Fighting Fentanyl: The Federal Response to a Growing Crisis

Senate Health, Education, Labor, and Pensions Committee

Witness: Christopher M. Jones, PharmD, DrPH, MPH, CAPT, US Public Health Service
Acting Director of National Center for Injury Prevention and Control, Centers for Disease Control and Prevention

Chair Murray, Ranking Member Burr, and distinguished members of the committee, thank you for the opportunity to be here today to discuss the Centers for Disease Control and Prevention’s efforts to address of our nation’s drug overdose crisis. I appreciate the committee’s dedicated support and attention to this pressing public health issue and we at CDC are committed to continuing our work to tackle the growing crisis. 

Over the past two decades, drug overdose deaths have claimed far too many lives, with more than 250 Americans now dying each day from an overdose.¹ These sobering statistics represent individuals, families, and communities that have been deeply and forever impacted by this crisis. However, there is hope in knowing that we can alter this trajectory. Drug overdoses can be prevented and people with substance use disorders can recover. At CDC, we are working tirelessly to prevent overdose and substance-use related harms so that we can save lives and all people can achieve optimal health and well-being.  

The drug overdose crisis is complex and requires a multi-sector, multi-pronged response. That is why I am pleased and privileged to be joined by colleagues from the Office of National Drug Control Policy (ONDCP), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Health Resources and Services Administration (HRSA) to discuss the federal government’s comprehensive response to curtail substance use and overdose, particularly from illicitly made fentanyl. Together we can stop drug overdoses and save lives.

The latest provisional mortality data from CDC indicate that more than 107,000 Americans died from a drug overdose in the 12-months ending in January 2022. Of these deaths, it is estimated that 80,590 of these deaths, or 75%, involved at least one opioid, with 71,450 (66.5%) involving synthetic opioids, primarily illicitly manufactured fentanyl or fentanyl analogs.² Stimulant overdose deaths are also on the rise, with approximately 33,128 (30.8%) deaths involving methamphetamine and 24,751 (23%) involving cocaine.³  The increases in overdose deaths have been experienced across the nation. The overdose crisis cuts across socioeconomics, demographics, political and religious affiliation, and geography. This is a crisis that impacts both large cities and rural communities. Particularly noteworthy are the recent unprecedented increases in overdoses among communities of color, including Black persons and American Indian and Alaska Native persons, with disparities in overdose deaths among these populations compared to White persons worsening during the COVID-19 pandemic.⁴ 

Driving the historic increases in overdose deaths, particularly since 2013, is the continued proliferation of a highly potent and unpredictable illicit drug market saturated with synthetic opioids, especially illicitly manufactured fentanyl and fentanyl analogs (IMFs), which are easier and less costly to make, distribute, and sell. Introduced primarily as adulterants in, or replacements for white powder heroin in drug markets east of the Mississippi River, IMFs are now widespread in these white powder heroin markets, increasingly expanding into drug markets in the western United States, and readily available as pressed counterfeit pills that resemble commonly misused prescription drugs such as oxycodone and alprazolam throughout the U.S. ⁵ Data from the Drug Enforcement Administration and other law enforcement partners also indicate that IMFs are found in some illicit supplies of other drugs such as methamphetamine and cocaine, adding an additional concern about unintentional exposure to these highly potent drugs among individuals who may have little prior exposure to opioids – exponentially raising their risk for overdose. Illicitly manufactured fentanyl is highly potent, and CDC data shows that over half of decedents with an IMF-related overdose had no pulse when first responders arrived at the scene.^{6 7}

The recent increases in overdose deaths highlight the need to ensure people most at risk of overdose can access care, as well as the urgent need to expand prevention and response activities with a focus on health equity. As the nation’s public health and prevention agency, CDC is leading the public health approach in collaboration with our state, local, territorial, and tribal partners. Our top priority is to address the overdose crisis by rapidly tracking the evolving epidemic and using this information to equip people on the ground to save lives in their community. We work to ensure that data is driving decision making and planning so that the response to the overdose crisis meets local needs, particularly in communities hardest hit by IMFs. Communities use this information to inform where they should focus their efforts including activities such as providing naloxone, decreasing stigma, increasing linkage to care, and improving bystander education and response.

