Faculty Bibliography

BACKGROUND AND AIMS/OBJECTIVE:Individuals with opioid use disorder (OUD) suffer disproportionately from COVID-19. To inform clinical management of OUD patients, research is needed to identify characteristics associated with COVID-19 progression and death among this population. We aimed to investigate the role of OUD and specific comorbidities on COVID-19 progression among hospitalized OUD patients. DESIGN/METHODS:Retrospective cohort study of merged electronic health records (EHR) from five large private health systems SETTING: New York City, New York, USA, 2011-2021 PARTICIPANTS: Adults with a COVID-19 encounter and OUD or opioid overdose diagnosis between March 2020-February 2021 MEASUREMENTS: Primary exposure included diagnosis of OUD/opioid overdose. Risk factors included age, sex, race/ethnicity and common medical, substance use and psychiatric co-morbidities known to be associated with COVID-19 severity. Outcomes included COVID-19 hospitalization and subsequent intubation, acute kidney failure, severe sepsis and death. FINDINGS/RESULTS:Of 110,917 COVID-19+ adults, 1.17% were ever diagnosed with OUD/opioid overdose. OUD patients had higher risk of COVID-19 hospitalization (adjusted risk ratio [aRR]: 1.40 [95% confidence interval (CI) 1.33, 1.47]), intubation (adjusted aood ratio [aOR]: 2.05 [95% CI 1.74, 2.42]), kidney failure (aRR: 1.51 [95% CI 1.34, 1.70)), sepsis (aRR: 2.30 [95% CI 1.88, 2.81]), and death (aRR: 2.10 [95% CI 1.84, 2.40)]. Among hospitalized OUD patients, risks for COVID-19 outcomes included being male; older; of a race/ethnicity other than white, Black or Hispanic; and having co-morbid chronic kidney disease, diabetes, obesity or cancer. Protective factors included having asthma, hepatitis-C, and chronic pain. CONCLUSIONS:Opioid use disorder patients appears to have a substantial risk for COVID-19-associated morbidity and mortality, with particular comorbidities and treatments potentially moderating this risk.

PURPOSE/UNASSIGNED:As part of COVID-19 control policy, the Centers for Disease Control and Prevention has advised local jurisdictions to permit the formation of homeless encampments to prevent community disease spread. This new federal public health guidance is in conflict with existing police policies in many jurisdictions to raze or evict homeless encampments upon discovery. However, no empirical research on homeless encampment policy actions exists. METHODS/UNASSIGNED:This study utilized interrupted time series to estimate the impact of the 2017 closure of "the Hole"-a longstanding encampment of homeless people who use drugs in the Bronx, New York City-on crime complaints. Daily crime complaints originating from public spaces within 1 mile of the encampment were captured during the 30-day periods before and after closure. RESULTS/UNASSIGNED:Closure was associated with no short-term changesin complaints [IRR=1.01; 95% CI (0.81-1.27)], with daily complaints remaining at baseline levels during the post-closure period [IRR 0.99; 95% CI (0.98-1.00)]. DISCUSSION/UNASSIGNED:Findings preliminarily suggest that the presence of a homeless encampment may not have been associated with increased levels of crime in the neighborhood where it was located. Future research is necessary to understand the health and social impacts of homeless encampments and inform municipal policymakers.

The ways in which prescription drug monitoring programs (PDMPs) have been integrated into clinical practice remain understudied, and research into PDMP implementation in states where PDMP use by providers is mandated remains scant. This qualitative study describes how use of a state-mandated PDMP influenced clinical practice and opioid analgesic prescribing. We conducted face-to-face, in-depth interviews with 53 New York State-licensed primary care physicians who reported that they currently prescribed opioid analgesic medication, including those providers who reported consistent use of the PDMP (n = 38) in this sample. We used a thematic analytic approach to identify patterns of PDMP implementation into practice following enactment of the New York State legislative usage mandate. Among physicians who consistently used the PDMP, we found two distinct groups: (1) physicians who reported no change in their clinical practice and (2) physicians who acknowledged changes to both clinical practice and administrative management. In the latter group, most physicians felt the PDMP had benefited their patient relationships by fostering dialogue around patient substance use; however, some used the PDMP to dismiss patients from care. Findings suggest that increased education for providers relating to judicious prescribing, opioid use disorder, and best practice for PDMP utilization are needed.

