How the CDC Tracks and Responds

to the U.S. Drug Overdose Epidemic

Grant Baldwin, PhD, MPH

Director, Division of Overdose Prevention

April 16, 2021

The findings and conclusions in this presentation are those of the authors and do not necessarily
represent the official position of the Centers for Disease Control and Prevention.
Rapid Increase in Drug Overdose Death - Rates by County

2003 2012

2006 2018
SOURCE: NCHS Data Visualization Gallery
 D e a t h s p e r 1 0 0 , 0 0 0 p o p u l a ti o
Waves of the U.S. Opioid Overdose Epidemic

Wave 1 Prescription opioid deaths

climb in the late 1990s

Wave 2 Heroin deaths rise in 2010

Synthetic opioid deaths – illicit

Wave 3 fentanyl and analogs - skyrocket in
12 2013
11
10
9 Over 495,000 people have died
8
from an opioid overdose since 1999
7
6
5
4
3
2
1
0
2000 2002 2004 2006 2008 2010 2012 2014 2016 2018

Natural and semi-synthetic opioids Heroin

Methadone Synthetic Opioids Excluding Methadone
SOURCE: National Vital Statistics System Mortality File
 D e a t h s p e r 1 0 0 , 0 0 0 p o p u l a ti o
Drug Overdose Deaths Involving Cocaine and Psychostimulants with Abuse
Potential in the US are Increasing Too
Cocaine-involved death rate increased almost 3-fold since
2013. 76 percent of deaths in 2019 involved an opioid.

Other psychostimulant-involved death rate increased over 4-fold

since 2013. 54 percent of deaths in 2019 involved an opioid.

6
TOTAL DEATHS 2013-2019 Cocaine-Involved 72,009
5 Other Psychostimulant-Involved 60,359

0
2000 2002 2004 2006 2008 2010 2012 2014 2016 2018

Opioid Deaths Nested in a Broadening Cocaine Psychostimulants with Abuse Potential

Drug Overdose Epidemic.
SOURCES: National Vital Statistics System Mortality File & Hedegaard, Miniño, & Warner (2021) NCHS Data Brief 409
 Majority of Opioid Deaths
Involve Other Non-Opioid Drugs

Source: Gladden, O’Donnell, Mattson, Seth (2019). MMWR 68 (34), 737

 Death Rates
The 10 Most Frequent Combinations of Opioid and Stimulant
Deaths Accounted for Almost 77 Percent of Deaths
Most Overdose
Deaths Involve
More Than One
Illicit Substance

* IMFs include fentanyl and fentanyl analogs

More than 3 in 5 people who died from drug overdose had an
Source: O’Donnell, Gladden, Mattson, Hunter, Davis (2020). MMWR. 69(35), 1189.
1 Year Change
identified opportunity for linkage to care or life-saving actions.
Death Rates
A growing proportion of ALL drug overdose deaths
in the U.S. involve synthetic opioids since 2013

1 Year Change
Source: Mattson, Tanz, Quinn, Kariisa, Patel, and Davis (2021). MMWR. 70(6), 202
 Death Rates

Polysubstance epidemic
driven by fentanyl
1 Year Change
Source: Gladden, O’Donnell, Mattson, Seth (2019)
State Unintentional Drug Overdose Reporting System
Note:: IMF is illicitly manufactured fentanyl. Refer to source for other footnotes
 An Everybody Problem
The opioid overdose epidemic is impacting most
populations in America now

From 2015 to 2018

• Opioid overdose death rates increased among both sexes,
persons aged ≥25 years old, all races/ethnicities, and all levels
of urbanization.
• The largest relative change occurred among males (47%),
blacks (25%), persons aged 35-44 years old (51%), and in large
fringe metro (52%) and large central metro areas (50%)

In 2019
• Opioid overdoses took the lives of 49,858 Americans in 2019.
This is a double the number in 2013 (25,052) and nearly 6
times the number in 2000 (8,047)

