Fatal overdoses involving synthetic opioids such as fentanyl increased sharply during the past decade. Recent data indicate declines in deaths with illegally manufactured fentanyls detected beginning in mid-2023. However, timely data on nonfatal overdoses involving fentanyl are limited. Emergency department (ED) data from CDC's National Syndromic Surveillance Program during October 2020-March 2024 were analyzed. Quarterly trends in rates of suspected nonfatal overdose of unintentional or undetermined intent involving fentanyl or fentanyl analogs (fentanyl-involved nonfatal overdoses) (i.e., the number of ED visits for fentanyl-involved nonfatal overdose per 10,000 total ED visits) were analyzed overall and by age group, sex, and race and ethnicity. During quarter (Q) 4 (October-December) 2020 to Q3 (July-September) 2023, rates of fentanyl-involved nonfatal overdose ED visits increased 8.7% per quarter, from 1.4 to 3.5 per 10,000 ED visits, then declined 11.0% per quarter, to 2.9 per 10,000 ED visits, from Q3 2023 to Q1 (January-March) 2024. Trends increased among a majority of demographic groups through mid-2023, with the highest rates and the largest increases among non-Hispanic American Indian or Alaska Native persons (e.g., 11.9 per 10,000 ED visits in Q3 2023, and an average quarterly increase of 9.0%, respectively). Providers in EDs have an important role in preventing fentanyl-involved nonfatal overdoses. Buprenorphine, a medication used to treat opioid use disorder that can be initiated in an ED, might benefit persons who use EDs as a main source of medical care. In addition, comprehensive services, including screening and treatment of co-occurring mental health conditions, as well as evidence-based prevention, treatment, and recovery support services, might be initiated in EDs because these might be particularly important in communities at high risk for fentanyl overdoses.

Background and Objectives: Historically, care for newborns with neonatal abstinence syndrome (NAS) focused on pharmacotherapy provided in a neonatal intensive care setting. The understanding of optimal care models is evolving and focuses on nonpharmacologic practices (e.g., skin-to-skin/kangaroo care) in settings that minimize overstimulation. We describe the prevalence of nonpharmacologic practices and policies specific to the support of newborns with NAS among US hospitals.Methods: Data from the 2022 Maternity Practices in Infant Nutrition and Care (mPINC) survey were used to determine the prevalence of evidence-based practices and policies related to the management of infants with NAS in US hospitals that provide maternity care. Likert scale response options describing implementation of these practices included few (0%-19%), some (20%-49%), many (50%-79%), or most (≥80%) infants.Results: Three-quarters of hospitals (74.8%) had policies regarding the provision of nonpharmacologic practices for newborns with NAS. About half of hospitals reported that most (≥80%) newborns with NAS experienced skin-to-skin/kangaroo care (52.1%) and rooming-in (50.7%), while 34.3% of hospitals reported that most (≥80%) newborns with NAS were breastfed or provided expressed breast milk. Smaller hospitals and hospitals with lower levels of neonatal care more often reported rooming-in for most (≥80%) newborns with NAS.Conclusions: While 3 in 4 hospitals have policies in place regarding nonpharmacologic care practices, only about half are implementing the practices for most newborns with NAS. Identifying barriers to implementation of nonpharmacologic practices could help efforts to increase these practices when caring for newborns with NAS.

Medetomidine, a nonopioid sedative not approved for use in humans, has periodically been detected in illegally manufactured opioids across North America since 2022. On May 11, 2024, the Chicago Department of Public Health (CDPH) and the Illinois Department of Public Health were alerted by hospitals and the Illinois Poison Center to an increase in emergency medical services responses for suspected opioid-involved overdoses with atypical symptoms, mostly clustered on Chicago's West Side. CDPH and CDC investigated and identified 12 confirmed, 26 probable, and 140 suspected overdoses involving medetomidine mixed with opioids among patients treated at three hospitals in Chicago's West Side during May 11-17, 2024. Medetomidine had not been previously identified in Chicago's illegal drug supply. Fentanyl was identified in all drug samples and blood specimens containing medetomidine. Most patients were male, non-Hispanic Black or African American, and aged 45-64 years; most patients with confirmed cases experienced bradycardia and had no or only a partial response to naloxone. This cluster is the largest reported for confirmed medetomidine-involved overdoses. Multisector surveillance, including by health care providers, toxicology laboratories, and public health personnel, was essential for quickly identifying and responding to new adulterants in the illegal drug supply. Because all specimens and samples in this investigation that contained medetomidine also contained natural or synthetic opioids, administering naloxone for all suspected opioid-involved overdoses remains crucial.

Background: The opioid overdose crisis remains a public health concern, and rates of suicide with opioid involvement have increased. Objective: To describe the prevalence of and factors associated with self-reported past 30-day suicide attempt or attempt "only when high or in withdrawal from alcohol or drugs" among reproductive-age women with past 30-day nonmedical prescription opioid use. Methods: Estimates are reported among women 18-55 years from 338 locations in 35 states using 2018-2020 National Addictions Vigilance Intervention and Prevention Program data. Bivariate analysis and multinomial logistic regression identified prevalence of and factors associated with past 30-day suicide attempt and attempt "only when high or in withdrawal from alcohol or drugs." Results: Among 10,095 women, 2.7% reported a past 30-day suicide attempt, and 1.5% reported an attempt "only when high or in withdrawal from alcohol or drugs." The largest magnitude of association for suicide attempt was extreme alcohol problem (adjusted odds ratio [aOR] = 2.84, 95% confidence interval [CI]: 1.80-4.47), and the largest magnitude of association for attempt "only when high or in withdrawal from alcohol or drugs" was no stable living arrangement (aOR = 2.66, 95% CI: 1.78-3.98). Conclusion: Comprehensive, upstream suicide prevention initiatives and substance use treatment can address factors associated with suicide attempt among reproductive-age women.

