Fatal overdoses often happen when users are alone. Hotlines and sensors can save lives.

They die alone in bedrooms, bathroom stalls and cars. Each year in the United States, tens of thousands of fatal overdoses unfold as tragedies of solitude - with no one close enough to call 911 or deliver a lifesaving antidote.

Technology new and old might save some of those lives.

Motion detectors blare alarms when someone collapses inside a bathroom at a shelter or clinic. Biosensors detect slowed breathing triggered by an overdose and one day may be capable of automatically injecting overdose reversal medication. Simpler approaches - chat apps and hotlines - keep users connected to help if drugs prove too potent.

“Fear is a great motivator - it’s motivated me to at least have a connection with somebody if something did happen,” said Greg, a 57-year-old Oklahoma contractor who has called volunteers at the Never Use Alone hotline because he was concerned fentanyl might adulterate the methamphetamine he was using.

But even as public health advocates, companies and government officials hope tech can stem the staggering tide of solitary drug fatalities, they recognize that deploying these warning strategies on a larger scale could bring obstacles.

Some advocates fear communities might view the efforts as enabling drug abuse, an argument long made by opponents of efforts to reduce harm to drug users. For people who use drugs, concerns about privacy and arrest might impede acceptance. And then there’s the biggest obstacle: money. Governments are spending billions of dollars to ease the opioid epidemic but relatively little on such technologies.

State and federal agencies need to invest in figuring out whether these approaches work, said Ju Nyeong Park, an assistant professor at Brown University’s Center of Biomedical Research Excellence on Opioids and Overdose.

“Technology is a part of our lives. Sure, it can be a source of entertainment,” Park said. “It could also be a preventative tool.”

The emergence of such tools underscores the grim reality that most U.S. overdose deaths don’t happen in public spaces. The nation continues to record more than 100,000 drug deaths a year, although officials have noted a decline in recent months.

One federal study estimated at least 64 percent of overdose victims died in their home and one-third happened with a potential helper not responding - usually because they were in a different room.

That’s what happened to Chase Hughes, of Jackson, Mich. The 24-year-old worked a steady job installing mobile homes. But he battled depression and addiction to pain pills for years. According to relatives, Hughes had been drug-free for about three weeks since joining Narcotics Anonymous.

In October 2023, his father recalls hearing Hughes, who lived with his parents, enter his bedroom about 2 a.m. It wasn’t until about 18 hours later that Hughes’s 4-year-old niece discovered him in bed dead of a fentanyl overdose.

His father, Bryan Hughes, is a state corrections lieutenant with experience reviving victims. He had the overdose reversal medication naloxone in his truck. Maybe, he said, if they’d had a biosensor, it could have alerted him to his son’s altered breathing.

“It’s heartbreaking,” the father said. “I could have helped my kid. He was right there, and I didn’t know.”

Drug users have long relied on companions, or “spotters,” to monitor for overdoses. As the illicit drug supply has become increasingly toxic and unpredictable, those affected by addiction and groups that seek to reduce the harms of drugs advocate “never use alone” campaigns. That can mean keeping on hand Narcan, a nasal spray version of naloxone, which is available over the counter and distributed by health organizations in person, by mail and free through vending machines.

In Canada, consumption sites where people can use their own drugs under supervision are common. Those facilities are controversial in the United States because of questions about their legality under federal law and community complaints that they attract drug dealers and crime.

Two city-sanctioned sites in New York have intervened in more than 1,000 overdoses, according to the nonprofit that operates them. A state-sponsored facility in Rhode Island is scheduled to open soon.

[State confirms 2023 fatal drug overdoses in Alaska shot up to all-time high]

A simple solution

Virtual services such as hotlines and chat apps that allow people to use drugs while communicating with trained staff and people with experience using drugs offer a less controversial - and out-of-sight - alternative.

“People won’t travel even half an hour to go use drugs in a supervised location,” said Keith Humphreys, a former White House drug policy adviser who is now a Stanford University psychiatrist specializing in addiction. “But if they can use it at home and it’s super easy to log into one of these things, then they are going to be more willing to accept advice, support and so on.”

In Canada, a government-funded pilot overdose hotline in Alberta aimed at preventing rural overdoses was scrapped hours before it was to launch in 2020 - a local health official called the concept “frankly dangerous.”

“People thought that it was enabling,” said Monty Ghosh, an addiction doctor and researcher who helped create the program.

But as Canada’s fatal overdoses increased and the coronavirus pandemic worsened social isolation, the country’s federal government later that year funded a hotline and text line, the National Overdose Response Service.

Ghosh’s team worked with the company Brave Technology Co-Op and Grenfell Ministries founder Rebecca Morris-Miller, who started a similar program on a shoestring budget and one phone line in Vancouver at the start of the pandemic.

The Canadian national hotline receives hundreds of calls a month from rural users and city residents.

“We’ve got military guys, health professionals, med students, older people … we’ve got firefighters. We’ve got a ton of trades professionals,” said Lisa Morris-Miller, who took over as the group’s director after Rebecca, her sister, died of an overdose in 2022.

In the United States, the nonprofit Never Use Alone started in 2019 as a largely unfunded national toll-free hotline run by volunteers with experience using drugs, or who have lost someone to drugs.

Greg in Oklahoma kept a hotline card on a magnetic board. Greg, who spoke on the condition he be identified by his middle name because he worries about backlash from family and friends, called for the first time last May. At 2:03 a.m., he connected with a volunteer operator nearly 1,000 miles away in Michigan.

