In this journal club, a medical student and an addiction psychiatrist review a thematic analysis of successful prevention efforts in states with declining rates of opioid-related overdose deaths.
In 2016, drug-related overdoses became the number 1 cause of death in Americans under 55 years of age,1 with opioids as the primary culprit. Although significant state-by-state variability exists, with some geographical areas impacted more than others, opioid-related overdose deaths have been a national epidemic with the death rate at historic highs in the first quarter of 2021.2 Aside from federal legislative efforts, states have independently implemented policies and deployed resources to address this issue. Interestingly, some states that had high overdose deaths in 2016 experienced a drastic decline in 2017 upon implementation of prevention and response efforts. In this article, the authors qualitatively examine the efforts of these successful states and look for common denominators.3
Question: What are the core elements of overdose prevention and response activities in states with high rates of opioid-related overdose deaths that experienced a decrease in overdose deaths from 2016 to 2017?
Type of Study: Retrospective qualitative thematic analysis of successful states’ overdose prevention programs based on predetermined categories to organize their activities.
Population: Individuals from Massachusetts, New Hampshire, New Mexico, and Utah who died by opioid-related overdose from 2016 to 2017 and who have been reported to the Centers for Disease Control and Prevention (CDC)’s Wide-ranging Online Data for Epidemiological Research.
Methods: Mortality data from the CDC was used in identifying the 25 states with the highest age-adjusted opioid-related overdose mortality rates in 2016. Only the 4 states that experienced a decrease in age-adjusted mortality rates from 2016 to 2017 were selected for analysis. The authors then used data from the 4 states’ progress reports (generated for the CDC as condition of their funding), to identify overdose-related programs and their outcomes. This was supplemented by an environmental scan of websites and other strategic planning documents to further capture information on overdose prevention and response. Three of the authors then compiled draft program narratives summarizing their findings. Ten predetermined categories developed according to the 3 authors’ reviews and supplemented by CDC’s recommended prevention strategies were used to organize activities implemented by each of the 4 states. For each of the states, overdose program implementers were also tasked to review the draft program narratives to ensure accuracy and comprehensiveness. Data regarding historical progression of some of the efforts pre-2016 was also considered.
Statistical Analysis: The 3 authors performed a systematic content analysis of the completed program narratives using an iterative thematic approach to coding to elucidate prevention activities and to generate hypotheses for further research. Analysis used the organizing categories as the first level in the hierarchical coding framework. The authors distilled descriptions of each activity in a category into thematic codes to identify common themes across multiple program narratives, which were then used to identify activities implemented by all 4 states (dubbed “core activities”). Additionally, thematic codes that did not occur across all 4 programs narratives yet were believed by the 3 authors to exemplify approaches tailored to the local content were used to identify context specific activities (“additional elements”).
Results: From the predetermined categories, the following core elements of overdose prevention and response were identified: comprehensive state policies; strategic planning; local engagement; data access, capacity, and dissemination; targeted training for professional audiences; treatment infrastructure; and harm reduction (Table).
The authors also developed a list of additional elements that some states utilized. These includes ways to handle populations with needs uniquely specific to the area (rural communities, homelessness, ethnic/minorities such as Hispanic or tribal populations, diversion/drug courts). All 4 also described various approaches to public awareness through campaigns specific to the local context and hotlines for access to resources. Although the approaches differ, they all focus on linkage to treatment resources (ie, the hub-and-spoke model in New Hampshire or the peer support and coaches in New Mexico and Massachusetts).
The Bottom Line: Data from the opioid epidemic serves as a valuable opportunity to understand how states can be successful in their efforts towards overdose prevention and response. The authors identified comprehensive state policies, strategic planning efforts, local engagement, data collection and dissemination, targeted training for professional audiences, treatment infrastructure, and harm reduction, as the core elements of overdose programs in states that experienced a decline in the rate of opioid involved overdose deaths from 2016 to 2017. These elements contribute to successful overdose prevention and responses, and such activities can be extrapolated to other public health crises beyond just the opioid overdose epidemic, especially as new drug threats emerge.
Comments: This study represents an attempt at elucidating the core elements of successful overdose prevention and response programs. These can broadly help states consider new policies, partnerships, and activities to enhance their own programs against the current, and future, overdose deaths. Comprehensive policies, timely dissemination of key data, and building capacity through training, treatment infrastructure, and harm reduction activities are prevention efforts shared by the 4 successful states; however, each state tailored its programs to its own context, with emphasis on the needs of the target population. These elements are also enmeshed by partnerships and collaborations among various segments of the public health response and public and private sectors. The 4 states had robust foundations of multifaceted policies (ie, Good Samaritan laws, PDMP access, and policies to enhance naloxone distribution) which preceded the development of programmatic efforts.
In addition, all 4 states also had comprehensive strategic planning at both state and local levels in the form of commissions, workgroups, and advisory committees. Another common theme was the local engagement by state health departments, which facilitated support and capacity building via technical assistance (implementation and evaluation of prevention activities, using data to inform interventions, and disseminating evidence-based data to inform interventions). Aggregating data also allowed for targeted identification of populations disproportionately affected and interventions. Training pharmacists, law enforcement, and other professional audiences as well as using harm reduction activities (such as syringe and naloxone distribution) were also strong building blocks.
It is important to note that all 4 states evaluated received opioid-focused funding from the CDC, as well as from other federal and nonfederal sources, in order to implement prevention and overdose reduction strategies, and/or to improve overdose data collection.
The question is, are these findings generalizable to other drug related overdose deaths or epidemics? This is one of the limitations—yet of importance given that we are currently also dealing with a quiet methamphetamine overdose epidemic that is quietly on the rise.4 The 4 states had program narratives that included description of drug overdose more broadly, beyond just opioids, which is reassuring.