Access to and use of cannabis in the United States has increased as new product types emerge in the marketplace, and as additional states legalize its use for medical and nonmedical purposes. To tailor education messages for preventing adverse health effects of cannabis use, understanding the routes of use of these products in the general population is important. The 2022 Behavioral Risk Factor Surveillance System included a newly revised optional marijuana module comprising questions on marijuana routes of use among adults aged ≥18 years who used marijuana during the past 30 days (current use). Twenty-two states and two territories administered the optional marijuana module in 2022. Weighted prevalences (with 95% CIs) of current and daily or near-daily marijuana use, as well as prevalence of each route of use, were reported overall and by demographic characteristics and, among women aged ≤49 years, by pregnancy status. Among the 15.3% of respondents who reported current marijuana use, smoking was the most frequent route (79.4%), followed by eating (41.6%), vaping (30.3%), and dabbing (inhaling heated concentrated cannabis) (14.6%). Vaping and dabbing were most prevalent among persons aged 18-24 years. Intervention measures intended for persons who smoke cannabis are important; however, understanding health outcomes associated with other routes of use might have substantial public benefit.

BACKGROUND: Little is known about how symptoms or symptom clusters of Post-COVID Conditions (PCC) impact an individual's return to pre-COVID health. METHODS: We used four state-level COVID-19 case reporting systems and patient-reported survey data to identify patients with PCC and associations with an individual's return to pre-COVID health after laboratory-confirmed SARS-CoV-2 infection. Participants had a positive SARS-CoV-2 test between March-December 2020. Weighted regression models were used to 1) estimate prevalence of PCC; 2) identify risk factors associated with developing PCC; and 3) examine associations between PCC symptom clusters and return to pre-COVID health. Factor analysis was used to statistically identify post-COVID symptom clusters. FINDINGS: Prevalence of PCC in this population-based sample was 29·9% for persons with SARS-CoV-2 infection, during the pre-delta variant period (March-December 2020); 77·2% of persons experiencing PCC had not returned to pre-COVID health within 8-60 weeks after infection. Female sex, acute COVID-19 illness severity, and number of pre-existing comorbidities were significant risk factors associated with PCC. Myalgic encephalomyelitis/chronic fatigue syndrome-like symptoms, upper-respiratory symptoms, and gastrointestinal symptoms were significantly associated with not returning to pre-COVID health. INTERPRETATION: Understanding PCC symptom clustering may provide insight into pathophysiology, severity of PCC, and management for patients who have not returned to their usual state of health after SARS-CoV-2 infection. Tracking PCC can help measure the impact of COVID-19 vaccination and acute COVID-19-specific treatments on reducing PCC in the US.

During 2023, approximately 72,000, or nearly seven in 10, drug overdose deaths in the United States were estimated to involve illegally manufactured fentanyls (IMFs). Carfentanil, a fentanyl analog 100 times more potent than fentanyl, has reemerged in the U.S. drug supply. Using CDC's State Unintentional Drug Overdose Reporting System data, this report describes trends in overdose deaths during January 2021-June 2024, overall and with IMFs detected, by U.S. Census Bureau region, and in deaths with carfentanil detected, in 45 states and the District of Columbia (DC). Numbers of deaths with carfentanil detected by state during January 2023-June 2024 in 49 states and DC are also reported. The number of overdose deaths with IMFs detected declined from 2022 to 2023 in the Northeast (3.2% decline), Midwest (7.8%), and South (2.8%) regions; deaths in the West increased 33.9%. The percentage of deaths with IMFs detected was steady at approximately 70%-80% in the Northeast, Midwest, and South. In contrast, the percentage of deaths with IMFs detected in the West increased from 48.5% during January-March 2021 to 66.5% during April-June 2024. Overdose deaths with carfentanil detected increased approximately sevenfold, from 29 during January-June 2023 to 238 during January-June 2024; during January 2023-June 2024, overdose deaths with carfentanil detected were reported in 37 states. Overdose prevention efforts that address the widespread presence of IMFs, including carfentanil, and can rapidly adapt to other potent opioids in the drug supply might result in lasting reductions in overdose deaths across the entire United States.

BACKGROUND: The Massachusetts Child Psychiatry Access Program for Moms and PRogram In Support of Moms are designed to help obstetric practices address perinatal depression. The PRogram in Support of Moms includes the statewide Massachusetts Child Psychiatry Access Program for Moms program, plus proactive implementation support. OBJECTIVE: The goal of this study was to understand the impact of these programs on perinatal generalized anxiety disorder and posttraumatic stress disorder symptoms among individuals screening positive for depression. STUDY DESIGN: We conducted a secondary analysis of 2017-2022 data from a cluster randomized controlled trial of Massachusetts Child Psychiatry Access Program for Moms vs PRogram In Support of Moms. We included participants completing a generalized anxiety disorder or posttraumatic stress disorder screen at baseline (n=254) with antenatal Edinburgh Postnatal Depression Scale scores ≥10. We assessed changes in generalized anxiety disorder and posttraumatic stress disorder symptoms from pregnancy (4-25 weeks of gestational age or 32-40 weeks of gestational age), 4-12 weeks postpartum, and 11-13 months postpartum. We conducted a difference-in-difference analysis to compare symptom change from pregnancy to postpartum. We used adjusted linear mixed models with repeated measures to examine the impact of the Massachusetts Child Psychiatry Access Program for Moms and PRogram In Support of Moms on changes in the Generalized Anxiety Disorder 7 and the Posttraumatic Stress Disorder Checklist. RESULTS: Mean Generalized Anxiety Disorder 7 scores decreased by 3.6 (Massachusetts Child Psychiatry Access Program for Moms) and 6.3 (PRogram In Support of Moms) points from pregnancy to 4-12 weeks postpartum. Mean Posttraumatic Stress Disorder Checklist scores decreased by 6.2 and 10.0 points, respectively, at 4-12 weeks postpartum among individuals scree ning positive on the Generalized Anxiety Disorder 7 (n=83) or Posttraumatic Stress Disorder Checklist (n=58) in pregnancy. Generalized Anxiety Disorder 7 and Posttraumatic Stress Disorder Checklist scores decreased among both groups at 11-13 months postpartum. These changes were clinically meaningful. PRogram In Support of Moms conferred a statistically significant greater decrease (2.7 points) on the Generalized Anxiety Disorder 7 than the Massachusetts Child Psychiatry Access Program for Moms at 4-12 weeks postpartum. No differences were found between the Massachusetts Child Psychiatry Access Program for Moms and PRogram In Support of Moms in Posttraumatic Stress Disorder Checklist or Generalized Anxiety Disorder 7 change at 11-13 months, although both were associated with a reduction in generalized anxiety disorder and posttraumatic stress disorder symptoms at 4-12 weeks and 11-13 months postpartum. CONCLUSION: Both the Massachusetts Child Psychiatry Access Program for Moms and PRogram In Support of Moms could help to improve symptoms for individuals experiencing co-occurring symptoms of depression, generalized anxiety disorder, or posttraumatic stress disorder. PRogram In Support of Moms may confer additional benefits in the early postpartum period, although this difference was not clinically significant.

