wed vs rx stat

NYC RxStat: A Collabora0ve Approach to Surveillance of Prescrip0on Drug Misuse and Associated Consequences

April 23, 2014 Atlanta Marrio2 Marquis

1

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

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

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

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

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

RxStat: Central Focus and Unifying Goal

Reduce Overdose Deaths

7

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

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

Layering and Repor0ng Data


10

Data Sources


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

PUBLIC HEALTH DATA SOURCES

Michelle Nolan, MPH, RxStat Data Analyst

New York City Department of Health and Mental Hygiene

12

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

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

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

Num

ber

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

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

-adj

uste

d ra

te p

er 1

00,0

00

Num

ber

Number of unintentional opioid analgesic poisoning deaths

Age-adjusted rate per 100,000

Opioid Analgesic Overdose Deaths Increased 233% from 2000 to 2012, NYC


16

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

-adj

uste

d ra

te p

er 1

00,0

00

Num

ber

Number of unintentional heroin poisoning deaths Age-adjusted rate per 100,000

Heroin Overdose Deaths Increased 84% from 2010 to 2012, NYC


17

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

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

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

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

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

PUBLIC SAFETY DATA SOURCES

Michael Clarke, JD, Special Counsel

New York City Mayor’s Office of Criminal JusGce

23

New York County DA Drug Prosecu0ons Involving Opioid Analgesics

(2012, 2013)

Source: New York County District Attorney’s Office

Num

ber of ProsecuGo

ns

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

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

= Burglary

= Robbery

New York City Pharmacy Robberies

and Burglaries 2012 -‐ 2013

Note: Image created using Google Maps

26

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

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

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.

OPIOID ANALGESICS IN NEW YORK CITY: A QUALITATIVE STUDY

Alex Harocopos, MS, Senior RxStat Data Analyst


30

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

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

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

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

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

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

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

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

USING DATA TO INFORM OPIOID POLICIES AND STRATEGIES IN NEW YORK CITY

Ellenie Tuazon, MPH, Research and Surveillance Analyst


39

Data Driven Ini0a0ves


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


Overdose PrevenGon Programs

ED Guidelines

Opioid Prescribing Guidelines Emergency

AcGon Plan

DHS Naloxone Project

HHC Prescribing

HHC Prescribing

DHS Naloxone Project

40

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

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

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

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

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

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

Available at: hWp://www.youtube.com/watch?v=ozJ6W69rOuU&feature=youtube

49

Overdose (OD) Preven0on: Naloxone

50

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

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

NYC Department of Homeless Services (DHS)

More than half DHS Peace Officers are trained and carry naloxone in all city shelters

53


•  All NYPD officers in the 120 precinct on Staten Island (approximately 180) have been trained to carry and dispense naloxone

•  Reported reversals

54

New York State Good Samaritan Law

55

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

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

wed vs rx stat

Health & Medicine