Background

U.S. drug overdose deaths increased to historic levels in recent years, with provisional estimates indicating more than 111,000 deaths in the 12 months ending October 2023 [1], most of which involved a high-potency opioid (i.e., illicitly made fentanyl and fentanyl analogs) from the illicit drug supply [1]. This dynamic, evolving, and complex problem requires solutions that are tailored and culturally relevant for cities and counties. The solutions include public health acting as the convener for multi-sector collaboration overdose surveillance, harm reduction services, low barrier access to all services and recovery support for people who use drugs (PWUDs). Federal funds have been used to support cities and counties with high overdose burdens to build a strong foundation of cooperation, partnership, and infrastructure across public health, behavioral health, health systems, community organizations, and public safety. This paper describes a federally funded 4-year effort to assist cities and counties with activities that enhance overdose prevention and response infrastructure, support cohesive programs, and address health inequities in overdose.

The Centers for Disease Control and Prevention (CDC)’s Division of Overdose Prevention, in collaboration with the National Association of City and County Health Officials (NACCHO), funded local health departments (LHD) to work on overdose prevention and response-related activities. This collaborative effort, Implementing Overdose Prevention Strategies at the Local Level (IOPSLL), has funded 45 LHDs or their fiscal representatives since 2019 in cities/counties with some of the highest overdose burdens in the country. LHDs were able to be funded during multiple cohorts.

In 2020, the Office of the Assistant Secretary for Planning and Evaluation convened a workgroup of U.S. Department of Health and Human Services (HHS) experts in overdose prevention and substance use disorders and developed the HHS Overdose Prevention Strategy [2]. Based on the four pillars of primary prevention, harm reduction, evidence-based treatment, and recovery support, the strategy incorporates principles related to enhancing equity, using data and evidence to guide actions, improving coordination, collaboration, and integration across multiple sectors, and reducing stigma. Each HHS Strategy and Guiding Principle can be implemented at multiple levels of the social-ecological model (SEM) to develop a more holistic approach to address overdose.

The SEM was developed to understand how various risk and protective factors contribute to childhood adversity. It describes the individual, relationship, community, and policy factors that increase adversity and can be used to assess how prevention strategies can affect short- and long-term health outcomes [3, 4]. Risk factors for overdose are found at multiple levels of the SEM and include physical and mental health, social connections, access to healthcare, and treatment for substance use disorder [5].

To the best of our knowledge there currently is no published literature that summarizes the overdose prevention strategies and activities that have been implemented by LHDs and their partners on the ground. As federal agencies continue to fund localities to conduct overdose prevention activities, an understanding of the strengths and gaps is needed to identify how LHDs can provide more holistic and comprehensive programming. The current paper summarizes programmatic activities of IOPSLL funding recipients and examines implementation gaps and areas of opportunity. Programmatic activities are categorized by the SEM-level of implementation and the HHS Strategy and Guiding Principles. The results of this study will inform policy considerations and future overdose prevention programming at the local level.

Methods

In 2019, NACCHO, with support from CDC Cooperative Agreement 5 NU38OT000306-03-00 titled Strengthening Public Health Systems and Services through National Partnerships to Improve and Protect the Nation’s Healthbegan accepting applications for IOPSLL. Each applicant was funded for 18 months, and since 2019, four cohorts with a total of 45 LHDs have been funded to conduct overdose prevention and surveillance activities. The LHDs were required to implement overdose prevention and response strategies with the greatest impact on the overdose burden [6, 7], which are also reflected in the HHS Prevention Strategies Guiding Principles. Each IOPSLL cohort had different funding requirements. The strategy areas required for funding included surveillance and data sharing, linkages to care, provider and health systems support, partnerships with public safety and first responders, communication campaigns, stigma reduction, health equity, and harm reduction. Table 1 provides details regarding the different IOPSLL funding cycles and the required and optional overdose prevention activities of each funding opportunity. Each of the 45 recipients received between $190,000 and $750,000 per year as well as support from a suite of technical assistance (TA) providers. Table 1 also shows the average funds received per year for each cohort. These providers included members of a high-capacity public health department and programmatic support from CDC and NACCHO staff, as well as experts in data, surveillance, and evaluation. Two jurisdictions (Milwaukee, WI and Seattle and King County, WA) were funded during two different cohorts. See Fig. 1 for the IOPSLL program logic model.

