Responding to America’s Overdose Crisis: An Examination of Legislation to Build Upon the Support Act

Chair Guthrie, Ranking Member Eshoo, and distinguished members of the committee, thank you for the opportunity to be here today to discuss the Centers for Disease Control and Prevention (CDC)’s efforts, authorized by the SUPPORT Act, to address the public health and prevention aspects of our nation’s substance use, drug overdose, and mental health crisis. I appreciate the committee’s dedicated support and attention to these pressing public health issues as we at CDC are committed to working with all sectors to address these challenges so that individuals, families, and communities can achieve optimal health and well-being.

Over the past two decades, America’s substance use and overdose crisis has profoundly impacted individuals, families, and communities across our nation. Over one million Americans have died from a fatal drug overdose since 2000.¹ CDC’s most recent provisional data show that approximately 300 Americans are dying each day from a drug overdose and many millions more struggle with substance use and the health and social consequences that come along with them.² 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.

Among the nearly 110,000 Americans that are predicted to have died from a drug overdose in the 12-month period ending in December 2022, over 75% involved at least one opioid, with 75,217 (68.6%) involving synthetic opioids, primarily illicitly manufactured fentanyl or fentanyl analogs. Layered on the already historic number of opioid-involved overdose deaths, overdoses involving stimulants are also on the rise, with approximately 34,711 (31.6%) deaths involving psychostimulants with abuse potential such as methamphetamine and 27,943 (25.5%) involving cocaine.² In a majority of these deaths, opioids are co-involved, underscoring the polysubstance nature and the complexity of the crisis we are facing.

Fentanyl is highly potent and acts fast. CDC data show that over half of individuals who died of an overdose involving illicitly manufactured fentanyl (IMF) had no pulse when first responders arrived at the scene.³ Particularly concerning, unintentional exposure to IMF among individuals who may have little prior exposure to opioids, such as those using stimulants like methamphetamine, cocaine, or counterfeit pills containing pressed IMF, exponentially raises their risk for overdose. Fentanyl has permeated not only the illicit opioid, methamphetamine, and cocaine supply but is showing up more and more in counterfeit prescription pills. This is especially impacting drug overdose deaths among adolescents aged 10-19, which we have seen rise 65% from July 2019 to December 2021, even as overall illicit substance use among youth has declined.⁴ Trends in adolescent (ages 10-19) overdose deaths due to IMF are particularly stark: of the 68 median monthly overdose deaths during July through December 2021, 62 involved IMF.

In addition to the proliferation of IMF and the resurgence of stimulants like methamphetamine, the ever-changing drug landscape continues to present emerging threats. Among persons who use drugs, a recent study of drug paraphernalia toxicology testing at syringe services sites in Maryland found 84% of tested materials contained illicitly manufactured fentanyl. This toxicology testing, supported by CDC funding, also found over 80% of samples tested contained xylazine, a non-opioid veterinary tranquilizer that causes respiratory arrest and necrotic lesions and while administration of naloxone remains critically important given the prevalence of IMF, xylazine does not respond to naloxone.⁵ In April 2023, the Office of National Drug Control Policy (ONDCP) designated xylazine-adulterated fentanyl as an emerging threat.⁶

Behind these concerning statistics are individuals, families, and communities that have been deeply and forever impacted by this crisis. However, there is hope in knowing that we can alter the trajectory of the overdose epidemic. Drug overdoses can be prevented, people with substance use disorders (SUD) can and do recover, and prevention efforts that stop youth from initiating substance use in the first place work. At CDC, we are working tirelessly to prevent overdose and substance-use related harms so that we can save lives today, build a strong foundation of prevention to protect the next generation, and help all people achieve optimal health and well-being. CDC prioritizes five key strategies aligning with the HHS-wide Overdose Prevention Strategy to address this crisis: 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 works alongside ONDCP in support of the National Drug Control Strategy as we have implemented these programs.

The SUPPORT Act authorizes CDC, as the nation’s public health and prevention agency, to lead the public health approach to this crisis 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 helping health departments and communities use these data to save lives. As a part of this work, CDC is improving fatal and non-fatal overdose data collection efforts, improving the use of prescription drug monitoring programs, and supporting communities to use these data to drive public health prevention actions. CDC also supports state, local, and territorial health departments, as well as tribes, to implement evidence-based prevention activities that can save lives.

