Introduction: The Evolving Role of Local Health Departments
Outside the Burke County Public Health building, the words “Mental Health” can be found on the backside of a repurposed sign. Similar scenes unfold across North Carolina, where empty annex buildings and abandoned offices bear traces of defunct local management entities, case management companies, and area mental health centers. These scenes serve as illustrations of the ever-shifting onus of responsibility for behavioral health services, from private providers to community mental health programs, to managed care, and more recently to insurance plans.1–4 A yellowed copy of the Morganton News Herald dated January 25, 1978, proudly boasts the opening of the Burke County Human Resource Center, which included Foothills Mental Health (one of the aforementioned area mental health centers).5 Burke County Public Health administration now occupies the portion of the building that once included sofas for group therapy and offices for individual therapy. Even when the sign reading “mental health” was turned around the right way, the service lineup did not include treatment for substance use. A long history of stigma and lack of evidence-based treatments for substance use coupled with limited funding created a challenge for many community leaders to undertake mitigation of the disease.6,7 The influx of opioid settlement funds and the guidelines provided by the North Carolina Memorandum of Agreement (NC MOA)7 have now equipped counties to assert their role as stewards of the system of care by leveraging the expertise of local public health departments.
To define the renewed role of public health in mitigating the opioid crisis, it is crucial to contextualize public health functions within the ongoing changes in the behavioral health system. For two decades, MCOs managed behavioral health contracts, monitored health outcomes, and oversaw provider networks in North Carolina. In 2021, Medicaid transformation enabled other insurance plans to oversee Medicaid funding and provider contracts,3 and in 2023, the North Carolina Department of Health and Human Services (NCDHHS) reduced the number of MCOs from six to four.4 This ever-changing managed care landscape has created uncertainty for providers in the network and disruptions within the system of care, illustrating the need to empower local governments to manage behavioral health systems locally, via public health. The emergence of substance use as a top priority in county health assessments across North Carolina further emphasizes the importance of identifying the negative effects of the disease in order to improve population health outcomes.8 Healthy Communities NC reported Burke County as having the highest rate of drug overdose deaths in the Western region from 2012 to 2019.9
Burke County’s Approach
Using Public Health 3.010 as a guide, Burke County, North Carolina, has leveraged the skills of public health to create strategies for effective opioid abatement by incorporating Collective Impact Theory11 and focusing on population-level root causes to implement data-driven interventions. The resulting strategies have included: mobilizing the community; prioritizing local data; systems surveillance; leveraging funding sources; and formalizing regional partnerships.
Mobilize the Community
The involvement of county stakeholders, individuals with lived experiences, and the broader community in planning and decision-making is a cornerstone of the NC MOA. Burke County Public Health has assumed a backbone role in the collective impact model, fostering community mobilization through alignment and shared priorities. In 2020, Burke County formed the Burke County Opioid Response (BCOR) committee to oversee opioid settlement fund utilization, establish priorities, vet recommendations, and monitor outcomes. This committee’s first significant decision was hiring an Opioid Settlement Coordinator who later became the Director of Behavioral Health for Burke County. This role is crucial for community mobilization. For instance, in summer 2023, following an alert about a spike in emergency department overdose visits, BCOR and the Director of Behavioral Health swiftly approved a resolution for purchasing naloxone for community distribution.
Another equally important example of how Burke County has mobilized the community is the establishment of the Peers Partnering for Excellence (PPE) coalition. PPE is a group of peer support specialists who live and/or work in Burke County. Early in the planning process, BCOR identified peer support as an evidence-based intervention with high impact in increasing engagement with treatment and saving lives through harm reduction. PPE was designed to develop the peer support network in Burke County and provide recommendations for the opioid settlement strategic plan and to the County Board of Commissioners. The vision for PPE is to empower members to advocate for the peer support profession, to mentor new peer support specialists or those who want to become peer support specialists and establish a direct pipeline to local government leadership to influence policy and practice.
