Associations of Adolescent School Social Networks, Gender Norms, and Adolescent-to-Young Adult Changes in Male Gender Expression With Young Adult Substance Use

PURPOSE

Male gender expression (MGE), which is shaped by sociocultural pressures around masculinity, has been previously associated with health. This study examines associations of adolescent social network variables and school gender norms with MGE changes from adolescence to young adulthood, and associations of these changes with young adult substance use.

METHODS

Analyzing data from Waves I (1994-95, adolescents, aged 12-18) and IV (2008-09, young adults, 24-32) of a nationally representative longitudinal cohort study, male participants' MGE was assessed in each wave using a validated, empirically derived measure. Linear regression was used to evaluate associations of adolescent-to-young adult MGE changes between waves with adolescent social network characteristics and school gender norms. Logistic regression was used to examine associations between adolescent-to-young adult MGE changes and young adult substance uses (cigarette, marijuana, heavy alcohol, and recreational drug use, and prescription drug misuse).

RESULTS

Among 4,776 male participants, adolescent-to-young adult MGE changes were significantly associated with school gender norms such that adolescents whose MGE markedly departed from their schools' average exhibited greater MGE changes in the direction of their schools' average (β = -0.83, p < .01) relative to those who were more similar to school means. Adolescent-to-young adult increases in MGE were significantly associated with greater odds of all young adult substance use behaviors except prescription drug misuse.

DISCUSSION

Adolescents' MGE relative to other males at their school was associated with MGE changes toward school norms, with implications for young adult substance use. Adolescent gender norms may be an underexplored strategy for interventions to reduce substance misuse.

Closing Gaps in Public Services for US Residents With Intellectual and Developmental Disabilities

This Viewpoint describes existing public health and social service systems for persons with intellectual and developmental disabilities as they transition to adult care, barriers and opportunities faced in service access, and potential actions to narrow these gaps and enhance equity.

Predictors of mental health among U.S. adults during COVID-19 early pandemic, mid- pandemic, and post-vaccine eras

BACKGROUND

A collective trauma like COVID-19 impacts individuals differently due to socio-contextual and individual characteristics. Younger adults, minorities, affiliates of certain political parties, and residents of some regions of the United States reported experiencing poorer mental health during the pandemic. Being diagnosed with COVID-19, or losing a friend/family to it, was related to more adverse mental health symptoms. While the negative impact of COVID-19 on health outcomes has been studied, mental health changes during this pandemic need further exploration.

METHODS

In a study of 8,612 U.S. households, using three surveys collected from a nationally representative panel between May 2020 and October 2021, using a repeated cross-sectional design, a linear mixed effect regression model was performed to investigate factors associated with the mental health status, based on the Mental Health Inventory-5, of individuals throughout different phases of the COVID-19 pandemic, and whether an improvement over time, especially after vaccines became available, was observed.

RESULTS

An overall improvement in mental health was observed after vaccines became available. Individuals with no COVID-related death in their household, those not wearing masks, those identifying as members of the Republican Party, race/ethnicities other than Asian, men, older adults, and residents of the South were less likely than others to report mental health challenges.

CONCLUSIONS

Our results highlight the need for widespread mental health interventions and health promotion to address challenges during the COVID-19 pandemic and beyond. Due to the worse mental health observed among Asians, younger adults, women, low-income families, those with a higher level of concern for COVID-19, people who lost someone to COVID-19, and/or individuals with histories of opioid use disorder and criminal legal involvement, over the period of this study, targeted attention needs to be given to the mental health of these groups.

Gender identity, stimulant drug use, and criminal justice history on internalized stigma among a nationally representative sample of adults who misuse opioids

PURPOSE

The rise of fatal stimulant use among adults who use opioids is a public health problem. Internalized stigma is a barrier to substance use treatment, which is greater for women and populations with criminal justice involvement.

METHODS

Using a nationally representative sample of adults in the United States from a probability-based survey on household opinions in 2021, we examined characteristics of women (n = 289) and men (n = 416) who misuse opioids. In gender-stratified multivariable linear regression, we investigated factors associated with internalized stigma, and tested for the interaction of stimulant use and criminal justice involvement.

RESULTS

Compared to men, women reported greater mental health symptom severity (3.2 vs. 2.7 on a 1 to 6 scale, p < 0.001). Internalized stigma was similar between women (2.3 ± 1.1) and men (2.2 ± 0.1). Among women and not men, however, stimulant use was positively associated with internalized stigma (0.36, 95% CI [0.07, 0.65]; p = 0.02). Interaction between stimulant use and criminal justice involvement was negatively associated with internalized stigma among women (- 0.60, 95% CI [- 1.16, -0.04]; p = 0.04); among men, the interaction was not significant. Predictive margins illustrate among women, stimulant use eliminated the gap in internalized stigma such that women with no criminal justice involvement had a similar level of internalized stigma as women with criminal justice involvement.

CONCLUSION

Internalized stigma between women and men who misuse opioids differed based on stimulant use and criminal justice involvement. Future research should assess whether internalized stigma influences treatment utilization among women with criminal justice involvement.

Endorsement of COVID-19 misinformation among criminal legal involved individuals in the United States: Prevalence and relationship with information sources

Criminal legal system involvement (CLI) is a critical social determinant of health that lies at the intersection of multiple sources of health disparities. The COVID-19 pandemic exacerbates many of these disparities, and specific vulnerabilities faced by the CLI population. This study investigated the prevalence of COVID-19-related misinformation, as well as its relationship with COVID-19 information sources used among Americans experiencing CLI. A nationally representative sample of American adults aged 18+ (N = 1,161), including a subsample of CLI individuals (n = 168), were surveyed in February-March 2021. On a 10-item test, CLI participants endorsed a greater number of misinformation statements (M = 1.88 vs. 1.27) than non-CLI participants, p < .001. CLI participants reported less use of government and scientific sources (p = .017) and less use of personal sources (p = .003) for COVID-19 information than non-CLI participants. Poisson models showed that use of government and scientific sources was negatively associated with misinformation endorsement for non-CLI participants (IRR = .841, p < .001), but not for CLI participants (IRR = .957, p = .619). These findings suggest that building and leveraging trust in important information sources are critical to the containment and mitigation of COVID-19-related misinformation in the CLI population.

