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The COVID-19 pandemic has negatively impacted youth mental health, particularly as a result of school closures, social isolation, family economic hardship, fear of family loss or illness, and reduced access to healthcare. However, states have many strategies to choose from to improve youth mental health and reduce suicide.

The 2020 holiday season is coinciding with a nationwide surge of COVID-19 cases. With great concern that holiday travel to see loved ones may exacerbate community spread of the virus, many states are increasing public health measures before the winter holiday season. As of November 16, 2020, 13 states and D.C. had a quarantine requirement for out-of-state travelers. The U.S. territories also have instituted travel restrictions to limit the spread of COVID-19.

Reconciling the tension between public health and civil liberties is one of the most significant challenges of public health law and ethics. The Supreme Court of the United States historically upheld state authority to enact and enforce public health laws that temporarily limit a person’s civil liberties, such as quarantine and isolation powers that restrict a person’s freedom of assembly in order to prevent the spread of contagious disease. There have been many legal challenges to the public health orders issued to slow the spread of COVID-19—many of the claims asserting violations of First Amendment rights of assembly, association, and expression—but they’ve largely been rejected by the courts. However, courts have treated claims asserting violations of the free exercise of religion more favorably, which may indicate an impending shift in how courts analyze the impact state and territorial actions may have on religious organizations.

How the Emergence of Xylazine Impacts Overdose Prevention Policy overdose prevention policy, overdose crisis, fatal overdoses, emergence of xylazine, illicit drug supply, toxicological testing, withdrawal symptoms, xylazine test strips, drug paraphernalia laws, drug checking, legislative action, drug supply, substance use disorders, controlled substance, opioid use disorder, centers for disease control, health care, harm reduction services, psychoactive substances, department of public health, illegal drug, type of drug, opioid crisis, prescription opioid, astho, association of state and territorial health officials JoAnne McClure, Victoria Pless How states are considering overdose policy changes as xylazine continues to emerge in the illicit drug market. Developing and adopting policies to reduce fatal overdoses can help public health leaders address the ever evolving and complex national overdose crisis. More than 109,000 fatal overdoses occurred in 2022, with the majority involving illicitly manufactured fentanyl. Adding to the overdose challenge is the emergence of xylazine, a non-opioid tranquilizer (i.e., sedative), that is being increasingly mixed with fentanyl in the illicit drug supply. As of November 2022, xylazine was found in the illicit drug supply in 48 of 50 states and Puerto Rico. Xylazine is currently associated with one in ten fatal fentanyl (11%) overdoses, a near-threefold increase from 2.9% in 2019. Toxicological testing for xylazine is not uniform and, as a result, its involvement in fatal overdoses may be underestimated. Some states have taken initiatives such as Indiana (HB 1286) and South Carolina, to improve the consistency of toxicological testing for xylazine. With xylazine’s addition to the overdose crisis, states are beginning to adopt laws to better regulate the supply of xylazine and detect its presence in the illicit drug supply. What is Xylazine? Xylazine, also known as “tranq” or “tranq dope,” is a central nervous system depressant causing drowsiness, slowed breathing, reduced heart rate, and hypotension, which can increase the risk of a fatal overdose. Xylazine is approved for veterinary use in the United States but is not FDA-approved for human medicine. Xylazine, can be added to substances that are ingested orally, snorted, sniffed, or—mostly commonly—injected intravenously, and has been added to or used to cut heroin and fentanyl to prolong their effects. People who use drugs may be unaware of xylazine’s presence, which can put them at a higher risk of fatal overdose. Xylazine use is associated with skin ulcers, lesions, abscesses that left untreated, can lead to amputation. People who develop a physical dependency on xylazine may develop severe withdrawal symptoms. Although symptoms of xylazine use and opioid use are similar—making