Faculty Bibliography

Importance/UNASSIGNED:Treatment with methadone or buprenorphine is the current standard of care for opioid use disorder. Given the paucity of research identifying which patients will respond best to which medication, both medications should be accessible to all patients so that patients can determine which works best for them. However, given differences in the historical contexts of their initial implementation, access to each of these medications may vary along racial/ethnic lines. Objective/UNASSIGNED:To examine the extent to which capacity to provide methadone and buprenorphine vary with measures of racial/ethnic segregation. Design, Setting, and Participants/UNASSIGNED:This cross-sectional study included all counties and county-equivalent divisions in the US in 2016. Data on racial/ethnic population distribution were derived from the American Community Survey, and data on locations of facilities providing methadone and buprenorphine were obtained from Substance Abuse and Mental Health Services Administration databases. Data were analyzed from August 22, 2018, to September 11, 2019. Exposures/UNASSIGNED:Two county-level measures of racial/ethnic segregation, including dissimilarity (representing the proportion of African American or Hispanic/Latino residents who would need to move census tracts to achieve a uniform spatial distribution of the population by race/ethnicity) and interaction (representing the probability that an African American or Hispanic/Latino resident will interact with a white resident and vice versa, assuming random mixing across census tracts). Main Outcomes and Measures/UNASSIGNED:County-level capacity to provide methadone or buprenorphine, defined as the number of facilities providing a medication per 100 000 population. Results/UNASSIGNED:Among 3142 US counties, there were 1698 facilities providing methadone (0.6 facilities per 100 000 population) and 18 868 facilities providing buprenorphine (5.9 facilities per 100 000 population). Each 1% decrease in probability of interaction of an African American resident with a white resident was associated with 0.6 more facilities providing methadone per 100 000 population. Similarly, each 1% decrease in probability of interaction of a Hispanic/Latino resident with a white resident was associated with 0.3 more facilities providing methadone per 100 000 population. Each 1% decrease in the probability of interaction of a white resident with an African American resident was associated with 8.17 more facilities providing buprenorphine per 100 000 population. Similarly, each 1% decrease in the probability of interaction of a white resident with a Hispanic/Latino resident was associated with 1.61 more facilities providing buprenorphine per 100 000 population. Conclusions and Relevance/UNASSIGNED:These findings suggest that the racial/ethnic composition of a community was associated with which medications residents would likely be able to access when seeking treatment for opioid use disorder. Reforms to existing regulations governing the provisions of these medications are needed to ensure that both medications are equally accessible to all.

Importance/UNASSIGNED:Little is known about changes in marijuana use and cannabis use disorder (CUD) after recreational marijuana legalization (RML). Objectives/UNASSIGNED:To examine the associations between RML enactment and changes in marijuana use, frequent use, and CUD in the United States from 2008 to 2016. Design, Setting, and Participants/UNASSIGNED:This survey study used repeated cross-sectional survey data from the National Survey on Drug Use and Health (2008-2016) conducted in the United States among participants in the age groups of 12 to 17, 18 to 25, and 26 years or older. Interventions/UNASSIGNED:Multilevel logistic regression models were fit to obtain estimates of before-vs-after changes in marijuana use among respondents in states enacting RML compared to changes in other states. Main Outcomes and Measures/UNASSIGNED:Self-reported past-month marijuana use, past-month frequent marijuana use, past-month frequent use among past-month users, past-year CUD, and past-year CUD among past-year users. Results/UNASSIGNED:The study included 505 796 respondents consisting of 51.51% females and 77.24% participants 26 years or older. Among the total, 65.43% were white, 11.90% black, 15.36% Hispanic, and 7.31% of other race/ethnicity. Among respondents aged 12 to 17 years, past-year CUD increased from 2.18% to 2.72% after RML enactment, a 25% higher increase than that for the same age group in states that did not enact RML (odds ratio [OR], 1.25; 95% CI, 1.01-1.55). Among past-year marijuana users in this age group, CUD increased from 22.80% to 27.20% (OR, 1.27; 95% CI, 1.01-1.59). Unmeasured confounders would need to be more prevalent in RML states and increase the risk of cannabis use by 1.08 to 1.11 times to explain observed results, indicating results that are sensitive to omitted variables. No associations were found among the respondents aged 18 to 25 years. Among respondents 26 years or older, past-month marijuana use after RML enactment increased from 5.65% to 7.10% (OR, 1.28; 95% CI, 1.16-1.40), past-month frequent use from 2.13% to 2.62% (OR, 1.24; 95% CI, 1.08-1.41), and past-year CUD from 0.90% to 1.23% (OR, 1.36; 95% CI, 1.08-1.71); these results were more robust to unmeasured confounding. Among marijuana users in this age group, past-month frequent marijuana use and past-year CUD did not increase after RML enactment. Conclusions and Relevance/UNASSIGNED:This study's findings suggest that although marijuana legalization advanced social justice goals, the small post-RML increase in risk for CUD among respondents aged 12 to 17 years and increased frequent use and CUD among adults 26 years or older in this study are a potential public health concern. To undertake prevention efforts, further studies are warranted to assess how these increases occur and to identify subpopulations that may be especially vulnerable.

