Last data update: Apr 22, 2024. (Total: 46599 publications since 2009)
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Query Trace: Mack KA [original query] |
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Suicidal thoughts and behaviors among high school students - Youth Risk Behavior Survey, United States, 2021
Gaylor EM , Krause KH , Welder LE , Cooper AC , Ashley C , Mack KA , Crosby AE , Trinh E , Ivey-Stephenson AZ , Whittle L . MMWR Suppl 2023 72 (1) 45-54 Suicide is the third leading cause of death among high school-aged youths aged 14-18 years. The 2021 suicide rate for this age group was 9.0 per 100,000 population. Updating a previous analysis of the Youth Risk Behavior Survey during 2009-2019, this report uses 2019 and 2021 data to examine high school students' reports of suicidal thoughts and behaviors. Prevalence estimates are reported by grade, race and ethnicity, sexual identity, and sex of sexual contacts. Unadjusted logistic regression models were used to calculate prevalence differences comparing 2019 to 2021 and prevalence ratios comparing suicidal behavior between subgroups across demographic characteristics to a referent group. From 2019 to 2021, female students had an increased prevalence of seriously considered attempting suicide (from 24.1% to 30%), an increase in making a suicide plan (from 19.9% to 23.6%), and an increase in suicide attempts (from 11.0% to 13.3%). In addition, from 2019 to 2021, Black or African American (Black), Hispanic or Latino (Hispanic), and White female students had an increased prevalence of seriously considered attempting suicide. In 2021, Black female students had an increased prevalence of suicide attempts and Hispanic female students had an increased prevalence of suicide attempts that required medical treatment compared with White female students. Prevalence of suicidal thoughts and behaviors remained stable overall for male students from 2019 to 2021. A comprehensive approach to suicide prevention with a focus on health equity is needed to address these disparities and reduce prevalence of suicidal thoughts and behaviors for all youths. School and community-based strategies include creating safe and supportive environments, promoting connectedness, teaching coping and problem solving, and gatekeeper training. |
Research, practice, and data informed investigations of child and youth suicide: A science to service and service to science approach
Colpe L , Blair JM , Kurikeshu R , Mack KA , Nashelsky M , O'Connor S , Pearson J , Pilkey D , Warner M , Weintraub B . J Safety Res 2024 Background: Suicide rates for children and adolescents have been increasing over the past 2 decades. In April 2023, the National Institute of Mental Health (NIMH) convened a two-day workshop to address child and youth suicide. Purpose: The workshop focus was to discuss the state of the science and stimulate a collaborative response between researchers, death investigators, and data collection teams to build a science to service and service to science approach toward understanding - and ultimately preventing – this growing problem of child and youth suicide. Highlights: Topics that meeting participants highlighted as worthy of further consideration for research and practice were: increasing awareness among death investigators, medical examiners, and coroners that child suicide deaths under age 10 years do occur and should be investigated and documented accordingly; emphasizing the value of science based protocols for child and youth death investigations to enhance consistency of approaches; and articulating needs for postvention services to suicide loss survivors. Outcomes: The importance of collecting an accurate and complete cause and manner of death (i.e., unintentional, suicide, homicide, undetermined) among all child decedents, and demographic information such as race, ethnicity, and sexual/gender minority status was underscored as critical for enhanced surveillance. For prevention efforts, approaches to assessing and understanding suicidal thoughts and behaviors among diverse groups of children, and the variability in proximal and distal risk factors are needed to inform opportunities for preventive interventions for diverse communities. The need for consistent measures and processes to improve death investigations, fatality review committees, and coordination between data collection systems and agencies was also raised. Practical applications: Collaborations among researchers, death investigators, and data collection teams can help to fully describe the child and youth suicide crisis and provide actionable information for new research, and prevention and response efforts. © 2023 |
Notes from the field: Recent changes in suicide rates, by race and ethnicity and age group - United States, 2021
Stone DM , Mack KA , Qualters J . MMWR Morb Mortal Wkly Rep 2023 72 (6) 160-162 Suicide is a serious public health problem in the United States. After 2 consecutive years of declines in suicide (47,511 in 2019 and 45,979 in 2020), 2021 data indicate an increase in suicide to 48,183, nearly returning to the 2018 peak (48,344) with an age-adjusted rate of 14.1 suicides per 100,000 population (versus 14.2 in 2018).* To understand how this increase is distributed across racial and ethnic groups, CDC analyzed changes in racial and ethnic age-adjusted and age-specific suicide rates during 2018–2021. | | Suicides were identified from the National Vital Statistics System multiple cause-of-death mortality files for 2018–2021. Age-adjusted rates and 95% CIs were calculated using the direct method and the 2000 U.S. standard population. Hispanic or Latino (Hispanic) persons could be of any race, and racial groups excluded persons of Hispanic ethnicity. Persons with unknown ethnicity were excluded from race and ethnicity groups but were included in the overall total. Differences in rates from 2018 to 2021 were compared using z-tests when deaths were ≥100; p-values <0.05 were considered statistically significant. When deaths were <100, differences in rates were considered significant if CIs based on a gamma distribution did not overlap. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.† |
Non-fatal injury data: characteristics to consider for surveillance and research
Carmichael AE , Ballesteros MF , Qualters JR , Mack KA . Inj Prev 2022 28 (3) 262-268 BACKGROUND: All data systems used for non-fatal injury surveillance and research have strengths and limitations that influence their utility in understanding non-fatal injury burden. The objective of this paper was to compare characteristics of major data systems that capture non-fatal injuries in the USA. METHODS: By applying specific inclusion criteria (eg, non-fatal and non-occupational) to well-referenced injury data systems, we created a list of commonly used non-fatal injury data systems for this study. Data system characteristics were compiled for 2018: institutional support, years of data available, access, format, sample, sampling method, injury definition/coding, geographical representation, demographic variables, timeliness (lag) and further considerations for analysis. RESULTS: Eighteen data systems ultimately fit the inclusion criteria. Most data systems were supported by a federal institution, produced national estimates and were available starting in 1999 or earlier. Data source and injury case coding varied between the data systems. Redesigns of sampling frameworks and the use of International Classification of Diseases, 9th Revision, Clinical Modification/International Classification of Diseases, 10th Revision, Clinical Modification coding for some data systems can make longitudinal analyses complicated for injury surveillance and research. Few data systems could produce state-level estimates. CONCLUSION: Thoughtful consideration of strengths and limitations should be exercised when selecting a data system to answer injury-related research questions. Comparisons between estimates of various data systems should be interpreted with caution, given fundamental system differences in purpose and population capture. This research provides the scientific community with an updated starting point to assist in matching the data system to surveillance and research questions and can improve the efficiency and quality of injury analyses. |
