Exhibit A Special Grant Conditions.pdf

Exhibit A: Special Grant Conditions

Centers for Disease Control and Prevention

NATIONAL CENTER FOR INJURY PREVENTION AND CONTROL

Overdose Data to Action: Limiting Overdose through Collaborative Actions in Localities

(OD2A: LOCAL)

CDC-RFA-CE-23-0003

05/08/2023

Table of Contents A. Funding Opportunity Description B. Award Information C. Eligibility Information D. Required Registrations E. Review and Selection Process F. Award Administration Information G. Agency Contacts H. Other Information I. Glossary

Part I. Overview

Applicants must go to the synopsis page of this announcement at www.grants.gov and click on the "Subscribe" button link to ensure they receive notifications of any changes to CDC-RFA-CE- 23-0003. Applicants also must provide an e-mail address to www.grants.gov to receive notifications of changes.

A. Federal Agency Name:

Centers for Disease Control and Prevention (CDC) B. Notice of Funding Opportunity (NOFO) Title:

Overdose Data to Action: Limiting Overdose through Collaborative Actions in Localities

(OD2A: LOCAL)

C. Announcement Type: New - Type 1:

This announcement is only for non-research activities supported by CDC. If research is proposed, the application will not be considered. For this purpose, research is defined at https://www.gpo.gov/fdsys/pkg/CFR-2007-title42-vol1/pdf/CFR-2007-title42-vol1-sec52- 2.pdf. Guidance on how CDC interprets the definition of research in the context of public health can be found at https://www.hhs.gov/ohrp/regulations-and-policy/regulations/45-cfr- 46/index.html (See section 45 CFR 46.102(d)).

New-Type 1

D. Agency Notice of Funding Opportunity Number:

CDC-RFA-CE-23-0003

E. Assistance Listings Number:

https://www.grants.gov/ https://www.grants.gov/ https://www.gpo.gov/fdsys/pkg/CFR-2007-title42-vol1/pdf/CFR-2007-title42-vol1-sec52-2.pdf https://www.gpo.gov/fdsys/pkg/CFR-2007-title42-vol1/pdf/CFR-2007-title42-vol1-sec52-2.pdf https://www.hhs.gov/ohrp/regulations-and-policy/regulations/45-cfr-46/index.html https://www.hhs.gov/ohrp/regulations-and-policy/regulations/45-cfr-46/index.html

93.136 F. Dates:

1. Due Date for Letter of Intent (LOI):

04/06/2023 Recommended but not Required An LOI is requested, but not required. LOIs should indicate the intention to apply and to which components. The purpose of an LOI is to allow CDC program staff to estimate the number of applications and plan for the review of submitted applications. The LOI should contain the following information:

• Name of jurisdiction intending to apply to this NOFO.

• A preliminary decision about whether the applicant intends to apply for either or both of the optional and competitive surveillance components (Component B and/or Component C). This preliminary decision should be clearly and succinctly stated, “Plan to apply to Component B, but not Component C”. If the applicant does not plan to apply for either Component B or Component C, please write, “Will not apply for Component B or Component C”.

When submitting the LOI, please follow these instructions to help CDC rapidly identify and process your LOI:

• Send LOI via email to OD2A_LOCAL@cdc.gov.

• The subject of the email should be “LOI Overdose Data to Action: Limiting Overdose through Collaborative Actions in Localities (OD2A: LOCAL)”.

• The email with the LOI should be addressed to “OD2A: LOCAL Team, Division of

Overdose Prevention, CDC”.

2. Due Date for Applications:

05/08/2023 11:59 p.m. U.S. Eastern Standard Time, at www.grants.gov.

3. Due Date for Informational Conference Call First Informational Call

When: March 13, 2023, 03:00 PM – 5: 00 PM Eastern Time (US and Canada)

Topic: OD2A: LOCAL First National Informational Call

Register in advance for this webinar:

https://us02web.zoom.us/webinar/register/WN_OAipA2W9Th-m9kB2TeKiHw

After registering, you will receive a confirmation email containing information about joining the webinar.

This two-hour call provides a comprehensive overview of the required strategies of the NOFO, presenting eligibility requirements, prevention strategies, a walk-through of the application and selection process, and a discussion of Component A, which is required for all applicants.

Throughout the session, participants will have the opportunity to ask questions. All potential mailto:OD2A_LOCAL@cdc.gov https://www.grants.gov/ https://us02web.zoom.us/webinar/register/WN_OAipA2W9Th-m9kB2TeKiHw applicants are encouraged to attend this call. A recording will be posted here following the webinar.

Second Informational Call

When: March 14, 2023, 12:00 PM – 1:30 PM Eastern Time (US and Canada)

Topic: OD2A: LOCAL Second National Informational Call

Register in advance for this webinar:

https://us02web.zoom.us/webinar/register/WN_H3rwiCStRQi3_ikTOVJdWA

After registering, you will receive a confirmation email containing information about joining the webinar.

This 90- minute call focuses on the optional and competitive NOFO strategies in Components B (Drug product and/or paraphernalia testing) and C (Linkage to and retention in care surveillance). Throughout the session, participants will have the opportunity to ask questions about both optional and competitive strategies. All potential applicants are encouraged to attend this call, although it will be of particular benefit to jurisdictions planning to apply for optional strategies. A recording will be posted here following the webinar.