Adolescence is an important period of risk for substance use initiation and substance use-related adverse outcomes. To examine youth substance use trends and patterns, CDC analyzed data from the 2009-2019 Youth Risk Behavior Survey. This report presents estimated prevalence of current (i.e., previous 30-days) marijuana use, prescription opioid misuse, alcohol use, and binge drinking and lifetime prevalence of marijuana, synthetic marijuana, cocaine, methamphetamine, heroin, injection drug use, and prescription opioid misuse among U.S. high school students. Logistic regression and Joinpoint analyses were used to assess 2009-2019 trends. Prevalence of current and lifetime substance use by demographics, frequency of use, and prevalence of co-occurrence of selected substances among students reporting current prescription opioid misuse are estimated using 2019 data. Multivariable logistic regression analysis was used to determine demographic and substance use correlates of current prescription opioid misuse. Current alcohol, lifetime cocaine, methamphetamine, heroin, and injection drug use decreased during 2009-2019. Lifetime use of synthetic marijuana (also called synthetic cannabinoids) decreased during 2015-2019. Lifetime marijuana use increased during 2009-2013 and then decreased during 2013-2019. In 2019, 29.2% reported current alcohol use, 21.7% current marijuana use, 13.7% current binge drinking, and 7.2% current prescription opioid misuse. Substance use varied by sex, race/ethnicity, grade, and sexual minority status (lesbian, gay, or bisexual). Use of other substances, particularly current use of alcohol (59.4%) and marijuana (43.5%), was common among students currently misusing prescription opioids. Findings highlight opportunities for expanding evidence-based prevention policies, programs, and practices that aim to reduce risk factors and strengthen protective factors related to youth substance use, in conjunction with ongoing initiatives for combating the opioid crisis.

Cardiovascular conditions are significant contributors to morbidity and mortality among pregnant and postpartum women.1 | | We used data from the MarketScan Commercial Claims and Encounters database to identify women 12 to 55 years of age who delivered from 2017 to 2019. Delivery hospitalizations and cardiovascular diagnoses and procedures (ie, conditions) were identified using International Classification of Diseases-10th Revision-Clinical Modification codes. Cardiovascular conditions included acute heart failure or pulmonary edema; acute myocardial infarction; arrhythmia; conduction disorders; cardiac arrest, ventricular fibrillation, or ventricular flutter; cardiomyopathy; congenital heart and great artery defects; conversion of cardiac rhythm; endocarditis, myocarditis, or pericarditis; hypertensive heart disease; ischemic heart disease; nonrheumatic valve disorders; pulmonary heart disease; rheumatic heart disease; and other heart diseases and complications. We calculated the prevalence of hospitalizations with any cardiovascular condition in the year postpartum. Among these patients, we calculated the prevalence of cardiovascular conditions at delivery hospitalization and the frequency of postpartum hospitalizations. For postpartum hospitalizations with cardiovascular conditions, we calculated timing relative to delivery hospitalization and the prevalence (95% CI) of specific cardiovascular conditions by timing since delivery hospitalization (early postpartum [1–42 days] vs late postpartum [43–365 days]), accounting for clustering at the patient level. The data were collected and statistically deidentified. The data are also compliant with the conditions set forth in sections 164.514(a) and 164.51(b)(1)(ii) of the Health Insurance Portability and Accountability Act of 1996 Privacy Rule; therefore, approval from an Institutional Review Board was not sought.

BACKGROUND: Perinatal depression is a common and undertreated condition, with potential deleterious effects on maternal, obstetric, infant, and child outcomes. We aimed to compare the effectiveness of two systems-level interventions in the obstetric setting-the Massachusetts Child Psychiatry Access Program (MCPAP) for Moms and the PRogram In Support of Moms (PRISM)-in improving depression symptoms and participation in mental health treatment among women with perinatal depression. METHODS: In this cluster-randomised, active-controlled trial, obstetric practices across Massachusetts (USA) were allocated (1:1) via covariate adaptive randomisation to either continue participating in the MCPAP for Moms intervention, a state-wide, population-based programme, or to participate in the PRISM intervention, which involved MCPAP for Moms plus a proactive, multifaceted, obstetric practice-level intervention with intensive implementation support. English-speaking women (aged ≥18 years) who screened positive for depression (Edinburgh Postnatal Depression Scale [EPDS] score ≥10) were recruited from the practices. Patients were followed up at 4-25 weeks of gestation, 32-40 weeks of gestation, 0-3 months postpartum, 5-7 months postpartum, and 11-13 months postpartum via telephone interview. Participants were masked to the intervention; investigators were not masked. The primary outcome was change in depression symptoms (EPDS score) between baseline assessment and 11-13 months postpartum. Analysis was done by intention to treat, fitting generalised linear mixed models adjusting for age, insurance status, education, and race, and accounting for clustering of patients within practices. This trial is registered with ClinicalTrials.gov, NCT02760004. FINDINGS: Between July 29, 2015, and Sept 20, 2021, ten obstetric practices were recruited and retained; five (50%) practices were randomly allocated to MCPAP for Moms and five (50%) to PRISM. 1265 participants were assessed for eligibility and 312 (24·7%) were recruited, of whom 162 (51·9%) were enrolled in MCPAP for Moms practices and 150 (48·1%) in PRISM practices. Comparing baseline to 11-13 months postpartum, EPDS scores decreased by 4·2 (SD 5·2; p<0·0001) among participants in MCPAP for Moms practices and by 4·3 (SD 4.5; p<0·0001) among those in PRISM practices (estimated difference between groups 0·1 [95% CI -1·2 to 1·4]; p=0·87). INTERPRETATION: Both the MCPAP for Moms and PRISM interventions were equally effective in improving depression symptoms. This finding is important because the 4-point decrease in EPDS score is clinically significant, and MCPAP for Moms has a lower intensity and greater population-based reach than does PRISM. FUNDING: US Centers for Disease Control and Prevention.

