December 2021 Monthly Overdose Report

Download the entire PDF report here: Maine Monthly Overdose Report for December 2021

*Note: The timing of the monthly overdose report has been substantially delayed during the last several months due to pandemic-related issues. The toxicology reports are currently returning to the Office of the Chief Medical Examiner in as much as 10 weeks following death; this is 3 to 4 times longer than the pre-pandemic turn around time. For more information see the full report.

The monthly overdose report, funded jointly by the Maine Office of the Attorney General and the Office of Behavioral Health, provides an overview of statistics regarding suspected and confirmed fatal and nonfatal drug overdoses in Maine during each month. Data for the report is collected at the Office of Chief Medical Examiner and as part of the Maine Naloxone Distribution Initiative. Year-to-date numbers will be updated with each new monthly report, as cases are finalized, and their overdose status is confirmed or ruled out. The totals are expected to shift as this evolution occurs. In addition, due to the smaller sample size in any given month, totals are expected to fluctuate due to the effects of random variation.

Whereas the overall number of overdose deaths is a critical indicator of individual and societal stress, this metric itself can be quite resistant to public policy interventions due to its complexity. Overdose fatalities occur because of multiple unique and interacting factors such as underlying medical conditions and drug lethality. For that reason, this monthly report will develop ways to monitor components that can be directly affected by specific public health education and harm reduction interventions. For example, reports will be given on the number of decedents that had access to naloxone and the number who were alone while using.

Number of suspected and confirmed fatal overdoses

Fatal Drug Overdoses in Maine December 2021

Fatal Drug Overdoses in Maine January – December 2021

The December 2021 total of 51 fatal drug overdoses consists of 39 confirmed drug deaths and 12 suspected drug deaths. The cumulative January – December 2021 total is 632, 16 of which are suspected. The graph below shows the considerable monthly fluctuation since January 2020. Although the 2020 average is 42, the range extends from 33 to 53. The average for 2021 is 53, and the range is 41 to 67. For more information regarding definitions of fatal overdoses, including data collected and case completion timelines see the full report. The proportion of fatal to nonfatal overdoses decreased from 9% to 7% between January and December of this year.

*Note: The timing of the monthly overdose report has been substantially delayed during the last several months due to pandemic-related issues. The toxicology reports are currently returning to the Office of the Chief Medical Examiner in as much as 10 weeks following death; this is 3 to 4 times longer than the prepandemic turn around time. For more information see the full report.

Composite total of fatal and nonfatal overdoses

The month of December included 51 fatal overdoses. This is just below the average monthly number in 2021. Nonfatal overdoses for December are down slightly from November, but still greater than the beginning of the year. During December, there were an estimated 769 fatal and nonfatal drug overdoses statewide, of which 51 (7%) were suspected and confirmed fatal overdoses. The remaining 718 (93%) were nonfatal overdoses: 333 (43%) emergency department visits; 198 (25%) EMS patents who were not transported to the emergency room, 176 (23%) reversals reported by community members to the Maine Naloxone Distribution Initiative, and an estimated 11 (1%) law enforcement reversals without EMS present. The minimum total of reported nonfatal overdose incidents for January – December 2021 was 8,898 which was compiled by deduplicating data derived from multiple statewide sources. There were also an unknown number of nonfatal overdoses in which 911 was not called and no reversal report was provided to the Maine Naloxone Distribution Initiative.

Fatal OverdosesEmergency Department
EMS Not Transported
Community Reversals
Law Enforcement
Without EMS 
Nonfatal (estimated)
Total Overdoses
Total %7%47%25%22%<1%100%
*Emergency department, EMS Not Transported, Community Reversals, and Law Enforcement Without EMS are nonfatal overdoses. Fatal overdoses in those categories have been removed.

Distribution of drug deaths by Maine county

The following table shows the frequency distribution of deaths at the county level. The December 2021 totals can be compared either to the percent of the census population on the far left or the percent of all Maine drug deaths for 2019, 2020, and January-December 2021. Caution must be exercised with these small numbers. They are likely to fluctuate randomly, without any significant statistical meaning.

