Public health detailing to increase naloxone access in NYC pharmacies.

BACKGROUND: Drug overdose is a public health crisis in the United States. Opioid overdose deaths are preventable using naloxone, an opioid antagonist that reverses the effect of an opioid and prevents fatal overdose. OBJECTIVES: This study aimed to evaluate changes in naloxone standing order status, attitudes, and practice behavior after an 8-week public health detailing campaign on increasing naloxone access conducted among pharmacists in independent pharmacies in New York City (NYC). METHODS: Campaign recommendations were to (1) enroll in the NYC pharmacy naloxone standing order program, (2) offer naloxone to at-risk patients, and (3) educate patients on how to use naloxone. Evaluation was performed using initial and follow-up surveys administered to pharmacists during detailing visits and Department of Health and Mental Hygiene data on pharmacies in the standing order program. RESULTS: Detailing visits were completed with 1153 pharmacists; follow-up visits were completed with 457 (40%). Self-reported attitudes and practice behavior related to the 3 campaign recommendations improved (P < 0.01). After the campaign, 519 new pharmacies enrolled in the standing order program. CONCLUSIONS: The detailing campaign substantially increased the number of pharmacies enrolled in the standing order program and was associated with improved attitudes and practice behavior related to naloxone provision to varying degrees. Other jurisdictions could consider detailing pharmacists as a strategy to increase naloxone access.

Implementation of buprenorphine services in NYC syringe services programs: a qualitative process evaluation.

BACKGROUND: Syringe services programs (SSPs) hold promise for providing buprenorphine treatment access to people with opioid use disorder (OUD) who are reluctant to seek care elsewhere. In 2017, the New York City Department of Health and Mental Hygiene (DOHMH) provided funding and technical assistance to nine SSPs to develop "low-threshold" buprenorphine services as part of a multipronged initiative to lower opioid-related overdose rates. The aim of this study was to identify barriers to and facilitators of implementing SSP-based buprenorphine services. METHODS: We conducted 26 semi-structured qualitative interviews from April 2019 to November 2019 at eight SSPs in NYC that received funding and technical assistance from DOHMH. Interviews were conducted with three categories of staff: leadership (i.e., buprenorphine program management or leadership, eight interviews), staff (i.e., buprenorphine coordinators or other staff, eleven interviews), and buprenorphine providers (six interviews). We identified themes related to barriers and facilitators to program implementation using thematic analysis. We make recommendations for implementation based on our findings. RESULTS: Programs differed in their stage of development, location of services provided, and provider type, availability, and practices. Barriers to providing buprenorphine services at SSPs included gaps in staff knowledge and comfort communicating with participants about buprenorphine, difficulty hiring buprenorphine providers, managing tension between harm reduction and traditional OUD treatment philosophies, and financial constraints. Challenges also arose from serving a population with unmet psychosocial needs. Implementation facilitators included technical assistance from DOHMH, designated buprenorphine coordinators, offering other supportive services to participants, and telehealth to bridge gaps in provider availability. Key recommendations include: (1) health departments should provide support for SSPs in training staff, building health service infrastructure and developing policies and procedures, (2) SSPs should designate a buprenorphine coordinator and ensure regular training on buprenorphine for frontline staff, and (3) buprenorphine providers should be selected or supported to use a harm reduction approach to buprenorphine treatment. CONCLUSIONS: Despite encountering challenges, SSPs implemented buprenorphine services outside of conventional OUD treatment settings. Our findings have implications for health departments, SSPs, and other community organizations implementing buprenorphine services. Expansion of low-threshold buprenorphine services is a promising strategy to address the opioid overdose epidemic.

Increasing Access to Buprenorphine in Safety-Net Primary Care Clinics: The New York City Buprenorphine Nurse Care Manager Initiative.

The Buprenorphine Nurse Care Manager Initiative (BNCMI) sought to increase access to opioid use disorder treatment in underserved New York City populations by expanding buprenorphine treatment capacity in safety-net primary care clinics.During 2016 to 2020, BNCMI added 116 new buprenorphine providers across 27 BNCMI clinics, and 1212 patients were enrolled; most patients identified as Latinx or Hispanic and were Medicaid beneficiaries.BNCMI increased access to buprenorphine, reached underserved populations, and is part of the New York City Health Department's multipronged approach to reducing opioid overdose deaths.

