Drug overdose deaths , including those involving opioids, continue to increase in the United States. In the last two decades, the number of drug overdose deaths has quadrupled, rising from 16,849 in 1999 to over 70,000 in 2017 totaling more than 700,000 drug overdose deaths during this time period.1 The majority of these drug overdose deaths involved an opioid, including two-thirds of all drug overdose deaths in 2017.2 And the COVID-19 pandemic brought an unprecedented increase in overdose deaths, peaking in May 2020.3 An outbreak can be defined as a localized epidemic, where more cases than expected are noted in a specific area or group of people over a particular period of time. To support jurisdictions in identifying, assessing, and responding to overdose outbreaks the Centers for Disease Control and Prevention (CDC) funded the Council for State and Territorial Epidemiologists (CSTE) to develop a toolkit of resources for jurisdictions to improve the use of overdose surveillance data and guide public health prevention and response activities with the goal of reducing morbidity and mortality.
Purpose of the Toolkit
The purpose of this specific toolkit is to provide guidance, tools, and techniques featuring real examples of jurisdiction-based activities to epidemiologists and other public health professionals seeking to better prepare, detect, and respond to drug overdoses in their communities. The guidance presented in this toolkit reflects the tools identified and prepared through participation in the CSTE Overdose Spike Alert Advisory Workgroup, whose membership includes CDC, state and local health department representatives, and CSTE staff members and consultants.
Due to an ever-changing drug environment and an increase in lethal drugs there is a greater need to work more closely with public health response partners and law enforcement. Rapid identification and assessment of outbreaks are critical to respond to the opioid overdose epidemic, as are efforts to effectively prevent these events from occurring. Response partners include harm reduction, treatment program, and substance use disorder policy management. These responders must have the expertise and tools to quickly answer questions about the potential outbreak and put it into perspective.
An important point to consider initially is the scope of the outbreak. Below are a few key questions:
- Is this a small cluster of overdoses that is limited in scope, or is it a bigger problem?
- Is the outbreak evolving into an endemic problem or is it decreasing over time?
- Does it involve multiple states or counties?
(localized epidemic) - more cases of a particular disease than expected in a given area or among a specialized group of people over a particular period of time.
- Public Health Surveillance
It’s also important to consider what factors may be driving the outbreak. Below are a few key considerations.
- Has there been a change in the illicit drug market, such as increased supply of fentanyl in the heroin or counterfeit prescription market, increased distribution of extremely potent fentanyl analogs such as carfentanil, increased potency of illicit products due to changes in mixing of drugs, or adulteration of cocaine or other non-opioid drugs with fentanyl and other non-fentanyl synthetic opioids?
- Has there been a change in opioid prescribing or access to opioid prescriptions (e.g., closure of a pill mill)?
- Are there changes in polysubstance misuse patterns?
- Have use of illicit opioids or injection of opioids substantially increased?9
- What other new or different risk factors may have come into play?
- Are there demographic similarities between cases?
- Have there been an increase in related calls to poison control?
- Have other public health jurisdictions noted similar trends?
This Overdose Spike Toolkit is designed to provide responders with a comprehensive approach to conducting a timely and effective investigation in response to a notable increase in overdose deaths in a city, county, or region. This guide addresses overdose from both prescription and illicit substances but applies to other conditions as well (such as COVID-19, etc.). Specifically, the document and its resource links can be used to support a responder’s efforts to:
- Gather quantitative and qualitative data
Gather quantitative and qualitative data to aid in developing a public health response to an overdose outbreak including:
- Distributing naloxone
- Recognizing the need for multiple doses of naloxone to reverse some overdoses
- Development of public health messaging and recommendations to health professionals, law enforcement, harm reduction partners, and populations at risk.
- Identify key risk factors
- Characterize populations
- Support efforts
- Identifying strategies
- Provide situational awareness
- Have conversations
This Overdose Spike Toolkit includes resources, tools, and investigation steps that can support states’ efforts to respond to overdose outbreaks. The Toolkit begins with a review of key surveillance systems and their utility for overdose investigations. The Toolkit then describes and overdose investigation in a series of steps:
- Prepare for and detect a spike or cluster of overdoses
- Maintain situational awareness of drug overdose related threats
- Define and find related cases
- Generate hypotheses about likely causes using descriptive epidemiology
- Evaluate hypotheses with additional analyses to identify a source of the spike or cluster
- Institute control and prevention measures
- Decide when the spike or cluster is over or become endemic and maintain surveillance
- Communicate findings and conduct an evaluation of the investigation
- Identify and develop a plan to address lessons learned
CSTE was well positioned to provide technical assistance for two reasons: 1) CSTE serves as the professional home for almost 2,000 epidemiologists representing all 50 states, many territories and many local and tribal jurisdictions; 2) CSTE routinely provides professional development to the epidemiologic workforce through communities of practice and workgroups, toolkits, webinars and an annual conference. This toolkit reflects the CSTE mission to:
- Promote effective use of epidemiologic data to guide public health practice and improve health,
- Support effective public health surveillance and epidemiologic practice through training, capacity development, and peer consultation, and
- Develop standards for practice.
Organization of the Toolkit
The toolkit is organized around an alerting framework including 4 stages:
- 1.) Identify and Prepare Stage
During the Identify and Prepare stage the developing team identifies key stakeholders (includes response partners) to work with, explores spikes working with response partners, and decides the data sources and surveillance systems to be used. The team also will identify how spike occurrence(s) will be identified, and what condition(s) (in this case which overdoses) will be included. This stage includes all work that is done before an abnormal event, such as a spike, has occurred.
- 2.) Investigate Stage
- 3.) Respond Stage
- 4.) Evaluate Stage
CSTE Overdose Spike Toolkit December 2021. Retrieved from [insert web link].
This product was developed by CSTE and Thought Bridge, LLC with subject matter support and review from CDC. The Overdose Spike project and the associated toolkit was funded through CDC’s National Center for Injury Prevention and Control, Cooperative Agreement Number 1NU1ROT000018-01-00. The findings are those of the consultants and do not necessarily represent the views of the Centers for Disease Control and Prevention.
- Scholl, L. Drug and Opioid-Involved Overdose Deaths – United States, 2013-2017. MMWR 67, (2018).
- Hedegaard. H. Drug Overdose Deaths in the United States, 1999-2017. 8 (2018).
- Joseph Friedman and Samir Akre. COVID-19 and the Drug Overdose Crisis: Uncovering the Deadliest Months in the United States, January‒July 2020. AJPH 111, 1284_1291, https://doi.org/10.2105/AJPH.2021.306256