Faculty Bibliography

BACKGROUND:As of July 2018, 45 United States (US) states and the District of Columbia have enacted an overdose Good Samaritan law (GSL). These laws, which provide limited criminal immunity to individuals who request assistance during an overdose, may be of importance in the current wave of the overdose epidemic, which is driven primarily by illicit opioids including heroin and fentanyl. There are substantial differences in the structures of states' GSL laws which may impact their effectiveness. This study compared GSLs which have legal provisions protecting from arrest and laws which have more limited protections. METHODS:Using national county-level overdose mortality data from 3109 US counties, we examined the association of enactment of GSLs with protection from arrest and GSLs with more limited protections with subsequent overdose mortality between 2013 and 2018. Since GSLs are often enacted in conjunction with Naloxone Access Laws (NAL), we examined the effect of GSLs separately and in conjunction with NAL. We conducted these analyses using hierarchical Bayesian spatiotemporal Poisson models. RESULTS:GSLs with protections against arrest enactment in conjunction with a NAL were associated with 7% lower rates of all overdose deaths (rate ratio (RR): 0.93% Credible Interval (CI): 0.89-0.97), 10% lower rates in opioid overdose deaths (RR: 0.90; CI: 0.85-0.95) and 11% lower rates of heroin/synthetic overdose mortality (RR: 0.89; CI: 0.82-0.96) two years after enactment, compared to rates in states without these laws. Significant reductions in overdose mortality were not seen for GSLs with protections for charge or prosecution. CONCLUSION/CONCLUSIONS:GSLs with more expansive legal protections combined with a NAL, were associated with lower rates of overdose deaths, although these risk reductions take time to manifest. Policy makers should consider enacting and implementing more expansive GSLs with arrest protections to increase the likelihood people will contact emergency services in the event of an overdose.

Background: Opioid use disorder (OUD) among pregnant women has increased dramatically over the past two decades nationally and is associated with increased risks of adverse pregnancy and birth outcomes. To increase access to effective treatment, several states have enacted policies mandating priority treatment access. We evaluated the impact of priority access policies on buprenorphine prescriptions to women of childbearing age (15-44).
Method(s): We extracted buprenorphine prescription data from the IQVIA XPonent database from 2006 to 2017, accounting for 90% of national retail outpatient prescriptions. We compared the change in rate of buprenorphine prescriptions dispensed to women of childbearing age by OB/GYN specialists pre-and post-policy enactment in counties in states with a priority access policy with the contemporaneous change in rate in counties in states with no such policy. Rate ratios and 95% CIs were estimated using spatiotemporal Bayesian hierarchical models, adjusted for calendar year, county-level variables (population density, birth rate, race, income, insurance, unemployment), state-level fixed effects, and state-level time-varying policies (Medicaid expansion and policies that consider OUD during pregnancy child abuse, grounds for civil commitment, and/or reportable to child protective services).
Result(s): Priority access policies existed in 17 states and Washington DC in 2006, were enacted in 10 states from 2006 to 2016, and expired in 5 states from 2006 to 2016. The adjusted rate ratio (95% CI) for buprenorphine prescriptions comparing counties in states with priority access policies to counties in states with no such policies was 1.84 (1.49, 2.28).
Conclusion(s): Priority access policies increased buprenorphine prescribing to women of childbearing age. Future research should investigate whether priority access policies could also improve birth outcomes

BACKGROUND:The rise in opioid-related mortality and opioid-related emergency department (ED) visits has stimulated research on whether broader economic declines, such as the Great Recession, affect opioid-related morbidity. We examine in New York City whether one measure of morbidity-opioid-related ED visits-responded acutely to the large negative "shock" of the Great Recession. METHODS:Data comprise outpatient "treat and release" opioid-related ED visits in New York City for the 72 months spanning January 2006 to December 2011, taken from the Statewide Emergency Department Database (n = 150,246). We modeled the monthly incidence of opioid-related ED visits using Autoregressive, Integrated, Moving Average (ARIMA) time-series methods to control for patterning in ED visits before examining its potential association with the economic shock of the Great Recession. RESULTS:New York City shows a mean of 1761 outpatient ED visits per month for opioid dependence and abuse. Unexpectedly large drops in employment coincide with fewer than expected opioid dependence and abuse ED visits in that same month. The result (coefficient = 0.046, 95% Confidence Interval [CI]: 0.002, 0.090) represents a 0.8% drop in overall incidence of opioid dependence and abuse ED visits during the Great Recession. We, however, observe no association between the Great Recession and ED visits for prescription opioid overdose or heroin overdose, or with inpatient ED visits for opioid dependence and abuse. CONCLUSIONS:Findings, if replicated, indicate distinct short-term reductions in opioid-related morbidity following the Great Recession. This result diverges from previous findings of increased opioid use following extended economic downturns.

