- Steven  Newmark,  Michelle  Nolan,  Michael   Clarke,  Alexandra  Harocopos  and  Ellenie  Tuazon

1. NYC
RxStat:
A
Collabora0ve
Approach
to
Surveillance
of
Prescrip0on
Drug
Misuse
and
Associated
Consequences
April
23,
2014
Atlanta
Marrio2
Marquis
1

2. Learning
Objec0ves
1. Describe
how
public
health/public
safety
partnership
informs
City’s
response
to
opioid
analgesic
misuse
2. Real-­‐Gme
data
in
acGon:
Use
Gmely
data
to
shape
response
to
public
health
events
3. Data-­‐driven
policy:
Use
data
to
inform
City’s
opioid-­‐related
policies
and
strategies
2

3. Disclosure
Statement
Steven
Newmark,
Michelle
Nolan,
Michael
Clarke,
Alexandra
Harocopos
and
Ellenie
Tuazon
have
no
financial
relaGonships
with
proprietary
enGGes
that
produce
health
care
goods
and
services
3

4. Outline
• RxStat
Overview
(Steven
Newmark,
NYC
Office
of
the
Mayor)
• Public
Health
Data
Sources
(Michelle
Nolan,
NYC
Dept.
of
Health
and
Mental
Hygiene)
• Public
Safety
Data
Sources
(Michael
Clarke,
NYC
Mayor’s
Office
of
Criminal
JusFce)
• Opioid
Analgesics
in
New
York
City:
A
Qualita0ve
Study
(Alexandra
Harocopos,
NYC
Dept.
of
Health
and
Mental
Hygiene)
• Data
Driven
Opioid
Policies
and
Strategies
in
New
York
City
(Ellenie
Tuazon,
NYC
Dept.
of
Health
and
Mental
Hygiene)
4

5. RXSTAT
OVERVIEW
Steven
Newmark,
JD/MPA,
Sr.
Policy
Advisor
&
Counsel
to
the
Deputy
Mayor
for
Health
and
Human
Services
New
York
City
Office
of
the
Mayor
5

6. Opioid
Analgesics
Are
a
Public
Health
Crisis
in
New
York
City
*Paone D, Bradley O’Brien D, Shah S, Heller D. Opioid analgesics in New York City: misuse, morbidity and
mortality update. Epi Data Brief. April 2011. Available at
http://www.nyc.gov/html/doh/downloads/pdf/epi/epi-data-brief.pdf .
6

7. RxStat:
Central
Focus
and
Unifying
Goal
Reduce
Overdose
Deaths
7

8. RxStat:
Four
Core
Principles
• Timely,
accurate
analysis
of
drug
misuse
indicators
from
mulGple
sources
(e.g.,
mortality,
EDs,
PMP,
drug
treatment,
law
enforcement,
etc.)
• Develop
strategies
based
on
analysis
of
exisGng
and
newly
available
data
• Rapid
deployment
of
public
health
and
public
safety
resources
to
high
priority
areas
• Rigorous
follow-­‐up
to
ensure
strategies
are
effecGve
8

9. RxStat
• Public
health
&
public
safety
collaboraGon
– Housed
at
NYC
Department
of
Health
&
Mental
Hygiene
(DOHMH)
leverages
experGse
and
infrastructure
• “Real-­‐Gme”
(enhanced)
surveillance
• ParGcipants
and
stakeholders
at
city,
state,
and
federal
organizaGons
• Monthly
RxStat
Data
MeeGngs
9

10. Layering
and
Repor0ng
Data
Reduce
Overdose
Deaths
10

11. Data
Sources
Reduce
Overdose
Deaths
PMP
Data
Treatment
Admissions
Poison
Control
Drug
ProsecuGons
HospitalizaGons
Jail
Data
Mortality
DEA
ARCOS
Pharmacy
Crime
Price/Purity
QualitaGve
Research
Medicaid
Fraud
Data
Syndromic
QualitaGve
Research
Mortality
Pharmacy
Crime
DEA
ARCOS
Drug
ProsecuGons
11

12. PUBLIC
HEALTH
DATA
SOURCES
Michelle
Nolan,
MPH,
RxStat
Data
Analyst
New
York
City
Department
of
Health
and
Mental
Hygiene
12

13. Outline
• Describe
opioid
analgesic
use
and
misuse
in
New
York
City
• Discuss
an
example
of
how
real-­‐Gme
data
was
used
to
inform
a
public
health
response
13

