sticks, carrots, and everything else: how nys oasas is using …€¦ · the opioid and drug...

January 31, 2020

Sticks, Carrots, and Everything

Else: How NYS OASAS is Using

Policy to Address the Opioid and

Drug Overdose Crisis Marc Manseau, MD, MPH

Chief Medical Officer, NYS OASAS

February 7, 2020

January 31, 2020 2

Disclosures

None

January 31, 2020 3

Objectives

(1) To understand a public/population approach to the opioid

crisis, and how this connects to clinical care and the

addiction treatment system;

(2) To review key policy, regulatory, and clinical support

initiatives undertaken by NYS OASAS.

(3) To engage addiction medicine providers and experts in a

discussion about how addiction medicine as a field and

NYSAM in particular can partner with NYS OASAS going

forward.

January 31, 2020 4

The Opioid and

Drug Overdose

Crisis

January 31, 2020 5

The Opioid and Drug Overdose Crisis

• In 2017, there were 70,237 drug overdose deaths in the United States –

• Surpassing highest number of deaths in any year due to AIDS

• Surpassing motor vehicle accident related deaths

• Drug overdose death rate increased by 9.6% in the last year assessed

• 19.8 to 21.7 to per 100,000 in 2017

• Drug overdose deaths involving high potency synthetic opioids (e.g. fentanyl)

increased by 45% in the last year assessed (2017)

The opioid epidemic has contributed to the first

multiyear decrease in life expectancy in the US in a

century

*From CDC Report, “Drug Overdose Deaths in the United States, 1999–2017”*:

https://www.cdc.gov/nchs/products/databriefs/db329.htm

January 31, 2020 6




January 31, 2020 7




January 31, 2020 8

1,802

2,248

2,444

2,235

1,452

1,9282,063

1,855

354517

690 667

36 90 126 1100

500

1,000

1,500

2,000

2,500

2015 2016 2017 2018*

New York State (excluding NYC) Drug Overdose Deaths for Selected Drugs (Not Mutually Exclusive)

All Drug Overdose Deaths

All Opioids

Cocaine

Psychostimulants with Abuse Potential

New York State (excluding NYC) Drug Overdose Deaths for Selected Drugs

2015 2016 2017 2018*

All Drug Overdose Deaths 1,802 2,248 2,444 2,235

All Opioids 1,452 1,928 2,063 1,855

Cocaine 354 517 690 667

Psychostimulants with Abuse Potential 36 90 126 110

*2018 Data is Preliminary and Subject to Change

Source: Provisional drug overdose death counts.

National Center for Health Statistics. 2019. Data as

of September 2019.

Accessed at: https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm

https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm

January 31, 2020 9

1,452

1,928 2,0631,855

350

320381

3801,802

2,248

2,444

2,235

0

600

1,200

1,800

2,400

2015 2016 2017 2018*

New York State (excluding NYC) Drug Overdose Deaths

Opioid Non-Opioid

New York State (excluding NYC) Drug Overdose Deaths

2015 2016 2017 2018*

Opioid 1,452 1,928 2,063 1,855

Non-Opioid 350 320 381 380

Total 1,802 2,248 2,444 2,235




of September 2019.



January 31, 2020 10

532

1,095

1,455 1,365

920

833

608490

1,452

1,9282,063

1,855

0

500

1,000

1,500

2,000

2015 2016 2017 2018*

New York State (excluding NYC) Opioid Overdose Deaths

Does Not Include Synthetic Opioids (excluding Methadone)- e.g., Fentanyl

Includes Synthetic Opioids (excluding Methadone)- e.g., Fentanyl

New York State (excluding NYC) Opioid Overdose Deaths

2015 2016 2017 2018*

Includes Synthetic Opioids (excluding Methadone)- e.g., Fentanyl 532 1,095 1,455 1,365

Does Not Include Synthetic Opioids (excluding Methadone)- e.g., Fentanyl 920 833 608 490

All Opioid Deaths 1,452 1,928 2,063 1,855




of September 2019.



