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Kelly MA, Puddy RW, Siddiqi SM, Nelson C, Ntazinda AH, Kucik JE, Hall D, Murray CT, Tomoaia-Cotisel A. Distilling the Fundamentals of Evidence-Based Public Health Policy. Public Health Rep 2024:333549241256751. [PMID: 38910545 DOI: 10.1177/00333549241256751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024] Open
Abstract
Public health policy interventions are associated with many important public health achievements. To provide public health practitioners and decision makers with practical approaches for examining and employing evidence-based public health (EBPH) policy interventions, we describe the characteristics and benefits that distinguish EBPH policy interventions from programmatic interventions. These characteristics include focusing on health at a population level, focusing on upstream drivers of health, and involving less individual action than programmatic interventions. The benefits of EBPH policy interventions include more sustained effects on health than many programs and an enhanced ability to address health inequities. Early childhood education and universal preschool provide a case example that illustrates the distinction between EBPH policy and programmatic interventions. This review serves as the foundation for 3 concepts that support the effective use of public health policy interventions: applying core component thinking to understand the population health effects of EBPH policy interventions; understanding the influence of existing policies, policy supports, and the context in which a particular policy is implemented on the effectiveness of that policy; and employing a systems thinking approach to identify leverage points where policy implementation can have a meaningful effect.
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Affiliation(s)
- Megan A Kelly
- Office of Policy, Performance, and Evaluation, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Richard W Puddy
- Office of Policy, Performance, and Evaluation, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sameer M Siddiqi
- RAND Corporation, Arlington, VA, USA
- Amazon Web Services, Amazon.com, Inc, Seattle, WA, USA
| | - Christopher Nelson
- RAND Corporation, Santa Monica, CA, USA
- Pardee RAND Graduate School, Santa Monica, CA, USA
| | - Alexandra H Ntazinda
- RAND Corporation, Santa Monica, CA, USA
- Pardee RAND Graduate School, Santa Monica, CA, USA
| | - James E Kucik
- Office of Policy, Performance, and Evaluation, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Office of the Director, Office of Public Health Data, Surveillance, and Technology, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Diane Hall
- Office of Policy, Performance, and Evaluation, Centers for Disease Control and Prevention, Atlanta, GA, USA
- Office of Rural Health, National Center for State, Tribal, Local, and Territorial Public Health Infrastructure and Workforce, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Christian T Murray
- Office of Policy, Performance, and Evaluation, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Rishworth A, King B, Holmes LM. Digital geographies of care: Telehealth landscapes of addiction treatment during the COVID-19 pandemic. Health Place 2024; 89:103296. [PMID: 38917673 DOI: 10.1016/j.healthplace.2024.103296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 03/23/2024] [Accepted: 06/11/2024] [Indexed: 06/27/2024]
Abstract
The COVID-19 pandemic has created new digital health care landscapes for the management of substance use and misuse. While telehealth was prohibited for addiction treatment prior to the pandemic, the severity of COVID-19 precipitated telehealth expansion for the delivery of individual and group-based treatment. Research has highlighted benefits and challenges of telehealth; however, little is known about the impacts of telehealth on the quality, use, and effectiveness of treatment. Fewer studies examine how these emerging digital geographies of care transform the spaces and landscapes of substance misuse. This article examines how telehealth affects landscapes of opioid use disorder care in Pennsylvania, West Virginia, and Kentucky during the COVID-19 pandemic. Our findings reveal that while telehealth extends access to treatment for opioid use disorder (OUD), it also creates new care inequities within and between providers and clientele that can undermine effective care and recovery.
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Affiliation(s)
- Andrea Rishworth
- Department of Geography, Geomatics and Environment, University of Toronto, Mississauga, Mississauga, Ontario, Canada.
| | - Brian King
- Department of Geography, The Pennsylvania State University, State College, University Park, PA, United States.
| | - Louisa M Holmes
- Department of Geography, The Pennsylvania State University, State College, University Park, PA, United States.
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Spence C, Kurz ME, Sharkey TC, Miller BL. Scoping Literature Review of Disease Modeling of the Opioid Crisis. J Psychoactive Drugs 2024:1-14. [PMID: 38909286 DOI: 10.1080/02791072.2024.2367617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/28/2024] [Indexed: 06/24/2024]
Abstract
Opioid misuse continues to cause significant harm. To investigate current research, we conducted a scoping literature review of disease spread models of opioid misuse from January 2000 to December 2022. In total, 85 studies were identified and examined for the opioids modeled, model type, data sources used and model calibration and validation. Most of the studies (58%, 49) only modeled heroin; the next largest categories were prescription opioids and unspecified opioids which accounted for 9% (8) each. Most models were theoretical compartmental models (57) or applied compartmental models (21). Previously published research was the most used data source (38), and a majority of the model validation involved the researchers setting initial conditions to verify theoretical results (30). To represent typical opioid use more accurately, multiple opioids need to be incorporated into the disease spread models, and applying different modeling techniques may allow other insights into opioid misuse spread.
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Affiliation(s)
- Chelsea Spence
- Department of Industrial Engineering, Clemson University, Clemson, SC, USA
| | - Mary E Kurz
- Department of Industrial Engineering, Clemson University, Clemson, SC, USA
| | - Thomas C Sharkey
- Department of Industrial Engineering, Clemson University, Clemson, SC, USA
| | - Bryan Lee Miller
- Department of Sociology, Anthropology and Criminal Justice, Clemson University, Clemson, SC, USA
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Johnson CE, Chrischilles EA, Arndt S, Carnahan RM. State-level factors associated with implementation of prescription drug monitoring program integration and mandatory use policies, United States, 2009-2020. J Am Med Inform Assoc 2024:ocae160. [PMID: 38905012 DOI: 10.1093/jamia/ocae160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 06/04/2024] [Accepted: 06/16/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Prescription drug monitoring programs (PDMPs) have been widely adopted as a tool to address the prescription opioid epidemic in the United States. PDMP integration and mandatory use policies are 2 approaches states have implemented to increase use of PDMPs by prescribers. While the effectiveness of these approaches is mixed, it is unclear what factors motivated states to implement them. This study examines whether opioid dispensing, adverse health outcomes, or other non-health-related factors motivated implementation of these PDMP approaches. METHODS Time-to-event analysis was performed using lagged state-year covariates to reflect values from the year prior. Extended Cox regression estimated the association of states' rates of opioid dispensing, prescription opioid overdose deaths, and neonatal opioid withdrawal syndrome with implementation of PDMP integration and mandatory use policies from 2009 to 2020, controlling for demographic and economic factors, state government and political factors, and prior opioid policies. RESULTS In our main model, prior opioid dispensing (HR 2.31, 95% CI 1.17, 4.57), neonatal opioid withdrawal syndrome hospitalizations (HR 1.55, 95% CI 1.09, 2.19), and number of prior opioid policies (HR 2.13, 95% CI 1.13, 4.00) were associated with mandatory use policies. Prior prescription opioid overdose deaths (HR 1.21, 95% CI 1.08, 1.35) were also associated with mandatory use policies in a model that did not include opioid dispensing or neonatal opioid withdrawal syndrome. No study variables were associated with implementation of PDMP integration. CONCLUSION Understanding state-level factors associated with implementing PDMP approaches can provide insights into factors that motivate the adoption of future public health interventions.
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Affiliation(s)
- Christian E Johnson
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA 52242, United States
| | - Elizabeth A Chrischilles
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA 52242, United States
| | - Stephan Arndt
- Department of Psychiatry, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, United States
- Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, IA 52242, United States
| | - Ryan M Carnahan
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA 52242, United States
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Knudsen HK, Walker DM, Mack N, Kinnard EN, Huerta TR, Glasgow L, Gilbert L, Garner BR, Dasgupta A, Chandler R, Walsh SL, Tin Y, Tan S, Sprunger J, Sprague-Martinez L, Salsberry P, Saucier M, Rudorf M, Rodriguez S, Oser CB, Oga E, Nakayima J, Linas BS, Lefebvre RC, Kosakowski S, Katz RE, Hunt T, Holman A, Holloway J, Goddard-Eckrich D, Fareed N, Christopher M, Aldrich A, Adams JW, Drainoni ML. Reducing perceived barriers to scaling up overdose education and naloxone distribution and medications for opioid use disorder in the United States in the HEALing (helping end addiction long-term®) communities study. Prev Med 2024; 185:108034. [PMID: 38857770 DOI: 10.1016/j.ypmed.2024.108034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 06/04/2024] [Accepted: 06/05/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Scaling up overdose education and naloxone distribution (OEND) and medications for opioid use disorder (MOUD) is needed to reduce opioid overdose deaths, but barriers are pervasive. This study examines whether the Communities That HEAL (CTH) intervention reduced perceived barriers to expanding OEND and MOUD in healthcare/behavioral health, criminal-legal, and other/non-traditional venues. METHODS The HEALing (Helping End Addiction Long-Term®) Communities Study is a parallel, wait-list, cluster randomized trial testing the CTH intervention in 67 communities in the United States. Surveys administered to coalition members and key stakeholders measured the magnitude of perceived barriers to scaling up OEND and MOUD in November 2019-January 2020, May-June 2021, and May-June 2022. Multilevel linear mixed models compared Wave 1 (intervention) and Wave 2 (wait-list control) respondents. Interactions by rural/urban status and research site were tested. RESULTS Wave 1 respondents reported significantly greater reductions in mean scores for three outcomes: perceived barriers to scaling up OEND in Healthcare/Behavioral Health Venues (-0.26, 95% confidence interval, CI: -0.48, -0.05, p = 0.015), OEND in Other/Non-traditional Venues (-0.53, 95% CI: - 0.84, -0.22, p = 0.001) and MOUD in Other/Non-traditional Venues (-0.34, 95% CI: -0.62, -0.05, p = 0.020). There were significant interactions by research site for perceived barriers to scaling up OEND and MOUD in Criminal-Legal Venues. There were no significant interactions by rural/urban status. DISCUSSION The CTH Intervention reduced perceived barriers to scaling up OEND and MOUD in certain venues, with no difference in effectiveness between rural and urban communities. More research is needed to understand facilitators and barriers in different venues.
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Affiliation(s)
- Hannah K Knudsen
- Department of Family and Community Medicine, Ohio State University, Suite 5000, 700 Ackerman Rd, Columbus, OH 43202, USA.
| | - Daniel M Walker
- Department of Family and Community Medicine, Ohio State University, Suite 5000, 700 Ackerman Rd, Columbus, OH 43202, USA.
| | - Nicole Mack
- Center for Official Statistics, RTI International, 3040 East Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709, USA.
| | - Elizabeth N Kinnard
- Section of Infectious Diseases, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, 801 Massachusetts Avenue, Boston, MA 02118, USA.
| | - Timothy R Huerta
- CATALYST, Center for the Advancement of Team Science, Analytics, and Systems Thinking, Department of Family and Community Medicine, Department of Biomedical Informatics, The Ohio State University, 540 W. Spring St., Columbus, OH 43215, USA.
| | - LaShawn Glasgow
- Center for Program and Policy Evaluation to Advance Community Health, RTI International, 3040 East Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709, USA.
| | - Louisa Gilbert
- School of Social Work, Columbia University, 1255 Amsterdam Ave., New York, NY 10027, USA.
| | - Bryan R Garner
- Department of Internal Medicine, The Ohio State University, 2050 Kenny Road Columbus, OH 43221, USA.
| | - Anindita Dasgupta
- School of Social Work, Columbia University, 1255 Amsterdam Ave., New York, NY 10027, USA.
| | - Redonna Chandler
- National Institute on Drug Abuse, 301 North Stonestreet Ave, Bethesda, MD 20892, USA.
| | - Sharon L Walsh
- Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, 845 Angliana Avenue, Room 202, Lexington, KY 40508, USA.
| | - Yjuliana Tin
- General Internal Medicine, University of Colorado School of Medicine, 12631 E 17th Ave Aurora, CO 80045, USA.
| | - Sylvia Tan
- Center for Clinical Research, RTI International, 3040 East Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709, USA.
| | - Joel Sprunger
- Center for Addiction Research, University of Cincinnati College of Medicine, 3131 Harvey Ave, Suite 204, Cincinnati, OH 45229, USA.
| | | | - Pamela Salsberry
- College of Public Health, The Ohio State University, 1841 Neil Avenue, Columbus, OH 43210, USA.
| | - Merielle Saucier
- Clinical Addiction Research and Evaluation Unit, Section of General Internal Medicine, Boston Medical Center, 801 Massachusetts Avenue, Boston, MA 02118, USA.
| | - Maria Rudorf
- General Internal Medicine, Boston Medical Center, 801 Massachusetts Avenue, Boston, MA 02118, USA.
| | - Sandra Rodriguez
- School of Social Work, Columbia University, 1255 Amsterdam Ave., New York, NY 10027, USA.
| | - Carrie B Oser
- Department of Sociology, Center on Drug & Alcohol Research, Center for Health Equity Transformation, University of Kentucky, 1531 Patterson Office Tower, Lexington, KY 40506, USA.
| | - Emmanuel Oga
- Center for Public Health Surveillance and Technology, RTI International, 3040 East Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709, USA.
| | - Julie Nakayima
- Center on Drug and Alcohol Research, University of Kentucky, 845 Angliana Avenue, Lexington, KY 40508, USA.
| | - Beth S Linas
- Center for Public Health Surveillance and Technology, RTI International, 3040 East Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709, USA.
| | - R Craig Lefebvre
- Communication Practice Area, RTI International, 3040 East Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709, USA.
| | - Sarah Kosakowski
- General Internal Medicine, Boston Medical Center, 801 Massachusetts Avenue, Boston, MA 02118, USA.
| | - Rachel E Katz
- Addiction Services, Clinical & Support Options, 8 Atwood Dr Suite 201, Northampton, MA 01060, USA.
| | - Timothy Hunt
- School of Social Work, Columbia University, 1255 Amsterdam Ave., New York, NY 10027, USA.
| | - Ari Holman
- School of Social Work, Columbia University, 1255 Amsterdam Ave., New York, NY 10027, USA.
| | - JaNae Holloway
- Center for Clinical Research, RTI International, 3040 East Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709, USA.
| | - Dawn Goddard-Eckrich
- School of Social Work, Columbia University, 1255 Amsterdam Ave., New York, NY 10027, USA.
| | - Naleef Fareed
- Biomedical Informatics, The Ohio State University, 370 W. 9th Avenue, Columbus, OH 43210, USA.
| | - Mia Christopher
- Center for Public Health Surveillance and Technology, RTI International, 3040 East Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709, USA.
| | - Alison Aldrich
- CATALYST, Center for the Advancement of Team Science, Analytics, and Systems Thinking, The Ohio State University, Suite 5000, 700 Ackerman Rd, Columbus, OH 43202, USA.
| | - Joella W Adams
- Center for Public Health Surveillance and Technology, RTI International, 3040 East Cornwallis Road, PO Box 12194, Research Triangle Park, NC 27709, USA.
| | - Mari-Lynn Drainoni
- Section of Infectious Diseases, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine/Boston Medical Center, and Department of Health Law, Policy and Management, Boston University School of Public Health, 801 Massachusetts Avenue, Room 2014, Boston, MA, 02118, USA.
