Examining Rural/Urban Differences in Prescription Opioid Misuse Among US Adolescents

Telehealth-guided provider-to-provider communication to improve rural health: A systematic review

INTRODUCTION

Telehealth may address healthcare disparities for rural populations. This systematic review assesses the use, effectiveness, and implementation of telehealth-supported provider-to-provider collaboration to improve rural healthcare.

METHODS

We searched Ovid MEDLINE®, CINAHL®, EMBASE, and Cochrane CENTRAL from 1 January 2010 to 12 October 2021 for trials and observational studies of rural provider-to-provider telehealth. Abstracts and full text were dual-reviewed. We assessed the risk of bias for individual studies and strength of evidence for studies with similar outcomes.

RESULTS

Seven studies of rural uptake of provider-to-provider telehealth documented increases over time but variability across geographic regions. In 97 effectiveness studies, outcomes were similar with rural provider-to-provider telehealth versus without for inpatient consultations, neonatal care, outpatient depression and diabetes, and emergency care. Better or similar results were reported for changes in rural clinician behavior, knowledge, confidence, and self-efficacy. Evidence was insufficient for other clinical uses and outcomes. Sixty-seven (67) evaluation and qualitative studies identified barriers and facilitators to implementing rural provider-to-provider telehealth. Success was linked to well-functioning technology, sufficient resources, and adequate payment. Barriers included lack of understanding of rural context and resources. Methodologic weaknesses of studies included less rigorous study designs and small samples.

DISCUSSION

Rural provider-to-provider telehealth produces similar or better results versus care without telehealth. Barriers to rural provider-to-provider telehealth implementation are common to practice change but include some specific to rural adaptation and adoption. Evidence gaps are partially due to studies that do not address differences in the groups compared or do not include sufficient sample sizes.

Leveraging Parents and Peer Recovery Supports to Increase Recovery Capital in Emerging Adults With Polysubstance Use: Protocol for a Feasibility, Acceptability, and Appropriateness Study of Launch

BACKGROUND

Emerging adults (aged 18-26 years) are the most at-risk yet underserved age group among people with substance use disorder, especially rural emerging adults, and polysubstance use is common. Recovery capital is lower among emerging adults than older adults, and evidence-based treatments are typically unavailable or not developmentally tailored, especially in rural areas. Both supportive parents (or parental figures) and peer recovery support services (PRSS) can be leveraged to better support these emerging adults. Previous research indicates parents can be engaged to deliver contingency management (CM), an extensively researched evidence-based intervention for substance use.

OBJECTIVE

This protocol describes a funded pilot of Launch, a novel, scalable service package that pairs web-based coaching for parents to deliver CM for emerging adults (CM-EA) at home and in-person PRSS with educational and vocational goal setting. Specifically, this protocol describes feasibility, acceptability, and appropriateness testing (implementation-related outcomes) and steps taken to prepare for a future large-scale trial of Launch.

METHODS

Upon the recruitment of 48 emerging adult and parent pairs from sites serving primarily rural clients, participants will be randomized into 1 of 3 conditions for this randomized controlled trial: virtual parent coaching to deliver CM-EA, in-person PRSS for emerging adults, or both sets of services. Emerging adult eligibility includes polysubstance use, a substance use disorder, and availability of a consenting parent. Emerging adults will be interviewed at baseline and 6 months about substance use, quality of life, recovery capital, parental relationship, and Launch implementation-related outcomes (6-month follow-up only). Parents, peer workers delivering PRSS, and parent CM-EA coaches will be interviewed about implementation-related outcomes at the end of the study period. Peer workers and CM-EA coaches will be asked to complete checklists of services delivered after each session. Finally, payers and providers will be interviewed for additional insights into Launch implementation and to identify key outcomes of Launch. Data analysis for emerging adult outcomes will be primarily descriptive, but parent CM-EA training adherence will be assessed using nested mixed-effects regression models of repeated measures.

RESULTS

Launch is currently ongoing, with funding received in August 2023, and is expected to end in September 2025, with data analysis and results in December 2026. Participants are expected to begin enrolling in June 2024.

CONCLUSIONS

While this pilot is limited by the small sample size and restriction to emerging adults with an involved parent, this is mitigated by the study's strengths and is appropriate for the pilot stage. Launch uses an innovative combination of existing strategies to generate better outcomes for emerging adults while remaining scalable. This pilot will provide insights into the feasibility and acceptability of Launch from the perspectives of service recipients, providers, and payers to inform a larger-scale effectiveness trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06414993; https://clinicaltrials.gov/study/NCT06414993.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/60671.

Opioid use, prescribing and fatal overdose patterns among racial/ethnic minorities in the United States: A scoping review and conceptual risk environment model

ISSUES

To date, there has been no synthesis of research addressing the scale and nuances of the opioid epidemic in racial/ethnic minority populations in the United States that considers the independent and joint impacts of dynamics such as structural disadvantage, provider bias, health literacy, cultural norms and various other risk factors.

APPROACH

Using the "risk environment" framework, we conducted a scoping review on PubMed, Embase and Google Scholar of peer-reviewed literature and governmental reports published between January 2000 and February 2024 on the nature and scale of opioid use, opioid prescribing patterns, and fatal overdoses among racial/ethnic minorities in the United States, while also examining macro, meso and individual-level risk factors.

KEY FINDINGS

Results from this review illuminate a growing, but fragmented, literature lacking standardisation in racial/ethnic classification and case reporting, specifically in regards to Indigenous and Asian subpopulations. This literature broadly illustrates racial/ethnic minorities' increasing nonmedical use of opioids, heightened burdens of fatal overdoses, specifically in relation to polydrug use and synthetic opioids, with notable elevations among Black/Latino subgroups, in addition uneven opioid prescribing patterns. Moreover, the literature implicates a variety of unique risk environments corresponding to dynamics such as residential segregation, provider bias, overpolicing, acculturative stress, patient distrust, and limited access to mental health care services and drug treatment resources, including medications for opioid use disorder.

IMPLICATIONS

There has been a lack of rigorous, targeted study on racial/ethnic minorities who use opioids, but evidence highlights burgeoning increases in usage, especially polydrug/synthetic opioid use, and disparities in prescriptions and fatal overdose risk-phenomena tied to multi-level forms of entrenched disenfranchisement.

CONCLUSION

There is a need for further research on the complex, overlapping risk environments of racial/ethnic minorities who use opioids, including deeper inclusion of Indigenous and Asian individuals, and efforts to generate greater methodological synergies in population classification and reporting guidelines.

Perception of opioids among medical students: unveiling the complexities and implications

CONTEXT

From 2000 to 2019, drug overdoses, combined intentional and unintentional, were the number one cause of death for Americans under 50 years old,with the number of overdoses increasing every year. Between 2012 and 2018, approximately 85 % of all opioid users obtained their opioids through prescriptions from healthcare providers, predominantly physicians. Increased education about the severity of this issue may increase the likelihood of physicians integrating alternative forms of care such as cognitive behavioral approaches, nonopioid therapies, and nonpharmacologic therapies into treatment plans for chronic pain.

OBJECTIVES

This study investigates medical students' beliefs, experiences, and perceived impact of opioids at Ohio University Heritage College of Osteopathic Medicine (OU-HCOM) and University of Toledo College of Medicine and Life Sciences (UT).

METHODS

A total of 377 students from OU-HCOM (years 1-4, n=312) and UT (years 1-2, n=65) were surveyed on their beliefs, experiences, and perceived impact of opioids. Multiple t tests were conducted to compare the difference in perceived severity and stigma between participants who were impacted by the epidemic and those who were not. A Kendall rank test was performed to analyze the relationship between the county drug overdose rate and perceived severity for medical students. p <0.05 defined statistical significance for all statistical tests performed in this study.

RESULTS

In comparing medical students' personal experiences with the opioid crisis, it was found that many more participants had experiences with an affected classmate or patient (4.1; 95 % CI, 4.0-4.2), as opposed to direct experiences within their family or group of friends (1.9; 95 % CI, 1.8-2.0). However, this group of participants who directly experienced the opioid crisis were found to be more likely to view the crisis as more severe in Ohio's adult population than those without that direct experience (p=0.03, α=0.05). The difference in experience and severity outlook did not make one group of medical students more likely to hold a stigma toward those struggling with opioid addiction (p=0.3, α=0.05). The study did not find a significant relationship between the county drug overdose rate and the perceived severity among medical students (R=0.05, p=0.6, α=0.05).

CONCLUSIONS

This study gave an insight into the beliefs, experiences, and perceived impact of opioids within a group of 377 medical students. It was shown that differences in background can lead to differences in perception of the crisis. Knowing these differences can lead to beneficial changes in education and curriculum design in medical education.