The cumulative January-December 2021 percentages of deaths in many counties fall within plus or minus 0%-1% of the 2019 census distribution, including Aroostook, Franklin, Hancock, Kennebec, Knox, Lincoln, Oxford, Piscataquis, Somerset, and Waldo. Counties that are 2% or more higher than the census proportions include Androscoggin (+3%), Penobscot (+6%), and Washington (+2%). Counties that are 2% or more lower than the census proportion include Cumberland (-4%), Sagadahoc (-2%), and York (-4%).

CountyPercent of 2019
Census Population
Jan-Dec 2020
Dec 2021
Est. N=51
Cumulative Jan-Dec 2021
Est. N=632
Androscoggin8%33…….(9%)52.(10%) 5….(10%)72…..(11%)

Race, ethnicity, and other demographic indicators of decedents

During January – December of 2021, out of 628 confirmed and suspected fatal overdoses for which race was reported, 587 (94%) of the victims were identified as White, 22 (4%) as Black or African American, and 15 (2%) as American Indian/Alaska Native. Out of the 622 fatal overdoses for whom ethnicity was reported, 612 (99%) were reported as not Hispanic, and 10 (1%) were identified as Hispanic. Out of the 632 cases, 43 (7%) were identified as having a military background. Prior overdose history was reported for 211 (33%) of the victims. Transient housing status was reported for 62 (10%) of the victims.

Demographic IndicatorNumber of decedents
Percent of decedents
Race and Ethnicity
Black or African American224%
American Indian/Alaska Native152%
Not Hispanic61299%
Military Background437%
Prior Overdose History21133%
Person Experiencing Homelessness6210%

Age and sex composition of decedents

The following table displays the age and sex composition* of the monthly fatal overdose population. The cumulative proportion of males has stayed roughly the same since 2019. During 2021, it was 459 (71%), which is the same as 2020 and slightly higher than the same as the level in 2019 (68%). In December it increased to 86%. The cumulative age distribution in January – December 2021 compared to 2020 and 2019 shows increasingly more decedents in older categories. The percentage of those 18-39 decreased overall by 6%. The percentage of those 40-59 rose by 4%, and the percentage of those over 60 rose 1%. There has been 2 decedents under 18 in 2021.

Jan-Dec 2020
Jan-Dec 2021
Est. N=632
Est. N=51
Percent Males258..(68%)357(71%)451.(71%)44(86%)
Percent under 180….(0%)2(<1%)2..(<1%)0…..(0%)
Percent 18-39171..(45%)213..(42%)250.(40%)21(41%)
Percent 40-59175..(46%)235..(47%)315.(50%)29..(57%)
Percent 60+33….(9%)54(11%)65..(10%)1…..(2%)
*Systematic gender data are not reported on the death certificate.

Basic incident patterns in fatal overdoses

The following table highlights some event characteristics among suspected and confirmed overdoses. Roughly similar to 2020, during January – December of 2021, both EMS and police responded to most fatal overdoses, 76%. Law enforcement was more likely to respond to a scene alone (17%) than EMS (6%). The overwhelming majority (96%) of drug overdoses were ruled as accidental manner of death.

Based on the death investigation records, during January – December of 2021, naloxone was administered to 31% of the victims at the scene or in the ambulance, whether by EMS, bystanders, or law enforcement. This is higher than the 29% reported as administered by EMS, bystanders, or law enforcement at the scene in 2020 and considerably higher than the 28% found in the toxicology reports for 2020 fatal overdose victims. This may be due to the greater availability of police trained to administer it through programs like the Attorney General’s Naloxone Distribution Initiative or ODMAP. It may also be due to the greater availability in the community due to the Maine Naloxone Distribution Initiative. Although most cases had bystanders present at the scene when first responders arrived, the details about who may have been present at the time of the overdose were usually unclear. However, bystanders, including family and friends, administered naloxone during 9% of the fatal overdoses, often in addition to EMS and/or law enforcement. The 2020 drug death report documents only 4% of victims who had received bystander-administered naloxone.

Based on 517 suspected and confirmed drug death cases with EMS records during January – December of 2021, 252 (49%) of victims were already deceased when EMS arrived. Of the remaining 265 (51%), resuscitation was attempted either at the scene or in the ambulance during transport to the emergency room. Of the 265 cases who were still alive when EMS arrived, 80 were transported, and 185 did not survive to be transported. Thus, out of 265 fatal cases with EMS response, only 80 (16%) remained alive long enough to be transported, but died during transport or at the hospital.