Associations between partisan media consumption, opioid use disorder stigma, and opioid policy support: An exploration of the media's role in the ongoing opioid epidemic

We report on a preliminary investigation into the relationship between partisan media consumption (PMC) among U.S. adults and their (1) opioid use disorder (OUD) stigma, (2) national OUD policy support (e.g., Medicaid coverage for OUD treatment), (3) local OUD policy support (e.g., safe injection sites), (4) discriminatory OUD policies (e.g., denying housing), and (5) carceral OUD policies (e.g., jailing people who use opioids). We performed a cross-sectional survey of a nationally-representative sample of U.S. adults (n = 6,515) from October 1-November 19, 2021. We surveyed a sample of U.S. adults ages 18 and older drawn from NORC's AmeriSpeak® Panel. AmeriSpeak is a probability-based ongoing panel of over 40,000 households designed to represent the U.S. household population. Cross-sectional analyses revealed significant relationships between PMC and OUD stigma (b = 0.29, p <.001, CI95 = 0.14,0.43), support for national (b = -0.31, p <.01, CI95 = -0.54,-0.09) and local policy responses (b = -0.38, p <.001, CI95 = -0.59,-0.17), and support for discriminatory opioid use disorder policies (b = 0.27, p <.01, CI95 = 0.07,0.45). After controlling for self-reported political affiliation and other potential covariates, Republican-leaning media consumption was significantly associated with increased OUD stigma, less support for national and local harm reduction or rehabilitative policies, and more support for discriminatory policies against individuals experiencing OUD. The opposite associations were observed for Democratic-leaning media consumption. Markers for racism mediated the relationship between PMC and support for carceral policies (indirect path b = -0.41,p <.001, CI95 = -0.50,-0.31). Our results indicate that public health advocates must collaborate with conservative leaders to find bipartisan common ground for targeted communication campaigns.

Age Trends And State Disparities In Firearm-Related Suicide In The US, 1999-2020

Using data from the Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System, we analyzed trends in firearm suicide across the life course, comparing age-related trends over time (2015-20 versus 1999-2014) and stratified by differences in state firearm policy environments. Overall, we found stable trends in firearm suicide rates across the life course, although with higher overall rates across all age groups in 2015-20 versus in 1999-2014. Ages 14-16 was the only age group with an accelerating life-course trend in firearm suicide rates in 2015-20 versus in 1999-2014. The state policy environment was associated with significant differences in firearm suicide, with an average of 4.62 more deaths per 100,000 people per year in states with less- versus more-strict environments. This was in contrast to nonfirearm suicides, for which we observed no consistent differences between states. The largest overall differences in firearm suicide between states occurred in adulthood through middle age. These findings can inform further research on health care-based approaches to reducing firearm suicide, such as health care screening for firearm ownership, screening for suicide risk among firearm owners, and motivational interviewing to promote safe firearm storage.

Caregiving for Older Adults With Dementia During the Time of COVID-19: A Multi-State Exploratory Qualitative Study

This qualitative semi-structured interview study explores how 64 family caregivers for older adults with Alzheimer's Disease and related dementias across eight states experienced and executed caregiving decisions before and during the COVID-19 pandemic. First, caregivers experienced challenges communicating with loved ones and healthcare workers in all care settings. Second, caregivers displayed resilient coping strategies in adapting to pandemic restrictions, finding novel strategies to balance risks while preserving communication, oversight, and safety. Third, many caregivers modified care arrangements, with some avoiding and others embracing institutional care. Finally, caregivers reflected on the benefits and challenges of pandemic-related innovations. Certain policy changes reduced caregiver burden and could improve care access if made permanent. Telemedicine's increasing use highlights the need for reliable internet access and accommodations for individuals with cognitive deficits. Public policies must pay greater attention to challenges faced by family caregivers, whose labor is both essential and undervalued.

Openness to change among COVID misinformation endorsers: Associations with social demographic characteristics and information source usage

RATIONALE

Misinformation is a major concern for public health, with its presence and impact strongly felt in the COVID-19 pandemic. Misinformation correction has drawn strong research interest. In contrast, relatively little attention has been given to the likelihood of favorable behavioral change post correction (i.e., openness to change).

OBJECTIVE

This study seeks to identify the characteristics of COVID misinformation endorsers who are open to adopt more self-protective behaviors after misinformation correction.

METHODS

COVID misinformation endorsers (N = 1991) in a large, nationally representative survey (fielded in October and November 2021) were asked how likely they would adopt self-protective behaviors if a source they trusted debunked their prior misperceptions. Multiple linear regression estimated the relationships between openness to change and socio-demographics, health-related factors, and health information source usage patterns.

RESULTS

Less than half of the misinformation endorsers in the sample (41.3%) indicated any openness to change. Openness to change was positively associated with minority status and negatively associated with leaning Republican in political affiliation, higher income, being currently unvaccinated or unsure about vaccination status, better health, and a greater number of misinformation items endorsed. Past-month use of government, community, and personal sources for health information positively predicted openness. The use of online media was negatively associated with openness.

CONCLUSIONS

Openness to change is not guaranteed after misinformation correction. Targeted interventions based on openness to change are needed to enhance the public health impact of misinformation correction efforts.

Health Care Provider Stigma Toward Patients With Substance Use Disorders: Protocol for a Nationally Representative Survey

BACKGROUND

The US overdose epidemic is an escalating public health emergency, accounting for over 100,000 deaths annually. Despite the availability of medications for opioid use disorders, provider-level barriers, such as negative attitudes, exacerbate the treatment gap in clinical care settings. Assessing the prevalence and intensity of provider stigma, defined as the negative perceptions and behaviors that providers embody and enact toward patients with substance use disorders, across providers with different specialties, is critical to expanding the delivery of substance use treatment.

OBJECTIVE

To thoroughly understand provider stigma toward patients with substance use disorders, we conducted a nationwide survey of emergency medicine and primary care physicians and dentists using a questionnaire designed to reveal how widely and intensely provider attitudes and stigma can impact these providers' clinical practices in caring for their patients. The survey also queried providers' stigma and clinical practices toward other chronic conditions, which can then be compared with their stigma and practices related to substance use disorders.

METHODS

Our cross-sectional survey was mailed to a nationally representative sample of primary care physicians, emergency medicine physicians, and dentists (N=3011), obtained by American Medical Association and American Dental Association licensees based on specified selection criteria. We oversampled nonmetropolitan practice areas, given the potential differences in provider stigma and available resources in these regions compared with metropolitan areas. Data collection followed a recommended series of contacts with participants per the Dillman Total Design Method, with mixed-modality options offered (email, mail, fax, and phone). A gradually increasing compensation scale (maximum US$250) was implemented to recruit chronic nonresponders and assess the association between requiring higher incentives to participate and providers stigma. The primary outcome, provider stigma, was measured using the Medical Condition Regard Scale, which inquired about participants' views on substance use and other chronic conditions. Additional survey measures included familiarity and social engagement with people with substance use disorders; clinical practices (screening, treating, and referring for a range of chronic conditions); subjective norms and social desirability; knowledge and prior education; and descriptions of their patient populations.

RESULTS

Data collection was facilitated through collaboration with the National Opinion Research Center between October 2020 and October 2022. The overall Council of American Survey Research Organizations completion rate was 53.62% (1240/2312.7; physicians overall: 855/1681.9, 50.83% [primary care physicians: 506/1081.3, 46.79%; emergency medicine physicians: 349/599.8, 58.2%]; dentists: 385/627.1, 61.4%). The ineligibility rate among those screened is applied to those not screened, causing denominators to include fractional numbers.

CONCLUSIONS

Using systematically quantified data on the prevalence and intensity of provider stigma toward substance use disorders in health care, we can provide evidence-based improvement strategies and policies to inform the development and implementation of stigma-reduction interventions for providers to address their perceptions and treatment of substance use.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47548.

