To reduce overdose morbidity and mortality, state and territorial health agencies should implement equitable harm reduction policies that leverage community strengths.

The U.S. overdose crisis continues, with provisional data indicating approximately 107,000 overdose deaths occurring in 2022. While provisional data show a plateau in recent rates of overdose deaths, continued effort is needed to develop and implement policies and programming to reduce overdose rates. The Association of State and Territorial Health Officials (ASTHO) supports state and territorial health officials (S/THOs) and state and territorial health agencies (S/THAs) to implement innovative and effective programming to reduce overdose morbidity and mortality.

Using the current evidence base and promising practices, ASTHO outlined policy recommendations in the Journal of Public Health Management and Practice to respond to the ongoing overdose crisis. ASTHO selected the following policies that S/THAs can implement to reduce overdose-related harms:

1. Increase community distribution of naloxone.
2. Legalize fentanyl test strips and drug checking equipment.
3. Remove barriers to establish syringe services programs.
4. Enhance substance use peer support programs.

Rationale of Policy Selections

ASTHO conducted a literature review to identify key policy strategies to reduce overdose. From there, we used an impact versus feasibility matrix to determine the four previously listed policies. Finally, we included explicit integration of health equity and stigma reduction to ensure that the harms caused by ineffective and prejudicial policies implemented in the past are mitigated. As communities with the highest risk of overdose have often been under resourced, incorporating the voices and perspectives of people with lived or living experience from these communities in the policy-making process is critical. Further, as stigma continues to be an issue, narrative change should be embraced as a key activity to reduce stigma and improve outcomes.

Policy Recommendations

Increase Community Distribution of Naloxone

Naloxone is a life-saving medication that reverses opioid overdoses. Reaching a high level of community saturation is a priority, particularly with fentanyl permeating the drug supply. As of July 28, 2023, FDA has approved two naloxone products for over-the-counter use: Narcan, a 4 mg naloxone hydrochloride nasal spray, and RiVive, a 3 mg nasal spray. By working with overdose education and naloxone distribution (OEND) programs that often partner directly with people who use drugs, and those who may witness an overdose, naloxone can get to those who are most likely to need it. OEND programs consider their communities and determine the best partners to work with to distribute naloxone effectively. S/THAs can be effective partners by sharing data and infrastructure to get naloxone into the hands of those who need it.

Legalize Fentanyl Test Strips and Drug Checking Equipment

Fentanyl is a potent synthetic opioid that is found in the illicit drug supply and has contributed to both fatal and nonfatal overdoses. To detect fentanyl in a substance, an individual can use fentanyl test strips (FTS) to make an informed decision about their drug use. Drug paraphernalia laws of the 1970s have often made products such as FTS illegal, but states are changing laws to legalize drug checking equipment. By using jurisdictional data about fentanyl-related overdoses, S/THAs can provide recommendations to update drug checking policies.

Remove Barriers to Establish Syringe Services Programs

Syringe services programs (SSPs) are evidence- and community-based initiatives that address overdose and infectious disease-related harms, such as syringe disposal, linkage to substance use disorder treatment, vaccination, and testing. These trusted programs often work with community partners to increase access to treatment, including medication-assisted treatment. To reduce barriers to establishing SSPs, S/THAs can educate decision makers and work with community leaders to determine the best program structure based on community needs.

Enhance Substance Use Peer Support Programs

Peers provide crucial support for people who use drugs in their recovery journey, and often increase a person’s linkage to care and access to services. Certified peer support specialists work in core competencies identified by the SUD recovery community and bring their lived experience and skills to this work, differing from traditional services providers. Peers can improve health outcomes and their services should be reimbursed through all jurisdictional Medicaid plans. By collaborating with Medicaid agencies, services programs, peer support groups, and other policymakers, S/THOs and S/THA staff can identify reimbursement strategies.

State and territorial health officials are well-positioned to play a leading role in reducing overdose-related harms. Through the above policies, we believe that the risk of overdose will decrease, driving improved health outcomes for many people who use drugs or those with an SUD.

Read our article in the Journal of Public Health Management and Practice: Reducing Overdose through Policy Interventions: ASTHO’s Recommendations for State and Territorial Health Officials and Agencies

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Victoria Pless, MPH, PMP, is the Assistant Director for Overdose Prevention at ASTHO. She provides technical assistance to health officials and agencies in their overdose prevention and surveillance activities. Her subject matter expertise in overdose includes harm reduction, public health and public safety partnerships, and policy interventions.

JoAnne McClure, MSW, is a Senior Analyst for State Health Policy at ASTHO. She provides public health leaders and agencies with policy-related technical assistance such as resources and training in policy development frameworks and communication strategies, as well as monitoring legislative landscapes in overdose prevention, immunization, and infectious disease.

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