Communities That HEAL Intervention and Mortality Including Polysubstance Overdose Deaths: A Randomized Clinical Trial.

Importance: The HEALing Communities Study (HCS) evaluated the effectiveness of the Communities That HEAL (CTH) intervention in preventing fatal overdoses amidst the US opioid epidemic. Objective: To evaluate the impact of the CTH intervention on total drug overdose deaths and overdose deaths involving combinations of opioids with psychostimulants or benzodiazepines. Design, Setting, and Participants: This randomized clinical trial was a parallel-arm, multisite, community-randomized, open, and waitlisted controlled comparison trial of communities in 4 US states between 2020 and 2023. Eligible communities were those reporting high opioid overdose fatality rates in Kentucky, Massachusetts, New York, and Ohio. Covariate constrained randomization stratified by state allocated communities to the intervention or control group. Trial groups were balanced by urban or rural classification, 2016-2017 fatal opioid overdose rate, and community population. Data analysis was completed by December 2023. Intervention: Increased overdose education and naloxone distribution, treatment with medications for opioid use disorder, safer opioid prescribing practices, and communication campaigns to mitigate stigma and drive demand for evidence-based interventions. Main Outcomes and Measures: The primary outcome was the number of drug overdose deaths among adults (aged 18 years or older), with secondary outcomes of overdose deaths involving specific opioid-involved drug combinations from death certificates. Rates of overdose deaths per 100 000 adult community residents in intervention and control communities from July 2021 to June 2022 were compared with analyses performed in 2023. Results: In 67 participating communities (34 in the intervention group, 33 in the control group) and including 8 211 506 participants (4 251 903 female [51.8%]; 1 273 394 Black [15.5%], 603 983 Hispanic [7.4%], 5 979 602 White [72.8%], 354 527 other [4.3%]), the average rate of overdose deaths involving all substances was 57.6 per 100 000 population in the intervention group and 61.2 per 100 000 population in the control group. This was not a statistically significant difference (adjusted rate ratio [aRR], 0.92; 95% CI, 0.78-1.07; P = .26). There was a statistically significant 37% reduction (aRR, 0.63; 95% CI, 0.44-0.91; P = .02) in death rates involving an opioid and psychostimulants (other than cocaine), and nonsignificant reductions in overdose deaths for an opioid with cocaine (6%) and an opioid with benzodiazepine (1%). Conclusion and Relevance: In this clinical trial of the CTH intervention, death rates involving an opioid and noncocaine psychostimulant were reduced; total deaths did not differ statistically. Community-focused data-driven interventions that scale up evidence-based practices with communications campaigns may effectively reduce some opioid-involved polysubstance overdose deaths. Trial Registration: ClinicalTrials.gov Identifier: NCT04111939.

Housing instability increases for stimulant-involved overdose deaths after linking surveillance data to electronic health records in Kentucky.

BACKGROUND: According to the U.S. Centers for Disease Control and Prevention, approximately 10.2 % of fatal overdoses in 2022 were among people experiencing homelessness or housing instability. In the United States, the majority of all drug overdoses now involve stimulants. METHODS: We linked stimulant-involved fatal overdose records occurring between 2017 and 2021 from Kentucky's Drug Overdose Fatality Surveillance System to the electronic health records (EHR) of the state's largest safety-net hospital network. We used State Unintentional Drug Overdose Reporting System (SUDORS) definitions of homelessness or housing instability to establish baseline estimates before linking decedents to medical records. After linkage, we augmented SUDORS data with structured administrative billing codes, semi-structured address data, and unstructured clinical notes identifying homelessness from the EHR. RESULTS: There were 313 individuals with stimulant-involved fatal overdoses linked to at least one medical encounter in the EHR (2017-2021). Thirty-three individuals (10.5 %) were identified as having unstable housing according to SUDORS. After linkage, 130 individuals (41.5 %) had evidence of housing instability. For this period, these 313 individuals represent 8.0 % of stimulant-involved overdoses in KY or 38.5 % of stimulant-involved overdoses from residents of the primary and secondary catchment area of our healthcare network. CONCLUSIONS: The single-site increase in observed housing instability in stimulant-involved fatal overdoses suggests that increased data linkage between state medicolegal death investigation system and EHRs would significantly improve the public health surveillance of overdoses.

