Disparities in the accuracy of reporting opioid overdoses to 9-1-1 by race and sex of overdose victim, Marion County, Indiana, 2011-2020.

OBJECTIVES: To assess the prevalence of emergency medical incidents wherein naloxone was administered but overdose was not described as the chief complaint during the 9-1-1 call, including differences by overdose victim race/ethnicity and sex. METHODS: We computed the percentage of 9-1-1 calls in Marion County, Indiana, from 2011 to 2020, wherein naloxone was administered but the caller did not describe overdose as the chief complaint. We estimated a logistic regression to examine the associations between reporting of overdose as the chief complaint and race and sex of the overdose victim. RESULTS: Almost one-fifth of 9-1-1 calls preceding naloxone administration did not describe overdose as the chief complaint. 9-1-1 callers were more likely to describe a non-overdose as the chief complaint when the overdose victim was Black or female. CONCLUSION: 9-1-1 callers are less likely to use terminology describing overdose when the overdose victim is female or Black, than when the victim is male or White. Inaccurate terminology when calling 9-1-1 could delay naloxone administration, thereby increasing risk of overdose death and hypoxic brain injury. Some 9-1-1 callers may be avoiding overdose terminology to prevent a police response, or due to lack of knowledge about overdose identification, but further research is needed to determine the mechanisms underlying these findings.

Estimating the incidence of substance exposed newborns with child welfare system involvement.

BACKGROUND: Prenatal substance use can have negative health consequences for both mother and child and may also increase the likelihood of child welfare involvement. The rate of newborns with substance exposure has increased dramatically. As of 2016, federal law requires notification of all infants to child welfare agencies so that a plan of safe care can be developed and referrals to services can be offered. OBJECTIVE: Child welfare agencies have not historically collected consistent, systematic data identifying substance exposed newborns. We utilized a unique strategy to identify substance exposed newborns with child welfare involvement. PARTICIPANTS & SETTING: We used data from the National Child Abuse & Detection System (NCANDS) which captures N = 3,189,034 unique child protective services investigations for children under the age of 1 between 2004 and 2017. METHODS: We calculated the incidence of substance exposed newborns investigated by child welfare agencies and compared with other administrative data on prenatal substance exposure. We also analyzed this rate by infant demographic characteristics (race/ethnicity, sex, rurality). RESULTS: Between 2004 and 2017, approximately 13 % of infants reported to child protective services were likely reported because of substance exposure at birth, and the rate of substance exposed newborns with child welfare involvement increased from 3.79 to 12.90 per 1000 births, an increase of 240 %, over this period. CONCLUSIONS: Understanding the extent of the substance use crisis for child welfare involvement is important for policymakers to support children and families.

Operationalizing person-centered care in residential substance use disorder treatment.

INTRODUCTION: Person-centered care (PCC) is an ethical imperative with eight domains, but operation of some PCC domains in substance use disorder (SUD) treatment has been underexplored. OBJECTIVE: We sought to identify strategies for operationalizing eight PCC domains in SUD treatment facilities and themes across these strategies. METHODS: We recruited 36 clients and staff from a large publicly funded behavioral health system for individual, semi-structured qualitative interviews. Interviews explored preferences and care experiences for each PCC domain. We analyzed data using iterative categorization, identifying specific operationalization strategies and themes across operationalization strategies within each domain. RESULTS: PCC operationalization themes for residential SUD treatment included addressing social vulnerability of clients (e.g., through assistance with housing and navigation of criminal/legal systems), involving peer support specialists (e.g., to provide emotional support and aid transition out of care), supporting the client's family throughout treatment (e.g., providing progress updates; increasing visitation opportunities in residential treatment), and facilitating patient choice within each domain (e.g., treatment type; housing type; roommate preferences in residential treatment.). DISCUSSION & CONCLUSION: Some PCC operationalization strategies are unique to SUD treatment. Several PCC operationalization strategies applied to multiple domains, suggesting conceptual overlap between domains.

Key person-centered care domains for residential substance use disorder treatment facilities: former clients' perspectives.

