This document summarizes a presentation on data-driven trends related to prescription drug abuse. It outlines national trends in doctor shopping, overdoses, drugged driving, and opioid/heroin overdose deaths. It also evaluates the effectiveness of some state laws and programs aimed at reducing doctor shopping and responding to overdoses. Some promising policy strategies discussed include reducing inappropriate prescribing, focusing on overdose response, improving prescription drug monitoring programs, and linking overdose victims to treatment.

1. Trending Topics Track:
Data-Driven Trends
Presenters:
• John Carnevale, Carnevale Associates, LLC
• Sherry L. Green, Sherry L. Green &
Associates, LLC
• Denise Paone, New York City Department of
Health and Mental Hygiene
• Ellenie Tuazon, New York City Department of
Health and Mental Hygiene
Moderator: Nancy Hale, Operation UNITE

2. Disclosures
• John T. Carnevale, PhD; Sherry L. Green, JD; Denise
Paone, EdD; Ellenie Tuazon, MPH; and Nancy Hale
have disclosed no relevant, real, or apparent
personal or professional financial relationships with
proprietary entities that produce health care goods
and services.

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– Kelly Clark – Employment: Publicis Touchpoint Solutions;
Consultant: Grunenthal US
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center
– Carla Saunders – Speaker’s bureau: Abbott Nutrition

4. Learning Objectives
1. Chart national trends in the Rx drug diversion
method known as doctor shopping.
2. Evaluate the effectiveness of state laws, policies
and programs targeted to reduce doctor
shopping.
3. Describe a data-driven, collaborative approach
that has reduced overdose deaths in NYC.
4. Outline the technical assistance manual that
jurisdictions may use to replicate the NYC RxStat
initiative.

5. Prescription Drug Abuse Data Trends
and Policy/Program Responses
Presentation to the National Rx Drug Abuse Summit
April 7, 2015
John T. Carnevale, Ph.D.
President, Carnevale Associates, LLC
John@carnevaleassociates.com
www.carnevaleassociates.com

6. John T. Carnevale, Ph.D., has disclosed no relevant, real or
apparent personal or professional financial relationships
with proprietary entities that produce health care goods
And services.

7. Today’s National Drug Problem
• U.S. Federal drug control policy targets illicit drug use, illegal drug use
(underage use of alcohol and tobacco), non-medical use of prescription drugs,
and synthetic drugs.
– In 2013, an estimated 24.6 million Americans aged 12 or older were current (past
month) illicit drug users—this represents 9.4 percent of the population aged 12 or
older. Marijuana remains the most commonly used illicit drug, with 19.8 million
users.
• Non-medical use of prescription drugs is the second largest category of drugs
abused 6.5 million or 2.5 percent were nonmedical users of prescription drugs
(the number in 2013 is similar to the number of users in 2002 to 2012 (ranging
from 6.1 million to 7.1 million).
• Attention is now focused on the (re)emergence of heroin, which appears to be
increasing in use (particularly in the Northeast) because it is a relatively
cheaper and more plentiful alternative to pain medication—we are entering
what may be described as an opioid epidemic.
[7]
Source: SAMHSA, National Survey on Drug Use and Health, 2014.

8. Illicit Drug Use, 2013
24,573
19,810
1,549
289
1,333
6,484
0 5,000 10,000 15,000 20,000 25,000 30,000
Illicit Drugs
Marijuana
Cocaine
Heroin
Hallucinogens
Prescription Drugs
Number of Users in Thousands, 2013
[8]
Source: SAMHSA, National Survey on Drug Use and Health, 2014.

9. Prescription Drug Abuse Remains a Major Problem: It
Remains Second Behind Marijuana Use
[9]
0.3
0.5
1.3
1.5
6.5
19.8
24.6
0 5 10 15 20 25 30
Heroin
Inhalants
Hallucinogens
Cocaine
Psychotheraputics
Marijuana
Illicit Drugs
(Millions of Past Month Illicit Drug Use Among Persons Aged 12 or Older: 2013)
Source: SAMHSA, National Survey on Drug Use and Health, 2014.