Early vs. Later Experiences of Violence and Polysubstance Use Among Adults Who Inject Drugs.

BACKGROUND: People who inject drugs (PWID) experience high rates of violence, especially in early childhood, increasing their likelihood of engaging in risky substance use behavior in adulthood. Additionally, complex trauma has been reported among PWID due to witnessing and experiencing an overdose, further highlighting the need to examine the role of multiple experiences of trauma on their vulnerability to substance misuse. METHODS: Our study of 350 PWID from rural Kentucky examined differences in polysubstance use between participants who experienced violence earlier (≤15 years old) versus later (≥16 years old) in their childhood. RESULTS: Findings highlighted a direct association between experiences of early childhood violence and polysubstance use in adulthood. Additionally, our sample of PWID who experienced violence early in their childhood reported higher rates of severe substance use disorder and mental health distress. CONCLUSIONS: Tailored approaches that incorporate trauma-informed care may help to address the disproportionate rates of substance use and related adverse effects among PWID.

Estimating occupation-related crashes in light and medium size vehicles in Kentucky: A text mining and data linkage approach.

Occupational motor vehicle (OMV) crashes are a leading cause of occupation-related injury and fatality in the United States. Statewide crash databases provide a good source for identifying crashes involving large commercial vehicles but are less optimal for identifying OMV crashes involving light or medium vehicles. This has led to an underestimation of OMV crash counts across states and an incomplete picture of the magnitude of the problem. The goal of this study was to develop and pilot a systematic process for identifying OMV crashes in light and medium vehicles using both state crash and health-related surveillance databases. A two-fold process was developed that included: 1) a machine learning approach for mining crash narratives and 2) a deterministic data linkage effort with crash state data and workers compensation (WC) claims records and emergency medical service (EMS) data, independently. Overall, the combined process identified 5,302 OMV crashes in light and medium vehicles within one year's worth of crash data. Findings suggest the inclusion of multi-method approaches and multiple data sources can be implemented and used to improve OMV crash surveillance in the United States.

Temporal Trends and Racial Disparities in Long-Term Survival After Stroke.

BACKGROUND AND OBJECTIVES: Few studies have examined trends and disparities in long-term outcome after stroke in a representative US population. We used a population-based stroke study in the Greater Cincinnati Northern Kentucky region to examine trends and racial disparities in poststroke 5-year mortality. METHODS: All patients with acute ischemic strokes (AISs) and intracerebral hemorrhages (ICHs) among residents ≥20 years old were ascertained using ICD codes and physician-adjudicated using a consistent case definition during 5 periods: July 1993-June 1994 and calendar years 1999, 2005, 2010, and 2015. Race was obtained from the medical record; only those identified as White or Black were included. Premorbid functional status was assessed using the modified Rankin Scale, with a score of 0-1 being considered "good." Mortality was assessed with the National Death Index. Trends and racial disparities for each subtype were analyzed with logistic regression. RESULTS: We identified 8,428 AIS cases (19.3% Black, 56.3% female, median age 72) and 1,501 ICH cases (23.5% Black, 54.8% female, median age 72). Among patients with AIS, 5-year mortality improved after adjustment for age, race, and sex (53% in 1993/94 to 48.3% in 2015, overall effect of study year p = 0.009). The absolute decline in 5-year mortality in patients with AIS was larger than what would be expected in the general population (5.1% vs 2.8%). Black individuals were at a higher risk of death after AIS (odds ratio [OR] 1.23, 95% CI 1.08-1.39) even after adjustment for age and sex, and this effect was consistent across study years. When premorbid functional status and comorbidities were included in the model, the primary effect of Black race was attenuated but race interacted with sex and premorbid functional status. Among male patients with a good baseline functional status, Black race remained associated with 5-year mortality (OR 1.4, 95% CI 1.1-1.7, p = 0.002). There were no changes in 5-year mortality after ICH over time (64.4% in 1993/94 to 69.2% in 2015, overall effect of study year p = 0.32). DISCUSSION: Long-term survival improved after AIS but not after ICH. Black individuals, particularly Black male patients with good premorbid function, have a higher mortality after AIS, and this disparity did not change over time.

