New York Public Health Now

s3e02 Celebrating Progress and Charting the Path Forward: NYSDOH's Dr. David Holtgrave and Allan Clear Discuss New York State's Downward Overdose Trends

• New York State Deparment of Health (NYSDOH) • Season 3 • Episode 2

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In this episode of New York Public Health Now, Commissioner McDonald and Executive Deputy Commissioner Morne welcome the Department of Health's own Dr. David Holtgrave and Allan Clear to discuss the encouraging trends, indicating a decline in fatal drug overdoses across the state and nation. The nationally-recognized leaders explore the potential reasons behind this positive trend and outline strategies to maintain and accelerate the life-saving progress.

This episode provides a comprehensive data-driven analysis of the overdose trends in New York, including both fatal and non-fatal incidents, and an in-depth conversation about the harm reduction initiatives spearheaded by the New York State Department of Health over the past decades.

Guests discuss how these evidence-based programs have been instrumental in saving lives and reducing the devastating impact of the overdose crisis.

If you have an idea for topics we should discuss, please let us know: PublicHealthNowPodcast@health.ny.gov

Jim McDonald:

Welcome to New York Public Health Now. I'm Dr. Jim McDonald, Commissioner of the New York State Department of Health, coming to you from downtown Albany, the 14th floor of Corning Tower, where we talk about the why, so you can decide what to do. I'm here with Johanne Morne, Executive Deputy Commissioner. Johanne, how are you today?

Johanne Morne:

Thanks so much. I'm excellent, glad to be here today to talk about all the trends and the important trends in fatal overdose data that we're seeing in New York State. Is such a great conversation for us to have.

Jim McDonald:

Yeah, it's a great topic, and I'm glad to have Dr. David Holtgrave back with us today, Senior Advisor here at the New York State Department. Hey, Dr. Holtgrave, how are you today?

David Holtgrave:

Great, Dr. McDonald, it's a pleasure to be with you once again.

Jim McDonald:

Yeah, and it's interesting, through the magic of Zoom, we're going to have Allan Clear with us again from the New York State Department Health, and really good to have everybody with us today. You know, it's really interesting when I think about Allan Clear, he's really someone who not just represents the New York State Department of Health, but really responsible for program planning, design implementation relating to overdose prevention, HIV prevention, low threshold buprenorphine and access to care. This includes what most think of as traditional medical care as well as mental health services. So really the full spectrum of healthcare. Allan really has a rich, rich history in working in public health. He's worked in the field of drug user health since 1990, First as the Executive Director of the Lower East Side Harm Reduction Center, which was one of the first syringe exchange programs in New York State. That's right, Alan was doing this when it was controversial, and then he ran the Harm Reduction Coalition for over 20 years. The Harm Reduction Coalition developed the field of harm reduction through their conferences, trainings and policy work. You know, Allan, in many ways, is one of the, really, the people who first thought of harm reduction and got it started for us. So Allan, thank you for bringing your storied career to the conversation today.

Allan Clear:

Thank you for having me. It's wonderful to be here today.

Jim McDonald:

So I'm here today with Dr. David Holtgrave, and Dr. Holtgrave, you were on our last episode of our podcast New York Public Health now, and you previously outlined your impressive 35 year career in areas of drug prevention, control and substance use policy here in New York State, as well as at the federal level in DC. Now, according to data we have from the Centers for Disease Control and Prevention, fatal drug overdoses are down across the United States, as well as here in New York State, and that includes New York City as well, and the patterns of decline suggest this downturn is real. So it looks like there's actually some encouraging news.

Johanne Morne:

That's right. It is very, very encouraging news. And Dr. Holtgrave, what questions must we address next to maintain and even accelerate the life saving trajectory that we're on?