10. Pain Relievers Used the Most: 4.5 Million of the
6.5 Million Prescription Drug Abusers Use Pain Meds
[10]
Source: SAMHSA, National Survey on Drug Use and Health, 2014.

11. Past Year Initiates of Specific Illicit Drugs: 2013
[11]
169
601
603
1,180
1,539
2,427
0 500 1,000 1,500 2,000 2,500 3,000
Heroin
Cocaine
Stimulants
Tranquilizers
Pain Relievers
Marijuana
(Numbers in Thousands)
Source: SAMHSA, National Survey on Drug Use and Health, 2014.

12. Pain Reliever Initiation is Declining
[12]
Source: SAMHSA, National Survey on Drug Use and Health, 2014.
0
500
1000
1500
2000
2500
3000
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
NumbersinThousands
2,456
2,193
1,539

13. Overdoses and ER visits Remain a Significant
Consequence of Prescription Drug Abuse
[13]
• Drug overdose was the leading cause of injury-related death in 2013 –
more than motor vehicle crashes.1
 Drug overdoses: 38,851
 Motor vehicle crashes: 33,804
• The drug overdose death rate more than doubled from 1999 through
2013.2
• In 2011, more than 1.4 million emergency visits were related to
pharmaceuticals compared to 1.2 million visits for illicit drugs.3
Sources:
1. Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS) [online].
(2014)
2. Centers for Disease Control and Prevention. National Vital Statistics System mortality data.
3. Substance Abuse and Mental Health Services Administration. Highlights of the 2011 Drug Abuse Warning Network (DAWN)
findings on drug-related emergency department visits. The DAWN Report. Rockville, MD: US Department of Health and Human
Services, Substance Abuse and Mental Health Services Administration; 2013 and CDC National Hospital Ambulatory Medical
Care Survey: 2011 Emergency Department Summary Tables

14. Drugged Driving is Increasing and
Prescription Drug Use is a Factor
[14]
• NHTSA recently completed (2014) the National Roadside
Survey (NRS) for the first time since 2007.1
• The NRS found:
 About 20.0% of drivers tested positive for at least one drug in
2014, up from 16.3% in 2007.
 Presence of Rx drugs for weekend drivers was 4.9% in 2014, up
from 3.9% in 2007.
 Some 12.6% of drivers had evidence of marijuana use in their
systems, up from 8.6% in 2007.
Source: Results of the 2013–2014 National Roadside Survey of Alcohol and Drug Use by Drivers NHTSA’s Office of Behavioral Safety
Research Berning, Compton, and Wochinger.
1. Note: The NRS was conducted during 2013 and 2014 at a representative sample of 300 locations across the country. More than 9,000
drivers participated in the voluntary and anonymous survey. This was the fifth such survey on driver alcohol use conducted since 1973.
This is the second such survey (last was in 2007) that has collected information on the use of drugs that could affect driving, including both
illegal and legal drugs.

15. Opioid Poisoning Deaths Remain High, But Are Stabilizing;
Heroin Poisoning Deaths are Increasing (39% increase in 2013)
Source: CDC/NCHS, National Vital Statistics System, Mortality File.
Note: Deaths are classified using the International Classification of Diseases, Tenth Revision (ICD–10). Approximately
25% of drug-poisoning deaths lack information on the specific drugs involved. Some of these deaths may have involved
heroin, opioid analgesics, or both.
NumbersInThousands
Number of drug-poisoning deaths involving opioid analgesics and heroin
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
50,000
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
All Opioid Analgesics Heroin

16. Where do Rx Drug Abusers Get Their drugs?
The data say they get them from friends
16
Source: SAMHSA, NSDUH 2014
Note: Totals may not sum to 100% because of rounding or because suppressed estimates.
The Other category includes the sources: “Wrote Fake Prescription,” “Stole from Doctor’s
Office/Clinic/Hospital/Pharmacy,” and “Some Other Way.”