Changes in suicide rates - United States, 2019 and 2020
Ehlman DC , Yard E , Stone DM , Jones CM , Mack KA . MMWR Morb Mortal Wkly Rep 2022 71 (8) 306-312 Suicide was among the 10 leading causes of death in the United States in 2020 among persons aged 10-64 years, and the second leading cause of death among children and adolescents aged 10-14 and adults aged 25-34 years (1). During 1999-2020, nearly 840,000 lives were lost to suicide in the United States. During that period, the overall suicide rate peaked in 2018 and declined in 2019 and 2020 (1). Despite the recent decline in the suicide rate, factors such as social isolation, economic decline, family stressors, new or worsening mental health symptoms, and disruptions to work and school associated with the COVID-19 pandemic have raised concerns about suicide risk in the United States. During 2020, a total of 12.2 million U.S. adults reported serious thoughts of suicide and 1.2 million attempted suicide (2). To understand how changes in suicide death rates might have varied among subpopulations, CDC analyzed counts and age-adjusted suicide rates during 2019 and 2020 by demographic characteristics, mechanism of injury, county urbanization level, and state. From 2019 to 2020, the suicide rate declined by 3% overall, including 8% among females and 2% among males. Significant declines occurred in seven states but remained stable in the other states and the District of Columbia. Despite two consecutive years of declines, the overall suicide rate remains 30% higher compared with that in 2000 (1). A comprehensive approach to suicide prevention that uses data driven decision-making and implements prevention strategies with the best available evidence, especially among disproportionately affected populations (3), is critical to realizing further declines in suicide and reaching the national goal of reducing the suicide rate by 20% by 2025 (4). |
Drugs and Drug Classes Involved in Overdose Deaths Among Females, United States: 1999-2017
Carmichael AE , Schier JG , Mack KA . J Womens Health (Larchmt) 2021 31 (3) 425-430 Background: Drug overdose deaths among U.S. women have risen steadily from 1999 to 2017, especially among certain ages. Various studies report involvement of drugs and drug classes in overdose deaths. Less is known, however, regarding the combinations that are most often indicated on death certificates, particularly among females. Analyzing mutually, exclusive drug/drug class combinations listed on death certificates of females are the objective of this study. Materials and Methods: Mortality data for U.S. female residents were obtained from the 1999 to 2017 National Vital Statistics System (n = 260,782). Analyses included deaths with an underlying cause of death based on International Classification of Diseases, 10th Revision (ICD-10) codes for drug overdoses. The drug/drug class involved included individual 4-digit ICD-10 codes in the range T36.0-T50.9, including poisoning deaths due to all drugs, excluding alcohol. Years from 1999 to 2017 were grouped in six 3-year categories with the most recent year (2017) left separate for analysis. All drug overdose deaths were analyzed in mutually exclusive categories. Results: From 1999 to 2017, the top-listed drug/drug class overall and by year grouping was solely "other and unspecified drugs, medicaments and biological substances"; however, that listing dropped from 25.8% from the 1999 to 2001 period to 14.1% in 2017. Overall, the next most frequent single drug/drug class mentions were "natural and semisynthetic opioids" (20,951; 8.0%) and "cocaine" (10,882; 4.2%). Two of the top five drug/drug class combinations included benzodiazepines ("natural and semisynthetic opioids"/"benzodiazepines" and "methadone"/"benzodiazepines"). Conclusions: Analyzing trends in drugs and drug classes involved in female drug overdose deaths is a critical foundation for developing gender-responsive public health interventions. Reducing high-risk drug use by improving prescribing practices, preventing drug use initiation, and addressing use of multiple drugs can help prevent overdose deaths. |
Changes in suicide rates - United States, 2018-2019
Stone DM , Jones CM , Mack KA . MMWR Morb Mortal Wkly Rep 2021 70 (8) 261-268 Suicide is the 10th leading cause of death in the United States overall, and the second and fourth leading cause among persons aged 10-34 and 35-44 years, respectively (1). In just over 2 decades (1999-2019), approximately 800,000 deaths were attributed to suicide, with a 33% increase in the suicide rate over the period (1). In 2019, a total of 12 million adults reported serious thoughts of suicide during the past year, 3.5 million planned a suicide, and 1.4 million attempted suicide (2). Suicides and suicide attempts in 2019 led to a lifetime combined medical and work-loss cost (i.e., the costs that accrue from the time of the injury through the course of a person's expected lifetime) of approximately $70 billion (https://wisqars.cdc.gov:8443/costT/). From 2018 to 2019, the overall suicide rate declined for the first time in over a decade (1). To understand how the decline varied among different subpopulations by demographic and other characteristics, CDC analyzed changes in counts and age-adjusted suicide rates from 2018 to 2019 by demographic characteristics, county urbanicity, mechanism of injury, and state. Z-tests and 95% confidence intervals were used to assess statistical significance. Suicide rates declined by 2.1% overall, by 3.2% among females, and by 1.8% among males. Significant declines occurred, overall, in five states. Other significant declines were noted among subgroups defined by race/ethnicity, age, urbanicity, and suicide mechanism. These declines, although encouraging, were not uniform, and several states experienced significant rate increases. A comprehensive approach to prevention that uses data to drive decision-making, implements prevention strategies from CDC's Preventing Suicide: A Technical Package of Policy, Programs, and Practices with the best available evidence, and targets the multiple risk factors associated with suicide, especially in populations disproportionately affected, is needed to build on initial progress from 2018 to 2019 (3). |
Societal determinants of violent death: The extent to which social, economic, and structural characteristics explain differences in violence across Australia, Canada, and the United States