The SUPPORT Act’s focus on improving data and evidence-based prevention has enabled CDC to scale a national comprehensive data and prevention program called Overdose Data to Action (OD2A). OD2A currently funds 47 states, Washington D.C., and 16 city and county health departments to advance unique and critical public health efforts that complement the work of other agencies. This includes innovative data collection, analysis, and dissemination activities that allow health departments to monitor data trends and to tailor the implementation of prevention efforts using evidence-informed and evidence-based strategies.

CDC uses data to understand drivers of both nonfatal and fatal overdose, including their scope and magnitude, who is most impacted, and to track trends over time to inform prevention and response efforts. CDC has developed two key data systems to improve the timeliness and comprehensiveness of both nonfatal and fatal overdose data as part of OD2A. CDC’s Drug Overdose Surveillance and Epidemiology (DOSE) System analyzes data from electronic health records and hospital discharge records to rapidly identify overdose clusters and changes in suspected drug overdose-related emergency department visits at the local, state, and regional levels. DOSE captures near-real time data on emergency department visits involving all suspected drug overdoses, including demographic characteristics of those who overdose. Ohio has used these near real-time data to issue local alerts to local health departments, coroners, health care providers, hospitals, and other state health partners to coordinated community response.

CDC’s State Unintentional Drug Overdose Reporting System (SUDORS) collects comprehensive information on drug overdose deaths in 47 states and the District of Columbia. SUDORS data are collected from medical examiner/coroner reports, death scene investigation reports, and toxicology testing to give more information on the circumstances that surround overdose deaths and guide community responses.  For example, SUDORS data indicated that 2 in 3 people who died from a drug overdose had an identified opportunity for linkage to care or life-saving actions. In addition, nearly half of overdose deaths occurred while a bystander was present.⁷ This data has led health departments to increase distribution of naloxone and bystander education efforts. SUDORS data also identify specific substances causing or contributing to overdose deaths as well as emerging drug threats and polysubstance overdose trends. CDC disseminates both DOSE and SUDORS data through interactive data dashboards accessible via CDC’s website.

In addition, CDC has made great strides, through its support for medical examiners and coroners, in improving the timeliness and completeness of drug overdose death certificate data. By reporting monthly provisional drug overdose death data, we are able to identify trends in overdose counts by drug class, within four to five months as opposed to two years. These improvements allow us to address substances of concern and identify changing demographic risk patterns. In addition to timely data, the completeness of drug overdose death certificates has greatly improved in recent years, which provides a fuller picture of the substances contributing to an overdose death, such as fentanyl and its analogs. As of 2021, specific-drug reporting on death certificates rose to 95%, up from approximately 85% in 2016.⁸

As the overdose crisis has broadened, flexibility to address emerging trends has been key to preventing overdose and related harms and helping health departments across the country adapt strategies to meet their local needs. The ability to support prevention activities related to new and/or emerging substances identified through syndromic overdose surveillance systems will allow the agency to continue to scale support quickly and efficiently to jurisdictions.

The ability to identify the substances involved in overdose is crucial to addressing the emergency. CDC is strengthening national public health testing capacity by developing advanced laboratory tests for fentanyl analogs, including a high-resolution method capable of identifying over 200 synthetic opioid-related compounds. CDC’s high-resolution libraries help U.S. laboratories identify these compounds and will soon include over 300 additional drugs, including synthetic cannabinoids, benzodiazepines, cathinones, and other psychoactive drugs. CDC also develops and provides reference materials (Traceable Opioid Material® Kits or TOM Kits®) to assure accurate and reliable measurements for fentanyl analogs and other drugs of abuse across state, local, and private clinical laboratories.

CDC works with state and local communities to ensure funded programs and resources are identifying and addressing trends in the overdose landscape that are evident through these data systems. Building on knowledge gained from the past four years under OD2A, CDC will begin funding two new programs in September 2023. Overdose Data to Action in States (OD2A:S) will provide approximately $200M in funding to state health departments to continue expanding innovative data efforts like SUDORS and DOSE, while also attending to the current and emerging drivers of the overdose epidemic, including a greater emphasis on harm reduction, linkage to care and navigation programs, and innovative connections across health systems, public safety, and community organizations. Recognizing that more resources are needed at the local level, CDC will also provide approximately $80M in direct funding to local city and county, as well as territorial, health departments through the Overdose to Action: Limiting Overdose through Collaborative Actions in Localities (OD2A: LOCAL) program. Designed to close a distinct gap in funding for local health jurisdictions, this program supports overdose-related surveillance and public safety infrastructure to address health equity and strengthen communities to prevent drug-related harms. CDC anticipates funding up to 40 local city, county, and territorial health departments for the first year of this program, with the recognition that there are many local jurisdictions that could benefit from this program long-term.

