Like communities and cities across the country, New York City (NYC) has experienced increasing deaths from overdoses due to opioids, which include both opioid analgesics (prescription painkillers) heroin. In NYC, opioid overdoses are the leading cause of deaths from accidental injuries and a leading cause of premature mortality. From 2000 to 2013, rates of overdose death from opioid analgesics increased 256% in New York City. In 2013, about 1 New Yorker died every other day from an opioid analgesic overdose. Rates of heroin overdose deaths doubled in the City between 2010 and 2013, after four successive years of declining rates between 2006 and 2010. In 2013, 420 New Yorkers died from unintentional heroin overdose deaths. These unintentional overdoses are preventable with the right combination of prevention and care strategies.
Nationally, the opioid epidemic is of high priority. In March, 2015, the United States Department of Health and Human Services (HHS), called for a three-part approach to reduce opioid overdose and the prevalence of opioid use disorders (or addiction), including promotion of safer opioid prescribing practices, and increased access to naloxone and medication-assisted treatment.1 In NYC, the Department of Health and Mental Hygiene has included these key strategies in its response to the opioid epidemic, as well as several other key public health strategies, including the use of data to understand the extent and distribution of the problem, providing access to harm reduction services, and raising public awareness and reducing stigma.
Public Health Data to Monitor the Magnitude of the Opioid Epidemic
Public health data allows us to identify trends in drug-related deaths (or mortality) and other health-related consequences of drug use, such as hospitalizations, and emergency department visits. For example, our mortality data enabled us to identify that rates of overdose deaths involving opioid analgesics (prescription painkillers) were four times higher in Staten Island than any other New York City borough in 2011. In addition, prescribing patterns of opioid analgesics also varied across boroughs, with Staten Island residents filling prescriptions for these medications at more than double the rate of residents in all other boroughs. The Department also found that heroin-involved overdose deaths increased for three consecutive years, from 3.1 per 100,000 New Yorkers in 2010 to 6.2 per 100,000 New Yorkers in 2013. Using data such as these, the Department partners with communities, providers, and other stakeholders to develop and implement interventions to reduce the adverse health consequences of opioid misuse and overdose.
Judicious Prescription Painkiller (Opioid Analgesic) Prescribing
A key departmental initiative is the development and dissemination of guidelines for health care providers that promote judicious opioid analgesic prescribing. Although opioid analgesics are a very important medication to control certain types of pain, their role in treating chronic pain and for use over long period of time is not well-proven in scientific studies. Moreover, the risks of long-term opioid analgesic use may well outweigh the benefits, particularly increasing the risk of addiction and of overdose deaths. NYC is similar to communities around the country in that rising rates of opioid analgesic prescribing have accompanied the increases in opioid analgesic overdose deaths.
To reduce the risk of addiction and overdose, the Department’s guidance for prescribers recommends judicious use of opioid analgesics, only when other medications are ineffective and for only as long as needed to control pain. Our guidelines, first published in 2011, are available on-line at the Department’s website.2 In 2013, we conducted a public health detailing campaign in Staten Island to disseminate these guidelines, through one-to-one educational visits with over 1,000 prescribers, and we will be conducting a similar campaign in the Bronx this spring.
The Department has also tailored opioid prescribing guidelines for emergency departments, in collaboration with local clinicians. To date, these prescribing guidelines for emergency department clinicians have been adopted by 39 emergency departments across New York City.
Opioid Overdose Prevention and Access to Naloxone
Since 2009, the Department has supported opioid overdose prevention training and access to naloxone, a medication that can reverse an overdose from both opioid analgesics and heroin. Naloxone is a safe and easy-to-use medication that can be used by laypeople who have been trained to recognize an overdose and administer naloxone to the person experiencing an overdose. New York State’s Opioid Overdose Prevention Act, passed in 2006), makes it legal for laypeople to use naloxone to reverse an overdose, and for clinicians to prescribe it for this use in communities. The Department has distributed over 30,000 intranasal naloxone kits to New Yorkers through registered opioid overdose prevention programs. These registered programs are located in a diverse array of community-based and other organizations, such as syringe exchange programs, addiction treatment programs, housing programs, and organizations serving veterans. Additional kits are also being distributed by the New York State Department of Health. Over 550 overdose reversals have been reported in New York City — a number which is considerably under-reported.
