Faculty Bibliography

BACKGROUND AND AIMS/OBJECTIVE:Prescription drug monitoring programs (PDMP), defined as state-level databases used in the USA that collect prescribing information when controlled substances are dispensed, have varied substantially between states and over time. Little is known about the combinations of PDMP features that, collectively, may produce the greatest impact on prescribing and overdose. We aimed to (1) identify the types of PDMP models that have developed from 1999 to 2016, (2) estimate whether states have transitioned across PDMP models over time, and (3) examine whether states have adopted different types of PDMP models in response to the burden of opioid overdose. METHODS:A latent transition analysis of PDMP models based on an adaptation of nine PDMP characteristics classified by prescription opioid policy experts as potentially important determinants of prescribing practices and prescription opioid overdose events. RESULTS:We divided the time period into three intervals (1999-2004, 2005-2009, 2010-2016), and found three distinct PDMP classes in each interval. The classes in the first and second interval can be characterized as "No/Weak", "Proactive", and "Reactive" types of PDMPs, and in the third interval as "Weak", "Cooperative", and "Proactive". The meaning of these classes changed over time: until 2009, states in the "No/Weak" class had no active PDMP, whereas states in the "Proactive" class were more likely to proactively provide unsolicited information to PDMP users, provide open access to law enforcement, and require more frequent data reporting than states in the "Reactive" class. In 2010-2016, the "Weak" class resembled the "Reactive" class in previous intervals. States in the "Cooperative" class in 2010-2016 were less likely than states in the "Proactive" class proactively to provide unsolicited reports, or to provide open access to law enforcement; however, they were more likely than those in the "Proactive" class to share PDMP data with other states, and to report more federal drug schedules. CONCLUSIONS:Since 1999, US states have tended to transition to more robust classes of prescription drug monitoring programs (PDMPs). Opioid overdose deaths in prior years predicted the state's PDMP class but did not predict transitions between PDMP classes over time.

PURPOSE/OBJECTIVE:In 1991, California implemented a law that mandated a background check for all firearm purchases with limited exceptions (comprehensive background check or CBC policy) and prohibited firearm purchase and possession for persons convicted within the past 10 years of certain violent crimes classified as misdemeanors (MVP policy). We evaluated the population effect of the simultaneous implementation of CBC and MVP policies in California on firearm homicide and suicide. METHODS:Quasi-experimental ecological study using the synthetic control group methodology. We included annual firearm and nonfirearm mortality data for California and 32 control states for 1981-2000, with secondary analyses up to 2005. RESULTS:The simultaneous implementation of CBC and MVP policies was not associated with a net change in the firearm homicide rate over the ensuing 10 years in California. The decrease in firearm suicides in California was similar to the decrease in nonfirearm suicides in that state. Results were robust across multiple model specifications and methods. CONCLUSIONS:CBC and MVP policies were not associated with changes in firearm suicide or homicide. Incomplete and missing records for background checks, incomplete compliance and enforcement, and narrowly constructed prohibitions may be among the reasons for these null findings.

This exploratory analysis investigates relationships of place characteristics to HIV testing among people who inject drugs (PWID). We used CDC's 2012 National HIV Behavioral Surveillance (NHBS) data among PWID from 19 US metropolitan statistical areas (MSAs); we restricted the analytic sample to PWID self-reporting being HIV negative (N = 7477). Administrative data were analyzed to describe the 1. Sociodemographic Composition; 2. Economic disadvantage; 3. Healthcare Service/Law enforcement; and 4. HIV burden of the ZIP codes, counties, and MSAs where PWID lived. Multilevel models tested associations of place characteristics with HIV testing. Fifty-eight percent of PWID reported past-year testing. MSA-level per capita correctional expenditures were positively associated with recent HIV testing among black PWID, but not white PWID. Higher MSA-level household income and imbalanced sex ratios (more women than men) in the MSA were associated with higher odds of testing. HIV screening for PWID is suboptimal (58%) and needs improvement. Identifying place characteristics associated with testing among PWID can strengthen service allocation and interventions in areas of need to increase access to HIV testing.

