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.

BACKGROUND AND AIM/OBJECTIVE:Sedative, hypnotic or anxiolytic use disorders (SHA-UD) are defined by significant impairment or distress caused by recurrent sedative, hypnotic or anxiolytic use. This study aimed to measure trends in the prevalence of SHA-UD diagnoses in adolescent and young adult US Medicaid enrollees from 2001 to 2019. DESIGN/METHODS:Annual, cross-sectional study, 2001-2019. SETTING/METHODS:Medicaid Analytic eXtracts (MAX) and Transformed Medicaid Analytic Files (TAF) from 42 US states with complete data. PARTICIPANTS/CASES/METHODS:Adolescents (13-17 years) and young adults (18-29 years) with ≥10 months Medicaid enrollment in the calendar year; analytic sample contained 5.7 (2001) to 13.2 (2019) million persons per year. MEASUREMENTS/METHODS:Annual prevalence of SHA-UD in adolescent and young adult Medicaid enrollees [defined as an inpatient or outpatient ICD code (304.1x, 305.4x, F13.1x, F13.2x) in the calendar year] was stratified by sex, race/ethnicity, receipt of a benzodiazepine, z-hypnotic or barbiturate prescription, and selected mental health diagnoses. Absolute and relative percent-changes from 2001 vs. 2019 were summarized. Secondary analyses were restricted to states with more consistent data capture. FINDINGS/RESULTS:The prevalence of SHA-UD diagnoses statistically significantly increased for adolescents (0.01% to 0.04%) and young adults (0.05% to 0.24%) from 2001 to 2019. Increasing trends were observed in sex and race/ethnicity subgroups, with greatest relative increases among Non-Hispanic Black (624%) and Hispanic (529%) young adults. The trend increased among those with and without a benzodiazepine, z-hypnotic or barbiturate prescription; i.e. young adults with (2001 = 0.39% to 2019 = 1.77%) and without (2001 = 0.03% to 2019 = 0.18%) a prescription. Most adolescents (76%) and young adults (91%) with a SHA-UD diagnosis in 2019 had a comorbid substance use disorder. CONCLUSIONS:Sedative, hypnotic or anxiolytic use disorders (SHA-UD) diagnoses increased 3- to 5-fold between 2001 and 2019 for adolescent and young adult US Medicaid enrollees, with prevalence remaining low in adolescents. The increase over two decades may be attributed to changes in the availability, use and misuse of sedative, hypnotic and anxiolytic medications and to increased detection, awareness and diagnosing of SHA-UD.

BACKGROUND:Identifying the most effective state laws and provisions to reduce opioid overdose deaths remains critical. METHODS:Using expert ratings of opioid laws, we developed annual state scores for three domains: opioid prescribing restrictions, harm reduction, and Medicaid treatment coverage. We modeled associations of state opioid policy domain scores with opioid-involved overdose death counts in 3133 counties, and among racial/ethnic subgroups in 1485 counties (2013-2020). We modeled a second set of domain scores based solely on experts' highest 20 ranked provisions to compare with the all-provisions model. RESULTS:From 2013 to 2020, moving from non- to full enactment of harm reduction domain laws (i.e., 0 to 1 in domain score) was associated with reduced county-level relative risk (RR) of opioid overdose death in the subsequent year (adjusted RR = 0.84, 95 % credible interval (CrI): 0.77, 0.92). Moving from non- to full enactment of opioid prescribing restrictions and Medicaid treatment coverage domains was associated with higher overdose in 2013-2016 (aRR 1.69 (1.35, 2.11) and aRR 1.20 (1.11, 1.29) respectively); both shifted to the null in 2017-2020. Effect sizes and direction were similar across racial/ethnic groups. Results for experts' highest 20 ranked provisions did not differ from the all-provision model. CONCLUSIONS:More robust state harm reduction policy scores were associated with reduced overdose risk, adjusting for other policy domains. Harmful associations with opioid prescribing restrictions in 2013-2016 may reflect early unintended consequences of these laws. Medicaid coverage domain findings did not align with experts' perceptions, though data limitations precluded inclusion of several highly ranked Medicaid policies.