Substance use among rural adolescents with incarcerated parents: Evidence from a state-wide sample

PURPOSE

Incarceration rates are highest in rural communities, disproportionately exposing rural children to parental incarceration (PI). Substance use is a pressing public health issue-and a key driver of incarceration-in rural areas, yet limited research has examined PI as a social determinant of health for adolescent alcohol and drug use. This study links exposure to PI with rural adolescent substance use and examines the role of coresidence with parents in these associations.

METHODS

Data come from the 2019 Minnesota Student Survey, including 18,820 rural adolescents. Respondents self-reported experiences of PI (current, former, never), whether they lived with the parent at the time of incarceration, and past-year alcohol, marijuana, cocaine, heroin, and methamphetamine use.

FINDINGS

Over 22% of rural adolescents experienced PI. In adjusted logistic regression models, current PI was associated with greater past-year alcohol (aOR = 2.20), marijuana (aOR = 4.08), cocaine (aOR = 3.61), heroin (aOR = 4.96), and methamphetamine (aOR = 5.43) use compared to peers who never experienced PI. Current PI was also associated with greater counts of use. Associations between coresidence and substance use were largely nonsignificant.

CONCLUSIONS

The elevated risk for substance use in the context of rural PI and its adverse sequelae call for expanded prevention and intervention strategies that support adolescent health alongside targeted decarceration efforts in rural communities that reduce the number of families put in the potentially compromising situation of PI.

Adolescent Substance Use Disorder in Primary Care: Challenges in Treatment Referral Beyond Access Availability

OBJECTIVE

Fatal overdoses are the third leading cause of death in the pediatric population. Substance use disorders (SUD) screening is not routinely done in primary care practices. Early screening and intervention for adolescent SUD could mitigate future harm.

METHODS

We conducted a 3-month pilot adapting universal screening using the CRAFFT tool in patients aged 12 to 17 presenting to an urban and a rural primary care practice during well-child and acute/sick-child visits. We collaborated with our pediatric addiction service to ensure access availability for further assessment and treatment for all positively screened patients; this was broadly communicated to primary care providers.

RESULTS

There was a higher CRAFFT completion rate in the urban site (90%, vs 52.6% in our rural site). The majority of CRAFFT questionnaires were completed during acute/sick-child visits in both study sites. Moreover, we found a higher positive screen rate in our rural practice (14.6%, vs 2.4% in our urban practice). Only 27% of positively screened patients had substance use addressed by their providers. No pediatric addiction referrals were made.

CONCLUSIONS

Findings suggest provider-level barriers exist despite having adequate specialty referral sources and institutional encouragement. Future work is needed to explore these barriers.

Use of Primary Care and Emergency Departments for Substance Use Treatment: The Rural and Urban Divide

Background: Alcohol and illicit substance use remain significant public health issues in the United States. In this analysis, we assessed differences in the use of primary care and emergency departments (EDs) for treatment of substance use among rural and urban sexual minorities (SMs).Methods: Data come from the National Survey on Drug Use and Health (NSDUH, 2015-2019). Survey-weighted multivariable linear and logistic regression analyses were used to assess the relationship between sexual identity and the use of primary care settings or EDs for treatment of substance use, stratified by urbanicity of residence.Results: Among the entire sample, 7.9% reported residing in rural environments with slightly more SMs living in urban (7.3%) relative to rural (5.4%) locales. Both rural (β=-0.20; 95% CI: -0.29, -0.10) and urban SMs (β=-0.13; 95% CI: -0.16, -0.11) self-reported worse overall health. Urban SMs, but not rural SMs, had significantly higher odds of reporting use of primary care treatment for substance use (aOR 2.80; 95% CI: 2.13, 3.68). ED treatment for substance use was greater among both rural (aOR = 2.99; 95% CI: 1.01, 8.87) and urban SMs (aOR = 3.02; 95% CI: 2.12, 4.30) as was overall number of ED visits among both rural (β = 0.48; 95% CI: 0.24, 0.72) and urban SMs (β = 0.23; 95% CI: 0.19, 0.28) .Conclusion: These findings suggest increased reliance on EDs for treatment of alcohol or substance use among rural SMs. Future research should examine whether increasing culturally competent primary care services for SMs in rural areas may be a key intervention point for reducing health disparities.

Opioid Use Disorder Community Education Events: Rural Public Health Implications

The opioid overdose epidemic continues to disproportionately impact underserved rural areas throughout the nation, with many of these rural areas experiencing greater opioid-related mortality rates than their urban counterparts. With limited treatment infrastructure and resources, two rural communities in Southeast Utah utilized community-based participatory research collaboration principles to develop, implement, and evaluate a series of evidence-based community opioid education events. This practical and quantitative study surveying 123 participants describes the collaborative efforts of two rural communities in addressing the devastating impacts of the opioid overdose epidemic and reflects on the success of the events via descriptive analysis of summary data. These events increased participants' reported perceptions of and knowledge in four main education areas: stigma reduction, prevention and treatment awareness, naloxone education and use, and resource location awareness. Post-event surveys further supported these results, revealing improved learning in each of these four areas, indicating increased knowledge toward opioid use disorder treatments and stigma reduction. In addition, participants identified key takeaways such as local resource awareness and dismantling stigma as effective strategies to reduce the negative effects of the opioid overdose epidemic. This model for rural community education supports previous research and serves as an effective strategy of public health practice to address the opioid overdose epidemic on a local level.

Associations between Family Factors and Youth Substance Use Across the Rural-Urban Continuum: A Person-/Variable-Centered Approach

Few studies have evaluated the influence of both family factors and geographic location on youth substance use. To address this gap, a person-/variable-centered approach was used to: (1) identify latent profiles of family risk and protective factors for substance use, (2) test profile membership as a predictor of lifetime and 30-day substance use, (3) test rurality, as measured by school geographic location, as a predictor, and (4) explore interaction effects between profile membership and rurality. Youth (N=9,104; 53% female) residing in a state in the southeastern U.S. completed a statewide substance abuse and risk behavior survey including questions about family risk and protective factors and substance use behaviors. Using latent profile analysis to identify subgroups of participants with similar means and variances on the family factors, four latent profiles emerged. Risk of 30-day and lifetime substance use varied across profiles, with the profile characterized by high family-level protective factors and low family-level risk factors indicating the lowest risk for substance use. Urban youth had increased odds of reporting lifetime marijuana use compared to suburban youth; however, geographic location did not appear to confer significantly increased or decreased risk across other substances. No significant interaction results were found. These results emphasize the importance of family functioning on substance use regardless of geographic location, and that evidence-based prevention programming that reduces family risk, strengthens family protection, and is accessible to all types of communities is important to reducing or delaying substance use among youth.

Multidisciplinary Strategies for Preventing Opioid Misuse and Escalation by Targeting Mental Health Symptoms and Conditions

We aim to review the association between childhood-onset mental health conditions and increased risk for early substance use including opioid misuse and opioid use disorders (OUD). The association between mental health conditions and opioid misuse suggests youth with mental health conditions may benefit from opioid prevention efforts that concurrently address mental health. To aid in the identification of youth with mental health conditions who could benefit from interventions, we will review opportunities and challenges associated with screening for mental health symptoms or substance use in settings where youth at high risk for mental health conditions present. We will also review how research projects within the National Institutes of Health's Helping to End Addiction Long-term (HEAL) Prevention Cooperative are addressing mental health within opioid misuse and OUD prevention interventions for youth.

Pain management: A deeper look at rural and urban nurses' perceptions and experiences

PURPOSE

About 11.4 million individuals admitted to misusing an opioid in the past year. The purpose of this study was to determine if nurses' definitions of pain management differed by location, and to assess the challenges treating patients with pain management concerns. This study fills a gap by comparing quantitative and qualitative feedback from nurses on pain management concerns in their practice location.

METHODS

Data were collected using an electronic survey emailed to licensed nurses across the United States. The mixed methods survey used multiple choice, select all that apply, and open-ended responses to gather data on nurses' perceptions of pain management. One hundred and eighty nurses completed the survey and were included in the study. Sixty-six percent practiced in an urban hospital.

FINDINGS

Rural and urban nurses defined pain management as nonopioids and opioids. Seventy-one percent of urban nurses defined pain management as physical therapy compared to only 61% of rural nurses. Similarly, 62% of urban nurses identified homeopathic medicines and treatments as pain management techniques compared to 52% of rural nurses. From the qualitative data, 32% of rural nurses stated that patients with pain management concerns only want pain medications compared to 14% of urban nurses.

CONCLUSIONS

Nurses have a critical position in and valuable perspective on the opioid epidemic. Rural communities are relatively disadvantaged in combatting the opioid epidemic. The finding that rural residents only want pain medication instead of alternative pain management options further challenges the country's rural health care workforce.

Eating disorder risk in rural US adolescents: What do we know and where do we go?

