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

Rural-urban differences in dental opioid prescribing among adolescent/young adult and adult Medicaid beneficiaries

Introduction

There are ongoing concerns about opioid prescribing for surgical and non-surgical dental needs among adolescent/young adult and adult patients. Although there are known differences in the overall opioid prescription rates in rural areas compared to urban areas, the contribution of dental opioid prescriptions is still unclear. This study aims to examine the factors associated with receiving an opioid prescription following a dental visit.

Materials and methods

This cross-sectional study utilized the 2021 Centers for Medicare & Medicaid Services unredacted Transformed Medicaid Statistical Information System Analytic Files to examine Medicaid and CHIP adolescent/young adult beneficiaries aged 12-20 and adults aged 21-64 who are non-dually eligible for Medicare and had a dental visit in 2021. Multilevel logistic regression models were used to predict the odds of receiving a dental opioid prescription.

Results

The results of the adolescent/young adult models show that for every percentage point increase in the percentage of non-Hispanic Black residents in a county, the odds of receiving a dental opioid prescription increase by 0.8% in rural areas. However, with every percentage point increase in the Hispanic population, the odds of receiving a dental opioid prescription decrease by 0.3% in rural areas and 0.7% in urban areas. The adult models show that compared to non-Hispanic white beneficiaries, non-Hispanic Black beneficiaries are 8% more likely to receive a dental opioid prescription if they live in rural areas and 18% more likely if they live in urban areas, while all other racial and ethnic groups are significantly less likely to receive a dental opioid prescription. With every unit increase in the concentrated disadvantage index, the odds of receiving a dental opioid prescription increase by 17% among rural adults and 24% among urban adults.

Discussion

Our findings on rural-urban disparities in opioid prescriptions suggest that prescription patterns in dental settings are significant and inequitable across various beneficiary- and county-level factors and areas of residence. These variations in prescription patterns highlight the known disparities in access to preventive dental care and the need for targeted interventions to address the healthcare needs of rural residents.

Community-level Factors and their Associations with Changing Opioid Overdose Fatality Rates in Kentucky, 2019-2021

Introduction

Kentucky has one of the highest opioid overdose fatality rates in the United States, which has increased significantly from 2019 to 2020. The COVID-19 pandemic has caused lasting effects on mental health and health care, which have been linked with increased opioid overdose. These effects are exacerbated in Appalachian regions, where there is a lack of sufficient access to community pharmacies and adequate health care.

Purpose

In this study, we characterize changes in opioid overdose fatality rates in Kentucky from 2019 to 2021, with a specific focus on changes in Appalachian vs non-Appalachian counties. We aim to identify associations between community-level factors and opioid overdose fatality rates and how such associations may have changed from 2019 to 2021.

Methods

County-level data were used to fit a marginal GEE-type negative binomial model to determine factors associated with opioid overdose fatality rates in 2019 (before the COVID-19 pandemic) and 2021 (during the COVID-19 pandemic).

Results

Opioid overdose fatality rates increased from 2019 to 2021 (Rate Ratio: 1.82). This increase was much larger in adjacent-to-metropolitan (RR: 2.54) and Appalachian (RR: 2.38) counties. Age was associated with opioid overdose fatality rates in both 2019 and 2021, and the observed association for age was stronger in 2021. Appalachian status was associated with opioid overdose fatality rates in 2021. Metropolitan county status was associated with opioid overdose fatality rates in 2019, whereas adjacent-to-metropolitan county status was associated with opioid overdose fatality rates in 2021.

Implications

Adjacent-to-metropolitan status's association with overdose fatalities in 2021 may indicate a differential effect of COVID-19 on suburban communities. Future studies should investigate additional factors related to COVID-19 as well the lasting effects of the pandemic on the landscape of opioid overdose in Kentucky.

Long-term prescribed opioid use after hospitalization or emergency department presentation among opioid naïve adults (2014-2020)-A population-based descriptive cohort study

AIMS

The aim of this work is to describe opioid initiation and long-term use after emergency department (ED) visits or hospitalizations in New South Wales, Australia, by patient, admission and clinical characteristics.

METHODS

This is a population-based cohort study, including all hospitalizations and ED visits between 2014 and 2020, linked to medicine dispensings, deaths and cancer registrations (Medicines Intelligence Data Platform), among adults with no opioid dispensings in the previous year. Outcome measures were opioid initiations (dispensed within 7 days of discharge) and long-term use (90 days of continuous exposure, 90-270 days after initiation).