Wilkins NJ , Zhang X , Mack KA , Clapperton AJ , Macpherson A , Sleet D , Kresnow-Sedacca MJ , Ballesteros MF , Newton D , Murdoch J , Mackay JM , Berecki-Gisolf J , Marr A , Armstead T , McClure R . SSM Popul Health 2019 8 100431 In this ecological study, we attempt to quantify the extent to which differences in homicide and suicide death rates between three countries, and among states/provinces within those countries, may be explained by differences in their social, economic, and structural characteristics. We examine the relationship between state/province level measures of societal risk factors and state/province level rates of violent death (homicide and suicide) across Australia, Canada, and the United States. Census and mortality data from each of these three countries were used. Rates of societal level characteristics were assessed and included residential instability, self-employment, income inequality, gender economic inequity, economic stress, alcohol outlet density, and employment opportunities). Residential instability, self-employment, and income inequality were associated with rates of both homicide and suicide and gender economic inequity was associated with rates of suicide only. This study opens lines of inquiry around what contributes to the overall burden of violence-related injuries in societies and provides preliminary findings on potential societal characteristics that are associated with differences in injury and violence rates across populations. |
Fall-related traumatic brain injury in children ages 04 years
Haarbauer-Krupa J , Haileyesus T , Gilchrist J , Mack KA , Law CS , Joseph A . J Safety Res 2019 70 127-133 Introduction: Falls are the leading cause of traumatic brain injury (TBI) for children in the 0–4 year age group. There is limited literature pertaining to fall-related TBIs in children age 4 and under and the circumstances surrounding these TBIs. This study provides a national estimate and describes actions and products associated with fall-related TBI in this age group. Method: Data analyzed were from the 2001–2013 National Electronic Injury Surveillance System–All Injury Program (NEISS–AIP), a nationally representative sample of emergency departments (ED). Case narratives were coded for actions associated with the fall, and product codes were abstracted to determine fall location and product type. All estimates were weighted. Results: An estimated 139,001 children younger than 5 years were treated annually in EDs for nonfatal, unintentional fall-related TBI injuries (total = 1,807,019 during 2001–2013). Overall, child actions (e.g., running) accounted for the greatest proportion of injuries and actions by others (e.g., carrying) was highest for children younger than 1 year. The majority of falls occurred in the home, and involved surfaces, fixtures, furniture, and baby products. Conclusions: Fall-related TBI in young children represents a significant public health burden. The majority of children seen for TBI assessment in EDs were released to home. Prevention efforts that target parent supervision practices and the home environment are indicated. Practical applications: Professionals in contact with parents of young children can remind them to establish a safe home and be attentive to the environment when carrying young children to prevent falls. |
Opioid-related US hospital discharges by type, 1993-2016
Peterson C , Xu L , Florence C , Mack KA . J Subst Abuse Treat 2019 103 9-13 Objective: To classify and compare US nationwide opioid-related hospital inpatient discharges over time by discharge type: 1) opioid use disorder (OUD) diagnosis without opioid overdose, detoxification, or rehabilitation services, 2) opioid overdose, 3) OUD diagnosis or opioid overdose with detoxification services, and 4) OUD diagnosis or opioid overdose with rehabilitation services. Methods: Survey-weighted national analysis of hospital discharges in the Healthcare Cost and Utilization Project National Inpatient Sample yielded age-adjusted annual rates per 100,000 population. Annual percentage change (APC) in the rate of opioid-related discharges by type during 1993–2016 was assessed. Results: The annual rate of hospital discharges documenting OUD without opioid overdose, detoxification, or rehabilitation services quadrupled during 1993–2016, and at an increased rate (8% annually) during 2003–2016. The discharge rate for all types of opioid overdose increased an average 5–9% annually during 1993–2010; discharges for non-heroin overdoses declined 2010–2016 (3–12% annually) while heroin overdose discharges increased sharply (23% annually). The rate of discharges including detoxification services among OUD and overdose patients declined (−4% annually) during 2008–2016 and rehabilitation services (e.g., counselling, pharmacotherapy) among those discharges decreased (−2% annually) during 1993–2016. Conclusions: Over the past two decades, the rate of both OUD diagnoses and opioid overdoses increased substantially in US hospitals while rates of inpatient detoxification and rehabilitation services identified by diagnosis codes declined. It is critical that inpatients diagnosed with OUD or treated for opioid overdose are linked effectively to substance use disorder treatment at discharge. |
Drug overdose deaths among women aged 30-64 years - United States, 1999-2017
VanHouten JP , Rudd RA , Ballesteros MF , Mack KA . MMWR Morb Mortal Wkly Rep 2019 68 (1) 1-5 The drug epidemic in the United States continues to evolve. The drug overdose death rate has rapidly increased among women (1,2), although within this demographic group, the increase in overdose death risk is not uniform. From 1999 to 2010, the largest percentage changes in the rates of overall drug overdose deaths were among women in the age groups 45-54 years and 55-64 years (1); however, this finding does not take into account trends in specific drugs or consider changes in age group distributions in drug-specific overdose death rates. To target prevention strategies to address the epidemic among women in these age groups, CDC examined overdose death rates among women aged 30-64 years during 1999-2017, overall and by drug subcategories (antidepressants, benzodiazepines, cocaine, heroin, prescription opioids, and synthetic opioids, excluding methadone). Age distribution changes in drug-specific overdose death rates were calculated. Among women aged 30-64 years, the unadjusted drug overdose death rate increased 260%, from 6.7 deaths per 100,000 population (4,314 total drug overdose deaths) in 1999 to 24.3 (18,110) in 2017. The number and rate of deaths involving antidepressants, benzodiazepines, cocaine, heroin, and synthetic opioids each increased during this period. Prescription opioid-related deaths increased between 1999 and 2017 among women aged 30-64 years, with the largest increases among those aged 55-64 years. Interventions to address the rise in drug overdose deaths include implementing the CDC Guideline for Prescribing Opioids for Chronic Pain (3), reviewing records of controlled substance prescribing (e.g., prescription drug monitoring programs, health insurance programs), and developing capacity of drug use disorder treatments and linkage to care, especially for middle-aged women with drug use disorders. |
The need to improve information on road user type in National Vital Statistics System mortality data
