Faculty Bibliography

BACKGROUND:Most patients in specialty drug treatment programs that are not federally licensed Opioid Treatment Programs (OTPs) programs do not receive medications for opioid use disorder (MOUD). METHODS:We linked results from a survey of non-OTP treatment program directors in New Jersey (n = 81) to statewide administrative records of admissions for opioid use to those programs between July 2021-June 2022. Using multi-level regression, we examined the association of three types of factors with planned MOUD use: program survey responses, client-level factors, and program-level client characteristic mix. RESULTS:Of 9583 opioid treatment admissions in non-OTP settings, 41 % included treatment plans involving MOUD. Programs where directors reported staff concerns about buprenorphine's efficacy or diversion had a lower proportion of clients with planned MOUD, as did programs reporting too little physical space to prescribe. Being self-referred to treatment, unemployed and not looking for work, aged 30-49, heroin use (vs. prescription opioid use), and stimulant use in addition to opioids, were positively associated with planned MOUD; while non-Medicaid insurance, and Black and Hispanic race/ethnicity, were negatively associated with planned MOUD. Clients were more likely to have planned MOUD if their programs had a higher proportion of clients aged 30 or older, heroin as primary "drug of abuse," stimulant use, and not working but actively looking for work. CONCLUSION/CONCLUSIONS:Findings suggest addressing program staff attitudes toward buprenorphine could help increase planned MOUD. There is also a need to improve access for clients with non-Medicaid insurance, address within-program race and ethnic disparities, and address employment-related barriers to medication.

PURPOSE/OBJECTIVE:To synthesize the available evidence on the extent to which area-level socioeconomic conditions are associated with drug overdose deaths in the United States. METHODS:We performed a systematic review (in MEDLINE, EMBASE, PsychINFO, Web of Science, EconLit) for papers published prior to July 2022. Eligible studies quantitatively estimated the association between an area-level measure of socioeconomic conditions and drug overdose deaths in the US, and were published in English. We assessed study quality using the Effective Public Health Practice Project Quality Assessment Tool. The protocol was preregistered at Prospero (CRD42019121317). RESULTS:We identified 28 studies that estimated area-level effects of socioeconomic conditions on drug overdose deaths in the US. Studies were scored as having moderate to serious risk of bias attributed to both confounding and in analysis. Socioeconomic conditions and drug overdose death rates were moderately associated, and this was a consistent finding across a large number of measures and differences in study designs (e.g., cross-sectional versus longitudinal), years of data analyzed, and primary unit of analysis (e.g., ZIP code, county, state). CONCLUSIONS:This review highlights the evidence for area-level socioeconomic conditions are an important factor underlying the geospatial distribution of drug overdose deaths in the US and the need to understand the mechanisms underlying these associations to inform future policy recommendations. The current evidence base suggests that, at least in the United States, employment, income, and poverty interventions may be effective targets for preventing drug overdose mortality rates.

BACKGROUND:Offering medications for opioid use disorder (MOUD) in carceral settings significantly reduces overdose. However, it is unknown to what extent individuals in jails continue MOUD once they leave incarceration. We aimed to assess the relationship between in-jail MOUD and MOUD continuity in the month following release. METHODS:We conducted a retrospective cohort study of linked NYC jail-based electronic health records and community Medicaid OUD treatment claims for individuals with OUD discharged from jail between 2011 and 2017. We compared receipt of MOUD within 30 days of release, among those with and without MOUD at release from jail. We tested for effect modification based on MOUD receipt prior to incarceration and assessed factors associated with treatment discontinuation. RESULTS:Of 28,298 eligible incarcerations, 52.8 % received MOUD at release. 30 % of incarcerations with MOUD at release received community-based MOUD within 30 days, compared to 7 % of incarcerations without MOUD (Risk Ratio: 2.62 (2.44-2.82)). Most (69 %) with MOUD claims prior to incarceration who received in-jail MOUD continued treatment in the community, compared to 9 % of those without prior MOUD. Those who received methadone (vs. buprenorphine), were younger, Non-Hispanic Black and with no history of MOUD were less likely to continue MOUD following release. CONCLUSIONS:MOUD maintenance in jail is strongly associated with MOUD continuity upon release. Still, findings highlight a gap in treatment continuity upon-reentry, especially among those who initiate MOUD in jail. In the wake of worsening overdose deaths and troubling disparities, improving MOUD continuity among this population remains an urgent priority.

