Faculty Bibliography

BACKGROUND AND AIMS/OBJECTIVE:Evidence from high-income countries has linked duration and compliance with treatment for substance use disorders (SUDs) with reductions in substance use and improvements in mental health. Generalizing these findings to other regions like South America, where opioid and injection drug use is uncommon, is not straightforward. We examined if length of time in treatment and compliance with treatment reduced subsequent substance use and presence of psychiatric comorbidities. DESIGN/METHODS:Prospective cohort analysis (3 assessments, 18 months) using inverse probability weighting to account for confounding and loss to follow-up. SETTINGS/METHODS:Outpatient/inpatient programs in Región Metropolitana, Chile. PARTICIPANTS/METHODS:Individuals initiating publicly funded treatment (n = 399). MEASUREMENTS/METHODS:Exposures included length of time in (0-3, 4-7, 8 + months, currently in) and compliance with treatment (not completed, completed, currently in) measured in the intermediate assessment (12 months). Primary outcomes were past-month use of primary substance (most problematic) and current psychiatric comorbidities (major depressive episode, panic, anxiety or post-traumatic stress disorders) measured 6 months later (18 months). Secondary outcomes included past month use of alcohol, cannabis, cocaine powder and cocaine paste. FINDINGS/RESULTS:18.3% [95% confidence interval (CI) = 14.7%-22.6%] of individuals participated for 3 or fewer months in treatment and 50.1% (95% CI = 45.2%-55.1%) did not complete their treatment plan at 12 months. Participating for 8 + months in treatment was associated with lower risk of past month use of primary substance at 18 months [vs. 0-3 months, risk ratio (RR) = 0.62, 95% CI = 0.38-1.00] and completion of treatment (vs. not completed, RR = 0.49, 95% CI = 0.30-0.80). Neither participating 8 + months (vs. 0-3 months, RR = 0.83, 95% CI = 0.57-1.22) nor treatment completion (vs. not completed, RR = 1.02, 95% CI = 0.72-1.46) were associated with lower risk of psychiatric comorbidity at 18 months. CONCLUSIONS:Longer time in treatment and compliance with treatment for substance use disorders in Chile appears to be associated with lower risk of substance use but not current comorbid psychiatric conditions 18 months after treatment initiation.

OBJECTIVES/OBJECTIVE:To evaluate the predictive performance of different data sources to forecast fatal overdose in Rhode Island neighborhoods, with the goal of providing a template for other jurisdictions interested in predictive analytics to direct overdose prevention resources. METHODS:We evaluated seven combinations of data from six administrative data sources (American Community Survey (ACS) five-year estimates, built environment, emergency medical services non-fatal overdose response, prescription drug monitoring program, carceral release, and historical fatal overdose data). Fatal overdoses in Rhode Island census block groups (CBGs) were predicted using two machine learning approaches: linear regressions and random forests embedded in a nested cross-validation design. We evaluated performance using mean squared error and the percentage of statewide overdoses captured by CBGs forecast to be in top percentiles from 2019 to 2021. RESULTS:Linear models trained on ACS data combined with one other data source performed well, and comparably to models trained on all available data. Those including emergency medical service, prescription drug monitoring program, or carceral release data with ACS data achieved a priori goals for percentage of statewide overdoses captured by CBGs prioritized by models on average. CONCLUSIONS:Prioritizing neighborhoods for overdose prevention with forecasting is feasible using a simple-to-implement model trained on publicly available ACS data combined with only one other administrative data source in Rhode Island, offering a starting point for other jurisdictions.