17. Media/Communication
– Social marketing campaigns
– Pharmacy and “point of sale” advertising campaigns
– Media advocacy campaigns
– General public education and information dissemination
Enforcement
– Enforcement of prescriber and pain clinic laws
– Tip and Reward Programs
– Law Enforcement Training
– Drug testing
Institutional Practices
– Prescriber education
– Patient education and brief interventions
– Pain Management/Pain Clinic standards and best practices
– Electronic health records initiatives
– Protocols for pharmaceutical care at hospital discharge
– Online Rx management accounts
Policy Options for Rx Drug Abuse: A
Sampling of Numerous Strategies
Regulations/Laws
– Prescription Drug Monitoring Program (PMPs)
– Drug manufacturer requirements regarding prescriber
education
– Patient review and restriction programs
– Physical exam prior to prescribing laws
– Requiring proper identification before dispensation
– Model pain clinic regulations
– Restricted internet access to Rx Drugs
– Doctor shopping laws
– Rx limits of sale
– Prescriber requirements to regularly see patients using
controlled substances
– Advertising restrictions for scheduled drugs
– Naloxone access
– DEA guidelines for communicating controlled substances Rx
to pharmacies
– DEA prescriber licensing requirements
– Parental liability laws
Structural
– “Take-Back” Locations (including disposals and drop boxes)
– Altering the physical environment
– Abuse-Deterrent Formulation and packaging of medications

18. Are the Policy Strategies Effective:
Evidence is Generally Spotty
• Rates of Dr. Shopping are declining since 2008, although the cause of this decline is
not statistically determined. 1
• Two studies have demonstrated the effectiveness of PMPs and best practices:
– Simeone and Holland (2006): found that PDMPs reduce the per capita supply of prescription pain
relievers and stimulants and in so doing reduce the probability of abuse for these drugs. It was the
first study to show that states which are proactive in their approach to regulation are more effective
in reducing the per capita supply of prescription pain relievers and stimulants than states which are
reactive in their approach to regulation.
– Brandeis Center of Excellence (2012): found that states with PMPs were less likely to experience
diversion; states with “proactive” PMPs had less availability of pain relievers compared to states that
were not proactive.
• A 2011 Carnevale Associates, LLC study analyzed prescription drug Take-Back
Programs and found:
– No evidence to date suggesting that take-back programs are effective in limiting access to
prescription drugs by those who are at the heart of the epidemic.
– Research is needed to determine whether take-back programs achieve environmental or substance
abuse outcomes.
– Limited data strongly indicate that ongoing bin-based (ongoing drop-off) programs appear to be the
most cost efficient; event-based programs and mailbacks are costly.
• Research is needed about the effectiveness of other public policy options.
1. Doctor Shopping Behavior and the Diversion of Opioid Analgesics: 2008-2012. Ron Simeone, Simeone Associates, Inc. and
IMS Government Solutions. August 14, 2014

19. The Current Policy Debate: Are Pain Medication
Abusers are Switching to Heroin?
• The past year heroin
incidence rate was 19
times higher among
those who reported
prior nonmedical pain
reliever use than among
those who did not.1
• Data on heroin initiation
rates do not (yet?)
reflect a large switching
effect.
0
500
1000
1500
2000
2500
3000
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Pain Relievers Heroin
NumbersInThousands
1. Based on pooled 2002-2011 NSDUH Data. Associations of Nonmedical Pain Reliever
Use and Initiation of Heroin Use in the United States Pradip K. Muhuri, Joseph C.
Gfroerer, M. Christine Davies
Initiation of Heroin Use and
Nonmedical Use of Pain Relievers
Source: SAMHSA, NSDUH 2014

20. 2023
John T. Carnevale, Ph.D.
President, Carnevale Associates, LLC
John@carnevaleassociates.com
www.carnevaleassociates.com

21. Data Driven Trends
A Closer Look at Selected Policies/Programs
Sherry L. Green
CEO and Manager
Sherry L. Green & Associates, LLC
National Rx Drug Abuse Summit
April 7, 2015
Atlanta, Georgia

22. Sherry L. Green, J.D., has disclosed no relevant, real or
apparent personal or professional financial relationships
with proprietary entities that produce health care goods
and services.

23. Learning Objectives
1. Chart national trends in the Rx drug diversion
method known as doctor shopping, overdoses,
drugged driving, opioid and heroin overdose
deaths.
2. Evaluate the effectiveness of and describe state
laws, policies and programs targeted to reduce
doctor shopping and respond to overdoses.