AIMS/OBJECTIVE:To use simulation to estimate the impact of alcohol taxation on drinking, non-fatal violent victimization and homicide in New York City (NYC). We simulate the heterogeneous effects of alcohol price elasticities by income, level of consumption and beverage preferences, and examine whether taxation can reduce income inequalities in alcohol-related violence. DESIGN/METHODS:Agent-based modeling simulation. SETTING/METHODS:NYC, USA. PARTICIPANTS/METHODS:Adult population aged 18-64 years in the year 2000 in the 59 community districts of NYC. The population of 256 500 agents approximates a 5% sample of the NYC population. MEASUREMENTS/METHODS:Agents were parameterized through a series of rules that governed alcohol consumption and engagement in violence. Six taxation interventions were implemented based on extensive reviews and meta-analyses, increasing universal alcohol tax by 1, 5 and 10%, and beer tax by 1, 5 and 10%. FINDINGS/RESULTS:Under no tax increase, approximately 12.2% [95% credible interval (prediction interval, PI) = 12.1-12.3%] were heavy drinkers. Taxation decreased the proportion of heavy drinkers; a 10% tax decreased heavy drinking to 9.6% (95% PI = 9.4-9.8). Beer taxes had the strongest effect on population consumption. Taxation influenced those in the lowest income groups more than the highest income groups. Alcohol-related homicide decreased from 3.22 per 100 000 (95% PI = 2.50-3.73) to 2.40 per 100 000 under a 10% universal tax (95% PI = 1.92-2.94). This translates into an anticipated benefit of ~1200 lives/year. CONCLUSION/CONCLUSIONS:Reductions in alcohol consumption in a large urban environment such as New York City can be sustained with modest increases in universal taxation. Alcohol tax increases also have a modest effect on alcohol-related violent victimization. Taxation policies reduce income inequalities in alcohol-related violence.

Importance/UNASSIGNED:Prescription opioids are involved in 40% of all deaths from opioid overdose in the United States and are commonly the first opioids encountered by individuals with opioid use disorder. It is unclear whether the pharmaceutical industry marketing of opioids to physicians is associated with mortality from overdoses. Objective/UNASSIGNED:To identify the association between direct-to-physician marketing of opioid products by pharmaceutical companies and mortality from prescription opioid overdoses across US counties. Design, Setting, and Participants/UNASSIGNED:This population-based, county-level analysis of industry marketing information used data from the Centers for Medicare & Medicaid Services Open Payments database linked with data from the Centers for Disease Control and Prevention on opioid prescribing and mortality from overdoses. All US counties were included, with data on overdoses from August 1, 2014, to December 31, 2016, linked to marketing data from August 1, 2013, to December 31, 2015, using a 1-year lag. Statistical analyses were conducted between February 1 and June 1, 2018. Main Outcomes and Measures/UNASSIGNED:County-level mortality from prescription opioid overdoses, total cost of marketing of opioid products to physicians, number of marketing interactions, opioid prescribing rates, and sociodemographic factors. Results/UNASSIGNED:Between August 1, 2013, and December 31, 2015, there were 434 754 payments totaling $39.7 million in nonresearch-based opioid marketing distributed to 67 507 physicians across 2208 US counties. After adjustment for county-level sociodemographic factors, mortality from opioid overdoses increased with each 1-SD increase in marketing value in dollars per capita (adjusted relative risk, 1.09; 95% CI, 1.05-1.12), number of payments to physicians per capita (adjusted relative risk, 1.18; 95% CI, 1.14-1.21, and number of physicians receiving marketing per capita (adjusted relative risk, 1.12; 95% CI, 1.08-1.16). Opioid prescribing rates also increased with marketing and partially mediated the association between marketing and mortality. Conclusions and Relevance/UNASSIGNED:In this study, across US counties, marketing of opioid products to physicians was associated with increased opioid prescribing and, subsequently, with elevated mortality from overdoses. Amid a national opioid overdose crisis, reexamining the influence of the pharmaceutical industry may be warranted.

Individuals with recent/acute HIV-infection have an increased likelihood of disease transmission. To evaluate effectiveness of identifying recent infections, we compared networks of recently and long-term HIV-infected individuals. The Transmission Reduction Intervention Project included two separate arms of recruitment, networks of recently HIV-infected individuals and networks of long-term HIV-infected individuals. Networks of each were recruited and tested for HIV and syphilis infection. The per-seed yield ratios of recruitment were compared between arms. Overall, 84 (41.6%) of 202 participants were identified as HIV-positive. HIV prevalence was higher (p < 0.001) among networks of recent seeds (33/96, 34.4%) compared to long-term seeds (6/31, 19.4%). More individuals were identified with active syphilis infection (p = 0.007) among networks of recent seeds (15/96, 15.6%), compared to networks of long-term seeds (3/31, 9.7%). Network-based recruitment of recently HIV-infected individuals was more effective at identifying HIV and syphilis infection. Allocation of public health resources may be improved by targeting interventions toward networks of recently HIV-infected individuals.

