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McCann NC, LaRochelle MR, Morgan JR. Out-of-pocket spending and health care utilization associated with initiation of different medications for opioid use disorder: Findings from a national commercially insured cohort. J Subst Use Addict Treat 2024; 159:209281. [PMID: 38122988 PMCID: PMC10947919 DOI: 10.1016/j.josat.2023.209281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/05/2023] [Accepted: 12/15/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Buprenorphine and naltrexone are effective medications for opioid use disorder (MOUD). Naltrexone requires complete detoxification from opioids before initiation while buprenorphine does not, which leads to a differential clinical induction challenge. Few studies have evaluated economic costs associated with MOUD initiation. METHODS We conducted a retrospective cohort analysis using the 2014-2019 Merative MarketScan database. We included individuals diagnosed with opioid use, abuse, or dependence from 2014 to 2019 who initiated one of three MOUD types: 1) buprenorphine, 2) extended-release naltrexone, or 3) oral naltrexone. We calculated total and monthly out-of-pocket spending, for overall and MOUD-specific claims, for the three months prior through three months after MOUD initiation. We also calculated utilization of detoxification, inpatient, and outpatient services monthly over this period. RESULTS Our cohort included 27,133 individuals; 19,536, 1886, and 5711 initiated buprenorphine, extended-release naltrexone, and oral naltrexone, respectively. Individuals who initiated naltrexone had the highest out-of-pocket spending over the study period. MOUD-specific spending did not contribute substantially to total out-of-pocket spending. Difference in overall spending by MOUD type was driven by a subset of individuals who initiated naltrexone and had very high out-of-pocket spending in the month prior to MOUD initiation. In this month, mean monthly out-of-pocket spending for high-spenders (above 90th percentile within MOUD type category) was $5734 (95 % confidence interval [CI]: $5181-$6286) and $4622 (95 % CI: $4161-$5082) for those who initiated oral and extended-release naltrexone, respectively, compared with $1852 (95 % CI: $1754-$1950) for those who initiated buprenorphine. In the month prior to MOUD initiation, those who initiated naltrexone also had higher detoxification, inpatient, and outpatient episode/visit frequency. In the month prior to initiation, 28.8 % (95 % CI: 27.7 %-30.0 %) and 25.5 % (95 % CI: 23.6 %-27.5 %) of individuals who initiated oral and extended-release naltrexone had detoxification episodes, compared with 9.7 % (95 % CI: 9.3 %-10.1 %) of those who initiated buprenorphine. CONCLUSION Findings suggest that individuals who initiated naltrexone utilized more intensive health services, including detoxification, in the period prior to MOUD initiation, resulting in significantly higher out-of-pocket spending. Out-of-pocket spending is a patient-centered outcome reflecting potential patient burden. Our results should be considered as part of the shared decision-making process between patients and providers when choosing treatment for OUD.
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Affiliation(s)
- Nicole C McCann
- Department of Health Law, Policy, and Management, Boston University School of Public Health, United States of America.
| | - Marc R LaRochelle
- Grayken Center for Addiction, Boston Medical Center, United States of America; Department of Medicine, Boston University School of Medicine, United States of America
| | - Jake R Morgan
- Department of Health Law, Policy, and Management, Boston University School of Public Health, United States of America
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Bovell-Ammon BJ, Yan S, Dunn D, Evans EA, Friedmann PD, Walley AY, LaRochelle MR. Prison Buprenorphine Implementation and Postrelease Opioid Use Disorder Outcomes. JAMA Netw Open 2024; 7:e242732. [PMID: 38497959 PMCID: PMC10949092 DOI: 10.1001/jamanetworkopen.2024.2732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 01/24/2024] [Indexed: 03/19/2024] Open
Abstract
Importance Agonist medications for opioid use disorder (MOUD), buprenorphine and methadone, in carceral settings might reduce the risk of postrelease opioid overdose but are uncommonly offered. In April 2019, the Massachusetts Department of Correction (MADOC), the state prison system, provided buprenorphine for incarcerated individuals in addition to previously offered injectable naltrexone. Objective To evaluate postrelease outcomes after buprenorphine implementation. Design, Setting, and Participants This cohort study with interrupted time-series analysis used linked data across multiple statewide data sets in the Massachusetts Public Health Data Warehouse stratified by sex due to differences in carceral systems. Eligible participants were individuals sentenced and released from a MADOC facility to the community. The study period for the male sample was January 2014 to November 2020; for the female sample, January 2015 to October 2019. Data were analyzed between February 2022 and January 2024. Exposure April 2019 implementation of buprenorphine during incarceration. Main Outcomes and Measures Receipt of MOUD within 4 weeks after release, opioid overdose, and all-cause mortality within 8 weeks after release, each measured as a percentage of monthly releases who experienced the outcome. Segmented linear regression analyzed changes in outcome rates after implementation. Results A total of 15 225 individuals were included. In the male sample there were 14 582 releases among 12 688 individuals (mean [SD] age, 35.0 [10.8] years; 133 Asian and Pacific Islander [0.9%], 4079 Black [28.0%], 4208 Hispanic [28.9%], 6117 White [41.9%]), a rate of 175.7 releases per month; the female sample included 3269 releases among 2537 individuals (mean [SD] age, 34.9 [9.8] years; 328 Black [10.0%], 225 Hispanic [6.9%], 2545 White [77.9%]), a rate of 56.4 releases per month. Among male participants at 20 months postimplementation, the monthly rate of postrelease buprenorphine receipt was higher than would have been expected under baseline trends (21.2% vs 10.6% of monthly releases; 18.6 additional releases per month). Naltrexone receipt was lower than expected (1.0% vs 6.0%; 8.8 fewer releases per month). Monthly rates of methadone receipt (1.4%) and opioid overdose (1.8%) were not significantly different than expected. All-cause mortality was lower than expected (1.9% vs 2.8%; 1.5 fewer deaths per month). Among female participants at 7 months postimplementation, buprenorphine receipt was higher than expected (31.6% vs 9.5%; 12.4 additional releases per month). Naltrexone receipt was lower than expected (3.4% vs 7.2%) but not statistically significantly different. Monthly rates of methadone receipt (1.1%), opioid overdose (4.8%), and all-cause mortality (1.6%) were not significantly different than expected. Conclusions and Relevance In this cohort study of state prison releases, postrelease buprenorphine receipt increased and naltrexone receipt decreased after buprenorphine became available during incarceration.
