Comparing Projected Fatal Overdose Outcomes and Costs of Strategies to Expand Community-Based Distribution of Naloxone in Rhode Island

IMPORTANCE

In 2021, the state of Rhode Island distributed 10 000 additional naloxone kits compared with the prior year through partnerships with community-based organizations.

OBJECTIVE

To compare various strategies to increase naloxone distribution through community-based programs in Rhode Island to identify one most effective and efficient strategy in preventing opioid overdose deaths (OODs).

DESIGN, SETTING, AND PARTICIPANTS

In this decision analytical model study conducted from January 2016 to December 2022, a spatial microsimulation model with an integrated decision tree was developed and calibrated to compare the outcomes of alternative strategies for distributing 10 000 additional naloxone kits annually among all individuals at risk for opioid overdose in Rhode Island.

INTERVENTIONS

Distribution of 10 000 additional naloxone kits annually, focusing on people who inject drugs, people who use illicit opioids and stimulants, individuals at various levels of risk for opioid overdose, or people who misuse prescription opioids vs no additional kits (status quo). Two expanded distribution implementation approaches were considered: one consistent with the current spatial distribution patterns for each distribution program type (supply-based approach) and one consistent with the current spatial distribution of individuals in each of the risk groups, assuming that programs could direct the additional kits to new geographic areas if required (demand-based approach).

MAIN OUTCOMES AND MEASURES

Witnessed OODs, cost per OOD averted (efficiency), geospatial health inequality measured by the Theil index, and between-group variance for OOD rates.

RESULTS

A total of 63 131 simulated individuals were estimated to be at risk for opioid overdose in Rhode Island based on current population data. With the supply-based approach, prioritizing additional naloxone kits to people who use illicit drugs averted more witnessed OODs by an estimated mean of 18.9% (95% simulation interval [SI], 13.1%-30.7%) annually. Expanded naloxone distribution using the demand-based approach and focusing on people who inject drugs had the best outcomes across all scenarios, averting an estimated mean of 25.3% (95% SI, 13.1%-37.6%) of witnessed OODs annually, at the lowest mean incremental cost of $27 312 per OOD averted. Other strategies were associated with fewer OODs averted at higher costs but showed similar patterns of improved outcomes and lower unit costs if kits could be reallocated to areas with greater need. The demand-based approach reduced geospatial inequality in OOD rates in all scenarios compared with the supply-based approach and status quo.

CONCLUSIONS AND RELEVANCE

In this decision analytical model study, variations in the effectiveness, efficiency, and health inequality of the different naloxone distribution expansion strategies and approaches were identified. Future efforts should be prioritized for people at highest risk for overdose (those who inject drugs or use illicit drugs) and redirected toward areas with the greatest need. These findings may inform future naloxone distribution priority settings.

The estimated costs and benefits of a hypothetical supervised consumption site in Providence, Rhode Island

BACKGROUND

Overdose deaths have increased dramatically in the United States, including in Rhode Island. In July 2021, the Rhode Island government passed legislation supporting a two-year pilot program authorizing supervised consumption sites (SCSs) in response to this crisis. We estimated the costs and benefits of a hypothetical SCS in Providence, Rhode Island.

METHODS

We utilized a decision analytic mathematical model to compare costs and outcomes for people who inject drugs under two scenarios: (1) a SCS that includes syringe services provision, and (2) a syringe service program only (i.e., status quo). We assumed 0.95% of injections result in overdose, the SCS would serve 400 clients monthly and have a net cost of $783,899 annually, 46% of overdoses occurring outside of the SCS result in an ambulance run and 43% result in an emergency department (ED) visit, 0.79% of overdoses occurring within the SCS result in an ambulance run and ED visit, and the SCS would lead to a 25.7% reduction in fatal overdoses near the site. The model was developed from a modified societal perspective with a one-year time horizon.

