Over the past 2 decades, the United States has experienced an unprecedented opioid epidemic, with devastating impacts on communities across the nation. According to the Centers for Disease Control and Prevention (CDC), the number of drug overdose deaths increased by approximately 5% from 2018 to 2019 and has quadrupled since 1999.1 The increase in opioid overdose morbidity and mortality across the United States began with the widespread overprescribing of opioid medications in the late 1990s, followed by increases in heroin-related overdoses in 2010, and then synthetic opioid-related (such as fentanyl) overdoses in 2013.2 Currently, there is an increase in the use of stimulants, such as methamphetamine and cocaine, and other illicit drugs in conjunction with opioids.3 In addition, the convergence of the opioid epidemic and COVID-19 pandemic has created many challenges. The pandemic has produced difficult conditions such as unemployment, social isolation, increased stress, and disrupted access to care, which are exacerbating the current opioid crisis and resulting in a surge of fatal drug overdoses.4 These trends indicate a need for widespread implementation of evidence-based programs, strategies, and policies across the spectrum of prevention, treatment, and harm reduction. The purpose of this commentary is to review the current CDC framework for prioritizing evidence-based strategies to address the opioid epidemic and describe recommendations to expand them in states and territories.
Role of Evidence-Based Approaches in Overdose Prevention and Surveillance
Opioid overdoses and opioid use disorder are multifaceted problems that require public health, health care, public safety, and community-based agencies to implement comprehensive, complementary evidence-based strategies. In public health practice, strategies are considered evidence-based if they incorporate the following 5 key elements:
- Are supported by high-quality scientific evidence;
- Utilize systematic data and information;
- Are recommended by subject matter experts;
- Are preferred and prioritized by affected communities; and
- Are based on sound program evaluation.5
State and territorial health agencies (S/THAs) require adequate capacity to implement and evaluate evidence-based strategies to prevent overdoses, such as access to resources, foundational infrastructure, collaborative partnerships, and a trained workforce. To effectively respond to the overdose crisis, S/THA staff must engage with stakeholders and partners to avoid duplication of work. The combination of evidence, expertise, and community engagement forms the foundation of an effective and successful overdose prevention strategy.6
Promising Strategies to Prevent Opioid Overdoses
To address the opioid overdose epidemic, CDC identified 10 strategies by scanning scientific literature to examine interventions that have been successfully implemented in at least one jurisdiction and have proven effective at reducing overdose deaths as well as the risk factors that contribute to overdose.6 These strategies include the following:
- Targeted naloxone distribution;
- Medication-assisted treatment (MAT);
- Academic detailing;
- Eliminating prior authorization requirements for medications for opioid use disorder;
- Screening for fentanyl in routine clinical toxicology testing;
- 911 Good Samaritan laws;
- Naloxone distribution in treatment centers and criminal justice settings;
- MAT in criminal justice settings and on release;
- Initiating buprenorphine-based MAT in emergency departments; and
- Syringe service programs (SSPs).
Evidence-based strategies can only successfully prevent overdose to the extent that the community or political environment allows.
Prevention activities are typically categorized by 3 levels: primary, secondary, and tertiary7 (Figure). All these 10 evidence-based strategies fall under at least one of these 3 defined tiers of prevention. For example, academic detailing, an organized instructional campaign that trains health care workers in best practices for prescribing potentially addictive opioids or using the prescription drug monitoring program (PDMP) to mitigate opioid prescribing risk, lies within the primary tier.4 Within the secondary tier sits the strategy of implementing SSPs, which works to prevent substance use disorder by providing screening and treatment of people who use drugs (PWUD). On a tertiary level, the strategy of targeted naloxone distribution aims to prevent adverse outcomes through the dissemination of trainings and kits.6
Evidence-Based Strategies Leveraged by States
Targeted naloxone distribution works by providing training and naloxone kits to PWUD and those who often encounter overdoses, such as first responders, so that they can adequately recognize, respond to, and reverse an opioid overdose.6 In California, for example, distribution of more than 601 000 units of naloxone through collaboration between the Substance Abuse and Mental Health Services Administration and the California State Legislature led to approximately 31 750 known overdose reversals, playing an important role in addressing the overdose crisis in the state.8 Delaware implemented academic detailing to address overdose in the state.6 For instance, the state's department of health created educational materials tailored for use by health care providers and offers continuing medical education for training around opioid prescribing.9 This strategy demonstrates effectiveness in overdose prevention by raising awareness about safe prescribing practices and alternative treatments to opioids for chronic pain.