14. Opioid
Analgesic
Use
and
Misuse
in
NYC
• In
2012,
700,000
New
Yorkers
filled
more
than
2
million
opioid
analgesic
prescripGons
• In
2010-­‐2011,
4%
(162,000)
of
New
Yorkers
aged
12
and
older
reported
past
year
opioid
analgesic
misuse
• In
2011,
the
rate
of
emergency
department
visits
a2ributed
to
opioid
analgesic
misuse/
abuse
was
141.3/100,000
New
Yorkers
14

15. Opioids
Were
Involved
In
73%
of
Overdose
Deaths
in
NYC
0
100
200
300
400
500
600
700
800
900
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Number
Year of Death
Total
Opioids
Heroin
Opioid
Analgesics
NOTE:
Drugs
not
mutually
exclusive
Source: New York City Office of the Chief Medical Examiner & New
York City Department of Health and Mental Hygiene 2000-2012
15

16. 59 66
78 81
93
130
152
131 137
151
173
220
201
0.9
1
1.3 1.3
1.5
2
2.4
2
2.1
2.3
2.6
3.3
3.0
0
0.5
1
1.5
2
2.5
3
3.5
0
50
100
150
200
250
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Age-adjustedrateper100,000
Number
Number of unintentional opioid analgesic poisoning deaths
Age-adjusted rate per 100,000
Opioid
Analgesic
Overdose
Deaths
Increased
233%
from
2000
to
2012,
NYC
Source: New York City Office of the Chief Medical Examiner & New
York City Department of Health and Mental Hygiene 2000-2012
16

17. 373
416 400
438
358
379 388
301 317
288
209
284
382
5.9
6.3 6.3
6.9
5.7
5.9
6.1
4.7
4.9
4.4
3.1
4.2
5.7
0
1
2
3
4
5
6
7
8
0
50
100
150
200
250
300
350
400
450
500
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Age-adjustedrateper100,000
Number
Number of unintentional heroin poisoning deaths
Age-adjusted rate per 100,000
Heroin
Overdose
Deaths
Increased
84%
from
2010
to
2012,
NYC
Source: New York City Office of the Chief Medical Examiner & New
York City Department of Health and Mental Hygiene 2000-2012
17

18. What
About
Heroin?
• Increases
in
heroin-­‐related
overdose
deaths
beginning
in
2011
preceded
decreases
in
opioid
analgesic-­‐related
overdose
deaths
in
2012
• Similarly
the
increase
in
heroin
deaths
in
New
York
City
aher
2010
was
not
preceded
by
a
decrease
in
the
prescribing
of
opioid
analgesics,
suggesGng
that
the
heroin
overdose
increase
occurred
independent
of
any
changes
in
prescripGon
opioid
availability
18

19. Emergency
Ac0on
Plan
• Early
January,
2014:
Mid-­‐AtlanGc
and
Northeast
states
reported
an
increase
in
the
number
of
overdoses
related
to
heroin
containing
fentanyl
• February,
2014:
Mass
media
coverage
of
heroin
following
the
death
of
a
public
figure
in
New
York
City
19

20. Within
24
Hours:
• NYC
DOHMH
data
review
of:
– Syndromic
surveillance
• No
detectable
increase
in
the
number
of
emergency
department
visits
for
overdose
– Poison
Control
Data
• No
increase
in
the
number
of
consultaGons
for
heroin
or
fentanyl
20

21. Within
24
Hours:
• Conferences
took
place
with:
– Medical
Examiner
• No
increase
in
the
number
of
overdose
cases
• Heroin
cases
to
be
tested
for
fentanyl
– Syringe
Exchange
Programs
• No
reported
increase
in
fatal
or
non
fatal
overdoses
– NYPD
and
DEA
labs
• No
reported
increase
heroin
samples
tested
containing
fentanyl
21

22. Emergency
Ac0on
Plan
Response
• NYC
DOHMH
released
two
advisories
regarding
cases
of
fentanyl-­‐associated
overdoses
in
Mid-­‐AtlanGc
and
Northeast
United
States:
1.
A
Health
Alert
Network
le2er
for
clinicians
2. A
“Dear
Colleague”
le2er
for
program
staff
working
with
drug
users
22

