtained an estimated date of first drug use, which ranged from age 12 to early 20s. There were 8 with one or more periods of sobriety in adulthood, including 2 who were sober in the two weeks prior to death.

What are the takeaways? “We saw a lot of missed opportunities,” Buescher said.

None of the cases showed consistent treatment for health issues or mental health issues or medication-assisted treatment for substance use disorder. Recommendations for treatment would be made with little or no support or follow-up. Sometimes, people simply declined.

Dr. Jon Lepley

The report makes 29 policy recommendations. In a series of follow-ups to Buescher’s presentation, panelists expounded on three of the main themes: reducing stigma; improving coordination among care providers, law enforcement and employers; and expanding harm reduction initiatives.

Medication-assisted treatment saves lives, said Dr. Jon Lepley, LG Health director of addiction medicine, and the squeamishness of physicians, families and sometimes substance users themselves to take advantage of it is a public health tragedy.

People seek treatment where there’s the least amount of stigma, he went on. Clinics frequently have policies that create mistrust and keep people away, he said.

Some of those policies are mandated by law, such as observed urine testing at methadone sites.

This chart, presented by Dr. Jon Lepley, shows rates of medication-assisted treatment for substance abuse in Lancaster County and Pennsylvania (left) and their respective overdose death rates, right. Lancaster County’s ongoing implementation of MAT is yielding results, Lepley said. Click to enlarge.

Jodi O’Reilly, executive director of The Gate House, gave an overview of the many ways organizations fail to coordinate care with each other, exchange information or provide the ancillary services, such as transportation, needed for people to succeed in treatment.

“We need more of everything,” she said.

Exchanging information about cases is made difficult not only by institutional silos, but by the constraints imposed by laws on patient privacy and health information exchange, she and others said.

Melinda Zipp, director of outreach services for the Lancaster County Harm Reduction Project, and Becca Moyer, director of specialty programs for Blueprints for Addiction Recovery, called for expanding harm reduction services.

As the name implies, harm reduction involves providing supplies such as fentanyl test strips or syringes to drug users to reduce risk to life and health. Used appropriately, it benefits not only individual users but the community, Moyer said, by limiting the potential spread of disease and other spillover consequences of drug use. Mainly, it keeps people alive, Zipp said; “If you’re dead, you can’t recover.”

Thursday’s forum is part of a broad effort to share the review team’s findings with local stakeholders. The report will be provided to the Lancaster County commissioners and the state Department of Health and is available for download on the Joining Forces website.

The commissioners are in charge of allocating money from Lancaster County’s share of nationwide opioid settlement funds. To date, funding has gone toward initiatives such as the district attorney’s “Pathways to Recovery” diversion program, medication-assisted treatment at the County Prison. and drug take-back, education and prosecutor support of diversion courts through the Drug Task Force.

Many groups will be working to implement the recommendations, the report says. It also calls on policymakers and funding organizations to consider providing support as well as revisiting and updating laws and regulations.

State law should align with federal law and recommendations, Lepley said, urging the audience to advocate for change.