Need for Improved Timeliness of Reporting on Drug Overdose Fatalities: The HEALing Communities Study.

OBJECTIVE: Timely data on drug overdose deaths can help identify community needs, evaluate the effectiveness of interventions, and allocate resources. We identified variations in death investigation and reporting systems within and between states that affect the timeliness and accuracy of death certificate information. METHODS: The HEALing Communities Study (HCS) is a community-engaged, data-driven approach to combating the opioid crisis in 67 communities in 4 states: Kentucky, Massachusetts, New York, and Ohio. HCS conducted a survey of coroners and medical examiners to understand variability in drug overdose death data. We compared survey results in Massachusetts, New York, and Ohio with national data to investigate the completeness of provisional death counts by type of death investigation system. RESULTS: Communities in each HCS state had different ways of collecting and reporting mortality data. Completion of death certificates for drug overdoses ranged from <2 weeks in 23% (7 of 31) of those surveyed to more than 3 months in 10% (3 of 31) of those surveyed. Variabilities in the timeliness of reporting drug overdose deaths were not associated with type of coroner or medical examiner office in each state, urban versus rural setting, or specificity of drug information on the death certificate. CONCLUSION: Having specific drug information on the death certificate may increase death certificate quality, comparability, and accuracy. We recommend the following: (1) all coroners and medical examiners should be trained on conducting death investigations, interpreting toxicology reports, and completing death certificates; (2) 1 office in each state should oversee all coroners and medical examiners to increase data consistency; and (3) communities should identify and address barriers to timely death certification.

Expanding access to Medication for Opioid Use Disorder (MOUD) in jails: A comprehensive program evaluation.

INTRODUCTION: Individuals with opioid use disorder (OUD) transitioning from jails or prisons to the community are at high risk of overdose-related death shortly after release. Buprenorphine, methadone, and extended-release naltrexone are FDA-approved medications for opioid use disorder (MOUD) to reduce overdose risk and increase treatment engagement. Despite the evidence, many correctional facilities in the United States do not provide MOUD to their incarcerated population. Albany County Jail and Rehabilitative Services Center (ACCRSC) is a jail in New York State that provides comprehensive MOUD and overdose prevention services to all incarcerated individuals with OUD. METHODS: MOUD program participants' data was collected during custody and after release to determine whether the program's primary goals of preventing overdose-related mortality and MOUD continuation after release were met. Other quality-of-life metrics were used for program improvements, such as program participants' physical and mental well-being, postrelease housing, employment, access to mental health services, and re-incarceration. RESULTS: This study included 375 unique individuals who received MOUD treatment at the jail between January 19, 2019, and the end of December 2020, with 56.2 % continuing their treatment and 43.7 % initiating MOUD during custody. Among those who initiated MOUD at ACCRSC, 93.3 % were enrolled in buprenorphine. We identified eight program participant deaths after release within a year after incarceration. The average time between release and death was 233 days, with the shortest time between release and death being 107 days. We found that over half (53.6 %) of program participants using buprenorphine picked up their prescriptions after exiting ACCRSC. Among those who did not, nearly 16 % were unable to do so because they were transferred to another jail or prison that did not provide MOUD care. Overall, nearly 80 % of program participants who were transferred to another correctional facility could not continue their medication. CONCLUSIONS: MOUD in correctional settings appears to reduce overdose deaths immediately after release. Administering buprenorphine and other types of MOUD in a jail setting has shown relatively high retention for people to fill their first prescription of buprenorphine outside the jail. To ensure high MOUD retention among incarcerated populations, all correctional facilities must provide MOUD care.

"It's just another tool on my toolbelt": New York state law enforcement officer experiences administering naloxone.

BACKGROUND: Although naloxone is widely acknowledged as a life-saving intervention and a critical tool for first responders, there remains a need to explore how law enforcement officers have adapted to a shifting scope of work. Past research has focused mainly on officer training, their abilities to administer naloxone, and to a lesser extent on their experiences and interactions working with people who use drugs (PWUD). METHODS: A qualitative approach was used to explore officer perspectives and behaviors surrounding responses to incidents of suspected opioid overdose. Between the months of March and September 2017, semi-structured interviews were conducted with 38 officers from 17 counties across New York state (NYS). RESULTS: Analysis of in-depth interviews revealed that officers generally considered the additional responsibility of administering naloxone to have become "part of the job". Many officers reported feeling as though they are expected to wear multiple hats, functioning as both law enforcement and medical personnel and at times juggling contradictory roles. Evolving views on drugs and drug use defined many interviews, as well as the recognition that a punitive approach to working with PWUD is not the solution, emphasizing the need for cohesive, community-wide support strategies. Notable differences in attitudes toward PWUD appeared to be influenced by an officer's connection to someone who uses drugs and/or due to a background in emergency medical services. CONCLUSION: Law enforcement officers in NYS are emerging as an integral part of the continuum of care for PWUD. Our findings are capturing a time of transition as more traditional approaches to law enforcement appear to be shifting toward those prioritizing prevention and diversion. Widespread adoption of naloxone administration by law enforcement officers in NYS is a powerful example of the successful integration of a public health intervention into police work.

