To: Bill de Blasio
From: Erika Kissick, PA-S
Date: January 20, 2018
Title: Opioid Crisis: Interventions to Address the NYC Opioid Overdose Epidemic
Statement of Issue: Statistics indicate that opioids-often used as pain relief like hydrocodone, oxycodone, fentanyl, morphine, heroin, and opium-have thrown NYC in the midst of an addiction crisis (NY Dept. of Health, pg. 6). An estimated 80% of drug overdoses in New York City involved an opioid in 2016 (NYC Health Dept, pg. 10). Both prescription and illicitly attained opioids contribute to this epidemic but “street” use of the most powerful opioids, like fentanyl, are increasing in prevalence. Statistics show that although prescription opioids do make up some proportion of overdose at 18%, over 90% of fatal 2016 overdoses involve more than one opioid substance—and usually includes either heroin or fentanyl in the New York City area (NYC Health Dept., pg. 10). Many users begin opioids by using prescribed medications in unintended ways. Fentanyl is a main culprit of fatality since 2015; fentanyl is often added to illegally manufactured “street” pills, or “cut” with cocaine and/or heroin and was involved in at least 50% of NYC overdoses in 2016 (NYC Health Dept., pg. 10). Some demographic groups are at higher risk than others. 78% of all opioid overdoses in NYC are male. Statistics indicate that misuse is widespread across racial demographics, opioid overdoses for white New Yorkers was at 43% in 2016, while black New Yorkers and Latinos at 31%. In fact, this epidemic also spans age groups with the following percentages/total overdose in the NYC area: 31% of 25-34 year olds, 21% of 35-44 year olds, 27% of 45-54 year olds, and 20% of 55-64 year olds.Better understanding of regulations and harm reduction policies is key to changing the current policies surrounding opioids.
• According to the CDC, where someone lives is a huge determinant for opioid prescription levels in the community. Policy should track locale and severity.
- Inconsistent provider prescription results in a variation of opioid use outcomes depending on provider type and amount; data suggests that areas with more dentists and PCPs prescribe more opioids than those without. Despite current regulations on opioid prescribing, three times as many prescription opioids were prescribed in 2015 than 1999 (CDC).
• Individuals with mental health issues, like previous substance abuse disorders, are at an increased risk of opioid overdose. Individuals with affected mental capacity are expected to respond effectively to the potential of drug abuse, despite the lack of mental health resources available addressing the origin of their mental health problems. These individuals may be using drugs as a means of self-treatment because necessary resources are not available to them in their communities. Additionally, it must be mentioned that intentional overdose as a means of suicide is at increased risk for these individuals.
• Lower SES is another contributing factor to opioid overdose. Areas with higher poverty rates have higher indication of opioid overdose. Addiction can worsen poverty. Fighting any addiction is difficult, and though treatment centers do exist that focus on this epidemic, they are often costly and inaccessible to those with lower SES statuses. Interestingly, unemployment and lack of insurance increases risk of addiction.
• Individuals with poorer health are at an increased risk of opioid overdose. Comorbid disease type affects opioid prescription levels. Chronic pain, diabetes, arthritis, or other disabilities were associated with higher than average numbers of opioid prescriptions.
Politics: Because treatment is so costly, financial conservative politicians may refuse to fund efforts fighting opioid addiction, especially since the origins of the epidemic are so convoluted. Additionally, lobbyists for pharmaceutical companies may resist changes in policy due to fear of decreased profits.
Social: This issue affects many demographics across the board, but is often met with a stigma attached to drug use. For example, some people may think, “Why waste money on someone that brought the disease to himself…no one forced him to try heroin”. Often, users are blamed entirely for the addiction without sympathy.
Economic: Any solution will be costly and will take time. Finding funds for better medical services in addition to other measures, must be widespread due to the fact that this issue encompasses many demographics.