Overdose Experiences Among a Sample of Women in Jail with Opioid Use Disorder.

Background:  Previous non-fatal overdose may increase risk of overdose fatality for women reentering the community following incarceration, but pre-incarceration overdose experiences are understudied. This study describes the prevalence and correlates of non-fatal overdose prior to jail among women with opioid use disorder (OUD). Methods: Women (N = 700) were randomly selected from eight Kentucky jails, screened for OUD, and interviewed as part of the NIDA-funded Kentucky Justice Community Opioid Innovation Network (JCOIN) trial. Descriptive statistics were used to examine women's prior overdose experiences, while bivariate analyses and logistic regression were used to identify correlates of overdose in the 90 days prior to jail. Results: Analyses found that 55.4% of women had overdosed in their lifetime, and 21.4% overdosed in the 90 days prior to jail. Of those who overdosed in the 90 days prior to jail, heroin (80.7%) was the most-commonly used drug prior to overdose, 35.2% received emergency, medically-attended services post-overdose, and 92.4% were administered naloxone - primarily by acquaintances. Overdosing in the 90 days prior to jail was positively correlated with identifying as a sexual minority, being from an urban community, childhood victimization, as well as recent heroin, fentanyl, and injection drug use. Conclusions: Findings indicate that prior overdose is common among jailed women with OUD, and although naloxone was often administered, few women received medically-attended services post-overdose. Results highlight the importance of distributing naloxone to community members and women reentering the community from jail, and suggest additional research is needed to understand factors inhibiting medical care following an overdose.

Heavy-metal associated breast cancer and colorectal cancer hot spots and their demographic and socioeconomic characteristics.

PURPOSE: Cancer registries offer an avenue to identify cancer clusters across large populations and efficiently examine potential environmental harms affecting cancer. The role of known metal carcinogens (i.e., cadmium, arsenic, nickel, chromium(VI)) in breast and colorectal carcinogenesis is largely unknown. Historically marginalized communities are disproportionately exposed to metals, which could explain cancer disparities. We examined area-based metal exposures and odds of residing in breast and colorectal cancer hotspots utilizing state tumor registry data and described the characteristics of those living in heavy metal-associated cancer hotspots. METHODS: Breast and colorectal cancer hotspots were mapped across Kentucky, and area-based ambient metal exposure to cadmium, arsenic, nickel, and chromium(VI) were extracted from the 2014 National Air Toxics Assessment for Kentucky census tracts. Among colorectal cancer (n = 56,598) and female breast cancer (n = 77,637) diagnoses in Kentucky, we used logistic regression models to estimate Odds Ratios (ORs) and 95% Confidence Intervals to examine the association between ambient metal concentrations and odds of residing in cancer hotspots, independent of individual-level and neighborhood risk factors. RESULTS: Higher ambient metal exposures were associated with higher odds of residing in breast and colorectal cancer hotspots. Populations in breast and colorectal cancer hotspots were disproportionately Black and had markers of lower socioeconomic status. Furthermore, adjusting for age, race, tobacco and neighborhood factors did not significantly change cancer hotspot ORs for ambient metal exposures analyzed. CONCLUSION: Ambient metal exposures contribute to higher cancer rates in certain geographic areas that are largely composed of marginalized populations. Individual-level assessments of metal exposures and cancer disparities are needed.

Generational and Gender Patterns of Prescription Opioid Misuse Among Black Adults.

INTRODUCTION: Opioid-related overdose mortality disproportionally affects Black adults in Kentucky, particularly overdoses associated with prescription opioid misuse (POM). Black adults also face other consequences of POM, such as disparate health and legal outcomes. While several factors effect POM, such as generational factors and gender, these risk factors are understudied among Black adults with a history of POM. Current literature primarily focuses on White individuals who use opioids. METHOD: The present study qualitatively examined reasons for POM, prescription opioids misused, how prescription opioids are obtained, and initiation of POM among Black adults using thematic analysis. Participants included a sample (n = 39) of Black adults from a southern state, stratified by gender and age across four cohorts: born (1) 1995-2001, (2) 1980-1994, (3) 1970-1979, and (4) 1955-1969. RESULTS: Results revealed similarities and differences in these themes across age cohorts and gender. CONCLUSIONS: Implications for findings include the importance of culturally responsive interventions that utilize dual diagnosis treatment and idiographic approaches due to heterogeneous experiences with POM among Black adults.

