Harm Reduction and Treatment Among People at High Risk of Overdose.

Importance: Rates of overdose deaths involving synthetic opioids remain high, increasingly involve stimulants combined with opioids, and are increasing rapidly in racially and ethnically minoritized communities, yet little is known about access to harm reduction and treatment services in these groups. Objective: To characterize access and barriers to harm reduction and treatment in a racially and ethnically diverse population of people who use drugs. Design, Setting, and Participants: A cross-sectional telephone survey of people recruited from 39 treatment, harm reduction, and social service organizations in Milwaukee County, Wisconsin; Flint and Detroit, Michigan; and statewide in New Jersey was conducted from January 30 to July 28, 2023. Adults who used cocaine, methamphetamine, or opioids in the past 30 days called a study hotline and completed an interview in English or Spanish. Exposures: Overdose experience, drug types used (opioids only, stimulants only, and polysubstance), and social risk factors (eg, financial instability and criminal legal involvement). Main Outcomes and Measures: Recent use of any harm reduction services, fentanyl test strips, naloxone possession, treatment, and self-reported barriers to services. Results: Of the total sample of 1240 adults, 486 (39.2%) were Black non-Hispanic, 183 (14.8%) were Hispanic, and 464 (37.4%) were White non-Hispanic. In the past 30 days, 826 individuals (66.6%) were polysubstance users, 135 (10.9%) used only opioids, and 279 (22.5%) used only stimulants. A total of 349 respondents (28.1%) experienced a prior-year overdose. Compared with those without a prior-year overdose, people with overdose were more likely to possess naloxone (80.7% vs 68.2%; P < .001), possess fentanyl test strips (36.8% vs 23.5%; P < .001), and use harm reduction services (63.4% vs 53.0%; P = .003), while differences in treatment use were nonsignificant (52.0% vs 46.6%; P = .24). Among stimulant-only users, 51.4% possessed naloxone compared with 77.3% of opioid-only users (P < .001) and 77.6% of polysubstance users (P < .001), with similar disparities in fentanyl test strip possession. Conclusions and Relevance: In this cross-sectional study of people who used drugs in the past 30 days, findings highlighted low use of harm reduction and treatment services among people who use stimulants. Additional communication regarding their importance may help increase the use of the services amidst a rapidly changing drug supply.

"What I should be doing is harm reduction, if I'm doing my job right": Engagement with harm reduction principles among prosecutors enacting drug policy reform in the United States.

BACKGROUND: Prosecutorial discretion to pursue or decline criminal charges is a powerful mechanism determining criminal justice outcomes among people who use drugs (PWUD). In the US, prosecutors are increasingly employing this tool to prevent arrest, incarceration, and subsequent health and social harms among PWUD. Many cite harm reduction as a basis for these reforms; however, the extent of prosecutors' knowledge and understanding of harm reduction principles, and how they are operationalized in the policy process, remains unclear. METHODS: We assess references to and application of harm reduction in the policy design and implementation process of prosecutorial drug policy reform in 14 US jurisdictions. In-depth-interviews (N = 16) were conducted with elected prosecutors and their policy staff from November 2021-April 2022. Through initial structured analysis, policymakers' understanding and utilization of the term 'harm reduction' emerged as a salient theme which we conducted secondary thematic analysis to further explore. RESULTS: While all participants identified as progressive, there was wide variation in their ideologies, policy provisions, and engagement with harm reduction principles. Eleven participants explicitly referred to 'reducing harms of drug use' or 'harm reduction' as guiding their policy approach; the remainder did not invoke 'harm reduction' by name but highlighted relevant concepts like racial equity and 'public health approaches' as core policy tenets. While some prosecutors demonstrated familiarity with traditional harm reduction principles (meeting PWUD where they are, reducing harms to them), others focused on harm to the wider community (the 'public,' businesses, etc). Invocation of harm reduction was not always consistent with specific policy provisions: prosecutors implemented policies ranging from unconditional non-prosecution of drug possession to diversion, some of which were odds with core harm reduction principles of dignity and justice (i.e., involving coercive treatment incentives/requirements). CONCLUSIONS: As prosecutors shift their approach to redress the harms caused by drug criminalization, clarity is needed on what a harm reduction approach to using discretionary powers entails. Targeting reform-minded prosecutors with messaging on the principles, evidence base, and best practices of harm reduction is merited.

