BACKGROUND: Opioid use disorder (OUD) affects millions of individuals each year in the United States. Patient retention in medications for opioid use disorder (MOUD) treatment is suboptimal. This study examines and quantifies the associations between each additional month of buprenorphine or methadone use and nonprescribed opioid use. METHODS: Data were obtained from an 18-month longitudinal, observational cohort study of patients (age ≥ 18 years) treated for OUD. Patients completed a baseline self-reported questionnaire between March 2018 and December 2019 and were asked to complete follow-up questionnaires at approximately 3-, 6-, 12-, and 18-months post-baseline until May 2021. Patients treated with buprenorphine or methadone, without taking other MOUD at least 12 months prior to baseline, were included. Outcomes included past 30-day use of prescription opioids nonmedically, heroin, or illegally made fentanyl. A multivariable, multilevel regression model with a binomial distribution and a logit link was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS: This study included 353 patients taking buprenorphine (mean [standard deviation, SD] age 39 [11] years; 226 [64%] female), and 785 patients taking methadone (mean [SD] age 42 [12] years; 392 [50%] female). Each additional month of MOUD treatment was associated with a 25% decrease in the odds of past 30-day nonprescribed opioid use for patients taking buprenorphine (aOR [95% CI] = 0.75 [0.68-0.83]), and a 17% decrease for patients taking methadone (aOR = 0.83 [0.79-0.87]). The COVID-19 pandemic (aOR = 9.29 [2.96-29.17]; aOR = 3.19 [1.74-5.86]) and MOUD adverse reaction experiences (aOR = 3.07 [1.11-8.48]; aOR = 2.51 [1.01-6.22]) were significantly associated with higher odds of nonprescribed opioid use among buprenorphine and methadone groups. CONCLUSION: Among patients treated with buprenorphine or methadone, with each additional treatment month since baseline, those who continued with treatment appeared to be more likely to report 17% to 25% decreased odds of past 30-day nonprescribed opioid use. Our findings can be used by clinicians in the shared decision-making process with patients, emphasizing the value of sustained retention in MOUD.

This cohort study investigates patterns of buprenorphine treatment retention among US youth aged 10 to 18 years from 2015 to 2021. | eng

BACKGROUND: Although substance use rates among adolescents have decreased, drug overdose deaths among adolescents have increased since 2020, driven largely by illegally made fentanyl (IMF). This study explores substance use patterns and characteristics of adolescents who were assessed for substance use disorder (SUD) treatment to inform prevention and response strategies. METHODS: A convenience sample of adolescents aged 10-18 years assessed for SUD treatment from September 2017 to December 2021 was analyzed using the Comprehensive Health Assessment for Teens. The percentage of lifetime and past 30-day substance use was examined. Adolescent characteristics (e.g., demographics, history of overdoses or hospital visits due to drug/alcohol use) were analyzed by lifetime substances used. RESULTS: Among 5,377 assessments, most were male (58.7%), aged 16-18 years (50.5%), non-Hispanic White (43.1%), enrolled in school (87.3%), and living with their parent(s) (72.4%). The most commonly reported lifetime substances used were marijuana (68.0%), alcohol (54.2%), and prescription opioid misuse (13.6%). The most common past 30-day substance use combination was alcohol and marijuana (35.6%). The percentage of assessments indicating past-year overdoses or hospital visits due to drug/alcohol use was greatest among those who reported lifetime use of IMF (24.0%), followed by heroin (21.4%) and cocaine (15.3%). Overall, 2.3% reported lifetime IMF use and 0.6% thought IMF was causing them the most problems. CONCLUSIONS: Findings inform opportunities to address substance use and increased IMF-involved overdose among adolescents. Continued overdose prevention and response strategies such as evidence-based education campaigns, naloxone distribution and harm reduction efforts, and evidence-based SUD treatment expansion are needed.

Xylazine has been increasingly detected in illegally manufactured fentanyl (IMF) products and overdose deaths in the United States; most xylazine-involved overdose deaths involve IMF. A convenience sample of U.S. adults aged ≥18 years was identified from those evaluated for substance use treatment during July 2022-September 2023. Data were collected using the Addiction Severity Index-Multimedia Version clinical assessment tool. Among 43,947 adults, 6,415 (14.6%) reported IMF or heroin as their primary lifetime substance-use problem; 5,344 (12.2%) reported recent (i.e., past-30-day) IMF or heroin use. Among adults reporting IMF or heroin as their primary lifetime substance-use problem, 817 (12.7%) reported ever using xylazine. Among adults reporting recent IMF or heroin use, 443 (8.3%) reported recent xylazine use. Among adults reporting IMF or heroin use recently or as their primary lifetime substance-use problem, those reporting xylazine use reported a median of two past nonfatal overdoses from any drug compared with a median of one overdose among those who did not report xylazine use; as well, higher percentages of persons who reported xylazine use reported other recent substance use and polysubstance use. Provision of nonjudgmental care and services, including naloxone, wound care, and linkage to and retention of persons in effective substance use treatment, might reduce harms including overdose among persons reporting xylazine use.

