Letter to CDC Director Redfield on Lack of Opioid Dollars to Large Local Jurisdictions

July 13, 2018

Dear Dr. Redfield:

As leaders of the public health departments for Chicago, Houston, Los Angeles County, New York City, and Philadelphia, we represent five of the largest cities and counties in the country with a combined population of over 25 million people. We are also all members of the Big Cities Health Coalition (BCHC), which has 30 member cities, and collectively impacts more than 55 million (or one-in-six) Americans.

We are concerned that our five local health jurisdictions have been deemed ineligible for the recent Public Health Crisis Response Notice of Funding Opportunity (NOFO): 2018 Opioid Overdose Crisis Cooperative Agreement (Crisis NOFO). This Crisis NOFO was established as a mechanism for the CDC to rapidly fund a roster of pre-approved health departments during public health emergencies. This roster includes our five jurisdictions which are home to communities with complex health needs, making them particularly vulnerable to overdose (OD) deaths. Our health agencies are often the first to detect outbreaks, epidemics and other public health emergencies—and are bestequipped to design and implement life-saving responses tailored to our populations. It is crucial that the nation’s largest jurisdictions have the resources needed to reduce deaths among our most vulnerable residents. As such, excluding us is counter to the spirit and purpose of the Crisis NOFO.

The CDC has a long history of providing timely and direct support to the nation’s large counties and cities amidst pressing public health crises. Many historic innovations in addressing public health concerns—from HIV and tuberculosis to sexually transmitted infections and emergency preparedness—have resulted from direct funding and partnership between these jurisdictions and the CDC. Given this long and successful relationship, we are surprised that the largest local health authorities would be deemed ineligible for the Opioid Crisis NOFO, especially as the opioid overdose epidemic contin-ues to claim so many lives in our large metropolitan areas.

The increasing prevalence of opioid use disorders (OUD) and rates of drug overdose deaths are an urgent medical and public health issue. Despite efforts to decrease inappropriate prescribing of opioids, the number of patients with OUD has risen annually for the past decade. In 2016, the U.S. saw over 63,000 OD deaths, an increase of 28% from 2015. Two-thirds of these OD deaths involved opioids; increasingly, heroin and synthetic opioids (fentanyl, carfentanyl) are driving opioid-related OD deaths. Furthermore, we know that individuals with a prior, nonfatal OD are 2-3 times more likely to subsequently die of an OD in comparison to individuals who use drugs and have not previously had an OD.

• In 2016 in New York City, there were 1,425 unintentional drug OD deaths—this was the sixth consecutive year of increased deaths. This translates to 20.7 deaths per 100,000 New Yorkers, which is higher than the nationwide rate. Opioids were involved in 82% of these OD deaths. Provisional 2017 data indicate that fentanyl was present in more than half of all OD deaths; this is a dramatic increase from 2000-2013 when fentanyl was present in fewer than 4% of OD drug deaths per year.
• In Los Angeles County, an estimated 422,000 adults 18 years or older, or about 5.5% of the adult population, reported misusing prescription drugs in the past year ( 2015). In the County, an average of 400 deaths per year from 2006-2012 were associated with a positive test for prescription opioids. Between 2006-2013, hospitalizations and emergency department visits related to opioid diagnoses have increased 30% and 171%, respectively, with a substantial increase in costs associated with hospitalizations from opioid diagnoses.
• In Chicago, there were 741 opioid related overdose deaths. The rate of opioid related overdose deaths (26.7 per 100,000 individuals) was substantially higher than the rate in Illinois (14.7 per 100,000 individuals) and the rate in the U.S. (13.3 per 100,000). More than 90% of these deaths involved heroin and/or fentanyl, and the rate of overdose deaths involving fentanyl increased dramatically to 15.1 per 100,000 individuals from 2.7 in 2015. Preliminary numbers from 2017 indicate that opioid-related overdose deaths have continued to rise.
• In Houston, city EMS transported 3,277 non-alcohol drug overdoses during the year ending June 1, 2018, including 593 (15%) due to opioids. In calendar year 2017, the Harris County Institute of Forensic Science (aka Harris County Medical Examiner’s Office) reported 616 drug-related deaths and 257 (42%) involved opioids. Accidental deaths involving heroin rose 78% increase between June 2017 and December 2017 with a 58% increase in fentanyl deaths during the same period. Texas has not suffered the epidemic of heroin overdoses seen in other parts of the country because the heroin in Texas is Mexican Black Tar, which cannot be easily mixed with fentanyl. However other types of heroin are increasingly common.
• In Philadelphia, 1,217 persons died of drug overdose in 2017, of whom 88% had an opioid in their system. This translates to an overdose mortality rate of 78 per 100,000 persons, twice as high as three years earlier and approximately four times the national overdose mortality rate. It is also 30% higher than AIDS deaths in Philadelphia at the peak of the city’s AIDS crisis. Philadelphia has responded with efforts to reduce over-prescribing of opioids, help addicted people get into treatment, prevent fatal overdoses, and address a surge in opioid-related homelessness, but the city is overwhelmed by the crisis.

As “first responders” to the present opioid epidemic, large metropolitan areas have helped pave the way for responses on the national scale. With large and diverse population centers served by major medical systems, academic centers, and complex infrastructure, metropolitan areas are incubators for the latest and most effective responses to the opioid epidemic. In fact, we are already innovating and taking action. For example, Chicago created a pharmaceutical representative license; Philadelphia has made naloxone available in libraries; and Los Angeles County created and distributed safe prescribing guidelines on the administration of pain medication in all emergency departments and over 80 urgent care centers throughout the County.
Mary T. Bassett, MD, MPH
Commissioner, New York City Department of
Health and Mental Hygiene
Thomas Farley, MD, MPH
Commissioner, Philadelphia Department of
Public Health
Barbara Ferrer, PhD, MPH, MEd
Director, Los Angeles County Department of
Public Health
Julie Morita, MD
Commissioner, Chicago Department of Public
Health
Stephen Williams, MEd, MPA
Director, Houston Department of Health
Nonetheless, we cannot do this alone. Excluding large local health authorities from receiving funding will undermine this crucial work at a time when OD deaths are rising to unprecedented levels. This omission could greatly damage our nation’s ability to ensure that both the government and private sector are implementing the most effective and cost-efficient interventions. The current opioid epidemic shows no signs of reversing, though promising results have emerged in several jurisdictions. Future progress in addressing the opioid epidemic requires a sustained investment to support comprehensive, multifaceted approaches in local communities across the country, not just at the state level. Without dedicated resources for large local health departments, we will have limited capacity to address these critical public health issues. It is not clear why the decision was made to exclude our health agencies from receiving Opioid Overdose Crisis Cooperative Agreement funds when the Public Health Crisis Response NOFO mechanism exists and our jurisdictions have already been pre-approved for funding. This decision establishes a dangerous precedent that could leave city and county health agencies unfunded during public health crises, which would endanger the health and safety of the populations we serve. We respectfully urge you to include the pre-approved, directly-funded large urban jurisdictions as eligible recipients for this and any future Public Health Crisis Response funding announcements. Further, we look forward to the opportunity to work with you as you develop subsequent funding opportunities. Please do not hesitate to reach out to any one of us directly. Or, to reach us collectively, you may also contact Chrissie Juliano (cjuliano@naccho.org), Director of the Big Cities Health Coalition.

Sincerely,