The New York City Department of Health and Mental Hygiene (NYC DOHMH) is one of the world's largest public health agencies, serving over 8 million New Yorkers. NYC DOHMH's Bureau of Alcohol and Drug Use Prevention, Care and Treatment (BADUPCT) works to reduce morbidity and mortality related to alcohol and substance use among New Yorkers through contracting and oversight of prevention, treatment, harm reduction, and recovery and support services; policy analysis and development; epidemiology, surveillance, and evaluation; development and dissemination of treatment and management guidelines; harm reduction initiatives; public and provider outreach and education; and community involvement and interagency collaboration. Within BADUPCT is the Center for Disease Control Technical Assistance (CDC-TA) team that supports local health departments (LHDs) across the country to implement successful programs and strategies to tackle the opioid overdose crisis in their communities. Based on evidence-based initiatives developed by BADUPCT, the CDC-TA team adapts this programming to fit the unique needs of the partner LHDs and their respective communities. The CDC-TA team collaborates closely with the National Association for County and City Health Officials (NACCHO), the funding partner, to support the partner sites in meeting their grant-funded deliverables and objectives.

The CDC-TA team provides the partner LHDs with information and assistance for a suite of evidence-based programs including, hospital-based non-fatal overdose response (Relay), prescription drug monitoring programs (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. The TA is delivered through various modes, including individual calls, all-site calls, and an immersive summit hosted in NYC in March 2020.

Partner LHDs adapted at least one evidence-based strategy or program developed by NYC DOHMH, collaborated, and shared experiences with other partner sites to build a peer-to-peer network of health departments doing substance use work. Through introspection, they also identified and evaluated their existing practices so that the CDC-TA team could provide program-specific support. Additionally, all sites examined stigma within their communities with the help of an anti-stigma subject matter expert. Each site conducted surveys to assess the stigma of a population or demographic of interest within their community. Depending on specific site restraints (capacity, funding, political will, etc.), the CDC-TA team recommended that sites develop a media campaign, per the survey results, to address knowledge, attitude, and beliefs within their community. In addition to addressing stigma, these campaigns would help address health inequities within the LHDs communities by promoting access to harm reduction and treatment services. 

With the onset of the COVID-19 pandemic, in-person site visits were put on hold indefinitely. To account for this, the CDC-TA team has been developing an online learning series that covers the entire suite of BADUPCT technical assistance programming. Overall, with the community partner's help, the CDC-TA team created seven asynchronous learning modules that will be freely available online through NACCHO University— not limited to the partner LHDs included in this specific CDC-TA project. The modules will allow health departments across the country to access and learn from NYC DOHMH programming, broadening the TA project's reach and ability to disseminate successful strategies to tackle the opioid overdose crisis while reducing health inequities.

Simultaneously, a comprehensive evaluation is being conducted by a professional consulting firm, Joslyn Levy & Associates. This evaluation aims to understand how well the CDC-TA project addressed the six sites' needs and how well these sites integrated the CDC-TA into their ongoing interventions or used the CDC-TA as a starting point for implementing new interventions to address the opioid crisis in their communities. 

This practice was successful, in part, because of the community partnerships, stakeholder buy-in, and the ability to translate the already existing evidence-based NYC DOHMH substance use programs to fit the specific needs of the various communities. Additionally, due to the impact COVID-19 had on the LHDs' capacity to continue this programming, the flexibility and adaptability of the partner sites and the CDC-TA team was imperative. Lastly, the practice built peer-to-peer networks between the partner sites that can be sustained over time.

Supporting LHDs to develop and enhance their capacity to launch programs based on the DOHMH's existing portfolio of opioid prevention and response initiatives will help reduce the burden of unintentional opioid overdose deaths nationally. Additionally, with the creation of the free online learning series, health departments across the country, not initially included in the TA program, will have access to this evidence-based substance use programming, allowing for a more far-reaching, sustained impact.

NYC DOHMH website: https://www1.nyc.gov/site/doh/index.page

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:

1. Public Health Emergencies: Opioid Crisis and Covid-19
2. PDMP and Mortality Surveillance
3. MOUD: Low-threshold Buprenorphine, Naloxone, and Overdose Education
4. Syndromic Surveillance and RAR
5. The Relay Program and Evaluation
6. Anti-Stigma work
7. 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

The CDC-TA project aims to increase LHDs' capacity to respond effectively to the opioid overdose crisis by exploring, planning, and implementing innovative and collaborative approaches within their respective communities. This project is currently under-going a rigorous evaluation by an evaluation consulting firm, Joselyn Levy & Associates, to understand better if the goals and objectives of this project were met. 

Six LHDs were funded through the Centers for Disease Control and Prevention (CDC) for two years beginning in March 2019 to implement or improve interventions to address the growing opioid overdose epidemic in their communities. The National Association of County Health Officials (NACCHO) is administering the project across the six counties, and BADUPCT provides technical assistance through the CDC-TA team. The six LHDs were divided into two cohorts. The first cohort began in March 2019 and includes Tarrant County, TX (Fort Worth), Houston, TX, and Minneapolis, MN; the second cohort started in August 2019 and includes Seattle, WA, Denver, CO, and Marion County, IN (Indianapolis). This iteration of CDC-TA, for both cohorts, ends on February 28th, 2021. 