it difficult to differentiate whether someone has used one or both substances—overdose reversal agents (e.g., naloxone) do not counteract the effects of xylazine. Public health leaders still recommend that naloxone be administered for a suspected opioid overdose because xylazine has been detected in substances alongside fentanyl. For a person experiencing a xylazine-involved overdose, public health leaders emphasize the need to seek treatment beyond naloxone. In addition to public health’s work to address xylazine in the illicit drug supply, some state and territorial legislatures are expanding or protecting access to xylazine test strips as well as steps to limit access to xylazine through the state drug schedule. Legalizing Drug-Checking Equipment Drug-checking equipment, such as fentanyl test strips, are evidence-based interventions that allow a person who uses drugs to test their supply for an adulterated substance. State drug paraphernalia laws historically prohibited drug checking equipment, limiting the possession, distribution and use of items like fentanyl test strips. To make fentanyl test strips more widely available to prevent overdose, legislatures rapidly changed their laws to either explicitly legalize fentanyl test strips or generally legalize drug checking equipment. As of July 5, 2023 more than 33 jurisdictions legally authorize the use of fentanyl test strips, 12 of which (Alaska, Colorado, Guam, Maine, Maryland, Nebraska, New York, the Commonwealth of the Northern Mariana Islands, Pennsylvania, South Carolina, Utah, and Vermont) generally authorize the possession and use of drug-checking equipment. Similar to fentanyl, people may not know whether they are exposed to xylazine when using other substances, increasing the risk for harm. New test strips can detect the presence of xylazine, however state drug paraphernalia laws that criminalize drug checking equipment may limit the accessibility of xylazine test strips to prevent overdose. In 2023, at least three states—Illinois (HB 3203), New Hampshire (HB 287), and Utah (SB 86)—enacted legislation to authorize or decriminalize use of drug-checking equipment for fentanyl and xylazine, ensuring that xylazine test strips are lawful and able to be distributed. Additionally, states that previously passed legislation to allow for fentanyl-specific drug checking are amending their statutes to include all drug checking to ensure the legal possession of xylazine test strips. For example, Delaware enacted (SB 189) that specifically legalized xylazine test strips. Two other states—Vermont (H 222) and New Jersey (SB 3957)—enacted laws expanding the authorization of fentanyl test strips to allow for all harm reduction supplies, including drug checking equipment, which would permit the use of xylazine test strips. The Question of Scheduling Drugs are scheduled based on their acceptable medical use and potential for misuse and severe psychological and/or physical dependence, with drugs in Schedule I being the most tightly regulated. Xylazine is not a controlled substance under the federal Controlled Substance Act so it is not DEA scheduled or controlled. Nevertheless, xylazine is subject to FDA regulation under the federal Food, Drug, and Cosmetic Act and state law. Prior to 2023, only two states directly or indirectly scheduled xylazine. Florida codified xylazine as a Schedule I substance in 2016, and xylazine could fall under Massachusetts’ Schedule VI designation, which applies to prescription drugs. As state and territorial leaders take steps to schedule xylazine, policymakers should consider whether scheduling or other criminal penalties will deter people from seeking care if they fear being arrested for unknowingly testing positive for exposure or xylazine use. Another consideration for leaders before scheduling xylazine is whether scheduling will also make possession of test strips illegal under the jurisdiction's drug paraphernalia law. In 2023 at least nine states–Delaware (SB 189), Illinois (HB 3873), Louisiana (HB 106), Michigan (HB 4913), New Jersey (A 5448), New York (A 5914), Oklahoma (SB 668), Rhode Island (HB 5922), and West Virginia (SB 546)—considered legislation to schedule xylazine as a controlled substance. Of those, Delaware, Rhode Island, and West Virginia enacted laws scheduling xylazine in 2023. In addition to legislative action, at least two governors (Ohio and Pennsylvania) took executive action to schedule xylazine. ASTHO’s overdose prevention and state health policy teams continue to monitor these important public health issues. website yes