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.

Effect of vaccination coordinators on socioeconomic disparities in immunization among the 2006 Connecticut birth cohort.

OBJECTIVES: We examined socioeconomic status (SES) disparities and the influence of state Immunization Action Plan-funded vaccination coordinators located in low-SES areas of Connecticut on childhood vaccination up-to-date (UTD) status at age 24 months. METHODS: We examined predictors of underimmunization among the 2006 birth cohort (n = 34,568) in the state's Immunization Information System, including individual demographic and SES data, census tract SES data, and residence in an area with a vaccination coordinator. We conducted multilevel logistic regression analyses. RESULTS: Overall, 81% of children were UTD. Differences by race/ethnicity and census tract SES were typically under 5%. Not being UTD at age 7 months was the strongest predictor of underimmunization at age 24 months. Among children who were not UTD at age 7 months, only Medicaid enrollment (adjusted odds ratio [AOR] = 0.6; 95% confidence interval [CI] = 0.5, 0.7) and residence in an area with a vaccination coordinator (AOR = 0.7; 95% CI = 0.6, 0.9) significantly decreased the odds of subsequent underimmunization. CONCLUSIONS: SES disparities associated with underimmunization at age 24 months were limited. Efforts focused on vaccinating infants born in low SES circumstances can minimize disparities.

Drug checking in the fentanyl era: Utilization and interest among people who inject drugs in San Diego, California.

BACKGROUND: In North America, overdose rates have steeply risen over the past five years, largely due to the ubiquity of illicitly manufactured fentanyls in the drug supply. Drug checking services (DCS) represent a promising harm reduction strategy and characterizing experiences of use and interest among people who inject drugs (PWID) is a priority. METHODS: Between February-October 2022, PWID participating in a cohort study in San Diego, CA and Tijuana, Mexico completed structured surveys including questions about DCS, socio-demographics and substance use behaviors. We used Poisson regression to assess factors associated with lifetime DCS use and characterized experiences with DCS and interest in free access to DCS. RESULTS: Of 426 PWID, 72% were male, 59% Latinx, 79% were experiencing homelessness and 56% ever experienced a nonfatal overdose. One third had heard of DCS, of whom 57% had ever used them. Among the latter, most (98%) reported using fentanyl test strips (FTS) the last time they used DCS; 66% did so less than once per month. In the last six months, respondents used FTS to check methamphetamine (48%), heroin (30%) or fentanyl (29%). Relative to White/non-Latinx PWID, those who were non-White/Latinx were significantly less likely to have used DCS [adjusted risk ratio (aRR): 0.22; 95% CI: 0.10, 0.47), as were PWID experiencing homelessness (aRR:0.45; 95% CI: 0.28, 0.72). However, a significant interaction indicated that non-White/Latinx syringe service program (SSP) clients were more likely to have used DCS than non-SSP clients (aRR: 2.79; CI: 1.09, 7.2). Among all PWID, 44% expressed interest in free access to FTS, while 84% (of 196 PWID) expressed interest in advanced spectrometry DCS to identify and quantify multiple substances. CONCLUSIONS: Our findings highlight low rates of DCS awareness and utilization, inequities by race/ethnicity and housing situation, high interest in advanced spectrometry DCS versus FTS, and the potential role of SSPs in improving access to DCS, especially among racial/ethnic minorities.

Asymmetric type F botulism with cranial nerve demyelination.

We report a case of type F botulism in a patient with bilateral but asymmetric neurologic deficits. Cranial nerve demyelination was found during autopsy. Bilateral, asymmetric clinical signs, although rare, do not rule out botulism. Demyelination of cranial nerves might be underrecognized during autopsy of botulism patients.

Impact of 2-dose vaccination on varicella epidemiology: Connecticut--2005-2008.