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Scheidell JD, Townsend TN, Zhou Q, Manandhar-Sasaki P, Rodriguez-Santana R, Jenkins M, Buchelli M, Charles DL, Frechette JM, Su JIS, Braithwaite RS. Reducing overdose deaths among persons with opioid use disorder in connecticut. Harm Reduct J 2024; 21:103. [PMID: 38807226 PMCID: PMC11131266 DOI: 10.1186/s12954-024-01026-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 05/20/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND People in Connecticut are now more likely to die of a drug-related overdose than a traffic accident. While Connecticut has had some success in slowing the rise in overdose death rates, substantial additional progress is necessary. METHODS We developed, verified, and calibrated a mechanistic simulation of alternative overdose prevention policy options, including scaling up naloxone (NLX) distribution in the community and medications for opioid use disorder (OUD) among people who are incarcerated (MOUD-INC) and in the community (MOUD-COM) in a simulated cohort of people with OUD in Connecticut. We estimated how maximally scaling up each option individually and in combinations would impact 5-year overdose deaths, life-years, and quality-adjusted life-years. All costs were assessed in 2021 USD, employing a health sector perspective in base-case analyses and a societal perspective in sensitivity analyses, using a 3% discount rate and 5-year and lifetime time horizons. RESULTS Maximally scaling NLX alone reduces overdose deaths 20% in the next 5 years at a favorable incremental cost-effectiveness ratio (ICER); if injectable rather than intranasal NLX was distributed, 240 additional overdose deaths could be prevented. Maximally scaling MOUD-COM and MOUD-INC alone reduce overdose deaths by 14% and 6% respectively at favorable ICERS. Considering all permutations of scaling up policies, scaling NLX and MOUD-COM together is the cost-effective choice, reducing overdose deaths 32% at ICER $19,000/QALY. In sensitivity analyses using a societal perspective, all policy options were cost saving and overdose deaths reduced 33% over 5 years while saving society $338,000 per capita over the simulated cohort lifetime. CONCLUSIONS Maximally scaling access to naloxone and MOUD in the community can reduce 5-year overdose deaths by 32% among people with OUD in Connecticut under realistic budget scenarios. If societal cost savings due to increased productivity and reduced crime costs are considered, one-third of overdose deaths can be reduced by maximally scaling all three policy options, while saving money.
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Affiliation(s)
- Joy D Scheidell
- Department of Health Sciences, University of Central Florida, PO Box 160000, Orlando, FL, 32816, USA.
| | - Tarlise N Townsend
- Department of Population Health, New York University Grossman School of Medicine, 227 E. 30th St, New York, NY, 10016, USA
- Center for Opioid Epidemiology and Policy, New York University Grossman School of Medicine, New York, NY, USA
| | - Qinlian Zhou
- Department of Population Health, New York University Grossman School of Medicine, 227 E. 30th St, New York, NY, 10016, USA
| | - Prima Manandhar-Sasaki
- Department of Population Health, New York University Grossman School of Medicine, 227 E. 30th St, New York, NY, 10016, USA
| | - Ramon Rodriguez-Santana
- HIV Prevention Program, Connecticut Department of Public Health, 410 Capitol Avenue, MS #11APV, Hartford, CT, 06134-0308, USA
| | - Mark Jenkins
- Connecticut Harm Reduction Alliance, 28 Grand St, Hartford, CT, 06106, USA
| | - Marianne Buchelli
- HIV Prevention Program, Connecticut Department of Public Health, 410 Capitol Avenue, MS #11APV, Hartford, CT, 06134-0308, USA
- TB, HIV, STD and Viral Hepatitis Section, Connecticut Department of Public Health, 410 Capitol Avenue, MS #11APV, Hartford, CT, 06134, USA
| | - Dyanna L Charles
- Department of Population Health, New York University Grossman School of Medicine, 227 E. 30th St, New York, NY, 10016, USA
| | - Jillian M Frechette
- Department of Population Health, New York University Grossman School of Medicine, 227 E. 30th St, New York, NY, 10016, USA
| | - Jasmine I-Shin Su
- Department of Population Health, New York University Grossman School of Medicine, 227 E. 30th St, New York, NY, 10016, USA
| | - R Scott Braithwaite
- Department of Population Health, New York University Grossman School of Medicine, 227 E. 30th St, New York, NY, 10016, USA
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Cerdá M, Hamilton AD, Hyder A, Rutherford C, Bobashev G, Epstein JM, Hatna E, Krawczyk N, El-Bassel N, Feaster DJ, Keyes KM. Simulating the Simultaneous Impact of Medication for Opioid Use Disorder and Naloxone on Opioid Overdose Death in Eight New York Counties. Epidemiology 2024; 35:418-429. [PMID: 38372618 DOI: 10.1097/ede.0000000000001703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
BACKGROUND The United States is in the midst of an opioid overdose epidemic; 28.3 per 100,000 people died of opioid overdose in 2020. Simulation models can help understand and address this complex, dynamic, and nonlinear social phenomenon. Using the HEALing Communities Study, aimed at reducing opioid overdoses, and an agent-based model, Simulation of Community-Level Overdose Prevention Strategy, we simulated increases in buprenorphine initiation and retention and naloxone distribution aimed at reducing overdose deaths by 40% in New York Counties. METHODS Our simulations covered 2020-2022. The eight counties contrasted urban or rural and high and low baseline rates of opioid use disorder treatment. The model calibrated agent characteristics for opioid use and use disorder, treatments and treatment access, and fatal and nonfatal overdose. Modeled interventions included increased buprenorphine initiation and retention, and naloxone distribution. We predicted a decrease in the rate of fatal opioid overdose 1 year after intervention, given various modeled intervention scenarios. RESULTS Counties required unique combinations of modeled interventions to achieve a 40% reduction in overdose deaths. Assuming a 200% increase in naloxone from current levels, high baseline treatment counties achieved a 40% reduction in overdose deaths with a simultaneous 150% increase in buprenorphine initiation. In comparison, low baseline treatment counties required 250-300% increases in buprenorphine initiation coupled with 200-1000% increases in naloxone, depending on the county. CONCLUSIONS Results demonstrate the need for tailored county-level interventions to increase service utilization and reduce overdose deaths, as the modeled impact of interventions depended on the county's experience with past and current interventions.
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Affiliation(s)
- Magdalena Cerdá
- From the Department of Population Health, New York University School of Medicine, New York, NY
| | - Ava D Hamilton
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Ayaz Hyder
- Division of Environmental Health Sciences, College of Public Health, Ohio State University, Columbus, OH
| | - Caroline Rutherford
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Georgiy Bobashev
- Center for Data Science, RTI International, Research Triangle Park, NC
| | - Joshua M Epstein
- Department of Epidemiology, New York University School of Global Public Health, New York, NY
| | - Erez Hatna
- Department of Epidemiology, New York University School of Global Public Health, New York, NY
| | - Noa Krawczyk
- From the Department of Population Health, New York University School of Medicine, New York, NY
| | | | - Daniel J Feaster
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL
| | - Katherine M Keyes
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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Nataraj N, Rikard SM, Zhang K, Jiang X, Guy GP, Rice K, Mattson CL, Gladden RM, Mustaquim DM, Illg ZN, Seth P, Noonan RK, Losby JL. Public Health Interventions and Overdose-Related Outcomes Among Persons With Opioid Use Disorder. JAMA Netw Open 2024; 7:e244617. [PMID: 38568691 PMCID: PMC10993074 DOI: 10.1001/jamanetworkopen.2024.4617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 02/05/2024] [Indexed: 04/05/2024] Open
Abstract
Importance Given the high number of opioid overdose deaths in the US and the complex epidemiology of opioid use disorder (OUD), systems models can serve as a tool to identify opportunities for public health interventions. Objective To estimate the projected 3-year association between public health interventions and opioid overdose-related outcomes among persons with OUD. Design, Setting, and Participants This decision analytical model used a simulation model of the estimated US population aged 12 years and older with OUD that was developed and analyzed between January 2019 and December 2023. The model was parameterized and calibrated using 2019 to 2020 data and used to estimate the relative change in outcomes associated with simulated public health interventions implemented between 2021 and 2023. Main Outcomes and Measures Projected OUD and medications for OUD (MOUD) prevalence in 2023 and number of nonfatal and fatal opioid-involved overdoses among persons with OUD between 2021 and 2023. Results In a baseline scenario assuming parameters calibrated using 2019 to 2020 data remained constant, the model projected more than 16 million persons with OUD not receiving MOUD treatment and nearly 1.7 million persons receiving MOUD treatment in 2023. Additionally, the model projected over 5 million nonfatal and over 145 000 fatal opioid-involved overdoses among persons with OUD between 2021 and 2023. When simulating combinations of interventions that involved reducing overdose rates by 50%, the model projected decreases of up to 35.2% in nonfatal and 36.6% in fatal opioid-involved overdoses among persons with OUD. Interventions specific to persons with OUD not currently receiving MOUD treatment demonstrated the greatest reduction in numbers of nonfatal and fatal overdoses. Combinations of interventions that increased MOUD initiation and decreased OUD recurrence were projected to reduce OUD prevalence by up to 23.4%, increase MOUD prevalence by up to 137.1%, and reduce nonfatal and fatal opioid-involved overdoses among persons with OUD by 6.7% and 3.5%, respectively. Conclusions and Relevance In this decision analytical model study of persons with OUD, findings suggested that expansion of evidence-based interventions that directly reduce the risk of overdose fatality among persons with OUD, such as through harm reduction efforts, could engender the highest reductions in fatal overdoses in the short-term. Interventions aimed at increasing MOUD initiation and retention of persons in treatment projected considerable improvement in MOUD and OUD prevalence but could require a longer time horizon for substantial reductions in opioid-involved overdoses.
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Affiliation(s)
- Nisha Nataraj
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - S. Michaela Rikard
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kun Zhang
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Xinyi Jiang
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gery P. Guy
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ketra Rice
- Division of Injury Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Christine L. Mattson
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - R. Matthew Gladden
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Desiree M. Mustaquim
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Zachary N. Illg
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Puja Seth
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rita K. Noonan
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jan L. Losby
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
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Khorassani F, Espejo G. Evaluation of the Impact of Pharmacist-Driven Physician Naloxone Training on an Inpatient Psychiatric Unit. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2024; 48:148-152. [PMID: 38279070 DOI: 10.1007/s40596-024-01934-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/02/2024] [Indexed: 01/28/2024]
Abstract
OBJECTIVES The purpose of this study was to evaluate the impact of pharmacist-driven naloxone training of resident physicians as part of discharge prescribing from an inpatient psychiatric unit. METHODS This is a prospective pilot study in which psychiatric resident physicians (N = 21) were educated on naloxone administration, prescribing, and counseling. A ten-question survey was designed and delivered immediately pre- and post-training to assess resident knowledge of and comfort with naloxone prescribing. Respondents were asked to rate ten statements on a scale from 1 to 5, with 1 corresponding to "strongly disagree" and 5 corresponding to "strongly agree." The primary objective was to evaluate the impact of training on prescriber knowledge and attitudes using the designed questionnaire. The secondary objective was to assess the difference in naloxone prescribing pre- and post-training implementation. Descriptive statistics and paired t-tests were conducted to assess statistical significance. RESULTS Prior to training, 11 resident physicians (approximately 50%) agreed or strongly agreed that they felt knowledgeable about naloxone and approximately 70% (n = 15) felt confident identifying patients who would benefit from naloxone at discharge. Only 10% of resident physicians (n = 2) felt comfortable counseling patients on and administering naloxone during an overdose pre-training compared to 100% after training. Thirty-seven patients were discharged and counseled on naloxone use during the study period. CONCLUSION Pharmacist-driven naloxone training significantly increased physician knowledge and comfort prescribing naloxone and resulted in an increase in naloxone prescriptions upon discharge from an inpatient psychiatric unit.
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Affiliation(s)
- Farah Khorassani
- University of California Irvine School of Pharmacy and Pharmaceutical Sciences, Irvine, CA, USA.
| | - Gemma Espejo
- University of California Irvine School of Medicine, Irvine, CA, USA
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Lee YK, Gold MS, Blum K, Thanos PK, Hanna C, Fuehrlein BS. Opioid use disorder: current trends and potential treatments. Front Public Health 2024; 11:1274719. [PMID: 38332941 PMCID: PMC10850316 DOI: 10.3389/fpubh.2023.1274719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/29/2023] [Indexed: 02/10/2024] Open
Abstract
Opioid use disorder (OUD) is a major public health threat, contributing to morbidity and mortality from addiction, overdose, and related medical conditions. Despite our increasing knowledge about the pathophysiology and existing medical treatments of OUD, it has remained a relapsing and remitting disorder for decades, with rising deaths from overdoses, rather than declining. The COVID-19 pandemic has accelerated the increase in overall substance use and interrupted access to treatment. If increased naloxone access, more buprenorphine prescribers, greater access to treatment, enhanced reimbursement, less stigma and various harm reduction strategies were effective for OUD, overdose deaths would not be at an all-time high. Different prevention and treatment approaches are needed to reverse the concerning trend in OUD. This article will review the recent trends and limitations on existing medications for OUD and briefly review novel approaches to treatment that have the potential to be more durable and effective than existing medications. The focus will be on promising interventional treatments, psychedelics, neuroimmune, neutraceutical, and electromagnetic therapies. At different phases of investigation and FDA approval, these novel approaches have the potential to not just reduce overdoses and deaths, but attenuate OUD, as well as address existing comorbid disorders.