IMPORTANCE: Given the high number of opioid overdose deaths in the US and the complex epidemiology of opioid use disorder (OUD), systems models can serve as a tool to identify opportunities for public health interventions. OBJECTIVE: To estimate the projected 3-year association between public health interventions and opioid overdose-related outcomes among persons with OUD. DESIGN, SETTING, AND PARTICIPANTS: This decision analytical model used a simulation model of the estimated US population aged 12 years and older with OUD that was developed and analyzed between January 2019 and December 2023. The model was parameterized and calibrated using 2019 to 2020 data and used to estimate the relative change in outcomes associated with simulated public health interventions implemented between 2021 and 2023. MAIN OUTCOMES AND MEASURES: Projected OUD and medications for OUD (MOUD) prevalence in 2023 and number of nonfatal and fatal opioid-involved overdoses among persons with OUD between 2021 and 2023. RESULTS: In a baseline scenario assuming parameters calibrated using 2019 to 2020 data remained constant, the model projected more than 16 million persons with OUD not receiving MOUD treatment and nearly 1.7 million persons receiving MOUD treatment in 2023. Additionally, the model projected over 5 million nonfatal and over 145 000 fatal opioid-involved overdoses among persons with OUD between 2021 and 2023. When simulating combinations of interventions that involved reducing overdose rates by 50%, the model projected decreases of up to 35.2% in nonfatal and 36.6% in fatal opioid-involved overdoses among persons with OUD. Interventions specific to persons with OUD not currently receiving MOUD treatment demonstrated the greatest reduction in numbers of nonfatal and fatal overdoses. Combinations of interventions that increased MOUD initiation and decreased OUD recurrence were projected to reduce OUD prevalence by up to 23.4%, increase MOUD prevalence by up to 137.1%, and reduce nonfatal and fatal opioid-involved overdoses among persons with OUD by 6.7% and 3.5%, respectively. CONCLUSIONS AND RELEVANCE: In this decision analytical model study of persons with OUD, findings suggested that expansion of evidence-based interventions that directly reduce the risk of overdose fatality among persons with OUD, such as through harm reduction efforts, could engender the highest reductions in fatal overdoses in the short-term. Interventions aimed at increasing MOUD initiation and retention of persons in treatment projected considerable improvement in MOUD and OUD prevalence but could require a longer time horizon for substantial reductions in opioid-involved overdoses.

Substance use often begins during adolescence, placing youths at risk for fatal overdose and substance use disorders (SUD) in adulthood. Understanding the motivations reported by adolescents for using alcohol, marijuana, and other drugs and the persons with whom they use these substances could guide strategies to prevent or reduce substance use and its related consequences among adolescents. A cross-sectional study was conducted among adolescents being assessed for SUD treatment in the United States during 2014-2022, to examine self-reported motivations for using substances and the persons with whom substances were used. The most commonly reported motivation for substance use was "to feel mellow, calm, or relaxed" (73%), with other stress-related motivations among the top reasons, including "to stop worrying about a problem or to forget bad memories" (44%) and "to help with depression or anxiety" (40%); one half (50%) reported using substances "to have fun or experiment." The majority of adolescents reported using substances with friends (81%) or using alone (50%). These findings suggest that interventions related to reducing stress and addressing mental health concerns might reduce these leading motivations for substance use among adolescents. Education for adolescents about harm reduction strategies, including the danger of using drugs while alone and how to recognize and respond to an overdose, can reduce the risk for fatal overdose.

This study examines mean yearly out-of-pocket cost for naloxone dispensed from retail pharmacies by payer between 2018 and 2022 and by prescription characteristics and payer in 2022. | eng

OBJECTIVE: Opioid use disorder (OUD) affects approximately 5.6 million people in the United States annually, yet rates of the use of effective medication for OUD (MOUD) treatment are low. We conducted an observational cohort study from August 2017 through May 2021, the MOUD Study, to better understand treatment engagement and factors that may influence treatment experiences and outcomes. In this article, we describe the study design, data collected, and treatment outcomes. METHODS: We recruited adult patients receiving OUD treatment at US outpatient facilities for the MOUD Study. We collected patient-level data at 5 time points (baseline to 18 months) via self-administered questionnaires and health record data. We collected facility-level data via questionnaires administered to facility directors at 2 time points. Across 16 states, 62 OUD treatment facilities participated, and 1974 patients enrolled in the study. We summarized descriptive data on the characteristics of patients and OUD treatment facilities and selected treatment outcomes. RESULTS: Approximately half of the 62 facilities were private, nonprofit organizations; 62% focused primarily on substance use treatment; and 20% also offered mental health services. Most participants were receiving methadone (61%) or buprenorphine (32%) and were predominately non-Hispanic White (68%), aged 25-44 years (62%), and female (54%). Compared with patient-reported estimates at baseline, 18-month estimates suggested that rates of abstinence increased (55% to 77%), and rates of opioid-related overdoses (7% to 2%), emergency department visits (9% to 4%), and arrests (15% to 7%) decreased. CONCLUSIONS: Our results demonstrated the benefits of treatment retention not only on abstinence from opioid use but also on other quality-of-life metrics, with data collected during an extended period. The MOUD Study produced rich, multilevel data that can lay the foundation for an evidence base to inform OUD treatment and support improvement of care and patient outcomes.