Examining identity disclosure: Racial and ethnic identity amongst Multiracial/ethnic adults in the United States.

OBJECTIVES: Providing personal demographic information is routine practice in the United States, and yet, little is known about the impacts of this process. This study aims to examine the experiences and perspectives of Multiracial/ethnic adults in the United States when disclosing racial/ethnic identity. METHODS: Seventeen semistructured interviews were conducted with adults identifying as Multiracial/ethnic. The Multiracial/ethnic identities of participants included Black or African American and White; Black or African American, American Indian or Alaska Native (AI/AN) and Hispanic or Latino; Black or African American and Hispanic or Latino; Black or African American and AI/AN; AI/AN and White and Asian, Native Hawaiian or Pacific Islander and White. Multiple participants reported identifying with multiple ethnic groups for any single broad category. Three identified as sexual minorities. Nine were Millennials; six were Gen X; one was Gen Z; one was Baby Boomer. Qualitative data were analyzed using staged hybrid inductive-deductive thematic analysis. RESULTS: Disclosure of racial and ethnic identities presents a unique stressor for Multiracial/ethnic populations due to methods used to obtain data, perceived mismatch of identity and phenotype and exposure to prejudice. Social norms, constructs and movements impact the categories that a Multiracial/ethnic person indicates to external parties. CONCLUSIONS: The stress and negative feelings that Multiracial/ethnic adults face when identifying their race/ethnicity underscore the broader implications of standard demographic questions on feelings of inclusivity and visibility within a population. PATIENT OR PUBLIC CONTRIBUTION: Gathering data on individuals' racial and ethnic backgrounds is a standard practice, and yet, it can pose challenges for those who identify with multiple groups or do not see their identities reflected in the options provided. Such individuals may feel excluded or experience unfair treatment when disclosing their identity, leading to significant stress. As the frequency of this data collection increases, it is essential that the questions are posed empathetically and equitably, with a strong commitment to enhancing inclusivity throughout the process.

A content analysis of legal policy responses to xylazine in the illicit drug supply in the United States.

BACKGROUND: Xylazine is a veterinary sedative that is quickly spreading in the U.S. illicit drug supply and is increasingly associated with fatal overdoses and severe wounds. In response, xylazine has been deemed an emerging public health threat and several policy initiatives have been introduced to combat its spread and negative broad health impact. We aimed to synthesize trends in all-time U.S. policy responses to xylazine in the drug supply. METHODS: In April 2024, we systematically identified and categorized proposed and enacted policy initiatives that related to human xylazine consumption by searching LexisNexis and Thomas Reuters Westlaw legal databases. RESULTS: Of 58 unique policy initiatives, most were introduced in 2023 (n = 37/58, 64 %) and concentrated in Northeastern states. Penalties for xylazine possession, often tied to state drug scheduling changes, were the most common provision (n = 34/58; 59 %) and Schedule III was the most frequently proposed scheduling level (n = 17/30; 57 %). Other provisions included proposals to enhance: test strip access (n = 11/58; 19 %), public awareness and education (n = 3/58; 5 %), xylazine-specific research (n = 4/58; 7 %), and surveillance (n = 8/58; 14 %). CONCLUSION: U.S. state and federal policy responses to xylazine grew rapidly in 2023, were most concentrated in states affected most by xylazine, and scheduling was the most commonly proposed policy approach. Research measuring policy effects should be prioritized as policies are implemented.

Experience of Personal Loss Due to Drug Overdose Among US Adults.