Table 1 Description of the Implementing Overdose Prevention Programs at the Local Level (IOPSLL) required and optional strategies and number of sites by cohort
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Fig. 1
figure 1

Logic model for implementing overdose response strategies at the local level and outline of overdose prevention strategies at the local level and outline of overdose prevention strategies used by local health departments and their desired outcomes

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Activity inventory

Each funded LHD developed a workplan that guided their overdose prevention efforts throughout the funding period. Each site’s workplan implemented between two and fifteen (mean number of activities=4.9 per funded site) that were directly linked to the required strategy areas of the funding opportunity and were comprised of multiple objectives. Workplan activities (n=222) were extracted into an Excel spreadsheet to describe the LHD’s overdose prevention activities. The spreadsheet included information about strategies, activities, objectives, and population of focus. Notes from monthly calls with the LHDs were used to add additional context to activities. A total of 220 workplan activities were coded. Two activities were removed because the LHDs did not implement them while they were receiving IOPSLL funding.

Coding

Workplan activities were extracted and coded according to the SEM level (i.e., individual, relationship, community, and policy), HHS Overdose Prevention Strategy (i.e., primary prevention, harm reduction, evidence-based treatment, and recovery support), and guiding principles (i.e., equity; data and evidence; coordination, collaboration, and integration; and reducing stigma). A codebook was developed with key definitions and examples for each code and was provided to the coding team which consisted of six persons (initials: AW, SH, MG, FH, NF, KS). The SEM and HHS Overdose Prevention Strategies and Guiding Principles were used to develop the codebook [2, 4]. For the SEM, an activity was coded at the individual level if it directly benefitted the population of focus. The relationship level referred to activities that directly benefitted persons closely connected to those at risk of overdose such as family, friends, first responders, and healthcare providers. An activity was coded at the community level when the focus was on the larger community in which PWUDs resided such as schools, neighborhoods, and libraries. Lastly, the policy level referred to activities that focused on supporting or changing social norms or policies that influence overdose prevention and response.

One member of the team compared all coding responses and identified discrepancies (n=79). Three members of the coding team met to discuss the workplan activities and to reconcile the coding discrepancies until a consensus was reached. Coding occurred between October 2022 to July 2023.

Analysis

Final codes were uploaded into R version 4.3.1 (2023-06-16 ucrt) for analysis to identify the distribution of the codes and the co-occurrence of SEM level and HHS Overdose Prevention Strategies and Guiding Principles.

Results

Table 2 describes the activities that were coded for each LHD. Most activities among IOPSLL recipients occurred at the community level of the SEM and under the Coordination, Collaboration, and Integration guiding principle.

Table 2 Activities that have been funded and implemented during the four years of the Implementing Overdose Prevention Programs at the Local Level (IOPSLL) program.
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Figure 2 shows where the activities fell on the levels of the SEM by HHS Overdose Prevention Strategy and Guiding Principle. As seen in Fig. 2, 55.9% (n=123) of coded activities occurred at the community level, 32.3% (n=71) at the individual level, 8.6% (n=19) at the relationship level, and 3.2% (n=7) at the policy level. Figure 2 also includes the number and percent of total activities implemented under each SEM level and each HHS Overdose Prevention Strategy and Guiding Principle. Fifty-two activities (23.6%) implemented by the IOPSLL recipients focused on the HHS Guiding Principle of coordination, collaboration, and integration and the majority were implemented at the individual level (57.7%, n=30). These activities included linking persons who have experienced a nonfatal overdose to care at emergency departments through emergency medical, paramedic services, post-overdose response programs, and other forms of low-threshold care. The types of care provided included harm reduction materials and other forms of treatment such as medication for opioid use disorder (MOUD) and in-patient services.