Background: In 2021, approximately 1 in 5 adults in the United States experienced chronic pain (1). The Centers for Disease Control and Prevention’s “CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022” (2) recommends maximizing nonpharmacologic and nonopioid therapies for pain as appropriate for the specific condition and patient. Whereas previous research reported the prevalence of use of nonpharmacologic and opioid therapies for pain (3), this study adds information about prescription nonopioids, over-the-counter pain relievers, and exercise. | | Objective: To estimate the prevalence of use of pharmacologic and nonpharmacologic therapies among adults with chronic pain in the United States. | | Methods and Findings: We used the 2020 National Health Interview Survey (NHIS) (31 568 total respondents) to identify adults who self-reported pain on most days or every day in the past 3 months (unweighted n = 7422) (4). Respondents reported use of pharmacologic (prescription opioids, prescription nonopioids, over-the-counter pain relievers) and nonpharmacologic (physical or occupational therapy [PT/OT], cognitive behavioral therapy [CBT], exercise, complementary therapies) pain management therapies in the past 3 months. We report therapy prevalence overall and by demographic characteristics. Adjusted prevalence was estimated using predictive margins from multivariable logistic regression models. All analyses account for the complex NHIS survey design. This study was exempt from institutional review board review. | | In 2020, approximately 54 million adults self-reported chronic pain. Among pharmacologic therapies, use of over-the-counter pain relievers in the past 3 months was most prevalent (75.5%), followed by prescription nonopioids (31.3%) and prescription opioids (13.5%) (Table 1). Among nonpharmacologic therapies, exercise was most prevalent (55.0%), followed by complementary therapies (36.7%), PT/OT (17.2%), and CBT (2.6%). Pharmacologic therapy use alone was reported by 26.6% of adults, with most (22.4%) reporting nonopioid use only and 1.0% reporting opioid use only. Most adults (60.2%) reported using both pharmacologic and nonpharmacologic therapies, with 50.9% reporting nonopioid and nonpharmacologic therapy use and 7.7% reporting combined use of opioids, nonopioids, and nonpharmacologic therapy.

BACKGROUND: Syringe services programs (SSPs) are community-based prevention programs that provide a range of harm reduction services to persons who inject drugs. Despite their benefits, SSP laws vary across the United States. Little is known regarding how legislation surrounding SSPs may have influenced HIV transmission over the COVID-19 pandemic, a period in which drug use increased. This study examined associations between state SSP laws and HIV transmission among the Medicaid population before and after the COVID-19 pandemic. METHODS: State-by-month counts of new HIV diagnoses among the Medicaid population were produced using administrative claims data from the Transformed Medicaid Statistical Information System from 2019 to 2020. Data on SSP laws were collected from the Prescription Drug Abuse Policy System. Associations between state SSP laws and HIV transmission before and after the start of the COVID-19 pandemic were evaluated using an event study design, controlling for the implementation of COVID-19 nonpharmaceutical interventions and state and time fixed effects. RESULTS: State laws allowing the operation of SSPs were associated with 0.54 (P = 0.044) to 1.18 (P = 0.001) fewer new monthly HIV diagnoses per 100,000 Medicaid enrollees relative to states without such laws in place during the 9 months after the start of the COVID-19 pandemic. The largest effects manifested for population subgroups disproportionately affected by HIV, such as male and non-Hispanic Black Medicaid enrollees. CONCLUSION: Less restrictive laws on SSPs may have helped mitigate HIV transmission among the Medicaid population throughout the COVID-19 pandemic. Policymakers can consider implementing less restrictive SSP laws to mitigate HIV transmission resulting from future increases in injection drug use. DISCLAIMER: The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

BACKGROUND: Nonmedical use (NMU) of prescription psychotherapeutic drugs (PPD) may increase risk for significant morbidity and mortality in the overdose crisis. OBJECTIVE: This study examines sources of PPD using real-world data from adolescents and adults reporting past 30-day NMU of PPDs. METHODS: A convenience sample of individuals aged ≥10 years assessed for substance use disorders (SUD) treatment was analyzed using the 2014-2022 National Addictions Vigilance Intervention and Prevention Program datasets. PPD include prescription opioids, prescription tranquilizers/sedatives, and prescription stimulants. RESULTS: Overall, among assessments of adolescents aged 10-18 years (N = 1991) and young adults aged 19-24 years (N = 15,166), "family/friend" (46.08-47.41 %) and "dealer" (33.82-42.71 %) were the most common sources. Among assessments of adults aged ≥25 years (N = 89,225), "own prescription" was the most common source and increased in frequency as age increased. Across all age groups, "family/friend" was the most frequent source for all drug classes (41.96-48.76 %) except for nonmedically used buprenorphine/methadone, for which "own prescription" was the most common source (51.85 %) among adults. CONCLUSIONS: Our study demonstrates heterogeneity in sources of nonmedically used PPD across age groups. Tailored prevention strategies for different age groups and improving timely access to medical care to ensure proper treatment of chronic medical conditions including SUD are needed.

