Opioid-Prescribing Trends in San Diego County, 2008-2019.

CONTEXT: In 2019, drug overdoses accounted for 70 630 deaths in the United States, 70.6% of which involved an opioid. Approximately 28% of these deaths involved prescription medications, representing a significant number nationally. Local, state, and national efforts continue to address the impact of prescription medications within the ongoing opioid epidemic. OBJECTIVE: This study examines trends in opioid prescription patterns from 2008 to 2019 in San Diego County, California, a major metropolitan area and the fifth most populous county in the United States. A timeline of events highlighting local, state, and national milestones is included to better contextualize distinct trends. DESIGN: Collection and analysis of annual Prescription Drug Monitoring Program (PDMP) data for San Diego County. SETTING: San Diego County, California. PARTICIPANTS: Prescribing physicians using the Controlled Substance Utilization Review and Evaluation System (CURES 2.0), California's PDMP. MAIN OUTCOME MEASURES: Prescribing data for all opioids were aggregated by formulation and strength and then converted into morphine milligram equivalents (MME) per person using CDC (Centers for Disease Control and Prevention) conversion guidelines and local population estimates. Additional outcomes analyzed include the number of prescriptions dispensed, number of pills per prescription, pill strength, and specific drug. RESULTS: Total opioids prescribed increased by 29.7% from 2008 (399 MME per person) to 2012 (517 MME per person) and subsequently decreased by 54.4% from 2012 to 2019 (235 MME per person). The annual decrease in total MME from 2012 to 2019 averaged 5.9%. However, the 2-year decrease in MME from 2017 to 2019 was 35.1%, indicating an accelerated reduction in recent years. CONCLUSIONS: Opioid-prescribing trends in San Diego County from 2008 to 2019 are defined by 2 distinct periods. These trends may serve as an example of how local, state, and national efforts focusing on prescriber outreach, patient education, and regulatory oversight can address the impact of prescription opioids on the ongoing opioid epidemic.

Development of Culturally Appropriate Support Strategies to Increase Uptake of Nicotine Replacement Therapy Among Russian- and Chinese-Speaking Smokers in New York City.

Approximately 80,000 New York City smokers are Chinese or Russian speakers. To increase utilization of smoking cessation services among these populations, the Department of Health and Mental Hygiene developed linguistically and culturally tailored outreach strategies to promote and enhance its annual Nicotine Patch and Gum Program. In 2010, online web applications in Chinese and Russian were introduced. In 2011, input was sought from the community to develop Russian-language radio and newspaper ads, and a Russian-speaking liaison provided phone-assisted online enrollment support. In 2012, Chinese newspaper ads were introduced, and a Cantonese- and Mandarin-speaking liaison was hired to provide enrollment support. In 2010, 51 Russian speakers and 40 Chinese speakers enrolled in the program via web application. In 2011, 510 Russian speakers applied via the web application, with 463 assisted by the Russian-speaking liaison; forty-four Chinese speakers applied online. In 2012, 394 Russian speakers applied via the web application; 363 were assisted by the Russian-speaking liaison. Eighty-five Chinese smokers applied online via the web application; seventy were assisted by the Chinese-speaking liaison. Following the implementation of culturally tailored cessation support interventions, ethnic Russian smokers' uptake of cessation support increased tenfold, while Chinese smokers' uptake doubled. Although linguistically appropriate resources are an essential foundation for reaching immigrant communities with high smoking rates, devising culturally tailored strategies to increase quit rates is critical to programmatic success.

Active Monitoring of Travelers Arriving from Ebola-Affected Countries - New York City, October 2014-April 2015.

The Ebola virus disease (Ebola) outbreak in West Africa has claimed approximately 11,300 lives (1), and the magnitude and course of the epidemic prompted many nonaffected countries to prepare for Ebola cases imported from affected countries. In October 2014, CDC and the Department of Homeland Security (DHS) implemented enhanced entry risk assessment and management at five U.S. airports: John F. Kennedy (JFK) International Airport in New York City (NYC), O'Hare International Airport in Chicago, Newark Liberty International Airport in New Jersey, Hartsfield-Jackson International Airport in Atlanta, and Dulles International Airport in Virginia (2). Enhanced entry risk assessment began at JFK on October 11, 2014, and at the remaining airports on October 16 (3). On October 21, DHS exercised its authority to direct all travelers flying into the United States from an Ebola-affected country to arrive at one of the five participating airports. At the time, the Ebola-affected countries included Guinea, Liberia, Mali, and Sierra Leone. On October 27, CDC issued updated guidance for monitoring persons with potential Ebola virus exposure (4), including recommending daily monitoring of such persons to ascertain the presence of fever or symptoms for a period of 21 days (the maximum incubation period of Ebola virus) after the last potential exposure; this was termed "active monitoring." CDC also recommended "direct active monitoring" of persons with a higher risk for Ebola virus exposure, including health care workers who had provided direct patient care in Ebola-affected countries. Direct active monitoring required direct observation of the person being monitored by the local health authority at least once daily (5). This report describes the operational structure of the NYC Department of Health and Mental Hygiene's (DOHMH) active monitoring program during its first 6 months (October 2014-April 2015) of operation. Data collected on persons who required direct active monitoring are not included in this report.

