Let us address the epidemiology of overdose deaths in New York City. Like cities and states around the United States, New York City is in the midst of an opioid overdose epidemic. In 2016, someone died every seven hours of an overdose in New York City, resulting in 1,374 confirmed deaths. More New Yorkers die from overdose than from suicides, homicides, and car crashes combined. Approximately eighty percent of overdose deaths in 2016 involved opioids: heroin, fentanyl, and/or prescription painkillers. Fentanyl, a drug 50 to 100 times more potent than heroin and morphine, is being illicitly produced and mixed into the illicit drug supply – often without the knowledge of the person taking the drug. Fentanyl is deadly in very small quantities, and it drove the 45% increase in overdose deaths from 2015 to 2016 in NYC.
Nearly every part of the city has seen increases in drug overdose deaths. In 2016, Bronx and Staten Island residents had the highest rates of drug overdose deaths, 28 and 32 per 100,000 people respectively, but Bronx and Brooklyn residents had the greatest numbers of overdose deaths, at 308 deaths and 297 deaths. This epidemic is affecting people of every race and from every neighborhood. Although middle-aged people have the highest rates of overdose, it is the leading cause of mortality among NYC residents aged 25 to 34 years.
Principles to Address the Opioid Epidemic: Reduce Stigma and Address the Continuum of Substance Use
Two key principles underpin our initiatives. First, we must dismantle the profound stigma around substance misuse and addiction. This stigma surfaces in myriad ways, such as the misconception that substance use disorders (addiction) are moral or character failures and the use of negative words like “junkie” or “addict.” Stigma prevents individuals and their families from seeking help, and it may discourage health professionals from treating people with dignity and respect or from choosing to work in the field of substance use services.
Second, we must acknowledge the continuum of substance use in our society and design appropriate interventions along this continuum. Most people who use alcohol or drugs do so with no harmful consequences. They simply need awareness about the potential health risks of substances and strategies to remain safe and healthy. Some people who use substances experience harmful consequences – perhaps as minor as a twisted ankle while tipsy, but perhaps a very serious one, like an overdose – but do not have an addiction or substance use disorder. People who use substances in ways that pose health risks need targeted interventions to reduce that risk: counseling, education, and in the case of opioids, naloxone, an emergency medication that reverses an opioid overdose.
Only a small number of people who use substances have a substance use disorder (or addiction) and will benefit from effective treatment, either methadone or buprenorphine. In New York City, these treatments are widely available. Not all people with opioid addiction might choose the structure of methadone maintenance programs, so the NYC Health Department is working to expand availability of buprenorphine treatment in primary care settings. Nationwide, only one in ten people with a substance use disorder enters treatment. People who are not interested in treatment or unable to enter treatment can still benefit from other interventions, like harm reduction services, naloxone for overdose prevention, primary care and mental health care.
HealingNYC: New York City’s Response to the Opioid Overdose Epidemic
We know that the opioid overdose epidemic can be turned around with a comprehensive public health approach. Under HealingNYC, Mayor Bill de Blasio’s $38 million plan announced in March 2017, City agencies are working together to prevent opioid overdose deaths, prevent opioid misuse and addiction, connect New Yorkers to effective treatment, and reduce the supply of dangerous opioids. The NYC Health Department is undertaking six main activities to meet the goals of HealingNYC.
- Distribute naloxone kits. Under New York State law, laypeople can be trained to recognize overdose and carry and administer naloxone, an easy-to-use emergency medication that reverse the effect of an opioid overdose and restores someone’s breathing. The NYC Health Department, along with many community partners, trains people in how to recognize an overdose and administer naloxone. The training is free and open to everyone, but we are particularly interested in reaching people who use drugs and their friends and families. Since the program began in 2009, the Health Department has distributed more than 60,000 doses of naloxone. Nearly 1,000 overdose reversals have been reported, and more than 450 of them were in 2016 alone. Under HealingNYC, the City will distribute more than 100,000 naloxone kits annually, including to community organizations such as syringe exchange programs, drug treatment programs, shelters, and the Rikers jail visit house. Additionally, more than 20,000 police officers will be equipped with naloxone. Naloxone is also available in more than 700 NYC pharmacies, including all the major chains, under a standing order so that individuals can request naloxone without a prescription. Most insurance now pays for at least one formulation of naloxone, and a New York State program entitled N-CAPS covers co-pays of up to $40.
- Educate New Yorkers about effective ways to prevent overdose, treat addiction and substance misuse. To reduce opioid overdose deaths, we need to raise public awareness and provide easy opportunities to connect people to care. So far, the NYC Health Department has run three media campaigns dedicated to overdose awareness and prevention. The most recent campaign, “I Saved a Life,” featured six New Yorkers who used naloxone to reverse an opioid overdose. More media campaigns on opioids will be coming. In addition, the Health Department ran a series of campaigns about NYC Well, a free and confidential service for mental illness and substance use available by phone (1-888-NYC-WELL), text (text WELL to 65173), and chat (www.nyc.gov/nycwell) in over 200 languages.
- Rapid assessment and response. Applying an infectious disease public health model, the NYC Health Department investigates clusters or increases in overdoses and then creates targeted responses. In the last six months, our efforts have focused on disseminating information and risk reduction strategies around fentanyl and distributing naloxone in highly affected communities.
- Judicious opioid prescribing. While opioid analgesics (painkillers) are a critical part of care for patients with acute pain and end of life and cancer pain, they can pose serious risks to people who take them, including overdose and addiction. The NYC Health Department has been educating prescribers on judicious – or safer – opioid prescribing practices. Our guidelines include the recommendation that three days’ worth of an opioid prescription is often sufficient to treat acute pain, that opioids should be avoided whenever possible, and that prescribing benzodiazepines (like Ativan or Xanax) in conjunction with opioids increases the risk of overdose. To get this message out, we have conducted one-on-one educational visits with more than 3,000 providers in Staten Island, the Bronx, and South Brooklyn.
- Non-fatal overdose response system. Individuals who experience a nonfatal overdose are at increased risk for having a subsequent fatal overdose. In June, the NYC Health Department launched a new program, Relay, to reach people in the hours after surviving an opioid overdose. On call 24/7, our Wellness Advocates – people with lived experience with substance use – meet with the individual while they’re still in the emergency department. The Wellness Advocate engages the patient voluntarily, provides tailored risk reduction information, naloxone, and offers to link the patient to needed services, such as drug treatment, syringe exchange, mental health and primary care. The Wellness Advocate follows up with the individual for up to 90 days. Relay is currently active in three emergency departments and will expand to at least ten over the next 18 months.
- Increase access to medication for addiction treatment. Opioid use disorders can be effectively treated, and the most effective forms of treatment include the use of the methadone or buprenorphine. Currently, in NYC, there are no wait lists to obtain methadone treatment. Additionally, we believe more people will obtain treatment if buprenorphine treatment were more widely available in primary care and addiction treatment settings, so we are working to expand access to buprenorphine in NYC. We are training physicians, nurse practitioners and physician assistants so that they may obtain certification to prescribe buprenorphine and then offering them technical assistance and mentoring to start offering this treatment in practice. Additionally, we will fund 14 primary care organizations to implement the nurse care manager buprenorphine treatment model that has been demonstrated to be effective in Massachusetts.
Opioid overdose is a grave and complex challenge facing our city and country. Together with New Yorkers, health care and social service partners, and across City government, the NYC Health Department is working to implement a range of initiatives that will help turn this epidemic around.