Mack KA , Hedegaard H , Ballesteros MF , Warner M , Eames J , Sauber-Schatz E . Traffic Inj Prev 2019 20 (3) 1-6 OBJECTIVES: Both the National Vital Statistics System (NVSS) and the Fatality Analysis Reporting System (FARS) can be used to examine motor vehicle crash (MVC) deaths. These 2 data systems operate independently, using different methods to collect and code information about the type of vehicle (e.g., car, truck, bus) and road user (e.g., occupant, motorcyclist, pedestrian) involved in an MVC. A substantial proportion of MVC deaths in NVSS are coded as "unspecified" road user, which reduces the utility of the NVSS data for describing burden and identifying prevention measures. This study aimed to describe characteristics of unspecified road user deaths in NVSS to further our understanding of how these groups may be similar to occupant road user deaths. METHODS: Using data from 1999 to 2015, we compared NVSS and FARS MVC death counts by road user type, overall and by age group, gender, and year. In addition, we examined factors associated with the categorization of an MVC death as unspecified road user such as state of residence of decedent, type of medical death investigation system, and place of death. RESULTS: The number of MVC occupant deaths in NVSS was smaller than that in FARS in each year and the number of unspecified road user deaths in NVSS was greater than that in FARS. The sum of the number of occupant and unspecified road user deaths in NVSS, however, was approximately equal to the number of FARS occupant deaths. Age group and gender distributions were roughly equivalent for NVSS and FARS occupants and NVSS unspecified road users. Within NVSS, the number of MVC deaths listed as unspecified road user varied across states and over time. Other categories of road users (motorcyclists, pedal cyclists, and pedestrians) were consistent when comparing NVSS and FARS. CONCLUSIONS: Our findings suggest that the unspecified road user MVC deaths in NVSS look similar to those of MVC occupants according to selected characteristics. Additional study is needed to identify documentation and reporting challenges in individual states and over time and to identify opportunities for improvement in the coding of road user type in NVSS. |
US hospital discharges documenting patient opioid use disorder without opioid overdose or treatment services, 2011-2015
Peterson C , Xu L , Mikosz CA , Florence C , Mack KA . J Subst Abuse Treat 2018 92 35-39 Background: Understanding more about circumstances in which patients receive an opioid use disorder (OUD) diagnosis might illuminate opportunities for intervention and ultimately prevent opioid overdoses. This study aimed to describe patient and clinical characteristics of hospital discharges documenting OUD among patients not being treated for opioid overdose, detoxification, or rehabilitation. Methods: We assessed patient, payer, and clinical characteristics of nationally-representative 2011-2015 National Inpatient Sample discharges documenting OUD, excluding opioid overdose, detoxification, and rehabilitation. Discharges were clinically classified by Diagnostic Related Group (DRG) for analysis. Results: Annual discharges grew 38%, from 347,137 (2011) to 478,260 (2015), totaling 2 million discharges during the study period. The annual discharge rate increased among all racial/ethnic groups, but was highest among the non-Hispanic black population until 2015, when non-Hispanic whites had a slightly higher rate (164 versus 162 per 100,000 population). Female patients and Medicaid and Medicare as primary payer accounted for an increasing annual proportion of discharges. Just 14 DRGs accounted for nearly 50% of discharges over the study period. The most prevalent primary treatment received during OUD inpatient stays was for psychoses (DRG 885; 16% of discharges) and drug and alcohol abuse or dependence symptoms (including withdrawal) or (non-opioid) poisoning (DRG 894, 897, 917, 918; 12% of discharges). Conclusions: Now nearly half a million yearly US hospital discharges for a range of primary treatment include patients' diagnosis of OUD without opioid overdose, detoxification, or rehabilitation services. Inpatient stays present an important opportunity to link OUD patients to treatment to reduce opioid-related morbidity and mortality. |
Ability to monitor driving under the influence of marijuana among non-fatal motor-vehicle crashes: An evaluation of the Colorado electronic accident reporting system
Peterson AB , Sauber-Schatz EK , Mack KA . J Safety Res 2018 65 161-167 Introduction: As more states legalize medical/recreational marijuana use, it is important to determine if state motor-vehicle surveillance systems can effectively monitor and track driving under the influence (DUI) of marijuana. This study assessed Colorado's Department of Revenue motor-vehicle crash data system, Electronic Accident Reporting System (EARS), to monitor non-fatal crashes involving driving under the influence (DUI) of marijuana. Methods: Centers for Disease Control and Prevention guidelines on surveillance system evaluation were used to assess EARS' usefulness, flexibility, timeliness, simplicity, acceptability, and data quality. We assessed system components, interviewed key stakeholders, and analyzed completeness of Colorado statewide 2014 motor-vehicle crash records. Results: EARS contains timely and complete data, but does not effectively monitor non-fatal motor-vehicle crashes related to DUI of marijuana. Information on biological sample type collected from drivers and toxicology results were not recorded into EARS; however, EARS is a flexible system that can incorporate new data without increasing surveillance system burden. Conclusions: States, including Colorado, could consider standardization of drug testing and mandatory reporting policies for drivers involved in motor-vehicle crashes and proactively address the narrow window of time for sample collection to improve DUI of marijuana surveillance. Practical applications: The evaluation of state motor-vehicle crash systems' ability to capture crashes involving drug impaired driving (DUID) is a critical first step for identifying frequency and risk factors for crashes related to DUID. |
The epidemiology of unintentional and violence-related injury morbidity and mortality among children and adolescents in the United States
Ballesteros MF , Williams DD , Mack KA , Simon TR , Sleet DA . Int J Environ Res Public Health 2018 15 (4) Injuries and violence among young people have a substantial emotional, physical, and economic toll on society. Understanding the epidemiology of this public health problem can guide prevention efforts, help identify and reduce risk factors, and promote protective factors. We examined fatal and nonfatal unintentional injuries, injuries intentionally inflicted by other (i.e., assaults and homicides) among children ages 0-19, and intentionally self-inflicted injuries (i.e., self-harm and suicides) among children ages 10-19. We accessed deaths (1999-2015) and visits to emergency departments (2001-2015) for these age groups through the Centers for Disease Control and Prevention's (CDC) Web-based Injury Statistics Query and Reporting System (WISQARS), and examined trends and differences by age, sex, race/ethnicity, rural/urban status, and injury mechanism. Almost 13,000 children and adolescents age 0-19 years died in 2015 from injury and violence compared to over 17,000 in 1999. While the overall number of deaths has decreased over time, there were increases in death rates among certain age groups for some categories of unintentional injury and for suicides. The leading causes of injury varied by age group. Our results indicate that efforts to reduce injuries to children and adolescents should consider cause, intent, age, sex, race, and regional factors to assure that prevention resources are directed at those at greatest risk. |
Illicit drug use, illicit drug use disorders, and drug overdose deaths in metropolitan and nonmetropolitan areas - United States