Examining pica in NYC pregnant women with elevated blood lead levels.

We sought to describe the impact of pica, the craving for and intentional ingestion of substances not defined as food, as a risk factor for lead poisoning in New York City (NYC) pregnant women. In order to describe pregnant women with elevated blood lead levels (BLLs) who report pica, NYC health department data from 491 cases of lead-poisoned pregnant women from January 2001 to June 2009 were reviewed. Descriptive frequencies were obtained for women reporting pica. Data were compared between women reporting and not reporting pica. In NYC, of the 43 (9%) lead-poisoned pregnant women reporting pica, 42 (97.7%) were immigrants and 28 (64.6%) had consumed soil. Compared to lead-poisoned pregnant women not reporting pica, women reporting pica had higher peak BLLs (29.5 vs. 23.8 µg/dL, P = 0.0001), were more likely to have had a BLL ≥ 45 µg/dL (OR = 3.3, 95% CI, 1.25, 8.68) and receive chelation (OR = 10.88, 95% CI, 1.49, 79.25), more likely to have emigrated from Mexico (OR = 3.05, 95% CI, 1.38­6.72), and less likely to have completed high school (OR = indeterminate; 0 vs. 34%; P = 0.003). Among NYC lead-poisoned pregnant women, pica was associated with higher peak BLLs. Providers in NYC, and possibly other urban settings, should be vigilant and question pregnant women, especially immigrants, about pica and strongly consider testing this at-risk population for lead poisoning.

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.

An intervention to improve cause-of-death reporting in New York City hospitals, 2009-2010.

INTRODUCTION: Poor-quality cause-of-death reporting reduces reliability of mortality statistics used to direct public health efforts. Overreporting of heart disease has been documented in New York City (NYC) and nationwide. Our objective was to evaluate the immediate and longer-term effects of a cause-of-death (COD) educational program that NYC's health department conducted at 8 hospitals on heart disease reporting and on average conditions per certificate, which are indicators of the quality of COD reporting. METHODS: From June 2009 through January 2010, we intervened at 8 hospitals that overreported heart disease deaths in 2008. We shared hospital-specific data on COD reporting, held conference calls with key hospital staff, and conducted in-service training. For deaths reported from January 2009 through June 2011, we compared the proportion of heart disease deaths and average number of conditions per death certificate before and after the intervention at both intervention and nonintervention hospitals. RESULTS: At intervention hospitals, the proportion of death certificates that reported heart disease as the cause of death decreased from 68.8% preintervention to 32.4% postintervention (P < .001). Individual hospital proportions ranged from 58.9% to 79.5% preintervention and 25.9% to 45.0% postintervention. At intervention hospitals the average number of conditions per death certificate increased from 2.4 conditions preintervention to 3.4 conditions postintervention (P < .001) and remained at 3.4 conditions a year later. At nonintervention hospitals, these measures remained relatively consistent across the intervention and postintervention period. CONCLUSION: This NYC health department's hospital-level intervention led to durable changes in COD reporting.

Provider Attitudes and Practices on Treating Tobacco Dependence in New York City After 10 years of Comprehensive Tobacco Control Efforts.

To design strategies for provider education and implementation of clinical guidelines, this study investigated how physicians (1) approach tobacco cessation, including barriers to screening and treatment, (2) prioritize tobacco cessation, and (3) perceive the role of public health. Semi-structured focus groups were conducted with 30 New York City physicians across specialties. Physicians reported that they: (1) understand risks of smoking, as well as basic counseling and medications for smoking cessation; (2) do not always follow clinical guidelines for treatment of smoking cessation; (3) prioritize treatment of patients based upon a number of criteria; and (4) see the role of public health and the city health department as separate from the clinical environment, despite population-level interventions to reduce smoking. Physicians understand the importance of treating tobacco dependence, but identified barriers to treatment, some of which are health system-related. Further, patients who do not yet present with smoking-related illness may receive less intense interventions.

Pertussis: The Identify, Isolate, Inform Tool Applied to a Re-emerging Respiratory Illness.