F. Executive Summary:

Summary Paragraph Overdose Data to Action: Limiting Overdose through Collaborative Actions in Localities (OD2A: LOCAL) will support city or county local health departments (LHDs), special district health departments, and territories to use data to drive actions that reduce overdose morbidity and mortality in communities, with a primary focus on opioids and/or stimulants.

The NOFO has three components:

• Component A: Core Prevention and Surveillance Strategies (required)

• Component B: Drug Product and/or Paraphernalia Testing (optional)

• Component C: Linkage to and Retention in Care Surveillance (optional)

Within the five years, recipients will:

• Decrease nonfatal and fatal drug overdoses, overall and especially among disproportionately affected and underserved populations, with a primary focus on overdoses involving opioids and/or stimulants, including polysubstance use.

• Reduce health inequities related to overdose by closing gaps in access to care and services.

• Integrate harm reduction strategies and principles.

• Improve linkage to and re-engagement and retention in services, care, treatment, and recovery, focused on opioid use disorder (OUD) and stimulant use disorder (StUD).

• Build overdose surveillance infrastructure.

• Track and address emerging drug threats.

https://www.cdc.gov/drugoverdose/od2a/index.html https://us02web.zoom.us/webinar/register/WN_H3rwiCStRQi3_ikTOVJdWA https://www.cdc.gov/drugoverdose/od2a/index.html

1. Background

A. Funding Opportunity Description

Part II. Full Text

• Track linkage to and retention in care.

a. Eligible Applicants:

Open Competition

b. NOFO Type:

CA (Cooperative Agreement)

c. Approximate Number of Awards Up to 40 recipients will be funded to conduct activities under Component A. Among those 40, up to 20 will be funded for Component B and up to 20 will be funded for Component C.

d. Total Period of Performance Funding:

$400,000,000

e. Average One Year Award Amount:

$80,000,000 Component A: $2,000,000 Component B: $250,000 - $325,000 Component C: $250,000 - $325,000

f. Total Period of Performance Length:

5 year(s)

g. Estimated Award Date:

August 01, 2023

h. Cost Sharing and / or Matching Requirements:

No Cost sharing or matching funds are not required for this program. Although no statutory matching requirement for this NOFO exists, leveraging other resources and related ongoing efforts to promote sustainability is strongly encouraged.

Consistent with the cited authority for this announcement and applicable grants regulations, sources for cost sharing or matching may include complementary foundation funding, other U.S.

government funding sources including programs supported by HHS or other agencies (e.g., Department of Justice, Department of Agriculture, Department of Education, Department of Housing and Urban Development, Department of Transportation, Environmental Protection Agency, National Park Service) and other funding sources. Applicants should coordinate with multiple sectors such as public health, transportation, education, health care delivery, and agriculture.

a. Overview U.S. drug overdose deaths increased to historic levels in recent years, with provisional estimates indicating over 108,000 predicted deaths occurring in the 12 months ending May 2022. While increases are seen across the U.S. and in most populations, recent increases were highest among certain racial/ethnic minority populations, including non-Hispanic Black (44%) and Native Hawaiian/Other Pacific Islander persons (44%). Systemic racism and its impacts on social determinants of health have resulted in disparities in access to, linkage to, and retention in treatment for substance use disorders, compounding risk in certain populations.

While most overdose deaths involve opioids, deaths involving stimulants alone or with opioids have also substantially increased. Data from substance use disorder treatment programs also show an increase in persons reporting stimulants as the primary substance of use at treatment admission.

There is an increasing need to support localities to build an infrastructure of overdose surveillance, harm reduction, recovery, and care in communities most impacted by the overdose crisis. The evolving drug problem is local, complex and dynamic, requiring locally tailored and culturally-relevant solutions. A strong foundation of cooperation and partnership across public health, behavioral health, health systems, community organizations, and public safety is necessary to build overdose infrastructure and cohesive programs that have multiple access points and address health inequities in overdose.

Addressing disparities in overdose is an overarching goal within every strategy in this NOFO.

Activities must be culturally-relevant to those disproportionately affected by overdose and historically underserved, including persons recently released from incarceration, people experiencing homelessness, certain racial and ethnic groups, and anyone who has experienced a non-fatal overdose. Foundational to programmatic success, local health departments will need to leverage new and existing partners. Data generated through surveillance, prevention programs and by partners should be used to inform program implementation, focus on those at highest risk, and reduce health inequities.

This NOFO has three components:

• Component A (Required, up to 40 recipients selected): All applicants must apply to this component.

• Component B (Optional and competitive, up to 20 recipients selected from the 40 selected in Component A).

• Component C (Optional and competitive, up to 20 recipients selected from the 40 selected in Component A).

