Faculty Bibliography

BACKGROUND AND OBJECTIVE/OBJECTIVE:Youth overdose deaths have remained elevated in recent years as the illicit drug supply has become increasingly contaminated with fentanyl and other synthetics. There is a need to better understand fatal drug combinations and how trends have changed over time and across sociodemographic groups in this age group. METHODS:We used the National Vital Statistics System's multiple cause of death datasets to examine trends in overdose deaths involving combinations of synthetic opioids with benzodiazepine, cocaine, heroin, prescription opioids, and other stimulants among US youth aged 15 to 24 years from 2018 to 2022 across age, sex, race and ethnicity, and region. RESULTS:Overdose death counts rose from 4652 to 6723 (10.85 to 15.16 per 100 000) between 2018 and 2022, with a slight decrease between 2021 and 2022. The largest increases were deaths involving synthetic opioids only (1.8 to 4.8 deaths per 100 000). Since 2020, fatal synthetic opioid-only overdose rates were higher than polydrug overdose rates involving synthetic opioids, regardless of race, ethnicity, or sex. In 2022, rates of synthetic-only overdose deaths were 2.49-times higher among male youths compared with female youths and 2.15-times higher among those aged 20 to 24 years compared with those aged 15 to 19 years. CONCLUSIONS:Polydrug combinations involving synthetic opioids continue to contribute to fatal youth overdoses, yet deaths attributed to synthetic opioids alone are increasingly predominant. These findings highlight the changing risks of the drug supply and the need for better access to harm-reduction services to prevent deaths among youth.

BACKGROUND AND AIMS/OBJECTIVE:US regulatory changes allowed for additional methadone take-home doses following COVID-19 onset. How dispensing practices changed and which factors drove variation remains unexplored. We determined daily methadone dispensing trajectories over six months before and after regulatory changes due to COVID-19 using state sequence analysis and explored correlates. DESIGN/METHODS:Retrospective chart review of electronic health records. SETTINGS/METHODS:Nine opioid treatment programs (OTPs) across nine US states. PARTICIPANTS/METHODS:Adults initiating treatment in 2019 (n = 328) vs. initiating 1 month after the COVID-19 regulatory changes of March 2020 (n = 376). MEASUREMENTS/METHODS:Type of daily methadone medication encounter (in-clinic, weekend/holiday take-home, take-home, missed dose, discontinued) based on OTP clinic; cohort (pre vs. post-COVID-19); and patient substance use, clinical and sociodemographic characteristics. FINDINGS/RESULTS:Following COVID-19 regulatory changes, allotted methadone take-home doses increased from 3.5% to 13.8% of total person-days in treatment within the first 6 months in care. Clinic site accounted for the greatest variation in methadone dispensing (6.2% and 9.5% of the variation of discrepancy between sequences pre- and post-COVID-19, respectively). People who co-use methamphetamine had a greater increase in take-homes than people who did not use methamphetamine (from 3.7% pre-pandemic to 21.2% post-pandemic vs. 3.5% to 12.5%) and higher discontinuation (average 3.6 vs. 4.7 months among people who did not use methamphetamine pre-COVID-19; average 3.3 vs. 4.6 months post-COVID-19). In the post-COVID-19 cohort, females had a higher proportion of missed doses (17.2% vs. 11.9%) than males. People experiencing houselessness had a higher proportion of missed doses (19% vs. 12.3%) and shorter stays (average 3.5 vs. 4.5 months) when compared with those with stable housing. CONCLUSION/CONCLUSIONS:Daily methadone dispensing trajectories in the US both before and following COVID-19 regulatory changes appeared to depend more on the opioid treatment programs' practices than individual patient characteristics or response to treatment.

An increasing number of U.S. states have legalized cannabis, but the effect on adolescent and young adult psychosis-related hospitalizations remains under-studied. Using data from Denver Health between 2005 and 2020, we examined associations between implementation of the Ogden Memo (expanding use of medical cannabis in Colorado, October 2009) and Amendment 64 (legalizing adult-use cannabis in Colorado, November 2012) and trends in psychosis-related emergency department and hospital visits with and without cannabis use disorder (CUD) among youth aged 10-29. Patients with psychosis hospitalizations were predominately male (68 %), white (53 %), and Medicaid recipients (59 %). Significant increases (p < 0.05) were observed in the monthly average rate of psychosis hospitalizations between pre-Ogden memo (21.9 per 100,000) and post-Ogden memo pre-legalization (28.0 per 100,000) and post-legalization (32.3 per 100,000). Similarly, significant increases (p < 0.05) were observed in the monthly average rate of psychosis hospitalizations involving CUD between pre-Ogden memo (2.0 per 100,000), post-Ogden memo and pre-legalization (3.4 per 100,000), and post-legalization (8.5 per 100,000). Interrupted time series modeling found a significant difference in the trends for psychosis hospitalizations involving CUD following recreational legalization (change in average monthly rate went from 0.02/100,000 (95 % CI -0.02, 0.06) to 0.11/100,000 (95 % CI 0.09, 0.13), (difference (0.09 (95 %CI 0.05, 0.14)). Findings suggest an increase in overall hospital encounters for psychosis among youth after the legalization of recreational cannabis. Given the adoption of increasingly permissive cannabis laws, there is a need to plan effective public health responses that could mitigate unintended consequences related to cannabis use.

