Faculty Bibliography

BACKGROUND:Between 2022 and 2023, overdose mortality decreased among non-Hispanic (NH) white people but stayed the same or increased among people of colour in the USA. County racialised economic segregation may contribute to overdose mortality. METHODS:measures, one for higher-income NH white and lower-income black residents and another for higher-income NH white and lower-income Hispanic residents. Models included random effects for county, year and county-year interaction, and fixed effects for proportion male, proportion aged 25-44, land area, state and year. We estimated relative risk (RR) by quintile (least vs most privileged) and the difference in overdose mortality per 100 000 (RD) had all counties shifted to the risk of the most advantaged counties (Q5). RESULTS:Counties with the highest proportion of lower-income racially minoritised residents (Q1) had an increased RR of overdose deaths compared with Q5 counties, both overall (aRRs 1.64 (1.51-1.78); 1.40 (1.29-1.52)), and among subgroups. Had all counties experienced the risk of Q5 counties, we estimated an average reduction in overdose deaths overall (RDs per 100 000: -7.20 (-8.25 to -6.10); -6.37 (-7.38 to -5.25)) and among subgroups. CONCLUSION/CONCLUSIONS:County racialised economic segregation was associated with overdose mortality risk in 2018-2022. Investment in evidence-based strategies to reduce overdose risk in places experiencing harms related to racialised economic segregation is critical.

IMPORTANCE/UNASSIGNED:There has been a national increase in fatal and nonfatal overdoses involving stimulants, and 4.5 million US individuals meet criteria for stimulant use disorder (UD), with the highest prevalence in young adults. However, limited information exists on trends in diagnosed stimulant UD. OBJECTIVE/UNASSIGNED:To estimate trends in the proportion of adolescent and young adult Medicaid enrollees diagnosed with a stimulant UD from 2001 to 2020. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:A repeated cross-sectional study (2001-2020) was conducted using administrative health care claims data from Medicaid (public insurance program in US). Publicly insured adolescents (aged 13-17 years) and young adults (aged 18-24 or 25-29 years) from 42 US states were included. Data were analyzed from January 2025 to July 2025. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Stimulant UD was defined as an inpatient or outpatient International Classification of Diseases diagnosis code in the year, with cocaine UD and noncocaine psychostimulant UD evaluated separately. The annual proportion with stimulant UD diagnoses was stratified by age group, sex, race and ethnicity, and presence of attention-deficit/hyperactivity disorder (ADHD) diagnosis or stimulant prescription in the year. Differences comparing 2001 with 2020 were summarized. Characteristics of those diagnosed with stimulant UD in 2020 were described. RESULTS/UNASSIGNED:The sample included 5.7 million (2001) to 16.1 million Medicaid enrollees (2020) per year; in 2020, 54.2% were female, and 7.1 million were adolescents. From 2001 to 2020, the proportion diagnosed with noncocaine psychostimulant UD increased from 0.09% to 0.49% (prevalence ratio [PR], 5.47 [95% CI, 5.20-5.75]) in those aged 18 to 24 years, from 0.13% to 1.63% (PR, 12.55 [95% CI, 11.83-13.31]) for ages 25 to 29 years, and from 0.10% to 0.91% among young adults aged 18 to 29 years. Among adolescents, the proportion diagnosed with noncocaine psychostimulant UD varied between 0.03% and 0.07%. The proportion diagnosed with cocaine UD was stable in young adults (range, 0.17%-0.34% [18-24 years] and 0.53%-0.79% [25-29 years]) and declined in adolescents (from 0.04% to 0.01%). Cocaine and noncocaine psychostimulant UD diagnoses were 2 to 4 times more common in patients with an ADHD diagnosis or stimulant prescription. Most patients diagnosed with a stimulant UD in 2020 were also diagnosed with a mental health disorder (68%-82%) or other substance UD (72%-78%). CONCLUSIONS AND RELEVANCE/UNASSIGNED:The prevalence of noncocaine psychostimulant UD diagnoses in young adult Medicaid patients increased over the last 2 decades, potentially associated with an increasing use of prescription and illicit stimulants along with increased clinical detection. These trends raise concerns given recent rises in stimulant-involved overdose fatalities and stress the need for evidence-based stimulant UD treatments for young people.