BACKGROUND: While person-centered care (PCC) includes multiple domains, residential substance use disorder (SUD) treatment clients may value certain domains over others. We sought to identify the PCC domains most valued by former residential SUD treatment clients. We also sought to explore conceptual distinctions between potential theoretical PCC subdomains. METHODS: We distributed an online survey via social media to a national convenience sample of former residential SUD treatment clients. Respondents were presented with ten PCC domains in an online survey: (a) access to evidence-based care; (b) integration of care; (c) diversity/respect for other cultures; (d) individualization of care; (e) emotional support; (f) family involvement in treatment; (g) transitional services; (h) aftercare; (i) physical comfort; and (j) information provision. Respondents were asked to select up to two domains they deemed most important to their residential SUD treatment experience. We used descriptive statistics to identify response frequencies and logistic regression to predict relationships between selected domains and respondents' race, gender, relationship status, parenting status, and housing stability. RESULTS: Our final sample included 435 former residential SUD treatment clients. Diversity and respect for different cultures was the most frequently selected domain (29%), followed by integration of care (26%), emotional support (26%), and individualization of care (26%). Provision of information was the least frequently chosen domain (3%). Race and ethnicity were not predictive of selecting respect for diversity. Also, parental status, relationship status and gender were not predictive of selecting family integration. Employment and housing status were not predictive of selecting transitional services. CONCLUSIONS: While residential SUD treatment facilities should seek to implement PCC across all domains, our results suggest facilities should prioritize (a) operationalizing diversity, (b) integration of care, and (c) emotional support. Significant heterogeneity exists regarding PCC domains deemed most important to clients. PCC domains valued by clients cannot be easily predicted based on client demographics.

Barriers to medications for opioid use disorder in the court system: provider availability, provider "trustworthiness," and cost.

BACKGROUND: Medications for opioid use disorder (MOUD) significantly decrease mortality but courts rarely refer participants with opioid use disorder to MOUD providers. Previous qualitative work suggests routine court referrals to MOUD providers are more likely if court team members perceive providers as "trustworthy." Court team members may also be less likely to refer participants to MOUD if they consider MOUD unaffordable, particularly in Florida, which has not expanded Medicaid. Our aims were to explore court team members' 1) perceptions of availability of local trustworthy MOUD providers, 2) characteristics associated with perceptions of availability of local trustworthy MOUD providers, including beliefs about MOUD efficacy, and 3) perceptions of MOUD affordability. METHODS: An online survey was distributed to all criminal problem-solving court and dependency court team members in Florida in 2019 and 2020. Likert scale questions assessed respondent agreement with statements about the availability of any MOUD providers, the availability of trustworthy MOUD providers, and the affordability of MOUD for court participants. An open-ended question explored MOUD barriers. Spearman's rho, Friedman, Kruskal Wallis, and Mann-Whitney U tests were used for analyzing quantitative data and iterative categorization for qualitative data. RESULTS: One hundred fifty-one respondents completed quantitative questions (26% response rate), and 42 completed the qualitative question. Respondents were more likely to agree that local MOUD providers are more available than trustworthy MOUD providers. Perceptions of trustworthy provider availability differed significantly by MOUD type and were associated with MOUD efficacy beliefs. Qualitative results suggest that MOUD providers offering counseling and individualized treatment are more trustworthy. CONCLUSIONS: Court team MOUD beliefs may influence their perceptions of providers, or negative experiences with providers may influence court team MOUD beliefs. Improving court team perceptions of local MOUD providers may be critical for facilitating court participant treatment access.

Prenatal Substance Use Policies And Infant Maltreatment Reports.

We studied the effect of state punitive and supportive prenatal substance use policies on reports of infant maltreatment to child protection agencies. Punitive policies criminalize prenatal substance use or define it as child maltreatment, whereas supportive policies provide pregnant women with priority access to substance use disorder treatment programs. Using difference-in-differences methods, we found that total infant maltreatment reports increased by 19.0 percent after punitive policy adoption during the years of our study (2004-18). This growth was driven by a 38.4 percent increase in substantiated reports in which the mother was the alleged perpetrator. There were no changes in unsubstantiated reports after the adoption of punitive policies. We observed no changes in infant maltreatment reports after the adoption of supportive policies. Findings suggest that punitive policies lead to large increases in substantiated infant maltreatment reports, which in turn may lead to child welfare system involvement soon after childbirth in states with these policies. Policy makers should design interventions that emphasize support services and improve well-being for mothers and infants.