Adolescence is a vulnerable period for the development of eating disorders, but there are disparities in eating disorder risk among adolescents. One population that may be at increased risk but is vastly understudied, is adolescents residing in rural regions within the United States. Rural communities face many mental and physical health disparities; however, the literature on rural adolescent eating disorder risk is nearly nonexistent. In this paper we summarize the scant literature on disordered eating and eating disorder risk and prevalence among rural US adolescents. We also detail eating disorder risk factors that may have unique influence in this population, including socioeconomic status, food insecurity, healthcare access, body image, and weight stigma. Given the presence of numerous eating disorder risk factors, we speculate that rural adolescents may be a particularly vulnerable population for eating disorders and we propose critical next steps in research for understanding eating disorder risk among the understudied population of rural adolescents. PUBLIC SIGNIFICANCE: Rural adolescents may be at increased risk for eating disorders due to disproportionate burden of known risk factors, though this relationship remains understudied. We present a summary of the literature on prevalence and unique risk factors, proposing that this may be a high-risk population. We detail next steps for research to understand eating disorder risk in this population to inform future prevention, identification, and treatment efforts needed in this community.

Implementation and Preliminary Effectiveness of a Multidisciplinary Telemedicine Pilot Initiative for Patients with Chronic Non-Cancer Pain in Rural and Underserved Areas at a Major Academic Medical Center

Background

Arkansas lacks adequate access to high-quality pain care, as evidenced, in part, by it having the second highest opioid prescribing rate in the United States. To improve access to high-quality treatment of chronic pain, we developed the Arkansas Improving Multidisciplinary Pain Care and Treatment (AR-IMPACT) Telemedicine Clinic, a multidisciplinary and interprofessional team of specialists who provide evidence-based pain management for patients with chronic pain.

Methods

We conducted a single-arm pilot trial of the AR-IMPACT Telemedicine Clinic with rural, university-affiliated primary care clinics. We assessed the AR-IMPACT Telemedicine Clinic using an implementation framework and preliminary effectiveness measures. Specifically, we assessed 5 of the 8 implementation outcomes of the framework (ie, penetration, adoption, acceptability, appropriateness, and feasibility) using a mixed methods approach. To evaluate implementation outcomes, we used surveys, interviews, and administrative data. We used electronic health record data to measure preliminary effectiveness (ie, changes in average morphine milligram equivalents per day and pain and depression scores).

Results

The AR-IMPACT team saw 23 patients that were referred by 13 primary care physicians from three rural, university-affiliated primary care clinics over one year. Of the 19 patients willing to participate in the pilot study, 12 identified as women, 31.6% identified as Black, and over 50% had less than a bachelor's level education. Patients rated the clinic positively with high overall satisfaction. Referring physicians indicated high levels of appropriateness, acceptability, and feasibility of the program. AR-IMPACT team members identified several barriers and facilitators to the feasibility of implementing the program. No changes in preliminary effectiveness measures were statistically significant.

Conclusion

Overall, the AR-IMPACT Telemedicine Clinic obtained moderate penetration and adoption, was highly acceptable to patients, was highly acceptable and appropriate to providers, and was moderately feasible to providers and AR-IMPACT team members.

Trends in Prescribing Opioids, Benzodiazepines, and Both Among Adults with Alcohol Use Disorder in New York State

BACKGROUND

Alcohol use disorder (AUD) is a highly prevalent public health problem that contributes to opioid- and benzodiazepine-related morbidity and mortality. Even though co-utilization of these substances is particularly harmful, data are sparse on opioid or benzodiazepine prescribing patterns among individuals with AUD.

OBJECTIVE

To estimate temporal trends and disparities in opioid, benzodiazepine, and opioid/benzodiazepine co-prescribing among individuals with AUD in New York State (NYS).

DESIGN/PARTICIPANTS

Serial cross-sectional study analyzing merged data from the NYS Office of Addiction Services and Supports (OASAS) and the NYS Department of Health Medicaid Data Warehouse. Subjects with a first admission to an OASAS treatment program from 2005-2018 and a primary AUD were included. A total of 148,328 subjects were identified.

MEASURES

Annual prescribing rates of opioids, benzodiazepines, or both between the pre- (2005-2012) and post- (2013-2018) Internet System for Tracking Over-Prescribing (I-STOP) periods. I-STOP is a prescription monitoring program implemented in NYS in August 2013. Analyses were stratified based on sociodemographic factors (age, sex, race/ethnicity, and location).

RESULTS

Opioid prescribing rates decreased between the pre- and post-I-STOP periods from 25.1% (95% CI, 24.9-25.3%) to 21.3% (95% CI, 21.2-21.4; P <.001), while benzodiazepine (pre: 9.96% [95% CI, 9.83-10.1%], post: 9.92% [95% CI, 9.83-10.0%]; P =.631) and opioid/benzodiazepine prescribing rates remained unchanged (pre: 3.01% vs. post: 3.05%; P =.403). After I-STOP implementation, there was a significant decreasing trend in opioid (change, -1.85% per year, P <.0001), benzodiazepine (-0.208% per year, P =.0184), and opioid/benzodiazepine prescribing (-0.267% per year, P <.0001). Opioid, benzodiazepine, and co-prescription rates were higher in females, White non-Hispanics, and rural regions.

CONCLUSIONS

Among those with AUD, opioid prescribing decreased following NYS I-STOP program implementation. While both benzodiazepine and opioid/benzodiazepine co-prescribing rates remained high, a decreasing trend was evident after program implementation. Continuing high rates of opioid and benzodiazepine prescribing necessitate the development of innovative approaches to improve the quality of care.

How the Identity of Substance Users Shapes Public Opinion on Opioid Policy

How do media portrayals of potential policy beneficiaries' identities sway public support for these policies in a public health setting? Using a pre-registered vignette experiment, we show that the racial identity of substance users depicted in news media shapes public opinion on policies to address the opioid crisis. People display biases in favor of their own racial identity group that manifest in their support for both treatment-based policies and punitive policies. We show that these biases may be moderated by the type of initial drug used by a substance user and associated levels of perceived blame. Extending theories of group politics, we also assess favoritism based on gender and residential context identities, but find no such biases. These results highlight the continued centrality of race in the formation of policy preferences.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11109-022-09845-8.

Applications of research evidence during processes to acquire approvals for syringe services program implementation in rural counties in Kentucky

INTRODUCTION

Despite decades of empirical research in the US and internationally documenting the benefits of implementing syringe services programs (SSPs), their implementation may be controversial in many jurisdictions. Better understanding how research evidence is applied during SSP implementation processes may enable the public health workforce to advocate for program scale up. This study explores applications of research evidence during processes to acquire approvals for SSP implementation in rural counties in Kentucky.

METHODS

In-depth interviews were conducted among eighteen stakeholders (e.g. health department directors, SSP operators) involved in SSP implementation in rural Kentucky counties. Stakeholders were asked to describe the contexts surrounding SSP implementation processes. Interviews were transcribed and analysed for applications of research evidence. Research evidence-related quotes were subsequently categorised based on the typologies for applications of research evidence developed by Weiss et al. (instrumental, conceptual, and symbolic) and a fourth category for instances when research evidence was not used.

RESULTS

Instrumental applications of research evidence occurred at the intrapersonal and interpersonal levels to dispel concerns about SSPs and formed the basis for implementation support. SSP proponents used research evidence in a conceptual manner to address underlying attitudes and beliefs that were not evidence-based. Participants reported symbolic research evidence applications to justify pre-existing attitudes and beliefs about meeting the public health needs of people who inject drugs. Lastly, in some instances, research evidence was met with scepticism and an unwillingness to consider its merits.

CONCLUSION

Applications of research evidence during SSP implementation approval processes in rural Kentucky counties were heterogeneous in nature. Better understanding the diversity of ways in which research evidence may be employed during SSP implementation processes may support efforts to improve the public health of people who inject drugs.Key messagesApplications of research evidence during SSP implementation approval processes in rural Kentucky counties were heterogeneous in nature.Instrumental applications of research evidence occurred at the intrapersonal and interpersonal levels to dispel concerns about SSPs and formed the basis for implementation support.SSP proponents used research evidence in a conceptual manner to address underlying attitudes and beliefs that were not evidence-based.

Prescription Opioid Resiliency and Vulnerability: A Mixed-Methods Comparative Case Study

Despite declines in prescription opioid overdoses, rural areas continue to have higher prescription opioid overdose rates than urban areas. We aim to understand high overdose places were resilient to the prescription opioid overdose crisis (better than predicted), while others were vulnerable (worse than predicted). First, we predicted prescription opioid overdose mortality in 2016-18 for N = 2,013 non-metropolitan counties using multivariable regression accounting. Second, we constructed a resiliency-vulnerability typology using observed, predicted, and residual values from the regression. Third, we selected a high-overdose resilient and vulnerable community for case study analysis using interviews, focus groups, and observations. High-overdose resilient and vulnerable places had disability-dispensing-overdose pathways, legacies of mining, and polysubstance drug abuse. Resilient places were larger population micropolitans with extensive health and social services, norms of redemption and acceptance of addiction, and community-wide mobilization of public and non-profit resources. Vulnerable places were smaller, more remote, lacked services, and stigmatized addiction.