January 31, 2020 11


*From NYC Health Epi Data Brief: Unintentional Drug Poisoning (Overdose) Deaths in New York

City in 2018. August 2019, No. 116

January 31, 2020 12

The Opioid and Drug Overdose Crisis• The number and rate of overdose deaths decreased in New York City

(NYC) in 2018, after 7 consecutive years of increases in overdose deaths. • In 2018 there were 1,444 unintentional drug overdose deaths in NYC,

compared with 1,482 in 2017, a decrease of 38 deaths. • The rate of overdose death decreased 3% from 21.1 per 100,000

residents in 2017 to 20.5 per 100,000 residents in 2018. • In 2018, opioids were involved in 80% of overdose deaths.• For the second year in a row, fentanyl was the most common substance

involved in drug overdose deaths, present in 60% of overdose deaths in 2018.

*From NYC Health Epi Data Brief: Unintentional Drug Poisoning (Overdose) Deaths in New York City in

2018. August 2019, No. 116

January 31, 2020 13

Overdose Death Data Received from New York City Office of Chief Medical Examiner (OCME)

• OCME Cases – 2016 number of cases = 1,402 – 2017 number of cases = 1,487– 2018 number of cases = 1,382– Total = 4,271

• Linkage of OCME to OASAS Client Data System (CDS)

• Match number (Match rate)– 2016 number of matches = 643 (46%) – 2017 number of matches = 862 (58%) – 2018 number of matches = 831 (60%)– Total Number of cases matched = 2,336 (55%)

January 31, 2020 14

Number of Deaths by County of Residence(Comparison of data received from OCME for 2016 - 2018)

324

368376

248

247

267

322

365

256239

274

206

112 10298

75

125

175

225

275

325

375

425

2016 2017 2018

Bronx

New York

Kings

Queens

Richmond

January 31, 2020 15

Number of Decedents with Fentanyl Found in Toxicology by County of Residence for CY 2016 - CY 2018

137

196

240

126

179

145

96

142 155

87

138108

54 61

69

0

50

100

150

200

250

300

2016 2017 2018

BRONX

KINGS

NEW YORK

QUEENS

RICHMOND

January 31, 2020 16

Substances Found in Toxicology for CY 2016 - CY 2018(Ranked by Number of Occurrences – High to Low)

Fentanyl 2,201Heroin 1,949Cocaine 1,866Benzos 1,131Alcohol 1,098Other Opioid 921Methadone 544Stimulants/Amphetamines 200Sedatives/Tranquilizers 89Hallucinogens 72Marijuana 9

January 31, 2020 17

Time Between Date of Death and Last CDS Discharge Date For Matches 2016 - 2018

Data source: CDS extract June 16, 2019.

Time Between Death & Discharge Total Percentages

Dead before Discharge 21 0.90%

Dead at Discharge 42 1.80%

Dead within 1 month after Discharge 412 17.64%

Dead within 1 to 3 months after Discharge 200 8.56%

Dead within 3 to 6 months after Discharge 173 7.41%

Dead within 6 months to 1 year after Discharge 215 9.20%

Dead after 1 year after Discharge 1,273 54.49%

Total 2,336 100.00%

January 31, 2020 18

Summary of FindingsOCME decedents compared to other NYC residents who received

treatment were more likely to:

• Have a primary substance of abuse of heroin and less likely to be

receiving MAT at discharge

• Not be part of the labor force – and less likely to be employed

• Have a co-occurring mental health disorder

• Leave treatment against clinical advice and less likely to complete

treatment.

January 31, 2020 19

January 31, 2020 20

January 31, 2020 21

“A period of relative abstinence during incarceration may have led to diminished physiological tolerance to drugs, increasing the risk of overdose.”