The high overdose mortality rates in the United States poses several questions: Why have they been increasing exponentially since 1979? Why are they so high? And how can they be greatly reduced? Building on past research, the causes of the increase seem to be deeply rooted in US social and economic structures and processes, rather than due only to opioid prescription patterns or the advent of synthetic opioids. Given this, we consider what changes might be needed to reverse the exponentially-increasing overdose mortality. We use a path dependency argument to argue that the United States political, economic, and public health systems have helped create this crisis and, unfortunately, continue to heighten it. These same systems suggest that proposals to expand harm reduction and drug treatment capacity, to decriminalize or legalize drugs, or to re-industrialize the country sufficiently to reduce "communities of despair" will not be enacted at a scale sufficient to end the overdose crisis. We thus suggest that in the United States serious improvements in overdose rates and related policies and structures require massive social movements with a broad social change agenda.

As resolution for opioid-related claims and litigation against pharmaceutical manufacturers and other stakeholders, state and local governments are newly eligible for millions of dollars of settlement funding to address the overdose crisis in the United States. To inform effective use of opioid settlement funds, we propose a simple framework that highlights the principal determinants of overdose mortality: the number of people at risk of overdose each year, the average annual number of overdoses per person at risk, and the average probability of death per overdose event. We assert that the annual number of overdose deaths is a function of these three determinants, all of which can be modified through public health intervention. Our proposed heuristic depicts how each of these drivers of drug-related mortality - and the corresponding interventions designed to address each term - operate both in isolation and in conjunction. We intend for this framework to be used by policymakers as a tool for identifying and evaluating public health interventions and funding priorities that will most effectively address the structural forces shaping the overdose crisis and reduce overdose deaths.

BACKGROUND AND AIMS:Longitudinal studies have revealed that substance use treatment use is often recurrent among patients; the longitudinal patterns and characteristics of those treatment trajectories have received less attention, particularly in the global south. This study aimed to disentangle heterogeneity in treatment use among adult patients in Chile by identifying distinct treatment trajectory groups and factors associated with them. DESIGN:National-level registry-based retrospective cohort. SETTING AND PARTICIPANTS:Adults admitted to publicly funded substance use disorder treatment programs in Chile from November 2009 to November 2010 and followed for 9 years (n = 6266). MEASUREMENTS:Monthly treatment use; type of treatment; ownership of the treatment center; discharge status; primary substance used; sociodemographic. FINDINGS:A seven-class treatment trajectory solution was chosen using latent class growth analysis. We identified three trajectory groups that did not recur and had different treatment lengths: Early discontinuation (32%), Less than a year in treatment (19.7%) and Year-long episode, without recurrence (12.3%). We also identified a mixed trajectory group that had a long first treatment or two treatment episodes with a brief time between treatments: Long first treatment, or immediate recurrence (6.3%), and three recurrent treatment trajectory groups: Recurrent and decreasing (14.2%), Early discontinuation with recurrence (9.9%) and Recurrent after long between treatments period (5.7%). Inpatient or outpatient high intensity (vs. outpatient low intensity) at first entry increased the odds of being in the longer one-episode groups compared with the Early discontinuation group. Women had increased odds of belonging to all the recurrent groups. Using cocaine paste (vs. alcohol) as a primary substance decreased the odds of belonging to long one-episode groups. CONCLUSIONS:In Chile, people in publicly funded treatment for substance use disorder show seven distinct care trajectories: three groups with different treatment lengths and no recurring episodes, a mixed group with a long first treatment or two treatment episodes with a short between-treatment-episodes period and three recurrent treatment groups.

