Drug User Health

Harm Reduction Initiative

Early in the HIV/AIDS Epidemic, injection drug use was one of the major risk factors for new HIV transmissions in New York State (NYS).  The AIDS Institute recognizes that harm reduction strategies are needed to prevent the transmission of HIV, hepatitis B and C and other blood-borne diseases in people who inject drugs (PWID), their sexual partners, and children.

Recent research and evaluation of SEPs and the Expanded Syringe Access Program in NYS show that HIV seroprevalence in PWID decreased from 52% in 1990 to 20% in 2000, declined further to an estimated 8-10% in 2009, and declined to less than 3% in 2018. 

In May 1992, the New York State Department of Health (NYSDOH) filed emergency regulations for authorization to conduct hypodermic syringe and needle exchange programs. Section 80.135 of Title 10 of the State of New York Official Codes, Rules and Regulations provides the regulatory authority by which community-based, not-for-profit organizations, and government entities may be granted a waiver to obtain, possess, and furnish hypodermic syringes and needles without a prescription in programs designed to reduce the transmission of HIV. The target population is PWID who are not ready, willing, or able to abstain from drug use or enter substance use treatment programs. The regulations require that syringe exchange services be provided within a comprehensive harm reduction model, where clients can learn methods for risk reduction for themselves and their partners. Programs must elicit community support to receive approval of their waiver applications.

In November 2019, new regulations were promulgated that permit health care facilities, community-based organizations and local health departments to apply for Second Tier Syringe Exchange Program (STSEP) waiver authorization. STSEP approval allows entities that are already interacting with PWIDs, such as Emergency Departments, STI clinics, or behavioral health programs, to furnish syringes to their patients/clients. Given the opioid epidemic in NYS, STSEP will expand access to new, sterile syringes in venues already accessed by PWID.

The Harm Reduction Initiative supports comprehensive and complementary services with funds from the NYSDOH. Harm Reduction Initiative contractors receive funding to provide an array of services to PWID, their families, and communities. Funds provide harm reduction, HIV/HCV/STD prevention education and services to people who use drugs (PWUD) which includes intakes and assessment, individual and group counseling and education, support groups, acupuncture, mental health services, behavioral interventions, referrals and linkage and navigation to health care, supportive services, and medication for opioid use disorder treatment. In 2018, Drug User Health Hubs were added to some programs to provide wrap around services for people at risk of overdose including accessible buprenorphine and primary care services for PWUD.

In addition to the provision of sterile injection equipment and supplies, harm reduction services may include:

  • Engagement and education on risk reduction practices related to sexual and drug-using behaviors with an emphasis on opioid overdose prevention and safety planning;
  • Distribution and demonstration of male and female condoms, dental dams, and opioid overdose kits containing naloxone;
  • Demonstration of safer injection techniques;
  • Distribution of other harm reduction supplies and literature;
  • Behavioral interventions delivered to individuals and groups;
  • Community level interventions to neighborhoods, law enforcement and substance users to promote and provide opioid overdose prevention training and anti-stigma campaigns regarding PWUD;
  • HIV/STD/HCV education, counseling and testing and linkage to treatment and care;
  • Provision of supportive services, partner notification assistance, PrEP and PEP promotion, care management, health care services, legal assistance, and housing services;
  • COVID-19 prevention education and provision of supplies such as masks gloves, hand sanitizer and/or soap to clients; and
  • Drug User Health Hub services, including opioid overdose aftercare to individuals who have experienced an overdose and/or their significant others; buprenorphine prescribing, induction and maintenance; and activities to reduce barriers to access to care and other services. Programs must provide referrals for these services if they are unable to provide them directly. (Please see the About the AIDS Institute description of Drug User Health Hubs for more information on these sites.)

There are currently 24 approved harm reduction/syringe exchange programs in NYS: 14 in New York City, and one each in Buffalo/Jamestown/Niagara Falls/Lockport, Rochester, Ithaca/Binghamton/Norwich, Mount Vernon, Albany/Schenectady/Troy/Catskill/Hudson, Syracuse/Utica/Watertown, Plattsburgh/Ticonderoga, Poughkeepsie/Newburgh/Kingston/Monticello and Nassau/Suffolk Counties on Long Island.

Program models include street-side services, mobile vans, storefront or drop in centers, walking teams, special arrangements, emergency exchange, web-based/mail order, and the Peer Delivered Syringe Exchange (PDSE) model.