Harm Reduction Policy Support among Students at Two U.S. Universities.

Background: The U.S. is undergoing an opioid overdose crisis. Harm reduction (HR) policies are associated with decreased overdose deaths and incidence of communicable diseases, yet legality of HR policies differs across U.S. jurisdictions. College student perceptions of HR policies are underexplored, even though their voting behavior has increased in recent years. We sought to compare their support of different HR policies and to explore relationships between demographic characteristics and support for HR policies. Methods: We collected cross-sectional, convenience sample survey data from undergraduate students at two large public universities, one in the Midwest and one in the Southeast, during Fall 2018/Spring 2019. We analyzed data using descriptive statistics and logistic regressions. Results: The final sample included 1,263 respondents. Good Samaritan laws (n = 833, 66%) and naloxone distribution (n = 476, 37.7%) were most commonly supported, while heroin maintenance treatment (n = 232, 18.4%) and heroin decriminalization (n = 208, 16.5%) were least supported. Democrat/liberal or less religious/spiritual respondents supported HR policies more than their Republican/conservative or religious/spiritual counterparts. Midwestern students were more likely to support syringe services programs. Conclusion: HR education initiatives could target religious and/or Republican/conservative students, as they have lower HR support. Among HR policies, Good Samaritan policies may be easiest to pass in college communities.

A pilot study of U.S. college students' 12-step orientation and the relationship with medications for opioid use disorder.

Objective: To examine undergraduate college students' attitudes toward 12-step support group utilization for opioid use disorder (OUD) and associations with previous experience with medications for OUD (MOUD). Participants: A convenience sample of undergraduate students at two major U.S. universities during Fall 2018 and Spring 2019. Method: A cross-sectional online survey of agreement with three 12-step orientation measures, MOUD experience, and demographic variables. Results: 1,281 students responded. Among 12-step orientation measures, respondents were most likely to agree that people with OUD should reach out to others in recovery. MOUD experience was significantly and negatively associated with agreement on each 12-step orientation measure. Religiosity/spirituality was positively associated with agreement that people with OUD should accept lack of control over OUD while placing trust in a higher power. Conclusion: Students with MOUD experience may be aware of anti-MOUD stigma in peer support groups and thus less likely to agree with 12-step orientation measures.

Criminal problem-solving and civil dependency court policies regarding medications for opioid use disorder.

Background: Criminal problem-solving courts and civil dependency courts often have participants with substance use disorder (SUD), including opioid use disorder (OUD). These courts refer participants to treatment and set treatment-related requirements for court participants to avoid incarceration or to regain custody of children. Medications for opioid use disorder (MOUD) are the most effective treatment for OUD but are underutilized by court system participants. Little is known about variation in court policies for different MOUDs. Also, more information is needed about types of policies for each MOUD, including whether participants may begin MOUD, continue previously begun MOUD, or complete the court program with MOUD. Methods: An online survey was distributed to criminal problem-solving and civil dependency judges in Florida in 2019 and 2020, yielding data from 58 judges (a 24% response rate). We used nonparametric statistics to test hypotheses with ordinal data. A Friedman's test for related samples or Cochran's Q was used to make within-group comparisons between policies and MOUDs. Results: We found considerable policy variation, with more permissive policies for naltrexone than buprenorphine or methadone, and more permissive policies for continuing MOUD than for initiating MOUD or completing a court program with MOUD. For each medication, less than one quarter of judges indicated their court always permits MOUD, with most indicating that MOUD is permitted sometimes or usually. Conclusion: Because respondents rarely chose "never" or "always" for any MOUD policy, most courts appear to be making MOUD decisions on a case-by-case basis. A clearer understanding of this decision-making process is needed. Some court participants may be required to discontinue MOUD before completing a court program, even if they were permitted to start or continue MOUD treatment. Discontinuation of MOUD without medical justification is contrary to the standard of care for individuals with OUD and increases their risk of overdose.

The Effect of State-Level Sex Education Policies on Youth Sexual Behaviors.

