Boston Public Health Commission: A City Health’s Department Perspective On

the Opiate Epidemic

Rita Nieves, RN, MPH, LICSW Deputy Director

Boston Public Health Commission April 3, 2017

1

BPHC’s Recovery Services Bureau

2

Coordinates substance use prevention activities, provides substance use treatment services, as well as other addiction resources and referral services to Boston residents.

Set the direction and priorities for the City’s

comprehensive system of prevention, treatment and recovery support services in order to make progress toward restored health, sustained recovery, and support the reintegration and active participation into family life of the residents of Boston, their families, and neighborhoods affected by substance use.

Recovery Services Bureau – Services provided

3

Access to Care PAATHS (Providing Access to Addictions Treatment, Hope and

Support) AHOPE (Access, Harm-Reduction, Overdose Prevention, &

Education) Treatment and Recovery Support Men’s Health and Recovery Program -outpatient South Boston Collaborative- outpatient MOM’s Project- outpatient Entre Familia- family residential for women and children Transitions – Transitional and Stabilization Support

Prevention and Risk Reduction Overdose Prevention Mobile Sharps Team Outreach Team

4

Boston Data

*Age-adjusted rates. Boston resident clients ages 12+. Self-identified as primary, secondary, or tertiary drug of abuse. DATA SOURCE: Bureau of Substance Abuse Services, Massachusetts Department of Public Health

164.9

217.3

116.1

280.8

349.7

243.7

0

100

200

300

400

500

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Age-

Adju

sted

Rat

e pe

r 100

,000

U

niqu

e Re

siden

t Clie

nts

Ages

12+

Treatment Admissions by Drug Type

Boston Residents, 2006-2015

Non-Heroin Opioids Other Possible Rx Abuse Drugs

n=1,364 Rx clients and 635 Non Heroin Opioid Clients in 2015

164.9

217.3

116.1

280.8

349.7

243.7

0

100

200

300

400

500

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Age-

Adju

sted

Rat

e pe

r 100

,000

U

niqu

e Re

siden

t Clie

nts

Ages

12+

Treatment Admissions by Drug Type

Boston Residents, 2006-2015

Non-Heroin Opioids Other Possible Rx Abuse Drugs

n=1,364 Rx clients and 635 Non Heroin Opioid Clients in 2015

Prescription Drug Overdose Mortality* Boston Residents

8.4 6.3

10.6

6.2 4.5

12.5

7.8 5.3

10.5

2.9 3.1

13.6 15.5

9.7

21.6

10.0 10.5

24.3

0.0

10.0

20.0

30.0

Female Male Black Latino White

Boston Sex Race/Ethnicity

Deat

hs p

er

100

,000

Pop

ulat

ion

2007-2009 2010-2012 2013-2015* Average annual age-adjusted rate of residents ages 12+. CDC prescription-drug-overdose-death case definition includes accidental, intentional, and undetermined intent. + Data not shown for Asian residents due to small count. DATA SOURCE: Boston Resident Deaths, Massachusetts Department of Public Health DATA ANALYSIS: Boston Public Health Commission Research and Evaluation Office

Prescription Drug Overdose Mortality*

Excluding Fentanyl Code (T40.4) Boston Residents

* Average annual age-adjusted rate of residents ages 12+. CDC prescription-drug-overdose-death case definition includes accidental, intentional, and undetermined intent. + Data not shown for Asian residents due to small count. DATA SOURCE: Boston Resident Deaths, Massachusetts Department of Public Health DATA ANALYSIS: Boston Public Health Commission Research and Evaluation Office

7.4

5.3

9.7

5.1 4.1

11.2

7.1

5.1

9.2

2.6 3.1

12.2

6.8

4.9

8.8

3.2 2.6

12.0

0.0

5.0

10.0

15.0

Female Male Black Latino White

Boston Sex Race/Ethnicity

Deat

hs p

er

100

,000

Pop

ulat

ion

2007-2009 2010-2012 2013-2015

Fentanyl Overdose Mortality* Boston Residents

* Average annual age-adjusted rate of residents ages 12+. Fentanyl refers to ICD10 code T40.4. Approx. 96% of ICD40.4 listed fentanyl in 2015. CDC prescription-drug-overdose-death case definition includes accidental, intentional, and undetermined intent. + Data not shown for Asian residents due to small count. DATA SOURCE: Boston Resident Deaths, Massachusetts Department of Public Health DATA ANALYSIS: Boston Public Health Commission Research and Evaluation Office