Mack KA , Jones CM , Ballesteros MF . MMWR Surveill Summ 2017 66 (19) 1-12 PROBLEM/CONDITION: Drug overdoses are a leading cause of injury death in the United States, resulting in approximately 52,000 deaths in 2015. Understanding differences in illicit drug use, illicit drug use disorders, and overall drug overdose deaths in metropolitan and nonmetropolitan areas is important for informing public health programs, interventions, and policies. REPORTING PERIOD: Illicit drug use and drug use disorders during 2003-2014, and drug overdose deaths during 1999-2015. DESCRIPTION OF DATA: The National Survey of Drug Use and Health (NSDUH) collects information through face-to-face household interviews about the use of illicit drugs, alcohol, and tobacco among the U.S. noninstitutionalized civilian population aged ≥12 years. Respondents include residents of households and noninstitutional group quarters (e.g., shelters, rooming houses, dormitories, migratory workers' camps, and halfway houses) and civilians living on military bases. NSDUH variables include sex, age, race/ethnicity, residence (metropolitan/nonmetropolitan), annual household income, self-reported drug use, and drug use disorders. National Vital Statistics System Mortality (NVSS-M) data for U.S. residents include information from death certificates filed in the 50 states and the District of Columbia. Cases were selected with an underlying cause of death based on the ICD-10 codes for drug overdoses (X40-X44, X60-X64, X85, and Y10-Y14). NVSS-M variables include decedent characteristics (sex, age, and race/ethnicity) and information on intent (unintentional, suicide, homicide, or undetermined), location of death (medical facility, in a home, or other [including nursing homes, hospices, unknown, and other locations]) and county of residence (metropolitan/nonmetropolitan). Metropolitan/nonmetropolitan status is assigned independently in each data system. NSDUH uses a three-category system: Core Based Statistical Area (CBSA) of ≥1 million persons; CBSA of <1 million persons; and not a CBSA, which for simplicity were labeled large metropolitan, small metropolitan, and nonmetropolitan. Deaths from NVSS-M are categorized by the county of residence of the decedent using CDC's National Center for Health Statistics 2013 Urban-Rural Classification Scheme, collapsed into two categories (metropolitan and nonmetropolitan). RESULTS: Although both metropolitan and nonmetropolitan areas experienced significant increases from 2003-2005 to 2012-2014 in self-reported past-month use of illicit drugs, the prevalence was highest for the large metropolitan areas compared with small metropolitan or nonmetropolitan areas throughout the study period. Notably, past-month use of illicit drugs declined over the study period for the youngest respondents (aged 12-17 years). The prevalence of past-year illicit drug use disorders among persons using illicit drugs in the past year varied by metropolitan/nonmetropolitan status and changed over time. Across both metropolitan and nonmetropolitan areas, the prevalence of past-year illicit drug use disorders declined during 2003-2014. In 2015, approximately six times as many drug overdose deaths occurred in metropolitan areas than occurred in nonmetropolitan areas (metropolitan: 45,059; nonmetropolitan: 7,345). Drug overdose death rates (per 100,000 population) for metropolitan areas were higher than in nonmetropolitan areas in 1999 (6.4 versus 4.0), however, the rates converged in 2004, and by 2015, the nonmetropolitan rate (17.0) was slightly higher than the metropolitan rate (16.2). INTERPRETATION: Drug use and subsequent overdoses continue to be a critical and complicated public health challenge across metropolitan/nonmetropolitan areas. The decline in illicit drug use by youth and the lower prevalence of illicit drug use disorders in rural areas during 2012-2014 are encouraging signs. However, the increasing rate of drug overdose deaths in rural areas, which surpassed rates in urban areas, is cause for concern. PUBLIC HEALTH ACTIONS: Understanding the differences between metropolitan and nonmetropolitan areas in drug use, drug use disorders, and drug overdose deaths can help public health professionals to identify, monitor, and prioritize responses. Consideration of where persons live and where they die from overdose could enhance specific overdose prevention interventions, such as training on naloxone administration or rescue breathing. Educating prescribers on CDC's guideline for prescribing opioids for chronic pain (Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain-United States, 2016. MMWR Recomm Rep 2016;66[No. RR-1]) and facilitating better access to medication-assisted treatment with methadone, buprenorphine, or naltrexone could benefit communities with high opioid use disorder rates. |
Research on the translation and implementation of Stepping On in three Wisconsin communities
Schlotthauer AE , Mahoney JE , Christiansen AL , Gobel VL , Layde P , Lecey V , Mack KA , Shea T , Clemson L . Front Public Health 2017 5 128 OBJECTIVE: Falls are a leading cause of injury death. Stepping On is a fall prevention program developed in Australia and shown to reduce falls by up to 31%. The original program was implemented in a community setting, by an occupational therapist, and included a home visit. The purpose of this study was to examine aspects of the translation and implementation of Stepping On in three community settings in Wisconsin. METHODS: The investigative team identified four research questions to understand the spread and use of the program, as well as to determine whether critical components of the program could be modified to maximize use in community practice. The team evaluated program uptake, participant reach, program feasibility, program acceptability, and program fidelity by varying the implementation setting and components of Stepping On. Implementation setting included type of host organization, rural versus urban location, health versus non-health background of leaders, and whether a phone call could replace the home visit. A mixed methodology of surveys and interviews completed by site managers, leaders, guest experts, participants, and content expert observations for program fidelity during classes was used. RESULTS: The study identified implementation challenges that varied by setting, including securing a physical therapist for the class and needing more time to recruit participants. There were no implementation differences between rural and urban locations. Potential differences emerged in program fidelity between health and non-health professional leaders, although fidelity was high overall with both. Home visits identified more home hazards than did phone calls and were perceived as of greater benefit to participants, but at 1 year no differences were apparent in uptake of strategies discussed in home versus phone visits. CONCLUSION: Adaptations to the program to increase implementation include using a leader who is a non-health professional, and omitting the home visit. Our research demonstrated that a non-health professional leader can conduct Stepping On with adequate fidelity, however non-health professional leaders may benefit from increased training in certain aspects of Stepping On. A phone call may be substituted for the home visit, although short-term benefits are greater with the home visit. |
Physician dispensing of oxycodone and other commonly used opioids, 2000-2015, United States
