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Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
Wed vs rx stat
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Wed vs rx stat

259

Published on

- Steven …

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

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  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  

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