IMPORTANCE: Two states modified laws to remove or substantially reduce criminal penalties for any drug possession. The hypothesis was that removing criminal penalties for drug possession may reduce fatal drug overdoses due to reduced incarceration and increased calls for help at the scene of an overdose. OBJECTIVE: To evaluate whether decriminalization of drug possession in Oregon and Washington was associated with changes in either direction in fatal drug overdose rates. DESIGN, SETTING, AND PARTICIPANTS: This cohort study used a synthetic control method approach to examine whether there were changes in drug possession laws and fatal drug overdose rates in Oregon and Washington in the postpolicy period (February 1, 2021, to March 31, 2022, in Oregon and March 1, 2021, to March 31, 2022, in Washington). A counterfactual comparison group (synthetic controls) was created for Oregon and Washington, using 48 states and the District of Columbia, that did not implement similar policies during the study period (January 1, 2018, to March 31, 2022). For 2018-2021, final multiple cause-of-death data from the National Vital Statistics System (NVSS) were used. For 2022, provisional NVSS data were used. Drug overdose deaths were identified using International Statistical Classification of Diseases and Related Health Problems, 10th Revision underlying cause-of-death codes X40-X44, X60-X64, X85, and Y10-Y14. EXPOSURES: In Oregon, Measure 110 went into effect on February 1, 2021. In Washington, the Washington Supreme Court decision in State v Blake occurred on February 25, 2021. MAIN OUTCOME: Monthly fatal drug overdose rates. RESULTS: Following the implementation of Measure 110, absolute monthly rate differences between Oregon and its synthetic control were not statistically significant (probability = 0.26). The average rate difference post Measure 110 was 0.268 fatal drug overdoses per 100 000 state population. Following the implementation of the policy change in Washington, the absolute monthly rate differences between Washington and synthetic Washington were not statistically significant (probability = 0.06). The average rate difference post Blake was 0.112 fatal drug overdoses per 100 000 state population. CONCLUSIONS AND RELEVANCE: This study found no evidence of an association between legal changes that removed or substantially reduced criminal penalties for drug possession in Oregon and Washington and fatal drug overdose rates. Additional research could examine potential other outcomes as well as longer-term associations with fatal drug overdose overall and across racial and ethnic groups.

Opioid prescribing varies widely, and prescribed opioid dosages for an individual can fluctuate over time. Patterns in daily opioid dosage among patients prescribed long-term opioid therapy have not been previously examined. This study uses a novel application of time-series cluster analysis to characterize and visualize daily opioid dosage trajectories and associated demographic characteristics of patients newly initiated on long-term opioid therapy. We used 2018 to 2019 data from the IQVIA Longitudinal Prescription (LRx) all-payer pharmacy database, which covers 92% of retail pharmacy prescriptions dispensed in the United States. We identified a cohort of 277,967 patients newly initiated on long-term opioid therapy during 2018. Patients were stratified into 4 categories based on their mean daily dosage during a 90-day baseline period (<50, 50-89, 90-149, and ≥150 morphine milligram equivalent [MME]) and followed for a 270-day follow-up period. Time-series cluster analysis identified 2 clusters for each of the 3 baseline dosage categories <150 MME and 3 clusters for the baseline dosage category ≥150 MME. One cluster in each baseline dosage category comprised opioid dosage trajectories with decreases in dosage at the end of the follow-up period (80.7%, 98.7%, 98.7%, and 99.0%, respectively), discontinuation (58.5%, 80.0%, 79.3%, and 81.7%, respectively), and rapid tapering (50.8%, 85.8%, 87.5%, and 92.9%, respectively). These findings indicate multiple clusters of patients newly initiated on long-term opioid therapy who experience discontinuation and rapid tapering and highlight potential areas for clinician training to advance evidence-based guideline-concordant opioid prescribing, including strategies to minimize sudden dosage changes, discontinuation, or rapid tapering, and the importance of shared decision-making.

BACKGROUND: Limited data exist on risk factors for illicit stimulant use, including associations between prescription stimulant use/nonmedical use (NMU) and illicit stimulant use. METHODS: We used 2017-2021 data from adults assessed for substance use disorder (SUD) treatment using the National Addictions Vigilance Intervention and Prevention Program Addiction Severity Index-Multimedia Version® tool. Multivariable Poisson regression models analyzed associations between past 30-day prescription stimulant use as prescribed or NMU and past 30-day illicit stimulant use. Separate models examined past 30-day illicit stimulant, methamphetamine, and cocaine use. We explored problem severity across seven biopsychosocial domains (e.g., drug, psychiatric, family) by past 30-day prescription stimulant use/NMU and illicit stimulant use. RESULTS: Among 218,981 assessments, 1.8% reported prescription stimulant NMU; 1.6% reported use as prescribed. Past 30-day prescription stimulant NMU (vs. no use) was associated with past 30-day illicit stimulant use (adjusted prevalence ratio [aPR] [95% CI]: 2.67 [2.59, 2.75]), methamphetamine use (aPR: 2.81 [2.71, 2.92]), and cocaine use (aPR: 3.53 [3.33, 3.74]). Prescription stimulant use as prescribed (vs. no use) was associated with lower prevalence of past 30-day illicit stimulant use. Assessments reporting prescription stimulant NMU (vs. no use, or use as prescribed) appeared more likely to have moderate-to-extreme problem scores across biopsychosocial domains, indicating greater need for treatment or assistance. Assessments reporting prescription stimulant use as prescribed or NMU frequently reported opioids, alcohol, or other substances as their primary substance problem. CONCLUSIONS: Adults using illicit stimulants/nonmedically using prescription stimulants may benefit from care addressing polysubstance use, mental health, social, and recovery support services.

