New York Public Health Now
Join New York State Department of Health Commissioner Dr. James McDonald and Executive Deputy Commissioner Johanne Morne as they explore the critical issues, innovations, and initiatives that shape the health and well-being of the people of New York.
You will hear timely conversations with public health leaders on topics like air quality, climate change, opioids and harm reduction, Wadsworth Center, New York’s world-class public health laboratory, New York State of Health, our health insurance marketplace, Medicaid recertification and much more. If it matters to you, chances are we are talking about it on NYSDOH's podcast, New York Public Health Now.
New York Public Health Now
Life-Saving Economics: Naloxone’s Cost-Effective Role on the Opioid Crisis
In this episode of "New York Public Health Now," Commissioner Dr. Jim McDonald and Executive Deputy Commissioner Johanne Morne are joined by Dr. David Holtgrave as they explore the remarkable story of the cost effectiveness of naloxone in New York State.
This episode dives into the real-world impact of naloxone, illuminating stories, budget realities, and lives saved. Learn how New York’s overdose prevention and harm reduction programs are changing lives, the science of measuring cost effectiveness, and why ongoing community engagement remains vital.
If you have an idea for topics we should discuss, please let us know: PublicHealthNowPodcast@health.ny.gov
Hi. I'm Dr. Jim McDonald, Commissioner of the New York State Department of Health. Welcome to the first episode of season four of New York Public Health Now, our podcast, where we talk about the why, so you can help decide what to do. I'm thrilled to be here the 14th floor of Corning Tower on yet another sunny day, and glad to be here with my friend Johanne Morne, our Executive Deputy Commissioner.
Johanne Morne:Well, hello, hello. Glad to join you today and glad to be part of this conversation in a new season. I am also really glad you said it's sunny, but you know what it really is? My favorite season of the year. Fall is here. The colors are changing, and we're back at the table.
Jim McDonald:We're at the table, that's good. Naloxone is it cost effective? And it's our topic for today. Johanne, when you think about Naloxone and when you think about being cost effective, is there anything that comes to your mind as you're thinking about this? I mean, we're going to dive into this conversation with our own guest, Dr. David Holgrave, but as you think about the topic, what comes to mind as we first get into this? Is it cost effective? What would that mean to you?
Johanne Morne:Yeah. So I think the first thing I think about when you ask me if it's cost effective, is, what is the price that we put on a life?
Jim McDonald:Oh, there you go.
Johanne Morne:Right? So to me, yeah, it's cost effective. I'm really looking forward to hear what Dr. Holtgrave has to say as far as the actual efficiency, but at the end of the day, that's what I want to know. How much are we willing to pay to save a life?
Jim McDonald:Health economics, it's our topic today with Naloxone, is it cost effective? So Dr. David Holgrave has been at the New York State Department of Health as a special advisor to me, the Commissioner, since 2024 great to have Dr. Holgrave. Dr. Holgrave has worked for President Barack Obama in doing work with HIV and AIDS. He's done work for President Joe Biden in the Office of National Drug Control and policy. He's a former dean of the School of Public Health now in Albany. Former faculty at Johns Hopkins used to work at the Centers for Disease Control and Prevention. It's great to have Dr. Holgrave here at the New York State Department of Health. Hey, Dr. Holtgrave, how you doing today?
David Holtgrave:I'm doing great, Dr. McDonald, thanks for having me.
Jim McDonald:So it's good to have you back. We've had you last season and the season before. In the season before that, too, you're a frequent guest here because you're just, quite frankly, really good at what you do. But can you just tell us a little bit about yourself, and can you make it interesting, please? I want to know something about you. I
David Holtgrave:Well, I guess I would say, personally, one thing, I'm really committed to[is] rescue efforts, especially for dogs. I'm a dog person, quote, unquote, and usually have between one and three rescue dogs, usually German shepherds, and have two of them right now. So very interested in my off hours, you will usually find me surrounded by German shepherds
Jim McDonald:That is so good. I just want to ask you, if you or other dogs. wouldn't mind, can we name the German shepherd so we can give them a shout out in case they're listening?
David Holtgrave:Oh, sure, yeah, they might be listening. So one goes by Buddy, for short, and his real name is Cyrus, and the other one's name is Alexi.
Johanne Morne:I love it. I too. I'm a dog. Huge dog person as well. So I have, I have two Schnauzers, and just for the sake of it, I'll tell you that their names are Jake and Tilly.
Jim McDonald:I feel like I have to mention Daisy now, or schnoodal at home, a schnoodal, for those who don't know, is a Schneider poodle mix. But that's not why we gathered today to talk about dogs. Naloxone, is it cost effective? Spoiler alert, it is. But Johanne, let's just go further into that. Where are we going next with this conversation?