RESULTS

A hypothetical SCS in Providence would prevent approximately 2 overdose deaths, 261 ambulance runs, 244 ED visits, and 117 inpatient hospitalizations for emergency overdose care annually compared to a scenario that includes a syringe service program only. The SCS would save $1,104,454 annually compared to the syringe service program only, accounting only for facility costs and short-term costs of emergency overdose care and ignoring savings associated with averted deaths. Influential parameters included the percentage of injections resulting in overdose, the total annual injections at the SCS, and the percentage of overdoses outside of the SCS that result in an ED visit.

CONCLUSION

A SCS in would result in substantial cost savings due to prevention of costly emergency overdose care.

Surveillance of SARS-CoV-2 Antibodies in Early 2020 among Rhode Island Pregnancies

OBJECTIVE

Limited data are available on the performance of SARS-CoV-2 antibody assays and data collected during pregnancy vary widely. The objective of this study was to estimate the seroprevalence of antibodies against SARS-CoV-2 in pregnant individuals in Rhode Island and to evaluate whether the prevalence differed by month of collection, age, county of residence, or economic status as estimated by zip code.

METHODS

Pre-pandemic (2019) and early pandemic (2020) serum samples, collected for prenatal screening between 15 and 22 weeks of gestation, were analyzed utilizing two SARS-CoV-2 immunoglobulin G (IgG) automated assays that targeted the viral nucleocapsid (anti-N) or spike (anti-S) receptor binding domain proteins.

RESULTS

Among 756 pre-pandemic samples, one anti-S IgG and 13 anti-N IgG were identified. No samples were positive for both. Among 787 pandemic specimens, 16 (2.03%) were positive for both anti-N IgG and anti-S IgG. When stratified by month of collection, there was a significant increase in seropositivity rate (p=0.023). Seropositivity rates were associated with lower income levels (p=0.08) but this was not statistically significant. No trend by maternal age was found (p=0.70).

CONCLUSIONS

When a positive result was defined as both anti-N IgG and anti-S IgG, false positives were unlikely. Based on this methodology, serology could be utilized to monitor infection trends during pregnancy.

SARS-CoV-2 Variants in Rhode Island; May 2022 Update

BACKGROUND

Genomic surveillance allows identification of circulating SARS-CoV-2 variants. We provide an update on the evolution of SARS-CoV-2 in Rhode Island (RI).

METHODS

All publicly available SARS-CoV-2 RI sequences were retrieved from https://www.gisaid.org. Genomic analyses were conducted to identify variants of concern (VOC), variants being monitored (VBM), or non-VOC/non-VBM, and investigate their evolution.

RESULTS

Overall, 17,340 SARS-CoV-2 RI sequences were available between 2/2020-5/2022 across five (globally recognized) major waves, including 1,462 (8%) sequences from 36 non-VOC/non-VBM until 5/2021; 10,565 (61%) sequences from 8 VBM between 5/2021-12/2021, most commonly Delta; and 5,313 (31%) sequences from the VOC Omicron from 12/2021 onwards. Genomic analyses demonstrated 71 Delta and 44 Omicron sub-lineages, with occurrence of variant-defining mutations in other variants.

CONCLUSION

Statewide SARS-CoV-2 genomic surveillance allows for continued characterization of circulating variants and monitoring of viral evolution, which inform the local health force and guide public health on mitigation efforts against COVID-19.

Statewide evaluation of COVID-19 vaccine hesitancy in Rhode Island

BACKGROUND

Vaccines are effective in preventing Coronavirus Disease 2019 (COVID-19). Vaccine hesitancy defined as delay of acceptance or refusal of the vaccine is a major barrier to effective implementation.

METHODS

Participants were recruited statewide through an English and Spanish social media marketing campaign conducted by a local news station during a one-month period as vaccines were becoming available in Rhode Island (from December 21, 2020 to January 22, 2021). Participants completed an online survey about COVID-19 vaccines and vaccine hesitancy with constructs and items adopted from the Health Belief Model.