23. PUBLIC
SAFETY
DATA
SOURCES
Michael
Clarke,
JD,
Special
Counsel
New
York
City
Mayor’s
Office
of
Criminal
JusGce
23

24. New
York
County
DA
Drug
Prosecu0ons
Involving
Opioid
Analgesics
(2012,
2013)
Source: New York County District Attorney’s Office
Number
of
ProsecuGons
Involving
Opioid
Analgesics
• From
2012
to
2013,
there
was
an
8%
increase
in
prosecuGons
by
the
New
York
County
DA
involving
opioid
analgesics.
• In
2012
and
2013,
opioid
analgesics
were
involved
in
approximately
5%
of
all
drug
prosecuGons
in
New
York
County
(excluding
marijuana).
ProsecuGons
involving
opioid
analgesics:
• 2012=
545
• 2013=
587
24

25. Pharmacy
Robberies
&
Burglaries
for
Rx
Drugs,
NYC
(2012
&
2013)
Burglary
Robbery
Grand
Total
2012
2013
2012
2013
2012
+
2013
Bronx
8
16

4
0

28
Kings
8
8
=
4
1

21
New
York
0
8
 5
1

14
Queens
6
8
 2
1

17
Richmond
0
1
 0
0
=
1
Grand
Total
22
41
 15
3

81
This
database
can
be
used
to
monitor
trends
in
real
Gme.
As
of
March
27,
2014
there
had
been
8
burglaries
and
2
robberies
in
NYC
in
2014.
25

26.
=
Burglary
=
Robbery
New
York
City
Pharmacy
Robberies
and
Burglaries
2012
-­‐
2013
Note:
Image
created
using
Google
Maps
26

27. Controlled
Prescrip0on
Drugs
(CPD)
Loss/
Thed
Reports
(DEA
106
Forms),
NYC
• 211
incidents
reported
in
2013
– Includes
all
Schedule
II
–
V
controlled
substances
– 95
incidents
of
the
211
in
NYC
involved
opioid
analgesics
• Approximately
173,000
total
pills
lost
– Of
the
173,000
total
pills,
roughly
70%,
or
approximately
120,000,
were
opioid
analgesic
pills
27

28. Nearly
120,000
Opioid
Analgesic
Pills
Reported
Lost/Stolen
in
NYC
in
2013
Source: Drug Enforcement Administration
Armed
Robbery
4%
Customer
Theh
2%
Employee
Pilferage
16%
Lost
In
Transit
6%
Night
Break-­‐In
58%
Other
14%
28

29. Public
Safety
Data
Synthesis
29
• While
there
is
evidence
that
drug
prosecuGons
by
the
New
York
County
DA’s
Office
involving
opioid
analgesics
may
be
increasing,
they
account
for
a
small
percentage
of
total
drug
prosecuGons.
• Pharmacy
burglaries
and
robberies
account
for
small
proporGon
of
crime
in
NYC
and
do
not
appear
to
be
significant
source
of
diverted
opioid
analgesics.
– Incidents
of
CPD
loss/theh
in
NYC
that
were
reported
to
the
DEA
also
do
not
appear
to
be
a
significant
source
of
diverted
opioid
analgesics.
The
primary
category
of
loss
is
night
break-­‐in.

30. OPIOID
ANALGESICS
IN
NEW
YORK
CITY:
A
QUALITATIVE
STUDY
Alex
Harocopos,
MS,
Senior
RxStat
Data
Analyst
New
York
City
Department
of
Health
and
Mental
Hygiene
30

31. Study
Aims
To
explore:
-­‐ Circumstances
of
opioid
analgesic
(OA)
iniGaGon
-­‐ Trajectory
of
use
(including
transiGon
to
heroin)
-­‐ Mechanisms
of
diversion
from
medical
to
non-­‐medical
use
31

32. Data
Collec0on
• In-­‐depth
interviews
(n=20)
with
professionals
• Focus
groups
(n=5)
with
individuals
who
have
experience
of
OA
misuse
• In-­‐depth
interviews
(n=49)
with
current
or
recent
OA
misusers
(ongoing)
32

33. Demographic
Characteris0cs
Total
n**
49
Gender
Female
Male
19
30
Age
18
–
29
30
–
55
Median
age
28
21
28
Race/Ethnicity
Black
non-­‐Hispanic
Hispanic
White
non-­‐Hispanic
MulG-­‐racial
2
6
39
2
EducaGon
Did
not
complete
high
school
Completed
high
school
or
GED
Some
college
(includes
trade
school)
Completed
4
year
degree
or
higher
9
13
18
9
Annual
household
income*
Under
$10,000
$10,000
to
$24,999
$25,000
to
$39,999
$40,000
to
$59,999
$60,000
to
$99,999
More
than
$100,000
13
6
8
3
6
7
Profile
of
OA
misusers
*6
respondents
were
unable
to
esGmate
their
annual
household
income
**
data
collecGon
is
ongoing