The two talked casually as the operator noted Greg’s phone number, address and the substances he planned to use. She cautioned him to ensure pets were out of the way and that the front door remain unlocked in case emergency responders needed to enter quickly.

Within minutes, Greg wrapped a tourniquet around his arm. The operator, a former user who lost friends and family to overdoses, reassured him. “Just let me know once you’ve [injected] and then when you’ve pushed the plunger all the way down.”

He pierced the vein in his arm with the needle. About 45 seconds ticked by as the meth coursed through his body. Greg grunted. “I’m all right,” he said.

Never Use Alone has received more than 45,000 calls and says it has summoned emergency responders almost 200 times. Operator turnover has hampered the organization.

One of its experienced volunteers - the operator who engaged with Greg - recently left amid disputes about leadership and direction of the hotline. Greg said he no longer uses the hotline and instead has called the former operator when using.

In New England, SafeSpot - which began as a Never Use Alone branch - is expanding and professionalizing under the umbrella of Boston Medical Center. Last fall, Massachusetts became the first state to fund such a line, and has now allocated more than $1 million. SafeSpot employs 34 trained operators who field calls from throughout the country and use software to alert emergency responders in a caller’s home city. Operators have summoned rescuers to 19 overdoses, director Stephen Murray said.

Recordings of calls are erased after seven days. Many callers ask that friends or family be notified first in the event of an overdose. Operators caution users on moderating doses.

“We prevent a lot of overdoses through coaching,” Murray said.

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High tech but low demand?

While hotlines and chat apps are relatively simple, high-tech gadgets such as biosensors offer tantalizing promise - but face questions about practicality.

Researchers at MIT and Brigham and Women’s Hospital in Boston in August announced they had developed an experimental biosensor the size of a stick of gum that can be implanted under the skin and deliver naloxone if vital signs indicate an overdose. It’s three to five years away from being tested in humans, researchers said.

Resilient Lifescience, a Pittsburgh biotech company, is developing a less invasive naloxone-injecting biosensor device that would attach to the outside of a user’s stomach like an insulin pump. Its battery charge and adhesive patch would last one week, said CEO Brad Holden. He hopes to get Food and Drug Administration approval but studies could be time-consuming because real-world subjects wearing the devices might never overdose.

Skeptics warn drug users might not embrace such devices.

Some might fear powerful naloxone shots will prompt painful opioid withdrawal symptoms, particularly if a device gives a false reading when there is no overdose, said Travis N. Rieder, a bioethics expert at the Berman Institute of Bioethics at Johns Hopkins University. The devices could also give users a false sense of security, leading to riskier behavior and harm if the machines don’t work properly, he said.

“There’s something a little bit distressing about continually chasing the mythical techno solution, especially when some of them are going to have all sorts of implementation problems,” Rieder said.

FDA approval doesn’t guarantee an overdose prevention device will succeed in the market.

In a first-of-its-kind approval last year, the agency authorized the medical tech company Masimo to market the Opioid Halo for overdose prevention. A sensor attached to a user’s finger connects to a smartphone or to a small square device called a “health hub” to monitor vital signs. If someone’s breathing gets too shallow, the app alerts emergency contacts. The $250 device is available over the counter and can be prescribed for people using prescription opioids.

Sales are sluggish. No pharmacy chains are stocking the device, said Masimo CEO Joe Kiani. “The drugstores are telling us that people coming into their stores don’t normally buy products that are $200 [or more], so they’re afraid of it,” he said.

An upcoming real-world test could boost the device’s fortunes. In Nevada, the statewide recovery support nonprofit Foundation for Recovery recently used part of a $10,000 city grant to buy an initial batch of 10 Opioid Halo devices. The organization hopes to buy dozens more during the next year for users with smartphones and reliable WiFi.

‘Another chance at life’

For now, advocates say cheaper devices using less sophisticated technology not requiring FDA approval will save lives sooner.

Brave Technology, the Canadian company that helped start the hotline in that country, has developed a wearable sensor that activates a 103-decibel alarm if a user remains still more than 90 seconds. CEO Gordon Casey and chief operating officer Oona Krieg envision the wrist devices would cost $20 and be included in kits with clean needles, naloxone and other health supplies. In an early stage study in the United Kingdom, the company distributed 17 prototype devices. “It actually stopped two folks from dying,” Casey said.

But they said they have been unable to secure funding to further develop the devices and manufacture them in greater numbers.

The company is already selling similar motion sensors for bathrooms that detect whether someone has stopped moving. Krieg said it has sold more than 700 sensors to shelters, transit hubs, urgent care centers and other venues in the United States and Canada.

Such sensors have proven effective for public bathrooms, which pose challenges for governments and businesses grappling with solitary overdoses.

Eight years ago, staff at Boston’s Healthcare for the Homeless Program asked electrician John King to devise a system to alert if someone overdosed. After three months of design work, he installed a flashing-light alarm that blares if a person stops moving for at least two minutes. It proved so successful he started a company, Life Saver Alert, improving designs and selling more than 300 units to hospitals, clinics and shelters in 17 states.

King estimates his devices, with an average cost of about $4,300, have saved more than 3,500 lives. He rejects concerns they might entice users to take drugs.

“Why shouldn’t we give them another chance at life?” King said.