Faculty Bibliography

The US overdose crisis continues to worsen and is disproportionately harming Black and Hispanic/Latino people. Although the "War on Drugs" continues to shape drug policy-at the disproportionate expense of Black and Hispanic/Latino people-states have taken some steps to reduce War on Drugs-related harms and adopt a public health-centered approach. However, the rhetoric regarding these changes has, in many cases, outstripped reality. Using overdose Good Samaritan Laws (GSLs) as a case study, we argue that public health-oriented policy changes made in some states are undercut by the broader enduring environment of a structurally racist drug criminalization agenda that continues to permeate and constrict most attempts at change. Drawing from our collective experiences in public health research and practice, we describe 3 key barriers to GSL effectiveness: the narrow parameters within which they apply, the fact that they are subject to police discretion, and the passage of competing laws that further criminalize people who use illicit drugs. All reveal a persisting climate of drug criminalization that may reduce policy effectiveness and explain why current reforms may be destined for failure and further disadvantage Black and Hispanic/Latino people who use drugs. (Am J Public Health. 2023;113(S1):S43-S48. https://doi.org/10.2105/AJPH.2022.307037).

OBJECTIVES/OBJECTIVE:Before the coronavirus disease 2019 pandemic, federal law required in-person evaluation before buprenorphine initiation. Regulatory changes during the pandemic allow for buprenorphine initiation by audio-only or audiovisual telehealth. Little is known about treatment engagement after buprenorphine initiation conducted via audio-only telehealth. METHODS:A retrospective cohort study of 94 individuals who received initial treatment through an audio-only encounter between April 2020 and February 2021 was performed. Participant demographics, substance use history, withdrawal symptoms, 30-day treatment engagement, and adverse outcomes were determined by an electronic chart and REDcap database review. Subsequent buprenorphine prescriptions filled within 30 days of the initial encounter were tracked through the Rhode Island Prescription Drug Monitoring Program. RESULTS:Buprenorphine was prescribed for 94 individuals. Most (92 of 94 [97.9%]) filled their prescription within 30 days. Most had previously taken buprenorphine, including prescribed (42 of 92 [45.7%]) and nonprescribed (58 of 92 [63.0%]). Two thirds were in opioid withdrawal at the time of the call (61 of 92 [66.3%]) with a mean Subjective Opioid Withdrawal Scale of 26.8 (range, 4-57). Four individuals experienced precipitated withdrawal (4 of 94 [4.3%]), and 2 reported persistent withdrawal at their follow-up visit (2 of 94 [2.1%]). More than 70% filled a subsequent prescription for buprenorphine within 30 days of the end of their hotline prescription (65 of 92 [70.7%]), on average of 5.88 days (range, 0-28) after completion of their telehealth prescription. CONCLUSIONS:Expanding telehealth-delivered buprenorphine care has the potential to address treatment gaps and facilitate delivery of on-demand services during peak motivation. This evaluation of audio-only buprenorphine initiation found high rates of unobserved buprenorphine initiation and treatment continuation with low rates of complications.

Violations of the positivity assumption (also called the common support condition) challenge health policy research and can result in significant bias, large variance, and invalid inference. We define positivity in the single- and multiple-timepoint (i.e., longitudinal) health policy evaluation setting, and discuss real-world threats to positivity. We show empirical evidence of the practical positivity violations that can result when attempting to estimate the effects of health policies (in this case, Naloxone Access Laws). In such scenarios, an alternative is to estimate the effect of a shift in law enactment (e.g., the effect if enactment had been delayed by some number of years). Such an effect corresponds to what is called a modified treatment policy, and dramatically weakens the required positivity assumption, thereby offering a means to estimate policy effects even in scenarios with serious positivity problems. We apply the approach to define and estimate the longitudinal effects of Naloxone Access Laws on opioid overdose rates.

BACKGROUND:States have enacted multiple types of laws, with a variety of constituent provisions, in response to the opioid epidemic, often simultaneously. This temporal proximity and variation in state-to-state operationalization has resulted in significant challenges for empirical research on their effects. Thus, expert consensus can be helpful to classify laws and their provisions by their degree of helpfulness and impact. METHODS:We conducted a four-stage modified policy Delphi process to identify the top 10 most helpful and 5 most harmful provisions from eight opioid-related laws. This iterative consultation with six types of opioid experts included a preliminary focus group (n=12), two consecutive surveys (n=56 and n=40, respectively), and a final focus group feedback session (n=5). RESULTS:On a scale of very harmful (0) to very helpful (4), overdose Good Samaritan laws received the highest average helpfulness rating (3.62, 95% CI: 3.48-3.75), followed by naloxone access laws (3.37, 95% CI: 3.22-3.51), and pain management clinic laws (3.08, 95% CI: 2.89-3.26). Drug-induced homicide (DIH) laws were rated the most harmful (0.88, 95% CI: 0.66-1.11). Impact ratings aligned similarly, although Medicaid laws received the second highest overall impact rating (3.71, 95% CI: 3.45, 3.97). The two most helpful provisions were naloxone standing orders (3.94, 95% CI: 3.86-4.02) and Medicaid coverage of medications for opioid use disorder (MOUD) (3.89, 95% CI: 3.82). Mandatory minimum DIH laws were the most harmful provision (0.73, 95% CI 0.53-0.93); followed by requiring prior authorization for Medicaid coverage of MOUD (1.00 95% CI: 0.72-1.27). CONCLUSION/CONCLUSIONS:Overall, experts rated laws and provisions that facilitated harm reduction efforts and access to MOUD as most helpful. Laws and provisions rated as most harmful criminalized substance use and placed restrictions on access to MOUD. These ratings provide a foundation for evaluating the overall overdose policy environment for each state.

Overdose Good Samaritan Laws (GSLs) aim to reduce mortality by providing limited legal protections when an overdose bystander summons help. Most research into the impact of these laws is dated or potentially confounded by co-enacted naloxone access laws. Lack of awareness and trust in GSL protections, as well as fear of police involvement and legal repercussions, remain key deterrents of help-seeking. These barriers may be unequally distributed by race due to racist policing and drug policies, potentially producing racial disparities in the effectiveness of GSLs for reducing overdose mortality. We used 2015-2019 vital statistics data to estimate the effect of recent GSLs on overdose mortality, overall (eight states) and by Black/white race (four states). Given GSLs' near ubiquity, few unexposed states were available for comparison. We therefore proposed an "inverted" synthetic control method (SCM) to compare overdose mortality in new-GSL states to states with GSLs throughout the analytic period. The estimated relationships between GSLs and overdose mortality, both overall and stratified by Black/white race, were consistent with chance. An absence of effect could result from insufficient protection provided by the laws, insufficient awareness of them, and/or reticence to summon help not addressable by legal protections. The inverted SCM may be useful for evaluating other widespread policies.

Since early 2020 COVID-19 has swept across the United States, exposing shortcomings in the current healthcare delivery system. Although some interim efforts have been made to mitigate the spread of infection and maintain access to treatment for opioid use disorder, more permanent changes are needed to combat the ongoing opioid crisis. In this commentary, we describe the regulatory barriers to methadone maintenance treatment that disproportionately impact communities of color. We then discuss strategies supporting more equitable access to this proven treatment for opioid use disorder.