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

This cross-sectional study examines trends in naloxone dispensing by US retail pharmacies from 2019 to 2023, including prescriber specialty and product brand. | eng

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

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

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

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.

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

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

Background: When taken together, opioids and benzodiazepines can result in synergistic respiratory depression, which increases overdose risk (1). The percentage of all opioid overdose deaths involving benzodiazepines increased from 8.7% in 1999 to 21% in 2017 (1). Benzodiazepines were involved in 1-in-3 prescription opioid overdose deaths in 2017 (1). The fraction of patients receiving concurrent opioids and benzodiazepines increased 41% from 2002 to 2014 in the United States (2).

In response to the opioid overdose crisis, the Centers for Disease Control and Prevention (CDC) released the Guideline for Prescribing Opioids for Chronic Pain (CDC Guideline) in 2016, which included recommendations to initiate opioids carefully and only when expected benefits outweigh risks.1 Although opioid prescriptions have decreased in recent years,2 an estimated 9.4 million people misused opioids in 2020.3 Little is known about how prescriptions dispensed to opioid-naive individuals (i.e., those new to opioid therapy) have changed in recent years; previous research focused on commercially insured individuals from 2012 to 2017.4 Understanding these patterns is important given the association between initial opioid-prescribing characteristics, such as prescription duration, and the likelihood of long-term use.5 This study examines previous opioid prescription history and initial prescription characteristics among individuals with dispensed opioid prescriptions from 2017 through 2020 using a large all-payer pharmaceutical claims database.

BACKGROUND: While reduced exposure to prescription opioids may decrease risks, including overdose and opioid use disorder, abrupt tapering or discontinuation may pose new risks. OBJECTIVES: To examine potentially unsafe tapering and discontinuation among dosage changes in opioid prescriptions dispensed to US patients on high-dose long-term opioid therapy. DESIGN: Longitudinal observational study of adults (18 years) on stable high-dose (50 oral morphine milligram equivalents [MME] daily dosage) long-term opioid therapy during a 180-day baseline and a 360-day follow-up using all-payer pharmaceutical claims data, 2017-2019. MEASURES: Dosage tapering, increases, and/or stability during follow-up; sustained dosage stability, reductions, or discontinuation at the end of follow-up; and tapering rate. Patients could experience more than one outcome during follow-up. RESULTS: Among 595,078 patients receiving high-dose long-term opioid therapy in the sample, 26.7% experienced sustained dosage reductions and 9.3% experienced discontinuation. Among patients experiencing tapering, 62.0% experienced maximum taper rates between >10-40% reductions per month and 36.1% experienced monthly rates 40%. Among patients with mean baseline daily dosages 150 MME, 47.7% experienced a maximum taper rate 40% per month. Relative to baseline, 19.7% of patients experiencing tapering had long-term dosage reductions 40% per month at the end of follow-up. IMPLICATIONS: Dosage changes for patients on high-dose long-term opioid therapy may warrant special attention, particularly over shorter intervals, to understand how potentially sudden tapering and discontinuation can be reduced while emphasizing patient safety and shared decision-making. Rapid discontinuation of opioids can increase risk of adverse outcomes including opioid withdrawal.

Between 2012 and 2018, incidents of opioid-involved injuries surged and the number of children in foster care due to parental drug use disorder increased. Treatments for opioid use disorder (OUD) might prevent or reduce the amount of time that children spend in the child welfare system. Using administrative data, we examined the impact of Medicaid expansion and state support for methadone as a medication for opioid use disorder (MOUD) on first-time foster care placements. Results show that first-time foster care entries due to parental drug use disorder experienced a reduction of 28 per 100,000 children in Medicaid expansion states with methadone MOUD covered by their state Medicaid programs. The largest reduction was found among non-Hispanic Black children and the youngest children (age 0–1 years). Policies that increase OUD treatment access may reduce foster care placements by reducing parents’ drug use, a risk factor for child abuse/neglect and subsequent home removal. © 2021