Funding for this NOFO will prioritize jurisdictions with higher drug overdose burdens and larger populations and ensure geographic diversity. Applicants must describe their catchment area and calculate their unintentional or undetermined drug overdose (UUDO) death burden and population size as outlined in Appendix 1. An optional sample form is provided in Appendix 2b with detailed instructions in Appendix 2a to help applicants calculate their UUDO death burden and population size. Applicants are not required to use this form. If a different format is used it must contain three required pieces of information: (1) counties, cities, or territories in their service catchment area, (2) UUDO deaths, and (3) population. Upload this information to www.grants.gov in a document named “<Applicant Name> OD2A_ LOCAL_ Overdose_ Burden and Funding Form”. If an Excel file is used, do not convert to PDF. Upload in its original format.

b. Statutory Authorities Section 392A of the Public Health Service (PHS) Act (42 U.S.C. § 280b—1) and Section 311(c)(1) of the PHS Act (42 U.S.C. § 243).

c. Healthy People 2030 This NOFO supports the following Healthy People 2030 topic areas:

Addiction Drug and Alcohol Use Health Care Access and Quality Injury Prevention Mental Health and Mental Health Disorders - General

d. Other National Public Health Priorities and Strategies This NOFO supports the following national strategies:

HHS Overdose Prevention Strategy (https://www.hhs.gov/overdose-prevention/) National Drug Control Strategy (https://www.whitehouse.gov/wp-content/uploads/2022/04/National-Drug-Control-2022Strategy.pdf) Ending the HIV Epidemic (https://www.cdc.gov/endhiv/) HHS Health Equity Action Plan (https://www.hhs.gov/sites/default/files/hhs-equity-action-plan.pdf)

e. Relevant Work This program builds upon CDC’s historical funding opportunities related to reducing overdose and related harms, including:

Prevention BOOST Prevention for States: https://www.cdc.gov/drugoverdose/states/state_prevention.html Data-Driven Prevention Initiative: Data-Driven Prevention Initiative (DDPI) | Drug Overdose | CDC Injury Center Enhanced State Opioid Overdose Surveillance Program:

https://www.cdc.gov/drugoverdose/foa/state-opioid-mm.html Opioid Prevention in States – Surge Support via the Cooperative Agreement for Emergency Response: Opioid Funding - CDC Overdose Data to Action: https://www.cdc.gov/drugoverdose/od2a/index.html Implementing Overdose Prevention Strategies at the Local Level: Microsoft PowerPoint - RFA Info Webinar (naccho.org)

2. CDC Project Description

a. Approach

Bold indicates period of performance outcome.

https://www.grants.gov/ https://health.gov/healthypeople/objectives-and-data/browse-objectives/addiction https://health.gov/healthypeople/objectives-and-data/browse-objectives/drug-and-alcohol-use https://health.gov/healthypeople/objectives-and-data/browse-objectives/health-care-access-and-quality https://health.gov/healthypeople/objectives-and-data/browse-objectives/injury-prevention https://health.gov/healthypeople/objectives-and-data/browse-objectives/mental-health-and-mental-disorders https://www.hhs.gov/overdose-prevention https://www.whitehouse.gov/wp-content/uploads/2022/04/National-Drug-Control-2022Strategy.pdf https://www.whitehouse.gov/wp-content/uploads/2022/04/National-Drug-Control-2022Strategy.pdf https://www.cdc.gov/endhiv/ https://www.hhs.gov/sites/default/files/hhs-equity-action-plan.pdf https://www.hhs.gov/sites/default/files/hhs-equity-action-plan.pdf https://www.cdc.gov/drugoverdose/states/state_prevention.html https://www.cdc.gov/drugoverdose/foa/ddpi.html https://www.cdc.gov/drugoverdose/foa/ddpi.html https://www.cdc.gov/drugoverdose/foa/state-opioid-mm.html https://www.cdc.gov/drugoverdose/od2a/index.html https://www.naccho.org/uploads/downloadable-resources/IOPSLL-Pre-RFA-Info-Webinar.pdf https://www.naccho.org/uploads/downloadable-resources/IOPSLL-Pre-RFA-Info-Webinar.pdf

Strategies and Activities

Short-term Outcomes (1-2 years)

Intermediate Outcomes (3-4 Years)

Long-term Outcomes (5+ years)

FOUNDATIONAL ACTIVITIES FOR ALL STRATEGIES in OD2A: LOCAL

• Use data to inform action

• Establish partnerships

• Focus on health equity

COMPONENT A

PREVENTION

1A. Linkage to and retention in care (required):

Utilize navigators* to connect people to services; Initiate linkage to care activities, support retention in care, maintain recovery, and support reengagement in care

2A. Harm Reduction (required): Implement strategies that increase treatment entry, reduce drug use frequency and high-risk drug use practices, and improve the overall health of PWUD, with a focus on reducing overdose

3A. Stigma Reduction (optional) Address stigma that exists among different audiences—individuals with SUD, public safety, healthcare, and the public—across community, healthcare, and public safety

More timely, detailed, comprehensive, and actionable surveillance data (6A)

Increased use of navigators to link PWUD to care and services (1A)

Improved rapid and timely identification of changes in illicit drug market (B)

Increased data sharing and data use that informs prevention and response efforts (1A-6A, B, C,)

Increased partnerships, collaborations, and bidirectional referrals amongst

Enhanced ability of programs to respond to overdose trends for groups disproportionately affected by overdose (1A-6A, B, C)

