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Local Health Departments on the Front Lines of the Opioid Epidemic

Evans, Isabel, BA; Higgins, Francis, MSc; Stanford, Stacy, MSPH

Journal of Public Health Management and Practice: May/June 2019 - Volume 25 - Issue 3 - p 294–296
doi: 10.1097/PHH.0000000000001001
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National Association of County and City Health Officials, Washington, District of Columbia.

Correspondence: Isabel Evans, BA, National Association of County and City Health Officials, 1201 Eye St NW, Fourth Floor, Washington, DC 20005 (ievans@naccho.org).

The authors declare no conflicts of interest.

According to the Centers for Disease Control and Prevention's 2018 report, Morbidity and Mortality Weekly Report (MMWR),1 47 600 Americans died because of opioid-related overdoses in 2017—far outpacing the mortalities associated with car crashes in 2017 and those of the peak years of the AIDS epidemic. While success has been made in recent years to curb the severity of the epidemic, these recent numbers are a stark reminder of the continued suffering of individuals, families, and communities across the country.

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Introduction to the Epidemic

As a class of substances, opioids produce strong pain-relieving effects by attaching to opioid receptors in the brain, and their misuse is not a new phenomenon in the United States. In the 1900s, heroin was hailed as a miracle drug for its pain-relieving properties, and the 1970s saw an explosion in the development of semisynthetic opioid medications. Through a combination of medical misconceptions and deceptive marketing, prescription opioid use quickly became widespread.2

Although effective for pain relief, opioids can cause lethal overdose by depressing respiration. Since 1999, overdose deaths involving prescription opioids have quadrupled whereas heroin overdose deaths have seen similar increases in just the past decade.3 , 4 Even more concerning is the recent increase in the prevalence of synthetic opioids such as fentanyl. Often manufactured illicitly, fentanyl and its synthetic analogues are orders of magnitude stronger than heroin or prescription opioids and can be difficult to adjust, or cut, into proper dosage concentrations. The introduction of fentanyl into the domestic drug supply has been a major driver of rising death counts across the United States since drugs contaminated with fentanyl cause more rapid and severe overdoses.

The negative effects of opioid misuse extend beyond overdose deaths to include impacts on infectious disease prevalence, life expectancy, and workforce capacity. Rising rates of HIV/AIDS and hepatitis C (HCV) among the intravenous drug use (IDU) community burdens the health care system, and reports of infants born with neonatal abstinence syndrome continue to rise.5 , 6 Despite the availability of medications to treat opioid use disorder (OUD), including methadone and buprenorphine, the majority of people who need treatment of OUD are not receiving it.7 , 8

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The Role of Local Health Departments in Opioid Prevention and Response

Opioid misuse was declared a national public health emergency in October 2017, and the National Association of County and City Health Officials (NACCHO) affirms that local health departments (LHDs) play a critical role in responding to opioid misuse and overdose within their own communities. On the “front line” of the epidemic, LHDs are well suited to serve as conveners or supporters of coalitions and partnerships. This is critical, given that collaboration at the local level is essential to address the multifaceted nature of the opioid epidemic. The coordination of federal, state, and local partners, along with the engagement of community agencies and organizations, is imperative in implementing strategies to prevent and respond to opioid misuse and overdose.

Activities located within an LHD are beneficial because opioid use looks different across jurisdictions. During a crisis, communities often focus on the biggest threat at hand; while some communities struggle to control prescription opioids, others may be battling an illicit supply of synthetic opioids like fentanyl. The economics, demographics, and cultural characteristics of a community shape its particular landscape of drug use and misuse. Therefore, the community's interventions, for both prevention and response, need to be appropriate to address local concerns and consider local resources and systems. A national or statewide response, although necessary to create consistency and interoperability, cannot incorporate the specificity needed for relevant and effective activities at the local level. The connections LHDs have through NACCHO's membership network allow them to adapt evidence-based practices for their own needs and to share innovative strategies to quickly test solutions to find what works best in their communities.

Many LHDs have intensified efforts around prevention and response activities. They are often at the forefront of conducting monitoring and surveillance activities or supporting the implementation of prescription drug monitoring programs in collaboration with other agencies. By tapping into their role as educators and prevention experts, they can develop programs to raise awareness about the risks of overdose, educate the public and key stakeholders about drug use and harm reduction, and implement programs to prevent opioid misuse and overdose. Stigma around drug use remains prominent in communities across the nation, and many LHDs conduct activities to better understand, address, and reverse stigma, with the goal of improving outcomes for people who use drugs or seek treatment.

To support individuals living with OUD, LHDs can help their communities build out treatment options, including medication-assisted treatment, and can improve community linkages to care for OUD treatment, as well as for other physical and mental health services related to opioid use. They are also well-suited to support active drug use communities and to develop and enhance support systems for individuals engaging in treatment.

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How Can We Support LHD Efforts?

NACCHO's 2018 Forces of Change survey9 details that, although two-thirds of LHDs report conducting activities to address the opioid epidemic, major barriers remain. Despite their critical role, LHDs are underresourced to give the epidemic proper attention and often lack dedicated funding for opioid activities. The lack of dedicated funding for LHD opioid efforts is a feature of continued, across-the-board budget cuts to local public health. LHDs facing budget cuts and job losses cannot be expected to have the capacity to respond to emerging epidemics such as opioid misuse and overdose. Scattered and restrictive funding hamstrings response efforts, and a comprehensive approach can only be provided by diverting staff from other critical programs. Compounding the impact of diverted staff is a widespread lack of LHD staff expertise and training in opioid activity efforts, which is especially acute among small LHDs.