6 Additional Limitations
- Applicability to overdose prevention programs in other states. It does not address whether states that did not see a decrease in opioid related mortality shared the same core elements in their overdose prevention programs with those states that did. This information is necessary to determine both the importance of certain core elements when it comes to decreasing mortality and the applicability of these core elements in other states. If other states were found to have implemented the same core elements and failed to see a decrease in opioid overdose mortality, it would limit the external validity of this study.
- Longitudinal view of the outcomes. The scope of the study was focused on states with decreased opioid overdose mortality from 2016 to 2017. However, it should be asked whether the states involved in the study experienced a plateau or a further decrease in their opioid overdose mortality in subsequent years. If a state involved in the study was found to have an increase in their opioid overdose mortality in subsequent years, it may indicate that the drop in deaths from 2016 to 2017 was a natural fluctuation. Additionally, it would bring into question the possible correlation between decreased overdose mortality and the implementation of the core elements identified.
- The selection of states investigated in this study is not fully explained in the methods section. It was not discussed how the 4 states with decreased overdose mortality were selected from the 25 states with the highest mortality rates that were included for consideration. Additionally, the paper fails to identify the absolute or relative decrease in overdose mortality that the included states experienced. Although this is separate from the main goal of the paper, this information could be pertinent to how the findings may be interpreted. If one of the included states experienced a decline of 20 opioid deaths from 400 deaths in the previous year, this would be a 5% decline but may be more likely a product of variability and less likely related to the implementation of the core elements discussed due to the low change in absolute mortality.
- Variability between states in reporting opioid-related overdose deaths to the CDC. Because of this, the death rates used to identify the 25 states with high rates of opioid overdose mortality and those 4 states who saw a decrease in opioid overdose mortality from 2016 to 2017 may be underreported in some states more than others. More information on how these states, especially the 4 with decreased opioid overdose mortality, report deaths to the CDC could support the finding that mortality decreased in these states and was not a result of underreporting. This variability exists because states have different policies and capacities for postmortem testing. For example, some state laboratories may not evaluate the deceased for synthetic opioids, like fentanyl, or may avoid toxicology screens altogether in certain situations. Another possible confounding factor revolves around the reported cause of death. Some opioid related overdose deaths may not be reported to the CDC as an overdose, but instead could be reported as a related cause like anoxic brain injury. Given interstate variability in reporting, it may be pertinent to acknowledge how the 4 states identified in this study report their opioid overdose deaths to the CDC and how this reporting compares to the other 25 states with high rates of opioid overdose mortality.
- The paper does not detail how the 10 categories they used to organize activities in overdose prevention program narratives were determined. It mentions that categories were developed by the authors’ review of data obtained by the preliminary environmental scan and informed by CDC’s recommended evidence-based prevention strategies, but it does not explain further how the authors came to the conclusion to use the 10 categories listed. Given that the 7 core elements are derived from these 10 categories, it would be relevant to address how the authors decided upon them. This would provide readers with better insight into this study and could serve to validate the choice of the 10 categories.
- This study mentions that only activities with opioid-related CDC funding were included and that separate nonfederal and federal non-CDC donations may have been made that were beyond the scope of the study. Such donations, however, could have had a substantial impact on additional activities in the states that experienced a decrease in overdose mortality. Although the purpose of the study was not focused on attributing changes in overdose mortality to any particular funding, choosing to ignore these other sources may influence what activities were identified as the most prominent or impactful, since only a subset of activities is being investigated. Even within the states included in the analysis, authors state that CDC funding varied with 3 states receiving funding for both implementing prevention strategies and improving data collection, while New Hampshire only received funding to improve data collection. Identifying if the states being investigated had additional funding, and how this funding compared to the funding in other states, would be relevant to interpreting the results of this study. If states were working with similar amounts of funding, it would detract from the number of possible confounding factors in this study. If funding was not similar across states, it still may be pertinent to compare the states that had decreased opioid-related overdose mortality from 2016 to 2017 to other states that did not experience a decrease but who had a similar amount of funding. This could help either elucidate more core elements or strengthen the argument for those identified in this study.
Despite the limitations, this is an important study with the data providing valuable insight. Since the beginning of the COVID-19 pandemic, overdose related deaths are once again on the rise with a 20% increase noted in the 12-month period ending last June. The 4 states evaluated here interestingly sustained much lower numbers of deaths compared to the national average.5
Dr Stanciu is assistant professor of psychiatry at Dartmouth’s Geisel School of Medicine and Director of Addiction Services at New Hampshire Hospital, Concord, NH. He is Addiction Section Editor for Psychiatric TimesTM. William Fletes is a fourth-year medical student at Dartmouth’s Geisel School of Medicine who rotated through the Addiction Services at New Hampshire Hospital, Concord, NH.
1. Rudd RA, Seth P. Increases in drug and opioid-involved overdose deaths—United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65:1445-1452.
2. Ahmad FB, Rossen LM, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics. 2021.
3. Robinson AB, Ali N, Costa O, et al. A thematic analysis of overdose prevention and response efforts in states experiencing declines in rates of opioid-involved overdose deaths. Public Health Reports. 2021:333549211026816.
4. Mattson CL, Tanz LJ, Quinn K, et al. Trends and geographic patterns in drug and synthetic opioid overdose deaths—United States, 2013–2019. MMWR Morb Mortal Wkly Rep. 2021;70:202-207.
5. Baumgartner JC, Radley DC. The spike in drug overdose deaths during the COVID-19 pandemic and policy options to move forward. March 25, 5021. Accessed August 12, 2021. https://www.commonwealthfund.org/blog/2021/spike-drug-overdose-deaths-during-covid-19-pandemic-and-policy-options-move-forward