Johanne Morne:Sure. Well, let's start at the beginning. For anyone who's not aware. Dr. Holgrave, what is naloxone?
David Holtgrave:So naloxone is a medication that's really effective at reducing the effects of an overdose. And how it works is opioids really bind to receptors in the brain and throughout the nervous system, and naloxone is an opioid antagonist, and it can knock opioids off of those receptors, and it can replace them, and that's really important, because if someone's experiencing an overdose, they may have a lot of trouble breathing, they may lose consciousness, and Naloxone can come in and reverse that overdose really quickly. It's really effective.
Jim McDonald:I remember sitting at this very table. I want to say it was about six months ago, you and I were having a regular meeting. We were talking about overdose related work, like we often do, and I asked you the question about, you know, how do we know if naloxone is cost effective? Have we measured that? And we started brainstorming the idea for this study that you did. And I just think, why study the cost effectiveness of any medication?
David Holtgrave:Maybe I'll start by telling a story from when I worked at the Centers for Disease Control and Prevention, when I directed their HIV Prevention Division, we would go see the White House Office of Management and Budget about once a year or so. And a little bit oversimplifying, but generally, they had three questions for us, how do you spend the HIV prevention money you were given? How do we know it's effective, and how do we know it's cost effective? And that last question wasn't about how can we get by cheaply, or how can we minimize these efforts. It was really about saying any budget, no matter how big it is, is finite, and if we have a finite amount of resources, a finite amount of money to spend, we want to get the most public health impact. We want to save the most lives. We want to get the most years of life saved that we possibly can out of it. And that's really to me, what the heart of cost effectiveness is, and much of economic evaluation we're trying to buy, if you will, as much health benefit as we can for the resources available to us.
Jim McDonald:It's running you remind me of this I defined in public health many, many years ago. Like if you had to define public health, one of the ways to define public health is limited resources, optimal outcome.
Johanne Morne:We do have resources, and we have certainly a long standing conversation in New York State as it relates to the distribution of naloxone, so we understand well how effective it can be. But talking about, you know what it is you learned and what it is you published on, what does it mean in the big picture of an opioid response?
David Holtgrave:Absolutely. Well, I would start by saying it's been it was a real honor to get to work on this paper with the commissioner and three of our great colleagues, Allan Clear, Liz Shady, Lucilla Zamboni from the Office of Drug User Health and Dr. Ju Park from Brown University, so I wanted to give a shout out to all of our great colleagues on this paper.
Jim McDonald:Oh, hey, you remind me, Dr. Zamboni will be with us at an upcoming episode on a related topic.
David Holtgrave:One of the things that's so important about how the Office of Drug User Health and the Department of Health overall goes about naloxone distribution is it's through the opioid overdose prevention programs, which are so important here in the state. And by doing that, they can provide not only the product of naloxone, but some training that goes with it. And also they can keep track of not only the distributions, but also how often it's actually used. And knowing the number of administrations, even if it's an underestimate, is really important. It's, I kind of think of naloxone sometimes like fire extinguishers. You want a fire extinguisher in every building. You really hope you never have to use many of those fire extinguishers. Same is true of naloxone. And if you don't know the number of administrations or even a reasonable estimate, it's much harder to know kind of how many lives did I save from how much Naloxone I distributed? So I think that's a really important piece that's unique to the Department of Health.
Johanne Morne:Can I just touch on the training for a second? So when I look at the actual unit of naloxone, it seems fairly easy to administer, right? We've come a long way. Yes. So why are we investing in training? Why does the training matter?
David Holtgrave:I think it matters because one we just to make sure that people are comfortable with how to use it. I agree with you. It's really straightforward. It's really easy. I think one of the other things that's helpful that the opioid overdose prevention program can help with is sometimes the drug supply is changing with fentanyl now, we see adulterants like xylazine, and you really still want to use naloxone. Naloxone will work on the fentanyl part of the overdose, but if xylazine is there, Naloxone doesn't help the xylazine part still got to use Naloxone, got to go after the opioid for sure, but it's important to know that if the person has also ingested xylazine, it's really important to support their breathing over time, and so the nuance of some of the additional information we give does tweak a little bit over time as the drug supply changes.
Jim McDonald:So I'd like to talk a little bit about the results, like we just published this paper in the Journal of Public Health Management in practice. And, you know, but we have results here, and I think it'd be nice to talk a little bit about those results. So can you tell us a little bit about what did we find we were studying? Was Naloxone, cost effective? But what did we actually find?
