Faculty Bibliography

BACKGROUND:Prescription opioid overdose (POD) and heroin overdose (HOD) rates have quadrupled since 1999. Community-level socioeconomic characteristics are associated with opioid overdoses, but whether this varies by urbanicity is unknown. METHODS:In this serial cross-sectional study of zip codes in 17 states, 2002-2014 (n = 145,241 space-time units), we used hierarchical Bayesian Poisson space-time models to analyze the association between zip code-level socioeconomic features (poverty, unemployment, educational attainment, and income) and counts of POD or HOD hospital discharges. We tested multiplicative interactions between each socioeconomic feature and zip code urbanicity measured with Rural-Urban Commuting Area codes. RESULTS:Percent in poverty and of adults with ≤ high school education were associated with higher POD rates (Rate Ratio [RR], 5% poverty: 1.07 [95% credible interval: 1.06-1.07]; 5% low education: 1.02 [1.02-1.03]), while median household income was associated with lower rates (RR, $10,000: 0.88 [0.87-0.89]). Urbanicity modified the association between socioeconomic features and HOD. Poverty and unemployment were associated with increased HOD in metropolitan areas (RR, 5% poverty: 1.12 [1.11-1.13]; 5% unemployment: 1.04 [1.02-1.05]), and median household income was associated with decreased HOD (RR, $10,000: 0.88 [0.87-0.90]). In rural areas, low educational attainment alone was associated with HOD (RR, 5%: 1.09 [1.02-1.16]). CONCLUSIONS:Regardless of urbanicity, elevated rates of POD were found in more economically disadvantaged zip codes. Economic disadvantage played a larger role in HOD in urban than rural areas, suggesting rural HOD rates may have alternative drivers. Identifying social determinants of opioid overdoses is particularly important for creating effective population-level interventions.

BACKGROUND AND AIMS/OBJECTIVE:Prescription drug monitoring programs (PDMP), defined as state-level databases used in the USA that collect prescribing information when controlled substances are dispensed, have varied substantially between states and over time. Little is known about the combinations of PDMP features that, collectively, may produce the greatest impact on prescribing and overdose. We aimed to (1) identify the types of PDMP models that have developed from 1999 to 2016, (2) estimate whether states have transitioned across PDMP models over time, and (3) examine whether states have adopted different types of PDMP models in response to the burden of opioid overdose. METHODS:A latent transition analysis of PDMP models based on an adaptation of nine PDMP characteristics classified by prescription opioid policy experts as potentially important determinants of prescribing practices and prescription opioid overdose events. RESULTS:We divided the time period into three intervals (1999-2004, 2005-2009, 2010-2016), and found three distinct PDMP classes in each interval. The classes in the first and second interval can be characterized as "No/Weak", "Proactive", and "Reactive" types of PDMPs, and in the third interval as "Weak", "Cooperative", and "Proactive". The meaning of these classes changed over time: until 2009, states in the "No/Weak" class had no active PDMP, whereas states in the "Proactive" class were more likely to proactively provide unsolicited information to PDMP users, provide open access to law enforcement, and require more frequent data reporting than states in the "Reactive" class. In 2010-2016, the "Weak" class resembled the "Reactive" class in previous intervals. States in the "Cooperative" class in 2010-2016 were less likely than states in the "Proactive" class proactively to provide unsolicited reports, or to provide open access to law enforcement; however, they were more likely than those in the "Proactive" class to share PDMP data with other states, and to report more federal drug schedules. CONCLUSIONS:Since 1999, US states have tended to transition to more robust classes of prescription drug monitoring programs (PDMPs). Opioid overdose deaths in prior years predicted the state's PDMP class but did not predict transitions between PDMP classes over time.

PURPOSE/OBJECTIVE:In 1991, California implemented a law that mandated a background check for all firearm purchases with limited exceptions (comprehensive background check or CBC policy) and prohibited firearm purchase and possession for persons convicted within the past 10 years of certain violent crimes classified as misdemeanors (MVP policy). We evaluated the population effect of the simultaneous implementation of CBC and MVP policies in California on firearm homicide and suicide. METHODS:Quasi-experimental ecological study using the synthetic control group methodology. We included annual firearm and nonfirearm mortality data for California and 32 control states for 1981-2000, with secondary analyses up to 2005. RESULTS:The simultaneous implementation of CBC and MVP policies was not associated with a net change in the firearm homicide rate over the ensuing 10 years in California. The decrease in firearm suicides in California was similar to the decrease in nonfirearm suicides in that state. Results were robust across multiple model specifications and methods. CONCLUSIONS:CBC and MVP policies were not associated with changes in firearm suicide or homicide. Incomplete and missing records for background checks, incomplete compliance and enforcement, and narrowly constructed prohibitions may be among the reasons for these null findings.