The significant reduction in HIV transmission among PWID is attributed to the improvement in syringe access in NYS, with the implementation and growth of SEPs since 1992. Approximately ten million syringes are exchanged annually through these programs. SEPs also accept household-generated sharps from non-SEP participants and conduct community sweeps to remove syringes that are not properly disposed. Referrals provided by SEPs continue to increase and are made to: medication for opioid use disorder treatment programs, health care services, HIV/HCV counseling, testing and treatment, and social services.

Contact:

Allan Clear
Director, Office of Drug User Health
(212) 417-4770
allan.clear@health.ny.gov

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Expanded Syringe Access Program (ESAP)

In May 2000, the New York State Legislature enacted Chapter 56 of the Laws of 2000 creating the Expanded Syringe Access Program (ESAP). The purpose of this program is to reduce the transmission of blood-borne diseases, including HIV and hepatitis, by enhancing access to clean, sterile syringes.

Under this program, up to ten syringes may be sold or furnished to a person 18 years of age or older without a prescription by pharmacists, health care facilities, and health care practitioners who have registered with the New York State Department of Health (NYSDOH).

From December 31, 2019 to July 30, 2020, ESAP registered 3,494 providers who furnish sterile syringes, this includes: 3,391 pharmacies; 49 health care facilities; and 54 practitioners. About 4 million syringes are sold without a prescription annually in New York State.  Several syringe exchange programs (SEP) offer ESAP vouchers to clients to redeem at a pharmacy for 10 syringes when the SEP is closed.

Programs seeking to offer ESAP services can complete an application (DOH 4410) and submit to the Bureau of Narcotic Enforcement (BNE). Please see the following link for the application:

To find ESAP-registered pharmacies, medical providers or Article 28 facilities where syringes can be obtained without a prescription, email ESAP@health.ny.gov or visit the NYSDOH ESAP website at:

Contact:

Clara De Sanctis Johnson
Office of Drug User Health
ESAP@health.ny.gov

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Opioid Overdose Prevention Program

Opioid overdose is a significant and growing problem throughout all regions of New York State (NYS).

Among NYS residents, the number of overdose deaths involving any opioid increased from 1,074 in 2010 to 3,224 in 2017, with a 7 percent increase from 2016 to 2017. The age-adjusted rate of deaths involving all opioids in NYS tripled between 2010 and 2017, from 5.4 to 16.1 deaths per 100,000 population. In 2018, there were 8,219 outpatient emergency room visits statewide for opioid overdoses and 3,056 hospitalizations. County-level data on the impact of opioids may be found at http://www/health.ny.gov/statistics/opioid.

Fentanyl, a drug 10-100 times more powerful than heroin, has become the primary driver of fatal and non-fatal opioid overdoses in NYS.  It is often present not only in drugs marketed as heroin, but also in crack and powder cocaine and in pills. Because a wide range of street drugs contain fentanyl, many individuals who do not think they are ingesting opioids are placing themselves at risk for an opioid overdose.

Fatal opioid overdoses are preventable, especially if individuals in the community are trained to recognize that an overdose is occurring and to respond immediately by calling 911 and administering naloxone. Naloxone is an FDA-approved medication which reverses opioid overdoses.  Naloxone has been used in hospitals and by emergency medical services personnel for more than 50 years. It now has broad use in the community.

Since April 2006, it has been legal in NYS for trained non-medical persons to administer naloxone to individuals experiencing an opioid overdose. The AIDS Institute registers eligible programs to do the training and either provide naloxone to the trained individuals or to direct them to one of more than 2,600 pharmacies throughout NYS which have standing orders for this medication.

The AIDS Institute provides naloxone to registered programs outside of New York City (NYC); and the New York City Department of Health and Mental Hygiene provides naloxone to programs within NYC. Eligible programs include hospitals; diagnostic and treatment centers; health care practitioners; drug treatment programs; not-for-profit community-based organizations; state and local government agencies such as health departments and school districts; public safety agencies; colleges, universities and trade schools; and pharmacies. The responders include individuals who are themselves at risk for an overdose; their families and friends; individuals working for agencies serving persons at risk for an overdose; and others in the community who may be positioned to intervene. There are over 800 approved opioid overdose prevention programs in NYS. These programs have trained over 500,000 individuals, more than 168,000 of whom were trained in 2019 alone. More than 11,600 naloxone administrations have been documented for community (non-public safety) responders, with more than 2,750 occurring in 2019 alone. These figures represent only those administrations reported and are, therefore, believed to substantially underrepresent the actual number of naloxone administrations.