OBJECTIVE: To quantify discrepancies between opioid prescribing and dispensing via the percentage of patients with Electronic Medical Record (EMR) prescriptions who subsequently filled the prescription within 90 days, defined as congruence, and compared opioid congruence with related medications. DATA SOURCES: Deidentified data from the IBM MarketScan Explorys Claims-EMR Dataset. STUDY DESIGN: In this retrospective, observational study, we examined congruence for commonly prescribed controlled substances-opioids, stimulants, and benzodiazepines. Congruence was stratified by age group and sex. DATA COLLECTION/EXTRACTION METHODS: Continuously enrolled adults aged 18-64 years with an EMR encounter (excluding inpatient settings) and ≥ 1 prescription for selected classes between 1/1/2016 and 10/2/2017. PRINCIPAL FINDINGS: During the study period, 1,353,478 adults had ≥1 EMR encounter. Patients with stimulants prescriptions had the highest congruence (83%) corresponding to 7151 claims for 8,635 EMR prescriptions, followed by opioids (66%; 62,766/95,690) and benzodiazepines (64%; 30,181/47,408). Chi-square testing showed congruence differed by age group within opioids (P < .0001) and benzodiazepines (P < .0001) and was higher among females within benzodiazepines (P < .0001). CONCLUSIONS: These findings demonstrate that relying on claims data alone for opioid prescribing measures might underestimate actual prescribing magnitude by as much as one-third in these data. Combined EMR and claims data can help future research better understand characteristics associated with congruence or incongruence between prescribing and dispensing.

In 2019, 49,860 drug overdose deaths in the USA involved opioids.1 Naloxone can reverse the effects of an opioid overdose. While the CDC Guideline for Prescribing Opioids for Chronic Pain recommends that clinicians consider prescribing naloxone when factors that increase risk for opioid overdose are present, such as higher opioid dosages and the use of both opioid and benzodiazepines,2 the extent of concurrent naloxone dispensing among this population is unknown. Previous research, limited to Medicare beneficiaries, indicated that very few patients received concurrent naloxone prescriptions.3 Similarly, naloxone prescriptions dispensed from retail pharmacies remain low.4 We examine concurrent naloxone dispensing among individuals with high-risk opioid prescriptions in the USA from 2015 to 2019.

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

BACKGROUND: Prescription opioid use during pregnancy has been associated with poor outcomes for mothers and infants. Studies using administrative data have estimated that 14%-22% of women filled a prescription for opioids during pregnancy; however, data on self-reported prescription opioid use during pregnancy are limited. METHODS: CDC analyzed 2019 data from the Pregnancy Risk Assessment Monitoring System (PRAMS) survey in 32 jurisdictions and maternal and infant health surveys in two additional jurisdictions not participating in PRAMS to estimate self-reported prescription opioid pain reliever (prescription opioid) use during pregnancy overall and by maternal characteristics among women with a recent live birth. This study describes source of prescription opioids, reasons for use, want or need to cut down or stop use, and receipt of health care provider counseling on how use during pregnancy can affect an infant. RESULTS: An estimated 6.6% of respondents reported prescription opioid use during pregnancy. Among these women, 21.2% reported misuse (a source other than a health care provider or a reason for use other than pain), 27.1% indicated wanting or needing to cut down or stop using, and 68.1% received counseling from a provider on how prescription opioid use during pregnancy could affect an infant. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Among respondents reporting opioid use during pregnancy, most indicated receiving prescription opioids from a health care provider and using for pain reasons; however, answers from one in five women indicated misuse. Improved screening for opioid misuse and treatment of opioid use disorder in pregnant patients might prevent adverse outcomes. Implementation of public health strategies (e.g., improving state prescription drug monitoring program use and enhancing provider training) can support delivery of evidence-based care for pregnant women.

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

The risk of maternal death in the U.S. is higher than peer nations and rising, and varies dramatically by the race and place of residence of the woman. Critical efforts to reduce maternal mortality include patient risk stratification and system-level quality improvement efforts targeting specific aspects of clinical care. These efforts are important for addressing the causes of an individual's risk, but research to date suggests that individual risk factors alone do not adequately explain between-group disparities in pregnancy-related death by race, ethnicity, or geography. The holistic review and multidisciplinary makeup of maternal mortality review committees (MMRC) make them well positioned to fill knowledge gaps about the drivers of racial and geographic inequity in maternal death. However, committees may lack the conceptual framework, contextual data, and evidence base needed to identify community-based contributing factors to death, and when appropriate to make recommendations for future action. By incorporating a multileveled, theory-grounded framework for causes of health inequity, along with indicators of the 'community vital signs' - the social and community context in which women live, work, and seek healthcare - MMRCs may identify novel underlying factors at the community level that enhance understanding of racial and geographic inequity in maternal mortality. By considering evidence-informed community and regional resources and policies for addressing these factors, novel prevention recommendations, including recommendations that extend outside the realm of the formal health care system, may emerge.