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Affiliation(s)
- Yu Kyung Lee
- Department of Psychiatry, Brigham and Women’s Hospital, Boston, MA, United States
| | - Mark S. Gold
- Department of Psychiatry, Washington University in St. Louis Euclid Ave, St. Louis, MO, United States
| | - Kenneth Blum
- Division of Addiction Research and Education, Center for Sports, Exercise, and Mental Health, Western University Health Sciences, Pomona, CA, United States
| | - Panayotis K. Thanos
- Behavioral Neuropharmacology and Neuroimaging Laboratory on Addictions, Department of Pharmacology and Toxicology, Jacobs School of Medicine and Biosciences, Clinical Research Institute on Addictions, State University of New York at Buffalo, Buffalo, NY, United States
| | - Colin Hanna
- Behavioral Neuropharmacology and Neuroimaging Laboratory on Addictions, Department of Pharmacology and Toxicology, Jacobs School of Medicine and Biosciences, Clinical Research Institute on Addictions, State University of New York at Buffalo, Buffalo, NY, United States
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Allen LD, Pollini RA, Vaglienti R, Powell D. Opioid Prescribing Patterns After Imposition of Setting-Specific Limits on Prescription Duration. JAMA HEALTH FORUM 2024; 5:e234731. [PMID: 38241057 PMCID: PMC10799257 DOI: 10.1001/jamahealthforum.2023.4731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 11/03/2023] [Indexed: 01/22/2024] Open
Abstract
Importance Despite their widespread adoption across the US, policies imposing one-size-fits-all limits on the duration of prescriptions for opioids have shown modest and mixed implications for prescribing. Objective To assess whether a prescription duration limit policy tailored to different clinical settings was associated with shorter opioid prescription lengths. Design, Setting, and Participants This cross-sectional study examined changes in opioid prescribing patterns for opioid-naive Medicaid enrollees aged 12 to 64 years before and after implementation of a statewide prescription duration limit policy in West Virginia in June 2018. Patients with cancer or Medicare coverage were excluded. The policy assigned a 7-day duration limit to opioid prescriptions for adults treated in outpatient hospital- or office-based practices, a 4-day limit for adults treated in emergency departments, and a 3-day limit for pediatric patients younger than 18 years regardless of clinical setting. Data were examined from January 1, 2017, through September 30, 2019, and data were analyzed from June 12 to October 30, 2023. Main Outcomes and Measures Whether a patient's initial opioid prescription was longer in days than the June 2018 policy limit for a given care setting before and after policy implementation. Interrupted time series models were used to calculate the association between the policy's implementation and outcomes. Results The analytic sample included 44 703 Medicaid enrollees (27 957 patients [62.5%] before policy implementation and 16 746 patients [37.5%] after policy implementation; mean [SD] age, 33.9 [13.4] years; 27 461 females [61.4%]). Among adults treated in outpatient hospital- or office-based settings, the duration limit policy was associated with a decrease of 8.83 (95% CI, -10.43 to -7.23) percentage points (P < .001), or a 56.8% relative reduction, in the proportion of prescriptions exceeding the 7-day limit. In the emergency department setting, the policy was associated with a decrease of 7.03 (95% CI, -10.38 to -3.68) percentage points (P < .001), a 37.5% relative reduction, in the proportion of prescriptions exceeding the 4-day limit. The proportion of pediatric opioid prescriptions longer than the 3-day limit decreased by 12.80 (95% CI, -17.31 to -8.37) percentage points (P < .001), a 26.5% relative reduction, after the policy's implementation. Conclusions and Relevance Results of this cross-sectional study suggest that opioid prescription duration limits tailored to different clinical settings are associated with reduced length of prescriptions for opioid-naive patients. Additional research is needed to evaluate whether these limits are associated with reductions in the incidence of opioid use disorder or with unintended consequences, such as shifts to illicit opioids.
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Affiliation(s)
- Lindsay D. Allen
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Robin A. Pollini
- Department of Epidemiology and Biostatistics, School of Public Health, West Virginia University, Morgantown
| | - Richard Vaglienti
- Center for Integrative Pain Management, West Virginia University, Morgantown
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12
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Brandeau ML. Responding to the US opioid crisis: leveraging analytics to support decision making. Health Care Manag Sci 2023; 26:599-603. [PMID: 37804456 DOI: 10.1007/s10729-023-09657-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 09/25/2023] [Indexed: 10/09/2023]
Abstract
The US is experiencing a severe opioid epidemic with more than 80,000 opioid overdose deaths occurring in 2022. Beyond the tragic loss of life, opioid use disorder (OUD) has emerged as a major contributor to morbidity, lost productivity, mounting criminal justice system costs, and significant social disruption. This Current Opinion article highlights opportunities for analytics in supporting policy making for effective response to this crisis. We describe modeling opportunities in the following areas: understanding the opioid epidemic (e.g., the prevalence and incidence of OUD in different geographic regions, demographics of individuals with OUD, rates of overdose and overdose death, patterns of drug use and associated disease outbreaks, and access to and use of treatment for OUD); assessing policies for preventing and treating OUD, including mitigation of social conditions that increase the risk of OUD; and evaluating potential regulatory and criminal justice system reforms.
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Affiliation(s)
- Margaret L Brandeau
- Department of Management Science and Engineering, Stanford University, Stanford, CA, USA.
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13
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Knudsen HK, Freeman PR, Oyler DR, Oser CB, Walsh SL. Scaling up overdose education and naloxone distribution in Kentucky: adoption and reach achieved through a "hub with many spokes" model. Addict Sci Clin Pract 2023; 18:72. [PMID: 38031180 PMCID: PMC10688494 DOI: 10.1186/s13722-023-00426-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 11/17/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Scaling up overdose education and naloxone distribution (OEND), an evidence-based practice for reducing opioid overdose mortality, in communities remains a challenge. Novel models and intentional implementation strategies are needed. Drawing upon the EPIS model's phases of Exploration, Preparation, Implementation, and Sustainment (Aarons et al. in Adm Policy Ment Health 38:4-23, 2011), this paper describes the development of the University of Kentucky's unique centralized "Naloxone Hub with Many Spokes" approach to implementing OEND as part of the HEALing Communities Study (HCS-KY). METHODS To scale up OEND in eight Kentucky counties, implementation strategies were utilized at two levels: a centralized university-based naloxone dispensing unit ("Naloxone Hub") and adopting organizations ("Many Spokes"). Implementation strategies varied across the EPIS phases, but heavily emphasized implementation facilitation. The Naloxone Hub provided technical assistance, overdose education resources, and no-cost naloxone to partner organizations. Implementation outcomes across the EPIS phases were measured using data from internal study management trackers and naloxone distribution data submitted by partner organizations. RESULTS Of 209 organizations identified as potential partners, 84.7% (n = 177) engaged in the Exploration/Preparation phase by participating in an initial meeting with an Implementation Facilitator about the HCS-KY OEND program. Adoption of the HCS-KY OEND program, defined as receipt of at least one shipment of naloxone, was achieved with 69.4% (n = 145) of all organizations contacted. During the Implementation phase, partner organizations distributed 40,822 units of naloxone, with partner organizations distributing a mean of 281.5 units of naloxone (SD = 806.2). The mean number of units distributed per county was 5102.8 (SD = 3653.3; range = 1057 - 11,053) and the mean county level distribution rate was 8396.5 units per 100,000 residents (SD = 8103.1; range = 1709.5-25,296.3). Of the partner organizations that adopted the HCS-KY OEND program, 87.6% (n = 127) attended a sustainability meeting with an Implementation Facilitator and agreed to transition to the state-funded naloxone program. CONCLUSIONS These data demonstrate the feasibility of this "Hub with Many Spokes" model for scaling up OEND in communities highly affected by the opioid epidemic. Trial registration ClinicalTrials.gov, NCT04111939. Registered 30 September 2019, https://clinicaltrials.gov/ct2/show/NCT04111939 .
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Affiliation(s)
- Hannah K Knudsen
- Department of Behavioral Science and Center on Drug & Alcohol Research, University of Kentucky, 845 Angliana Avenue, Room 204, Lexington, KY, 40508, USA.
| | - Patricia R Freeman
- Department of Pharmacy Practice and Science and Center for the Advancement of Pharmacy Practice, College of Pharmacy, University of Kentucky, Lexington, KY, 40536, USA
| | - Douglas R Oyler
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, 40536, USA
| | - Carrie B Oser
- Department of Sociology, Center on Drug & Alcohol Research, and Center for Health Equity Transformation, University of Kentucky, Lexington, KY, 40536, USA
| | - Sharon L Walsh
- Department of Behavioral Science and Center on Drug & Alcohol Research, University of Kentucky, 845 Angliana Avenue, Room 204, Lexington, KY, 40508, USA
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Lönn SL, Krauland MG, Fagan AA, Sundquist J, Sundquist K, Roberts MS, Kendler KS. The Impact of the Good Behavior Game on Risk for Drug Use Disorder in an Agent-Based Model of Southern Sweden. J Stud Alcohol Drugs 2023; 84:863-873. [PMID: 37650838 PMCID: PMC10765974 DOI: 10.15288/jsad.22-00413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 06/25/2023] [Indexed: 09/01/2023] Open
Abstract
OBJECTIVE Drug use disorder (DUD) is a worldwide problem, and strategies to reduce its incidence are central to decreasing its burden. This investigation seeks to provide a proof of concept for the ability of agent-based modeling to predict the impact of the introduction of an effective school-based intervention, the Good Behavior Game (GBG), on reducing DUD in Scania, Sweden, primarily through increasing school achievement. METHOD We modified an existing agent-based simulation model of opioid use disorder to represent DUD in Scania County, southern Sweden. The model represents every individual in the population and is calibrated with the linked individual data from multiple sources including demographics, education, medical care, and criminal history. Risks for developing DUD were estimated from the population in Scania. Scenarios estimated the impact of introducing the GBG in schools located in disadvantaged areas. RESULTS The model accurately reflected the growth of DUD in Scania over a multiyear period and reproduced the levels of affected individuals in various socioeconomic strata over time. The GBG was estimated to improve school achievement and lower DUD registrations over time in males residing in disadvantaged areas by 10%, reflecting a decrease of 540 cases of DUD. Effects were considerably smaller in females. CONCLUSIONS This work provides support for the impact of improving school achievement on long-term risks of developing DUD. It also demonstrated the value of using simulation modeling calibrated with data from a real population to estimate the impact of an intervention applied at a population level.
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Affiliation(s)
- Sara L. Lönn
- Center for Primary Health Care Research, Lund University, Malmö, Sweden
| | - Mary G. Krauland
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
- Public Health Dynamics Laboratory, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Abigail A. Fagan
- Department of Sociology and Criminology & Law, University of Florida, Gainesville, Florida
| | - Jan Sundquist
- Center for Primary Health Care Research, Lund University, Malmö, Sweden
- Department of Sociology and Criminology & Law, University of Florida, Gainesville, Florida
| | - Kristina Sundquist
- Center for Primary Health Care Research, Lund University, Malmö, Sweden
- Department of Family Medicine and Community Health, Icahn School of Medicine at Mount Sinai, New York, New York
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mark S. Roberts
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
- Public Health Dynamics Laboratory, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kenneth S. Kendler
- Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Richmond, Virginia
- Department of Psychiatry, Virginia Commonwealth University, Richmond, Virginia
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15
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Freeman PR, McAninch J, Dasgupta N, Oyler DR, Slavov K, Collins C, Hargrove S, Freeman E, Miracle D, Slavova S. Drugs involved in Kentucky drug poisoning deaths and relation with antecedent controlled substance prescription dispensing. Subst Abuse Treat Prev Policy 2023; 18:53. [PMID: 37658455 PMCID: PMC10474700 DOI: 10.1186/s13011-023-00561-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/21/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND The shift from prescription to illicit drugs involved in drug poisoning deaths raises questions about the current utility of prescription drug monitoring program (PDMP) data to inform drug poisoning (overdose) prevention efforts. In this study, we describe relations between specific drugs involved in Kentucky drug poisoning deaths and antecedent controlled substance (CS) dispensing. METHODS The study used linked death certificates and PDMP data for 2,248 Kentucky resident drug poisoning deaths in 2021. Death certificate literal text analysis identified drugs mentioned with involvement (DMI) in drug poisoning deaths. We characterized the concordance between each DMI and the CS dispensing history for this drug at varying timepoints since 2008. RESULTS Overall, 25.5% of all decedents had dispensed CS in the month before fatal drug poisoning. Over 80% of decedents were dispensed opioid(s) since 2008; the percentage was similar regardless of opioid involvement in the poisoning death. One-third of decedents had dispensed buprenorphine for treatment of opioid use disorder since 2008, but only 6.1% had dispensed buprenorphine in the month preceding death. Fentanyl/fentanyl analogs were DMI in 1,568 (69.8%) deaths, yet only 3% had received a fentanyl prescription since 2008. The highest concordance in the month preceding death was observed for clonazepam (43.6%). CONCLUSION Overall, concordance between CS dispensing history and the drugs involved in poisoning deaths was low, suggesting a need to reevaluate the complex relationships between prescription medication exposure and overdose death and to expand harm reduction interventions both within and outside the healthcare system to reduce drug poisoning mortality.
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Affiliation(s)
- Patricia R Freeman
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA.
| | - Jana McAninch
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Nabarun Dasgupta
- Injury Prevention Research Center, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Douglas R Oyler
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Krassimir Slavov
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Candice Collins
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Sarah Hargrove
- Kentucky Injury Prevention and Research Center, University of Kentucky, Lexington, KY, USA
| | - Edward Freeman
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Dustin Miracle
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Svetla Slavova
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY, USA
- Kentucky Injury Prevention and Research Center, University of Kentucky, Lexington, KY, USA
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Lemen PM, Garrett DP, Thompson E, Aho M, Vasquez C, Park JN. High-Dose Naloxone Formulations Are Not as Essential as We Thought. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.07.23293781. [PMID: 37645849 PMCID: PMC10462226 DOI: 10.1101/2023.08.07.23293781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Naloxone is a U.S. Food and Drug Administration (FDA) approved opioid antagonist for reversing opioid overdoses. Naloxone is available to the public, and can be administered through intramuscular (IM), intravenous (IV), and intranasal spray (IN) routes. Our literature review aimed to improve understanding regarding the adequacy of the regularly distributed two doses of low-dose IM or IN naloxone in effectively reversing fentanyl overdoses and whether high-dose naloxone formulations (HDNF) formulations are an optimal solution to this problem. Moreover, our initiative incorporated the perspectives and experiences of people who use drugs (PWUD), enabling a more practical and contextually-grounded analysis. We began by discussing the knowledge and perspectives of Tennessee Harm Reduction, a small peer-led harm reduction organization. A comprehensive literature review was then conducted to gather relevant scholarly works on the subject matter. The evidence indicates that, although higher doses of naloxone have been administered in both clinical and community settings, the vast majority of fentanyl overdoses can be successfully reversed using standard IM dosages with the exception of carfentanil overdoses and other more potent fentanyl analogs, which necessitate three or more doses for effective reversal. Multiple studies documented the risk of precipitated withdrawal using high doses of naloxone. Notably, the possibility of recurring overdose symptoms after resuscitation exists, contingent upon the half-life of the specific opioid. Considering these findings and the current community practice of distributing multiple doses, we recommend providing at least four standard doses of IN or IM naloxone to each potential bystander, and training them to continue administration until the recipient achieves stability, ensuring appropriate intervals between each dose. Based on the evidence, we do not recommend HDNF in the place of providing four doses of standard naloxone due to the higher cost, risk of precipitated withdrawal and limited evidence compared to standard IN and IM. All results must be taken into consideration with the inclusion of the lived experiences, individual requirements, and consent of PWUD as crucial factors. It is imperative to refrain from formulating decisions concerning PWUD in their absence, as their participation and voices should be integral to the decision-making process.
