1 get the skoop: skills and knowledge on overdose prevention bill matthews, rpa-c harm reduction...
TRANSCRIPT
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Get the SKOOP: Skills and Knowledge on
Overdose PreventionBill Matthews, RPA-C Harm Reduction CoalitionNovember 2012
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Objectives
Participants will be able to:
• Discuss the epidemiology and physiology of overdose; risk factors and response
• Offer a 10-20 minute overdose prevention training to other staff and clients
Number of drug poisoning deaths involving opioid analgesics by opioid analgesic category, heroin and cocaine: United States, 1999--2010
NOTES: Opioid analgesic categories are not mutually exclusive. Deaths involving more than one opioid analgesic category shown in this figure are counted multiple times. Natural and semi-synthetic opioid analgesics include morphine, oxycodone and hydrocodone; and synthetic opioid analgesics include fentanyl. SOURCE: CDC/NCHS, National Vital Statistics System; and Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980–2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htm
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Motor-Vehicle & Poisoning Death Rates, 2005- 2006
• Among adults aged 34-56 years, poisoning death rates were higher than motor –vehicle traffic death rates.
• 92% of poisoning deaths involved drugs.
National Vital Statistics System, mortality data,
http://www.cdc.gov/nchs/deaths.htm.
Motor vehicle traffic, poisoning, drug poisoning, and unintentional drug poisoning death rates: United States, 1999--2010
NOTES: Drug poisoning deaths are a subset of poisoning deaths. Unintentional drug poisoning deaths are a subset of drug poisoning deaths. SOURCE: CDC/NCHS, National Vital Statistics System; and Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980–2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htm. Intercensal populations http://www.cdc.gov/nchs/nvss/bridged_race/data_documentation.htm
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Opioid treatment admissions: 1999-2009 ages 12-24
0
2000
4000
6000
8000
10000
12000
14000
16000
NYC NYS
199920042009
NYS OASAS Data Warehouse
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Opioid treatment admissions: 1999-2009 ages 12-24
0
500
1,000
1,500
2,000
2,500
3,000
Nassau Erie Suffolk
199920042009
NYS OASAS Data Warehouse
Counties Reporting Increases in Heroin-Related Overdoses, 2008–2010
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National Drug Threat Assessment 2011
Percentage of patients and prescription drug overdoses, by risk group
MMWR / January 13, 2012 / Vol. 61 / No. 1
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Initial route of opioid abuse versus route of abuse at admission in a substance abuse treatment center.
Katz, Am J of Drug and Alcohol Abuse, 2011
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What is the most dispensed prescription drug in the United
States?
(number of prescriptions filled;generic and branded products, 2004-06)
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Top 10 Drugs Dispensed in 2010
1. Hydrocodone/Acetaminophen (Vicodin)2. Amoxicillin3 Hydrocodone/Acetaminophen (Lortab)4. Lipitor5. Levothyroxine 6. Lisinopril7. Simvastatin8. Plavix8. Nexium10. Singulair
Source: http://www.rxlist.com/script/main/hp.asp 13
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Opioid pain reliever (OPR) death rates, sales, and substance abuse treatment admission
rates increased in parallel
National Vital Statistics System (99-09); Automated Reports Consolidated Orders System (99-10); Treatment Admissions Data Set (99-09)Age-adjusted rates per 100,000 population for OPR deaths, crude rates per 10,000 population for OPR abuse treatment admissions, and
crude rates per 10,000 population for kilograms of OPR sold.
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Heroin Overdose Epidemiology
About 2% of heroin users die each year- many from heroin overdose
• 1990-98: 5,506 deaths in NYC• Average of 1-2/day in NYC• Up to 2/3 of heroin users experience at least
one nonfatal overdose• 2006: 979 OD deaths in NYC (70% due to
opioids) = ~ 685 opioid deaths
Sporer BMJ 2003, Galea 2003, Coffin Acad Emerg Med 2007
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What do we know about overdose?
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Who overdoses?
• Happens most often in dependent long term users with 5- 10 years of experience rather than new users
Sporer 2003, 2006
Drug poisoning death rates by age: United States, 1999--2010
CDC/NCHS, National Vital Statistics System; and Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980–2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htmIntercensal populations http://www.cdc.gov/nchs/nvss/bridged_race/data_documentation.htm
15-24
25-34
35-44
45-54
55-64
65 and over
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Physiology
• Generally happens over course of 1-3 hours- the stereotype “needle in the arm” death is only about 15%
• Opioids repress the urge to breath – decrease response to carbon dioxide -leading to respiratory depression and death
Slow breathing>Breathing stops>Heart stops>Circulation of blood to the brain stops
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Context of Opioid Overdose
• The majority of overdoses are witnessed (gives an opportunity for intervention)
• Fear of police may prevent calling 911
• Witnesses may try ineffectual things– Myths and lack of proper training– Abandonment is the worst response
Tracy 2005
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An Antidote exists
• Naloxone (Narcan), an injectable opioid antagonist will reverse the effects of opioids preventing a fatal overdose.
