Public Health Agencies Adapt Covid Lessons to Curb Overdoses, STDs, and Gun Violence

Know-how gained through the covid pandemic is seeping into other public health areas. But in a nation that has chronically underfunded its public health system, it’s hard to know which changes will stick.

LIVINGSTON, Mont. — Shannan Piccolo walked into a hotel with a tote bag full of Narcan and a speech about how easy it is to use the medicine that can reverse opioid overdoses.

“Hopefully your business would never have to respond to an overdose, but we’d rather have you have some Narcan on hand just in case,” Piccolo, director of Park City-County Health Department, said to the hotel manager.

The manager listened to Piccolo’s instructions on how to use Narcan, the brand name of the drug naloxone, and added four boxes of the nasal spray to the hotel’s first-aid kit.

The transaction took less than 10 minutes. It was the third hotel Piccolo had visited that hot July day in Livingston, a mountain town of roughly 8,000, where, as in much of the nation, health officials are worried about a recent rise in the use of the synthetic opioid fentanyl.

It was the first time the local health department offered door-to-door training and supplies to prevent overdose deaths. The underlying strategy was forged during the pandemic when public health officials distributed rapid tests and vaccines in high-risk settings.

“We learned this from covid,” said Dr. Laurel Desnick, the county’s public health officer. “We go to people who may not have time to come to us.”

The pandemic laid bare the gaps and disparities in the U.S. public health system, and often resulted in blowback against local officials trying to slow the coronavirus’s spread. But one positive outcome, in part fueled by a boost in federal dollars, is that health workers have started adapting lessons they learned from their covid-19 response to other aspects of their work.

For example, in Atlanta, the county health department planned to mail out at-home kits to test for diseases, a program modeled on the distribution of covid rapid tests. In Houston, health officials announced this month they’ll begin monitoring the city’s wastewater for monkeypox, a tactic broadly used to gauge how far and fast covid spread. And in Chicago, government agencies have tweaked covid collaborations to tag-team a rise in gun violence.

Some of these adaptations should cost little and be relatively simple to incorporate into the departments’ post-pandemic work, such as using vans purchased with covid relief money for vaccine delivery and disease testing. Other tools cost more money and time, including updating covid-borne data and surveillance systems to use in other ways.

Some public health workers worry that the lessons woven into their operations will fall away once the pandemic has passed.

“When we have public health crises in this country, we tend to have a boom-and-bust cycle of funding,” said Adriane Casalotti, with the National Association of County and City Health Officials.

Some federal pandemic relief funding is scheduled to last for years, but other allocations have already run dry. Local health workers will be left to prioritize what to fund with what remains.

Meanwhile, historically short-staffed and underfunded health departments are responding to challenges that intensified during the pandemic, including delayed mental health treatment and routine care.

“You’re not just starting from where you were 2½ years ago, there’s actually a higher mountain to climb,” Casalotti said. “But places that were able to build up some of their systems can adapt them to allow for more real-time understanding of public health challenges.”

In Atlanta, the Fulton County Board of Health has offered to mail residents free, at-home tests for sexually transmitted diseases. The state has historically had some of the highest rates of reported STDs in the nation.

“This program has the power to demonstrate the scalable effects of equitable access to historically underserved communities,” Joshua O’Neal, the county’s director of the sexual health programs, said in a press release announcing the kits.

The changes go beyond government. University of Texas researchers are trying out a statewide program to crowdsource data on fatal and nonfatal opioid overdoses. Those working on the project are frustrated the national effort to track covid outbreaks hasn’t extended to the overdose epidemic.

Dr. Allison Arwady, commissioner of the Chicago Department of Public Health, said her team is expanding the covid data-driven approach to track and report neighborhood-level data on opioid drug overdoses. Nonprofits and city agencies that have worked together through the pandemic now meet each month to look at the numbers to shape their response.

Arwady said the city is trying to use the pandemic-driven boost in money and attention for programs that can last beyond the covid emergency.

“Every day, we’re having these debates about, ‘How much do we continue on? How big do we go?’” Arwady said. “I feel like it’s such a moment. We’ve shown what we can do during covid, we’ve shown what we can do when we have some additional funding.”

