In 2016, New York City lost, on average, between three to four people per day to drug overdoses, with approximately 80% of these overdose deaths involving an opioid. The number of deaths resulting from opioid overdoses in 2016 exceeded the number of deaths from car accidents and homicides combined (The City of New York Office of the Mayor, Healing NYC: Preventing Overdoses, Saving Lives, 2017).
NYC Well, the 24/7/365, multi-channel access point for New Yorkers is one of 54 initiatives in ThriveNYC, aimed at improving mental health and substance use care access and outcomes. Since its launch in October 2016, NYC Well has connected almost 250,000 individuals to life-saving care for their emotional health and substance use concerns, including those struggling with opioid use and misuse. NYC Well also provides education around various opioids, overdose risk and prevention, connection to evidence-based treatments for opioid misuse, and crisis intervention and overdose prevention resources. Opioid concerns that NYC Well can help address, and specific strategies utilized by NYC Well toward establishing care connections are outlined below.
Overdose risks
The introduction of illicit fentanyl, a powerful synthetic opioid, has changed the risk of opioid overdose. Before 2015, fentanyl was involved in fewer than 5% of all overdose deaths in New York City, yet by the second half of 2016 it was involved in approximately half of all overdose deaths (The City of New York Office of the Mayor, Healing NYC: Preventing Overdoses, Saving Lives, 2017). Fentanyl is undetectable as it is odorless and tasteless. A user may not be seeking out fentanyl, and may not know that their supply is contaminated until it is too late. Fentanyl is now also found mixed into non-opioid drugs including cocaine and illegally manufactured pills.
The risk of overdose is high in individuals who have recently started using opioids, are returning to opioid use after a period of abstinence (such as after detoxification or incarceration), and in those who are engaging in polysubstance use, particularly when using multiple central nervous system depressants such as heroin and alcohol (WHO Information sheet on opioid overdose, 2014). However, all opioid users are now at increased risk of overdose due to the presence of fentanyl in the drug supply.
NYC Well counselors provide information and psychoeducation to individuals concerned about opioid use in themselves or a family member, emphasize the potential for undetected fentanyl as the source of potential overdose, and highlight the signs and symptoms of overdose.
Overdose Prevention
One of our biggest weapons in combating the addition of fentanyl into the supply of opioids and other substances is naloxone—a life-saving medication that can reverse the effects of an opioid overdose while waiting for emergency services to respond. Naloxone acts as an antagonist, blocking the opioid receptor for a period of time, preventing the physiological response. It is an easily administered medication that can be delivered through an intranasal spray or intramuscular injection without any medical training.
New York City has made significant efforts to make naloxone accessible within the community. Naloxone can be obtained without a prescription from participating pharmacies, and for free from community organizations. NYC Well counselors are available 24/7 by phone, text, and chat to discuss the life-saving effects of naloxone in reversing the effects of overdose. Education about naloxone and connection to free naloxone resources is offered to individuals and concerned family and friends, along with knowledge about how to administer naloxone while waiting for emergency services to arrive. Such discussion is particularly empowering to family members who may otherwise feel helpless in their worry for their loved one’s safety.
Treatment
While Naloxone is a vital tool in preventing opioid overdoses, the most effective treatment for opioid use disorders is medication assisted treatment (MAT). The most common of these, methadone and buprenorphine, have been extensively studied and are demonstrated evidence-based treatments for opioid dependence. MAT helps to reduce opioid withdrawal symptoms, reduces cravings, and often provides respite from the repetitive cycle of obtaining, using, and recovering from drug use. Stabilization through MAT can allow individuals to engage in interventions focused on recovery such as accessing behavioral health care, social support services, engaging in educational and vocational activities, and building or enhancing supportive relationships. MAT is becoming increasingly accessible, and buprenorphine is now available within primary care settings by qualified nurse practitioners and physician assistants (Comprehensive Addiction and Recovery Act (CARA) 2016).
NYC Well counselors provide information about MAT and connect individuals and their families with resources near their home that provide this evidence-based treatment.
Strategies for Establishing Care Connections
NYC Well incorporates screening for substance use into each telephonic, text, and chat-based intake, allowing exploration of substance use to become part of routine conversation, thereby reducing the associated stigma. This creates opportunity for judgement-free conversation about an individual’s substance use, and the impact that it is having on their mental health, their relationships, and/or their responsibilities. Related inquiry around impact of an individual’s emotional struggles on their substance use can also occur in this space. As noted earlier, active and meaningful conversations around substance use during NYC Well calls also provides an opportunity for psychoeducation regarding the presence of fentanyl in cocaine and illegally manufactured pills for non-opioid users.
Additionally, NYC Well offers a robust follow-up service, stemming from the understanding that individuals in crisis need proactive and consistent follow-up to ensure successful and sustained connection to care (Luxton, D., June, J., & Comtois, K. (2013). Crisis, 34(1), 32-41). By providing ongoing follow-up to New Yorkers struggling with opioid use and misuse, NYC Well ensures that resources for treatment and recovery are utilized.
Finally, the continuum of NYC Well services includes a thriving peer support line, which includes peer support specialists who have themselves emerged from and maintained their recovery from substance misuse, including opioids. NYC Well’s peer support service provides hope to New Yorkers reaching out about their opioid use struggles and reminds them that recovery is possible.
Kelly Clarke is the NYC Well Program Director at the Mental Health Association of New York City. Anitha Iyer, Ph.D. is the Chief Clinical Officer and Vice President, Crisis and Behavioral Health Technologies at the Mental Health Association of New York City. Contact them at kclarke@mhaofnyc.org and at aiyer@mhaofnyc.org.
