Multimorbidity and Inpatient Utilization Among Older Adults with Opioid Use Disorder in New York City.

BACKGROUND: Nationally, there is a sharp increase in older adults with opioid use disorder (OUD). However, we know little of the acute healthcare utilization patterns and medical comorbidities among this population. OBJECTIVE: This study describes the prevalence of chronic conditions, patterns of inpatient utilization, and correlates of high inpatient utilization among older adults with OUD in New York City (NYC). DESIGN: Retrospective longitudinal cohort study. PARTICIPANTS: Patients aged ≥55 with OUD hospitalized in NYC in 2012 identified using data from New York State's Statewide Planning and Research Cooperative System (SPARCS). MAIN MEASURES: The prevalence of comorbid substance use diagnoses, chronic medical disease, and mental illness was measured using admission diagnoses from the index hospitalization. We calculated the ICD-Coded Multimorbidity-Weighted Index (MWI-ICD) for each patient to measure multimorbidity. We followed the cohort through September 30, 2015 and the outcome was the number of rehospitalizations for inpatient services in NYC. We compared patient-level factors between patients with the highest use of inpatient services (≥7 rehospitalizations) during the study period to low utilizers. We used multiple logistic regression to examine possible correlates of high inpatient utilization. KEY RESULTS: Of 3669 adults aged ≥55 with OUD with a hospitalization in 2012, 76.4% (n=2803) had a subsequent hospitalization and accounted for a total of 22,801 rehospitalizations during the study period. A total of 24.7% of the cohort (n=906) were considered high utilizers and had a higher prevalence of alcohol and cocaine-related diagnoses, congestive heart failure, diabetes, schizophrenia, and chronic obstructive pulmonary disease. Multivariable predictors of high utilization included being a Medicaid beneficiary (adjusted odds ratio [aOR]=1.70, 95% confidence interval [CI]=1.37-2.11), alcohol-related diagnoses (aOR=1.43, 95% CI: 1.21-1.69), and increasing comorbidity measured by MWI-ICD (highest MWI-ICD quartile: aOR=1.98, 95% CI=1.59-2.48). CONCLUSIONS: Among older adults with OUD admitted to the hospital, multimorbidity is strongly associated with high inpatient utilization.

Gaps in naloxone ownership among people who inject drugs during the fentanyl wave of the opioid overdose epidemic in New York City, 2018.

Background: Community distribution of naloxone, a medication that reverses opioid overdose, is an effective public health strategy to prevent overdose deaths. However, data are limited on who has naloxone during the current fentanyl wave of the opioid overdose epidemic in the United States. We aim to determine correlates of naloxone ownership among a community sample of people who inject drugs (PWID) from New York City (NYC). Methods: Data were drawn from the National HIV Behavioral Surveillance Study among PWID. Participants were recruited via respondent-driven sampling. Eligible participants completed an interviewer-administered survey. Log-linked Poisson regression was used to determine adjusted prevalence ratios (aPR) and 95% confidence intervals (CIs) current naloxone ownership. Results: Of 503 PWID, 60% currently owned naloxone. In the past 12 months, 74% witnessed an opioid overdose and 25% experienced one. Those who experienced current homelessness were less likely to own naloxone (aPR: 0.79; 95% CI: 0.68, 0.91), as were those who had been recently incarcerated (aPR: 0.83; 95% CI: 0.71, 0.97). Respondents who reported recent known or possible fentanyl use were more likely to own naloxone (aPR: 1.23; 95% CI: 1.07, 1.43) as were those who experienced an opioid overdose in the past 12 months (aPR: 1.33; 95% CI: 1.15, 1.53). Conclusions: The prevalence of naloxone ownership among PWID in NYC was high, potentially due to widespread community naloxone distribution programs; however, gaps in naloxone ownership existed. Interventions that further ease access to naloxone, such as reclassifying naloxone as an over-the-counter medication and making it available "off the shelf," should be considered. More research is needed to identify barriers to access, uptake, and sustained possession within this group to maximize the impact of naloxone distribution during the ongoing fentanyl wave of the opioid overdose epidemic.

Costs of opioid overdose education and naloxone distribution in New York City.