RESULTS

A total of 2,007 individuals completed the survey. Eight percent (n = 161) reported vaccine hesitancy. The sample had a median age of 58 years (interquartile range [IQR]: 45, 67), were majority female (78%), White (96%), Non-Hispanic (94%), employed (58%), and reported an annual individual income of $50,000 (59%). COVID-19 vaccine hesitancy was associated with attitudes and behaviors related to COVID-19. A one unit increase in concern about COVID-19 was associated with a 69% (Adjusted Odds Ratio: 0.31, 95% CI: 0.26-0.37) decrease in vaccine hesitancy. A one-level increase in the likelihood of getting influenza vaccine was associated with a 55% (AOR: 0.45 95% CI: 0.41-0.50) decrease in vaccine hesitancy.

CONCLUSIONS

COVID-19 vaccine hesitancy was relatively low in a state-wide survey in Rhode Island. Future research is needed to better understand and tailor messaging related to vaccine hesitancy.

Characterization of Shoulder Instability in Rhode Island: Incidence, Surgical Stabilization, and Recurrence

PURPOSE

To characterize shoulder instability within the state of Rhode Island from 2011 to 2019.

METHODS

The Rhode Island All-Payer Claims Database (APCD) was used to identify all patients that make an insurance claim related to a shoulder instability event. All patients in the APCD with an ICD-9 code of 718.31, 718.32, or 831.00 through 831.19 or an ICD-10 code of S43.001 through S43.086 or M24.41 through M25.319 between January 1, 2011 and December 31, 2019 were selected. Chi-square analysis was used to compare age- and sex-delimited subgroups; multivariate logistic regression was used to assess for factors influencing rates of surgical intervention and recurrent instability; and Kaplan-Meier failure and log-rank analyses was used to analyze variation in the time to surgery and recurrence between age-delimited subgroups.

RESULTS

The incidence of overall shoulder instability (subluxations and dislocations) in Rhode Island was 62.20 instability events (95% CI, 60.61-63.78) per 100,000 person-years. The incidence of dislocations and subluxations were 49.46 injuries (95% CI, 48.05-50.88) and 12.73 injuries (95% CI, 12.02-13.45) per 100,000 person-years, respectively. Bivariate analysis demonstrated that male patients had significantly increased rates of surgical stabilization (6.36% vs. 2.80%) and recurrent instability (16.30% vs. 9.85%) compared to their female counterparts. However, after controlling for age at the primary instability event and the type and directionality of the instability, the difference in recurrence rates between males and females is no longer statistically significant (p = 0.326). Contrary to sex, age maintained its significance with those patients aged 20 and younger and 21-40 years at significantly increased odds of surgical stabilization (3.12 and 1.99, respectively) and experiencing a recurrent instability event (3.96 and 2.77, respectively).

CONCLUSION

These data characterize the epidemiology of shoulder instability within the state of Rhode Island and demonstrate how increasing age at a primary instability event decreases the likelihood of both surgical stabilization and rates of recurrence.

A rapid ethnographic study of risk negotiation during the COVID-19 pandemic among unstably housed people who use drugs in Rhode Island

BACKGROUND

The COVID-19 pandemic has greatly exacerbated the United States' overdose crisis. However, the overlapping impacts of COVID-19 and the overdose crisis have not been experienced equally, with unstably housed people who use drugs (PWUD) disproportionately impacted. Amid these changes, there is a need to understand how risk is experienced and managed among unstably housed PWUD to address health and social needs more effectively.

METHODS

This project draws on ethnographic research conducted from June 2020 to April 2021 in Rhode Island. Data include 39 in-depth interviews with unstably housed PWUD and approximately 50 h of ethnographic fieldwork conducted alongside street-based outreach workers.

RESULTS

COVID-19 risks were primarily contextualized in relation to participants' prior experiences of overdose events and adverse health outcomes. However, participants had varying levels of risk tolerance that were managed in ways that allowed them to reassert control and agency within the uncertainty of overlapping public health crises. Given participants' level of structural vulnerabilities, COVID-19 risk was managed alongside meeting their basic needs to survive.

CONCLUSIONS

Findings demonstrate how COVID-related public health measures (e.g., stay-at-home orders, service closures) reinforced participants' structural vulnerabilities in ways that increased their risk of health and social harms. Implementing and scaling up programs that meet the basic needs of individuals, including permanent housing, social supports, and overdose prevention interventions (e.g., supervised consumption sites) is critically needed to address intersecting risks faced by unstably housed PWUD.