Purpose: Adolescents with opioid use disorder (OUD) or who experience opioid overdose are significantly less likely than adults to receive medications for opioid use disorder (MOUD). The extent to which addiction treatment facility characteristics contribute to this differential access is unknown. This study's objectives were to describe the quantity and characteristics of adolescent-serving addiction treatment facilities in the U.S., and examine associations between facility characteristics and offering maintenance MOUD.
Method(s): We performed a cross-sectional study using the 2017 National Survey of Substance Abuse Treatment Services (N-SSATS), a survey of all U.S. addiction treatment facilities. We compared characteristics of facilities that offered specialized adolescent programs versus those that did not ("adult-focused facilities"), including ownership, payments accepted, accreditation/licensure, location, and services. We used logistic regression to identify facility characteristics associated with offering maintenance MOUD (opioid agonist maintenance with buprenorphine or methadone, or extended-release naltrexone), and included interaction terms to test whether MOUD availability differed between facilities with specialized adolescent programs and adult-focused facilities.
Result(s): Among 13,585 addiction treatment facilities in the U.S., 3,537 (26.0%) offered specialized adolescent programs. These facilities were more likely than adult-focused facilities to accept insurance or be owned by a non-profit or state/local/tribal government (p<0.001 for all). Of the 3,537 facilities with adolescent programs, 92.4% (3,267) offered outpatient treatment, 11.7% (413) offered residential treatment, and 3.6% (129) offered inpatient treatment. Among facilities with adolescent-programs, 23.1% (816) offered maintenance MOUD, compared to 35.9% (3,612) of adult-focused facilities (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.49-0.58). While facilities with adolescent-programs and adult-focused facilities were equally likely to offer naltrexone as their only MOUD (OR, 0.92; 95% CI, 0.79-1.08), facilities with adolescent-programs were only half as likely to offer opioid agonist maintenance MOUD (OR, 0.51; 95% CI, 0.46-0.57). Among facilities with adolescent programs, non-profits were more likely than for-profits to offer maintenance MOUD (OR, 1.38; 95% CI, 1.08-1.75). Facilities that accepted any kind of insurance were significantly more likely to provide maintenance MOUD than those not accepting insurance or providing free/reduced-fee services. Cash-only facilities with adolescent-programs had the lowest rate of providing maintenance MOUD (13.2%), whereas cash-only adult-focused facilities had the highest rate of providing maintenance MOUD (41.5%). Facilities (both adult-focused and with adolescent programs) that offered inpatient services, or were licensed/accredited by a national authority were more likely to offer maintenance MOUD. Facilities in the Midwest, South, and West were less likely to provide maintenance MOUD than facilities in the Northeast; this negative association was strongest among facilities with adolescent-programs in the South (OR, 0.24; 95% CI 0.19-0.30; interaction term p<0.001) and West (OR, 0.15; 95% CI 0.12-0.19; interaction term p<0.001).
Conclusion(s): Only one-quarter of U.S. addiction treatment facilities offer specialized adolescent-programs, and these facilities are half as likely to offer maintenance MOUD as adult-focused facilities. This disparity may be even greater in the U.S. South and West. This may explain why adolescents are less likely to receive MOUD than adults by demonstrating that the facilities that serve them are also less likely to provide MOUD. Sources of Support: T32HD052459, K23DA045085, K01DA035387, 1K01DA042139-01A1
Copyright