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Affiliation(s)
- Benjamin J. Bovell-Ammon
- Departments of Medicine and of Healthcare Delivery and Population Sciences, Baystate Health, Springfield, Massachusetts
- Department of Medicine, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Shapei Yan
- Department of Medicine, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Devon Dunn
- Massachusetts Department of Public Health, Boston, Massachusetts
| | - Elizabeth A. Evans
- Department of Health Promotion and Policy, University of Massachusetts Amherst School of Public Health & Health Sciences, Amherst
| | - Peter D. Friedmann
- Office of Research and Department of Medicine, University of Massachusetts Chan Medical School—Baystate and Baystate Health, Springfield
| | - Alexander Y. Walley
- Department of Medicine, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Marc R. LaRochelle
- Department of Medicine, Boston Medical Center and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
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Hammerslag LR, Mack A, Chandler RK, Fanucchi LC, Feaster DJ, LaRochelle MR, Lofwall MR, Nau M, Villani J, Walsh SL, Westgate PM, Slavova S, Talbert JC. Telemedicine Buprenorphine Initiation and Retention in Opioid Use Disorder Treatment for Medicaid Enrollees. JAMA Netw Open 2023; 6:e2336914. [PMID: 37851446 PMCID: PMC10585416 DOI: 10.1001/jamanetworkopen.2023.36914] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/22/2023] [Indexed: 10/19/2023] Open
Abstract
Importance Early COVID-19 mitigation strategies placed an additional burden on individuals seeking care for opioid use disorder (OUD). Telemedicine provided a way to initiate and maintain transmucosal buprenorphine treatment of OUD. Objective To examine associations between transmucosal buprenorphine OUD treatment modality (telemedicine vs traditional) during the COVID-19 public health emergency and the health outcomes of treatment retention and opioid-related nonfatal overdose. Design, Setting, and Participants This retrospective cohort study was conducted using Medicaid claims and enrollment data from November 1, 2019, to December 31, 2020, for individuals aged 18 to 64 years from Kentucky and Ohio. Data were collected and analyzed in June 2022, with data updated during revision in August 2023. Exposures The primary exposure of interest was the modality of the transmucosal buprenorphine OUD treatment initiation. Relevant patient demographic and comorbidity characteristics were included in regression models. Main Outcomes and Measures There were 2 main outcomes of interest: retention in treatment after initiation and opioid-related nonfatal overdose after initiation. For outcomes measured after initiation, a 90-day follow-up period was used. The main analysis used a new-user study design; transmucosal buprenorphine OUD treatment initiation was defined as initiation after more than a 60-day gap in buprenorphine treatment. In addition, uptake of telemedicine for buprenorphine was examined, overall and within patients initiating treatment, across quarters in 2020. Results This study included 41 266 individuals in Kentucky (21 269 women [51.5%]; mean [SD] age, 37.9 [9.0] years) and 50 648 individuals in Ohio (26 425 women [52.2%]; mean [SD] age, 37.1 [9.3] years) who received buprenorphine in 2020, with 18 250 and 24 741 people initiating buprenorphine in Kentucky and Ohio, respectively. Telemedicine buprenorphine initiations increased sharply at the beginning of 2020. Compared with nontelemedicine initiation, telemedicine initiation was associated with better odds of 90-day retention with buprenorphine in both states (Kentucky: adjusted odds ratio, 1.13 [95% CI, 1.01-1.27]; Ohio: adjusted odds ratio, 1.19 [95% CI, 1.06-1.32]) in a regression analysis adjusting for patient demographic and comorbidity characteristics. Telemedicine initiation was not associated with opioid-related nonfatal overdose (Kentucky: adjusted odds ratio, 0.89 [95% CI, 0.56-1.40]; Ohio: adjusted odds ratio, 1.08 [95% CI, 0.83-1.41]). Conclusions and Relevance In this cohort study of Medicaid enrollees receiving buprenorphine for OUD, telemedicine buprenorphine initiation was associated with retention in treatment early during the COVID-19 pandemic. These findings add to the literature demonstrating positive outcomes associated with the use of telemedicine for treatment of OUD.
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Affiliation(s)
- Lindsey R. Hammerslag
- Institute for Biomedical Informatics, University of Kentucky College of Medicine, Lexington
| | - Aimee Mack
- Division of Health Sciences, The Ohio State University Wexner Medical Center, Columbus
| | - Redonna K. Chandler
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Laura C. Fanucchi
- Center on Drug and Alcohol Research, College of Medicine, University of Kentucky, Lexington
| | - Daniel J. Feaster
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - Marc R. LaRochelle
- Clinical Addiction Research & Education Unit, Boston University School of Medicine, Boston, Massachusetts
| | - Michelle R. Lofwall
- Center on Drug and Alcohol Research, College of Medicine, University of Kentucky, Lexington
| | - Michael Nau
- Division of Health Sciences, The Ohio State University Wexner Medical Center, Columbus
| | - Jennifer Villani
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Sharon L. Walsh
- Center on Drug and Alcohol Research, College of Medicine, University of Kentucky, Lexington
| | - Philip M. Westgate
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington
| | - Svetla Slavova
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington
| | - Jeffery C. Talbert
- Institute for Biomedical Informatics, University of Kentucky College of Medicine, Lexington
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Scherrer JF, Sullivan MD, LaRochelle MR, Grucza R. Validating opioid use disorder diagnoses in administrative data: a commentary on existing evidence and future directions. Addict Sci Clin Pract 2023; 18:49. [PMID: 37592369 PMCID: PMC10433556 DOI: 10.1186/s13722-023-00405-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 08/08/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND A valid opioid use disorder (OUD) identification algorithm for use in administrative medical record data would enhance investigators' ability to study consequences of OUD, OUD treatment seeking and treatment outcomes. MAIN BODY Existing studies indicate ICD-9 and ICD-10 codes for opioid abuse and dependence do not accurately measure OUD. However, critical appraisal of existing literature suggests alternative validation methods would improve the validity of OUD identification algorithms in administrative data. Chart abstraction may not be sufficient to validate OUD, and primary data collection via structured diagnostic interviews might be an ideal gold standard. CONCLUSION AND COMMENTARY Generating valid OUD identification algorithms is critical for OUD research and quality measurement in real world health care settings.
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Affiliation(s)
- Jeffrey F Scherrer
- Department of Family and Community Medicine, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis, MO, USA.
- Department of Psychiatry and Behavioral Neuroscience, School of Medicine, Saint Louis University, St. Louis, MO, USA.