David Holtgrave:

Thank you, Johanne. I think the new data allows us to ask questions like in detail, what did the new data show us? Why are we seeing this change, and what do we do now to take best advantage of this downturn? And I'll just summarize quickly, the United States data. CDC recently updated their website to show that for the 12 month period ending in April of 2024 there were 101,168 estimated fatal drug overdoses in the US. But if you compare that to the year ending April of 23 in that time period, it was 112,470 so that difference is 10, just a little over 10% and I think that's really encouraging news. We know that fatal overdoses went up a great deal from 2019 through 2021. Began to flatten a bit in the nation in later in 22 and 23 but now we're starting to see a downturn, and to see just over 10% nationally is really important.

Johanne Morne:

Oh, it's significantly important. Have we ever seen such declines, either in the city or the state as a whole?

David Holtgrave:

Well, these are important changes, not only in the nation, but here for us in New York. If we compare those two time periods I described the year ending April of 23 and the year ending April of 24 the decline went from 3,278 fatal overdoses to 3,067 or a 6.44% decrease. If we look at New York State, the rest of the state, outside of the city, it went down from 3,634 to 3,133 or a 13.79% decline. So very important declines seen across the state. And if we add those two numbers together for the state and the city, what we see is a decline from 6,912 to 6,200 and to put that in real terms, that means that there are 712 more New Yorkers still with us than if these changes had not occurred. Now, clearly, every life is precious, and there's still much more work to be done, but the fact that there are hundreds more New Yorkers still with us than if these changes had not occurred has real meaning for communities across the state.

Jim McDonald:

You know, Dr. Holtgrave, I think that's, you know, that's well said, but I want to just bring some context into the conversation. When we talk about fatal drug overdoses, I'm looking at some data in front of me for the United States in genera, and I look back to January of 2015 there are about roughly 50,000 fatal overdoses in the United States, and when I look at the peak of this, it looks like it was around sometime in 23 we had like 110,000 deaths nationally, and where we are now [with the data], you know, April of 24, we're looking at 90,000 overdose deaths. So still, you know, a lot of people are passing away, but I think we have to agree that 50,000 in 15 a different number than, of course, 110,000 in 23 and then down to 90,000 in April of 24, and so as I put that context around us, you know, you've been in this business for 35 years. How long has it been since we've seen fatal drug overdoses at this level in New York State? Could you give us some of that New York State context?

David Holtgrave:

Absolutely. I think there's really two parts to your important question, Commissioner McDonald. The first, as you said, it's taken some years. When we see changes in fatal drug overdoses, it's more like turning an ocean liner than it is turning a speedboat. Unfortunately, it takes time. But now, when we look at the numbers for the nation, we haven't seen fatal overdose numbers this low since June of 2021. For New York City, it's been since November of 22 and for the rest of New York State, it's been February of 2021, so it's really going back in time a couple or three years to earlier levels.

Jim McDonald:

Yeah. Thank you, Dr. Holtgrave. Allan, I want to get over to you a little bit you and I have talked a little bit about this, but I'd like to hear your perspective on the encouraging trends we're seeing. You know, it's difficult to know for certain the root cause or causes of the decline in fatal overdoses, but you've been around a long time. What are your thoughts about the sources of these decreases?

Allan Clear:

Yeah, as you say, Commissioner, have been around a long time, and the AIDS Institute, New York State, Department of Health has traveled along that path with me. From the early 1990s the health department has adopted an approach of harm reduction to work with people who use drugs, and we certainly saw the significance of that when we introduced syringe exchange in New York State. Part of the problem has been that we cannot get ahead of the drug market. It keeps changing, and it's got more and more deadly. So we went from prescription drugs to fentanyl, or from heroin to fentanyl, and now we've got additives in there. So I think what we're seeing is a result of the work that we've put in over the last few decades, and part of that work is listening to people who use drugs as to what might work for them.

Johanne Morne:

Yeah, thanks so much for that, Allan. You know, I heard a story recently on NPR's Morning Edition. It was describing a number of possible causes for the nationwide trend in the decline of drug overdose deaths, including increased use of Naloxone and safer choices among those who use drugs. So are any of the other potential reasons they discussed in that NPR piece, do any of those strike home as a possible point of relevance in New York State and New York City?