The effects of COVID-19 on New York State's Drug User Health Hubs and syringe service programs: a qualitative study.

BACKGROUND: Syringe service programs (SSPs) deliver critical harm reduction services to people who inject drugs (PWID). Some SSPs in New York State received enhanced funding to provide additional services to combat opioid overdose fatalities. These SSPs, known as Drug User Health Hubs, provide buprenorphine for the treatment of opioid use disorder and other health-related services in addition to their syringe services. While the COVID-19 pandemic posed widespread challenges to the delivery of health services nationwide, the effect of the pandemic on SSPs uniquely impacts PWID. This study examines the impact of COVID-19 on service delivery of Drug User Health Hubs and stand-alone SSPs in New York State. METHODS: Between July 2020 and September 2020, we performed eleven semi-structured virtual interviews with staff from three Health Hub SSPs and three stand-alone SSPs. The interviews explored the effect of the COVID-19 pandemic on SSPs and their clients as well as the changes implemented in response. Interviews were recorded and transcribed. We performed content analysis to identify emerging themes from the data. RESULTS: Due to the COVID-19 pandemic, some SSPs temporarily shut down while others limited their hours of operation. SSPs modified their service delivery to maintain syringe services and naloxone distribution over other services such as STI and HCV testing. They virtualized components of their services, including telemedicine for the provision of buprenorphine. While SSPs found virtualization to be important for maintaining their services, it negatively impacted the intimate nature of client interactions. Participants also described the impact of the pandemic on the well-being of PWID, including isolation, worsened mental health challenges, and increased drug overdoses. CONCLUSIONS: In response to the COVID-19 pandemic, SSPs demonstrated innovation, adaptability, and togetherness. Despite the challenges posed by the pandemic, SSPs continued to be key players in maintaining access to sterile supplies, buprenorphine, and other services for PWID. In addition to adapting to COVID-19 restrictions, they also responded to the dynamic needs of their clients. Sustainable funding and recognition of the critical role of SSPs in supporting PWID can help to improve outcomes for PWID.

What is the prevalence of and trend in opioid use disorder in the United States from 2010 to 2019? Using multiplier approaches to estimate prevalence for an unknown population size.

Opioid-related overdose deaths have increased since 2010 in the U.S., but information on trends in opioid use disorder (OUD) prevalence is limited due to unreliable data. Multiplier methods are a classical epidemiological technique to estimate prevalence when direct estimation is infeasible or unreliable. We used two different multiplier approaches to estimate OUD prevalence from 2010 to 2019. First, we estimated OUD in National Survey on Drug Use and Health (NSDUH), and based on existing capture-recapture studies, multiplied prevalence by 4.5x. Second, we estimated the probability of drug poisoning death among people with OUD (Meta-analysis indicates 0.52/100,000), and divided the number of drug poisoning deaths in the US by this probability. Estimates were weighted to account for increase in drug-related mortality in recent years due to fentanyl. Estimated OUD prevalence was lowest when estimated in NSDUH with no multiplier, and highest when estimated from vital statistics data without adjustment. Consistent findings emerged with two methods: NSDUH data with multiplier correction, and vital statistics data with multiplier and adjustment. From these two methods, OUD prevalence increased from 2010 to 2014; then stabilized and slightly declined annually (survey data with multiplier, highest prevalence of 4.0% in 2015; death data with a multiplier and correction, highest prevalence of 2.35% in 2016). The number of US adolescent and adult individuals with OUD in 2019 was estimated between 6.7-7.6 million. When multipliers and corrections are used, OUD may have stabilized or slightly declined after 2015. Nevertheless, it remains highly prevalent, affecting 6-7 million US adolescents and adults.

The impact of the national stay-at-home order on emergency department visits for suspected opioid overdose during the first wave of the COVID-19 pandemic.