Do Cottage Foods Really Come from a Cottage? Beth Giambrone Even if you're not familiar with the term "cottage foods," chances are you have purchased them—think getting a loaf of bread from your weekend farmers market or cookies from a friend's home-based baking business. In some cases, they can also be sold online. So, what exactly are they? Cottage foods are home-based, home-made food products prepared outside a commercial kitchen and sold to the public. Cottage food producers operate at a small scale, often from a home kitchen, selling goods in the jurisdiction where they are created. Cottage foods are exempt from many state food and safety regulations, with supporters of expanding cottage food laws asserting that existing laws burden small business and restrict competition and consumer freedom. Those opposing the expansion of cottage foods argue the need to ensure food safety and to protect consumers from food borne illness. Here's a primer on cottage foods and how they're regulated. What's the difference between a cottage food kitchen and a commercial kitchen? Commercial kitchens (sometimes known as shared use kitchens) are large, industrial spaces where food can be produced in high volumes; they can also be rented out for shared use. While every state subjects commercial kitchens to food safety inspection and regulations, a few states require inspection of microenterprise or home kitchens producing cottage foods. Does the government have a role in regulating cottage foods? While several federal agencies regulate commercial food products—such as USDA for meat processing and FDA for produce—cottage foods are not subject to federal regulation because they are typically only sold within a state and not across state lines. At the state level, cottage food producers are subject to the health and safety laws and regulations of the state in which they are operating. Some states require cottage food producers to register their business or to have training and/or certification in safe food handling. Currently, all 50 states and Washington D.C. have some sort of cottage food law in place. Under most state laws, cottage food producers are exempt from food safety laws that apply to food establishments. These exempt rules are usually based on the type of food product produced, the point of sale, and the labeling requirements associated with the food. Although cottage food producers are exempt from certain requirements, all states allow the Department of Health to investigate complaints related to foodborne illness and fine producers if there are violations. Since the 2020 legislative sessions, at least 17 states (Alabama, Arkansas, California, Connecticut, Florida, Iowa, Illinois, Maryland, Missouri, Mississippi, New Hampshire, New Jersey, Oklahoma, Tennessee, Utah, West Virginia, and Wyoming) considered bills related to cottage foods, often centering around product sales, food products, and labeling. An overview of the conditions and a snapshot of the laws passed in states are below. What are common cottage food products? Most state laws limit which food products can be produced and sold as cottage foods. And while specific allowable foods vary state to state, some common restrictions on the type of food sold include foods requiring temperature control (e.g., meat and dairy products) and fermented or pickled foods. Foods such as dairy-free baked goods (e.g., breads and biscuits), candies, and jams are popular cottage food products. Over the last few years, states have expanded the types of foods that qualify to be a cottage food. In 2021, Illinois enacted SB 2007, amending the types of foods permissible under the cottage food law from a delineated list of canned foods (e.g. jams and syrups) to a general standard that mirrors the FDA definition of "low-acid canned food." The New Jersey legislature passed A 3991 in 2022 to exempt raw, unprocessed honey from the state's cottage food regulations. The bill is currently awaiting action by the governor. Oklahoma enacted its "Homemade Food Freedom Act" (HB 1032) in 2021. This new law allows any packaged food or beverage (excluding alcoholic beverages, unpasteurized milk, or cannabis products) to be considered a cottage food rather than only baked goods made without meat or fresh fruits. Additionally, the law allows beekeepers who produce less than 500 gallons of honey per year to qualify for the state's food freedom exemptions if the honey is produced from hives located in the state and sold directly to the consumer. Similarly, the 2022 "Tennessee Food Freedom Act" (HB 813/SB 693) broadly expands the types of homemade foods eligible for sale under the cottage food law to include any non-time/temperature-controlled food item or non-alcoholic beverage. What limitations do states place on cottage food sales? Most states limit cottage food producers to direct-to-consumer sales, such as at a farmers market or roadside stand. More than half of states allow online and direct-to-consumer sales as long as they are to in-state consumers only. While the producer is usually required to deliver the products, at least five states allow delivery by a third party. Several states have considered allowing the sale of cottage food in retail settings. In 2020, Wyoming enacted HB 84, which increased the gross sales cap for producers and allowed producers of non-temperature controlled foods (e.g., jams, vegetables, dried soup mixes) to use third-party vendors like a retail shop rather than solely relying on gross sales. Furthermore, the Wyoming legislature expanded the use of third-party vendors to include the sale of eggs in 2021 by enacting HB 118. A 2021 Arkansas law (HB 248) also allows for the sale of cottage food products at retail stores. Additionally, many states define cottage foods based on the number of items sold or the annual gross sales. The gross sales cap limits vary greatly across states, ranging from $3,000 to $250,000. At least twenty states have no gross sales limit. At least one state (Ohio) places a limit on meals sold per week from home kitchens. What are common labeling requirements for cottage foods? Most states require cottage food producers label their goods. While specific labeling requirements vary state to state, producers generally must provide the name of the product, a list of ingredients, known allergens (e.g., nuts), contact information of the producer, and a statement declaring the product was made in a kitchen exempt from licensing and inspection regulations. In some states, cottage food producers are allowed to use an identification number in place of contact information on product labels. Maryland enacted HB 1017 in 2020, which allows cottage food producers to use a unique identification number issued by the Department of Health in lieu of the business name and address. Arkansas HB 248 (referenced above) also allows producers to use an identification number. What's next? State policy surrounding cottage foods is constantly evolving, with more foodstuffs exempt from state food and safety regulations increasing the risk of foodborne illness outbreaks necessitating a public health response. ASTHO will continue monitoring these changes and provide relevant updates. website yes

As the number of COVID-19 vaccinations grows, some states are looking at their vaccination rates to determine when to loosen measures that mitigate the spread of COVID-19, such as venue capacity limits, business closure times, and masking requirements. As vaccinations allow businesses to reopen and customers to return, questions have arisen about whether venues or services—especially those that bring people in close contact for long periods of times—such as retail stores, concert venues, entertainment venues, air travel, cruise ships, etc., can require patrons or customers to verify that they received a COVID-19 vaccine. So far, state policy makers have had mixed views on the issue.

Approximately 700 women die annually in the U.S. between 2007-2016 as a result of pregnancy or its complications, according to CDC data. This is one of the highest maternal mortality rates in the developed world. On top of that, there are stark disparities along racial lines, with Black and American Indian/Alaska Native women having higher rates of pregnancy-related deaths compared to white women.

ASTHO staff identified a range of evidence-supported policies considered by state legislatures that could prevent ACEs. This report synthesizes these research and policy proposals and is intended for public health practitioners and policymakers who are considering adopting similar policies.

Examining state and federal policies to increase access to tele behavioral health services.

Continuing ASTHO’s Legislative Prospectus series—which highlights the top 10 public health policy issues for 2022—this post focuses on mental and behavioral health, as well as supporting the public health workforce.