Mortality during Resource Booms and Busts

Using national data on county-level mortality, coal mining, and shale development, we examine the effects of resource booms and busts on mortality in the United States. We find evidence that decreases in operating coal mines increased total all-cause mortality, non-drug mortality, and opioid overdose mortality, especially for counties with greater than 10 operating coal mines in 2000. Our model results for drug overdose mortality and opioid overdose mortality are sensitive to the panel's start year. For shale development, the shale boom is associated with increases in non-drug suicides but otherwise had little impact on mortality. Our findings suggest a potential role for job-training programs and the cultivation of local healthcare resources in regions suffering coal busts and suicide prevention in areas with shale development.

Rural depopulation and the rural-urban gap in cognitive functioning among older adults

PURPOSE

As the population ages, the number of people with cognitive impairment will rapidly increase. Although previous research has explored the rural-urban gap in physical health, few studies have analyzed cognitive health. The purpose of this study was to examine rural-urban differences in cognitive health, with a focus on the moderating effect of population decline.

METHODS

The study used individual-level nationally representative data from the 2000-2016 waves of the Health and Retirement Study (N = 152,444) merged to county-level contextual characteristics. Hierarchical linear models were used to predict the cognitive functioning of US adults aged 50 and over by rural-urban residence, county depopulation, and their interactions while controlling for individual-level and county-level demographic and contextual factors.

FINDINGS

Older adults living in rural counties had lower cognitive functioning than urban adults. The interaction between living in a rural and depopulated county was statistically significant (P < .001). The rural penalty in cognitive functioning was 40% larger for those who lived in counties that lost population between 1980 and 2010 compared to those who lived in stable or growing rural counties. These results were independent of race-ethnicity, gender, age, education, income, region, employment status, marital status, physical health, and depression as well as the county's racial-ethnic composition, age structure, economic and educational disadvantage, and health care shortages.

CONCLUSIONS

The results have important implications for those seeking to reduce health disparities both between rural and urban older adults and among different groups of rural people. Interventions targeting those living in rural depopulating areas are particularly warranted.

Misuse of Prescription Opioids and Suicidal Behaviors Among Black Adolescents: Findings from the 2017 and 2019 Youth Risk Behavior Survey

PURPOSE

Although some studies have examined the association between prescription opioid misuse and mental health outcomes, few have investigated the effects of prescription opioid misuse on suicidal behaviors among Black adolescents. The objective of this study was to investigate the cross-sectional association between prescription opioid misuse and suicidal ideation, suicide plan, and suicide attempt among Black adolescents.

METHODS

Data for this study came from the 2017 and 2019 Youth Risk Behavior Survey. An analytic sample of 4798 Black adolescents aged 14-18 years (51.2% female) was analyzed using binary logistic regression. The outcome variables investigated were suicidal ideation, suicide plan, and suicide attempt, and the main explanatory variable was prescription opioid misuse.

RESULTS

Of the 4798 Black adolescents, 15% reported ever misusing prescription opioids; 16.2% experienced suicidal ideation; 14% made a suicide plan; and 11.3% attempted suicide during the past 12 months. In the multivariate logistic regression models, Black adolescents who misused prescription opioids had 1.39 times higher odds of making a suicide plan and 1.65 times higher odds of making a suicide attempt during the past 12 months when compared to their counterparts who did not misuse prescription opioids. Other significant factors associated with suicidal behaviors include female sex, school bullying, cyberbullying, depressive symptoms, and illicit drug use. In addition, physical activity had a protective effect on suicide attempt.

CONCLUSION

The findings of the present study demonstrate the effects of prescription opioid misuse and its association with suicidal behaviors among Black adolescents.

Young adult opioid misuse indicates a general tendency toward substance use and is strongly predicted by general substance use risk

OBJECTIVE

To examine whether young adult opioid misuse reflects a general tendency toward substance use and is influenced by general substance use risk or whether it is a different phenomenon from other drug use.

METHODS

At ages 23 (2016) and 26 (2019), a panel of young adults (n = 3794 to 3833) in the United States self-reported their past-month substance use (opioid misuse, heavy drinking, cigarettes, cannabis) and substance-specific risk factors (perceptions of harm; approval of use; and use of each substance by friends and romantic partners). Structural equation models examined non-opioid and opioid-specific associations between latent risk and substance use factors.

RESULTS

Opioid misuse and opioid-specific risk factors shared significant variance with latent substance use and latent substance use risk, respectively, which were strongly associated. A statistically significant residual correlation between opioid-specific risk and opioid misuse remained.

CONCLUSION

Young adult opioid misuse reflects a general tendency toward substance use and is strongly predicted by risk for substance use. Opioid-specific risk factors play only a small independent role. Existing evidence-based substance use interventions may be effective in preventing opioid misuse among young adults.

Provider and Patient-panel Characteristics Associated With Initial Adoption and Sustained Prescribing of Medication for Opioid Use Disorder

OBJECTIVES

Limited information is available regarding provider- and patient panel-level factors associated with primary care provider (PCP) adoption/prescribing of medication for opioid use disorder (MOUD).

METHODS

We assessed a retrospective cohort from 2015 to 2018 within the Pennsylvania Medicaid Program. Participants included PCPs who were Medicaid providers, with no history of MOUD provision, and who treated ≥10 Medicaid enrollees annually. We assessed initial MOUD adoption, defined as an index buprenorphine/buprenorphine-naloxone or oral/extended release naltrexone fill and sustained prescribing, defined as ≥1 MOUD prescription(s) for 3 consecutive quarters from the PCP. Independent variables included provider- and patient panel-level characteristics.

RESULTS

We identified 113 rural and 782 urban PCPs who engaged in initial adoption and 36 rural and 288 urban PCPs who engaged in sustained prescribing. Rural/urban PCPs who issued increasingly larger numbers of antidepressant and antipsychotic medication prescriptions had greater odds of initial adoption and sustained prescribing (P < 0.05) compared to those that did not prescribe these medications. Further, each additional patient out of 100 with opioid use disorder diagnosed before MOUD adoption increased the adjusted odds for initial adoption 2% to 4% (95% confidence interval [CI] = 1.01-1.08) and sustained prescribing by 4% to 7% (95% CI = 1.01-1.08). New Medicaid providers in rural areas were 2.52 (95% CI = 1.04-6.11) and in urban areas were 2.66 (95% CI = 1.94, 3.64) more likely to engage in initial MOUD adoption compared to established PCPs.

CONCLUSIONS

MOUD prescribing adoption was concentrated among PCPs prescribing mental health medications, caring for those with OUD, and new Medicaid providers. These results should be leveraged to test/implement interventions targeting MOUD adoption among PCPs.

The effect of state policies on rates of high-risk prescribing of an initial opioid analgesic

BACKGROUND

Multiple state policies, such as prescription drug monitoring programs (PDMPs) and duration limits, have been implemented to decrease high-risk opioid prescribing. Studies demonstrate that many policies decrease certain opioid prescribing behaviors, but few examine their intended effects on the targeted high-risk prescribing practices, nor disentangle the effects of concurrent state or federal policies likely to influence those practices.

METHODS

Forty-one million initial prescriptions for new opioid episodes from 2007 to 2018 were identified using national pharmacy claims. We identified high-risk initial prescriptions, defined as >7 days' supply, average daily MME >90, or concurrent with benzodiazepines and estimated three multivariable logistic regression models to assess the association between policies and outcomes controlling for patient, prescriber, and county characteristics.

RESULTS

Initial prescriptions for >7 days declined from 23.8% in 2007 to 14.9% in 2018, associated with mandatory and interoperable PDMPs and prescription duration limits but not other policies examined. Initial prescriptions with daily MME > 90 declined from 13.2% to 1.9%, associated with pain management clinic laws but not consistently with other policies. Initial prescriptions concurrent with benzodiazepines declined only modestly from 6.9% to 6.5%, associated with pain management clinic laws but not other policies examined.

CONCLUSIONS

The opioid policy environment has changed rapidly with a range of different policies being implemented addressing high-risk prescribing. PDMP laws mandating prescriber use and pain clinic laws both appear efficacious but decrease different types of high-risk opioid prescribing. New policies should be considered in light of the prevalence of the problem being addressed.

