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Background Data on fatal and non-fatal overdose provide important information about the magnitude of the overdose crisis. We consider these metrics in tandem and estimated the ratio of opioid overdose-related emergency department (ED) visits to opioid overdose deaths. A lower ratio could indicate more fatal overdoses, fewer overdose reversals with naloxone or a combination of both.Methods Data are from the Maryland Vital Statistics Administration (opioid overdose deaths), the Health Services Cost Review Commission (non-fatal ED visits for opioid overdose). We generated 2020 annual rates of fatal and non-fatal opioid overdose deaths for the state of Maryland and its 24 jurisdictions and estimated the ratio of opioid overdose-related ED visits to deaths.Results The 2020 visit-to-death ratio for Maryland was 1.7, and ranged from 0.9 to 3.8 across jurisdictions. We identified five counties that had above-median rates of opioid overdose-related ED visits and deaths, and low visit-to-death ratios.Conclusions Our findings indicate that there were nearly two ED visits for each opioid overdose death in Maryland, and there was substantial variation across counties. The visit-to-death ratio enables a better understanding of the relationship between fatal and non-fatal opioid overdose and is essential to averting deaths and evaluating overdose prevention efforts.