Through a collaboration that has included the AIDS Institute, the Division of Criminal Justice Services, the Harm Reduction Coalition (HRC), the Office of Addiction Services and Supports (OASAS) and Albany Medical College, more than 60,000 law enforcement personnel have become trained overdose responders. Public safety overdose responders are documented as having administered naloxone more than 7,500 times between June 2014 and December 2019.

The AIDS Institute collaborated with the Department of Corrections and Community Supervision (DOCCS) and HRC to bring overdose training and naloxone to individuals leaving DOCCS facilities., These trainings are currently taking place in all DOCCS facilities. Individuals, upon transitioning from a correctional setting, are given the option of taking naloxone with them. A growing number of county jails are implementing overdose training and provision of naloxone upon release. Through a collaboration that has included the AIDS Institute, the State Education Department, OASAS, HRC and the New York Center for School Health, school nurses and other school personnel are trained in opioid overdose response and provided with naloxone. In some cases, local school districts are becoming registered opioid overdose programs. In other cases, they are working with other registered overdose programs, such as local health departments. More than 100 school districts have registered programs.

Through the NYS Naloxone Co-payment Assistance Program (N-CAP), NYS covers co-payments of up to $40 for individuals with prescription drug coverage as part of their health insurance resulting no or lower out-of-pocket expenses. For more information on naloxone access in pharmacies and on N-CAP, visit https://www.health.ny.gov/diseases/aids/general/opioid_overdose_prevention/directories.htm

For information about training and programs, please send an email to overdose@health.ny.gov  or visit the website at: www.health.ny.gov/overdose.

Contact:

Mark R. Hammer
Office of Drug User Health
(212) 417-4669
Mark.Hammer@health.ny.gov

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Safe Sharps Collection Program

Safe disposal is critically important for the health and safety of New Yorkers and the environment. In addition to the hospitals and nursing homes in New York State (NYS) that are mandated by law to accept used sharps as a free community service, the Expanded Syringe Access Program (ESAP) implemented the NYS Safe Sharps Collection Program.

Through the NYS Safe Sharps Collection Program, pharmacies, health clinics, community-based organizations, public transportation facilities, housing projects, county landfills, waste transfer stations, police stations, bus depots, airports, community colleges, town halls, shelters, parks and other venues have become settings for safe sharps collection.

Currently, 300 syringe disposal collection sites are in 36 counties throughout NYS. At the end of the 2019 calendar year, 90 collection sites reported disposing over 14,740 lbs. of used syringes.

Programs interested in offering a syringe kiosk or wall mounted sharps container at their location can complete a safe sharps site application (DOH 4275) to become a collection site.  To obtain the application, visit http://www.health.ny.gov/forms/doh-4275.pdf.

Participating organizations are required to comply with state and local hazardous waste regulations. Approved safe sharps collection site applications are eligible to obtain a sharps collection kiosk and/or wall mounted unit from the New York State Department of Health (NYSDOH). NYSDOH also makes available small personal sharps containers, known as Fitpacks.

To locate collection sites, hospitals and nursing homes in your region, visit the NYSDOH ESAP website:

Contact:

Clara De Sanctis Johnson
Office of Drug User Health
ESAP@health.ny.gov

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Drug User Health Hubs

The AIDS Institute’s Office of Drug User Health has enhanced many of its Harm Reduction/Syringe Exchange Programs (SEPs) to become comprehensive Drug User Health Hubs. The array of services offered via the hubs are varied and are determined and defined by the needs of the participants who are served by the agency. Categories of services may include accessible buprenorphine; opioid overdose prevention; supportive services and counselling for individuals who have experienced an overdose; referrals from community including law enforcement, emergency departments (EDs), families and emergency services; and anti-stigma activities related to drug use and people who use drugs (PWUD). The services are delineated as follows:

Medical

  • Accessible buprenorphineservices include an eligibility assessment for buprenorphine, medical intake and assessment, buprenorphine prescribing and induction, dosage determination and maintenance. Buprenorphine may also be used as a tool for crisis intervention in instances when illicit substances that are available are too potent and likely to cause an opioid overdose. Prescribing includes follow-up sessions with staff to promote treatment adherence.
  • Safer injection education aims to reduce invasive infections such as staph and includes medical care for abscesses resulting from injection drug use.
  • HCV testing, diagnosis and treatment in an environment that is supportive of the individual drug user’s well-being.
  • Triage/presenting issue service is a rapid assessment of a client’s presenting problem and appropriate treatment, referral, or linkage and navigation to a collaborating provider. Testing and counseling for HIV/HCV/STD and hepatitis A and B vaccinations may be included in these encounters.