The Relationship between Substance Use Stigma and COVID-19 Vaccine Hesitancy

Two parallel public health epidemics affecting the United States include the COVID-19 pandemic and a rise in substance use disorders (SUDs). Limited research has examined the potential relationship between these two epidemics. Our objective was therefore to perform an exploratory study in order to examine the association between public stigma toward people with a past history of opioid, methamphetamine, cocaine, and alcohol use disorder and COVID-19 vaccine hesitancy. A national sample of U.S. adults (N = 6515) completed a survey which assessed the degree of negative perceptions toward individuals with a past history of substance use disorders (referred to as substance use stigma) and COVID-19 vaccine hesitancy, along with variables such as racial prejudice, source of health news, and other demographics. We evaluated four multivariable logistic regression models to predict COVID-19 vaccine hesitancy, utilizing substance use stigma toward opioids, methamphetamine, cocaine, and alcohol use as independent variables. We found that COVID-19 vaccine hesitancy was positively associated with substance use stigma toward opioid (AOR = 1.34, p < 0.05), methamphetamine (AOR = 1.40, p < 0.01), and cocaine (AOR = 1.28, p < 0.05) use, but not alcohol use (AOR = 1.06, n.s.). Predictive models that incorporate substance use stigma may therefore improve our ability to identify individuals that may benefit from vaccine hesitancy interventions. Future research to understand the underlying reasons behind the association between substance use stigma and COVID-19 vaccine hesitancy may help us to construct combined interventions which address belief systems that promote both substance use stigma and vaccine hesitancy.

Randomized evaluation of a school-based, trauma-informed group intervention for young women in Chicago

This study explores whether a school-based group counseling program for adolescent girls, implemented at scale, can mitigate trauma-related mental health harms. In a randomized trial involving 3749 Chicago public high school girls, we find that participating in the program for 4 months induces a 22% reduction in posttraumatic stress disorder symptoms and find significant decreases in anxiety and depression. Results surpass widely accepted cost-effectiveness thresholds, with estimated cost-utility well below $150,000 per quality adjusted life year. We find suggestive evidence that effects persist and may even increase over time. Our results provide the first efficacy trial of such a program specifically designed for girls, conducted in America's third largest city. These findings suggest the promise of school-based programs to mitigate trauma-related harms.

An Inclusive Approach to Addiction Care-Helping the Helpers

This Viewpoint discusses the idea of helping the helpers, those who are supporters or caregivers to individuals with substance use disorder.

Latent class analysis of medical mistrust and COVID-19 vaccine hesitancy among adults in the United States just prior to FDA emergency use authorization

Using a nationally representative household sample, we sought to better understand types of medical mistrust as a driver of COVID-19 vaccine hesitancy. We used survey responses to conduct a latent class analysis to classify respondents into categories and explained this classification as a function of sociodemographic and attitudinal variables using multinomial logistic regression models. We then estimated the probability of respondents agreeing to receive a COVID-19 vaccine conditional on their medical mistrust category. We extracted a five-class solution to represent trust. The high trust group (53.0 %) is characterized by people who trust both their doctors and medical research. The trust in own doctor group (19.0 %) trust their own doctors but is ambiguous when it comes to trusting medical research. The high distrust group (6.3 %) neither trust their own doctor nor medical research. The undecided group (15.2 %) is characterized by people who agree on some dimensions and disagree on others. The no opinion group (6.2 %) did not agree nor disagree with any of the dimensions. Relative to the high trust group, those who trust their own doctors are almost 20 percentage points less likely to plan to get vaccinated (average marginal effect (AME) = 0.21, p <.001), and those who have high distrust are 24 percentage points less likely (AME = -0.24, p <.001) to report planning to get the vaccine. Results indicate that beyond sociodemographic characteristics and political attitudes, people's trust archetypes on parts of the medical field significantly predict their probability of wanting to get vaccinated. Our findings suggest that efforts to combat vaccine hesitancy should focus on building capacity of trusted providers to speak with their patients and parents of their patients, to recommend COVID-19 vaccination and build a trusting relationship; and increase trust and confidence in medical research.

Critical access medication for opioid use disorder (MOUD) treatment facilities in the continental United States

Research objective

Medication opioid use disorder (MOUD) treatment is the first-line approach to the treatment of opioid use disorder (OUD). This analysis seeks to identify "critical access" MOUD facilities that ensure geographic access for MOUD patients. Using public-source data and spatial analysis, we identify the top 100 "critical access" MOUD units across the continental U.S.

Study design

We use locational data from SAMHSA's Behavioral Health Treatment Services Locator and DATA 2000 waiver buprenorphine providers. We identify the closest MOUDs to each ZIP Code Tabulation Area (ZCTA)'s geographic centroid. We then construct a difference-in-distance metric by computing the difference in this distance measure between closest and second-closest MOUD, multiplied by ZCTA population, ranking MOUDs by difference-distance scores.

Population studied

All listed MOUD treatment facilities and all listed ZCTA's across the continental U.S., and all listed MOUD providers proximate to these areas.

Principal findings

We identified the top 100 critical access MOUD units in the continental United States. Many critical providers were in rural areas in the central United States, as well as a band extending east from Texas to Georgia. Twenty-three of the top 100 critical access providers were identified as providing naltrexone. Seventy-seven were identified as providing buprenorphine. Three were identified as providing methadone.

Conclusions

Significant areas of the United States are dependent on a single critical access MOUD provider.

Implications for policy or practice

Place-based supports may be warranted to support MOUD treatment access in areas dependent upon critical access providers.

Predicting Hospitalization among Medicaid Home- and Community-Based Services Users Using Machine Learning Methods

We compare multiple machine learning algorithms and develop models to predict future hospitalization among Home- and Community-Based Services (HCBS) Users. Furthermore, we calculate feature importance, the score of input variables based on their importance to predict the outcome, to identify the most relevant variables to predict hospitalization. We use the 2012 national Medicaid Analytic eXtract data and Medicare Provider Analysis and Review data. Predicting any hospitalization, Random Forest appears to be the most robust approach, though XGBoost achieved similar predictive performance. While the importance of features varies by algorithm, chronic conditions, previous hospitalizations, as well as use of services for ambulance, personal care, and durable medical equipment were generally found to be important predictors of hospitalization. Utilizing prediction models to identify those who are prone to hospitalization could be useful in developing early interventions to improve outcomes among HCBS users.

Behavioral Crisis and First Response: Qualitative Interviews with Chicago Stakeholders

Improving interactions between first responders and individuals experiencing behavioral crisis is a critical public health challenge. To gain insight into these interactions, key informant qualitative interviews were conducted with 25 Chicago stakeholders. Stakeholders included directors and staff of community organizations and shelters that frequently engage first responders. Interviews included granular depictions related to the expectations and outcomes of 911 behavioral crisis calls, and noted areas requiring improved response. Stakeholders called 911 an average of 2 to 3 times per month, most often for assistance related to involuntary hospitalization. Engagements with first responders included unnecessary escalation or coercive tactics, or conversely, refusal of service. While stakeholders lauded the value of police trained through the city's Crisis Intervention Team program, they emphasized the need for additional response strategies that reduce the role of armed police, and underscored the need for broader social and behavioral health services for individuals at-risk of such crises.

