Public Health Approach to Addressing the Opioid Epidemic in NYC

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1 Public Health Approach to Addressing the Opioid Epidemic in NYC Hillary Kunins, MD, MPH Assistant Commissioner Bureau of Alcohol and Drug Use Prevention, Care and Treatment New York City Department of Health and Mental Hygiene Healthfirst 2017 Fall Provider Symposium November 17, 2017 Contents 1. Knowing the problem: NYC overdose mortality 2. Key principles 3. NYC Health Department responses to the opioid epidemic

Number Age-adjusted mortality rate per 100,000 More New Yorkers die from overdose than from suicides, homicides and motor vehicle crashes combined Drug overdose is a leading cause of premature death

2 Number Age-adjusted mortality rate per 100,000 More New Yorkers die from overdose than from suicides, homicides and motor vehicle crashes combined Drug overdose is a leading cause of premature death among NYC residents and top cause of death for NYC residents age 25 to 34 Source: Li W, Huynh M, Lee E, Lasner-Frater L, Castro A, Kelley D, Kennedy J, Maduro G, Sebek K, Sun Y, Van Wye G. Summary of Vital Statistics, New York, NY: New York City Department of Health and Mental Hygiene, Office of Vital Statistics, Drug Overdose Deaths Increased Last 6 Consecutive Years; 45% Increase 2015 to NYC, * Number of unintentional drug poisoning deaths Age-adjusted rate per 100,000 0

3 Number of overdoses Percent involving fentanyl Nearly All Drug Overdoses Involve Opioids All overdoses 72% involve heroin or fentanyl 4/5 involve any opioid Nearly 3/4 involve heroin or fentanyl Source: New York City Office of the Chief Medical Examiner & New York City Department of Health and Mental Hygiene * *Data for 2015 and 2016 are provisional and subject to change (Published June 13, 2017) Increase in Fentanyl Driving Increases in Overdose Deaths Number of unintentional drug poisoning deaths (overdoses), by quarter, New York City, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Confirmed drug overdoses Source: New York City Office of the Chief Medical Examiner & New York City Department of Health and Mental Hygiene * *Data for 2015 and 2016 are provisional and subject to change (Published June 13, 2017) Percent involving fentanyl

4 Age-Adjusted Rate per 100,000 Number Overdose Death Rates are Highest in the South Bronx and Staten Island Rate of unintentional drug poisoning (overdose) deaths (per 100,000 residents), New York City, Top 5 neighborhoods Overdose Deaths, NYC, 2016 Highest Rate Among Staten Island Residents Largest Number Among Bronx Residents 28.1 Rate of drug overdose death, by borough of residence, Number of drug overdose deaths, by borough of residence, Source: New York City Office of the Chief Medical Examiner & New York City Department of Health and Mental Hygiene, 2016* *Data for 2016 are provisional and subject to change. (Published June 13, 2017)

percent over 5 years 12 overall strategies Collaborative effort

5 The City s Response: HealingNYC $38M investment announced by the Mayor in March 2017 Goal: decrease opioid overdose deaths by 35 percent over 5 years 12 overall strategies Collaborative effort among multiple agencies Key Principles Stigma Equity Pyramid of Use

6 Drug Use, Stigma and Language Significant stigma related to substance use and treatment Misconception of substance use disorder as a moral failing Negative words reflect stigma: Addict, abuser, junkie, doctor shopper, substance abuse, clean Consequences and implications of stigma Risk to personal safety Barriers to willingness to seek help In our communities, people are dying. Our brothers, sisters, fathers, mothers, sons and daughters are dying every day from drug overdoses but we aren t talking about it. The shame and silence are killing us. (Hector, Bronx, NY) Equity Through Public Health Consequences of drug use mediated through criminal justice and social service policies Criminal justice and social service policies can cause health and social harms EG: Criminal justice history may preclude access to housing; associated with better substance use outcomes Excessive use of incarceration as a drug control measure Discriminatory enforcement of drug laws by race Drug use consequences therefore vary by race A public health approach to drug use CAN reduce inequities IF applied across all populations

Black New Yorkers: Lower/equivalent Rates of Drug Use but Arrest Black New Yorkers more likely to be arrested for drug-related charge East Harlem's rate of marijuana possession arrests 110 times

