Episode 26: Dr. Denise Paone and Angela Jeffers, The Relay Program, NYC Department of Health and Mental Hygiene
Dr. Denise Paone and Angela Jeffers from New York City's Department of Health and Mental Hygiene speak about The Relay Program, a non-fatal opioid overdose response service for the New York City community.
Intro Voices [00:00:05] Where do I go? It only happened once. I think I was singled out. The phone calls began about one month ago. What is hazing? Something happened to me when I was younger. I'm worried about my safety. He said he was sorry. Can someone help me? Where can I get help? Can someone help me?
Intro Voices [00:00:31] This is “You Matter”, a podcast for the NYU community developed by the Department of Public Safety.
Karen Ortman [00:00:37] Hi, everyone, and welcome back to “You Matter”, a podcast created to teach, inspire and motivate members of the NYU community who have been victimized in some form or fashion and to identify resources both on and off campus that can help. I am your co-host, Karen Ortman, Assistant Vice President of field operations at the Department of Public Safety and a retired law enforcement professional.
Oatile Ramsey [00:01:01] And I'm your co-host, Oatile Ramsey, an NYU Stern alumni and a current graduate student at Gallatin studying inclusive economic development. If any information presented today is triggering or disturbing, please feel free to contact the Wellness Exchange at 212-443-9999 or NYU Department of Public Safety and the Victim Services Unit at 212-998-2222.
Karen Ortman [00:01:29] Today we introduce Dr. Denise Paone, senior director of research and surveillance in the Bureau of Alcohol and Drug Use Prevention, Care and Treatment at the New York City Department of Health and Mental Hygiene, as well as Angela Jeffers. Angela is the director of the Relay Program, a non-fatal opioid overdose response program run by the Department of Health and Mental Hygiene in New York City. Thank you so much to our guests for joining us today.
Denise Paone [00:01:58] Thanks for having us.
Karen Ortman [00:02:00] So, Dr. Paone, I want to turn to you first and ask you to address this current opioid epidemic that we are experiencing, not only here in New York City, but nationally. And if you could just speak to how we got here.
Denise Paone [00:02:21] OK, so unlike what we see nationally, the overdose epidemic has primarily been driven by opioid analgesics or painkillers. In New York City, we have a different story. And that really has to do because we've had a very long history of a very strong heroin market in New York City. So heroin has played a large part in overdose, back for decades. That's not to say that painkillers, opioids, analgesics did not play a role in New York City, but we really saw an uptick in those like around 2010, 2011. And a lot of the work we did at the Health Department was to address what we call encouraging doctors to prescribe judiciously. I mean, we've really seen a downturn now. But what's also really contributed to this overdose epidemic is fentanyl and fentanyl is a very powerful medication. It's 100 times stronger than morphine. And so what we know from the data here in New York City, really from the NYPD lab, is that fentanyl is found sometimes in heroin, in cocaine, in pills. I mean, it really has driven, excuse me, this increase in overdose deaths.
Karen Ortman [00:03:46] Well, so you mentioned fentanyl. What is fentanyl?
Denise Paone [00:03:50] So there's pharmaceutical fentanyl, which is a very important and effective medication primarily used in surgery. What we're talking about is non-pharmaceutical fentanyl.
Karen Ortman [00:04:03] What's the difference?
Denise Paone [00:04:05] Well, it's manufactured primarily in China. There is no control over it. It's shipped into the country in different ways and it's cut into different, you know, drugs. And so there's really, there's no control. And because it is so powerful, just a very little bit of it can really have very deadly consequences. So we do a lot of messaging around to people who use drugs to alert them that the substances they're using might have fentanyl and how to protect themselves.
Karen Ortman [00:04:36] So could you also explain to our listeners the relationship between opioids, painkillers and heroin?
Denise Paone [0:04:49] So in the end, they're both the same. You know, they're both pain medications.
Karen Ortman [00:04:53] Does one lead to the other, though?
Denise Paone [00:04:55] Not necessarily. I mean, some people who, you know, their pathway may have been for legitimate medical reasons were prescribed painkillers and developed a dependency and never, you know, progressed to something else. But they have an opioid use disorder. Some people never go through that pathway and use heroin. But they'll have - it’s the same disorder and it can be treated in the same way with medications, which is a big part of the work we do. You know, thinking about like, well, what do we do to try to reduce this epidemic? So what the city's been doing, starting in 2017, the mayor announced a new initiative called Healing NYC and invested $60 million annually. A lot of those initiatives live with us at the Health Department. And there are two major things that we can do. One is to increase access to this medication called naloxone. And naloxone is a medication that reverses opioid involved overdose deaths. The Health Department was committed to distributing 100,000 naloxone kits to anyone in New York City who wanted them. We exceeded that and actually distributed 125,000 in 2018. This is really important, I think, also for your audience to know that there are three ways that you could obtain a naloxone kit. You could call the health department where we do our own trainings. People come for a short training to see, to learn the signs and symptoms of an overdose and how you administered naloxone. They could call to be referred to other programs that we sponsor, overdose prevention programs. Or they could actually go into pharmacies without a prescription, they can get a naloxone kit. And most insurance pays at least partly for the naloxone. But there's definite access to naloxone in New York City. And we've done a lot of advertising. You probably have seen it.