Wastewater threshold as an indicator of COVID-19 cases in correctional facilities for public health response: A modeling study.

Although prison facilities are not fully isolated from the communities in which they are located, most of the population is confined and requires high levels of health vigilance and protection. This study aimed to examine the dynamic relationship between facility-level wastewater viral concentrations and the probability of at least one positive COVID-19 case within the facility. The study period was from January 11, 2021 to May 8, 2023. Wastewater samples were collected and analyzed for SARS-CoV-2 (N1) and pepper mild mottle virus (PMMoV) three times weekly across 14 prison facilities in Kentucky (USA). Positive clinical case reports were also provided. A hierarchical Bayesian facility-level temporal model with a latent lagged process was developed. We modeled facility-specific SARS-CoV-2 (N1) normalized by the PMMoV wastewater concentration ratio threshold associated with at least one COVID-19 clinical case at an 80 % probability. The threshold differed among facilities. Across the 14 facilities, our model demonstrates a mean capture rate of 94.95 % via the N1/PMMoV ratio threshold with pts≥0.5. However, as the pts threshold was set higher, such as at ≥0.9, the mean capture rate of the model was reduced to 60 %. This robust performance underscores the effectiveness of the model for accurately detecting the presence of positive COVID-19 cases among incarcerated people. The findings of this study provide a facility-specific threshold model for public health response based on frequent wastewater surveillance.

Association of Food and Housing Insecurity on Outcomes in Pregnant Patients With Substance Use Disorder.

OBJECTIVES: Food insecurity (FI) may be associated with worsened neonatal abstinence syndrome severity in infants born to individuals with substance use disorder. This study evaluates FI and housing insecurity (HI) influence on maternal and neonatal outcomes. METHODS: This was a cohort study of patients receiving obstetric care through a multispecialty program in Kentucky from 2015 to 2023. Inclusion criteria were: (1) program participants over age 18 consenting to observational research, (2) delivering at University of Kentucky, and (3) not withdrawing from research at any time. Initially, a subset of patients for whom FI and HI concerns were heightened were screened. In 2019, FI and HI screening became standard of care at the clinic. Housing was assessed on enrollment. A validated 2-question Hunger Vital Sign FI screen was utilized for a subset of patients. Maternal and neonatal outcomes, including adverse delivery outcomes, maternal comorbidities, and birth complications, were observed. Fisher's exact and 2 sample t tests were performed. RESULTS: Of 494 participants, 188 (38%) identified at risk for HI. At enrollment, 221 (45%) individuals reported owning their primary residence, 85 (17%) were in group residential treatment, 34 (6.9%) had no housing, and 134 (27%) lived at another's residence. Disposition of a child to a relative or not the patient's own care was greater with HI, 51% versus 47%. Of 155 respondents, 96 (62%) reported FI, associated with increased neonatal intensive care unit (NICU) admission, 86% versus 74%. Using the validated tool, Abuse Assessment Screen, abuse was significantly greater with FI, 76% versus 58%. Edinburgh Postpartum Depression Scales >12 indicating depression were more common with FI, 63% versus 32%, P < .05. Anxiety scores were also higher with FI, P < .05. Patients with FI were more likely to experience abuse. CONCLUSIONS: FI and HI were health-related needs associated with increased anxiety, depression, infant NICU admission, and loss of child custody.

Examining the social and behavioral dynamics of substance use in a longitudinal network study in rural Appalachia.