January 31, 2020 22

January 31, 2020 23

• Over 4,000 premature deaths

– 28 years of potential lost life per death

Public Health Burden of AlcoholEvery year, in New York excessive alcohol

use causes:

1

2

• Over 5,000 motor vehicle injuries and deaths

Nearly 19% of adults in New York report binge or

heavy drinking (some counties >25%)

Alcohol = #1 primary substance for SUD treatment1 Centers for Disease Control and Prevention. Alcohol Related Disease Impact (ARDI) application2 2013-2015 NYS Department of Motor Vehicles Data as of May, 2017

3

4

3 New York State Behavioral Risk Factor Surveillance System (BRFSS)4 OASAS Client Data System

January 31, 2020 24


January 31, 2020 25

The Opioid and Drug Overdose Crisis• Buprenorphine & methadone . . .

• Lower rates of opioid use• Improved social functioning• Decreased injection drug use• Reduced risk & transmission of

HV/HCV• Better quality of life• Reduced criminal activity

(methadone)• Reduced cravings• Improved maternal & fetal

outcomes in pregnant women

January 31, 2020 26

And not forgetting about alcohol again . . .

January 31, 2020 27

And not forgetting about alcohol again . . .

January 31, 2020 28


• A review of the situation . . . • A public health crisis of a highly lethal disease

• Treatments that have been shown to be ineffective and

in fact likely dangerous

• Other treatments that have been shown to be highly

effective and life-saving

• The dangerous treatments are widely utilized and the

safe treatments are under-utilized

• (There are also effective, low-risk, under-utilized

treatments for AUD – a chronic crisis)

January 31, 2020 29


January 31, 2020 30


• Tension/conflict between public health and individual clinical care

January 31, 2020 31

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January 31, 2020 35

No MAT

January 31, 2020 36October 8, 2019 1

Initiation of Pharmacotherapy Upon New Episode of Alcohol Abuse or Dependence

The percentage of individuals who initiate pharmacotherapy with at least 1 prescription for alcohol treatment medication within 30 days following an index visit with a diagnosis of alcohol abuse or dependence.

2016Statewide: 2.1%

January 31, 2020 37

Withdrawal

Management &

Crisis Stabilization

in NY

January 31, 2020 38

Withdrawal Management & Crisis

Stabilization in NY

• In 2018 (Medicaid data) . . . . • For OUD diagnosis:

• 21,961 unique members received ‘detox’ services

• 9,541 (43.5%) received MAT after discharge

• 14,476 unique members received inpatient services

• 6,177 (43%) received MAT after discharge

• 2,308 unique members received Part 820 residential

services

• 1,433 (62%) received MAT during their stay

January 31, 2020 39


Stabilization in NY

• In 2018 (Medicaid data) . . . . • For AUD diagnosis:

• 19,384 unique members received ‘detox’ services

• 3,318 (17%) received MAT after discharge

• 11,316 unique members received inpatient services

• 2,423(21.4%) received MAT after discharge

• 1,232 unique members received Part 820 residential

services

• 562 (45.6%) received MAT during their stay

January 31, 2020 40


Stabilization in NY

Detox - OUD

Buprenorphine Methadone

Naltrexone

Rehab - OUD


Naltrexone

Residential - OUD


Naltrexone

January 31, 2020 41


Stabilization in NY

Detox - AUD

Acamprosate Disulfiram

Naltrexone

Rehab - AUD


Naltrexone

Residential - AUD


Naltrexone

January 31, 2020 42


Stabilization in NY

0 10 20 30 40 50 60 70 80 90

Central

Hudson

Long Island

NYC

Western

MAT for OUD

Residential Rehab Detox

January 31, 2020 43


Stabilization in NY

0 10 20 30 40 50 60 70 80 90

Central

Hudson

Long Island

NYC

Western

MAT for AUD

Residential Rehab Detox

January 31, 2020 44

Stick: Guidance on

Medical Protocols for

Withdrawal

Management in OASAS

Certified Programs

January 31, 2020 45

Guidance on Medical Protocols for

Withdrawal Management in OASAS

Certified Programs• The OASAS Chief Medical Officer has the responsibility of reviewing

