Over the past 20 years, the Centers for Disease Control and Prevention (CDC) has reported more than 350 000 deaths from opioid overdose in the United States. Although the primary catalyst of these deaths has been prescription medication, the increased use of heroin and synthetic opioids (eg, fentanyl) sweeping the country has stressed the already limited resources allocated to public health services.1 , 2 In 2017, a public health emergency was declared to address the surge of opioid overdoses and deaths.3 With the growing opioid problem, local health departments (LHDs) are being called to play a more active role in addressing this issue.
Although LHDs are on the front lines when it comes to public health, these agencies have not played a prominent role in addressing substance abuse outside of tobacco and alcohol. In 2016, only 9% of LHDs reported providing clinical services to address substance abuse. In contrast, the focus has been more educational. More LHDs (34%) reported directly providing population-based preventive services focused on substance abuse. While local public health's role in the direct provision of both clinical and preventive substance use services has increased over the past 10 years, most services are provided by other organizations independent of LHD funding; 89% of LHDs reported that substance abuse services have been provided by others.4
In addition, data are limited about the role LHDs play in addressing opioid use and abuse specifically. In the National Association of County and City Health Officials' (NACCHO's) 2017 Forces of Change Survey, 69% of LHDs indicated that they were engaged in multisectoral partnerships to deal with the opioid crisis—half of whom were the leaders of that partnership.5 These collaborations include a variety of stakeholders, such as those from the health care (90%), secular nonprofit (71%), and education (70%) sectors; in addition, the role of the LHD varies from one partnership to another.
However, more information regarding LHD capacity is needed to determine how local public health agencies can better utilize their resources in these collaborations. This article highlights various elements that drive the LHD role in addressing the opioid epidemic.
NACCHO distributed the 2018 Forces of Change Survey to a statistically representative sample of 966 LHDs across all regions of the United States—representing approximately one-third of all LHDs—from March to May 2018 (n = 591; 61% response rate). NACCHO used a stratified random sampling design, with LHDs stratified by 2 variables: size of the population served and state. For stratification by size of population served, 3 categories were used: small (<50 000 people served), medium (50 000-499 999 people served), and large (≥500 000 people served). Because LHDs with large population sizes represent a relatively small portion of all LHDs, these LHDs were oversampled to ensure a sufficient number of responses for the analysis. Two states (ie, Hawaii and Rhode Island) were excluded from the study because they had no LHDs.
The survey included questions regarding LHDs' capacity to address the opioid crisis, partners with which LHDs have worked to conduct opioid-related activities, and select barriers that impeded LHDs from addressing the issue. Responses were self-reported; NACCHO did not independently verify responses. Nationally, representative estimates were weighted to account for sampling design and nonresponse. Additional information about the survey methods is available in the 2018 Forces of Change technical documentation.6
LHD Capacity to Address Opioid Use and Abuse
Findings from the 2018 Forces of Change Survey suggest that many LHDs report insufficient staffing or budget capacity to address opioid use and abuse in their communities. In 2018, an estimated 1990 LHD employees nationwide had some job responsibilities devoted to working on opioid-related activities. According to previous research, an estimated 147 000 employees comprised the total LHD workforce in 2016.4 In comparison, approximately 1% of local public health staff in the United States play a role in reducing opioid use.
In addition, only 38% of LHDs that conducted activities focused on opioid use reported dedicating general funds to such activities. Agencies serving larger populations were likely to have funding capacity, with 46% of large LHDs reporting they dedicate general funds; 38% of medium LHDs and 35% of small LHDs reported the same.
Local Public Health Partnerships on Opioid Use and Abuse
Although previous literature indicates that LHDs partner with diverse organizations,4 Forces of Change findings highlight the low likelihood that LHDs collaborate with nontraditional sectors to combat the opioid epidemic. For instance, less than half of LHDs that conducted opioid-related activities reported partnering with businesses (45%), the media (45%), and federal agencies (23%) (Table 1). Meanwhile, 84% of LHDs work with local or state government agencies and 73% collaborate with the health care sector on this issue (Table 1). However, LHDs serving larger populations were more likely to engage in some cross-sector partnerships than agencies serving smaller populations.
Barriers to LHD Opioid Use and Abuse Response Efforts
Barriers to tackling the opioid crisis throughout the community were diverse and varied among LHDs. For those LHDs that did not conduct activities addressing opioid use and abuse in 2017, the most common barrier reported was a lack of dedicated funding for opioids programming (68%) (Table 2). In addition, more than half of these LHDs (53%) lacked staff expertise or training in opioids-related work. Meanwhile, less than 15% of LHDs not conducting activities indicated insufficient community partnerships or lack of understanding the issues as challenges to supporting opioids-related work.
Although no dedicated funding was cited as a challenge regardless of size of population served, barriers for LHDs serving larger populations differed from barriers for those serving smaller populations. For example, limited community partnerships were a barrier reported by LHDs in jurisdictions with fewer than 50 000 people. In contrast, not the responsibility of the health department was often reported by LHDs in jurisdictions with a population of 500 000 or more.
The 2018 Forces of Change Survey provides a snapshot of LHD capacity, partnerships, and barriers to addressing the opioid crisis. Findings show a clear connection between the urgency of addressing opioid use and abuse in many communities and the lack of funds accessible to local public health agencies for performing opioids-related work. Although program-specific grant opportunities may be available, they are often limited in scope and insufficient to fully support the needed capabilities within and across communities. For example, the CDC has focused its efforts on bolstering prevention activities by equipping organizations with resources, improving data collection, and supporting the use of evidence-based strategies.7 As a consequence, LHDs must determine their unique role in tackling the opioid epidemic by considering their staffing and funding capacities in conjunction with the priorities of federal agencies and their local communities.
Furthermore, Forces of Change data indicate that LHDs are coordinating and partnering with a wide range of stakeholders, including law enforcement, education, health care, policy makers, philanthropy, and advocates. In small jurisdictions, however, LHDs are less likely to collaborate with nontraditional partners to combat opioid use and abuse. This finding may suggest the availability of organizations to address diverse public health issues in larger jurisdictions than in smaller communities, where the LHD is expected to be the primary service provider. Future research should explore the reasons underpinning the lack of nontraditional partnerships. Local partnerships are critical to meeting the unique needs of each community, so additional research should determine the role of nontraditional partners in supporting opioid-related activities, such as by providing additional funding or subject matter expertise.
Finally, results indicate a gap in identifying local areas that require assistance, as well as in the evaluation of prevention efforts. LHDs must expand their data collection and analysis efforts to gain a complete picture of the opioid crisis within their community and the best practices to address the priority issues. In addition, local public health agencies should consider supporting health care providers and health systems with data, tools, and guidance for evidence-based decision-making related to appropriate opioid-prescribing behavior and patient safety. To address both concerns, NACCHO's Opioids Project8 has supported 4 jurisdictions affected by the opioid epidemic to increase the LHDs' data surveillance efforts and partnerships with the health care sector.
1. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths—United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65(5051):1445–1452.
2. Hedegaard H, Warner M, Miniño AM. Drug overdose deaths in the United States, 1999-2016. NCHS Data Brief. 2017;(294):1–8.
4. National Association of County and City Health Officials. 2016 National Profile of Local Health Departments. http://nacchoprofilestudy.org
. Published January 2017. Accessed June 15, 2018.
6. National Association of County and City Health Officials. 2018 Forces of Change Survey Technical Documentation. Washington, DC: National Association of County and City Health Officials; http://nacchoprofilestudy.org/forces-of-change
. Accessed June 15, 2018.