Community-based naloxone coverage equity for the prevention of opioid overdose fatalities in racial/ethnic minority communities in Massachusetts and Rhode Island

BACKGROUND AND AIMS

Opioid-related overdose death rates continue to rise in the United States, especially in racial/ethnic minority communities. Our objective was to determine if US municipalities with high percentages of non-white residents have equitable access to the overdose antidote naloxone distributed by community-based organizations.

METHODS

We used community-based naloxone data from the Massachusetts Department of Public Health and the Rhode Island non-pharmacy naloxone distribution program for 2016-18. We obtained publicly available opioid-related overdose death data from Massachusetts and the Office of the State Medical Examiners in Rhode Island. We defined the naloxone coverage ratio as the number of community-based naloxone kits received by a resident in a municipality divided by the number of opioid-related overdose deaths among residents, updated annually. We used a Poisson regression with generalized estimating equations to analyze the relationship between the municipal racial/ethnic composition and naloxone coverage ratio. To account for the potential non-linear relationship between naloxone coverage ratio and race/ethnicity we created B-splines for the percentage of non-white residents; and for a secondary analysis examining the percentage of African American/black and Hispanic residents. The models were adjusted for the percentage of residents in poverty, urbanicity, state and population size.

RESULTS

Between 2016 and 2018, the annual naloxone coverage ratios range was 0-135. There was no difference in naloxone coverage ratios among municipalities with varying percentages of non-white residents in our multivariable analysis. In the secondary analysis, municipalities with higher percentages of African American/black residents had higher naloxone coverage ratios, independent of other factors. Naloxone coverage did not differ by percentage of Hispanic residents.

CONCLUSIONS

There appear to be no municipal-level racial/ethnic inequities in naloxone distribution in Rhode Island and Massachusetts, USA.

Towards an Improved Substance Use Disorder Treatment Landscape in Rhode Island - Barriers, Current Progress, and Next Steps

Expanding addiction treatment services in Rhode Island has never been more urgent. Today, we face colliding syndemics of COVID-19, preventable drug overdoses, and HIV, with another year of record overdoses. While the treatment of substance use disorder (SUD) is an essential component of general medical care, numerous barriers prevent broader treatment access for patients in Rhode Island. Buprenorphine and methadone therapy have restrictions that are not applied to other areas in medicine, including for more dangerous medications. In this piece, we highlight existing barriers to care, applaud current progress being made in our state, and provide recommendations for next steps to turn the tide of this deadly epidemic. We hope that these proposed changes will help develop a robust treatment landscape for all patients with SUD in Rhode Island.

Trends and Risk Factors for Overlapping Stimulant and Opioid Prescriptions - Rhode Island, April 1, 2016-March 31, 2020

OBJECTIVE

To investigate possible trends and risk factors for overlapping stimulant and opioid prescriptions in Rhode Island (RI).

METHODS

All RI residents with a stimulant prescription dispensed between April 1, 2016 and March 31, 2020 were obtained from the RI Prescription Drug Monitoring Program (PDMP). Individuals were stratified by overlapping stimulant/opioid exposure and compared by demographic and prescription characteristics.

RESULTS

While stimulant prescribing remained relatively constant, the percent of individuals with an overlapping opioid prescription declined. Individuals prescribed overlapping stimulant/opioid prescriptions differed significantly as a function of age, sex, payment method, type of stimulant prescribed, and prescriber type.

CONCLUSIONS

Among residents who were dispensed at least one stimulant prescription, individuals who were older, female, and on Medicare insurance were more likely to have an overlapping stimulant/opioid prescription. The RI PDMP can be used to identify trends and risk factors regarding prescribing patterns, which can inform future health policy and practice.

Gambling: A Ubiquitous Behavior Among Rhode Island's Young Adults

OBJECTIVES

Gambling is a prevalent behavior associated with numerous consequences. The purpose of the current study was to assess the prevalence of gambling and problem gambling in Rhode Island young adults and to identify sociodemographic correlates of gambling.