Source: Wilson et al (2020); Seth et al. (2018); and Hedegaard et al. (2020)
 The Drug Overdose Epidemic Appears to Have Worsened During
COVID-19 Pandemic – By Drug Class

December 17, 2020

Drug overdose deaths 

Number of Deaths during 12-month period

Approximately 81,230 drug overdose deaths

have never been higher. occurred in the United States in the 12-
months ending in May 2020
 Increase began in 2019 and appears to have
accelerated during the COVID-19 pandemic.
 Synthetic opioids are the primary driver -
12-month count of these deaths increased
38.4% ending in May 2020.
 Overdose deaths involving cocaine (26.5%)
and psychostimulants (34.8%) also increased
in the same period
SOURCE: CDC. Health Alert Network (HAN) No. 438 – Increase in Fatal Drug Overdoses Across the United States Driven by Synthetic Opioids Before and During the COVID-19 Pandemic. 2020.
 The Drug Overdose Epidemic Appears to Have Worsened During
COVID-19 Pandemic – By State

Percentage change in 12-months ending provisional Percentage change in 12-months ending provisional
count of all fatal overdoses count of fatal overdoses involving synthetic opioids
June 2019 to May 2020
50 STATES June 2019 to May 2020
36 STATES

LEGEND >=20% increase 0% to 9% increase LEGEND >= 50% increase 0% to 9% increase

10% to 19% increase 1% to 10% decrease 25% to 49% increase 1% to 10% decrease
10% to 24% increase Data Not Available

SOURCE: CDC. Health Alert Network (HAN) No. 438 – Increase in Fatal Drug Overdoses Across the United States Driven by Synthetic Opioids Before and During the COVID-19 Pandemic. 2020.
 Lifetime Prevalence of Substance Use and Mean
Number of Other Substances Used - 2018

The more widely used a

drug, the less likely users
are to use other drugs

Less frequently consumed

substances are rarely the
first used and often added
later in substance use
trajectories

Source: Compton, Valentin, and Dupont (2021) adapted from Eric Wish. Molecular Psychiatry, 26.1: 41-50.
 Drug Use Patterns in the United States - 2019
Past Year Illicit Drug Use Past Year Initiates
(+400K)
(-301K)
(+105K)
(-261K)
(-100K)
1 in 5 People Aged 12
and Older Used Illicit (+154K)
Drugs in 2019 (-203K)
(-12K) Difference from 2018
in Parentheses.
(-21K)
Increase in BLUE
(-67K)

MILLIONS MILLIONS

Almost 20 percent INCREASE in users – over The number of past year initiates of substances declined
9.5 million more people – from 2015 alone in many categories from 2018

SOURCE: National Survey on Drug Use and Health (NSDUH) - 2020

Changing pattern in co-occurring opioid and nonopioid
drug use in the United States between 2011 and 2018

 Survey of past month co-use of

prescription and illicit opioids and 12
nonopioid psychoactive drug classes in
national sample of persons entering
treatment of opioid use disorder.

 Past-month illicit opioid use increased

from 45% in 2011 to 70% in 2018.

 Use of prescription opioids alone

dropped from 55% to 30%.

 Past-month use of at least 1 nonopioid

drug occurred in nearly all participants
(> 90%), with significant increases in
Prevalence rate of past month non-opioid drug use methamphetamine (+85%)

Source: Cicero, Ellis, & Kasper (2020). AJPH, 110(2), 244-250.

 Prevalence of specific substance use
disorders (SUDs) among VA patients with an
opioid use disorder (OUD) diagnosis in 2017

Source: Lin, Bohnert, Blow, Gordon, Ignacio, Kim, & Ilgen (2021). Addiction, 116(1), 96-104.
 Polysubstance Use in the U.S.
 Polysubstance use is not new and is common among persons
struggling with use disorders.

 The pattern of substances used is changing.

 Some polysubstance use is occurring without user’s knowledge of

drug contamination.