Background: Naloxone is an opioid antagonist medication that can be administered by lay people or medical professionals to reverse opioid overdoses and reduce overdose mortality. Cost was identified as a potential barrier to providing expanded overdose education and naloxone distribution (OEND) in New York City (NYC) in 2017. We estimated the cost of delivering OEND for different types of opioid overdose prevention programs (OOPPs) in NYC. Methods: We interviewed naloxone coordinators at 11 syringe service programs (SSPs) and 10 purposively sampled non-SSPs in NYC from December 2017 to September 2019. The samples included diverse non-SSP program types, program sizes, and OEND funding sources. We calculated one-time start up costs and ongoing operating costs using micro-costing methods to estimate the cost of personnel time and materials for OEND activities from the program perspective, but excluding naloxone kit costs. Results: Implementing an OEND program required a one-time median startup cost of $874 for SSPs and $2,548 for other programs excluding overhead, with 80% of those costs attributed to time and travel for training staff. SSPs spent a median of $90 per staff member trained and non-SSPs spent $150 per staff member. The median monthly cost of OEND program activities excluding overhead was $1,579 for SSPs and $2,529 for non-SSPs. The costs for non-SSPs varied by size, with larger, multi-site programs having higher median costs compared to single-site programs. The estimated median cost per kit dispensed excluding and including overhead was $19 versus $25 per kit for SSPs, and $36 versus $43 per kit for non-SSPs, respectively. Conclusions: OEND operating costs vary by program type and number of sites. Funders should consider that providing free naloxone to OEND programs does not cover full operating costs. Further exploration of cost-effectiveness and program efficiency should be considered across different types of OEND settings.

The New York City Prescriber Notification Program: Assessing the Feasibility of a Patient Overdose Death Notification Pilot.

Opioid analgesics and benzodiazepines remain substantial contributors to unintentional drug overdose deaths in the United States. To promote judicious prescribing and improve care for patients with substance use disorders, the New York City Department of Health and Mental Hygiene piloted the Prescriber Notification Program, an educational initiative to deliver targeted public health messaging to providers who had prescribed opioid analgesics and/or benzodiazepines to patients who died from overdose in New York City. This article reports on provider responses to receipt of patient death notifications and program feasibility. Findings demonstrate that a majority of prescribers were not aware of patient deaths prior to receiving notification letters. Public health authorities considering prescriber notification systems should address barriers to implementation and sustainability-in particular, consistent and routine access to and linkage of overdose mortality and prescription monitoring data-as part of planning such programs.

Implementing a Methadone Delivery System in New York City in Response to COVID-19.

Opioid agonist medication, including methadone, is considered the first-line treatment for opioid use disorder. Methadone, when taken daily, reduces the risk of fatal overdose; however, overdose risk increases following medication cessation. Amid an overdose epidemic accelerated by the proliferation of fentanyl, ensuring continuity of methadone treatment during the COVID-19 pandemic is a vital public health priority. (Am J Public Health. 2021;111(12):2115-2117. https://doi.org/10.2105/AJPH.2021.306523).

Trends in inpatient discharges with drug or alcohol admission diagnoses to a skilled nursing facility among older adults, New York City 2008-2014.

BACKGROUND: Recent research shows an increase in drug and alcohol-related hospitalizations in the USA, especially among older adults. However, no study examines trends in discharges to a skilled nursing facility (SNF) after a drug or alcohol-related hospitalization. Older adults are more likely to need post-hospital care in a SNF after a hospitalization due to an increased presence of chronic diseases and functional limitations. Therefore, the objective of this study was to estimate trends in drug or alcohol-related hospitalizations with discharge to a SNF among adults age 55 and older. METHODS: We analyzed data from New York State's Statewide Planning and Research Cooperative System to calculate the number of cannabis, cocaine, opioid, and alcohol-related hospitalizations in New York City that resulted in discharge to a SNF from 2008 to 2014 among adults age 55 and older. Using New York City population estimates modified from US Census Bureau, we calculated age-specific rates per 100,000 adults. Trend tests were estimated using joinpoint regressions to calculate annual percentage change (APC) with 95% confidence intervals (CI) and stratified by adults age 55-64 and adults age 65 and older. RESULTS: During the study period, among adults age 55-64, there were significant increases in cocaine, cannabis, and opioid-related hospitalizations that resulted in discharge to a SNF. For adults ≥ 65 years, there were sharp increases across all substances with larger increases in opioids (APC of 10.66%) compared to adults 55-64 (APC of 6.49%). For both age groups and among the four substances, alcohol-related hospitalizations were the leading cause of discharge to a SNF. CONCLUSIONS: We found an increase in hospital discharges to SNFs for patients age 55 and older admitted with alcohol or drug-related diagnoses. Post-acute and long-term care settings should prepare to care for an increase in older patients with substance use disorders by integrating a range of harm reduction interventions into their care settings.

