While primarily a local-level strategy, RxStat engages and leverages the capacities of state and federal authorities in addition to local government agencies. As a partnership, RxStat aims to integrate data-driven policing with actionable public health interventions and data (Heller et al., 2014). With respect to the analysis of disparate data sources and implementation of collaborative programming, RxStat aimed to adhere to a public health framework, with interventions focused at the population level and analyses conducted using epidemiologic methods (Heller et al., 2014). RxStat was formed and convenes voluntarily; the group is not guided by a policy or legislative mandate, nor is membership and attendance mandated within agencies. As an intervention, RxStat has not remained static, but has evolved alongside the overdose epidemic (Table 1).

The partnership was founded as an intergovernmental data-sharing vehicle and part of the Bloomberg Administration’s Mayoral Task Force on Prescription Painkiller Abuse. After the 2013 mayoral transition to the de Blasio Administration, Task Force members voluntarily formalized into the NYC RxStat Workgroup and continued to meet monthly under the joint leadership of the NYC Department of Health and Mental Hygiene (DOHMH) and New York/New Jersey High Intensity Drug Trafficking Area (NY/NJ HIDTA). To focus cross-sector response and coordination, the partnership expanded in 2016 to include the NYC RxStat Operations Group, which convened quarterly overdose fatality reviews to identify cross-agency touchpoints and service gaps. As of December 2021, RxStat comprised 38 local, state, and federal member agencies (Table A1).

Since RxStat’s inception, it has received support from the Office of National Drug Control Policy (ONDCP) and Bureau of Justice Assistance (BJA) (High Intensity Drug Trafficking Area Program, 2020). The Centers for Disease Control and Prevention (CDC) has elevated RxStat as the template for jurisdictions seeking to integrate overdose response across the health and safety sectors (Centers for Disease Control and Prevention, 2022). To scale the RxStat model, the CDC Foundation developed a public health and safety toolkit to guide state and local PHPSP implementation (Rubel & Roe, 2022). Likewise, through its Overdose Data to Action (OD2A) program, the CDC has made substantial national investments in PHPSPs, recognizing their potential to address the overdose epidemic by bridging knowledge, data, and service gaps (Centers for Disease Control and Prevention, 2022).

Given the differences in approach between public health and public safety, a shared understanding of the sectors is necessary to structure responses. Public health, as conventionally defined, is the practice of protecting and improving the health of a given population (El-Sayed, 2016). An expansive definition may include public functions that touch social determinants of health—e.g., housing and homeless services, public space and recreation, and social benefits and food access services—in addition to the healthcare sector. Interventions often are guided by epidemiology, the science of population patterns of disease (Windle et al., 2019). The size of the population notwithstanding, a public health approach prioritizes population-level prevention, education, and service delivery over individually focused approaches.

Public safety, as conventionally defined, is the practice of protecting against threats to the wellbeing of individuals and communities (Friedman, 2022). Public safety includes law enforcement and criminal justice authorities, as well as non-enforcement first responders such as emergency medical services and fire response. Public safety actors inform interventions using both case-level intelligence and population-level trends in crime and enforcement. Public safety interventions generally are executed at the individual level and prioritize enforcement, service linkage, and emergency response over preventive approaches.

Given the operational differences between public health and safety, US drug policy traditionally has occurred in parallel with little integration or collaboration (Saloner et al., 2018). Some researchers have identified areas of overlap and collaboration, (Shepherd & Sumner, 2017) which share the goals to promote public wellbeing and reduce overdose deaths. Others have suggested that such partnerships may have unintended consequences with respect to increased criminalization of overdose and residual negative impacts on health (Allen et al., 2021). As such, the integration of health and safety for overdose response remains a policy experiment.

Despite the innovation of RxStat and national proliferation of PHPSPs, however, no prior research has assessed PHPSP implementation in any jurisdiction. To fill this gap and inform national replication efforts, we conducted a qualitative stakeholder evaluation of RxStat to identify successes, challenges, and opportunities for growth. Ours is the first empirical study of a PHPSP in the US and reports on RxStat, the US’s first and national model PHPSP.