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Many opioid overdoses are preventable!
Get the SKOOP!
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Legal Status- New Overdose Law in New York State (Effective April 1,
2006)• Protects the non-medical person who administers
naloxone in setting of overdose from liability.– “shall be considered first aid or emergency
treatment”.– “shall not constitute the unlawful practice of a
profession”.• Allows the medical provider to provide naloxone for
secondary administration.• NYSDOH created regulations for implementation of
opioid overdose prevention programs.• Naloxone must be dispensed by MD, PA, NP by
federal regulation
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Components of Opioid Overdose Prevention Training
• What is naloxone?• What are opioids?• Prevention and understanding risk factors:• Overdose recognition• Action Call 911
– Rescue breathing- using dummy– Naloxone administration and how it works– Recovery position
• Report and get refill• Legality
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What is Naloxone?
• Naloxone (Narcan) is an injectable opioid antagonist which reverses the effects of opioids preventing fatal overdose
• What else will it do?
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Naloxone (Narcan)
• Opioid antagonist which reverses opioid overdose
• Pushes most other opioids off the receptors, then sits on the receptor preventing it from being activated for 30-90 minutes
• Analogy- getting the wrong key stuck in a lock
NOP Opioid Receptor binding pockethttp://www.nature.com/nature/journal/v485/n7398/fig_tab/485314a_F1.html
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Naloxone preparations
• Injectable – Inexpensive: $4.50 per dose – Well-documented efficacy – Requires injection, drawing from a medical
vial into a syringe
• Intranasal– More expensive: $19.25 per dose– Less well-documented efficacy– Requires assembly of spay device with nasal
adaptor and naloxone capsule
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Intramuscular naloxone
• A face mask for rescue breathing
• Two safety syringes
• 2 pre-filled vials of Naloxone
• 2 alcohol swabs
• 2 latex gloves
• 1 brochure reviewing OD and rescue steps.
• Contact information for program
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Papaver Somniferum“Poppy Plant”
.
WHAT ARE OPIOIDS?
Most commonly used opioids • Heroin• Codeine• Demerol• Morphine• Darvocet • Fentanyl • Dilaudid • Methadone• Opium
• Hydrocodone • Oxycodone • Levorphanol • Vicodin • OxyContin • Tylenol 3• Tylox • Percocet• Percodan
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Boston Public Health Commission
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Naloxone does not work for substances that are not opioids
• Alcohol• Benzodiazepines
– Xanax, Valium, Klonopin
• Tricyclics– Elavil (amitriptylene)
• GBH• Ketamine
• Cocaine• Amphetamines• Methamphetamine• Ecstasy
Overdose deaths in New York City involve multiple drugs
(2008)Nearly all unintentional drug overdose deaths (98%)involve more than one substance, including alcohol.
Opioids were the most commonly noted drug type(74%). Types of opioids included heroin,
methadone, and prescription pain relievers.
Other drugs commonly found were: cocaine (53%),benzodiazepines (35%), antidepressants (26%),
and alcohol (43%).
NYC VITAL SIGNS Volume 9, No. 1, NYCDOHMH
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What are the Risk Factors for Opioid Overdose?
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Risk Factors for Opioid Overdose
• Reduced Tolerance• Illness• Depression• Unstable housing
• Mixing Drugs• Changes in the Drug
Supply• History of previous
overdose• Using in a new
environment
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Mixing Drugs: Major Risk for Overdose
• Using an opioid with other depressants such as alcohol or benzodiazepines
• Cocaine is a stimulant but:– High doses can reduce the respiratory drive– Wears off sooner than heroin in a speedball– Involved in about 53% of opioid overdose
deaths in NYC
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Major risk factor: Lowered tolerance
• Tolerance- repeated use of a substance may lead to the need for increased amounts to product the same effect
• Abstinence decreases tolerance increasing overdose risk– Incarceration– Hospitalization– Drug treatment/ Detox/ Therapeutic communities– Sporatic patterns of drug use
– Sporer 2007, Binswanger 2007
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Risk factor: Overdose Death following Incarceration
Cause of Death in the 2 weeks post-incarceration
Washington State Corrections – studied 30,237 inmates released (7/99-12/03)
Former Inmates were:– 12.7 times more likely to die vs. WS residents of same
age, race, and sex– 129 times more likely to die of overdose vs WS residents
• Opioids: 60%• Cocaine and other stimulants: 74%
• Binswanger et al., 2007
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Illness and overdose
Overdose is more likely in the presence of significant illness
• Liver disease: notably cirrhosis• Advanced AIDS• Coronary disease• Pulmonary disease: notably pneumonia
• Wang 2005, Darke 2006
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Other risk factors • Major changes in opioid supply/
Variations in strength of street drugs >1000 deaths USA 2006 with
fentanyl • Depression• History of previous overdose• Injection drug use
Sporer 2006, Wines 2007, Pollini 2006http://www.whitehousedrugpolicy.gov/news/fentnyl%5Fheroin
%5Fforum,
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Prevention Messages
• Use with others who know what to do if an overdose happens – make a plan
• Be aware of companions at all times when using• Be careful if using alone, especially if:
– Mixing different classes of drugs– Using after abstinence– (And watch out for others in these situations)
• Use a trusted source – one that you know• “Taste” (test) your shot• Control your own shot
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What does an Opioid Overdose Look Like?