Delivering Opioid Overdose Prevention in Bars and Nightclubs: A Public Awareness Pilot in New York City.

Drug seizure data indicate the presence of fentanyl in the cocaine supplies nationally and in New York City (NYC). In NYC, 39% of cocaine-only involved overdose deaths in 2017 also involved fentanyl, suggesting that fentanyl in the cocaine supply is associated with overdose deaths. To raise awareness of fentanyl overdose risk among people who use cocaine, the NYC Department of Health and Mental Hygiene pilot tested an awareness campaign in 23 NYC nightlife venues. Although 87% of venue owners/managers were aware of fentanyl, no participating venues had naloxone on premises prior to the intervention. The campaign's rapid dissemination reached people at potential risk of opioid overdose in a short period of time following the identification of fentanyl in the cocaine supply. Public health authorities in states with high rates of opioid-involved overdose death should consider similar campaigns to deliver overdose prevention education in the context of a drug supply containing fentanyl.

Relay: A Peer-Delivered Emergency Department-Based Response to Nonfatal Opioid Overdose.

Relay, a peer-delivered response to nonfatal opioid overdoses, provides overdose prevention education, naloxone, support, and linkage to care to opioid overdose survivors for 90 days after an overdose event. From June 2017 to December 2018, Relay operated in seven New York City emergency departments and enrolled 649 of the 876 eligible individuals seen (74%). Preliminary data show high engagement, primarily among individuals not touched by harm reduction or naloxone distribution networks. Relay is a novel and replicable response to the opioid epidemic.

Overdose Deaths Involving Fentanyl and Fentanyl Analogs - New York City, 2000-2017.

Unintentional drug overdose deaths have climbed to record high levels, claiming approximately 70,000 lives in the United States in 2017 alone (1). The emergence of illicitly manufactured fentanyl* (a synthetic, short-acting opioid with 50-100 times the potency of morphine) mixed into heroin, cocaine, and counterfeit pills, with or without the users' knowledge, has increased the risk for fatal overdose (2,3). The New York City (NYC) Department of Health and Mental Hygiene (DOHMH) conducts routine overdose mortality surveillance by linking death certificates with toxicology findings from the NYC Office of the Chief Medical Examiner (OCME). A 55% increase in the rate of fatal drug overdose in NYC was observed from 2015 to 2017, resulting in the highest number of overdose deaths recorded since systematic reporting began in 2000. Toxicology data indicate that this unprecedented increase in overdose deaths is attributable to fentanyl. Early identification of increased fentanyl involvement enabled DOHMH to respond rapidly to the opioid overdose epidemic by increasing awareness of the risks associated with fentanyl and developing effective risk reduction messaging. These results strongly suggest that, wherever possible, jurisdictions should consider integrating toxicology findings into routine overdose surveillance and work with local medical examiners or coroners to include fentanyl in the literal text on death certificates.

Increased Presence of Fentanyl in Cocaine-Involved Fatal Overdoses: Implications for Prevention.

After remaining stable from 2010 to 2014, the  rate of cocaine-involved overdose death increased sharply from 2015 to 2016. This study aims to determine the contribution of opioids, and fentanyl in particular, to the increase in cocaine-involved overdose death from 2015 to 2016. Using New York City death certificate data linked to medical examiner toxicology data, we identified all overdose deaths where post-mortem toxicology results were positive for cocaine from 2010 to 2016. We analyzed cocaine-involved overdose deaths by co-occurring substances. Age-adjusted rates per 100,000 residents were calculated for 6-month intervals from 2010 to 2016. Data suggest that increased deaths involving opioids, specifically fentanyl, accounted for most of the increase in cocaine-involved deaths from 2015 to 2016.