While there is a growing interest by S/THA staff and leadership to incorporate innovative overdose prevention strategies, implementing certain evidence-based strategies, such as SSPs, may be met with resistance from community members or political leaders due to the stigma around drug use and the strategies themselves. In addition, while S/THAs have the authority to adopt certain evidence-based strategies for reducing overdose deaths, they only can influence the implementation of others. For example, an S/THA may have the authority to implement an academic detailing program but may lack the authority to initiate buprenorphine-based MAT in emergency departments. Robust partnerships are needed to achieve implementation of many of these strategies, and taking an evidence-based approach ensures that resources of the health agency and partners are being used effectively.
From Data to Action: Recommendations for Expanding Evidence-Based Strategies in Practice
In supporting state and territorial health officials in their work, the Association of State and Territorial Health Officials (ASTHO) documents, examines, and offers guidance for its members on the impact and formation of health policy and to provide them with technical assistance on improving the health of their residents.10 ASTHO maintains a strong commitment to upholding evidence-based strategies and promotes a culture where they undergird all of its work. ASTHO recognizes a need for an expansion of these strategies. S/THAs can address barriers and expand the implementation of evidence-based strategies through the following actions.
Stigma is a barrier to effective implementation of each of the 10 evidence-based strategies to prevent overdose deaths. S/THAs have begun addressing stigma to increase the effectiveness of their overdose prevention strategies. For example, the Maryland Department of Health engaged harm reduction and community partners to create a workshop series, Regrounding Our Response, that aims to raise awareness about public health concepts crucial to reducing stigma around substance use.11
The evidence-based practices that support overdose prevention may not be as comprehensible to those without a scientific or health-related background. It is crucial to communicate nuanced content and frame it in an easily digestible way that demonstrates impact to a variety of audiences. Condensing complex language may serve a dual purpose in demystifying the evidence, thereby shedding stigma in the process. For example, in North Carolina, messages of support from the NC Harm Reduction Coalition and state health officials, as well as data gathered by the NC Division of Public Health helped allay community concerns and garner buy-in to establish syringe service programs throughout the state.12
Identifying and appealing to various interests and perspectives of leadership, S/THA partners, and stakeholders are key steps in the effort to expand implementation of CDC's 10 evidence-based strategies to address the crisis. A targeted message from S/THAs aimed at leaders and stakeholders should demonstrate value for their immediate- and long-term interests, as well as meet the needs of the larger community. It is not possible for S/THAs to lead a comprehensive response to the overdose epidemic using these 10 evidence-based strategies without collaborating with relevant partners. S/THAs do not have the authority to implement these strategies on their own but can leverage their influence with partners such as hospitals, law enforcement, and community organizations to increase uptake of these strategies. Health agencies can rely on the evidence to dispel misconceptions around these strategies and partner with trusted authorities and community champions who can serve as a conduit for disseminating accurate information and raising awareness. To effectively expand use of the 10 evidence-based strategies, it is necessary to anticipate challenges that may arise from policy makers. While working within the confines of a political atmosphere, S/THAs should attempt to align interests and leverage common objectives. It is also necessary to identify feasible funding mechanisms that support a comprehensive approach, allowing for these strategies to work in tandem to affect overdose prevention and surveillance efforts. States such as Rhode Island, for instance, offer grants to local health departments and community-based organizations to implement activities that address the overdose epidemic.13
Putting evidence-based strategies into action is an evolving process that takes time to adopt, and each S/THA has differing levels of capacity to implement these strategies. Incorporating the evidence behind the 10 strategies into funding applications, communications, and strategic planning can address barriers such as stigma and challenging political climates. Infusing evidence into program work, partner discussions, and strategic plans sets the stage for evidence-based strategies to be incorporated into practice and inform policy. Many states have launched opioid data dashboards to track key surveillance trends, informing prevention and response efforts.14
Implementing each of CDC's 10 evidence-based strategies to prevent opioid overdoses represents a true comprehensive state or territorial response to the epidemic. To implement these strategies, S/THAs can exercise their authority to lead a strategy and their influence to collaborate with partners on the implementation of other strategies.15 Still, there is a need for further investment in these strategies, as evidenced by more than 81 000 overdose deaths occurring nationally from June 2019 to May 2020. Prior to the COVID-19 pandemic, the opioid epidemic was one of the largest public health crises in recent history and is expected to become more pressing once the pandemic subsides.16 Because of the burden on public health agencies and health care providers, ASTHO is working to enhance and support S/THAs in implementing these strategies. S/THAs, along with federal, state, and local governments, are uniquely positioned to provide the leadership and support necessary to address this crisis. ASTHO will work proactively with public health leaders and engage with partners to ensure that health agency leaderships are adequately equipped and supported in their endeavors to mitigate this public health crisis.