CDC prioritizes five key strategies that align with the HHS-wide Overdose Prevention Strategy to address the evolving drug overdose crisis and reduce substance use related harms: 1) monitoring, analyzing, and communicating trends; 2) building state, tribal, local, and territorial capacity; 3) supporting providers, health systems, payors, and employers; 4) partnering with public safety and community organizations; and 5) raising public awareness and reducing stigma. CDC’s mission is to end this crisis by using data to drive innovation, tailoring prevention in local communities, partnering broadly, and addressing underlying factors, including a central focus on health inequities, and preventing or reducing adverse childhood experiences, which are key risk factors for substance use and overdose.
 

Data are essential for informing a public health response to the overdose crisis. CDC uses data to understand drivers of both nonfatal and fatal overdose, including its scope and magnitude, who is most impacted, and to track trends over time to inform prevention and response efforts. CDC’s National Center for Health Statistics (NCHS) maintains strong working relationships with state vital records offices and has made great strides in improving the timeliness and completeness of drug overdose death certificates in recent years. In fact, the improvements in the timeliness of these data have now made it possible to provide provisional drug overdose death data on a monthly basis, allowing for the identification of trends in overdose counts by drug class within 4-5 months as opposed to within two years.  NCHS has also now released provisional drug overdose death data on CDC’s online analysis system WONDER, enabling for the first time, detailed analyses of overdose death counts and rates by demographic and geographic characteristics. These improvements allow us to assess overdose death trends at a national level and adjust our use of resources in a timelier manner. In addition, the completeness of drug overdose death certificates has greatly improved in recent years, with approximately 95% of drug overdose death certificates listing specific drugs contributing to the overdose, up from approximately 75% a decade ago. To continue to advance improvements in the death certification process, CDC has recently established a Coordinating Office for Medical Examiners and Coroners that will continue to seek improvements in the speed, accuracy, and completeness of data received.  

CDC’s National Center for Injury Prevention and Control has developed two key data systems to improve the timeliness and comprehensiveness of both nonfatal and fatal overdose data as part of the Overdose Data to Action (OD2A) cooperative agreement. These two systems provide more information about substances contributing to nonfatal overdoses and contextual information about what led to an overdose death.  CDC’s Drug Overdose Surveillance and Epidemiology (DOSE) System was developed to analyze data from electronic health records to rapidly identify outbreaks and provide situational awareness of changes in suspected drug overdose-related emergency department visits at the local, state, and regional levels ensuring consistent and accurate reporting across all entities that make it easier to compare data across states. DOSE captures timely data on emergency department visits involving all suspected drug overdoses, including demographic characteristics of those who overdose such as sex, age, and county of patient residence. Since 2019, forty-one states and the District of Columbia have provided data to CDC on a monthly basis which is publicly accessible through an Interactive dashboard. This data improves coordination and strategic planning for intervention and response efforts among health departments, community members, healthcare providers, public health, law enforcement, and government agencies. 

CDC’s State Unintentional Drug Overdose Reporting System (SUDORS) collects comprehensive information on drug overdose deaths in 47 states and the District of Columbia. The data are collected from death certificates and medical examiner/coroner reports (including scene findings, autopsy reports, and full postmortem toxicology findings) to help inform overdose prevention and response efforts by 1) lending a better understanding of the circumstances that surround overdose deaths, 2) identifying specific substances causing or contributing to overdose deaths as well as emerging and polysubstance overdose trends, and 3) improving the timeliness and accuracy of overdose data. In 2016, SUDORS began as part of CDC’s Enhanced State Opioid Overdose Surveillance (ESOOS) program, to provide comprehensive data on opioid-involved overdose deaths. In 2019, SUDORS expanded to collect data on all unintentional and undetermined intent drug overdose deaths. Through this data, we have gleaned integral information that can help inform prevention in communities. For example, recent SUDORS data indicated that more than 3 in 5 people who died from a drug overdose had an identified opportunity for linkage to care or life-saving actions.⁸ In addition, 40% of overdose deaths occurred while a bystander was present.⁹  CDC disseminates both DOSE and SUDORS data through interactive data dashboards accessible via CDC’s website.  