Impact of a prescription drug monitoring program use mandate on potentially problematic patterns of opioid analgesic prescriptions in New York City.

PURPOSE: To evaluate New York State's mandate that prescribers query the prescription drug monitoring program (PDMP) prior to prescribing Schedule II-IV medications. METHODS: We conducted an interrupted time series analysis of opioid analgesic prescriptions dispensed to adult New York City (NYC) residents using data from New York State's PDMP. Our main outcomes were the rate of (a) greater than or equal to five prescriber episodes, (b) greater than or equal to five prescriber and greater than or equal to five pharmacy episodes, and (c) paying for prescriptions with both cash and insurance, per quarter, per 100 000 NYC residents. We defined three periods: (a) the baseline period (January 2011 to July 2012), (b) the anticipatory period (September 2012 to July 2013) after mandate law enactment but before mandate implementation, and (c) the postmandate period (September 2013 to December 2015). For each outcome, we used autoregressive linear regression models to account for correlation in outcomes over time. RESULTS: At the end of the postmandate period, the rate of greater than or equal to five prescriber episodes was 58% lower than expected (absolute difference: -17.2 per 100 000 NYC residents; 95% CI, -31.2 to -3.1), the rate of greater than or equal to five prescriber and greater than or equal to five pharmacy episodes was 88% lower than expected (absolute difference: -8.6; 95% CI, -11.0 to -6.3), and the rate of cash and insurance payment episodes was 50% lower than expected (absolute difference: -145.4; 95% CI, -279.4 to -11.6). CONCLUSIONS: While outcomes were relatively rare, New York State's PDMP mandate was associated with significant decreases in rates of potentially problematic patterns of opioid analgesic prescriptions.

Underutilization of medications to treat opioid use disorder: What role does stigma play?

There is consensus in the scientific literature that the opioid agonist medications methadone and buprenorphine are the most effective treatments for opioid use disorder. Despite increasing opioid overdose deaths in the United States, these medications remain substantially underutilized. For no other medical conditions for which an effective treatment exists is that treatment used so infrequently. In this commentary, we discuss the potential role of stigma in the underutilization of these opioid agonist medications for addiction treatment. We outline stigma toward medications for addiction treatment and suggest that structural and policy barriers to methadone and buprenorphine may contribute to this stigma. We offer pragmatic public health solutions to reduce stigma and expand access to these effective treatments.

Estimating the Risk of Exposure to Fentanyl in New York City: Testing Drug Residue in Used Syringes.

OBJECTIVES: To estimate the risk of exposure to fentanyl among syringe exchange program (SEP) participants in New York City. METHODS: We recruited a convenience sample from 11 SEPs in New York City between March and June 2017. Consenting participants (n = 434) received a labeled syringe for their next injection. We tested collected syringes with gas chromatography-mass spectrometry and liquid chromatography-quadrupole-time-of-flight mass spectrometry. Fentanyl or fentanyl analogs detected in quantities greater than 10% of the residue mass were reported. RESULTS: The final analysis included 271 syringes; 46 (17.0%) contained fentanyl or a fentanyl analog. Fentanyl was the most frequently identified fentanyl compound, identified in 36 (13.3%) syringes. Furanylfentanyl was detected in 10 (3.7%) syringes, and 4-fluoroisobutyryl fentanyl was detected in 5 (1.8%) syringes. CONCLUSIONS: The risk of exposure to fentanyl in syringes used by SEP participants was significantly lower significantly lower than the amount of fentanyls identified among overdose decedents in New York City. Further research is needed to understand how people who use drugs have adapted to fentanyl in the drug market. Understanding the risk of exposure to fentanyls is critical to development of targeted public health messaging.

Promoting Health Department Opioid-Prescribing Guidelines for New York City Emergency Departments: A Qualitative Evaluation.

To address the epidemic of opioid misuse and overdose, the New York City Department of Health and Mental Hygiene partnered with an expert panel of emergency medicine physicians to develop voluntary guidelines for judicious prescribing of opioids upon discharge from an emergency department. A qualitative evaluation of the guidelines was conducted using semistructured interviews with emergency department directors and providers. The guidelines were widely supported by respondents and cited as helpful in easing difficult negotiations with patients requesting opioids. Involvement of the expert panel in development of guidelines was particularly valuable in ensuring their credibility. Health departments should consider partnering with emergency physicians to promote the public health goal of judicious opioid prescribing.

