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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 )

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) between correlates of interest and current naloxone possession. 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.

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.

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.

Background Past studies have identified frequent criminal legal system (CLS) involvement among overdose decedents and highlight the need for connecting individuals at risk of overdose with effective interventions during CLS encounters. While some programs divert individuals at risk of overdose to treatment during CLS encounters, eligibility is frequently restricted to those with limited prior CLS involvement. However, differences by race/ethnicity have not been examined. Objective We assessed racial disparities in CLS involvement and eligibility for diversion following arrest for misdemeanor drug possession among New York City (NYC) overdose decedents. Methods We matched death certificates for 5018 NYC residents who died of an unintentional drug overdose between 2008 and 2015 with CLS data and compared CLS involvement by race/ethnicity. We compared prior felony involvement at the first misdemeanor drug arrest by race/ethnicity among 2719 decedents with at least one misdemeanor drug arrest. Results Higher proportions of Black (86 %, 95 % CI: 83.9, 87.9) and Latino (84 %, 95 % CI: 82.2, 86.0) decedents had ever been arrested than White decedents (73 %, 95 % CI: 71.5, 75.2). At the first misdemeanor drug arrest, Black and Latino decedents were twice as likely as White decedents to have a prior felony conviction, adjusted for age at arrest and gender (RR = 2.08, 95 % CI: 1.71, 2.54 and 2.14, 95 % CI: 1.77, 2.59, respectively). Conclusions Given racial disparities in CLS involvement among NYC overdose decedents, diversion eligibility is inequitable by race/ethnicity. Diversion programs that restrict eligibility based on prior CLS involvement will have racially disparate effects.

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.

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.

Background In August 2010, extended-release OxyContin® products, including oxycodone 80 mg, were reformulated and released as abuse-deterrent medications. This paper describes changes in individual prescription filling patterns that followed the reformulation of oxycodone 80 mg. Methods Using New York State prescription monitoring program data, we conducted a retrospective analysis of a cohort of New York City residents who had filled at least three consecutive prescriptions for oxycodone 80 mg immediately prior to the reformulation. We classified cohort members into one of three groups (continuers, switchers, and discontinuers) based on prescription filling patterns post-reformulation. Descriptive analyses were conducted to identify prevalence of filling patterns. Differences in median morphine milligram equivalents (MME) pre- and post-reformulation were compared using the Wilcoxon signed-rank sum test. Analyses were completed in 2018. Results A cohort of 4,098 New York City residents filled continuous prescriptions for oxycodone 80 mg immediately prior to reformulation. Post-reformulation, 14% of the cohort discontinued filling opioid analgesic prescriptions; 46% continued to fill prescriptions for oxycodone 80 mg; and 40% switched to a different opioid analgesic, most commonly oxycodone 30 mg. Post-reformulation, the median MME dose decreased significantly among all three groups: 45 mg among continuers, 150 mg among switchers, and 360 mg among discontinuers. Conclusion Post-reformulation, more than half the cohort changed their filling patterns. Following reformulation, median MME dose decreased significantly among the cohort. We hypothesize that the dramatic decrease in MME dose prompted many to transition to heroin in order to avoid severe withdrawal.

This study evaluates racial differences in opioid overdose deaths in New York City for 2017.

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.

With the opioid overdose mortality rates rising nationally, The New York City Department of Health and Mental Hygiene (NYC DOHMH) has worked to expand overdose rescue training (ORT) and naloxone distribution. This study sought to determine rates of overdose witnessing and naloxone use among overdose rescue-trained visitors to the NYC jails on Rikers Island. We conducted a six-month prospective study of visitors to NYC jails on Rikers Island who received ORT. We collected baseline characteristics of study participants, characteristics of overdose events, and responses to witnessed overdose events, including whether the victim was the incarcerated individual the participant was visiting on the day of training. Bivariate analyses compared baseline characteristics of participants who witnessed overdoses to those who did not, and of participants who used naloxone to those who did not. Overall, we enrolled 283 participants visiting NYC's Rikers Island jails into the study. Six months after enrollment, we reached 226 participants for follow-up by phone. 40 participants witnessed 70 overdose events, and 28 participants reported using naloxone. Of the 70 overdose events, three victims were the incarcerated individuals visited on the day of training; nine additional victims were recently released from jail and/or prison. Visitors to persons incarcerated at Rikers Island witness overdose events and are able to perform overdose rescues with naloxone. This intervention reaches a population that includes not only those recently released, but also other people who experienced overdose.

Introduction: Recent increases in drug overdose deaths, both in New York City and nationally, highlight the need for timely data on psychoactive drug-related morbidity. We developed drug syndrome definitions for syndromic surveillance to monitor drug-related emergency department (ED) visits in real time. Materials and Methods: We used 2012 archived syndromic surveillance data from New York City hospitals to develop definitions for psychoactive drug-related syndromes. The dataset contained ED visit-level information that included patients’ chief complaints, dates of visits, ZIP codes of residence, discharge diagnoses, and dispositions. After manually reviewing chief complaints, we developed a classification scheme comprising 3 categories (overdose, drug mention, and drug abuse/misuse), which we used to define 25 psychoactive drug syndromes. From July 2013 through December 2015, the New York City Department of Health and Mental Hygiene performed daily syndromic surveillance of psychoactive drug-related ED visits using the 25 syndrome definitions. Results: Syndromic surveillance triggered 4 public health investigations, supported 8 other public health investigations that had been triggered by other mechanisms, and resulted in the identification of 5 psychoactive drug-related outbreaks. Syndromic surveillance also identified a substantial increase in synthetic cannabinoid-related visits (from an average of 3 per week in January 2014 to >300 per week in July 2015) and an increase in heroin overdose visits (from 80 to 171 in the first 3 quarters of 2012 and 2014, respectively) in a single neighborhood. Practice Implications: Syndromic surveillance using these novel definitions enabled monitoring of trends in psychoactive drug-related morbidity, initiation and support of public health investigations, and targeting of interventions. Health departments can refine these definitions for their jurisdictions using the described methods and integrate them into existing syndromic surveillance systems.

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.