The city also opened a new safety center modeled on its covid-response base to counter gun violence. Employees from across city departments are working together on safety issues for the first time by tracking data, connecting people in highest-risk areas to services, and supporting local efforts such as funding neighborhood block clubs and restoring safe spaces.

Separately, neighborhood-based organizations created to handle covid contact tracing and education are shifting focus to address food security, violence prevention, and diabetes education. Arwady said she hopes to continue grassroots public health efforts in areas with long-standing health disparities by using a patchwork of grants to retain 150 of the 600 people initially hired through pandemic relief dollars.

“The message I’ve really been telling my team is, ‘This is our opportunity to do things that we have long wanted to do,’” Arwady said. “We built some of that up and I just, I’m gonna kick and scream before I let that all get dismantled.”

Back in Montana, Desnick said not every change relies on funding.

When flooding destroyed buildings and infrastructure in and around Yellowstone National Park in June, the Park County health department used a list of contacts gathered during the pandemic to send updates to schools, churches, and businesses.

Desnick posts regular public health video updates that began with covid case counts and broadened to include information on flood levels, federal cleanup assistance, and ice cream socials for people to meet first responders.

Piccolo, the county’s health director, spent roughly an hour on that day in July going to hotels in Livingston’s core to offer opioid overdose response training and supplies. Three hotel managers took the offer, two asked her to come back later, and one scheduled an all-staff training for later that week. Piccolo plans to extend the program to restaurants and music venues.

It’s that kind of adaptation to her job that doesn’t require the continuing flow of covid aid. The state supplied the Narcan boxes. Otherwise, she said, “it’s just about taking the time to do this.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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The Blackfeet Nation’s Plight Underscores the Fentanyl Crisis on Reservations

The deadly synthetic opioid has spread across the nation during the pandemic, and the problem is disproportionately affecting Native Americans.

BROWNING, Mont. — As the pandemic was setting in during summer 2020, Justin Lee Littledog called his mom to tell her he was moving from Texas back home to the Blackfeet Indian Reservation in Montana with his girlfriend, stepson, and son.

They moved in with his mom, Marla Ollinger, on a 300-acre ranch on the rolling prairie outside Browning and had what Ollinger remembers as the best summer of her life. “That was the first time I’ve gotten to meet Arlin, my first grandson,” Ollinger said. Another grandson was soon born, and Littledog found maintenance work at the casino in Browning to support his growing family.

But things began to unravel over the next year and a half. Friends and relatives saw Littledog’s 6-year-old stepson walking around town alone. One day, Ollinger received a call from her youngest son as one of Littledog’s children cried in the background. He was briefly unable to wake Littledog’s girlfriend.

Ollinger asked Littledog whether he and his girlfriend were using drugs. Littledog denied it. He explained to his mom that people were using a drug she had never heard about: fentanyl, a synthetic opioid that is up to 100 times as potent as morphine. He said he would never use something so dangerous.

Then, in early March, Ollinger woke up to screams. She left her grandchildren sleeping in her bed and went into the next room. “My son was laying on the floor,” she said. He wasn’t breathing.

She followed the ambulance into Browning, hoping that Littledog had just forgotten to take his heart medication and would recover. He was pronounced dead shortly after the ambulance arrived at the local hospital.

Littledog was among four people to die from fentanyl overdoses on the reservation that week in March, according to Blackfeet health officials. An additional 13 people who live on the reservation survived overdoses, making a startling total for an Indigenous population of about 10,000 people.

Fentanyl has taken root in Montana and in communities across the Mountain West during the pandemic, after formerly being prevalent mostly east of the Mississippi River, said Keith Humphreys of the Stanford-Lancet Commission on the North American Opioid Crisis.

Montana law enforcement officials have intercepted record numbers of pale-blue pills made to look like prescription opioids such as OxyContin. In the first three months of 2022, the Montana Highway Patrol seized over 12,000 fentanyl pills, more than three times the number from all of 2021.

Nationwide, at least 103,000 people died from drug overdoses in 2021, a 45% increase from 2019, according to data from the Centers for Disease Control and Prevention. About 7 of every 10 of those deaths were from synthetic opioids, primarily fentanyl.