Fig. 2
figure 2

The intersection of Implementing Overdose Prevention Programs at the Local Level (IOPSLL) activities across the Social Ecological Model by HHS Overdose Prevention Strategies and Guiding Principles and the activity numbers and percentages.

This figure shows the number of activities being implemented at each level of the social ecological model (SEM) in each of the eight HHS Overdose Prevention Strategies and Guiding Principles across the 45 IOPSLL sites. The HHS Overdose Prevention Strategies and Guiding Principles are represented by abbreviations in the figure and a legend is included. The Strategies and Guiding Principle abbreviations and number of activities are shown in circles of varying size and color intensity as visual indicators of how many activities are being implemented at each SEM level

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Fifty-one activities (23.1%) focused on the HHS Strategy of harm reduction and almost half of those (49.0%, n=25) occurred at the individual level. Most of these activities were centered on the distribution of harm reduction materials such as syringes, naloxone, and fentanyl test strips. CDC funds may not be used for purchasing syringes or naloxone and the LHDs braided other funding sources to support this work. Other innovative examples included community drug checking using Fourier transform infrared (FTIR) spectrometers and public health vending machines which are usually stocked with naloxone, testing strips, syringes, and other harm reduction materials.

Forty-seven activities (21.4%) focused on the HHS Guiding Principle of data and evidence, the preponderance (95.7%, n=45) of which occurred at the community level. Most used surveillance activities to enhance data sharing and to understand overdose “hotspots” in communities. This knowledge was often used to inform resource distribution, post-overdose response and spike alert systems for partners and providers, and to notify the public about increases in overdoses and/or substance use-related hospitalizations.

Twenty-four (10.9%) activities focused on the HHS Guiding Principle of reducing stigma, most of which (70.8%, n=17) occurred at the community level and included media campaigns over billboard and radio. Several campaigns were also comprised of messaging about connection to harm reduction and treatment services.

Fourteen (6.4%) activities focused on the HHS Strategy of primary prevention with much (78.6%, n=11) occurring at the community level. Community-level primary prevention activities centered on communication campaigns about overdose risks.

Eleven (5.0%) activities focused on the HHS Strategy of recovery support with most (54.5%, n=6) taking place at the community level. These activities included linking people to services such as recovery housing and holding community education opportunities on recovery.

Seven (3.2%) activities focused on the HHS Strategy of evidence-based treatment, and more than half (57.1%, n=4) occurred at the individual level. Most activities involved implementing media campaigns and were centered on access to treatment.

Fourteen (6.4%) activities focused on the HHS Guiding Principle of equity, most of which (57.1%, n=8) occurred at the community level. Activities were centered on overdose response programs in diverse communities and peer navigation services to high-risk priority communities.

Table 2 describes the partnerships developed or strengthened during the IOPSLL program. Most (n=31) IOPSLL-funded LHDs leveraged relationships with public and private entities (n=69 unique partners) to provide and implement overdose prevention resources and activities.

Table 3 summarizes the relationship between the SEM level and HHS Overdose Prevention coded IOPSLL activities. Forty-five activities were focused on data and evidence intervention implemented in the community setting, 30 activities revolved around providing linkages to care for individuals, and 25 activities were harm reduction interventions for individuals.