Importance: Since 1999, over 1 million people have died of a drug overdose in the US. However, little is known about the bereaved, meaning their family, friends, and acquaintances, and their views on the importance of addiction as a policy priority. Objectives: To quantify the scope of the drug overdose crisis in terms of personal overdose loss (ie, knowing someone who died of a drug overdose) and to assess the policy implications of this loss. Design, Setting, and Participants: This cross-sectional study used data from a nationally representative survey of US adults (age ≥18 years), the fourth wave of the COVID-19 and Life Stressors Impact on Mental Health and Well-Being (CLIMB) study, which was conducted from March to April 2023. Main Outcomes and Measures: Respondents reported whether they knew someone who died of a drug overdose and the nature of their relationship with the decedent(s). They also reported their political party affiliation and rated the importance of addiction as a policy issue. Logistic regression models estimated the associations between sociodemographic characteristics and political party affiliation and the probability of experiencing a personal overdose loss and between the experience of overdose loss and the perceived salience of addiction as a policy issue. Survey weights adjusted for sampling design and nonresponse. Results: Of the 7802 panelists invited to participate, 2479 completed the survey (31.8% response rate); 153 were excluded because they did not know whether they knew someone who died of a drug overdose, resulting in a final analytic sample of 2326 (51.4% female; mean [SD] age, 48.12 [0.48] years). Of these respondents, 32.0% (95% CI, 28.8%-34.3%) reported any personal overdose loss, translating to 82.7 million US adults. A total of 18.9% (95% CI, 17.1%-20.8%) of all respondents, translating to 48.9 million US adults, reported having a family member or close friend die of drug overdose. Personal overdose loss was more prevalent among groups with lower income (<$30 000: 39.9%; ≥$100 000: 26.0%). The experience of overdose loss did not differ across political party groups (Democrat: 29.0%; Republican: 33.0%; independent or none: 34.2%). Experiencing overdose loss was associated with a greater odds of viewing addiction as an extremely or very important policy issue (adjusted odds ratio, 1.37; 95% CI, 1.09-1.72) after adjustment for sociodemographic and geographic characteristics and political party affiliation. Conclusions and Relevance: This cross-sectional study found that 32% of US adults reported knowing someone who died of a drug overdose and that personal overdose loss was associated with greater odds of endorsing addiction as an important policy issue. The findings suggest that mobilization of this group may be an avenue to facilitate greater policy change.

Emerging models of de facto drug policy reforms in the United States.

BACKGROUND: Health and human rights organizations have endorsed drug decriminalization to promote public health-oriented approaches to substance use. In the US, policymakers have begun to pursue this via prosecutorial discretion-or the decision by a prosecutor to decline criminal charges for drug possession in their jurisdiction. This study characterizes drivers of adoption, policy design and implementation processes, and barriers to impact and sustainability of this approach to inform evolving policy efforts promoting the health of people who use drugs (PWUD). METHODS: We conducted n=22 key informant interviews with policymakers and national policy experts representing 13 jurisdictions implementing de facto drug policy reforms. Analyses were informed by the Exploration, Preparation, Implementation and Sustainment (EPIS) framework and analyzed using a hybrid inductive-deductive approach. RESULTS: Drivers of policy adoption included racial inequities, perceived failures of criminalization, and desires to prioritize violent crime given resource constraints. Three distinct policy typologies are described with varying conditions for eligibility, linkage to services, and policy transparency and dissemination. Public misinformation, police resistance and political opposition were seen as threats to sustainability. CONCLUSIONS: Given evidence that criminalization amplifies drug-related harms, many policymakers are adopting de facto drug policy reforms in the absence of formal legislation. This is the first study to systematically describe relevant implementation processes and emerging policy models. Findings have implications for designing rigorous evaluations on health outcomes and informing sustainable evidence-based policies to promote health and racial equity of PWUD in the US.

Association of buprenorphine retention and subsequent adverse outcomes following non-fatal overdose: An analysis using statewide linked Maryland databases.

