Faculty Bibliography

BACKGROUND:Medicaid expansion via the Affordable Care Act, more recent legislation and Medicaid 1115 waivers offer opportunity to increase health care access among individuals involved in the carceral system. Effective enrollment of new beneficiaries and temporary suspension and reactivation of existing Medicaid benefits upon release is key to the success of these efforts. This study aims to characterize how jails, prisons and Medicaid agencies are implementing Medicaid suspension and enrollment programs and identifies barriers and facilitators to implementation. METHODS:We conducted 19 semi-structured interviews with 36 multi-state leaders in carceral facilities, Medicaid agencies, local health departments and national policy experts from 2020 to 2021. Interviews covered 4 domains: (1) the role of policy in influencing carceral and reentry Medicaid practices, (2) implementation strategies to suspend and enroll incarcerated individuals into Medicaid, (3) barriers and facilitators to successful implementation, and (4) variation in implementation between jails and prisons. RESULTS:Participants identified logistical challenges with suspension and enrollment, including limited infrastructure for data sharing between carceral facilities and Medicaid agencies, burdensome bureaucratic requirements, and challenges with Medicaid renewal, particularly in the jail environment. They offered opportunities to overcome barriers, such as the creation of specialized incarcerated Medicaid benefit categories and provision of in-reach services via managed care organizations. Participants also called for improvements to Medicaid reactivation processes, as even when facilities successfully suspended benefits, individuals faced significant challenges and delays reactivating benefits upon release. Participants also called for further loosening of the Medicaid Inmate Exclusion Policy. DISCUSSION/CONCLUSIONS:Findings highlight the need to update data sharing infrastructure, which will be critical to the implementation of the 1115 waivers, as carceral facilities will be subject to Medicaid billing and reporting requirements. In addition to investing in the ability to newly enroll and suspend Medicaid benefits, attention towards improving timely reactivation practices is needed, particularly given the highly elevated risk of mortality immediately after release. Participants calls for further reforms to the Medicaid Inmate Exclusion Policy are consistent with proposed legislation. CONCLUSIONS:Findings can critically inform the successful implementation of Medicaid-based reforms to improve the health of incarcerated and formerly incarcerated people.

OBJECTIVE:To evaluate the completeness and quality of Medicaid comprehensive managed care (CMC) data in national MAX/TAF research files. STUDY SETTING AND DESIGN/METHODS:This observational study compared CMC with fee-for-service (FFS) enrollee data in 2001-2019 Medicaid MAX/TAF inpatient, outpatient, and pharmacy files. Completeness was assessed as the proportion of enrollees with any claim and mean claims per enrollee with any claim. Quality was assessed as the proportion of inpatient and outpatient claims with primary diagnosis and procedure codes and the proportion of prescription drug claims with fill dates, National Drug Codes (NDC), days supplied, and quantity dispensed. Acceptable ranges for each study measure were defined as the national FFS mean ± 2 standard deviations. DATA SOURCES AND ANALYTIC SAMPLE/UNASSIGNED:We analyzed secondary data on 45 states from 2001 to 2013 (MAX) and 50 states and DC from 2014 to 2019 (TAF). The sample included adults aged 18-64 with continuous calendar-year enrollment who were eligible for full Medicaid benefits and ineligible for Medicare. We determined CMC enrollment rates and assessed data completeness and quality among state-years with ≥10% CMC penetration, comparing CMC with FFS enrollees. PRINCIPAL FINDINGS/RESULTS:Across 891 state-years, 194,364,647 enrollees met inclusion criteria. Of 540 state-years (60.6%) with ≥10% CMC enrollment, CMC data were largely comparable to national FFS distributions for all inpatient (n = 430; 79.6%), outpatient (n = 467, 86.5%), and prescription (n = 459, 85.0%) completeness criteria and for all inpatient (n = 449, 83.1%), outpatient (n = 511, 94.6%), and prescription (n = 528, 97.8%) quality criteria. Overall completeness (92.3%) and quality (84.6%) improved substantially by 2019. CONCLUSIONS:Completeness and quality of CMC data were largely comparable to FFS data, with increasing state-years meeting criteria over time. Further research on national Medicaid populations should assess and address differences in data completeness and quality by plan type across states, over time, and in relation to specific study samples and measures of interest.