Black men who have sex with men (MSM) have been consistently reported to have the highest estimated HIV incidence and prevalence among MSM. Despite broad theoretical understanding that discrimination is a major social and structural determinant that contributes to disparate HIV outcomes among Black MSM, relatively little extant research has empirically examined structural discrimination against sexual minorities as a predictor of HIV outcomes among this population. The present study therefore examines whether variation in policies that explicitly discriminate against lesbian, gay, and bisexual (LGB) people and variation in policies that explicitly protect LGB people differentially predict metropolitan statistical-area-level variation in late HIV diagnoses among Black MSM over time, from 2008 to 2014. HIV surveillance data on late HIV diagnoses among Black MSM in each of the 95 largest metropolitan statistical areas in the United States, from 2008 to 2014, were used along with data on time-varying state-level policies pertaining to the rights of LGB people. Results from multilevel models found a negative relationship between protective/supportive laws and late HIV diagnoses among Black MSM, and a positive relationship between discriminative laws and late HIV diagnoses among Black MSM. These findings illuminate the potential epidemiological importance of policies pertaining to LGB populations as structural determinants of HIV outcomes among Black MSM. They suggest a need for scrutiny and elimination of discriminatory policies, where such policies are currently in place, and for advocacy for policies that explicitly protect the rights of LGB people where they do not currently exist.

BACKGROUND:Both increases and decreases in patients' prescribed daily opioid dose have been linked to increased overdose risk, but associations between 30-day dose trajectories and subsequent overdose risk have not been systematically examined. OBJECTIVE:To examine the associations between 30-day prescribed opioid dose trajectories and fatal opioid overdose risk during the subsequent 15 days. DESIGN/METHODS:Statewide cohort study using linked prescription drug monitoring program and death certificate data. We constructed a multivariable Cox proportional hazards model that accounted for time-varying prescription-, prescriber-, and pharmacy-level factors. PARTICIPANTS/METHODS:All patients prescribed an opioid analgesic in California from March to December, 2013 (5,326,392 patients). MAIN MEASURES/METHODS:Dependent variable: fatal drug overdose involving opioids. Primary independent variable: a 16-level variable denoting all possible opioid dose trajectories using the following categories for current and 30-day previously prescribed daily dose: 0-29, 30-59, 60-89, or ≥90 milligram morphine equivalents (MME). KEY RESULTS/RESULTS:Relative to patients prescribed a stable daily dose of 0-29 MME, large (≥2 categories) dose increases and having a previous or current dose ≥60 MME per day were associated with significantly greater 15-day overdose risk. Patients whose dose decreased from ≥90 to 0-29 MME per day had significantly greater overdose risk compared to both patients prescribed a stable daily dose of ≥90 MME (aHR 3.56, 95%CI 2.24-5.67) and to patients prescribed a stable daily dose of 0-29 MME (aHR 7.87, 95%CI 5.49-11.28). Patients prescribed benzodiazepines also had significantly greater overdose risk; being prescribed Z-drugs, carisoprodol, or psychostimulants was not associated with overdose risk. CONCLUSIONS:Large (≥2 categories) 30-day dose increases and decreases were both associated with increased risk of fatal opioid overdose, particularly for patients taking ≥90 MME whose opioids were abruptly stopped. Results align with 2022 CDC guidelines that urge caution when reducing opioid doses for patients taking long-term opioid for chronic pain.

This article traces the evolution of the Big Events framework since it began as an attempt to understand why sociopolitical transitions in the Former Soviet Union, South Africa, and Indonesia were followed by HIV outbreaks. Big Events frameworks have evolved over time, but all versions try to concretize how macrosocial changes lead to social, personal and environmental changes that shape risk environments and drug use or other behavioral patterns in ways that may lead to epidemics. Important stages in the evolution of the Big Events framework included understanding that the sequelae of Big Events were contingent rather than deterministic, and the development of new survey measures to understand pathways through which Big Events affect social and epidemiologic outcomes. On a broader level, the Big Events framework is a useful crystallization and application of more abstract sociological, social epidemiologic and Marxist frameworks about upstream/downstream relationships and how major social changes are related to epidemics. As such, they raise issues of how to conduct research on dialectical interaction processes. On another level, this article traces the Big Events "style of thought" as Mannheim (Mannheim, 1971) termed it, within the historical context of changes in public health and social science theory, particularly during and after the 1960s.