Chronic pain (i.e., pain lasting ≥3 months) is a debilitating condition that affects daily work and life activities for many adults in the United States and has been linked with depression (1), Alzheimer disease and related dementias (2), higher suicide risk (3), and substance use and misuse (4). During 2016, an estimated 50 million adults in the United States experienced chronic pain, resulting in substantial health care costs and lost productivity (5,6). Addressing chronic pain and improving the lives of persons living with pain is a public health imperative. Population research objectives in the National Pain Strategy, which was released in 2016 by the Interagency Pain Research Coordinating Committee, call for more precise estimates of the prevalence of chronic pain and high-impact chronic pain (i.e., chronic pain that results in substantial restriction to daily activities) in the general population and within various population groups to guide efforts to reduce the impact of chronic pain (3). Further, a 2022 review of U.S. chronic pain surveillance systems identified the National Health Interview Survey (NHIS) as the best source for pain surveillance data (7). CDC analyzed data from the 2019-2021 NHIS to provide updated estimates of the prevalence of chronic pain and high-impact chronic pain among adults in the United States and within population groups defined by demographic, geographic, socioeconomic, and health status characteristics. During 2021, an estimated 20.9% of U.S. adults (51.6 million persons) experienced chronic pain, and 6.9% (17.1 million persons) experienced high-impact chronic pain. New findings from this analysis include that non-Hispanic American Indian or Alaska Native (AI/AN) adults, adults identifying as bisexual, and adults who are divorced or separated are among the populations experiencing a higher prevalence of chronic pain and high-impact chronic pain. Clinicians, practices, health systems, and payers should vigilantly attend to health inequities and ensure access to appropriate, affordable, diversified, coordinated, and effective pain management care for all persons (8).

IMPORTANCE: During the COVID-19 pandemic, US emergency department (ED) visits for psychiatric disorders (PDs) and drug overdoses increased. Psychiatric disorders and substance use disorders (SUDs) independently increased the risk of COVID-19 hospitalization, yet their effect together is unknown. OBJECTIVE: To assess how comorbid PD and SUD are associated with the probability of hospitalization among ED patients with COVID-19. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cross-sectional study analyzed discharge data for adults (age ≥18 years) with a COVID-19 diagnosis treated in 970 EDs and inpatient hospitals in the United States from April 2020 to August 2021. EXPOSURES: Any past diagnosis of (1) SUD from opioids, stimulants, alcohol, cannabis, cocaine, sedatives, or other substances and/or (2) PD, including attention-deficit/hyperactivity disorder (ADHD), anxiety, bipolar disorder, major depression, other mood disorder, posttraumatic stress disorder (PTSD), or schizophrenia. MAIN OUTCOMES AND MEASURES: The main outcome was any hospitalization. Differences in probability of hospitalization were calculated to assess its association with both PD and SUD compared with PD alone, SUD alone, or neither condition. RESULTS: O 274 219 ED patients with COVID-19 (mean [SD] age, 54.6 [19.1] years; 667 638 women [52.4%]), 18.6% had a PD (mean age, 59.0 years; 37.7% men), 4.6% had a SUD (mean age, 50.1 years; 61.7% men), and 2.3% had both (mean age, 50.4 years; 53.1% men). The most common PDs were anxiety (12.9%), major depression (9.8%), poly (≥2) PDs (6.4%), and schizophrenia (1.4%). The most common SUDs involved alcohol (2.1%), cannabis (1.3%), opioids (1.0%), and poly (≥2) SUDs (0.9%). Prevalence of SUD among patients with PTSD, schizophrenia, other mood disorder, or ADHD each exceeded 21%. Based on significant specific PD-SUD pairs (Q < .05), probability of hospitalization of those with both PD and SUD was higher than those with (1) neither condition by a weighted mean of 20 percentage points (range, 6 to 36; IQR, 16 to 25); (2) PD alone by 12 percentage points (range, -4 to 31; IQR, 8 to 16); and (3) SUD alone by 4 percentage points (range, -7 to 15; IQR, -2 to 7). Associations varied by types of PD and SUD. Substance use disorder was a stronger predictor of hospitalization than PD. CONCLUSIONS AND RELEVANCE: This study found that patients with both PD and SUD had a greater probability of hospitalization, compared with those with either disorder alone or neither disorder. Substance use disorders appear to have a greater association than PDs with the probability of hospitalization. Overlooking possible coexisting PD and SUD in ED patients with COVID-19 can underestimate the likelihood of hospitalization. Screening and assessment of both conditions are needed.