BACKGROUND:Firearm violence remains a leading cause of death and injury in the United States. Prior research supports that alcohol exposures, including individual-level alcohol use and alcohol control policies, are modifiable risk factors for firearm violence, yet additional research is needed to support prevention efforts. OBJECTIVES/OBJECTIVE:This scoping review aims to update a prior 2016 systematic review on the links between alcohol exposure and firearm violence to examine whether current studies indicate causal links between alcohol use, alcohol interventions, and firearm violence-related outcomes. ELIGIBILITY CRITERIA/METHODS:Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines, a comprehensive search of published studies was conducted, replicating the search strategy of the prior review but focusing on studies published since 2015. The review included published studies of humans, conducted in general populations of any age, gender, or racial/ethnic group, that examined the relationship between an alcohol-related exposure and an outcome involving firearm violence or risks for firearm violence. Excluded were small studies restricted to special populations, forensic or other technical studies, non-original research articles such as reviews, and studies that relied solely on descriptive statistics or did not adjust for confounders. SOURCES OF EVIDENCE/METHODS:The review included published studies indexed in PubMed, Web of Science, and Scopus. Eligible articles were published on or after January 1, 2015. The latest search was conducted on December 15, 2023. CHARTING METHODS/METHODS:Using a structured data collection instrument, data were extracted on the characteristics of each study, including the dimension of alcohol exposure, the dimension of firearm violence, study population, study design, statistical analysis, source of funding, main findings, and whether effect measure modification was assessed and, if so, along what dimensions. Two authors independently conducted title/abstract screening, full-text screening, and data extraction until achieving 95% agreement, with discrepancies resolved through discussion. RESULTS:The search yielded 797 studies. Of these, 754 were excluded and 43 met the final inclusion criteria. Studies addressed a range of alcohol exposures and firearm violence-related outcomes, primarily with cross-sectional study designs; 40% considered effect measure modification by any population characteristic. Findings from the 21 studies examining the relationship of individual-level alcohol use or alcohol use disorder (AUD) with firearm ownership, access, unsafe storage, or carrying indicated a strong and consistent positive association. Seven studies examined associations of individual-level alcohol use or AUD with firearm injury or death; these also indicated a pattern of positive associations, but the magnitude and precision of the estimates varied. Eight studies examined the impact of neighborhood proximity or density of alcohol outlets and found mixed results that were context- and study design-dependent. Two studies linked prior alcohol-related offenses to increased risk of firearm suicide and perpetration of violent firearm crimes among a large cohort of people who purchased handguns, and two studies linked policies prohibiting firearm access among individuals with a history of alcohol-related offenses to reductions in firearm homicide and suicide. Finally, four studies examined alcohol control policies and found that greater restrictiveness was generally associated with reductions in firearm homicide or firearm suicide. CONCLUSIONS:Findings from this scoping review continue to support a causal relationship between alcohol exposures and firearm violence that extends beyond acute alcohol use to include AUD and alcohol-related policies. Policies controlling the availability of alcohol and prohibiting firearm access among individuals with alcohol-related offense histories show promise for the prevention of firearm violence. Additional research examining differential impacts by population subgroup, alcohol use among perpetrators of firearm violence, policies restricting alcohol outlet density, and randomized or quasi-experimental study designs with longitudinal follow-up would further support inferences to inform prevention efforts.