Two types of sex education are generally offered in the U.S. abstinence-only and comprehensive sex education. There is no clear scientific consensus over which approach minimizes the risk of unintended pregnancy and sexually transmitted diseases for youth. While there have been many studies of specific programs in clinical or quasi-experimental settings, there are very few evaluations of how state-level sex education policies affect the youth population. We estimate the impact of various state-level sex education policies on youth sexual activity and contraceptive use using data from four waves of the Youth Risk Behavior Surveillance System from 39 states. We found that states that require sexuality (sex and/or HIV/STD) education and contraceptive content or states that mandate education but leave the actual content up to local districts have lower rates of sexually active youth and higher rates of contraception use when youth are sexually active. States that require sexuality education and require abstinence content increase the rate at which youth are sexually active, and youth in those states are less likely to use hormonal birth control if they are sexually active. In conclusion, we found that state policies regarding sex and HIV/STD education had statistically significant effects that are meaningful in magnitude from a public health perspective.

Whose opinion matters about medications for opioid use disorder? A cross-sectional survey of social norms among court staff.

Background: Criminal problem-solving and dependency courts set treatment standards for opioid use disorder (OUD) but sometimes prohibit or limit utilization of medications for OUD (MOUD). Court staff beliefs about MOUD inform court treatment policies. Court staff MOUD policies may also be influenced by social norms, meaning perceptions of opinions of other individuals/entities about MOUD, including opinions of fellow staff in their court, staff in other courts, the state supreme court, other state agencies, the National Association of Drug Court Professionals (NADCP), federal agencies, and local peer support groups. To date no study has examined social norms among court staff with respect to MOUD. Methods: We distributed an online cross-sectional survey in 2019 to all criminal problem-solving and dependency court staff in Florida. Respondents were asked to identify the extent to which they cared about different entities'/individuals' opinions about MOUD and the extent to which they perceived each of those entities/individuals as encouraging MOUD. We hypothesized that court role and court type would be associated with responses. We used descriptive statistics, logistic regressions, and difference of proportions tests to analyze data. Results: 20% of the population (n = 119) completed the survey. Respondents cared most about the opinions of external treatment providers with whom they collaborate, fellow staff in their court, and the NADCP regarding MOUD. Fewer than half felt that any of these entities/individuals encourage methadone or oral buprenorphine. Additionally, fewer than 11% of respondents felt that local twelve-step peer support groups encourage the use of any form of MOUD. Conclusions: MOUD education should target all members of court teams, including collaborating treatment providers. Since court staff care relatively little about the MOUD opinions of staff in other courts, changes in opinions in one court may not affect changes in opinions in a neighboring court. The NADCP should more explicitly state its support for MOUD, and specifically oral buprenorphine and methadone treatment.

State Policies That Treat Prenatal Substance Use As Child Abuse Or Neglect Fail To Achieve Their Intended Goals.

The US is experiencing a complex substance abuse crisis. Not only has opioid overdose mortality increased sharply, by 400 percent from 1999 to 2017, but opioid use during pregnancy contributed to a 300 percent increase in neonatal abstinence syndrome (NAS)-a postnatal drug withdrawal syndrome in infants that is identified at birth-from 1999 to 2013. States have taken myriad policy approaches to combat the opioid crisis and its consequences, and some states have adopted punitive policies toward prenatal substance use. Using data for the period 2000-14 from the State Inpatient Databases of the Healthcare Cost and Utilization Project, this study examined the effect of state-level policies that treat prenatal substance use as child abuse or neglect on the incidence of NAS, maternal narcotic exposure, and substance use treatment admissions for pregnant women. We employed a difference-in-differences approach to estimate the effect of these policies. We did not find evidence that punitive prenatal substance use policies reduced NAS or maternal narcotic exposure at birth; however, we did find evidence that these policies may deter women from seeking substance use treatment during pregnancy. Policy makers might reconsider the efficacy of punitive policies and investigate increasing access to and reducing the cost of treatment for pregnant and parenting women.

Population Health Initiatives Among Hospitals: Associated Hospital Characteristics.

EXECUTIVE SUMMARY: This study explored how hospitals define population health and the factors associated with hospitals' population health initiatives. Data came from the 2015 American Hospital Association (AHA) Population Health Survey, the 2015 AHA Annual Survey, and the 2015 AHA Health Information Technology Supplement. Descriptive statistics described the sample of 1,386 nonfederal acute care hospitals and variables of interest. Multivariate logistic regression explored associations between population health commitment among hospitals and hospital characteristics. While hospitals defined population health in several ways, most (83%) responded that they were committed to population health activities. Multivariate regression results indicated that hospitals with lower levels of health information technology sophistication were less likely to commit to population health activities. For-profit hospitals were also less likely to commit to population health, compared to not-for-profit hospitals. System members were more likely to commit to population health initiatives, compared to independent hospitals. The variation in the definition of population health has implications for developing strategies to improve outcomes. These results present preliminary evidence on the relationship between hospital characteristics and hospital commitment to population health efforts.