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Kehne A, Bernstein SJ, Thomas J, Bicket MC, Bohnert ASB, Madden EF, Powell VD, Lagisetty P. Improving Access to Care for Patients Taking Opioids for Chronic Pain: Recommendations from a Modified Delphi Panel in Michigan. J Pain Res 2023; 16:2321-2330. [PMID: 37456356 PMCID: PMC10348368 DOI: 10.2147/jpr.s406034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023] Open
Abstract
Purpose About 5-8 million US patients take long-term opioid therapy for chronic pain. In the context of policies and guidelines instituted to reduce inappropriate opioid prescribing, abrupt discontinuations in opioid prescriptions have increased and many primary care clinics will not prescribe opioids for new patients, reducing access to care. This may result in uncontrolled pain and other negative outcomes, such as transition to illicit opioids. The objective of this study was to generate policy, intervention, and research recommendations to improve access to care for these patients. Participants and Methods We conducted a RAND/UCLA Modified Delphi, consisting of workshops, background videos and reading materials, and moderated web-based panel discussions held September 2020-January 2021. The panel consisted of 24 individuals from across Michigan, identified via expert nomination and snowball recruitment, including clinical providers, health science researchers, state-level policymakers and regulators, care coordination experts, patient advocates, payor representatives, and community and public health experts. The panel proposed intervention, policy, and research recommendations, scored the feasibility, impact, and importance of each on a 9-point scale, and ranked all recommendations by implementation priority. Results The panel produced 11 final recommendations across three themes: reimbursement reform, provider education, and reducing racial inequities in care. The 3 reimbursement-focused recommendations were highest ranked (theme average = 4.2/11), including the two top-ranked recommendations: increasing reimbursement for time needed to treat complex chronic pain (ranked #1/11) and bundling payment for multimodal pain care (#2/11). Four provider education recommendations ranked slightly lower (theme average = 6.2/11) and included clarifying the spectrum of opioid dependence and training providers on multimodal treatments. Four recommendations addressed racial inequities (theme average = 7.2/11), such as standardizing pain management protocols to reduce treatment disparities. Conclusion Panelists indicated reimbursement should incentivize traditionally lower-paying evidence-based pain care, but multiple strategies may be needed to meaningfully expand access.
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Affiliation(s)
- Adrianne Kehne
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Steven J Bernstein
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Jennifer Thomas
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Mark C Bicket
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Amy S B Bohnert
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Erin Fanning Madden
- Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, Detroit, MI, USA
| | - Victoria D Powell
- Palliative Care Program, Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Geriatrics Research, Education, and Clinical Center, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI, USA
| | - Pooja Lagisetty
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
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Treitler P, Samples H, Hermida R, Crystal S. Association of a State Prescribing Limits Policy with Opioid Prescribing and Long-term Use: an Interrupted Time Series Analysis. J Gen Intern Med 2023; 38:1862-1870. [PMID: 36609812 PMCID: PMC10271990 DOI: 10.1007/s11606-022-07991-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 12/22/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Prescription opioids were a major initial driver of the opioid crisis. States have attempted to reduce overprescribing by enacting policies that limit opioid prescriptions, but the impacts of such policies on new prescribing and subsequent transitions to long-term use are not fully understood. OBJECTIVE To examine the association of implementation of a state prescribing limits policy with opioid prescribing and transitions to long-term opioid use. DESIGN Interrupted time series analyses assessing trends in new opioid prescriptions and long-term use before and after policy implementation. PATIENTS A total of 130,591 New Jersey Medicaid enrollees ages 18-64 who received an initial opioid prescription from January 2014 to December 2019. INTERVENTIONS New Jersey's opioid prescribing limit policy implemented in March 2017. MAIN MEASURES Total new opioid prescriptions, percentage of new prescriptions with >5 days' supply, and transition to long-term opioid use, defined as having opioid supply on day 90 after the initial prescription. KEY RESULTS Policy implementation was associated with a significant monthly increase in new opioid prescriptions of 0.86 per 10,000 enrollees, halving the pre-policy decline in the prescribing rate. Among new opioid prescriptions, the percentage with >5 days' supply decreased by about 1 percentage point (-0.76 percentage points, 95% CI -0.89, -0.62) following policy implementation. However, policy implementation was associated with a significant monthly increase in the rate of initial prescriptions with supply on day 90 (9.95 per 10,000 new prescriptions, 95% CI 4.80, 15.11) that reversed the downward pre-implementation trend. CONCLUSIONS The New Jersey policy was associated with a reduction in initial prescriptions with >5 days' supply, but not with an overall decline in new opioid prescriptions or in the rate at which initial prescriptions led to long-term use. Given their only modest benefits, policymakers and clinicians should carefully weigh potential unintended consequences of strict prescribing limits.
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Affiliation(s)
- Peter Treitler
- Institute for Health, Health Care Policy & Aging Research, Rutgers University, New Brunswick, NJ USA
- School of Social Work, Rutgers University, New Brunswick, NJ USA
| | - Hillary Samples
- Institute for Health, Health Care Policy & Aging Research, Rutgers University, New Brunswick, NJ USA
- School of Public Health, Rutgers University, Piscataway, NJ USA
| | - Richard Hermida
- Institute for Health, Health Care Policy & Aging Research, Rutgers University, New Brunswick, NJ USA
| | - Stephen Crystal
- Institute for Health, Health Care Policy & Aging Research, Rutgers University, New Brunswick, NJ USA
- School of Social Work, Rutgers University, New Brunswick, NJ USA
- School of Public Health, Rutgers University, Piscataway, NJ USA
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Chhatwal J, Mueller PP, Chen Q, Kulkarni N, Adee M, Zarkin G, LaRochelle MR, Knudsen AB, Barbosa C. Estimated Reductions in Opioid Overdose Deaths With Sustainment of Public Health Interventions in 4 US States. JAMA Netw Open 2023; 6:e2314925. [PMID: 37294571 PMCID: PMC10257094 DOI: 10.1001/jamanetworkopen.2023.14925] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 04/08/2023] [Indexed: 06/10/2023] Open
Abstract
Importance In 2021, more than 80 000 US residents died from an opioid overdose. Public health intervention initiatives, such as the Helping to End Addiction Long-term (HEALing) Communities Study (HCS), are being launched with the goal of reducing opioid-related overdose deaths (OODs). Objective To estimate the change in the projected number of OODs under different scenarios of the duration of sustainment of interventions, compared with the status quo. Design, Setting, and Participants This decision analytical model simulated the opioid epidemic in the 4 states participating in the HCS (ie, Kentucky, Massachusetts, New York, and Ohio) from 2020 to 2026. Participants were a simulated population transitioning from opioid misuse to opioid use disorder (OUD), overdose, treatment, and relapse. The model was calibrated using 2015 to 2020 data from the National Survey on Drug Use and Health, the US Centers for Disease Control and Prevention, and other sources for each state. The model accounts for reduced initiation of medications for OUD (MOUDs) and increased OODs during the COVID-19 pandemic. Exposure Increasing MOUD initiation by 2- or 5-fold, improving MOUD retention to the rates achieved in clinical trial settings, increasing naloxone distribution efforts, and furthering safe opioid prescribing. An initial 2-year duration of interventions was simulated, with potential sustainment for up to 3 additional years. Main Outcomes and Measures Projected reduction in number of OODs under different combinations and durations of sustainment of interventions. Results Compared with the status quo, the estimated annual reduction in OODs at the end of the second year of interventions was 13% to 17% in Kentucky, 17% to 27% in Massachusetts, 15% to 22% in New York, and 15% to 22% in Ohio. Sustaining all interventions for an additional 3 years was estimated to reduce the annual number of OODs at the end of the fifth year by 18% to 27% in Kentucky, 28% to 46% in Massachusetts, 22% to 34% in New York, and 25% to 41% in Ohio. The longer the interventions were sustained, the better the outcomes; however, these positive gains would be washed out if interventions were not sustained. Conclusions and Relevance In this decision analytical model study of the opioid epidemic in 4 US states, sustained implementation of interventions, including increased delivery of MOUDs and naloxone supply, was found to be needed to reduce OODs and prevent deaths from increasing again.
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Affiliation(s)
- Jagpreet Chhatwal
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Peter P. Mueller
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
| | - Qiushi Chen
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
- Harold and Inge Marcus Department of Industrial and Manufacturing Engineering, The Pennsylvania State University, University Park
| | - Neeti Kulkarni
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
| | - Madeline Adee
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
| | - Gary Zarkin
- RTI International, Research Triangle Park, North Carolina
| | - Marc R. LaRochelle
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Boston Medical Center, Boston, Massachusetts
| | - Amy B. Knudsen
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
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Davis MT, Bohler R, Hodgkin D, Hamilton G, Horgan C. The role of health plans in addressing the opioid crisis: A qualitative study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 149:209022. [PMID: 36935064 PMCID: PMC10198902 DOI: 10.1016/j.josat.2023.209022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 02/16/2023] [Accepted: 03/13/2023] [Indexed: 03/19/2023]
Abstract
INTRODUCTION Health plans are key players in substance use treatment in the United States, and the opioid crisis presents new challenges for them. This article is part of the HEALing Communities Study (HCS) funded by NIH, which seeks to facilitate communities' adoption of activities that might reduce overdose deaths, including overdose prevention education and naloxone distribution, medication for opioid use disorder, and safer opioid prescribing. We examine how health plans in one state (Massachusetts) are adapting to encourage and sustain activities that help communities to address opioid use disorder (OUD). METHODS We conducted semi-structured interviews with managers of behavioral health services at eight health plans in Massachusetts that that have Medicare, Medicaid, and commercial lines of business. Two plans in this sample contract with a specialized behavioral health organization ("carve-out"). The interviewees also completed a survey on policies regarding access to treatment and opioid prescribing. Interviews were recorded and transcribed and analyzed using thematic analysis. Analysis of the data included intended influence of the policies at three levels: member level (micro), group or community level (meso), and system or institutional level (macro). RESULTS All health plans developed strategies to increase access to treatment for OUD, primarily through eliminating or decreasing cost-sharing, eliminating pre-authorization for MOUD, and increasing supply of providers. Health plans encourage qualified practitioners to offer MOUD, but most do not provide incentives or training. Identifying high risk populations is a focus of health plans in this sample. Naloxone is a covered benefit in all health plans, although with variation in monthly limits and cost-sharing. Most health plans take measures to influence opioid prescribing. Health plans' activities are predominately aimed at the micro (member) level with little ability to influence at the macro (wider system-level changes). CONCLUSION This study provides insight into how health plans develop strategies to address the rise in OUD and fatal opioid overdoses, many of which are key in the HCS initiative. How active a role health plans play in addressing the opioid crisis varies, even within the insurance industry in one state (Massachusetts).
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Affiliation(s)
- Margot Trotter Davis
- Institute for Behavioral Health, Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, United States of America.
| | - Robert Bohler
- Institute for Behavioral Health, Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, United States of America
| | - Dominic Hodgkin
- Institute for Behavioral Health, Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, United States of America
| | - Greer Hamilton
- Boston University School of Social Work, United States of America
| | - Constance Horgan
- Institute for Behavioral Health, Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, United States of America
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21
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Richardson NJ, Ray B, Smiley-McDonald HM, Davis CS, Kral AH. National survey findings on law enforcement agency drug response practices, overdose victim outcomes, and Good Samaritan Laws. Drug Alcohol Depend 2023; 248:109916. [PMID: 37236060 DOI: 10.1016/j.drugalcdep.2023.109916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 05/05/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND The United States continues to experience unprecedented rates of overdose mortality. Addressing the overdose epidemic has been challenging for policy makers given the lack of effectiveness of existing drug control policy measures. More recently, the implementation of harm reduction-based policies such as Good Samaritan Laws has led to increasing scholarly attention aimed at evaluating their effectiveness at reducing the likelihood of criminal justice-related sanctions for individuals following an overdose incident. The results of these studies, however, have been mixed. METHODS This study utilizes data from a nationally representative survey of law enforcement agencies designed to provide national information on services, policies, practices, operations, and resources of law enforcement drug response around overdoses to assess whether state Good Samaritan Laws reduce the likelihood of overdose victims being cited or being jailed following an overdose incident. RESULTS In general, findings indicate that although most agencies reported that overdose victims were not incarcerated or cited following an overdose incident, that this did not vary by whether agencies were in a state that had a GSL arrest protection for possession of controlled substances. CONCLUSIONS GSLs are often written in complex and confusing language that officers and people who use drugs do not fully understand, which may deter their being used for their intended purpose. Although GSLs are well-intentioned, these findings highlight the need for training and education for law enforcement and people who use drugs around the scope of these laws.
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Affiliation(s)
- Nicholas J Richardson
- Division for Applied Justice Research, RTI International, Research Triangle Park, NC, USA.
| | - Bradley Ray
- Division for Applied Justice Research, RTI International, Research Triangle Park, NC, USA
| | - Hope M Smiley-McDonald
- Division for Applied Justice Research, RTI International, Research Triangle Park, NC, USA
| | - Corey S Davis
- Network for Public Health Law, Harm Reduction Legal Project, Los Angeles, CA, USA
| | - Alex H Kral
- Community Health Research Division, RTI International, Berkeley, CA, USA
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22
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Claypool AL, DiGennaro C, Russell WA, Yildirim MF, Zhang AF, Reid Z, Stringfellow EJ, Bearnot B, Schackman BR, Humphreys K, Jalali MS. Cost-effectiveness of Increasing Buprenorphine Treatment Initiation, Duration, and Capacity Among Individuals Who Use Opioids. JAMA HEALTH FORUM 2023; 4:e231080. [PMID: 37204803 PMCID: PMC10199347 DOI: 10.1001/jamahealthforum.2023.1080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 03/26/2023] [Indexed: 05/20/2023] Open
Abstract
Importance Buprenorphine is an effective and cost-effective medication to treat opioid use disorder (OUD), but is not readily available to many people with OUD in the US. The current cost-effectiveness literature does not consider interventions that concurrently increase buprenorphine initiation, duration, and capacity. Objective To conduct a cost-effectiveness analysis and compare interventions associated with increased buprenorphine treatment initiation, duration, and capacity. Design and Setting This study modeled the effects of 5 interventions individually and in combination using SOURCE, a recent system dynamics model of prescription opioid and illicit opioid use, treatment, and remission, calibrated to US data from 1999 to 2020. The analysis was run during a 12-year time horizon from 2021 to 2032, with lifetime follow-up. A probabilistic sensitivity analysis on intervention effectiveness and costs was conducted. Analyses were performed from April 2021 through March 2023. Modeled participants included people with opioid misuse and OUD in the US. Interventions Interventions included emergency department buprenorphine initiation, contingency management, psychotherapy, telehealth, and expansion of hub-and-spoke narcotic treatment programs, individually and in combination. Main Outcomes and Measures Total national opioid overdose deaths, quality-adjusted life years (QALYs) gained, and costs from the societal and health care perspective. Results Projections showed that contingency management expansion would avert 3530 opioid overdose deaths over 12 years, more than any other single-intervention strategy. Interventions that increased buprenorphine treatment duration initially were associated with an increased number of opioid overdose deaths in the absence of expanded treatment capacity. With an incremental cost- effectiveness ratio of $19 381 per QALY gained (2021 USD), the strategy that expanded contingency management, hub-and-spoke training, emergency department initiation, and telehealth was the preferred strategy for any willingness-to-pay threshold from $20 000 to $200 000/QALY gained, as it was associated with increased treatment duration and capacity simultaneously. Conclusion and Relevance This modeling analysis simulated the effects of implementing several intervention strategies across the buprenorphine cascade of care and found that strategies that were concurrently associated with increased buprenorphine treatment initiation, duration, and capacity were cost-effective.