Between May 2020 and December 2021, there were 159,872 drug overdose deaths in the US. Higher eviction rates have been associated with higher overdose mortality. Amid the economic turmoil caused by the COVID-19 pandemic, 43 states and Washington, DC, implemented eviction moratoria of varying durations. These moratoria reduced eviction filing rates, but their impact on fatal drug overdoses remains unexplored. We evaluated the effect of these policies on county-level overdose death rates by focusing on the dates the state eviction moratoria were lifted. We obtained mortality data from NCHS and eviction moratoria dates from the COVID-19 US State Policy Database. We employed a longitudinal targeted minimum-loss-based estimation with Super Learner to flexibly estimate the average treatment effect (ATE) of never lifting the moratoria. Lifting state eviction moratoria was associated with a 0.14 per 100,000 higher rate of monthly overdose mortality (95%CI: -0.03, 0.32), although confidence intervals were wide and included zero. Eviction moratoria may not be sufficient to prevent overdose mortality during crises such as the COVID-19 pandemic.

As the United States grapples with an ongoing overdose crisis, states and jurisdictions are adopting novel approaches to reduce overdose mortality. In one novel approach, public health researchers and leaders in Rhode Island leveraged the state's robust surveillance data and collaborations between government, academic, and community-based organizations (CBOs) to launch the PROVIDENT (PReventing OVerdose using Information and Data from the EnvironmeNT) project, a population-based randomized controlled research trial (NCT05096429) in December 2019. The PROVIDENT trial utilizes machine learning (ML) methods to identify neighborhoods at risk of future overdose deaths at the census-block-group level to inform community-level overdose prevention resource distribution. To disseminate the ML model predictions, our research team developed an interactive, online mapping dashboard in close collaboration with three statewide CBOs. We measured whether these organizations utilized the PROVIDENT dashboard to allocate harm-reduction services based on ML model predictions and collected information about their data-driven decision-making processes. This case study describes how we assembled and piloted this overdose forecasting dashboard for use by CBOs between November 2021 and August 2024. By measuring dashboard logins, completed surveys, and engagement with ongoing training, we illustrate how organizations utilized ML and surveillance data to inform their outreach efforts and generate valuable insights at a neighborhood level.

To meet the needs of diverse communities, public health authorities are increasingly reliant on hyperlocal interventions targeting specific health issues and distinct populations. To facilitate epidemiological evaluation of hyperlocal interventions on community-level outcomes, we developed a framework of six practice-based considerations for researchers: spatial zone of impact, temporal resolution of impact, outcome of interest, definition of a plausible comparison group, micro vs. macro impacts, and practitioner engagement. We applied this framework to a case study of an impact evaluation of the New York City (NYC) overdose prevention centers (OPCs) on neighborhood-level drug-related arrests. We used drug arrest data from NYC from January 1, 2014, to September 30, 2023 and US Census data to conduct synthetic control modeling, comparing pre- and post-OPC arrests in the neighborhoods surrounding the two NYC OPCs (East Harlem and Washington Heights). We conducted sensitivity analyses to validate our results and compare our findings with those from a prior published study. Our findings indicate no significant change in drug-related arrests following the OPC openings. The mean absolute differences in daily drug-related arrests between the OPCs and their synthetic controls were 0.63 (p = 0.19) in East Harlem and 0.14 (p = 0.22) in Washington Heights. Sensitivity analyses corroborated our main results. Overall, findings demonstrate how our framework can be used to guide future epidemiological evaluations of diverse, hyperlocal public health interventions.

We estimated the extent to which different pain management practices, considered together as well as individually, mediated the relationship between chronic pain or physical disability and new-onset opioid use disorder (OUD) in a large cohort of adult Medicaid patients. Considering the plausibility of the assumptions required to identify different mediational estimands, we estimated natural indirect effects when considering mediation through the group of mediators together and estimated interventional indirect effects when considering mediation through each pain management practice individually. We estimated each effect using a nonparametric one-step estimator. The pain management variables we examined mediated all of the total effect of chronic pain on OUD risk and nearly half of the total effect of physical disability on OUD risk. High-dose, long-duration opioid prescribing and co-prescription of opioids with benzodiazepines, gabapentinoids, and muscle relaxants each contributed substantially to the increased risk of OUD due to chronic pain (contributing to 10-37% of the overall effect) and more moderately to the increased risk of OUD due to physical disability (contributing to 3-19% of the overall effect). Antidepressant or anti-inflammatory prescribing and physical therapy generally did not contribute to increased OUD risk, and, in some cases, even contributed to small reductions in risk.