INTRODUCTION: Patients receiving buprenorphine after a non-fatal overdose have lower risk of future nonfatal or fatal overdose, but less is known about the relationship between buprenorphine retention and the risk of adverse outcomes in the post-overdose year. OBJECTIVE: To examine the relationship between the total number of months with an active buprenorphine prescription (retention) and the odds of an adverse outcome within the 12 months following an index non-fatal overdose. MATERIALS AND METHODS: We studied a cohort of people with an index non-fatal opioid overdose in Maryland between July 2016 and December 2020 and at least one filled buprenorphine prescription in the 12-month post-overdose observation period. We used individually linked Maryland prescription drug and hospital admissions data. Multivariable logistic regression models were used to examine buprenorphine retention and associated odds of experiencing a second non-fatal overdose, all-cause emergency department visits, and all-cause hospitalizations. RESULTS: Of 5439 people, 25% (n=1360) experienced a second non-fatal overdose, 78% had an (n=4225) emergency department visit, and 37% (n=2032) were hospitalized. With each additional month of buprenorphine, the odds of experiencing another non-fatal overdose decreased by 4.7%, all-cause emergency department visits by 5.3%, and all-cause hospitalization decreased by 3.9% (p<.0001, respectively). Buprenorphine retention for at least nine months was a critical threshold for reducing overdose risk versus shorter buprenorphine retention. CONCLUSIONS: Buprenorphine retention following an index non-fatal overdose event significantly decreases the risk of future overdose, emergency department use, and hospitalization even among people already on buprenorphine.

Barriers and facilitators to use of buprenorphine in state-licensed specialty substance use treatment programs: A survey of program leadership.

INTRODUCTION: Medications for opioid use disorder (MOUD), including buprenorphine, reduce overdose risk and improve outcomes for individuals with opioid use disorder (OUD). However, historically, most non-opioid treatment program (non-OTP) specialty substance use treatment programs have not offered buprenorphine. Understanding barriers to offering buprenorphine in specialty substance use treatment settings is critical for expanding access to buprenorphine. This study aims to examine program-level attitudinal, financial, and regulatory factors that influence clients' access to buprenorphine in state-licensed non-OTP specialty substance use treatment programs. METHODS: We surveyed leadership from state-licensed non-OTP specialty substance use treatment programs in New Jersey about organizational characteristics, including medications provided on- and off-site and percentage of OUD clients receiving any type of MOUD, and perceived attitudinal, financial, and regulatory barriers and facilitators to buprenorphine. The study estimated prevalence of barriers and compared high MOUD reach (n = 36, 35 %) and low MOUD reach (n = 66, 65 %) programs. RESULTS: Most responding organizations offered at least one type of MOUD either on- or off-site (n = 80, 78 %). However, 71 % of organizations stated that fewer than a quarter of their clients with OUD use any type of MOUD. Endorsement of attitudinal, financial, and institutional barriers to buprenorphine were similar among high and low MOUD reach programs. The most frequently endorsed government actions suggested to increase use of buprenorphine were facilitating access to long-acting buprenorphine (n = 95, 96 %), education and stigma reduction for clients and families (n = 95, 95 %), and financial assistance to clients to pay for medications (n = 90, 90 %). CONCLUSIONS: Although non-OTP specialty substance use programs often offer clients access to MOUD, including buprenorphine, most OUD clients do not actually receive MOUD. Buprenorphine uptake in these settings may require increased financial support for programs and clients, more robust education and training for providers, and efforts to reduce the stigma associated with medication among clients and their families.

Substance use and treatment characteristics among pregnant and non-pregnant females, 2015-2019.

INTRODUCTION: In the United States (US), pregnant females who use substances face increased morbidity and mortality risks compared to non-pregnant females. This study provides a national snapshot of substance use and treatment characteristics among US reproductive-aged females, including those who are pregnant. METHODS: Our sample included females aged 15-44 years (n=97,830) from the 2015-2019 National Survey on Drug Use and Health (NSDUH) data. We calculated weighted percentages of past-month alcohol or drug use and past-year substance use disorder (SUD), stratified by pregnancy status. We also calculated weighted percentages of past-year treatment setting and payer. Pearson chi-square tests were conducted to determine if percentages were statistically significantly different. RESULTS: Compared to non-pregnant females, pregnant females had lower prevalence of past-month illicit drug use excluding cannabis (1.6% vs. 4.3%, p<0.01), cannabis use (5.3% vs. 12.5%, p<0.01), binge drinking (4.5% vs. 29.3%, p<0.01) and past-year SUD (7.1 vs. 8.8%, p<0.01). Less than 13% of females with SUD received treatment regardless of pregnancy status, but treatment use was higher among pregnant females compared to non-pregnant females (12.8% vs. 10.5%). However, there were no statistically significant differences in past-year treatment use, setting, or treatment payer. DISCUSSION: The prevalence of substance use and SUD was lower among pregnant females compared to non-pregnant females in 2015-2019. Low uptake of substance use treatment suggests that barriers exist to treatment-seeking among reproductive-aged women. Further exploration of stigma, payment, and access to treatment, and how they differ by pregnancy status, is needed.

