Faculty Bibliography

Medicaid enrollment varies considerably among states. This study examined the association of Medicaid enrollment with the use of substance health services in the longitudinal National Epidemiologic Survey on Alcohol and Related Conditions of 2001-2005. Instrumental variable methods were used to assess endogeneity of individual-level Medicaid enrollment using state-level data as instruments. Compared to the uninsured, Medicaid covered adults were more likely to use substance use disorder treatment services over the next three years. States that have opted to expand Medicaid enrollment under the Affordable Care Act will likely experience further increases in the use of these service over the coming years.

OBJECTIVES:To present and discuss recent patterns of prescription opioid sales throughout Brazil. METHODS:We graphed linear trends of opioid prescriptions sold from registered pharmacies across Brazil from 2009 to 2015. We then calculated the change in rate of prescriptions sold per 1000 persons in 2015 compared with 2009. RESULTS:Opioid sales increased across Brazil from 1 601 043 prescriptions in 2009 to 9 045 945 prescriptions in 2015, corresponding to a 465% increase in 6 years. The largest absolute increase was for codeine products (rate ratio (RR) = 5.30; 95% confidence interval [CI] = 5.29, 5.31), accounting for more than 98% of prescriptions in both years. Oxycodone had the largest relative increase (RR = 11.39; 95% CI = 11.19, 11.59), and fentanyl products had the smallest absolute and relative increase (RR = 2.91; 95% CI = 2.78, 3.03). CONCLUSIONS:Given rapid increases in opioid sales across Brazil, it is critical to introduce effective prescribing and monitoring methods that allow patients to access necessary medications without escalating risk of opioid misuse and related consequences. Careful surveillance of supply and subsequent outcomes are needed to prevent the development of another devastating opioid epidemic in the Americas.

BACKGROUND:Most recent research on adolescent drug use has focused on alcohol, tobacco, and marijuana. Less is known about the recent epidemiology of adolescent cocaine use, which has serious health consequences. PURPOSE:To describe recent trends in cocaine use by U.S. high school students, and identify differences in lifetime and repeated use across sex and racial/ethnic groups. METHODS:We used data from the national Youth Risk Behavior Surveys (YRBS) from 1999 to 2015. We estimated the prevalence of lifetime cocaine use (LCU) and repeated lifetime cocaine use (RLCU) across years by race/ethnicity and sex and tested for linear and quadratic trends. RESULTS:The prevalence of LCU decreased from 1999 to 2015 (9.54%-5.19%). RLCU also decreased (5.13%-2.84%). Despite the overall decline, LCU and RLCU both rose between 2009-2015 (LCU:2.78%-5.19%, RLCU:1.58%-2.84%). Boys had higher rates of LCU and RLCU than girls (LCU:6.42% vs 4.65%; RLCU:3.69% vs 2.18%). American Indian/Alaskan Native, Native Hawaiian/Pacific Islander, and Hispanic adolescents had the highest overall prevalence of LCU. Black adolescents' LCU patterns differed from other racial/ethnic groups. The prevalence of LCU among Black boys increased over time, while the prevalence for Black girls remained consistently low. CONCLUSIONS:Adolescent cocaine use is less common today than in the 1990s. However, rates of adolescent cocaine use have risen across all racial/ethnic groups in the past few years. Public health efforts should address at risk groups with particularly high or rising rates of cocaine use.

BACKGROUND:Treatment for opioid use disorder involving opioid-based pharmacotherapies is considered most effective when accompanied by psychosocial interventions. Peer-led support groups are widely available and have been described by many as fundamental to the recovery process. However, some individuals using medications face stigma in these settings, which can be contradictory and counterproductive to their recovery. METHODS:This paper describes the development of the "Ability, Inspiration and Motivation" or "AIM" group, an alternative peer support group that aims to remove medication stigma from peer recovery. Qualitative interviews with staff, peers, and clients of a community-based buprenorphine treatment program were used to establish the core components of the curriculum to support client needs. RESULTS:Staff, peers, and clients of the buprenorphine program indicated a need and desire to establish a peer recovery group that recognizes persons on medication as being in recovery and destigmatizes use of medication to treat opioid addiction. A respectful environment, holistic perspective on health, spirituality, sharing, and celebration were all established as necessary pillars of the AIM group curriculum. CONCLUSIONS:The community-based effort to establish and develop the AIM group demonstrates that combining the strengths of a peer support with evidence-based medication treatment is both possible and desirable. Shifting the culture of peer recovery groups to support the use of medications may have implications for improving treatment retention and should be considered as a potential strategy to reduce the burden of the opioid epidemic.