CDC also funds 11 Tribal Epidemiology Centers and 15 tribes or tribal-serving organizations for overdose prevention activities to improve data quality, completeness, accuracy, and timeliness among this high-risk population. This funding supports efforts to address opioid overdose prevention with strategies that are developed by tribal communities and ensure the strengths inherent to tribal organizations are incorporated and scaled across the country.

CDC’s scaled investments in activities to link people to care and treatment across health care, community, and criminal justice settings, complement the work of other agencies focused on funding substance use treatment and recovery support services delivery. For example, with OD2A funding, Illinois has funded harm reduction organizations in local communities to increase referrals to treatment services and evaluate outcomes.

Harm reduction reduces negative consequences associated with drug use and encompasses a broad array of practices and services for people who use drugs to prevent overdose and infectious disease transmission, improve wellbeing, and offer low barrier access to health care services, such as substance use and mental health disorder treatment.. For example, access to fentanyl test strips (FTS) provides people who use drugs with the ability to detect the presence of fentanyl so they can take steps to reduce risk of overdose. CDC supports the purchase of FTS through Overdose Data to Action. As the nation continues to respond to the overdose crisis, CDC also recognizes the need to stop rising numbers of infectious diseases associated with drug use, such as hepatitis C infections and HIV. The SUPPORT Act reauthorized CDC’s Infectious Diseases and Opioid Epidemic program, allowing CDC to build upon efforts to prevent and respond to infections commonly associated with illicit drug use. CDC advances this work by supporting and increasing access to syringe services programs (SSPs); supporting state and local health departments to conduct viral hepatitis surveillance for early detection and response of outbreaks associated with injection drug use; and supporting communications between harm reduction programs, public sector, and partners to improve SSP capacity, needs, and access and strengthen the public sector’s knowledge of the safety and effectiveness of syringe services programs. Finally, in collaboration with SAMHSA, CDC provides technical assistance on a range of harm reduction topics to state, territorial, local, and tribal partners, the private sector, and community-based organizations to prevent drug overdoses and reduce the infectious disease consequences of substance use through the National Harm Reduction Technical Assistance Center (NHRTAC).

CDC also implements targeted activities to better understand and prevent drug-related harms among children. Substance use during pregnancy increases risk for maternal and infant complications. CDC is supporting several data collection activities to better understand prenatal substance use to improve the health of mothers and infants. CDC works with the Council of State and Territorial Epidemiologists to provide technical assistance to state, local, tribal, or territorial jurisdictions to rapidly implement new standardized tracking criteria for neonatal abstinence syndrome (NAS). Using consistent criteria to define NAS for public health reporting helps ensure quality data are collected and women and their babies are connected with needed services. CDC also established MAT-LINK: MATernaL and Infant NetworK to Understand Outcomes Associated with Medication for Opioid Use Disorder during Pregnancy. This surveillance network of clinical sites identifies maternal, infant, and child health outcomes through six years of age.

In addition, CDC uses surveillance data to explore risk and protective factors for youth substance use and conducts research on its association with a variety of risks and behaviors. These data help inform where efforts should continue to focus to address youth substance use.

Recognizing that responding to the drug overdose crisis demands action at all levels, CDC works closely with both federal and national partners in both the public health and public safety sectors to scale best practices across community settings throughout the United States and to increase readiness to both respond to and prevent overdose and related harms.

CDC engages in collaborations across federal agencies to leverage all available resources to address and prevent drug overdose in communities. CDC continues to advance partnerships through multiple public health and public safety collaborations that aim to strengthen and improve efforts to reduce drug overdoses. The Overdose Response Strategy (ORS) is a unique collaboration between CDC and the High Intensity Drug Trafficking Areas (HIDTA) program at ONDCP that helps communities reduce fatal and non-fatal drug overdoses. ORS connects drug intelligence officers and public health analysts in all 50 states, Puerto Rico, and the U.S. Virgin Islands to collaborate and leverage supply and overdose data to problem-solve and address local and regional issues, including spikes in overdoses related to illicit fentanyl and stimulants.

