SummaryA multiagency, cross-disciplinary initiative in New York City, the Mayor’s Task Force on Prescription Painkiller Abuse develops and supports implementation of a constellation of policies and programs to reduce misuse of opioid analgesics (i.e., use without a prescription or use with a prescription in a manner other than prescribed) and associated health and safety consequences. Major initiatives thus far include development of prescribing guidelines for emergency department providers, increased sharing and coordinated use of the large amount of data available across agencies, public education campaigns, efforts to increase access to naloxone (a medication that can reverse an opioid overdose), and support for enhancements to the State’s prescription monitoring program. While it is too soon to know if the existing initiatives have reduced opioid analgesic misuse and its associated consequences, to date the effort has prompted many public and private hospital emergency departments to adopt recommended prescribing guidelines, and a preliminary analysis from the New York City Health and Hospitals Corporation's 11 emergency departments demonstrates a nearly 20-percent reduction in the rate of opioid analgesic prescribing after implementation of a series of strategies that included the emergency department guidelines.Suggestive: The evidence consists of post-implementation data on the number of hospital emergency departments adopting the opioid analgesic prescribing guidelines, along with preliminary trends in emergency department opioid prescriptions and anecdotal reports from providers about the value of the guidelines and related materials.
Developing OrganizationsOffice of the Mayor of New York City
An initiative of the Office of the Mayor of New York City, the task force functions as a collaboration of various agencies. More details can be found in the Planning and Development Process section.
Date First Implemented2011
Vulnerable Populations > Substance abusers; Urban populations
Problem AddressedPrescribing of opioid analgesics has increased substantially in recent years, along with the consequences associated with their misuse, including emergency department (ED) visits, drug treatment admissions, and overdose deaths.
- Increased prescribing: Prescribing of opioid analgesics has increased nationally and in New York City (NYC), as outlined below:
- National trends: Between 1999 and 2010, sales of opioid analgesics to pharmacies, hospitals, and practitioners quadrupled.1
- NYC trends: Approximately 2.2 million prescriptions for opioid analgesics were filled by NYC residents in 2011, a 31-percent increase from 2008. Oxycodone accounted for approximately 1.1 million (53 percent) of all opioid prescriptions filled in 2011, a 73-percent increase from 2008.2
- Growing health consequences: Increased prescribing of opioid analgesics has coincided with a growing number of related health problems, as outlined below:
- National trends: Rates of ED visits related to opioid analgesics increased 164 percent between 2004 and 2011.2 The rate of treatment admissions related to opioid analgesics more than quadrupled between 1999 and 2009, from less than 1 to more than 4 per 10,000 people.3 Between 1999 and 2010, the number of Americans who died from opioid analgesic overdoses quadrupled, reaching more than 16,000 in 2010.4
- NYC trends: Rates of ED visits related to opioid analgesics rose 158 percent between 2004 and 2011,2 and noncrisis drug treatment admissions for opioid analgesics more than tripled between 2007 and 2012 (from 869 to 2,666).5 The rate of unintentional opioid analgesic overdose deaths increased 65 percent between 2005 and 2011, from 2.0 to 3.3 per 100,000 New Yorkers (an increase from 130 to 220 deaths). In 2011, an average of more than one overdose death involving an opioid analgesic occurred every other day in NYC.2
Description of the Innovative ActivityA multiagency, cross-disciplinary initiative in NYC , the Mayor’s Task Force on Prescription Painkiller Abuse develops and supports implementation of a constellation of policies and programs to reduce misuse of opioid analgesics and associated health and safety consequences. Major initiatives thus far include development of prescribing guidelines for ED providers, increased sharing and coordinated use of the large amount of data available across agencies, public education campaigns, efforts to increase access to naloxone, and support for enhancements to the State’s prescription monitoring program. More details are provided below:
- Evidence-based prescribing guidelines for EDs: Prior to creation of the task force, the NYC Department of Health and Mental Hygiene developed and disseminated voluntary, evidence-based guidelines for safe and judicious prescribing of opioid analgesics for primary care and other general practice settings. After its creation, the task force and the NYC Department of Health and Mental Hygiene worked with an expert clinical advisory panel to adapt these guidelines for ED-based prescribers. Based on this work, the mayor’s office released voluntary, ED-specific guidelines in January 2013. Among others, key recommendations in these guidelines include the following: that a short course of opioid analgesics generally be considered sufficient for acute pain; that ED providers avoid refilling lost, stolen, or destroyed prescriptions; and that ED providers avoid initiating treatment with long-acting opioid painkillers. As part of the release of the guidelines, posters that display their key recommendations are available to EDs for placement in locations where patients can easily see them.