BACKGROUND AND AIMS/OBJECTIVE:US regulatory changes allowed for additional methadone take-home doses following COVID-19 onset. How dispensing practices changed and which factors drove variation remains unexplored. We determined daily methadone dispensing trajectories over six months before and after regulatory changes due to COVID-19 using state sequence analysis and explored correlates. DESIGN/METHODS:Retrospective chart review of electronic health records. SETTINGS/METHODS:Nine opioid treatment programs (OTPs) across nine US states. PARTICIPANTS/METHODS:Adults initiating treatment in 2019 (n = 328) vs. initiating 1 month after the COVID-19 regulatory changes of March 2020 (n = 376). MEASUREMENTS/METHODS:Type of daily methadone medication encounter (in-clinic, weekend/holiday take-home, take-home, missed dose, discontinued) based on OTP clinic; cohort (pre vs. post-COVID-19); and patient substance use, clinical and sociodemographic characteristics. FINDINGS/RESULTS:Following COVID-19 regulatory changes, allotted methadone take-home doses increased from 3.5% to 13.8% of total person-days in treatment within the first 6 months in care. Clinic site accounted for the greatest variation in methadone dispensing (6.2% and 9.5% of the variation of discrepancy between sequences pre- and post-COVID-19, respectively). People who co-use methamphetamine had a greater increase in take-homes than people who did not use methamphetamine (from 3.7% pre-pandemic to 21.2% post-pandemic vs. 3.5% to 12.5%) and higher discontinuation (average 3.6 vs. 4.7 months among people who did not use methamphetamine pre-COVID-19; average 3.3 vs. 4.6 months post-COVID-19). In the post-COVID-19 cohort, females had a higher proportion of missed doses (17.2% vs. 11.9%) than males. People experiencing houselessness had a higher proportion of missed doses (19% vs. 12.3%) and shorter stays (average 3.5 vs. 4.5 months) when compared with those with stable housing. CONCLUSION/CONCLUSIONS:Daily methadone dispensing trajectories in the US both before and following COVID-19 regulatory changes appeared to depend more on the opioid treatment programs' practices than individual patient characteristics or response to treatment.

BACKGROUND:Recreational cannabis use is increasing in Mexico, where legalization is a possibility. The current area-level socioeconomic context of cannabis use has not been studied in the country, limiting our understanding and public health response. We aimed to analyze the association between the municipal socioeconomic environment and recreational cannabis use in Mexico. METHODS:We used data from the National Survey of Drug, Alcohol and Tobacco Consumption 2016-17, the National Health and Nutrition Survey 2023, the 2015 intercensal survey and the 2020 census to study the association of municipal income and municipal education with past-year recreational cannabis use. We fitted Poisson models with robust variance to obtain prevalence ratios and assessed for effect modification by individual-level sex and age, and household-level education. RESULTS:For every unit increase in municipal education, we observed a 1.5 % increase in the prevalence of recreational cannabis use in 2016-17, and a 2.9 % increase in 2023. For each unit increase in municipal income, we observed a 1.5 % increase in the prevalence of recreational cannabis use in 2016-17, and a 1.8 % increase in 2023. We found no effect modification except for a single age group (20- to 29-year-olds vs to 12- to 19-year-olds). CONCLUSION/CONCLUSIONS:Recreational cannabis use in Mexico is currently higher in more socioeconomically advantaged municipalities. Recreational cannabis use through socioeconomic areas should be monitored closely. Further research of the modifiable causes of this association could help inform current and future public health policies.

BACKGROUND:Wider availability of cannabis through medical and recreational legalization (MCL alone and RCL+MCL) has been hypothesized to contribute to reductions in opioid use, misuse, and related harms. We examined whether state adoption of cannabis laws was associated with changes in opioid outcomes overall and stratified by cannabis use. METHODS:Using National Survey on Drug Use and Health (NSDUH) data from 2015 to 2019, we estimated cannabis law associations with opioid (prescription opioid misuse and/or heroin use) misuse and use disorder. All logistic regression models (overall models and models stratified by cannabis use), included year and state fixed effects, individual level covariates, and opioid-related state policies. Stratified analyses were restricted to individuals who reported lifetime cannabis use prior to law adoption to reduce potential for collider bias. Estimates accounted for multiple comparisons using false discovery rate (FDR) corrections and sensitivity to unmeasured confounding using e-values. RESULTS:Overall, MCL and RCL adoption were not associated with changes in the odds of any opioid outcome. After restricting to respondents reporting past-year cannabis use, we observed decreased odds of past year opioid misuse (adjusted odds ratio [AOR]: 0.57 [95 % confidence interval [CI]: 0.38, 0.85]; FDR p-value: 0.07), among individuals in states with MCL compared to those in states without cannabis laws. RCLs were not associated with changes in the odds of any opioid outcome beyond MCL adoption. CONCLUSION/CONCLUSIONS:Comparing individuals in MCL alone states to those in states without such laws, we found an inconsistent pattern of decreased odds of opioid outcomes, which were more pronounced among people reporting cannabis use. The pattern did not hold for individuals in RCL states. In line with a substitution-oriented perspective, findings suggests that MCLs may be associated with reductions in opioid use among people using cannabis but additional work to replicate and expand on these findings is needed.