METHODS

Data from n=546 participants of the Rhode Island Young Adult Survey were used. Twelve types of gambling behaviors, and problem gambling, were assessed. Sociodemographic variables included age, race/ethnicity, gender, sexual orientation, social status, education, employment, and essential worker status.

RESULTS

The prevalence of any gambling was 62.3%, and odds of any gambling was 57% higher (95%CI = 1.08,2.27) among essential workers. The prevalence of problem gambling was 11.4%, and the odds were 3.6 times higher (95%CI = 1.32, 9.86) among persons who are transgender.

CONCLUSIONS

The prevalence of gambling and problem gambling are high among Rhode Island's young adults. Implementing programmatic and regulatory measures to prevent and treat problem gambling are vital.

Evaluating Housing Characteristics Associated With Childhood Lead Exposure in Providence, Rhode Island

OBJECTIVE

This research aims to take an in-depth look into the child, housing, and neighborhood characteristics associated with Providence children's likelihood of having elevated blood lead levels (BLLs).

DESIGN AND SETTING

The 2019 Providence, Rhode Island, Property Tax Assessor's database, containing each property owner's address, was geocoded and spatially joined with the 2017-2019 blood lead tests for children aged 0 to 6 years from the Rhode Island Department of Health.

MAIN OUTCOME MEASURES

The prevalence of elevated BLLs (≥5 μg/dL) overall, as well as by property type, number of properties owned, owner occupancy, assessed value, and neighborhood rates of old housing and poverty, was computed. We assessed the relationship between having elevated BLLs and these housing and neighborhood characteristics, adjusting for gender, age at test, and test method.

RESULTS

We found that, compared with children living in properties with landlords who owned only one property, children living in properties with landlords who owned 4 or more properties had lower odds of having elevated BLLs (odds ratio = 0.98; 95% confidence interval, 0.97-0.99). The proportion of houses built pre-1950 in the neighborhood was associated with increased odds of elevated BLLs. There was no significant association between owner-occupancy status and property type with children having elevated BLLs.

CONCLUSIONS

Children living in properties with landlords who owned 4 or more properties were less likely to have elevated BLLs. This association may suggest that the current lead legislation is having some impact, but public health efforts should address lead exposure in properties that are currently exempt from the law.

Antenatal Depression and Cesarean Delivery Among Recently-Delivered Nulliparous Women in Rhode Island

OBJECTIVE

Antenatal depression (AD) is frequently cited as a risk factor for cesarean delivery (CD) with limited supporting data.

STUDY DESIGN

We utilized 2016-2018 data from the Pregnancy Risk Assessment Monitoring System (PRAMS) survey for the state of Rhode Island. Nulliparous women who reported AD (n=242) were compared to women who did not (n=1,081). Maternal demographics, pregnancy and delivery characteristics were compared by AD status using population-weighted bivariable analyses and multivariable logistic regression.

RESULTS

17.7% reported AD, and 34% underwent CD. There was no difference in CD based on reported AD status (aOR 1.04; 95% CI 0.69, 1.56). However, there were significant differences between those reporting AD compared to those who did not: less education, more public insurance, use of Women, Infants and Children (WIC) benefits, tobacco use, and pre-gestational hypertension/diabetes.

CONCLUSION

In this large, population-based, state representative sample, we found no difference in CD among recently delivered nulliparous women with and without AD.

Examining Outcomes for Nulliparous, at Term, Singleton and Vertex Deliveries During the First Wave of the COVID-19 Pandemic in Rhode Island

BACKGROUND

During the initial wave of the COVID-19, there was uncertainty related to whether the pandemic would affect pregnancy delivery outcomes. We sought to identify whether changes in hospital policies and provider practices, driven by COVID-19, would influence delivery outcomes in nulliparous, term, singleton, vertex (NTSV) pregnancies in Rhode Island.

OBJECTIVE

We compare the delivery outcomes and associated factors for NTSV deliveries during the first wave of the COVID-19 pandemic in Rhode Island compared to patients who delivered the year prior.