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Continuum of Overdose
• Overdose is rarely immediate – can happen over 1-3 hours
• Heavy/ Uncontrollable Nodding– Still arousable– Snoring or loud breathing– May have excess drooling
• Overdose– Not responsive– Very shallow breathing, gurgling– Skin changes, blue lips and nails
• Fatal Overdose
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Recognizing a Stimulant Overdose(Naloxone won’t be effective unless an
opioid is also present)
• Fever
• Profuse sweating
• Rapid, (maybe irregular) heart beat
• Chest pain
• Seizures
• Heart attack, Stroke
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Stimulate the person overdosing
• Shake, call name loudly
• Sternal rub: rub knuckles hard up and down breast bone (it hurts!)
(Ice can work but this is easier)
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What NOT to do if a person is overdosing
• Leave without calling 911• Salt shots• Milk shots• Cocaine shots• Ice on genitals/ Shower• Hitting or burning feet or fingertips
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RESPONDING TO AN OPIOID OVERDOSE
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Step One: Get Help
• Call 911- “My friend is overdosing and not breathing”
• This phrase is more likely to bring paramedics with naloxone than EMT, who don’t carry it
• Give location
• Police may come
• New 911 law
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Check for breathing
• Chest rising and falling
• Nostrils moving in and out
• Mirror or glass by nose or mouth will fog up
• Touch moistened finger next to nostrils, feel for cool draft of inward breathing
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Step Two: Rescue breathing
Rescue breathing alone can sustain someone until EMS arrives
Mouth to mouth isusing a dummy for practice (if available)
Chest compressions notincluded (unlessResponder is trainedin CPR)
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Rescue Breathing
• Tilt back head to open airway
• Hold nose, lift chin
• Make a seal over the mouth with your mouth
• Start with 2 quick breaths then one breath about every 5 seconds until EMS arrives or person breathes on their own.
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Intramuscular naloxone
• A face mask for rescue breathing
• Two safety syringes
• 2 pre-filled vials of Naloxone
• 2 alcohol swabs
• 2 latex gloves
• 1 brochure reviewing OD and rescue steps.
• Contact information for program
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Administration:Naloxone Injection
• Inject into a muscle (subcutaneous and intravenous are also effective)
• Acts within 2-8 minutes• If no response in 2-5 minutes, give 2nd
naloxone injection • Lasts for 30 – 90 minutes• (reminder that if 911 has not been called
do it now!!)
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Injection Technique
• Inject into muscle of upper arm or front of thigh• Inject straight in, not at an angle• Rapidly push needle through skin into muscle
and then push syringe to inject the medication• Depth of whole needle is fine (maybe less
deep if person is skinny)• DON’T INJECT INTO THE CHEST, even if
you saw Pulp Fiction…
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Disposing of the Used Syringe
• If safety syringe, engage sheath
• Ask EMS to dispose of the needle or:
• Take to any SEP, hospital or nursing home for disposal, call first!
• Sharps accepted by some pharmacies and health care facilities
• Call DOH for disposal site near you (800-522-5006)
• Contact local Dept. of Public Works
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Recovery Position
• If you must leave the overdoser even for
a few minutes put them into the
recovery position so they won’t
choke on vomit
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Results: awake and breathing
Narcan wears off in 30-90 minutes
• Don’t leave the overdoser alone as sedation may return
• Reassure the overdoser if s/he is drug sick- the naloxone will wear off- don’t use more heroin to feel better!!
• Encourage survivor to go to the hospital
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Next Steps
• Report use of Naloxone to the program• Anonymous report of date, place, drugs
used and outcome
• Get a refill of the Naloxone• Even if just one dose was used• If kit is lost• If kit is confiscated• If naloxone is nearing expiration date
TIME FOR HANDS ON SKILLS PRACTICE
Practice these skills: 1. Rescue Breathing
2. Injection/intranasal Technique
3. Training a Partner
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Naloxone in Action
• Reverses opiate effect of sedation and respiratory depression
• Causes sudden withdrawal in the opioid dependent person – an unpleasant experience
• No psychoactive effects – low potential for diversion, is not addictive
• Routinely used by EMS (but in larger doses)• Has no effect if an opiate is not present• Sold over the counter in Italy since 1988
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More about Naloxone
• It is regulated but not a controlled substance
• Need to obtain from a licensed prescriber
• Should be stored at room temperature and away from direct light (in kit is OK)
• Has a limited shelf life. Note expiration date and obtain replacement
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More about Naloxone cont.