In addition to DOSE and SUDORS investments in states, localities, and territories, CDC continues to use other proprietary data sets to gain a holistic understanding of the factors that contribute to drug overdose and substance use related harms so communities know what interventions to choose and when to make adjustments based on the evolving crisis. This includes leveraging data sets within CDC and from our federal partners, including data related to substance use disorder and treatment, prescribing data, and using innovative data science tools, methods, and techniques, and advance modeling efforts to help communities allocate resources and interventions. CDC is also supporting medical examiners and coroners with increased toxicology testing as well as supporting labs to identify synthetic opioids through the provision of Traceable Opioid Material Kits that provide reference materials for fentanyl compounds and other synthetic opioids. In coming months, CDC will expand this portfolio to include stimulant reference materials. Finally, CDC works collaboratively with other federal partners to conduct research and leverage available data sources that help identify key information about emerging substance use patterns, prevalence, treatment availability, and the changing drug supply.  

CDC’s National Center for Injury Prevention and Control has funded state health departments for overdose prevention activities since 2015, beginning with a small subset of high-burden states. This program has since scaled to a national program that has not only provided support to every state that applies for funding but adapted as the overdose crisis evolved. Under the Overdose Data to Action (OD2A) program, CDC now funds 47 states, Washington DC, and 16 city and county health departments to advance surveillance efforts, which allows the departments to tailor the implementation of prevention efforts with a menu of strategies that support jurisdictions in addressing the primary drivers of overdose in their states and communities.  

As the overdose crisis has broadened, CDC has expanded the initial scope of its overdose prevention activities to address new challenges along with opioids misuse and overdose. This flexibility allows funded jurisdictions to meet the needs of today’s crisis, including investing in populations with a high percentage of individuals using stimulants like methamphetamine and cocaine, which we know are increasingly intertwined with illicit fentanyl and opioid overdose. CDC has also scaled investments in activities to link people to care and treatment across health care, community, and criminal justice settings. These activities include peer navigation, quick response teams, and harm reduction and represent an important compliment to the work of other agencies focused on funding substance use treatment and service delivery. The insights we have gained from OD2A have informed two new funding opportunities that were recently announced, including an announcement specifically to support state and territorial health departments (OD2A-S) and another to support local health departments (OD2A-Local). CDC is also partnering with other federal agencies to coordinate and leverage all resources to increase uptake of these important strategies. For example, The National Harm Reduction Technical Assistance Center (NHRTAC) is a joint project funded by CDC and SAMHSA. This program provides critical technical assistance to harm reduction programs, including syringe services programs (SSPs) to prevent the spread of infectious diseases, and other community-based programs and organizations that provide treatment, prevention, recovery, and harm reduction services including increasing access to fentanyl test strips (FTS) by allowing federal funds to be used to purchase FTS in an effort to curb the spike in drug overdose deaths.  

In addition to the Overdose Data to Action program, CDC, in partnership with the National Association of City and County Health Officials, supports local county health departments through the Implementing Overdose Prevention Strategies at the Local Level (IOPSLL) program. This program focuses on establishing linkages to care; supporting providers and health systems; enhancing surveillance and data sharing capabilities; improving partnerships with public safety and first responders; implementing harm reduction activities such as providing fentanyl test strips and educating about the use of naloxone; developing communications campaigns; and implementing innovative prevention projects. This program enables the implementation of innovations and promising strategies at the local level and is an essential source of funding for capacity-building that can increase readiness to participate in future funding opportunities aimed at local health departments.  

CDC also funds 11 Tribal Epidemiology Centers and 15 tribes or tribal-serving organizations for overdose prevention activities. These collaborations support efforts to improve data quality, completeness, accuracy, and timeliness among a high-risk population. Funding also supports regional strategic planning to address opioid overdose prevention so that strategies appropriate to tribal communities are developed by the communities impacted and the strengths inherent to tribal organizations are built upon and scaled across the country.

