Faculty Bibliography

Social science and public health literature has framed residential segregation as a potent structural determinant of the higher HIV burden among black heterosexuals, but empirical evidence has been limited. The purpose of this study is to test, for the first time, the association between racial segregation and newly diagnosed heterosexually acquired HIV cases among black adults and adolescents in 95 large US metropolitan statistical areas (MSAs) in 2008-2015. We operationalized racial segregation (the main exposure) using Massey and Denton's isolation index for black residents; the outcome was the rate of newly diagnosed HIV cases per 10,000 black adult heterosexuals. We tested the relationship of segregation to this outcome using multilevel multivariate models of longitudinal (2008-2015) MSA-level data, controlling for potential confounders and time. All covariates were lagged by 1 year and centered on baseline values. We preliminarily explored mediation of the focal relationship by inequalities in education, employment, and poverty rates. Segregation was positively associated with the outcome: a one standard deviation decrease in baseline isolation was associated with a 16.2% reduction in the rate of new HIV diagnoses; one standard deviation reduction in isolation over time was associated with 4.6% decrease in the outcome. Exploratory mediation analyses suggest that black/white socioeconomic inequality may mediate the relationship between segregation and HIV. Our study suggests that residential segregation may be a distal determinant of HIV among black heterosexuals. The findings further emphasize the need to address segregation as part of a comprehensive strategy to reduce racial inequities in HIV.

Russia has a widespread injection drug use epidemic with high prevalence of HIV and HCV among people who inject drugs (PWID). We conducted a mixed methods study of young (age 18-26) hard drug users in St. Petersburg. Thirty-nine structured and 10 semi-structured interviews were conducted. No HIV cases and two HCV cases were detected among the PWID subsample (n = 29). Amphetamine and other stimulants were common (70%), opioid use was rare and episodic. Consistent condom use was 10%. No PWID reported syringe-sharing, 51% reported other drug paraphernalia sharing. Most (89%) never or rarely communicated with older (30 +) opiate users. A new cohort of drug users in St. Petersburg may have emerged, which is much safer in its injection practices compared to previous cohorts. However, risky sexual practices among this new cohort may expose them to the possibility of sexual transmission of HIV and widespread drug paraphernalia sharing to the HCV epidemic.

INTRODUCTION/BACKGROUND:Prescription Drug Monitoring Program data can provide insights into a patient's likelihood of an opioid overdose, yet clinicians and public health officials lack indicators to identify individuals at highest risk accurately. A predictive model was developed and validated using Prescription Drug Monitoring Program prescription histories to identify those at risk for fatal overdose because of any opioid or illicit opioids. METHODS:From December 2018 to July 2019, a retrospective cohort analysis was performed on Maryland residents aged 18-80 years with a filled opioid prescription (n=565,175) from January to June 2016. Fatal opioid overdoses were identified from the Office of the Chief Medical Examiner and were linked at the person-level with Prescription Drug Monitoring Program data. Split-half technique was used to develop and validate a multivariate logistic regression with a 6-month lookback period and assessed model calibration and discrimination. RESULTS:Predictors of any opioid-related fatal overdose included male sex, age 65-80 years, Medicaid, Medicare, 1 or more long-acting opioid fills, 1 or more buprenorphine fills, 2 to 3 and 4 or more short-acting schedule II opioid fills, opioid days' supply ≥91 days, average morphine milligram equivalent daily dose, 2 or more benzodiazepine fills, and 1 or more muscle relaxant fills. Model discrimination for the validation cohort was good (area under the curve: any, 0.81; illicit, 0.77). CONCLUSIONS:A model for predicting fatal opioid overdoses was developed using Prescription Drug Monitoring Program data. Given the recent national epidemic of deaths involving heroin and fentanyl, it is noteworthy that the model performed equally well in identifying those at risk for overdose deaths from both illicit and prescription opioids.

Prescription and illicit opioids were involved in over 42,000 deaths in the USA in 2016. Rural counties experience higher rates of opioid prescribing and, although opioid prescribing rates have fallen in recent years, the rate of decline is less in rural areas. The sociocultural context of rural life may impact opioid misuse in important ways; however, little research directly explores this possibility. We performed a systematic review of English-language manuscripts in U.S. context to determine what is known about social networks, norms, and stigma in relation to rural opioid misuse. Of nine articles identified and reviewed, two had only primary findings associated with social networks, norms, or stigma, five had only secondary findings, and two had both primary and secondary findings. The normalization of prescription opioid use along with environmental factors likely impacts the prevalence of opioid misuse in rural communities. Discordant findings exist regarding the extent to which social networks facilitate or protect against nonmedical opioid use. Lastly, isolation, lack of treatment options, social norms, and stigma create barriers to substance use treatment for rural residents. Although we were able to identify important themes across multiple studies, discordant findings exist and, in some cases, findings rely on single studies. The paucity of research examining the role of social networks, norms, and stigma in relation to nonmedical opioid use in rural communities is evident in this review. Scholarship aimed at exploring the relationship and impact of rurality on nonmedical opioid use is warranted.