Navigating the Digital Divide: Barriers to Telehealth in Rural Areas.

Telehealth allows information-sharing and clinical care at a distance via telecommunication and information technologies. While telehealth promises to increase access for underserved populations (particularly those in rural areas), roadblocks are slowing widespread availability. These roadblocks have created disparities that are most acute in rural areas, and for racial minorities, the elderly, and those with low levels of educational attainment. The success of telehealth relies on having reliable, high-quality broadband access, facilitating interstate licensing for providers and parity in reimbursement for telehealth. However, due to various structural barriers, telehealth is not being adopted as quickly in rural areas, where it is most needed. We describe broadband access by state, state adoption of the Interstate Medical Licensure Compacts (IMLCs), which facilitates the practice of telehealth across states, and state adoption of telehealth parity laws. We discuss each of these in turn and provide policy recommendations.

Good Samaritan harm reduction policy and drug overdose deaths.

OBJECTIVE: To examine the effects of a harm reduction policy, specifically Good Samaritan (GS) policy, on overdose deaths. DATA SOURCES/STUDY SETTING: Secondary data from multiple cause of death, mortality records paired with state harm reduction and substance use prevention policy. STUDY DESIGN: We estimate fixed effects Poisson count models to model the effect of GS policy on overdose deaths for all, prescription, and illicit drugs, controlled substances, and opioids, while controlling for other harm reduction and substance use prevention policies. DATA COLLECTION/EXTRACTION METHODS: We merge secondary data sources by state and year between 1999 and 2016. PRINCIPAL FINDINGS: We fail to identify a statistically significant effect of GS policy in reducing overdose deaths broadly. CONCLUSIONS: While we are unable to identify an effect of GS policy on overdose deaths, GS policy may have important effects on first-stage outcomes not investigated in this paper. Given recent state policy changes and rapid increase in many categories of overdose deaths, additional research should continue to examine the implementation and effects of harm reduction policy specifically and substance use prevention policy broadly.

The impact of expanded health insurance coverage for unauthorized pregnant women on prenatal care utilization.

OBJECTIVE: The objective of this study was to investigate the effect of expanding Medicaid health insurance coverage for unauthorized women on prenatal care utilization. DESIGN AND SAMPLE: A natural experiment design was used. We examined the prenatal care utilization of 20,876 unauthorized women from Nebraska, which expanded Medicaid coverage for unauthorized women, and South Carolina, which has never expanded coverage. MEASURES: Measurements of prenatal care utilization included adequate prenatal care using the Kotelchuck Index and the number of prenatal care visits. The policy independent variable of interest was an interaction between the policy years (2007-2009) and Nebraska residence. Demographic characteristics were included as covariates. Analysis entailed a difference-in-difference approach to compare prenatal care utilization by state, both before and after legislation was passed to fund care among unauthorized women in Nebraska. RESULTS: Women with insurance coverage were more likely to utilize prenatal services. Unauthorized women living in Nebraska during Medicaid expansion were 28% more likely to receive adequate prenatal care (OR = 1.28, p < 0.01) and had about one more prenatal care visit (IRR = 1.05, p < 0.01) than women who did not have expanded Medicaid coverage. CONCLUSIONS: Findings have important public health policy implications to support improved birth outcomes among native-born infants of unauthorized women.

Maternal Health of Undocumented Women With and Without Medicaid Access in Nebraska, 2007-2011.

