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

The jeong and haan of Vincent van Gogh: neuropeptides of bondedness and loss

We introduce two Korean-named yet transcultural feelings, jeong and haan, to fill gaps in neuroscientific understanding of mammalian bondedness, loss, and aggression. Jeong is a visceral sense of connectedness to a person, place, or thing that may arise after proximity, yet does not require intimacy. The brain opioid theory of social attachment (BOTSA) supports the idea that jeong involves increased activity of enkephalins and beta-endorphins. We propose that withdrawal of jeong-related neuropeptides leads to original haan, a sense of "missingness" that is too subtle to be grossly dysphoric. Through narrative, cognitive appraisals, or moral assignments, however, original haan may transform into the feeling of constructed haan-resentment, bitterness, grievance, sorrow, or suppressed anger. In males, the transformation may be driven by arginine vasopressin, an ancient fight-or-flight neurohormone. Constructed haan may also be driven by vasopressin in females, though data is more sparse, and in both sexes it may depend on situational or societal context. Endogenous opioids inhibit vasopressin, so that when jeong diminishes, vasopressin release may become disinhibited. This relationship implies a companion to the BOTSA, which we articulate as the brain opioid and vasopressin theory of original and constructed haan (BOVTOCH). To illustrate, we reflect on borderline personality disorder, and Vincent van Gogh's self-severing of his ear while living and working with Paul Gauguin, and fearing abandonment by him; yet to understand Van Gogh more completely we also present the brain opioid theory of stable euphoric creativity (BOTSEC), to model the subjective "highs" associated with creative flow states. Together these brain opioid theories may help to explain how feelings related to social bondedness can influence a range of phenomena. For example, opioid drug dependence may be, at least partly, a maladaptive response to feelings of isolation or disconnectedness; the health protective effects of social bonds could be related to tonic exposure to endogenous opioids and their anti-inflammatory properties; endogenous opioid-based social relational enhancement may contribute to placebo responding. Finally we conclude by pointing out the possibility of virtuous cycles of social connectedness and creativity, when feelings of bondedness and euphoric flow reinforce one another through endogenous opioid elevation.

Spatial patterns of rural opioid-related hospital emergency department visits: A machine learning analysis

As opioid-related overdose emergency department visits continue to rise in the United States, there is a need to understand the location and magnitude of the crisis, especially in at-risk rural areas. We analyzed sets of ZIP code level electronic health records for emergency department visits from 6 hospitals for two rural regions of Maryland with higher opioid-related overdose rates. Analysis of the demographics of visits found Black or African American emergency department visits in both rural regions were higher than the proportion of their population per region. We trained random forest models with socio-demographic factors and health risk factors on the visits data to understand drivers and risk factors for opioid misuse. The models ranked factors relating to opioid prescribing rates, race, housing, and poor mental health as highly important. Factors associated with opioid-related overdose emergency department visits were found to vary by race, gender, and location and may provide useful insights for designing mitigation initiatives.

Metro/Nonmetro Migration as a Risk Factor for Opioid Use Disorder Among Older Medicare Beneficiaries: A Longitudinal Analysis of 2013-2018 Data

Opioid use disorder (OUD) among older adults (65+) has drawn researchers' attention. Nonetheless, whether migration between a metropolitan (metro) and nonmetropolitan (nonmetro) county shapes the risk of OUD remains underexplored. The drift hypothesis argues that individuals susceptible to a certain health condition tend to move, increasing the prevalence of the health condition in the destinations. By contrast, the environmental breeder hypothesis claims that migration alters the exposures to residential environment factors, which are associated with the occurrence of health conditions. Applying fixed-effects modeling to longitudinal data of older Medicare beneficiaries moving at least once between 2013 and 2018 (N = 6,227, person-year = 28,874), this study finds that older beneficiaries moving between metro and nonmetro counties demonstrated a higher risk of OUD than those who did not move. The positive association between migration and OUD risk is particularly strong for those moving from metro to nonmetro counties and the drift hypothesis receives stronger support.

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

Introduction

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

Materials and methods

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

Results

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

Discussion

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

Dynamics of Perceived Social Isolation, Secondary Conditions, and Daily Activity Patterns Among Individuals With Stroke: A Network Analysis of Ecological Momentary Assessment Data

OBJECTIVE

To assess contemporaneous and temporal dynamics of perceived social isolation (PSI), secondary conditions, and daily activity patterns in individuals post-stroke.

DESIGN

Longitudinal observational study using ecological momentary assessment (EMA) as a real-time assessment of an individual's lived experiences. We conducted dynamic network analyses to examine longitudinal associations among EMA variables.

SETTINGS

Home and Community.