People in the US criminal justice system experience high rates of opioid use disorder, overdose, and other adverse outcomes. Expanding treatment is a key strategy for addressing the opioid epidemic, but little is known about whether the criminal justice system refers people to the highest standard of treatment: the use of the opioid agonist therapies methadone or buprenorphine. We used 2014 data from the national Treatment Episode Data Set to examine the use of agonist treatment among justice-involved people referred to specialty treatment for opioid use disorder. Only 4.6 percent of justice-referred clients received agonist treatment, compared to 40.9 percent of those referred by other sources. Of all criminal justice sources, courts and diversionary programs were least likely to refer people to agonist treatment. Our findings suggest that an opportunity is being missed to promote effective, evidence-based care for justice-involved people who seek treatment for opioid use disorder.

PURPOSE:This short communication examines the impact of the Patient Protection and Affordable Care Act (PPACA) on insurance coverage and substance use treatment access among persons with opioid use disorders. METHODS:Data came from the 2010-2015 National Surveys on Drug Use and Health. Among persons with heroin and opioid pain-reliever use disorders, measures of insurance coverage and treatment access were compared before and after the implementation of major PPACA provisions that expanded access to insurance in 2014. RESULTS:The prevalence of uninsured persons among those with heroin use disorders declined dramatically following PPACA implementation (OR 0.59, 95% CI 0.39-0.89), largely due to an increase in the prevalence of Medicaid coverage (OR 1.96, 95% CI 1.21-3.18). There was no evidence of an increase in the prevalence of treatment, but among persons who received treatment, there was an increase in the proportion whose treatment was paid for by insurance (OR 3.75, 95% CI 2.13-3.18). By contrast, there was no evidence the uninsured rate declined among persons with pain-reliever use disorders. CONCLUSIONS:The PPACA Medicaid expansion increased insurance coverage among persons with heroin use disorders, and likely plays an essential role in protecting the health and financial security of this high-risk group. More research is needed on the relationship between insurance acquisition and utilization of substance use treatment.

BACKGROUND:Opioid Agonist Treatment (OAT) is the standard of care for the treatment of opioid use disorders. However, most people in treatment do not receive OAT. This study evaluated whether there are racial and/or ethnic differences in OAT receipt among adults entering specialty treatment for opioid use disorders in publicly-funded treatment programs across the U.S. METHODS:Using data from the national Treatment: Episode Data Base, odds of OAT receipt were compared among black, Hispanic and white clients. Mediation analyses were used to explore whether any racial/ethnic differences in OAT receipt were explained by variation in clinical need or by other treatment, sociodemographic, or geographic characteristics. Interaction terms were used to assess whether this association was modified by primary opioid type. RESULTS:Only 28.7% of clients received OAT. Odds of OAT receipt were significantly higher odds among blacks (OR: 2.27(2.14-2.41)) and Hispanics (OR: 1.98(1.88-2.09)), compared to whites. Differences in clinical need accounted for a substantial portion of this difference (76.79% and 49.74%, respectively). Differences persisted after accounting for other potential explanatory variables (adjusted OR: 1.37 (1.24-1.52); 1.21(1.11-1.32)), but were only evident for primary heroin users (adjusted OR: 1.50 (1.34-1.69); 1.29 (1.17-1.42)) and not other opioid users. CONCLUSIONS:OAT receipt in treatment programs is low overall and particularly lacking among white heroin users. Differences in OAT receipt cannot be fully explained by differences in clinical need. More research is needed to understand and address barriers that underpin these differences so more patients with opioid use disorder can access evidenced-based treatment.

Calls to address crack-cocaine use in Brazil among homeless and street-frequenting populations who are in urgent need of health services have questioned the capacity of the Brazilian Unified Health System to attend to the nation's most marginalized citizens. In recent years, Brazil has launched several actions to escalate care for substance users, yet many obstacles hindering accessibility and effectiveness of services remain. Paradoxically, these actions have been implemented in the context of a growing economic crisis, and expanding services for a population of poor and stigmatized substance users while cutting other government programs tends to elicit harsh criticism from citizens. In consequence of such prospects, this commentary aims to discuss barriers marginalized substance users face in accessing health services that are at risk of worsening with government cutbacks. Using Rio de Janeiro as an example, we explore two primary issues: the resource-strained, under-staffed and decentralized nature of the Brazilian Unified Health System and the pervading stigma that bars vulnerable citizens from official structures and services. Abandoning initiated government efforts to increase access to health services would risk maintaining vulnerable citizens at the margins of public structures, inhibiting the opportunity to offer this population humane and urgently needed treatment and care.