Overdose deaths are disproportionately affecting Native Americans. The overdose death rate among Indigenous people was the highest of all racial groups in the first year of the pandemic and was about 30% higher than the rate among white people, according to a study co-authored by UCLA graduate student and researcher Joe Friedman.

In Montana, the opioid overdose death rate for Indigenous people was twice that of white people from 2019 to 2021, according to the state Department of Public Health and Human Services.

The reason, in part, is that Native Americans have relatively less access to health care resources, Friedman said. “With the drug supply becoming so dangerous and so toxic, it requires resources and knowledge and skills and funds to stay safe,” he said. “It requires access to harm reduction. It requires access to health care, access to medications.”

The Indian Health Service, which is responsible for providing health care to many Indigenous people, has been chronically underfunded. According to a 2018 report from the U.S. Commission on Civil Rights, IHS per patient expenditures are significantly less than those of other federal health programs.

“I think what we’re seeing now is deep-seated disparities and social determinants of health are kind of bearing out,” Friedman said, referring to the disproportionate overdose deaths among Native Americans.

Blackfeet Tribal Business Council member Stacey Keller said she has experienced the lack of resources firsthand while trying to get a family member into treatment. She said just finding a facility for detoxing was difficult, let alone finding one for treatment.

“Our treatment facility here, they’re not equipped to deal with opioid addiction, so they’re usually referred out,” she said. “Some of the struggles we’ve seen throughout the state and even the western part of the United States is a lot of the treatment centers are at capacity.”

The local treatment center doesn’t have the medical expertise to supervise someone going through opioid withdrawal. Only two detox beds are available at the local IHS hospital, Keller said, and are often occupied by other patients. The health care system on the reservation also doesn’t offer medication-assisted treatment. The nearest locations to get buprenorphine or methadone — drugs used to treat opioid addictions — are 30 to 100 miles away. That can be a burden to patients who are required by federal rules to show up each day at the approved dispensaries to receive methadone or must make weekly treks for buprenorphine.

Keller said tribal leaders have requested assistance from IHS to build out treatment and other substance use resources in the community, with no results.

The IHS’ Alcohol and Substance Abuse Program consultant, JB Kinlacheeny, said the agency has largely shifted to appropriating funds directly to tribes to run their own programs.

The Rocky Mountain Tribal Leaders Council, a consortium of Montana and Wyoming tribes, is working with the Montana Healthcare Foundation on a feasibility study for a treatment center operated by tribes to build capacity specifically for tribal members. Tribes across both states, including the Blackfeet, have passed resolutions supporting the effort.

Blackfeet political leaders declared a state of emergency in March after the fentanyl overdoses. A short time later, some of the tribal council chairman’s children were arrested on suspicion of selling fentanyl out of his home. The council removed Chairman Timothy Davis from his position as tribal leader in early April.

The tribe has created a task force to identify both the short- and long-term needs to respond to the opioid crisis. Blackfeet tribal police investigator Misty LaPlant is helping lead that effort.

Driving around Browning, LaPlant said she plans to train more people on the reservation to administer naloxone, a medication that reverses opioid overdoses. She also wants the tribe to host needle exchanges to reduce infections and the spread of diseases like HIV. There’s also hope, she said, that a reorganization of the tribal health department will result in a one-stop shop for Blackfeet Nation residents to find drug addiction resources on and off the reservation.

However, she said resolving some of the underlying issues — such as poverty, housing, and food insecurity — that make communities like the Blackfeet Nation vulnerable to the ongoing fentanyl crisis is a massive undertaking that won’t be completed anytime soon.

“You could connect historical trauma, unresolved traumas in general, and grief into what makes our community vulnerable,” she said. “If you look at the impact of colonialism and Indigenous communities and people, there’s a correlation there.”

Marla Ollinger is happy to see momentum building to fight opioid and fentanyl addiction in the wake of her son’s death and other people’s. As a mother who struggled to find the resources to save her son, she hopes no one else has to live through that experience.

“It’s heartbreaking to watch your children die unnecessarily,” she said.

This story is part of a partnership that includes Montana Public RadioNPR and KHN.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

USE OUR CONTENT

This story can be republished for free (details).