34. Emerging
Taxonomy
of
OA
Misusers
1. 18
to
30
years,
typically
iniGate
recreaGonally;
primarily
obtain
pills
through
street
sources
2. 31
years
and
above,
typically
iniGate
through
medical
treatment;
primarily
obtain
pills
through
medical
sources
3. Experienced
opioid
users
(i.e.
heroin
and
methadone);
obtain
pills
through
both
street
and
medical
sources
34

35. Market
Dynamics
• Fractured
market
driven
predominantly
by
diversion
from
prescripGons
• Varying
levels
of
monitoring
by
doctors
– ConGnuum
ranges
from:
negligent
→
loose
→
rouGne
→
judicious
• Wide
variety
of
diversion
schemes
idenGfied
– Broad
range
of
criminal
complexity
– Visits
to
mulGple
prescribers
not
cited
as
a
primary
concern
35

36. Market
Dynamics
Diffuse
nature
of
sales
networks
compounded
by
social
proximity
of
buyers
and
sellers
– PrescripGon
opioid
sales
ohen
occur
within
closed
community
networks,
not
via
community
outsiders
36

37. Market
Dynamics
• Scarcity
of
OA
pills
in
some
networks
has
led
to
an
increase
in
price
• Heroin
is
increasingly
available
in
OA-­‐using
networks
• Selling
OAs
may
fund
other
drug
use
(e.g.,
heroin,
crack)
37

38. Risk
awareness
and
service
u0liza0on
• Limited
understanding
of
risk
reducGon
– Awareness
of
risks
associated
with
sharing
needles,
but
not
of
sharing
paraphernalia
• Knowledge
of
overdose
prevenGon
is
ohen
lacking
• New
user
cohorts
tend
to
be
isolated
from
community
health
services
• Need
for
greater
acceptance
of,
and
access
to
medically-­‐assisted
models
(i.e.,
buprenorphine
and
methadone)
38

39. USING
DATA
TO
INFORM
OPIOID
POLICIES
AND
STRATEGIES
IN
NEW
YORK
CITY
Ellenie
Tuazon,
MPH,
Research
and
Surveillance
Analyst
New
York
City
Department
of
Health
and
Mental
Hygiene
39

40. Data
Driven
Ini0a0ves
Reduce
Overdose
Deaths
MME
Calculator
Emergency
AcGon
Plan
NYPD
Naloxone
Project
Staten
Island
Detailing
ED
Guidelines
Overdose
PrevenGon
Programs
Opioid
Prescribing
Guidelines
Media
Campaign
Media
Campaign
MME
Calculator
Staten
Island
Detailing
NYPD
Naloxone
Project
Overdose
PrevenGon
Programs
ED
Guidelines
Opioid
Prescribing
Guidelines
Emergency
AcGon
Plan
DHS
Naloxone
Project
HHC
Prescribing
HHC
Prescribing
DHS
Naloxone
Project
40

41. Opioid
Prescribing
Guidelines
• Less
ohen:
avoid
prescribing
opioids
for
chronic
non-­‐cancer,
non-­‐end-­‐of-­‐life
pain
 e.g.,
low
back
pain,
arthriGs,
headache,
fibromyalgia
• Shorter
duraGon:
when
opioids
are
warranted
for
acute
pain,
3-­‐day
supply
usually
sufficient
• Lower
doses:
if
dosing
reaches
100
Morphine
Milligram
Equivalents
(MME)
,
reassess
and
reconsider
other
approaches
to
pain
management
• Avoid
whenever
possible
prescribing
opioids
in
paGents
taking
benzodiazepines
CitaGon:
Paone
D,
Dowell
D,
Heller
D.
PrevenGng
misuse
of
prescripGon
opioid
drugs.
City
Health
InformaGon.
2011;
30(4):
23-­‐30
New
York
City
Opioid
Treatment
Guidelines,
Clinical
Advisors:
Nancy
Chang,
MD;
Marc
N.
Gourevitch,
MD,
MPH;
Mark
P.
Jarre2,
MD,
MBA;
Andrew
Kolodny,
MD;
Lewis
Nelson,
MD;
Russell
K.
Portenoy,
MD;
Jack
Resnick,
MD;
Stephen
Ross,
MD;
Joanna
L.
Starrels,
MD,
MS;
David
L.
Stevens,
MD;
Anne
Marie
SGlwell,
MD;
Theodore
Strange;
MD,
FACP;
Homer
Venters,
MD,
MS
41