Table 3 Contingency table that summarizes the relationship between the Social Ecological Model and HHS Overdose Prevention Strategies and Guiding Principles coded Implementing Overdose Prevention Programs at the Local Level (IOPSLL) activities
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Discussion

This paper describes local level overdose prevention and surveillance activities implemented through NACCHO and CDC’s IOPSLL program. We applied the SEM and HHS Overdose Prevention Strategies and Guiding Principles to showcase how federal-level initiatives may translate at the local level. As seen in Table 2, our study identified that IOPSLL-funded LHDs are implementing programs at multiple levels of the social ecology for people and communities at risk of overdose. Additionally, findings demonstrated that LHDs proposed implementation of programs that would support working at both the community and individual levels and that activities focused on improving community coordination, strengthening surveillance, providing harm reduction services, dispelling stigma, and ensuring that information and services reach key communities disproportionately impacted by overdose. IOPSLL recipients were most likely to engage in overdose prevention activities at the community level of the SEM and under the coordination, collaboration, and integration guiding principle. It is important to note that this is not a complete representation of the overdose prevention response of LHDs as the IOPSLL-funded jurisdictions only reported on their overdose prevention activities that they used the grant dollars to support.

LHDs serve as the hub of public health efforts in their communities. It is important to note that the majority of these LHDs received funding during the COVID-19 pandemic and that the responsibilities of local health departments were impacted during the pandemic. While some IOPSLL-funded activities were delayed due to the pandemic, local health departments and their partners recognized the overdose epidemic did not stop during the pandemic and they persevered while also adapting their activities to minimize the spread of COVID-19. They are well-equipped to collaborate with the many entities that commonly interact with persons affected by or at risk of overdose. This could include convening and leading a community task force to improve communication among local partners or taking a more targeted approach such as working with first responders or hospitals to enhance systems to better tailor services for PWUD. Additionally, a majority of IOPSLL-funded LHDs leveraged relationships with public and private entities to provide these services, such as naloxone training and distribution and care coordination. The LHD’s ability to coordinate efforts allowed them to play a unique and critical role in the overall community response to the overdose epidemic.

Harm reduction is a critical HHS Overdose Prevention Strategy and was commonly administered by IOPSLL recipients. Reducing the risks and harms associated with substance use is critical to keeping persons alive and within reach of services supporting them. In this sphere, IOPSLL recipients implemented numerous activities at both the community and individual levels. Many health departments, in keeping with their role as community collaborators, conducted naloxone trainings or other educational sessions for organizations such as local businesses or first responders. They also served PWUD directly by distributing naloxone and fentanyl test strips and operating or supporting local syringe services programs.

LHDs through IOPSLL implemented stigma reduction activities that mostly occurred at the community level. PWUD often experience stigma from family, service providers, and the greater public which negatively impacts their access to and use of healthcare services [8,9,10]. To better address stigma, many LHDs implemented communications campaigns such as CDC’s Stop Overdose [11] and others developed by their teams. Stigma reduction messaging was shared through various channels such as social media, radio, billboards, buses, and gas station ads. One jurisdiction partnered with a local peer recovery group to develop a digital and paper campaign that shared the peers’ experience with substance use and recovery. LHDs also implemented activities that focused on stigma reduction among those who are likely to interact and work with PWUD. These activities included training first responders to offer trauma-informed care and trainings for healthcare providers focused on some of the risk factors for developing a substance use disorder (SUD). Many of the LHDs engaged with the community and with people with lived and living experience to tailor their stigma reduction activities. Reducing stigma is essential to support overdose prevention services to facilitate recovery for PWUD.

LHDs recognized the need to support and enhance recovery services and implemented activities to facilitate recovery along with wellness to improve the quality of life for PWUD. These services included strengthening the recovery workforce, as well as enhancing and encouraging the use of recovery support services. LHDs have assisted with and enhanced this support in their communities through IOPSLL by hiring peer support workers to link persons to resources and to connect those in recovery to housing. Many barriers and challenges hinder the availability and uptake of recovery services. They include stigma, residential instability, financial insecurity, confidentiality concerns, and lack of access to treatment services and peer support groups [12,13,14]. LHDs should address these barriers and continue to assist and strengthen recovery support in their communities.