BACKGROUND: Marijuana is the most commonly used federally illicit substance among reproductive-age women in the United States. Updated information on marijuana use in this population can inform clinical and public health interventions. METHODS: Data from the 2013-2019 National Survey on Drug Use and Health was used to report weighted prevalence estimates of marijuana use in the past month, past 2-12 months, and past year among women aged 18-44 years with self-reported pregnancy status. Bivariate analyses and general linear regression models with Poisson distribution using appropriate survey procedures identified factors associated with past-year marijuana use by pregnancy status. RESULTS: Among pregnant women, 4.9% (95% confidence interval [CI]: 4.1-5.6) reported marijuana use in the past month, 10.4% (95% CI: 9.3-11.5) in the past 2-12 months, and 15.2% (95% CI: 13.9-16.6) in the past year. Among nonpregnant women, 11.8% (95% CI: 11.5-12.0) reported marijuana use in the past month, 7.8% (95% CI: 7.6-8.0) in the past 2-12 months, and 19.5% (95% CI: 19.2-19.9) in the past year. After adjusting for sociodemographic characteristics, past-year marijuana use was 2.3-5.1 times more likely among pregnant, and 2.1 to 4.6 times more likely among nonpregnant women who reported past-year tobacco smoking, alcohol use, or other illicit drug use compared to those reporting no substance use. CONCLUSIONS: Pregnant and nonpregnant women reporting marijuana use, alone or with other substances, can benefit from substance use screening and treatment facilitation.

BACKGROUND: Severe maternal morbidity (SMM) is broadly defined as an unexpected and potentially life-threatening event associated with labor and delivery. The Centers for Disease Control and Prevention (CDC) produced 21 different indicators based on International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) hospital diagnostic and procedure codes to identify cases of SMM. OBJECTIVES: To examine existing SMM indicators and determine which indicators identified the most in-hospital mortality at delivery hospitalization. METHODS: Data from the 1993-2015 and 2017-2019 Healthcare Cost and Utilization Project's National Inpatient Sample were used to report SMM indicator-specific prevalences, in-hospital mortality rates, and population attributable fractions (PAF) of mortality. We hierarchically ranked indicators by their overall PAF of in-hospital mortality. Predictive modeling determined if SMM prevalence remained comparable after transition to ICD-10-CM coding. RESULTS: The study population consisted of 18,198,934 hospitalizations representing 87,864,173 US delivery hospitalizations. The 15 top ranked indicators identified 80% of in-hospital mortality; the proportion identified by the remaining indicators was negligible (2%). The top 15 indicators were: restoration of cardiac rhythm; cardiac arrest; mechanical ventilation; tracheostomy; amniotic fluid embolism; aneurysm; acute respiratory distress syndrome; acute myocardial infarction; shock; thromboembolism, pulmonary embolism; cerebrovascular disorders; sepsis; both DIC and blood transfusion; acute renal failure; and hysterectomy. The overall prevalence of the top 15 ranked SMM indicators (~22,000 SMM cases per year) was comparable after transition to ICD-10-CM coding. CONCLUSIONS: We determined the 15 indicators that identified the most in-hospital mortality at delivery hospitalization in the US. Continued testing of SMM indicators can improve measurement and surveillance of the most severe maternal complications at the population level.

INTRODUCTION: Postpartum depression is a serious public health problem that can adversely impact mother-child interactions. Few studies have examined depressive symptoms in the later (9-10 months) postpartum period. METHODS: We analyzed data from the 2019 Pregnancy Risk Assessment Monitoring System (PRAMS) linked with data from a telephone follow-up survey administered to PRAMS respondents 9 to 10 months postpartum in 7 states (N = 1,954). We estimated the prevalence of postpartum depressive symptoms (PDS) at 9 to 10 months overall and by sociodemographic characteristics, prior depression (before or during pregnancy), PDS at 2 to 6 months, and other mental health characteristics. We used unadjusted prevalence ratios (PRs) to examine associations between those characteristics and PDS at 9 to 10 months. We also examined prevalence and associations with PDS at both time periods. RESULTS: Prevalence of PDS at 9 to 10 months was 7.2%. Of those with PDS at 9 to 10 months, 57.4% had not reported depressive symptoms at 2 to 6 months. Prevalence of PDS at 9 to 10 months was associated with having Medicaid insurance postpartum (PR = 2.34; P = .001), prior depression (PR = 4.03; P <.001), and current postpartum anxiety (PR = 3.58; P <.001). Prevalence of PDS at both time periods was 3.1%. Of those with PDS at both time periods, 68.5% had prior depression. CONCLUSION: Nearly 3 in 5 women with PDS at 9 to 10 months did not report PDS at 2 to 6 months. Screening for depression throughout the first postpartum year can identify women who are not symptomatic early in the postpartum period but later develop symptoms.

