April 3, 2017 The current opiate epidemic has spurred long-overdue scrutiny on the pharmaceutical production and distribution of opiate medication, but it also raises questions of public policy and law regarding the regulation of medical access to and use of opiate medications with high potential for addiction. Expert panelists will address the challenges that arise from efforts to balance restrictions on access to opiates to limit addiction while also preserving sufficient access for legitimate medical management of pain. Learn more on our website: http://petrieflom.law.harvard.edu/events/details/opiate-regulation-policies

1. Boston Public Health Commission:
A City Health’s Department Perspective On
the Opiate Epidemic
Rita Nieves, RN, MPH, LICSW
Deputy Director
Boston Public Health Commission
April 3, 2017
1

2. BPHC’s Recovery Services Bureau
2
 Coordinates substance use prevention activities,
provides substance use treatment services, as well
as other addiction resources and referral services
to Boston residents.
 Set the direction and priorities for the City’s
comprehensive system of prevention, treatment
and recovery support services in order to make
progress toward restored health, sustained
recovery, and support the reintegration and active
participation into family life of the residents of
Boston, their families, and neighborhoods affected
by substance use.

3. Recovery Services Bureau – Services provided
3
Access to Care
 PAATHS (Providing Access to Addictions Treatment, Hope and
Support)
 AHOPE (Access, Harm-Reduction, Overdose Prevention, &
Education)
Treatment and Recovery Support
 Men’s Health and Recovery Program -outpatient
 South Boston Collaborative- outpatient
 MOM’s Project- outpatient
 Entre Familia- family residential for women and children
 Transitions – Transitional and Stabilization Support
Prevention and Risk Reduction
 Overdose Prevention
 Mobile Sharps Team
 Outreach Team

4. 4
Boston Data

5. *Age-adjusted rates. Boston resident clients ages 12+. Self-identified as primary, secondary, or tertiary drug of abuse.
DATA SOURCE: Bureau of Substance Abuse Services, Massachusetts Department of Public Health
164.9
217.3
116.1
280.8
349.7
243.7
0
100
200
300
400
500
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Age-AdjustedRateper100,000
UniqueResidentClientsAges12+
Treatment Admissions by Drug Type
Boston Residents, 2006-2015
Non-Heroin Opioids Other Possible Rx Abuse Drugs
n=1,364 Rx clients and 635 Non Heroin Opioid Clients in 2015
164.9
217.3
116.1
280.8
349.7
243.7
0
100
200
300
400
500
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Age-AdjustedRateper100,000
UniqueResidentClientsAges12+
Treatment Admissions by Drug Type
Boston Residents, 2006-2015
Non-Heroin Opioids Other Possible Rx Abuse Drugs
n=1,364 Rx clients and 635 Non Heroin Opioid Clients in 2015

6. Prescription Drug Overdose Mortality*
Boston Residents
8.4
6.3
10.6
6.2
4.5
12.5
7.8
5.3
10.5
2.9 3.1
13.615.5
9.7
21.6
10.0 10.5
24.3
0.0
10.0
20.0
30.0
Female Male Black Latino White
Boston Sex Race/Ethnicity
Deathsper
100,000Population
2007-2009 2010-2012 2013-2015
* Average annual age-adjusted rate of residents ages 12+. CDC prescription-drug-overdose-death case definition includes accidental, intentional,
and undetermined intent.
+ Data not shown for Asian residents due to small count.
DATA SOURCE: Boston Resident Deaths, Massachusetts Department of Public Health
DATA ANALYSIS: Boston Public Health Commission Research and Evaluation Office

7. Prescription Drug Overdose Mortality*
Excluding Fentanyl Code (T40.4) Boston Residents
* Average annual age-adjusted rate of residents ages 12+. CDC prescription-drug-
overdose-death case definition includes accidental, intentional, and undetermined intent.
+ Data not shown for Asian residents due to small count.
DATA SOURCE: Boston Resident Deaths, Massachusetts Department of Public Health
DATA ANALYSIS: Boston Public Health Commission Research and Evaluation Office
7.4
5.3
9.7
5.1
4.1
11.2
7.1
5.1
9.2
2.6
3.1
12.2
6.8
4.9
8.8
3.2
2.6
12.0
0.0
5.0
10.0
15.0
Female Male Black Latino White
Boston Sex Race/Ethnicity
Deathsper
100,000Population
2007-2009 2010-2012 2013-2015

8. Fentanyl Overdose Mortality*
Boston Residents
* Average annual age-adjusted rate of residents ages 12+. Fentanyl refers to ICD10 code T40.4. Approx. 96% of ICD40.4 listed fentanyl in
2015. CDC prescription-drug-overdose-death case definition includes accidental, intentional, and undetermined intent.
+ Data not shown for Asian residents due to small count.
DATA SOURCE: Boston Resident Deaths, Massachusetts Department of Public Health
DATA ANALYSIS: Boston Public Health Commission Research and Evaluation Office
1.0 1.0 0.9 1.3
0.7 1.2 1.4
8.7
4.8
12.8
6.8
7.9
12.3
0.0
5.0
10.0
15.0
Female Male Black Latino White
Boston Sex Race/Ethnicity
Deathsper
100,000Population
2007-2009 2010-2012 2013-2015
n<5 n<5n<5 n<5n<5