Social isolation, residential stability, and opioid use disorder among older Medicare beneficiaries: Metropolitan and non-metropolitan county comparison

Research has shown that the prevalence of opioid use disorder (OUD) may rise substantially as society ages, but this issue receives the least attention in the literature. To address this gap, this study utilizes county-level data from multiple data sources (1) to investigate whether social isolation is associated with OUD prevalence among older Medicare beneficiaries, (2) to examine whether and how residential stability moderates the association between social isolation and OUD prevalence in US counties, and (3) to determine if there are any differences in these associations between metropolitan and non-metropolitan counties. The results show that social isolation is a significant factor for county-level OUD prevalence, regardless of metropolitan status. In addition, counties with high residential stability have low prevalence of OUD among older adults and this association is stronger in metropolitan than in non-metropolitan counties. Nonetheless, high levels of residential stability reinforce the positive relationship between social isolation and OUD prevalence. As a result, when developing policies and interventions aimed at reducing OUD among older adults, place of residence must be taken into account.

Trends in opioid misuse by cigarette smoking status among US adolescents: Results from National Survey on Drug Use and Health 2015-2018

Increasing rates of opioid-related emergency department visits and deaths among adolescents in the United States are a public health concern. Adolescent cigarette smoking may be a risk factor for opioid misuse; though, there is a paucity of research on adolescents' cigarette smoking and opioid misuse. This study investigates current trends and the association between cigarette smoking and opioid misuse among US adolescents. Using pooled youth samples (ages 12-17) from the National Survey on Drug Use and Health (NSDUH) 2015-2018 (N = 54,866), we calculated weighted estimates of past-year opioid misuse by cigarette smoking status across years. We further estimated a multivariable logistic regression model to examine the past-year opioid misuse by ever-cigarette-smoking, controlling for sociodemographics and other substance use. While there was a significant reduction in opioid misuse among the entire sample and among never-smokers over time (2.5% in 2015 to 1.9% in 2018), this trend was not significant among ever-smokers (14.2% in 2015 to 11.1% in 2018). Multivariable logistic regression showed ever-smokers (vs. never-smokers) had higher odds of past-year opioid misuse (aOR = 2.01; 95% CI = 1.66, 2.43). Findings suggest that comprehensive tobacco control policies and opioid misuse prevention programs are warranted to curb opioid misuse among adolescents.

Validation and threshold identification of a prescription drug monitoring program clinical opioid risk metric with the WHO alcohol, smoking, and substance involvement screening test

BACKGROUND

Prescription drug monitoring programs (PDMPs) are critical for pharmacists to identify risky opioid medication use. We performed an independent evaluation of the PDMP-based Narcotic Score (NS) metric.

METHODS

This study was a one-time, cross-sectional health assessment within 19 pharmacies from a national chain among adults picking-up opioid medications. The NS metric is a 3-digit composite indicator. The WHO Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) was the gold-standard to which the NS metric was compared. Machine learning determined optimal risk thresholds; Receiver Operating Characteristic curves and Spearman (P) and Kappa (K) coefficients analyzed concurrent validity. Regression analyses evaluated participant characteristics associated with misclassification.

RESULTS

The NS metric showed fair concurrent validity (area under the curve≥0.70; K=0.35; P = 0.37, p < 0.001). The ASSIST and NS metric categorized 37% of participants as low-risk (i.e., not needing screening/intervention) and 32.3% as moderate/high-risk (i.e., needing screening/intervention). Further, 17.2% were categorized as low ASSIST risk but moderate/high NS metric risk, termed false positives. These reported disability (OR=3.12), poor general health (OR=0.66), and/or greater pain severity/interference (OR=1.12/1.09; all p < 0.05; i.e., needing unmanaged-pain screening/intervention). A total of 13.4% were categorized as moderate/high ASSIST risk but low NS metric risk, termed false negatives. These reported greater overdose history (OR=1.24) and/or substance use (OR=1.81-12.66; all p < 0.05).

CONCLUSIONS

The NS metric could serve as a useful initial universal prescription opioid-risk screener given its: 1) low-burden (i.e., no direct assessment); 2) high accuracy (86.5%) of actionable data identifying low-risk patients and those needing opioid use/unmanaged pain screening/intervention; and 3) broad availability.

Health Risk Behaviors, Experiences, and Conditions Among Students Attending Private and Public High Schools

BACKGROUND

Approximately 8.8% of US high school students attended private schools in 2015. Few studies have characterized health risk behaviors among these students or compared prevalence of behaviors between students in private and public schools using a contemporary, nationally representative sample.

METHODS

Pooled 2007-2017 national Youth Risk Behavior Survey data were used to estimate the prevalence of 35 health risk behaviors for 89,848 public and private high school students. Unadjusted prevalence ratios were used to compare prevalence by school type. Differences in behaviors by school type were explored by sex and grade.

RESULTS

Among private school students, the prevalence ranged from 5.0% to 31.9% for sexual risk behaviors; from 0.8% to 30.1% for substance use behaviors; from 0.7% to 21.8% for behaviors related mental health and suicide; from 3.2% to 6.8% for violence victimization experiences; and from 3.1% to 52.9% for behaviors related to unhealthy diet and physical inactivity. Private school students were less likely than public school students to report most behaviors; differences by school type were generally consistent across sex and grade.

CONCLUSIONS

Students in both public and private schools reported health risk behaviors. Findings might inform prevention activities by identifying behaviors to prioritize in each school setting.

Examining Opioid Overdose Deaths across Communities Defined by Racial Composition: a Multiscale Geographically Weighted Regression Approach

To provide data that can guide community-targeted practices, policies, and interventions in urban metropolitan areas, we used geospatial analysis to examine the community-level opioid overdose death determinants and their spatial variation across a study area. We obtained spatial datasets containing multiple, high-quality measures of socioeconomic conditions, public health status, and demographics for analysis and visualization in geographic information systems. We employed a multiscale modeling approach (multiscale geographically weighted regression; MGWR) to provide a comprehensive and robust analysis of opioid overdose death determinants, explain how geospatial patterns vary across scales across Milwaukee County in 2019, and examine the differential influence of factors locally, regionally, and globally. We subsequently examined how associations varied with the racial/ethnic composition of communities by dividing Milwaukee County into White-majority, Black-majority, and Hispanic-majority regions according to census data and conducting separate, independent modeling processes. Overall, the multiscale model explained 83% of opioid overdose death variability across neighborhoods in Milwaukee County using 12 selected variables. Statistical analysis and geovisualization of patterns, trends, and clusters using MGWR unveiled dramatic racialized health disparities in Milwaukee, showing how factors that influenced opioid overdose deaths varied across diverse communities in Milwaukee. The observed geographic variation in relationships included the impact of naloxone availability and incarceration rates on overdose deaths with pronounced differences between White communities and communities of color. Understanding, community-level factors that contribute to overdose risk should guide targeted community-level solutions. Overall, our findings demonstrate the value of precision epidemiology using MGWR analysis for defining and guiding responses to public health challenges.

Social-Ecological Predictors of Opioid Use Among Adolescents With Histories of Substance Use Disorders

Adolescent opioid misuse is a public health crisis, particularly among clinical populations of youth with substance misuse histories. Given the negative and often lethal consequences associated with opioid misuse among adolescents, it is essential to identify the risk and protective factors underlying early opioid misuse to inform targeted prevention efforts. Understanding the role of parental risk and protective factors is particularly paramount during the developmental stage of adolescence. Using a social-ecological framework, this study explored the associations between individual, peer, family, community, and school-level risk and protective factors and opioid use among adolescents with histories of substance use disorders (SUDs). Further, we explored the potential moderating role of poor parental monitoring in the associations between the aforementioned risk and protective factors and adolescent opioid use. Participants included 294 adolescents (M _age = 16 years; 45% female) who were recently discharged from substance use treatment, and their parents (n = 323). Results indicated that lifetime opioid use was significantly more likely among adolescents endorsing antisocial traits and those whose parents reported histories of substance abuse. Additionally, adolescents reporting more perceived availability of substances were significantly more likely to report lifetime opioid use compared to those reporting lower perceived availability of substances. Results did not indicate any significant moderation effects of parental monitoring on any associations between risk factors and lifetime opioid use. Findings generally did not support social-ecological indicators of opioid use in this high-risk population of adolescents, signaling that the social-ecological variables tested may not be salient risk factors among adolescents with SUD histories. We discuss these findings in terms of continuing care options for adolescents with SUD histories that target adolescents' antisocial traits, perceived availability of substances, and parent histories of substance abuse, including practical implications for working with families of adolescents with SUD histories.

Hepatitis C virus infection and polysubstance use among young adult people who inject drugs in a rural county of New Mexico

AIMS

We assessed prevalence and correlates for hepatitis C virus (HCV) infection in young adult people who inject drugs (PWID) in rural New Mexico, where opioid use has been historically problematic.

