PURPOSE:Despite initiatives to improve opioid treatment access by increasing availability of buprenorphine, substantial barriers persist, impacting treatment engagement across New York State (NYS). Pharmacists play a critical role in dispensing buprenorphine, yet their knowledge and perceptions significantly affect medication accessibility. We evaluated pharmacists' knowledge and perceptions about buprenorphine dispensing at pharmacies across NYS and assessed variations based on pharmacy characteristics. METHODS:A 2019 NYS Department of Health survey collected data from pharmacists about their experiences and perspectives related to buprenorphine dispensing. Statistical analyses were conducted to describe the associations between pharmacies, region, and other characteristics. FINDINGS:Of responding pharmacies (n = 620) 54.8% were in New York City, 22.7% of pharmacists had previously declined a buprenorphine prescription, with 65.5% declining prescriptions in the last 6 months alone. Key barriers included stocking issues on the supply side (19.9%) and lack of demand by patients (14.7%). IMPLICATIONS:Pharmacists play a critical role in providing access to buprenorphine. Addressing pharmacist knowledge gaps and stigma through education initiatives may improve opioid treatment access. Additional studies are required to evaluate the extent of the existing buprenorphine pharmacy accessibility barriers and to identify approaches to addressing and eliminating those barriers.

In 2021, an 8 -mg intranasal naloxone product was approved by the Food and Drug Administration; however, no studies have examined outcomes among persons who receive the 8 -mg naloxone product and those who receive the usual 4 -mg product. During March 2022-August 2023, New York State Department of Health (NYSDOH) supplied some New York State Police (NYSP) troops with 8 -mg intranasal naloxone; other troops continued to receive 4 -mg intranasal naloxone to treat suspected opioid overdose. NYSP submitted detailed reports to NYSDOH when naloxone was administered. No significant differences were observed in survival, mean number of naloxone doses administered, prevalence of most postnaloxone signs and symptoms, postnaloxone anger or combativeness, or hospital transport refusal among 4 -mg and 8 -mg intranasal naloxone recipients; however, persons who received the 8 -mg intranasal naloxone product had 2.51 times the risk for opioid withdrawal signs and symptoms, including vomiting, than did those who received the 4 -mg intranasal naloxone product (95% CI = 1.51-4.18). This initial study suggests no benefits to law enforcement administration of higher-dose naloxone were identified; more research is needed to guide public health agencies in considering whether 8 -mg intranasal naloxone confers additional benefits for community organizations.

IMPORTANCE Patients with chronic pain often receive long-term opioid therapy (LOT), which places them at risk of opioid use disorder and overdose. This presents the need for alternative or companion treatments; however, few studies on the association of medical cannabis (MC) with reducing opioid dosages exist. OBJECTIVE To assess changes in opioid dosages among patients receiving MC for longer duration compared with shorter duration. DESIGN, SETTING, AND PARTICIPANTS This cohort study of New York State Prescription Monitoring Program data from 2017 to 2019 included patients receiving MC for chronic pain while also receiving opioid treatment. Of these, patients receiving LOT prior to receiving MC were selected. Individuals were studied for 8 months after starting MC. Data were analyzed from November 2021 to February 2022. EXPOSURES Selected patients were divided into 2 groups based on the duration of receiving MC: the nonexposure group received MC for 30 days or fewer, and the exposure group received MC for more than 30 days. MAIN OUTCOMES AND MEASURES The main outcome was opioid dosage, measured by mean daily morphine milligram equivalent (MME). Analyses were conducted for 3 strata by opioid dosage prior to receiving MC: MME less than 50, MME of 50 to less than 90, and MME of 90 or greater. RESULTS A total of 8165 patients were included, with 4041 (median [IQR] age, 57 [47-65] years; 2376 [58.8%] female) in the exposure group and 4124 (median [IQR] age, 54 (44-62) years; 2370 [57.5%] female) in the nonexposure group. Median (IQR) baseline MMEs for the exposure vs nonexposure groups were 30.0 (20.0-40.0) vs 30.0 (20.0-40.0) in the lowest stratum, 60.0 (60.0-70.0) vs 60.0 (60.0-90.0) in the middle stratum, and 150.0 (100.0-216.2) vs 135.0 (100.0-218.0) in the highest stratum. During follow-up, significantly greater reductions in opioid dosage were observed among the exposure group. A dose-response association of patients' opioid dosage at baseline was observed with the differences in the monthly MME reductions between exposure and nonexposure groups, with a difference of -1.52 (95% CI, -1.67 to -1.37) MME for the lowest stratum, -3.24 (95% CI, -3.61 to -2.87) MME for the middle stratum, and -9.33 (95% CI, -9.89 to -8.77) MME for the highest stratum. The daily MME for the last month of the follow-up period among patients receiving longer MC was reduced by 48% in the lowest stratum, 47% in the middle stratum, and 51% in the highest stratum compared with the baseline dosages. Among individuals in the nonexposure group, daily MME was reduced by only 4% in the lowest stratum, 9% in the middle stratum, and 14% in the highest stratum. CONCLUSIONS AND RELEVANCE In this cohort study of patients receiving LOT, receiving MC for a longer duration was associated with reductions in opioid dosages, which may lower their risk of opioid-related morbidity and mortality.