Jan-Dec 2020
Jan-Dec 2021
Est. N=632
Est. N=51
Public safety response
……EMS alone28(6%)37….(6%)5….(10%)
……Law enforcement alone107.(21%)108..(17%)10(20%)
……EMS and law enforcement365.(72%)480..(76%)36(71%)
Manner of death (suspected or confirmed)
Naloxone administration
Naloxone administration at the scene and/or
(presumably) in ambulance during transport to
emergency room
Naloxone administration reported at the scene83.(22%)188..(30%)12..(24%)
……Bystander only11(2%)37….(6%)5(10%)
……Law enforcement only8(2%)21….(3%)0….(0%)
……EMS only55..(11%)87..(14%)6..(12%)
……EMS and law enforcement4(1%)20….(3%)0….(0%)
……EMS and bystander8..(2%)14….(2%)0….(0%)
……Law enforcement and bystander0..(0%)5…..(1%)0….(0%)
……EMS, bystander, and law enforcement…….2..(<1%)1….(2%)

Key drug categories and combinations causing overdose deaths

The following table displays the overall pattern of the most prominent drug categories in confirmed drug deaths. As expected, nonpharmaceutical fentanyl was the most frequent cause of death mentioned on the death certificate so far for 2021 at 475 (77%), 9% higher than in 2020 (67%). 

Fentanyl is nearly always found in combination with multiple other drugs. Illicit stimulants have been increasingly mentioned as co-intoxicants of fentanyl during the past several years. Heroin involvement, declining each year, was reported as a cause in 4% of 2021 deaths, compared to 11% last year. Methamphetamine was cited as a cause in 27% of the overdoses, which is 7% more than 2020. Cocaine-involved fatalities January – December constituted 25% of cases, slightly more than the 23% in 2020. Fentanyl is found in combination with cocaine in 20% of 2021 cases, and in combination with methamphetamine in 21%. Xylazine and nonpharmaceutical tramadol were identified as co-intoxicants with fentanyl for the first time in 2021. Among 616 confirmed deaths caused by fentanyl from January – December, the number and percent of cases with xylazine listed as an additional cause in fentanyl deaths is 51 (8%) of confirmed overdose deaths, and 24 (4%) with tramadol listed as one of the causes of death. 

Cause of death (alone or in
combination with other drugs)
Sample size for complete cases only
Jan-Dec 2020
Jan-Dec 2021
Nonpharmaceutical opioids
……Fentanyl or fentanyl analogs336.(67%)475..(77%)30..(77%)
Nonpharmaceutical Stimulants
Pharmaceutical opioids**118.(23%)110..(18%)4..(10%)
Key combinations
……Fentanyl and heroin47(9%)18….(3%)1….(3%)
……Fentanyl and cocaine97.(19%)123..(20%)9..(23%)
……Fentanyl and methamphetamine/amphetamine70.(14%)128..(21%)10..(26%)
……Fentanyl and xylazine0(0%)51….(8%)0….(0%)
……Fentanyl and tramadol0(0%)24….(4%)0….(0%)
**Nonpharmaceutical tramadol is now being combined with fentanyl in pills and powders for illicit drug use. When found in combination with fentanyl, and in the absence of a known prescription, tramadol is no longer counter as a pharmaceutical opioid.

Highlight of the month regarding substance use disorder public policy response

Maine Recovery Coach Certification Board

The State’s effort to define and maintain the highest standards of recovery coach professional practices and ethics reached a significant milestone in January 2022 with the first individual reaching the threshold for experience and supervision and other criteria to be eligible for state certification. This state designation will allow individuals trained through the basic recovery coach academy course to continue their training and education and receive state certification. Certification requires 500 hours of coaching with at least 25 of those hours being actively supervised. It is anticipated that receiving state designation will accelerate the ability of recovery coaches to be employed in a number of settings including hospital emergency departments. MaineCare Opioid Health Homes, and correctional facilities. All the application materials for certification are available for download on the Maine Recovery Coach Certification Board website at

For more information regarding the State of Maine’s response to the drug crisis in Maine see the Leadership section of the Maine Drug Data Hub.