- The AHEAD Institute, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis, MO, USA.
| | - Mark D Sullivan
- Department of Psychiatry and Behavioral Science, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Marc R LaRochelle
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, School of Medicine and Boston Medical Center, Boston University, Boston, MA, USA
| | - Richard Grucza
- Department of Family and Community Medicine, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis, MO, USA
- The AHEAD Institute, Saint Louis University School of Medicine, 1402 South Grand Blvd, St. Louis, MO, USA
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5
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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: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Bovell-Ammon BJ, Fox AD, LaRochelle MR. Prior Incarceration Is Associated with Poor Mental Health at Midlife: Findings from a National Longitudinal Cohort Study. J Gen Intern Med 2023; 38:1664-1671. [PMID: 36595198 PMCID: PMC10212902 DOI: 10.1007/s11606-022-07983-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 12/12/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND People with mental illnesses and people living in poverty have higher rates of incarceration than others, but relatively little is known about the long-term impact that incarceration has on an individual's mental health later in life. OBJECTIVE To evaluate prior incarceration's association with mental health at midlife. DESIGN Retrospective cohort study PARTICIPANTS: Participants from the National Longitudinal Survey of Youth 1979 (NLSY79)-a nationally representative age cohort of individuals 15 to 22 years of age in 1979-who remained in follow-up through age 50. MAIN MEASURES Midlife mental health outcomes were measured as part of a health module administered once participants reached 50 years of age (2008-2019): any mental health history, any depression history, past-year depression, severity of depression symptoms in the past 7 days (Center for Epidemiologic Studies Depression [CES-D] scale), and mental health-related quality of life in the past 4 weeks (SF-12 Mental Component Score [MCS]). The main exposure was any incarceration prior to age 50. KEY RESULTS Among 7889 participants included in our sample, 577 (5.4%) experienced at least one incarceration prior to age 50. Prior incarceration was associated with a greater likelihood of having any mental health history (predicted probability 27.0% vs. 16.6%; adjusted odds ratio [aOR] 1.9 [95%CI: 1.4, 2.5]), any history of depression (22.0% vs. 13.3%; aOR 1.8 [95%CI: 1.3, 2.5]), past-year depression (16.9% vs. 8.6%; aOR 2.2 [95%CI: 1.5, 3.0]), and high CES-D score (21.1% vs. 15.4%; aOR 1.5 [95%CI: 1.1, 2.0]) and with a lower (worse) SF-12 MCS (-2.1 points [95%CI: -3.3, -0.9]; standardized mean difference -0.24 [95%CI: -0.37, -0.10]) at age 50, when adjusting for early-life demographic, socioeconomic, and behavioral factors. CONCLUSIONS Prior incarceration was associated with worse mental health at age 50 across five measured outcomes. Incarceration is a key social-structural driver of poor mental health.
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Affiliation(s)
- Benjamin J Bovell-Ammon
- Department of Medicine, The Miriam Hospital, Lifespan, Providence, RI, USA.
- Department of Medicine, Boston Medical Center, 801 Massachusetts Ave, 2nd floor, Boston, MA, 02118, USA.
| | - Aaron D Fox
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Marc R LaRochelle
- Department of Medicine, Boston Medical Center, 801 Massachusetts Ave, 2nd floor, Boston, MA, 02118, USA
- Department of Medicine, Boston University School of Medicine, Boston, MA, USA
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7
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Mavragani A, Bradley H, Li W, Bernson D, Dammann O, LaRochelle MR, Stopka TJ. Small Area Forecasting of Opioid-Related Mortality: Bayesian Spatiotemporal Dynamic Modeling Approach. JMIR Public Health Surveill 2023; 9:e41450. [PMID: 36763450 PMCID: PMC9960038 DOI: 10.2196/41450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 12/14/2022] [Accepted: 12/26/2022] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Opioid-related overdose mortality has remained at crisis levels across the United States, increasing 5-fold and worsened during the COVID-19 pandemic. The ability to provide forecasts of opioid-related mortality at granular geographical and temporal scales may help guide preemptive public health responses. Current forecasting models focus on prediction on a large geographical scale, such as states or counties, lacking the spatial granularity that local public health officials desire to guide policy decisions and resource allocation. OBJECTIVE The overarching objective of our study was to develop Bayesian spatiotemporal dynamic models to predict opioid-related mortality counts and rates at temporally and geographically granular scales (ie, ZIP Code Tabulation Areas [ZCTAs]) for Massachusetts. METHODS We obtained decedent data from the Massachusetts Registry of Vital Records and Statistics for 2005 through 2019. We developed Bayesian spatiotemporal dynamic models to predict opioid-related mortality across Massachusetts' 537 ZCTAs. We evaluated the prediction performance of our models using the one-year ahead approach. We investigated the potential improvement of prediction accuracy by incorporating ZCTA-level demographic and socioeconomic determinants. We identified ZCTAs with the highest predicted opioid-related mortality in terms of rates and counts and stratified them by rural and urban areas. RESULTS Bayesian dynamic models with the full spatial and temporal dependency performed best. Inclusion of the ZCTA-level demographic and socioeconomic variables as predictors improved the prediction accuracy, but only in the model that did not account for the neighborhood-level spatial dependency of the ZCTAs. Predictions were better for urban areas than for rural areas, which were more sparsely populated. Using the best performing model and the Massachusetts opioid-related mortality data from 2005 through 2019, our models suggested a stabilizing pattern in opioid-related overdose mortality in 2020 and 2021 if there were no disruptive changes to the trends observed for 2005-2019. CONCLUSIONS Our Bayesian spatiotemporal models focused on opioid-related overdose mortality data facilitated prediction approaches that can inform preemptive public health decision-making and resource allocation. While sparse data from rural and less populated locales typically pose special challenges in small area predictions, our dynamic Bayesian models, which maximized information borrowing across geographic areas and time points, were used to provide more accurate predictions for small areas. Such approaches can be replicated in other jurisdictions and at varying temporal and geographical levels. We encourage the formation of a modeling consortium for fatal opioid-related overdose predictions, where different modeling techniques could be ensembled to inform public health policy.
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Affiliation(s)
| | | | - Wenjun Li
- Department of Public Health, University of Massachusetts Lowell, Lowell, MA, United States
| | - Dana Bernson
- Office of Population Health, Department of Public Health, The Commonwealth of Massachusetts, Boston, MA, United States
| | - Olaf Dammann
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, United States.,Department of Gynecology and Obstetrics, Hannover Medical School, Hannover, Germany
| | - Marc R LaRochelle
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, United States.,Grayken Center for Addiction, Boston Medical Center, Boston, MA, United States
| | - Thomas J Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, United States.,Department of Urban and Environmental Policy and Planning, Tufts University, Medford, MA, United States.,Department of Community Health, Tufts University, Medford, MA, United States
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8
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Morgan JR, LaRochelle MR. Commentary on Karnik et al.: Harmonization now-the need for consistent, validated measures to identify opioid use disorder in observational data. Addiction 2022; 117:2448-2449. [PMID: 35762525 DOI: 10.1111/add.15977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 06/09/2022] [Indexed: 01/17/2023]
Affiliation(s)
- Jake R Morgan
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Marc R LaRochelle
- Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA, USA
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9
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Morgan JR, Quinn EK, Chaisson CE, Ciemins E, Stempniewicz N, White LF, Linas BP, Walley AY, LaRochelle MR. Variation in Initiation, Engagement, and Retention on Medications for Opioid Use Disorder Based on Health Insurance Plan Design. Med Care 2022; 60:256-263. [PMID: 35026792 PMCID: PMC8852217 DOI: 10.1097/mlr.0000000000001689] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The association between cost-sharing and receipt of medication for opioid use disorder (MOUD) is unknown. METHODS We constructed a cohort of 10,513 commercially insured individuals with a new diagnosis of opioid use disorder and information on insurance cost-sharing in a large national deidentified claims database. We examined 4 cost-sharing measures: (1) pharmacy deductible; (2) medical service deductible; (3) pharmacy medication copay; and (4) medical office copay. We measured MOUD (naltrexone, buprenorphine, or methadone) initiation (within 14 d of diagnosis), engagement (second receipt within 34 d of first), and 6-month retention (continuous receipt without 14-d gap). We used multivariable logistic regression to assess the association between cost-sharing and MOUD initiation, engagement, and retention. We calculated total out-of-pocket costs in the 30 days following MOUD initiation for each type of MOUD. RESULTS Of 10,513 individuals with incident opioid use disorder, 1202 (11%) initiated MOUD, 742 (7%) engaged, and 253 (2%) were retained in MOUD at 6 months. A high ($1000+) medical deductible was associated with a lower odds of initiation compared with no deductible (odds ratio: 0.85, 95% confidence interval: 0.74-0.98). We found no significant associations between other cost-sharing measures for initiation, engagement, or retention. Median initial 30-day out-of-pocket costs ranged from $100 for methadone to $710 for extended-release naltrexone. CONCLUSIONS Among insurance plan cost-sharing measures, only medical services deductible showed an association with decreased MOUD initiation. Policy and benefit design should consider ways to reduce cost barriers to initiation and retention in MOUD.