Background The COVID-19 pandemic has amplified the need for wide deployment of effective harm reduction strategies in preventing opioid overdose mortality. Placing naloxone in the hands of key responders, including law enforcement officers who are often first on the scene of a suspected overdose, is one such strategy. New York State (NYS) was one of the first states to implement a statewide law enforcement naloxone administration program. This article provides an overview of the law enforcement administration of naloxone in NYS between 2015 and 2020 and highlights key characteristics of over 9000 opioid overdose reversal events. Methods Data in naloxone usage report forms completed by police officers were compiled and analyzed. Data included 9133 naloxone administration reports by 5835 unique officers located in 60 counties across NYS. Descriptive statistics were used to examine attributes of the aided individuals, including differences between fatal and non-fatal incidents. Additional descriptive analyses were conducted for incidents in which law enforcement officers arrived first at the scene of suspected overdose. Comparisons were made to examine year-over-year trends in administration as naloxone formulations were changed. Quantitative analysis was supplemented by content analysis of officers’ notes ( n = 2192). Results In 85.9% of cases, law enforcement officers arrived at the scene of a suspected overdose prior to emergency medical services (EMS) personnel. These officers assessed the likelihood of an opioid overdose having occurred based on the aided person’s breathing status and other information obtained on the scene. They administered an average of 2 doses of naloxone to aided individuals. In 36.8% of cases, they reported additional administration of naloxone by other responders including EMS, fire departments, and laypersons. Data indicated the aided survived the suspected overdose in 87.4% of cases. Conclusions With appropriate training, law enforcement personnel were able to recognize opioid overdoses and prevent fatalities by administering naloxone and carrying out time-sensitive medical interventions. These officers provided life-saving services to aided individuals alongside other responders including EMS, fire departments, and bystanders. Further expansion of law enforcement naloxone administration nationally and internationally could help decrease opioid overdose mortality.

In the commentary by Strang et al., ‘Clinical provision of improvised nasal naloxone without experimental testing and without regulatory approval: imaginative shortcut or dangerous bypass of essential safety procedures?’, published online 3 February 2016, Dr Strang and his co-authors argue that providers who utilize an off-label intranasal (i.n.) device to increase access to naloxone are acting unethically and dangerously. We disagree strongly, as the lead author himself stated in a previous publication: ‘These studies are vital, but they must not delay implementation. While we dither, people continue to die from overdose’ 1. Off-label use of medications is a legal, justified and common practice in many countries, including the United States and United Kingdom 2, 3. Off-label prescribing permits practitioners to respond nimbly to emerging or individualized patient needs not served adequately by existing products or formulations. Providers in many countries realized more than a decade ago that needles were obstructing naloxone access for many populations, from parents with addicted children to prisoners at release. The need for broader access to naloxone in the time of a raging public health crisis is a perfect example of a situation in which off-label prescribing can and should provide a safety valve 4. Nasal naloxone was trialed formally by emergency medical services (EMS) in Denver in 2002, and adopted by other EMS agencies because of its efficacy and safety 5. The first bystander naloxone program to use nasal naloxone was in Boston, where providing injectable naloxone to laypersons was deemed unacceptable and nasal naloxone had been the EMS standard of care for years 6, 7. This program has been associated with reduced overdose mortality 8. As of 2013, 37.5% of organizations in the United States that distribute naloxone reported providing intranasal only; an additional 11.8% provide both i.n. and intranasally (i.m.) 9. The authors’ statement that ‘…the failure of effect of i.n. naloxone, for whatever reason, can delay the time to naloxone injection until an ambulance arrives’, ignores the fact that if no naloxone at all is available—as is the case in many places that have delayed naloxone access—administration would also be delayed until the ambulance arrived. Moreover, further development of nasal and other formulations, such as the lead author's patent for buccal naloxone, may never have happened without the pressure of grassroots efforts. We think it important to draw readers’ attention to the authors’ disclosure of involvement in the development of both a nasal and a buccal naloxone, and believe that this needs to be considered when Dr Strang and his colleagues state unequivocally: ‘clinicians should prescribe take-home naloxone only as one of its licensed formulations’. apparently supporting products in which they have an interest. P.C. has led studies of naloxone access funded by U.S. federal agencies. Unrelated to this paper, P.C. has led investigations involving use of ledipasvir/sofosbuvir donated from Gilead and naltrexone (not naloxone) donated from Alkermes, and J.R. owns stock in Alkermes. M.D. is engaged in ongoing volunteer medical advisement and oversight to the New York State Department of Health law enforcement naloxone program that uses intranasal naloxone. M.D. is a recipient of a $20 000 NYS DoH grant to create law enforcement training for opioid overdose response that used intranasal naloxone. M.D. has served as an unpaid expert witness. S.S. and L.B. are involved in ongoing paid and volunteer efforts to increase access to naloxone, including nasal naloxone.