METHODS

Participants were 18-29 years old with self-reported injection drug use in the past 90 days. We conducted testing for HCV antibodies (anti-HCV) and HCV ribonucleic acid (RNA) and assessed sociodemographic and risk exposures. We provided counseling and referrals to prevention services and drug treatment. We estimated prevalence ratios (PR) to assess bivariate associations with HCV infection; and adjusted PRs using modified Poisson regression methods.

RESULTS

Among 256 participants tested for anti-HCV, 156 (60.9 %) had been exposed (anti-HCV positive), and of 230 tested for both anti-HCV and HCV RNA, 103 (44.8 %) had current infection (RNA-positive). The majority (87.6 %) of participants were Hispanic. Almost all (96.1 %) had ever injected heroin; 52.4 % and 52.0 % had ever injected methamphetamine or cocaine, respectively. Polysubstance injecting (heroin and any other drug) was associated with significantly higher prevalence of HCV infection (76.0 %) compared to injecting only heroin (24.0 %) (PR: 3.17 (95 % CI:1.93, 5.23)). Years of injecting, history of non-fatal opioid-involved overdose, polysubstance injecting, and stable housing were independently associated with HCV infection.

CONCLUSIONS

HCV is highly prevalent among young adult PWID in rural NM. The high reported prevalence of polysubstance injecting and its association with HCV infection should be considered in prevention planning.

Income inequality and opioid prescribing rates: Exploring rural/urban differences in pathways via residential stability and social isolation

While opioid prescribing rates have drawn researchers' attention, little is known about the mechanisms through which income inequality affects opioid prescribing rates and even less focuses on whether there is a rural/urban difference in mediating pathways. Applying mediation analysis techniques to a unique ZIP code level dataset from several sources maintained by the Centers for Medicare and Medicaid Services, we explicitly examine two mechanisms through residential stability and social isolation by rural/urban status and find that (1) income inequality is not directly related to opioid prescribing rates, but it exerts its influence on opioid prescribing via poor residential stability and elevated social isolation; (2) social isolation accounts for two-thirds of the mediating effect of income inequality on opioid prescribing rates among urban ZIP codes, but the proportion halves among rural ZIP codes; (3) residential stability plays a larger role in understanding how income inequality matters in rural than in urban ZIP codes; and (4) beneficiary characteristics only matter in urban ZIP codes. These findings offer nuanced insight into how income inequality affects opioid prescribing rates and suggests that the determinants of opioid prescribing rates vary by rural/urban status. Future research may benefit from identifying place-specific factors for opioid prescribing rates.

Evaluating the Effectiveness of a Web-Based Program (POP4Teens) to Prevent Prescription Opioid Misuse Among Adolescents: Randomized Controlled Trial

Background

Prescription opioid (PO) use is common among adolescents in the United States. Despite recent declines from unprecedented peaks in adolescent PO use (eg, in 2012-2013), there is seemingly paradoxical evidence that PO-related consequences (eg, opioid use disorder and overdoses) are increasing. These trends and their possible consequences emphasize the importance of prevention efforts targeting PO misuse. To our knowledge, we have developed the first interactive web-based program (POP4Teens [P4T]) focused specifically on the prevention of PO misuse among adolescents.

Objective

This study aimed to evaluate the effectiveness of P4T, a web-based program designed to prevent adolescent PO misuse, in comparison with JustThinkTwice (JTT), an active control website, on PO-related attitudes, knowledge, risk perception, and intentions to use.

Methods

We conducted a web-based randomized controlled trial in 2018. A total of 406 adolescents (aged 12-17 years) were randomly assigned to either P4T or JTT. The outcome variables were attitudes, knowledge, and risk perceptions associated with PO misuse, intentions to use POs, and program feedback. Data were collected at baseline and at 1, 3, and 6 months.

Results

Both programs resulted in significant and sustained improvements in intention to use POs, increased perceived risk, impacted expectancies consistent with prevention, and improved PO refusal skills. P4T produced significantly greater increases in PO-related knowledge than JTT did, and it was reportedly easier to use and more liked. Baseline scores for youth reporting past-year medical use of POs, friends who engage in nonmedical use of POs, and/or poor mental health underscored their at-risk status compared with youth from the other groups.

Conclusions

P4T positively impacted all study variables that are known to prevent PO misuse among teens. Moreover, its web-based nature simplifies the dissemination and implementation of this novel tool designed to help meet the challenges of the evolving national opioid crisis.

Trial Registration

ClinicalTrials.gov NCT02737696; https://clinicaltrials.gov/ct2/show/NCT02737696

Factors Associated with Sterile Syringe Acquisition among People Who Inject Drugs in West Virginia

BACKGROUND

Syringe services programs (SSPs) are evidence-based interventions that provide essential overdose and infectious disease prevention resources to people who inject drugs (PWID). Little research has examined factors associated with sterile syringe acquisition at SSPs among rural PWID populations.

OBJECTIVES

We aim to identify factors associated with PWID in a rural county in West Virginia having recently acquired sterile syringes at an SSP.

METHODS

PWID (n = 420) completed a survey that included measures related to sociodemographics, structural vulnerabilities, and substance use. We used multivariable Poisson regression with robust variance estimation to examine independent associations with sterile syringe acquisition at an SSP.

RESULTS

Sixty-five percent of our sample reported having recently acquired sterile syringes at an SSP. Factors associated with recent sterile syringes acquisition at an SSP included: being older (aPR [adjusted prevalence ratio]: 1.011, 95% CI: 1.003-1.019), single (aPR: 0.862, 95% CI: 0.755-0.984), experiencing food insecurity (aPR: 1.233, 95% CI: 1.062-1.431), recently injecting fentanyl (aPR: 1.178, 95% CI: 1.010-1.375) and prescription opioid pain relievers (aPR: 0.681, 95% CI: 0.551-0.842), and recent naloxone acquisition (aPR: 1.360; 95% CI: 1.178-1.569). Receptive syringe sharing was inversely associated with acquiring sterile syringes at an SSP (aPR: 0.852; 95% CI: 0.741-0.979).

CONCLUSION

PWID accessing sterile syringes at an SSP was associated with several sociodemographic, structural, and substance use factors. Ensuring rural SSP operations are tailored to local PWID population-level needs is paramount to the prevention of infectious disease outbreaks and overdose fatalities.

Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion

IMPORTANCE

Opioids are frequently prescribed to children and adolescents after surgery. Prescription opioid misuse is associated with high-risk behavior in youth. Evidence-based guidelines for opioid prescribing practices in children are lacking.

OBJECTIVE

To assemble a multidisciplinary team of health care experts and leaders in opioid stewardship, review current literature regarding opioid use and risks unique to pediatric populations, and develop a broad framework for evidence-based opioid prescribing guidelines for children who require surgery.

EVIDENCE REVIEW

Reviews of relevant literature were performed including all English-language articles published from January 1, 1988, to February 28, 2019, found via searches of the PubMed (MEDLINE), CINAHL, Embase, and Cochrane databases. Pediatric was defined as children younger than 18 years. Animal and experimental studies, case reports, review articles, and editorials were excluded. Selected articles were graded using tools from the Oxford Centre for Evidence-based Medicine 2011 levels of evidence. The Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument was applied throughout guideline creation. Consensus was determined using a modified Delphi technique.

FINDINGS

Overall, 14 574 articles were screened for inclusion, with 217 unique articles included for qualitative synthesis. Twenty guideline statements were generated from a 2-day in-person meeting and subsequently reviewed, edited, and endorsed externally by pediatric surgical specialists, the American Pediatric Surgery Association Board of Governors, the American Academy of Pediatrics Section on Surgery Executive Committee, and the American College of Surgeons Board of Regents. Review of the literature and guideline statements underscored 3 primary themes: (1) health care professionals caring for children who require surgery must recognize the risks of opioid misuse associated with prescription opioids, (2) nonopioid analgesic use should be optimized in the perioperative period, and (3) patient and family education regarding perioperative pain management and safe opioid use practices must occur both before and after surgery.

CONCLUSIONS AND RELEVANCE

These are the first opioid-prescribing guidelines to address the unique needs of children who require surgery. Health care professionals caring for children and adolescents in the perioperative period should optimize pain management and minimize risks associated with opioid use by engaging patients and families in opioid stewardship efforts.

Distribution of Physician Specialties by Rurality

PURPOSE

Physicians of all specialties are more likely to live and work in urban areas than in rural areas. Physician availability affects the health and economy of rural communities. This study aimed to measure and update the availability of physician specialties in rural counties.

METHODS

This analysis included all counties with a Rural-Urban Continuum Code (RUCC) between 4 and 9. Geographically identified physician data from the 2019 American Medical Association Masterfile was merged with 2019 County Health Rankings, the Census Bureau's 2010 county-level population data, and 2010 Topologically Integrated Geographic Encoding and Referencing shapefiles. Multivariate logistic regression was performed to assess the availability of physicians by specialty in rural counties.

