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When Effects Cannot be Estimated: Redefining Estimands to Understand the Effects of Naloxone Access Laws

Rudolph, Kara E; Gimbrone, Catherine; Matthay, Ellicott C; Díaz, Iván; Davis, Corey S; Keyes, Katherine; Cerdá, Magdalena
Violations of the positivity assumption (also called the common support condition) challenge health policy research and can result in significant bias, large variance, and invalid inference. We define positivity in the single- and multiple-timepoint (i.e., longitudinal) health policy evaluation setting, and discuss real-world threats to positivity. We show empirical evidence of the practical positivity violations that can result when attempting to estimate the effects of health policies (in this case, Naloxone Access Laws). In such scenarios, an alternative is to estimate the effect of a shift in law enactment (e.g., the effect if enactment had been delayed by some number of years). Such an effect corresponds to what is called a modified treatment policy, and dramatically weakens the required positivity assumption, thereby offering a means to estimate policy effects even in scenarios with serious positivity problems. We apply the approach to define and estimate the longitudinal effects of Naloxone Access Laws on opioid overdose rates.
PMCID:9373236
PMID: 35944151
ISSN: 1531-5487
CID: 5310592

Hospital Standards of Care for People with Substance Use Disorder

Englander, Honora; Davis, Corey S
PMID: 35984354
ISSN: 1533-4406
CID: 5300292

A modified Delphi process to identify experts' perceptions of the most beneficial and harmful laws to reduce opioid-related harm

Hamilton, Leah K; Wheeler-Martin, Katherine; Davis, Corey S; Martins, Silvia S; Samples, Hillary; Cerdá, Magdalena
BACKGROUND:States have enacted multiple types of laws, with a variety of constituent provisions, in response to the opioid epidemic, often simultaneously. This temporal proximity and variation in state-to-state operationalization has resulted in significant challenges for empirical research on their effects. Thus, expert consensus can be helpful to classify laws and their provisions by their degree of helpfulness and impact. METHODS:We conducted a four-stage modified policy Delphi process to identify the top 10 most helpful and 5 most harmful provisions from eight opioid-related laws. This iterative consultation with six types of opioid experts included a preliminary focus group (n=12), two consecutive surveys (n=56 and n=40, respectively), and a final focus group feedback session (n=5). RESULTS:On a scale of very harmful (0) to very helpful (4), overdose Good Samaritan laws received the highest average helpfulness rating (3.62, 95% CI: 3.48-3.75), followed by naloxone access laws (3.37, 95% CI: 3.22-3.51), and pain management clinic laws (3.08, 95% CI: 2.89-3.26). Drug-induced homicide (DIH) laws were rated the most harmful (0.88, 95% CI: 0.66-1.11). Impact ratings aligned similarly, although Medicaid laws received the second highest overall impact rating (3.71, 95% CI: 3.45, 3.97). The two most helpful provisions were naloxone standing orders (3.94, 95% CI: 3.86-4.02) and Medicaid coverage of medications for opioid use disorder (MOUD) (3.89, 95% CI: 3.82). Mandatory minimum DIH laws were the most harmful provision (0.73, 95% CI 0.53-0.93); followed by requiring prior authorization for Medicaid coverage of MOUD (1.00 95% CI: 0.72-1.27). CONCLUSION/CONCLUSIONS:Overall, experts rated laws and provisions that facilitated harm reduction efforts and access to MOUD as most helpful. Laws and provisions rated as most harmful criminalized substance use and placed restrictions on access to MOUD. These ratings provide a foundation for evaluating the overall overdose policy environment for each state.
PMID: 35908313
ISSN: 1873-4758
CID: 5287742

The Importance of Federal Action Supporting Overdose-Prevention Centers

Naeem, Aneeqah H; Davis, Corey S; Samuels, Elizabeth A
PMID: 35593724
ISSN: 1533-4406
CID: 5283702

Laws Forbidding Pregnancy Discrimination in Substance Use Disorder Treatment Are Not Associated With Treatment Access

Davis, Corey S; McNeer, Elizabeth; Patrick, Stephen W
OBJECTIVES/OBJECTIVE:To determine if state laws that forbid substance use disorder treatment providers from refusing services based on pregnancy are associated with improved ability to secure an initial appointment for opioid use disorder treatment with methadone and buprenorphine. METHODS:Ten states in which a "secret shopper" study was conducted were stratified based on whether they have a law that forbids substance use disorder treatment providers from refusing to treat individuals because of pregnancy. We tested for differences in percent of pregnant versus nonpregnant callers offered an initial appointment for medication for opioid use disorder treatment between states with a law and those without. We also tested for differences in acceptance based on caller insurance type. RESULTS:Four states with 1461 callers had relevant laws; 6 states with 2495 callers did not. None of the laws apply to all providers. In both groups of states, nonpregnant callers were significantly more likely to obtain a buprenorphine appointment (75.1% vs 60.1% in states with a law, P < 0.01; 73.1% vs 62.3% in states without, P < 0.01). No significant differences were found in methadone appointment access either between pregnant and nonpregnant callers or between pregnant callers in states with a law compared to those without. CONCLUSIONS:Laws that forbid providers from refusing to treat potential patients because they are pregnant were not associated with success in obtaining an initial appointment for medication for opioid use disorder treatment. States should consider expanding those laws to apply to all treatment providers and ensure that currently covered providers are in compliance.
PMID: 34282081
ISSN: 1935-3227
CID: 4967482

Principles and Metrics for Evaluating Oregon's Innovative Drug Decriminalization Measure