Implementation of the 988 Suicide & Crisis Lifeline: Estimating State-Level Increases in Call Demand Costs and Financing.

BACKGROUND: Per federal law, "988" became the new three-digit dialing code for the National Suicide & Crisis Lifeline on July 16, 2022 (previously reached by dialing "1-800-283-TALK"). AIMS OF THE STUDY: This study aimed to produce state-level estimates of: (i) annual increases in 988 Lifeline call volume following 988 implementation, (ii) the cost of these increases, and (iii) the extent to which state and federal funding earmarked for increases in 988 Lifeline call volume are sufficient to meet call demand. METHOD: A 50 state pre-post policy implementation design was used. State-level Lifeline call volume data were obtained. For each state, we calculated the absolute difference in number of Lifeline calls in the four-month periods between August-November 2021 (pre-988 implementation) and August-November 2022 (post-988 implementation), and also expressed this difference as percent change and rate per 100,000 population. The difference call volume was multiplied by a published estimate of the cost of a single 988 Lifeline call (USD 82), and then by multiplied by three to produce annual, 12-month state-level cost increase estimates. These figures were then divided by each state's population size to generate cost estimates per state resident. State-level information on the amount of state (FY 2023) and federal SAMHSA (FY 2022) funding earmarked for 988 Lifeline centers in response to 988 implementation were obtained from legal databases and government websites and expressed as dollars per state resident. State-level differences between per state resident estimates of increased cost and funding were calculated to assess the extent to which state and federal funding earmarked for increases in 988 Lifeline call volume were sufficient to meet call demand. RESULTS: 988 Lifeline call volume increased in all states post-988 implementation (within-state mean percent change = +32.8%, SD = +20.5%). The total estimated cost needed annually to accommodate increases in 988 Lifeline call volume nationally was approximately USD 46 million. The within-state mean estimate of additional cost per state resident was +USD 0.16 (SD = +USD 0.11). The additional annual cost per state resident exceeded USD 0.40 in three states, was between USD 0.40- USD 0.30 in three states, and between USD 0.30 - USD 0.20 in seven states. Twenty-two states earmarked FY 2023 appropriations for 988 Lifeline centers in response to 988 (within-state mean per state resident = USD 1.51, SD = USD 1.52) and 49 states received SAMHSA 988 capacity building grants (within-state mean per state resident = USD 0.36, SD = USD 0.39). State funding increases exceeded the estimated cost increases in about half of states. CONCLUSIONS: The Lifeline's transition to 988 increased 988 Lifeline call volume in all states, but the magnitude of the increase and associated cost was heterogenous across states. State funding earmarked for increases in 988 Lifeline center costs is sufficient in about half of states. Sustained federal funding, and/or increases in state funding, earmarked for 988 Lifeline centers is likely important to ensuring that 988 Lifeline centers have the capacity to meet call demand in the post-988 implementation environment.

Effects of state opioid prescribing cap laws on providers' opioid prescribing patterns among patients with chronic non-cancer pain.