OBJECTIVES/OBJECTIVE:The escalating overdose crisis in the United States points to the urgent need for new and novel data tools. Overdose data tools are growing in popularity but still face timely delays in surveillance data availability, lack of completeness, and wide variability in quality by region. As such, we need innovative tools to identify and prioritize emerging and high-need areas. Forecasting offers one such solution. Machine learning methods leverage numerous datasets that could be used to predict future vulnerability to overdose at the regional, town, and even neighborhood levels. This study aimed to understand the multi-level factors affecting the early stages of implementation for an overdose forecasting dashboard. This dashboard was developed with and for statewide harm reduction providers to increase data-driven response and resource distribution at the neighborhood level. METHODS:As part of PROVIDENT (Preventing OVerdose using Information and Data from the EnvironmeNT), a randomized, statewide community trial, we conducted an implementation study where we facilitated three focus groups with harm reduction organizations enrolled in the larger trial. Focus group participants held titles such as peer outreach workers, case managers, and program coordinators/managers. We employed the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework to guide our analysis. This framework offers a multi-level, four-phase analysis unique to implementation within a human services environment to assess the exploration and preparation phases that influenced the early launch of the intervention. RESULTS:Multiple themes centering on organizational culture and resources emerged, including limited staff capacity for new interventions and repeated exposure to stress and trauma, which could limit intervention uptake. Community-level themes included the burden of data collection for program funding and statewide efforts to build stronger networks for data collection and dashboarding and data-driven resource allocation. DISCUSSION/CONCLUSIONS:Using an implementation framework within the larger study allowed us to identify multi-level and contextual factors affecting the early implementation of a forecasting dashboard within the PROVIDENT community trial. Additional investments to build organizational and community capacity may be required to create the optimal implementation setting and integration of forecasting tools.

BACKGROUND:Medications for opioid use disorder are associated with a lower risk of drug overdoses at the individual level. However, little is known about whether these effects translate to population-level reductions. We investigated whether county-level efforts to increase access to medication for opioid use disorder in 2012-2014 were associated with opioid overdose deaths in New York State during the first years of the synthetic opioid crisis. METHODS:We performed an ecologic county-level study including data from 60 counties (2010-2018). We calculated rates of people receiving medication for opioid use disorder among the population misusing opioids in 2012-2014 and categorized counties into quartiles of this exposure. We modeled synthetic and nonsynthetic opioid overdose death rates using Bayesian hierarchical models. RESULTS:Counties with higher rates of receiving medications for opioid use disorder in 2012-2014 had lower synthetic opioid overdose deaths in 2016 (highest vs. lowest quartile: rate ratio [RR] = 0.33, 95% credible interval [CrI] = 0.12, 0.98; and second-highest vs. lowest: RR = 0.20, 95% CrI = 0.07, 0.59) and 2017 (quartile second-highest vs. lowest: RR = 0.22, 95% CrI = 0.06, 0.83), but not 2018. There were no differences in nonsynthetic opioid overdose death rates comparing higher quartiles versus lowest quartile of exposure. CONCLUSIONS:A spatio-temporal modeling approach incorporating counts of the population misusing opioids provided information about trends and interventions in the target population. Higher rates of receiving medications for opioid use disorder in 2012-2014 were associated with lower rates of synthetic opioid overdose deaths early in the crisis.

BACKGROUND:Identifying the most effective state laws and provisions to reduce opioid overdose deaths remains critical. METHODS:Using expert ratings of opioid laws, we developed annual state scores for three domains: opioid prescribing restrictions, harm reduction, and Medicaid treatment coverage. We modeled associations of state opioid policy domain scores with opioid-involved overdose death counts in 3133 counties, and among racial/ethnic subgroups in 1485 counties (2013-2020). We modeled a second set of domain scores based solely on experts' highest 20 ranked provisions to compare with the all-provisions model. RESULTS:From 2013 to 2020, moving from non- to full enactment of harm reduction domain laws (i.e., 0 to 1 in domain score) was associated with reduced county-level relative risk (RR) of opioid overdose death in the subsequent year (adjusted RR = 0.84, 95 % credible interval (CrI): 0.77, 0.92). Moving from non- to full enactment of opioid prescribing restrictions and Medicaid treatment coverage domains was associated with higher overdose in 2013-2016 (aRR 1.69 (1.35, 2.11) and aRR 1.20 (1.11, 1.29) respectively); both shifted to the null in 2017-2020. Effect sizes and direction were similar across racial/ethnic groups. Results for experts' highest 20 ranked provisions did not differ from the all-provision model. CONCLUSIONS:More robust state harm reduction policy scores were associated with reduced overdose risk, adjusting for other policy domains. Harmful associations with opioid prescribing restrictions in 2013-2016 may reflect early unintended consequences of these laws. Medicaid coverage domain findings did not align with experts' perceptions, though data limitations precluded inclusion of several highly ranked Medicaid policies.