- Comprehensive surveillance system: NYC’s public health and public safety agencies have large amounts of data that can be used to reduce opioid analgesic misuse and its consequences. Historically, these data have not been available in real time or shared across organizations. To address this issue, the task force created RxStat in partnership with New York/New Jersey High Intensity Drug Trafficking Area (HIDTA), a Federal grant program managed by the Office of National Drug Control Policy that focuses on reducing illicit drug use and its harms. RxStat functions as a formal, collaborative group that leverages relevant public health and safety data from multiple agencies to support efforts to monitor and address opioid analgesic misuse. Some highlights of the new system are outlined below:
- Timely and accessible data: Individual agencies have made a concerted effort to make data more accessible and timely. For example, the NYC Department of Health and Mental Hygiene changed its processes to review opioid-related overdose deaths on a monthly rather than annual basis.
- Regular cross-agency meetings: Each month, representatives from city, State, and Federal agencies (including the Drug Enforcement Administration) meet to share results of data analysis and conclusions, helping the city identify and respond to problems in a timely and effective manner. During these meetings, representatives of participating agencies regularly report on critical indicators that measure the impact of opioid analgesic misuse on the city (e.g., the number of unintentional drug poisoning deaths for the current year to date, with comparisons to the previous year). In addition to the monthly sessions, partners communicate with each other on a regular basis, sharing both the results of data analysis and their perspectives.
- Dedicated staff: In addition to Department of Health and Mental Hygiene staff augmenting their current surveillance work, three dedicated, full-time staff work on RxStat, conducting quantitative and qualitative data analysis and coordinating RxStat activities.
- Public education campaigns: The NYC Department of Health and Mental Hygiene has conducted two television advertising campaigns to raise awareness of the risks of opioid analgesic misuse. These 30-second ads underscore the serious health consequences of misusing opioid analgesics, which can mistakenly be perceived as safe since they are prescribed by a doctor.
The New York City Police Department has also created classes for high school and college students to highlight the risks of prescription drugs.
- Reform of prescription monitoring program: The task force supported reform of New York State’s prescription monitoring program (PMP), a statewide database of controlled-substance prescriptions filled by New York residents. In 2012, new legislation (Internet System for Tracking Over-Prescribing Act, or I-STOP) specified provisions to enhance the State’s PMP. Prior to I-STOP, the PMP provided prescribers with information for patients who had filled prescriptions from two or more providers at two or more pharmacies in the past month. Consequently, the prescriber could not see older information or evaluate patterns of prescriptions filled at a single pharmacy. In addition, pharmacists were not required to report prescriptions in real time, meaning that the newest information was frequently not available. Recognizing the system’s limitations, many prescribers did not use the database. The task force supported passage of I-STOP by engaging in discussions with key members of the State legislature, the attorney general’s office, and the Governor’s office, and also submitted a letter to top State officials recommending several major changes to the system, most of which were included in the final legislation. Key enhancements included in I-STOP are outlined below:
- Database consultation: Prescribers have a duty to consult the database prior to prescribing. Pharmacists are now allowed to consult the database before dispensing controlled substances.
- Completeness of viewable data: All controlled-substance prescriptions filled during the previous 6 months can now be viewed.
- Real-time reporting: Pharmacists must report the dispensing of controlled substances to the system in real time.
- Data for research and education: Data can be disclosed to local health departments for the purposes of public health research and education and to local government units for research and analysis.
- Electronic prescribing: Electronic submission of all prescriptions will be required in the future.
- Provider education and training: The legislation created a New York State Department of Health workgroup, which, among other activities, focused on developing recommendations related to prescriber education.
Context of the InnovationThe Mayor of the City of New York is head of the executive branch of NYC’s government. The mayor’s office administers all city services and enforces all city and State laws within the city.