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Affiliation(s)
- Jake R Morgan
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA
- OptumLabs Visiting Scholar, OptumLabs, Eden Prairie, MN
| | - Emily K Quinn
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA
| | | | | | | | | | - Benjamin P Linas
- Epidemiology, Boston University School of Public Health
- Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA
| | - Alexander Y Walley
- Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA
| | - Marc R LaRochelle
- Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA
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10
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Abstract
IMPORTANCE The association between incarceration and long-term mortality risk is unknown and may contribute to racial disparities in overall life expectancy. OBJECTIVE To determine whether incarceration in the US is associated with an increase in mortality risk and whether this association is different for Black compared with non-Black populations. DESIGN, SETTING, AND PARTICIPANTS This generational retrospective cohort study used data from the National Longitudinal Survey of Youth 1979, a nationally representative cohort of noninstitutionalized youths aged 15 to 22 years, from January 1 to December 31, 1979, with follow-up through December 31, 2018. A total of 7974 non-Hispanic Black and non-Hispanic non-Black participants were included. Statistical analysis was performed from October 26, 2019, to August 31, 2021. EXPOSURES Time-varying exposure of having experienced incarceration during follow-up. MAIN OUTCOMES AND MEASURES The main outcome was time to death. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% CIs, adjusted for baseline sociodemographic, economic, and behavioral risk factors. Models were evaluated for the full cohort and stratified by race. RESULTS Of the 7974 individuals included in our sample, 4023 (50.5%) were male, and 2992 (37.5%) identified as Black (median age, 18 [IQR, 17-20] years). During a median follow-up of 35 years (IQR, 33-37 years), 478 participants were incarcerated and 818 died. Unadjusted exposure to at least 1 incarceration between 22 and 50 years of age was 11.5% (95% CI, 10.4%-12.7%) for Black participants compared with 2.5% (95% CI, 2.1%-2.9%) for non-Black participants. In the multivariable Cox proportional hazards model with the full cohort, time-varying exposure to incarceration was associated with an increased mortality rate (adjusted HR [aHR], 1.35; 95% CI, 0.97-1.88), a result that was not statistically significant. In the models stratified by race, incarceration was significantly associated with increased mortality among Black participants (aHR, 1.65; 95% CI, 1.18-2.31) but not among non-Black participants (aHR, 1.17; 95% CI, 0.68-2.03). CONCLUSIONS AND RELEVANCE In this cohort study with 4 decades of follow-up, incarceration was associated with a higher mortality rate among Black participants but not among non-Black participants. These findings suggest that incarceration, which was prevalent and unevenly distributed, may have contributed to the lower life expectancy of the non-Hispanic Black population in the US.
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Affiliation(s)
- Benjamin J. Bovell-Ammon
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
- The Miriam Hospital, Lifespan, Providence, Rhode Island
| | - Ziming Xuan
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
| | - Michael K. Paasche-Orlow
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
| | - Marc R. LaRochelle
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
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11
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Slavova S, LaRochelle MR, Root ED, Feaster DJ, Villani J, Knott CE, Talbert J, Mack A, Crane D, Bernson D, Booth A, Walsh SL. Operationalizing and selecting outcome measures for the HEALing Communities Study. Drug Alcohol Depend 2020; 217:108328. [PMID: 33091844 PMCID: PMC7531340 DOI: 10.1016/j.drugalcdep.2020.108328] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/15/2020] [Accepted: 09/15/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND The Helping to End Addiction Long-termSM (HEALing) Communities Study (HCS) is a multisite, parallel-group, cluster randomized wait-list controlled trial evaluating the impact of the Communities That HEAL intervention to reduce opioid overdose deaths and associated adverse outcomes. This paper presents the approach used to define and align administrative data across the four research sites to measure key study outcomes. METHODS Priority was given to using administrative data and established data collection infrastructure to ensure reliable, timely, and sustainable measures and to harmonize study outcomes across the HCS sites. RESULTS The research teams established multiple data use agreements and developed technical specifications for more than 80 study measures. The primary outcome, number of opioid overdose deaths, will be measured from death certificate data. Three secondary outcome measures will support hypothesis testing for specific evidence-based practices known to decrease opioid overdose deaths: (1) number of naloxone units distributed in HCS communities; (2) number of unique HCS residents receiving Food and Drug Administration-approved buprenorphine products for treatment of opioid use disorder; and (3) number of HCS residents with new incidents of high-risk opioid prescribing. CONCLUSIONS The HCS has already made an impact on existing data capacity in the four states. In addition to providing data needed to measure study outcomes, the HCS will provide methodology and tools to facilitate data-driven responses to the opioid epidemic, and establish a central repository for community-level longitudinal data to help researchers and public health practitioners study and understand different aspects of the Communities That HEAL framework.