LHDs engaged in and supported primary prevention efforts through IOPSLL in addition to providing harm reduction, treatment, and recovery services to PWUDs in their communities. LHDs participated in several primary prevention activities with all but three being implemented at the community level. Examples of IOPSLL-supported activities included academic detailing on safe opioid prescribing, non-opioid pain management options among prescribers and pharmacists and implementing overdose prevention communication campaigns for the public. One LHD expanded the reach of the PAX Good Behavior Game [15] to local school districts to reduce substance use and fatal overdoses by enhancing students’ resiliency. Effective prevention strategies are multidisciplinary and should occur at each of the SEM levels [4]; Findings demonstrate the importance of LHDs implementing activities at the individual, relationship, and policy levels in addition to showcasing the strengths of primary prevention at the community level.

The ability to work at both the community and individual levels is an important strength of health departments. Their ability to understand and mobilize community-wide care is key; however, services should ultimately reach those at risk of overdose. The IOPSLL program emphasizes the need to meet persons where they are and continue to distribute resources such as naloxone to those most likely to experience or witness an overdose. This ground-level work is also a vital conduit to further services and offers an opportunity to provide education to PWUD [16]. Continuing to deliver these services will ensure that vital tools are in the hands of those who need them while also deepening the mutual relationship and understanding between the health department and those at risk of overdose.

Study findings presented gaps in services or areas where implementation was low and highlighted HHS Overdose Prevention Strategies and Guiding Principles that can be implemented by LHDs to make their overdose prevention programs more robust. IOPSLL recipients implemented activities in all Strategies and Guiding Principles; however, they were less likely to provide evidence-based treatment or to conduct equity-related efforts to address systematic disparities in the burden of overdose across the community. In some cases, such as MOUD, the health department was not always positioned to begin offering clinical services and CDC’s funds cannot be used for direct medical/clinical care or substance use treatment. However, their capacity to work with medical providers to enhance community awareness of treatment, improve linkages to care, and increase the level of care by educating providers about the epidemic and dispelling stigmatizing myths about their patients who use drugs may be supported. Additionally, funding requirements heavily influence certain activities being implemented. For example, the lack of evidence-based treatment interventions being implemented can be attributed to funding restrictions. LHDs were not allowed to used funds to the provision of direct medical care. Funding opportunities with fewer restrictions allow jurisdictions to use grant money to implement overdose preventions that are necessary and tailored to their local community contexts.

Other findings showed that LHDs and their partners could better support a comprehensive response to the overdose epidemic if they were able to expand or refine the scope of their services. Thus, dedicated services are warranted for subpopulations disparately impacted by the burden of overdose within communities. Some IOPSLL participant activities pointed a path forward for local efforts to better support groups at high risk of overdose. For example, some LHDs implemented programs to work with people with a history of substance use who were recently incarcerated or developed a focused communications campaign aimed at educating black, Indigenous, and people of color (BIPOC) communities on the risk of overdose and how to access support services.

Additionally, IOPSLL recipients were able to implement efforts in under-used levels of the socio-ecological model but were noticeably less likely to engage at both the relationship and policy level. Relationship-level activities, or those that directly benefit persons closely connected to those at risk of overdose such as family, friends, first responders, and healthcare providers, are important to raising the overall recovery capital for PWUD. IOPSLL recipients did perform numerous activities in this regard such as working with pharmacists or emergency medical services (EMS) to improve their individual capacity to provide services to those in need. However, data also show that the connection between health departments and the friends and families of those at risk could be deepened. A holistic response to the epidemic can only be mounted by ensuring that all PWUD’s social connections have the tools, training, information, and resources they need to support their loved ones.

Evidence-based policies can help prevent overdose, but LHDs are not always able to fully implement these policies, as they may be hinge upon federal policy and/or other types of state laws and regulations. However, an effort to elevate local voices by providing a forum or improving their internal capacity to implement policies in their communities should be considered. Additionally, increasing collaboration with other local governments and educating local elected officials about health department initiatives may be beneficial to address local regulatory barriers. Ultimately, policy discussions should be influenced by the best information on the ground, something LHDs and their partners are well equipped to provide [17].