Prescription drug monitoring programs (PDMPs) are a crucial component of federal and state governments' response to the opioid epidemic. Evidence about the effectiveness of PDMPs in reducing prescription opioid-related adverse outcomes is mixed. We conducted a systematic review to examine whether PDMP implementation within the U.S. is associated with changes in four prescription opioid-related outcome domains: opioid prescribing behaviors, opioid diversion and supply, opioid-related morbidity and substance use disorders, and opioid-related mortality. We searched for eligible publications in Embase, Google Scholar, MEDLINE, and Web of Science. A total of 29 studies, published between 2009 and 2019, met the inclusion criteria. Of the 16 studies examining PDMPs and prescribing behaviors, 11 found that implementing PDMPs reduced prescribing behaviors. All three studies on opioid diversion and supply reported reductions in the examined outcomes. In the opioid-related morbidity and substance use disorders domain, seven out of eight studies found associations with prescription opioid-related outcomes. Four out of eight studies on the opioid-related mortality domain reported reduced mortality rates. Despite the mixed findings, there is emerging evidence that implementation of state PDMPs reduces opioid prescriptions, opioid diversion and supply, and opioid-related morbidity and substance use disorder outcomes. When PDMP characteristics were examined, mandatory access provisions were associated with reductions in prescribing behaviors, diversion outcomes, hospital admissions, substance use disorders, and mortality rates. Inconsistencies in the evidence base across outcome domains are due to analytical approaches across studies and, to some extent, heterogeneities in PDMP policies implemented across states and over time.

OBJECTIVE/UNASSIGNED:Given changes in U.S. marijuana laws, attitudes, and use patterns, individuals with pain may be an emerging group at risk for nonmedical cannabis use and cannabis use disorder. The authors examined differences in the prevalence of nonmedical cannabis use and cannabis use disorder among U.S. adults with and without pain, as well as whether these differences widened over time. METHODS/UNASSIGNED:Data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC, 2001-2002; N=43,093) and NESARC-III (2012-2013; N=36,309) were analyzed using logistic regression. Risk differences of past-year nonmedical cannabis use, frequent (at least three times a week) nonmedical use, and DSM-IV cannabis use disorder were estimated for groups with and without moderate to severe pain, and these risk differences were tested for change over time. RESULTS/UNASSIGNED:Any nonmedical cannabis use was more prevalent in respondents with than without pain (2001-2002: 5.15% compared with 3.74%; 2012-2013: 12.42% compared with 9.02%), a risk difference significantly greater in the 2012-2013 data than in the 2001-2002 data. The prevalence of frequent nonmedical cannabis use did not differ by pain status in the 2001-2002 survey, but was significantly more prevalent in those with than without pain in the 2012-2013 survey (5.03% compared with 3.45%). Cannabis use disorder was more prevalent in respondents with than without pain (2001-2002: 1.77% compared with 1.35%; 2012-2013: 4.18% compared with 2.74%), a significantly greater risk difference in the data from 2012-2013 than from 2001-2002. CONCLUSIONS/UNASSIGNED:The results suggest that adults with pain are a group increasingly vulnerable to adverse cannabis use outcomes, warranting clinical and public health attention to this risk. Psychiatrists and other health care providers treating patients with pain should monitor such patients for signs and symptoms of cannabis use disorder.

