Public Health Detailing—A Successful Strategy toPromote Judicious Opioid Analgesic Prescribing

Jessica A. Kattan, MD, MPH, Ellenie Tuazon, MPH, Denise Paone, EdD, Deborah Dowell, MD, MPH, Linda Vo, MPH, Joanna L. Starrels,MD, MS, Christopher M. Jones, PharmD, MPH, and Hillary V. Kunins MD, MPH, MS

Objectives. To evaluate knowledge and prescribing changes following a 2-month

public health detailing campaign (one-to-one educational visits) about judicious opioid

analgesic prescribing conducted among health care providers in Staten Island, New York

City, in 2013.

Methods. Three detailing campaign recommendations were (1) a 3-day supply of

opioids is usually sufficient for acute pain, (2) avoid prescribing opioids for chronic

noncancer pain, and (3) avoid high-dose opioid prescriptions. Evaluation consisted of

a knowledge survey, and assessing prescribing rates and median day supply per pre-

scription. Prescribingdata fromthe3-monthperiodbefore the campaignwere compared

with 2 sequential 3-month periods after the campaign.

Results. Among 866 health care providers visited, knowledge increased for all 3

recommendations (P< .01). After the campaign, the overall prescribing rate decreased

similarly in Staten Island and other New York City counties (boroughs), but the high-dose

prescribing rate decreasedmore in Staten Island than in other boroughs (P< .01).Median

day supply remained stable in Staten Island and increased in other boroughs.

Conclusions. The public health detailing campaign improved knowledge and likely

prescribing practices and could be considered by other jurisdictions to promote ju-

dicious opioid prescribing. (Am J Public Health. 2016;106:1430–1438. doi:10.2105/

AJPH.2016.303274)

Opioid analgesic misuse and overdoseconstitute a national public health crisis.1

In New York City, opioid analgesic overdosedeaths increased 267% (from 0.9 to 3.3 per100 000 New Yorkers) between 2000 and2011. Among New York City’s 5 counties(boroughs), Staten Island’s opioid analgesicoverdose death rate was more than 3 timeshigher than that of other boroughs in 2011.2

Nationally, rising rates of opioid analgesic–associated overdose deaths have occurredconcurrently with increases in opioid pre-scribing.3 In addition, higher dosages and longerduration of opioid treatment are associatedwithincreased overdose risk.4–6 Compared withother New York City boroughs, Staten Islandpatterns of filled opioid prescriptions carry in-creased overdose risk, including higher percapita rates of opioid prescriptions and ofhigh-doseopioidprescriptions (> 100 total dailymorphine milligram equivalents [MME]), andlonger median prescription duration.7 In light

of the association between opioid prescribingpractices and opioid overdose risk, effectivestrategies that change opioid prescribingpatterns are urgently needed, particularly toencourage practices consistent with judiciousopioid prescribing, such as those included in theCenters for Disease Control and Prevention’srecently released guidelines, and thosepreviously released by the New York CityDepartment of Health and Mental Hygiene(DOHMH).3–6,8,9

In response to the disproportionate opioidanalgesic overdose death rate and higher-risk

prescribing practices identified in Staten Is-land, DOHMH conducted a public healthdetailing campaign on judicious opioid pre-scribing among Staten Island health careproviders during June 10 through August 6,2013. Public health detailing, modeled afterthe pharmaceutical sales strategy, is an ap-proach used to facilitate change in clinicalpractice through brief one-to-one educa-tional visits. Public health detailing campaignsare focused on specific clinical topics, em-phasize a limited number of keymessages, andoffer practice tools, provider information, andpatient education resources at the one-to-onevisits.10 Previous public health detailingcampaigns conducted by DOHMH success-fully changed self-reported clinical practicebehavior.11 A meta-analysis of educationaloutreach visits by trained persons to healthcare professionals, as is performed in publichealth detailing, found associated changes inprescribing practices.12 In Utah, a detailingcampaign specifically designed to changeopioid prescribing practices demonstratedthat group detailing of health care providerswas associated with improved self-reportedopioid prescribing practices.13 In 1 NorthCarolina county, evaluation of a one-to-oneopioid analgesic detailing campaign that fo-cused on chronic pain suggested that theintervention changed prescribing behaviors,but did not report opioid prescription data orself-reported prescribing practices.14 In lightof this body of literature, we hypothesizedthat knowledge changes promoted by our

ABOUT THE AUTHORSAt the time of the study, Jessica A. Kattan, Hillary V. Kunins, Denise Paone, and Ellenie Tuazon were with the New YorkCity Department of Health and Mental Hygiene, Queens, NY. Deborah Dowell, Christopher M. Jones, and Linda Vo werewith the Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Atlanta, GA.Joanna L. Starrels was with Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY.

