Opioid prescribing and opioid-overdose deaths in Michigan: Urban-rural comparisons and changes across 2013-2017

Examining the association of rurality with opioid-related morbidity and mortality in Georgia: A geospatial analysis

INTRODUCTION

The US opioid epidemic continues to escalate, with overdose deaths being the most-used metric to quantify its burden. There is significant geographic variation in opioid-related outcomes. Rural areas experience unique challenges, yet many studies oversimplify rurality characterizations. Contextual factors, such as area deprivation, are also important to consider when understanding a community's need for treatment services and prevention programming. This study aims to provide a geospatial snapshot of the opioid epidemic in Georgia using several metrics of opioid-related morbidity and mortality and explore differences by rurality across counties.

METHODS

This was a spatial ecologic study. Negative binominal regression was used to model the relationship of county rurality with four opioid-related outcomes - overdose mortality, emergency department visits, inpatient hospitalizations, and overdose reversals - adjusting for county-level sex, racial/ethnic, and age distributions. Area Deprivation Index was also included.

RESULTS

There was significant geographic variation across the state for all four opioid-related outcomes. Counts remained highest among the metro areas. For rates, counties in the top quartile of rates varied by outcome and were often rural areas. In the final models, rurality designation was largely unrelated to opioid outcomes, with the exception of medium metro areas (inversely related to hospitalizations and overdose reversals) and non-core areas (inversely related to hospitalizations), as compared to large central metro areas. Higher deprivation was significantly related to increased ED visits and hospitalizations, but not overdose mortality and reversals.

CONCLUSIONS

When quantifying the burden of the opioid epidemic in a community, it is essential to consider multiple outcomes of morbidity and mortality. Understanding what outcomes are problematic for specific communities, in combination with their demographic and socioeconomic context, can provide insight into gaps in the treatment continuum and potential areas for intervention. Additionally, compared to demographic and socioeconomic factors, rurality may no longer be a salient predictor of the severity of the opioid epidemic in an area.

Forecasting drug-overdose mortality by age in the United States at the national and county levels

The drug-overdose crisis in the United States continues to intensify. Fatalities have increased 5-fold since 1999 reaching a record high of 108,000 deaths in 2021. The epidemic has unfolded through distinct waves of different drug types, uniquely impacting various age, gender, race, and ethnic groups in specific geographical areas. One major challenge in designing interventions and efficiently delivering treatment is forecasting age-specific overdose patterns at the local level. To address this need, we develop a forecasting method that assimilates observational data obtained from the CDC WONDER database with an age-structured model of addiction and overdose mortality. We apply our method nationwide and to three select areas: Los Angeles County, Cook County, and the five boroughs of New York City, providing forecasts of drug-overdose mortality and estimates of relevant epidemiological quantities, such as mortality and age-specific addiction rates.

Drug Overdose Mortality of Residents and Visitors to Cities

Background: The ongoing drug epidemic in the United States has shown that there are geographic differences in overdose fatalities. This article introduces a new way to study spatial differences in drug-related mortality, by distinguishing the fatalities of residents and visitors to a region. Methods: Using records of United States deaths from 2001 to 2020, this study examined fatal overdoses among residents and visitors to U.S. metropolitan areas. Results: The findings revealed that the drug fatality levels of residents and visitors differed from one another in many cities. These differences were most pronounced in larger metro areas, where the drug mortality of visitors was disproportionately high. Conclusions: Discussion focuses on implications and possible explanations for these findings, as well as their potential connection to classical conditioning of drug tolerance. More generally, comparing the fatalities of residents and visitors may provide a way to tease apart the roles of person-specific and location-specific contributors to overdose risk.

Broadband internet subscription rates and opioid prescribing via telemedicine during the COVID-19 pandemic

PURPOSE

In response to the COVID-19 pandemic, the US DEA allowed controlled substance prescriptions to be issued following a telemedicine encounter. This study evaluated changes in opioid prescribing in Kentucky counties with low and high rates of broadband subscription before, during, and after a series of statewide emergency declarations that may have affected health care access.

METHODS

The study used the prescription drug monitoring program to analyze records of opioid analgesic prescriptions dispensed to opioid-naïve individuals in high (N = 26) and low (N = 94) broadband access counties during 3 periods: before a state of emergency (SOE) and executive order (EO) limiting nonemergent health care services (January 2019-February 2020), while the EO was active (March-April 2020), and after health care services began reopening (May-December 2020). Marginal generalized estimating equations-type negative binomial models were fit to compare prescription counts by broadband access over the 3 periods.

FINDINGS

Rates of opioid dispensing to opioid-naïve individuals decreased significantly during the EO, but increased nearly to pre-SOE levels after health care services began reopening. Dispensing rates in low broadband counties were higher than those in high broadband counties during all time periods, although these differences were negligible after adjusting for potential confounders. During the EO, prescriptions were written for longer days' supply in both county types.

CONCLUSIONS

The overall dramatic reduction in opioid prescribing rates should be considered when evaluating annual opioid prescribing trends. However, broadband subscription rate did not appear to influence opioid prescriptions dispensed in Kentucky during the EO.