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Affiliation(s)
- Anneke L. Claypool
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - Catherine DiGennaro
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - W. Alton Russell
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
- School of Population and Global Health, McGill University, Montreal, Quebec, Canada
| | - Melike F. Yildirim
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - Alan F. Zhang
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - Zuri Reid
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - Erin J. Stringfellow
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - Benjamin Bearnot
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
| | - Bruce R. Schackman
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Keith Humphreys
- Veterans Affairs and Stanford University Medical Centers, Palo Alto, California
| | - Mohammad S. Jalali
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
- MIT Sloan School of Management, Cambridge, Massachusetts
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23
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Butler C, Stechlinski P. Modeling Opioid Abuse: A Case Study of the Opioid Crisis in New England. Bull Math Biol 2023; 85:45. [PMID: 37088864 PMCID: PMC10122875 DOI: 10.1007/s11538-023-01148-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 03/22/2023] [Indexed: 04/25/2023]
Abstract
For the past two decades, the USA has been embroiled in a growing prescription drug epidemic. The ripples of this epidemic have been especially apparent in the state of Maine, which has fought hard to mitigate the damage caused by addiction to pharmaceutical and illicit opioids. In this study, we construct a mathematical model of the opioid epidemic incorporating novel features important to better understanding opioid abuse dynamics. These features include demographic differences in population susceptibility, general transmission expressions, and combined consideration of pharmaceutical opioid and heroin abuse. We demonstrate the usefulness of this model by calibrating it with data for the state of Maine. Model calibration is accompanied by sensitivity and uncertainty analysis to quantify potential error in parameter estimates and forecasts. The model is analyzed to determine the mechanisms most influential to the number of opioid abusers and to find effective ways of controlling opioid abuse prevalence. We found that the mechanisms most influential to the overall number of abusers in Maine are those involved in illicit pharmaceutical opioid abuse transmission. Consequently, preventative strategies that controlled for illicit transmission were more effective over alternative approaches, such as treatment. These results are presented with the hope of helping to inform public policy as to the most effective means of intervention.
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Affiliation(s)
- Cole Butler
- Department of Mathematics and Statistics, University of Maine, 5752 Neville Hall, Orono, ME, 04469, USA
| | - Peter Stechlinski
- Department of Mathematics and Statistics, University of Maine, 5752 Neville Hall, Orono, ME, 04469, USA.
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24
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CERDÁ MAGDALENA, KRAWCZYK NOA, KEYES KATHERINE. The Future of the United States Overdose Crisis: Challenges and Opportunities. Milbank Q 2023; 101:478-506. [PMID: 36811204 PMCID: PMC10126987 DOI: 10.1111/1468-0009.12602] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
Policy Points People are dying at record numbers from overdose in the United States. Concerted action has led to a number of successes, including reduced inappropriate opioid prescribing and increased availability of opioid use disorder treatment and harm-reduction efforts, yet ongoing challenges include criminalization of drug use and regulatory and stigma barriers to expansion of treatment and harm-reduction services. Priorities for action include investing in evidence-based and compassionate policies and programs that address sources of opioid demand, decriminalizing drug use and drug paraphernalia, enacting policies to make medication for opioid use disorder more accessible, and promoting drug checking and safe drug supply.
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Affiliation(s)
- MAGDALENA CERDÁ
- Center for Opioid Epidemiology and PolicyNYU Grossman School of Medicine
| | - NOA KRAWCZYK
- Center for Opioid Epidemiology and PolicyNYU Grossman School of Medicine
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Brothers S, Palayew A, Simon C, Coulter A, Strichartz K, Voyles N, Vincent L. Patient experiences of methadone treatment changes during the first wave of COVID-19: a national community-driven survey. Harm Reduct J 2023; 20:31. [PMID: 36894968 PMCID: PMC9996563 DOI: 10.1186/s12954-023-00756-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/13/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND During COVID-19, the Substance Abuse and Mental Health Services Administration (SAMHSA) allowed Methadone Maintenance Treatment (MMT) programs to relax in-person MMT requirements to reduce COVID-19 exposure. This study examines patient-reported changes to in-person methadone clinic attendance requirements during COVID-19. METHODS From June 7, 2020, to July 15, 2020, a convenience sample of methadone patients (N = 392) were recruited in collaboration with National Survivors Union (NSU) in 43 states and Washington D.C. through social media (Facebook, Reddit, Twitter, and Web site pop-ups). The community-driven research (CDR) online survey collected information on how patient take-home methadone dosing and in-person drug testing, counseling, and clinic visit frequency changed prior to COVID-19 (before March 2020) to during COVID-19 (June and July 2020). RESULTS During the study time period, the percentage of respondents receiving at least 14 days of take-home doses increased from 22 to 53%, while the percentage receiving one or no take-home doses decreased from 22.4% before COVID-19 to 10.2% during COVID-19. In-person counseling attendance decreased from 82.9% to 19.4%. While only 3.3% of respondents accessed counseling through telehealth before COVID-19, this percentage increased to 61.7% during COVID-19. Many respondents (41.3%) reported visiting their clinics in person once a week or more during COVID-19. CONCLUSIONS During the first wave of COVID-19, methadone patients report decreased in-person clinic attendance and increased take-home doses and use of telehealth for counseling services. However, respondents reported considerable variations, and many were still required to make frequent in-person clinic visits, which put patients at risk of COVID-19 exposure. Relaxations of MMT in-person requirements during COVID-19 should be consistently implemented and made permanent, and patient experiences of these changes should be explored further.
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Affiliation(s)
- Sarah Brothers
- Department of Sociology, Pennsylvania State University, University Park, USA.
| | - Adam Palayew
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Caty Simon
- Methadone Advocacy Working Group, National Survivors Union, Greensboro, NC, USA.,NC Survivors Union, Greensboro, NC, USA.,Whose Corner Is It Anyway, Holyoke, MA, USA
| | - Abby Coulter
- Methadone Advocacy Working Group, National Survivors Union, Greensboro, NC, USA
| | - Knina Strichartz
- Methadone Advocacy Working Group, National Survivors Union, Greensboro, NC, USA
| | - Nick Voyles
- Methadone Advocacy Working Group, National Survivors Union, Greensboro, NC, USA
| | - Louise Vincent
- Methadone Advocacy Working Group, National Survivors Union, Greensboro, NC, USA.,NC Survivors Union, Greensboro, NC, USA
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26
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Ramdin C, Chandran K, Nelson L, Mazer-Amirshahi M. Trends in naloxone prescribed at emergency department discharge: A national analysis (2012-2019). Am J Emerg Med 2023; 65:162-167. [PMID: 36638613 DOI: 10.1016/j.ajem.2023.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 12/22/2022] [Accepted: 01/03/2023] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND While having access to naloxone is recommended for patients at risk for opioid overdose, little is known about trends in national naloxone prescribing rates in emergency departments (EDs) both for co-prescription with opioids and for patients who presented with opioid abuse or overdose. This study aims to evaluate the change in naloxone prescribing and opioid/naloxone co-prescribing at discharge using national data. METHODS We conducted an IRB exempt retrospective review of data collected by the National Hospital Ambulatory Medical Care Survey from 2012 to 2019. The primary outcome was trend in rate of naloxone prescribing at discharge from ED visits. We also computed the proportion of visits where naloxone was both administered in the ED and prescribed at discharge, where naloxone and opioids were co-prescribed at discharge, and where an opioid was administered during the ED visit and naloxone was prescribed at discharge. All data were summarized using descriptive statistics and Spearman's Rho (SR) or Pearson's correlation (PR) were used to describe trends. RESULTS There was an estimated total of 250,365 patient visits where naloxone was prescribed at discharge with an increasing rate over time (0% of all ED visits in 2012 to 0.075% in 2019, p = 0.002). There were also increases in naloxone being both administered in the ED and prescribed at discharge (PC: 0.8, p = 0.02) as well as in naloxone and opioid co-prescribing (SR: 0.76, P = 0.03). There was an increase in utilization of opioids during the ED visit and naloxone prescribing at discharge for the same visit (SR: 0.80, p = 0.02). CONCLUSION There are increases in naloxone prescribing at discharge, naloxone and opioid co-prescribing, and opioid utilization during the same visit where naloxone is prescribed at discharge. Future studies should be done to confirm such trends, and targeted interventions should be put into place to increase access to this life-saving antidote.
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Affiliation(s)
- Christine Ramdin
- Rutgers New Jersey Medical School, Department of Emergency Medicine, United States.
| | - Kira Chandran
- Georgetown University, School of Medicine, United States
| | - Lewis Nelson
- Rutgers New Jersey Medical School, Department of Emergency Medicine, United States
| | - Maryann Mazer-Amirshahi
- Georgetown University, School of Medicine, United States; Department of Emergency Medicine, MedStar Washington Hospital Center, United States
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27
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Bohler RM, Freeman PR, Villani J, Hunt T, Linas BS, Walley AY, Green TC, Lofwall MR, Bridden C, Frazier LA, Fanucchi LC, Talbert JC, Chandler R. The policy landscape for naloxone distribution in four states highly impacted by fatal opioid overdoses. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 6:100126. [PMID: 36643788 PMCID: PMC9838196 DOI: 10.1016/j.dadr.2022.100126] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Expanding access to naloxone is one of the most impactful interventions in decreasing opioid-related mortality. However, state distribution rates of naloxone are insufficient to meet community need. The current study sought to better understand this gap by focusing on state policies that may facilitate or impede naloxone distribution in four states highly impacted by fatal opioid overdoses - Kentucky, Massachusetts, New York, and Ohio. Methods We provide a descriptive analysis of the policy landscape impacting naloxone distribution through pharmacy and community channels in the four states participating in the HEALing Communities Study (HCS). Publicly available data and the expertise of the research team were used to describe each state's naloxone access laws (NALs), Medicaid coverage of naloxone, and community overdose education and naloxone distribution infrastructure. Data presented in this study represent the most current policy landscape through September 2022. Results Variation exists between specific components of the NALs of each state, the structure of Medicaid coverage of naloxone, and the community distribution infrastructure networks. Massachusetts and New York have a statewide standing order, but other states use different strategies short of a statewide standing order to expand access to naloxone. Quantity limits specific to naloxone may limit access to Medicaid beneficiaries in some states. Conclusion States participating in the HCS have developed innovative but different mechanisms to ensure naloxone access. Policies were dynamic and moved towards greater access. Research should consider the policy landscape in the implementation and sustainability of interventions as well as the analysis of outcomes.
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Affiliation(s)
- Robert M. Bohler
- Institute for Behavioral Health, Brandeis University, 415 South Street, Waltham, MA 02453, United States,Corresponding author. (R.M. Bohler)
| | - Patricia R. Freeman
- Department of Pharmacy Practice and Science, University of Kentucky, Lexington, KY, United States
| | - Jennifer Villani
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD, United States
| | - Tim Hunt
- School of Social Work, Social Intervention Group (SIG), Center for Healing of Opioid and Other Substance Use Disorders (CHOSEN), Columbia University, New York, NY, United States
| | - Beth S. Linas
- RTI International, Research Triangle Park, NC, United States
| | - Alexander Y. Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, United States
| | - Traci C. Green
- Institute for Behavioral Health, Brandeis University, 415 South Street, Waltham, MA 02453, United States
| | - Michelle R. Lofwall
- Departments of Behavioral Science and Psychiatry, Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Carly Bridden
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, United States
| | - Lisa A. Frazier
- Center for Health Outcomes and Policy Evaluation Studies, College of Public Health, The Ohio State University, Columbus, OH, United States
| | - Laura C. Fanucchi
- Department of Internal Medicine, Division of Infectious Disease, Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Jeffery C. Talbert
- Institute for Biomedical Informatics, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Redonna Chandler
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD, United States
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28
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Rodriguez RD, Dailey Govoni T, Rajagopal V, Green JL. Evaluating the effectiveness of reformulated extended-release oxycodone with abuse-deterrent properties on reducing non-oral abuse among individuals assessed for substance abuse treatment with the Addiction Severity Index-Multimedia Version (ASI-MV). Curr Med Res Opin 2023; 39:579-587. [PMID: 36762423 DOI: 10.1080/03007995.2023.2178080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
OBJECTIVE Original brand extended-release (ER) oxycodone tablets (OC) for oral use were reformulated (ORF) with abuse-deterrent properties (ADP) against inhalation and injection routes in August 2010. This product transition provided an opportunity to compare "before and after" reformulation abuse trends. Our goal was to assess the change in abuse of brand oxycodone ER from before and after introduction of ORF. METHODS Change in self-reported non-oral "OxyContin®" abuse in the previous 30 days during 2 years pre- and 4 years post-reformulation was assessed among adults evaluated for substance use and treatment planning using the Addiction Severity Index-Multimedia Version (ASI-MV®). Comparator opioids were used to provide a frame of reference for changes in abuse due to competing population-level opioid abuse interventions and other factors unrelated to the reformulation. A proportion (PR) and abuse report dispensing ratio (ARDR) are reported because a single measure of abuse has not been identified that can optimally describe opioid abuse or changes in opioid abuse. RESULTS Interrupted time-series analyses indicated an immediate decline in non-oral abuse measures post-reformulation (PR=-52.1%; ARDR=-32.2%). Significant decreases from pre- to post-reformulation in non-oral abuse overall were observed (PR [95% CI]=-30.7% [-46.9%, -9.5%]; ARDR=-29.3% [-37.5%, -20.1%]). Comparator opioids did not demonstrate similar trends over the period. CONCLUSIONS Methodology applied in this study suitably assessed the effectiveness of an ADP product. Among individuals assessed for substance use, a differential decline in non-oral abuse of brand ER oxycodone was observed since introduction of ORF.
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Affiliation(s)
| | | | | | - Jody L Green
- Inflexxion, A Division of Uprise Health, Irvine, CA, USA
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29
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Spadaro A, Agarwal AK, Sangha HK, Perrone J, Delgado MK, Lowenstein M. Motivation to Carry Naloxone: A Qualitative Analysis of Emergency Department Patients. Am J Health Promot 2023; 37:200-209. [PMID: 35686433 PMCID: PMC9949384 DOI: 10.1177/08901171221107908] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Our aim was to explore perspectives of patients who received naloxone in the emergency department (ED) about (1) naloxone carrying and use following an ED visit and (2) motivation for performing these behaviors. DESIGN Semi-structured interviews of patients prescribed naloxone at ED discharge. SETTINGS Three urban academic EDs in Philadelphia, PA. PARTICIPANTS 25 participants completed the in-depth, semi-structured interviews and demographic surveys. Participants were majority male, African American, and had previously witnessed or experienced an overdose. METHODS Interviews were recorded, transcribed and analyzed using content analysis. We used a hybrid inductive-deductive approach that included prespecified and emergent themes. RESULTS We found that naloxone carrying behavior was variable and influenced by four main motivators: (1) naloxone access; (2) personal experience and salience of naloxone, (3) comfort with naloxone administration, and (4) societal influences on naloxone carrying. In particular, those with personal history of overdose or close friends or family at risk were motivated to carry naloxone. CONCLUSIONS Participants in this study reported several important motivators for naloxone carrying after an ED visit, including ease of naloxone access and comfort, perceived risk of experiencing or encountering an overdose, and social influences on naloxone carrying behaviors. EDs, health systems, and public health officials should consider these factors influencing motivation when designing future interventions to increase access, carrying, and use of naloxone.