IMPORTANCE/UNASSIGNED:Given the personal and social burdens of opioid use disorder (OUD), understanding time trends in OUD prevalence in large patient populations is key to planning prevention and treatment services. OBJECTIVE/UNASSIGNED:To examine trends in the prevalence of OUD from 2005 to 2022 overall and by age, sex, and race and ethnicity. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This serial cross-sectional study included national Veterans Health Administration (VHA) electronic medical record data from the VHA Corporate Data Warehouse. Adult patients (age ≥18 years) with a current OUD diagnosis (using International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10-CM] codes) who received outpatient care at VHA facilities from January 1, 2005, to December 31, 2022, were eligible for inclusion in the analysis. MAIN OUTCOMES AND MEASURES/UNASSIGNED:The main outcome was OUD diagnoses. To test for changes in prevalence of OUD over time, multivariable logistic regression models were run that included categorical study year and were adjusted for sex, race and ethnicity, and categorical age. RESULTS/UNASSIGNED:The final sample size ranged from 4 332 165 to 5 962 564 per year; most were men (89.3%-95.0%). Overall, the annual percentage of VHA patients diagnosed with OUD almost doubled from 2005 to 2017 (0.60% [95% CI, 0.60%-0.61%] to 1.16% [95% CI, 1.15%-1.17%]; adjusted difference, 0.55 [95% CI, 0.54-0.57] percentage points) and declined thereafter (2022: 0.97% [95% CI, 0.97%-0.98%]; adjusted difference from 2017 to 2022, -0.18 [95% CI, -0.19 to -0.17] percentage points). This trend was similar among men (0.64% [95% CI, 0.63%-0.64%] in 2005 vs 1.22% [95% CI, 1.21%-1.23%] in 2017 vs 1.03% [95% CI, 1.02%-1.04%] in 2022), women (0.34% [95% CI, 0.32%-0.36%] in 2005 vs 0.68% [95% CI, 0.66%-0.69%] in 2017 vs 0.53% [95% CI, 0.52%-0.55%] in 2022), those younger than 35 years (0.62% [95% CI, 0.59%-0.66%] in 2005 vs 2.22% [95% CI, 2.18%-2.26%] in 2017 vs 1.00% [95% CI, 0.97%-1.03%] in 2022), those aged 35 to 64 years (1.21% [95% CI, 1.19%-1.22%] in 2005 vs 1.80% [95% CI, 1.78%-1.82%] in 2017 vs 1.41% [95% CI, 1.39%-1.42%] in 2022), and non-Hispanic White patients (0.44% [95% CI, 0.43%-0.45%] in 2005 vs 1.28% [95% CI, 1.27%-1.29%] in 2017 vs 1.13% [95% CI, 1.11%-1.14%] in 2022). Among VHA patients aged 65 years or older, OUD diagnoses increased from 2005 to 2022 (0.06% [95% CI, 0.06%-0.06%] to 0.61% [95% CI, 0.60%-0.62%]), whereas among Hispanic or Latino and non-Hispanic Black patients, OUD diagnoses decreased from 2005 (0.93% [95% CI, 0.88%-0.97%] and 1.26% [95% CI, 1.23%-1.28%], respectively) to 2022 (0.61% [95% CI, 0.59%-0.63%] and 0.82% [95% CI, 0.80%-0.83%], respectively). CONCLUSIONS AND RELEVANCE/UNASSIGNED:This serial cross-sectional study of national VHA electronic health record data found that the prevalence of OUD diagnoses increased from 2005 to 2017, peaked in 2017, and declined thereafter, a trend primarily attributable to changes among non-Hispanic White patients and those younger than 65 years. Continued public health efforts aimed at recognizing, treating, and preventing OUD are warranted.

IMPORTANCE/UNASSIGNED:Opioid-related overdose accounts for almost 80 000 deaths annually across the US. People who use drugs leaving jails are at particularly high risk for opioid-related overdose and may benefit from take-home naloxone (THN) distribution. OBJECTIVE/UNASSIGNED:To estimate the population impact of THN distribution at jail release to reverse opioid-related overdose among people with opioid use disorders. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This study developed the agent-based Justice-Community Circulation Model (JCCM) to model a synthetic population of individuals with and without a history of opioid use. Epidemiological data from 2014 to 2020 for Cook County, Illinois, were used to identify parameters pertinent to the synthetic population. Twenty-seven experimental scenarios were examined to capture diverse strategies of THN distribution and use. Sensitivity analysis was performed to identify critical mediating and moderating variables associated with population impact and a proxy metric for cost-effectiveness (ie, the direct costs of THN kits distributed per death averted). Data were analyzed between February 2022 and March 2024. INTERVENTION/UNASSIGNED:Modeled interventions included 3 THN distribution channels: community facilities and practitioners; jail, at release; and social network or peers of persons released from jail. MAIN OUTCOMES AND MEASURES/UNASSIGNED:The primary outcome was the percentage of opioid-related overdose deaths averted with THN in the modeled population relative to a baseline scenario with no intervention. RESULTS/UNASSIGNED:Take-home naloxone distribution at jail release had the highest median (IQR) percentage of averted deaths at 11.70% (6.57%-15.75%). The probability of bystander presence at an opioid overdose showed the greatest proportional contribution (27.15%) to the variance in deaths averted in persons released from jail. The estimated costs of distributed THN kits were less than $15 000 per averted death in all 27 scenarios. CONCLUSIONS AND RELEVANCE/UNASSIGNED:This study found that THN distribution at jail release is an economical and feasible approach to substantially reducing opioid-related overdose mortality. Training and preparation of proficient and willing bystanders are central factors in reaching the full potential of this intervention.