Correspondence should be sent to Jessica A. Kattan, MD, MPH, New York City Department of Health and Mental Hygiene,Bureau of Alcohol and Drug Use Prevention, Care, and Treatment, 42-09 28th St, 19th Floor, CN#14, Queens, NY 11101(e-mail: jkattan@health.nyc.gov). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.

This article was accepted May 16, 2016.doi: 10.2105/AJPH.2016.303274

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detailing campaign would improve opioidprescribing practices in Staten Island.

Our detailing campaign on judiciousopioid prescribing in Staten Island was basedon DOHMH’s judicious opioid prescribingguidelines that had been released citywide in2011.9 As kick-off events to the detailingcampaign, we convened 2 physician confer-ences focused on judicious opioid prescribingthat were led by the Health Commissionerand held at the main Staten Island hospitals.

Promotion of judicious opioid prescribingwas one part of DOHMH’s multiprongedpublic health response that was implementedduring 2011 to 2013 to address the opioidanalgesic overdose crisis. In addition to theStaten Island detailing campaign and theguidelines upon which it was based, salientcomponents of the multipronged responseincluded dissemination of borough-specificoverdose mortality data highlighting thedisproportionate overdose mortality ratein Staten Island, airing public service an-nouncements featuring Staten Islanders, andadapting guidelines for emergency de-partments citywide. Full details are publishedelsewhere.15 These efforts occurred in addi-tion to ongoing, previously establishedDOHMH initiatives to increase access tomedication-assisted treatment of opioid usedisorder (e.g., methadone, buprenorphine),and to support harm-reduction strategies(e.g., distribution of naloxone), both ofwhichaddress all types of opioid drugs, includingheroin. Concurrently, there was substantiallocal Staten Island media coverage about therisks of opioid analgesics, and a state law(Internet System for Tracking Over-Prescribing [I-STOP]) took effect in August2013 requiring prescribers to review patientdata in New York State’s PrescriptionMonitoring Program (PMP), a registry offilled controlled substance prescriptions, be-fore prescribing controlled substances.16

Among all of these elements, the only sourcesof messaging addressing specific prescribingrecommendations during 2011 to 2013 wereDOHMH’s citywide judicious opioid pre-scribing guidelines (2011) and the emergencydepartment–adapted version (January 2013),and the Staten Island public health detailingcampaign and its accompanying kick-offphysician conferences (June–August 2013).

Our objective was to evaluate changesin knowledge and prescribing practices

associated with DOHMH’s public healthdetailing campaign to promote judiciousopioid prescribing conducted in Staten Island.

METHODSOur intervention design for the public

health detailing campaign used a broad andinclusive public health approach—targetinga large proportion of health care providers ina community, regardless of individual pre-scribing practices. We included physicians,nurse practitioners (NPs), and physician as-sistants (PAs), because all of these professionsare permitted to prescribe opioids in NewYork State.We obtained health care providerinformation from the National ProviderIdentifierRegistry; at the time of the detailingcampaign, an estimated 1648 physicians, NPs,and PAs with identified specialties wereknown to practice in Staten Island; of these,1182 were targeted on the basis of beingspecialties likely to involve outpatient, non–end-of-life care (e.g., internal medicine, or-thopedic surgery).

InterventionTo conduct the public health detailing

campaign, health department representativesarrived unannounced to practices, first in-troducing front-desk staff to the campaign,and then either waiting to visit with healthcare providers or returning at a mutuallyagreed upon time. Strategies used to highlightthe campaign’s relevance to health careproviders and other office staff includedshowing visual displays of the dispropor-tionate opioid analgesic overdose death rate inStaten Island and framing the problem asa community issue. During the one-to-onevisits with health care providers, health de-partment representatives delivered detailingcampaign recommendations and provided“action kits” that contained additional re-sources. Detailing campaign recommenda-tions, based on the previously publishedDOHMH judicious opioid prescribingguidelines, were (1) a 3-day supply of opioidsis usually sufficient for acute pain, (2) avoidprescribing opioids for chronic noncancerpain, (3) avoid high-dose opioid prescriptions(i.e., ‡ 100 total daily MMEs).9 Regardingthe latter recommendation, instruction on