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Affiliation(s)
- Anthony Spadaro
- Department of Emergency Medicine, Perelman School of Medicine and the Center for Public Health Initiatives at the University of Pennsylvania, Philadelphia, PA, USA
| | - Anish K. Agarwal
- Department of Emergency Medicine, Perelman School of Medicine the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Hareena K. Sangha
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Mucio Kit Delgado
- Department of Emergency Medicine, Perelman School of Medicine the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Margaret Lowenstein
- Division of General Internal Medicine, Perelman School of Medicine and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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Abstract
INTRODUCTION The opioid epidemic has evolved into a combined stimulant epidemic, with escalating stimulant and fentanyl-related overdose deaths. Primary care providers are on the frontlines grappling with patients' methamphetamine use. Although effective models exist for treating opioid use disorder in primary care, little is known about current clinical practices for methamphetamine use. METHODS Six semistructured group interviews were conducted with 38 primary care providers. Interviews focused on provider perceptions of patients with methamphetamine use problems and their care. Data were analyzed using inductive and thematic analysis and summarized along the following dimensions: (1) problem identification, (2) clinical management, (3) barriers and facilitators to care, and (4) perceived needs to improve services. RESULTS Primary care providers varied in their approach to identifying and treating patient methamphetamine use. Unlike opioid use disorders, providers reported lacking standardized screening measures and evidence-based treatments, particularly medications, to address methamphetamine use. They seek more standardized screening tools, Food and Drug Administration-approved medications, reliable connections to addiction medicine specialists, and more training. Interest in novel behavioral health interventions suitable for primary care settings was also noteworthy. CONCLUSIONS The findings from this qualitative analysis revealed that primary care providers are using a wide range of tools to screen and treat methamphetamine use, but with little perceived effectiveness. Primary care faces multiple challenges in effectively addressing methamphetamine use among patients singularly or comorbid with opioid use disorders, including the lack of Food and Drug Administration-approved medications, limited patient retention, referral opportunities, funding, and training for methamphetamine use. Focusing on patients' medical issues using a harm reduction, motivational interviewing approach, and linkage with addiction medicine specialists may be the most reasonable options to support primary care in compassionately and effectively managing patients who use methamphetamines.
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Bresett JW, Kruse-Diehr AJ. Medications for Opioid Use Disorder in Rural United States: A Critical Review of the Literature, 2004-2021. Subst Use Misuse 2023; 58:111-118. [PMID: 36420639 DOI: 10.1080/10826084.2022.2149244] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The opioid epidemic continues to be problematic in the United States (US). Medications for opioid use disorder (MOUD) are a commonly used evidence-based approach to treating affected individuals, but little is known about its use in the rural US. We reviewed published literature and summarized access, barriers, and approaches to MOUD delivery in rural areas. METHODS We conducted a search using databases in EBSCOhost, such as Academic Search Complete, Medline, and APA PsycArticles, using a priori aims. Articles published after 2004 were included if they were cross-sectional, analyzed secondary data, collected quantitative or qualitative primary data, were longitudinal or reported intervention results. Studies were excluded if they were conducted outside the US or did not present data. RESULTS A total of 13 articles met all criteria. Themes from the articles included increase in rural areas with waivered physicians able to prescribe buprenorphine, barriers to physician prescribing, waivered physicians choosing not to prescribe, and inability to assess quality of MOUD practices in rural US settings. CONCLUSIONS Additional studies of MOUD delivery in rural areas are needed to help explicate themes found in this review. Having a stronger understanding of prescribers operating practices and program roll-out in rural areas may help address some identified barriers and deliver a stronger quality treatment practice for individuals with substance-use disorder.
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Affiliation(s)
- John W Bresett
- School of Human Sciences, Southern Illinois University at Carbondale, Carbondale, Illinois, USA
| | - Aaron J Kruse-Diehr
- Department of Family and Community Medicine, University of Kentucky College of Medicine, Lexington, Kentucky, USA
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Pamplin JR, Rouhani S, Davis CS, King C, Townsend TN. Persistent Criminalization and Structural Racism in US Drug Policy: The Case of Overdose Good Samaritan Laws. Am J Public Health 2023; 113:S43-S48. [PMID: 36696623 PMCID: PMC9877371 DOI: 10.2105/ajph.2022.307037] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2022] [Indexed: 01/26/2023]
Abstract
The US overdose crisis continues to worsen and is disproportionately harming Black and Hispanic/Latino people. Although the "War on Drugs" continues to shape drug policy-at the disproportionate expense of Black and Hispanic/Latino people-states have taken some steps to reduce War on Drugs-related harms and adopt a public health-centered approach. However, the rhetoric regarding these changes has, in many cases, outstripped reality. Using overdose Good Samaritan Laws (GSLs) as a case study, we argue that public health-oriented policy changes made in some states are undercut by the broader enduring environment of a structurally racist drug criminalization agenda that continues to permeate and constrict most attempts at change. Drawing from our collective experiences in public health research and practice, we describe 3 key barriers to GSL effectiveness: the narrow parameters within which they apply, the fact that they are subject to police discretion, and the passage of competing laws that further criminalize people who use illicit drugs. All reveal a persisting climate of drug criminalization that may reduce policy effectiveness and explain why current reforms may be destined for failure and further disadvantage Black and Hispanic/Latino people who use drugs. (Am J Public Health. 2023;113(S1):S43-S48. https://doi.org/10.2105/AJPH.2022.307037).
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Affiliation(s)
- John R Pamplin
- John R. Pamplin II is with the Department of Epidemiology, Columbia University Mailman School of Public Health, and the Center for Opioid Epidemiology and Policy, New York University Grossman School of Medicine, New York, NY. Saba Rouhani is with the Department of Epidemiology at the New York University School of Global Public Health, New York, NY, and the Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Corey S. Davis is with the Center for Opioid Epidemiology and Policy, New York University Grossman School of Medicine, New York, NY, and the Network for Public Health Law, Edina, MN. Carla King is with the Center for Opioid Epidemiology and Policy, New York University Grossman School of Medicine, New York, NY. Tarlise N. Townsend is with the Center for Opioid Epidemiology and Policy, New York University Grossman School of Medicine, and the New York University Rory Meyers College of Nursing, New York, NY
| | - Saba Rouhani
- John R. Pamplin II is with the Department of Epidemiology, Columbia University Mailman School of Public Health, and the Center for Opioid Epidemiology and Policy, New York University Grossman School of Medicine, New York, NY. Saba Rouhani is with the Department of Epidemiology at the New York University School of Global Public Health, New York, NY, and the Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Corey S. Davis is with the Center for Opioid Epidemiology and Policy, New York University Grossman School of Medicine, New York, NY, and the Network for Public Health Law, Edina, MN. Carla King is with the Center for Opioid Epidemiology and Policy, New York University Grossman School of Medicine, New York, NY. Tarlise N. Townsend is with the Center for Opioid Epidemiology and Policy, New York University Grossman School of Medicine, and the New York University Rory Meyers College of Nursing, New York, NY
| | - Corey S Davis
- John R. Pamplin II is with the Department of Epidemiology, Columbia University Mailman School of Public Health, and the Center for Opioid Epidemiology and Policy, New York University Grossman School of Medicine, New York, NY. Saba Rouhani is with the Department of Epidemiology at the New York University School of Global Public Health, New York, NY, and the Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Corey S. Davis is with the Center for Opioid Epidemiology and Policy, New York University Grossman School of Medicine, New York, NY, and the Network for Public Health Law, Edina, MN. Carla King is with the Center for Opioid Epidemiology and Policy, New York University Grossman School of Medicine, New York, NY. Tarlise N. Townsend is with the Center for Opioid Epidemiology and Policy, New York University Grossman School of Medicine, and the New York University Rory Meyers College of Nursing, New York, NY
| | - Carla King
- John R. Pamplin II is with the Department of Epidemiology, Columbia University Mailman School of Public Health, and the Center for Opioid Epidemiology and Policy, New York University Grossman School of Medicine, New York, NY. Saba Rouhani is with the Department of Epidemiology at the New York University School of Global Public Health, New York, NY, and the Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Corey S. Davis is with the Center for Opioid Epidemiology and Policy, New York University Grossman School of Medicine, New York, NY, and the Network for Public Health Law, Edina, MN. Carla King is with the Center for Opioid Epidemiology and Policy, New York University Grossman School of Medicine, New York, NY. Tarlise N. Townsend is with the Center for Opioid Epidemiology and Policy, New York University Grossman School of Medicine, and the New York University Rory Meyers College of Nursing, New York, NY
| | - Tarlise N Townsend
- John R. Pamplin II is with the Department of Epidemiology, Columbia University Mailman School of Public Health, and the Center for Opioid Epidemiology and Policy, New York University Grossman School of Medicine, New York, NY. Saba Rouhani is with the Department of Epidemiology at the New York University School of Global Public Health, New York, NY, and the Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Corey S. Davis is with the Center for Opioid Epidemiology and Policy, New York University Grossman School of Medicine, New York, NY, and the Network for Public Health Law, Edina, MN. Carla King is with the Center for Opioid Epidemiology and Policy, New York University Grossman School of Medicine, New York, NY. Tarlise N. Townsend is with the Center for Opioid Epidemiology and Policy, New York University Grossman School of Medicine, and the New York University Rory Meyers College of Nursing, New York, NY
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Animal Control and Field Services Officers' Perspectives on Community Engagement: A Qualitative Phenomenology Study. Animals (Basel) 2022; 13:ani13010068. [PMID: 36611678 PMCID: PMC9817778 DOI: 10.3390/ani13010068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/19/2022] [Accepted: 12/22/2022] [Indexed: 12/28/2022] Open
Abstract
Very little is known about the prevalence, scope, and methods of community engagement employed by animal control and field services officers to address the issue of animal cruelty and neglect. This study used a phenomenological approach to understand how officers defined community engagement. The researchers conducted semi-structured interviews with twenty-nine animal control and field services officers. The definitions of community engagement varied greatly across this sample of U.S. officers. However, most officers agreed that strategies such as relationship-building, providing assistance or information, and allowing time for compliance were among the most effective community engagement strategies. In addition, several barriers to incorporating community engagement strategies in the work of animal control professionals were identified. Future research and policymaking should seek to establish a consistent definition of community engagement in animal control and field services that can then be optimized for specific communities through rigorous evaluation.
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Eller AJ, DiDomizio EE, Madden LM, Oliva JD, Altice FL, Johnson KA. Strengthening systems of care for people with or at risk for HIV, HCV and opioid use disorder: a call for enhanced data collection. Ann Med 2022; 54:1714-1724. [PMID: 35775786 PMCID: PMC9377256 DOI: 10.1080/07853890.2022.2084154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
BACKGROUND The syndemic between opioid use disorder (OUD), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) results in excessive burdens on the healthcare system. Integrating these siloed systems of care is critical to address all three conditions adequately. In this implementation project, we assessed the data capacity of the health system to measure a cascade of care (COC) across HIV, HCV and OUD services in five states to help guide public health planning. MATERIALS AND METHODS Data for this study were gathered from publicly available datasets and reports from government (SAMSHA, CMS, HRSA and CDC) sites. We created, where possible, COCs for HIV, HCV, and OUD spanning population estimate, diagnosis, treatment initiation, treatment retention, and patient outcomes for each of five states in the study. RESULTS The process of data collection showed that baseline COCs examining the intersections of OUD, HIV, and HCV cannot be produced and that there are missing data in all states examined. Collection of specific data points is not consistent across all states. States are better at reporting HIV cascades due to federal requirements. Only gross estimates could be made for OUD cascades in all states because data are separated by payer source, leaving no central point of data collection from all sources. Data for HCV were not publicly available. CONCLUSION It is difficult to assess the strategies needed or the progress made towards increasing treatment access and decreasing the burden of disease without the ability to construct an accurate baseline. Using integrated COCs with relevant benchmarks can not only guide public health planning, but also provide meaningful targets for intervention.KEY MESSAGESWhile HIV COCs are available for most states at least annually, they are not disaggregated for populations with co-occurring OUD or HCV.Data to calculate HCV COC are not available and data to calculate OUD COC are partially available, but only for specific payers.States do not have systems in place to measure the scope of the syndemic or to identify targets for quality improvement activities.
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Affiliation(s)
- Anthony J. Eller
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- CONTACT Anthony J. Eller Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Elizabeth E. DiDomizio
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Lynn M. Madden
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jennifer D. Oliva
- Department of Mental Health Law & Policy, University of South Florida, Tampa, FL, USA
| | - Frederick L. Altice
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Kimberly A. Johnson
- Center for Health & Pharmaceutical Law, Seton Hall University School of Law, Newark, NJ, USA
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Han X, Li H, Tang YL, Palfrey J, Zhu J. The association of state-level drug and opioid overdose deaths with the capacity of behavioural health professionals in the United States. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:e4585-e4593. [PMID: 35715970 DOI: 10.1111/hsc.13862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 03/31/2022] [Accepted: 05/05/2022] [Indexed: 06/15/2023]
Abstract
As behavioural health occupations have diversified, more specialists such as social workers and counsellors are involved in providing substance use disorder treatment services. This study examined the association between changes in the number of different types of behavioural health professionals and changes in drug and opioid overdose deaths in the United States. Using publicly available state-level data from 2008 to 2017, we constructed multivariate linear regression models with state- and year fixed-effects to examine the effect of changes in the number of different types of behavioural health professionals (i.e. psychiatrists, psychologists, social workers and counsellors) on changes in drug and opioid overdose deaths at the state level, controlling for state population characteristics and other state-level factors. After controlling for confounding factors, a 1% increase in the number of social workers and counsellors at the state level was significantly associated with a 0.215% reduction in drug overdose deaths per 100,000 state population and with a 0.358% reduction in opioid overdose deaths per 100,000 state population. We did not find statistically significant associations between changes in drug overdose death rates and increases in the number of psychiatrists or psychologists alone. Our findings suggest efforts to facilitate a prepared and skilled workforce, such as expanding the capacity of social workers and counsellors, to maximise access to substance use disorder treatment services.