 The proliferation of synthetic drugs - especially illicitly

manufactured fentanyl and fentanyl analog - greatly elevates the
overdose risk of polysubstance use.

 Persons struggling with multiple substance use disorders face

greater challenges accessing treatment and recovery services –
especially during COVID-19 pandemic.
Prescription Opioid Use
Continued declines
have brought
normalized per capita
prescription opioid use
below the 2001 level

The greatest reduction in

prescription opioid use
has been in the
highest risk segment,
which contain more than
90 MMEs per day
 Cost of Opioid $480.7B Value of lives lost from
opioid overdose deaths $34.8B Health care spending and
opioid use disorder treatment
Overdose Deaths
and Opioid Use $390.0B Reduced quality of life from
opioid use disorder $31.3B Lost productivity from opioid
use disorder
Disorder
2017 $68.7B Lost productivity from opioid
overdose deaths $14.8B Criminal justice

$1.2 TRILLION

SOURCE: Florence et al. (2021)

 Unintentional Poisoning
Driving Declines in Life
Expectancy

Contribution of 14 Broad Causes of

Death to Decline in U.S. Life
Expectancy
2014 to 2017

SOURCE: Harper et al., Annual Review of Public Health (2020)

 1 Pain Being Designated The Fifth Vital Sign

2021 2 Under Appreciation of Addictive Potential of

Prescription Opioids
How We Got Here?
3 Aggressive Marketing of Prescription Opioids to
Clinicians

4 Clinicians Who Ran Pill Mills that Profited from Over

Prescribing

5 Sophisticated Actions of Drug Traffickers to Open New

Heroin Markets

6
Potency and Ease of Making, Trafficking, & Profiting
from Illicitly Fentanyl and Fentanyl Analogs
UNITED STATES
OPIOID OVERDOSE EPIDEMIC
7 Mixing or Co-Use of Illicit Fentanyl with Other Drugs –
Especially Cocaine and Methamphetamines
 Two groups of people with two different
sets of needs
With Opioid Use Disorder

Need access
to services

At Risk for Opioid Use Disorder

Protect from
dangerous drugs
 Expand the provision and use of naloxone and overdose
prevention education

Expand access to and provision of treatment for

Where do substance use disorders

we go from
here? Intervene early with individuals at the highest risk
for overdose

Improve detection of overdose outbreaks due to fentanyl,

novel psychoactive substances (e.g., fentanyl analogs), or
other drugs to facilitate an effective response
SOURCE: CDC. Health Alert Network (HAN) No. 438. 2020.
Division of Overdose Prevention GOALS

VISION ONE: Reduce opioid overdose now

End drug overdose and related harms
MISSION
To monitor, prevent, and reduce harms associated
with drug use, misuse, and overdose
TWO: Identify and address emerging drug trends and
associated public health outcomes
THREE: Prevent drug use initiation or drug misuse
among youth and young adults

STRATEGIES
Guiding Principles
Division of Overdose Prevention
 NATURE OF SUBSTANCE USE DISORDER: A substance use disorder is a chronic,
relapsing brain disease not a moral failing. Physiological changes in the body are
driving decision-making and use.
 CONTEXT COUNTS: Substance use is influenced and reinforced by past and
present life experiences and circumstances. As a result, prevention, treatment,
& recovery activities need to attend to these life course and contextual factors.
 DATA: Data are the bedrock of decision-making and action. Data guide what
we do, where we do it, and allow us to know if our actions are making a
difference.
 PREVENTION: Prevention works. Evidence-based programs informed by data
and strengthened by partnerships can be tailored and scaled up.
 RECOVERY: Recovery is possible. The public health sector can be a bridge and
linkage safety net to comprehensive treatment and recovery services.
1 of 2
Guiding Principles
Division of Overdose Prevention
 SYSTEM OF SUPPORT: We need a system of care and supports
that protects at every turn. Overdoses should never happen if that
system is optimized.
 LIFT EACH OTHER UP: We need to end stigma and lift each other
up – individuals, families, and communities.
 VULNERABLE POPULATIONS: It is important to address disparities
and social determinants of health that have impacted historically
underserved and/or vulnerable populations (e.g., minorities, the
homeless, and rural populations).
 EQUITY: Achieving the highest level of health for all populations.