42. New
York
City
Emergency
Department
Discharge
Opioid
Prescribing
Guidelines
Clinical
Advisory
Group:
Jason
Chu,
MD,
Brenna
Farmer,
MD,
Beth
Y.
Ginsburg,
MD,
Stephanie
H.
Hernandez,
MD,
James
F.
Kenny,
MD,
MBA,
FACEP,
Nima
Majlesi,
DO,
Ruben
Olmedo,
MD,
Dean
Olsen,
DO,
James
G.
Ryan,
MD,
Bonnie
Simmons,
DO,
Mark
Su,
MD,
Michael
Touger,
MD,
Sage
W.
Wiener,
MD.
Emergency
Department
Guidelines
Released
January,
2013
Adopted
by
38
NYC
emergency
departments
42

43. NYC
Health
and
Hospitals
Corpora0on
(HHC)
• All
11
HHC
emergency
departments
use
NYC
Emergency
Department
Discharge
Prescribing
Guidelines
• Built
systems
to
evaluate
ED
prescribing
trends
43

44. Staten
Island
Public
Health
“Detailing”
Campaign
• 1-­‐on-­‐1
“detailing”
visits
from
Health
Department
representaGves
• Deliver
key
prescribing
recommendaGons,
clinical
tools,
paGent
educaGon
materials
• ~1,000
Staten
Island
physicians,
nurse
pracGGoners,
physicians
assistants
• June–August
2013
44

45. 45

46. Morphine
Milligram
Equivalent
(MME)
Calculator
• A
tool
to
calculate
total
MME
per
day
• Gives
alert
for
dosages
>100
MME
• Quick
and
easy
to
use
• Web-­‐based
applicaGon
– Search
for
“NYC
MME
Calculator”
h2p://www.nyc.gov/html/doh/html/mental/MME.html
• Smartphone
app
46

47. 47

48. Media
Campaigns
• Campaign
One:
– Goal:
Increase
awareness
of
risk
of
opioid
analgesic
overdose
– Ran
twice
(2012,
2013)
• Campaign
Two:
– Goal:
Reduce
sGgma
and
raise
awareness
of
opioid
analgesic
misuse
– 2
tesGmonials
• Mom
lost
son
to
opioid
analgesic
overdose
• NYC
resident
in
recovery
– Ran
2013
and
2014
48

49. Available
at:
hWp://www.youtube.com/watch?v=ozJ6W69rOuU&feature=youtube
49

50. Overdose
(OD)
Preven0on:
Naloxone
50

51. In
New
York
State,
trained
laypersons
can
legally
administer
naloxone
for
OD
preven0on
• Per
NYS
Public
Health
Law
“Opioid
Overdose
PrevenGon
Program”
– EffecGve
April
1,
2006
• Laypersons
can
become
Trained
Overdose
Responders
• Trained
Overdose
Responders
can
legally
carry
and
use
naloxone
51

52. Intranasal
Naloxone
Distribu0on
in
NYC
Since
2010
Other
(e.g.,
shelters,
hospitals)
14%
Syringe
Exchange
Programs
73%
>25,000
kits
distributed
>200
reversals
reported
(underrepor0ng)
Drug
Treatment
Programs
13%
52

53. NYC
Department
of
Homeless
Services
(DHS)
More
than
half
DHS
Peace
Officers
are
trained
and
carry
naloxone
in
all
city
shelters
53

54. NYPD
Naloxone
Project
• All
NYPD
officers
in
the
120
precinct
on
Staten
Island
(approximately
180)
have
been
trained
to
carry
and
dispense
naloxone
• Reported
reversals
54

55. New
York
State
Good
Samaritan
Law
55

56. Summary
• Opioid
misuse
and
its
health
consequences
consGtute
a
public
health
crisis
• MulG-­‐pronged
approaches
are
needed
• Changing
prescribing
pa2erns
is
key
• Raising
public
awareness
• MulG-­‐agency
use
of
naloxone
• Ensuring
access
to
effecGve
treatment
• This
problem
is
preventable!
56

57. Conclusion
• RxStat
is
a
collaboraGon
between
NYC
public
health
and
public
safety
toward
one
unifying
goal:
Reduce
overdose
deaths
in
NYC
• Timely/real-­‐Gme
data
informs
comprehensive,
mulG-­‐pronged
responses
to
opioid
analgesic
misuse
57