David Holtgrave:Sure? So we found that in a two year period, from April of '23 to March of'25 that there were a little over 6,500 administrations of naloxone among persons who were experiencing an overdose and survived. And that's really important, because that's a reasonable estimate, then, of the number of lives that we save. So probably these efforts have saved over 6,500 lives in that two year period. And if we compare that to the budget for the program, each life was saved at a cost of about $4,100. And$4,100 to save a life is a tremendous public health bargain. Also, we could estimate, from those estimated lives saved, how many years of life did we save? And that was a little over 204,000 years of life saved. So huge benefit there. And if you look at the budget compared to years of life saved, it was $133 so if you can imagine being able to buy a year of life for $133 a tremendous public health bargain again. And then one other way that we looked at this was the Department of Health and Human Services, for many years, has said, Well, it's hard to put $1 value on a life, and when they think about valuing a Statistical Life. They suggest using a number of ranges, not because there's one magic number you should use, but rather for consistency and transparency. If you have a lot of analyzes going on the field, if everybody agrees to some numbers that they're going to use, the results become more comparable. So we use three values that they recommend, about 6 million, about 13 million and about 19 million per statistical life saved. And if you do that, it suggests that the value of statistical lives saved here was between a little over 39 million to a little over 128 billion. And another way to say that is, for every dollar invested in the program, the statistical life valuation is about $3,219 a tremendous ratio. So this is one of those rare kinds of things that we see in public health, things like some smoking cessation programs, some vaccination programs. You'll see these kind of great return on investments, but this is really a good return.
Jim McDonald:So the return on investment, let's just talk about that, because I think that number $3,219 to $1 I think that's astronomical. Can you explain that again? Just a little bit so we can really understand because that is kind of the point. Like in the answer the question is, is it cost effective? The answer is, it is cost effective, but it's really cost effective, right? Yes. And so can, let's just talk about that number that 3,219 for every dollar.
David Holtgrave:Absolutely. So I think there's a couple of ways to think about it, one of which is that, because that ratio is so big, the $1 to 3,219 it suggests that these results are really robust. So even if somebody looked at this paper and said, Oh, I might have made an adjustment here or an adjustment there, in some other way, this is really robust to Is it the administration, the Naloxone, by itself? Is it part any uncertainty. So it's hard to argue that the fundamental finding is wrong in some way. I think the other thing that this suggests to me is the finding is so impressive and robust is that it suggests that even though in New York we went in 2023 from over 6000 fatal overdoses a year to in 2024 about 4,000 fatal overdoses a year, approximately, we that's such a great benefit to go from 6,000 to 4,000 roughly, in the over that year. But we still have work to do. We still have about 4,000 overdoses that are fatal each year in the state of New York. And what this paper, I think, suggests to me, is naloxone is such a good tool for us to be able to use. It's worth the investment to make sure that we're providing it as many places as we can, in as many ways as we can, to do the rest of the work that's still before us. of a larger package, what is it that's allowing our state to see those reductions? Yeah, well, it's a great it's a great question. Johanne, I think that very reasonable people can have different points of view on exactly what the most important factor is and what goes into that package. I think for me, a good argument can be made that naloxone is incredibly important, whether in the state or nationally, as one really key driver there, because if we're looking at the metric of fatal overdoses, we're really talking about when someone's having an overdose, how do we intervene so that doesn't become a fatality? And that's exactly what naloxone is meant to do. I think, though, when we think about all the metrics we could look at, we could also be looking at non fatal overdoses. We could be looking at the well being of persons who use drugs and their families and their communities. There's a wide variety of other metrics that we can be examining here as well too. But for the specific metric of reducing drug fatalities. I think this is one really key factor, and especially if we compare it with drug checking programs to make sure we know what's in the drug supply. We can pair it with early access to drug treatment. We can combine it with programs like providing stable housing to persons who are unstably housed. All of those things can make it even more effective package I think.
Jim McDonald:You know, it's interesting. I was thinking about something we talked about earlier. We had this paper published in the Journal of Public Health Management in practice, which is a peer reviewed journal. Would you mind just explaining what a peer reviewed journal is? Part of it, because I don't know how many articles you published off top of my head, but when I remember when you first came to me as a candidate for this job, your curriculum vitae, your resume, was like over 100 pages long. How many articles have you published in your career? By the way, do you know off top of your head?
David Holtgrave:If you combine everything, probably a little over 400 if you look at just peer reviewed ones, it's probably in the 350 range, something like that.
Jim McDonald:Yeah so, you published over 350 articles, so you would know what a peer reviewed journal is. So what does it mean when your article is peer reviewed?