MMEs is generally not a routine part ofclinical training, and, therefore, was antici-pated to be novel technical information forhealth care providers. Resources in the actionkit included a letter from the city HealthCommissioner, a copy of the DOHMH ju-dicious opioid prescribing guidelines, NewYork City borough-specific data on opioidanalgesic overdose deaths and prescribingpatterns, information about an online MMEcalculator developed by DOHMH, and pa-tient informational material.

Figure 1 shows a poster for patient ex-amination rooms developed for the detailingcampaign with messaging tailored to StatenIslanders. Representatives attempted to gar-ner buy-in from as many office staff as pos-sible, recognizing that non–health careprovider staff members play an instrumentalrole in championing new practice initiatives.Our operational protocol allowed represen-tatives to detail additional health care pro-viders whomet targeting criteria but who hadnot been identified with the National Pro-vider Identifier Registry when encounteredin the field. An initial and follow-up visit wasattempted for each health care provider.Ninety-one percent of initial visits werecompleted during the first 4 weeks of thedetailing campaign. All follow-up visits werecompleted during the last 4 weeks of thedetailing campaign. The average time be-tween initial and follow-up visitswas 4weeks.The average duration of initial and follow-upvisits were each 13 minutes.

The 2 main outcomes were changes inknowledge among detailed health care pro-viders and changes in opioid prescribingpatterns among all Staten Island prescribers.

Evaluating Knowledge ChangeData source. To evaluate changes in health

care provider knowledge, representativesverbally administered a brief, standardizedsurvey to health care providers at initial(baseline) and follow-up visits including 1question on each of the 3 recommendations(Table 1). At all visits, the survey was ad-ministered before discussion of the recom-mendations and reviewing kit material.

Measures and statistical analysis. We di-chotomized responses as consistent (correct)or inconsistent (incorrect) with recommen-dations. Among health care providers with

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FIGURE 1—Patient Examination Room Poster Promoted During Opioid Analgesic Public Health Detailing Campaign: Staten Island, NY, 2013

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both baseline and follow-up visit surveys, wecompared the proportion of responses thatwere consistent with recommendationsat baseline versus at follow-up by using theMcNemar test. To assess for differencesamong participants lost to follow up, wecompared baseline responses of health careproviders who completed both baseline andfollow-up visit surveys to those with onlybaseline surveys.

Evaluating Opioid AnalgesicPrescribing Patterns

Data source. To evaluate changes in opioidprescribing patterns among Staten Islandprescribers, we used de-identified data fromNew York State’s PMP about schedule IIopioid prescriptions written by New YorkCity prescribers and filled by New York Cityresidents, with borough as the most specificgeographic unit available. We defined NewYork City prescribers’ location by licenselocation; for prescribers with more than 1license location, we used the most frequentlocation.

Measures and statistical analysis. We cal-culated 3 prescribing indicators: prescribingrate (number of prescriptions per 10 000New York City residents), high-dose pre-scribing rate (number of high-dose pre-scriptions, defined as greater than 100 totaldaily MMEs per 10 000 New York Cityresidents), and median day supply per

prescription. We calculated these indicatorsfor three 3-month periods: precampaignperiod (March–May 2013), postcampaignperiod 1 (September–November 2013), andpostcampaign period 2 (December 2013–February 2014) to assess immediate andlonger-term changes.

We compared these indicators for StatenIsland versus the other 4 New York Cityboroughs combined (Bronx, Brooklyn,Manhattan, and Queens) by New York Citylicense location. We combined the other 4New York City boroughs because previousPMP analysis clearly indicated that StatenIsland patterns of filled opioid prescriptionscarried increased overdose risk comparedwith the other boroughs. We age-adjustedrates by using New York City populationestimates for 2013 and Census 2000 USstandard population. We tested rate changesbetween the precampaign period and post-campaign periods 1 and 2 for Staten Island andseparately for the other New York Cityboroughs by using z-test comparisons. Tocompare rate changes over time betweenStaten Island and the other New York Cityboroughs, we used a difference-in-differencesmethod, testing rate trends with Poisson re-gression model, with offset of person-time.The model included main effect terms(borough, time) and an interaction termbetween the main effects (borough*time).We performed analyses in SAS version 9.2(SAS Institute Inc, Cary, NC).

