A Model Practice must be responsive to a particular local public health problem or concern. An innovative practice must be -
Please state the Responsiveness and Innovation of your practice
Illicitly manufactured fentanyl and fentanyl analogs are largely responsible for a five-fold increase in US synthetic opioid overdose fatalities between 2013 and 2016. Sharp mortality spikes have been evident on both US coasts and in the Southeast and Midwest. Overdoses mortality involving fentanyl/analogs in Colorado remains relatively low, with 112 deaths statewide in 2017 of which 18 occurred in Denver. While people who use substances in many other communities have somewhat adjusted to widespread fentanyl/analog contamination over time, people who use substances in Denver are at high risk for unexpected changes in potency and lethality of illicit drugs. The overdose epidemic led to the CDC Opioid Emergency Response funding vehicle, which permitted the development of an early warning system before it was too late.
To our knowledge this is the first pre-event “early warning system” created specifically to detect and then warn affected populations and those in their social networks about the threat of fentanyl contamination in the illicit drug supply. With an estimated 4.82% of adult Coloradans having used an illicit drug other than marijuana in the past month, a sudden and unsuspected change in drug potency and lethality could be disastrous.
Upon reflection, no single used data stream could be expected to reliably and precisely reflect sudden changes in the makeup of the illicit drug supply, and none specifically targeted fentanyl/analogs. However, teammates had success with multi-indicator dashboards in the past and access to and experience with many possible sources of data. Therefore, we could integrate a variety of data, some of which might be leading but non-specific indicators, while others might be trailing indicators of great specificity. Since our vision was to alert the community at risk at the earliest opportunity, data would need to be available and interpretable in near real time. To avoid falling victim to our biases, we brainstormed a longer list of possible data indicators, and then narrowed them down, using CDC evaluation criteria proposed for surveillance systems. Based on these and other criteria we narrowed down 13 indicator candidates to five. While the data sources available to other communities might differ, any community can benefit by following a similar brainstorming and winnowing process informed by the same logic. Evaluations of data sources included describing each data source in terms of how it was collected, the format of the data, frequency in which it was received, whether it was a leading or lagging indicator, usefulness, simplicity, flexibility, data quality, acceptability (including cost), sensitivity, positive predictive value, representativeness, and timeliness.
Two selected data sources are common and well-established: emergency department syndromic surveillance for opioid overdoses (using a standard CDC query) and medical examiner overdose cases. Three more novel data sources were also included: drug seizures by local police, EMS cases, and urine drug screens from patients in addiction treatment. Local police performed gas chromatography/mass spectroscopy (GC/MS) on seized drugs for cases going to trial, but the addition of modest funding allowed them to test a random selection of drugs for fentanyl/analog contamination. We looked at EMS cases that responded only after unusually high doses of naloxone were administered, as an indirect indicator of overdose involving a potent opiate. Finally, a laboratory company (Precision Diagnostics, San Diego, CA) that routinely uses GC/MS on all urine drug tests enabled us to look at cumulative, de-identified results from patients in drug rehabilitation. Since we had little reason to believe data from other municipalities in the metropolitan area should systematically deviate from Denver County we utilized regional data when available. Data from broader surrounding regions and states made available by the laboratory company allowed us to look at emerging trends that might be approaching from further north, south, east and west.
Historic data was used, when available, to set control limits to help detect unusual trends, accented by color changes in the display. Retrospective analysis of consistency (Cronbach’s alpha) reassured that they measured related trends. Indicator metrics for each week were stacked vertically so patterns could be easily observed. Careful attention to “at a glance” visibility into the data is another principle other LHDs could utilize.
We reviewed data and dashboards several times, both with those who provided and best understood their data and other experts (including people who use drugs and those who care for them). This helped avoid misinterpretation and facilitated improved data display, while also enhancing easy communications among our various partners. Such iterative review by diverse stakeholders is another step other LHDs could use to their benefit.
Weekly periodicity of indicators was selected to increase the stability of estimates while allowing prompt detection. This balance has worked well with the data sets we selected.
Dashboards have been created weekly for 32 weeks (since May 5, 2019). Adding additional weekly data requires only a few keystrokes, so it has been possible to maintain operations in the absence of ongoing funding for several weeks (an alternate funding source will support forensic tests on a random sample of drug seizures). The Colorado Department of Public Health and Environment has agreed to fund maintenance and extension of the dashboard to other issues like synthetic marijuana in coming months, using CDC Overdose Data 2 Action cooperative agreement funds.
In parallel, DDPHE conducted focus groups and key informant interviews to help define message content and branding and identify how messages should effectively be delivered. One important conclusion of this assessment was to message around safe use, and not a call to abstinence that might cause users to disengage. It was discovered that the use of government logos would not increase distrust, but that official websites might be avoided by some segments of the population who use drugs.
Distribution of information to over 100 community-based entities will help ensure the message can be delivered by partners trusted by different segments of the target population. Social media also enables echoing of messages by partners who might appeal more to those who do not trust government. In short, many lessons were learned from direct and respectful communication directly with affected stakeholders, which also helped our team leverage existing relationships for communication rather than recreate them. The November 5th alert generated 313 mentions on radio, television, newspapers, Facebook, Twitter, and You Tube with a reach of 31,610,286 people and an earned medial value of $292,395. Past Health Alert Network alerts to health care providers have reached over 650 addressees, with a 99.8% delivery rate and 38% open rate.
As mentioned, the early warning system was tested by a real event in November. A single large seized specimen of counterfeit heroin was found to contain fentanyl, and Denver Police Department immediately notified health authorities. This notification preceded signal of a spike in the weekly dashboard, but partners agreed that community, media, and health professional notification should occur anyway due to the size and unusual nature of the seizure. Following the alert, record, or near-record, elevations in fentanyl positive urines, EMS rescues requiring high naloxone doses, and emergency department encounters for opioid overdose were noted for two weeks, then returning toward normal. This provided reassurance that the system was sensitive to changes in the drug supply, and that either the period of risk was short term or that alerting of the affected populations had been effective.