FINDINGS

Of the 1,947 rural counties in our sample, 1,825 had at least 1 physician. Specialties including emergency medicine, cardiology, psychiatry, diagnostic radiology, general surgery, anesthesiology, and OB/GYN were less available than primary care physicians (PCPs) in all rural counties. The probability of a rural county having a PCP was the highest in RUCC 4 (1.0) and lowest in RUCC 8 (0.93). Of all primary care specialties, family medicine was the most evenly distributed across the rural continuum, with a probability of 1.0 in RUCC 4 and 0.88 in RUCC 9.

CONCLUSIONS

Family medicine is the physician specialty most likely to be present in rural counties. Policy efforts should focus on maintaining the training and scope of practice of family physicians to serve the health care needs of rural communities where other specialties are less likely to practice.

Comorbid chronic pain and opioid misuse in youth: Knowns, unknowns, and implications for behavioral treatment

Chronic pain and opioid misuse occur in pediatric populations and can be associated with a range of negative adverse outcomes that may persist into adulthood. While the association between chronic pain, opioid prescribing, and opioid-related adverse consequences is reasonably well established in adults, the relation in pediatric patients is not well understood and the long-term impact of opioid exposure during childhood is yet to be fully revealed. The present review draws from the available literature on chronic and acute pediatric pain prevalence and treatment, opioid misuse, and adolescent substance use to address knowns and unknowns of comorbid pediatric chronic pain and opioid misuse. Additionally, gaps in knowledge regarding the prevalence and etiology of co-occurring chronic pain and opioid misuse in youth are identified. Hypothesized, modifiable risk factors associated with both pediatric pain and opioid misuse are considered. Due to a lack of empirically supported integrated treatments for comorbid chronic pain and opioid misuse in youth, this review examines the evidence base and best practices from both the chronic pain and opioid treatment literature to guide treatment recommendations for these comorbid conditions in youth. Recommendations are then provided to promote screening and mitigate risk of chronic pain and opioid misuse across a range of pediatric settings. Lastly, a comprehensive agenda to prevent and treat chronic pain and opioid misuse in adolescents and young adults is discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The Opioid Hydra: Understanding Overdose Mortality Epidemics and Syndemics Across the Rural-Urban Continuum

The rapid increase of fatal opioid overdoses over the past two decades is a major U.S. public health problem, especially in non-metropolitan communities. The crisis has transitioned from pharmaceuticals to illicit synthetic opioids and street mixtures, especially in urban areas. Using latent profile analysis, we classify n = 3,079 counties into distinct classes using CDC fatal overdose rates for specific opioids in 2002-2004, 2008-2012, and 2014-2016. We identify three distinct epidemics (prescription opioids, heroin, and prescription-synthetic opioid mixtures) and one syndemic involving all opioids. We find that prescription-related epidemic counties, whether rural or urban, have been "left behind" the rest of the nation. These communities are less populated and more remote, older and mostly white, have a history of drug abuse, and are former farm and factory communities that have been in decline since the 1990s. Overdoses in these places exemplify the "deaths of despair" narrative. By contrast, heroin and opioid syndemic counties tend to be more urban, connected to interstates, ethnically diverse, and in general more economically secure. The urban opioid crisis follows the path of previous drug epidemics, affecting a disadvantaged subpopulation that has been left behind rather than the entire community. County data on opioid epidemic class membership are provided.

Social norms associated with nonmedical opioid use in rural communities: a systematic review

Prescription and illicit opioids were involved in over 42,000 deaths in the USA in 2016. Rural counties experience higher rates of opioid prescribing and, although opioid prescribing rates have fallen in recent years, the rate of decline is less in rural areas. The sociocultural context of rural life may impact opioid misuse in important ways; however, little research directly explores this possibility. We performed a systematic review of English-language manuscripts in U.S. context to determine what is known about social networks, norms, and stigma in relation to rural opioid misuse. Of nine articles identified and reviewed, two had only primary findings associated with social networks, norms, or stigma, five had only secondary findings, and two had both primary and secondary findings. The normalization of prescription opioid use along with environmental factors likely impacts the prevalence of opioid misuse in rural communities. Discordant findings exist regarding the extent to which social networks facilitate or protect against nonmedical opioid use. Lastly, isolation, lack of treatment options, social norms, and stigma create barriers to substance use treatment for rural residents. Although we were able to identify important themes across multiple studies, discordant findings exist and, in some cases, findings rely on single studies. The paucity of research examining the role of social networks, norms, and stigma in relation to nonmedical opioid use in rural communities is evident in this review. Scholarship aimed at exploring the relationship and impact of rurality on nonmedical opioid use is warranted.

Preliminary Evaluation of a Prescription Opioid Misuse Prevention Program Among Rural Middle School Students

Adolescent opioid misuse, addiction, and overdose have emerged as national health crises. Nearly 17% of high school students have misused prescription opioids. The purpose of this study was to evaluate the reach and acceptability of a widely-used prescription opioid misuse prevention program, This Is (Not) About Drugs© (TINAD), and its preliminary efficacy at improving opioid misuse knowledge, opioid misuse attitudes, self-efficacy to avoid opioid misuse, and intentions to misuse opioids. Participants were 576 7th grade students (M_age = 11.8; 51% boys; 39% Hispanic, 31% White, 20% Black) from a rural county in the southeastern U.S. All participants received the TINAD program and completed pretest and immediate posttest assessments. The program was school-based and implemented in collaboration with school teachers and administrators. Over 91% of all eligible students in the school district participated in the TINAD program. Most participants found the program acceptable-over 83% of students liked the program. Approximately 9% of participants reported prior misuse of prescription opioids. After participating in TINAD, students self-reported higher knowledge and self-efficacy as well as safer attitudes. However, there was no change in intentions to misuse opioids in the future. Effects of the program were consistent across gender, socioeconomic status, race/ethnicity, and previous opioid misuse. TINAD is acceptable and shows promise for improving opioid-related cognitions. However, more rigorous experimental and longitudinal research is needed to understand whether TINAD reduces opioid misuse over time. Given the limited research on adolescent opioid misuse prevention, this study lays the ground work for future randomized control trials.

Urban-Rural Disparities in Opioid Use Disorder Prevention and Response Activities: A Cross-Sectional Analysis

PURPOSE

Urban and rural areas have been differentially impacted by opioid use disorder (OUD) and related adverse outcomes, yet little systematic study of the urban-rural divide in OUD prevention and response activities exists. This study compares policy and programmatic activities to tackle the opioid crisis in metropolitan versus nonmetropolitan areas, and within their subclassifications.

METHODS

All county governments in 5 purposively selected states were surveyed. Metropolitan and nonmetropolitan counties, and their subclassifications, were compared in their reported implementation of 19 opioid policy and programmatic activities, using 2-sample proportion and 1-way analysis of variance (ANOVA) tests with Bonferroni-corrected multiple comparisons.

FINDINGS

Of the 358 counties surveyed, 171 (response rate = 48%) responses were obtained. The implementation rate of nonmetropolitan counties was lower than that of metropolitan counties for all activities, although not all differences were statistically significant. Within nonmetropolitan areas, the implementation rate of noncore counties was lower than that of micropolitan counties for all activities, and statistically significant differences were found for providing treatment and rehabilitation facilities, allowing arrest alternatives for opioid offenses, and providing opioid detection and treatment training to first responders, among other activities.

CONCLUSIONS

The results of this study corroborate claims that nonmetropolitan areas, and particularly noncore areas, face greater barriers to implementing opioid policy and programmatic activities. This study identifies activity areas where rural counties are especially lacking and federal and state governments could support efforts for bending the curve of the opioid crisis.

Relationship between risky behaviors and non-prescription opioid use among Asian American youth

Asian Americans (AA) are a highly understudied population and are often considered the "model minority" for health. However, there is a dearth of research on risky behaviors associated with opioid use in AA teens. Data among AA youth aged 12 to 16 was collected from the 2017 Youth Risk Behavior Surveillance System. Multivariate logistic regression models were run to determine associations between opioid use and risky behaviors, controlling for age and sex. Findings showed that opioid use is significantly associated with weapon carrying, risky sexual behavior, and body image. These conclusions inform public health practice on substance abuse treatment in AA teens.