Karen Ortman [00:07:02] That is interesting. So anyone interested in obtaining naloxone can obtain it?
Denise Paone [00:07:07] Absolutely. And it's fairly easy to do that. And it's easy to administer. So we really encourage people, if there's someone in your life, a friend, a family member or roommate that you know has an issue with opioids, to learn how to administer naloxone because you really can save a life.
Oatile Ramsey [00:07:28] Turning to Angela. I was wondering what Relay was and how it serves New York City residents.
Angela Jeffers [00:07:34] Something that we know is that people who experience a non-fatal opioid overdose are two to three times more likely to experience a subsequent oftentimes fatal overdose. We also know that people who overdose are transported to emergency departments. And oftentimes emergency departments around New York City don't have standardized protocols for handling people that come in for overdoses. That's changed quite a bit in the last few years. So as a result of these factors, Relay was created to serve this really vulnerable population of people who have overdosed. So what Relay does is we collaborate with emergency departments around the city so that when they have a patient that has survived an overdose come into their emergency department, they can call us 24 hours a day, seven days a week, and we'll dispatch someone called a wellness advocate. And this is a peer advocate, someone who has firsthand lived experience with substance use, who will then travel to the hospital, get there within an hour and engage with the patient in the hospital bedside, offer them support, overdose, risk reduction, counseling. They’ll offer them overdose response training, train them how to use naloxone and work with them in the emergency department to identify any support services they might be interested in at that moment. So that might include drug treatment like methadone or buprenorphine. That might mean harm reduction services like Syringe Service Program and it might mean other support services like case management or emergency housing or mental health services. Our wellness advocates, once the patient is discharged, continue to follow that patient for an additional 90 days to continue to offer them peer support and connection and linkage to support services.
Karen Ortman [00:09:42] Does the person in the hospital who just experienced the overdose have to consent for the advocate to become involved in their case.
Angela Jeffers [00:09:54] Yeah. No, this is not a required service. Patients consent into the program and consent to continued follow up with our wellness advocate.
Karen Ortman [00:10:07] So you said that the wellness advocate has a background in firsthand, is it a stretch to say actual addiction?
Angela Jeffers [00:10:18] Yeah.
Karen Ortman [00:10:19] It is a stretch?
Angela Jeffers [00:10:20] No, no, it's not a stretch.
Karen Ortman [00:10:22] OK, so the wellness advocate is a recovering addict.
Angela Jeffers [00:10:27] Many of our wellness advocates have former experience using drugs. Many of them come to us already as trained peer advocates. A good many of them are called certified recovery peer advocates or CRPAs, which is a New York state certification that requires 46 hours of training, 500 hours of work experience and passing of a certification exam. They also get 36 hours of onboard training to learn how to run the program and ongoing supervision and training with the program. And many of them come to us already with lots of years of experience working as peer advocates in the substance use or harm reduction fields.
Karen Ortman [00:11:22] How many wellness advocates do you have?
Angela Jeffers [00:11:26] So right now, I believe, we are expanding. We currently are at twelve hospitals across New York City across all five boroughs, including two NYU sites, NYU Langone Tisch and NYU Langone, Brooklyn in Sunset Park, we’re expanding to a total of fifteen hospitals by the end of June this year. I believe, to answer your question, we're expanding. So it's hard for me to keep track of the numbers. I believe right now we have 60 wellness advocates and so we'll be increasing those numbers a bit by the end of the year.
Karen Ortman [00:12:04] So how did the both of you become involved in relay? Doctor Paone, how did you become involved in relay?
Denise Paone [00:12:13] Basically, as part of our bureau work in how to address and really be committed to helping to reduce overdose deaths in New York City. And I think it's important, you know, to just point out that the work we do is very evidence based in New York City. And as Angela pointed out, we know from the science that people who have had a non-fatal overdose are at great risk for a recurrence, a subsequent overdose. And this is where, you know, Relay came in. We saw a need, we saw this gap. And so we developed this program.
Karen Ortman [00:12:47] Okay. And Angela?
Angela Jeffers [00:12:50] So I moved to New York City 15 years ago, and my first job here was working with a program that did HIV risk reduction, HIV education and reproductive health care with women in methadone clinics in the South Bronx. And I started a peer program within that program. And so I've been doing work in substance use and with peers for quite some time and continue to work in the Bronx and in substance use. And so it's just been sort of a natural progression that I landed here.
