November 2023 Monthly Overdose Report

Download the entire PDF report here: Maine Monthly Overdose Report for November 2023

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.

Overview: Composite total of fatal and nonfatal overdoses

During November, the proportion of fatal overdoses averaged 7.4% of total overdoses. Monthly proportion of 2023 fatalities fluctuated from a low of 4.2% in March and a high of 7.8% in April. During November 2023, there were an estimated 638 fatal and nonfatal drug overdoses statewide, of which 47 (7.4%) were suspected and confirmed fatal overdoses. The remaining 591 (92.6%) were nonfatal overdoses: 253 (40.0%) emergency department visits; 213 (33.4%) EMS patents who were not transported to the emergency room, 101 (15.8%) reversals reported by community members to the Maine Naloxone Distribution Initiative, and an estimated 24 (3.8%) law enforcement reversals without EMS present. 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 Overdoses	Emergency Department Nonfatal	EMS Not Transported to the ED Nonfatal	Reported Community Reversals Nonfatal	Law Enforcement Without EMS  Nonfatal (estimated)	Total Overdoses
Jan ’22	45	295	206	178	39	763
Feb ’22	48	333	185	153	37	756
Mar ’22	65	458	201	202	30	956
Apr ’22	60	290	178	189	26	743
May ’22	47	402	248	186	41	924
Jun ’22	66	482	250	177	44	1013
Jul ’22	66	347	287	183	40	923
Aug ’22	64	385	272	255	37	1013
Sep ’22	55	458	256	153	33	955
Oct ’22	65	283	238	177	27	790
Nov ’22	66	287	206	200	20	779
Dec ’22	76	362	212	198	14	862
2022 Total	723	4,382	2,739	2,251	388	10,483
2022 Total %	6.9%	41.8%	26.1%	21.5%	3.7%	100%
Jan ’23	54	296	219	184	62	815
Feb ’23	49	348	226	192	45	860
Mar ’23	41	382	256	237	68	984
Apr ’23	63	270	218	202	51	804
May ’23	49	295	221	165	61	791
Jun ’23	58	378	228	219	52	935
Jul ’23	50	339	248	173	49	859
Aug ’23	40	330	247	152	44	813
Sep ’23	54	389	231	141	41	856
Oct ’23	54	316	229	147	34	780
Nov ’23	47	253	213	101	24	638
2023 Total	559	3,596	2,536	1,913	531	9,135
2023 Total %	6.1%	39.4%	27.8%	20.9%	5.8%	100%

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Number of suspected and confirmed fatal overdoses

Law Enforcement Response to Fatal and Nonfatal Overdose Incidents

Due to the method used to deduplicate nonfatal overdose incidents to derive a composite number of overdoses for the month, the activity of law enforcement officials and EMS is under represented in the above chart. See the full report for the process involved. The table below shows the public safety response to fatal and nonfatal overdose events in January – November 2023 as well as 2022.

	Maine EMS	Law Enforcement
Fatal Overdose Response 2022	582	672
Nonfatal Overdose Response 2022	9,376	1,471
Total Overdose Response 2022	9,958	2,143
Fatal Overdose Response Jan – Nov 2023	449	520
Nonfatal Overdose Response Jan – Nov 2023	8,177	981
Total Overdose Response Jan – Nov 2023	8,626	1,501

County Distribution of Suspected Nonfatal Overdoses

The following table shows the distribution of nonfatal overdoses at the county level. Due to how overdose reversals are reported by community partners and emergency departments, only EMS overdoses are included. The October 2023 monthly totals can be compared to the percentage of census population, the percentages of nonfatal overdoses in the center column, or the percentages of nonfatal overdoses during 2023. Caution must be exercised with these small numbers. They are likely to fluctuate randomly, without any significant statistical meaning. The January – October percentages for most counties fall within 0 to 1 percentage points of the 2020 census distribution. Penobscot County is 3 percentage points higher and Androscoggin County is 2 percentage points higher than the 2020 census proportion. York County is 4 percentage points lower and Sagadahoc County is 2 percentage points lower than the 2020 census proportion.