Mack KA , Jones CM , McClure RJ . Pain Med 2017 19 (5) 990-996 Objective.: An average of 91 people in the United States die every day from an opioid-related overdose (including prescription opioids and heroin). The direct dispensing of opioids from health care practitioner offices has been linked to opioid-related harms. The objective of this study is to describe the changing nature of the volume of this type of prescribing at the state level. Methods.: This descriptive study examines the distribution of opioids by practitioners using 1999-2015 Automation of Reports and Consolidated Orders System data. Analyses were restricted to opioids distributed to practitioners. Amount distributed (morphine milligram equivalents [MMEs]) and number of practitioners are presented. Results.: Patterns of distribution to practitioners and the number of practitioners varied markedly by state and changed dramatically over time. Comparing 1999 with 2015, the MME distributed to dispensing practitioners decreased in 16 states and increased in 35. Most notable was the change in Florida, which saw a peak of 8.94 MMEs per 100,000 persons in 2010 (the highest distribution in all states in all years) and a low of 0.08 in 2013. Discussion.: This study presents the first state estimates of office-based dispensing of opioids. Increases in direct dispensing in recent years may indicate a need to monitor this practice and consider whether changes are needed. Using controlled substances data to identify high prescribers and dispensers of opioids, as well as examining overall state trends, is a foundational activity to informing the response to potentially high-risk clinical practices. |
Injury deaths among U.S. females: CDC resources and programs
Mack KA , Peterson C , Zhou C , MacConvery E , Wilkins N . J Womens Health (Larchmt) 2017 26 (4) 307-312 Injury death rates are lower for women than for men at all ages, but we have a long way to go in understanding the circumstances of injury fatalities among females. This article presents resources that can be used to examine the most recent data on injury fatalities among females and highlights activities of CDC's Injury Center. The National Center for Injury Prevention and Control's (NCIPC's) Web-based Injury Statistics Query and Reporting System, an online surveillance database, can be used to examine injury deaths. We present examples that show the 2015 number of female fatal injuries by age group and injury cause and method, as well as a 2008-2014 county-level map of female fatal injury rates. In 2015, there were 68,572 injury fatalities of females of age ≥1 year, equivalent to 1 death every 7 minutes. Injuries were the leading cause of death for females of ages 1-41 years and the sixth-ranked cause of female death overall. Falls were the leading cause of injury death overall (and for women ≥70 years), unintentional poisonings were second, and motor vehicle traffic injuries were third. NCIPC funds national organizations, state health agencies, and other groups to develop, implement, and promote effective injury and violence prevention and control practices. Five key programs are discussed. Presenting data on injury fatalities is an essential element in identifying meaningful prevention efforts. Further investigation of the causes and impact of female injury fatalities can refine the public health approach to reduce this injury burden. |
Modified Delphi consensus to suggest key elements of Stepping On Falls Prevention Program
Mahoney JE , Clemson L , Schlotthauer A , Mack KA , Shea T , Gobel V , Cech S . Front Public Health 2017 5 21 Falls among older adults result in substantial morbidity and mortality. Community-based programs have been shown to decrease the rate of falls. In 2007, the Centers for Disease Control and Prevention funded a research study to determine how to successfully disseminate the evidence-based fall prevention program (Stepping On) in the community setting. As the first step for this study, a panel of subject matter experts was convened to suggest which parts of the Stepping On fall prevention program were considered key elements, which could not be modified by implementers. METHODS: Older adult fall prevention experts from the US, Canada, and Australia participated in a modified Delphi technique process to suggest key program elements of Stepping On. Forty-four experts were invited to ensure that the panel of experts would consist of equal numbers of physical therapists, occupational therapists, geriatricians, exercise scientists, and public health researchers. Consensus was determined by percent of agreement among panelists. A Rasch analysis of item fit was conducted to explore the degree of diversity and/or homogeneity of responses across our panelists. RESULTS: The Rasch analysis of the 19 panelists using fit statistics shows there was a reasonable and sufficient range of diverse perspectives (Infit MnSQ 1.01, Z score -0.1, Outfit MnSQ 0.96, Z score -0.2 with a separation of 4.89). Consensus was achieved that these elements were key: 17 of 18 adult learning elements, 11 of 22 programming, 12 of 15 exercise, 7 of 8 upgrading exercises, 2 of 4 peer co-leader's role, and all of the home visits, booster sessions, group leader's role, and background and training of group leader elements. The top five key elements were: (1) use plain language, (2) develop trust, (3) engage people in what is meaningful and contextual for them, (4) train participants for cues in self-monitoring quality of exercises, and (5) group leader learns about exercises and understands how to progress them. DISCUSSION: The Delphi consensus process suggested key elements related to Stepping On program delivery. These elements were considered essential to program effectiveness. Findings from this study laid the foundation for translation of Stepping On for broad US dissemination. |
Trends in the distribution of opioids in Puerto Rico, 1999-2013
El Burai Felix S , Mack KA , Jones CM . P R Health Sci J 2016 35 (3) 165-9 OBJECTIVE: Limited information has been published about opioid prescribing practices in Puerto Rico. The objective of this study was to create baseline trends of opioids distributed over a period of fourteen years in Puerto Rico. METHODS: We examined data from the U.S. Drug Enforcement Administration's Automation of Reports and Consolidated Orders System (ARCOS) for the period 1999-2013. ARCOS data reflects the amount of controlled substances legally dispensed. Analyses include the distribution of opioids (in morphine milligram equivalent kg per 10,000 persons) by year and entity (pharmacy, hospital, practitioner). RESULTS: The distribution of four drugs (fentanyl, hydromorphone, methadone, oxycodone) increased over 100% between 1999 and 2013. The distribution of two drugs (hydrocodone and meperidine) declined between 1999 and 2013. Oxycodone distribution grew from 0.13 MME kg grams per 10,000 persons in 1999 to 0.29 MME kg in 2013. CONCLUSION: ARCOS data showed that the overall amount of opioid pain relievers distributed in Puerto Rico increased by 68% between 1999 and 2013. Currently, prescription opioid pain reliever overdose deaths in Puerto Rico do not appear to be skyrocketing as they are in the mainland U.S. However, the ongoing problem with prescription opioid pain reliever overdoses in certain areas should serve as a warning to monitor consumption of opioid pain relievers, as well as changes in prescription drug abuse, overdoses, and deaths. |
Location of fatal prescription opioid-related deaths in 12 states, 2008-2010: Implications for prevention programs