Prior work suggests opioid prescribing cap laws are not associated with changes in opioid prescribing among patients with chronic pain. It is unknown how these effects differ by provider specialty, provider opioid prescribing volume, or patient insurer. This study assessed effects of state opioid prescribing cap laws on opioid prescribing among providers of patients with chronic non-cancer pain, by high volume prescribing, provider specialty, and patient insurer. We identified 224,290 providers of patients with low back pain, fibromyalgia, or headache from the IQVIA administrative database. Using a difference-in-differences approach, we examined impacts of opioid prescribing cap laws implemented between 2016 and 2018 on the annual proportion of a provider's patient panel who received any opioid prescription, as well as on dose and duration of opioid prescriptions. For providers overall, high volume prescribers, all specialties, and patient insurance categories, prescribing cap laws were associated with non-significant changes of <1.0, 1.5, and 3.5 percentage points in the proportion of chronic non-cancer patients receiving any opioid prescription, a prescription with 7 days' supply, or with >50 morphine milligram equivalents (MME)/day, per year, respectively. There were two exceptions with high dose prescribing: prescribing cap laws were associated with a 1.5 percentage point increase in the proportion of high-volume prescribers' patient panel receiving an opioid prescription with ≥50 MME/day, and a 3.0 percentage point decrease in the same measure among surgeons. Among nearly all measured subgroups of providers and patient insurers, opioid prescribing cap laws were not associated with changes in opioid prescribing.

Expanding buprenorphine in U.S. jails: One county's response to addressing the fears of diversion.

INTRODUCTION: The overdose crisis continues to be a major public health emergency in the United States. While effective medications for opioid use disorder (MOUD), such as buprenorphine, have ample scientific evidence to their effectiveness, they are underutilized in the United States and particularly in criminal justice settings. One rationale against the expansion of MOUD in carceral settings cited by jail, prison, and even Drug Enforcement Administration leaders is the potential for diversion of these medications. However, currently little data exist to support this claim. Instead, successful examples from early expansion states could help to change attitudes and calm misconceptions around diversion fears. RESULTS: In this commentary, we discuss the experience of one county jail that successfully expanded buprenorphine treatment and did not suffer significant impacts related to diversion. Instead, the jail found that their holistic and compassionate approach to buprenorphine treatment improved conditions both for incarcerated individuals and jail staff. CONCLUSION: Amid a changing policy landscape and a federal commitment to increase access to effective treatments in criminal justice settings, lessons can be learned from jails and prisons that have already or are working toward expansion of MOUD in their facilities. Ideally, these anecdotal examples, in addition to data, will help to encourage more facilities to incorporate buprenorphine into their opioid use disorder treatment strategies.

Implementation of State Laws Giving Pregnant People Priority Access to Drug Treatment Programs in the Context of Coexisting Punitive Laws.

BACKGROUND: In response to increased prenatal drug use since the 2000s, states have adopted treatment-oriented laws giving pregnant and postpartum people priority access to public drug treatment programs as well as multiple punitive policy responses. No prior studies have systematically characterized these state statutes or examined implementation of state priority access laws in the context of co-existing punitive laws. METHODS: We conducted legal mapping to examine state priority access laws and their overlap with state laws deeming prenatal drug use to be child maltreatment, mandating reporting of prenatal drug use to child protective services, or criminalizing prenatal drug use. We also conducted interviews with 51 state leaders with expertise on their states' prenatal drug use laws to understand how priority access laws were implemented. RESULTS: Thirty-three states and the District of Columbia have a priority access law, and more than 80% of these jurisdictions also have one of the punitive prenatal drug use laws described. Leaders reported major barriers to implementing state priority access laws, including the lack of drug treatment programs, stigma, and conflicts with punitive prenatal drug use laws. CONCLUSIONS: Our results suggest that state laws granting pregnant and postpartum people priority access to drug treatment programs are likely insufficient to significantly increase access to evidence-based drug treatment. Punitive state prenatal drug use laws may counteract priority access laws by impeding treatment seeking. Findings highlight the need to allocate additional resources to drug treatment for pregnant and postpartum people.

Creating Comprehensive Crisis Response Systems: An Opportunity to Build on The Promise of 988.

The implementation of a national suicide prevention hotline is imminent and will need to be supported by comprehensive crisis systems, which are currently rarely implemented in part due to their cost. In this Commentary paper we identify three core components of a high-functioning, integrated crisis service system. We identified regional crisis call centers, mobile response teams, and crisis receiving and stabilization centers as core components of an integrated crisis service system. We then outline how this approach has been used in Arizona. Building out these systems and sustainable funding models to support these systems is necessary to ensure that 988 implementation lives up to the promise of creating a lifeline to support services for individuals in crisis.