Netherland, Jules; Kral, Alex H; Ompad, Danielle C; Davis, Corey S; Bluthenthal, Ricky N; Dasgupta, Nabarun; Gilbert, Michael; Morgan, Riona; Wheelock, Haven
PMCID:8809225
PMID: 35107693
ISSN: 1468-2869
CID: 5180902

Permanent Methadone Treatment Reform Needed to Combat the Opioid Crisis and Structural Racism

Peterkin, Alyssa; Davis, Corey S; Weinstein, Zoe
Since early 2020 COVID-19 has swept across the United States, exposing shortcomings in the current healthcare delivery system. Although some interim efforts have been made to mitigate the spread of infection and maintain access to treatment for opioid use disorder, more permanent changes are needed to combat the ongoing opioid crisis. In this commentary, we describe the regulatory barriers to methadone maintenance treatment that disproportionately impact communities of color. We then discuss strategies supporting more equitable access to this proven treatment for opioid use disorder.
PMID: 33758114
ISSN: 1935-3227
CID: 4967432

Spatiotemporal Analysis of the Association between Pain Management Clinic Laws and Opioid Prescribing and Overdose Deaths

Cerdá, Magdalena; Wheeler-Martin, Katherine; Bruzelius, Emilie; Ponicki, William; Gruenewald, Paul; Mauro, Christine; Crystal, Stephen; Davis, Corey S; Keyes, Katherine; Hasin, Deborah; Rudolph, Kara E; Martins, Silvia S
Pain management clinic (PMC) laws were enacted by 12 states to promote appropriate opioid prescribing, but their impact is inadequately understood. We analyzed county-level opioid overdose deaths (National Vital Statistics System) and patients filling long-duration (≥30 day) or high-dose (≥90 morphine milligram equivalents) opioid prescriptions (IQVIA, Inc) in the United States from 2010-2018. We fit Besag-York-Mollié spatiotemporal models to estimate annual relative rates (RR) of overdose and prevalence ratios (PR) of high-risk prescribing associated with any PMC law and three provisions: payment restrictions, site inspections, and criminal penalties. Laws with criminal penalties were significantly associated with reduced PRs of long-duration and high-dose opioid prescriptions (adjusted PR: 0.82, 95% credible interval (CrI) 0.92-0.83, and 0.73, and 0.73, 0.74 respectively), and reduced RRs of total and natural/semi-synthetic opioid overdoses (adjusted RR: 0.86, 95% CrI: 0.80, 0.92; and 0.84, and 0.77, 0.92, respectively). Conversely, PMC laws were associated with increased relative rates of synthetic opioid and heroin overdose deaths, especially criminal penalties (adjusted RR: 1.83, 95% CrI: 1.59, 2.11; and 2.59, and 2.22, 3.02, respectively). Findings suggest laws with criminal penalties were associated with intended reductions in high-risk opioid prescribing and some opioid overdoses, but raise concerns regarding unintended consequences on heroin/synthetic overdoses.
PMID: 34216209
ISSN: 1476-6256
CID: 4967462

Prescription opioid laws and opioid dispensing in U.S. counties: Identifying salient law provisions with machine learning

Martins, Silvia S; Bruzelius, Emilie; Stingone, Jeanette A; Wheeler-Martin, Katherine; Akbarnejad, Hanane; Mauro, Christine M; Marziali, Megan E; Samples, Hillary; Crystal, Stephen; Davis, Corey S; Rudolph, Kara E; Keyes, Katherine M; Hasin, Deborah S; Cerdá, Magdalena
BACKGROUND:Hundreds of laws aimed at reducing inappropriate prescription opioid dispensing have been implemented in the United States, yet heterogeneity in provisions and their simultaneous implementation have complicated evaluation of impacts. We apply a hypothesis-generating, multi-stage, machine learning approach to identify salient law provisions and combinations associated with dispensing rates to test in future research. METHODS:Using 162 prescription opioid law provisions capturing prescription drug monitoring program (PDMP) access, reporting and administration features, pain management clinic provisions, and prescription opioid limits, we used regularization approaches and random forest models to identify laws most predictive of county-level and high-dose dispensing. We stratified analyses by overdose epidemic phases-the prescription opioid phase (2006-2009), heroin phase (2010-2012), and fentanyl phase (2013-2016)-to further explore pattern shifts over time. RESULTS:PDMP patient data access provisions most consistently predicted high dispensing and high-dose dispensing counties. Pain management clinic-related provisions did not generally predict dispensing measures in the prescription opioid phase but became more discriminant of high dispensing and high-dose dispensing counties over time, especially in the fentanyl period. Predictive performance across models was poor, suggesting prescription opioid laws alone do not strongly predict dispensing. CONCLUSIONS:Our systematic analysis of 162 law provisions identified patient data access and several pain management clinic provisions as predictive of county prescription opioid dispensing patterns. Future research employing other types of study designs is needed to test these provisions' causal relationships with inappropriate dispensing, and to examine potential interactions between PDMP access and pain management clinic provisions.
PMID: 34310445
ISSN: 1531-5487
CID: 4967492

Harm Reduction, By Mail: the Next Step in Promoting the Health of People Who Use Drugs

Hayes, Benjamin T; Favaro, Jamie; Davis, Corey S; Gonsalves, Gregg S; Beletsky, Leo; Vlahov, David; Heimer, Robert; Fox, Aaron D
PMCID:7953942
PMID: 33710493
ISSN: 1468-2869
CID: 4829602