RESULTSA total of 1069 health care providers were

surveyed at initial visits (90% of the totalnumber targeted [1182] during detailingcampaign planning). Among those surveyedat initial visits, 866 (81%) were surveyed atfollow-up visits. Baseline responses to the 3questions did not significantly differ betweenhealth care providers with both baseline andfollow-up visit surveys and those with onlybaseline surveys. At baseline, 64% of re-spondents responded that a 3-day supply isusually sufficient for acute pain, comparedwith 90% at follow-up (P< .001); 55%responded at baseline that evidence is in-sufficient for using opioids to treat chronicnoncancer pain, compared with 64% atfollow-up (P< .001); and, at baseline, 22%correctly reported DOHMH’s high-dosethreshold (100 total daily MME), comparedwith 58% at follow-up (P< .01; Table 1).Figure 2 shows the flow of health care pro-viders, starting with those known to practicein Staten Island according to the NationalProvider Identifier Registry and ending withthe final sample of those who completed bothbaseline and follow-up visit surveys.

The prescribing indicators for each detailingcampaign period are displayed in Table 2 andFigure 3. The prescribing rate in Staten Islanddecreased from 889 prescriptions per 10 000New York City residents in the precampaignperiod to 785 prescriptions per 10 000

TABLE 1—Health Care Provider Baseline and Follow-up Survey Responses—Opioid Analgesic Public Health Detailing Campaign:Staten Island, NY, 2013

Recommendation Survey QuestionCorrect BaselineResponse, No. (%)

Correct Follow-upResponse, No. (%) P a

A 3-d supply of opioid analgesics is

usually sufficient for acute pain. (N = 842)

Is a 3-d supply of opioids usually sufficient

to control acute pain in your patients?b537 (64) 762 (90) < .001

Avoid prescribing opioid analgesics

for chronic noncancer pain. (N = 814)

Is there evidence for using opioids to treat

chronic pain that is not related to cancer?c444 (55) 519 (64) < .001

Avoid high-dose opioid analgesic

prescriptions. (N = 780)

When prescribing opioids, it can be useful

to calculate the total morphine equivalents

that a patient is taking per day. How many

morphine equivalents do you consider to be a threshold

for increased overdose risk?d

171 (22) 454 (58) < .01

aP value generated from the McNemar test.bFor first survey question, correct baseline and follow-up response: yes; incorrect responses: no, sometimes, do not know.cFor second survey question, correct baseline and follow-up response: no; incorrect responses: yes, somewhat, do not know.dFor third survey question, correct baseline and follow-up response: 100 morphine milligram equivalents (MME); incorrect responses: 1–19MME, 20–49MME,50–99 MME, 101–119 MME, 120–149 MME, 150–199 MME, ‡ 200 MME, it depends, there is no threshold, do not know.

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Health care providers (HCPs) known topractice in Staten Island per NPI Registrya,b

(n = 1648)

Excluded HCPsbased on NPI

specialty(n = 466)

HCPs with no visitattemptedf

(n = 524)

Additional HCPs withtargeted specialties

identified in the fieldduring campaign

operationse

(n = 601)

HCPs targetedfor detailing

campaign basedon NPI specialtyc

(n = 1182)

HCPs visited byhealth department

representatives(n = 1242)

Attempted,unsuccessful HCP

visitsg

(n = 173)

HCP initial(baseline) visits

completed(n = 1069)

HCPs with baseline but nofollow-up visits completed

(n = 203)

HCPs with both baseline andfollow-up visits completed

(n = 866)

Phone/Internetverification process

prior to campaign, 20HCPs deleted and 3

HCPs addedd

(n = 1165)

HCPs with the potential to bevisited during campaign

(n = 1766)