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Affiliation(s)
- Xinxin Han
- School of Public Health and Emergency Management, Southern University of Science and Technology, Shenzhen, China
| | - Huihui Li
- School of Economics and Wang Yanan Institute for Studies in Economics, Xiamen University, Xiamen, China
| | - Yi-Lang Tang
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Emory University, Georgia
- Mental Health Service Line, Atlanta VA Medical Center, Decatur, Georgia, USA
| | - Judith Palfrey
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jiming Zhu
- Vanke School of Public Health, Tsinghua University, Beijing, China
- Institute for Healthy China, Tsinghua University, Beijing, China
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Hussain M, Ahmad SZ, Visvizi A. Government regulation and organizational effectiveness in the health-care supply chain. TRANSFORMING GOVERNMENT- PEOPLE PROCESS AND POLICY 2022. [DOI: 10.1108/tg-06-2022-0090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
In the context of the debate on ensuring health-care efficiency, this study aims to identify and prioritize factors and subfactors that influence organizational effectiveness (OE) in the health-care supply chain.
Design/methodology/approach
For the purpose of this qualitative study, triangulation was applied to identify, explore and systematically analyze the OE-related practices used by diverse stakeholders along the health-care supply chain. Sixty-two OE practices were thus identified. Subsequently, these were grouped in six different nodes before the analytical hierarchical process (AHP) was used to identify the weightings of specific practices (and related factors) and their impact on OE.
Findings
The findings suggest that external factors associated with government regulation, including government directives and branding, are the most critical factors that influence OE-related practices, while cost-related factors are the least important.
Originality/value
The originality of this study derives from the introduction of system theory supported by a modified supplier-input-process-output-customer (SIPOC) framework. Two important factors – government regulation and branding – have been introduced to the existing SIPOC chart as a valuable process structure for the health-care chain.
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Monnat SM. Demographic and Geographic Variation in Fatal Drug Overdoses in the United States, 1999-2020. THE ANNALS OF THE AMERICAN ACADEMY OF POLITICAL AND SOCIAL SCIENCE 2022; 703:50-78. [PMID: 37366474 PMCID: PMC10292656 DOI: 10.1177/00027162231154348] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
The U.S. drug overdose crisis has been described as a national disaster that has affected all communities. But overdose rates are higher among some subpopulations and in some places than they are in others. This article describes demographic (sex, racial/ethnic, age) and geographic variation in fatal drug overdose rates in the United States from 1999 to 2020. Across most of that timespan, rates were highest among young and middle-age (25-54 years) White and American Indian males and middle-age and older (45+ years) Black males. Rates have been consistently high in Appalachia, but the crisis has spread to several other regions in recent years, and rates are high across the urban-rural continuum. Opioids have been the main contributor, but overdoses involving cocaine and psychostimulants have also increased dramatically in recent years, demonstrating that our problem is bigger than opioids. Evidence suggests that supply-side interventions are unlikely to be effective in reducing overdoses. I argue that the U.S. should invest in policies that address the upstream structural drivers of the crisis.
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Affiliation(s)
- Shannon M Monnat
- Lerner Chair in Public Health Promotion and Population Health, director of the Center for Policy Research, and professor of sociology at Syracuse University. Her research examines demographic and geographic variation in health and mortality, with emphasis over the past several years on explaining variation in drug overdose mortality
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Bhullar MK, Gilson TP, Singer ME. Trends in opioid overdose fatalities in Cuyahoga County, Ohio: Multi-drug mixtures, the African-American community and carfentanil. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 4:100069. [PMID: 36846577 PMCID: PMC9948855 DOI: 10.1016/j.dadr.2022.100069] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 06/09/2022] [Accepted: 06/13/2022] [Indexed: 10/18/2022]
Abstract
Background Ohio's age-adjusted opioid overdose fatality rate is double the national average. In an ever-evolving epidemic, it is crucial to monitor trends to inform public health interventions. Methods A retrospective study was conducted using the Medical Examiner's decedent case files for all accidental opioid-related adult overdose deaths in Cuyahoga County (Cleveland), Ohio in 2017. Characterization of trends was based on autopsy/toxicology and first responder reports, medical records and death scene investigations. Results Of 543 accidental opioid-related adult overdose fatalities, 64.1% died from 3+ drugs. The most common cause of death (COD) drugs included fentanyl (63.4%), heroin (44.4%), cocaine (37.0%) and carfentanil (35.0%). There were four times as many African American decedents as two years prior. Three or more COD drugs was >50% more common in those with fentanyl (Prevalence Ratio (PR) = 1.56[1.34-1.70]; p<.001) or carfentanil (PR = 1.51[1.33-1.70]; p<.001) as a COD drug, more common with a history of prescription drug abuse (PR = 1.16[1.02-1.33]; p=.025), but less common in divorced/widowed decedents (PR = 0.83[0.71-0.97]; p=.022). Carfentanil was nearly 4 times as prevalent in those with previous illicit drug use (PR = 3.88[1.09-13.70]; p=.025), and less common in those with previous medical history (PR = 0.72[0.55-0.94]; p=.016) or age 50+ (PR = 0.72[0.53-0.97]; p=.031). Conclusions Accidental opioid-related overdose fatalities in Cuyahoga County adults were dominated by 3+ COD drugs, with cocaine/fentanyl mixtures driving sharp increases in African American fatalities. Carfentanil was more prevalent in people fitting the profile of recreational drug use. This data can inform harm reduction interventions.
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Affiliation(s)
- Manreet K Bhullar
- Cuyahoga County Medical Examiner's Office, 11001 Cedar Avenue, Cleveland, OH 44106, United States of America.,Case Western Reserve University, 10900 Euclid Ave, SOM WG-57, Cleveland, OH 44106, United States of America
| | - Thomas P Gilson
- Cuyahoga County Medical Examiner's Office, 11001 Cedar Avenue, Cleveland, OH 44106, United States of America
| | - Mendel E Singer
- Case Western Reserve University, 10900 Euclid Ave, SOM WG-57, Cleveland, OH 44106, United States of America
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Kentucky Pharmacists’ Experiences Dispensing Abuse Deterrent Opioid Analgesics. J Am Pharm Assoc (2003) 2022; 62:1836-1842. [DOI: 10.1016/j.japh.2022.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/28/2022] [Accepted: 07/28/2022] [Indexed: 11/18/2022]
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Dickson-Gomez J, Krechel S, Spector A, Weeks M, Ohlrich J, Green Montaque HD, Li J. The effects of opioid policy changes on transitions from prescription opioids to heroin, fentanyl and injection drug use: a qualitative analysis. Subst Abuse Treat Prev Policy 2022; 17:55. [PMID: 35864522 PMCID: PMC9306091 DOI: 10.1186/s13011-022-00480-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Beginning in the 1990s, nonmedical use of prescription opioids (POs) became a major public health crisis. In response to rising rates of opioid dependence and fatal poisonings, measures were instituted to decrease the prescription, diversion, and nonmedical use of POs including prescription drug monitoring programs (PDMPs), pain clinic laws, prescription duration limits, disciplining doctors who prescribed an excessive number of POs, and the advent of abuse deterrent formulations of POs. This paper explores the unintended effects of these policies in the descriptions of why people who use opioids transitioned from PO to injection or heroin/fentanyl use. METHODS We conducted 148 in-depth-interviews with people who use prescription opioids nonmedically, fentanyl or heroin from a rural, urban and suburban area in three states, Connecticut, Kentucky and Wisconsin. Interviews with people who use opioids (PWUO) focused on how they initiated their opioid use and any transitions they made from PO use to heroin, fentanyl or injection drug use. RESULTS The majority of participants reported initiating use with POs, which they used for medical or nonmedical purposes. They described needing to take more POs or switched to heroin or fentanyl as their tolerance increased. As more policies were passed to limit opioid prescribing, participants noticed that doctors were less likely to prescribe or refill POs. This led to scarcity of POs on the street which accelerated the switch to heroin or fentanyl. These transitions likely increased risk of overdose and HIV/HCV infection. CONCLUSIONS A careful analysis of how and why people say they transitioned from PO to heroin or fentanyl reveals many unintended harms of policy changes to prevent overprescribing and diversion. Results highlight the importance of mitigating harms that resulted from policy changes.
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Affiliation(s)
- Julia Dickson-Gomez
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, USA.
| | - Sarah Krechel
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, USA
| | - Antoinette Spector
- Department of Rehabilitative Sciences and Technology, University of Wisconsin, Milwaukee, USA
| | | | - Jessica Ohlrich
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, USA
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Salloum RG, Bilello L, Bian J, Diiulio J, Paz LG, Gurka MJ, Gutierrez M, Hurley RW, Jones RE, Martinez-Wittinghan F, Marcial L, Masri G, McDonnell C, Militello LG, Modave F, Nguyen K, Rhodes B, Siler K, Willis D, Harle CA. Study protocol for a type III hybrid effectiveness-implementation trial to evaluate scaling interoperable clinical decision support for patient-centered chronic pain management in primary care. Implement Sci 2022; 17:44. [PMID: 35841043 PMCID: PMC9287973 DOI: 10.1186/s13012-022-01217-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/20/2022] [Indexed: 11/10/2022] Open
Abstract
Background The US continues to face public health crises related to both chronic pain and opioid overdoses. Thirty percent of Americans suffer from chronic noncancer pain at an estimated yearly cost of over $600 billion. Most patients with chronic pain turn to primary care clinicians who must choose from myriad treatment options based on relative risks and benefits, patient history, available resources, symptoms, and goals. Recently, with attention to opioid-related risks, prescribing has declined. However, clinical experts have countered with concerns that some patients for whom opioid-related benefits outweigh risks may be inappropriately discontinued from opioids. Unfortunately, primary care clinicians lack usable tools to help them partner with their patients in choosing pain treatment options that best balance risks and benefits in the context of patient history, resources, symptoms, and goals. Thus, primary care clinicians and patients would benefit from patient-centered clinical decision support (CDS) for this shared decision-making process. Methods The objective of this 3-year project is to study the adaptation and implementation of an existing interoperable CDS tool for pain treatment shared decision making, with tailored implementation support, in new clinical settings in the OneFlorida Clinical Research Consortium. Our central hypothesis is that tailored implementation support will increase CDS adoption and shared decision making. We further hypothesize that increases in shared decision making will lead to improved patient outcomes, specifically pain and physical function. The CDS implementation will be guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework. The evaluation will be organized by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. We will adapt and tailor PainManager, an open source interoperable CDS tool, for implementation in primary care clinics affiliated with the OneFlorida Clinical Research Consortium. We will evaluate the effect of tailored implementation support on PainManager’s adoption for pain treatment shared decision making. This evaluation will establish the feasibility and obtain preliminary data in preparation for a multi-site pragmatic trial targeting the effectiveness of PainManager and tailored implementation support on shared decision making and patient-reported pain and physical function. Discussion This research will generate evidence on strategies for implementing interoperable CDS in new clinical settings across different types of electronic health records (EHRs). The study will also inform tailored implementation strategies to be further tested in a subsequent hybrid effectiveness-implementation trial. Together, these efforts will lead to important new technology and evidence that patients, clinicians, and health systems can use to improve care for millions of Americans who suffer from pain and other chronic conditions. Trial registration ClinicalTrials.gov, NCT05256394, Registered 25 February 2022. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01217-4.
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Affiliation(s)
- Ramzi G Salloum
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, 2004 Mowry Road, Gainesville, FL, 32610, USA
| | - Lori Bilello
- Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Jiang Bian
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, 2004 Mowry Road, Gainesville, FL, 32610, USA
| | | | - Laura Gonzalez Paz
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, 2004 Mowry Road, Gainesville, FL, 32610, USA
| | - Matthew J Gurka
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, 2004 Mowry Road, Gainesville, FL, 32610, USA
| | - Maria Gutierrez
- Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Robert W Hurley
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Ross E Jones
- Department of Community Health and Family Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Francisco Martinez-Wittinghan
- Department of Community Health and Family Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | | | - Ghania Masri
- Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Cara McDonnell
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, 2004 Mowry Road, Gainesville, FL, 32610, USA
| | | | - François Modave
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, 2004 Mowry Road, Gainesville, FL, 32610, USA
| | - Khoa Nguyen
- Department of Pharmacotherapy and Translational Research, University of Florida College of Pharmacy, Gainesville, FL, USA
| | | | - Kendra Siler
- CommunityHealth IT, Kennedy Space Center, Merritt Island, FL, USA
| | - David Willis
- CommunityHealth IT, Kennedy Space Center, Merritt Island, FL, USA
| | - Christopher A Harle
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, 2004 Mowry Road, Gainesville, FL, 32610, USA.
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Antoniou T, Men S, Tadrous M, Leece P, Munro C, Gomes T. Impact of a publicly funded pharmacy-dispensed naloxone program on fatal opioid overdose rates: A population-based study. Drug Alcohol Depend 2022; 236:109473. [PMID: 35523113 DOI: 10.1016/j.drugalcdep.2022.109473] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 04/21/2022] [Accepted: 04/21/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Studies examining the impact of pharmacy-dispensed naloxone programs on fatal opioid overdose rates are lacking. We examined the impact of the publicly funded Ontario Naloxone Program for Pharmacies (ONPP), implemented in June 2016, on provincial rates of opioid overdose deaths. METHODS We conducted a population-based interrupted time-series study between July 1, 2012 and December 31, 2018. We considered a parsimonious model with terms for time, ONPP implementation, and time following the ONPP implementation. Models were adjusted for population characteristics, number of pharmacies and rate of naloxone distributed through non-pharmacy sites within provincial public health units. RESULTS In the parsimonious model, the ONPP was associated with a non-significant 9% reduction in the level of fatal opioid overdoses (rate ratio [RR] 0.91; 95% confidence interval [CI] 0.79-1.06), a finding that was most pronounced in regions in the lowest tertile of implementation (RR 0.75; 95% CI 0.62-0.91). Following multivariable adjustment, there was an increase in the level (RR 1.06; 95% CI 0.94-1.19) and slope change (RR 1.06; 95% CI 1.02-1.10) of fatal overdose rates. CONCLUSION The ONPP is insufficient as a single intervention to meaningfully reduce rates of fatal opioid overdoses during a period in which the cause of these deaths shifted from prescription opioids to highly potent fentanyl analogs. Access to additional harm reduction, treatment, and other interventions is necessary to prevent deaths and optimize the health of people who use drugs.