24. Data on State Policy and Systems-Level Interventions
on Prescription Drug Overdose*
 Limited and inconsistent
 Critical need to improve evidence base, BUT. . .
* Haegerich, T.M., et al., What we know, and don’t know, about the impact of state policy
and systems-level interventions on prescription drug overdose. Drug Alcohol Depend.
(2014), http://dx.doi.org/10.1016/j.drugalcdep.2014.10.001

25. Promising Strategies
 Reduce inappropriate prescribing
 Reduce use of multiple prescribers
 Focus on overdose response

26. Prescribing Practices
 More informed prescribing
 More appropriate prescribing
 Changes in types and amounts of drugs prescribed

27.  Make state Prescription Drug Monitoring Program (PMP)
data more actionable
 Timely, efficient access within electronic health record
at time of treatment decisions
 Provide proactive alerts and analysis tools for PMP data

28.  Provide easily understood and applied risk assessment tools
 Screening, Brief Intervention and Referral to Treatment
(SBIRT)
 Develop clinical indicators for drug and alcohol abuse
 Request medication by name
 Multiple visits for some complaints

29.  Train on alternatives to controlled substances for pain
management
 Educate on diagnosing signs and symptoms of abuse
and addiction
 Create awareness of available services for addiction
treatment, pain management, mental health

30.  Implement clinical guidelines
 Adopt pain clinic legislation

31. Overdose Death Prevention
 Save people from dying
 Opportunity to treat their addiction

32.  Allow first responders, families, friends and appropriate
others to possess and administer Naloxone
 Co-prescribe Naloxone when prescribe opioids
 Adopt “Good Samaritan” protections for summoning
aid
 Eliminate fear of arrest and prosecution

33. Linkages to Treatment
 Stop continued abuse and addiction
 Stop social and economic consequences of abuse and
addiction
 Provide addict access to treatment with proper intensity
and length of stay

34.  ERs – prioritize assessment for overdose victims; involuntary
commitments
 Drug Courts
 Pre-trial diversion – prioritize diversion shortly after arrest
 Employee assistance programs (EAPs)

35.  Student assistance programs (SAPs)
 At-risk youth programs

36. Treatment
 Provide full continuum of evidence-based treatment
services
 Diversify funding
 Appropriations
 Medicaid, insurance

37. CONTACT INFORMATION
Sherry L. Green
CEO and Manager
Sherry L. Green & Associates, LLC
P.O. Box 2530
Santa Fe, NM 87504
sgreen586@gmail.com
505-692-0457 (cell)

38. RxSummit: Data-Driven Trends
Denise Paone, EdD
Ellenie Tuazon, MPH
New York City Department of Health and Mental
Hygiene

39. Disclosures
• Denise Paone has disclosed no relevant, real,
or apparent personal or professional financial
relationships with proprietary entities that
produce health care goods and services.
• Ellenie Tuazon has disclosed no relevant, real,
or apparent personal or professional financial
relationships with proprietary entities that
produce health care goods and services

40. Learning objectives
• Outline the technical assistance manual that
jurisdictions may use to replicate the NYC
RxStat initiative
• Describe a data-driven, collaborative approach
that has reduced overdose deaths in NYC

41. Outline
• Principles of RxStat
• Data sources
• Success of multi-pronged approach in Staten
Island
• Overdose prevention: naloxone
• Summary

42. PRINCIPLES OF RXSTAT

43. RxStat: Central focus and unifying
goal
Reduce
Overdose
Deaths

44. RxStat
• Public health & public safety collaboration
– Housed at NYC Department of Health & Mental
Hygiene (DOHMH); leverages expertise and
infrastructure
• “Real-time” (enhanced) surveillance
• Participants and stakeholders at city, state,
and federal organizations
• Monthly RxStat data meetings
• Received funding from two BJA grants in 2013
and 2014 + ONDCP supplemental funds