BACKGROUND: Prior studies have shown that individuals and their peers often have similar substance use behaviors, but the mechanisms driving these similarities - particularly in rural settings, are not well understood. The primary objectives of this analysis are to (1) identify factors that contribute to relationship turnover and maintenance within a rural network of persons who use drugs (PWUD), (2) determine whether assimilation and/or homophily shape participants use of injection drugs, heroin, and stimulants (methamphetamine and cocaine), and (3) assess the extent that these mechanisms influence networks ties and/or behaviors and whether these effects vary across time. METHODS: Sociometric network data were collected from a cohort of PWUD in rural Eastern Kentucky at baseline (2008-2010) and at four follow-up visits conducted approximately semiannually. Stochastic actor-oriented models (SAOMS) were used to model network structure and participant behaviors as jointly dependent variables and to identify characteristics associated with the maintenance, dissolution, and formation of network ties and changes in drug use behaviors. RESULTS: Findings suggest (1) greater network stability over time for reciprocal and transitive relationships, (2) both homophily and assimilation played a greater role in shaping injection drug use (IDU) initiation and cessation than they did in shaping heroin and stimulant use, and (3) the importance of these mechanisms appeared consistent over time. CONCLUSION: Given the stability of particular network structures and evidence of both homophily and assimilation with respect to drug-use behaviors, interventions that leverage social networks could be used to motivate health-promoting behaviors.

Racial Disparities in Blood Pressure at Time of Acute Ischemic Stroke Presentation: A Population Study.

BACKGROUND: Hypertension is a stroke risk factor with known disparities in prevalence and management between Black and White patients. We sought to identify if racial differences in presenting blood pressure (BP) during acute ischemic stroke exist. METHODS AND RESULTS: Adults with acute ischemic stroke presenting to an emergency department within 24 hours of last known normal during study epochs 2005, 2010, and 2015 within the Greater Cincinnati/Northern Kentucky Stroke Study were included. Demographics, histories, arrival BP, National Institutes of Health Stroke Scale score, and time from last known normal were collected. Multivariable linear regression was used to determine differences in mean BP between Black and White patients, adjusting for age, sex, National Institutes of Health Stroke Scale score, history of hypertension, hyperlipidemia, smoking, stroke, body mass index, and study epoch. Of 4048 patients, 853 Black and 3195 White patients were included. In adjusted analysis, Black patients had higher presenting systolic BP (161 mm Hg [95% CI, 159-164] versus 158 mm Hg [95% CI, 157-159], P<0.01), diastolic BP (86 mm Hg [95% CI, 85-88] versus 83 mm Hg [95% CI, 82-84], P<0.01), and mean arterial pressure (111 mm Hg [95% CI, 110-113] versus 108 mm Hg [95% CI, 107-109], P<0.01) compared with White patients. In adjusted subanalysis of patients <4.5 hours from last known normal, diastolic BP (88 mm Hg [95% CI, 86-90] versus 83 mm Hg [95% CI, 82-84], P<0.01) and mean arterial pressure (112 mm Hg [95% CI, 110-114] versus 108 mm Hg [95% CI, 107-109], P<0.01) were also higher in Black patients. CONCLUSIONS: This population-based study suggests differences in presenting BP between Black and White patients during acute ischemic stroke. Further study is needed to determine whether these differences influence clinical decision-making, outcome, or clinical trial eligibility.

Impact of Poverty on Stroke Recurrence: A Population-Based Study.

BACKGROUND AND OBJECTIVES: Poverty is associated with greater stroke incidence. The relationship between poverty and stroke recurrence is less clear. METHODS: In this population-based study, incident strokes within the Greater Cincinnati/Northern Kentucky region were ascertained during the 2015 study period and followed up for recurrence until December 31, 2018. The primary exposure was neighborhood socioeconomic status (nSES), defined by the percentage of households below the federal poverty line in each census tract in 4 categories (≤5%, >5%-10%, >10%-25%, >25%). Poisson regression models provided recurrence rate estimates per 100,000 residents using population data from the 2015 5-year American Community Survey, adjusting for age, sex, and race. In a secondary analysis, Cox models allowed for the inclusion of vascular risk factors in the assessment of recurrence risk by nSES among those with incident stroke. RESULTS: Of 2,125 patients with incident stroke, 245 had a recurrent stroke during the study period. Poorer nSES was associated with increased stroke recurrence, with rates of 12.5, 17.5, 25.4, and 29.9 per 100,000 in census tracts with ≤5%, >5%-10%, >10%-25%, and >25% below the poverty line, respectively (p < 0.01). The relative risk (95% CI) for recurrent stroke among Black vs White individuals was 2.54 (1.91-3.37) before adjusting for nSES, and 2.00 (1.47-2.74) after adjusting for nSES, a 35.1% decrease. In the secondary analysis, poorer nSES (HR 1.74, 95% CI 1.10-2.76 for lowest vs highest category) and Black race (HR 1.31, 95% CI 1.01-1.70) were both independently associated with recurrence risk, though neither retained significance after full adjustment. Age, diabetes, and left ventricular hypertrophy were associated with increased recurrence risk in fully adjusted models. DISCUSSION: Residents of poorer neighborhoods had a dose-dependent increase in stroke recurrence risk, and neighborhood poverty accounted for approximately one-third of the excess risk among Black individuals. These results highlight the importance of poverty, race, and the intersection of the 2 as potent drivers of stroke recurrence.