Opioid Overdose Prevention or Aftercare for an Overdose

  • Opioid overdose prevention (OOP) includes OOP training and provision of a naloxone overdose reversal kit.
  • Safer injection practices include safety planning education related to high-potency substances like fentanyl and strategies for reducing harm while using drugs. This includes the provision of syringes.
  • Aftercare for an opioid overdose may be a referral from an ED, emergency medical technician or other first responder for an individual who has experienced an overdose or for family members or significant others of victims of overdose. Hub staff or peers may be stationed in an ED to facilitate referrals for aftercare.
  • Development of a safety plan to reduce subsequent overdoses.

Law Enforcement Assisted Diversion

  • Law enforcement diversion services allows PWUD who are stopped by law enforcement for low level infractions to be diverted to the drug user health hub instead of being arrested and incarcerated. Clients can access needed services from the hub and can avoid involvement in the criminal justice system.
  • Hubs can accept law enforcement referrals of PWUD who require assistance but are not involved in the criminal justice system.

Anti-Stigma Activities

  • Cultural Competency for Provision of Services for People Who Use Drugs – Hub staff work with other providers to help them embrace a harm reduction philosophy in their practices and provision of services for PWUD.
  • Cultural Competency for Communities – Hub staff work with communities to destigmatize PWUD and foster dignity and respect for all community members.

Contact:

Allan Clear
Director, Office of Drug User Health
(212) 417-4770
allan.clear@health.ny.gov

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Buprenorphine Access Initiative

The goals of the Buprenorphine Access Initiative are to:

  • Increase the number of certified health care practitioners who prescribe buprenorphine.
  • Increase the number of patients who are prescribed buprenorphine.
  • Incorporate buprenorphine prescribing more broadly, so that individuals have access to buprenorphine at a range of settings including primary care clinics, harm reduction programs, federally qualified health centers, emergency departments (EDs), OB/GYN settings, housing services, and other community-based organizations.
  • Incorporate buprenorphine prescribing more broadly so specific populations, including younger opioid users and women of child-bearing age, have access to buprenorphine.

Expanding access of buprenorphine is a priority. The benefits of buprenorphine include:

  • Protecting people from experiencing an opioid overdose. If individuals continue to use additional opioids while on buprenorphine, buprenorphine provides a protective factor from a lethal overdose.
  • Improving adherence to other medications/therapies (HIV, HCV, Diabetes, and Hypertension).
  • Providing stability to meet responsibilities (work, child care, maintain housing, legal, etc.)
  • Reducing HIV and hepatitis transmission for those that are injecting opioids.
  • Increasing access points for meaningful engagement with supportive and health care services.
  • Help engage individuals into other services that improve factors relating to their social determinants of health.

Additional activities include:

Targeted/Ongoing Provider Education and Support

  • Support for new and existing buprenorphine prescribers by hosting buprenorphine waiver trainings around the state.
  • Provide technical assistance and mentoring opportunities to new prescribers.
  • Create and deliver targeted provider education activities and resources for providers, local health departments and other community stakeholders.
  • Creating guidelines for client-centered buprenorphine service delivery with best practices to provide meaningful, non-punitive supportive services for individuals accessing buprenorphine.

Buprenorphine Working Group

The AIDS Institute convened the first statewide Buprenorphine Working Group, comprised of 35 buprenorphine providers and subject matter experts from around the state. The purpose of this working group is to:

  • Serve as a leading body of providers who offer guidance and recommendations related to the expansion and implementation of buprenorphine efforts statewide.
  • Assist in the development of educational kits to distribute to providers, to include appropriate resources and materials for both providers and patients.
  • Inform the Buprenorphine Consumer Advisory Group on the lived experience of accessing and utilizing buprenorphine.

Contact

Narelle Ellendon, RN
Opioid Program Manager
Office of Drug User Health
212-417-4668
narelle.ellendon@health.ny.gov
buprenorphine@health.ny.gov

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Suicide Prevention Program

In New York State (NYS), deaths due to both suicide and overdose pose a major public health concern. The burden of suicide in NYS has increased 29.1% from 1999 to 2016. Although NYS has a low per capita rate, we have one of the highest overall losses of life, losing approximately 1,700 New Yorkers each year to suicide. There are almost 9,000 hospitalizations and almost 12,000 emergency department (ED) visits due to self-harm. Data shows that the risk of a suicide attempt or death is highest within 30 days of discharge from an ED or inpatient psychiatric unit. Studies have also shown that patients who visited the ED for an opioid overdose are 100 times more likely to die by drug overdose in the year after being discharged and 18 times more likely to die by suicide relative to the general population. The risk of suicide among people who use drug (PWUD) and experienced a non-fatal intentional overdose is also greater compared with unintentional overdoses.