Impact of changes in protective behaviors and out-of-household activities by age on COVID-19 transmission and hospitalization in Chicago, Illinois

PURPOSE

Even with an efficacious vaccine, protective behaviors (social distancing, masking) are essential for preventing COVID-19 transmission and could become even more important if current or future variants evade immunity from vaccines or prior infection.

METHODS

We created an agent-based model representing the Chicago population and conducted experiments to determine the effects of varying adult out-of-household activities (OOHA), school reopening, and protective behaviors across age groups on COVID-19 transmission and hospitalizations.

RESULTS

From September-November 2020, decreasing adult protective behaviors and increasing adult OOHA both substantially impacted COVID-19 outcomes; school reopening had relatively little impact when adult protective behaviors and OOHA were maintained. As of November 1, 2020, a 50% reduction in young adult (age 18-40) protective behaviors resulted in increased latent infection prevalence per 100,000 from 15.93 (IQR 6.18, 36.23) to 40.06 (IQR 14.65, 85.21) and 19.87 (IQR 6.83, 46.83) to 47.74 (IQR 18.89, 118.77) with 15% and 45% school reopening. Increasing adult (age ≥18) OOHA from 65% to 80% of prepandemic levels resulted in increased latent infection prevalence per 100,000 from 35.18 (IQR 13.59, 75.00) to 69.84 (IQR 33.27, 145.89) and 38.17 (IQR 15.84, 91.16) to 80.02 (IQR 30.91, 186.63) with 15% and 45% school reopening. Similar patterns were observed for hospitalizations.

CONCLUSIONS

In areas without widespread vaccination coverage, interventions to maintain adherence to protective behaviors, particularly among younger adults and in out-of-household settings, remain a priority for preventing COVID-19 transmission.

Necessity for and Limitations of Price Transparency in American Health Care

Price transparency is an ethical and policy imperative for American health care. More transparent pricing would allow patients and families to make better decisions and would allow clinicians to deliver care with greater simplicity and integrity. This article also considers transparency's real-world patient care limitations and the extent to which price transparency is a reliable pathway to service delivery efficiency and market discipline.

Health Equity for Individuals With Intellectual and Developmental Disabilities

This Viewpoint discusses 3 types of systemic health inequity experienced by individuals with intellectual and developmental disabilities—stigma, exclusion, and devaluation of worth; underrepresentation in population epidemiology and research; and inadequate access to care and social services—and suggests potential approaches to ameliorating inequities in each of these areas.

A pilot study on COVID-19 vaccine hesitancy among healthcare workers in the US

To explore the attitude towards COVID-19 vaccination among healthcare workers in the US, we surveyed three groups of individuals (essential non-healthcare workers, general healthcare workers, and correctional healthcare workers). We found surprisingly high portions of healthcare workers with COVID-19 vaccine hesitancy/resistance, with 23% of correctional healthcare workers and 17% general healthcare workers (as compared to 12%) refusing to be vaccinated against COVID-19. Multivariate regression models suggest that current season flu vaccination (aOR = 3.34), relying on employer for COVID-19 information (aOR = 3.69), and living in the Midwest (aOR = 5.04) to be strongly associated with COVID-19 vaccine acceptance among essential workers and general healthcare workers. Current season flu vaccination (aOR = 7.52) is also strongly associated with COVID-19 vaccine acceptance among correctional healthcare workers. Potential mechanisms of vaccine hesitancy/resistance among healthcare workers involves low health literacy and employer mistrust. Our findings are highly relevant as we try to reach COVID-19 vaccination goals in the US.

Support for evidence-informed opioid policies and interventions: The role of racial attitudes, political affiliation, and opioid stigma

Political affiliation, racial attitudes, and opioid stigma influence public support for public health responses to address opioid use disorders (OUD). Prior studies suggest public perceptions of the opioid epidemic are less racialized and less politically polarized than were public perceptions of the crack cocaine epidemic. Analyzing a cross-sectional, nationally representative sample (n = 1161 U.S. adults) from the October 2020 AmeriSpeak survey, we explored how political affiliation, racial attitudes (as captured in the Color-Blind Racial Attitudes Scale [CoBRAS]), and OUD stigma were associated with respondents' expressed views regarding four critical domains. Respondents with unfavorable attitudes towards Black Americans were less likely to support expanding Medicaid funding, increasing government spending to provide services for people living with OUD, and distributing naloxone for overdose prevention. Democratic Party affiliation was associated with greater support for all three of the above measures, and increased support for mandatory treatment, which may be seen as a substitute for more punitive interventions. Black respondents were also less likely to support expanding Medicaid funding, increasing government spending to provide services for people living with OUD, and of distributing naloxone. Our finding suggest that negative attitudes towards African-Americans and political differences remain important factors of public opinion on responding to the OUD epidemic, even after controlling for opioid stigma. Our findings also suggest that culturally-competent dialogue within politically conservative and Black communities may be important to engage public support for evidence-informed treatment and prevention.

Estimating the Impact of Medicaid Expansion and Federal Funding Cuts on FQHC Staffing and Patient Capacity

Policy Points In the preexpansion period, federally qualified health centers (FQHCs) in Medicaid expansion states were significantly different from those in nonexpansion states. This gap widened as revenues in expansion states continued to grow at a faster rate after the expansion. If Medicaid expansion had occurred nationwide, FQHCs' revenue and capacity could have increased substantially. Over time, Medicaid could play a bigger role as it becomes a more stable funding source to allow for capital investments. Section 330 grants appear to have a larger impact on access to care. Given the varying levels of reliance on Medicaid, investing through federal grants might be more effective and equitable.

CONTEXT

The Health Resources and Services Administration's Health Center Program (HCP) plays a critical role as the national ambulatory safety net, delivering services to patients in medically underserved areas, regardless of their ability to pay. As the program has grown, health policy initiatives may have altered access to care for the underserved population. Understanding how federally qualified health centers (FQHCs) have been affected by past policies is important for anticipating the effects of future policies.

METHODS

By analyzing a national data set from the Uniform Data System, we examined, using two sets of random effects regressions, the potential impact of alternative policy actions affecting FQHCs. Our primary equation models the number of full-time equivalent staff, of patients served, and of visits provided in the subsequent year as a function of Medicaid revenues, Section 330 grants, and other revenues. Our secondary equation is a difference-in-differences analysis that models Medicaid revenues as a function of the states' status of Medicaid expansion.

FINDINGS

The expansion of Medicaid in nonexpansion states could have increased Medicaid revenues by 138%, staffing by 25%, and patients' visits by 24% in 2017. Compared to the impact of a "repeal" of Medicaid expansion, the percentage of reductions in staffing would be similar to those predicted by a 50% cut in Medicaid revenues or in Section 330 grants. On a dollar-for-dollar basis, the effects of one dollar of Section 330 grants were more than double that of one dollar of Medicaid revenue.