2 of 2
 Overdose Data to Action (OD2A)

 $300M per year for 3 years

 Seamless integration of data
and prevention programs
 66 jurisdictions funded
including 47 states and 16 hard
hit cities and counties
 At least twenty percent of
state funds go to the local
level as well to spur innovation
and multisector collaboration.

Empower
Surveillance PDMPs Health System Public Safety Linkage to Care Consumers Local Response
 DOSE Drug Overdose Surveillance and
Epidemiology System

 Faster Data: Incentivize data submissions to as rapidly as every 2 weeks.

 Greater Coverage: ED data with greater coverage (>75% of visits).

 Expanded Drugs: Suspected all drug, opioid, heroin, stimulant overdoses

required.

 More Comprehensive Sources: Leverage both syndromic data (24-48

hours) and hospital billing/claims data (3-4 weeks). Syndromic data from
the National Syndromic Surveillance Program (NSSP) or local syndromic
system.

OD2A
Morbidity
Getting more timely, comprehensive, localized, and actionable data
 SUDORS State Unintentional Drug
Overdose Reporting System

 More Comprehensive: Detailed information about deaths and their

circumstances from death certificates, medical examiner/coroner
reports, & toxicology results.

 Expanded Drugs: All drug overdose deaths. Not just opioid involved.

 Faster Data: Incentivize data submissions to as rapidly as 6-11 months

after death.

 Increased Capacity: More funding to ME/Cs

 Early Signal: Preliminary counts of opioid-involved deaths from clinical

and scene evidence one month after death (OPTIONAL)
OD2A
Mortality
Getting more timely, comprehensive, localized, and actionable data
 More detailed data informs future
prevention activities
 Substance abuse
 Mental health history
 Basic descriptors
diagnoses  Scene indication
 Compare across of drug use
demographics
 Substance abuse
treatment history  Route of drug
administration

 Recent release from institution  Substances present

 Overdose location  Substances
 Survival time contributing to death
OD2A
Mortality
Getting more timely, comprehensive, localized, and actionable data
 CDC supports innovation in local surveillance
 Funding and flexibility for state and local public health departments to:
⁻ Address key local surveillance needs
⁻ Provide insight on critical CDC data gaps

 66 recipients propose >175 surveillance projects

⁻ Vast majority of recipients' fund ≥2 projects with $400,000
⁻ Report preliminary aggregate data to CDC by summer 2021

7 CDC priorities

OD2A
Innovative
Getting more timely, comprehensive, localized, and actionable data
 CDC Guideline Implementation
Focus on four priority areas to maximize the uptake and use of the opioid prescribing
guideline for chronic pain outside of active cancer, palliative, & end-of-life care

Translation and Communication

1 Develop tools and resources about the guidelines for a variety of audiences – including
providers, health systems, and the general public.

Clinical Training
2 Educate providers through medical schools and ongoing continuing medical education
(CME) activities.

Health System Implementation

3 Educate providers, integrate into EHRs and other clinical decision support tools, adopt and
use quality metrics, and leverage within broader coordinated care activities.