Substance Use Disorder Treatment Providers' Knowledge and Opinions Toward Testing and Treatment of Chronic Hepatitis C in Rural North Carolina

Poor access to care has made western North Carolina vulnerable to an outbreak of hepatitis C viral infection (HCV), particularly among persons who inject drugs (PWID). As substance use disorder (SUD) treatment providers could potentially improve linkage to HCV testing and treatment, we sought to understand SUD providers, clinic and client characteristics; referral patterns; HCV knowledge; willingness to participate in additional trainings; and local linkage-to-care pathways for treatment of substance use and HCV. Online survey data were collected from 78 SUD providers serving PWID in eight western rural North Carolina counties. Providers' attitudes toward working with HCV+ clients were very positive. One-third of providers reported a low fund of knowledge regarding HCV, HCV treatment, and financial assistance opportunities. Non-prescribing providers rarely initiated discussions about HCV testing/treatment, but were receptive to training. Respondents indicated that HCV testing and treatment were best delivered at local health departments or primary care clinics but were open to other venues where PWID access care. The vast majority of prescribing and non-prescribing providers expressed interest in obtaining training in HCV treatments, how to obtain HCV medications and topics on advanced liver disease. Data from prescribing and non-prescribing SUD providers suggest opportunities to develop or expand integrated care models for HCV testing/treatment in PWID in rural Appalachian North Carolina.

Pharmacist attitudes and provision of harm reduction services in North Carolina: an exploratory study

BACKGROUND

Pharmacists are among the most accessible healthcare providers in the United States and uniquely positioned to provide harm reduction services. The availability of pharmacy-based harm reduction services and pharmacist attitudes toward delivering these services have been understudied to date. We examine North Carolina (NC) pharmacists' experiences with and attitudes about harm reduction services and explore differences between rural and urban pharmacists.

METHODS

A convenience sample of NC pharmacists participated in an anonymous, online survey regarding harm reduction services: non-prescription syringe sales; naloxone dispensing; and human immunodeficiency virus (HIV) and hepatitis C virus (HCV) screening. Urban-rural differences were analyzed using Pearson's chi-square or Fisher's exact tests. Open-ended responses were analyzed thematically.

RESULTS

Three hundred pharmacists responded to the survey; 68 (23%) practiced in rural counties. Dispensing non-prescription syringes and naloxone at least occasionally was reported by 77% (n = 231) and 88% (n = 263) pharmacists, respectively. Pharmacy-delivered HIV or HCV screening was rare. Urban pharmacists dispensed naloxone more frequently than rural pharmacies (p = 0.04). Only 52% of pharmacists agreed that persons who inject drugs should always be allowed to buy non-prescription syringes. Rural pharmacists' attitudes toward harm reduction services for persons who inject drugs were statistically, though marginally, less supportive when compared to urban pharmacists' attitudes. The most common barrier to non-prescription syringe access was requiring patients to provide proof of prescription injection medication use, which 21% of pharmacists reported was required by their pharmacy's policy on non-prescription syringe sales.

CONCLUSIONS

Although most pharmacies distributed naloxone and sold non-prescription syringes, pharmacy store policies and personal beliefs inhibited naloxone and non-prescription syringe dispensing. NC community pharmacies infrequently offer HIV and HCV screening. Paired with disseminating the evidence of the positive impact of harm reduction on individual and public health outcomes to NC pharmacists, institutional and systems changes to practice and policy may be important to promote harm reduction service availability, particularly for rural NC residents.

TRIAL REGISTRATION

N/A.

A systematic review of rural-specific barriers to medication treatment for opioid use disorder in the United States

BACKGROUND

Opioid-related deaths have risen dramatically in rural communities. Prior studies highlight few medication treatment providers for opioid use disorder in rural communities, though literature has yet to examine rural-specific treatment barriers.

OBJECTIVES

We conducted a systematic review to highlight the state of knowledge around rural medication treatment for opioid use disorder, identify consumer- and provider-focused treatment barriers, and discuss rural-specific implications.

METHODS

We systematically reviewed the literature using PsycINFO, Web of Science, and PubMed databases (January 2018). Articles meeting inclusion criteria involved rural samples or urban/rural comparisons targeting outpatient medication treatment for opioid use disorder, and were conducted in the U.S. to minimize healthcare differences. Our analysis categorized consumer- and/or provider-focused barriers, and coded barriers as related to treatment availability, accessibility, and/or acceptability.

RESULTS

Eighteen articles met inclusion, 15 which addressed consumer-focused barriers, while seven articles reported provider-focused barriers. Availability barriers were most commonly reported across consumer (n = 10) and provider (n = 5) studies, and included the lack of clinics/providers, backup, and resources. Acceptability barriers, described in three consumer and five provider studies, identified negative provider attitudes about addiction treatment, and providers' perceptions of treatment as unsatisfactory for rural patients. Finally, accessibility barriers related to travel and cost were detailed in four consumer-focused studies whereas two provider-focused studies identified time constraints.

CONCLUSIONS

Our findings consistently identified a lack of medication providers and rural-specific implementation challenges. This review highlights a lack of rural-focused studies involving consumer participants, treatment outcomes, or barriers impacting underserved populations. There is a need for innovative treatment delivery for opioid use disorder in rural communities and interventions targeting provider attitudes.