Allan Clear:

Yeah, absolutely. You started off with the Naloxone there. We have several pillars to our approach in New York State. One is distributing Naloxone far and wide throughout the state, and we do that with many populations, so everyone from librarians to fire departments to, our harm reduction programs through drug treatment programs. So naloxone is key to what we do. We've also made sure that people have access to buprenorphine, which is a medication that will prevent overdose and build a platform for people to enter into recovery. We have been working with our local health departments, really providing a lot of capacity building and training on how they can approach drug overdose in their jurisdictions, working with them and providing guidance. And you can't do this alone. We do this as a community, working with people who use drugs. They're the ones that are using Naloxone when they receive it from a syringe exchange program. We've really targeted high risk people. The direction we're going in now is checking the drug supply through some of our drug checking programs, which will provide more information for people who use drugs to make the informed decisions they need to stay alive, so the combination of Naloxone, buprenorphine providing a welcoming place for people to go. I mean, I think a lot of what we're doing is addressing stigma and messaging too. You don't have to have an opioid use disorder to die of a drug overdose. No one is particularly safe if you're using drugs, and that people should test their drugs using fentanyl test strips, even if they're not using opioids.

Jim McDonald:

Yeah, Allan, I think you brought up a lot of really important points there. When I think about fentanyl drug strips, like, in other words, why do people do drug checking? It's because if they thought they were going to use cocaine, cocaine and fentanyl. Look the. Same. They're both white powders. So, you know, because, quite frankly, some of the people who haven't overdosed death are people who used fentanyl instead of cocaine, because when people are selling drugs, they're not companies, they're just people. And I think about how Naloxone became a household name, we even saw it distributed in large quantity at our own State Fair, which is interesting, and I think about just how the prescribing of opioids just getting better in healthcare experiences. And I think, too, how we've normalized the conversation getting into treatment, getting buprenorphine is easier. So I think there's a lot of things that work, but there's also all the social drivers. And there's so much to this, it's really, I think, impossible to point to one particular, you know, thing that's really driving down the desk. But I'd like to hear more talking to Dr. David Holtgrave, Senior Policy Advisor here at the New York State Department of Health, and Allan Clear AIDS Institute Director for the Office of Drug User Health at the New York State Department of Health.

Johanne Morne:

Yes, and you know, I don't think I said it up front, so let me say now thanks to both of you for joining us today. You know the timely data regarding the overall downward trend of fatal drug overdoses. It's, it's encouraging. It's welcomed news. That said, we know we still have a lot of work to do. So when we think about the next year, when we think about 2025 what are some of the critical issues that we want and we need to monitor?

Jim McDonald:

Yeah, thank you, Johanne. Love that question. You know, Dr. Holtgrave, I just want to bring this concept to you. We do monitor fatal overdoses, but it's not the only metric we monitor. Non fatal overdoses, that's something we measure, too. Can you talk a little bit about how we measure non fatal overdoses, and what are we seeing when it comes to looking at non fatal overdoses?

David Holtgrave:

Absolutely. Dr. McDonald, that's exactly right. It's important to monitor drug fatal overdoses, but that doesn't capture non fatal overdoses or a number of other aspects with the well being of persons who may be using drugs or on their journey of recovery. And one way of reflecting the non fatal overdoses is the National Highway Traffic Safety Administration uses the emergency medical system data that they have so that when a first responder goes out to respond to an overdose, they collect data on whether or not that's a non fatal overdose or not. And what we've seen, if you look at September of 23 that year to September of 24 the number of all non fatal overdoses in the US is down about 12% and if you look at opioids specifically, it's down about 16.7%. That's really encouraging on the non fatal front as well. And I think it's important to emphasize the non fatal overdoses, because they're a very good predictor of a future fatal overdose. One of the strongest predictors of a fatal overdose is a prior non fatal overdose. Also, that particular dashboard that I'm mentioning lets us look a bit more at health equity. For instance, we can see on that dashboard that American Indian, Alaska Native communities and black communities have higher rates of non fatal overdoses than other communities. So in all of the numbers that we're talking about today, we need to be thinking about health disparities as well.