OBJECTIVE:The CDC recommends initiating opioids for pain treatment at the lowest effective dose and duration. We examine how interactions between dose, duration, and other medication factors (e.g., drug type) influence opioid use disorder (OUD) risk-a gap not considered by CDC guidelines. SUBJECTS/METHODS:Using Medicaid claims data (2016-2019) from 25 states, we analyzed opioid-naïve adults, newly diagnosed with musculoskeletal pain who initiated opioids within three months of diagnosis. A 6-month washout confirmed no prior opioid exposure or musculoskeletal diagnosis. METHODS:Initial opioids were categorized by "dose-days supplied" (low [>0-20 mg MME] to very high [>90 mg MME] dose, and short [1-7 days] to moderate [>7-30 days] supply), and by opioid type; physical therapy (PT) sessions were also recorded. Using Poisson regression models, we estimated the OUD risk associated with dose-days categories, adjusting for baseline demographics, clinical characteristics, and medications. We separately examined opioid dose-days and PT, and assessed PT's moderating effect on dose-days' impact. RESULTS:Among 30,536 patients, half initiated opioids at 20-50 MME for 1-7 days, and 20% received PT. OUD risk was 2-3 times higher for opioids initiated for >7-30 days compared to 1-7 days across doses, and 5.5 times higher for opioids initiated for >7-30 days at > 90 MME versus 1-7 days at < 20 MME. PT alone, neither affected OUD risk nor mitigated the increased risk from longer or higher-dose opioids. CONCLUSIONS:Our findings support the need for careful opioid prescribing and alternative pain management strategies, as the observed associations between initial prescription characteristics and OUD were not mitigated by adjunctive PT. PERSPECTIVE/CONCLUSIONS:This study demonstrated that initial opioid prescriptions of 7-30 days, especially above 90 MME/day, increased OUD risk in opioid-naïve patients with musculoskeletal pain; physical therapy did not mitigate the risk. Different opioids posed varied risks, even at the same dose and duration. Careful prescribing and alternative pain management are essential.

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.

OBJECTIVE:To examine nationwide trends in the prescribing of controlled medications to early adolescents, adolescents, and young adults enrolled in public insurance (Medicaid) from 2001 to 2019. METHODS:The study utilized US Medicaid data covering publicly insured enrollees from 43 states (2001-2019). Early adolescents (10-12y), adolescents (13-17y), and young adults (18-24y, 25-29y) with ≥ 10 months enrollment in each calendar year were included. Filled prescription for opioids, stimulants, benzodiazepines, Z-hypnotics, barbiturates, and gabapentin were identified. In each calendar year, annual proportions with 1 +  controlled medication, 2 +  classes of controlled medications, and each controlled medication were estimated. RESULTS:In 2019, the sample included 17.9 million enrollees (53 % female). The annual proportion prescribed any controlled medication peaked at 17.5 % in early adolescents (2003), 20.6 % in adolescents (2009), and 34.1 % (18-24y) and 47.0 % (25-29y) in young adults (2010). By 2019, the proportions declined to 11.7 % (early adolescents), 12.6 % (adolescents), 16.2 % (18-24y), and 23.9 % (25-29y). Trends varied by medication and age. The largest absolute decline was in the proportion with an opioid filled (2010 =29.8 %, 2019 =11.2 %, young adults 18-24y; 2003 =14.3 %, 2019 =4.4 %, adolescents). In contrast, the proportion with a stimulant fill increased, with eight-fold increases in young adults 25-29y (2001 =0.3 %, 2019 =2.6 %). Benzodiazepine and Z-hypnotic use peaked in 2010 and declined through 2019. CONCLUSIONS:In the past two decades, there were increases in stimulant prescriptions among young Medicaid enrollees. The declines in opioid, benzodiazepines, barbiturate and Z-hypnotic prescribing are encouraging and may indicate more cautious prescribing related to greater awareness of harms such as misuse and overdose, along with policy initiatives.