Objective: To describe trends in prevalent and incident stimulant prescribing between 2008 and 2017 in California. Method: Statewide trends were estimated by age and sex category for prevalent (any) and incident (no prescriptions in the preceding 2 years) stimulant prescribing while adjusting for area-level covariates. Results: Prevalent prescribing rates increased by 126%, while incident prescribing increased 23%. Patients aged 25 to 44 years experienced over 200% increases in prevalent prescribing and 34% to 55% increases in incident prescribing. Among patients older than 25, women had consistently higher prescribing rates than men. ZIP code tabulation areas with the largest minority populations had the lowest baseline prescribing rates but experienced the greatest annual prescription rate increases. Conclusion: Adult stimulant prescribing increased substantially for early working aged adults. Prescription rates were greater for women than men.

BACKGROUND:Prescription drug monitoring programs (PDMP), by reducing access to prescribed opioids (POs), may contribute to a policy environment in which some people with opioid dependence are at increased risk for transitioning from POs to heroin/other illegal opioids. This study examines how PDMP adoption and changes in the characteristics of PDMPs over time contribute to changes in fatal heroin poisoning in counties within states from 2002 to 2016. METHODS:Latent transition analysis to classify PDMPs into latent classes (Cooperative, Proactive, and Weak) for each state and year, across three intervals (1999-2004, 2005-2009, 2010-2016). We examined the association between probability of PDMP latent class membership and the rate of county-level heroin poisoning death. RESULTS:After adjustment for potential county-level confounders and co-occurring policy changes, adoption of a PDMP was significantly associated with increased heroin poisoning rates (22% increase by third year post-adoption). Findings varied by PDMP type. From 2010-2016, states with Cooperative PDMPs (those more likely to share data with other states, to require more frequent reporting, and include more drug schedules) had 19% higher heroin poisoning rates than states with Weak PDMPs (adjusted rate ratio [ARR] = 1.19; 95% CI = 1.14, 1.25). States with Proactive PDMPs (those more likely to report outlying prescribing and dispensing and provide broader access to law enforcement) had 6% lower heroin poisoning rates than states with No/Weak PDMPs (ARR = 0.94; 95% CI = 0.90, 0.98). CONCLUSION/CONCLUSIONS:There is a consistent, positive association between state PDMP adoption and heroin poisoning mortality. However, this varies by PDMP type, with Proactive PDMPs associated with a small reduction in heroin poisoning deaths. This raises questions about the potential for PDMPs to support efforts to decrease heroin overdose risk, particularly by using proactive alerts to identify patients in need of treatment for opioid use disorder. Future research on mechanisms explaining the reduction in heroin poisonings after enactment of Proactive PDMPs is merited.

BACKGROUND:Little is known about recent nonmedical prescription tranquilizer and stimulant use trends in Latin America. We tested whether recent trends among students in three South American countries differed by sex over time. METHODS:Three countries independently collected National School Students Survey on Drugs. Students in 8th, 10th, and 12th grades were sampled in Argentina (2007-2014, N = 328,202), Chile (2007-2015, N = 136,379), and Uruguay (2007-2016, N = 32,371). Weighted linear regression models predicted the prevalences and trends over time of past-year nonmedical tranquilizer and stimulant use by country, and tested whether trends differed by sex, adjusting for school type and grade. RESULTS:In Argentina from 2007 to 2014, past-year nonmedical prescription tranquilizer (girls: 2.8 to 2.6%, boys: 2.5 to 2.3%) and stimulant (girls: 1.7 to 1.3%, boys: 1.9 to 1.5%) use trends did not differ by sex. In Chile from 2007 to 2015, nonmedical prescription tranquilizer use trends significantly differed comparing girls (3.9 to 10%) with boys (3.2 to 6.9%); stimulant use trends did not differ comparing girls (1.6 to 2.0%) with boys (2.0 to 1.3%). In Uruguay from 2007 to 2014 and 2014-2016, past-year nonmedical prescription tranquilizer (girls: 5.1 to 6.6%; boys: 2.8 to 4.2%) and stimulant (girls: 1.8 to 0.7%; boys: 1.8 to 0.7%) use trends did not differ by sex. CONCLUSIONS:Trends of nonmedical prescription tranquilizer use recently increased in Chile and Uruguay, widening by sex over time in Chile only. The drivers of increasing tranquilizer use among girls in Chile and Uruguay merit further investigation.