BACKGROUND: Although national syndromic surveillance data reported declines in emergency department (ED) visits after the declaration of the national stay-at-home order for COVID-19, little is known whether these declines were observed for suspected opioid overdose. METHODS: This interrupted time series study used syndromic surveillance data from four states participating in the HEALing Communities Study: Kentucky, Massachusetts, New York, and Ohio. All ED encounters for suspected opioid overdose (n = 48,301) occurring during the first 31 weeks of 2020 were included. We examined the impact of the national public health emergency for COVID-19 (declared on March 14, 2020) on trends in ED encounters for suspected opioid overdose. RESULTS: Three of four states (Massachusetts, New York and Ohio) experienced a statistically significant immediate decline in the rate of ED encounters for suspected opioid overdose (per 100,000) after the nationwide public health emergency declaration (MA: -0.99; 95 % CI: -1.75, -0.24; NY: -0.10; 95 % CI, -0.20, 0.0; OH: -0.33, 95 % CI: -0.58, -0.07). After this date, Ohio and Kentucky experienced a sustained rate of increase for a 13-week period. New York experienced a decrease in the rate of ED encounters for a 10-week period, after which the rate began to increase. In Massachusetts after a significant immediate decline in the rate of ED encounters, there was no significant difference in the rate of change for a 6-week period, followed by an immediate increase in the ED rate to higher than pre-COVID levels. CONCLUSIONS: The heterogeneity in the trends in ED encounters between the four sites show that the national stay-at-home order had a differential impact on opioid overdose ED presentation in each state.

Evaluation of Drug-Related Risk Behaviors Among Females Diagnosed With Early Syphilis in New York State (Excluding New York City), 2013 to 2018.

ABSTRACT: This evaluation describes an increase in reported drug-related risk behaviors among females who are diagnosed with early syphilis over a 5-year span in New York State, excluding New York City. Integrating sexually transmitted infection prevention efforts with harm reduction services may help decrease syphilis rates in areas where drug-related risk behavior rates are high.

Occupational fatal injuries associated with mobile hand-fed wood chippers.

BACKGROUND: Workers are killed every year in wood chipper-related incidents despite the repeated hazard warnings. In-depth, comprehensive, and up-to-date studies are needed to identify causal, risk, and contributing factors and assess the current control measures so that an effective and proactive prevention approach can be developed. METHODS: Cases were identified from four online databases and manually reviewed to characterize and categorize the fatal events. RESULTS: The study identified 113 wood chipper-related worker deaths (1982-2016). The victims were killed in struck-by (57), caught-in (41), motor vehicle (7), electrical (4), fall (2), and heat stroke (2) incidents while performing chipper-related tasks. CONCLUSIONS: Chipper-related worker deaths are preventable. Young and inexperienced workers may be at higher risk for caught-in deaths. The current feed wheel control devices are not effective for workers to self-rescue. Fully automatic feed wheel stop devices are needed to prevent caught-in incidents.

An analysis of mercury exposures among the adult population in New York State.

The extent of methylmercury exposures among adults in New York State (NYS) has not been well characterized. Over the past few years, the NYS Heavy Metals Registry (HMR) has seen an increase in both blood mercury tests being reported, and nonoccupational exposures to mercury, which appear primarily due to fish consumption. This study will, (1) Characterize the adults who are tested for blood mercury in NYS; (2) Examine the circumstances for blood mercury testing; and (3) Characterize this population in terms of exposure history, specifically those individuals who are non-occupationally exposed through a diet of seafood consumption in reference to blood mercury levels. Data available from HMR laboratory results, including basic demographics and test results, were combined with data from telephone interviews. The interview contains information on the reasons for testing, possible sources of exposure, and the individual's work and home environment. Approximately 99 % of adults reported to the HMR, with identifiable exposures to mercury, had non-occupational exposures resulting from seafood consumption. Common types of fish consumed include salmon, tuna, and swordfish, with 90 % of adults eating seafood a few times or more per week. Information will be provided on the reasons for being tested and the range of blood mercury levels in relation to their seafood consumption. NYS residents who frequently eat fish should be aware of what types of fish contain mercury and avoid or reduce consumption of fish with high mercury levels.

Exposure sources and reasons for testing among women with low blood lead levels.

Previous research has focused on highly elevated blood lead (PbB). This study examined reasons for testing and potential sources of exposure among women with PbBs less than 0.72 µmol/l (15 µg/dl). A questionnaire was mailed to 18- to 49-year-old women in upstate New York, USA, who were PbB tested in 2007. The most common testing reason was pregnancy among 125 women who returned the questionnaire. Among women tested for PbB during pregnancy, doctors ordered approximately 80% of tests regardless of lead level. Few women with PbBs less than 0.24 µmol/l (5 µg/dl) reported a potential source of lead exposure. However, among women with PbBs of 0.24-0.71 µmol/L (5-14.9 µg/dl), 29.2% had a job and 21.2% had a hobby with potential lead exposure. There are systematic differences in reasons for testing and exposure sources among women with PbBs less than 0.72 µmol/l and these differences have implications for screening.