PARTICIPANTS

202 individuals with mild-to-moderate chronic stroke (median age=60 years; 45% women; 44% black; 90% ischemic stroke; median NIHSS score=2; N=202).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

EMA questions measured PSI, secondary conditions (pain, tiredness, stress, anxiety, worthlessness, difficulty concentrating, and cheerfulness), and daily activity patterns (being at home, being alone, and participating in productive activities).

RESULTS

The median EMA response rate was 84%. The contemporaneous model showed that PSI was associated with being home, alone, and all symptoms except pain. The temporal model revealed a pathway indicating that feelings of worthlessness predicted PSI (regression coefficient=0.06, P=.019), followed by stress (regression coefficient=0.06, P=.024), and then by being not at home (regression coefficient=-0.04, P=.013).

CONCLUSION

Implementing dynamic network analyses on EMA data can uncover dynamic connections among PSI, secondary conditions, and daily activity patterns after stroke. This study found a significant temporal association between PSI and negative emotions. Feeling isolated was followed by feeling stressed, which was followed by a tendency to be out of home, indicating adaptive behaviors in individuals with stroke. These findings highlight the importance of engaging in out-of-home or outdoor activities to mitigate PSI and negative emotions.

Social Vulnerability and the Prevalence of Opioid Use Disorder Among Older Medicare Beneficiaries in U.S. Counties

OBJECTIVES

Recent research has investigated the factors associated with the prevalence of opioid use disorder (OUD) among older adults (65+), which has rapidly increased in the past decade. However, little is known about the relationship between social vulnerability and the prevalence of OUD, and even less is about whether the correlates of the prevalence of OUD vary across the social vulnerability spectrum. This study aims to fill these gaps.

METHODS

We assemble a county-level data set in the contiguous United States (U.S.) by merging 2021 Medicare claims with the CDC's social vulnerability index and other covariates. Using the total number of older beneficiaries with OUD as the dependent variable and the total number of older beneficiaries as the offset, we implement a series of nested negative binomial regression models and then analyze by social vulnerability quartiles.

RESULTS

Higher social vulnerability is associated with higher prevalence of OUD in U.S. counties. This association cannot be fully explained by the differences in the characteristics of older Medicare beneficiaries (e.g., average age) and/or other social conditions (e.g., social capital) across counties. Moreover, the group comparison tests indicate correlates of the prevalence of OUD vary across social vulnerability quartiles in that the average number of mental disorders is positively related to OUD prevalence in the least and the most vulnerable counties and social capital benefits the less vulnerable counties.

DISCUSSION

A perspective drawing upon contextual factors, especially social vulnerability, may be more effective in reducing OUD among older adults in U.S. counties than a one-size-fits-all approach.

Association Between Opioid Use Disorder and Seizure Incidents Among Alcohol Use Disorder Patients

Many previous studies have discussed an association between alcohol use disorder (AUD) and seizure incidents. There are also case reports of seizures during opioid withdrawals. Therefore, it is possible that AUD patients may have a higher risk of seizures if they also have opioid use disorder (OUD). However, it remains unproven whether AUD patients with a dual diagnosis of OUD have higher seizure incidents, to our knowledge. This study explored seizure incidents among the patients with a dual diagnosis of AUD and OUD as well as seizures among AUD only or OUD only patients. This study utilized de-identified data from 30 777 928 hospital inpatient encounters at 948 healthcare systems over 4 years (9/1/2018-8/31/2022) from the Vizient^® Clinical Database for this study. Applying the International Classification of Diseases 10th Revision (ICD-10) diagnostic codes, AUD (1 953 575), OUD (768 982), and seizure (1 209 471) encounters were retrieved from the database to examine the effects of OUD on seizure incidence among AUD patients. This study also stratified patient encounters for demographic factors such as gender, age, and race, as well as the Vizient-categorized primary payer. Greatest gender differences were identified among AUD followed by OUD, and seizure patient groups. The mean age for seizure incidents was 57.6 years, while that of AUD was 54.7 years, and OUD 48.9 years. The greatest proportion of patients in all 3 groups were White, followed by Black, with Medicare being the most common primary payer in all 3 categories. Seizure incidents were statistically more common (P < .001, chi-square) in patients with a dual diagnosis of AUD and OUD (8.07%) compared to those with AUD only (7.55%). The patients with the dual diagnosis had a higher odd ratio than those with AUD only or OUD only. These findings across more than 900 health systems provide a greater understanding of seizure risks. Consequently, this information may help in triaging AUD and OUD patients in certain higher-risk demographic groups.