Public Health Detailing-A Successful Strategy to Promote Judicious Opioid Analgesic Prescribing.

OBJECTIVES: To evaluate knowledge and prescribing changes following a 2-month public health detailing campaign (one-to-one educational visits) about judicious opioid analgesic prescribing conducted among health care providers in Staten Island, New York City, in 2013. METHODS: Three detailing campaign recommendations were (1) a 3-day supply of opioids is usually sufficient for acute pain, (2) avoid prescribing opioids for chronic noncancer pain, and (3) avoid high-dose opioid prescriptions. Evaluation consisted of a knowledge survey, and assessing prescribing rates and median day supply per prescription. Prescribing data from the 3-month period before the campaign were compared with 2 sequential 3-month periods after the campaign. RESULTS: Among 866 health care providers visited, knowledge increased for all 3 recommendations (P < .01). After the campaign, the overall prescribing rate decreased similarly in Staten Island and other New York City counties (boroughs), but the high-dose prescribing rate decreased more in Staten Island than in other boroughs (P < .01). Median day supply remained stable in Staten Island and increased in other boroughs. CONCLUSIONS: The public health detailing campaign improved knowledge and likely prescribing practices and could be considered by other jurisdictions to promote judicious opioid prescribing.

Decrease in rate of opioid analgesic overdose deaths - Staten Island, New York City, 2011-2013.

From 2000 to 2011, the rate of unintentional drug poisoning (overdose) deaths involving opioid analgesics increased 435% in Staten Island, from 2.0 to 10.7 per 100,000 residents. During 2005-2011, disparities widened between Staten Island and the other four New York City (NYC) boroughs (Bronx, Brooklyn, Manhattan, and Queens); in 2011, the rate in Staten Island was 3.0-4.5 times higher than in the other boroughs. In response, the NYC Department of Health and Mental Hygiene (DOHMH) implemented a comprehensive five-part public health strategy, with both citywide and Staten Island-targeted efforts: 1) citywide opioid prescribing guidelines, 2) a data brief for local media highlighting Staten Island mortality and prescribing data, 3) Staten Island town hall meetings convened by the NYC commissioner of health and meetings with Staten Island stakeholders, 4) a Staten Island campaign to promote prescribing guidelines, and 5) citywide airing of public service announcements with additional airing in Staten Island. Concurrently, the New York state legislature enacted the Internet System for Tracking Over-Prescribing (I-STOP), a law requiring prescribers to review the state prescription monitoring system before prescribing controlled substances. This report describes a 29% decline in the opioid analgesic-involved overdose death rate in Staten Island from 2011 to 2013, while the rate did not change in the other four NYC boroughs, and compares opioid analgesic prescribing data for Staten Island with data for the other boroughs. Targeted public health interventions might be effective in lowering opioid analgesic-involved overdose mortality rates.

Illnesses and deaths among persons attending an electronic dance-music festival - New York City, 2013.

Outdoor electronic dance-music festivals (EDMFs) are typically summer events where attendees can dance for hours in hot temperatures. EDMFs have received increased media attention because of their growing popularity and reports of illness among attendees associated with recreational drug use. MDMA (3,4-methylenedioxymethamphetamine) is one of the drugs often used at EDMFs. MDMA causes euphoria and mental stimulation but also can cause serious adverse effects, including hyperthermia, seizures, hyponatremia, rhabdomyolysis, and multiorgan failure. In this report, MDMA and other synthetic drugs commonly used at dance festivals are referred to as "synthetic club drugs." On September 1, 2013, the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) received reports of two deaths of attendees at an EDMF (festival A) held August 31-September 1 in NYC. DOHMH conducted an investigation to identify and characterize adverse events resulting in emergency department (ED) visits among festival A attendees and to determine what drugs were associated with these adverse events. The investigation identified 22 cases of adverse events; nine cases were severe, including two deaths. Twenty-one (95%) of the 22 patients had used drugs or alcohol. Of 17 patients with toxicology testing, MDMA and other compounds were identified, most frequently methylone, in 11 patients. Public health messages and strategies regarding adverse health events might reduce illnesses and deaths at EDMFs.