INTRODUCTION: Four million infants are born in the United States to undocumented mothers. Nebraska granted Medicaid access to undocumented pregnant women from 1996 to 2010 and then discontinued access from 2010 to 2012. However, little is known about the maternal health of these undocumented women. The purpose of this study was to compare maternal health of undocumented women with and without access to Medicaid in Nebraska from 2007 to 2011. METHOD: A retrospective, longitudinal cohort design was conducted with 2007 to 2011 Nebraska birth certificate data. Study participants were 6,262 undocumented women. Groups of measures were created for demographics, prenatal, pregnancy, and delivery characteristics. Descriptive statistics were calculated and comparisons were conducted between women with and without access to Medicaid using chi-square and Student t tests. RESULTS: More than 60% of undocumented women had access to Medicaid, while 32% had no access to Medicaid. Undocumented women were predominately Hispanic (73.32%) and did not have a high school education (68.77%). The comparison of undocumented women with and without Medicaid revealed that women with Medicaid access had more than adequate prenatal care (17.86% vs. 14.80%) and a higher frequency of infant born with abnormal conditions (6.26% vs. 8.03%). Women without access to Medicaid more often had inadequate prenatal care (10.28% vs. 6.94%) and were obese prior to pregnancy (19.37% vs. 17.37%). CONCLUSIONS: Undocumented women who are prenatally obese and lack access to prenatal care may be at increased risk for poor maternal outcomes.

Association between Increased Emergency Contraception Availability and Risky Sexual Practices.

OBJECTIVE: We studied whether increased emergency contraception availability for women over age 18 was associated with a higher probability of risky sexual practices. DATA: A total of 34,030 individual/year observations on 3,786 women aged 18 and older were extracted from the National Longitudinal Survey of Youth, 1997 from October 1999 through November 2009. STUDY DESIGN: We modeled three binary outcome variables: any sexual activity; sexual activity with more than one partner; and any sex without a condom for women with multiple partners for women in states with state-level policy changes (prior to the 2006 FDA ruling) and for women in states subject to only the national policy change both jointly and separately. FINDINGS: We found different results when estimating the state and federal changes separately. The national change was associated with a reduction in the probability of sexual activity, a reduction in the likelihood of reporting multiple partnerships, and there was no relationship between the national policy change and unprotected sexual activity. There was no relationship between the probability of sexual activity or multiple partnerships for women in states with their own policy changes, but we did find that women in these states were more likely to report unprotected sex.

Association between increased availability of emergency contraceptive pills and the sexual and contraceptive behaviors of women.

In the United States (US), access to emergency contraceptive pills (ECPs) expanded to nationwide in 2006 when regulators allowed Plan B, a brand of emergency contraception, to be sold without prescription. Using data from the National Health and Nutrition Examination Survey from 2001 to 2010, I examined any association between increased access to these ECPs in the US and negative consequences. I found an association between increased access to ECPs and a 2.2 per cent higher probability of any sexual activity, a 5.2 per cent increase in the likelihood of reporting sex with multiple partners, an increase in the average number of partners by 0.35, and a -7.6 per cent decrease in the likelihood of injectable contraceptive use. These results suggest that policies in the US and other countries that expand access to ECPs should be paired with information on ECPs' lack of protection against sexually transmitted infections and relatively lower efficacy compared to other forms of contraception.

Changes in state prescription contraceptive mandates for insurers: the effect on women's contraceptive use.

CONTEXT: Access to effective contraceptives is critical to reducing levels of unintended childbearing in the United States. Since 1998, more than half the states have passed legislation requiring insurers that cover prescription drugs to cover prescription contraceptives approved by the Food and Drug Administration. An assessment of the impact of these laws on women's contraceptive use is needed to determine whether such policies are effective. METHODS: Information was collected on state contraceptive coverage policies, and contraceptive use data among women at risk of unintended pregnancy were drawn from Behavioral Risk Factor Surveillance System surveys conducted between 1998 and 2010. Logit regression analysis was used to calculate the marginal effects of state contraceptive coverage laws on insured and uninsured women's use of prescription methods. RESULTS: Insured women who lived in a state with a contraceptive coverage law were 5% more likely than their counterparts in states without such laws to use an effective method (i.e., a prescription method, condoms or sterilization). Among women who used such methods, those in contraceptive coverage states were 5% more likely than women in other states to use any prescription method, and 4% more likely to use the pill. No associations were found between contraceptive mandates and method use by uninsured women. Among both users and nonusers, contraceptive coverage was associated with a 5% increase in pill use. CONCLUSIONS: Contraceptive coverage mandates appear to play a role in increasing the use of prescription contraceptives among insured women, and hence may help to reduce the numbers of unintended pregnancies.