The impetus for creating the task force came in part from growing interest and concern among leaders in both public health and public safety agencies in the city government about the growing incidence of opioid analgesic misuse and related problems, including ED visits and overdose deaths. In addition, two well-publicized pharmacy robberies in a jurisdiction close to NYC created an urgency to address the issue. One of the robberies resulted in four murders, while the second ended with the death of a Federal agent. After these events, the Deputy Mayor for Health and Human Services and the Criminal Justice Coordinator discussed this issue with Mayor Michael Bloomberg, who expressed strong support for the idea of a cross-disciplinary initiative. Various stakeholders were charged with improving coordination and collaboration between public health and public safety agencies within the city to address this issue.
ResultsWhile it is too soon to know if the existing initiatives have reduced opioid analgesic misuse and its associated consequences, to date the effort has prompted many public and private hospital EDs to adopt recommended prescribing guidelines. A preliminary analysis from the 11 EDs of the New York City Health and Hospitals Corporation (HHC)—the city's public hospital system—found a nearly 20-percent reduction in the rate of opioid analgesic prescribing after implementation of a series of strategies that included the ED guidelines.
Suggestive: The evidence consists of post-implementation data on the number of hospital emergency departments adopting the opioid analgesic prescribing guidelines, along with preliminary trends in emergency department opioid prescriptions and anecdotal reports from providers about the value of the guidelines and related materials.
- Wide acceptance among EDs: Overall, 35 of the city’s roughly 50 EDs have adopted the prescribing guidelines, including all 11 public hospital EDs (i.e., HHC EDs) and 24 private ones.
- Fewer ED prescriptions for opioids in subset of hospitals: A preliminary analysis from HHC's 11 EDs found a nearly 20-percent reduction in the rate of opioid analgesic prescribing (to 50.8 per 1,000 patient visits) after implementation of a series of strategies that included the ED guidelines. HHC EDs had almost 1.3 million patient visits in 2013.
- Positive feedback from ED-based providers: Providers in EDs that have adopted the guidelines have given positive feedback on the program and the posters that explain the new prescribing guidelines to patients. In particular, they report routinely referring to the posters during discussions with patients about appropriate pain management.
Planning and Development ProcessSelected steps included the following:
- Forming task force: In late 2011, an announcement was made about the creation of the task force, to be co-chaired by the Deputy Mayor for Health and Human Services and the Criminal Justice Coordinator (who oversees criminal justice functions in the city). The task force consists of leaders from the city's major public health and safety agencies affected by opioid analgesic misuse. In addition to the offices of the two co-chairs, task force members come from the NYC Department of Health and Mental Hygiene, the Richmond County District Attorney's Office (included because Staten Island [Richmond County] is the NYC borough [county] most affected by the problem of opioid analgesic overdose), the Special Narcotics Prosecutor, the NYC Human Resources Administration (responsible for enforcement issues related to Medicaid), HHC, New York/New Jersey HIDTA, the NYC Police Department, the Drug Enforcement Administration, and the NYC Department of Education.
- Holding initial meeting and setting objectives: The task force first met in January 2012 to formulate specific objectives to guide its work. Identified priorities included expanding the collection and analysis of data related to the problem, identifying new public health and safety strategies and changes that could be made to existing laws, and increasing prevention and treatment.
- Agreeing on key strategies: Task force members reached broad agreement on key strategies to reduce opioid analgesic misuse: improving clinician prescribing practices; informing the city’s health and safety activities through data analysis and secure data-sharing; raising awareness through public education campaigns; effectively investigating, arresting, and prosecuting professionals who knowingly divert opioids; and promoting access to and appropriate use of naloxone.
- Forming workgroups: The task force created four workgroups to focus on the identified priorities, with a separate group set up to cover each of the following areas: prevention and treatment, data, law enforcement, and legislation.
- Ongoing meetings and communications: The task force and workgroups meet in person on an as-needed basis, typically every few months. Between meetings, members communicate via e-mail and other mechanisms as necessary.
Resources Used and Skills Needed
- Staffing: The three staff dedicated to RxStat were newly hired for the program. All other staff within the various agencies work on the task force and related activities as part of their regular job responsibilities.
- Costs: While hard data are not available, program-related costs tend to be minimal, limited primarily to salaries and benefits for the three individuals hired to support NYC RxStat.