Utilization of long-acting injectable monthly depot buprenorphine for opioid use disorder (OUD) in Kentucky, before and after COVID-19 related buprenorphine access policy changes.

INTRODUCTION: Long-acting injectable buprenorphine (LAI-bup) formulations have advantages over transmucosal buprenorphine (TM-bup), but barriers may limit their utilization. Several policies shifted during the COVID-19 pandemic to promote buprenorphine access. The federal government expanded telemedicine treatment for opioid use disorder and Kentucky (KY) Medicaid lifted prior authorization requirements (PAs) for LAI-bup (i.e., Sublocade®). This retrospective cohort study evaluated changes in LAI-bup access, utilization, and retention before and after these policy changes in KY. METHODS: Individual-level TM-bup and LAI-bup dispensing record data from KY's prescription drug monitoring program examined LAI-bup utilization and retention, without a >30-day gap in coverage, for patients starting a new episode of LAI-bup treatment. Two key time periods were examined: pre-policy changes (Apr 1, 2019 - Dec 31, 2019) and post-policy changes (Apr 1, 2020 - Dec 31, 2020). Data on PA requests among Medicaid managed care organizations and availability of LAI-bup Risk Evaluation and Mitigation Strategy (REMS)-certified pharmacies were also obtained. A multivariable Cox proportional hazard regression model analysis compared pre- versus post-policy period treatment discontinuation. RESULTS: The number of patients initiating LAI-bup increased from 211 to 481 over the two periods. By the end of the post-policy period, 24.3 % of eligible patients were retained on LAI-bup, versus 12.5 % in the pre-policy change period. The adjusted hazard ratio, comparing discontinuation during the post- versus pre-policy change periods, was 0.70 (95 % confidence interval: 0.55-0.89). There were also more REMS-certified pharmacies and providers in the post-policy change period. CONCLUSIONS: LAI-bup access, utilization, and retention increased after several policy changes.

Incidence Rates and Outcomes of Nodular and Superficial Spreading Melanoma along the Rural-Urban Continuum in Kentucky and Their Relationship to Provider Care Access.

OBJECTIVES: This study compared incidence rates, stage at presentation, and cause-specific mortality of nodular and superficial spreading melanoma along the rural-urban continuum in Kentucky. We compared resulting patterns in our data with sample demographic and other potential factors, including population by county and primary care provider rate. METHODS: Retrospective patient data were extracted from the Surveillance, Epidemiology, and End Results database from 2010 through 2017. These data were supplemented by environmental, demographic, and socioeconomic data derived from publicly accessible databases. Correlation and χ2 analyses were used to test for significant differences in outcome variables by US Department of Agriculture Rural-Urban Continuum Code (RUCC) categories and other potential predictor variables. RESULTS: Incidence rates by Kentucky county were not associated with RUCC or population; likewise, there was no relationship between stage at presentation and RUCC category. There was, however, a highly significant association between cause-specific mortality and RUCC; patients from rural areas were significantly more likely to die from melanoma than those in urban areas. This overall difference was due to differences in mortality for superficial spreading melanoma. CONCLUSIONS: Our results suggest that a disparity in patients' ability or tendency to access primary care and/or specialist providers postdiagnosis may be critical factors in determining the ultimate outcome of a melanoma diagnosis. Further studies should explore the availability of dermatologists and/or treatment options for melanoma in rural areas. Our data also provide additional support for inclusion of melanoma subtype in the American Joint Committee on Cancer guidelines.