Increased use of standardized indicators on toxicologic findings and linkage to care to support local and national surveillance (B, C)

Expanded and improved use of surveillance, program evaluation, and community data to drive prevention action that are community/population appropriate (1A-6A, B, C)

Increased number of PWUD that are engaged in care and harm reduction services (1A-4A)

Increased equitable delivery and improved access to care/services

Decreased fatal drug overdoses, overall:

• Primarily involving opioids and/or stimulants among populations disproportionately affected by overdose and underserved by overdose prevention programs and the healthcare system

Decreased nonfatal drug overdoses, overall:

• Primarily involving opioids and/or stimulants among populations disproportionately affected by overdose and underserved by overdose prevention programs and the healthcare system

Decreased illicit opioid and stimulant use, including co-use with other substances, and decreased prevalence of OUD and StUD

Improved health equity among groups disproportionately affected by overdose and those previously underserved by settings organizations and long-term overdose prevention working in recovery among programs and the 4A. Clinician and overdose PWUD as well as those healthcare system, health systems best prevention previously identifying and closing gaps practices (required) (1A-4A) underserved by in access to care and Improve clinical overdose prevention services management of pain Improved programs and the and of SUD and build identification healthcare system (1A- Increased adoption of harm healthcare of and 4A) reduction strategies and infrastructure to outreach to principles, including those improve care people in need Increased reports of of empathy, non-judgment, coordination, with a of care and supportive interactions and meeting people where focus on providing services for between PWUD and they are guideline concordant SUD (1A-4A) community care to reduce overdose organizations, public Expanded identification, Increased safety partners, and tracking, and mitigation of 5A. Health IT access to harm clinicians (2A-4A) emerging drug threats enhancements reduction (optional) Build health services for Decreased stigma Collection and use of data IT capacity to support PWUD, experienced by PWUD on linkage to and retention clinicians including (3A) in care among people at increased high-risk of overdose to SURVEILLANCE distribution of Decreased high risk improve care.

6A. Overdose naloxone opioid prescribing and Surveillance across settings increased use of Infrastructure(required) (2A, 3A) evidence-based pain Improve and enhance care (4A, 5A) overall capacity to Increased conduct overdose- capacity of Improved health related surveillance staff within the system and clinician workforce to capacity to provide COMPONENT B connect care for OUD and Toxicologic Testing of PWUD to care StUD (4A, 5A) Drug Product and/or and services Paraphernalia (1A-4A) (optional and competitive) Increased Using CDC guidance, clinician conduct laboratory capacity to toxicologic testing of initiate trauma drug products and/or sensitive and drug paraphernalia to person-centered track the lethality of the approaches (4A illicit drug market )

COMPONENT C Improved

Surveillance of Linkage awareness of to and Retention in harm reduction Care (optional and services for competitive) PWUD among Collect and analyze the general standardized data on public (1A-4A) linkage to and retention in care among persons Increased at high risk of overdose public using CDC guidance awareness of services, including treatment options and harm reduction support services among PWUD (1A-4A)

Improved attitudes and knowledge about stigma among individuals with SUD and among public health practitioners, clinicians, public safety and other professionals working with

PWUD (3A)

Increased clinician awareness of evidence-based practices for pain management (4A)

Increased clinician expertise and confidence to provide equitable OUD and StUD care (4A)

* Bolded outcomes are the outcomes CDC expects recipients to achieve or make progress on during the period of performance and that CDC expects recipients to measure and report. Bolded outcomes are described below. Recipients also may measure and report on unbolded outcomes included in the logic model and other outcomes.

Glossary of Acronyms SUD – Substance use disorder OUD – Opioid use disorder MOUD – Medications for opioid use disorder Health IT – health information technology PWUD – Persons who use drugs StUD – Stimulant use disorder

* Navigators can include peer navigators, certified peer recovery specialists, peer support specialists, case managers, patient navigators, community health workers, persons with lived experience, and other individuals who link PWUD to care and harm reduction resources. These are individuals familiar with the local public health landscape and who work directly with individuals with OUD and/or StUD to ensure they have the tools to address barriers to seeking care and who support people accessing treatment and supporting their retention (and reengagement if necessary) in SUD treatment and care, as well as support access to other services, such as harm reduction and social supports. CDC defines linkage using navigators as:

1) linkage to evidence-based treatment for substance use disorders- to include MOUD and other treatment (e.g., cognitive behavioral therapy [CBT], contingency management) and 2) linkage to harm reduction services.

i. Purpose The central goal in OD2A: LOCAL is to use data to drive action steps that reduce overdose morbidity and mortality in communities quickly, while addressing health disparities, with a primary focus on opioid, stimulant, and polysubstance use involving opioids and/or stimulants.

ii. Outcomes Measurable outcomes are essential for determining the extent to which the strategies and activities across the three NOFO components achieve the expected outcomes as described in the logic model. Recipients are expected to implement activities that will impact the logic model’s relevant short-, intermediate, and long-term outcomes listed. Recipients will report on short- and intermediate-term outcomes (see below) as part of annual reporting and through performance measures reporting, emphasizing outcomes associated with required activities. To identify how activities address health equity, recipients will be expected to report on how they are closing gaps and working with groups disproportionately affected by overdose and those previously underserved by overdose prevention programs and the healthcare system. Recipients also will be expected to make progress toward long-term outcomes. Recipients may also opt to track additional short- and intermediate-term outcomes of local relevance and importance.