1. Centers for Disease Control and Prevention. Understanding the epidemic. https://www.cdc.gov/drugoverdose/epidemic/index.html
. Published March 17, 2021. Accessed March 26, 2021.
2. Trends in opioid use, harms, and treatment. In: Phillips JK, Ford MA, Bonnie RJ, eds. Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use. Washington, DC: National Academies Press; 2017:chap 4. https://www.ncbi.nlm.nih.gov/books/NBK458661
. Accessed April 6, 2021.
3. NIDA. Rising stimulant deaths show that we face more than just an opioid crisis. National Institute on Drug Abuse Web site. https://www.drugabuse.gov/about-nida/noras-blog/2020/11/rising-stimulant-deaths-show-we-face-more-than-just-opioid-crisis
. Published November 12, 2020. Accessed April 08, 2021.
4. Centers for Disease Control and Prevention. HAN Archive—00438. https://emergency.cdc.gov/han/2020/han00438.asp
. Published March 27, 2020. Accessed March 31, 2021.
5. Brownson RC, Fielding JE, Maylahn CM. Evidence-based public health: a fundamental concept for public health practice. Annu Rev Public Health. 2009;30:175–201.
6. Centers for Disease Control and Prevention. Evidence-based strategies for preventing opioid overdose: what's working in the United States. http://www.cdc.gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdf
. Published 2018. Accessed March 25, 2021.
7. Butler J, Schuchat A, Cline T, Shah U, Nelson K. Implementing the 2017 President' challenge: primary, secondary & tertiary prevention of addiction & substance misuse. Oral Presentation at: The Association of State and Territorial Health Officials Annal Meeting; September 2016; Minneapolis, MN.
8. Department of Health Care Services. Naloxone Distribution Project. https://www.dhcs.ca.gov/individuals/Pages/Naloxone_Distribution_Project.aspx
. Published March 30, 2021. Accessed March 31, 2021.
9. National Academy of Science. Quality insights organizational commitment statement. https://nam.edu/wp-content/uploads/2019/04/Quality_Insights_NAM_Submission_4.3.19_swright.pdf
. Published April 13, 2019. Accessed March 28, 2021.
10. Association of State and Territorial Health Officials. About us. https://astho.org/About
. Published 2018. Accessed April 08, 2021.
11. Maryland Department of Health. Center for Harm Reduction Services. https://phpa.health.maryland.gov/Pages/accessharmreduction.aspx
. Published 2021. Accessed April 5, 2021.
12. Novick LF, Staley D, Novick CG. Developing Safe Syringe Exchange Programs: Role of the North Carolina Division of Public Health. J Public Health Manag Pract. 2019;25(4):390–397. doi:10.1097/PHH.0000000000001003
13. Prevent Overdose RI. Mini-grant opportunities. https://preventoverdoseri.org/mini-grants
. Published 2017. Accessed April 7, 2021.
14. New York State Department of Health. New York State Opioid Data Dashboard—state level. https://webbi1.health.ny.gov/SASStoredProcess/guest?_program=/EBI/PHIG/apps/opioid_dashboard/op_dashboard&p=sh
. Published 2021. Accessed April 12. 2021.
15. Fraser M, Philicia T. The role of public health agencies in convening partnerships and collaborations to respond to the opioid crisis. In: Butler J, Fraser M, eds. A Public Health Guide to Ending the Opioid Epidemic. 1st ed. Oxford, UK: Oxford University Press; 2019: Chapter 13.
16. Harvard News. A crisis on top of a crisis: COVID-19 and the opioid epidemic. https://www.hsph.harvard.edu/news/features/a-crisis-on-top-of-a-crisis-covid-19-and-the-opioid-epidemic
. Published February 16, 2021. Accessed April 6, 2021.