Opioids ease my pain: Early-life malnutrition and elderly outcomes

Despite a large body of evidence showing that early-life malnutrition influences adult outcomes, there is no evidence that early-life starvation causes use of opioids. Studying the long-term effects of a food shortage in Iran caused by WWII, we find that the rate of people who use drugs in this cohort increased significantly higher than in surrounding cohorts. Then, we examine a broad spectrum of outcomes for this cohort to shed light on potential causes of opioid use in the survivors of this cohort. Our findings suggest that pain contributes significantly to opioid use.

Neighborhood characteristics and opioid use disorder among older Medicare beneficiaries: An examination of the role of the COVID-19 pandemic

This study investigates how the associations between residential characteristics and the risk of opioid user disorder (OUD) among older Medicare beneficiaries (age≥65) are altered by the COVID-19 pandemic. Applying matching techniques and multilevel modeling to the Medicare fee-for-service claims data, this study finds that county-level social isolation, concentrated disadvantage, and residential stability are significantly associated with OUD among older adults (N = 1,080,350) and that those living in counties with low levels of social isolation and residential stability experienced a heightened risk of OUD during the pandemic. The results suggest that the COVID-19 pandemic has aggravated the impacts of residential features on OUD.

Multiscale dimensions of county-level disparities in opioid use disorder rates among older Medicare beneficiaries

Background

Opioid use disorder (OUD) among older adults (age ≥ 65) is a growing yet underexplored public health concern and previous research has mainly assumed that the spatial process underlying geographic patterns of population health outcomes is constant across space. This study is among the first to apply a local modeling perspective to examine the geographic disparity in county-level OUD rates among older Medicare beneficiaries and the spatial non-stationarity in the relationships between determinants and OUD rates.

Methods

Data are from a variety of national sources including the Centers for Medicare & Medicaid Services beneficiary-level data from 2020 aggregated to the county-level and county-equivalents, and the 2016-2020 American Community Survey (ACS) 5-year estimates for 3,108 contiguous US counties. We use multiscale geographically weighted regression to investigate three dimensions of spatial process, namely "level of influence" (the percentage of older Medicare beneficiaries affected by a certain determinant), "scalability" (the spatial process of a determinant as global, regional, or local), and "specificity" (the determinant that has the strongest association with the OUD rate).

Results

The results indicate great spatial heterogeneity in the distribution of OUD rates. Beneficiaries' characteristics, including the average age, racial/ethnic composition, and the average hierarchical condition categories (HCC) score, play important roles in shaping OUD rates as they are identified as primary influencers (impacting more than 50% of the population) and the most dominant determinants in US counties. Moreover, the percentage of non-Hispanic white beneficiaries, average number of mental health conditions, and the average HCC score demonstrate spatial non-stationarity in their associations with the OUD rates, suggesting that these variables are more important in some counties than others.

Conclusions

Our findings highlight the importance of a local perspective in addressing the geographic disparity in OUD rates among older adults. Interventions that aim to reduce OUD rates in US counties may adopt a place-based approach, which could consider the local needs and differential scales of spatial process.

County social isolation and opioid use disorder among older adults: A longitudinal analysis of Medicare data, 2013-2018

This study aims to fill three knowledge gaps: (1) unclear role of ecological factors in shaping older adults' risk of opioid use disorder (OUD), (2) a lack of longitudinal perspective in OUD research among older adults, and (3) underexplored racial/ethnic differences in the determinants of OUD in older populations. This study estimates the effects of county-level social isolation, concentrated disadvantage, and income inequality on older adults' risk of OUD using longitudinal data analysis. We merged the 2013-2018 Medicare population (aged 65+) data to the American Community Survey 5-year county-level estimates to create a person-year dataset (N = 47,291,217 person-years) and used conditional logit fixed-effects modeling to test whether changes in individual- and county-level covariates alter older adults' risk of OUD. Moreover, we conducted race/ethnicity-specific models to compare how these associations vary across racial/ethnic groups. At the county-level, a one-unit increase in social isolation (mean = -0.197, SD = 0.511) increased the risk of OUD by 5.5 percent (OR = 1.055; 95% CI = [1.018, 1.094]) and a one-percentage-point increase in the working population employed in primary industry decreases the risk of OUD by 1 percent (OR = 0.990; 95% CI = [0.985, 0.996]). At the individual-level, increases in the Medicare Hierarchical Condition Categories risk score, physical comorbidity, and mental comorbidity all elevate the risk of OUD. The relationship between county-level social isolation and OUD is driven by non-Hispanic whites, while Hispanic beneficiaries are less sensitive to the changes in county-level factors than any other racial ethnic groups. Between 2013 and 2018, US older adults' risk of OUD was associated with both ecological and individual factors, which carries implications for intervention. Further research is needed to understand why associations of individual factors with OUD are comparable across racial/ethnic groups, but county-level social isolation is only associated with OUD among non-Hispanic white beneficiaries.