Introduction: We evaluated how the Affordable Care Act (ACA) Medicaid eligibility expansion affected perinatal insurance coverage patterns for Medicaid-enrolled beneficiaries who gave birth overall and by race/ethnicity. We also examined state-level heterogeneous impacts. Methods: Using the 2011–2013 Medicaid Analytic eXtract and the 2016–2018 Transformed Medicaid Statistical Information System Analytic File databases, we identified 1.4 million beneficiaries giving birth in 2012 (pre-ACA expansion cohort) and 1.5 million in 2017 (post-ACA expansion cohort). We constructed monthly coverage rates for the two cohorts by state Medicaid expansion status and obtained difference-in-differences estimates of the association of Medicaid expansion with coverage overall and by race/ethnicity group (non-Hispanic White, non-Hispanic Black, and Hispanic). To explore state-level heterogeneous impacts, we divided the expansion and non-expansion states into groups based on the differences in the income eligibility limits for low-income parents in each state between 2012 and 2017. Results: Medicaid expansion was associated with 13 percentage points higher coverage in the 9 to 12 months before giving birth, and 11 percentage points higher coverage at 6 to 12 months postpartum. Hispanic birthing individuals had the greatest relative increases in coverage, followed by non-Hispanic White and non-Hispanic Black individuals. In Medicaid expansion states, those who experienced the greatest increases in income eligibility limits for low-income parents generally saw the greatest increases in coverage. In non-expansion states, there was less heterogeneity between state groupings. Conclusions: Pregnancy-related Medicaid eligibility did not have major changes in the 2010s. However, states’ adoption of ACA Medicaid expansion after 2012 was associated with increased Medicaid coverage before, during, and after pregnancy. The increases varied by race/ethnicity and across states. © 2023

Background Identification of risk factors for COVID-19-associated hospitalization is needed to guide prevention and clinical care.Objective To examine if age, sex, race/ethnicity, and underlying medical conditions is independently associated with COVID-19-associated hospitalizations.Design Cross-sectional.Setting 70 counties within 12 states participating in the Coronavirus Disease 2019-Associated Hospitalization Surveillance Network (COVID-NET) and a population-based sample of non-hospitalized adults residing in the COVID-NET catchment area from the Behavioral Risk Factor Surveillance System.Participants U.S. community-dwelling adults (≥18 years) with laboratory-confirmed COVID-19-associated hospitalizations, March 1- June 23, 2020.Measurements Adjusted rate ratios (aRR) of hospitalization by age, sex, race/ethnicity and underlying medical conditions (hypertension, coronary artery disease, history of stroke, diabetes, obesity [BMI ≥30 kg/m2], severe obesity [BMI≥40 kg/m2], chronic kidney disease, asthma, and chronic obstructive pulmonary disease).Results Our sample included 5,416 adults with COVID-19-associated hospitalizations. Adults with (versus without) severe obesity (aRR:4.4; 95%CI: 3.4, 5.7), chronic kidney disease (aRR:4.0; 95%CI: 3.0, 5.2), diabetes (aRR:3.2; 95%CI: 2.5, 4.1), obesity (aRR:2.9; 95%CI: 2.3, 3.5), hypertension (aRR:2.8; 95%CI: 2.3, 3.4), and asthma (aRR:1.4; 95%CI: 1.1, 1.7) had higher rates of hospitalization, after adjusting for age, sex, and race/ethnicity. In models adjusting for the presence of an individual underlying medical condition, higher hospitalization rates were observed for adults ≥65 years, 45-64 years (versus 18-44 years), males (versus females), and non-Hispanic black and other race/ethnicities (versus non-Hispanic whites).Limitations Interim analysis limited to hospitalizations with underlying medical condition data.Conclusion Our findings elucidate groups with higher hospitalization risk that may benefit from targeted preventive and therapeutic interventions.Competing Interest StatementDr. Anderson reports personal fees from AbbVie, personal fees from Pfizer, grants from Pfizer, grants from Merck, grants from Micron, grants from Paxvax, grants from Sanofi Pasteur, grants from Novavax, grants from MedImmune, grants from Regeneron, grants from GSK, outside the submitted work. Mr. Henderson, Ms. Kim, Ms. George, and Ms. Hill report grants from Council of State and Territorial Epidemiologists (CSTE), during the conduct of the study. Dr. Lynfield reports grants from CDC- Emerging Infections Program, during the conduct of the study; and Royalties from a book on infectious disease surveillance and compensation for AAP Red Book (Report from Committee on Infectious Disease) donated to Minnesota Dept of Health. Dr. Schaffner reports grants from CDC, during the conduct of the study; personal fees from VBI Vaccines, outside the submitted work. Dr. Talbot reports other from Seqirus, outside the submitted work.Funding StatementThis work was supported by the Centers of Disease Control and Prevention through an Emerging Infections Program cooperative agreement (grant CK17-1701) and through a Council of State and Territorial Epidemiologists cooperative agreement (grant NU38OT000297-02-00).Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:This analysis was exempt from CDC's Institutional Review Board, as it was considered part of public health surveillance and emergency response. Participating sites obtained approval for the COVID-NET surveillance protocol from their respective state and local IRBs, as required.All necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved regi try, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesData is not publically available at this time.

PURPOSE: To understand differences in health care utilization and medical expenditures by perinatal depression (PND) status during pregnancy and 1-year postpartum overall and by rural/urban status. METHODS: We estimated differences in health care utilization and medical expenditures by PND status for individuals with an inpatient live-birth delivery in 2017, continuously enrolled in commercial insurance from 3 months before pregnancy through 1-year postpartum (study period), using MarketScan Commercial Claims data. Multivariable regression was used to examine differences by rurality. FINDINGS: Ten percent of commercially insured individuals had claims with PND. A smaller proportion of rural (8.7%) versus urban residents (10.0%) had a depression diagnosis (p < 0.0001). Of those with PND, a smaller proportion of rural (5.5%) versus urban residents (9.6%) had a depression claim 3 months before pregnancy (p < 0.0001). Compared with urban residents, rural residents had greater differences by PND status in total inpatient days (rural: 0.7, 95% confidence interval [CI]: 0.6-0.9 vs. urban: 0.5, 95% CI: 0.5-0.6) and emergency department (ED) visits (rural: 0.7, 95% CI: 0.6-0.9 vs. urban: 0.5, 95% CI: 0.4-0.5), but a smaller difference by PND status in the number of outpatient visits (rural: 9.2, 95% CI: 8.2-10.2 vs. urban: 13.1, 95% CI: 12.7-13.5). Differences in expenditures for inpatient services by PND status differed by rural/urban status (rural: $2654; 95% CI: $1823-$3485 vs. urban: $1786; 95% CI: $1445-$2127). CONCLUSIONS: Commercially insured rural residents had more utilization for inpatient and ED services and less utilization for outpatient services. Rural locations can present barriers to evidence-based care to address PND.