STUDY DESIGN

This is a retrospective cohort study of patients who presented to Women & Infants Hospital for NTSV deliveries during April 2019, pre-COVID-19, and April 2020, during COVID-19.

RESULTS

During COVID-19, patients were more likely to have abnormal electronic fetal monitoring (AEFM) as an indication for cesarean section (p<.02) and less likely to have an elective cesarean delivery (p<.01). Patients during COVID-19 were more likely to have a midwife involved in their care compared to pre-COVID-19 (p<.001). The cesarean section rate was not statistically different between the two time periods.

CONCLUSION

Those delivering during the pandemic were more likely to have AEFM as an indication for cesarean delivery and less likely to have elective cesareans. They were more likely to have a midwife involved in their care. Further investigation into factors associated with changes in NTSV cesarean rates is warranted.

SARS-CoV-2 epidemic after social and economic reopening in three U.S. states reveals shifts in age structure and clinical characteristics

State-level reopenings in late spring 2020 facilitated the resurgence of severe acute respiratory syndrome coronavirus 2 transmission. Here, we analyze age-structured case, hospitalization, and death time series from three states-Rhode Island, Massachusetts, and Pennsylvania-that had successful reopenings in May 2020 without summer waves of infection. Using 11 daily data streams, we show that from spring to summer, the epidemic shifted from an older to a younger age profile and that elderly individuals were less able to reduce contacts during the lockdown period when compared to younger individuals. Clinical case management improved from spring to summer, resulting in fewer critical care admissions and lower infection fatality rate. Attack rate estimates through 31 August 2020 are 6.2% [95% credible interval (CI), 5.7 to 6.8%] of the total population infected for Rhode Island, 6.7% (95% CI, 5.4 to 7.6%) in Massachusetts, and 2.7% (95% CI, 2.5 to 3.1%) in Pennsylvania.

Association between initial opioid prescription diagnosis type and subsequent chronic prescription opioid use in Rhode Island: a population-based cohort study

OBJECTIVE

To identify initial diagnoses associated with elevated risk of chronic prescription opioid use.

DESIGN

Population-based, retrospective cohort study.

SETTING

State of Rhode Island.

PARTICIPANTS

Rhode Island residents with an initial opioid prescription dispensed between 1 April 2019 and 31 March 2020.

PRIMARY OUTCOME MEASURE

Subsequent chronic prescription opioid use, defined as receiving 60 or more days' supply of opioids in the 90 days following an initial opioid prescription.

RESULTS

Among the 87 055 patients with an initial opioid prescription, 3199 (3.7%) subsequently became chronic users. Patients who become chronic users tended to receive a longer days' supply, greater quantity dispensed, but a lower morphine milligram equivalents on the initial opioid prescription. Patients prescribed an initial opioid prescription for diseases of the musculoskeletal system and connective tissue (adjusted OR (aOR): 5.9, 95% CI: 4.7 to 7.6), diseases of the nervous system (aOR: 6.3, 95% CI: 4.9 to 8.0) and neoplasms (aOR: 5.6, 95% CI: 4.2 to 7.5) had higher odds of subsequent chronic prescription opioid use, compared with a referent group that included all diagnosis types with fewer than 15 chronic opioid users, after adjusting for confounders.

CONCLUSIONS

By focusing interventions and prescribing guidelines on specific types of diagnoses that carry a high risk of chronic prescription opioid use and diagnoses that would benefit equally or more from alternative management approaches, states and healthcare organisations may more efficiently decrease inappropriate opioid prescribing while improving the quality of patient care.

Characteristics of COVID-19 Workplace Clusters in Rhode Island

The COVID-19 pandemic has impacted certain workplace settings disproportionately, putting some industries at a higher risk for workplace transmission than others. This study examines workplace clusters in Rhode Island between March 2020 and May 2021. There were 14,580 cases associated with 2784 clusters during this period, with the largest number of workplace clusters occurring in manufacturing, food services, and retail. A better understanding of most impacted industries can inform sector-specific COVID-19 guidance and policy changes.