The Commonwealth of Massachusetts
Executive Office of Health and Human Services
Department of Public Health
250 Washington Street, Boston, MA 02108-4619
KATHLEEN E. WALSH
MAURA T. HEALEY Secretary
Governor
ROBERT GOLDSTEIN, MD, PhD
KIMBERLEY DRISCOLL Commissioner
Lieutenant Governor
Tel: 617-624-6000
www.mass.gov/dph
October 10th, 2024
Steven T. James
House Clerk
State House Room 145
Boston, MA 02133
Michael D. Hurley
Senate Clerk
State House Room 335
Boston, MA 02133
Dear Mr. Clerk,
Pursuant to Section 138 of Chapter 126 of the Acts of 2022, the Fiscal Year 2023 General
Appropriations Act, please find enclosed a report from the Department of Public Health entitled
“An Examination of Opioid-Related Overdose Deaths among Massachusetts Residents.”
Sincerely,
Robert Goldstein, MD, PHD
Commissioner
Department of Public Health
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 An Examination of Opioid-Related
Overdose Deaths among Massachusetts
Residents
July 2024
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Legislative Mandate
The following report is issued pursuant to Section 138 of Chapter 126 of the Acts of
2022, the Fiscal Year 2023 General Appropriations Act as follows:
a) Notwithstanding any general or special law to the contrary, the secretary of
health and human services, in collaboration with the commissioner of public
health, shall conduct or provide for an examination of the prescribing and
treatment history, including court-ordered treatment or treatment within the
criminal legal system, of persons in the commonwealth who suffered fatal
overdoses in calendar years 2019 to 2021, inclusive, and annually thereafter,
and shall report in an aggregate and de- identified form on trends discovered
through the examination. The secretary of health and human services may
contract with a nonprofit or educational entity to conduct data analytics on the
data set generated in the examination; provided, however, that the executive
office shall implement appropriate privacy safeguards consistent with state
and federal law.
b) To facilitate the examination pursuant to subsection (a), the department of
public health shall request, and the relevant offices and agencies shall provide,
information necessary to complete the examination from the division of
medical assistance, the executive office of public safety and security, the center
for health information and analysis, the office of patient protection, the
department of revenue and the chief justice of the trial court, which may
include, but shall not be limited to, data from the: (i) prescription drug
monitoring program established in section 24A of chapter 94C of the General
Laws; (ii) all-payer claims database established in section 12 of chapter 12C of
the General Laws; (iii) criminal offender record information database
established in section 172 of chapter 6 of the General Laws; and (iv) court
activity record information system established in section 9 of chapter 258E of
the General Laws. To the extent feasible, the department of public health shall
request data from the Massachusetts Sheriffs Association, Inc. relating to
treatment within houses of correction.
c) Not later than July 1, 2023, and annually thereafter, the secretary of health
and human services shall publish a report on the findings of the examination
including, but not limited to: (i) the overall prescription history of the
individuals, including both agonist and antagonist medications for opioid use
disorder; (ii) the mental and behavioral health and substance use treatment
history of the individuals, including an outcome comparison of voluntary versus
involuntary treatment, controlling for other factors; (iii) structural factors that
contribute to heightened risk of overdose including, but not limited to,
employment status, housing status, criminal legal involvement, income,
medical comorbidities including, but not limited to, bacterial or viral infections
and substance use sequalae and other demographic markers including, but not
limited to, race, ethnicity, age, gender identity, sexual orientation and
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 immigration status; (iv) trends in the substances observed in overdose events;
(v) whether the individuals had attempted to enter but were denied access to
mental or behavioral health or substance use treatment; (vi) whether the
individuals had received past treatment for a substance overdose; and (vii)
whether any individuals had been previously detained, committed or
incarcerated and, if so, whether they had received treatment and treatment
type during the detention, commitment or incarceration.
The reports shall be filed with the clerks of the house of representatives and senate, the
house and senate committees on ways and means, the joint committee on mental
health, substance use and recovery, the joint committee on public health and the joint
committee on health care financing.
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Executive Summary
Section 138 of Chapter 126 of the Acts of 2022 requires an examination of the prescribing and
treatment history, including court-ordered treatment or treatment within the criminal legal
system, of persons in the Commonwealth who suffered fatal overdoses in calendar years 2019
to 2021. This report contains the results of preliminary analyses that are responsive to the
reporting requirements outlined in the legislation.