Karen Ortman [00:13:26] Angela, can you give our listeners an example of someone who may have been served by Relay and what that experience would look like?
Angela Jeffers [00:13:39] Oftentimes when we work with participants and Relay, over the course of 90 days, we connect them to drug treatment services or harm reduction services in a sort of an ongoing process. But we last month had a case where our impact was felt very quickly. We had a participant come into one of our hospitals on a Friday night. This was somebody who overdosed on heroin. He was a regular heroin user and was eager to speak to one of our wellness advocates. He was interested in being involved in the program, interested in meeting with our wellness advocate on a regular basis, had previous experience in using buprenorphine to treat his addiction, but wasn't interested at that point in learning about buprenorphine. What he was really most interested in in the emergency department was learning about fentanyl, naloxone and learning how to not overdose again. And I feel like this is where our program really fits in a niche where I think a lot of people - you're going to ask a question?
Karen Ortman [00:14:51] I'm sorry, I hate to interrupt you. But so am I to believe that this person had no intentions of stopping using heroin. They just wanted to prevent the overdose. Is that correct?
Angela Jeffers [00:15:03] That’s correct. Yeah. And when that happens, a lot of people are not always willing and ready to stop using drugs. And our program is patient centered and based in the tenants of harm reduction. We meet people where they're at. And this person was not ready to stop. But this is where I think we fit in the healthcare system where I think a lot of times people have a hard time saying to their medical professional or their doctor, I'm not ready to stop using drugs, but I don't want to die. Yeah, how can I do that? And talking to a peer, it oftentimes is easier to have that conversation. So we talked to this guy, about naloxone, we educated him about fentanyl in the drug supply. We gave him some very individualized overdose risk reduction tips. He had been using alone. So we talked to him about not using alone. We talked to him about when you're using with someone else, taking turns. And we also talked to him about using drugs slowly. Those are some very specific risk reduction tips that we oftentimes share with people. And so this gentleman went on to continue to meet with his wellness advocate. And still is, this just happened a few weeks ago. And so fast forward two days to Sunday. A different hospital patient comes in, has overdosed. Wellness advocate gets called in, engages with this participant. And we find out through the course of our engagement with him that this new patient had been using drugs with the participant that we met with on Friday night who had gone out and used all of the risk reduction tips that we had given him - he was using with friends, they were taking turns, he had naloxone on hand. His friend overdosed. He used the naloxone kit that we gave him on Friday, reversed the overdose, called E.M.S. and E.M.S. came and took this new participant to a hospital where we then continued engaging with him as well.
Karen Ortman [00:17:16] So it worked.
Angela Jeffers [00:17:17] So it works.
Oatile Ramsey [00:17:17] That's incredible, that sounds great. I was curious, I wanted to take a step back and clarify something. You mentioned buprenorphine, you know, as a treatment and I was wondering if you'd speak more to that and what exactly that is.
Angela Jeffers [00:17:31] I'm going to turn that over to Denise.
Denise Paone [00:17:33] Yes. So it's really important when we think about, you know, some of the challenges around addiction, because oftentimes the way we approach it is not from science and evidence based. And even though we're in the midst of an opioid overdose epidemic, we have two medications that really are effective, methadone and buprenorphine. And I think it's really important for your listeners to know that buprenorphine can be prescribed from primary care doctors offices as well as many clinics around the city. And it's very effective. So we know that when somebody is in long-term treatment, it really reduces their risk of a fatal overdose. And people can learn about that by calling New York City Well or calling 188-NewYorkCityWell. And we can, you know, make referrals to that treatment.
Karen Ortman [00:18:34] Great. Thank you. Is there a limit to the services provided by the Relay program?
Angela Jeffers [00:18:41] That's a good question. And so, you know, we only respond to people who have overdosed. And so you can't elect into the program. You’ve got to reach out to us and say you want to be connected to appear. Once you are consented into the program and are working with us, we work with you only for 90 days.
Karen Ortman [00:19:02] OK. So there is a limit. So there's a 90 day limit.
Angela Jeffers [00:19:05] A 90 day limit, correct.
Karen Ortman [00:19:06] Is there a common resource offered to these clients beyond the 90 days? Is there an alternative program you send them to?
Angela Jeffers [00:19:18] So the goal of our program, we really think about ourselves as a bridge to long term services. That's what our goal is. We want to help people identify what long term support services they need and help connect them to those services. So that's our goal, is to connect them to long term services that are going to help support them to help reduce the likelihood that they're going to overdose again.