	% 2020 estimated Census population	Jan–Dec 2022 Est. N = 9377		Jan-Nov 2023 Est. N = 8177		Nov 2023 Est. N = 630
Androscoggin	8%	1055	11%	837	10%	60	10%
Aroostook	5%	490	5%	406	5%	35	6%
Cumberland	22%	2194	23%	1882	23%	154	24%
Franklin	2%	140	1%	132	2%	12	2%
Hancock	4%	287	3%	240	3%	16	3%
Kennebec	9%	922	10%	803	10%	53	8%
Knox	3%	245	3%	285	3%	25	4%
Lincoln	3%	162	2%	171	2%	13	2%
Oxford	4%	410	4%	326	4%	24	4%
Penobscot	11%	1293	14%	1173	14%	92	15%
Piscataquis	1%	90	1%	100	1%	7	1%
Sagadahoc	3%	130	1%	118	1%	8	1%
Somerset	4%	392	4%	403	5%	29	5%
Waldo	3%	199	2%	175	2%	11	2%
Washington	2%	221	2%	171	2%	19	3%
York	16%	1147	12%	955	12%	72	11%

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County Distribution of Suspected and Confirmed Fatal Overdoses

The following table shows the frequency distribution of deaths at the county level. The monthly total can be compared either to the percent of the census population on the far left, the percent of all Maine drug deaths for 2022, or the percent of drug deaths in 2023. Caution must be exercised with these small numbers. They are likely to fluctuate randomly, without any significant statistical meaning.

The cumulative January – November 2023 percentages of deaths in most counties fall within plus or minus 0 to 2 percentage points of the 2020 census distribution. Penobscot County and Androscoggin County are 4 percentage points higher than the 2020 census proportion. York County is 5 percentage points lower than the 2020 census proportion.

	% 2020 estimated Census population	Jan–Dec 2022		Jan-Nov 2023		Nov-2023
		Est. N = 723		Est. N = 557		Est N = 46
Androscoggin	8%	69	10%	65	12%	5	11%
Aroostook	5%	47	7%	34	6%	1	2%
Cumberland	22%	134	19%	110	20%	12	26%
Franklin	2%	13	2%	6	1%	0	0%
Hancock	4%	24	3%	20	4%	3	7%
Kennebec	9%	54	7%	55	10%	5	11%
Knox	3%	20	3%	15	3%	2	4%
Lincoln	3%	14	2%	6	1%	1	2%
Oxford	4%	36	5%	19	3%	1	2%
Penobscot	11%	109	15%	84	15%	4	9%
Piscataquis	1%	9	1%	15	3%	1	2%
Sagadahoc	3%	11	2%	5	1%	0	0%
Somerset	4%	35	5%	29	5%	2	4%
Waldo	3%	21	3%	10	2%	1	2%
Washington	2%	24	3%	23	4%	5	11%
York	16%	103	14%	61	11%	3	7%

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Race, ethnicity, and other demographic indicators of decedents

During the first eleven months of 2023, out of 558 confirmed and suspected fatal overdoses for which race was reported, 495 (89%) of the victims were identified as White, 23 (4%) as Black or African American, and 9 (2%) as American Indian/Alaska Native. Out of the 544 fatal overdoses for whom ethnicity was reported, 538 (99%) were reported as not Hispanic, and 6 (1%) were identified as Hispanic.

Out of the 559 cases for which military background was reported in January – November 2023, 31 (6%) were identified as having a military background. Out of the 47 cases in November 2023 where military background was reported, 3 (6%) were identified as having a military background.

Of 559 total suspected and confirmed overdose cases in 2023, undomiciled or transient housing status was reported for 65 (12%) of the victims. The largest totals of undomiciled persons were found in Cumberland County (22, 34%), Penobscot County (15, 23%), Androscoggin County (9, 14%), and Kennebec County (6, 9%). In November 2023, 8 decedents (17%) were identified as undomiciled.

Demographic Indicator	% of 2020 Census Population	Jan-Dec 2022 Race N=720 Ethnicity N=706	Jan-Nov 2023 Est. Race N=558 Ethnicity N=544	Nov 2023 Est. Race N=47 Ethnicity N=45
Race and Ethnicity
White	91%	670 (90%)	495 (89%)	41 (87%)
Black or African American	2%	17 (2%)	23 (4%)	2 (4%)
American Indian/Alaska Native	1%	14 (2%)	9 (2%)	0 (0%)
Other race, 2+ races combined, non-hispanic	7%	12 (2%)	11 (2%)	1 (2%)
Not Hispanic	98%	699 (99%)	544 (99%)	44 (98%)
Hispanic	2%	7 (1%)	6 (1%)	1 (2%)
Military Background		81 (11%)	31 (6%)	3 (6%)
Undomiciled/Transient Housing Status		81 (11%)	65 (12%)	8 (17%)

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 risen in recent years from 68% in 2019 to 71% in 2020 and 2021, 73% in 2022, and 73% in the first eleven months in 2023. The cumulative age distribution in January – November 2023 compared to 2022 shows 3 deaths under 18 in 2022 and 3 deaths under 18 in 2023, a 5 percentage point decrease in the proportion of those aged 18-39, a 4 percentage point increase in those aged 40-59, and no change in the proportion 60 and above.

