Issue

The drug overdose epidemic is a significant public health issue in the United States. The Centers for Disease Control and Prevention (CDC) Overdose Data to Action (OD2A) program aims to strengthen overdose surveillance, prevention, and evaluation efforts and use data to inform program improvements. Evaluation of OD2A strategies is required and vital for improving programs by demonstrating program effectiveness, understanding barriers and facilitators, and ensuring equity in service provision and access. Evaluation capacity varies across health departments implementing overdose prevention programs, which can make it more challenging to be responsive to the needs of the program.

Description

CDC Evaluation officers (EOs) created the Overdose Data to Action Evaluation Profiles Toolkit; eight profiles covering evaluation of specific overdose prevention topics. Each profile contains a description of the overdose prevention initiative, a logic model, a table outlining potential process and outcome evaluation questions, sample indicators, and evaluation methods. Each profile provides examples of programmatic data usage to produce actionable and timely findings. This session will provide an overview of the profiles’ development and utility.

Lessons Learned

CDC uses the evaluation profiles as a key resource in responses to requests for technical assistance from the field. Health departments funded by OD2A have shared that the profiles provide an intuitive structure that helps them facilitate participatory evaluation efforts with their overdose prevention partners. This, in turn, has increased engagement among partners. Health departments have also reported use of these profiles to develop health equity focused profiles or strengthen evaluations that attend to the needs of diverse populations and disproportionately affected groups.

Recommendations

As we seek to expand the evidence base for drug overdose prevention, it is important to prioritize the development and dissemination of evaluation tools and resources in the field to better understand promising practices and innovations that reduce drug overdoses.

Issue: Fatal opioid overdoses continue to rise in the U.S. Given the severity of the epidemic, substantial investment has been made to curb overdose and promote recovery across the nation. People with Lived Experience (PWLE) represent a knowledgeable group in the effects of opioid use disorder (OUD), as well as barriers to and facilitators of recovery. Yet, people with OUD are infrequently engaged in informing interventions to address OUD.

Description: The HEALing Communities Study (HCS) is a four-state randomized controlled trial to reduce opioid-related overdose deaths in participating communities. HCS employs a community-engaged, data-driven approach to select from a menu of evidence-based practices. During wave 1 of the two-wave study, some implementing communities noted slow uptake of new services such as medicines for OUD. Some communities implemented photovoice as a tool to engage PWLE to improve understanding of the local context of OUD and recovery support. Such understanding would inform selection and implementation of evidence-based practices.

Lessons Learned: Across three implementing states, 65 PWLE from 14 communities participated in photovoice. In one community, for example, the photovoice project identified community decline from employer departure and distance to OUD services as barriers to recovery. These results prompted implementation of a transportation program, and led to additional municipal funding for recovery services. Participants have scheduled to share results with state representatives and request recreation facilities for the community.

Recommendations: Engaging PWLE in photovoice to highlight barriers and facilitators to recovery in their community can provide unique insights that can be leveraged for recovery services. Photovoice is a compelling methodology to facilitate sharing of these insights and could be employed in other trials.

Background: To explore barriers and facilitators to opioid overdose prevention and surveillance work, the Pitt Public Health Evaluation Institute used a mixed-methods, community-engaged concept mapping (CM) approach with CDC-funded Overdose Data to Action (OD2A) partners. Beginning in June 2021, community partners participated in the 6-step process, including brainstorming factors that affected OD2A outcomes and sorting ideas into concepts. Using CM results, the evaluation team developed the Opioid Overdose Prevention Framework, a conceptual framework to describe and support the work of reducing fatal overdoses and racial disparities in overdose rates in Allegheny County.

Methods: Using CM data to evaluate barriers and facilitators to OD2A outcomes, we constructed a conceptual framework to describe how stigma and racism, factors rated as highly salient by community OD2A partners, crosscut and interact with all other factors. OD2A partners identified four primary factors for highest importance and future energy: Practical Resources, Staff-Related Factors, Community Factors, and Criminalization & Marginalization. These factors, all impacted by Stigma and Racism, are interrelated and overlapping, and exist in relationship with one another. Within the framework are concepts generated by partners, also rated highly in terms of importance and energy, to explain and guide the work of addressing the primary factors.

Conclusions: CM is a promising and novel approach to community-engaged evaluation of opioid overdose prevention and surveillance efforts. The Opioid Overdose Prevention Framework may be used to understand community perspectives and priorities for meeting the goals of decreased fatal overdoses and racial disparities in overdoses in Allegheny County. Future work will be more effective when all four factors are addressed as they relate to opioid overdose prevention and by incorporating and prioritizing anti-stigma and antiracist education, practices, and policies across all factors. The Opioid Overdose Prevention Framework can guide, support, and shift future community-, organizational-, and policy-level work.

BACKGROUND: Acute drug toxicity is a leading cause of death in the United States among persons experiencing homelessness or housing instability (e.g., transitional housing, motels, short stays with family). However, studies examining overdose deaths in this population have been limited in geography and lacked circumstantial data.

METHODS: Data on drug overdose deaths in 2021 were obtained from CDC’s State Unintentional Drug Overdose Reporting System (SUDORS) for 36 jurisdictions. Deaths were compared by homelessness/housing instability status using a chi-square test to evaluate count and percent differences in demographics, involved substances, medical history, and other circumstances.

RESULTS: Among 50,788 overdose deaths reported in 2021, 9.2% occurred among persons experiencing homelessness/housing instability (4,672), and 90.8% among persons not experiencing homelessness/housing instability (45,908). Opioids contributed to the majority of deaths in both groups (78.5% and 82.7%, respectively), with illicitly manufactured fentanyls (IMFs) involved in over 70% of all overdose deaths. However, a higher proportion of deaths among persons experiencing homelessness/housing instability co-involved stimulants and opioids (50.2% vs. 39.4%), largely driven by the high proportion of deaths involving methamphetamine (48.1% vs. 27.5%). A larger proportion of deaths among persons experiencing homelessness/housing instability also had evidence of injection drug use (29.1% vs. 18.5%), a recent emergency department visit (17.3% vs. 10.2%), and a recent release from an institutional setting (15.6% vs. 7.4%). In both groups, less than one-sixth of decedents had evidence of receiving treatment for a substance use disorder (SUD), and approximately one-quarter were reported to have a current mental health diagnosis.

CONCLUSIONS: Deaths from stimulant overdose, often with opioid co-involvement, have disproportionately impacted persons experiencing homelessness/housing instability. Diversification of overdose prevention efforts should include peer- and street-based harm reduction approaches and linkage to care for SUD and mental health.