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Affiliation(s)
- Svetla Slavova
- Department of Biostatistics, University of Kentucky, Healthy Kentucky Research Building RB2, Suite 260, 760 Press Avenue, Lexington, KY, 40536, USA.
| | - Marc R LaRochelle
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA, 02218, USA.
| | - Elisabeth D Root
- Department of Geography and Division of Epidemiology, The Ohio State University, and Translational Data Analytics Institute Columbus, The Ohio State University, 1036 Derby Hall, 154 N. Oval Mall, Columbus, OH, 43210, USA.
| | - Daniel J Feaster
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 NW 14th Street, Room 1059, Miami, FL, 33136, USA.
| | - Jennifer Villani
- National Institutes of Health, National Institute on Drug Abuse, 3WFN, MSC 6025, 301 North Stonestreet Avenue, Bethesda, MD, 20892, USA.
| | - Charles E Knott
- Social, Statistical and Environment Sciences Survey Research Division, RTI International, 3040 E. Cornwallis Road, Research Triangle Park, NC, 27709, USA.
| | - Jeffery Talbert
- Division of Biomedical Informatics, University of Kentucky College of Medicine, 267 Healthy Kentucky Research Building, 760 Press Avenue, Lexington, KY, 40536, USA.
| | - Aimee Mack
- Ohio Colleges of Medicine Government Resource Center, The Ohio State University Wexner Medical Center, 150 Pressey Hall, 1070 Carmack Road, Columbus, OH, 43210, USA.
| | - Dushka Crane
- Ohio Colleges of Medicine Government Resource Center, The Ohio State University Wexner Medical Center, 150 Pressey Hall, 1070 Carmack Road, Columbus, OH, 43210, USA.
| | - Dana Bernson
- Massachusetts Department of Public Health, 250 Washington Street, Boston, MA, 02108, USA.
| | - Austin Booth
- Biostatistics and Epidemiology Division, RTI International, 6110 Executive Blvd, Suite 900, Rockville, MD, 20852, USA.
| | - Sharon L Walsh
- Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky College of Medicine, 845 Angliana Avenue, Lexington, KY, 40508, USA.
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12
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Wu E, Villani J, Davis A, Fareed N, Harris DR, Huerta TR, LaRochelle MR, Miller CC, Oga EA. Community dashboards to support data-informed decision-making in the HEALing communities study. Drug Alcohol Depend 2020; 217:108331. [PMID: 33070058 PMCID: PMC7528750 DOI: 10.1016/j.drugalcdep.2020.108331] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/18/2020] [Accepted: 09/24/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND With opioid misuse, opioid use disorder (OUD), and opioid overdose deaths persisting at epidemic levels in the U.S., the largest implementation study in addiction research-the HEALing Communities Study (HCS)-is evaluating the impact of the Communities That Heal (CTH) intervention on reducing opioid overdose deaths in 67 disproportionately affected communities from four states (i.e., "sites"). Community-tailored dashboards are central to the CTH intervention's mandate to implement a community-engaged and data-driven process. These dashboards support a participating community's decision-making for selection and monitoring of evidence-based practices to reduce opioid overdose deaths. METHODS/DESIGN A community-tailored dashboard is a web-based set of interactive data visualizations of community-specific metrics. Metrics include opioid overdose deaths and other OUD-related measures, as well as drivers of change of these outcomes in a community. Each community-tailored dashboard is a product of a co-creation process between HCS researchers and stakeholders from each community. The four research sites used a varied set of technical approaches and solutions to support the scientific design and CTH intervention implementation. Ongoing evaluation of the dashboards involves quantitative and qualitative data on key aspects posited to shape dashboard use combined with website analytics. DISCUSSION The HCS presents an opportunity to advance how community-tailored dashboards can foster community-driven solutions to address the opioid epidemic. Lessons learned can be applied to inform interventions for public health concerns and issues that have disproportionate impact across communities and populations (e.g., racial/ethnic and sexual/gender minorities and other marginalized individuals). TRIAL REGISTRATION ClinicalTrials.gov (NCT04111939).
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Affiliation(s)
- Elwin Wu
- Social Intervention Group, Columbia University School of Social Work, 1255 Amsterdam Avenue, New York, NY, 10027, USA.
| | - Jennifer Villani
- National Institute on Drug Abuse, 3WFN RM 08A45 MSC 6025, 301 North Stonestreet Avenue, Rockville, MD, 20892, USA
| | - Alissa Davis
- Social Intervention Group, Columbia University School of Social Work, 1255 Amsterdam Avenue, New York, NY, 10027, USA
| | - Naleef Fareed
- CATALYST - The Center for the Advancement of Team Science, Analytics, and Systems Thinking, College of Medicine, The Ohio State University, 460 Medical Center Drive, Columbus, OH, 43210, USA; Department of Biomedical Informatics, College of Medicine, The Ohio State University, 1585 Neil Avenue, Columbus, OH, 43210, USA
| | - Daniel R Harris
- Institute for Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Kentucky, Lexington, KY, 40506, USA; Center for Clinical and Translational Sciences, University of Kentucky, Lexington, KY, 40506, USA
| | - Timothy R Huerta
- CATALYST - The Center for the Advancement of Team Science, Analytics, and Systems Thinking, College of Medicine, The Ohio State University, 460 Medical Center Drive, Columbus, OH, 43210, USA; Department of Biomedical Informatics, College of Medicine, The Ohio State University, 1585 Neil Avenue, Columbus, OH, 43210, USA
| | - Marc R LaRochelle
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA, 02218, USA
| | - Cortney C Miller
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Emmanuel A Oga
- RTI International, 6110 Executive Boulevard, Rockville, MD, 20852, USA
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13
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Wei J, Wood MJ, Dubreuil M, Tomasson G, LaRochelle MR, Zeng C, Lu N, Lin J, Choi HK, Lei G, Zhang Y. Association of tramadol with risk of myocardial infarction among patients with osteoarthritis. Osteoarthritis Cartilage 2020; 28:137-145. [PMID: 31629022 PMCID: PMC7047659 DOI: 10.1016/j.joca.2019.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/26/2019] [Accepted: 10/02/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Tramadol has been widely used among patients with osteoarthritis (OA); however, there is paucity of information on its cardiovascular risk. We aimed to examine the association of tramadol with risk of myocardial infarction (MI) among patients with OA. DESIGN Among OA patients aged 50-90 years without history of MI, cancer, or opioid use disorder in The Health Improvement Network database in the United Kingdom (2000-2016), three sequential propensity-score matched cohort studies were assembled, i.e., (1) patients who initiated tramadol or naproxen (negative comparator); (2) patients who initiated tramadol or diclofenac (positive comparator); and (3) patients who initiated tramadol or codeine (a commonly used weak opioid). The outcome was incident MI over six-months. RESULTS Among tramadol and naproxen initiators (n = 33,024 in each cohort), 77 (4.8/1000 person-years) and 46 (2.8/1000 person-years) incident MI occurred, respectively. The rate difference (RD) and hazard ratios (HR) for incident MI with tramadol initiation were 1.9 (95% confidence interval [CI] 0.6 to 2.3)/1000 person-years and 1.68 (95% CI 1.16 to 2.41) relative to naproxen initiation, respectively. Among tramadol and diclofenac initiators (n = 18,662 in each cohort), 58 (6.4/1000 person-years) and 47 (5.1/1000 person-years) incident MIs occurred, respectively. The corresponding RD and HR for incident MI were 1.2 (95%CI -2.1 to 14.1)/1000 person-years and 1.24 (95%CI 0.84 to 1.82), respectively. Among tramadol and codeine initiators (n = 42,722 in each cohort), 127 (6.1/1000 person-years) and 103 (5.0/1000 person-years) incident MI occurred, respectively, and the corresponding RD and HR were 1.1 (95%CI:-0.3 to 2.5)/1000 person-years and 1.23 (95%CI:0.95 to 1.60), respectively. CONCLUSIONS In this population-based cohort of patients with OA, the six-month risk of MI among initiators of tramadol was higher than that of naproxen, but comparable to, if not lower than, those of diclofenac or codeine.
