Fatal drug overdoses continue to represent a major public health threat in the United States. While a large proportion of overdoses are attributed to illicitly manufactured fentanyl, a growing number are due to polysubstance use, particularly combination with stimulants [1]. Trends seen in Tennessee are similar, with approximately 80 % of fatal overdoses involving fentanyl, and the majority attributed to polysubstance use [2], [3]. Education on bystanders’ responses, including naloxone administration and cardiopulmonary resuscitation (CPR), is becoming increasingly important as the drug overdose epidemic continues. While bystanders may be present during an overdose, barriers exist that could hinder the efficacy or ability of the bystander to undertake an appropriate response. Such barriers may include being unable to recognize the signs of an overdose or being unaware that the decedent was using drugs [4]. However, a feasibility study of bystander administration of public-access naloxone found that, with access and awareness, bystanders are able to respond effectively to an overdose event [5]. Increasing bystander presence, knowledge of response, and access to naloxone during an overdose is critical for swift intervention.

Existing research has found disparities in bystander presence, particularly among overdose decedents of different age groups [4]. Additionally, evidence in the literature suggests that presence of a bystander was a positive predictor for faster 911 calls and response, thus quicker administration of naloxone in a hospital setting [6]. This evidence suggests an opportunity for education and outreach on the importance of not using alone as an effective overdose harm reduction strategy [6]. However beyond these studies, there is a paucity of research examining bystander presence and response among overdose decedents. As such, the purpose of this study was to more comprehensively examine bystander presence and response to fatal drug overdoses by assessing the sociodemographic characteristics of overdose decedents, the relationship of the bystander to the decedent, and the response, or reasons for no response in Tennessee from 2019 to 2022.