AIMS/OBJECTIVE:To use simulation to estimate the impact of alcohol taxation on drinking, non-fatal violent victimization and homicide in New York City (NYC). We simulate the heterogeneous effects of alcohol price elasticities by income, level of consumption and beverage preferences, and examine whether taxation can reduce income inequalities in alcohol-related violence. DESIGN/METHODS:Agent-based modeling simulation. SETTING/METHODS:NYC, USA. PARTICIPANTS/METHODS:Adult population aged 18-64 years in the year 2000 in the 59 community districts of NYC. The population of 256 500 agents approximates a 5% sample of the NYC population. MEASUREMENTS/METHODS:Agents were parameterized through a series of rules that governed alcohol consumption and engagement in violence. Six taxation interventions were implemented based on extensive reviews and meta-analyses, increasing universal alcohol tax by 1, 5 and 10%, and beer tax by 1, 5 and 10%. FINDINGS/RESULTS:Under no tax increase, approximately 12.2% [95% credible interval (prediction interval, PI) = 12.1-12.3%] were heavy drinkers. Taxation decreased the proportion of heavy drinkers; a 10% tax decreased heavy drinking to 9.6% (95% PI = 9.4-9.8). Beer taxes had the strongest effect on population consumption. Taxation influenced those in the lowest income groups more than the highest income groups. Alcohol-related homicide decreased from 3.22 per 100 000 (95% PI = 2.50-3.73) to 2.40 per 100 000 under a 10% universal tax (95% PI = 1.92-2.94). This translates into an anticipated benefit of ~1200 lives/year. CONCLUSION/CONCLUSIONS:Reductions in alcohol consumption in a large urban environment such as New York City can be sustained with modest increases in universal taxation. Alcohol tax increases also have a modest effect on alcohol-related violent victimization. Taxation policies reduce income inequalities in alcohol-related violence.

Importance/UNASSIGNED:Prescription opioids are involved in 40% of all deaths from opioid overdose in the United States and are commonly the first opioids encountered by individuals with opioid use disorder. It is unclear whether the pharmaceutical industry marketing of opioids to physicians is associated with mortality from overdoses. Objective/UNASSIGNED:To identify the association between direct-to-physician marketing of opioid products by pharmaceutical companies and mortality from prescription opioid overdoses across US counties. Design, Setting, and Participants/UNASSIGNED:This population-based, county-level analysis of industry marketing information used data from the Centers for Medicare & Medicaid Services Open Payments database linked with data from the Centers for Disease Control and Prevention on opioid prescribing and mortality from overdoses. All US counties were included, with data on overdoses from August 1, 2014, to December 31, 2016, linked to marketing data from August 1, 2013, to December 31, 2015, using a 1-year lag. Statistical analyses were conducted between February 1 and June 1, 2018. Main Outcomes and Measures/UNASSIGNED:County-level mortality from prescription opioid overdoses, total cost of marketing of opioid products to physicians, number of marketing interactions, opioid prescribing rates, and sociodemographic factors. Results/UNASSIGNED:Between August 1, 2013, and December 31, 2015, there were 434 754 payments totaling $39.7 million in nonresearch-based opioid marketing distributed to 67 507 physicians across 2208 US counties. After adjustment for county-level sociodemographic factors, mortality from opioid overdoses increased with each 1-SD increase in marketing value in dollars per capita (adjusted relative risk, 1.09; 95% CI, 1.05-1.12), number of payments to physicians per capita (adjusted relative risk, 1.18; 95% CI, 1.14-1.21, and number of physicians receiving marketing per capita (adjusted relative risk, 1.12; 95% CI, 1.08-1.16). Opioid prescribing rates also increased with marketing and partially mediated the association between marketing and mortality. Conclusions and Relevance/UNASSIGNED:In this study, across US counties, marketing of opioid products to physicians was associated with increased opioid prescribing and, subsequently, with elevated mortality from overdoses. Amid a national opioid overdose crisis, reexamining the influence of the pharmaceutical industry may be warranted.

OBJECTIVE:This study investigated patient- and area-level characteristics associated with adolescent emergency department (ED) patients' risk of subsequent ED visits for self-harm. METHOD:Retrospective analysis of adolescent patients presenting to a California ED in 2010 (n = 480,706) was conducted using statewide, all-payer, individually linkable administrative data. We examined associations between multiple predictors of interest (patient sociodemographic factors, prior ED utilization, and residential mobility; and area-level characteristics) and odds of a self-harm ED visit in 2010. Patients with any self-harm in 2010 were followed up over several years to assess predictors of recurrent self-harm. RESULTS:Self-harm patients (n = 5539) were significantly more likely than control patients (n = 16,617) to have prior histories of ED utilization, particularly for mental health problems, substance abuse, and injuries. Residential mobility also increased risk of self-harm, but racial/ethnic minority status and residence in a disadvantaged zipcode decreased risk. Five-year cumulative incidence of recurrent self-harm was 19.3%. Admission as an inpatient at index visit, Medicaid insurance, and prior ED utilization for psychiatric problems or injury all increased recurrent self-harm risk. CONCLUSIONS:A range of patient- and area-level characteristics observable in ED settings are associated with risk for subsequent self-harm among adolescents, suggesting new targets for intervention in this clinical context.

OBJECTIVES/OBJECTIVE:To estimate the effect of California's prescription drug monitoring program's (PDMP) registration mandate on use of the PDMP. METHODS:We evaluated the effect of California's mandatory PDMP registration law by fitting time series models on the percentage of clinicians registered for California's PDMP and the percentage of clinicians who were active PDMP users (users who created ≥ 1 patient prescription reports in a given month) from 2010 through 2017. We also compared PDMP use among early PDMP adopters (clinicians who registered > 8 months before the mandatory registration deadline) versus late adopters (clinicians who registered ≤ 8 months before the deadline). RESULTS:Mandatory registration was associated with increases in active PDMP users: 53.5% increase for prescribers and 17.9% for pharmacists. Early adopters were 4 times more likely to be active PDMP users than were late adopters. CONCLUSIONS:Mandatory registration was associated with increases in PDMP registration and use, but most new registrants did not become active users. Public Health Implications. Mandatory PDMP registration increases PDMP use but does not result in widespread PDMP usage by all clinicians prescribing controlled substances.