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Affiliation(s)
- Jie Wei
- Health Management Center, Xiangya Hospital, Central South University, Changsha, Hunan, China,Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA,The Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Malissa J Wood
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maureen Dubreuil
- Boston University School of Medicine, Boston, Massachusetts, USA,VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Gunnar Tomasson
- Department of Public Health Sciences, University of Iceland, Stapi Hringbraut, 101 Reykjavik, Iceland
| | - Marc R. LaRochelle
- Clinical Addiction Research and Education Unit at Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Chao Zeng
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA,The Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA,Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Na Lu
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA,Arthritis Research Canada, Richmond, British Columbia, Canada
| | - Jianhao Lin
- Department of Orthopaedic Surgery, Peking University People’s Hospital, Beijing, China
| | - Hyon K. Choi
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA,The Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Guanghua Lei
- Department of Orthopaedic Surgery, Peking University People’s Hospital, Beijing, China,National Clinical Research Center of Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China,Correspondence to: Guanghua Lei, Department of Orthopaedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, China, 410008, ; Yuqing Zhang, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, Massachusetts, USA, 02114,
| | - Yuqing Zhang
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA,The Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA,Correspondence to: Guanghua Lei, Department of Orthopaedics, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha, Hunan, China, 410008, ; Yuqing Zhang, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, Massachusetts, USA, 02114,
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14
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Barocas JA, Wang J, Marshall BD, LaRochelle MR, Bettano A, Bernson D, Beckwith CG, Linas BP, Walley AY. Sociodemographic factors and social determinants associated with toxicology confirmed polysubstance opioid-related deaths. Drug Alcohol Depend 2019; 200:59-63. [PMID: 31100636 PMCID: PMC6588486 DOI: 10.1016/j.drugalcdep.2019.03.014] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 03/12/2019] [Accepted: 03/14/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIMS While prescribed and illicit opioid use are primary drivers of the national surges in overdose deaths, opioid overdose deaths in which stimulants are also present are increasing in the U.S. We determined the social determinants and sociodemographic factors associated with opioid-only versus polysubstance opioid overdose deaths in Massachusetts. Particular attention was focused on the role of stimulants in opioid overdose deaths. METHODS We analyzed all opioid-related overdose deaths from 2014 to 2015 in an individually-linked population database in Massachusetts. We used linked postmortem toxicology data to identify drugs present at the time of death. We constructed a multinomial logistic regression model to identify factors associated with three mutually exclusive overdose death groups based on toxicological results: opioid-related deaths with (1) opioids only present, (2) opioids and other substances not including stimulants, and (3) opioids and stimulants with or without other substances. RESULTS Between 2014 and 2015, there were 2,244 opioid-related overdose deaths in Massachusetts that had accompanying toxicology results. Toxicology reports indicated that 17% had opioids only, 36% had opioids plus stimulants, and 46% had opioids plus another non-stimulant substance. Persons older than 24 years, non-rural residents, those with comorbid mental illness, non-Hispanic black residents, and persons with recent homelessness were more likely than their counterparts to die with opioids and stimulants than opioids alone. CONCLUSIONS Polysubstance opioid overdose is increasingly common in the US. Addressing modifiable social determinants of health, including barriers to mental health services and homelessness, is important to reduce polysubstance use and overdose deaths.
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Affiliation(s)
- Joshua A. Barocas
- Division of Infectious Diseases, Boston Medical Center (BMC), 801 Massachusetts Ave, 2 Floor, Boston, MA, USA, 02118;,Boston University School of Medicine, 801 Massachusetts Ave, 2 Floor, Boston, MA, USA, 02118
| | - Jianing Wang
- Division of Infectious Diseases, Boston Medical Center (BMC), 801 Massachusetts Ave, 2 Floor, Boston, MA, USA, 02118;,Boston University School of Medicine, 801 Massachusetts Ave, 2 Floor, Boston, MA, USA, 02118
| | - Brandon D.L. Marshall
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Room 208, Box G-S121-2, Providence, RI 02912
| | - Marc R. LaRochelle
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Ave, 2 Floor, Boston, MA, USA, 02118
| | - Amy Bettano
- Massachusetts Department of Public Health, 250 Washington Street, 6th Floor, Boston, MA, 02108
| | - Dana Bernson
- Massachusetts Department of Public Health, 250 Washington Street, 6th Floor, Boston, MA, 02108
| | - Curt G. Beckwith
- Division of Infectious Diseases, Alpert Medical School of Brown University and the Miriam Hospital, 1125 N Main St, Providence, RI 02906
| | - Benjamin P. Linas
- Division of Infectious Diseases, Boston Medical Center (BMC), 801 Massachusetts Ave, 2 Floor, Boston, MA, USA, 02118;,Boston University School of Medicine, 801 Massachusetts Ave, 2 Floor, Boston, MA, USA, 02118
| | - Alexander Y. Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Ave, 2 Floor, Boston, MA, USA, 02118
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Stopka TJ, Amaravadi H, Kaplan AR, Hoh R, Bernson D, Chui KKH, Land T, Walley AY, LaRochelle MR, Rose AJ. Opioid overdose deaths and potentially inappropriate opioid prescribing practices (PIP): A spatial epidemiological study. Int J Drug Policy 2019; 68:37-45. [PMID: 30981166 PMCID: PMC6685426 DOI: 10.1016/j.drugpo.2019.03.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 01/09/2019] [Accepted: 03/02/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Opioid overdose deaths quintupled in Massachusetts between 2000 and 2016. Potentially inappropriate opioid prescribing practices (PIP) are associated with increases in overdoses. The purpose of this study was to conduct spatial epidemiological analyses of novel comprehensively linked data to identify overdose and PIP hotspots. METHODS Sixteen administrative datasets, including prescription monitoring, medical claims, vital statistics, and medical examiner data, covering >98% of Massachusetts residents between 2011-2015, were linked in 2017 to better investigate the opioid epidemic. PIP was defined by six measures: ≥100 morphine milligram equivalents (MMEs), co-prescription of benzodiazepines and opioids, cash purchases of opioid prescriptions, opioid prescriptions without a recorded pain diagnosis, and opioid prescriptions through multiple prescribers or pharmacies. Using spatial autocorrelation and cluster analyses, overdose and PIP hotspots were identified among 538 ZIP codes. RESULTS More than half of the adult population (n = 3,143,817, ages 18 and older) were prescribed opioids. Nearly all ZIP codes showed increasing rates of overdose over time. Overdose clusters were identified in Worcester, Northampton, Lee/Tyringham, Wareham/Bourne, Lynn, and Revere/Chelsea (Getis-Ord Gi*; p < 0.05). Large PIP clusters for ≥100 MMEs and prescription without pain diagnosis were identified in Western Massachusetts; and smaller clusters for multiple prescribers in Nantucket, Berkshire, and Hampden Counties (p < 0.05). Co-prescriptions and cash payment clusters were localized and nearly identical (p < 0.05). Overlap in PIP and overdose clusters was identified in Cape Cod and Berkshire County. However, we also found contradictory patterns in overdose and PIP hotspots. CONCLUSIONS Overdose and PIP hotspots were identified, as well as regions where the two overlapped, and where they diverged. Results indicate that PIP clustering alone does not explain overdose clustering patterns. Our findings can inform public health policy decisions at the local level, which include a focus on PIP and misuse of heroin and fentanyl that aim to curb opioid overdoses.
