Pandemic presents new challenges for US injury prevention: Priorities evolving
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* Teddi Nicolaus

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/52/5/1.1/F1.medium.gif)

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Even as new challenges in injury and violence prevention arise, workers continue to address traditional topics such as traumatic brain injuries, transportation safety, falls and drownings.

Photo by Dean Mitchell, courtesy iStockphoto

> “Mortality related to injury and violence in general has been going up… Communities are struggling with overdose and suicide, and we know that they share root causes and can be prevented.”
> 
> — Christopher Jones

This spring, public health workers who toil in the field of injury prevention received back-to-back reminders that their work is far from finished.

On May 10, the Centers for Disease Control and Prevention released new data showing gun-related deaths have soared to their highest level in 28 years, with gun-related homicides climbing 35% from 2019 to 2020. Guns were involved in 79% of all homicides and 53% of all suicides in 2020. May 11 brought equally sobering news: Provisional data from the National Center for Health Statistics showed drug overdoses killed 107,662 Americans in 2021 — more than in any previous year and up 15% from 2020.

Against a backdrop of challenges made worse by the social, emotional and economic toll of the COVID-19 pandemic, injuries and violence continue to be the leading cause of death in the U.S. for people ages 1-44. The category includes drug overdoses, motor vehicle crashes, unintentional falls, homicide and suicide. But injuries and violence affect everyone, no matter their age, race or economic status. Among the general population, unintentional injury was the fourth leading cause of death overall in 2020, surpassed only by heart disease, cancer and COVID-19, respectively.

According to the National Safety Council, preventable deaths rose in nearly all sectors in 2020, largely driven by secondary factors associated with the COVID-19 pandemic. From 2019 to 2020, deaths at home increased 21% and public deaths — defined as those that occur on public premises, such as drownings in swimming pools or hunting and recreational incidents — increased 13.5%. While the number of crashes and traffic injuries declined overall in 2020, fatal crashes increased by 6.8%. The fatality rate per 100 million vehicle miles traveled increased as well, reflecting a 21% jump from 2019 and the highest rate since 2007. Work deaths, with a 10% decline, were one of the few experiencing a decrease in 2020, likely due to a 9% decrease in hours worked during the pandemic, experts say.

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Photo by Ferlistockphoto, courtesy iStockphoto

“The field of injury prevention has greatly advanced, as the public health approach has yielded results on motor vehicle safety, workplace safety and reducing sports injuries, to name a few,” Richard Hamburg, MPA, executive director of Safe States Alliance, told *The Nation’s Health.* “But we still face multiple pandemics of drug overdoses and community violence and spikes in suicides and homicides. While unintentional deaths remain the leading cause of death for those ages 1-44, funding for injury prevention efforts are woefully inadequate. More needs to be done.”

In April, the Biden administration unveiled a landmark National Drug Control Strategy to lay out a road map to address addiction and drug trafficking. The plan calls for expanding access to naloxone, connecting more people to treatment, dismantling drug trafficking operations and reducing the supply of drugs like fentanyl. Funding for injury prevention efforts might also get a boost as Biden’s fiscal year 2023 proposed federal budget makes its way through Congress. The budget asks for a 21% increase in funding for CDC, including more money for CDC’s injury and violence prevention work, the bulk of which is accomplished through the CDC Injury Center. For three decades, the center has led the nation’s efforts to prevent injuries and violence and reduce their consequences through science-based public health approaches. As the center recognizes its 30th anniversary this year, leaders are working to address current challenges and looking to the future.

“Mortality related to injury and violence in general has been going up, and it underscores the importance of our work,” Christopher Jones, PharmD, DrPH, MPH, the center’s acting director, told *The Nation’s Health.* “Communities are struggling with overdose and suicide, and we know that they share root causes and can be prevented.”

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[Figure3](http://www.thenationshealth.org/content/52/5/1.1/F3)

Research shows that people who have safe, healthy childhoods are less likely to later die from drugoverdoses or suicide. In response, injury professionals have upped their focus on early interventions.

Photo by NickyLloyd, courtesy iStockphoto

## Childhood influences later risks for injury

Recognition has been growing in recent years of the role that childhood experiences play in raising injury risks in adulthood.

For example, research shows exposure to adverse childhood experiences, or ACEs, increase the risk for overdose and suicide. More than 60% of adults have experienced at least one ACE. Though preventable, they are associated with younger opioid initiation and an increased risk of overdose later in life.

To shine a light on the connection between overdose, suicide and ACEs, the center is working with injury and violence prevention partners, including APHA, to promote awareness that they are preventable and interrelated. The work includes “Urgent. Relatable. Preventable,” a new online hub. The resource provides numerous tools to help public health professionals spread the word with stakeholders, service providers and others about the connection between ACEs, overdose and suicide. The goal is to help communities develop more comprehensive policies and programs.