CONCLUSIONS

Both Medicaid eligibility and Section 330 funding support are important to the HCP, and Section 330 grants are particularly closely related to staffing and the provision of services. States' decisions not to participate in or to repeal Medicaid expansion, to reduce Medicaid payment rates, and federal funding cuts all could have a negative impact on FQHCs, resulting in thousands of low-income patients losing access to primary care.

Comparison of Ambulatory Care Access and Quality for Beneficiaries With Disabilities Covered by Medicare Advantage vs Traditional Medicare Insurance

Question

Do Medicare beneficiaries aged 18 to 64 years with disability entitlement have different rates of enrollment in Medicare Advantage (MA) vs traditional Medicare (TM) compared with other beneficiaries, and how do the 2 programs compare on rates of ambulatory care access and quality for beneficiaries with disabilities?

Findings

In this cohort study of a nationally representative sample of 7201 person-years for Medicare beneficiaries in 2015 through 2018, beneficiaries with disability entitlement were significantly less likely to enroll in MA compared with those without disability entitlement. However, enrollment in MA vs TM was associated with better outcomes on 2 of 3 access measures and 3 of 3 quality measures for beneficiaries with disabilities.

Meaning

Although Medicare beneficiaries with disabilities enrolled in MA at lower rates than other beneficiaries in this study, MA appeared to compare favorably with TM in meeting key ambulatory care access and quality measures for beneficiaries with disabilities.

Importance

Medicare beneficiaries with disabilities aged 18 to 64 years face barriers accessing ambulatory care. Past studies comparing Medicare Advantage (MA) with traditional Medicare (TM) have not assessed how well these programs meet the needs of beneficiaries with disabilities.

Objective

To compare differences in enrollment rates, ambulatory care access, and ambulatory care quality for beneficiaries with disabilities in MA vs TM.

Design, Setting, and Participants

This cohort study included a nationally representative, weighted sample of 7201 person-years for beneficiaries aged 18 to 64 years with disability entitlement in the Medicare Current Beneficiary Survey from 2015 through 2018. Differences in program enrollment and in measures of access and quality by program enrollment were compared after adjusting for demographic, insurance, social, health, and area characteristics and after reweighting the sample by propensity to enroll in MA as estimated by observed confounders. Data analyses were conducted between November 1, 2020, and November 11, 2021.

Exposures

Medicare Advantage vs TM program enrollment.

Main Outcomes and Measures

Six patient-reported measures of ambulatory care access (usual source of care, primary care usual source of care, specialist visit) and quality (cholesterol screening, influenza vaccination, colon cancer screening).

Results

The mean (SD) age of the overall study population was 52.1 (11.0) years; 49.5% were female and 50.5% were male; 1.6% were Asian/Pacific Islander; 17.4%, Black; 10.2% Hispanic; 1.4%, Native American; 65.1%, White, and 4.2%, multiracial. Among all beneficiaries living in the community, individuals with disability entitlement were less likely to enroll in MA than other beneficiaries (34.8% vs 41.2%). The final sample of beneficiaries with disabilities included 2444 person-years in MA and 4757 person-years in TM. Beneficiaries with disabilities in MA vs TM were more likely to be of a minority race or ethnicity (35.7% vs 27.6%) and less likely to be enrolled in private insurance (11.9% vs 25.0%). Comparing MA with TM among beneficiaries with disabilities, those in MA had significantly better rates of access to a usual source of care (90.2% vs 84.9%; adjusted propensity-weighted marginal difference [APWMD], 2.9%; 95% CI, 0.2%-5.7%), access to specialist visits (53.2% vs 44.8%; APWMD, 5.5%; 95% CI, 0.6%-10.5%), cholesterol screenings (91.1% vs 86.4%; APWMD, 3.8%; 95% CI, 0.9%-6.7%), influenza vaccinations (61.4% vs 51.5%; APWMD, 10.4%; 95% CI, 5.3%-15.5%), and colon cancer screenings (68.4% vs 54.6%; APWMD, 10.3%; 95% CI, 4.8%-15.8%).

Conclusions and Relevance

In this cohort study, Medicare beneficiaries with disabilities were enrolled in MA at significantly lower rates than those without disabilities. However, MA was associated with significantly better ambulatory care access and quality for these beneficiaries on 5 of 6 measures compared with TM.

Predictors of Mental Health among the General Population of U.S. Adults Eight Months into the COVID-19 Pandemic

Background:

The COVID-19 pandemic has had profound impacts on mental health. We examined whether mental health differed based on sociodemographic and background characteristics, political party affiliation, and concerns about COVID-19.

Methods:

A cross-sectional, national sample of 1095 U.S. adults were surveyed October 22–26, 2020. The survey collected information on demographics, risk and protective behaviors for COVID-19, and mental health using the Mental Health Inventory-5 (MHI-5) scale. Independent samples t-tests, one-way Analysis of Variance tests, and a multivariable linear regression model were conducted.

Results:

Regression results showed respondents with criminal justice (B = −6.56, 95% CI = −10.05, −3.06) or opioid misuse (B = −9.98, 95% CI = −14.74, −5.23) histories reported poorer mental health than those without. Those who took protective behaviors (e.g., wearing masks) reported poorer mental health compared to those who indicated protective behaviors were unnecessary (B = 7.00, 95% CI = 1.61, 12.38) while those who took at least one risk behavior (e.g., eating in a restaurant) reported better mental health than those who did not.

Conclusions:

Our study shows that certain groups have experienced poorer mental health during the COVID-19 pandemic, suggesting that mental health should continue to be monitored so that public health interventions and messaging help prevent the spread of COVID-19 without increasing poor mental health outcomes.

National variability in Americans' COVID-19 protective behaviors: Implications for vaccine roll-out

Protective behaviors such as mask wearing and physical distancing are critical to slow the spread of COVID-19, even in the context of vaccine scale-up. Understanding the variation in self-reported COVID-19 protective behaviors is critical to developing public health messaging. The purpose of the study is to provide nationally representative estimates of five self-reported COVID-19 protective behaviors and correlates of such behaviors. In this cross-sectional survey study of US adults, surveys were administered via internet and telephone. Adults were surveyed from April 30-May 4, 2020, a time of peaking COVID-19 incidence within the US. Participants were recruited from the probability-based AmeriSpeak® national panel. Brief surveys were completed by 994 adults, with 73.0% of respondents reported mask wearing, 82.7% reported physical distancing, 75.1% reported crowd avoidance, 89.8% reported increased hand-washing, and 7.7% reported having prior COVID-19 testing. Multivariate analysis (p critical value .05) indicates that women were more likely to report protective behaviors than men, as were those over age 60. Respondents who self-identified as having low incomes, histories of criminal justice involvement, and Republican Party affiliation, were less likely to report four protective behaviors, though Republicans and individuals with criminal justice histories were more likely to report having received COVID-19 testing. The majority of Americans engaged in COVID-19 protective behaviors, with low-income Americans, those with histories of criminal justice involvement, and self-identified Republicans less likely to engage in these preventive behaviors. Culturally competent public health messaging and interventions might focus on these latter groups to prevent future infections. These findings will remain highly relevant even with vaccines widely available, given the complementarities between vaccines and protective behaviors, as well as the many challenges in delivering vaccines.