Financial Aid and Public Housing Drug convictions impact eligibility for financial aid and public housing Sources: 2010 Census, New York State Division of Criminal Justice Services, Computerized

7 Black New Yorkers: Lower/equivalent Rates of Drug Use but Arrest Black New Yorkers more likely to be arrested for drug-related charge East Harlem's rate of marijuana possession arrests 110 times higher than Upper East Side Income Lower income worse overall health outcomes Criminal History 1 in 15 Black males over 18 is currently incarcerated Education Lower education attainment lower income Financial Aid and Public Housing Drug convictions impact eligibility for financial aid and public housing Sources: 2010 Census, New York State Division of Criminal Justice Services, Computerized Criminal History System (Oct 2014). Includes all fingerprintable misdemeanor arrests for NYS Penal Law Article as the most serious charge in an arrest event. Ages 16 and older. These tables show only the lowest level misdemeanor marijuana possession arrests and charges. The Pyramid of Use Treatment recipients Overdose Substance use disorder Harmful use Little or no use

DOHMH-led Strategies Goal 1: Prevent opioid overdose deaths Naloxone expansion Goal 2: Prevent opioid misuse and addiction Rapid Assessment and Response (RAR) Judicious opioid

in NYC Goal: distribute 100,000 kits annually Reach high risk communities/settings: Syringe exchange, treatment programs, Rikers Visitor House, shelters and other community-based

8 DOHMH-led Strategies Goal 1: Prevent opioid overdose deaths Naloxone expansion Goal 2: Prevent opioid misuse and addiction Rapid Assessment and Response (RAR) Judicious opioid prescribing Non-fatal overdose response system Public awareness campaign Goal 3: Connect New Yorkers to effective treatment Access to medication assisted treatment Naloxone Expansion in NYC Goal: distribute 100,000 kits annually Reach high risk communities/settings: Syringe exchange, treatment programs, Rikers Visitor House, shelters and other community-based organizations Equip more public safety officers (NYPD) Increase pharmacy participation in Health Department standing order program Raise public awareness Naloxone app available on ios/android

NYS Public Health Naloxone Program Naloxone prevents overdose death by reversing respiratory depression caused by opioids 2 formulations: intranasal (IN) and intramuscular

response legal and without liability 2006: legal for trained lay people to respond to an overdose and administer naloxone NYS 2014 Standing order for naloxone Prescribers can

9 NYS Public Health Naloxone Program Naloxone prevents overdose death by reversing respiratory depression caused by opioids 2 formulations: intranasal (IN) and intramuscular (IM) No effect in a patient who does not have opioids in their body Safe and effective in patients with opioids in their bodies Series of New York State laws make layperson response legal and without liability 2006: legal for trained lay people to respond to an overdose and administer naloxone NYS 2014 Standing order for naloxone Prescribers can give a standing order to trained laypeople and pharmacists to dispense naloxone Public Awareness Campaign Opioid Overdose and Naloxone I saved a life campaign launched in May 2017

Naloxone Distribution in NYC NYC Health Department has distributed over 66,000 doses of naloxone to Opioid Overdose Prevention Programs (OOPPs) since 2009 Dispense free naloxone to drug users, their

10 Naloxone Distribution in NYC NYC Health Department has distributed over 66,000 doses of naloxone to Opioid Overdose Prevention Programs (OOPPs) since 2009 Dispense free naloxone to drug users, their families and friends Over 950 overdose reversals reported Initial Adopters Syringe exchange AIDS service organizations Drug treatment Homeless shelters Recent Settings Rikers Visit House New York Police Department Pharmacies Future Expansion Probation & parole Courts Primary care* Emergency Departments* *Current limited implementation Three Ways Your Patients Can Obtain Naloxone 1. By prescription 2. At participating NYC pharmacy without prescription Health Commissioner standing order Available at ~750 pharmacies (all large chains) 3. At registered opioid overdose prevention programs

overdose prevention programs and pharmacies where naloxone is available Download

11 Stop OD NYC Naloxone mobile application released May, 2017 Learn to recognize and respond to an opioid overdose with naloxone Report naloxone use Find nearby opioid overdose prevention programs and pharmacies where naloxone is available Download available for ios and Android at: /services/mobile-apps.page

