Response Planning

• Identify thresholds for what constitutes an anomaly. These thresholds should be established by the jurisdiction where it will be applied and can vary between jurisdictions.
• Create a process for validating the outbreak and reducing the chance it is caused by a data quality error:
• Plan to have communication with partners that monitor other near real-time data to evaluate their sources and corroborate consistent increases.
• Consider tools such as Smartsheet, MS Teams, REDCap, or other web-based methods to centralize and share confidential information quickly rather than using email.
• Develop a decision tree that determines when an anomaly will activate a response
• Establish a fixed activation threshold may be difficult, consider the following factors:
• Current program response capacity
• A threshold number of overdoses that would exceed program response capacity and indicate the need for additional resources
• Consider the frequency of alerts that can be responded to avoid alert fatigue or overly tax resources. Set thresholds based on historic frequency that does not occur often, such as a peak number of overdoses seen only once a month.
• Low burden areas may want to monitor counts of overdoses over longer time frames. High burden areas may have enough power to detect increases daily or can use percent increases to adjust for changing total volume of visits reported.
• Consider which agencies or programs can provide the additional resources
• Example: Pennsylvania EpiCenter Alert Guidance: Thresholds for suspected overdose by facility location and by home location

Based on the information gathered, investigators can determine if an increase in overdose deaths is a:

• General gradual increase in overdoses occurring steadily over time
  • In the case of opioid use this type of increase may be a consequence of persistent changes over time in prescriptions for opioids, changes in polysubstance use patterns, increases in opioid use disorder (OUD) or changes in the type of opioid misused. Examples include:
  • Vital Signs: Overdoses of Prescription Opioid Pain Relievers — United States, 1999–2008
  • MMWR: Methadone Prescribing and Overdose and the Association with Medicaid Preferred Drug List Policies
• Limited increase in overdoses in a narrow geographic area and/or time frame – the spike or extremely high community burden may be identified as:
  • A change in the illicit drug supply linked to a very limited source (e.g., tainted supply from one illicit drug dealer or supplier) or geographic areas. These types of spikes may rapidly turn into widespread outbreaks. Here are examples in California, Connecticut, Georgia, and West Virginia. 
  • Related to exceptionally high levels of inappropriate prescribing of opioid pain relievers or other controlled substances in a specific geographic area. See example in Staten Island, New York City.  
  • Related to a single clinical provider.
• Widespread outbreak impacting a large geographic area :
  • An increase in overdose deaths identified as an outbreak are characterized by widespread changes in the illicit drug supply and use patterns and/or widespread changes in prescription, diversion, or misuse of prescription drugs.
  • Here are examples of widespread fentanyl and fentanyl analog outbreaks across multiple states as well as widespread state outbreaks in Florida, Ohio, and Massachusetts.  

Below are some examples of investigation goals you may consider when designing your inquiry.

• Determine the extent of the outbreak and how long the outbreak has been occurring
  • Note that identification of outbreaks occurs once a number of cases have already been detected, especially in scenarios where overdoses may spike rapidly
• Identify key changes in risk factors for overdose or opioid-related harms
• Understand similarities or connections among cases
• Implement and evaluate interventions to rapidly reduce the incidence of overdoses and the proportion of overdoses that are fatal
  • Rapid interventions could target known risk factors such as recent release from an institution and/or risk factors unique to the outbreak (e.g., specific group disproportionately affected by cocaine contaminated with fentanyl)
• Increase access to medication for opiod use disorder MOUD and linkage of high-risk individuals to treatment and harm reduction services, such as people with opioid use disorder released from incarceration, people seeking treatment at the ED for an opioid overdose, and people injecting drugs or using illicit opioids such as heroin or fentanyl.
• Support and enhance current systems:
  • Healthcare
  • Community Partners
  • Surveillance
  • Law Enforcement
  • ME/C
  • Public messaging and health communication

An incident action plan (IAP) formally documents incident goals, operational period objectives, and the response strategy defined by incident command during response planning. It contains general tactics to achieve goals and objectives within the overall strategy, while providing important information on event and response parameters. Equally important, the IAP facilitates dissemination of critical information about the status of response assets themselves. Because incident parameters evolve, action plans must be revised on a regular basis (at least once per operational period) to maintain consistent, up-to-date guidance across the system.

• DHHS What is an Incident Action Plan?
• IAP Example – Montgomery County, Ohio

• Determine what measures should be taken for further monitoring to ensure the outbreak remains resolved. Continue collaboration with neighboring jurisdictions if needed.
• Determine what measures should be taken for further monitoring to ensure the outbreak remains resolved or enhanced sustained response to the endemic problem.
• Identify opportunities for long-term community capacity-building to prevent and address future outbreaks.