Evaluation of a communications campaign to increase physician reporting to a surveillance system.

While all states have regulations requiring reporting of diseases from healthcare professionals and facilities, underreporting is substantial. To improve reporting to the New York State (NYS) Occupational Lung Disease Registry (OLDR), the NYS Department of Health's Bureau of Occupational Health initiated a multimedia campaign to increase case ascertainment and establish communication channels and partnerships for conducting prevention. The outreach campaign was successful in raising physician awareness about the OLDR, familiarizing physicians with reporting forms and procedures, and increasing physician reporting. It also raised awareness of the contribution of occupational factors to respiratory illness and other conditions. However, while our evaluation indicated it is possible to affect short-term outcomes, such as knowledge, attitudes, and behavior among health-care providers, the campaign was not as successful in promoting sustained reporting.

Maternal low-level lead exposure and fetal growth.

BACKGROUND: Limited epidemiologic studies have examined the association between maternal low-level lead exposure [blood lead (PbB) < 10 µg/dL] and fetal growth. OBJECTIVE: We examined whether maternal low-level lead exposure is associated with decreased fetal growth. METHODS: We linked New York State Heavy Metals Registry records of women who had PbB measurements with birth certificates to identify 43,288 mother-infant pairs in upstate New York in a retrospective cohort study from 2003 through 2005. We used multiple linear regression with fractional polynomials and logistic regression to relate birth weight, preterm delivery, and small for gestational age to PbB levels, adjusting for potential confounders. We used a closed-test procedure to identify the best fractional polynomials for PbB among 44 combinations. RESULTS: We found a statistically significant association between PbB (square root transformed) and birth weight. Relative to 0 µg/dL, PbBs of 5 and 10 µg/dL were associated with an average of 61-g and 87-g decrease in birth weight, respectively. The adjusted odds ratio for PbBs between 3.1 and 9.9 µg/dL (highest quartile) was 1.04 [95% confidence interval (CI), 0.89-1.22] for preterm delivery and 1.07 (95% CI, 0.93-1.23) for small for gestational age, relative to PbBs ≤ 1 µg/dL (lowest quartile). No clear dose-response trends were evident when all of the quartiles were assessed. CONCLUSIONS: Low-level PbB was associated with a small risk of decreased birth weight with a supralinear dose-response relationship, but was not related to preterm birth or small for gestational age. The results have important implications regarding maternal PbB.

Surveillance of work-related asthma in new york state.

OBJECTIVE: The objective of this paper is to determine the percent of adults with asthma attributable to work and describe characteristics of the work-related asthma population in New York State. Sociodemographic and control characteristics of those with and without work-related asthma are compared. METHODS: Data from three population-based surveys and one case-based surveillance system were analyzed. Work-relatedness of asthma was determined by self-report for the population-based surveys and by physician report for the case-based system. Self-reported sociodemographic and control characteristics were analyzed for the population-based surveys by work-relatedness. RESULTS: The percent of work-relatedness among adults with current asthma in New York State ranged from 10.6% to 44.5%. Significantly more adults with work-related asthma had poorly controlled asthma than those without work-related asthma. More adults with work-related asthma also tended to be employed in the manufacturing, educational services, and public administration industries than the general population. The most frequently reported exposure was dust. CONCLUSIONS: Adults with work-related asthma have decreased control and adverse socioeconomic impacts compared to those with asthma that is not work-related. Increased recognition and physician reporting is necessary to further prevent the impact of work-related exposures.

Adult blood lead reporting in New York State, 1994-2006.

OBJECTIVES: Laboratories that test New York State (NYS) employees and adult residents for lead exposure are required to report blood lead test results to the NYS Department of Health's Heavy Metals Registry. This registry is used to monitor exposures and to identify new high-risk occupational and nonoccupational activities. METHODS: We used interviews conducted with people having blood lead levels of > or = 25 micrograms/deciliter (microg/dL) reported to the Heavy Metals Registry to determine the primary source of lead exposure. We reviewed this information, together with demographic information, for the years 1994 through 2006. RESULTS: While overall there has been an increase in the number of tests being conducted on NYS residents since 1994, the vast majority of the increase is among those with the lowest blood lead levels (<10 microg/dL). Conversely, there has been a decline in the number of adults tested with blood lead levels of > or = 25 microg/dL in NYS due primarily to occupational exposures. However, nonoccupational exposures do represent a relatively large percentage of the individuals with severely elevated blood lead levels (> or = 60 microg/dL). CONCLUSIONS: Although a surveillance system based on blood lead levels cannot identify the true magnitude of adult lead poisoning, the NYS Heavy Metals Registry has proven to be an important tool for identifying situations in which adult lead poisoning is occurring, and assists in guiding lead poisoning prevention among adults.