Practical: Working alongside local and federal law enforcement agencies helps to address the legal issues facing this crisis. Especially important is the involvement of health care professionals, perhaps targeting dentists and PCPs since these professions were associated with higher than normal levels of opioid prescriptions. Other important healthcare personnel include ER and EMTs. Organizations like Narcotics Anonymous offer community resources for addicted individuals.
Legal: Laws aimed at providers should be offered and considered. Additionally, litigation protecting those in the presence of an overdose should be encouraged; other users may refuse to bring in a potential overdose due to fear of legal repercussions.
Quality-of-Care: Though Quality-of-Care is an issue in the opioid crisis, access to care should first be addressed. One cannot improve quality-of-care on a service that doesn’t exist. For instance, many use fentanyl unintentionally, a solution should offer some type of tracking method for healthcare providers, law enforcement, and even users to be aware of potential substance “cutting”. Lack of treatment options is a huge barrier that should be addressed in this issue.
Policy Options: #1
- The creation of a open sourced, anonymous database outlining current fentanyl and other powerful analogs with reports of nonfatal and fatal opioid overdoses within a specific geographic region for use of law enforcement, healthcare professionals, and users alike. This database should protect individuals from recognition (to avoid potential legal ramifications) but could help professionals identify problem locales while allowing users to avoid any areas with especially lethal “batches”. This database could be online and use existing structures, like Google Maps, to identify specific problem areas. This database should include every overdose type, both fatal and nonfatal as reported by local law and health authorities. Type of drug (i.e. heroin, MDMA, etc should be included if possible). This database should be available at both a local and national level and adjusted by population. Death confirmed by autopsy and type of opioid by locale when possible (either prescription vs illicit) Locale could be defined at first as a specific area, for example, a specific distance like a block per block basis. Law enforcement could also contribute by detailing seizure type of opioid confirmed by laboratory tests identifying at sites of both fatal and nonfatal overdoses. Healthcare professionals in Emergency Dept. and EMTs could add any findings while maintaining HIPAA, like the amount of naloxone used to treat the overdose, which is an indicator of the opioid strength. Areas could be sectioned off based on geographic location, for example, a specific city block as a parameter.
- Advantages: Increases community awareness for professionals and opioid users alike to track community trends and outline problem areas by a geographic region. This is relatively cheap way to encourage harm reduction by raising awareness of especially
fatal batches of drugs within an area. Rather than wholly focus on treatment of opioid
overdose due to these powerful analogs, raised awareness may reduce overdose
incidence through freely available information. This could also help to identify the issue
of opioid overdose varying with geography as it pertains to provider inconsistency; if
many of a provider’s same patients have higher levels of overdose within a specific
time frame and location, it may signify an issue at hand.
- Disadvantages: This would take additional time and effort of both legal and medical
professionals. Protecting patient information is essential, but could prove to be a barrier in
recording concise events. Funding could come from increased taxation, potentially from
existing revenue or funded through innovative means (perhaps through heavy taxation on
legalization of marijuana). It would be difficult to have direct comparisons for any two
overdose events due to so many variables like weight or “dealer”. Another big
disadvantage is that some drug users may use this database to seek out, rather than
avoid, areas of reportedly dangerous levels of opioids for a better “return on investment”.
Reporter bias could also make an area look better or worse, depending on how often data
is reported. Because it must protect patient information, other helpful demographics, like
sex and age, may not be available for use.
Policy Options: #2
Preventative interventions focusing on treating adolescents at risk for future substance
abuse and/or identified as having a mental disorder. Most substance abuse begins in
adolescence, so interventions (based on empirical data), should be established
addressing this critical stage of life. This policy should look to identify adolescents most at
risk for future drug use according to empirical research. Data suggest that those with
behavioral issues, other mental health disorders, or an abusive, or negligent home life are
most at risk and should be treated accordingly. Indicators could be arrests, indecent
inappropriate behavior as reported by teachers, sudden changes in grades or behavior,
extreme absences, and depression or anxiety are a few examples of possible indicators
for intervention. These interventions should teach appropriate coping mechanisms for
conflict resolution and foster healthy, secure social engagement, which are protective
measures against substance abuse with programs during school periods or even as an
alternative to legal ramifications, like jail time. This would possibly prevent incidence of
substance abuse, address the cognitive aspect of abuse, and serve as a counter to any
students with low SES.
