The United States is in the midst of a crisis, with an average of 130 Americans dying every day from an opioid-involved overdose. From 1999 to 2017, more than 700,000 people died from a drug overdose. In 2017, the number of overdose deaths involving opioids (including prescription opioids and illicit opioids, such as heroin and illicitly manufactured fentanyl) was six times higher than in 1999.

Nationwide, local health departments have struggled to address this growing crisis. In 2019, the Centers for Disease Control and Prevention awarded emergency funding to the National Association of City and County Health Organizations to help LHDs develop and improve their response. Using these funds, the NYC DOHMH created the Opioid Crisis Response Technical Assistance (CDC-TA) Project. The team provides our partners LHDs with information and assistance for a suite of evidence-based programs, including hospital-based non-fatal overdose response (Relay), prescription drug monitoring (PDMP), syndromic and mortality surveillance, medications for opioid use disorder (MOUD), anti-stigma and media campaigns, and rapid assessment and community engagement using BADUPCT's Rapid Assessment and Response (RAR) model.

This programming focuses on health equity by collaborating with NYC DOHMH Race to Justice staff and subject matter experts (SMEs). In 2016, NYC DOHMH launched Race to Justice to advance racial equity and social justice across all programs, policies, and practices. This work is done throughout the agency and engages staff to incorporate a health equity approach into all facets of their work. Our partnerships with these staff and subject matter experts allowed a health equity framework to be incorporated into the CDC-TA program.

Overall, the CDC-TA project aimed to support LHDs, enhancing their capacity to launch programs based on DOHMH's existing portfolio of opioid prevention and response initiatives. The technical assistance initially provided to LHDs included:

An in-person needs assessment conducted by CDC-TA at each LHD
The selection of programming, by LHDs, from the aforementioned portfolio of programming
Bi-weekly conference calls with each LHD
Monthly all site calls to build a peer-to-peer network
Work with NYC based anti-stigma expert to identify local stigma issues and develop surveys and campaigns to address the stigma surrounding substance use disorders
Ongoing access to research and resources provided by the CDC-TA team
A 3-day in-person summit hosted in NYC for sites to learn directly from leading experts and collaborate on their work

The NYC community, like many of our partner LHDs, was hit extremely hard by COVID-19. This presented incredibly unique challenges to the already vulnerable populations BADUPCT and our partners at the LHDs serve — people who use drugs (PWUDs). Even with the COVID-19 pandemic ongoing, the opioid crisis persists and presents challenges communities previously did not face. To name a few: COVID-19 restrictions on group sizes impacted encampments, closings, and changes to regularly scheduled hours affected how people could access care and treatment programs, and disruptions to the drug supply have led folks to seek out substances from unfamiliar sources.

LHDs, in addition to PWUDs, face unique challenges amidst a national emergency. LHDs staff have been reassigned from their usual scope of work to focus solely on COVID-19 related jobs. Unlike many of the partner LHDs, the CDC-TA team was exempt from being reassigned, which allowed the team to adapt the TA programming to fit the site's needs. With LHD staff limited in their capacity to continue their substance use programming as initially planned, the CDC-TA team created a new goal to fill in the gap. The CDC-TA team began developing and innovating new content for an online learning series covering the suite of technical assistance offered. This series also provided flexibility for NYC DOHMH staff focused on the emergency response, who were no longer readily available as a subject matter expert. Each module explains various initiatives or programs designed in NYC to respond to the opioid overdose crisis. Online learning, or e-learning, is an evidence-based practice focused on delivering education, "using a wide variety of instructional designs, including synchronous and asynchronous formats.".This learning style can be just as effective as face-to-face learning and expands access to learners with the addition of flexible scheduling (Lawn et al., 2017).

By innovating these modules, the TA team ensured that partner sites would have access to crucial substance use programming that could be completed on their own time, as many of the LHDs staff continue to be reassigned to focus on COVID-19 related tasks. These modules concentrate on the following topics:

Public Health Emergencies: Opioid Crisis and Covid-19
PDMP and Mortality Surveillance
MOUD: Low-threshold Buprenorphine, Naloxone, and Overdose Education
Syndromic Surveillance and RAR
The Relay Program and Evaluation
Anti-Stigma work
Communications (Knowledge Translation and Dissemination)

Initially, the TA was provided via site-to-site contacts (site visits, scheduled calls, and conferences) was time-limited and selective. This new style of delivering TA through an online learning series allows for flexibility and a more far-reaching impact, particularly in a time of crisis. The innovation of the first module, in particular, was useful and timely as it provided: concepts related to public health emergencies, LHDs roles and responsibilities, information about locating resources in an emergency setting, and a description of evidence-based practices as well as specific NYC DOHMH programs that adapted with the onset of the pandemic.The modules are being developed in coordination with subject matter experts and Pryco Solutions, a professional instructional design company, to provide subject-specific knowledge with a particular focus on health equity. These experts included Dr. Larry Yang, a leading expert in the emerging field of anti-stigma work, and other Race to Justice staff.

The CDC-TA project, including the modules, helps LHDs translate successful evidence-based programs to fit specific community needs, saving money, time, and resources that would otherwise be used to develop new, unevaluated programs from scratch. The evaluation of this particular TA program will be used to create a Best Practices Guide that will shape how TA is provided in the future.

Lawn, S., Zhi, X., & Morello, A. (2017). An integrative review of e-learning in the delivery of self-management support training for health professionals. BMC Medical Education, 17(1). doi:10.1186/s12909-017-1022-0

Evidence Based Practices References

Allen, B., Harocopos, A., & Chernick, R. (2019). Substance Use Stigma, Primary Care, and the New York State Prescription Drug Monitoring Program. Behavioral Medicine, 46(1), 52-62. doi:10.1080/08964289.2018.1555129

Nolan, M. L., Ehntholt, A., Merrill, T., Weiss, D., Lall, R., & Paone, D. (2019). Novel use of syndromic surveillance to monitor the impact of synthetic cannabinoid control measures on morbidity. Injury Epidemiology, 6(1). doi:10.1186/s40621-019-0210-2

Nolan, M. L., Kunins, H. V., Lall, R., & Paone, D. (2017). Developing Syndromic Surveillance to Monitor and Respond to Adverse Health Events Related to Psychoactive Substance Use: Methods and Applications. Public Health Reports, 132(1_suppl). doi:10.1177/0033354917718074

Welch, A. E., Jeffers, A., Allen, B., Paone, D., & Kunins, H. V. (2019). Relay: A Peer-Delivered Emergency Department–Based Response to Nonfatal Opioid Overdose. American Journal of Public Health, 109(10), 1392-1395. doi:10.2105/ajph.2019.305202

Stop Reinventing the Wheel: Helping Local Health Departments Address the Opioid Overdose Crisis

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