ASTHO conducted focus groups to examine overdose-related issues and identify potential engagement opportunities for public health and public safety around overdose prevention. This brief outlines key takeaways and is designed to serve as a guide for public health building and strengthening relationships with public safety.
The opioid crisis continues to claim the lives of thousands across the United States and has cost the economy billions in health care, mortality, and criminal justice costs. In 2018, it’s estimated that 67,367 people died of overdose, with opioids (prescription opioids, heroin, and other synthetic opioids other than methadone) made up almost 70% of overdose deaths. Provisional data for the twelve-month period ending December 2019 shows that there were 71,130 overdose deaths, with 50,178 overdose deaths attributed to opioids. The COVID-19 pandemic has also exacerbated the drug overdose crisis. Data shows that in the time of continued lockdowns and social distancing that overdose rates have increased, indicating a sustained need to support people with substance use disorder.
Learn how Hawaii and Iowa have leveraged policy change to improve overdose prevention.
How to Support Youth Post COVID-19 With More Flexible Policies Caitlin Langhorne Griffith, Victoria Pless, Martha Yeide Over the past few months, COVID-19 has highlighted how current policies and funding do not support an equitable approach to health. However, states and territories have begun to leverage statutory and regulatory flexibilities to improve health outcomes for the disproportionately affected during this pandemic. One of the ways that states and territories can support these groups and maximize these flexibilities during and post-COVID-19 is by deploying a Shared Risk and Protective Factor (SRPF) Framework to address negative health outcomes. Research has demonstrated that addressing both the risk and protective factors across sectors can lead to multiple improved health outcomes, including heart disease, asthma, depression, and substance use. Because youth are at increased risk of exposure to Adverse Childhood Experiences (ACEs), and have fewer supportive resources, they are a particularly vulnerable group potentially affected by COVID-19 policies and funding. ACEs are a risk factor shared across numerous health outcomes, such as substance use disorder, chronic disease, and mental health. However, implementing the SRPF Framework can promote protective factors in upstream ways, like reducing and mitigating the impact of ACEs. During the COVID-19 response, some areas where state officials can take advantage of policy flexibilities to better support youth and reduce some ACEs include youth experiencing food insecurity, youth with incarcerated parents, and youth witnessing violence in the home. Ultimately, these examples illustrate the benefits of extending innovative policies to decrease negative outcomes and promote health across the lifespan beyond COVID-19. Youth and Food Insecurity Food insecurity is a public health issue that plagues the United States and has been associated with negative health outcomes including obesity and unhealthy brain development. More than 11 million children in the U.S. live in food insecure homes, with an estimated 11 percent of households reporting food insecurity at least some time during 2018. New data show that food insecurity has increased for youth during the COVID-19 pandemic, with almost one in five of mothers — 17.4 percent —with children ages 12 and younger reporting their children were undereating because they could not afford enough food. When state officials closed schools to prevent the spread of COVID-19, food access was upended for youth who participate in free-or-low-cost school meal programs. States can mitigate this disruption by safeguarding access and expanding these programs to ensure the continued physical and mental development of youth. Jurisdictions have implemented innovative practices allowed under expanded flexibilities to ensure that youth receive regular nutrition during COVID-19. Vermont is conducting telephone appointments for the Women, Infants and Children (WIC) nutrition program due to social distancing, and has also expanded the list of foods available through WIC during the COVID-19 pandemic. Forty-seven states and territories have implemented the Pandemic Electronic Benefit Transfer (EBT) benefit passed as part of the CARES Act. This allows households to offset the cost of meals that would have been consumed at school by youth. Wyoming has adapted its WIC program services, which includes providing curbside deliveries and conducting phone screenings. Youth with Incarcerated Parents It is estimated that between 1.7-2.7 million youth have incarcerated parents. This leaves them at a higher risk of adverse outcomes, including mental health problems, poor school-based outcomes, and increased antisocial behavior later in life. Parental closeness between incarcerated parents and youth can be an effective strategy to promote resiliency, and jurisdictions are implementing programs focused on connecting the incarcerated individuals with loved ones. The Pennsylvania Department of Corrections has created a virtual visitation program for all state-run facilities, and all inmates are eligible to participate. In Connecticut, organizations such as Children with Incarcerated Parents have created programs that provide free calls with incarcerated parents each month during the COVID-19 pandemic. Other innovative avenues to connect children with incarcerated parents include the Governor of Illinois issuing an executive order suspending the transfer of some inmates from county jails into the Illinois Department of Corrections during the public health emergency. This approach may increase the likelihood that inmates remain geographically closer to home. Washington executive order 20-47 suspended statutes that limit an individual’s ability to receive post-conviction relief, as well as prosecutors’ and courts’ ability to file and process criminal cases. Washington executive order 20-50 broadened the Governor’s