Drug use is a public health problem associated with high mortality and morbidity, and is often accompanied by suboptimal engagement in health care. Harm reduction is a pragmatic public health approach encompassing all goals of public health: improving health, social well-being, and quality of life. Harm reduction prioritizes improving the lives of people who use drugs in partnership with those served without a narrow focus on abstinence from drugs. Evidence has shown that harm reduction oriented practice can reduce transmission of blood-borne illnesses, and other injection related infections, as well as preventing fatal overdose.

This is a brief report on the establishment of a new program in New York State prisons to prepare prisoners to avoid the increased risks of drug overdose death associated with the transition to the community by training them in overdose prevention and making available naloxone, a medication that quickly reverses the effects of an opioid overdose, to all prisoners as they re-enter the community. It is a milestone collaboration in the USA between public health, the correctional system, and a community-based harm reduction program in response to the growth of heroin and opioid analgesic use and related morbidity and mortality, working together to get naloxone into the hands of the people at high risk of overdosing and/or of witnessing an opioid overdose.

No discussion of overdose deaths caused by opioids1Bowman S. Eiserman J. Beletsky J. Stancliff S. Bruce R.D. Reducing the health consequences of opioid addiction in primary care.Am J Med. 2013; 126: 565-571Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar would be complete without pointing out the exceptional risk posed by methadone. The Centers for Disease Control and Prevention notes that “while methadone accounts for only 2 percent of painkiller prescriptions in the United States, it is involved in more than 30 percent of prescription painkiller overdose deaths” and that “six times as many people died of methadone overdoses in 2009 as died in 1999.”2Centers for Disease Control and Prevention (CDC). Prescription painkiller overdoses: methadone. Available at: http://www.cdc.gov/features/vitalsigns/methadoneoverdoses/. Accessed May 14, 2013.Google Scholar It appears that any effort to slow the rising number of opioid overdose deaths will require special attention to reducing the risk posed by methadone. Methadone is favored because it is an inexpensive generic medication, it has a long half-life,3PDR.net Web site. Drug summary: methadone hydrochloride tablets. Available at: http://www.pdr.net/drug-summary/methadone-hydrochloride-tablets?druglabelid=1597&id=1282. Accessed May 15, 2013.Google Scholar and it is thought to be more effective against neuropathic pain than other opioids.4Moulin D.E. Palma D. Watling C. Schulz V. Methadone in the management of intractable neuropathic noncancer pain.Can J Neurol Sci. 2005; 32: 340-343PubMed Google Scholar However, it can prolong QT interval, and its long half-life can lead to dose accumulation and such fatal complications as respiratory depression and torsades de pointes.5U.S. Food and Drug Administration (FDA). Information for healthcare professionals: methadone hydrochloride. Available at: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm142841.htm. Accessed May 15, 2013.Google Scholar No discussion of overdose deaths caused by opioids1Bowman S. Eiserman J. Beletsky J. Stancliff S. Bruce R.D. Reducing the health consequences of opioid addiction in primary care.Am J Med. 2013; 126: 565-571Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar would be complete without pointing out the exceptional risk posed by methadone. The Centers for Disease Control and Prevention notes that “while methadone accounts for only 2 percent of painkiller prescriptions in the United States, it is involved in more than 30 percent of prescription painkiller overdose deaths” and that “six times as many people died of methadone overdoses in 2009 as died in 1999.”2Centers for Disease Control and Prevention (CDC). Prescription painkiller overdoses: methadone. Available at: http://www.cdc.gov/features/vitalsigns/methadoneoverdoses/. Accessed May 14, 2013.Google Scholar It appears that any effort to slow the rising number of opioid overdose deaths will require special attention to reducing the risk posed by methadone. Methadone is favored because it is an inexpensive generic medication, it has a long half-life,3PDR.net Web site. Drug summary: methadone hydrochloride tablets. Available at: http://www.pdr.net/drug-summary/methadone-hydrochloride-tablets?druglabelid=1597&id=1282. Accessed May 15, 2013.Google Scholar and it is thought to be more effective against neuropathic pain than other opioids.4Moulin D.E. Palma D. Watling C. Schulz V. Methadone in the management of intractable neuropathic noncancer pain.Can J Neurol Sci. 2005; 32: 340-343PubMed Google Scholar However, it can prolong QT interval, and its long half-life can lead to dose accumulation and such fatal complications as respiratory depression and torsades de pointes.5U.S. Food and Drug Administration (FDA). Information for healthcare professionals: methadone hydrochloride. Available at: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm142841.htm. Accessed May 15, 2013.Google Scholar Reducing the Health Consequences of Opioid Addiction in Primary CareThe American Journal of MedicineVol. 126Issue 7PreviewAddiction to prescription opioids is prevalent in primary care settings. Increasing prescription opioid use is largely responsible for a parallel increase in overdose nationally. Many patients most at risk for addiction and overdose come into regular contact with primary care providers. Lack of routine addiction screening results in missed treatment opportunities in this setting. We reviewed the literature on screening and brief interventions for addictive disorders in primary care settings, focusing on opioid addiction. Full-Text PDF The ReplyThe American Journal of MedicineVol. 126Issue 11PreviewAlthough the article by Bowman et al1 did address the importance of naloxone prescription in primary care settings to prevent opioid overdoses in patients prescribed any opioid, the article did not address the prescribing of specific opioids for the treatment of chronic pain that could result in overdose. The focus of the article was on opioid addiction in primary care settings and sought to direct attention to 5 areas: (1) Addiction is present in primary care practices and should be screened for in a standardized manner; (2) brief motivational interviewing to engage patients in behavior change can be conducted even in busy primary care practices; (3) needles and syringes should be accessible in primary care to avoid the transmission of blood-borne diseases, such as human immunodeficiency virus and hepatitis C; (4) naloxone should be prescribed to prevent overdose; and (5) buprenorphine should be available to help treat opioid addiction. Full-Text PDF