Note. NPI =National Provider Identifier.aHCP types were physicians, nurse practitioners, and physician assistants.bRepresents HCPs with identified specialties.cTargeted specialties were those likely to involve outpatient, non–end-of-life care.dContact information for targeted HCPs from NPI-based list were preverified by calling and searching the Internet. Pertinent information was updated; HCPs were onlyremoved from the list at this point if definitive information was obtained indicating that an HCP was no longer practicing in Staten Island.eMethods by which health department representatives encountered these additional HCPs included identifying them while visiting practices of HCPs who were on NPI-based list, and canvassing assigned geographical territories for signage indicating practices of HCPs who were not on NPI-based list. Detailing campaign operationalprotocol allowed for health department representatives to detail additional HCPs who met targeting criteria but who had not been identified by using the NPI-based list,when encountered in the field.fReasons that visits were not attempted included upon arrival, health department representatives were told that HCPs had moved away and were no longer working atlocation; representatives did not attempt visit because running out of campaign time and already met quota by identifying and detailing additional HCPs who were not onNPI-based list; and office practices closed because of storm damage and no other indication of alternative practice location.gReasons that visits were attempted but unsuccessful included absent survey or visit information; HCPs known to work at particular practices and health departmentrepresentatives arrived at practices multiple times, but HCPs not present; HCPs known to work at particular practices but working irregular or reduced hours due to stormrecovery, therefore difficult to execute visit; HCPs temporarily working in multiple locations due to storm recovery, therefore difficult to execute visit.

FIGURE 2—Flowchart of Health Care Providers, Opioid Analgesic Public Health Detailing Campaign: Staten Island, NY, 2013

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New York City residents in postcampaignperiod 2, an 11.5% decrease (P< .05). In theother 4 New York City boroughs, the pre-scribing rate decreased from 550 prescriptionsper 10 000 New York City residents in theprecampaign period to 487 prescriptions per10 000 New York City residents in post-campaign period 2, an 11.5% decrease(P < .05). In difference-in-differences analysescomparing the precampaign period to post-campaign period 1, and, separately, the pre-campaign period to postcampaign period 2,the interaction terms did not differ fromzero (B= –0.0115; 95% confidence interval

[CI] = –0.0254, 0.0024; andB= –0.0035; 95%CI= –0.0175, 0.0106, respectively), dem-onstrating no significant differences in trendsin prescribing rates between Staten Island andthe otherNewYorkCity boroughs (Table 2).

The high-dose prescribing rate in StatenIsland decreased from 218 prescriptions per10 000 New York City residents in the pre-campaignperiod to191prescriptions per 10 000New York City residents in postcampaignperiod2, a 12.4%decrease (P< .05). In theother4 New York City boroughs, the high-doseprescribing rate decreased from 110 pre-scriptions per 10 000 New York City residents

in the precampaign period to 102 prescriptionsper 10 000 New York City residents in post-campaign period 2, a 7.3% decrease (P < .05;Table 2 and Figure 3). In difference-in-differences analysis comparing the pre-campaign period to postcampaign period 1,the interaction term did not differ fromzero (B=0.0207; 95% CI=–0.0078, 0.0492),demonstrating no significant difference in ratetrends between Staten Island and the otherNew York City boroughs. However, in thedifference-in-differences analysis comparingthe precampaign period to postcampaignperiod 2, the interaction term differed from

TABLE 2—Rates, Median Day Supply and Difference-in-Differences Regression Results for Opioid Analgesic Prescriptions and High-DosePrescriptions Filled by New York City Residents by Prescriber Location: New York City (NYC), March 2013–February 2014

Variables Precampaign Period Mar–May 2013 Postcampaign Period 1 Sept–Nov 2013 Postcampaign Period 2 Dec 2013–Feb 2014

Rate of prescriptions filled per 10000 residentsa (no. prescriptions; % changeb)

Opioid analgesic prescriptions

Staten Island 889 (45 509) 813 (41 903; –8.5*) 785 (40 635; –11.5*)

Other NYC 550 (454 123) 499 (413 380; –9.3*) 487 (404 047; –11.5*)

High-dose opioid analgesic prescriptions

(> 100 MME)c

Staten Island 218 (11 025) 201 (10 221; –7.8*) 191 (9 757; –12.4*)

Other NYC 110 (90 857) 104 (85 995; –5.5*) 102 (84 201; –7.3*)

Day supply, median (IQR)

Opioid analgesic prescriptions, median (IQR)

Staten Island 30 (10, 30) 30 (10, 30) 30 (10, 30)

Other New York City 20 (5, 30) 23 (5, 30) 23 (5, 30)

Difference-in-differences regression,d B (95% CI)

Opioid analgesic prescriptions, B (95% CI)