45. RxStat: Core principles
• Public health approach
– Track drug use and associated health consequences at a
population level
• Timely, accurate analysis of drug misuse indicators
from multiple sources (e.g., mortality, EDs, PMP,
drug treatment, law enforcement, etc.)
• Data-driven initiatives
• Rapid deployment of public health and public
safety resources to high priority areas
• Rigorous follow-up to ensure strategies are
effective

46. Common goal, different approaches
Public health Public safety
Population level Individual case level
Analysis of risk factors Identification of risky individuals
Demand-side behavior modification Supply-side behavior modification

47. Diverse approaches to existing data:
Prescription drug monitoring
• Prevention of problem drug use
• Address population level factors
that increase risk of overdose
PMP as a public health tool PMP as a law enforcement tool
• Prevention of drug-related crime
• Address individuals who
facilitate or participate in illegal
drug distribution
Policy Responses
• Opioid analgesic judicious
prescribing guidelines
• Staten Island public health
detailing campaign
• Focus on aberrant prescribers
and street distributors
Policy Responses

48. Technical Assistance manual
• Reviews key elements of RxStat
– Basics
– Getting started
– Building content (data, resources)
– Managing process
– Moving forward
• Details each of the RxStat datasets, including
analytic code
• Available to download:
http://www.pdmpassist.org/pdf/RxStat.pdf

49. DATA SOURCES

50. Data Sources
Reduce
Overdose
Deaths
PMP
Data
Treatment
Admissions
Poison
Control
Drug
Prosecutions
Hospitalizations
Jail
Data
Mortality
DEA
ARCOS
Pharmacy
Crime
Price/Purity
Qualitative
Research
Medicaid
Fraud Data
Syndromic
Mortality
PMP
Data

51. PHARMACY CRIMES

52. Pharmacy crimes data: Rx Crimes
• To track, investigate, and report on robberies
and burglaries of doctors’ offices and
pharmacies targeting CPDs
• Since Rx Crimes launched in 2012
– 550,000 pills reported stolen in NY and NJ
• 76% Painkillers
– Not a significant source of supply for illegal pill
market

53. MORTALITY

54. Real-time mortality
• NYC receives mortality data monthly and
reports data quarterly
• Prior to 2013 data was received annually and
reported with a 1.5 year lag
• NYC published preliminary 2013 mortality
data in July 2014
– Time lag for the CDC is currently > 1 year

55. 638
792
723
769
722
796
838
695
618 593
541
630
730
788
10.2
12.2
11.5
12.2
11.5
12.5
13.3
10.9
9.6
9.1
8.2
9.4
10.9
11.6
0
2
4
6
8
10
12
14
0
100
200
300
400
500
600
700
800
900
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Age-adjustedmortalityrateper100,000
Number
Year
Number of unintentional opioid analgesic poisoning deaths Age-adjusted rate per 100,000
Unintentional drug poisoning deaths, NYC,
2000–2013
Source: New York City Office of the Chief Medical Examiner &
New York City Department of Health and Mental Hygiene 2000-2013

56. Rate of unintentional drug poisoning deaths by
drug type, NYC 2000–2013
(Drugs not mutually exclusive)
Source: New York City Office of the Chief Medical Examiner &
New York City Department of Health and Mental Hygiene 2000-2013
0
1
2
3
4
5
6
7
8
9
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Age-AdjustedRateper100,000
Year
Heroin
Cocaine
Methadone
Benzodiazepines
Opioid Analgesics

57. Rate of unintentional drug poisoning deaths by
borough of residence
0
5
10
15
20
25
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Age-AdjustedRateper100,000
Year
Staten Island
Bronx
Manhattan
Brooklyn
Queens
Source: New York City Office of the Chief Medical Examiner &
New York City Department of Health and Mental Hygiene 2000-2013

58. Unintentional drug poisoning deaths by
neighborhood (UHF 42) of residence, NYC
2012 & 2013
Source: NYC Office of the Chief Medical Examiner and NYC
DOHMH Bureau of Vital Statistics, 2012 and 2013

59. PRESCRIPTION MONITORING
PROGRAM

60. PMP for public health surveillance
• To understand population level prescription
use trends over time
– Historically, used as law enforcement tool
– NYC DOHMH developed key indicators to evaluate
data using the PMP
• To inform data-driven initiatives