OBJECTIVE:Understand how insurance impacts access to services among people who have injected drugs. METHODS:1748 adults who have injected drugs were assessed at twice-annual study visits between 2006 and 2017 (18,869 visits). Use of specialty substance use treatment, receipt of buprenorphine, and having a regular source of medical care were assessed for association with concurrent insurance coverage. Random intercept logistic regression was used to adjust for potential confounders. RESULTS:When participants acquired insurance, they were more likely to report specialty substance use treatment (aOR 2.0, 95% CI 1.6 to 2.5), a buprenorphine prescription (aOR 3.3, 95% CI 2.0 to 5.5), and a regular source of medical care (aOR 6.3, 95% CI 5.1 to 7.8). CONCLUSION/CONCLUSIONS:Insurance is associated with increased use of three important services for individuals who inject drugs. IMPLICATIONS/CONCLUSIONS:Expanding insurance may facilitate access to substance use treatment and other needed health services.

OBJECTIVE:This study investigated patient- and area-level characteristics associated with adolescent emergency department (ED) patients' risk of subsequent ED visits for self-harm. METHOD:Retrospective analysis of adolescent patients presenting to a California ED in 2010 (n = 480,706) was conducted using statewide, all-payer, individually linkable administrative data. We examined associations between multiple predictors of interest (patient sociodemographic factors, prior ED utilization, and residential mobility; and area-level characteristics) and odds of a self-harm ED visit in 2010. Patients with any self-harm in 2010 were followed up over several years to assess predictors of recurrent self-harm. RESULTS:Self-harm patients (n = 5539) were significantly more likely than control patients (n = 16,617) to have prior histories of ED utilization, particularly for mental health problems, substance abuse, and injuries. Residential mobility also increased risk of self-harm, but racial/ethnic minority status and residence in a disadvantaged zipcode decreased risk. Five-year cumulative incidence of recurrent self-harm was 19.3%. Admission as an inpatient at index visit, Medicaid insurance, and prior ED utilization for psychiatric problems or injury all increased recurrent self-harm risk. CONCLUSIONS:A range of patient- and area-level characteristics observable in ED settings are associated with risk for subsequent self-harm among adolescents, suggesting new targets for intervention in this clinical context.

Prior research has found that places and people that are more economically disadvantaged have higher rates and risks, respectively, of sexually transmitted infections (STIs). Economic disadvantages at the level of places and people, however, are themselves influenced by economic policies. To enhance the policy relevance of STI research, we explore, for the first time, the relationship between state-level minimum wage policies and STI rates among women in a cohort of 66 large metropolitan statistical areas (MSAs) in the US spanning 2003-2015. Our annual state-level minimum wage measure was adjusted for inflation and cost of living. STI outcomes (rates of primary and secondary syphilis, gonorrhea and chlamydia per 100,000 women) were obtained from the CDC. We used multivariable hierarchical linear models to test the hypothesis that higher minimum wages would be associated with lower STI rates. We preliminarily explored possible socioeconomic mediators of the minimum wage/STI relationship (e.g., MSA-level rates of poverty, employment, and incarceration). We found that a $1 increase in the price-adjusted minimum wage over time was associated with a 19.7% decrease in syphilis rates among women and with an 8.5% drop in gonorrhea rates among women. The association between minimum wage and chlamydia rates did not meet our cutpoint for substantive significance. Preliminary mediation analyses suggest that MSA-level employment among women may mediate the relationship between minimum wage and gonorrhea. Consistent with an emerging body of research on minimum wage and health, our findings suggest that increasing the minimum wage may have a protective effect on STI rates among women. If other studies support this finding, public health strategies to reduce STIs among women should include advocating for a higher minimum wage.

BACKGROUND:Incarceration and HIV disproportionately impact African American communities. The mass incarceration of African American men is hypothesized to increase HIV acquisition risk for African American women. Interventions optimizing HIV care engagement and minimizing sexual risk behaviors for men living with HIV post-incarceration may decrease HIV incidence. METHODS:Using an agent-based model, we simulated a sexual and injection drug using network representing the African American population of Philadelphia. We compared intervention strategies for men living with HIV post-incarceration by the number of averted HIV transmissions to women within the community. Three interventions were evaluated: a 90-90-90 scenario scaling up HIV testing, ART provision, and ART adherence; a behavioral intervention decreasing sexual risk behaviors; and a combination intervention involving both. RESULTS:The status quo scenario projected 2,836 HIV transmissions to women over twenty years. HIV transmissions to women decreased by 29% with the 90-90-90 intervention, 23% with the behavioral intervention, and 37% with both. The number of men living with HIV receiving the intervention needed in order to prevent a single HIV transmission ranged between 6 and 10. CONCLUSION:Interventions to improve care engagement and decrease sexual risk behaviors post-incarceration for men living with HIV have the potential to decrease HIV incidence within African American heterosexual networks.