The following list outlines the short-, intermediate-, and long-term outcomes across the surveillance and prevention strategies. Refer to the logic model for additional information related to these outcomes. Recipients should develop SMART process and outcome objectives with nondirectional indicators to guide their evaluation activities and help communicate their progress to CDC and other individuals and entities with a vested interest in the program, who participate in the and could be affected by the program, and that collaborate as supporters and partners for the operation of the program (referred to as “partners” throughout this NOFO).

Recipients should strive to achieve short-term outcomes that will identify progress toward achieving surveillance and prevention objectives. Short-term outcomes presented in the logic model and listed below represent the more immediate outcomes that will lead to and enable progress toward achieving intermediate-term outcomes; however, recipients are only required to report short-term outcomes associated with required activities. Recipients are encouraged to identify short-term outcomes associated with optional activities. Recipients will report on progress toward achieving selected short-term outcomes within the annual performance report (APR). Short-term outcomes include:

• Increased use of navigators to link PWUD to care and services (Strategy 1A) o Navigators can include peer navigators, certified peer recovery specialists, peer support specialists, case managers, patient navigators, community health workers, persons with lived experience, and other individuals who link PWUD to care and harm reduction resources.

o Navigators are individuals familiar with the local public health landscape and who work directly with individuals with OUD and/or StUD to ensure they have the tools to address barriers to seeking care and who support people accessing treatment and supporting their retention (and reengagement if necessary) in SUD treatment and care, as well as support access to other services, such as harm reduction and social supports.

o CDC defines linkage using navigators as: 1) linkage to evidence-based treatment for substance use disorders- to include MOUD and other treatment (e.g., cognitive behavioral therapy [CBT], contingency management) and 2) linkage to harm reduction services.

• Improved rapid and timely identification of changes in illicit drug market (Component B)

• Increased data sharing and data use that informs prevention and response efforts

(Strategies 1A-6A, Component B, Component C)

• Increased partnerships, collaborations, and bidirectional referrals amongst organizations working in overdose prevention (Strategies 1A-4A)

• Improved identification of and outreach to people in need of care and services for SUD

(Strategies 1A-4A)

• Increased access to harm reduction services for PWUD, including increased distribution of naloxone across settings (Strategies 2A and 3A)

• Increased capacity of staff within the workforce to connect PWUD to care and services (Strategies 1A-4A)

• Increased clinician awareness of evidence-based practices for pain management (4A)

• Increased clinician expertise and confidence to provide equitable OUD and StUD care

(4A)

Recipients should strive to achieve intermediate-term outcomes for surveillance and prevention strategies throughout the cooperative agreement, building on programmatic achievements and applicable short-term outcomes. Intermediate-term outcomes will be reported within the annual performance report (APR) and through performance measures reporting. Intermediate-term outcomes include:

• Enhanced ability of programs to respond to overdose trends for groups disproportionately affected by the overdose epidemic (Strategies 1A-6A, Component B, Component C)

• Increased use of standardized indicators on toxicologic findings and linkage to care to support local and national surveillance (Component B, Component C)

• Expanded and improved use of surveillance, program evaluation, and community data to drive prevention action that are community/population appropriate, to inform the implementation and improvement of prevention and response efforts, especially for groups disproportionately affected by the overdose epidemic (Strategies 1A-6A, Component B, Component C)

• Increased number of PWUD that are engaged in care and harm reduction services, especially for groups disproportionately affected by the overdose epidemic, accounting for increased linkages to care (e.g., use of navigators to link people to evidence-based treatment and promote access and link PWUD to harm reduction services) and engagement in care (e.g., peer support groups or linkages to community-based self-help groups, increasing access and retention to care through strengthened telehealth infrastructure and resources) across various settings including community, healthcare, and public safety settings (Strategies 1A-4A)

• Increased equitable delivery and improved access to care/services (e.g., harm reduction services such as SSPs, treatment services, warm hand-off programs, post-overdose outreach, support services such as transportation assistance, recovery services) and long-term recovery among PWUD as well as those previously underserved by overdose prevention programs and the healthcare system (Strategies 1A-4A)

• Decreased high risk opioid prescribing and increased use of evidence-based pain care (Strategies 4A, 5A)

• Improved health system and clinician capacity to provide care for OUD and StUD (Strategies 4A, 5A

Across all components, all recipients should be positioned and are expected to impact long-term outcomes within five years or earlier after receiving funding. Long-term outcomes include:

• Decreased fatal drug overdoses, overall:

o Primarily involving opioids and/or stimulants; and o Among those disproportionately affected by the overdose epidemic and those previously underserved by overdose prevention programs and the healthcare system overall

• Decreased nonfatal drug overdoses, overall:

o Primarily involving opioids and/or stimulants; and o Among those disproportionately affected by the overdose epidemic and those previously underserved by overdose prevention programs and the healthcare system overall