Tobacco use disparities in rural communities.

PURPOSE: This exploratory study described facilitators and barriers to reducing tobacco disparities in 2 small rural communities and identified ways to reduce tobacco use. METHODS: This was a descriptive design using qualitative methods. We created a resource database for 2 rural Kentucky counties, using a Culture of Health Framework. We recruited 16 organizational stakeholders serving low-socioeconomic populations and conducted focus groups and key informant interviews. We also completed key informant interviews with 7 tobacco users. Lastly, we tailored Community Action Plans for each county based on the data and then solicited feedback from the key stakeholders. FINDINGS: The 2 counties were similar in population size, but County A had fewer resources than County B, and the stakeholders expressed differences toward tobacco use and quitting. County A stakeholders talked most about the protobacco culture and that tobacco users accept the risks of smoking outweighing the benefits of quitting; they also expressed concerns about youth use and the influences of family, society, and industry. County B stakeholders described ambivalence about the health effects of use and quitting. County A's Action Plan identified an opportunity to build Community Health Worker-delivered tobacco treatment into a new school-based health center. County B's Action Plan focused on reaching tobacco users by providing incentives for participation and tailoring messages to different audiences. CONCLUSIONS: Tobacco control resources and stakeholder perspectives vary in small rural communities, implying a need for tailored approaches. Tobacco users in rural areas are a critical population to target with cessation resources.

Higher First 30-Day Dose of Buprenorphine for Opioid Use Disorder Treatment Is Associated With Decreased Mortality.

OBJECTIVE: Buprenorphine is a medication for opioid use disorder that reduces mortality. This study aims to investigate the less well-understood relationship between the dose in the early stages of treatment and the subsequent risk of death. METHODS: We used Kentucky prescription monitoring data to identify adult Kentucky residents initiating transmucosal buprenorphine medication for opioid use disorder (January 2017 to November 2019). Average daily buprenorphine dose for days covered in the first 30 days of treatment was categorized as ≤8 mg, >8 to ≤16 mg, and >16 mg. Patients were followed for 365 days after the first 30 days of buprenorphine treatment. Endpoints were opioid-involved overdose death and death from other causes. Causes and dates of death were obtained using Kentucky death certificate records. Associations were evaluated using multivariable Fine and Gray models adjusting for patient baseline characteristics. RESULTS: In the cohort of 49,857 patients, there were 227 opioid-involved overdose deaths and 459 deaths from other causes. Compared with ≤8 mg, the adjusted subdistribution hazard ratio (aSHR) of opioid-involved overdose death decreased by 55% (aSHR, 0.45; 95% confidence interval [CI], 0.34-0.60) and 64% (aSHR, 0.36; 95% CI, 0.25-0.52) for patients receiving doses of >8 to ≤16 mg and >16 mg, respectively. The incidence of death from other causes was lower in patients receiving >8 to ≤16 mg (aSHR, 0.78; 95% CI, 0.62-0.98) and >16 mg (aSHR, 0.62; 95% CI, 0.47-0.80) versus ≤8 mg dose. CONCLUSIONS: Higher first 30-day buprenorphine doses were associated with reduced opioid-involved overdose death and death from other causes, supporting benefit of higher dosing in reducing mortality.

Characteristics of K-12 Teachers Considering Leaving Due to COVID-19 and for Other Reasons.

BACKGROUND: The COVID-19 pandemic has had drastic effects on K-12 teachers. Researchers partnered with a teacher advisory board to identify factors associated with K-12 teachers' consideration of leaving teaching during Fall 2020. METHODS: A web-based survey focused on teachers' working experiences was emailed to school union membership listservs in Indiana, Kentucky, and Ohio. A logistic regression model was developed to identify working conditions associated with teachers considering leaving the profession. RESULTS: Among 5873 K-12 teachers, 27% (n = 1319) were considering leaving the profession either because of COVID-19 (10%), for other reasons (6%) or were undecided (11%). Teachers who were midcareer, having taught 6-10 years, who perceived less supervisor support, whose job duties had changed significantly, who were dissatisfied with the COVID-19 related decision-making, who reported poor or fair mental health, and who were mostly or extremely afraid that a household member would get COVID-19 had higher odds of considering leaving teaching or being undecided about future career plans. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE AND EQUITY: Understanding factors influencing teachers' career decisions will help school leaders improve teacher retention amid challenging circumstances. CONCLUSION: In this study in 3 midwestern US states, limited supervisor support, significant job duty change, dissatisfaction with COVID-19-related decision-making, poor or fair mental health, and fear that a household member would get COVID-19 were associated with teachers' consideration of leaving the profession or being undecided about future career plans.