Advantages: Rather than creating a database detailing trends in the crisis, this would aim
to prevent the crisis from occurring through targeting those at risk before abuse begins.
This option would be more expensive and would have much more logistical involvement
than the previous policy. All involved would have to be available at specific times during
the school week and would have to be approved through the school itself. If funding is an
issue, perhaps students in Master’s Psychology programs could serve as the initiators of
this program in exchange for a thesis or other educational credit. This policy empowers
the community and is the policy that could most impact an individual.
Disadvantages: Correlation between the program and substance abuse would be difficult
and costly to determine. It would also be difficult to assess “at risk” students uniformly
between schools. Schools would also inherently have different resources between them,
so comparison between systems may lack in validity. Who would be responsible for
following this student through time? Retention would be another challenge in this policy.
How would we know that the student is honest while reporting his or her information?
Policy Options: #3
•Identify those areas with the highest opioid prescription and providers of said
prescribed opioids in a region and send educators to both public and private healthcare
organizations for evaluation and education. This information could be attained from
pharmacies or governmental agencies/heath services. Of particular focus should be
dentists and PCPs, whom the CDC states have the highest levels of opioid prescriptions
nationwide. Encourage involvement in PDMPs to address the logistical issues. Educate
at-risk providers about appropriate guidelines: opioids should not be first-line use for pain
relief, if used, should be combined with other pain relief that is not an opioid, providers
should establish treatment goals and risks with patients, immediate release opioids should
be used over extended release starting with the lowest possible dose, in cases of acute
pain, opioids should only be given for 3-8 days (CDC).
Advantages: This policy targets the origin of initial opioid medications which is the
starting point for many in the addiction cycle. It improves patient Quality-of-Care by
preventing exposure to opioids, thus, decreasing risk. It uses a targeted approach and so
should save money. This also may receive a positive response from insurance companies,
who may not have to cover expensive opioid medications using alternative therapies
instead.
Disadvantages: It may prevent new patients from opioid exposure, but it will do little for
those already addicted. In fact, it could increase existing patients’ risk for illicit opioid use
by restricting legally prescribed opioids for pain relief. Also, there would be no
consequence for a provider to ignore the advice given, so it may not be as effective as
planned.
Policy Recommendation:
Data shows that opioid overdose, both from prescribed and illicit means, is on the rise in NYC. Unequal risk, influenced by demographics and other external factors, and the frightening rate of opioid overdose should serve as indicators of its severity. Despite the stigma associated with addiction, addiction is a disease and should be treated through a medical, not criminal, perspective. Individuals often have little control over the risk factors that perpetuate addiction, like poverty or mental health, in addition to a genetic propensity for addiction. NYC’s naloxone programs serve to prevent fatality, but fail to address the complicated origins of opioid addiction. All of the policies mentioned would incur costs and each has both positive and negative features. Policy #1 would be the most comprehensive option to address opioid overdose. It would involve all those affected in the community to best propose solutions. Implementing this policy would not be straight forwards, and would involve additional resources for establishing and tracking an alert system. It also operates under the assumption that all entities would use it as intended. Long term, it would keep track of geographic and fatality measures by drug identification from which to create effective solutions tailored to an area.
References
https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf
http://www1.nyc.gov/assets/home/downloads/pdf/reports/2017/HealingNYC-Report.pdf
http://www.who.int/substance_abuse/information-sheet/en/
http://www.nejm.org/doi/pdf/10.1056/NEJMp1615145