Insurer/Pharmacy Benefit Manager Implementation

4 Proactive use of claims information and improvement in coverage and service delivery
payment models – including reimbursement for clinician counseling; coverage for non-
pharmacological treatments; and drug utilization review or prior authorization.
 CDC Opioid Prescribing Guideline UPDATE
 CDC is funding the Agency for Health Care Research and Quality to
update or conduct a total of 5 systematic reviews.
 Areas to update in the CDC Guideline may include:
– Additional detail on non-pharmacologic and non- opioid
pharmacologic therapies for chronic pain;
– Updated information on benefits and risks of nonpharmacologic,
nonopioid pharmacologic, and opioid therapies for chronic pain;
– Expanded guidance on acute pain;
– Expanded guidance on opioid tapering.
 CDC Injury Center established and requested input from an expert
workgroup under its Board of Scientific Counselors in December 2019.
 Input from patients, providers, and the public is sought via several
avenues including opportunities for public comment posted in federal
register notices.
 Overdose Response Strategy (ORS)

Public Health Analyst

(PHA) & Drug
Intelligence Officer (DIO)
Drug Intelligence Officer
ONLY

Today: ONDCP funding DIOs in every state and

HIDTA; CDC funding PHAs in 30 states
Goal: DIO and PHA positions in every state
Promoting What Works In Communities
• CDC reference document showcasing 10
best practices to prevent opioid overdose.

Harm Reduction Strategies:

• Targeted Naloxone Distribution
• 911 Good Samaritan Laws
• Syringe Services Programs

Medication Assisted Treatment (MAT):

• MAT Prior-Authorization
• MAT in Criminal Justice Settings and Upon
Release
• ED Buprenorphine Initiation

Academic Detailing
Fentanyl Toxicology Screening

https://www.cdc.gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdf

Combatting Opioid Overdose through
Community Level Intervention
(COOCLI)
Denver, CO
Example COOCLIs
• Warm hand offs and targeted re-entry care coordination prior to
release from incarceration in Philadelphia, PA.
• Providing outreach and engagement to individuals and families with
same-day supportive services in New York NY.
• Addressing the needs of mother and baby through a Plan of Safe
Care in Houston, TX
• Leverage bilingual and bicultural behavioral health support for case
management, recovery support services, and outreach in Boston,
MA.
• Using AmeriCorps Volunteers in Service to America (VISTA) to
implement prevention strategies in Colorado.
$8M in FY18 and FY19 from CDC
York County, PA

Ten Pilots
Planned
 Opioid Rapid Response Program
Training Preparedness
Increase Workforce Build State Capabilities
Capacity

Communication Deploy Resources

Establish Trusted Enhance State and
Contacts Local Capacity
Real stories
from real CDC RX Awareness
people Campaign

Phase 2 - Launched July 2020

Tele Jeni David Britton Tessa

 PARTNERSHIP

COMMUNITY
700+ COALITIONS
Drug Free
Communities
Program

Preventing and reducing substance use

among youth 18 and younger
 CDC Approach to Drug Overdose Prevention – Areas for Further Investment
Injury Center Perspective Focus on
s that strategie ore
Increase can save m
suppor t fo gthen lives right
local r Stren overdose Address now – like
communit post- ach – via stimulan naloxone
ies outre recovery ase n
Expand Overdose Incre tments in polysub ts and distributio
peer alists or i n ve s an d stance
speci ators
Response Strategy
b or a tory a u se
la t
navig al da
clinic es
sou r c
Bro
Implement awa aden
programs to illic reness
strengthen and it opioi of
Select Ideas Strengthen families, stig decreads
Update and ma se
linkage to and Scale up the support
retention in expand the CDC Public Health
opioid prescribing effective life
care and track and Safety skills, & foster
outcomes guideline Team (PHAST) suppor tive
approach for communities
collaboration Expand
locations for
overdose
ment prevention
Impleption education and
“Ado lerator” rts
Increase For tify effo the mobile outreach
Acce l of Support education to ad d re ss
modence- innovative training to& highest ri s
sk Expand e
evide approaches to decrease st po pu la tion to collect ffor ts
based ams igma
surveillance, among an d on suspectdata
progr nces overdose ed
modelling, and clinicians circumsta
data linkage deaths w
one month ithin
death of
BRAINSTORM
QUESTIONS
Back-Up
Slides
Surveillance and Data Enhancement Across
Leveraging Other Investments
CDC
NCEH and
 Ensure labsOPHPR
able to test for as many fentanyl
Improve
analogs federal,
in current usestate, and private laboratory capacity to detect synthetic opioids
as possible.
NCDDPHP and NCBDDD
 Provide accurate measurement of known
Rapidanalogs
fentanyl assessment of maternal
that allows opioid use and overdose to improve outcomes and
for comparability
savelabs.
across lives
NCHHSTP
 Increase lab throughput given demand.
Jurisdiction-level vulnerability assessments for risk of opioid overdose, HIV, and
Viraladd
 Readily Hepatitis to inform
new analogs prevention and intervention efforts
to testing
protocols/methods as they appear in the US.
CDC is supporting tribes to address the opioid overdose epidemic
 IOPSLL Implementing Overdose Prevention
Strategies at the Local Level