IMPORTANCE: Buprenorphine has been approved for opioid use disorder treatment, yet remains underutilized. Cost may present a barrier; little is known about how out-of-pocket costs vary. OBJECTIVE: To determine if out-of-pocket costs and prescription characteristics for buprenorphine varied by type of payer. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used all-payer data on retail pharmacy-dispensed buprenorphine prescriptions from January 1, 2015, through December 31, 2020, for adults (aged ≥18 years) in the US, excluding formulations primarily used to treat pain. Data were analyzed from July 2021 to June 2022. EXPOSURES: Type of payer (private and commercial, self-pay, Medicaid, Medicare, assistance, and unknown) for dispensed prescription. MAIN OUTCOMES AND MEASURES: All outcomes are prescription-level. Mean and median daily out-of-pocket costs were calculated overall and by payer type. Prescription characteristics (days supplied, patient age and sex, generic vs name brand formulations, and prescriber's location) were examined by payer type. RESULTS: Although mean daily out-of-pocket costs decreased overall from $4.79 (95% CI, $4.79-$4.80) in 2015  375 508 prescriptions) to $1.91 (95% CI, $1.90-$1.91) in 2020 (13 486 822 prescriptions), out-of-pocket costs continued to vary by payer in 2020. Medicaid had the lowest mean daily out-of-pocket cost across all years-$0.18 (95% CI, $0.18-$0.18) in 2015, and $0.10 (95% CI, $0.10-$0.10) in 2020. Private and commercial paid prescriptions fell from $4.80 (95% CI, $4.79-$4.81) per day in 2015 to $1.82 (95% CI, $1.82-$1.83) in 2020. Self-pay and assistance categories had the highest mean daily out-of-pocket costs across study years ($9.76 [95% CI, $9.74-$9.78] and $8.72 [95% CI, $8.71-$8.73], respectively, in 2015; $8.44 [95% CI, $8.43-$8.46] and $6.31 [95% CI, $6.30-$6.31], respectively, in 2020). Medicaid paid prescriptions had a mean supply of 15.59 days (95% CI, 15.58-15.59 days) and the lowest percentage of generic prescriptions (57.88%; 95% CI, 57.84%-57.92%). Out-of-pocket cost varied by prescriber location and patient characteristics; mean costs were highest for prescriptions written in the South ($2.91; 95% CI, $2.90-$2.91), metropolitan counties ($1.93; 95% CI, $1.93-$1.93), and for individuals aged 35 to 44 years ($2.10; 95% CI, $2.09-$2.10). CONCLUSIONS AND RELEVANCE: This cross-sectional study found that mean daily out-of-pocket costs for buprenorphine were lower in 2020 than in 2015, but variation by payer existed in all study years. Financial barriers to accessing and maintaining buprenorphine for opioid use disorder treatment may exist and differ by type of prescription coverage. Future research could monitor costs and identify potential barriers that may impact access and retention in care.

INTRODUCTION: Improving access to naloxone is an important public health strategy in the U.S. This study examines the state-level trends in naloxone dispensing from 2012 to 2019 for all 50 states and the District of Columbia. METHODS: Data from IQVIA Xponent were used to examine the trends and geographic inequality in annual naloxone dispensing rates and the number of naloxone prescriptions dispensed per high-dose opioid prescription from 2012 to 2019 and from 2016 to 2019 to correspond with the Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain release. Annual percentage change was estimated using linear regression. Analyses were conducted in 2020. RESULTS: Naloxone dispensing rates and the number of naloxone prescriptions per 100 high-dose opioid prescriptions increased from 2012 to 2019 across all states and the District of Columbia. Average state-level naloxone dispensing rates increased from 0.55 per 100,000 population in 2012 to 45.60 in 2016 and 292.31 in 2019. Similarly, the average number of naloxone prescriptions per 100 high-dose opioid prescriptions increased from 0.002 in 2012 to 0.24 in 2016 and 3.04 in 2019. Across both measures of naloxone dispensing, the geographic inequality gap increased during the study period. In 2019, the number of naloxone prescriptions dispensed per 100 high-dose opioid prescriptions ranged from 1.04 to 16.64 across states. CONCLUSIONS: Despite increases in naloxone dispensing across all states, dispensing rates remain low, with substantial variation and increasing disparities over time at the state level. This information may be helpful in efforts to improve naloxone access and in designing state-specific intervention programs.

The Centers for Disease Control and Prevention's (CDC) Guideline for Prescribing Opioids for Chronic Pain recommends that providers consider co-prescribing naloxone when factors that increase the risk of overdose are present. Naloxone is an opioid receptor antagonist that counteracts the effects of an opioid overdose. This paper explores trends in naloxone dispensing and out-of-pocket costs among commercially insured individuals in the United States. Administrative claims data from the IBM Watson Health MarketScan database are analyzed to assess trends in naloxone dispensing from 2015 to 2018. Descriptive statistics on concurrent dispensing of naloxone with opioid analgesics are performed among several at-risk populations. The rate of commercially insured individuals being co-dispensed naloxone increased between 2015 and 2018 across all population sub-groups. In 2018, 16.2 individuals were co-dispensed naloxone for every 1000 receiving an opioid dosage ≥ 90 MME/day compared to 0.9 in 2015, 27.6 individuals were co-dispensed naloxone for every 1000 concurrently dispensed benzodiazepines and an opioid dosage ≥ 90 MME/day compared to 7.6 in 2015, and 43.7 individuals were co-dispensed naloxone for every 1000 receiving an opioid dosage ≥90 MME/day with a past overdose compared to 17.6 in 2015. Median out-of-pocket cost for naloxone increased from $12 in 2015 to $25 in 2018. Despite increases in naloxone dispensing from 2015 to 2018, the provision of naloxone to the commercially insured population remains low. Opportunities remain to increase the supply of naloxone to at-risk populations. Considering ways to reduce out-of-pocket costs associated with naloxone may be a potential strategy to increase access to this life-saving drug.