authority to grant clemency to reduce the prison population. New Jersey Gov. Phil Murphy issued an executive order establishing an Emergency Medical Review Committee, which will review which inmates can be released to home confinement—identified by the Board of Parole—and outlined the process for ensuring those who are released are aware of reentry benefits. Youth Witnessing Violence in the Home Witnessing violence at home also is associated with a higher risk of negative health outcomes, as well as experiencing or perpetrating violence later in life. "Stay at home" or "shelter in place" orders during the COVID-19 response has corresponded with increased risk of family violence and increased calls to domestic violence hotlines, posing another public health crisis as many children have been exposed to violence in their homes. While trends also show a decrease in reports of child neglect and abuse, this decline may be due to restrictions on the child welfare surveillance systems that monitor and intervene in situations of abuse and neglect. State lawmakers have offered help to those experiencing domestic violence, despite restrictions on travel. Massachusetts and Maine ordered all state hotels to only provide rooms for vulnerable populations or essential workers, including those that may be experiencing domestic violence. New Hampshire established the COVID-19 Emergency Domestic and Sexual Violence Services Relief Fund for shelters across the state to aid those who may be experiencing domestic or sexual violence. Nevada developed a process for individuals to file online temporary domestic violence protective orders. The District of Columbia developed a process so individuals can file an extreme risk protection order through an online form and phone call, which can remove firearms from individuals who may be dangerous. Finally, California released a safety planning guide for those who may be experiencing domestic violence. The COVID-19 response has prompted states to provide flexibilities in funding and suspend or modify policies that would have made it more difficult to protect the public’s health — and in turn would have exacerbated negative health outcomes among youth. Through innovative practices these efforts have worked to mitigate the negative impacts of food insecurity, youth with incarcerated parents, and youth experiencing violence in the home. Health officials can be at the forefront of this innovation to ensure that protective factors are leveraged to reduce disparities and impact multiple outcomes with upstream approaches for youth. website
Supporting policies that reduce HIV stigma and promote health equity is an important public health issue.
State and territorial health agencies continue to be challenged by the opioid epidemic, which has been exacerbated by the COVID-19 pandemic. Addressing the opioid crisis requires a robust public health response, which could be helped by resources from pending and future opioid settlement funds.
Every year in mid-July is National Youth Sports Week—in 2021 it falls on July 19-23. It’s an important health observance because youth sports create strong connections with peers and caring adults, as well as promote socio-emotional skills and positive well-being. The Office of Disease Prevention and Health Promotion’s National Youth Sports Strategy outlines policies and strategies that support access to youth sports. NYSS Champions, including ASTHO, work to promote participation and recognize the positive health outcomes sports can have on youth, such as limiting the impacts of adverse childhood experiences and building resiliency.
This article in the Journal of Public Health Management and Practice addresses the syndemic of substance misuse, viral hepatitis, sexually transmitted infections, and mental health conditions. The technical package outlines evidence-based policies for state health officials to address public health issues, including improved health outcomes, increased access to treatment and services, and increased awareness of policy options.
Drawing on the current evidence base, promising practices, and ASTHO member experiences, this article outlines strategies and policies that public health leaders can implement to respond to overdose in their jurisdictions.
Overdose Prevention Policy Considerations: A Policy Playbook for State and Territorial Health Officials and Agencies overdose prevention, drug checking equipment, syringe services, health equity, reducing stigma, discriminatory policies, marginalized groups, war on drugs, underfunded communities, people of color, health care, substance use disorders, department of health, social determinants of health, illegal drug, drug enforcement administration, drug treatment, prevention strategies, federal government, federal agencies, prescription opioid, person of color, public safety, astho, association of state and territorial health officials Victoria Pless, Kayley Humm, Kaela Hurd, Arieana Love The widening racial and socioeconomic disparities in drug overdose death rates underscore the pressing need for health equity and reduced stigma in overdose prevention strategies. In addition, ongoing challenges in the illicit drug supply necessitate adjustments to overdose response protocols. State and territorial health agencies can play a crucial role in these efforts. This report details four key policy considerations that can help to prevent overdose, with a special emphasis on addressing health equity and reducing stigma. Get the Report (PDF) website yes
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
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Toxic stress contributes to a variety of negative outcomes for children. And unfortunately, COVID-19 has increased the likelihood of children experiencing childhood trauma, adverse childhood experiences (ACEs), and toxic stress. States and territories should have programmatic, and policy mechanisms to both prevent and mitigate the lifelong effects. A CDC Vital Signs Report found that preventing or mitigating ACEs could reduce depressive disorder by 44%, smoking by 33%, and unemployment by 15%.