This study probed the experiences and perspectives of RxStat members across agencies, disciplines, and levels of government. Between April and November 2021, in-depth interviews were conducted with 25 current and former RxStat members. At the time the study was conducted, 38 agencies participated in RxStat. Stakeholders were purposively sampled based on their involvement in RxStat (i.e., leadership roles and attendance frequency), the level of government with which they were affiliated as part of RxStat (i.e., local, state, or federal), and the discipline of the agency with which they were affiliated (i.e., public health, public safety, social and human services, or clinical medicine) (Patton, 2002). Potential stakeholders were solicited by email and provided a short description of the evaluation’s aims and purpose. We contacted 31 stakeholders, and 25 agreed to participate, yielding an 81% response rate. Stakeholders received no compensation for their time and are identified only by professional discipline. All study procedures were approved by the [BLINDED] Institutional Review Board.

Interviews were semi-structured and captured the following domains: perceptions of RxStat, including its purpose and goals; policy and programmatic successes of RxStat, including agency-level, policy, and interpersonal outcomes; challenges to cross-disciplinary engagement, including strategies to overcome areas of tension; and the use of data across sectors, including issues of data sharing, data access, and data interpretation and communication. The interview guide was developed as part of a review of the literature on public health and public safety partnerships, as well as gray literature specific to RxStat and PHPSPs.

Interviews ranged from 23 to 91 min in duration (mean=57 min) and were conducted via telephone or Zoom by the second author. Verbal informed consent was obtained prior to every interview, and interviews were audio recorded and professionally transcribed for analysis. Transcripts were analyzed using a thematic approach, with a codebook developed a priori by the first and second authors, organized around the interview guide, and iteratively modified throughout the data analysis (Guest et al., 2011). All transcripts were coded independently by the authors, with discrepancies resolved through consensus. Major emergent themes were identified, with sub-themes extrapolated and organized to generate a coherent thematic landscape.

Both authors are current academic professionals with prior experience in the applied public health sector related to substance use and overdose prevention. The second author also is a clinical mental health professional with expertise in the treatment of substance use disorders. The first author is an epidemiologist by training, with expertise in population-level interventions to prevent overdose deaths; the second author is a clinical psychologist by training, with expertise in individual-level interventions to treat substance use disorders. At the time this evaluation was conducted, neither author was employed by nor maintained affiliation with any RxStat member agency.

A total of 25 stakeholders participated in this evaluation (Table 2). Ten (40.0%) individuals identified their professional discipline as public health; 9 (36.0%) as public safety; 3 (12.0%) as social and human services; and 2 (8.0%) as clinical medicine. One (4.0%) self-identified as a drug policy analyst. Most respondents (n = 16; 64.0%) were current RxStat members, with a median involvement of 5.5 years (range=2–10 years). All respondents had attended the NYC RxStat Workgroup (n = 25; 100.0%), and nearly all had attended the NYC RxStat Operations Group (n = 20; 80.0%). Most (n = 22; 88.0%) held leadership positions at their respective agencies at the time of their involvement in RxStat.

Stakeholders expressed near unanimous consensus about the overarching goal of RxStat, referred to by many as its “North Star”: to reduce overdose deaths in NYC. Likewise, there was broad consensus that engagement of multiple sectors was necessary to reach this common goal. Several respondents discussed the political benefit of maintaining focus on a broad and high-level goal, strategically selected to bring stakeholders from divergent, even oppositional, sectors together into the same room.

Stakeholders described this ideological agnosticism as a tool to overcome cross-disciplinary tensions in NYC’s intergovernmental ecosystem, within which agencies were generally unaccustomed to collaboration. Despite a shared overarching goal, however, some respondents expressed reservations about the ability of RxStat to meaningfully impact population-level overdose mortality. Several stakeholders noted that overdose deaths in NYC had increased substantially since RxStat’s inception, with widening disparities by race and socioeconomic status. As such, stakeholders remained divided on the overall success of RxStat.