Jim McDonald:

Yeah, and Dr. Holtgrave, New York State collects other data that might inform this discussion as well.

David Holtgrave:

Yes, exactly.

Jim McDonald:

And I mean, if there's someone in the general public who'd wanted to access that information, how would they go about doing that?

David Holtgrave:

It's readily available on our website, and there's a great deal of very useful information. If you go to the New York State Department of Health website, click on health data, you'll see a number of public health topics, including opioids. And if you click on opioids, you'll get taken right to our opioid data dashboard. Or if you just want to Google New York State Department of Health opioid data dashboard, you'll get right there as well.

Johanne Morne:

Allan, Dr. Holtgrave was talking about the disparities that we see among some individuals. So what about building health equity?

Allan Clear:

Yeah, it's vitally important for people who use drugs, we don't think about the social justice issues when it comes to people who use drugs in general, but the way we have addressed drug use in this country has really impacted the life trajectory of many people who use drugs, especially historically. We've racialized the drug laws and we have, you know, we went into an era of mass incarceration, which has all kinds of repercussions in terms of dividing communities and families, preventing people from working and getting into higher education. There's no grants available and in some places, not even the right to vote. So part of what we've been doing, really is undoing some of that damage and beginning to look at people in terms of health equity, providing access to care where that care wouldn't normally be. Many people use drugs are excluded from services, and I think, the backbone of our work are the harm reduction programs for the people most entrenched in their drug use, and they offer a welcoming hand, which which sounds not that significant, but when you are a person who perhaps are unstably housed, you haven't eaten for a while, you struggle, you're using drugs, which makes sense when you're in that situation. Harm Reduction Program brings you in and draws you in and says, We can clothe you, feed you, provide some of your basic needs. And that kind of work really has a lasting impact on the community. It's not just a one and done. It's really providing a platform where people can begin to grow and thrive in ways which they hadn't been able to do before. One of the things we've done over the last few years is really expand access to harm reduction programs. We now have 30 programs with well over 100 sites, and those programs are offering a helping hand to people. And one of the theories around drug dependence is that the opposite of that kind of addiction is not recovery, but connection. And certainly, our programs are often that connection and welcoming people in to embrace them and show them the support that they need.

Johanne Morne:

So, Allan, based on what you've said, what Dr. Holtgrave has said, it seems to me, and certainly feel free to correct me, that you know, we certainly should take the time to acknowledge, if not celebrate, where we have made some gains. But what we have to ensure is that we sustain what's proven effective, if not, dare I say, double down on those efforts, so that we continue to move in the right direction. From where we are today, from where you were in the 90s, to where we are today. Do you see the the initiatives, the programming, the innovation, and from what you've just said, the person-centered work that New York State is doing is really sort of having a world impact and allowing New Yorkers to head in the right direction as we think about, how do we prevent overdose and how do we work with individuals who use drugs?

Allan Clear:

Yeah, you're absolutely right in terms of... a number of states that are innovators around lots of issues. I mean, for us, it's it's both HIV, but it's also the work we do around harm reduction, where we really are a crucible for developing this kind of work and these kind of interventions, and we are seeing the benefits of that now. So where we might be in the future, I think people should probably look towards where New York is heading, and we are heading in a direction of looking at the drug supply. We are really looking at how we can provide support for people who use drugs in ways that you know, are non traditional. We're also really thinking about how we address trauma, and with all the ideas we have and all the programs and the basis we have to build these off of, no one, I don't think wants to get too optimistic. But if we can continue in this direction, what we can do is life changing for both individuals, families and communities in New York State.

Johanne Morne:

Thanks for that. Dr. Holtgrave, was there anything you wanted to add?