Policy Responses to the Addiction Crisis

The COVID-19 pandemic is just one of two public health crises the new Biden administration will confront. The addiction crisis is the other. The opioid epidemic has already killed more Americans than World Wars I and II combined. And it is but the most visible sign of a broader population health challenge that includes methamphetamine, cocaine, benzodiazepines, and alcohol. This article presents practical legislative and executive actions that are required for addressing these challenges. The authors focus on two broad policy challenges: (1) improving financing and delivery of treatment for substance use disorders, and (2) reducing population exposure to addictive and lethal substances. Through both of these channels, a portfolio of well-implemented, evidence-informed policies can save many thousands of lives every year.

Ambulatory Care Access And Emergency Department Use For Medicare Beneficiaries With And Without Disabilities

Establishing care with primary care and specialist clinicians is critical for Medicare beneficiaries with complex care needs. However, beneficiaries with disabilities may struggle to access ambulatory care. This study uses the 2015-17 national Medicare Current Beneficiary Survey linked to claims and administrative data to explore these questions. Medicare beneficiaries (ages 21-64) with disabilities were 119 percent more likely to report difficulty accessing care and were 33 percent and 49 percent more likely to lack annual clinician evaluation and management visits for primary and specialty care, respectively, than those without disabilities. Beneficiaries (ages 21-64) with disabilities also had 42 percent, 67 percent, and 77 percent higher likelihood of having all-cause, nonemergent, and preventable emergency department (ED) visits. Furthermore, people with both a disability and a lack of specialist evaluation and management visits also had 21 percent, 48 percent, and 64 percent increased likelihood of all-cause, nonemergent, and preventable ED visits. Barriers to accessing ambulatory care may be a key contributor to the reliance of Americans with disabilities on ED services.

Reducing Opioid Mortality in Illinois (ROMI): A case management/peer recovery coaching critical time intervention clinical trial protocol

Individuals with a history of opioid use are disproportionately represented in Illinois jails and prisons and face high risks of overdose and relapse at community reentry. Case management and peer recovery coaching are established interventions that may be leveraged to improve linkage to substance use treatment and supportive services during these critical periods of transition. We present the protocol for the Reducing Opioid Mortality in Illinois (ROMI), a type I hybrid effectiveness-implementation randomized trial of a case management, peer recovery coaching and overdose education and naloxone distribution (CM/PRC + OEND) critical time intervention (CTI) compared to OEND alone. The CM/PRC + OEND is a novel, 12-month intervention that involves linkage to substance use treatment and support for continuity of care, skills building, and navigation and engagement of social services that will be implemented using a hub-and-spoke model of training and supervision across the study sites. At least 1000 individuals released from jails and prisons spanning urban and rural settings will be enrolled. The primary outcome is engagement in medication for opioid use disorder. Secondary outcomes include health insurance enrollment, mental health service engagement, and re-arrest/recidivism, parole violation, and/or reincarceration. Mixed methods will be used to evaluate process and implementation outcomes including fidelity to, barriers to, facilitators of, and cost of the intervention. Videoconferencing and other remote processes will be leveraged to modify the protocol for safety during the COVID-19 pandemic. Results of the study may improve outcomes for vulnerable persons at the margin of behavioral health and the criminal legal system.

Disaster Preparedness and Social Justice in a Public Health Emergency

The United States is now experiencing public health catastrophe on a scale not seen for more than a century. COVID-19 puts into stark relief the mutual obligations that reflect interdependence among participants in a common society. Drawing on the work of Amartya Sen concerning famine and related challenges, the author discusses the accompanying implications for social justice. Social justice in catastrophe requires strong social insurance structures and legal protections for the most vulnerable people, who would otherwise lack economic resources and political influence to protect their essential interests. Social justice also requires greater and more sustained attention to disaster preparedness and public health infrastructure-both of which are characteristically neglected, in part because the public health enterprise is identified with politically weak and often stigmatized populations.

Modeling Mitigation Strategies to Reduce Opioid-Related Morbidity and Mortality in the US

IMPORTANCE

The US opioid epidemic is complex and dynamic, yet relatively little is known regarding its likely future impact and the potential mitigating impact of interventions to address it.

OBJECTIVE

To estimate the future burden of the opioid epidemic and the potential of interventions to address the burden.

DESIGN, SETTING, AND PARTICIPANTS

A decision analytic dynamic Markov model was calibrated using 2010-2018 data from the National Survey on Drug Use and Health, Centers for Disease Control and Prevention, National Health and Nutrition Examination Survey, the US Census, and National Epidemiologic Survey on Alcohol and Related Conditions-III. Data on individuals 12 years or older from the US general population or with prescription opioid medical use; prescription opioid nonmedical use; heroin use; prescription, heroin, or combined prescription and heroin opioid use disorder (OUD); 1 of 7 treatment categories; or nonfatal or fatal overdose were examined. The model was designed to project fatal opioid overdoses between 2020 and 2029.

EXPOSURES

The model projected prescribing reductions (5% annually), naloxone distribution (assumed 5% reduction in case-fatality), and treatment expansion (assumed 35% increase in uptake annually for 4 years and 50% relapse reduction), with each compared vs status quo.

MAIN OUTCOMES AND MEASURES

Projected 10-year overdose deaths and prevalence of OUD.

RESULTS

Under status quo, 484 429 (95% confidence band, 390 543-576 631) individuals were projected to experience fatal opioid overdose between 2020 and 2029. Projected decreases in deaths were 0.3% with prescribing reductions, 15.4% with naloxone distribution, and 25.3% with treatment expansion; when combined, these interventions were associated with 179 151 fewer overdose deaths (37.0%) over 10 years. Interventions had a smaller association with the prevalence of OUD; for example, the combined intervention was estimated to reduce OUD prevalence by 27.5%, from 2.47 million in 2019 to 1.79 million in 2029. Model projections were most sensitive to assumptions regarding future rates of fatal and nonfatal overdose.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that the opioid epidemic is likely to continue to cause tens of thousands of deaths annually over the next decade. Aggressive deployment of evidence-based interventions may reduce deaths by at least a third but will likely have less impact for the number of people with OUD.

Patient-centered care's relationship with substance use disorder treatment utilization

BACKGROUND

Calls for more patient-centered care are growing in the substance use disorder (SUD) treatment field. However, evidence is sparse regarding whether patient-centered care improves access to, or utilization of, effective treatment services.

METHODS

Using nationally representative survey data from SUD treatment clinics in the United States, we examine the association between patient-centered clinical care and the utilization of six services: methadone, buprenorphine, behavioral treatment, routine medical care, HIV testing, and suicide prevention counseling. We measured clinics' practice of and emphasis on patient-centered care with two variables: (1) whether the clinic regularly invites patients into clinical decision-making processes, and (2) whether supervisors believe in patient-centered healthcare and shared decision-making practices within their clinics.