Easterling KW , Mack KA , Jones CM . J Safety Res 2016 58 105-9 INTRODUCTION: Prescription opioid pain reliever overdose is a major public health issue in the United States. To characterize the location of drug-related deaths, we examined fatal prescription opioid and illicit drug-related deaths reported in 12 states. METHODS: Data are from the Substance Abuse and Mental Health Services Administration's Drug Abuse Warning Network (DAWN). Medical examiners or coroners in 12 states (MA, MD, ME, NH, NM, OK, OR, RI, UT, VA, VT, WV) reported details of state-wide drug-related mortality during 2008-2010. DAWN data included location and manner of death, age, race, and drugs involved. Deaths were coded into three categories: prescription opioid-related, illicit drug-related, and cases that involved both a prescription opioid and an illicit drug. RESULTS: During a 3-year period, there were 14,091 opioid or illicit drug-related deaths in 12 states. More than half of the prescription opioid-related deaths in all states, except Maryland, occurred at home, rather than in public or in a health care facility. Although it was still the predominant category, lower percentages of illicit drug-related deaths occurred at home. CONCLUSION: Prescription opioid overdoses have increased substantially, and the location of the person at the time of death can have important public health implications for interventions. PRACTICAL APPLICATIONS: This paper highlights that bystander support can be a critical lifesaving factor in drug related deaths but may be more likely for illicit drug-related deaths than for prescription opioid-related deaths. |
Trends in methadone distribution for pain treatment, methadone diversion, and overdose deaths - United States, 2002-2014
Jones CM , Baldwin GT , Manocchio T , White JO , Mack KA . MMWR Morb Mortal Wkly Rep 2016 65 (26) 667-71 Use of the prescription opioid methadone for treatment of pain, as opposed to treatment of opioid use disorder (e.g., addiction), has been identified as a contributor to the U.S. opioid overdose epidemic. Although methadone accounted for only 2% of opioid prescriptions in 2009 (1), it was involved in approximately 30% of overdose deaths. Beginning with 2006 warnings from the Food and Drug Administration (FDA), efforts to reduce methadone use for pain have accelerated (2,3). The Office of the Assistant Secretary for Planning and Evaluation of the U.S. Department of Health and Human Services and CDC analyzed methadone distribution, reports of diversion (the transfer of legally manufactured methadone into illegal markets), and overdose deaths during 2002-2014. On average, the rate of grams of methadone distributed increased 25.1% per year during 2002-2006 and declined 3.2% per year during 2006-2013. Methadone-involved overdose deaths increased 22.1% per year during 2002-2006 and then declined 6.5% per year during 2006-2014. During 2002-2006, rates of methadone diversion increased 24.3% per year; during 2006-2009, the rate increased at a slower rate, and after 2009, the rate declined 12.8% per year through 2014. Across sex, most age groups, racial/ethnic populations, and U.S. Census regions, the methadone overdose death rate peaked during 2005-2007 and declined in subsequent years. There was no change among persons aged ≥65 years, and among persons aged 55-64 years the methadone overdose death rate continued to increase through 2014. Additional clinical and public health policy changes are needed to reduce harm associated with methadone use for pain, especially among persons aged ≥55 years. |
Injury surveillance: the next generation
Allegrante JP , Mitchell RJ , Taylor JA , Mack KA . Inj Prev 2016 22 Suppl 1 i63-i65 In recent years, we have seen a dramatic transformation of the knowledge economy. This transformation has been catalysed by the rapidly evolving capabilities of smart technologies and by increased recognition of the potential of using information being generated from ‘big data’ to empower society in a range of scientific endeavours designed to achieve the goal of improving the human condition. Former CDC Director William H Foege once wrote: “The reason for collecting, analysing, and disseminating information on a disease is to control that disease. Collection and analysis should not be allowed to consume resources if action does not follow.”1 The new sources of data, including big data and real-time data access, visualisation, electronic health records (eHealth), genomic risk profiling, data linkages and syndromic surveillance, have all contributed to the now-unfolding information revolution that has strengthened our public health capacity to direct and take action. Nowhere has this revolution become more apparent, nor more critical, than in the epidemiology, prevention and control of injury. | This supplement issue of Injury Prevention demonstrates that the science of surveillance has arrived as an essential element of contemporary injury prevention research and practice. The question is: how can new and ever-evolving technologies be harnessed by injury surveillance systems to achieve even better injury prevention and control benefits? The papers comprising this issue provide insights into answering this and related questions and point to the critical role new surveillance systems can play across a wide range of injury challenges. |
Trends in opioid analgesic-prescribing rates by specialty, U.S., 2007-2012
Levy B , Paulozzi L , Mack KA , Jones CM . Am J Prev Med 2015 49 (3) 409-13 INTRODUCTION: Opioid analgesic prescriptions are driving trends in drug overdoses, but little is known about prescribing patterns among medical specialties. We conducted this study to examine the opioid-prescribing patterns of the medical specialties over time. METHODS: IMS Health's National Prescription Audit (NPA) estimated the annual counts of pharmaceutical prescriptions dispensed in the U.S. during 2007-2012. We grouped NPA prescriber specialty data by practice type for ease of analysis, and measured the distribution of total prescriptions and opioid prescriptions by specialty. We calculated the percentage of all prescriptions dispensed that were opioids, and evaluated changes in that rate by specialty during 2007-2012. The analysis was conducted in 2013. RESULTS: In 2012, U.S. pharmacies and long-term care facilities dispensed 4.2 billion prescriptions, 289 million (6.8%) of which were opioids. Primary care specialties accounted for nearly half of all dispensed opioid prescriptions. The rate of opioid prescribing was highest for specialists in pain medicine (48.6%); surgery (36.5%); and physical medicine/rehabilitation (35.5%). The rate of opioid prescribing rose during 2007-2010 but leveled thereafter as most specialties reduced opioid use. The greatest percentage increase in opioid-prescribing rates during 2007-2012 occurred among physical medicine/rehabilitation specialists (+12.0%). The largest percentage drops in opioid-prescribing rates occurred in emergency medicine (-8.9%) and dentistry (-5.7%). CONCLUSIONS: The data indicate diverging trends in opioid prescribing among medical specialties in the U.S. during 2007-2012. Engaging the medical specialties individually is critical for continued improvement in the safe and effective treatment of pain. |
Preventing unintentional injuries in the home using the Health Impact Pyramid