Importance/UNASSIGNED:The Patient Protection and Affordable Care Act (ACA) permits states to expand Medicaid coverage for most low-income adults to 138% of the federal poverty level and requires the provision of mental health and substance use disorder services on parity with other medical and surgical services. Uptake of substance use disorder services with medications for opioid use disorder has increased more in Medicaid expansion states than in nonexpansion states, but whether ACA-related Medicaid expansion is associated with county-level opioid overdose mortality has not been examined. Objective/UNASSIGNED:To examine whether Medicaid expansion is associated with county × year counts of opioid overdose deaths overall and by class of opioid. Design, Setting, and Participants/UNASSIGNED:This serial cross-sectional study used data from 3109 counties within 49 states and the District of Columbia from January 1, 2001, to December 31, 2017 (N = 3109 counties × 17 years = 52 853 county-years). Overdose deaths were modeled using hierarchical Bayesian Poisson models. Analyses were performed from April 1, 2018, to July 31, 2019. Exposures/UNASSIGNED:The primary exposure was state adoption of Medicaid expansion under the ACA, measured as the proportion of each calendar year during which a given state had Medicaid expansion in effect. By the end of study observation in 2017, a total of 32 states and the District of Columbia had expanded Medicaid eligibility. Main Outcomes and Measures/UNASSIGNED:The outcomes of interest were annual county-level mortality from overdoses involving any opioid, natural and semisynthetic opioids, methadone, heroin, and synthetic opioids other than methadone, derived from the National Vital Statistics System multiple-cause-of-death files. A secondary analysis examined fatal overdoses involving all drugs. Results/UNASSIGNED:There were 383 091 opioid overdose fatalities across observed US counties during the study period, with a mean (SD) of 7.25 (27.45) deaths per county (range, 0-1145 deaths per county). Adoption of Medicaid expansion was associated with a 6% lower rate of total opioid overdose deaths compared with the rate in nonexpansion states (relative rate [RR], 0.94; 95% credible interval [CrI], 0.91-0.98). Counties in expansion states had an 11% lower rate of death involving heroin (RR, 0.89; 95% CrI, 0.84-0.94) and a 10% lower rate of death involving synthetic opioids other than methadone (RR, 0.90; 95% CrI, 0.84-0.96) compared with counties in nonexpansion states. An 11% increase was observed in methadone-related overdose mortality in expansion states (RR, 1.11; 95% CrI, 1.04-1.19). An association between Medicaid expansion and deaths involving natural and semisynthetic opioids was not well supported (RR, 1.03; 95% CrI, 0.98-1.08). Conclusions and Relevance/UNASSIGNED:Medicaid expansion was associated with reductions in total opioid overdose deaths, particularly deaths involving heroin and synthetic opioids other than methadone, but increases in methadone-related mortality. As states invest more resources in addressing the opioid overdose epidemic, attention should be paid to the role that Medicaid expansion may play in reducing opioid overdose mortality, in part through greater access to medications for opioid use disorder.

