About the Forum

The 2021 Virtual National Forum on Overdose Fatality Review offered a mix of general interest plenary panel discussions, guided virtual discussions, and café sessions for informal, small-group meetings. Each day hosted content around a specific theme or activity of OFR.

The forum was held February 16–18 and February 23–25, 2021.
Forum resources can be viewed using the button below.


The purpose of an OFR is to effectively identify system gaps and innovative community-specific overdose prevention and intervention strategies.

In practice, OFRs involve a series of confidential individual death reviews by a multidisciplinary team. A death review (also referred to as a “case review”) examines a decedent’s life cycle in terms of drug use history, comorbidity, major health events, social-emotional trauma (including adverse childhood experiences), encounters with law enforcement and the criminal justice system, treatment history, and other factors, including local conditions to facilitate a deeper understanding of the missed opportunities for prevention and intervention that may have prevented an overdose death.

By conducting a series of OFRs, jurisdictions begin to see patterns of need and opportunity, not only within specific agencies, but across systems. Blending input from public health, public safety, providers, and the community, OFR teams develop program and policy recommendations to improve coordination and collaboration between agencies and community conditions to prevent future overdose deaths.

These recommendations are presented to a governing committee that supports and provides resources for implementation and a framework for accountability for action. Examples of successful recommendations include the integration of peer recovery specialists into new settings, targeted naloxone distribution, and improved coordination of public safety and public health.

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