Receipt of multiple outpatient opioid prescriptions is associated with increased risk of adverse outcomes in youth: opioid prescribing trends, individual characteristics, and outcomes from 2005 to 2016

Data on all outpatient opioid prescriptions (N = 71,647) to youth below age 21 (N = 42,020) from 2005 to 2016 were extracted from electronic medical records within a university hospital system in New Mexico (NM) as were demographic details and markers of morbidity/mortality. Relative risk was calculated for markers of morbidity/mortality based on sociodemographic characteristics. The sample was primarily male (55.0%), Hispanic/Latinx (50.1%), English-speaking (88.9%), and publicly insured (50.1%). Mean age was 13.54 (SD = 6.50). From 2005 to 2016, overall frequency of opioid prescriptions increased by 86.6% (from 2470 to 4610) with the largest increase (206.2%) observed from 2005 to 2008 (2470-7562). Patients who were older, white, and non-Hispanic were more likely to receive multiple opioid prescriptions. Large relative increases in morbidity and mortality were documented, although base rates remained low. The percentage of individuals within the sample who experienced an overdose increased steadily from 0 in 2005 to 1.09% in 2016. Incidence of mortality increased from 0.12% of the sample to 1.39% in 2016. The proportion of individuals who received a medication for the treatment of opioid dependence increased from 0.06% in 2005 to 0.44% in 2016. Significantly increased risk of adverse outcomes was observed in patients receiving multiple opioid prescriptions, and in patients who were older, of minority race, received their first prescription in an outpatient clinic, and publicly insured or uninsured. Results add to the growing literature concerning opioid prescription rates over time. They also provide important information on potential additive risks of adverse outcomes when pediatric patients receive multiple opioid prescriptions.

Prevalence and Health Characteristics of Prescription Opioid Use, Misuse, and Use Disorders Among U.S. Adolescents

PURPOSE

The prevalence of past-year prescription opioid use (POU), nonmedical POU (NMPOU), and POU disorder (POUD) and their correlates were examined in a national sample of American adolescents (N = 41,579).

METHODS

This study used data from the public-use files of the 2015, 2016, and 2017 National Surveys on Drug Use and Health, which captured substance use and mental health problems among noninstitutionalized individuals. Prevalence and specific types of prescription opioids and other substances used and misused in the past year were examined among adolescents. Logistic regression analyses were conducted to determine correlates (demographics, other substances used, past-year major depressive episode, school enrollment, two-parent household, number of lifetime medical conditions, and survey year) of POU, NMPOU, and POUD.

RESULTS

Multiple substance use was common within the past year. The most frequently used prescription opioids were hydrocodone, codeine, oxycodone, and other opioids among adolescents. Cannabis use disorder and alcohol use disorder were comparatively prevalent among opioid misusers. Several correlates (demographics, other substances used, lifetime medical conditions, major depressive episode, and survey year) of POU, NMPOU, and POUD were found.

CONCLUSIONS

In this national sample, multiple substance use was common among adolescents with past-year POU and NMPOU. Clinical screening for opioid use problems, assessment, and treatment expansion for POUD can focus on persons with substance use, mental health, and/or behavioral problems. Longitudinal studies are needed to better elucidate temporal associations between POU and NMPOU/POUD among adolescents, and more prevention and treatment research on rural residents and minority groups is needed.

Optimism and opioid misuse among justice-involved children

AIM

Adolescents in the criminal justice system, called justice-involved children (JIC), are particularly vulnerable in the modern opioid misuse (OM) epidemic. After release, relapse and overdose occur at higher rates than the general population. The current study assesses optimism and likelihood of P30D consumption of non-prescription or illicit opioids among JIC.

METHODS

The study examines a sample of 79,960 JIC from the Florida Department of Juvenile Justice. Multivariate logistic regression was employed, controlling for gender, race, family income, age, history of mental problems, history of depression, and county of residence.

RESULTS

JIC who reported very low optimism on the final screen had over 8 times the odds of meeting criteria for P30D OM compared to those with high optimism while adjusting for covariates.

CONCLUSIONS

Further research is needed to understand the potential for optimism to serve as a protective factor. Optimism can be developed, and therefore can possibly be incorporated to design novel interventions or integrated into empirically validated treatment programs to precipitate uptake.

Trends in Drug Poisoning Deaths Among Adolescents and Young Adults in the United States, 2006-2015

OBJECTIVE

Despite the rising toll of drug poisoning deaths in the United States, the extent of the problem among adolescents and young adults ages 15-24 years has received relatively little attention. We examined sociodemographic characteristics and state trends in drug poisoning deaths among adolescents and young adults from 2006 to 2015 and estimated the costs of drug poisoning mortality in this population.

METHOD

We used the National Vital Statistics System's Multiple Cause of Death files from 2006 to 2015. We analyzed trends using Joinpoint regression analysis and calculated total costs of drug poisoning deaths, including medical costs, work loss costs, and quality of life loss, based on widely used cost estimates.

RESULTS

Drug poisoning death rates (per 100,000 population) in adolescents and young adults increased from 8.1 in 2006 to 9.7 in 2015. The rates increased significantly for Whites (1.7% per year) and Asian/Pacific Islanders (4.3% per year) from 2006 to 2015 and for Blacks (11.8% per year) from 2009 to 2015. By U.S. region, the rates increased significantly in the Midwest (4.4% per year) from 2006 to 2015 and in the Northeast (11.0% per year) from 2009 to 2015. Trends varied by age group, intent for drug poisoning, drug category (i.e., opioids, pharmaceutical drugs excluding opioids, illicit drugs excluding opioids, and unspecified drugs), urbanization level, and state. The estimated costs of drug poisoning deaths among adolescents and young adults totaled approximately $35 billion in 2015.

CONCLUSIONS

Trends in drug poisoning deaths and estimated costs inform state-specific prevention and intervention efforts.

Prescription opioid misuse among adolescents and emerging adults in the United States: A scoping review

The U.S. opioid epidemic is a critical public health problem. As substance use and misuse typically begin in adolescence and emerging adulthood, there is a critical need for prevention efforts for this key developmental period to disrupt opioid misuse trajectories, reducing morbidity and mortality [e.g., overdose, development of opioid use disorders (OUD)]. This article describes the current state of research focusing on prescription opioid misuse (POM) among adolescents and emerging adults (A/EAs) in the U.S. Given the rapidly changing nature of the opioid epidemic, we applied PRISMA Scoping Review (PRISMA-ScR) guidelines to identify empirical articles published in the past 5 years (January 2013-September 2018) from nine databases examining POM among A/EAs (ages 10-25) in the U.S. Seventy-six articles met our inclusion criteria focusing on POM in the following areas: cross-sectional surveys (n = 60), longitudinal cohort studies (n = 5), objective, non-self-reported data sources (n = 9), and interventions (n = 2). Final charted data elements were organized by methodology and sample, with results tables describing design, sample, interventions (where applicable), outcomes, and limitations. Most studies focused on the epidemiology of POM and risk/protective factors, including demographic (e.g., sex, race), individual (e.g., substance use, mental health), and social (e.g., peer substance use) factors. Despite annual national surveys conducted, longitudinal studies examining markers of initiation and escalation of prescription opioid misuse (e.g., repeated overdoses, time to misuse) are lacking. Importantly, few evidence-based prevention or early intervention programs were identified. Future research should examine longitudinal trajectories of POM, as well as adaptation and implementation of promising prevention approaches.

A preliminary examination of substance use risk among metropolitan and non-metropolitan girls involved in the juvenile justice system

Research is limited on geographic differences in substance use risk factors among juvenile justice-involved girls. This secondary data analysis from one state juvenile justice system, collected as part of the NIH/NIDA funded JJTRIALS cooperative agreement, assessed criminogenic needs at intake for 160 girls from metropolitan and non-metropolitan counties. Although girls from different geographic areas did not differ significantly on key variables of interest, including substance use risk and related criminality variables, findings suggest that substance use risk is related to criminal history, substance-related offenses, and relationship problems among justice-involved girls. Implications include gender-specific juvenile justice programming and research.

Are Rural Opioid Treatment Program (OTP) Facilities Associated with Lower Deaths?

Objectives: Rural areas have been particularly affected by the opioid epidemic in the U.S., with treatment options being scarce. This study focuses on opioid treatment programs (OTPs), which combine counseling services and opioid-related medication provision. In the South census region (comprised of 16 states and D.C.), 156 urban counties and 27 rural counties contained OTPs as of 2013. We examine whether their presence is associated with lower opioid-related death rates during 2014-2016. Methods: Coarsened exact matching (CEM) is used to match treated and untreated counties on demographic characteristics and opioid-related deaths from 2011 to 2013. Two treatments are considered: (1) if a county had an OTP in 2013; and (2) if an OTP existed in a neighboring county in 2013. The matched samples are then used in weighted least square regression models, with propensity score matching serving as a robustness check. Rural and urban counties are analyzed separately to determine if the impact of OTPs differs between these areas. Results: Results show that the presence of an OTP mostly has no statistical association with the rate of (or change in) future opioid deaths, in either rural or urban counties. Proximity to a neighboring county OTP displays a similar lack of association. Conclusions: The findings suggest that OTPs are not associated with fewer opioid-related deaths in the South over the near term, regardless of rural or urban location. These results could be attributed to outside factors that hinder this relationship. Continued assessment of varied approaches to the rural opioid crisis is encouraged.