INTRODUCTION: Screening for opioid misuse and treatment for opioid use disorder are critical for reducing morbidity and mortality. We sought to understand the extent of self-reported past 30-day buprenorphine use in various settings among women of reproductive age with self-reported nonmedical prescription opioid use being assessed for substance use problems. METHODS: The study collected data from individuals being assessed for substance use problems using the Addiction Severity Index-Multimedia Version in 2018-2020. We stratified the sample of 10,196 women ages 12-55 self-reporting past 30-day nonmedical prescription opioid use by buprenorphine use and setting type. We categorized setting types as: buprenorphine in specialty addiction treatment, buprenorphine in office-based opioid treatment, and diverted buprenorphine. We included each woman's first intake assessment during the study period. The study assessed number of buprenorphine products, reasons for using buprenorphine, and sources of buprenorphine procurement. The study calculated frequency of reasons for using buprenorphine to treat opioid use disorder outside of a doctor-managed treatment, overall and by race/ethnicity. RESULTS: Overall, 25.5 % of the sample used buprenorphine in specialty addiction treatment, 6.1 % used buprenorphine prescribed in office-based treatment, 21.7 % used diverted buprenorphine, and 46.7 % reported no buprenorphine use during the past 30 days. Among women who reported using buprenorphine to treat opioid use disorder, but not as part of a doctor-managed treatment, 72.3 % could not find a provider or get into a treatment program, 21.8 % did not want to be part of a program or see a provider, and 6.0 % reported both; a higher proportion of American Indian/Alaska Native women (92.1 %) reported that they could not find a provider or get into a treatment program versus non-Hispanic White (78.0 %), non-Hispanic Black (76.0 %), and Hispanic (75.0 %) women. CONCLUSIONS: Appropriate screening for nonmedical prescription opioid use to assess need for treatment with medication for opioid use disorder is important for all women of reproductive age. Our data highlight opportunities to improve treatment program accessibility and availability and support the need to increase equitable access for all women.

Objective(s): The opioid crisis affects the health and health care of pregnant and postpartum people and infants prenatally exposed to substances. A Learning Community (LC) among 15 states was implemented to improve services for these populations. States drafted action plans with goals, strategies, and activities. Materials and Methods: Qualitative data from action plans were analyzed to assess how reported activities aligned with focus areas each year. Year 2 focus areas were compared with year 1 to identify shifts or expansion of activities. States self-assessed progress at the LC closing meeting, reported goal completion, barriers and facilitators affecting goal completion, and sustainment strategies. Results: In year 2, many states included activities focused on access to and coordination of quality services (13 of 15 states) and provider awareness and training (11 of 15). Among 12 states participating in both years of the LC, 11 expanded activities to include at least one additional focus area, adding activities in financing and coverage of services (n = 6); consumer awareness and education (n = 5); or ethical, legal, and social considerations (n = 4). Of the 39 goals developed by states, 54% were completed, and of those not completed, 94% had ongoing activities. Barriers to goal completion included competing priorities and pandemic-related constraints, whereas facilitators involving use of the LC as a forum for information-sharing and leadership-supported goal completion. Sustainability strategies were continued provider training and partnership with Perinatal Quality Collaboratives. Conclusion: State LC participation supported sustainment of activities to improve health and health care for pregnant and postpartum people with opioid use disorder and infants prenatally exposed to substances.

Poor mental health among parents or primary caregivers is associated with poor mental and physical health in children; however, research often excludes the mental health of male caregivers including fathers. This analysis examines associations between caregiver mental health by caregiver sex and child health indicators (i.e., child's general health; child's history of diagnosed mental, behavioral, or developmental disorders (MBDDs)). Using parent-reported data on 97,728 US children aged 0-17 years from the National Survey of Children's Health (2016-2018), we estimated nationally representative, weighted proportions of children with parents or primary caregivers with poor mental health by caregiver sex, prevalence ratios (PR), and 95% confidence intervals (CI) for child health indicators by caregiver mental health and sex. Nationally, 7.2% of children had at least one caregiver with poor mental health; 2.8% had any male caregiver; and 5.1% had any female caregiver with poor mental health. Compared to children with all male caregivers with good mental health, children with any male caregiver with poor mental health were more likely to have poor general health (PR: 4.9, CI: 3.0-8.0) and have ≥1 diagnosed MBDDs (PR: 1.9, CI: 1.7-2.1); this remained significant when controlling for caregiver and household characteristics. Findings were similar when comparing children with any female caregiver with poor mental health to children with all female caregivers with good mental health. Our findings support previously published recommendations that promoting mental health among all types of caregivers by addressing gaps in research on fathers and male caregivers may further promote child health and wellness.

In Reply We appreciate Ramphul et al sharing estimates of the 2012 rate of in-hospital births with a neonatal abstinence syndrome (NAS) diagnosis. In our study1 of 2016 national incidence and cost estimates for in-hospital births with a NAS diagnosis, we did not make direct comparisons with earlier estimates2 owing to the 2015 transition from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and because earlier studies may not have limited the sample to in-hospital births.