RESULTS

The cohort included 16 153 096 admissions by 4.2 million opioid-naïve adults; 39.0% were ED presentations without hospital admission, 16.8% hospital admissions via ED and 44.2% direct hospital admissions. Opioids were initiated post-discharge for 6.2% of ED, 8.3% of hospital via ED and 10.0% of direct hospital admissions; of these 1.0%, 2.5% and 0.5% progressed to long-term opioid use, respectively. Initiation was lowest in obstetric admissions without surgery (1.0%), and highest among trauma admissions (25.4%), obstetric admissions with surgical intervention (19.8%) and non-trauma surgical admissions (12.0%). Long-term use was highest among medical admissions via ED (3.5%), trauma admissions (2.3%) and ED alone (1.0%). From 2014 to 2020, overall opioid initiations decreased 16% from 8.7% to 7.2%, and long-term opioid use decreased 33% from 1.3% to 0.8%.

CONCLUSIONS

Both opioid initiation and long-term use decreased over time; however, the higher rates of long-term use following trauma, and medical admissions via ED, warrant further surveillance. Strategies supporting appropriate prescribing and access to multidisciplinary pain services will facilitate best practice care.

Oxycodone initiation in Australia (2014-2018): Sociodemographic factors and preceding health service use

AIMS

Oxycodone is the most commonly prescribed strong opioid in Australia. This study describes health service antecedents and sociodemographic factors associated with oxycodone initiation.

METHODS

Population-based new user cohort study linking medicine dispensings, hospitalizations, emergency department visits, medical services and cancer notifications from New South Wales (NSW) for 2014-2018. New users had no dispensings of any opioid in the preceding year. We analysed health service use in the 5 days preceding initiation and proportion of people on treatment over 1 year and fitted an area-based, multivariable initiation model with sociodemographic covariates.

RESULTS

Oxycodone accounted for 30% of opioid initiations. Annually, 3% of the NSW population initiated oxycodone, and 5-6% were prevalent users; the new user cohort comprised 830 963 people. Discharge from hospital (39.3%), therapeutic procedures (21.4%) and emergency department visits (19.7%) were common; a hospital admission for injury (6.0%) or a past-year history of cancer (7.2%) were less common. At 1 year after initiation, 4.6% of people were using oxycodone. In the multivariable model, new use of oxycodone increased with age and was higher for people outside major cities, for example, an incidence rate ratio of 1.43 (95% confidence interval 1.36-1.51) for inner regional areas relative to major cities; there was no evidence of variation in rates of new use by social disadvantage.

CONCLUSION

About half of new oxycodone use in NSW was preceded by a recent episode of hospital care or a therapeutic procedure. Higher rates of oxycodone initiation in rural and regional areas were not explained by sociodemographic factors.

Race, economic status, and disparities in the receipt of benzodiazepine prescriptions in a large primary care sample

OBJECTIVE

To evaluate the relationship between race, economic status, and patient characteristics with benzodiazepine prescribing in an urban and suburban primary care context.

METHOD

This retrospective study used data from a previously described cohort of patients seen in a large Ohio healthcare system's primary care clinics from 2019 to 2020. Associations and interactions between race, economic status (using median income of patient ZIP code as a proxy), patient characteristics, and prescription of benzodiazepines were assessed using multivariable logistic regression.

RESULTS

455,537 patients had 1,643,473 primary care visits, and 5.8% of patients were prescribed a benzodiazepine. White patients were prescribed benzodiazepines more often than Multiracial/Multicultural, African American and Asian American patients (6.5%, 3.8%, 2.7% and 2.0% respectively). Patients from lower income ZIP codes were less likely to receive a prescription. Interaction effects were observed between race, patient economic status, gender, insurance status, and diagnoses (general anxiety disorder, insomnia, and panic disorder). The largest prescribing disparities by race were among patients with these three diagnoses. The largest disparity in prescription by income was seen in African American patients.

CONCLUSION

African American, Multicultural/Multiracial and Asian American patients were less likely than White patients to receive benzodiazepine prescriptions. Middle and lower-income patients are particularly susceptible to this prescribing disparity.

Drug Safety and Suicidality Risk of Chronic Pain Medications

Chronic pain is one of the main leading causes of disability in the world at present. A variety in the symptomatology, intensity and duration of this phenomenon has led to an ever-increasing demand of pharmacological treatment and relief. This demand for medication, ranging from well-known groups, such as antidepressants and benzodiazepines, to more novel drugs, was followed by a rise in safety concerns of such treatment options. The validity, frequency, and diversity of such concerns are discussed in this paper, as well as their possible effect on future prescription practices. A specific caution is provided towards the psychological safety and toll of these medications, regarding suicidality and suicidal ideation. Most significantly, this paper highlights the importance of pharmacovigilance and underscores the necessity of surveillance programs when considering chronic pain medication.

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.