BACKGROUND:Practical and motivational barriers can deter people from engaging in substance use disorder (SUD) treatment, even those who seek treatment. Care navigation is a psychosocial intervention that seeks to facilitate patients' timely access to care by identifying and intervening upon barriers. Few trials have tested the effectiveness of care navigation when embedding in real-world healthcare, and no trials have studied the process of implementing care navigation into clinical practice. This protocol describes a study that will evaluate whether care navigation can increase treatment engagement among patients seeking SUD treatment. METHODS:The Addressing Barriers to Care for Substance Use Disorder (ABC-SUD) study is a hybrid type I cluster-randomized effectiveness-implementation trial. It is conducted in a mental health access center of an integrated healthcare system in Washington state. Within this center, licensed mental health clinicians assess patient needs and use shared decision-making to establish SUD treatment plans for patients (usual care). This study tests whether an added care navigation intervention can improve patient engagement in SUD treatment. Care navigation begins after a treatment plan is made and provides up to 7 weeks of support focused on enhancing patient motivation to initiate and engage in treatment, problem-solving barriers (e.g., transportation logistics), and accommodating patient preferences (e.g., preferred language of care, cultural preferences). This trial uses a two period, two sequence crossover design. Clinicians are randomized to offer care navigation to patients during the first or second study period (i.e., clinicians are assigned to an initial study condition and switch conditions halfway through the trial). Care navigation is implemented with several strategies: leadership engagement, clinical workflow specifications, electronic health record (EHR) tools, training, performance improvement, and electronic learning collaborative. The primary outcome-obtained from EHRs and insurance claims-is engagement in SUD treatment, defined as ≥3 SUD treatment visits within 48 days of a treatment plan. This study uses standardized measures of implementation climate and outcomes to examine mechanisms with which the intervention strategies exert their impact on implementation and effectiveness outcomes. DISCUSSION/CONCLUSIONS:The ABC-SUD study will test whether care navigation improves SUD treatment engagement while concurrently generating information about its implementation in healthcare. TRIAL REGISTRATION/BACKGROUND:This study was prospectively registered at www. CLINICALTRIALS/RESULTS:gov (NCT06729957) on December 9, 2024.

INTRODUCTION/BACKGROUND:In Latin America and the Caribbean (LAC) the response to substance use has primarily been abstinence-based, acute-care-oriented treatments. While harm reduction services (HRS) and interventions have expanded in LAC over the last decade, the research evidence on such programs has been sparse and disjointed. OBJECTIVE:This scoping review will map peer-reviewed literature on HRS and interventions in LAC, and synthesize gaps and opportunities for policy, practice, and research. INCLUSION CRITERIA/METHODS:Studies conducted in LAC. The HRS that will be included in the search are opioid agonist therapy, syringe services programs, drug consumption facilities, safer consumption kits, managed alcohol programs, and drug-checking services. The scoping review will consider peer-reviewed original research, including qualitative, quantitative, and mixed-methods designs. We will exclude studies addressing harms associated with nicotine or tobacco use. We included original research written in English, Spanish, Portuguese, or French published between January 2013 and December 2024. METHODS:We will conduct literature searches in English (PubMed, Scopus, Web of Science), Spanish, Portuguese (SciELO and BIREME), and French (BIREME). Two reviewers will independently screen the literature. Extraction of characteristics of the studies using a template in Covidence. Data on the HRS and interventions studied and implemented in LAC will be summarized and presented in tables, graphs, and a narrative summary. We will use a narrative synthesis approach to summarize implications for policy, research, and practice identified in the literature. The review was registered in Open Science Framework (https://osf.io/qya7c/). DISCUSSION/CONCLUSIONS:The proposed scoping review will provide valuable information regarding the current state of HRS and interventions for PWUD in LAC. This in return can help guide future research for evaluating services that are already being implemented or unveil services needed in the region. To our knowledge, this is the first scoping review to map HRS in LAC using a systematic approach. Furthermore, among the strengths of this review are: the broad number of services, countries, and time, as well as the consultation with experts and knowledge users.