RESULTS

In 2017, only 23% of SUD treatment clinics regularly invited patients into care decision-making meetings when their cases were discussed. A composite variable captured clinical supervisors' own experience with and expectations for patient-clinician interaction within their clinics (Cronbach's alpha = 0.79). Results from regression models that controlled for several organizational and environmental factors show that patient-centered care was independently associated with greater utilization of four of six evidence-based services.

CONCLUSIONS

A minority of SUD clinics practice patient-centered healthcare in the United States. Given the connection to evidence-based services, increasing participatory mechanisms in SUD treatment service provision can facilitate patients' access to appropriate and evidence-based services.

Comparison of effectiveness and cost for different HIV screening strategies implemented at large urban medical centre in the United States

INTRODUCTION

Incident HIV infections persist in the United States (U.S.) among marginalized populations. Targeted and cost-efficient testing strategies can help in reaching HIV elimination. This analysis compares the effectiveness and cost of three HIV testing strategies in a high HIV burden area in the U.S. in identifying new HIV infections.

METHODS

We performed a cost analysis comparing three HIV testing strategies in Chicago: (1) routine screening (RS) in an inpatient and outpatient setting, (2) modified partner services (MPS) among networks of the recently HIV infected and diagnosed, and (3) a respondent drive sampling (RDS)-based social network (SN) approach targeting young African-American men who have sex with men. All occurred at the same academic medical centre during the following times: routine testing, 2011 to 2016; MPS, 2013 to 2016; SN: 2013 to 2014. Costs were in 2016 dollars and included personnel, HIV testing, training, materials, overhead. Outcomes included cost per test, HIV-positive test and new diagnosis. Sensitivity analyses were performed to assess the impact of population demographics.

RESULTS

The RS programme completed 57,308 HIV tests resulting in 360 (0.6%) HIV-positive tests and 165 new HIV diagnoses (0.28%). The MPS completed 146 HIV tests, resulting in 79 (54%) HIV-positive tests and eight new HIV diagnoses (5%). The SN strategy completed 508 HIV tests, resulting in 210 (41%) HIV-positive tests and 37 new HIV diagnoses (7.2%). Labour accounted for the majority of costs in all strategies. The estimated cost per new HIV diagnosis was $16,773 for the RS programme, $61,418 for the MPS programme and $15,683 for the SN testing programme. These costs were reduced for the RS and MPS strategies in sensitivity analyses limiting testing efficacy to the highest prevalence patient populations ($2,841 and $33,233 respectively).

CONCLUSIONS

The SN strategy yielded the highest proportion of new diagnoses, followed closely by the MPS programme. Both the SN strategy and RS programme were comparable in the cost per new diagnosis. A simultaneous approach that consists of RS in combination with SN testing may be most effective for identifying new HIV infections in settings with heterogeneous epidemics with both high rates of HIV prevalence and HIV testing.

Are Policy Strategies for Addressing the Opioid Epidemic Partisan? A View from the States

CONTEXT

In contrast to the Affordable Care Act, some have suggested the opioid epidemic represents an area of bipartisanship. This raises an important question: to what extent are Democrat-led and Republican-led states different or similar in their policy responses to the opioid epidemic?

METHODS

Three main methodological approaches were used to assess state-level policy responses to the opioid epidemic: a legislative analysis across all 50 states, an online survey of 50 state Medicaid agencies, and in-depth case studies with policy stakeholders in five states.

FINDINGS

Conservative states pursue hidden and targeted Medicaid expansions, and a number of legislative initiatives, to address the opioid crisis. However, the total fiscal commitment among these Republican-led states pales in comparison to states that adopt the ACA Medicaid expansion. Because the state legislative initiatives do not provide treatment, these states spend substantially less than states with Democratic control.

CONCLUSIONS

Rather than persistently working to retrench all programs, conservatives have relied on policy designs that emphasize devolution, fragmentation, and inequality to both expand and retrench benefits. This strategy, which allocates benefits differentially to different social groups and obfuscates responsibility, allows conservatives to avoid political blame typically associated with retrenchment.

Correlates of Patient-Centered Care Practices at U.S. Substance Use Disorder Clinics

OBJECTIVE

Substance use disorder treatment professionals are paying increased attention to implementing patient-centered care. Understanding environmental and organizational factors associated with clinicians' efforts to engage patients in clinical decision-making processes is essential for bringing patient-centered care to the addictions field. This study examined factors associated with patient-centered care practices in substance use disorder treatment.

METHODS

Data were from the 2017 National Drug Abuse Treatment System Survey, a nationally representative survey of U.S substance use disorder treatment clinics (outpatient nonopioid treatment programs, outpatient opioid treatment programs, inpatient clinics, and residential clinics). Multivariate regression analyses examined whether clinics invited patients into clinical decision-making processes and whether clinical supervisors supported and believed in patient-centered care practices.

RESULTS

Of the 657 substance use disorder clinics included in the analysis, about 23% invited patients to participate in clinical decision-making processes. Clinicians were more likely to engage patients in decision-making processes when working in residential clinics (compared with outpatient nonopioid treatment programs) or in clinics serving a smaller proportion of patients with alcohol or opioid use disorder. Clinical supervisors were more likely to value patient-centered care practices if the organization's administrative director perceived less regional competition or relied on professional information sources to understand developments in the substance use disorder treatment field. Clinicians' tendency to engage patients in decision-making processes was positively associated with clinical supervisors' emphasis on patient-centered care.

CONCLUSIONS

A minority of U.S. substance use disorder clinics invited patients into clinical decision-making processes. Therefore, patient-centered care may be unavailable to certain vulnerable patient groups.

Medicaid Benefits For Addiction Treatment Expanded After Implementation Of The Affordable Care Act

The Affordable Care Act (ACA) established a minimum standard of insurance benefits for addiction treatment and expanded federal parity regulations to selected Medicaid benefit plans, which required state Medicaid programs to make changes to their addiction treatment benefits. We surveyed Medicaid programs in all fifty states and the District of Columbia regarding their addiction treatment benefits and utilization controls in standard and alternative benefit plans in 2014 and 2017, when plans were subject to ACA parity requirements. The number of state plans that provided benefits for residential treatment and opioid use disorder medications increased substantially. States imposing annual service limits on outpatient addiction treatment decreased by over 50 percent. Fewer states required preauthorization for services, with the largest reductions for medications treating opioid use disorder. The ACA may have prompted state Medicaid programs to expand addiction treatment benefits and reduce utilization controls in alternative benefit plans. This trend was also observed among standard Medicaid plans not subject to ACA parity laws, which suggests a potential spillover effect.