• Emergency Medical Services give 1.2 to 1.6 milligrams of Naloxone which precipitates severe withdrawal in the dependent person
• Overdose prevention services recommend starting with 0.4 with an additional dose readily available – found to be effective in most instances
Role of EMSPatients receiving naloxone, not being transported to ER: deaths known to medical examiner•998 patients refused transport: none within 12 hours•552 patients refused transport: none within 48 hours•2241 patients discharged by EMS over 10 yrs: 14 within 48 hours; 3 (0.13%) of potential rebound overdoseLimitations: some medical evaluation, varying doses of naloxone; all SKOOP responders instructed to call EMS
•San Diego: Vilke Acad Emerg Med 2003; San Antonio: Wampler Prehosp Emerg Care 2011; Copenhagen: Rudolph Rescusitation 2011
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Safety in the field
Over 3,500 kits distributed
319 overdose reversals reported• 1 unsuccessful revival • 1 seizure• 1 vomited• Only 5 cases with more than 1 injection• No cases of re-treatment after naloxone wore off• Maxwell 2006
2010 survey of programs known to the Harm Reduction Coalition
• 189 local programs in 16 states
• 1996 - 2010:
–53,339 individuals have received kits
–10,194 overdose reversals reported
Personal communication Eliza Wheeler, Harm Reduction Coalition
Overdose fatality prevention programs that distribute naloxone:
USA, 2010
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Cocaine and heroin rates decreased while opioid analgesic rate increased
* P-Value less than .05; (2005 vs. 2009)
Opioid Analgesics*
Benzodiazepines*
Methadone
Cocaine*Heroin
Anti-Psychotics
Sedatives
Heroin-related Deaths, San Francisco, 1993-2010
*Data compiled from San Francisco Medical Examiner’s Reports, www.sfgsa.org **no data available for FY 2000-2001
0
20
40
60
80
100
120
140
160
1993-1994
1994-1995
1995-1996
1996-1997
1997-1998
1998-1999
1999-2000
2002-2003
2003-2004
2004-2005
2005-2006
2006-2007
2007-2008
2008-2009
2009-2010
Heroin-related deaths
Naloxone distribution begins, 2003
Effect of naloxone on overdose death: Chicago, US
Heroin overdoses dropping
Allegheny County Trends in Accidental Drug Overdose Deaths 2000-2006*
*Data is from Allegheny County Medical Examiners Annual Reports and includes all overdose deaths where these drugs were present at time of death, not necessarily cause of death.
Heroin Use in Allegheny County by Fiscal Year
*Data from Pennsylvania Department Of Health
Opioid maintenance and mortality
• Prospective study of opioid dependent patients applying for methadone treatment in Norway
• 3,789 subjects followed for up to 7 years
• Clausen Drug Alc Dep 2008
Results
Pre-treatment In treatment Post-treatment
Total mortalityOdds ratio
1 0.5 1.43
Total overdoseOdds ratio
1 0.20 1.40
Percent of deaths due to overdose
79% 27% 61%
Clausen 2008
7777
Maintenance therapy prevents overdose
French population in 1999 = 60,000,000
1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999
Year
No.
of
deat
hs
600
500
400
300
200
100
0
Patients receiving methadone (1998): N= 5,360
Patients receiving buprenorphine (1998): N= 55,000
Auriacombe et al., 2001
•Since the institution of buprenorphine and methadone maintenance in 1996 in France heroin overdose has dropped by 79%
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• "I did SOMETHING, you know, that made a difference. The whole world can’t see it but I know it made a difference. And that’s important . . . to me." --quote collected by Suzanne Carlberg-Racich, Chicago “You get nervous, you know – someone’s blue, someone’s dying. But you do it because we are all out here together and people are going out right and left.” --Boston man, age 29
"If you ever get in a meeting with some professional type people, tell ‘em that, you know, people like us–no, we’re not professionals, but if we have it at hand we can save somebody’s life with this stuff [naloxone]. . . it’s a lifesaver, there’s no question." --Program participant in Chicago; Maxwell S, et al. J Addict Dis. 2006;25(3):8996.
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RESOURCES
• Harm Reduction Coalition (harmreduction.org)
NYSDOH(www.health.state.ny.us - search for overdose)
• On-line CASAC training and credit– www.oasas.state.ny.us