PURPOSE: There is limited research linking data sources to evaluate the multifactorial impacts on the quality of treatment received and financial burden among young women with breast cancer. To address this gap and support future evaluation efforts, we examined the utility of combining patient survey and cancer registry data. PATIENT AND METHODS: We administered a survey to women, aged 18-39 years, with breast cancer from four U.S. states. We conducted a systematic response-rate analysis and evaluated differences between racial groups. Survey responses were linked with cancer registry data to assess whether surveys could reliably supplement registry data. RESULTS: A total of 830 women completed the survey for a response rate of 28.4 %. Blacks and Asian/Pacific Islanders were half as likely to respond as white women. Concordance between survey and registry data was high for demographic variables (Cohen's kappa [k]: 0.879 to 0.949), moderate to high for treatments received (k: 0.467 to 0.854), and low for hormone receptor status (k: 0.167 to 0.553). Survey items related to insurance status, employment, and symptoms revealed racial differences. CONCLUSION: Cancer registry data, supplemented by patient surveys, can provide a broader understanding of the quality of care and financial impacts of breast cancer among young women.

Evidence-based prevention strategies can reduce the transmission of SARS-CoV-2, the virus that causes COVID-19. Consistent and correct use of masks can prevent SARS-CoV-2 transmission, which predominantly occurs through inhalation and other exposure to respiratory droplets from infected persons. Mask use is particularly important because presymptomatic and asymptomatic spread is responsible for nearly 60% of COVID-19 cases.1,2 Universal and proper masking results in substantial community benefits.2 To better leverage the prevention benefit of masks on community transmission, many states require that people wear a mask in public. As of March 1, 2021, 36 states and the District of Columbia had a mask mandate in effect.

PURPOSE: Breast cancer is the leading cause of cancer-related deaths in women younger than 40 years. We aim to evaluate cost as a barrier to care among female breast cancer patients diagnosed between 18 to 39 years. METHODS: In early 2017, we distributed a survey to women diagnosed with breast cancer between the ages of 18 and 39 years, as identified by the central cancer registries of California, Georgia, North Carolina, and Florida. We used multivariable statistics to explore cost-related barriers to receiving breast cancer care for the 830 women that completed the survey. RESULTS: About half of the women (47.4%) reported spending more on breast cancer care than expected, and almost two-thirds (65.3%) had not discussed costs with their care team. A third of the patients (31.8%) indicated forgoing care due to cost. Factors associated with not receiving anticipated care due to cost included age less than35 years at diagnosis, self-insurance, comorbid conditions, and late-stage diagnosis. CONCLUSION: Previous studies using breast cancer registry data have not included detailed insurance information and care received by young women. Young women with breast cancer frequently forgo breast cancer care due to cost. Our results highlight the potential for policies that facilitate optimal care for young breast cancer patients which could include the provision of comprehensive insurance coverage.

Objective: Diabetes disproportionately affects low income individuals, many of whom are covered by Medicaid. Comorbidities and complications of diabetes can lead to chronic pain; however, little is known about opioid use patterns among Medicaid enrollees with diabetes. This study examined opioid dispensing among Medicaid enrollees by diabetes status.Methods: Medicaid claims data from 2014 were used to examine opioid dispensing by diabetes status among 622,992 adult enrollees aged 19-64 years. A logistic model adjusting for demographics and comorbidities was used to examine the association between diabetes and opioid dispensing among enrollees. Analyses were completed in 2019.Results: Overall, 61.6% of enrollees with diabetes filled at least one opioid prescription compared to 31.8% of enrollees without diabetes. A higher proportion of enrollees with diabetes had long-term opioid prescriptions (>90 days' supply) (with diabetes: 51.0% vs. without: 32.1%, p < 0.001). Characteristics of individual prescriptions, including daily morphine milligram equivalents (45.9 vs. 49.4), formulation (percent short-acting: 91.5% vs. 90.7%), and type of opioids (i.e. percent hydrocodone: 46.7 vs. 45.3), were similar for those with and without diabetes. After adjustment, enrollees with diabetes were 1.43 times more likely to receive an opioid prescription compared to those without (OR 1.43, 95% CI =1.40-1.46).Conclusions: Medicaid enrollees with diabetes were prescribed opioids more frequently and were more likely to have longer opioid supply than enrollees without diabetes. For practitioners who care for patients with diabetes, aligning pain management approaches with evidence-based resources, like the CDC Guideline for Prescribing Opioids for Chronic Pain, can encourage safer opioid prescribing practices.

An estimated 20.4% of US adults had chronic pain in 2016.1 Opioids are often prescribed for treating chronic pain, but evidence suggests that benefits may be limited, while harms may include addiction, overdose, and death.2,3 The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain (CDC Guideline) recommends non-pharmacologic and non-opioid pharmacologic therapies as the preferred therapies for chronic pain.3 Prior research has examined opioid and non-opioid pharmacologic therapies,4 little is known about how non-pharmacologic therapies are utilized for chronic pain. This study examined the prevalence of non-pharmacologic and pharmacologic (opioid and non-opioid) therapies among ambulatory care visits with a non-cancer chronic pain associated primary diagnosis.