	% of 2020 Census Population	Jan-Dec 2022 N=723	Jan-Nov 2023 Est. N=559	Nov 2023 Est. N=47
Percent Males	49%	527…(73%)	409 (73%)	36 (77%)
Percent under 18	19%	3…(<1%)	3 (<1%)	0 (0%)
Percent 18-39	26%	295…(41%)	204 (36%)	14 (30%)
Percent 40-59	27%	333..(46%)	277 (50%)	26 (55%)
Percent 60+	29%	92…(13%)	75 (13%)	7 (15%)

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Basic incident patterns in fatal overdoses

The following table highlights some event characteristics among suspected and confirmed overdoses. Both EMS and police responded to most fatal overdoses (74%) in 2023. In 2023, law enforcement was more likely to respond to a scene alone (19%) than EMS (6%). The overwhelming majority (93%) of drug overdoses were ruled, or suspected of being, accidental manner of death. Of the 559 confirmed or suspected fatal overdoses in 2023, 196 (35%) had a history of prior overdose.

During 2023, 26% of fatal overdose cases had naloxone administered at the scene by EMS, bystanders, or law enforcement. This rate is higher than the 22% of fatal overdose cases in which naloxone was reportedly administered at the scene in 2020, and slightly higher than the proportion in 2022 (21%). 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 14% (78) of the fatal overdoses, often in addition to EMS and/or law enforcement. This is higher than 2022 (12%), 2021 (9%), and 2020 (4%).

Based on 447 suspected and confirmed drug death cases with EMS involvement during the first eleven months of 2023, 251 (56%) of victims were already deceased when EMS arrived. In the remaining 196 (44%) cases, resuscitation was attempted either at the scene or in the ambulance during transport to the emergency room. Of those 196 who were still alive when EMS arrived, only 59 (30%) remained alive long enough to be transported but died during transport or at the emergency room and 136 (69%) did not survive to be transported and 1 had an unknown status. This is likely due to the high number of cases with fentanyl as a cause of death and individuals using alone. Fentanyl acts more quickly than other opioids and there is less time for victims to be found alive.

	Jan–Dec 2022		Jan–Nov 2023		Nov-2023
	Est. N = 723		Est. N = 559		Est. N = 47
EMS response alone	38	5%	33	6%	2	4%
Law enforcement alone	131	18%	106	19%	9	19%
EMS and law enforcement	541	75%	413	74%	34	72%
Private transport to Emergency Dept.	13	2%	4	1%	1	2%
Naloxone administration reported at the scene	182	25%	143	26%	14	30%
Bystander only administered	44	6%	36	6%	6	13%
Law enforcement only administered	31	4%	15	3%	2	4%
EMS only administered	49	7%	38	7%	1	2%
EMS and law enforcement administered	11	2%	13	2%	2	4%
EMS and bystander administered	26	4%	34	6%	1	2%
Law enforcement and bystander administered	5	1%	12	2%	2	4%
EMS, bystander, and law enforcement administered	6	1%	4	1%	0	0%
Naloxone administered by unspecified person	0	0%	1	0%	0	0%
History of prior overdose	269	37%	196	35%	20	43%

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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, for those 513 confirmed cases in 2023, nonpharmaceutical fentanyl was the most frequent cause of death mentioned on the death certificate at 403 (77%).

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 2% (12) of 2023 deaths and 3% (19) of 2022 deaths, compared to 11% (57) in 2020. Methamphetamine was cited as a cause of death in 31% (162) of the overdoses, a slight decrease from 33% in 2022. Cocaine-involved fatalities January – November constituted 36% (189) of cases, an increase from 30% in 2022 and 25% in 2021. Fentanyl is found as a co-intoxicant with cocaine in 84% (158) of 2023 cocaine-involved cases, and as a co-intoxicant with methamphetamine in 82% (133) of methamphetamine-involved cases. Xylazine and nonpharmaceutical tramadol were identified as co-intoxicants with fentanyl for the first time in 2021. Among 513 confirmed deaths in 2023 the number and percent of cases with xylazine listed as an additional cause in fentanyl deaths is 42 (8%) of confirmed overdose deaths, and 3 (1%) with tramadol listed along with fentanyl. 