In addition to supporting states, localities, territories, and tribes, CDC continues to advance partnerships through multiple public health and public safety collaborations that aim to strengthen and improve efforts to reduce drug overdoses. These partnerships allow for effective implementation of programs and help advance promising strategies that address rising overdoses in communities. The Overdose Response Strategy (ORS) is a unique collaboration between CDC and the High Intensity Drug Trafficking Areas (HIDTA) program at ONDCP designed to enhance public health and public safety partnerships. The mission of the ORS is to help communities reduce fatal and non-fatal drug overdoses by connecting public health and public safety agencies, sharing information, and supporting evidence-based interventions. More specifically, under the program, drug intelligence officers and public health analysts collaborate and leverage supply and overdose data to problem-solve and address local and regional issues, including spikes in overdoses related to illicit fentanyl. Given the potential impact of this program, CDC has expanded its investment in this partnership to support the public health component in all 50 states, Puerto Rico and the U.S. Virgin Islands.   

The ORS also supports the Combatting Overdose through Community-level Intervention program, to implement innovative strategies within a targeted geographic area to build the evidence base for response activities that other communities can employ. Projects include efforts on post-overdose strategies to link people to care using patient navigators and recovery coaches; justice-involved populations and access to medications for opioid use disorder (MOUD); buprenorphine induction in emergency departments; and training and provision of trauma-informed care.  

One example from the program is the Martinsburg Initiative in West Virginia. The Initiative is an innovative, police-school-community partnership focused on opioid overdose prevention that can act as a model for other communities. Through a partnership between the Martinsburg Police Department, Berkeley County Schools, and Shepherd University, this project expands community resources and links law enforcement, schools, communities, and families in a dynamic partnership that assesses participants’ ACE scores and subsequently links them to necessary resources and supports. Through a strategic focus that targets at-risk children and families experiencing challenges, this initiative aims to assess, identify, and reduce the root cause of substance use through a trauma-informed and collaborative approach.  

CDC also partners with the Office of Justice Programs, Bureau of Justice Assistance’s Comprehensive Opioid, Stimulant, and Substance Abuse Program (COSSAP) to support effective state, local, and tribal responses to illicit substance use. These demonstration projects promote public safety, and support access to treatment and recovery services in the criminal justice system in order to reduce overdose deaths. This partnership has focused on rural responses, expanding use of the Overdose Detection Mapping Application Program (ODMAP) in states and tribes, harm reduction education and training for law enforcement, building bridges between jail and community-based treatment, and overdose fatality review (OFR) implementation. 

In an epidemic of this scale, public education and empowerment to combat stigma has never been more important. This is true not only for individuals who use drugs, but also anyone—friend, parent, caregiver, or community member—who may encounter someone experiencing an overdose. CDC’s public messages and campaigns have evolved along with the epidemic. For example, CDC’s Rx Awareness campaign initially focused on increasing awareness of the risks associated with prescription opioids when prescription opioids were the primary driver of overdose deaths. As the crisis evolved, the campaign shifted to focus on messages of hope in recovery with a focus on equity and inclusion. Most recently, CDC’s latest messaging includes four mini-campaigns, entitled “Stop Overdose,” and focuses on raising awareness of fentanyl, naloxone, polysubstance use, and decreasing stigma with a particular focus on 18-34 year olds – a group experiencing some of the highest rates of overdose in recent years. Launched in late 2021, these new mini campaigns have reached over 1 billion views, showing not only the importance of these messages, but the need for messages in reaching all populations, especially young adults.  

We cannot reverse current trends without a holistic effort that fully leverages the health system and health care providers to address substance use disorder and overdose. Recent research shows that touchpoints with the health system present an important opportunity to engage at-risk patients in care for substance use-related challenges and overdose prevention. This includes advancing efforts for prevention, screening, linkage to care, and retention in treatment towards long-term recovery. In particular, CDC’s work in health systems and funding to jurisdictions includes a focus on improving upstream prescribing and pain care, enhancing linkage to care and treatment across various health care settings, from primary care to emergency departments, utilizing peer navigators to help individuals seek and connect to recovery options, and reducing stigma among clinicians and providers so that people feel safe seeking the care they need.  