BACKGROUND: We sought to evaluate whether race/ethnicity disparities in severe COVID-19 outcomes persist in the era of vaccination. METHODS: Population-based age-adjusted monthly rate ratios (RR) of laboratory-confirmed COVID-19-asssociated hospitalizations were calculated among adult patients from COVID-19-Associated Hospitalization Surveillance Network (COVID-NET) during March 2020 - August 2022, by race/ethnicity. Among randomly sampled patients, July 2021-August 2022, RRs for hospitalization, intensive care unit (ICU) admission, and in-hospital mortality were calculated for Hispanic, Black, American Indian/Alaskan Native (AI/AN), and Asian/Pacific Islander (API) versus White persons. RESULTS: Based on data from 353,807 hospitalized patients, hospitalization rates were higher among Hispanic, Black and AI/AN versus White persons during March 2020 - August 2022, yet the magnitude of the disparities declined over time (for Hispanic, RR=6.7; 95%CI: 6.5-7.1 in June 2020 vs RR<2.0 after July 2021; for AI/AN, RR=8.4; 95%CI: 8.2-8.7in May 2020 vs RR<2.0 after March 2022; and for Black persons RR=5.3; 95%CI: 4.6-4.9 in July 2020 vs RR<2.0 after February 2022; all p≤0.001). Among 8,706 sampled patients during July 2021 - August 2022, hospitalization and ICU admission RRs were higher for Hispanic, Black, and AI/AN (range for both hospitalization and ICU admission: 1.4-2.4) and lower for API (range for both: 0.6-0.9) versus White persons. All other race and ethnicity groups had higher in-hospital mortality rates versus White persons (RR range: 1.4-2.9). CONCLUSIONS: Race/ethnicity disparities in COVID-19-associated hospitalizations declined but persist in the era of vaccination. Developing strategies to ensure equitable access to vaccination and treatment remains important.

BACKGROUND: The objective was to assess mental health and substance use disorders (MSUD) at delivery hospitalization and readmissions after delivery discharge. METHODS: This is a population-based retrospective cohort study of persons who had a delivery hospitalization during January to September in the 2019 Nationwide Readmissions Database. We calculated 90-day readmission rates for MSUD and non-MSUD, overall and stratified by MSUD status at delivery. We used multivariable logistic regressions to assess the associations of MSUD type, patient, clinical, and hospital factors at delivery with 90-day MSUD readmissions. RESULTS: An estimated 11.8% of the 2,697,605 weighted delivery hospitalizations recorded MSUD diagnoses. The 90-day MSUD and non-MSUD readmission rates were 0.41% and 2.9% among delivery discharges with MSUD diagnoses, compared to 0.047% and 1.9% among delivery discharges without MSUD diagnoses. In multivariable analysis, schizophrenia, bipolar disorder, stimulant-related disorders, depressive disorders, trauma- and stressor-related disorders, alcohol-related disorders, miscellaneous mental and behavioral disorders, and other specified substance-related disorders were significantly associated with increased odds of MSUD readmissions. Three or more co-occurring MSUDs (vs one MSUD), Medicare or Medicaid (vs private) as the primary expected payer, lowest (vs highest) quartile of median household income at residence zip code level, decreasing age, and longer length of stay at delivery were significantly associated with increased odds of MSUD readmissions. CONCLUSION: Compared to persons without MSUD at delivery, those with MSUD had higher MSUD and non-MSUD 90-day readmission rates. Strategies to address MSUD readmissions can include improved postpartum MSUD follow-up management, expanded Medicaid postpartum coverage, and addressing social determinants of health.

BACKGROUND: People with a maternal substance use disorder (SUD) may experience a lack of access to necessary healthcare and more specifically, postpartum healthcare. It is not known whether increased insurance coverage introduced by Medicaid expansion has improved postpartum healthcare utilization among this population. METHODS: Oregon 2008-2016 birth certificates and Medicaid claims were used to examine whether continuous insurance enrollment and postpartum healthcare utilization increased post-Medicaid expansion in a population with and without SUD (n = 9,337). International Classification of Diseases codes were used to identify deliveries, SUD, and postpartum healthcare. Univariable and multivariable generalized linear regression with standard errors clustered by individual were used to estimate the association between Medicaid expansion and postpartum healthcare utilization, stratified by maternal SUD. RESULTS: Among the 10.3% with SUD, expansion was not associated with increased continuous enrollment or postpartum healthcare utilization. Among those without SUD, post-expansion deliveries were associated with increased continuous enrollment (+105.0 days; 95% CI=96.9-113.2), total (+4.4; 95% CI=2.9-6.0), postpartum (+0.3; 95% CI=0.2-0.4), inpatient (+0.9; 95% CI=0.7-1.1), outpatient (+2.3; 95% CI=1.4-3.3), office (+0.9; 95% CI=0.2-1.6), and emergency department (+0.3; 95% CI=0.1-0.5) visits. Among deliveries to postpartum people with SUD, 27.2% had opioid use disorder (OUD); expansion was associated with increased OUD medication use (12.0% vs 18.3%) and number of fills (6.7 vs 16.6). CONCLUSIONS: Medicaid expansion in Oregon was only associated with increased Medicaid-financed healthcare utilization for postpartum people without SUD, with the exception of those with OUD, demonstrating the need for assessing various strategies to improve postpartum healthcare utilization.