“A real challenge for us, a real worry for us, is that we know what works — it’s just not being implemented at scale in ways that can protect people,” Grant Baldwin, PhD, director of the center’s Division of Overdose Prevention, told *The Nation’s Health.* “So we have a ways to go.”

Despite a very minor downturn in 2018, drug overdose deaths were on the rise even before the pandemic, driven largely by illicit drugs, Baldwin said. But the pandemic increased the risk for overdose deaths through social isolation and disruptions in access to services and supports. People were more frequently using illicit drugs alone and drugs were more likely to be laced with fentanyl, a dangerous synthetic opioid that has been linked to thousands of overdose deaths.

Baldwin is keenly aware that the nation wants action on reversing the opioid epidemic, which takes the life of one person every five minutes in the U.S.

“It’s our North Star,” Baldwin said. “We are very extensively focused on what we can do right now, immediately, to address and reduce drug overdose deaths. This is a problem that demands urgent action right in this exact moment.”

One such measure, Overdose Data to Action, remains at the forefront of the center’s work to turn the tide on the opioid epidemic. The program supports 66 jurisdictions in collecting high quality, comprehensive, and timely data on nonfatal and fatal overdoses and in using those data to inform prevention and response efforts. Another program, the Drug-Free Communities Program, mobilizes community leaders to identify and respond to the drug problems unique to their community and change local community environmental conditions tied to substance use.

Highlighting the power of partnerships, the center’s Overdose Response Strategy, at work throughout the U.S., including Puerto Rico and the U.S. Virgin Islands, pairs drug intelligence officers with public health analysts to share data and implement evidence-based programs, including connecting people involved in the criminal justice system with services, such as medication for opioid use disorder.

“One major challenging moment is when people are released from incarceration,” Baldwin said. “That transition period is a very elevated risk point for people having an overdose, so how do we make sure the services and supports are in place in that key transition point?”

The center also implements programs to reduce suicides, said Judy Qualters, PhD, MPH, director of the center’s Division of Injury Prevention. The Comprehensive Suicide Prevention Program currently funds 10 state health departments and one university with the goal of reducing suicide by 10% among disproportionately affected populations, Qualters said. Massachusetts and Maine are working to identify and support middle-age adults at risk by implementing “gatekeeper training,” she said, which teaches community members how to identify people at risk of suicide and refer them to care.

Moreover, Colorado, Connecticut and Tennessee are working with their state departments of education to advance and provide programs to promote coping and problem-solving skills and implement positive youth development activities in schools to prevent suicide among school-age children and youth. In addition, the University of Pittsburgh is working to promote connectedness and decrease social isolation among veterans in Pennsylvania through community engagement by implementing community greening projects.

“Our vision is ‘no lives lost to suicide,’” Qualters told *The Nation’s Health.* “We recognize that preventing suicide takes a multi-pronged approach that includes a focus on upstream risk and protective factors to foster healthy and resilient communities.”

Widening its focus on upstream prevention efforts, the CDC Injury Center has ramped up work to reverse potentially traumatic but preventable events that occur before age 18. Reducing ACEs is one of the three main priorities of CDC’s Division of Violence Prevention, said Greta Massetti, PhD, MPH, the division’s acting director. ACEs can include neglect, experiencing or witnessing violence, having a family member attempt or die by suicide, growing up in a household with substance use, or experiencing racism or bullying. The division also works to increase the number of people exposed to prevention strategies proven to reduce violence, as well as to expand understanding of how to prevent firearm-related injuries and deaths.

Strategies that focus on underlying conditions can reduce disparities and the risk for violence while also strengthening protective factors at the individual, family, and community levels, Massetti said.

“Decades of research have identified effective violence prevention strategies, yet widespread implementation has not been achieved,” Massetti told *The Nation’s Health.* “A comprehensive approach is needed to help reduce violence across the United States.”

Demonstrating the power that prevention programs can bring to bear, and the interrelatedness of prevention strategies, Oregon saw a 14% drop in suicides among people ages 24 and younger in 2020 compared to 2019. Jill Baker, coordinator of youth suicide prevention policy at Oregon Health Authority, credits the decline to historic investments in statewide infrastructure for youth suicide prevention.

“To make real progress in our field, we have to invest in the entire continuum of prevention, intervention, treatment and postvention care,” Baker told *The Nation’s Health.* “This includes supporting safe storage of firearms.”

Recognizing that high suicide rates tend to correlate with availability of firearms, Oregon’s focus includes improving access to safe gun storage, she said.

“There is never one reason someone dies by suicide, and there will never be one prevention strategy that makes the only difference,” Baker said.

For more information on U.S. injury trends and CDC’s Injury Center, visit [www.cdc.gov/injury](http://www.cdc.gov/injury). For resources on preventing ACEs and related suicides and overdoses, visit [www.urgentrelatedpreventable.org](http://www.urgentrelatedpreventable.org)

*   Copyright The Nation’s Health, American Public Health Association