Funding SourcesU.S. Department of Justice Harold Rogers Prescription Drug Monitoring Program; New York/New Jersey HIDTA
The New York/New Jersey HIDTA provides funding for the salaries and benefits of the three full-time staff assigned to RxStat who work out of the NYC Department of Health and Mental Hygiene. The Harold Rogers Prescription Drug Monitoring Program supports RxStat through a Data-Driven, Multidisciplinary Approaches to Reducing Rx Abuse grant. Participating agencies provide in-kind support to the program by allowing task force and workgroup members to attend meetings and engage in related activities as part of their regular job responsibilities.
Tools and Other ResourcesMore information about the ED prescribing guidelines, including a link to the poster being used in EDs that adopt the guidelines, can be found by going to the NYC government Web site (http://www.nyc.gov) and searching on the phrase "ED opioid guidelines."
More information on the general opioid prescribing guidelines developed prior to creation of the task force is available at: http://www.nyc.gov/html/doh/downloads/pdf/chi/chi30-4.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .).
Readers may be interested in the following data sources related to opioid prescribing and misuse:
- Substance Abuse and Mental Health Services Administration National Surveys on Drug Use and Health (prevalence of drug misuse)
- New York State Department of Health, Bureau of Narcotic Enforcement Prescription Monitoring Program (data on controlled substance prescriptions filled)
- New York City Poison Control Center (calls related to opioid analgesics)
- Substance Abuse and Mental Health Services Administration Drug Abuse Warning Network (ED visits related to opioid analgesic misuse/abuse)
- New York State Office of Alcoholism and Substance Abuse Services Client Data Systems (drug treatment admissions)
- New York City Department of Health and Mental Hygiene Office of Vital Statistics (opioid analgesic overdose deaths using death certificate data, which is subsequently linked to toxicology data from the New York City Office of the Chief Medical Examiners)
- New York City Police Department (pharmacy robberies and burglaries)
- New York County District Attorney’s office (drug prosecutions)
- U.S. Drug Enforcement Administration Automation of Reports and Consolidated Orders System (opioid analgesic distribution data)
Getting Started with This Innovation
- Share data and perspectives on magnitude and impact of problem: While the problem of opioid analgesic misuse is generally well known, collecting and disseminating data that document the magnitude and impact of the problem locally can help to bring key stakeholders on board and guide future actions.
- Secure high-level, public commitment from leaders: The task force was set up as a formal initiative of the mayor. Additionally, the mayor held a press conference to announce the new ED prescribing guidelines. The use of a formal press conference served to underscore the importance of the issue to the mayor and sent a strong signal to area hospitals. Additionally, the Health Commissioner held two conferences with prescribers on Staten Island, urging them to follow the Health Department’s opioid prescribing guidelines for general practice.
Sustaining This Innovation
- Encourage everyone to contribute and listen: The effectiveness of the task force and workgroups depends on the ability to keep all key stakeholders communicating with and listening to each other. Meetings should be conducted to elicit everyone’s input, with efforts made to avoid allowing a few individuals or departments to dominate the discussion. Participants should be reminded to listen to and respect each other, and to lift out of the “silo” mentality that may have existed before the creation of the program.
- Share perspectives: Individual agencies will remain engaged in the program for as long as they get something positive out of it. To that end, program leaders should regularly share recent results of data analysis about the magnitude of the problem and progress made in tackling it. This strategy serves to remind participants of the ongoing importance of their work.
- Involve clinicians and other stakeholders as appropriate: Each initiative has an impact on various stakeholders in the community, including those who prescribe and dispense opioids. As appropriate, these stakeholders should be asked to participate in the development process. For example, a group of clinical advisers provided valuable guidance on the ED prescribing guidelines, particularly with respect to making them relevant and useful in real-world clinical settings. In addition, having a group of clinicians “endorse” the guidelines helped make the broader clinician community more receptive to them.
Additional ConsiderationsSince this article was written, the Office of the Mayor of New York City has undergone an administrative transition; the mayor is no longer Michael Bloomberg.
Contact the InnovatorJessica Kattan, MD, MPH
Drug Use Policy Coordinator
New York City Department of Health and Mental Hygiene
Bureau of Alcohol and Drug Use Prevention, Care and Treatment
Innovator DisclosuresDr. Kattan reported having no financial interests or business/professional affiliations relevant to the work described in the profile, other than the funders listed in the Funding Sources section.
References/Related ArticlesMayor’s Task Force on Prescription Painkiller Abuse. Interim report. January 2013. Available at: http://www.nyc.gov/html/cjc/downloads/pdf
Original publication: March 12, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: March 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.