Mirrors Overdose Data to Action activities in

local communities.
Funds high capacity, high burden counties to
conduct overdose surveillance, prevention,
and response work.
Total of $6.7 Million in Funding

Los Angeles County, CA Seattle and King County, WA

ROUND 1 Marion County, IN City of Milwaukee, WI ROUND 1
December 2019 – July 2021
Los Angeles County, CA
Marion County, IN
Seattle and King County, WA
City of Milwaukee, WI

December 2019 – July 2021

Jefferson County, AL Ocean County, NJ
ROUND 2 Seminole County, FL
Volusia County, FL
Ulster County, NY
Dayton and Montgomery County, OH
December 2020 – July 2022 Camden County, NJ Lorain County, OH
 Cornerstone Projects
Answer a common question and address shared informational
needs regarding the overdose crisis

Fentanyl
2016 Presence and status of fentanyl analogs in ORS states

911 Good Samaritan Laws

2017 Law enforcement knowledge, understanding, and experience
implementing Good Samaritan Laws

Linkage to Care
2018 Prearrest diversion, drug courts, linkage upon release from
incarceration, post-overdose outreach, and safe stations.

Overdose Prevention in Jails

2019 Correctional staff knowledge of jail-based overdose
prevention strategies available
 Adverse Experiences and Health
• OBESITY • HOMICIDES • CAR CRASHES • PTSD
• ANXIETY • DEPRESSION • DEMENTIA •
Diseases of STDS
Disconnection • SUICIDE • HIV • HEPTITIS C • CIRRHOSIS
and Despair • UNWANTED PREGNANCY • ADDICTION (E.G.
GAMBLING, SEX, FOOD) • SUBTANCE USE DISORDER

• ABUSE (PHYSICAL, SEXUAL, VERBAL, EMOTIONAL)

Adverse • ALCOHOL ABUSE • DRUG USE • MENTAL ILLNESS
Childhood • DOMESTIC VIOLENCE • NEGLECT
• DIVORCE/SEPARATION
Experiences • INCARCERATED HOUSEHOLD MEMBER

• INEFFECTIVE SCHOOLS • INCOME INEQUALITY

• CRIME • POVERTY • SOCIAL EXCLUSION
Adverse • RACISM • SEXISM • UNEMPLOYMENT
Societal • HOMOPHOBIA • FOOD INSECURITY
Conditions • HOPELESSNESS • LIMITED HEALTH CARE ACCESS
• HOUSING INSECURITY • ENVIRONMENTAL HAZARDS

THE ROOTS AND GROWTH OF POOR HEALTH OUTCOMES

 An innovative and holistic
police-school-community partnership

 Focuses on ACES to create a trauma informed community

working to build resilience in children.
 Partnership between Berkeley County Schools, Martinsburg
Police Department, Shepherd University and community
organizations including The Boys & Girls Club of the Eastern
Panhandle.
 Program advocates for children with high ACE scores and
connect individuals and their families with the services they
need to succeed.
 Program is tiered and provides school supports, prevention
programs, and wrap-around services for children and
families in need.