Changes in State Technical Assistance Priorities and Block Grant Funds for Addiction After ACA Implementation

Objectives. To assess states' provision of technical assistance and allocation of block grants for treatment, prevention, and outreach after the expansion of health insurance coverage for addiction treatment in the United States under the Affordable Care Act (ACA). Methods. We used 2 waves of survey data collected from Single State Agencies in 2014 and 2017 as part of the National Drug Abuse Treatment System Survey. Results. The percentage of states providing technical assistance for cross-sector collaboration and workforce development increased. States also shifted funds from outpatient to residential treatment services. However, resources for opioid use disorder medications changed little. Subanalyses indicated that technical assistance priorities and allocation of funds for treatment services differed between Medicaid expansion and nonexpansion states. Public Health Implications. The ACA's infusion of new public and private funds enabled states to reallocate funds to residential services, which are not as likely to be covered by health insurance. The limited allocation of block grant funds for effective opioid medications is concerning in light of the opioid crisis, especially in states that did not implement the ACA's Medicaid expansion.

Impact of Medicaid Restrictions on Availability of Buprenorphine in Addiction Treatment Programs

OBJECTIVES

To examine how utilization restrictions on state Medicaid benefits for buprenorphine are related to addiction treatment programs' decision to offer the drug.

METHODS

We used data from 2 waves of the National Drug Abuse Treatment System Survey conducted in 2014 and 2017 in the United States to assess the relationship of utilization restrictions to buprenorphine availability.

RESULTS

The proportion of programs offering buprenorphine was 43.2% in states that did not impose any utilization restrictions, 25.5% in states that imposed only annual limits, 17.3% in states that imposed only prior authorization, and 12.8% in states that imposed both. Programs in states requiring prior authorization from Medicaid had substantially lower odds of offering buprenorphine (odds ratio = 0.50; 95% confidence interval = 0.29, 0.87).

CONCLUSIONS

Medicaid prior authorization was linked to lower odds of buprenorphine provision among addiction treatment programs. Public Health Implications. State Medicaid prior authorization requirements are linked to reduced odds of buprenorphine provision among addiction treatment programs and may discourage prescribing.

Identifying Chicago's High Users of Police-Involved Emergency Services

OBJECTIVES

To identify individuals at risk for behavioral health (BH)-involved encounters with police in Chicago, Illinois.

METHODS

We linked Chicago Police Department (CPD) arrest and Fire Department (CFD) BH-involved ambulance event data. We identified at-risk individuals who accumulated at least 1 BH-involved ambulance and at least 1 arrest event between May 2016 and April 2017. We identified a high-use subgroup displaying most intensive services use. We identified high-use locations with highest volume of ambulance events with only CFD data.

RESULTS

Of 83 392 individuals and 116 105 events in the linked emergency events data, 1842 at-risk individuals accounted for 2.2% of individuals, 5.6% of all events, and 16% of BH-involved CFD events with police involvement. A total of 330 high-use individuals accounted for 0.4% of individuals, 2% of events, and 4.7% of CFD events with police involvement. Top-100 high-use locations accounted for 9% of CFD events, and individuals of high-use location events are largely distinct from high-use individuals.

CONCLUSIONS

Integrated police and ambulance data hold promise to identify individuals at risk for BH-involved encounters with police and to support proactive interventions to prevent or improve response at these encounters.

Evidence-based treatment for opioid use disorders: A national study of methadone dose levels, 2011-2017

The nation's methadone maintenance treatment (MMT) programs play a central role in addressing the current opioid epidemic. Considerable evidence documents the treatment effectiveness of MMT and, in turn, the importance of adequate dosing to MMT's effectiveness. Yet, as recently as 2011, 41% of patients received doses below the level of 80 mg/day. Using survey data from a nationally representative sample of MMT programs in 2011 and 2017, we examine (1) the extent to which the nation's MMT programs are meeting evidence-based standards for methadone dose level and (2) characteristics of MMT programs that are associated with variation in performance. Our results show that 43% of MMT patients receive <80 mg/day in 2017, and 23% of methadone maintenance patients receive daily doses below 60 mg. Results from multivariate regression analysis of the 2017 survey data show that private for-profit and public organizations significantly under-dosed patients compared to private nonprofit providers. Under-dosing also was more common in programs that serve high proportions of African-American patients. These results are concerning because MMT remains the medication of choice for vulnerable patients with the most severe opioid use disorders, and for-profit providers treat a growing proportion of MMT patients.

Harm reduction when it's for our own kids: comment on Hagit Bonny-Noach, "The evolution of Israeli public policy for drug-using backpackers

Hagit Bonny-Noach notes the challenging history of illicit substance use among Israeli backpackers. Few Israeli practices are more normative than the backpacking-trip as a rite of passage. Unsurprisingly, backpacking in far-off locales provides occasion to experiment with the various intoxicating experiences young adult life has to offer.

Some such experimentation is expected, and often developmentally appropriate. It also carries real risks and causes real harms. Israeli policymakers’ efforts to address this issue underscore both the necessity and the difficulty of harm reduction. Bonny-Noach usefully notes the importance of social class as both a facilitator and a barrier to effective public health policies to protect young adults from drug-related harms.

Association of Buprenorphine-Waivered Physician Supply With Buprenorphine Treatment Use and Prescription Opioid Use in Medicaid Enrollees

IMPORTANCE

Expanding treatment for opioid addiction has been recognized as an essential component of a comprehensive national response to the opioid epidemic. The Drug Addiction Treatment Act and its amendments attempted to improve access to treatment by involving office-based physicians in the provision of buprenorphine treatment.

OBJECTIVES

To estimate the association of availability of buprenorphine-waivered physicians with buprenorphine treatment use and, secondarily, with prescription opioid use among Medicaid enrollees.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation study used state-level panel data analysis to estimate the association between the number of buprenorphine-waivered physicians and the Medicaid-covered buprenorphine prescribing rate and opioid prescribing rate among Medicaid fee-for-service and managed care enrollees throughout the United States between January 1, 2011, and December 31, 2016.

MAIN OUTCOMES AND MEASURES

Buprenorphine prescribing rate and opioid prescribing rate, measured as the number of buprenorphine prescriptions and opioid prescriptions covered by Medicaid on a quarterly basis per 1000 enrollees.

RESULTS

The sample included 1059 quarterly observations. Two additional 100-patient-waivered physicians per 1 000 000 residents (approximately a 10% increase) were associated with an increase in the quarterly number of Medicaid-covered buprenorphine prescriptions of 0.46 (95% CI, 0.24-0.67) per 1000 enrollees and a reduction in the quarterly number of opioid prescriptions of 1.01 (95% CI, -1.87 to -0.15) per 1000 enrollees. Furthermore, 5 additional 30-patient-waivered physicians per 1 000 000 residents (approximately a 10% increase) were associated with an increase in the quarterly number of Medicaid-covered buprenorphine prescriptions of 0.37 (95% CI, 0.22-0.52) per 1000 enrollees and a reduction in the quarterly number of opioid prescriptions of 0.96 (95% CI, -1.85 to -0.07) per 1000 enrollees. A 10% increase in the number of buprenorphine-waivered physicians was associated with an approximately 10% increase in the Medicaid-covered buprenorphine prescribing rate and a 1.2% reduction in the opioid prescribing rate.

CONCLUSIONS AND RELEVANCE

Expanding capacity for buprenorphine treatment holds the potential to improve access to opioid addiction treatment, which may further reduce prescription opioid use and slow the ongoing opioid epidemic in the United States.