ALL medical protocols for withdrawal management (crisis stabilization

and ancillary withdrawal) for all programs applying for OASAS

certification or re-certification

• Reviewed about a dozen, noted many problems with safety and

quality clinical care

• This is not the best use of time for the only doctor at a state addiction

agency during an opioid/drug overdose crisis

January 31, 2020 46



Certified Programs• Changed process to attestation by program medical director that

medical protocol(s) for withdrawal management meet clearly defined

clinical criteria in guidance

• Real example protocols provided (with program names redacted)

• Medical directors can request edits, which will be considered

• OASAS CMO retains the right to review protocols and request

changes as necessary, and OASAS retains right to take administrative

action as necessary

January 31, 2020 47



Certified Programs• Objective monitoring

• Objective measures (vital signs, COWS, CIWA-AR, etc.)

• Toxicology screening

• Safety

• Assessment (risk factors for serious or complicated withdrawal)

• Behavioral health risk

• Contraindications (indicating need for higher LOC)

• Preventive care

• Emergency protocols

• Overdose prevention

January 31, 2020 48



Certified Programs• Involvement of medical professionals

• Stabilization on medication-assisted treatment

• Opioids: For patients with opioid use disorder and in opioid withdrawal, transition to and stabilization on medication-assisted

treatment (MAT) rather than tapering withdrawal management medications is the safest and most evidence-based standard of care. Not only does MAT increase rates of continued follow-up in the community and enhance chances for recovery, but the risk of overdose death is high after detoxification from opioids, and MAT is protective. All protocols should emphasize stabilization on MAT as routine practice, with rare exceptions for patient refusal or significant contraindications. Protocols should generally begin with using buprenorphine to treat symptoms of opioid withdrawal, followed by presenting MAT options to patients once they are comfortable (i.e., remaining on buprenorphine, transitioning to methadone, or transitioning to long-acting naltrexone injection). When a program has the ability to perform a methadone induction, protocols can include starting with methadone as an option for appropriate patients, as indicated. For patients who choose long-acting naltrexone injection upon admission, protocols can include an opioid-free detoxification option prior to naltrexone induction. To accommodate patients who refuse all MAT options once comfortable on buprenorphine, protocols can include a buprenorphine taper option, though discharging patients without any MAT should be the exception.

January 31, 2020 49



Certified Programs• Stabilization on medication-assisted treatment (cont.)

• Alcohol: MAT for alcohol use disorder can be very helpful for many patients, is an evidence-based practice, and is under-utilized.

Therefore, protocols should include routinely offering naltrexone and/or acamprosate to patients with alcohol use disorder and starting them on their choice of MAT prior to discharge.

• Patient comfort

• Timing

• Ancillary medications

• Tobacco

January 31, 2020 50



Certified Programs• Level of care assessment

• LOCADTR (Level of Care for Alcohol and Drug Treatment

Referral)

• Transition to continued care

• Overdose prevention

• Continuity support

January 31, 2020 51

Stick: Standards for

Person-centered

Medication

Treatment

January 31, 2020 52

Background and Purpose• To assist program medical directors in revising policies and protocols to

be consistent with OASAS regulations.

• To assist medical providers working at OASAS certified programs to

practice consistent with OASAS regulations and person-centered

concepts.

• To set community standards of care for addiction treatment in NYS.

• NOT to supplant clinical judgment or interfere with shared decision-

making within provider-patient relationship, as long as barriers to MAT

are not unnecessary, prohibitive, and/or causing unreasonable delays.

• NOT to redefine basic concepts in Addiction Medicine or redefine the

field by any specific philosophy, “harm reduction” or otherwise. (Though

harm reduction is one important tool out of many that are consistent with

person-centered care.)

January 31, 2020 53

From SAMHSAPerson-centered care—also known as patient-centered care—means consumers have control over their services, including the amount, duration, and scope of services, as well as choice of providers. Person-centered care also is respectful and responsive to the cultural, linguistic, and other social and environmental needs of the individual.

