Overdose Detection Technologies—A New Frontier in Preventing Solitary Drug Overdose Deaths

Drug overdose is a persistent health challenge in the US that has worsened during the COVID-19 pandemic. Unintentional drug overdoses have claimed over a million lives since 1999 and resulted in over 100,000 deaths in 2021,¹ in part due to an unpredictable illicit drug supply. The pandemic has catalyzed unprecedented disruptions at every level of society, and exacerbated social isolation and economic and mental distress, which may be fueling drug use and addiction.

Solitary drug use is an under-addressed issue. At least 50% of people who use illicit opioids do so when they are alone, which can protect against stigmatization, theft, violence, and external distractions during drug use episodes, but can also increase the risk of death.^2-4 From May 2020 through April 2021, two-thirds of overdose deaths monitored by the Centers for Disease Control and Prevention⁴ did not include evidence of a bystander, and only 9% of drug use episodes leading to death were directly witnessed. These trends are concerning since naloxone administration requires a bystander who is trained, equipped and willing to respond to an overdose within minutes. Even when present, bystanders may be reluctant to assist (or leave prematurely) fearing that that they will be held responsible by law enforcement.⁵ Given that some users of illicit opioids may have subsequent respiratory depression after being revived with naloxone, and that naloxone cannot reverse nonopioid toxic effects, removing barriers to seeking medical attention is a critical step that is often missed. Interventions that increase real-time overdose detection and response could help prevent solitary drug-related deaths and complement existing interventions such as naloxone administration, medications for opioid use disorder, and overdose prevention centers. Recent innovations in the emerging field of overdose detection technologies (ODTs) may help reduce deaths.

Community members, organizations and researchers have developed novel ODTs that actively or passively monitor, detect, and alert responders of a potential overdose event (Table 1). Based on existing literature, ^6-10 company websites and our knowledge, we categorized ODTs as: (1) telephone-based technologies; (2) mobile apps; (3) stationary wired or wireless devices; and (4) wearable biosensors. Lower-technology approaches such as scheduled room checks, callbacks and timers are sometimes employed but are time intensive and lack the consistency and reliability that ODTs can offer. Notably, ODTs are designed to respect autonomy by allowing individuals to opt in and decide who responds to emergencies.

Table 1:

Overdose Detection Technologies, 2022

Mode of Delivery	Developer	Type of Technology	Year First Available	Cost for Organizationsa	Cost for Individuals	Can alert bystanders	Can alert EMS	Reference
Telephone hotline	Never Use Alone Inc.	Never Use Alone	2019	None	Costs associated with telephone	No	Yes	6,7
Mobile app	Kevin German	Canary-Prevent Overdose	2018	None	Costs associated with smartphone	Yes	No	6, 7
	Brave Technology Co-op	Brave	2020	None	Costs associated with smartphone	Yes	Yes	6-8
Stationary wired or wireless device	Brave Technology Co-op	Reverse motion sensors	2019	$$	None	Yes	Yes	7,8
	Life Saver Alert LLC	Single-use reverse motion bathroom sensor	2019	$$	None	Yes	No	7
	Brave Technology Co-op	Brave Button	2018	$	None	Yes	Yes	7,8
	Lifeguard Digital Health	Various	2022	$	None	Yes	Yes	7
	NA	Push-activated intercom, various	Various	$	None	Yes	Yes	7
	NA	Pull-activated alarm, various	Various	$	None	Yes	Yes	7
Wearable biosensor	University of Washington b	Accelerometer to detect apnea plus naloxone autoinjector	N/A	Unknown	Unknown	No	No	9
	Masimo	Masimo Wearable SafetyNet Alert	Unknown	None	$$	Yes	Yes	7

Abbreviations: EMS, emergency medical services, NA, not applicable.

^a$ indicates low to medium cost, $$ indicates medium to high cost

^bStill in development and has not been approved by the US Food and Drug Administration.

Telephone services such as the Never Use Alone hotline can provide remote monitoring during periods of drug use, emergency medical services (EMS) dispatch, emotional support and linkage to ancillary services.^6,7 In the case of Apps, such as Canary-Prevent Overdose and Brave,^7,8 regular access to a smartphone, electricity and internet connection is required, which can be a challenge among individuals experiencing homelessness or economic disadvantage. Additionally, these services require a pre-determined, trained bystander to respond to each event. However, unlike telephone services, a benefit of encrypted app-based services such as Brave is user privacy, as they disclose the individual’s location and telephone number to EMS only during emergencies. This is similar to telephone-based peer networks that use “spotting” where drug use events are supervised over the telephone by trusted neighbors equipped with naloxone and remain undisclosed to authorities.⁶

While free telephone and apps have been adopted by some individuals who use opioids, they do require users’ awareness, acceptability and adoption, which may be challenging given the substantial stigmatization, poverty and criminalization faced by these individuals.⁶ Wearable biosensors that can monitor movement or oxygen levels have also received attention in recent years, although they are in earlier development and will likely be more costly and pose similar challenges.^7,9

In contrast to mobile interventions, there are devices designed for monitored spaces frequented by opioid users, such as clinical and housing facilities (Table 1).⁷ These ODTs are designed to reduce the cognitive and time burdens among staff of monitoring private spaces in busy workplaces. For instance, the Brave Button is a wall-mounted wireless push-activated device that has been piloted in a supportive housing facility and can be activated by users or bystanders to anonymously send a text alert to trained responders (facility staff and/or residents) of the need for a safety check-in. Unlike traditional intercom systems that require verbal communication between a drug user and staff, such push-activated systems can offer an easy method of communication where the activator (i.e., the person overdosing or a bystander) remains anonymous. The system does not require the user to own a cellphone because it relies on a staff-operated telephone.

Passive motion detection systems that do not require user activation could enhance monitoring capability within high-risk environments (Table 1).⁷ Bathroom sensors can passively detect the reduction of micromovements (i.e., those associated with breathing and consciousness) in a private enclosed space such as a bathroom stall. If an individual is motionless within a short timeframe (typically 2-3 minutes), the system sends an emergency text to responders, who can administer naloxone and call EMS. To protect privacy, these sensors do not record any audio or video. Passive systems have another potentially powerful use, the detection of other medical emergencies involving unconsciousness, which could reduce the stigma associated with identifying overdose emergencies.

Given the significant stigma and secrecy around drug use and inadequate adoption and coverage of community-based naloxone programs, technological devices alone cannot address the issue of overdoses.^4,8 The training and equipping of responders must be a key component of ODT interventions. The development of some ODT-assisted interventions (eg, Never Use Alone and Brave) has been led by people with lived experience through community participatory approaches, which prioritize meaningful participation by drug users in the intervention development process^6,7 More work to engage and reach specific populations such as minoritized groups and youth will benefit the adoption of these technologies.

Amid historically high rates of opioid and nonopioid overdose deaths, social isolation, and other potential health concerns in community settings, novel ODTs are important harm reduction measures to consider evaluating, while existing overdose interventions, such as naloxone and medications for opioid use disorder, reach scale. A small number of ODTs have been piloted but have not been rigorously evaluated in the US. Understanding the impact, scalability and cost effectiveness of these interventions is an important goal. If successful, such technology-assisted interventions may represent a major expansion in the field of overdose prevention.