Following federal regulatory changes during the COVID-19 pandemic, Rhode Island expanded methadone access for opioid treatment programs (OTPs) in March 2020. The policy, which permitted take-home dosing for patients, contrasted with longstanding restrictions on methadone. This study used patient-level OTP admission and discharge records to compare six-month retention before and after the policy change. We conducted a retrospective cohort study of 1,248 patients newly admitted to OTPs between March 18 and June 30 of 2019 (pre-policy) and 2020 (post-policy). We used logistic regression to estimate associations with retention before and after the policy and used a machine learning approach, the Heterogeneous Treatment Effect (HTE)-Scan, to explore heterogeneity in retention across subgroups. Overall, we found no change in retention following the policy, with an adjusted OR of 1.08 (95% CI: 0.80-1.45) and adjusted RR of 1.03 (0.90-1.18). Using HTE-Scan, we identified two subgroups with significantly increased retention above the overall cohort: (1) patients with below high school education and past-month arrest and (2) male, non-Hispanic white or Hispanic/Latino patients reporting heroin or fentanyl use with past-month arrest. We identified no subgroups with significantly decreased retention. Collectively, findings suggest that expanded methadone access may benefit vulnerable populations without harming overall retention.

BACKGROUND AND AIM/OBJECTIVE:Sedative, hypnotic or anxiolytic use disorders (SHA-UD) are defined by significant impairment or distress caused by recurrent sedative, hypnotic or anxiolytic use. This study aimed to measure trends in the prevalence of SHA-UD diagnoses in adolescent and young adult US Medicaid enrollees from 2001 to 2019. DESIGN/METHODS:Annual, cross-sectional study, 2001-2019. SETTING/METHODS:Medicaid Analytic eXtracts (MAX) and Transformed Medicaid Analytic Files (TAF) from 42 US states with complete data. PARTICIPANTS/CASES/METHODS:Adolescents (13-17 years) and young adults (18-29 years) with ≥10 months Medicaid enrollment in the calendar year; analytic sample contained 5.7 (2001) to 13.2 (2019) million persons per year. MEASUREMENTS/METHODS:Annual prevalence of SHA-UD in adolescent and young adult Medicaid enrollees [defined as an inpatient or outpatient ICD code (304.1x, 305.4x, F13.1x, F13.2x) in the calendar year] was stratified by sex, race/ethnicity, receipt of a benzodiazepine, z-hypnotic or barbiturate prescription, and selected mental health diagnoses. Absolute and relative percent-changes from 2001 vs. 2019 were summarized. Secondary analyses were restricted to states with more consistent data capture. FINDINGS/RESULTS:The prevalence of SHA-UD diagnoses statistically significantly increased for adolescents (0.01% to 0.04%) and young adults (0.05% to 0.24%) from 2001 to 2019. Increasing trends were observed in sex and race/ethnicity subgroups, with greatest relative increases among Non-Hispanic Black (624%) and Hispanic (529%) young adults. The trend increased among those with and without a benzodiazepine, z-hypnotic or barbiturate prescription; i.e. young adults with (2001 = 0.39% to 2019 = 1.77%) and without (2001 = 0.03% to 2019 = 0.18%) a prescription. Most adolescents (76%) and young adults (91%) with a SHA-UD diagnosis in 2019 had a comorbid substance use disorder. CONCLUSIONS:Sedative, hypnotic or anxiolytic use disorders (SHA-UD) diagnoses increased 3- to 5-fold between 2001 and 2019 for adolescent and young adult US Medicaid enrollees, with prevalence remaining low in adolescents. The increase over two decades may be attributed to changes in the availability, use and misuse of sedative, hypnotic and anxiolytic medications and to increased detection, awareness and diagnosing of SHA-UD.

BACKGROUND:Buprenorphine and methadone are US Food and Drug Administration-approved medications for opioid use disorder (MOUD). Although utilization of MOUD was increasing pre-COVID-19, it is not well understood how this trend shifted during and "after" the COVID-19 pandemic in Rhode Island. This analysis will consider the differential utilization of MOUD over time and by key demographic factors. METHODS:We utilized two of Rhode Island's statewide databases to examine aggregate counts of dispensed buprenorphine and methadone from January 1, 2017, to December 31, 2023. Data were stratified by age group, sex assigned at birth, and race/ethnicity (where available). Counts were stratified into pre-COVID-19 (Q1 2017-Q1 2020), COVID-19 (Q2 2020-Q4 2022), and endemic COVID-19 (2023) eras. Averages and annualized percent change for each period were calculated to understand how utilization changed over time. RESULTS:Before COVID-19, buprenorphine and methadone utilization were increasing annually. During COVID-19, utilization declined annually by 0.40% and 0.43%, respectively. In the endemic COVID-19 time period, buprenorphine and methadone utilization declined more rapidly at 2.59% and 1.77%, respectively. Declines were more dramatic for adults aged 18-34. CONCLUSIONS:We observed a decline in MOUD utilization during and after COVID-19 in Rhode Island, primarily driven by substantial decreases in MOUD use among the youngest group of adult residents. Interventions specifically tailored to youth, such as school-based or primary healthcare-based programs, may be particularly effective in engaging with youth in substance use disorder treatment.