Person- and family-centered treatment planning is a collaborative process where care recipients participate in the development of treatment goals and services provided, to the greatest extent possible. Person- and family-centered treatment planning is care planning that is strength-based and focuses on individual capacities, preferences, and goals. Individuals and families are core participants in the development of the plans and goals of treatment.

Effective person-centered care planning strengthens the voice of the individual, builds resiliency, and fosters recovery. It is important to note that while person-centered planning is respectful and responsive to the needs of the individual, it also occurs within the professional responsibilities of providers and care teams.

January 31, 2020 54

Standards for Person-centered Medication Treatment

Access to medication-assisted treatment: Medication-assisted treatment (MAT) for opioid use disorder and other substance use disorders is evidence-based and life-saving. Therefore, any individual who chooses to engage in MAT should be offered this service. Programs must accept clients on all forms of MAT, and admission should happen on the same day that a client presents requesting MAT services. This includes people seeking treatment with poly-substance use (e.g., benzodiazepines, fentanyl, cannabis, etc.). For clients not on MAT but for whom it would be helpful and appropriate, providers should educate them on all appropriate MAT options as well as the risks of not choosing MAT, and ensure that they can access the form they choose, either directly from the treatment program or via a linkage agreement with another treatment program (e.g., access to methadone from a partnering Opioid Treatment Program (OTP)).

January 31, 2020 55


Psychosocial treatment and counseling: Psychosocial interventions, supports, and counseling are extremely helpful for many people working towards recovery from addiction. However, MAT is effective and life-saving even for individuals who are unwilling and/or unable to engage in psychosocial services. Furthermore, many individuals who are initially unwilling to engage in counseling may be easier to engage in such services after a period of stabilization on MAT. Therefore, MAT services must be offered to clients regardless of their ability or willingness to engage in psychosocial treatment. This means that admission cannot be denied and clients cannot be discharged solely on the basis of refusal or inability to engage in psychosocial treatment and counseling. The onus is then on programs to engage clients in any services deemed necessary, including by using peer services, rather than programs making MAT services contingent upon patient engagement in psychosocial services.

January 31, 2020 56


Continued substance use and poly-drug use: Even in the context of continued substance use and/or poly-drug use (including non-prescribed benzodiazepines), evidence shows that it is safer and leads to better outcomes long-term, including decreased mortality, if clients remain on MAT. Therefore, MAT should not be discontinued and clients should not be administratively discharged solely on the basis of continued substance use and/or poly-drug use. Also, policies that summarily exclude individuals from being admitted because of poly-substance use are not permitted. Rather, providers should work with clients over time to engage them in addressing their on-going substance use, using harm reduction principles and motivational interventions. Providers should continue using clinical judgment to withhold individual doses of full opioid agonist medications for intoxication and/or sedation.

January 31, 2020 57


Prescribed medications: Clients are often prescribed medications that have the potential to interact with continued drug use and/or MAT in an unsafe manner (e.g., opioid pain medications, benzodiazepines). However, the Food and Drug Administration recently clarified that it is better practice and safer for clients to start and/or continue MAT in this context rather than leave the substance use disorder untreated, because “the harm caused by untreated opioid addiction can outweigh these risks.” Therefore, programs cannot refuse to admit clients or discharge clients solely because they are on another medication that confers increased risk of overdose or other adverse outcomes. Rather, providers should work with clients and coordinate care with their outside prescribers over time to move towards safer medication regimens.

January 31, 2020 58


Toxicology screening/testing: Toxicology screens should be used as a clinical tool rather than a surveillance mechanism. The results should be used to inform the treatment plan. Results should be discussed with the patient from a supportive, clinical perspective, as opposed to a punitive one.