61. Key public health PMP indicators
• Number of prescriptions, patients, prescriber,
pharmacies
• Rate of opioid analgesic prescriptions filled
overall and by drug type
• Median day supply
• Rate of patients filling opioid analgesic
prescriptions
• Rate of high dose opioid analgesic prescriptions
filled

62. 15% of prescribers wrote 83% of
opioid analgesic prescriptions
48%
2%
37%
15%
14%
49%
1%
34%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Prescribers Prescriptions
Prescribing frequency
Very Frequent
Prescribers
530-10,185 Rx/year
Frequent
Prescribers
50-529 Rx/year
Occasional
Prescribers
4-49 Rx/year
Rare Prescribers
1-3 Rx/year
Prescriptions filled by NYC residents, 2012
15%
83%
Percent
Source: New York State Department of Health, Bureau of Narcotic
Enforcement, Prescription Drug Monitoring Program, 2012 62
Note: Schedule II
opioid analgesics

63. Two-thirds of patients filled only one prescription;
one-third filled 78% of all opioid analgesic
prescriptions
63%
22%
14%
9%
5%
6%
8%
14%
10%
49%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Patients Prescriptions
Prescription Frequency
15 prescriptions
5 prescriptions
3 prescriptions
2 prescriptions
1 prescription
Prescriptions filled by NYC residents, 2012
Percent
Source: New York State Department of Health, Bureau of Narcotic
Enforcement, Prescription Drug Monitoring Program, 2012 63
37%
78%
Note: Schedule II opioid
analgesics

64. Patients visiting multiple prescriber and
multiple pharmacies are rare
• In 2012, 1.2% (9,137) of patients visited 4+
prescribers and 4+ pharmacies
– Filled 7.9% (170,282) of all prescriptions
– Visited 15,042 unique prescribers
– Visited 2,913 unique pharmacies
Source: New York State Department of Health, Bureau of Narcotic Enforcement, Prescription Drug Monitoring Program, 2012

65. Oxycodone filled more than hydrocodone
0
50
100
150
200
250
300
350
400
450
500
NYC Bronx Brooklyn Manhattan Queens Staten Island
Age-adjustedrateofprescriptionsfilled
per1,000residents
Borough of Residence
2013 Opioid Analgesics
2013 Oxycodone
2013 Hydrocodone
Source: New York State Department of Health, Bureau of Narcotic
Enforcement, Prescription Drug Monitoring Program, 2013
Note: Schedule II opioid analgesics
Rates are adjusted to 2000 US Standard population

66. Median day supply varies across New York City
0
5
10
15
20
25
30
NYC Bronx Brooklyn Manhattan Queens Staten
Island
MedianSupply,Days
Borough of Residence
Source: New York State Department of Health, Bureau of Narcotic
Enforcement, Prescription Drug Monitoring Program, 2013
Note: Schedule II opioid analgesics
Median day supply is calculated from day supply of each prescription filled in the year.

67. Staten Island residents fill more high dose opioid
analgesic prescriptions
0
20
40
60
80
100
120
140
NYC Bronx Brooklyn Manhattan Queens Staten Island
Rateofprescriptionsfilledper1,000
residents
Borough of Residence
Note: Schedule II opioid analgesics +
hydrocodone
High dose is any opioid analgesic prescription with a calculated morphine
equivalent dose (MED) greater than 100. Among patients receiving opioid
prescriptions, overdose rates increase with increasing doses of prescribed opioids.
Source: New York State Department of Health, Bureau of Narcotic
Enforcement, Prescription Drug Monitoring Program, 2013
Rates are adjusted to 2000 US Standard population

68. QUALITATIVE COMPONENT

69. Objectives of qualitative research
• In-depth understanding
• Focus on behaviors and practices
• Adds context
• Utilizes interviews and observational
techniques

70. Specific aims
• Focus on three key areas:
- Circumstances of opioid analgesic (OA)
initiation
- Trajectory of use (including transitions to
heroin)
- Mechanisms of diversion from medical to non-
medical use