Local jurisdictions such as cities and counties are often at the forefront of addressing a response regardless of the larger forces influencing the direction of the epidemic. LHDs need sufficient infrastructure and capacity to ensure a robust and equitable response. The lessons from CDC and NACCHO’s IOPSLL program have highlighted both the strengths local communities already exhibit and the opportunities that remain to expand and enhance their overdose prevention and response capabilities. LHDs were especially successful in implementing overdose prevention activities at the community and individual levels that aimed reduce stigma, link overdose prevention resources and wraparound services, and distribute harm reduction materials to people at risk of experiencing or witnessing an overdose. Our study also identified gaps services and identified that LHDs should provide activities related to evidence-based treatment and health equity and incorporate overdose prevention activities at the relationship and policy SEM levels.

Limitations

The data included in our study only represent activities that were funded and supported under IOPSLL, and LHDs notably support additional overdose prevention programming. Furthermore, many of the activities implemented under IOPSLL were multidisciplinary and could have been coded under more than one HHS Overdose Prevention Strategy or Guiding Principle. Additionally, funding requirements likely impacted activities implemented and reported on by LHDs and could have influenced the observed patterns in our study results. For example, cohort 4 jurisdictions were required to embed health equity components into their work and reporting documents. For this reason, a majority of health equity activities were implemented by cohort 4 LHDs. LHDs in the other cohorts may have conducted health equity activities but did not specify them in their required reporting. These results may be an underestimate of the strategies used because activities were not double-coded. Furthermore, the currently available deliverables do not include evaluation data and thus no outcome conclusions can be made.

Additionally, a few limitations are related to the IOPSLL program composition and data collection. The request for application was not standardized between cohorts and may have influenced the activities chosen. Each IOPSLL cohort received varying degrees of TA and other project support as the program evolved from year 1 to 4. The data used to inform this paper draws from each site’s IOPSLL project workplan, which was self-reported and contained differing levels of detail from jurisdictions which led to the recategorization of some activities to fit the HHS framework. While IOPSLL sites did collect evaluation data, the process was not standardized, and the results of the evaluation are beyond the scope of this paper.

Strengths

This study includes multiple cohorts that span across 4 years and varied geographic regions with different priority populations. Additionally, the coders and authors of this paper came from diverse backgrounds and brought unique expertise in public health and evaluation. This is the first paper to provide a descriptive landscape of overdose prevention activities LHDs implement across the nation. Our findings can be used to guide and inform newly funded Overdose Data to Action: Limiting Overdose through Collaborative Actions in Localities (OD2A: LOCAL) jurisdictions and other LHDs as they design and implement activities to prevent overdoses in their communities.

Conclusions

This paper uses the HHS Overdose Prevention Strategies and Guiding Principles and the SEM to describe the landscape of federally funded overdose prevention activities at the local level. Localities have primarily implemented activities focused on the individual and community levels of the social ecology, with most centered around the HHS Overdose Prevention Strategies and Guiding Principles of coordination, collaboration, and integration; harm reduction; and data and evidence. Continuing these efforts is important, as is ensuring that LHDs explore opportunities to enhance and expand the scope of their overdose prevention work in various strategy areas across the social ecology.

Supporting health systems' capacity to provide evidence-based treatment, increasing equitable services to disproportionately affected populations, expanding recovery supports for PWUD, and/or driving anti-stigma efforts in various settings are all interventions that LHDs have already started to implement. However, enhancing and scaling up these efforts is possible. LHDs can also reach beyond PWUD or the community organizations that work with them: they can provide overdose prevention education and resources and engage and empower friends, families, and other persons who may directly interact with PWUD. Developing, elevating, and disseminating robust evidence-based interventions tailored for the local level will be important as federal agencies continue to directly fund localities for overdose prevention, response, and surveillance. Such interventions seize available opportunities to address the overdose epidemic through a multi-pronged approach in addition to capitalize on the strengths of LHDs.