Pertussis, commonly referred to as "whooping cough," is a highly contagious acute respiratory infection that has exhibited cyclical outbreaks throughout the last century. Although vaccines have provided some immunity, many populations, including infants and pregnant women, remain at risk for serious illness. Through the use of the novel "Identify, Isolate, Inform" (3I) tool, emergency department (ED) providers can readily recognize key symptoms of the disease and risk factors for exposure, thus curbing its transmission through early initiation of antimicrobial therapy and post-exposure prophylaxis. The three classic stages of pertussis include an initial catarrhal stage, characterized by nonspecific upper respiratory infection symptoms, which may advance to the paroxysmal stage, revealing the distinctive "whooping cough." This cough can persist for weeks to months leading into the convalescent stage. Household contacts of patients with suspected pertussis or other asymptomatic, high-risk populations (infants, pregnant women in their third trimester, and childcare workers) may benefit from post-exposure prophylactic therapy. The Pertussis 3I tool can also alert healthcare professionals to the proper respiratory droplet precautions during contact with a symptomatic patient, as well as isolation practices until antimicrobial treatment is in progress. ED personnel should then inform local public health departments of any suspected cases. All of these actions will ultimately aid public health in controlling the incidence of pertussis cases, thus ensuring the protection of the general public from this re-emerging respiratory illness.

Cannabinoid Hyperemesis Syndrome: Public Health Implications and a Novel Model Treatment Guideline.

INTRODUCTION: Cannabinoid hyperemesis syndrome (CHS) is an entity associated with cannabinoid overuse. CHS typically presents with cyclical vomiting, diffuse abdominal pain, and relief with hot showers. Patients often present to the emergency department (ED) repeatedly and undergo extensive evaluations including laboratory examination, advanced imaging, and in some cases unnecessary procedures. They are exposed to an array of pharmacologic interventions including opioids that not only lack evidence, but may also be harmful. This paper presents a novel treatment guideline that highlights the identification and diagnosis of CHS and summarizes treatment strategies aimed at resolution of symptoms, avoidance of unnecessary opioids, and ensuring patient safety. METHODS: The San Diego Emergency Medicine Oversight Commission in collaboration with the County of San Diego Health and Human Services Agency and San Diego Kaiser Permanente Division of Medical Toxicology created an expert consensus panel to establish a guideline to unite the ED community in the treatment of CHS. RESULTS: Per the consensus guideline, treatment should focus on symptom relief and education on the need for cannabis cessation. Capsaicin is a readily available topical preparation that is reasonable to use as first-line treatment. Antipsychotics including haloperidol and olanzapine have been reported to provide complete symptom relief in limited case studies. Conventional antiemetics including antihistamines, serotonin antagonists, dopamine antagonists and benzodiazepines may have limited effectiveness. Emergency physicians should avoid opioids if the diagnosis of CHS is certain and educate patients that cannabis cessation is the only intervention that will provide complete symptom relief. CONCLUSION: An expert consensus treatment guideline is provided to assist with diagnosis and appropriate treatment of CHS. Clinicians and public health officials should identity and treat CHS patients with strategies that decrease exposure to opioids, minimize use of healthcare resources, and maximize patient safety.

Etiology of nonspecific cause of death coding in New York City motor vehicle crash-related fatalities.

OBJECTIVES: Nearly 20 percent of New York City's (NYC) accidental deaths are related to motor vehicles crashes (MVCs). Detailed International Classification of Disease (ICD-10; World Health Organization [WHO] 2007) cause-of-death coding of MVC-related fatalities improves surveillance and resulting identification of prevention strategies. We investigated ICD-10 codes in these fatalities and the potential to make them more specific. METHODS: We defined "nonspecific" MVC ICD-10 codes as all globally unspecific codes (V870-V878, V892) and any codes with nonspecific components regarding vehicle involved, decedent position in vehicle, or MVC setting. We calculated nonspecific-code frequency for 1999-2008 MVC deaths. We reviewed a random 10 percent sample of 2007-2008 MVC deaths (N=61) and medical examiner (ME) records of all nonspecific death certificates (N=52), including police accident reports ("full PAR") and summaries prepared by onsite police officers ("brief PAR") to determine whether MEs had sufficient information available but did not include that information at death certification. RESULTS: Among 1999-2008 NYC MVC deaths, 82.9 percent had nonspecific ICD-10 cause-of-death codes. Similarly, of the 61 recent randomly sampled MVC deaths, 52 (85.2%) had nonspecific codes. Of 52 nonspecific death certificates from the random sample, 38 (73.1%) death certificates had adequate information available on full or brief PAR to be more specific at the time of death certification. Consistent with MEs' reports of high reliance on the brief PAR, most nonspecific death certificates (76.9%) lacked adequate information in the brief PAR to be more specific. CONCLUSION: Specific ICD-10 codes for MVC deaths depends on the level of detail provided by the ME in the "How Injury Occurred" and "If Transportation Injury Specify" death certificates sections. We have worked to ensure that key information is available to MEs in the brief PAR and educated MEs on the importance of this information to reduce the frequency of nonspecific codes and enhance injury prevention research.