BACKGROUND: Estimates of cardiac arrest occurring during delivery guide evidence-based strategies to reduce pregnancy-related death. OBJECTIVE: To investigate rate of, maternal characteristics associated with, and survival after cardiac arrest during delivery hospitalization. DESIGN: Retrospective cohort study. SETTING: U.S. acute care hospitals, 2017 to 2019. PARTICIPANTS: Delivery hospitalizations among women aged 12 to 55 years included in the National Inpatient Sample database. MEASUREMENTS: Delivery hospitalizations, cardiac arrest, underlying medical conditions, obstetric outcomes, and severe maternal complications were identified using codes from the International Classification of Diseases, 10th Revision, Clinical Modification. Survival to hospital discharge was based on discharge disposition. RESULTS: Among 10 921 784 U.S. delivery hospitalizations, the cardiac arrest rate was 13.4 per 100 000. Of the 1465 patients who had cardiac arrest, 68.6% (95% CI, 63.2% to 74.0%) survived to hospital discharge. Cardiac arrest was more common among patients who were older, were non-Hispanic Black, had Medicare or Medicaid, or had underlying medical conditions. Acute respiratory distress syndrome was the most common co-occurring diagnosis (56.0% [CI, 50.2% to 61.7%]). Among co-occurring procedures or interventions examined, mechanical ventilation was the most common (53.2% [CI, 47.5% to 59.0%]). The rate of survival to hospital discharge after cardiac arrest was lower with co-occurring disseminated intravascular coagulation (DIC) without or with transfusion (50.0% [CI, 35.8% to 64.2%] or 54.3% [CI, 39.2% to 69.5%], respectively). LIMITATIONS: Cardiac arrests occurring outside delivery hospitalizations were not included. The temporality of arrest relative to the delivery or other maternal complications is unknown. Data do not distinguish cause of cardiac arrest, such as pregnancy-related complications or other underlying causes among pregnant women. CONCLUSION: Cardiac arrest was observed in approximately 1 in 9000 delivery hospitalizations, among which nearly 7 in 10 women survived to hospital discharge. Survival was lowest during hospitalizations with co-occurring DIC. PRIMARY FUNDING SOURCE: None.

BACKGROUND: Adults with disabilities are at increased risk for SARS-CoV-2 infection and severe disease; whether adults with disabilities are at an increased risk for ongoing symptoms after acute SARS-CoV-2 infection is unknown. OBJECTIVES: To estimate the frequency and duration of long-term symptoms (>4 weeks) and health care utilization among adults with and without disabilities who self-report positive or negative SARS-CoV-2 test results. METHODS: Data from a nationwide survey of 4510 U.S. adults administered from September 24, 2021-October 7, 2021, were analyzed for 3251 (79%) participants who self-reported disability status, symptom(s), and SARS-CoV-2 test results (a positive test or only negative tests). Multivariable models were used to estimate the odds of having ≥1 COVID-19-like symptom(s) lasting >4 weeks by test result and disability status, weighted and adjusted for socio-demographics. RESULTS: Respondents who tested positive for SARS-CoV-2 had higher odds of reporting ≥1 long-term symptom (with disability: aOR = 4.50 [95% CI: 2.37, 8.54] and without disability: aOR = 9.88 [95% CI: 7.13, 13.71]) compared to respondents testing negative. Among respondents who tested positive, those with disabilities were not significantly more likely to experience long-term symptoms compared to respondents without disabilities (aOR = 1.65 [95% CI: 0.78, 3.50]). Health care utilization for reported symptoms was higher among respondents with disabilities who tested positive (40%) than among respondents without disabilities who tested positive (18%). CONCLUSIONS: Ongoing symptoms among adults with and without disabilities who also test positive for SARS-CoV-2 are common; however, the frequency of health care utilization for ongoing symptoms is two-fold among adults with disabilities.

The association between thromboembolic events (TE) and COVID-19 infection is not completely understood at the population level in the United States. We examined their association using a large US healthcare database. We analyzed data from the Premier Healthcare Database Special COVID-19 Release and conducted a case-control study. Thestudy population consisted of men and non-pregnant women aged18years with (cases) or without (controls) an inpatient ICD-10-CM diagnosis of TE between 3/1/2020 and 6/30/2021. Using multivariable logistic regression, we assessed the association between TE occurrence and COVID-19 diagnosis, adjusting for demographic factors and comorbidities. Among 227,343 cases, 15.2% had a concurrent or prior COVID-19 diagnosis within 30days of their index TE. Multivariable regression analysis showed a statistically significant association between a COVID-19 diagnosis and TE among cases when compared to controls (adjusted odds ratio [aOR]1.75, 95% CI 1.72-1.78). The association was more substantial if a COVID-19 diagnosis occurred 1-30days prior to index hospitalization (aOR3.00, 95% CI 2.88-3.13) compared to the same encounter as the index hospitalization. Our findings suggest an increased risk of TE among persons within 30days of beingdiagnosed COVID-19, highlighting the need for careful consideration of the thrombotic risk among COVID-19 patients, particularly during the first month following diagnosis.

OBJECTIVE(S): To understand how contraception method use differed between women prescribed and not prescribed medications for opioid use disorder (MOUD) among commercially-insured and Medicaid-insured women. STUDY DESIGN: IBM Watson Health MarketScan Commercial Claims and Encounters database and the Multi-State Medicaid database were used to calculate the 1) crude prevalence and 2) adjusted odds ratios (adjusted for demographic characteristics) of using long-acting reversible or short-acting hormonal contraception methods or female sterilization compared with none of these methods (no method) in 2018 by MOUD status among women with OUD, aged 20 to 49 years, with continuous health insurance coverage through commercial insurance or Medicaid for six years. Claims data was used to define contraception use. Fisher exact test or (2) test with a p-value 0.0001, based on the Holm-Bonferroni method, and 95% confidence intervals were used to determine statistically significant differences for prevalence estimates and adjusted odds ratios, respectively. RESULTS: Only 41% of commercially-insured and Medicaid-insured women with OUD were prescribed MOUD. Medicaid-insured women with OUD prescribed MOUD had a significantly lower crude prevalence of using no method (71.1% vs 79.0%) and higher odds of using female sterilization (aOR, 1.33; 95% CI: 1.06 - 1.67 vs no method) than those not prescribed MOUD. Among commercially-insured women there were no differences in contraceptive use by MOUD status and 66% used no method. CONCLUSIONS: Among women with six years of continuous insurance coverage, contraceptive use differed by MOUD status and insurance. Prescribing MOUD for women with OUD can be improved to ensure quality care. IMPLICATIONS: Only two in five women with OUD had evidence of being prescribed MOUD, and majority did not use prescription contraception or female sterilization. Our findings support opportunities to improve prescribing for MOUD and integrate contraception and MOUD services to improve clinical care among women with OUD.