INTRODUCTION/BACKGROUND:People with chronic pain are at increased risk of opioid misuse. Less is known about the unique risk conferred by each pain management treatment, as treatments are typically implemented together, confounding their independent effects. This study estimated the extent to which pain management treatments were associated with risk of opioid use disorder (OUD) for those with chronic pain, controlling for baseline demographic and clinical confounding variables and holding other pain management treatments at their observed levels. METHODS:Data were analyzed in 2024 from 2 chronic pain subgroups within a cohort of non-pregnant Medicaid patients aged 35-64 years, 2016-2019, from 25 states: those with (1) chronic pain and physical disability (CPPD) (N=6,133) or (2) chronic pain without disability (CP) (N=67,438). Nine pain management treatments were considered: prescription opioid (1) dose and (2) duration; (3) number of opioid prescribers; opioid co-prescription with (4) benzo- diazepines, (5) muscle relaxants, and (6) gabapentinoids; (7) nonopioid pain prescription, (8) physical therapy, and (9) other pain treatment modality. The outcome was OUD risk. RESULTS:Having opioids co-prescribed with gabapentin or benzodiazepine was statistically significantly associated with a 37-45% increased OUD risk for the CP subgroup. Opioid dose and duration also were significantly associated with increased OUD risk in this subgroup. Physical therapy was significantly associated with an 18% decreased risk of OUD in the CP subgroup. DISCUSSION/CONCLUSIONS:Coprescription of opioids with either gabapentin or benzodiazepines may substantially increase OUD risk. More positively, physical therapy may be a relatively accessible and safe pain management strategy.

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.

BACKGROUND:Individuals with opioid use disorder have high rates of hospital admissions, which represent a critical opportunity to engage patients and initiate medications for opioid use disorder (MOUD). However, few patients receive MOUD and, even if MOUD is initiated in the hospital, patients may encounter barriers to continuing MOUD in the community. OBJECTIVE:Describe hospital providers' experiences and perspectives to inform initiatives and policies that support hospital-based MOUD initiation and continuation in community treatment programs. DESIGN/METHODS:As part of a broader implementation study focused on inpatient MOUD (NCT#04921787), we conducted semi-structured interviews with hospital providers. PARTICIPANTS/METHODS:Fifty-seven hospital providers from 12 community hospitals. APPROACH/METHODS:Thematic analysis examined an emergent topic on challenges transitioning patients to outpatient MOUD treatment and related impacts on MOUD initiation by inpatient providers. KEY RESULTS/RESULTS:Participants described structural barriers to transitioning hospitalized patients to continuing outpatient MOUD including (a) limited outpatient buprenorphine prescriber availability, (b) the siloed nature of addiction treatment, and (c) long wait times. As a result of observing these structural barriers, participants experienced a sense of futility that deterred them from initiating MOUD. Participants proposed strategies that could better support these patient transitions, including developing partnerships between hospitals and outpatient addiction treatment and supporting in-reach services from community providers. CONCLUSIONS:We identified concerns about inadequate and inaccessible community-based care and transition pathways that discouraged hospital providers from prescribing MOUD. As hospital-based opioid treatment models continue to expand, programmatic and policy strategies to support inpatient transitions to outpatient addiction treatment are needed. NCT TRIAL NUMBER/UNASSIGNED:04921787.