Other respondents framed RxStat’s goal as a moving target, with overdose mortality reduction as the primary, but not exclusive, goal. Secondary goals were described in three terms: agency-level policy and practice changes; relationship building across agencies; and individual and institutional attitudinal and cultural changes (Table 3). Several respondents spoke of the success of RxStat as an education and anti-stigma vehicle, identifying value in changing the culture of drug policymaking. These benefits were characterized as intangible but highly valuable. Culture change, such as the use of person-centered language (e.g., “person who uses drugs,” rather than “drug user” or “drug addict”) in conversation and agency communications, as well as an increased acceptance of evidence-based treatment modalities like opioid agonist therapy, were attributed primarily to information transferred from public health professionals to public safety professionals.

Several individuals also found RxStat a beneficial networking opportunity with respect to their own careers. Networking across agencies at a relatively high level helped several respondents more efficiently navigate the complexity of NYC government, both personally and for their staff and/or colleagues within their home agency.

For several stakeholders, these secondary successes were insufficient without measurable reductions to overdose mortality. Some viewed the ability for interpersonal or attitudinal changes to meaningfully translate to drug policy reform with skepticism. Such skepticism notably was expressed more consistently among public health, social and human services, and clinical medicine professionals, with public safety stakeholders more optimistic about the transformative potential of the partnership.

Respondents noted a desire for responses across sectors to connect concretely to overdose mortality reduction, RxStat’s “North Star.” However, stakeholders from public health and public safety reported the perception that other disciplines were not tailoring strategies toward direct overdose reduction. To ensure that RxStat remains an evidence-based vehicle for overdose policy innovation, RxStat leadership and staff could inventory and characterize RxStat initiatives across agencies to ensure that partnership-involved or -sponsored responses are evidence-based, a practice of systematic organizational assessment that has been executed successfully in other domains (e.g., child welfare, (US Department of Health and Human Services, 2017) clinical medicine, (Miake-Lye et al., 2020) and homeless services (Guarino et al., 2009)).

Likewise, several stakeholders suggested that the inclusion of non-governmental stakeholders—e.g., harm reduction service providers, drug policy advocates, and substance use disorder treatment providers—in RxStat could increase accountability, provide a balance between the potentially competing interests of public health and public safety, and maintain RxStat’s focus on overdose prevention (Petchel et al., 2020). Non-governmental membership in RxStat could mirror the successful composition of child, (Quinton, 2017) elder abuse, (Burnett et al., 2021) and domestic violence (Storer et al., 2013) fatality review panels in jurisdictions nationally.

Relatedly, no iteration of RxStat maintained or distributed meeting minutes or attendance logs. As such, we were unable to assess the specific topics and quality of meetings or track changes in engagement and follow-up as part of this study. By centralizing record keeping within the offices of the public health and public safety co-chairs, RxStat leadership would be better equipped to become a vehicle for policy change. Recording and distributing meeting minutes publicly also could serve as a public engagement and accountability tool, consistent with other interagency groups in NYC (e.g., the NYC Board of Correction (New York City Board of Correction, 2022)).

Data sharing was the foundational task of RxStat and remains central to the partnership. However, several public health stakeholders expressed reservations about the utility and reciprocity of interagency data sharing. Given the different data security and privacy standards of participating disciplines, all RxStat member agencies could adhere to a mutually compliant standard of data protection and de-identification to facilitate sharing across disciplinary norms (Schmit et al., 2019).

Furthermore, several members, particularly those without analytic expertise, desired a roster of available data sources and indicators to inform interventions. One strategy is to convene an analytic subgroup comprised of agency analysts with direct access to necessary data sources to procure data in advance of meetings and coordinate interagency sharing. For initiatives identified as RxStat programs and policies, the group could engage expert, non-partisan analytic support from academia or the research sector to ensure that initiatives are rigorously evaluated, consistent with prior research identifying a desire from public health professionals for enhanced practitioner-evaluator engagement (van der Graaf et al., 2017). Where available, RxStat could leverage external federal support—e.g., CDC, BJA, or ONDCP—for such evaluation research.