BACKGROUND:Prescription drug monitoring programs (PDMPs) that collect and distribute information on dispensed controlled substances have been adopted by nearly all US states. We know little about program characteristics that modify PDMP impact on prescription opioid overdose deaths. METHODS:We measured associations between adoption of any PDMP and changes in fatal prescription opioid overdoses in 2002-2016 across 3,109 counties in 49 states. We then measured changes related to the adoption of "proactive PDMPs", which report outlying prescribing/dispensing patterns and provide broader access to PDMP data by law enforcement. Comparisons were made within three time intervals that broadly represent the evolution of PDMPs (2002-2004, 2005-2009, 2010-2016). We modeled overdoses using Bayesian space-time models. RESULTS:Adoption of electronic PDMP access was associated with 9% lower rates of fatal prescription opioid overdoses after three years (rate ratio [RR]=0.91, 95% credible interval [CI]: 0.88-0.93) with well-supported effects for methadone (RR=0.86, CI: 0.82-0.90) and other synthetic opioids (RR=0.82, CI: 0.77-0.86). Compared to states with no/weak PDMPs, proactive PDMPs were associated with fewer deaths attributed to natural/semi-synthetic opioids (2002-2004: RR=0.72 (0.66-0.78); 2005-2009: RR=0.93 (0.90-0.97); 2010-2016: 0.89 (0.86-0.92)) and methadone (2002-2004: RR=0.77 (0.69-0.85); 2010-2016: RR=0.90 (0.86-0.94)). Unintended effects were observed for synthetic opioids other than methadone (2005-2009: RR=1.29 (1.21-1.38); 2010-2016: RR=1.22 (1.16-1.29)). CONCLUSIONS:State adoption of PDMPs was associated with fewer prescription opioid deaths overall while proactive PDMPs alone were associated with fewer deaths related to natural/semi-synthetic opioids and methadone, the specific targets of these programs.

PURPOSE/OBJECTIVE:The purpose of this study was to estimate the effect of firearm involvement during violent victimization on the level of distress experienced and daily functioning within sociodemographic subgroups. METHODS:We used cross-sectional data from the National Crime Victimization Survey (n = 5698) and Targeted Maximum Likelihood Estimation. Sociodemographic subgroups were defined by age, race, sex, and socioeconomic position. Outcomes included experiencing the victimization as severely distressing and problems in the workplace or at school, or with peers or family. RESULTS:Among people victimized with a firearm, nearly 40% experienced the victimization as severely distressing and 28% reported daily functioning problems as a result of the victimization, compared with 25% and 27% of those victimized without a firearm. In most of the subgroups examined, a greater proportion of people described the event as severely distressing when a firearm was involved in the victimization, ranging up to 19 percentage points higher among women and among black respondents (95% CI for women = 10%-28%; for blacks = 6%-31%). CONCLUSIONS:Our findings suggest an almost universal negative response to firearm involvement during a violent victimization as compared with violent victimizations involving other or no weapons. These findings highlight the need for efforts by medical and mental health practitioners to address the potential sequelae of experiencing severe distress during a firearm victimization.

The opioid/overdose crisis in the United States and Canada has claimed hundreds of thousands of lives and has become a major field for research and interventions. It has embroiled pharmaceutical companies in lawsuits and possible bankruptcy filings. Effective interventions and policies toward this and future drug-related outbreaks may be improved by understanding the sociostructural roots of this outbreak. Much of the literature on roots of the opioid/overdose outbreak focuses on (1) the actions of pharmaceutical companies in inappropriately promoting the use of prescription opioids; (2) "deaths of despair" based on the deindustrialization of much of rural and urban Canada and the United States, and on the related marginalization and demoralization of those facing lifetimes of joblessness or precarious employment in poorly paid, often dangerous work; and (3) increase in occupationally-induced pain and injuries in the population. All three of these roots of the crisis-pharmaceutical misconduct and unethical marketing practices, despair based on deindustrialization and increased occupational pain-can be traced back, in part, to what has been called the "one-sided class war" that became prominent in the 1970s, became institutionalized as neo-liberalism in and since the 1980s, and may now be beginning to be challenged. We describe this one-sided class war, and how processes it sparked enabled pharmaceutical corporations in their misconduct, nurtured individualistic ideologies that fed into despair and drug use, weakened institutions that created social support in communities, and reduced barriers against injuries and other occupational pain at workplaces by reducing unionization, weakening surviving unions, and weakening the enforcement of rules about workplace safety and health. We then briefly discuss the implications of this analysis for programs and policies to mitigate or reverse the opioid/overdose outbreak.