Karen Ortman [00:19:43] Can you describe the professionals associated with the Relay program? Are you in a building together? When someone goes for counseling with a wellness advocate is it at a hospital or is it in a building called Relay Program Building? What is it?
Angela Jeffers [00:20:09] That's a good question. So we are located at the offices of the New York City Department of Health and Mental Hygiene. We're run out of that office. We respond to calls from hospitals from that office, Monday through Friday, 7:00 a.m. to 7:00 p.m. But we're a 24/7 program. So we also have staff who are on call round the clock. And so we have staff who respond to calls from home.
Karen Ortman [00:20:41] Mm hmm.
Angela Jeffers [00:20:41] Overnights and on weekends, when the staff are meeting with participants during the 90 days of follow up, we meet with them wherever they need to be met with. Again, we meet people where they're at. So they want to meet at McDonald's to have a conversation, we meet with them there. If they want somebody to escort them to a methadone clinic we will escort them there. If they need somebody to go sit with them at HRA all day we will go sit with them at HRA all day.
Karen Ortman [00:21:15] So you really provide a personal sort of service for whatever the need might be. That's great. Do you operate beyond the boundaries of New York City?
Angela Jeffers [00:21:27] We don't. So as Denise mentioned, Healing NYC, which is New York City's response to the opioid crisis funds Relay, as well as Health and Hospitals, to run peer led programs in emergency departments across the city. So Relay is in private hospitals in New York City, and our colleagues at health and hospitals run a somewhat similar peer led programs in their EDs. So we function within the confines of New York City's five boroughs. However, there are similar peer led programs popping up around the state and in different jurisdictions around the country. I think this model of utilizing peers to engage with people is working and people are trying to really promote it both within emergency departments and throughout hospital systems.
Karen Ortman [00:22:29] Do you have a 1-800-number?
Angela Jeffers [00:22:32] No, we do not.
Karen Ortman [00:22:34] OK, so you have a 24/7 operation and you have, I guess, wellness advocates on call. So those calls I presume come from the hospitals to that number. They do not come from the client.
Angela Jeffers [00:22:52] Right.
Oatile Ramsey [00:22:52] Thank you so much. We've touched on a lot in this conversation. I was wondering if there's anything else you'd like to share with our listeners about Relay that we haven't quite discussed yet.
Angela Jeffers [00:23:04] Yeah, so we have been running now for two and a half years. And from when we launched in June of 2017 through December, we have engaged over fourteen hundred participants and distributed over twenty two hundred naloxone kits. And I think one of the interesting things that we have identified as that over 60 percent of the people that we have distributed naloxone kits to have reported that this is the first time they've ever been given a naloxone kit. So this indicates to us that we are reaching individuals who are at risk, who aren't otherwise being touched by other efforts to address the opioid crisis. So we do feel like we're successfully reaching the people that we really want to be reaching.
Karen Ortman [00:23:59] Congratulations on that, by the way. It's a great service you're providing. Dr. Paone?
Denise Paone [00:24:04] Yeah, I think it's important to also raise the issue of stigma, which really is entrenched and very powerful when we're talking about drugs and people who use drugs. We're very careful to use very person centered language because language really stigmatizes people. And I think that we really know that one of the challenges is because of the stigma, which really has negative consequences. We don't always use the best treatment. So oftentimes we think that people need to be detoxed. Detox is not treatment that actually increases the risk for an overdose. So I think that, you know, helping to reduce stigma is really important in the long run. Again, because we have those treatments that I mentioned that are very, very effective, like methadone and buprenorphine. And so anything that we all can do to help contribute to decreasing stigma actually has positive, you know, outcomes for people who use drugs.
Karen Ortman [00:25:13] Sure. You mentioned being person centered. Can you explain to our listeners what that means?
Denise Paone [00:25:19] Right. I'm sure you're familiar with people, maybe you don't hear it as often, but, you know, they would refer to people who use drugs as junkies or even just defining them as addicts as it makes up their whole being, is that they're an addict. So we just use our words, like we tell children, people who use drugs. People who have an opioid use disorder. And we center that, that it can be treated within the medical community and therefore, we should use the evidence base that we know. It's like for a diabetic, you wouldn't say, “Well, we know insulin really is the standard of care, but we're gonna chastise people that they should just eat a better diet and maybe withhold their insulin,” you know? So there's like, yeah.
Karen Ortman [00:26:03] Almost like victim blaming.
Denise Paone [00:26:04] Victim blaming, yeah. You're blaming the victim.
Karen Ortman [00:26:06] Okay. Thank you very much.
Oatile Ramsey [00:26:10] Thank you to our guests, Dr. Paone and Angela and to all our listeners for joining us for today's episode of “You Matter.” Please share, like, and subscribe to “You Matter” on Apple Podcast, Google Play or Spotify.