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Affiliation(s)
- Tony Antoniou
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada; Department of Family and Community Medicine, Unity Health, Toronto, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Ontario Drug Policy Research Network, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada.
| | | | - Mina Tadrous
- ICES, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; Women's College Research Institute, Toronto, Ontario, Canada
| | - Pamela Leece
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Public Health Ontario, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Charlotte Munro
- Ontario Drug Policy Research Network, Toronto, Ontario, Canada
| | - Tara Gomes
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada; Ontario Drug Policy Research Network, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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43
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Inoue K, Ritz B, Arah OA. Causal Effect of Chronic Pain on Mortality Through Opioid Prescriptions: Application of the Front-Door Formula. Epidemiology 2022; 33:572-580. [PMID: 35384895 PMCID: PMC9148671 DOI: 10.1097/ede.0000000000001490] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 03/24/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Chronic pain is the leading cause of disability worldwide and is strongly associated with the epidemic of opioid overdosing events. However, the causal links between chronic pain, opioid prescriptions, and mortality remain unclear. METHODS This study included 13,884 US adults aged ≥20 years who provided data on chronic pain in the National Health and Nutrition Examination Survey 1999-2004 with linkage to mortality databases through 2015. We employed the generalized form of the front-door formula within the structural causal model framework to investigate the causal effect of chronic pain on all-cause mortality mediated by opioid prescriptions. RESULTS We identified a total of 718 participants at 3 years of follow-up and 1260 participants at 5 years as having died from all causes. Opioid prescriptions increased the risk of all-cause mortality with an estimated odds ratio (OR) (95% confidence interval) = 1.5 (1.1, 1.9) at 3 years and 1.3 (1.1, 1.6) at 5 years. The front-door formula revealed that chronic pain increased the risk of all-cause mortality through opioid prescriptions; OR = 1.06 (1.01, 1.11) at 3 years and 1.03 (1.01, 1.06) at 5 years. Our bias analysis showed that our findings based on the front-door formula were likely robust to plausible sources of bias from uncontrolled exposure-mediator or mediator-outcome confounding. CONCLUSIONS Chronic pain increased the risk of all-cause mortality through opioid prescriptions. Our findings highlight the importance of careful guideline-based chronic pain management to prevent death from possibly inappropriate opioid prescriptions driven by chronic pain.
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Affiliation(s)
- Kosuke Inoue
- From the Department of Social Epidemiology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Beate Ritz
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, California, USA
- Department of Environmental Health Sciences, UCLA Fielding School of Public Health, Los Angeles, California, USA
- Department of Neurology, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Onyebuchi A. Arah
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, California, USA
- Department of Statistics, UCLA College, Los Angeles, California, USA
- Center for Social Statistics, UCLA, Los Angeles, California, USA
- California Center for Population Research, UCLA Los Angeles, California, USA
- Department of Public Health, Research Unit for Epidemiology, Aarhus University, Aarhus, Denmark
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44
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Stringfellow EJ, Lim TY, Humphreys K, DiGennaro C, Stafford C, Beaulieu E, Homer J, Wakeland W, Bearnot B, McHugh RK, Kelly J, Glos L, Eggers SL, Kazemi R, Jalali MS. Reducing opioid use disorder and overdose deaths in the United States: A dynamic modeling analysis. SCIENCE ADVANCES 2022; 8:eabm8147. [PMID: 35749492 PMCID: PMC9232111 DOI: 10.1126/sciadv.abm8147] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Opioid overdose deaths remain a major public health crisis. We used a system dynamics simulation model of the U.S. opioid-using population age 12 and older to explore the impacts of 11 strategies on the prevalence of opioid use disorder (OUD) and fatal opioid overdoses from 2022 to 2032. These strategies spanned opioid misuse and OUD prevention, buprenorphine capacity, recovery support, and overdose harm reduction. By 2032, three strategies saved the most lives: (i) reducing the risk of opioid overdose involving fentanyl use, which may be achieved through fentanyl-focused harm reduction services; (ii) increasing naloxone distribution to people who use opioids; and (iii) recovery support for people in remission, which reduced deaths by reducing OUD. Increasing buprenorphine providers' capacity to treat more people decreased fatal overdose, but only in the short term. Our analysis provides insight into the kinds of multifaceted approaches needed to save lives.
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Affiliation(s)
| | - Tse Yang Lim
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Keith Humphreys
- Veterans Affairs and Stanford University Medical Centers, Palo Alto, CA, USA
| | | | | | | | - Jack Homer
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA, USA
- Homer Consulting, Barrytown, NY, USA
| | - Wayne Wakeland
- Systems Science Program, Portland State University, Portland, OR, USA
| | - Benjamin Bearnot
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - R. Kathryn McHugh
- Division of Alcohol, Drugs, and Addiction, McLean Hospital, Harvard Medical School, Boston, MA, USA
| | - John Kelly
- Center for Addiction Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Lukas Glos
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Sara L. Eggers
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Reza Kazemi
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Mohammad S. Jalali
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA, USA
- Corresponding author.
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45
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Abstract
The opioid crisis remains one of the greatest public health challenges in the United States. The crisis is complex, with long delays and feedbacks between policy actions and their effects, which creates a risk of unintended consequences and complicates policy decision-making. We present SOURCE (Simulation of Opioid Use, Response, Consequences, and Effects), an operationally detailed national-level model of the opioid crisis, intended to enhance understanding of the crisis and guide policy decisions. Drawing on multiple data sources, SOURCE replicates how risks of opioid misuse initiation and overdose have evolved over time in response to behavioral and other changes and suggests how those risks may evolve in the future, providing a basis for projecting and analyzing potential policy impacts and solutions. The opioid crisis is a major public health challenge in the United States, killing about 70,000 people in 2020 alone. Long delays and feedbacks between policy actions and their effects on drug-use behavior create dynamic complexity, complicating policy decision-making. In 2017, the National Academies of Sciences, Engineering, and Medicine called for a quantitative systems model to help understand and address this complexity and guide policy decisions. Here, we present SOURCE (Simulation of Opioid Use, Response, Consequences, and Effects), a dynamic simulation model developed in response to that charge. SOURCE tracks the US population aged ≥12 y through the stages of prescription and illicit opioid (e.g., heroin, illicit fentanyl) misuse and use disorder, addiction treatment, remission, and overdose death. Using data spanning from 1999 to 2020, we highlight how risks of drug use initiation and overdose have evolved in response to essential endogenous feedback mechanisms, including: 1) social influence on drug use initiation and escalation among people who use opioids; 2) risk perception and response based on overdose mortality, influencing potential new initiates; and 3) capacity limits on treatment engagement; as well as other drivers, such as 4) supply-side changes in prescription opioid and heroin availability; and 5) the competing influences of illicit fentanyl and overdose death prevention efforts. Our estimates yield a more nuanced understanding of the historical trajectory of the crisis, providing a basis for projecting future scenarios and informing policy planning.
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46
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Kolla G, Touesnard N, Gomes T. Addressing the overdose crisis in North America with bold action. Addiction 2022; 117:1194-1196. [PMID: 35373484 DOI: 10.1111/add.15844] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 02/01/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Gillian Kolla
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, British Columbia, Canada.,MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Natasha Touesnard
- Canadian Association of People who Use Drugs, Dartmouth, Nova Scotia, Canada
| | - Tara Gomes
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.,Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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47
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Gugala E, Briggs O, Moczygemba LR, Brown CM, Hill LG. Opioid harm reduction: A scoping review of physician and system-level gaps in knowledge, education, and practice. Subst Abus 2022; 43:972-987. [PMID: 35426772 DOI: 10.1080/08897077.2022.2060423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background: Harm reduction includes treatment and prevention approaches rather than abstinence, as a public health strategy for mitigating the opioid epidemic. Harm reduction is a new strategy for many healthcare professionals, and gaps in knowledge and practices may lead to barriers to optimal treatment. Our objective was to identify and describe gaps in physicians' knowledge, education, and practice in harm reduction strategies related to opioid overdose. Methods: We searched the PubMed, CINAHL, and Web of Science databases for articles published between 2015 and 2021, published in English, containing empirical evidence, addressing opioid harm reduction, and identifying gaps in physicians' knowledge, education, or practice. Results: Thirty-seven studies were included. Studies examined how physicians' perceptions or stigma influenced harm reduction efforts and addressed clinical knowledge gaps in overdose treatment and prevention and OUD treatment. Less than half of the studies addressed access issues at the system level, above the individual healthcare professional. Conclusion: Individual-level interventions should be addressed with professional continuing education and curricular-based changes through experiential and interprofessional education. System-level gaps can be remedied by increasing patient access to care, creating policies favorable to harm reduction, and extending resources to provide harm reduction strategies.
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Affiliation(s)
- Emma Gugala
- TxCORE and PhARM Program, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
| | - Owanate Briggs
- TxCORE and PhARM Program, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
| | - Leticia R Moczygemba
- TxCORE and PhARM Program, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
| | - Carolyn M Brown
- TxCORE and PhARM Program, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
| | - Lucas G Hill
- TxCORE and PhARM Program, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
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48
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Alexander GC, Ballreich J, Mansour O, Dowdy DW. Effect of reductions in opioid prescribing on opioid use disorder and fatal overdose in the United States: a dynamic Markov model. Addiction 2022; 117:969-976. [PMID: 34590369 DOI: 10.1111/add.15698] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/01/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIMS Despite prescribing declines between 2011 and 2019, opioid morbidity and mortality in the United States continued to rise during this period. We estimated the relationship between opioid prescribing, opioid use disorder (OUD) and fatal opioid overdose in the United States. DESIGN Dynamic Markov model. SETTING United States, using data from the National Survey on Drug Use and Health, Centers for Disease Control and Prevention, National Health and Nutrition Examination Survey and National Epidemiologic Survey on Alcohol and Related Conditions III. PARTICIPANTS Simulated US individuals 12+ years of age from the general population or with prescription opioid medical use, prescription opioid non-medical use, illicit opioid (e.g. heroin, illicit fentanyl) use, prescription OUD, illicit OUD with a history of prior prescription opioid non-medical use or non-fatal or fatal opioid overdose. MEASUREMENTS Active OUD cases and fatal prescription opioid overdoses. FINDINGS Between 2010 and 2019, opioid prescribing declined 42.5%. Although fatal opioid overdoses increased by 103.2%, these reductions in opioid prescribing averted an estimated 9600 [95% uncertainty interval (UI) = 7205, 15 478] deaths starting in 2011 relative to continued prescribing at 2010 levels-and are projected to avert another 50 918 (95% UI = 38 829, 79 795) overdose deaths between 2020 and 2029. The median time from initial opioid prescription to fatal opioid overdose was 5.2 years. Of the 2.4 million (95% UI = 2.2 million, 2.7 million) individuals in the United States with estimated active OUD in 2019, 65% (95% UI = 59%, 71%) were attributable to initial opioid use occurring prior to 2011, whereas 14% (95% UI = 12%, 17%) were attributable to initial opioid use occurring between 2017 and 2019. The impact, by 2029, of additional reductions in prescribing initiated in 2020 would be more than three times greater than that of similar reductions initiated in 2025. CONCLUSIONS Observed reductions in opioid prescribing volume in the United States from 2010 to 2019 appear to have saved approximately 9600 lives by 2019 and are anticipated to avert more than 50 000 fatal overdoses by 2029.
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Affiliation(s)
- G Caleb Alexander
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD, USA.,Monument Analytics, Baltimore, MD, USA
| | - Jeromie Ballreich
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Monument Analytics, Baltimore, MD, USA.,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD, USA.,Monument Analytics, Baltimore, MD, USA
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49
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Quinn PD, Chang Z, Bair MJ, Rickert ME, Gibbons RD, Kroenke K, D’Onofrio BM. Associations of opioid prescription dose and discontinuation with risk of substance-related morbidity in long-term opioid therapy. Pain 2022; 163:e588-e595. [PMID: 34326295 PMCID: PMC8795234 DOI: 10.1097/j.pain.0000000000002415] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/28/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Efforts to reduce opioid-related harms have decreased opioid prescription but have provoked concerns about unintended consequences, particularly for long-term opioid therapy (LtOT) recipients. Research is needed to address the knowledge gap regarding how risk of substance-related morbidity changes across LtOT and its discontinuation. This study used nationwide commercial insurance claims data and a within-individual design to examine associations of LtOT dose and discontinuation with substance-related morbidity. We identified 194,839 adolescents and adults who initiated opioid prescription in 2010 to 2018 and subsequently received LtOT. The cohort was followed for a median of 965 days (interquartile range, 525-1550), of which a median of 176 days (119-332) were covered by opioid prescription. During follow-up, there were 17,582 acute substance-related morbidity events, defined as claims for emergency visits, inpatient hospitalizations, and ambulance transportation with substance use disorder or overdose diagnoses. Relative to initial treatment, risk was greater within individual during subsequent periods of >60 to 120 (adjusted odds ratio [OR], 1.29; 95% CI, 1.12 to 1.49) and >120 (OR, 1.48; 95% CI, 1.24-1.76) daily morphine milligram equivalents. Risk was also greater during days 1 to 30 after discontinuations than during initial treatment (OR, 1.19; 95% CI, 1.05-1.35). However, it was no greater than during the 30 days before discontinuations, indicating that the risk may not be wholly attributable to discontinuation itself. Results were supported by a negative control pharmacotherapy analysis and additional sensitivity analyses. They suggest that LtOT recipients may experience increased substance-related morbidity risk during treatment subsequent to initial opioid prescription, particularly in periods involving higher doses.
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Affiliation(s)
- Patrick D. Quinn
- Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, Indiana
| | - Zheng Chang
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Matthew J. Bair
- VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center, Indianapolis, Indiana
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Regenstrief Institute, Indianapolis, Indiana
| | - Martin E. Rickert
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana
| | - Robert D. Gibbons
- Center for Health Statistics, University of Chicago, Chicago, Illinois
- Department of Medicine, University of Chicago, Chicago, Illinois
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
| | - Kurt Kroenke
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Regenstrief Institute, Indianapolis, Indiana
| | - Brian M. D’Onofrio
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, Indiana
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50
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Holeksa J. Dealing with low access to harm reduction: a qualitative study of the strategies and risk environments of people who use drugs in a small Swedish city. Harm Reduct J 2022; 19:23. [PMID: 35246162 PMCID: PMC8894830 DOI: 10.1186/s12954-022-00602-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 02/17/2022] [Indexed: 12/02/2022] Open
Abstract
Background The development of harm reduction has been limited in many areas of Sweden. This study aims to understand the implications that this has for the life circumstances and risk management of people who use drugs in areas of low access. Methods Eleven qualitative, semi-structured interviews were undertaken with people who use drugs in a small urban centre with no needle and syringe exchange program (NSP) or Housing First policy. Results Participants reported many solutions to lack of NSP, including travel to an external NSP, creating bridging distribution networks, stealing, borrowing, reusing, ordering online, and smuggling injection equipment. They were at risk of having their equipment confiscated by police. Participants were mostly homeless, and to address exclusion from housing services, were forced to frequently find new temporary solutions, sheltering themselves in public places, with friends, in cars, among others. Participants felt the lack of services reflected stigmatized notions of drug use and heightened their exclusion from general society. For example, they avoided accessing other health care services for fear of discrimination. These issues caused high levels of stress and anxiety, in addition to serious risk for many somatic and psychological health conditions, including HIV and HCV transmission. Conclusion Lack of harm reduction services placed a great burden on study participants to develop strategies due to gaps in official programming. It also contributes to a vicious cycle of exclusion from services. The implementation of such evidence-based programs will reduce this burden, as well as provide the indirect, symbolic effect of inclusion.
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Affiliation(s)
- Julie Holeksa
- Department of Social Work, Faculty of Health and Society, Malmö University, Citadellsvägen 7, 211 18, Malmö, Sweden.
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