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.

INTRODUCTION/BACKGROUND:People who use drugs (PWUD) are at risk of HIV infection, but the frequency and distribution of transmission-associated behaviors within rural communities is not well understood. Further, while interventions designed to more explicitly affirm individuals' sexual orientation and behaviors may be more effective, descriptions of behavior variability by orientation are lacking. We sought to describe how disease transmission behaviors and overdose risk vary by sexual orientation and activity among rural PWUD. METHODS:From 01/2018-03/2020, rural PWUD participating in the Rural Opioid Initiative were surveyed across 8 sites. Collected data included: demographics; experiences with drug use, overdose, and healthcare; stigma; gender identity; and sexual orientation and partners. Participants were categorized as: monosexual by orientation and behavior (Mono-only), monosexual by orientation but behaviorally bisexual (Mono/Bi), and bisexual by orientation (Bi+). Analyses included descriptive summaries, bivariate examination (chi-square), and logistic regression (relative risk [RR] and 95 % confidence interval [CI]). RESULTS:The 1455 participants were 84.8 % Mono-only, 3.2 % Mono/Bi, and 12.0 % Bi+. Compared to Mono-only men, Mono/Bi and Bi+ men had greater risk of transactional sex (RR = 9.71, CI = 6.66-14.2 and RR = 5.09, CI = 2.79-9.27, respectively) and sharing syringes for injection (RR = 1.58, CI = 1.06-2.35 and RR = 1.85, CI = 1.38-2.47). Compared to Mono-only women, Mono-Bi and Bi+ women had greater risk of transactional sex (RR = 4.47, CI = 2.68-7.47 and RR = 2.63, CI = 1.81-3.81); and Bi+ women had greater risk of sharing syringes for injection (RR = 1.49, CI = 1.23-1.81), sharing syringes to mix drugs (RR = 1.44, CI = 1.23-1.69), and experiencing an overdose (RR = 1.32, CI = 1.12-1.56). Bi+ men and women both more frequently reported selling sex as a source of income (versus Mono-only, both p < 0.050) and measures of perceived stigma (all p < 0.050). CONCLUSIONS:Rural PWUD who are bisexual by orientation or behavior are significantly more likely to engage in behaviors associated with infectious disease transmission and to experience stigma and drug overdose. Given the growing recognition of bisexuality as a distinct orientation that warrants individualized consideration, interventions that are specifically acknowledging and affirming to the circumstances of this group are needed.

BACKGROUND:Medications for opioid use disorder are associated with a lower risk of drug overdoses at the individual level. However, little is known about whether these effects translate to population-level reductions. We investigated whether county-level efforts to increase access to medication for opioid use disorder in 2012-2014 were associated with opioid overdose deaths in New York State during the first years of the synthetic opioid crisis. METHODS:We performed an ecologic county-level study including data from 60 counties (2010-2018). We calculated rates of people receiving medication for opioid use disorder among the population misusing opioids in 2012-2014 and categorized counties into quartiles of this exposure. We modeled synthetic and nonsynthetic opioid overdose death rates using Bayesian hierarchical models. RESULTS:Counties with higher rates of receiving medications for opioid use disorder in 2012-2014 had lower synthetic opioid overdose deaths in 2016 (highest vs. lowest quartile: rate ratio [RR] = 0.33, 95% credible interval [CrI] = 0.12, 0.98; and second-highest vs. lowest: RR = 0.20, 95% CrI = 0.07, 0.59) and 2017 (quartile second-highest vs. lowest: RR = 0.22, 95% CrI = 0.06, 0.83), but not 2018. There were no differences in nonsynthetic opioid overdose death rates comparing higher quartiles versus lowest quartile of exposure. CONCLUSIONS:A spatio-temporal modeling approach incorporating counts of the population misusing opioids provided information about trends and interventions in the target population. Higher rates of receiving medications for opioid use disorder in 2012-2014 were associated with lower rates of synthetic opioid overdose deaths early in the crisis.