In 2013, the Department began a collaboration with the New York Police Department to pilot a naloxone program through which police officers are trained as overdose responders. Increased access to naloxone for those at high risk of witnessing an overdose is a key part of preventing fatal overdoses from opioids including prescription painkillers and heroin.
Access to Services for New Yorkers Who Use Opioids
Treatment and Harm Reduction
Effective treatment for opioid use disorders (or addiction) can save lives and help individuals recover, regaining physical, mental, and social health. Scientific studies of the treatment for opioid addiction show that treatment is particularly effective with medication-assisted treatment. The most extensive scientific evidence demonstrates that use of one of two medications, methadone or buprenorphine (also known as Suboxone®) can reduce deaths from opioids, reduce drug use, and, most importantly, help individuals regain their ability to participate in their communities, families, and workplaces.
One advantage of buprenorphine is that it is available through prescriptions in primary care as well as in specialized drug treatment settings. Having buprenorphine available in primary care settings can help attract people in need of treatment for their addiction who might not choose to seek care in specialized settings. The Department is working in various ways to increase access to and awareness of medication-assisted treatment, supporting buprenorphine practice change for primary care practices and trainings for physicians, and will provide funding for several primary care and addiction treatment programs to incorporate buprenorphine into their practices. In April, 2015, the Department released an updated guidance for buprenorphine treatment in primary care settings.3
Harm reduction services are also a critical part of care and treatment for New Yorkers who use heroin and/or prescription painkillers. Arising out of the HIV/AIDS epidemic, harm reduction is an approach that seeks to reduce the consequences of drug use, originally through the provision of sterile injection equipment to individuals who inject drugs, but now refers to a larger array of services and counseling approaches that help people take steps to reduce risks from drug use, even if entering addiction treatment is not their immediate goal. The Department supports NCY’s syringe access programs, which have led the development of harm reduction practices, including distribution of naloxone to people at risk for overdose. The City’s syringe access programs provide numerous health-related services, including health and mental health care, and linkage to treatment for HIV, hepatitis C and other health conditions; overdose prevention; access to housing and food, and many other services.
Raising Awareness and Reducing Stigma
By raising awareness of opioid misuse and overdose, the Department seeks to educate New Yorkers about the risks of prescription painkillers, and availability of effective services for individuals in need of help. We recently developed and aired two testimonial-style TV ads focused on the risks associated with opioid analgesics, featuring Staten Islanders; one shared the experience of an individual in recovery from opioid analgesic dependence, and the other showed a parent who lost a child to opioid analgesic overdose.4 Following our departmental multi-prong approach, as well as other state efforts, opioid analgesic overdose deaths decreased by 29% in Staten Island in 2013.
Underlying the Department’s efforts is the overall goal to reduce the stigma associated with drug use and addiction. Stigma impedes our ability to reduce the risks from opioid addiction, causing individuals to be reluctant to disclose their drug use and seek help, and providers to identify and offer services. Together with the behavioral health and entire health community – including providers and individuals receiving services – we can lessen stigma by speaking about addiction and overdose, and supporting access to effective prevention and treatment strategies. Using evidence-based treatment service and policy strategies along with efforts to raise awareness and reduce stigma, the Department will continue to champion efforts to reduce overdose and other consequences of opioid use disorders and addiction in New York City.
- United States Department of Health and Human Services. ASPE Issue Brief: Opioid Abuse in the U.S. and HHS Actions to Address Opioid-Drug Related Overdoses and Death, March 26, 2015. Available at: http://aspe.hhs.gov/sp/reports/2015/OpioidInitiative/ib_OpioidInitiative.pdf, accessed, April 13, 2015.
- Paone D, Dowell D, Heller D. Preventing misuse of prescription opioid drugs. City Health Information, 2011; 30(4): 23-30. Available at: http://www.nyc.gov/html/doh/downloads/pdf/chi/chi30-4.pdf, accessed April 13, 2015.
- Kattan J, Fox AD, Cunningham CO, Paone D, Harrison M, Kunins HV. Buprenorphine – An Office-Based Treatment for Opioid Use Disorder. City Health Information, 2015; 34(1): 1-8. Available at: http://www.nyc.gov/html/doh/downloads/pdf/chi/chi-34-1.pdf, accessed April 13, 2015.
- New York City Department of Health and Mental Hygiene Opioid Awareness Public Service Announcements. Available at: http://www.nyc.gov/html/doh/html/mental/prescription-tv-ads.shtml, accessed April 13, 2015.