Opioid analgesics and benzodiazepines remain substantial contributors to unintentional drug overdose deaths in the United States. To promote judicious prescribing and improve care for patients with substance use disorders, the New York City Department of Health and Mental Hygiene piloted the Prescriber Notification Program, an educational initiative to deliver targeted public health messaging to providers who had prescribed opioid analgesics and/or benzodiazepines to patients who died from overdose in New York City. This article reports on provider responses to receipt of patient death notifications and program feasibility. Findings demonstrate that a majority of prescribers were not aware of patient deaths prior to receiving notification letters. Public health authorities considering prescriber notification systems should address barriers to implementation and sustainability-in particular, consistent and routine access to and linkage of overdose mortality and prescription monitoring data-as part of planning such programs.

BACKGROUND:The ways in which prescription drug monitoring programs (PDMPs) have been integrated into primary care practice remain understudied, and research into physician utilization of PDMPs in states where PDMP use is mandated remains scant. OBJECTIVES:To characterize primary care physician perspectives on and utilization of a mandatory PDMP in New York City. METHODS:We conducted face-to-face, in-depth interviews with primary care physicians who reported that they currently prescribed opioid analgesic medication. We used a thematic analytic approach to characterize physician perspectives on the PDMP mandate and physician integration of mandatory PDMP use into primary care practice. RESULTS:Primary care providers demonstrated a continuum of PDMP utilization, ranging from consistent use to the specifications of the mandate to inconsistent use to no use. Providers reported a range of perspectives on the purpose and function of the PDMP mandate, as well as a lack of clarity about the mandate and its enforcement. CONCLUSION:Findings suggest a need for increased clinical and public health education about the use of PDMPs as clinical tools to identify and treat patients with potential substance use disorders in primary care.

OBJECTIVES:To compare the characteristics of individual overdose decedents in Rhode Island, 2016-2020 to the neighborhoods where fatal overdoses occurred over the same time period. METHODS:We conducted a retrospective analysis of fatal overdoses occurring between January 1, 2016 and June 30, 2020. Using individual- and neighborhood-level data, we conducted descriptive analyses to explore the characteristics of individuals and neighborhoods most affected by overdose. RESULTS:Most overdose decedents during the study period were non-Hispanic White. Across increasingly more White and non-Hispanic neighborhoods, rates of fatal overdose per 100,000 person-years decreased. An opposite pattern was observed across quintiles of average neighborhood poverty. CONCLUSIONS:Rates of fatal overdose were higher in less White, more Hispanic, and poorer neighborhoods, suggesting modest divergence between the characteristics of individuals and the neighborhoods most severely affected. These impacts may not be uniform across space and may accrue differentially to more disadvantaged and racially/ethnically diverse neighborhoods.

BACKGROUND:Mandates for prescriber use of prescription drug monitoring programs (PDMPs), databases tracking controlled substance prescriptions, are associated with reduced opioid analgesic (OA) prescribing but may contribute to care discontinuity and chronic opioid therapy (COT) cycling, or multiple initiations and terminations. OBJECTIVE:To estimate risks of COT cycling in New York City (NYC) due to the New York State (NYS) PDMP mandate, compared to risks in neighboring New Jersey (NJ) counties. DESIGN/METHODS:We estimated cycling risk using Prentice, Williams, and Peterson gap-time models adjusted for age, sex, OA dose, payment type, and county population density, using a life-table difference-in-differences design. Failure time was duration between cycles. In a subgroup analysis, we estimated risk among patients receiving high-dose prescriptions. Sensitivity analyses tested robustness to cycle volume considering only first cycles using Cox proportional hazard models. PARTICIPANTS/METHODS:The cohort included 7604 patients dispensed 12,695 prescriptions. INTERVENTIONS/METHODS:The exposure was the August 2013 enactment of the NYS PDMP prescriber use mandate. MAIN MEASURES/METHODS:We used monthly, patient-level data on OA prescriptions dispensed in NYC and NJ between August 2011 and July 2015. We defined COT as three sequential months of prescriptions, permitting 1-month gaps. We defined recurrence as re-initiation of COT after at least 2 months without prescriptions. The exposure was enactment of the PDMP mandate in NYC; NJ was unexposed. KEY RESULTS/RESULTS:Enactment of the NYS PDMP mandate was associated with an adjusted hazard ratio (HR) for cycling of 1.01 (95% CI, 0.94-1.08) in NYC. For high-dose prescriptions, the risk was 1.16 (95% CI, 1.01-1.34). Sensitivity analyses estimated an overall risk of 1.01 (95% CI, 0.94-1.11) and high-dose risk of 1.09 (95% CI, 0.91-1.31). CONCLUSIONS:The PDMP mandate had no overall effect on COT cycling in NYC but increased cycling risk among patients receiving high-dose opioid prescriptions by 16%, highlighting care discontinuity.