• Decreased illicit opioid and stimulant use, including co-use with other substances (i.e., polysubstance use involving opioids and/or stimulants), and decreased prevalence of OUD and StUD

• Improved health equity among groups disproportionately affected by the overdose epidemic and those previously underserved by overdose prevention programs and the healthcare system overall, identifying and closing gaps in access to care and services

• Increased adoption of harm reduction strategies and principles, including those of empathy, non-judgment, and meeting people where they are

• Expanded identification, tracking, and mitigation of emerging drug threats

• Collection and use of data on linkage to and retention in care among people at high risk of overdose to improve care

iii. Strategies and Activities

I. OVERVIEW OF COMPONENTS

This NOFO has three components, described below, that consist of required and optional strategies within Component A and two optional and competitive components (Component B and Component C) that fund surveillance enhancements (See Table 1).

• Component A (Required) will competitively fund up to 40 recipients to implement required and optional prevention strategies within three settings: the community, public safety, and healthcare settings. Linkage to and retention in care and recovery, and harm reduction are required strategies in all three settings, and clinician and health system best practices are required in health system settings. All other prevention strategies, although extremely important parts of a coordinated overdose response, are optional in this NOFO.

In addition, this NOFO includes three specific required prevention activities:

o Use of navigators is required for all linkage-related activities within both the linkage to and retention in care strategy, including linkage to evidence-based treatment for substance use disorder—to include medications for opioid use disorder (MOUD) and other treatment (e.g., cognitive behavioral therapy, contingency management) across all settings and linkage to services such as harm reduction across all settings.

Navigators are individuals familiar with the local public health landscape and who work directly with individuals with opioid use disorder (OUD) and/or stimulant use disorder (StUD) to ensure they have the tools to address barriers to seeking care and who support people accessing treatment and supporting their retention (and re-engagement if necessary) in SUD treatment and care, as well as support access to other services, such as harm reduction and social supports.

CDC defines linkage using navigators as: 1) linkage to evidence-based treatment for substance use disorders- to include MOUD and other treatment (e.g., cognitive behavioral therapy [CBT], contingency management) and 2) linkage to harm reduction services.

o Naloxone distribution is required within the harm reduction strategy across all settings (purchase of naloxone is not allowed in this NOFO, but activities supporting distribution are required. See Appendix 3 for a list of what is allowable under the harm reduction strategy).

o Strategies to support implementation of clinical care concordant with the CDC Clinical Practice Guideline for Prescribing Opioids for Pain – United States, 2022 is required within the clinician and health system best practices strategy, specifically in the healthcare setting. Funding for the direct provision of clinical care is not allowed in this NOFO, but activities which support implementation of evidence-based care such as training and academic detailing may be supported.

This component also funds surveillance infrastructure to help jurisdictions collect essential data on drug overdose burden and health disparities as well as key characteristics of drug overdoses such as location, demographics, and trends.

• Component B (Optional and Competitive) will fund up to 20 of Component A recipients to conduct toxicologic testing of drug products and/or paraphernalia to track illicit drug market trends and identify emerging threats. Data collected from this component should support NOFO prevention activities.

• Component C (Optional and Competitive) will fund up to 20 of Component A recipients to establish a surveillance system to measure linkage to and retention in care for substance use disorder (SUD). Expanding and standardizing surveillance of linkage to and retention in care at the local level will complement prevention-focused activities by providing a better understanding of the cascade of care (CoC) for SUD, including referral to, initiation of, retention in, and loss to follow-up in evidence-based treatment for SUD and related support services. Data collected from this component should support NOFO prevention activities.

Table 1: Required and optional activities by three NOFO components

Component A: Required component with up to 40 recipients funded List of Strategies in Component A Strategy Required

Prevention (Strategies 1A– 5A) Prevention Settings Community Public Safety Health Systems

1A. Linkage to and retention in care

Required Required Required

2A. Harm reduction Required Required Required 3A. Stigma reduction Optional Optional Optional 4A. Clinician and health system best practices N/A N/A Required

5A. Health IT enhancements N/A N/A Optional

Surveillance (Strategy 6A):

Overdose surveillance infrastructure

Required

Component B: Optional and competitive component to support drug product and/or paraphernalia testing with up to 20 recipients funded Component C: Optional and competitive component to support linkage to and retention in care surveillance with up to 20 recipients funded

A. Foundational Activities Across All Components

Three foundational activities provide the lens through which all strategies and activities in all components are developed and implemented. All applicants funded in OD2A: LOCAL must clearly describe where and how these foundational activities will take place. It is through these activities that jurisdictions will achieve programmatic success.

• Use data to inform action:

o Component A: Intentional, coordinated, and regular examination of local data sources will inform programmatic activities, strong partnerships, and a commitment to reducing disparities in overdose, access to and retention in evidence-based harm reduction, and SUD treatment and care.

o Component B: Toxicologic findings from drug products and paraphernalia should be used to inform harm reduction and linkage to care prevention activities funded through Component A of this NOFO. Data can also be used to investigate how changes in the illicit drug market contribute to drug overdose trends, to identify, understand and respond to drug overdose outbreaks, and to raise awareness among persons who use drugs (PWUD), policymakers, public health, and the general public.

o Component C: Linkage to and retention in care surveillance data should be used to improve and enhance linkage to care prevention activities funded through Component A of this NOFO.