In 2017, prescription opioids were involved in 36% of opioid-involved overdose deaths in the United States (1). Prescription opioids can be obtained by prescription or through diversion (the channeling of regulated drugs from legal to illegal sources) (2). Among new heroin users, 66%-83% reported that their opioid use began with the misuse of a prescription opioid (3). "Misuse" is generally defined as drugs taken for a purpose other than that directed by the prescribing physician, in greater amounts, more often, or for a longer duration than prescribed (2). Exposure to prescription opioids can be lessened by ensuring recommended prescribing, thereby potentially reducing the risk for misuse, opioid use disorder, and overdose (4). Sex and age groups with high exposure to prescription opioids are not well defined. Using a retail pharmaceutical database from IQVIA,* nationwide trends in opioid prescription fill rates for adult outpatients by age and sex were examined during 2008-2018. Opioid prescription fill rates were disproportionately higher among men and women aged >/=65 years and women of all ages. For reasons not well understood, these disparities persisted over 11 years even as the opioid fill rate declined for each age group and sex. Interventions to improve prescribing practices by following evidence-based guidelines that include weighing the benefits and risks for using prescription opioids for each patient and adopting a multimodal approach to pain management could improve patient safety while ameliorating pain. These efforts might need to consider the unique needs of women and older adults, who have the highest opioid prescription fill rates.

This cross-sectional study examines the national incidence rate of neonatal abstinence syndrome using data from the 2016 Healthcare Cost and Utilization Project Kids' Inpatient Database.

Background: In recent years, most insurance plans eliminated cost-sharing for breast cancer screening and recommended screening intervals changed, and newer modalities-digital mammography and breast tomosynthesis-became more widely available. The objectives of this study are to examine how these changes affected utilization, frequency, and costs of breast cancer screening among commercially insured women, and to understand factors associated with utilization and frequency of screening. Materials and Methods: This study used commercial insurance claims data for women 50 to 64 years of age, continuously enrolled in commercial insurance plans during 2012-2016. Results: Of the 685,737 eligible women, 20% were not screened, 40% received annual screening, 24% received biennial screening, and 16% were screened less frequently than recommended during the time period examined. Sociodemographic factors such as age <60 years, rurality, and fee-for-service insurance were associated with low screening utilization. Patients who received annual screening incurred approximately 1.78 times higher costs compared to those who received biennial screening during the study period. Digital mammography was the most costly and commonly used modality along with computer-aided detection. Conclusions: Evidence-based interventions to promote screening among women who are screened less frequently are needed along with interventions to move toward biennial screening rather than annual screening. Increasing provider awareness regarding breast cancer screening rates and frequency among various sociodemographic groups is essential to guide provider recommendations and shared decision making. The results of this study can guide targeted public health interventions to reduce barriers to screening, and can also serve as inputs for economic analyses of screening interventions and programs.

BACKGROUND: The CDC Guideline for Prescribing Opioids for Chronic Pain recommends considering prescribing naloxone when factors that increase risk for overdose are present (e.g., history of overdose or substance use disorder, opioid dosages >/=50 morphine milligram equivalents per day [high-dose], and concurrent use of benzodiazepines). In light of the high numbers of drug overdose deaths involving opioids, 36% of which in 2017 involved prescription opioids, improving access to naloxone is a public health priority. CDC examined trends and characteristics of naloxone dispensing from retail pharmacies at the national and county levels in the United States. METHODS: CDC analyzed 2012-2018 retail pharmacy data from IQVIA, a health care, data science, and technology company, to assess U.S. naloxone dispensing by U.S. Census region, urban/rural status, prescriber specialty, and recipient characteristics, including age group, sex, out-of-pocket costs, and method of payment. Factors associated with naloxone dispensing at the county level also were examined. RESULTS: The number of naloxone prescriptions dispensed from retail pharmacies increased substantially from 2012 to 2018, including a 106% increase from 2017 to 2018 alone. Nationally, in 2018, one naloxone prescription was dispensed for every 69 high-dose opioid prescriptions. Substantial regional variation in naloxone dispensing was found, including a twenty-fivefold variation across counties, with lowest rates in the most rural counties. A wide variation was also noted by prescriber specialty. Compared with naloxone prescriptions paid for with Medicaid and commercial insurance, a larger percentage of prescriptions paid for with Medicare required out-of-pocket costs. CONCLUSION: Despite substantial increases in naloxone dispensing, the rate of naloxone prescriptions dispensed per high-dose opioid prescription remains low, and overall naloxone dispensing varies substantially across the country. Naloxone distribution is an important component of the public health response to the opioid overdose epidemic. Health care providers can prescribe or dispense naloxone when overdose risk factors are present and counsel patients on how to use it. Efforts to improve naloxone access and distribution work most effectively with efforts to improve opioid prescribing, implement other harm-reduction strategies, promote linkage to medications for opioid use disorder treatment, and enhance public health and public safety partnerships.