BBorough –0.4722 (–0.4818, –0.4625) –0.4722 (–0.4818, –0.4625)

BPostcampaign –0.0826 (–0.0958, –0.0693) –0.1135 (–0.1269, –0.1001)

BBorough*postcampaign –0.0115 (–0.0254, 0.0024) –0.0035 (–0.0175, 0.0106)

High-dose opioid analgesic prescriptions,c

B (95% CI)

BBorough –0.6662 (–0.6859, –0.6464) –0.6652 (–0.6850, –0.6454)

BPostcampaign –0.0757 (–0.1026, –0.0488) –0.1224 (–0.1496, –0.0951)

BBorough*postcampaign 0.0207 (–0.0078, 0.0492) 0.0462 (0.0174, 0.0751)

Note. CI= confidence interval; IQR= interquartile range; MME=morphine milligram equivalent. Analysis includes Schedule II (excluding codeine-2) opioid analgesicprescriptions. Prescriptionswritten by veterinarians,written under institutional licenses,missing prescriber ID, ormissing patient ID are excluded.Data are limited toNewYorkCityprescriberswhowroteat least1opioidanalgesicprescription fromMarch2013toFebruary2014. Analysis is limited toprescriberswith license locationin the5NewYorkCityboroughs (counties). Staten Island is reportedseparatelyandcomparedwiththeother4boroughscombined(Bronx,Brooklyn,Manhattan,andQueens). The total number of Staten Island prescribers and other New York City prescribers represented in this table are 2529 and 38871, respectively.

Source. New York State Bureau of Narcotics Enforcement, Prescription Monitoring Program, New York State, 2013–2014.aRates are number of opioid analgesic prescriptions filled per 10 000 NYC residents. Age-adjusted rates are calculated using intercensal estimates updatedDecember 2014, and are weighted to US Census Standard 2000.bPercent change between the precampaign period and postcampaign periods 1 and 2were tested for Staten Island, and separately for the otherNYC boroughsby using z-test comparisons.cA high-dose opioid analgesic prescription is greater than 100 MME. One MME is equivalent to 1 mg of morphine.dTo compare rate changes over time between Staten Island and the other New York City boroughs, a difference-in-differences approach was taken; rate trendswere tested using Poisson regression model with offset of person-time. Age was included in the model to control for confounding.

*P < .05.

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zero (B= 0.0462; 95% CI= 0.0174, 0.0751),indicating that rate trends in high-dose pre-scribing between Staten Island and the otherNew York City boroughs were significantlydifferent at postcampaign period 2 (Table 2).

The median day supply in Staten Islandwas 30 (maximum allowable) in all studyperiods. In the other 4 New York Cityboroughs, the median day supply was 20 inthe precampaign period and increased to 23 inboth postcampaign periods (Table 2).

DISCUSSIONEvaluation of DOHMH’s public health

detailing campaign to promote judicious opioidprescribing in Staten Island demonstrated anassociation with improvements in health careprovider knowledge about opioid prescribingrecommendations, and suggested a decreasein the rate of high-dose prescribing. To ourknowledge, this is the first published study ofa one-to-one detailing campaign about judi-cious opioid prescribing that both found anassociation with improvements in opioid an-algesic–related knowledge and suggesteda change in prescribing practices. This extendsthe findings of previously published studies onopioid analgesic detailing initiatives, which

found changes in self-reported prescribing be-havior, but did not include prescribing data.13,14

Like these previous studies, our detailingcampaign was conducted in the context ofa multipronged public health response.

The smallest increase in knowledge wasobserved for the recommendation related toinsufficient evidence for use of opioids to treatchronic noncancer pain. This finding likelyreflects the extensive promotion and use ofopioids for chronic noncancer pain in theUnited States in the past.17,18 Only recentlyhave several studies highlighted the lack ofevidence for pain relief or improved functionfrom long-term opioid use for chronic non-cancer pain.17,19–22 Repeated dissemination ofthese findings and of evidence-based clinicalguidelines such as the DOHMH prescribingguidelines for opioids is warranted to promotepractices consistent with scientific evidence.