BACKGROUND AND AIMS/OBJECTIVE:US regulatory changes allowed for additional methadone take-home doses following COVID-19 onset. How dispensing practices changed and which factors drove variation remains unexplored. We determined daily methadone dispensing trajectories over six months before and after regulatory changes due to COVID-19 using state sequence analysis and explored correlates. DESIGN/METHODS:Retrospective chart review of electronic health records. SETTINGS/METHODS:Nine opioid treatment programs (OTPs) across nine US states. PARTICIPANTS/METHODS:Adults initiating treatment in 2019 (n = 328) vs. initiating 1 month after the COVID-19 regulatory changes of March 2020 (n = 376). MEASUREMENTS/METHODS:Type of daily methadone medication encounter (in-clinic, weekend/holiday take-home, take-home, missed dose, discontinued) based on OTP clinic; cohort (pre vs. post-COVID-19); and patient substance use, clinical and sociodemographic characteristics. FINDINGS/RESULTS:Following COVID-19 regulatory changes, allotted methadone take-home doses increased from 3.5% to 13.8% of total person-days in treatment within the first 6 months in care. Clinic site accounted for the greatest variation in methadone dispensing (6.2% and 9.5% of the variation of discrepancy between sequences pre- and post-COVID-19, respectively). People who co-use methamphetamine had a greater increase in take-homes than people who did not use methamphetamine (from 3.7% pre-pandemic to 21.2% post-pandemic vs. 3.5% to 12.5%) and higher discontinuation (average 3.6 vs. 4.7 months among people who did not use methamphetamine pre-COVID-19; average 3.3 vs. 4.6 months post-COVID-19). In the post-COVID-19 cohort, females had a higher proportion of missed doses (17.2% vs. 11.9%) than males. People experiencing houselessness had a higher proportion of missed doses (19% vs. 12.3%) and shorter stays (average 3.5 vs. 4.5 months) when compared with those with stable housing. CONCLUSION/CONCLUSIONS:Daily methadone dispensing trajectories in the US both before and following COVID-19 regulatory changes appeared to depend more on the opioid treatment programs' practices than individual patient characteristics or response to treatment.

BACKGROUND:Wider availability of cannabis through medical and recreational legalization (MCL alone and RCL+MCL) has been hypothesized to contribute to reductions in opioid use, misuse, and related harms. We examined whether state adoption of cannabis laws was associated with changes in opioid outcomes overall and stratified by cannabis use. METHODS:Using National Survey on Drug Use and Health (NSDUH) data from 2015 to 2019, we estimated cannabis law associations with opioid (prescription opioid misuse and/or heroin use) misuse and use disorder. All logistic regression models (overall models and models stratified by cannabis use), included year and state fixed effects, individual level covariates, and opioid-related state policies. Stratified analyses were restricted to individuals who reported lifetime cannabis use prior to law adoption to reduce potential for collider bias. Estimates accounted for multiple comparisons using false discovery rate (FDR) corrections and sensitivity to unmeasured confounding using e-values. RESULTS:Overall, MCL and RCL adoption were not associated with changes in the odds of any opioid outcome. After restricting to respondents reporting past-year cannabis use, we observed decreased odds of past year opioid misuse (adjusted odds ratio [AOR]: 0.57 [95 % confidence interval [CI]: 0.38, 0.85]; FDR p-value: 0.07), among individuals in states with MCL compared to those in states without cannabis laws. RCLs were not associated with changes in the odds of any opioid outcome beyond MCL adoption. CONCLUSION/CONCLUSIONS:Comparing individuals in MCL alone states to those in states without such laws, we found an inconsistent pattern of decreased odds of opioid outcomes, which were more pronounced among people reporting cannabis use. The pattern did not hold for individuals in RCL states. In line with a substitution-oriented perspective, findings suggests that MCLs may be associated with reductions in opioid use among people using cannabis but additional work to replicate and expand on these findings is needed.