Section 138 of Chapter 126 specifically directs reporting on:
1. the overall prescription history of the individuals, including both agonist and antagonist
medications for opioid use disorder;
2. the mental and behavioral health and substance use treatment history of the
individuals, including an outcome comparison of voluntary versus involuntary treatment,
controlling for other factors;
3. structural factors that contribute to heightened risk of overdose including, but not
limited to, employment status, housing status, criminal legal involvement, income,
medical comorbidities including, but not limited to, bacterial or viral infections and
substance use sequalae and other demographic markers including, but not limited to,
race, ethnicity, age, gender identity, sexual orientation, and immigration status;
4. trends in the substances observed in overdose events;
5. whether the individuals had attempted to enter but were denied access to mental or
behavioral health or substance use treatment;
6. whether the individuals had received past treatment for a substance overdose;
7. whether any individuals had been previously detained, committed or incarcerated and, if
so, whether they had received treatment and treatment type during the detention,
commitment, or incarceration.
DPH determined that this evaluation can best be accomplished by using and expanding the
Public Health Data Warehouse (PHD) instead of building a new system. The Public Health Data
Warehouse (PHD) is authorized by Section 237 of Chapter 111. It provides access to timely,
linkable, longitudinal data from across state and local government agencies to enable secure
analysis of priority population health trends. Section 237 mandates that the Department
prioritize analyses of fatal and non-fatal opioid overdoses.
By linking Death Certificate Records with Prescription Monitoring Program data, All-Payer
Claims Data, the Bureau of Substance Addiction Services Treatment Data, and the Department
of Correction Prison Data, DPH analyzed the prescription histories of people who died of an
opioid-related overdose or any drug-related overdose. Results show that people who died of
either an opioid-related overdose or any drug overdose from 2019 through 2022 were more
likely to have had a prescription for certain drugs (MOUD, opioid, benzodiazepine, or stimulant)
the further away in time from the death. Looking back to 2011, people were more likely to have
had a prescription for an opioid compared to the other drugs. This shows a need for greater use
of and retention in MOUD.
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To compare involuntary and voluntary treatment episodes, those with a Section 35 treatment
episode were compared to those with a voluntary treatment episode (WMS +/- CSS). Section 35
treatment episodes more frequently were aged 18-29, female and non-Hispanic white. They
more frequently had prior BSAS treatment enrollment within 6 months, were recently
incarcerated, had a previous documented psychiatric diagnoses and receipt of benzodiazepine
prescription, and were more likely living in rural areas of Massachusetts.
To assess outcomes between voluntary versus involuntary treatment while controlling for
differences, a case-crossover analysis was conducted that included only those individuals who
experienced both involuntary and voluntary treatment episodes. Analyses showed that those
released from a Section 35 commitment had significantly greater odds of experiencing a non-
fatal opioid overdose in both the 30- and 90-days following Section 35 as compared to the 30-
and 90-day period following voluntary treatment.
Those released from a Section 35 commitment had greater odds of dying of any cause in both
the 30- and 90-days following Section 35 as compared to the 30- and 90-day period following
voluntary treatment. This result was not statistically significant, but the association is similar to
the trends observed for non-fatal overdose.
Several analyses demonstrated that there are structural factors related to the heightened risk
of overdose, including recent release from a county correctional facility; Black non-Hispanic,
American Indian non-Hispanic, and Hispanic race or ethnicity; homeless housing status;
criminal/legal involvement; less than a high school education; a mental health disability
diagnosis; and a history of a prior work-related injury. Massachusetts communities with more
significant social determinants of health (SDoH) challenges and fewer assets (social capital)
exhibited higher opioid overdose mortality rates. Additionally, communities with higher ratios
of Black, Hispanic, American Indian, or Alaska Native (AIAN), and Multiracial residents relative
to white non-Hispanic residents coupled with more significant SDoH challenges had the highest
opioid overdose mortality rates1.
By linking Death Certificate Records with post-mortem toxicology results, trends related to what
substances are present in opioid-related overdose deaths were analyzed. Fentanyl continues to
be a driver of both opioid-related and all drug-related overdose. After fentanyl, cocaine is the
drug most found in post-mortem toxicology of both opioid-related and all drug-related
overdoses.
By linking Emergency Medical Services (EMS), Hospitalization, Death, and BSAS records
through the PHD, we can identify who had received medical treatment for a past opioid-
related overdose and who had received any treatment within the BSAS system.62% of
people who experienced a fatal opioid-related overdose from 2019 through 2021 had
1Massachusetts Department of Public Health. 2023. 2023 Report on Priority Public Health Trends from the Public Health Data
Warehouse. https://www.mass.gov/doc/phd-2023-legislative-report-0.
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ever enrolled in BSAS treatment prior to their fatal overdose. 45% of these people had
at least one prior opioid-related overdose before their fatal opioid-related overdose.