OBJECTIVE/UNASSIGNED:Self-harm rates among U.S. adolescents have risen substantially. Health and social outcomes among contemporary self-harming youths are infrequently tracked and poorly understood. This study investigated long-term health service utilization (emergency department [ED] visits and inpatient admissions) and inpatient costs among a recent cohort of adolescents with deliberate self-harm. METHODS/UNASSIGNED:This retrospective cohort study used statewide, all-payer, longitudinally linked discharge data from California. All residents ages 10-19 presenting to EDs in 2010 with deliberate self-harm (N=5,396) were compared with two control groups: a random sample of adolescent ED patients with other complaints, matched on sex, age, residential zip code, and month of index visit (general control patients, N=14,921), and matched ED patients with psychiatric complaints but no self-harm (psychiatric control patients, N=15,835). Outcomes included 5-year rates of ED visits, inpatient admissions, and inpatient costs, overall and for psychiatric and nonpsychiatric complaints separately. RESULTS/UNASSIGNED:Self-harm patients' ED use, inpatient admissions, and inpatient costs were significantly higher than those of general control patients (by 39%, 81%, and 21%, respectively), when the analysis controlled for confounding demographic and utilization characteristics. Associations mostly persisted, although smaller in magnitude, in comparisons between self-harm and psychiatric control patients. Psychiatric and nonpsychiatric complaints contributed to self-harming adolescents' excess health service utilization and costs. CONCLUSIONS/UNASSIGNED:Deliberate self-harm among adolescents was found to be associated with long-lasting and costly patterns of health service utilization, often but not exclusively for psychiatric complaints. Future research should investigate the pathways underlying these associations and incorporate service utilization as a key patient outcome.

BACKGROUND:Predicting which individuals who are prescribed buprenorphine for opioid use disorder are most likely to experience an overdose can help target interventions to prevent relapse and subsequent consequences. METHODS:We used Maryland prescription drug monitoring data from 2015 to identify risk factors for nonfatal opioid overdoses that were identified in hospital discharge records in 2016. We developed a predictive risk model for prospective nonfatal opioid overdoses among buprenorphine patients (N = 25,487). We estimated a series of models that included demographics plus opioid, buprenorphine and benzodiazepine prescription variables. We applied logistic regression to generate performance measures. RESULTS:About 3.24% of the study cohort had ≥1 nonfatal opioid overdoses. In the model with all predictors, odds of nonfatal overdoses among buprenorphine patients were higher among males (OR = 1.39, 95% CI:1.21-1.62) and those with more buprenorphine pharmacies (OR = 1.19, 95% CI:1.11-1.28), 1+ buprenorphine prescription paid by Medicaid (OR = 1.21, 95% CI:1.02-1.48), Medicare (OR = 1.93, 95% CI:1.63-2.43), or a commercial plan (OR = 1.98, 95% CI:1.30-2.89), 1+ opioid prescription paid by Medicare (OR = 1.30, 95% CI:1.03-1.68), and more benzodiazepine prescriptions (OR = 1.04, 95% CI:1.02-1.05). The odds were lower among those with longer days of buprenorphine (OR = 0.64, 95% CI:0.60-0.69) or opioid (OR = 0.79, 95% CI:0.65-0.95) supply. The model had moderate predictive ability (c-statistic = 0.69). CONCLUSIONS:Several modifiable risk factors, such as length of buprenorphine treatment, may be targets for interventions to improve clinical care and reduce harms. This model could be practically implemented with common prescription-related information and allow payers and clinical systems to better target overdose risk reduction interventions, such as naloxone distribution.

BACKGROUND:Violent injuries are a leading cause of morbidity and mortality among youths. Little is known about adolescents' patterns of and risk factors for repeat assault injuries, yet understanding who is at risk for repeated assaults is important for intervention and prevention efforts. Investigating these questions in population-based adolescent samples is particularly critical. OBJECTIVE:Our aim was to estimate the 5-year cumulative incidence of and risk factors for repeat emergency department (ED) visits for assault injury among adolescents experiencing an index assault visit, and compare the method of injury for adolescents' first and second visits. METHODS:Statewide, longitudinal data from California were used to follow 17,845 adolescents who reported to an ED with assault-related injuries in 2010. Incidence rate ratios were estimated to examine risk factors for repeat assault injury within 1 year and 5 years following the index visit. RESULTS:A total of 3273 (18.3%) assaulted adolescents experienced one or more additional assault injury ED visits during the full follow-up period. Only 37.3% of these repeat assaults occurred within the first year following the index assault. Of adolescents with a repeat assault injury, the method of injury often changed and followed no clear pattern. Sociodemographic characteristics (e.g., older age, black race) and history of prior ED visits for assault and mental health problems predicted increased risk of repeat assault. CONCLUSIONS:Previous work may underestimate the rate of repeated assault among adolescents. Adolescents with a history of violence involvement and mental health problems are at elevated risk for repeated assault, and should be targeted for intervention.