Pain, particularly chronic pain, can lead to impaired physical functioning, poor mental health, and a reduced quality of life. A key aim of pain management is the provision of individualized, patient-centered care that focuses on optimizing function and supporting activities of daily living. CDC provides guidance to clinicians, as well as tools and resources for patients and clinicians, to help advance comprehensive pain care. One important way CDC promotes patient-centered pain care is through recommendations in its 2016 CDC Guideline for Prescribing Opioids for Chronic Pain and accompanying training and ancillary resources.  

Since release of the Guideline in 2016, CDC has stayed at the forefront of new research and collaborated with the Agency for Healthcare Research and Quality to conduct five formal systematic reviews of new available evidence on noninvasive, nonpharmacological treatment and nonopioid pharmacological treatment of chronic pain. As a result of these reviews and the new scientific evidence that has accrued since 2016, CDC determined that an update of the Guideline, and an expansion to certain acute conditions, was warranted. The draft 2022 CDC Clinical Practice Guideline for Prescribing Opioids was posted for a 60-day public comment period from February 10, 2022, to April 11, 2022. Release of a final updated Guideline is anticipated in late 2022, along with a suite of translation and communication resources to facilitate effective implementation.

Finally, focusing on preventing substance use in the first place is a core component of CDC’s work and the long-term solution to reversing the decades-long overdose crisis. A key element of this work is advancing upstream prevention strategies to prevent Adverse Childhood Experiences, or ACEs – potential traumatic events like experiencing abuse or neglect, witnessing violence in the home or community, and growing up in a household with mental health or substance use problems. Research shows that ACEs are strongly linked to increased risk for substance use, including increased risk for prescription opioid misuse, opioid injection, cocaine and amphetamine use and use disorder, and earlier age of initiation for these substances. Additionally, losing a loved one to overdose or suicide are themselves ACEs that can increase the risk of overdose or suicide in the future. Thus, preventing exposure to these early adversities is an important step in reducing the risk for overdose and suicide, and many other health risk behaviors and health outcomes throughout the lifespan. Focusing on shared risk and protective factors at the individual, family, and community levels helps to create safe, supportive, and nurturing relationships and environments and reduces these risks. Upstream prevention of ACEs and other violence and adversity among children and youth can have a profound impact on the trajectory of substance use, overdose, and mental health in the United States. CDC appreciates the support of Congress to address these intertwined crises through an integrated public health approach. 

CDC also partners with ONDCP on youth prevention efforts through the Drug Free Communities (DFC) Support Program. DFC, the nation’s leading effort to mobilize communities to prevent and reduce substance use among youth is administered by ONDCP and managed by CDC. The DFC Program funds community-based coalitions to strengthen the infrastructure among local partners to create and sustain a reduction in local youth substance use. The DFC coalitions focus efforts on youth and in many instances, promote health equity and aim to reduce disparities that impact youth substance use, and address the risk and protective factors that negatively impact health outcomes in communities. More than 700 community coalitions across the country receive funding of up to $125,000 per year to strengthen collaboration among local partners and create an infrastructure that reduces youth substance use.  

The drug overdose crisis continues to evolve, and our response must be nimble and flexible to the changing situations in communities throughout our country. We know that public health thrives when the approach is comprehensive, coordinated, and can quickly adapt and respond to current and emerging needs. Data are foundational to this effort. ​​ This is especially true with an overdose crisis driven by an extremely potent illicit substance, like fentanyl. CDC is continuously using data to drive prevention action in states, territories, tribes, and local communities. We are continuing to make vital strides in accelerating data collection, analysis, and dissemination of nonfatal and fatal overdoses and increasing the use of innovative data science and modeling efforts to fight the current crisis and predict where it will go next.  

For far too long the tragic consequences of overdose have devasted families and communities across the country, and the continued proliferation of illicitly made fentanyl has only exacerbated the challenges we face. CDC is committed to using data, science, innovation, and collaboration as part of a whole-of-government approach to save lives and bring an end to our nation’s overdose crisis.