• Establish Partnerships: For Component A, Component B, and Component C strong partnerships will be foundational for programmatic success. Recipients will need to leverage new and existing partners for successful program implementation, to engage with people with lived experience and community partners to address stigma, and to advance health equity by reaching populations at disproportionate risk of overdose and those historically underserved within the locality. Data generated through surveillance, by prevention programs, and by partners should be used to inform program implementation, to focus on those at highest risk and to reduce health disparities. Localities and states will be expected to coordinate and cooperate.

• Focus on health equity o Component A: Activities must identify and be tailored to those disproportionately affected by overdose, and work to overcome disparities in accessing services and care – including harm reduction.

o Component B: Recipients should conduct testing of drug products and paraphernalia that are commonly associated with drug overdose deaths in their jurisdiction and work with partners and people with lived experience to interpret and disseminate findings to those disproportionately at risk for overdose.

o Component C: Recipients should collect surveillance data to measure and improve linkage to and retention in care, especially among people at higher risk of overdose and/or historically underserved.

As described throughout this NOFO, these foundational activities will guide implementation of the three components across multiple settings—all with the desired objective to accomplish the central goal of reducing overdose morbidity and mortality among disproportionately affected and underserved populations (See Figure 1, Appendix 12: Map of foundational activities, key settings, strategies and goals for the NOFO).

A.1 Data to Action Framework Underlying this NOFO is a four-stage data to action framework (synthesize and analyze, prioritize, implement, and evaluate) (See Figure 2, Appendix 13: Data to Action Framework).

The data-to-action framework describes how multiple sources of data (e.g., surveillance data, process and outcome evaluation data, programmatic data, community data from partners including those with lived experience with drug use, and scientific evidence on effective programs) should be integrated and iteratively used to select, evaluate, improve, and scale-up up drug overdose prevention activities funded through this cooperative agreement. This framework builds on and updates previous work describing how to translate data into action to prevent opioid overdose funded by Prescription Drug Overdose Prevention for States (CDC-RFA-CE15- 1501). Through use of this framework, recipients will work together with their communities to use data and evidence to save lives, achieving significant reductions in overdose and in disparities in overdose, in five years.

Recipients will need to triangulate surveillance data, research on evidence-based and promising practices, feedback and interpretations of community partners, and evaluation findings to inform their prevention strategies. Examples of how to integrate the four data to action stages into your work are provided below:

• Synthesize and Analyze: Surveillance analyses and surveillance infrastructure funding will be used to synthesize and analyze data across multiple sources, and produce timely, easy-to-understand, actionable findings that assist in at least one of the following:

o Inform the selection of prevention programs o Focus programs on areas and/or groups at high risk of overdose o Identify and respond to emerging drug threats o Improve prevention program implementation in other ways

• Prioritize: Allocation of resources to surveillance and prevention programs should be prioritized in conversation with partners to maximize impacts on drug overdose in the short-term while decreasing health disparities and expanding capacity over the five-year funding period. Recipients will need to develop a prioritization process to allocate OD2A: LOCAL funds by using different types of evidence (e.g., drug overdose burden including data on populations at greatest risk of overdose, literature on evidence-based or evidence-informed programs (e.g., CDC’s Evidence-based strategies to prevent fatal overdose), and analyses of current drug overdose trends) as well as community capacity, context, and knowledge (e.g., gaps analyses of service gaps and populations historically underserved, feasibility of implementation, potential program reach, and community insight, feedback and buy-in) in the prioritization process.

• Implement: Recipients must select prevention activities that are evidence-based or evidence-informed. The primary purpose of prevention activities must be to reduce drug overdoses and health disparities and focus on populations historically underserved and at disproportionate overdose risk based on the best data and evidence available. As the drug crisis and the science on how to address it are rapidly evolving, recipients may propose promising or evidence-informed programs or practices aligned with the strategies of this

NOFO.

• Evaluate: Local evaluation efforts should be concentrated on critical prevention programs or key data gaps that can inform ongoing efforts to strengthen activities and improve the impact of the recipient’s current prevention programs. Responding to evaluation requirements in OD2A: LOCAL will demonstrate use of this data to action stage. Recipients must participate in CDC’s efforts to evaluate OD2A: LOCAL and engage in local evaluation activities that track progress on program activities and intermediate outcomes, measure program impact on drug overdoses and health disparities, identify implementation opportunities and barriers, and make adaptions to activities in response to findings, using surveillance, evaluation, and other program data.

Partnerships are a foundational activity and often rely on sharing and use of data. The next section provides in-depth guidance on how the data to action steps can be integrated into efforts to establish and strengthen partnerships.

Recipients are expected to document their progress on data to action in workplans and Annual Progress Reports submitted to CDC each year.