David Holtgrave:So peer reviewed is really important. Because what it really suggests is that when you send that paper in, the editors are going to look at it themselves, and they're going to send it out to the field as well, and they're going to send it out to at least 1,2,3,4, people who are going to review it. Often you don't know who those reviewers are, and they're going to give you their candid comments, and especially if it's done in a blind way, well, they're not going to hold back with their opinions about the paper, and that's actually really helpful, because it gives a real debate sometimes over what's the appropriate way to do the analysis, makes you think about things you might not have thought of before, and sometimes it's helpful that it'll improve the paper. You say, "well, I could have done it that way. I'm doing it this way, but I'm gonna be real clear" and transparency is key to science. You can say,"I'm gonna be super clear in the paper." I could have done it one of three ways I chose method B, here's what A and C would have done. And let me just say that. And I think that makes science more reproducible, more transparent and more informative to people. So it's a good quality assurance.
Jim McDonald:you submit a paper to a journal doesn't mean the journal is going to accept it for publication. You know that what they do is have an editor review it, then an editor sends it to peer reviewers, then they decide whether they're going to accept it for publication or not. And part of I think it's important is, you know, when you put something in a peer reviewed journal like this, is Naloxone cost effective? In other words, we did a health economic analysis here and other people checked our math as it were, what you really came down to was, it's really cost effective. So Johanne, we started the conversation was, is a cost effective and you said, well, what's the value of a human life? And I mean, you know, Health and Human Services has a statistical number, which is a little bit uncomfortable to talk about, but when you look at these statistical numbers, it's really for doing health and economic evaluation. So you can understand this. Because really what you're trying to is put this in context. Because really one things we have to get back to is, if public health means I have limited resources to get an optimal outcome, and that's true, by the way, because we don't print money at the New York State Department of Health, we have to make decisions. It's obvious that naloxone is a cost effective public health intervention tool, and so I think that's really an important thing to know, and that's part of what this study did. By the way, I don't think I've ever seen a study that's actually illustrated this before. I think it's one of the things we noticed and we did this, is no one else has done this before.
David Holtgrave:That's right, there had been some modeling studies, a lot of them use distribution numbers rather than administration numbers. And one study in another state looked at administration numbers correlated with fatal overdoses over time. But we're the first ones, I think that used our administration numbers in this way to look at what that whole economic evaluation.
Jim McDonald:And there's a difference right between distribution and administration like, I don't know how many hundreds of thousands of doses we distribute, but they're not all administered, right? It's kind of like your fire extinguisher example. Like, we have five extinguishers all over the state, but not all them are used. But really, what we looked at in this study was sure there's all kinds naloxone. That's why you looked at the whole budget for the whole program. Well, you looked as how many were actually used, and that's really what I think made this study unique, but also powerful.
David Holtgrave:And one thing I'll put in as kind of a public service announcement is we know from a particular data set in the state of New York that about 63% of fatal overdoses occur in the home. And I think when people first hear that number, they're surprised that that's the percentage that occur in the home. I think it makes a good argument that everyone in New York, whether you think you're ever going to need Naloxone or not, if you can access it, get it, be prepared to use it, learn how to use it. And you never know in your home, your neighborhood, your community, your family, it doesn't hurt to have it doesn't hurt to carry it with you or have it around. So I just wanted to put in that plug.
Johanne Morne:That's a really significant point. And you know, the other thing that I want to point out as well, and certainly give huge shout out to the team and to everyone that contributed to this, is understanding that the the purchase, the delivery, the training, the administration, it takes a lot of people to get us to where we are, where we were able to now have a published article, peer reviewed, that actually helps to define what is the return on investment for all of the work that's being done. And I just really, I have to underscore how important the community partners are in these discussions and in the success that we're seeing as it relates to the reduction of fatal drug overdoses.
David Holtgrave:Absolutely. And I think the point you raise is when we do work in substance use harm reduction or other services. [You] really have to start with, where is the person at in their journey? And you can't do that in any other way than starting by listening. In fact, when somebody says, "where do you begin in public health", I would say, "Listen, that's what you do first." And so just to underscore your point,
Jim McDonald:Well, thank you so much for joining us. It was Johanne. great to have Dr. David Holgrave with us, national expert on
Johanne Morne:notified when we release a new episode, which overdose, opiate policy, HIV policy, well recognized public health educator. And what we learned today is also someone who rescues German shepherds, and that's a great thing to be known for as well. And I do want to congratulate the team who worked on this study. It was great to have this study published in the Journal of Public Health Management Practice. But you know, Dr. Zamboni, Liz Shady, Allan Clear and Dr. Park. Really great to see this study published as well. So we are now bringing a wrap to today's episode at New York Public Health Now podcast, as always, if there's a topic of interest you would like to hear us talk about, go ahead and send us an email at publichealthnowpodcast@health.ny.gov happens about every other week.
Jim McDonald:And if you'd like what you hear, please leave a review for the New York Public Health Now Podcast. I'm Health Commissioner, Dr. Jim McDonald.
Johanne Morne:And I'm Johanne Morne.
David Holtgrave:And I'm David Holtgrave.
Jim McDonald:And thank you for listening.