Mack KA , Liller KD , Baldwin G , Sleet D . Health Educ Behav 2015 42 115s-22s Injuries continue to be the leading cause of death for the first four decades of life. These injuries result from a confluence of behavioral, physical, structural, environmental, and social factors. Taken together, these illustrate the importance of taking a broad and multileveled approach to injury prevention. Using examples from fall, fire, scald, and poisoning-related injuries, this article illustrates the utility of an approach that incorporates a social-environmental perspective in identifying and selecting interventions to improve the health and safety of individuals. Injury prevention efforts to prevent home injuries benefit from multilevel modifications of behavior, public policy, laws and enforcement, the environment, consumer products and engineering standards, as demonstrated with Frieden's Health Impact Pyramid. A greater understanding, however, is needed to explain the associations between tiers. While interventions that include modifications of the social environment are being field-tested, much more work needs to be done in measuring social-environmental change and in evaluating these programs to disentangle what works best. |
Prescription practices involving opioid analgesics among Americans with Medicaid, 2010
Mack KA , Zhang K , Paulozzi L , Jones C . J Health Care Poor Underserved 2015 26 (1) 182-98 Recent state-based studies have shown an increased risk of opioid overdose death in Medicaid populations. To explore one side of risk, this study examines indicators of potential opioid inappropriate use or prescribing among Medicaid enrollees. We examined claims from enrollees aged 18-64 years in the 2010 Truven Health MarketScan(R) Multi-State Medicaid database, which consisted of weighted and nationally representative data from 12 states. Pharmaceutical claims were used to identify enrollees (n=359,368) with opioid prescriptions. Indicators of potential inappropriate use or prescribing included overlapping opioid prescriptions, overlapping opioid and benzodiazepine prescriptions, long acting/extended release opioids for acute pain, and high daily doses. In 2010, Medicaid enrollees with opioid prescriptions obtained an average 6.3 opioid prescriptions, and 40% had at least one indicator of potential inappropriate use or prescribing. These indicators have been linked to opioid-related adverse health outcomes, and methods exist to detect and deter inappropriate use and prescribing of opioids. |
Alcohol involvement in opioid pain reliever and benzodiazepine drug abuse-related emergency department visits and drug-related deaths - United States, 2010
Jones CM , Paulozzi LJ , Mack KA . MMWR Morb Mortal Wkly Rep 2014 63 (40) 881-5 The abuse of prescription drugs has led to a significant increase in emergency department (ED) visits and drug-related deaths over the past decade. Opioid pain relievers (OPRs) and benzodiazepines are the prescription drugs most commonly involved in these events. Excessive alcohol consumption also accounts for a significant health burden and is common among groups that report high rates of prescription drug abuse. When taken with OPRs or benzodiazepines, alcohol increases central nervous system depression and the risk for overdose. Data describing alcohol involvement in OPR or benzodiazepine abuse are limited. To quantify alcohol involvement in OPR and benzodiazepine abuse and drug-related deaths and to inform prevention efforts, the Food and Drug Administration (FDA) and CDC analyzed 2010 data for drug abuse-related ED visits in the United States and drug-related deaths that involved OPRs and alcohol or benzodiazepines and alcohol in 13 states. The analyses showed alcohol was involved in 18.5% of OPR and 27.2% of benzodiazepine drug abuse-related ED visits and 22.1% of OPR and 21.4% of benzodiazepine drug-related deaths. These findings indicate that alcohol plays a significant role in OPR and benzodiazepine abuse. Interventions to reduce the abuse of alcohol and these drugs alone and in combination are needed. |
Vital signs: variation among states in prescribing of opioid pain relievers and benzodiazepines - United States, 2012
Paulozzi LJ , Mack KA , Hockenberry JM . MMWR Morb Mortal Wkly Rep 2014 63 (26) 563-8 Persons in the United States consume opioid pain relievers (OPR) at a greater rate than any other nation. They consume twice as much per capita as the second ranking nation, Canada. Overprescribing of opioid pain relievers can result in multiple adverse health outcomes, including fatal overdoses. Opioid pain relievers were involved in 16,917 overdose deaths in 2011; in 31% of these deaths, benzodiazepine sedatives were also cited as contributing causes (CDC WONDER, unpublished data, 2014). High rates of prescribing these controlled substances are important determinants of rates of fatal overdose and drug abuse. Overall state prescribing rates of OPR vary widely. Variation in prescribing rates for higher-risk opioid prescriptions (e.g., those for long-acting or extended-release [LA/ER] formulations) or those for high daily dosage have not been examined. LA/ER OPR are more prone to abuse, and high-dose formulations are more likely to result in overdoses, so they deserve special attention. Benzodiazepines are commonly prescribed in combination with OPR, even though this combination increases the risk for overdose. Interstate variation in prescribing rates for benzodiazepines has not been measured. |
Risk of adverse health outcomes with increasing duration and regularity of opioid therapy
Paulozzi LJ , Zhang K , Jones CM , Mack KA . J Am Board Fam Med 2014 27 (3) 329-38 PURPOSE: The purpose of this study was to examine trends in frequency and daily dosage of opioid use and related adverse health outcomes in a commercially insured population. METHODS: We examined medical claims from the Truven Health MarketScan commercial claims database for 789,457 continuously enrolled patients ages 18 to 64 years to whom opioids were dispensed during the first half of 2008. We tracked them every 6 months until either opioid use was discontinued or the end of 2010. We compared outcomes among all opioid users with those for patients who used opioids with only limited interruptions during the index period, referred to as "daily users." We contrasted the experience of daily users, other users, and nonusers for various outcomes. RESULTS: Of all claimants, 10.7% had at least one opioid prescription during the first 6 months of 2008. Of these, 39.9% continued through a second 6-month period, and 18.0% continued through the end of 2010. Only 9.0% of all users qualified as daily users, but 87.1% of them continued some use of opioids through the end of 2010. Only 43.8% of all users who continued use through 2010 initially qualified as daily users. Among all users who continued use through 2010, days of use and daily dosage increased with duration of use. Among daily users, only dosage increased, rising from 101 to 114 morphine milligram equivalents/day over the 3 years. The prevalence of benzodiazepine use was greater for daily than all users, exceeding 40% among daily users who continued opioid use for 3 years. Drug abuse and overdose rates increased with longer use. Daily users accounted for 25.0%, other users for 43.6%, and nonusers for 31.4% of opioid analgesic overdoses. CONCLUSIONS: Adverse health outcomes can increase with accumulating opioid use and increasing dosage. Existing guidelines developed by specialty societies for managing patients using opioids daily or nearly daily do not address the larger number of patients who use opioids intermittently over periods of years. Practitioners should consider applying such guidelines to patients who use opioids less frequently. |
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