In 2006, the Advisory Committee on Immunization Practices recommended that children routinely receive 2 varicella vaccine doses in place of the 1 dose previously recommended. This recommendation's initial impact on varicella epidemiology in Connecticut was assessed. Reported incidence and case-specific data were compared for 2005 and 2008. Varicella incidence decreased from 48.7 cases/100,000 persons in 2005 to 24.5 in 2008. Age-specific incidence decreased significantly (P < .05) among children aged 1-14 years. Reported varicella incidence has declined in Connecticut after implementation of routine 2-dose varicella vaccination for children. Continued surveillance is needed to determine the recommendation's full impact.

Attitudes Toward Individuals With Mental Illness and Substance Use Disorders Among Resident Physicians.

OBJECTIVE: Resident physicians frequently provide care for individuals diagnosed with mental illness and substance use disorders (SUDs). Clinicians-including psychiatrists and addiction professionals-have been shown to possess negative attitudes toward these individuals, which is concerning since negative attitudes may have an adverse impact on patient engagement, treatment, and outcomes. However, little is known about resident physicians' attitudes toward individuals with mental illness and SUDs. The objective of this study was to examine the attitudes of emergency medicine, internal medicine, and obstetrics-gynecology residents toward individuals with diagnoses of schizophrenia, multiple SUDs, co-occurring schizophrenia and SUDs, and major depressive disorder. METHODS: A web-based questionnaire, including demographic information, level of training, and the 11-item Medical Condition Regard Scale (MCRS) for individuals with 4 different diagnoses, which assesses the degree to which clinicians find individuals with a given medical condition to be enjoyable, treatable, and worthy of medical resources, was sent to residents across the United States from May 2016 to April 2017. RESULTS: A total of 411 resident physicians completed the questionnaire. Respondents had more negative attitudes toward individuals with diagnoses of SUDs with and without schizophrenia than toward those individuals with diagnoses of schizophrenia or major depressive disorder alone. Senior residents possessed more negative attitudes toward individuals with SUDs than did junior residents. Emergency medicine residents had more negative attitudes than the other resident physician groups. CONCLUSIONS: The attitudes of resident physicians toward individuals with SUDs with and without schizophrenia were negative and were worse among emergency medicine residents and senior residents. Additional research and programmatic work are needed to understand the reasons for these negative attitudes and to develop interventions during residency training to improve them.

Legionnaires' Disease Outbreak at a Resort in Cozumel, Mexico.

Background. A Legionnaires' disease (LD) outbreak at a resort on Cozumel Island in Mexico was investigated by a joint Mexico-United States team in 2010. This is the first reported LD outbreak in Mexico, where LD is not a reportable disease. Methods. Reports of LD among travelers were solicited from US health departments and the European Working Group for Legionella Infections. Records from the resort and Cozumel Island health facilities were searched for possible LD cases. In April 2010, the resort was searched for possible Legionella exposure sources. The temperature and total chlorine of the water at 38 sites in the resort were measured, and samples from those sites were tested for Legionella. Results. Nine travelers became ill with laboratory-confirmed LD within 2 weeks of staying at the resort between May 2008 and April 2010. The resort and its potable water system were the only common exposures. No possible LD cases were identified among resort workers. Legionellae were found to have extensively colonized the resort's potable water system. Legionellae matching a case isolate were found in the resort's potable water system. Conclusions. Medical providers should test for LD when treating community-acquired pneumonia that is severe or affecting patients who traveled in the 2 weeks before the onset of symptoms. When an LD outbreak is detected, the source should be identified and then aggressively remediated. Because LD can occur in tropical and temperate areas, all countries should consider making LD a reportable disease if they have not already done so.

Beyond content: leadership development through a journal club.

CDC designed its Health Systems Integration Program to prepare leaders to function at the interface of public health and health care. Specific Health Systems Integration Program competencies in the areas of communication, analysis and assessment, and health systems were developed to nurture evidence-based decision-making and leadership skills crucial for future public health leaders. The program therefore designed an innovative journal club as part of its competency-based curriculum not only to meet the standard goals for a journal club-critical reading, interpretation, and acquiring content knowledge-but also to foster leadership development. This report describes the Health Systems Integration Program journal club format, its implementation, challenges, and key elements of success. Other programs using a journal club model as a learning format might consider using the Health Systems Integration Program's innovative approach that focuses on leadership development.