DPH could not conduct analyses on whether individuals had attempted to enter but
were denied access to mental or behavioral health or substance use treatment, as there
are no data or data sources available that include information on people who were
denied access to mental or behavioral health or substance use treatment.
DPH will be able to report on an in-depth evaluation of treatment programs within houses of
correction later in 2024. In the next year, DPH will continue work to bring into the PHD the
additional datasets needed to refine the requested analyses. Continuing to provide accurate
and detailed data analyses related to the opioid crisis in Massachusetts is critical to ensuring
ongoing appropriate allocation of resources and access to care. We present this report so
approaches and resources to end the epidemic can continue to be allocated effectively.
Introduction
Fatal drug overdoses, driven in Massachusetts by opioids, remain a persistent public health
problem. From 2019 through 2022, 89% of all drug overdoses were opioid-related in
Massachusetts. In 2022, an estimated record high 2,359 Massachusetts residents died of an
opioid-related overdose2.
The Public Health Data Warehouse (PHD), which combines individually linkable data across 24
state and county data sources with three community-level datasets, has been critical for
generating insight on public health priorities not available from single sources of data. The PHD
includes data related to public health, health care, public safety, the criminal/legal system, and
the Social Determinants of Health.
2
Massachusetts Department of Public Health. (2023 December). Data Brief: Opioid-Related Overdose Deaths among
Massachusetts Residents. Mass.gov.
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Section 138 of Chapter 126 of the Acts of 2022 requires an examination of the prescribing and
treatment history, including court-ordered treatment or treatment within the criminal legal
system, of persons in the Commonwealth who suffered fatal overdoses in calendar years 2019
to 2021.
To facilitate this examination, the legislation specifies six agencies that shall provide data:
1. Division of Medical Assistance
2. Executive Office of Public Safety and Security
3. Center for Health Information and Analysis
4. Office of Patient Protection
5. Department of Revenue
6. Chief Justice of the Trial Court
It further specifies four datasets/databases to be included:
1. Prescription Monitoring Program
2. All-Payer Claims Database
3. Criminal Offender Record Information Database
4. Court Activity Record Information System.
It goes on to specify that to the extent feasible, the Department of Public Health (DPH) shall
request data from the Massachusetts Sheriffs Association, Inc. relating to treatment within
Houses of Correction.
Additionally, it directs reporting on this examination including, but not limited to seven areas:
1. the overall prescription history of the individuals, including both agonist and antagonist
medications for opioid use disorder;
2. the mental and behavioral health and substance use treatment history of the
individuals, including an outcome comparison of voluntary versus involuntary treatment,
controlling for other factors;
3. structural factors that contribute to heightened risk of overdose including, but not
limited to, employment status, housing status, criminal legal involvement, income,
medical comorbidities including, but not limited to, bacterial or viral infections and
substance use sequalae and other demographic markers including, but not limited to,
race, ethnicity, age, gender identity, sexual orientation, and immigration status;
4. trends in the substances observed in overdose events;
5. whether the individuals had attempted to enter but were denied access to mental or
behavioral health or substance use treatment;
6. whether the individuals had received past treatment for a substance overdose;
7. whether any individuals had been previously detained, committed or incarcerated and, if
so, whether they had received treatment and treatment type during the detention,
commitment, or incarceration.
The examinations required by this legislation are a natural extension of work that was initially
conducted pursuant to Chapter 55 of the Acts of 2015 as amended by Chapter 133 of the Acts
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of 2016 and which is presently conducted utilizing the Public Health Data Warehouse (PHD)
pursuant to Chapter 111 Section 237 of the General Laws3,4,5. As such, DPH has determined that
these examinations can best be accomplished by using and expanding the already existing PHD 6.
This is the second report made pursuant to Section 138.
Background on the Public Health Data Warehouse
The Public Health Data Warehouse (PHD) is authorized by Section 237 of Chapter 111. It
provides access to timely, linkable, longitudinal data from across state and local government
agencies to enable secure analysis of priority population health trends. The PHD is a nationally
recognized innovation, proven as an effective tool for accelerating data analysis and
dissemination of actionable information to guide the Commonwealth’s response to priority
public health issues. Section 237 mandates that the Department prioritize analyses of fatal and
non-fatal opioid overdoses. Since the examination required by Section 138 aligns with the
mandate in Section 237 and the PHD already includes much of the data – although not all --
needed to conduct the required examination for Section 138, DPH determined that this
evaluation can best be accomplished by using and expanding the PHD instead of building a new
system.
Of the data-providing agencies outlined in the legislation, the PHD does not currently include
data from the Office of Patient Protection, the Department of Revenue, or the Chief Jus