The main idea behind mobilizing the community is to create a network of advocates, individuals with lived experience, and stakeholders with decision-making authority who are aligned to the cause, can communicate and work together to achieve goals, are resilient in their response, and are empowered to help their communities.
Prioritize Local Data
Identifying the true number of overdose fatalities in Burke County is not always simple. Given the delays in certifying overdose deaths, real-time data are often scarce. To address this, Burke County formed the Overdose Fatality Review/Public Health & Safety Team (OFR/PHAST) in October 2023. Modeled after Child Fatality Review teams, OFR/PHAST conducts case reviews to identify intervention opportunities and prevent future overdose deaths.
Due to the length of time it takes for a “pending” death certificate to be certified as an overdose fatality, the most recent data published for fatality rates are often two years behind. To have a more real-time understanding of the prevalence in Burke County and to identify trends and factors specific to the area, there was a need to establish a team to collect and analyze what we called “local data for local decisions.” In October 2023, the Burke County Board of Health approved the charter formally creating the OFR/PHAST. This team will be able to perform case reviews for overdose deaths that include information from their families, medical claims data, and historical information about justice involvement or DSS involvement, with the intention of identifying opportunities for intervention or systems change to prevent future overdose fatalities. Burke County Public Health plays a central role as the coordinator and data repository for the OFR/PHAST.
Systems Surveillance
Public health’s origins in disease surveillance highlight its role in tracking and controlling health threats. During the COVID-19 pandemic, public health officials demonstrated their expertise in surveillance and response. Similarly, opioid crisis surveillance involves tracking overdose mortality rates, nonfatal overdose occurrences, hospital presentations, and naloxone distribution. Public health departments are ideally positioned to conduct these analyses methodically, informing funding recommendations for treatment options and resources using opioid settlement funds.
Systems surveillance encompasses local gap analyses, such as Recovery Ecology12 inventories, to thoroughly understand resource availability and accessibility. Public health departments, with their methodological rigor and impartiality, are well-suited to conducting these analyses.
Leverage Funding Sources
Public health departments can access grants that may be out of reach for treatment providers or nonprofits. Burke County Public Health has successfully partnered with organizations for state and federal grants, supporting programs like Adult Treatment Court and medication-assisted treatment (MAT). The Opioid Settlement Project Coordinator plays a key role in integrating funding streams across the county, enhancing efficiency and accountability and reducing duplication of efforts.
Formalize Regional Partnerships
As counties and municipalities have been finalizing their collaborative strategic planning processes, it has become apparent that many of the identified gaps can be most effectively addressed on a regional basis. Lack of access to housing and long-term treatment facilities are examples of issues that span across multiple counties. Using a Recovery Ecology Inventory12 model for evaluating recovery capital, Burke County is currently contracting with the Fletcher Group to map assets and opportunities that will lay the groundwork for a formal partnership in the western counties of North Carolina. This will allow for the work of each county to be scaled up on a regional level, so counties can collectively work toward larger systemic issues like housing shortages and unsheltered populations.
Conclusion
These strategies illustrate how public health can act as the backbone for systems change in opioid abatement. The vision outlined in Public Health 3.0 to meet the health needs of the 21st century aligns with managing interventions for opioid use disorder and shifting the curve positively toward treatment and recovery rather than overdose fatalities.
Reintegrating substance use within public health has fostered an evolving dynamic that is empowering local governments to reclaim control of their local continuums of care. While the origination of this change stems from the opioid crisis, confirming substance use (and behavioral health as a whole) as a tenet of public health will allow local health departments to proactively address substance use trends as they emerge, with a well-developed collaborative of community partners.
Acknowledgments
I would like to extend my deepest gratitude to Public Health Director Danny Scalise for his unwavering support of our opioid abatement work in Burke County. His dedication and assistance have been instrumental in our efforts to address this critical issue.
I am also profoundly grateful to Dr. Gary Walby, CEO of Complex Systems Innovations, whose insights and guidance have significantly shaped my understanding of the system of care and systems change, and whose expertise and mentorship have been invaluable.
Disclosure of interests
No conflicts of interest were disclosed.