Lead exposure among target shooters.

The New York State Heavy Metals Registry receives reports on all New Yorkers tested for lead. The Registry was reviewed for information on individuals who had lead exposure from target shooting. Overall, 598 individuals have been reported with exposures from target shooting. Over one-half had nonoccupational exposures. These individuals were reported more frequently with elevated blood lead levels (over 40 microg/dL) than those with occupational exposures. Hobby target shooters are at significant risk of having elevated blood lead levels. Because of the potential for serious lead exposure as a result of target shooting, efforts should be made to inform target shooters of the health risks and methods that can reduce exposure to themselves, other range users, and their families.

Characteristics of patients with work-related asthma seen in the New York State Occupational Health Clinics.

OBJECTIVE: The objective of this study was to characterize the work-related asthma population seen by the New York State Occupational Health Clinic Network (OHCN) to determine which industries, occupations, and causal agents are associated with work-related asthma in New York State (NYS). METHODS: The OHCN patient database was analyzed to identify those patients with a diagnosis of work-related asthma and medical charts were then abstracted for data on demographics, clinical history, disease severity, industry, occupation, and putative agent. RESULTS: The OHCN patients with work-related asthma were most commonly employed in the service and manufacturing industries. Common occupations included teachers, farm operators/managers, and construction trades. The most frequently reported putative agents associated with work-related asthma were dust, indoor air, mold, and solvents. CONCLUSIONS: Our findings suggest the potential importance of prevention of workplace exposure in reducing adult asthma in NYS.

The effect of message type on physician compliance with disease reporting requirements.

OBJECTIVE: Despite the existence of mandatory reporting laws, the underreporting of disease conditions to public health authorities is widespread. This article describes an evaluation of the effects of using different appeals to promote complete and timely reporting to the New York State Occupational Lung Disease Registry (NYS OLDR). METHODS: Three-hundred sixty-eight physicians who had not reported patients were randomly assigned to receive correspondence emphasizing either the legal obligation to report, the public health benefits of reporting, or both. Chi-square tests were used to determine if the proportion of physicians who subsequently reported patients differed by message group. Chi-square tests and the Kruskall Wallis rank sum test were used to test for differences in the completeness and timeliness of reports received from physicians in the three message groups. RESULTS: Physicians receiving correspondence describing the legal obligation to report were more likely to report patients than those receiving only the benefit message, while those receiving correspondence describing the public health benefits of reporting submitted more complete reports than those receiving only the obligation message. CONCLUSIONS: To maximize physician reporting, it is important for public health agencies to emphasize both the legal and public health basis for reporting conditions in correspondence to physicians.

The NIOSH Fatality Assessment and Control Evaluation (FACE) program: a New York case study illustrating the impact of a farm manure pump PTO entanglement.

The New York Fatality Assessment and Control Evaluation (FACE) program is designed to identify and study fatal occupational injuries in New York State. The New York FACE program is supported by the National Institute for Occupational Safety and Health (NIOSH) and administered by the New York State Department of Health (NYS DOH) in cooperation with Cornell University. New York FACE investigators evaluate information from multiple sources, conduct objective on-site investigations, and then summarize their findings in narrative reports that include recommendations for preventing similar events in the future. These recommendations are distributed to employers, workers, and other organizations as an educational tool for promoting workplace safety. The following case study involved a 53-year-old dairy farm owner who was fatally injured while transferring manure from an underground storage pit to a manure lagoon. At the time of the incident, the farmer was utilizing a manure pump that was connected to a tractor via a power take-off (PTO) shaft. The farmer reached across the unshielded PTO shaft in order to operate a hand crank that adjusted the manure pump chute. As he did this, his clothing became entangled in the PTO shaft, wrapping the farmer's body around the shaft. New York FACE investigators concluded that to help prevent similar incidents from occurring in the future: PTO-powered equipment should not be operated unless the PTO shield is in place and in good condition; Power to equipment should be turned off prior to making mechanical adjustments; Manure handling systems should be designed to facilitate operator safety; Farm workers should be healthy and well rested prior to performing hazardous activities and; Dairy farm workers should be trained in manure handling safety and knowledgeable about other manure hazards.