Cause of death (alone or in combination with other drugs) Sample size for confirmed cases only	Jan–Dec 2022		Jan–Nov 2023		Nov-2023
	Est. N = 723		Est. N = 513		Est. N = 18
Fentanyl or fentanyl analogs	560	77%	403	77%	18	75%
Heroin	19	3%	12	2%	1	4%
Cocaine	213	29%	189	36%	11	46%
Methamphetamine	234	32%	162	31%	7	29%
Pharmaceutical opioids**	156	22%	96	18%	4	17%
Fentanyl and heroin	18	2%	12	2%	1	4%
Fentanyl and cocaine	171	24%	158	30%	10	42%
Fentanyl and methamphetamine	189	26%	133	26%	6	25%
Fentanyl and xylazine	46	6%	42	8%	1	4%
Fentanyl and tramadol	10	1%	3	1%	0	0%

Highlight of the Month

1,000 Maine Lives Campaign

The Maine Medical Association (MMA), the Maine Osteopathic Association (MOA), the Maine Hospital Association (MHA) and over 20 additional medical and professional specialty societies earlier this month launched the 1000 Maine Lives Campaign which is intended to reduce fatal drug overdoses in the state by 1000 lives over the next five years.  

Erik Steele, D.O., Immediate Past President of the MMA conceived the Campaign during his year as President of the physician group. “Our goal is expansion of access to lifesaving OUD care into every corner of Maine, and engage every part of the healthcare delivery system in this lifesaving work – we want you to be able to walk in to any emergency department, your doctor’s office, any hospital, and get this help,” said Dr. Steele.

“1000 of our fellow Mainers – people we know, work with, love.  We are committed to trying to prevent the loss of the equivalent of a small Maine town during the next five years”, added Dr. Steele.

In addition to MMA, MOA and MHA, additional participants in the campaign include Greater Portland Health, the Maine Primary Care Association, The Maine Association of Physician Assistants, the Maine Academy of Family Physicians, the Maine Association of Psychiatric Physicians, the Maine Chapter of the American College Physicians, Maine Health and Northern Light Health Care.

Governor Mills applauded this effort when Dr. Steele described it during the Governor’s 5^th Annual Opioid Response Summit on July 20.  The State of Maine is a partner in the Campaign.  “We welcome the leadership of Maine’s medical community in combatting the opioid epidemic and strongly support the goal of the 1000 Lives Campaign”, said Gordon Smith, the State’s Director of Opioid Response. “Although overdoses in Maine have lessened this year, Maine people are still losing too many friends and family members to substance use disorder and highly lethal drugs like fentanyl.  This effort is a welcome step to helping more individuals enter treatment, find recovery supports, and most important, stay alive.”

This campaign is indebted to the work of Dr. Donald Berwick and the Institute for Healthcare Improvement (IHI).  Over twenty years ago, the Institute launched its 100,000 lives campaign focused on saving 100,000 lives in this country by reducing the number of medical errors in the nation’s hospitals.  Thousands of hospitals joined the campaign and over time, hundreds of thousands of lives were saved.  Similar to this effort, the new campaign seeks to prevent OUD deaths by implementing a set of health care site-and clinician-specific interventions to improve the treatment of substance use disorder (OUD).  The interventions will be chosen based on their ability to reduce deaths.  The campaign will be led by Maine’s physician and other clinician leadership, partnering with the State of Maine, opioid treatment providers, outpatient and residential treatment centers and other key stakeholders.  Health care organizations and clinicians will assume the leadership role that this effort requires, and take the lead in convincing health care organizations and clinicians to sign on to these increased efforts.

“Despite strong efforts, too many Mainers continue to die each year of opioid overdoses.  It is time for the entire healthcare continuum to recognize substance use disorder for the chronic illness that it is and to embrace every opportunity to treat this disease when patients are ready and to provide harm reduction treatment and support for those who continue to use substances,” said Renee Fay-LeBlanc, MD, Medical Director of Greater Portland Health. 

The Campaign formally began on Jan. 1, 2024.

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