To mitigate the substantial threats of the opioid epidemic, an investment of sufficient and stable funding is essential if LHDs are to bolster their workforce and address the dynamic health needs of their communities.

A potential solution to support increased, sustainable funding streams for LHDs engaging in this type of work is a model based on the Ryan White funding structure for HIV/AIDS. Legislation based on this model, the “Comprehensive Addiction Resources Emergency Act,” has been proposed but has yet to be approved out of the Senate HELP Committee and brought to the floor for a vote. By ensuring sustainable and adequate funding, this type of legislation could support long-term, comprehensive programs and enhance workforce capacity.

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What's Next

Over the past 5 years, the domestic opioid epidemic has jumped to the forefront of public health. A majority of LHDs conduct opioid-related activities, and national and local media report heavily on the subject. However, it is vital to consider the context in which opioids have become a national crisis.

The opioid epidemic skyrocketed to public consciousness on the back of the immense suffering addiction has inflicted on American communities. The current epidemic has come into focus with the “face” of a white male from a rural area, often linked to prescription opioids. Despite the truth this portrayal conveys, it fails to paint a full picture of those whose lives have been affected by opioid misuse. Recent public health surveillance shows increasing rates of opioid misuse and overdose among women, racial minorities, and urban populations.10 , 11 Public health must negotiate how to benefit from the surge in interest and funding surrounding drug use and misuse among the demographic prominently shown in the media, while still ensuring that critical issues among underrepresented populations are properly addressed.

Getting ahead of the media narrative and preparing for the next full-blown crisis are critical to an efficient public health system that effectively safeguards the health of the nation. Expanding work with currently underserved communities is only one part of this equation. As LHDs work to ameliorate consequences of this epidemic, they will also confront the overwhelming evidence that the current spike in opioid overdose deaths is a symptom of a larger polysubstance use epidemic. Deaths from cocaine, methamphetamines, and other drugs continue to rise.12 Likewise, many indicators show that diseases associated with IDU, such as HIV/AIDS and HCV, are also increasing.

There will always be another crisis, and the lessons learned from a variety of domestic drug use epidemics tell us that when we fail to prepare, we fail far too many. Instead of reactionary responses to each new public health emergency, LHDs have a unique opportunity to harness the national conversation around opioids to push for structural improvements in our official response to drug use of all kinds. Systematic funding issues will need to be addressed to make this vision a reality, but the shocking statistics and stories of the past 5 years make clear the undeniable need to bolster our ability to prevent and respond to the health threats of the future (Figure).

FIGURE

FIGURE

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References

1. Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and opioid-involved overdose deaths—United States, 2013-2017. https://www.cdc.gov/mmwr/volumes/67/wr/mm675152e1.htm?s_cid=mm675152e1_w. Published January 3, 2019. Accessed January 31, 2019.
2. Meier B. Origins of an epidemic: Purdue Pharma knew its opioids were widely abused. NYTimes.com Web site. https://www.nytimes.com/2018/05/29/health/purdue-opioids-oxycontin.html. Published May 29, 2018. Accessed January 31, 2019.
3. Wide-Ranging Online Data for Epidemiologic Research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2017. http://wonder.cdc.gov. Accessed January 31, 2019.
4. Hedegaard H, Miniño A, Warner M. Drug overdose deaths in the United States, 1999-2017. https://www.cdc.gov/nchs/products/databriefs/db329.htm. Published November 29, 2018. Accessed January 31, 2019.
5. Wejnert C, Hess KL, Hall HI, et al Vital Signs: trends in HIV diagnoses, risk behaviors, and prevention among persons who inject drugs—United States. https://www.cdc.gov/mmwr/volumes/65/wr/mm6547e1.htm?s_cid=mm6547e1_w. Published August 14, 2017. Accessed January 31, 2019.
6. cdc.gov. Increase in hepatitis C infections linked to worsening opioid crisis. https://www.cdc.gov/nchhstp/newsroom/2017/hepatitis-c-and-opioid-injection-press-release.html. Published December 21, 2017. Accessed January 31, 2019.
7. tfah.org. Pain in the nation: the drug, alcohol, and suicide crises and need for a National Resiliency Strategy. https://www.tfah.org/report-details/pain-in-the-nation/. Accessed January 31, 2019.
8. Jones CM, Campopiano M, Baldwin G, McCance-Katz E. National and state treatment need and capacity for opioid agonist medication-assisted treatment. Am J Public Health. 2015;105(8):e55–e63.
9. National Association of County and City Health Officials. The Forces of Change in America's local public health system. http://nacchoprofilestudy.org/wp-content/uploads/2018/12/2018-Forces-of-Change-Main-Report.pdf. Published 2018. Accessed February 6, 2019.
10. Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and opioid-involved overdose deaths—United States, 2013-2017. MMWR Morb Mortal Wkly Rep. 2018;67(5152):1419–1427.
11. cdc.gov. Prescription painkiller overdoses. https://www.cdc.gov/vitalsigns/prescriptionpainkilleroverdoses/index.html. Published September 4, 2018. Accessed January 31, 2019.
12. cdc.gov. Overdose deaths involving opioids, cocaine, and psychostimulants—United States, 2015-2016. https://www.cdc.gov/mmwr/volumes/67/wr/mm6712a1.htm?s_cid=mm6712a1_w. Published March 30, 2018. Accessed January 31, 2019.
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