1.0 1.0 0.9 1.3 0.7 1.2 1.4

8.7

4.8

12.8

6.8 7.9

12.3

0.0

5.0

10.0

15.0

Female Male Black Latino White

Boston Sex Race/Ethnicity

Deat

hs p

er

100

,000

Pop

ulat

ion

2007-2009 2010-2012 2013-2015

n<5 n<5 n<5 n<5 n<5

n=106 Rx overdose deaths in 2015

0.0

5.0

10.0

15.0

20.0

25.0

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Age-

Adju

sted

Rat

e pe

r 10

0,00

0 Re

siden

ts A

ges 1

2+

Total RX wt Fentanyl (T40.4) w/o Fentanyl

n<5 n<5 n<5

Prescription Drug Overdose Mortality* Boston Residents, 2006-2015

* Age-adjusted rate for residents ages 12+. CDC prescription drug overdose death case definition includes overdoses with accidental, intentional, and undetermined intent. Approx. 96% of overdose deaths with code T40.4 listed fentanyl as the synthetic opiate in 2015. DATA SOURCE: Boston Resident Deaths, Massachusetts Department of Public Health DATA ANALYSIS: Boston Public Health Commission Research and Evaluation Office

Boston EMS NRI Incidents – Historical Perspective

1013 1085

1381 1518

2037

2601

232 353 431 508

809

1196

9 14 16 13 23 31 10 13 20 37 47 67

2010 2011 2012 2013 2014 2015

NRI Cases Narcan Administered Cardiac Arrest RME

Boston’s Response to Opioid Epidemic and Efforts to Date

Strategies Youth prevention Overdose prevention & Narcan administration

trainings Environmental strategies First responder partnerships

Expanding access to treatment

Youth Prevention

Life Skills Training – evidence-based curriculum for Boston 9th graders 95 students completed or in progress

Citywide Media Campaign Focuses on increasing the perception of harm

related to prescription drug misuse Positive Parenting Materials Tools for parents to engage children in

conversations about alcohol and drug use

City-wide Prevention Assessment

• BPHC & the Mayor’s Office of Recovery Services partnered with Blue Cross Blue Shield Foundation of MA to coordinate Boston’s first ever city-wide prevention strategy A planning process to assess the capacity of existing youth substance use prevention services in the City of Boston and Suffolk County. Focus on middle and high school aged youth and their families. Create recommendations for coordination across city departments and community partners in youth substance use prevention services

Overdose Prevention & Narcan Administration Trainings

One hour in length Training: Factors that increase risk for overdose How to recognize an overdose Protocol for responding to an overdose (including

the Good Sam Law) Referral to recovery services https://www.youtube.com/watch?v=DGn-

1ktzhpA&t=2s [8 min YouTube video with basics]

Overdose Prevention & Narcan Administration Trainings

Expanded to multiple groups: High-risk populations (jail, shelters, detoxes, SA

treatment programs, sober homes) Medical and mental health treatment providers Business community and public places Family and friends of people at risk for

overdose Public safety and law enforcement(Probation,

Corrections, Park Rangers) ~200 Boston residents trained per week Expanded drop in hours for active users at

AHOPE, serving 75-100 people day

Environmental Strategies

Installed Drug Kiosks in 12 police stations throughout the city for safe disposal of potentially dangerous prescription drugs

Environmental Strategies

Safe bathroom strategy initiatives to reduce overdoses in public spaces

First Responder Partnerships

All Boston First Responders Carry Narcan

• Boston EMS: real time reports on Narcotic-Related

Illness (NRI) patients, coordinated response for high-risk patients

• Boston Fire: partnership to expand OD prevention, follow up in residences that have witnessed an overdose

• Boston Police: distributing SUD resources, providing referrals

PAATHS (Providing Access to Addictions Treatment, Hope & Support) Assessing unique treatment needs Making recommendations and referrals Facilitating access to treatment programs Connecting clients to OD prevention and risk

reduction services [Average 150 walk-in clients per week & 100 hotline calls per week]

311 for Recovery Services

Partnership initiative with 311, Mayor’s Office Constituent Service Hotline, and the PAATHS program to create a primary entry to recovery services and improve access to all services

Confidential 24/7 referral center for addiction treatment & recovery services

Free to call from anywhere in Boston

Ongoing Challenges • Access to levels of care

• Wait times • Insufficient lengths of stay • Lack of services for people who aren’t treatment ready

• Transitions between levels of care • Insurance coverage • Co-occurring Disorders (mental health and medical) • Places for people to go (engagement centers, day

programs) • Stigma (institutional barriers) • Limited funding for prevention efforts