BACKGROUND:Recreational cannabis use is increasing in Mexico, where legalization is a possibility. The current area-level socioeconomic context of cannabis use has not been studied in the country, limiting our understanding and public health response. We aimed to analyze the association between the municipal socioeconomic environment and recreational cannabis use in Mexico. METHODS:We used data from the National Survey of Drug, Alcohol and Tobacco Consumption 2016-17, the National Health and Nutrition Survey 2023, the 2015 intercensal survey and the 2020 census to study the association of municipal income and municipal education with past-year recreational cannabis use. We fitted Poisson models with robust variance to obtain prevalence ratios and assessed for effect modification by individual-level sex and age, and household-level education. RESULTS:For every unit increase in municipal education, we observed a 1.5 % increase in the prevalence of recreational cannabis use in 2016-17, and a 2.9 % increase in 2023. For each unit increase in municipal income, we observed a 1.5 % increase in the prevalence of recreational cannabis use in 2016-17, and a 1.8 % increase in 2023. We found no effect modification except for a single age group (20- to 29-year-olds vs to 12- to 19-year-olds). CONCLUSION/CONCLUSIONS:Recreational cannabis use in Mexico is currently higher in more socioeconomically advantaged municipalities. Recreational cannabis use through socioeconomic areas should be monitored closely. Further research of the modifiable causes of this association could help inform current and future public health policies.

BACKGROUND AND AIM/OBJECTIVE:Sedative, hypnotic or anxiolytic use disorders (SHA-UD) are defined by significant impairment or distress caused by recurrent sedative, hypnotic or anxiolytic use. This study aimed to measure trends in the prevalence of SHA-UD diagnoses in adolescent and young adult US Medicaid enrollees from 2001 to 2019. DESIGN/METHODS:Annual, cross-sectional study, 2001-2019. SETTING/METHODS:Medicaid Analytic eXtracts (MAX) and Transformed Medicaid Analytic Files (TAF) from 42 US states with complete data. PARTICIPANTS/CASES/METHODS:Adolescents (13-17 years) and young adults (18-29 years) with ≥10 months Medicaid enrollment in the calendar year; analytic sample contained 5.7 (2001) to 13.2 (2019) million persons per year. MEASUREMENTS/METHODS:Annual prevalence of SHA-UD in adolescent and young adult Medicaid enrollees [defined as an inpatient or outpatient ICD code (304.1x, 305.4x, F13.1x, F13.2x) in the calendar year] was stratified by sex, race/ethnicity, receipt of a benzodiazepine, z-hypnotic or barbiturate prescription, and selected mental health diagnoses. Absolute and relative percent-changes from 2001 vs. 2019 were summarized. Secondary analyses were restricted to states with more consistent data capture. FINDINGS/RESULTS:The prevalence of SHA-UD diagnoses statistically significantly increased for adolescents (0.01% to 0.04%) and young adults (0.05% to 0.24%) from 2001 to 2019. Increasing trends were observed in sex and race/ethnicity subgroups, with greatest relative increases among Non-Hispanic Black (624%) and Hispanic (529%) young adults. The trend increased among those with and without a benzodiazepine, z-hypnotic or barbiturate prescription; i.e. young adults with (2001 = 0.39% to 2019 = 1.77%) and without (2001 = 0.03% to 2019 = 0.18%) a prescription. Most adolescents (76%) and young adults (91%) with a SHA-UD diagnosis in 2019 had a comorbid substance use disorder. CONCLUSIONS:Sedative, hypnotic or anxiolytic use disorders (SHA-UD) diagnoses increased 3- to 5-fold between 2001 and 2019 for adolescent and young adult US Medicaid enrollees, with prevalence remaining low in adolescents. The increase over two decades may be attributed to changes in the availability, use and misuse of sedative, hypnotic and anxiolytic medications and to increased detection, awareness and diagnosing of SHA-UD.