Prevention Goal: Prevent unnecessary exposure to opioids and new cases of addiction Judicious opioid prescribing: Less often Shorter duration (3 days for acute pain) Lowest effective dose

12 DOHMH-led Strategies Goal 1: Prevent opioid overdose deaths Naloxone expansion Goal 2: Prevent opioid misuse and addiction Rapid Assessment and Response (RAR) Judicious opioid prescribing Non-fatal overdose response system Public awareness campaign Goal 3: Connect New Yorkers to effective treatment Access to medication assisted treatment Judicious Opioid Prescribing is Prevention Goal: Prevent unnecessary exposure to opioids and new cases of addiction Judicious opioid prescribing: Less often Shorter duration (3 days for acute pain) Lowest effective dose Not with benzodiazepines Prescriber education: 1:1 educational visits with opioid action kits Three campaigns conducted to date: SI, Bronx, South Brooklyn Reached more than 3000 prescribers

Age-Adjusted Rate per 100,000 Rates of Opioid Analgesic Overdose Deaths in Staten Island Decreased 29% from 2011 to 2013 12.0 10.0 8.0 6.0 4.0 2.0 0.

who come to the emergency department (ED) after a nonfatal overdose Deploy Wellness Advocates 24/7 to targeted EDs in highrisk neighborhoods Provide naloxone, risk

13 Age-Adjusted Rate per 100,000 Rates of Opioid Analgesic Overdose Deaths in Staten Island Decreased 29% from 2011 to December 2008 December 2009 December 2010 December 2011 December 2012 December 2013 December Relay: New NYC Nonfatal Overdose Response System Engage individuals who come to the emergency department (ED) after a nonfatal overdose Deploy Wellness Advocates 24/7 to targeted EDs in highrisk neighborhoods Provide naloxone, risk reduction messages, and connection to other services follow up for up to 90 days 10 hospitals over 3 years First wave: Staten Island, Bronx, Upper Manhattan, Brooklyn >90 patients engaged to date

14 DOHMH-led Strategies Goal 1: Prevent opioid overdose deaths Naloxone expansion Goal 2: Prevent opioid misuse and addiction Rapid Assessment and Response (RAR) Judicious opioid prescribing Non-fatal overdose response system Public awareness campaign Goal 3: Connect New Yorkers to effective treatment Access to medication assisted treatment Opioids and Substance Use Disorder Treatment Principles Substance use disorders are chronic illnesses People with substance use disorder may need long term, or even life long treatment Identifying patients with possible substance use disorder and offering treatment can be life saving Opioid use disorder treatment is effective, particularly with methadone or buprenorphine Treatment of other illnesses, including mental health disorders, trauma, and medical illness may improve outcomes Social support, employment, and concrete services may also improve outcomes

15 Why Pharmacotherapy for Treatment of Opioid Use Disorder? More effective than treatment without medication 1 Decreases mortality, reduces drug use, helps individuals regain ability to participate in communities, families and workplaces 2, 3 Decreases health care costs 4 More patients avoid relapse with buprenorphine maintenance compared to detox 5 1. Thomas, C. P. et al. (2014). Medication-assisted treatment with buprenorphine: assessing the evidence. Psychiatric Services, 65(2): Davoli M et al. (2007). Risk of fatal overdose during and after specialist drug treatment: the VEdeTTE study, a national multi-site prospective cohort study. Addiction, 102(12): Ball JC, Ross A. (1991). The effectiveness of methadone maintenance treatment: patients, programs, services, and outcomes. New York: Springer-Verlag. 4. Mohlman, Mary Kate, et al. (2016). Impact of medication-assisted treatment for opioid addiction on Medicaid expenditures and health services utilization rates in Vermont." Journal of Substance Abuse Treatment, 67: Weiss RD et al (2011). Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence. A 2-phase randomized controlled trial. Arch Gen Psych, 68: Methadone and Buprenorphine: What Are the Differences? Methadone Full opioid agonist Decades of data showing effectiveness Available in opioid treatment programs Highly regulated Supervised dosing Take home dosing with progression in treatment Buprenorphine Partial opioid agonist; ceiling to side effects Approved for outpatient use U.S. in 2002 Available in primary care, not only in drug treatment Take home dosing Physicians need certification