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Affiliation(s)
- Thomas J Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, United States.
| | - Harsha Amaravadi
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, United States
| | - Anna R Kaplan
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, United States
| | - Rachel Hoh
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, United States
| | - Dana Bernson
- Massachusetts Department of Public Health, Boston, MA, United States
| | - Kenneth K H Chui
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, United States
| | - Thomas Land
- University of Massachusetts Medical School, Division of Clinical Informatics, Worcester, MA, United States (T. Land)
| | - Alexander Y Walley
- Massachusetts Department of Public Health, Boston, MA, United States; Boston University School of Medicine/Boston Medical Center, Boston, MA, United States
| | - Marc R LaRochelle
- Boston University School of Medicine/Boston Medical Center, Boston, MA, United States
| | - Adam J Rose
- Boston University School of Medicine/Boston Medical Center, Boston, MA, United States; RAND Corporation, Boston, MA, United States
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Abstract
IMPORTANCE An American Academy of Orthopaedic Surgeons guideline recommends tramadol for patients with knee osteoarthritis, and an American College of Rheumatology guideline conditionally recommends tramadol as first-line therapy for patients with knee osteoarthritis, along with nonsteroidal anti-inflammatory drugs. OBJECTIVE To examine the association of tramadol prescription with all-cause mortality among patients with osteoarthritis. DESIGN, SETTING, AND PARTICIPANTS Sequential, propensity score-matched cohort study at a general practice in the United Kingdom. Individuals aged at least 50 years with a diagnosis of osteoarthritis in the Health Improvement Network database from January 2000 to December 2015, with follow-up to December 2016. EXPOSURES Initial prescription of tramadol (n = 44 451), naproxen (n = 12 397), diclofenac (n = 6512), celecoxib (n = 5674), etoricoxib (n = 2946), or codeine (n = 16 922). MAIN OUTCOMES AND MEASURES All-cause mortality within 1 year after initial tramadol prescription, compared with 5 other pain relief medications. RESULTS After propensity score matching, 88 902 patients were included (mean [SD] age, 70.1 [9.5] years; 61.2% were women). During the 1-year follow-up, 278 deaths (23.5/1000 person-years) occurred in the tramadol cohort and 164 (13.8/1000 person-years) occurred in the naproxen cohort (rate difference, 9.7 deaths/1000 person-years [95% CI, 6.3-13.2]; hazard ratio [HR], 1.71 [95% CI, 1.41-2.07]), and mortality was higher for tramadol compared with diclofenac (36.2/1000 vs 19.2/1000 person-years; HR, 1.88 [95% CI, 1.51-2.35]). Tramadol was also associated with a higher all-cause mortality rate compared with celecoxib (31.2/1000 vs 18.4/1000 person-years; HR, 1.70 [95% CI, 1.33-2.17]) and etoricoxib (25.7/1000 vs 12.8/1000 person-years; HR, 2.04 [95% CI, 1.37-3.03]). No statistically significant difference in all-cause mortality was observed between tramadol and codeine (32.2/1000 vs 34.6/1000 person-years; HR, 0.94 [95% CI, 0.83-1.05]). CONCLUSIONS AND RELEVANCE Among patients aged 50 years and older with osteoarthritis, initial prescription of tramadol was associated with a significantly higher rate of mortality over 1 year of follow-up compared with commonly prescribed nonsteroidal anti-inflammatory drugs, but not compared with codeine. However, these findings may be susceptible to confounding by indication, and further research is needed to determine if this association is causal.
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Affiliation(s)
- Chao Zeng
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Maureen Dubreuil
- Boston University School of Medicine, Boston, Massachusetts
- VA Boston Healthcare System, Boston, Massachusetts
| | - Marc R. LaRochelle
- Clinical Addiction Research and Education Unit, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Na Lu
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jie Wei
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Hyon K. Choi
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Guanghua Lei
- Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yuqing Zhang
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
- Boston University School of Medicine, Boston, Massachusetts
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17
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Rose AJ, McBain R, Schuler MS, LaRochelle MR, Ganz DA, Kilambi V, Stein BD, Bernson D, Chui KKH, Land T, Walley AY, Stopka TJ. Effect of Age on Opioid Prescribing, Overdose, and Mortality in Massachusetts, 2011 to 2015. J Am Geriatr Soc 2018; 67:128-132. [PMID: 30471102 DOI: 10.1111/jgs.15659] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/26/2018] [Accepted: 09/27/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To examine the effect of age on the likelihood of PIP of opioids and the effect of PIP on adverse outcomes. DESIGN Retrospective cohort study. SETTING Data from multiple state agencies in Massachusetts from 2011 to 2015. PARTICIPANTS Adult Massachusetts residents (N=3,078,163) who received at least one prescription opioid during the study period; approximately half (1,589,365) aged 50 and older. MEASUREMENTS We measured exposure to 5 types of PIP: high-dose opioids, coprescription with benzodiazepines, multiple opioid prescribers, multiple opioid pharmacies, and continuous opioid therapy without a pain diagnosis. We examined 3 adverse outcomes: nonfatal opioid overdose, fatal opioid overdose, and all-cause mortality. RESULTS The rate of any PIP increased with age, from 2% of individuals age 18 to 29 to 14% of those aged 50 and older. Older adults also had higher rates of exposure to 2 or more different types of PIP (40-49, 2.5%; 50-69, 5%; ≥70, 4%). Of covariates assessed, older age was the greatest predictor of PIP. In analyses stratified according to age, any PIP and specific types of PIP were associated with nonfatal overdose, fatal overdose, and all-cause mortality in younger and older adults. CONCLUSION Older adults are more likely to be exposed to PIP, which increases their risk of adverse events. Strategies to reduce exposure to PIP and to improve outcomes in those already exposed will be instrumental to addressing the opioid crisis in older adults. J Am Geriatr Soc 67:128-132, 2019.