9. n=106 Rx overdose
deaths in 2015
0.0
5.0
10.0
15.0
20.0
25.0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Age-AdjustedRateper
100,000ResidentsAges12+
Total RX wt Fentanyl (T40.4) w/o Fentanyl
n<5 n<5n<5
Prescription Drug Overdose Mortality*
Boston Residents, 2006-2015
* Age-adjusted rate for residents ages 12+. CDC prescription drug overdose death case definition
includes overdoses with accidental, intentional, and undetermined intent. Approx. 96% of
overdose deaths with code T40.4 listed fentanyl as the synthetic opiate in 2015.
DATA SOURCE: Boston Resident Deaths, Massachusetts Department of Public Health
DATA ANALYSIS: Boston Public Health Commission Research and Evaluation Office

10. Boston EMS NRI Incidents – Historical Perspective
1013 1085
1381
1518
2037
2601
232
353 431
508
809
1196
9 14 16 13 23 3110 13 20 37 47 67
2010 2011 2012 2013 2014 2015
NRI Cases Narcan Administered Cardiac Arrest RME

11. Boston’s Response to Opioid Epidemic and Efforts to Date
Strategies
 Youth prevention
 Overdose prevention & Narcan administration
trainings
 Environmental strategies
 First responder partnerships
 Expanding access to treatment

12. Youth Prevention
Life Skills Training – evidence-based curriculum for
Boston 9th graders
 95 students completed or in progress
Citywide Media Campaign
 Focuses on increasing the perception of harm
related to prescription drug misuse
Positive Parenting Materials
 Tools for parents to engage children in
conversations about alcohol and drug use

13. City-wide Prevention Assessment
• BPHC & the Mayor’s Office of Recovery Services partnered
with Blue Cross Blue Shield Foundation of MA to coordinate
Boston’s first ever city-wide prevention strategy
 A planning process to assess the capacity of existing youth
substance use prevention services in the City of Boston and
Suffolk County.
 Focus on middle and high school aged youth and their
families.
 Create recommendations for coordination across city
departments and community partners in youth substance
use prevention services

14. Overdose Prevention & Narcan Administration Trainings
One hour in length Training:
 Factors that increase risk for overdose
 How to recognize an overdose
 Protocol for responding to an overdose (including
the Good Sam Law)
 Referral to recovery services
 https://www.youtube.com/watch?v=DGn-
1ktzhpA&t=2s [8 min YouTube video with basics]

15. Overdose Prevention & Narcan Administration Trainings
Expanded to multiple groups:
 High-risk populations (jail, shelters, detoxes, SA
treatment programs, sober homes)
 Medical and mental health treatment providers
 Business community and public places
 Family and friends of people at risk for
overdose
 Public safety and law enforcement(Probation,
Corrections, Park Rangers)
~200 Boston residents trained per week
 Expanded drop in hours for active users at
AHOPE, serving 75-100 people day

16. Environmental Strategies
Installed Drug Kiosks in 12 police stations
throughout the city for safe disposal of
potentially dangerous prescription drugs

17. Environmental Strategies
Safe bathroom strategy
initiatives to reduce
overdoses in public
spaces

18. First Responder Partnerships
All Boston First Responders Carry Narcan
• Boston EMS: real time reports on Narcotic-Related
Illness (NRI) patients, coordinated response for high-
risk patients
• Boston Fire: partnership to expand OD prevention,
follow up in residences that have witnessed an
overdose
• Boston Police: distributing SUD resources, providing
referrals

19. PAATHS (Providing Access to
Addictions Treatment, Hope &
Support)
 Assessing unique treatment needs
 Making recommendations and referrals
 Facilitating access to treatment programs
 Connecting clients to OD prevention and risk
reduction services
[Average 150 walk-in clients per week & 100 hotline
calls per week]

20. 311 for Recovery Services
 Partnership initiative with 311, Mayor’s
Office Constituent Service Hotline, and the
PAATHS program to create a primary entry to
recovery services and improve access to all
services
 Confidential 24/7 referral center for
addiction treatment & recovery services
 Free to call from anywhere in Boston

21. Ongoing Challenges
• Access to levels of care
• Wait times
• Insufficient lengths of stay
• Lack of services for people who aren’t treatment ready
• Transitions between levels of care
• Insurance coverage
• Co-occurring Disorders (mental health and medical)
• Places for people to go (engagement centers, day
programs)
• Stigma (institutional barriers)
• Limited funding for prevention efforts