January 31, 2020 59

Standards for Person-centered Medication TreatmentTransition planning/post-treatment planning (formerly discharge planning): There are times when providers will determine that a client needs a different level/type of care to have the best chances of success in their recovery. Examples include but are not limited to: a client who would benefit from an intensive outpatient program, a person with significant psychiatric symptoms who would benefit from an integrated treatment program, an individual who is on buprenorphine or long-acting injectable naltrexone but would benefit from a methadone trial, or a client who has been found to be diverting buprenorphine and would therefore benefit from observed dosing in an OTP. In all but the rare exceptions mostly involving serious staff/client safety concerns, programs should not administratively discharge clients or taper MAT, and should continue to treat clients (including with MAT) while they are being referred to a different setting/program and while making every effort to coordinate a warm handoff to the receiving treatment team. Even when a person declines referral to a different treatment setting, programs should continue to provide treatment while attempting to engage the person in transitioning to the recommended level of care.

January 31, 2020 60

Other “Sticks”

January 31, 2020 61

Other “Sticks”• MAT coverage requirements without

prior authorization

• LOCADTR medical necessity

requirement

• Parity enforcement

• 28-day no-PA/CR/UM rule for bedded &

outpatient programs

January 31, 2020 62

Other OASAS

Initiatives –

Carrots &

Everything Else

January 31, 2020 63

Overview of Measures – HEDIS/QARRMeasure Description

Follow-Up After High-Intensity Care for Substance Use Disorder (FUI)

The percentage of inpatient hospitalization, residential or detox visits for a substance use disorder diagnosis that resulted in a follow-up visit.

Initiation of Pharmacotherapy upon New Episode of OpioidDependence

The percentage of members who receive at least 1 MAT within 30 days of an opioid diagnosed visit.

Initiation of Pharmacotherapy upon New Episode of AlcoholAbuse or Dependence

The percentage of members who receive at least 1 MAT within 30 days of an alcohol diagnosed visit.

Pharmacotherapy for Opioid Use Disorder (POD) (i.e. Adherence to MAT)

The percentage of new opioid use disorder (OUD) pharmacotherapy events with OUD MAT for 180 or more days among members with an OUD diagnosis

January 31, 2020 64

OTP’s Implementation of Person-Centered Care

Essential Components of Person-Centered Care’s Implementation • Patients have access to all MAT treatment options• Use of risk- benefits clinical/medical decisions • Peer integration to improve outreach and engagememt• Access to medication should not solely be reliant on engagement in care• Adressing need for reduction in stringent administrative bureaucracy• Access to treatment and remaining engaged in treatment

Rate Enhancement approved by OASAS based on requirements: • Final criteria STILL PENDING, but for example:• Providing each of the medications (including buprenorphine at window)• Expanded and individualized pick up schedule • Peer services • Implementation of at least one EBP

January 31, 2020 65

Expanding Centers of Treatment

Innovation (COTIs) and Telehealth• 20 COTI providers serving 35 counties supported by 81 mobile treatment and

transportation vehicles

• Tele-practice, Peer Support, Medication-Assisted Treatment (MAT)

• Nearly 14,000 people have been engaged by COTI clinicians and peers, 9,000 admitted to treatment, 8,000 received MAT

• Between 2016 and 2018, COTI counties saw an 25% decrease in opioid overdose deaths, while those not served saw a 5% decrease. COTI counties saw 48% decline in opioid overdose-related ED visits.

• Expanding COTI service models to serve all counties

January 31, 2020 66

MAT in Correctional System• “Diversion” programs: arrest, pre-trial, opioid & drug courts• Increasing the availability of Medication-Assisted Treatment (MAT)

in State and Local Correctional Facilities• MAT in 45 County Correctional Facilities

• NYC (Rikers) and 31 other counties offer buprenorphine and/or methadone (23 local/county facilities provide all 3 options)

• More on the way• MAT options in 11 DOCCS facilities

• 4 long-acting naltrexone only• 7 buprenorphine and/or methadone• Expanding buprenorphine imminently• DOCCS applying to become first state-operated correctional OTP in USA• All facilities offer addiction services

January 31, 2020 67

Managing SUDs in Emergency Departments• New York State public health law, effective as of 2016, requires hospitals to have and train

staff on Discharge Planning Procedures.