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Affiliation(s)
- Adam J Rose
- RAND Corporation, Boston, Massachusetts.,Section of General Internal Medicine, School of Medicine, Boston University, Boston, Massachusetts
| | | | | | - Marc R LaRochelle
- Section of General Internal Medicine, School of Medicine, Boston University, Boston, Massachusetts
| | - David A Ganz
- RAND Corporation, Santa Monica, California.,David Geffen School of Medicine, Los Angeles, California.,Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | | | - Bradley D Stein
- RAND Corporation, Pittsburgh, Pennsylvania.,School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dana Bernson
- Massachusetts Department of Public Health, Boston, Massachusetts
| | | | - Thomas Land
- School of Medicine, University of Massachusetts, Worcester, Massachusetts
| | - Alexander Y Walley
- Section of General Internal Medicine, School of Medicine, Boston University, Boston, Massachusetts
| | - Thomas J Stopka
- School of Medicine, Tufts University, Boston, Massachusetts.,Tufts Clinical and Translational Sciences Institute, Boston, Massachusetts
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Barocas JA, White LF, Wang J, Walley AY, LaRochelle MR, Bernson D, Land T, Morgan JR, Samet JH, Linas BP. Estimated Prevalence of Opioid Use Disorder in Massachusetts, 2011-2015: A Capture-Recapture Analysis. Am J Public Health 2018; 108:1675-1681. [PMID: 30359112 DOI: 10.2105/ajph.2018.304673] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To estimate the annual prevalence of opioid use disorder (OUD) in Massachusetts from 2011 to 2015. METHODS We performed a multisample stratified capture-recapture analysis to estimate OUD prevalence in Massachusetts. Individuals identified from 6 administrative databases for 2011 to 2012 and 7 databases for 2013 to 2015 were linked at the individual level and included in the analysis. Individuals were stratified by age group, sex, and county of residence. RESULTS The OUD prevalence in Massachusetts among people aged 11 years or older was 2.72% in 2011 and 2.87% in 2012. Between 2013 and 2015, the prevalence increased from 3.87% to 4.60%. The greatest increase in prevalence was observed among those in the youngest age group (11-25 years), a 76% increase from 2011 to 2012 and a 42% increase from 2013 to 2015. CONCLUSIONS In Massachusetts, the OUD prevalence was 4.6% among people 11 years or older in 2015. The number of individuals with OUD is likely increasing, particularly among young people.
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Affiliation(s)
- Joshua A Barocas
- Joshua A. Barocas, Jianing Wang, Jake R. Morgan, and Benjamin P. Linas are with the Division of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA. Laura F. White is with the Department of Biostatistics, Boston University School of Public Health. Alexander Y. Walley, Marc R. LaRochelle, and Jeffrey H. Samet are with the Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center. Dana Bernson is with the Massachusetts Department of Public Health, Boston. Thomas Land is with the University of Massachusetts Medical School, Boston
| | - Laura F White
- Joshua A. Barocas, Jianing Wang, Jake R. Morgan, and Benjamin P. Linas are with the Division of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA. Laura F. White is with the Department of Biostatistics, Boston University School of Public Health. Alexander Y. Walley, Marc R. LaRochelle, and Jeffrey H. Samet are with the Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center. Dana Bernson is with the Massachusetts Department of Public Health, Boston. Thomas Land is with the University of Massachusetts Medical School, Boston
| | - Jianing Wang
- Joshua A. Barocas, Jianing Wang, Jake R. Morgan, and Benjamin P. Linas are with the Division of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA. Laura F. White is with the Department of Biostatistics, Boston University School of Public Health. Alexander Y. Walley, Marc R. LaRochelle, and Jeffrey H. Samet are with the Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center. Dana Bernson is with the Massachusetts Department of Public Health, Boston. Thomas Land is with the University of Massachusetts Medical School, Boston
| | - Alexander Y Walley
- Joshua A. Barocas, Jianing Wang, Jake R. Morgan, and Benjamin P. Linas are with the Division of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA. Laura F. White is with the Department of Biostatistics, Boston University School of Public Health. Alexander Y. Walley, Marc R. LaRochelle, and Jeffrey H. Samet are with the Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center. Dana Bernson is with the Massachusetts Department of Public Health, Boston. Thomas Land is with the University of Massachusetts Medical School, Boston
| | - Marc R LaRochelle
- Joshua A. Barocas, Jianing Wang, Jake R. Morgan, and Benjamin P. Linas are with the Division of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA. Laura F. White is with the Department of Biostatistics, Boston University School of Public Health. Alexander Y. Walley, Marc R. LaRochelle, and Jeffrey H. Samet are with the Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center. Dana Bernson is with the Massachusetts Department of Public Health, Boston. Thomas Land is with the University of Massachusetts Medical School, Boston
| | - Dana Bernson
- Joshua A. Barocas, Jianing Wang, Jake R. Morgan, and Benjamin P. Linas are with the Division of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA. Laura F. White is with the Department of Biostatistics, Boston University School of Public Health. Alexander Y. Walley, Marc R. LaRochelle, and Jeffrey H. Samet are with the Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center. Dana Bernson is with the Massachusetts Department of Public Health, Boston. Thomas Land is with the University of Massachusetts Medical School, Boston
| | - Thomas Land
- Joshua A. Barocas, Jianing Wang, Jake R. Morgan, and Benjamin P. Linas are with the Division of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA. Laura F. White is with the Department of Biostatistics, Boston University School of Public Health. Alexander Y. Walley, Marc R. LaRochelle, and Jeffrey H. Samet are with the Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center. Dana Bernson is with the Massachusetts Department of Public Health, Boston. Thomas Land is with the University of Massachusetts Medical School, Boston
| | - Jake R Morgan
- Joshua A. Barocas, Jianing Wang, Jake R. Morgan, and Benjamin P. Linas are with the Division of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA. Laura F. White is with the Department of Biostatistics, Boston University School of Public Health. Alexander Y. Walley, Marc R. LaRochelle, and Jeffrey H. Samet are with the Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center. Dana Bernson is with the Massachusetts Department of Public Health, Boston. Thomas Land is with the University of Massachusetts Medical School, Boston
| | - Jeffrey H Samet
- Joshua A. Barocas, Jianing Wang, Jake R. Morgan, and Benjamin P. Linas are with the Division of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA. Laura F. White is with the Department of Biostatistics, Boston University School of Public Health. Alexander Y. Walley, Marc R. LaRochelle, and Jeffrey H. Samet are with the Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center. Dana Bernson is with the Massachusetts Department of Public Health, Boston. Thomas Land is with the University of Massachusetts Medical School, Boston
| | - Benjamin P Linas
- Joshua A. Barocas, Jianing Wang, Jake R. Morgan, and Benjamin P. Linas are with the Division of Infectious Diseases, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA. Laura F. White is with the Department of Biostatistics, Boston University School of Public Health. Alexander Y. Walley, Marc R. LaRochelle, and Jeffrey H. Samet are with the Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center. Dana Bernson is with the Massachusetts Department of Public Health, Boston. Thomas Land is with the University of Massachusetts Medical School, Boston
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