16 Adult Patients with Opioid Use Disorders Frequently Do Not Receive Medication Treatment Nationally representative sample using insurance claims data base; patients with opioid use disorders Proportion who received injectable naltrexone or buprenorphine: 25% (2010); 16% (2014) Morgan JP, et al, J Substance Abuse Treatment, 2017 (in press) Nationally representative sample of private sector addiction programs (2007) <30% offered addiction medication for opioid use disorder 35% of eligible patients received medication treatment for opioid use disorder (versus 70% of patients eligible for other psychotropic medications) Knudsen HK, et al, J Addiction Medicine, 2011 Access To and Uptake of Pharmacotherapy for Opioid Use Disorder in NYC Methadone 30,000 patients in care No waiting list and flexible patient cap Buprenorphine 1,800 physicians prescribed in ,000 patients received at least one prescription ~6,000 received > 6 months of treatment Goal: an additional 20,000 New Yorkers receiving pharmacotherapy by 2022 Challenges But, too few trained to prescribe buprenorphine Significant stigma towards addiction medicines

17 NYC Approach to Increasing Access to Medications for Addiction Treatment Fund 14 safety net health centers to implement buprenorphine treatment Fund 4 adolescent and emerging adult programs in NYC (with NYS support) Fund selected syringe exchange programs to start buprenorphine treatment Train 1,500 MDs, NPs and PAs to prescribe buprenorphine (>500 trained) Offer implementation assistance following training Raise public awareness about methadone/buprenorphine treatment No waiting list for methadone in NYC DOHMH-led Strategies Goal 1: Prevent opioid overdose deaths Naloxone expansion Goal 2: Prevent opioid misuse and addiction Rapid Assessment and Response (RAR) Judicious opioid prescribing Non-fatal overdose response system Public awareness campaign Goal 3: Connect New Yorkers to effective treatment Access to medication assisted treatment

18 Thanks! Want help to implement buprenorphine treatment in your practice? EXTRA SLIDES

19 Additional NYC Health Department Strategies Syringe exchange programs Increase funding to $6m by FY18 for NYC s 14 syringe exchange programs Substance use workforce development Training institute to improve quality of care in substance use treatment Enhance training and placement of peer workers Health profession curriculum and pipeline development Improve health professional schools curriculum on substance use Engage medical school and nursing school students The City s Response: HealingNYC Goal 1: Prevent opioid overdose deaths Goal 2: Prevent opioid misuse and addiction Goal 3: Connect New Yorkers to effective treatment Goal 4: Reduce the supply of dangerous opioids Strategy 1: Distribute 100,000 naloxone kits citywide Strategy 2: Invest in early interventions for youth to prevent opioid misuse and addiction Strategy 3: Educate New Yorkers about effective treatment for opioid misuse and addiction Strategy 4: Connect up to five of the communities at highest risk with targeted prevention messages and care Strategy 5: Educate clinicians to reduce overprescribing Strategy 7: Increase access to medicationassisted treatment for addiction for 20,000 additional New Yorkers by 2022 Strategy 8: Make NYC Health + Hospitals a system of excellence, delivering increased and effective opioid services Strategy 9: Target treatment and expand resources to people in the criminal justice system Strategy 10: Use data to target outreach and take action Strategy 11: Expand the NYPD s enforcement against dealers of opioids that cause overdose deaths Strategy 12: Expand the NYPD s capacity to disrupt the trafficking of opioids into New York City Strategy 6: Expand crisis intervention services for nonfatal overdose

20 Contact Information Hillary Kunins, MD, MPH Assistant Commissioner Bureau of Alcohol and Drug Use Prevention, Care and Treatment New York City Department of Health and Mental Hygiene

The Opioid Epidemic: Overdose Data in NYC

The Opioid Epidemic: Overdose Data in NYC Sindhu Shamasunder, MPH Bureau of Alcohol and Drug Use Prevention, Care and Treatment NYC Department of Health and Mental Hygiene The burden of drug overdose Nationally,