Health Assessment of Adult Male Eastern Wild Turkeys (Meleagris gallopavo silvestris) from Western Kentucky, USA.

Wild turkeys (Meleagris gallopavo) are an important game species throughout the geographic range. Populations throughout multiple regions of the US have been declining, including in Kentucky, US, raising concerns among managers and resource users. To better understand the overall population health, we performed postmortem examinations and targeted pathogen, mineral, and toxicant testing on 36 adult male, apparently healthy, wild turkeys that were hunter harvested in western Kentucky during April 2018. We found that birds were in fair to good nutritional condition with no significant gross or microscopic lesions. Ticks (Amblyomma spp.) and lice (three species) were present on 94 and 31% of birds, respectively. We commonly detected intestinal nematodes and cestodes and found coccidian oocysts in 39% and capillarid eggs in 6% of birds. The prevalences of lymphoproliferative disease virus and reticuloendotheliosis virus were 39 and 11%, respectively. Spleen samples tested with PCR were positive for Borrelia burgdorferi, Haemoproteus sp., and Leucocytozoon sp. in 11, 83, and 3%, respectively. Based on a subjective histologic assessment of testis tissues, most birds had widespread and abundant sperm present. Mineral analysis and broad toxicant screening on liver samples from 32 turkeys were unremarkable. Further work is needed to assess potential population risk factors and to determine individual- and population-level impacts of pathogens on adults and poults.

The variation in preventable hospitalization in patients with type 2 diabetes in Kentucky before and after the Medicaid expansion.

BACKGROUND: Hospitalizations are more resource intensive and expensive than outpatient care. Therefore, type 2 diabetes-related preventable hospitalization are a major topic of research efficiency in the healthcare system. OBJECTIVES: Analyze county level variation in type 2 diabetes-related preventable hospitalization rates in Kentucky before the Medicaid expansion (2010-2013) and after the Medicaid expansion (2014-2017). DESIGN: Geographic mapping and cluster analysis. SETTING: Data for a state of the United States of America. METHODS: We used the KID data to generate geographic mapping for type 2 diabetes-related preventable hospitalizations to visualize rates. We included all Kentucky discharges of age 18 years and older with the ICD9/10 principal diagnosis code for type 2 diabetes. Then, we conducted cluster analysis techniques to compare county-level variation in type 2 diabetes-related preventable hospitalization rates across Kentucky counties pre- and post-Medicaid expansion. MAIN OUTCOME AND MEASURES: County type 2 diabetes-related preventable hospitalization pre- and post-Medicaid expansion. RESULTS: From 2010-2017, type 2 diabetes-related preventable hospitalization discharge rates reduced significantly in the period of the post-Medicaid expansion (P=.001). The spatial statistics analysis revealed a significant spatial clustering of counties with similar rates of type 2 diabetes-related preventable hospitalization in the south, east, and southeastern Kentucky pre- and post-Medicaid expansion (positive z-score and positive Moran's Index value (P>.05). Also, there was a significant clustering of counties with low type 2 diabetes-related preventable hospitalization rates in the north, west, and central regions of the state pre-Medicaid expansion and post-Medicaid expansion (positive z-score and positive Moran's Index value (P>.05). CONCLUSION: Kentucky counties in the southeast have experienced a significant clustering of highly avoidable hospitalization rates during both periods. Focusing on the vulnerable counties and the economic inequality in Kentucky could lead to efforts to lowering future type 2 diabetes-related preventable hospitalization rates. LIMITATIONS: We used de-identified data which does not provide insights into the frequency of hospitalizations per patient. An individual patient may be hospitalized several times and counted as several individuals.