A.2 Establish Partnerships Fundamental to data-to-action are the partnerships that enable it. Strong, multi-sectoral partnerships such as those between public health and public safety, harm reduction, health systems, and the involvement of persons who use drugs or have a history of OUD and/or StUD are essential for addressing overdose in the local setting. In an environment of increasing overdoses related to polysubstance use, partnerships can address risks posed by opioids, stimulants, and other drugs through increased, and coordinated information tracking and sharing, post-overdose outreach programs, and community re-entry supports. For example, partnerships should represent various demographic groups; ensure strategies that recruit and reach diverse participants from a variety of sectors, representing those disproportionately impacted by overdose, historically underserved, and including those who use drugs and those with lived experience; provide input on implementing programs (e.g., linkage to care, naloxone distribution, overdose education) and determine impact of these programs. Program planning and implementation should include ongoing social participation from populations of interests (under-resourced communities, groups that are at higher risk of overdose and individuals with lived experience) and foster shared decision-making among program participants. Table 2 provides guidance on how recipients will be expected to engage partners and people with lived experience through the four stages of the data-to-action model.

https://www.cdc.gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdf https://www.cdc.gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdf

CDC has developed several related frameworks for addressing overdose through partnerships.

The Public Health and Safety Team (PHAST) Toolkit and the Overdose Fatality Review Practitioner’s Guide are two frameworks which build upon one another to engage partners in efforts to convene multi-sector groups including those that represent groups at higher risk for overdose, individuals with lived experience, specific racial and ethnic communities and other entities to share information on the overdose crisis. These frameworks support coalitions to work together to examine data and develop focused strategies and interventions for a local response and to monitor progress. Recipients should leverage and engage existing local partnerships, including OFRs and PHAST teams, and Drug Free Communities, building coalitions with clear objectives related to the strategies in this NOFO, and ensuring that key partners from public safety, public health, health systems, harm reduction, social services and persons who use drugs are among those engaged meaningfully. New partnerships will likely need to be developed to facilitate entry, trust, and engagement with communities that are historically underserved.

Table 2 – Engaging Partners through the Data-to-Action Framework

Four Stages

Description of use of data and evidence

Engage partners and people with lived experiences

Synthesize and Analyze

Recipients must analyze data to produce easy- to-understand and actionable findings that respond to data gaps and needs of key partners.

• Partners help document current harm reduction and treatment capacity, including critical gaps.

• Partners provide data from non-traditional sources (e.g., syringe services programs (SSPs), SUD treatment programs, services for people experiencing homelessness, experiences of PWUD).

• Partners help identify emerging threats.

• Collaborate and coordinate with partners to interpret the data to become meaningful and actionable.

Prioritize

Allocation of resources to surveillance and prevention programs should be prioritized in conversation with partners to maximize impacts on drug overdose in the short-term while decreasing health disparities and expanding capacity over the five-year funding period. Factors considered in prioritizing capacity to gather high quality data, and evidence-based prevention

• Partners and people with lived experience help identify realistic and actionable goals.

• Program priorities align with priorities of partners.

• Ensure activities are not duplicative.

• Complement and/or expand other actions occurring in local jurisdictions.

• Select most impactful approaches and programs.

https://www.cdcfoundation.org/sites/default/files/files/PHAST_Web_Toolkit_Pilot_Version_2.0_For_Dissemination.pdf https://www.cossapresources.org/Tools/OFR

Four Stages

Description of use of data and evidence

Engage partners and people with lived experiences investments, in consultation with partners, include local drug overdose burden, populations at greatest risk, populations historically underserved, feasibility of implementing programs to reduce drug overdoses, and partner support and buy-in.

Implement

Recipients must implement prevention activities aimed to reduce drug overdoses and health disparities and focus on populations historically underserved and at disproportionate overdose risk based on the best data and evidence available. As the drug crisis and the science on how to address it are rapidly evolving, recipients may implement promising or evidence-informed programs or practices aligned with the strategies of this NOFO.

• Partners can share resources.

• Partners help gain buy-in.

• Coordinate with other programs.

• Increase the reach of programs.

• Partners can provide feedback on quality improvement measures and program monitoring efforts to ensure interventions have sufficient scope and high fidelity.

Evaluate

Recipients must measure program impact on drug overdoses and health disparities, as well as implementation opportunities and barriers, using surveillance, evaluation, and other program data. Findings should also be used to determine if new data need to be acquired to enhance prevention efforts.

• Incorporate feedback from partners and their clients.

• Partners and clients help interpret evaluation findings.

• Partners and clients identify strategies to address challenges and translate opportunities into improved interventions.

A.3 Health Equity Advancing health equity and addressing disparities in overdose and access to SUD care and harm reduction services is a priority for CDC’s Division of Overdose Prevention. This funding should be used to reduce and eliminate health disparities and advance health equity in public health efforts to address the overdose crisis. Thus, the work conducted by recipients should promote

II. COMPONENT A: REQUIRED CORE PREVENTION AND SURVEILLANCE

STRATEGIES

interventions at the local level that address health disparities in overdose and improve equitable access to overdose prevention tools including MOUD and evidence-based treatment for StUD as well as harm reduction services. Recipients will utilize surveillance, evaluation, and other program data to identify the local populations at highest and most disparate risk of overdose, prioritize activities that focus on populations at disproportionate risk, clearly describe how activities and partners will engage historically underserved populations using culturally relevant messaging and interventions, and specify what efforts will improve health equity within the local jurisdiction.