• OASAS has revised regulations to ensure that the addiction treatment system is able to engage people in a person-centered way, immediately following hospital discharge.

• As of April 12, 2019 NYS Public Health Law requires hospital to prepare policies and procedures and treatment protocols for appropriate use of MAT.

• OASAS using SOR monies to fund hospitals/EDs to innovate around engaging this population.

• OASAS in collaboration with other state agencies including OMH and DOH have begun to engage providers who are already doing this work across NYS.

January 31, 2020 68

Coaching for Addiction Recovery (CARE)• NIDA-funded study in collaboration with Center on Addiction. Testing intervention

to get SUD outpatient providers ready to meet VBP metrics and engage in measurement-based care.

• 30 clinics randomized to receive intervention during different time periods (staggered).

• Will implement and provide feedback on Treatment Progress Assessment (TPA-8) measure.

• Trainings will be in-person and/or web-based and will include:• Program change management (leadership)• Data literacy (leadership)• TPA-8 implementation (leadership & staff)• Person-centered care (leadership & staff)• Shared decision-making (staff)• MAT options (staff)

January 31, 2020 69

Synergy with

Other

Stakeholders

January 31, 2020 70

Synergy with Other Stakeholders

• NYS DOH

• Federal government

• Payers

January 31, 2020 71

THANK YOU

• ATAR

• Bill Hogan & Gary Dollard

• Certification

• Commissioner

• Counsel

• SOTA

January 31, 2020 72

Questions and

Discussion

January 31, 2020 73

Selected ReferencesBinswanger IA et al. Release from prison--a high risk of death for former inmates. N Engl J Med. 2007 Jan 11;356(2):157-65.

del Campo EJ, John DS, Kauffman CC. Evaluation of the 21-day outpatient heroin detoxification. Int J Addict. 1977 Oct;12(7):923-35.

Evans IVR et al. Association Between the New York Sepsis Care Mandate and In-Hospital Mortality for Pediatric Sepsis. JAMA. 2018 Jul 24;320(4):358-367.

Friedmann PD, Suzuki J. More beds are not the answer: transforming detoxification units into medication induction centers to address the opioid epidemic. Addict Sci Clin Pract. 2017 Nov 15;12(1):29.

Hedegaard H, Miniño AM, Warner M. Drug overdose deaths in the United States, 1999–2017. NCHS Data Brief, no 329. Hyattsville, MD: National Center for Health Statistics. 2018. https://www.cdc.gov/nchs/data/databriefs/db329-h.pdf

Levy MM et al. Mortality Changes Associated with Mandated Public Reporting for Sepsis. The Results of the New York State Initiative. Am J Respir Crit Care Med. 2018 Dec 1;198(11):1406-1412.

https://www.cdc.gov/nchs/data/databriefs/db329-h.pdf

January 31, 2020 74

Selected ReferencesNational Academies of Sciences, Engineering, and Medicine 2019. Medications for Opioid Use Disorder Save Lives. Washington, DC: The National Academies Press. https://doi.org/10.17226/25310.

NYC Health Epi Data Brief: Unintentional Drug Poisoning (Overdose) Deaths in New York City in 2018. August 2019, No. 11. https://www1.nyc.gov/assets/doh/downloads/pdf/epi/databrief116.pdf

Rösner S et al. Acamprosate for alcohol dependence. Cochrane Database Syst Rev. 2010 Sep 8;(9):CD004332.

Rösner S et al. Opioid antagonists for alcohol dependence. Cochrane Database Syst Rev. 2010 Dec 8;(12):CD001867.

Strang J et al. Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study. BMJ. 2003 May 3;326(7396):959-60.

Williams AR et al. Development of a Cascade of Care for responding to the opioid epidemic. Am J Drug Alcohol Abuse. 2019;45(1):1-10.

https://doi.org/10.17226/25310

https://www1.nyc.gov/assets/doh/downloads/pdf/epi/databrief116.pdf

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