71. Enhancing surveillance using
qualitative methods
• Opioid study – three key aims:
- Circumstances of opioid analgesic (OA)
initiation
- Trajectory of use (including transitions to heroin)
- Mechanisms of diversion from medical to non-
medical use
• Three-phase study included focus groups (n=5)
and in-depth interviews (n=110)
• Currently analyzing data and writing up findings

72. Key findings from qualitative research
• Identified heterogeneous groups of opioid
initiates
– Recreational
– Medical
– Experienced opioid users
• Levels of prescribing oversight exist on a
continuum
aberrant → loose → routine → judicious
• Participants who transitioned to heroin were
entrenched OA users
– Many new heroin initiates were not in touch with
harm reduction services

73. Elements of multipronged data
approach
• Timely data collection
• Public health population level approach to
data analysis
• Qualitative data adds nuance to interpretation
of quantitative data

74. Summary
• Public health/public safety collaborations can
work well
• Continuing data access difficulties despite
collective buy-in
– PMP
– Treatment data
• Real-time data presents new challenges for
response

75. DATA DRIVEN APPROACHES: STATEN
ISLAND 2011–2013

76. Neighborhoods with high rates of OA prescriptions
have high rates of unintentional (overdose) deaths
involving opioid analgesics
*Paone D, Bradley O’Brien D, Shah S, Heller D. Opioid analgesics in New York City: misuse, morbidity and mortality update. Epi Data
Brief. April 2011. Available at http://www.nyc.gov/html/doh/downloads/pdf/epi/epi-data-brief.pdf .
OA PRESCRIPTION RATES OA MORTALITY RATES

77. Data-driven initiatives
Reduce
Overdose
Deaths
MAT
Access
Emergency
Action
Plan
Naloxone
Access
Staten
Island
Detailing
Overdose
Prevention
Programs
Opioid
Prescribing
Guidelines
Media
Campaigns

78. Opioid prescribing guidelines
• Less often: avoid prescribing opioids for
chronic non-cancer, non-end-of-life pain
 e.g., low back pain, arthritis, headache,
fibromyalgia
• Shorter duration: when opioids are
warranted for acute pain, 3-day supply
usually sufficient
• Lower doses: if dosing reaches 100
Morphine Milligram Equivalents (MME) ,
reassess and reconsider other
approaches to pain management
• Avoid whenever possible prescribing
opioids in patients taking
benzodiazepines
Citation: Paone D, Dowell D, Heller D. Preventing misuse of prescription opioid drugs. City Health Information. 2011; 30(4): 23-30
New York City Opioid Treatment Guidelines, Clinical Advisors: Nancy Chang, MD; Marc N. Gourevitch, MD, MPH; Mark P. Jarrett,
MD, MBA; Andrew Kolodny, MD; Lewis Nelson, MD; Russell K. Portenoy, MD; Jack Resnick, MD; Stephen Ross, MD; Joanna L. Starrels,
MD, MS; David L. Stevens, MD; Anne Marie Stilwell, MD; Theodore Strange; MD, FACP; Homer Venters, MD, MS

79. New York City Emergency Department Discharge Opioid Prescribing Guidelines Clinical Advisory Group: Jason Chu,
MD, Brenna Farmer, MD, Beth Y. Ginsburg, MD, Stephanie H. Hernandez, MD, James F. Kenny, MD, MBA, FACEP,
Nima Majlesi, DO, Ruben Olmedo, MD, Dean Olsen, DO, James G. Ryan, MD, Bonnie Simmons, DO, Mark Su, MD,
Michael Touger, MD, Sage W. Wiener, MD.
Emergency Department guidelines
Released
January, 2013
Adopted by 38
NYC
emergency
departments

80. Staten Island public health
“Detailing” campaign
• 1-on-1 “detailing” visits from
Health Department representatives
• Deliver key prescribing
recommendations, clinical tools,
patient education materials
• ~1,000 Staten Island physicians,
nurse practitioners, physicians
assistants
• June–August 2013

