Video Transcript: Understanding the Opioid Crisis Case-by-Case: Overdose Fatality Reviews in Wisconsin

Mallory O’Brien, Assistant Professor, Medical College of Wisconsin, discusses the Wisconsin’s Overdose Fatality Review process, a joint effort of the State Departments of Justice and Public Health, that brings together all of the stakeholders to share specific case information to understand the overdose, the events leading up to it, and what opportunities the can uncover for actions that can be taken to address the overall crisis.

Dr. O’Brien participated in the panel “Opioids and the Law Enforcement Response: Partnerships for Public Safety and Improved Outcomes,” presented by the National Institute of Justice at the 2018 International Association of Chiefs of Police annual conference. This video was filmed following the panel.


MALLORY O’BRIEN: So, in Wisconsin, the Attorney General decided that it was very important for us to consider overdoses in a new way and develop an overdose fatality review process. 

So, in partnership with our State Department of Justice and our State Department of Public Health, we are engaging in overdose fatality reviews.  You’re bringing all of your stakeholders to the table to start sharing specific case information. 

So, those couple of things that this does is it gets your stakeholders to the table, it’s multi-disciplinary.  So, instead of just focusing on one aspect of overdoses, it allows us to look at the spectrum.  So, through this in-depth case review of what do we know about the actual overdose, but what do we know about everything that led up to that overdose. It allows us a view into what are those missed opportunities for intervention and prevention.  And so, once we start looking at a series of case reviews, we can then see trends.  We can identify opportunities for intervention and prevention.  We’ve learned through the experience of doing the multiple reviews that having multiple agencies and multiple stakeholders in the room for the conversation is very important to ensuring that you have complete information. 

We know that there’s no one single agency that can address the overdose issue.  And we need everybody in the room to be thinking about what are those opportunities that we’re missing.  And we need them in the room to really be sharing that detailed information because that’s how this works. 
We look at the overdose itself, but we really want to look at what happened leading up to that overdose, maybe going back five, six years, what led to the beginning of that addiction.  And then we look at the process moving forward.  How many opportunities, how many touches did we have with that individual before it led to the unfortunate death?  And we try and determine then what could we have done differently at multiple stages to have addressed the issues to have prevented the overdose death. 

The first step in actually beginning a process is getting the right stakeholders to the table.  So, bring people together to say, “This is something that we’re interested in doing.  We want to start sharing information.  We want to think about how we can do things differently.”  So, the first thing to do is to get your stakeholders.  The second is develop some confidentiality agreement so that people can actually share that sensitive information in the room, develop protocols for how you’re going to choose cases that you’re going to be reviewing.  And one of the things that’s really important when you’re thinking about doing an overdose fatality review or any review is that you have some accountability.  So, if you’re developing a recommendation or an opportunity for change, then you have the ability to ensure that that is implemented and followed, because nobody wants to sit around the room and have a conversation about an overdose.  They want to see that there’s action taken as a result of these conversations.

Date Created: May 20, 2019