As a first step in understanding the needs of the six LHDs, the CDC-TA team worked with each health department to develop a Needs and Assets Assessment. These assessments considered the LHD's capacity, community resources, partnerships with other agencies and stakeholders, and the political and social context of the work that each site is doing to address the opioid crisis. The Needs and Assets Assessment format varied slightly for each of the two cohorts, and the topics covered had a somewhat different emphasis and weight across the cohorts. However, both surfaced issues that are important to consider when evaluating the selection, implementation, and potential impacts of LHD interventions for addressing the opioid crisis.

The work that the CDC-TA team engaged in with the six LHDs in the early stages of the grant period helped ensure that each LHD had clear objectives, goals, and deliverables for NACCHO and provided them with a comprehensive assessment of their communities needs and assets. The bi-weekly calls with each LHD highlighted areas where the CDC-TA team could focus their efforts in identifying and developing TA materials, connecting the LHDs with subject matter experts, and facilitating connections between the six health departments. This early work helped the CDC-TA team identify areas with the highest need for TA and develop a strategy for continued engagement to ensure progress for each LHD toward reaching their goals in addressing the opioid crisis in their communities.

Each of the six LHDs had received grants through NACCHO to implement interventions to address their community's opioid crisis. The CDC-TA team, which is also grant-funded through NACCHO, was created to complement the LHDs funding. Each of the LHDs receives this funding by completing their NACCHO deliverables, which varies depending on their Community Action Plan. 

The CDC-TA team worked with various stakeholders, in addition to the LHDs. Specific stakeholders were involved from the beginning, including NYC DOHMH leadership, subject matter experts, and Race to Justice staff. As the TA project evolved, primarily due to the COVID-19 pandemic, innovative partnerships were needed. The CDC-TA team re-allocated resources from the travel budget to hire a professional instructional design company, Pryco Solutions, to develop the modules. This relationship was imperative as Pryco Solutions had the knowledge and extensive experiences developing and designing online learning experiences for adults through comprehensive education and learning theories (allowing for our modules' easy understanding). The CDC-TA also built a new partnership with NACCHO University to disseminate the modules to a broader audience. These new partnerships allowed TA to be provided innovatively at no charge and no time-limit for accessing the modules. Additionally, by translating and sharing this information to both the partner sites and other settings (including potentially under-resourced communities and municipalities), the practice of providing technical assistance is more equitable and far-reaching.

The CDC-TA project's costs include consulting with subject matter experts, hiring an evaluation consulting team, JLA, developing modules with Pryco Solutions, and NYC DOHMH leadership who supervise this project. Although there were various costs associated with this practice, it is likely cheaper to translate an already existing program rather than creating an entirely new program that has not been proven successful. Similarly, developing the modules has incurred an up-front cost, but they will be free to maintain through NACCHO University and DOHMH and are freely available to public health professionals and the public nationally. 

Currently, a process and short-term outcome evaluation are underway with an external evaluation consulting team, JLA. The evaluation aims to understand how well the CDC-TA addressed the needs of the six sites and how well sites were able to integrate the CDC-TA into their ongoing interventions or use the CDC-TA as a starting point for implementing new interventions to address the opioid crisis in their communities. The evaluation will address lessons learned and help inform best practices for implementing similar strategies in other jurisdictions and sustaining and scaling similar projects within NYC DOHMH. The results will be in a format that allows incorporation into a future best practices guide for providing TA to local health departments (LHDs).

The evaluation will focus on the following principal questions:

1. What characteristics or factors related to the municipality, the LHD, and the LHD's engagement with community stakeholders might impact the successful planning and implementation of chosen strategies?

2. What are the primary facilitators, barriers, and challenges around engaging and utilizing the TA provided?

3. How useful was the CDC-TA content and delivery mode to the sites in their planning and implementation efforts?

The evaluation will combine a review of each site's key objectives and interventions with a series of key informant interviews. The review will synthesize the information detailed in the Needs and Assets Assessments and the Community Action Plans, including the objectives and activities proposed by each site, each site's goals, resources and context, and the requested CDC-TA. This information will be supplemented by key informant interviews with participants from the six LHDs, NACCHO representatives, the CDC-TA team, and subject matter experts who provided additional support, including BADUPCT staff and Dr. Larry Yang. All interviews, both group and individual, will be conducted in January 2021.

Partner collaborations are vital to the success and sustainability of this program. It was essential to understand the contexts of each partner LHD. Across the country, county and state governments have different approaches in addressing the opioid crisis, and their allocation of resources varies based on these approaches and local circumstances. These observed differences note vastly different policies and interventions that comprise the varying political climates for the six LHDs. While a few have strong support from their local and state governments to address the opioid crisis with innovative and aggressive interventions, others have minimal support from their local governments. These differences are apparent in state laws that directly address or impact the opioid crisis. For example, the protections afforded by Good Samaritan laws related to opioid overdoses vary widely from state to state. Similarly, while naloxone is legally available across the six counties in this initiative, the extent to which states promote naloxone access and use vary. Understanding these differences allowed for more tailored TA to be provided to each LHD. 

Throughout the project, the CDC-TA team focused on building a peer to peer network among the LHDs. This network allows for a sustained network of local health departments to foster collaboration regarding substance use programs long after the grant funding period is over. The six local health departments involved in this project and other LHDs not included will also have access to the free online learning series hosted by NACCHO University. Partner LHDs and other sites can visit and re-visit the CDC-TA programming as needed, making the program more sustainable over time. These modules can adapt, if necessary, to fit the needs of a changing opioid epidemic, as new NYC DOHMH substance use programs become evaluated. 

The evaluation findings will be incorporated into the next series of CDC-TA programming, starting early in 2021 through NACCHO's IOPSLL grant, along with a Best Practices Guide for this unique type of collaborative work.