Public health and public safety partnerships also focus on building the evidence base for local responses tailored to communities. 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); and training and provision of trauma-informed care. CDC also partners with the Bureau of Justice Assistance’s Comprehensive Opioid, Stimulant, and Substance Abuse Program to focus on rural responses, harm reduction education and training for law enforcement, overdose fatality review (OFR) implementation, and expanding use of the Overdose Detection Mapping Application Program (ODMAP) in states and tribes.

We cannot reverse current trends without a holistic effort that fully leverages the health system and health care providers to address SUD and overdose. 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 treatment and recovery supports; and reducing stigma among clinicians and providers so that people feel safe seeking the care they need.

Advancing prevention efforts and addressing stigma also includes supporting clinicians in providing safe and effective pain care. We know that pain affects the lives of millions of Americans and improving care for those living with pain is a public health imperative. In 2021, more than 51 million U.S. adults, about 1 in 5, experienced chronic pain, and 6.9% (17.1 million persons) experienced high-impact chronic pain, or pain that substantially restricts daily activities.⁹ CDC’s 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain,¹⁰ released in November 2022, supports clinicians in communicating with patients about the benefits and risks of pain treatments, including the use of opioid therapy. These voluntary recommendations are intended to assist and guide shared decision-making between clinicians and patients. CDC is working with health system and public health partners to support implementation of the Guideline by creating and disseminating a range of support materials such as trainings, fact sheets, and clinical decision support tools.

In an epidemic of this scale, public education and empowerment to combat stigma have never been more important. 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. CDC’s latest campaigns to stop overdose focus on raising awareness of fentanyl, naloxone, and polysubstance use, and decreasing stigma with a particular focus on 18 to 34-year-olds, a group experiencing some of the highest rates of overdose in recent years. These new mini-campaigns have reached over 3 billion views.

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. Recent CDC data show that young people are struggling with mental health challenges – with 42% of high school students reporting feeling persistently sad or hopeless and 1 in 5 high school students reporting suicidal thoughts in 2021.¹¹ These trends are connected to the substance use and overdose challenges among young people. A recent CDC study found that about 40% of adolescents who died of a drug overdose had a history of mental health conditions or mental health treatment.¹² And data from SAMHSA’s National Survey on Drug Use and Health consistently show that youth who have mental health challenges reported higher prevalence of substance use, across a range of substances.¹³ These statistics highlight the paramount importance of addressing upstream, root drivers that increase risk for substance use and mental health challenges in the first place.

CDC collects data on adverse childhood experiences (ACEs) to improve our understanding of the relationship between parental substance use, mental health, long-term health, and behavioral outcomes to inform prevention efforts. ACEs are preventable and potentially traumatic events that occur in childhood such as experiencing or witnessing violence, abuse, or neglect, having a caregiver who struggles with SUD or mental health challenges, or losing a loved one to overdose. Research consistently shows that ACEs are strongly linked to increased risk for substance use initiation, initiating at an earlier age, and developing an SUD.¹⁴ ACEs are also linked to increased risk for later mental health challenges as well as risk for suicide.¹⁵ Fortunately, decades of research show that ACEs can be prevented and there are a range of public health strategies that can be implemented to prevent them.¹⁶ By preventing ACEs and promoting positive childhood experiences, we have a substantial opportunity to get ahead of the substance use and mental health challenges facing our nation.

CDC conducts surveillance and data collection to inform activities that prevent child, youth, and adult trauma. ACEs data collected from these surveys helps inform evidence-based interventions and directs resources to communities experiencing disproportionate rates of ACEs. In addition, CDC’s Essentials for Childhood: Preventing Adverse Childhood Experiences through Data to Action program supports recipients in the establishment or expansion of state-wide ACEs data collection that will inform evidence-based prevention and the promotion of positive childhood experiences.

With continued support, CDC can bolster community-level efforts to foster resiliency among youth and families and address some of the earliest risk factors among youth for mental health challenges, substance use, and overdose later in life.

The continuation of a data driven comprehensive overdose prevention program will enable CDC to advance critical public health actions and innovations to reach communities impacted by the overdose and mental health crises facing our country. Flexibility to respond to novel and emerging substances and dynamic trends contributing to overdose and related harms will ensure CDC and public health can be nimble in responding to ever-evolving threats.

For far too long, the tragic consequences of substance use and overdose have devasted families and communities across the country, and the continued proliferation of illicitly made fentanyl and the resurgence of methamphetamine 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.