The greater decrease in the rate of high-dose prescribing in Staten Island comparedwith the other New York City boroughs wasplausibly influenced by the public healthdetailing campaign. To our knowledge, thedetailing campaign in Staten Island was theonly source of specific information regardinghigh-dose prescribing and MMEs that wasdisseminated in New York City during thestudy period. Furthermore, concurrent

messaging on opioids in the media and relatedto I-STOP did not address high-dose pre-scribing during this time period. The magni-tude of decrease in the rate of high-doseprescribing did not reach statistical significanceuntil postcampaign period 2. This lag might beattributable to the time it took for prescriberbehavior to become engrained, or the timeneeded to taper down high-dose prescriptions.

The lack of decrease in median day supplyper prescription in Staten Island and the in-crease in the other New York City boroughswereunexpected and concerning.Thisfindingmight reflect increased use of opioids to treatchronic pain (which would be inconsistentwith the detailing campaign messages); alter-natively, this finding could also be observed ifthe number of prescriptions for acute paindecreased disproportionately to the decrease inthe number of prescriptions for chronic pain.Future research should explore systems-levelstrategies as mechanisms to decrease medianday supply, including default settings for opioidprescriptions in electronic health records andprior authorization policies consistent withjudicious opioid-prescribing principles.

The fact that overall prescribing rates de-creased across all New York City boroughs isfavorable for the public health of NewYorkers. This trend might reflect

889

550

218

110

813

499

201

104

785

487

191

102

0

100

200

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600

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800

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1000

Staten Island Other NYC Staten Island Other NYC

Pres

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tions

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0 00

0 Re

side

nts

Opioid Analgesic Prescriptions

Precampaign period Mar–May 2013

Postcampaign period 1 Sep–Nov 2013

Postcampaign period 2 Dec 2013–Feb 2014

High-dose Opioid Analgesic Prescriptions

Note. Analysis includes Schedule II (excluding codeine-2) opioid analgesic prescriptions. Prescriptions written by veterinarians, written under institutional licenses, missingprescriber ID, or missing patient ID are excluded. Data are limited to New York City prescribers who wrote at least 1 opioid analgesic prescription from March 2013 toFebruary 2014. Analysis is limited to prescribers with license location in the 5 New York City boroughs (counties). Rates are number of opioid analgesic prescriptions filledper 10 000 New York City residents. Age-adjusted rates are calculated by using intercensal estimates updated December 2014, and are weighted to US Census Standard2000. A high-dose opioid analgesic prescription is greater than 100 morphine milligram equivalents (MME). One MME is equivalent to 1 mg of morphine.

Source. New York State Bureau of Narcotics Enforcement, Prescription Monitoring Program, New York State, 2013–2014.

FIGURE 3—Rate of Opioid Analgesic Prescriptions and High-Dose Prescriptions Filled by New York City Residents by Prescriber Location:New York City (NYC), March 2013–February 2014

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implementation of the I-STOP law requiringreviewof patient PMPdata before prescribinga controlled substance, or, perhaps, mightsignal an increased general awareness aboutopioid analgesic–associated risks, given theincreasing attention to this topic up to thenational level.16,23

Public health interventions regardingopioid analgesics should be considered in thecontext of heroin because opioid analgesicsand heroin are chemically similar, their ep-idemiological trends are potentially inter-twined, and certain interventions can addressboth (e.g., medication-assisted treatmentand naloxone). In a separate analysis, wefound a 29% decrease from 2011 to 2013 inthe opioid analgesic overdose mortality ratein Staten Island compared with the other 4New York City boroughs, after DOHMH’smultipronged opioid analgesic public healthresponse. During the same period, heroinoverdose mortality rates increased similarlyin both Staten Island and the other 4 NewYork City boroughs, while the opioid an-algesic overdose mortality rate in the other 4New York City boroughs did not change.15

A practical challenge of planning thedetailing campaign was that no up-to-date,comprehensive list of health care providers inStaten Island was available for DOHMH touse. We used the free, publically availableNational Provider Identifier Registry; thisinformation was imperfect, as health de-partment representatives identified and de-tailed health care providers that met ourcriteria for targeting, but had not been de-tected through the National Provider Iden-tifier Registry. The challenge of reliablyidentifying and locating health care providerswas exacerbated by the timing of the detailingcampaign, which was conducted less than 1year after Hurricane Sandy, when Staten Is-landers were still recovering from stormdamage. Upon arrival, health departmentrepresentatives encountered office practicesunder repair or closed because of stormdamage; in addition, some health care pro-viders had reduced work hours or weretemporarilyworking from2 locations becauseof rebuilding efforts. Lacking access toa gold-standard list of practicing health careproviders is not unique to this intervention,and reflects a broader problem faced by publichealth that limits program planning targetinghealth care providers (S. C. Shih, written

communication, April 2016). Despite thischallenge, we detailed close to the numberof health care providers targeted.