Lastly, RxStat was founded on the assumption that public health and public safety are natural collaborators. Stakeholders from multiple sectors, however, described divergent disciplinary approaches as potential roadblocks to effective collaboration. Prior researchers have detailed the challenges to cross-sector collaboration, consistent with the organizational, material, and ideological challenges described by RxStat stakeholders (Zhu et al., 2019). To maximize RxStat’s collaborative potential, a thorough and forthright review of member agency strategic drug policy goals, tools, and capacities could be conducted as part of any RxStat restructuring to allow members to identify clear points of collaboration, as well as points of impasse, to ground meetings strategy and planning meetings in realistic areas of overlap and compromise (Bryson et al., 2015).

Stakeholders across sectors emphasized the need for external accountability to ensure that policy changes were realized within and across agencies. Given that most RxStat member agencies are local compared to state or federal, the NYC Office of the Mayor was suggested as a potential central body to oversee policy implementation across NYC agencies. In the absence of a legislative charge, similar to most OFR panels, (Haas et al., 2019) the strategic use of a central authority agency could ensure that necessary changes are implemented uniformly across RxStat member agencies (Conroy et al., 2021).

Likewise, while some stakeholders described RxStat’s breadth as a strength, the diversity of expertise was perceived by others as unwieldy with respect to the execution of concrete tasks. To maximally leverage this diversity, some stakeholders suggested the formation of targeted subcommittees to move policies and programs from ideas to actions. Subcommittee topics could cover, for example, primary prevention strategies, work with youth and families, criminal justice diversion, and cross-sector data analytics, among other topics.

Stakeholders concurred that RxStat is grounded in a “public health approach,” measuring population-level patterns and trends and implementing population-level responses. Some stakeholders suggested, however, that as RxStat evolved, its implementation may have shifted toward a case-based model more consistent with a “public safety approach.” (Goff et al., 2019) An emphasis on data and commitment to evidence-based strategies under RxStat could help reorient the partnership as a vehicle utilizing public health methods.

Relatedly, as RxStat is fundamentally a partnership of equals, co-chairs from public health and public safety jointly lead the group. Some stakeholders, however, described intergovernmental politics as a primary factor in determining which strategies, interventions, and approaches were elevated over others. To defuse these politics, the inclusion of a third, non-governmental co-chair to represent the community-based nature of overdose prevention and response could ensure that RxStat remains collaborative and maximizes the strengths of all parties (Towe et al., 2016).

This study has three primary limitations. First, interviews were restricted to members of RxStat, a single initiative in NYC. Given NYC’s unique intergovernmental architecture and drug policy history, findings may not generalize to PHPSPs in other jurisdictions and contexts. However, as PHPSPs modeled on RxStat have proliferated nationally, findings about RxStat are likely to provide insight for practitioners and policymakers in other settings.

Second, since its inception, RxStat has taken three forms over 10 years. Given this length of time, it is possible that responses may be subject to recall bias for participants no longer involved in RxStat. However, as most stakeholders (64%) were current RxStat members and participation in RxStat constitutes an “elite” source of insight, (Scally et al., 2021) we believe the risk of recall bias to be minimal.

Third, RxStat was founded during the first wave of the overdose epidemic in 2012, a time during which public health prevention efforts focused on opioid analgesic-involved overdose deaths (Paone et al., 2015). Thus, it is possible that interviews with former RxStat members may not reflect the current “fourth wave” of the overdose epidemic, which is driven by fentanyl, stimulants, and polysubstance use (Ciccarone, 2021). However, given that all respondents were drug policy professionals with content expertise and that interviews focused the operational and intergroup dynamics of RxStat, not specific overdose knowledge, we believe that our findings are applicable to the current post-pandemic period and may inform cross-disciplinary workgroups tasked with jointly responding to other public health problems across injury prevention, infectious disease, and chronic disease.

This study, the first evaluation of any PHPSP to reduce overdose deaths, found that RxStat, the nation’s first and model PHPSP, faced distinct challenges to implementation, despite numerous successes. We detailed a series of opportunities and strategies for RxStat and other PHPSPs modeled on its approach to optimize collaboration across sectors and ensure population-level impact. Despite a lack of success along its primary goal, overdose mortality reduction, RxStat and other PHPSPs may serve several secondary and less tangible functions, such as delivering anti-stigma education and facilitating professional relationship development.