David Holtgrave:

I agree with what Allan just described, and also to say, I think that what's so exciting about the new numbers is that for a long time as fatal overdoses were going up, the conversation was, what do we do to be able to at least flatten the number of fatal overdoses in the US? And when we saw that happen for a while, then the conversation was, what can we do to try and get the numbers to start to go down? And now that we're seeing that the numbers are going down, and it's enough of a pattern now that I think the national conversation in the media is that people are generally in agreement that this is real, that this is a decline. That allows us to have a really important and exciting new conversation. And that is exactly as you said, Johanne, we're not done. We have to double down on our efforts. But how can we best evaluate which of the possible causes of this decline is having the most impact, and how can we emphasize those programs and policies? And also it can let us have a conversation about, how do we keep this downward trajectory going, and how do we even accelerate it? And I think that's a new and welcome conversation, and it also lets us think more broadly about given that we want to continue this downward trajectory, how long would it take for us to think about being able to prevent all fatal overdoses in the US, and how can we best go about it? It's a very important conversation. We're by no means done. There's a lot of impact still to have, and a lot of health equity to build, but it's an exciting new chapter in this conversation. And I think it also says that the services that are out there now really matter and are having an impact. And that's really an important point in all of this as well, too. So thank you for letting me express those few points of view.

Jim McDonald:

Yeah, thank you, Dr. Holtgrave, and I really like the way you framed that. When I look at the data, you know, January of 2015, nationwide, 50,000 overdose deaths. In 2024, 110,000 overdose deaths. Here we sit now in April of 24 with 90,000 overdose deaths. And these are per month data points, and it's really just staggering numbers, so there's an awful lot to do, but I think it's important to frame the conversation about what do we do to prevent all overdose deaths? Because I really think we have to look at this and say, overdose deaths are preventable. They really are. It's not a contagious illness, it's something that can be prevented. And some of that is doing what we're doing, and another is looking at other priorities that optimize everyone's social determinants of health, whether it's housing, education, transportation, access to care, whether it's mental health or any type of health care, and really working on other things where we address what we need to do to eliminate health disparities and really help everyone achieve health equity. And as we get time to end our conversation, I want to pick up on something you said, Allan, which is the opposite of addiction is connection. And I think that concept, the opposite of addiction being connection, is such a really important concept. So I want to thank you both for joining us today for this conversation. Thank you, Allan Clear, and thank you Dr. David Holtgrave, and, of course, our co host, Executive Deputy Commissioner at the New York State Department of Health. Johanne Morne.

Allan Clear:

Thank you all so much. This is this is great, and let's hope we'll come back in a year and say it's plummeted even further.

David Holtgrave:

Thank you so much for having this very important conversation today.

Jim McDonald:

So that's going to wrap it up for today's episode of New York Public Health Now podcast. As always, if there's a topic of interest you'd like to hear us talk about, send us an email at PublicHealthNowPodcast@health.ny.gov

Johanne Morne:

and to hear the latest New York Public Health Now episode on your favorite podcast player app like Apple Podcasts, Overcast, Spotify, YouTube, search by our podcast title, New York Public Health Now, or by keyword, NYSDOH, then tap the subscribe or follow button to be notified when we release a new episode that happens about every other week. And

Jim McDonald:

if you like what you hear, please leave a review for the New York Public Health now podcast. I'm your health commissioner, Dr Jim McDonald,

Johanne Morne:

I'm Johanne Morne.

Allan Clear:

I'm Allan Clear

David Holtgrave:

and I'm David Holtgrave. and thank you for listening.

Monica Pomeroy:

New York Public Health Now is a production of New York State Department of Health's Public Affairs Group. Michael Wren is the executive producer and engineer, with additional production support provided by Sarah Snyder, Genine Babakian, Barbara Stubblebine, Alicia Biggs, Monica Pomeroy and Kyle Kotary, copyright 2024 All rights Reserved. We welcome your feedback. Please email us at PublicHealthNowPodcast@health.ny.gov

People on this episode

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Dr. James McDonald

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Dr. Neil Muscatiello

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Johanne Morne

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Allan Clear

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Dr. David Holtgrave

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