BACKGROUND AND AIMS/OBJECTIVE:Debates about lowering the blood alcohol concentration (BAC) limit for drivers are intensifying in the United States and other countries, and the World Health Organization recommends the limit for adults should be 0.05%. In January 2016, Uruguay implemented a law setting zero-BAC limit for all drivers. This aimed to assess the effect of this policy on the frequency of moderate/severe-injury and fatal traffic crashes. DESIGN/METHODS:A quasi experimental study in which a synthetic control model was used with controls consisting of local areas in Chile as the counterfactual for outcomes in Uruguay, matched across population counts and pre-intervention period outcomes. Sensitivity analyses were also conducted. SETTING/METHODS:Uruguay and Chile. CASES/METHODS:Panel data with crash counts by outcome per locality-month (2013-2017). INTERVENTION AND COMPARATOR/UNASSIGNED:A zero-blood alcohol concentration law implemented 9 Jan 2016 in Uruguay, alongside a continued 0.03g/dL BAC threshold in Chile. MEASUREMENTS/METHODS:Per capita moderate/severe injury (i.e., moderate or severe), severe injury, and fatal crashes (2016-2017). FINDINGS/RESULTS:Our base synthetic control model results suggested a reduction in fatal crashes at 12 months (20.9%; p-value=0.018, 95% CI: [-0.340, -0.061]). Moderate-/severe-injury crashes did not decrease significantly (10.2%, p=0.312 [-.282, .075]). The estimated effect at 24 months was smaller and with larger confidence intervals for fatal crashes (14%; p =0.048 [-.246, -.026]) and largely unchanged for moderate/severe-injury crashes (-9.4%, p=.302 [-.248, .075]). Difference-in-differences analyses yielded similar results. As a sensitivity test, a synthetic control model relying on an inferior treatment-control match pre-intervention (measured by mean squared error) yielded similar sized differences that were not statistically significant. CONCLUSIONS:Implementation of a law setting a zero blood-alcohol concentration threshold for all drivers in Uruguay appears to have resulted in a reduction in fatal crashes in the following 12 months and 24 months.

Big Events are periods during which abnormal large-scale events like war, economic collapse, revolts, or pandemics disrupt daily life and expectations about the future. They can lead to rapid change in health-related norms, beliefs, social networks and behavioural practices. The world is undergoing such Big Events through the interaction of COVID-19, a large economic downturn, massive social unrest in many countries, and ever-worsening effects of global climate change. Previous research, mainly on HIV/AIDS, suggests that the health effects of Big Events can be profound, but are contingent: Sometimes Big Events led to enormous outbreaks of HIV and associated diseases and conditions such as injection drug use, sex trading, and tuberculosis, but in other circumstances, Big Events did not do so. This paper discusses and presents hypotheses about pathways through which the current Big Events might lead to better or worse short and long term outcomes for various health conditions and diseases; considers how pre-existing societal conditions and changing 'pathway' variables can influence the impact of Big Events; discusses how to measure these pathways; and suggests ways in which research and surveillance might be conducted to improve human capacity to prevent or mitigate the effects of Big Events on human health.

More than 750,000 people in the United States died from an overdose between 1999 and 2018; two-thirds of those deaths involved an opioid. In this review, we present trends in opioid overdose rates during this period and discuss how the proliferation of opioid prescribing to treat chronic pain, changes in the heroin and illegally manufactured opioid synthetics markets, and social factors, including deindustrialization and concentrated poverty, contributed to the rise of the overdose epidemic. We also examine how current policies implemented to address the overdose epidemic may have contributed to reducing prescription opioid overdoses but increased overdoses involving illegal opioids. Finally, we identify new directions for research to understand the causes and solutions to this critical public health problem, including research on heterogeneous policy effects across social groups, effective approaches to reduce overdoses of illegal opioids, and the role of social contexts in shaping policy implementation and impact. Expected final online publication date for the Annual Review of Public Health, Volume 42 is April 1, 2021. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

PURPOSE/OBJECTIVE:There are well-established associations between parental/peer relationships and adolescent substance use, but few longitudinal studies have examined whether adolescents change their substance use in response to changes in their parents' behavior or peer networks. We employ a within-person change approach to address two key questions: Are changes in parenting and peer factors associated with changes in adolescent marijuana and alcohol use? Are there sensitive periods when changes in parenting and peer factors are more strongly associated with changes in adolescent marijuana and alcohol use? METHODS:We analyzed longitudinal data collected annually on 503 boys, ages 13-19, recruited from Pittsburgh public schools. Questionnaires regarding parental supervision, negative parenting practices, parental stress, physical punishment, peer delinquency, and peer drug use were administered to adolescents and their caretakers. Alcohol and marijuana use were assessed by a substance use scale adapted from the National Youth Survey. RESULTS:Reductions in parental supervision and increases in peer drug use and peer delinquency were associated with increases in marijuana frequency, alcohol frequency, and alcohol quantity. Increases in parental stress were associated with increases in marijuana and alcohol frequency. The magnitudes of these relationships were strongest at ages 14-15 and systematically decreased across adolescence. These associations were not due to unmeasured stable confounders or measured time-varying confounders. CONCLUSIONS:Reducing or mitigating changes in parenting and peer risk factors in early adolescence may be particularly important for preventing substance use problems as adolescents transition into young adulthood.

Opioid-related mortality increased by nearly 400% between 2000 and 2018. In response, federal, state, and local governments have enacted a heterogeneous collection of opioid-related policies in an effort to reverse the opioid crisis, producing a policy landscape that is both complex and dynamic. Correspondingly, there has been a rise in opioid-policy related evaluation studies, as policymakers and other stakeholders seek to understand which policies are most effective. In this paper, we provide an overview of methodological challenges facing opioid policy researchers when evaluating the effects of opioid policies using observational data, as well as some potential solutions to those challenges. In particular, we discuss the following key challenges: (1) Obtaining high-quality opioid policy data; (2) Appropriately operationalizing and specifying opioid policies; (3) Obtaining high-quality opioid outcome data; (4) Addressing confounding due to systematic differences between policy and non-policy states; (5) Identifying heterogeneous policy effects across states, population subgroups, and time; (6) Disentangling effects of concurrent policies; and (7) Overcoming limited statistical power to detect policy effects afforded by commonly-used methods. We discuss each of these challenges and propose some ways forward to address them. Increasing the methodological rigor of opioid evaluation studies is imperative to identifying and implementing opioid policies that are most effective at reducing opioid-related harms.