This study had several limitations. First, theevaluation of knowledge change about pre-scribing recommendations did not havea nondetailed comparison group becauseidentifying an appropriate comparison groupwas not feasible (the majority of health careproviders who met our inclusion criteria inStaten Island were detailed, leaving fewnondetailed health care providers). However,the paired analysis accounted for individualchange in responses from pre- to posttest.

Second, prescribing patterns for StatenIsland prescribers who were detailed couldnot be compared with nondetailed StatenIsland prescribers because PMP data used foranalysis were de-identified. Our approachstrengthens the study findings, because in-clusion of all Staten Island prescribers biasesthe results toward the null as not all prescribersreceived the intervention.

Third, thewidespread attentionon the risksof opioid analgesics in Staten Island and onI-STOP implementation statewide precludesdefinitive attribution of knowledge andoverall prescribing changes to the publichealth detailing campaign. However, wehypothesize that the observed knowledgechanges and greater decreases in high-doseprescribing in Staten Islandwere influencedbythe public health detailing campaign because,to our knowledge, the Staten Island detailingcampaign along with the kick-off physicianconferences at 2 Staten Island hospitals werethe only sources of specific messaging aboutDOHMH prescribing recommendationsduring the study period. This messaging in-cluded technical information regardinghigh-dose prescribing and MMEs, which isnot common knowledge to health care pro-viders (as evidenced by the low percentage[22%] of baseline survey respondents correctlyanswering the question about high-doseprescribing). These factors increase the plau-sibility that the greater decreases in high-doseprescribing in Staten Islandwere influencedbythe detailing campaign.

Finally, an assessment of opioid analgesicand heroin overdose mortality using the sameanalytic periods as for the prescribing dataanalysis used in this study was not possiblebecause of small borough-level numbers andunstable rate estimates.

In conclusion, this study demonstrated thata public health detailing campaign can im-prove health care provider knowledge aboutopioid prescribing practices andmight changespecific prescribing behavior. With nationalrates of opioid analgesic overdose deathscontinuing at epidemic levels, and the recentrelease of the Centers for Disease Control andPrevention’s national guidelines for judiciousopioid prescribing, an urgency exists to helphealth care providers change prescribingpractices.8,24 Public health detailing could beconsidered by other jurisdictions as a strategyto promote judicious opioid prescribing,particularly in high-risk areas. Together witha comprehensive public health approach toaddress opioid analgesic misuse and overdose,prescriber detailingmight play a critical role inreducing morbidity and mortality related toopioids.

CONTRIBUTORSJ. A. Kattan led article writing, directed the detailingcampaign, and contributed to study conceptualization anddesign, data analysis, and interpretation. E. Tuazon anal-yzed and interpreted data, and contributed to drafting andrevising the article. D. Paone and H. V. Kunins con-tributed to study conceptualization and design, in-terpretation of data, and drafting and revising the article.D. Dowell and C.M. Jones contributed to study con-ceptualization and design, and revising the article. LindaVo contributed to study design, analysis and interpretationof data, and revising the article. J. L. Starrels contributed tostudy design and revising the article. All authors read andapproved the final version of the article.

ACKNOWLEDGMENTSThis study was supported in part by funding from theCenters for Disease Control and Prevention underCDC-RFA-HM08-805.

We would like to acknowledge Vibhuti Arya, DaniellaBradleyO’Brien,MagdaDesdunes,Marissa Kaplan-Dobbs,Michelle Dresser, Sungwoo Lim, Colleen Mccullough,Kimberly Sebek, Sarah Chen-Ju Shih, Leslie Short, of theNewYorkCityDepartmentofHealth andMentalHygieneat the time of the study; and the OnCall detailing team.

Note.Thefindings andconclusions in this report are thoseof the authors and do not necessarily represent the officialposition of the Centers for Disease Control and Prevention.

HUMAN PARTICIPANT PROTECTIONThe New York City Department of Health and MentalHygiene institutional review board determined this studyto be program evaluation.

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