Next-of-kin interviews to guide overdose prevention strategies: Findings from Baltimore County, Maryland

Despite recent declines in overdose deaths in Maryland, Baltimore County, and the nation, families who have lost loved ones to overdose remain an underutilized resource in shaping overdose response efforts. To better understand their experiences and inform overdose prevention strategies, Baltimore County Department of Health (BCDH) conducted interviews with family members or close acquaintances who lost a loved one to overdose.

Potential participants were identified through medical examiner records and invited via personalized letters. After screening for knowledge of confidential information pertaining to cause of death, 32 family members /close acquaintances voluntarily participated from 2022 to 2024. A licensed clinical social worker conducted one-on-one interviews (60-90 min in length). Interviews focused on family members' experiences prior to the overdose, the overdose events themselves, including use of naloxone, interactions with medical and treatment systems, and recommendations. Interviews were manually coded and analyzed by four qualitative researchers using thematic analysis guided by Grounded Theory.

Most respondents were parents (72%) of the decedents, followed by partners (16%), siblings, and former partners (6% each). Decedents were predominantly male (81%), White (78%), non-Hispanic (97%), with an average age of 49. Themes were organized into three domains: (1) circumstances and stressors leading up to the overdose, (2) non-fatal and fatal overdose events, and (3) reflections and system recommendations. In Domain 1, families described marked changes in their loved one's behavior as drug use escalated, fractured relationships, emotional exhaustion, and the struggle to balance support with tough love. Domain 2 revealed experiences with multiple non-fatal overdoses, limited use of naloxone and mixed experiences with medical systems. Domain 3 highlighted calls for financial and navigational support for treatment, better integration of mental health and substance use, high-quality treatment, greater information about overdose circumstances, and more family guidance about addiction and supporting someone with substance use dependency.

Families face profound emotional and systems challenges. They often witness multiple non-fatal overdoses, frequentlyat home with limited use of naloxone. Findings suggest the need for family-centered naloxone education programs, greater awareness of treatment options, and family support programs to position families as key partners in overdose prevention and response.