Deaths from drug overdoses, alcohol and suicides- known together as “deaths of despair”- have significantly increased between 2005-2017. Opioid use and misuse have a distinctly strong relationship with suicide as compared with other substance use disorders. It can be challenging to know exactly how many opioid overdose deaths are actual suicides, and the intentions of someone with opioid use disorder (OUD) who overdoses may not always be clear. However, the connection between opioid overdose and suicide has appeared to increase over time. Between 1999 and 2014, there have been significant increases in suicides involving opioids among all age groups except teens and young adults; in those aged 55-64, the rate quadrupled. Recent data also suggests that the true proportion of suicides among opioid overdose deaths is somewhere between 20% and 30%, but it could be even higher.

Suicide is preventable. A comprehensive approach to suicide prevention includes the following:

Other prevention measures include understanding shared risk factors (such as adverse childhood experiences and other forms of trauma), addressing the larger mental health context of opioid use and misuse, recognizing the signs of an overdose, knowing the warning signs for suicide, and using surveillance data to monitor non-fatal suicide related events in your county.

NYS Department of Health has been working in conjunction with the NYS Office of Mental Health and Suicide Prevention Center of New York on the Emergency Department Self Harm and Non-Fatal Suicide Related Outcomes grant, to collect and disseminate syndromic surveillance data of suspected suicide-related ED visits (intentional self-harm, unintentional self-harm, suicide attempts, suicidal ideation and intentional overdoes) across upstate New York to county health and mental hygiene departments. Syndromic surveillance is a “near-real-time” method of detecting health events earlier than would otherwise be possible with traditional public health surveillance methods. The goals of syndromic surveillance data are to increase situational awareness and mobilize a rapid response to clusters of heightened activity. Syndromic surveillance data are de-identified and cannot be used for engagement or direct follow-up. The data can be used to monitor how well current response efforts are working and to adjust, as needed. The data may also alert you to something occurring in your area that is causing a chain reaction or start of an epidemic of self-harm. Trends in syndromic surveillance data may also highlight gaps in services, geographic areas for intervention or the need for cross-sector collaboration with organizations that target shared risk factors.

Preventing fatal overdoses and the deaths of despair associated with it demands that we utilize effective harm reduction strategies in addition to addressing the risk factors for suicide that may overlap in those who use opioids. Expanding naloxone distribution and improving access to medication for opioid use disorder (MOUD) may reduce rates of both suicide and overdose. Suicide prevention should also be integrated in critical transition periods during MOUD. The risks of death among those receiving medication-assisted therapy are highest when the

Contact:

Glynnis Hunt
Office of Drug User Health
518-402-7525
Glynnis.Hunt@health.ny.gov

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Local Health Department (LHD) Initiative

Local communities play a critical role in responding to the opioid epidemic in New York State (NYS). Using funds from the Centers for Disease Control and Prevention (CDC), contracts are in place with 24 local health departments (LHDs) in high need counties to prevent and respond to the opioid crisis. These counties were selected based on a combination of two measures: 1) counties that had a higher than NYS mean number of deaths due to opioid overdoses (excluding NYC); and 2) counties that had a burden measure that combined opioid deaths, emergency rooms visits and hospitalizations.

The LHDs are implementing a group of strategies with multiple stakeholders covering four general areas: establishing linkages to care, supporting providers and health systems, partnering with public safety, and empowering individuals.  Activities include expanding/integrating peer support services, increasing access to naloxone and buprenorphine, improving utilization of drug overdose data, and educating providers about CDC guidelines for prescribing opioids. Activities are implemeted in various settings, such as emergency departments, correctional settings, primary care and OB/GYN offices, family planning clinics, pharmacies, and the community at large. When implementing these activities, the LHDs weave in the overarching principles of harm reduction, trauma-informed care, and addressing stigma.

Image of NYS Map: Opioid Prevention and Response Strategies Selected by Funded Counties, 2019

Contact:

Paige Allen
Office of Drug User Health
518-473-5408
opioidprevention@health.ny.gov

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