82. Morphine Milligram Equivalent (MME)
calculator
• A tool to calculate total MME per day
• Gives alert for dosages >100 MME
• Quick and easy to use
• Web-based application
– Search for “NYC MME Calculator”
http://www.nyc.gov/html/doh/html/mental/MME.html
• Smartphone app

83. Media campaigns
• Campaign One:
– Goal: Increase awareness of risk of opioid analgesic overdose
– Ran twice (2012, 2013)
• Campaign Two:
– Goal: Reduce stigma and raise awareness of opioid analgesic
misuse
– 2 testimonials
• Mom lost son to opioid analgesic overdose
• NYC resident in recovery
– Ran 2013 and 2014

84. Staten Island opioid-analgesic poisoning mortality
decreased 29% from 2011 to 2013
0.0
2.0
4.0
6.0
8.0
10.0
12.0
2007
December
2008
December
2009
December
2010
December
2011
December
2012
December
2013
December
Age-AdjustedRateper100,000
Staten Island All other boroughs
1
2 3 4
5
6
7
8
91. May 2011: EDB: Staten Island mortality and PMP analyses highlighted
2. November 2011: CHI: opioid prescribing guidelines
3. August 2012: I-STOP passed
4. Late 2012 and 2013: media campaign 1
5. January 2013: ED opioid prescribing guidelines
6. June 2013: NYC COH Staten Island town hall
7. June-August 2013: Staten Island detailing campaign
8. August 2013: I-STOP in effect
9. Late 2013 and 2014: media campaign 2
Source: New York City Office of the Chief Medical Examiner &
New York City Department of Health and Mental Hygiene 2000-2013

85. Rates of high dose prescriptions filled decreased
in Staten Island by 9%
0
20
40
60
80
100
120
140
160
NYC Bronx Brooklyn Manhattan Queens Staten Island
Rateofprescriptionsfilledper1,000
residents
Borough of Residence
2012 2013
Note: Schedule II opioid analgesics +
hydrocodone
High dose is any opioid analgesic prescription with a
calculated morphine equivalent dose (MED) greater than 100.
Among patients receiving opioid prescriptions, overdose rates
increase with increasing doses of prescribed opioids.
Source: New York State Department of Health, Bureau of Narcotic
Enforcement, Prescription Drug Monitoring Program, 2012 and 2013
Rates are adjusted to 2000 US Standard population

86. OVERDOSE (OD) PREVENTION:
NALOXONE

87. Overdose education and naloxone
distribution
• 2006: New York State law enables lay people to train
to respond to an overdose and administer naloxone
• 2011: New York State Good Samaritan Law
• 2014: Standing order legislation:
– Allow for individuals other than MDs, PAs, and
NPs to dispense a medication requiring a
prescription
• 61 registered overdose prevention programs in NYC

88. Intranasal naloxone kits were dispensed by different types
of Opioid Overdose Prevention Programs
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
2009
(Jul-Dec)
2010 2011 2012 2013 2014
(Jan-Jun)
NumberofINkitsdispensed
Other
Drug Treatment
SEP
n=17,295
Year of naloxone dispensing

89. Naloxone distribution in NYC
• NYC Department of Homeless Services (DHS)
– More than half DHS Peace Officers are trained and
carry naloxone in all city shelters
• NYC Department of Corrections
– Rikers Island Visit House
• NYPD
– NYPD officers trained to carry and dispense naloxone
– Started as pilot in response to high opioid overdose
rates in Staten Island

90. Summary
• Opioid overdose deaths are preventable
• RxStat is a collaboration between NYC public health
and public safety toward one unifying goal: Reduce
overdose deaths in NYC
• Population level approach addresses overall risk
factors
– Doctor shopping is a rare event
– Important to use PMP metrics that can be applied across a
jurisdiction
• Multi-pronged data driven approaches have
demonstrated success
– Measurable and replicable

91. Trending Topics Track:
Data-Driven Trends
Presenters:
• John Carnevale, Carnevale Associates, LLC
• Sherry L. Green, Sherry L. Green &
Associates, LLC
• Denise Paone, New York City Department of
Health and Mental Hygiene
• Ellenie Tuazon, New York City Department of
Health and Mental Hygiene
Moderator: Nancy Hale, Operation UNITE