BackgroundIn an effort to increase effective intervention following opioid overdose, the New York State Department of Health (NYSDOH) has implemented programs where bystanders are given brief education in recognizing the signs of opioid overdose and how to provide intervention, including the use of naloxone. The current study sought to assess the ability of NYSDOH training to increase accurate identification of opioid and non-opioid overdose, and naloxone use among heroin users.MethodsEighty-four participants completed a test on overdose knowledge comprised of 16 putative overdose scenarios. Forty-four individuals completed the questionnaire immediately prior to and following standard overdose prevention training. A control group (n=40), who opted out of training, completed the questionnaire just once.ResultsOverdose training significantly increased participants’ ability to accurately identify opioid overdose (p<0.05), and scenarios where naloxone administration was indicated (p<0.05). Training did not alter recognition of non-opioid overdose or non-overdose situations where naloxone should not be administered.ConclusionsThe data indicate that overdose prevention training improves participants’ knowledge of opioid overdose and naloxone use, but naloxone may be administered in some situations where it is not warranted. Training curriculum could be improved by teaching individuals to recognize symptoms of non-opioid drug over-intoxication.

Addiction to prescription opioids is prevalent in primary care settings. Increasing prescription opioid use is largely responsible for a parallel increase in overdose nationally. Many patients most at risk for addiction and overdose come into regular contact with primary care providers. Lack of routine addiction screening results in missed treatment opportunities in this setting. We reviewed the literature on screening and brief interventions for addictive disorders in primary care settings, focusing on opioid addiction. Screening and brief interventions can improve health outcomes for chronic illnesses including diabetes, hypertension, and asthma. Similarly, through the use of screening and brief interventions, patients with addiction can achieve improved health outcome. A spectrum of low-threshold care options can reduce the negative health consequences among individuals with opioid addiction. Screening in primary care coupled with short interventions, including motivational interviewing, syringe distribution, naloxone prescription for overdose prevention, and buprenorphine treatment are effective ways to manage addiction and its associated risks and improve health outcomes for individuals with opioid addiction.

The aim of this pilot study was to assess the effectiveness of buprenorphine/naloxone (BUP/NX) among marginalized, opioid-dependent individuals in terms of retention in and cycling into and out of a harm-reduction program. This pilot study enrolled 100 participants and followed them from November 2005 to July 2008. The overall proportion of patients retained in the program at the end of 3, 6, 9, and 12 months was 68%, 63%, 56%, and 42%, respectively. This pilot study demonstrated that BUP/NX could be successfully used to treat marginalized heroin users.