Mental health and Multiracial/ethnic adults in the United States: a mixed methods participatory action investigation.

Introduction: Addressing gaps in the integration of justice, diversity, equity, and inclusion (J-DEI) in public health research and practice, this study investigates the mental health of Multiracial and multiethnic adults in the United States (U.S.). A rapidly growing racial/ethnic group in the U.S., Multiracial and multiethnic populations are often excluded or underrepresented in standard public health research and practice, and little is known about their mental health or associated risk and protective factors. Methods: To investigate this knowledge gap, an electronic cross-sectional survey was conducted in two waves in 2022, pulling from various community sources, with 1,359 respondents in total. Complementing this, seventeen semi-structured interviews were performed with a subset of survey participants. Data were analyzed using a mix of statistical methods and staged hybrid inductive-deductive thematic analysis. Results: Findings indicate over half of the participants endorsed at least one mental health concern with prevalence of anxiety, depression, post-traumatic stress disorder, and suicidal thoughts and behaviors surpassing available national estimates. Exposure to trauma, discrimination, and microaggressions were found to play a significant role in these outcomes. Conversely, strong social support and strong ethnic identity emerged as protective factors. Qualitative insights brought forward the challenges faced by individuals in navigating bias and stigma, especially in the context of mental health care. Despite these barriers, emerging themes highlighted resilience, the importance of secure identity formation, and the critical role of community and cultural support. Conclusions: The marked prevalence of mental health concerns among Multiracial and multiethnic populations emphasizes the pressing need for tailored interventions and inclusive research methodologies. Recognizing and addressing the unique challenges faced by these communities is imperative in driving mental health equity in the U.S. The findings advocate for community-engaged practices, interdisciplinary collaborations, and the importance of addressing mental health challenges with cultural sensitivity, particularly in historically oppressed and marginalized groups. Future efforts must focus on refining these practices, ensuring that public health initiatives are genuinely inclusive and equitable.

Development and Implementation of State and Federal Child Welfare Laws Related to Drug Use in Pregnancy.

Policy Points Over the past several decades, states have adopted policies intended to address prenatal drug use. Many of these policies have utilized existing child welfare mechanisms despite potential adverse effects. Recent federal policy changes were intended to facilitate care for substance-exposed infants and their families, but state uptake has been incomplete. Using legal mapping and qualitative interviews, we examine the development of state child welfare laws related to substance use in pregnancy from 1974 to 2019, with a particular focus on laws adopted between 2009 and 2019. Our findings reveal policies that may disincentivize treatment-seeking and widespread implementation challenges, suggesting a need for new treatment-oriented policies and refined state and federal guidance. CONTEXT: Amid increasing drug use among pregnant individuals, legislators have pursued policies intended to reduce substance use during pregnancy. Many states have utilized child welfare mechanisms despite evidence that these policies might disincentivize treatment-seeking. Recent federal changes were intended to facilitate care for substance-exposed infants and their families, but implementation of these changes at the state level has been slowed and complicated by existing state policies. We seek to provide a timeline of state child welfare laws related to prenatal drug use and describe stakeholder perceptions of implementation. METHODS: We catalogued child welfare laws related to prenatal drug use, including laws that defined child abuse and neglect and established child welfare reporting standards, for all 50 states and the District of Columbia (DC), from 1974 to 2019. In the 19 states that changed relevant laws between 2009 and 2019, qualitative interviews were conducted with stakeholders to capture state-level perspectives on policy implementation. FINDINGS: Twenty-four states and DC have passed laws classifying prenatal drug use as child abuse or neglect. Thirty-seven states and DC mandate reporting of suspected prenatal drug use to the state. Qualitative findings suggested variation in implementation within and across states between 2009 and 2019 and revealed that implementation of changes to federal law during that decade, intended to encourage states to provide comprehensive social services and linkages to evidence-based care to drug-exposed infants and their families, has been complicated by existing policies and a lack of guidance for practitioners. CONCLUSIONS: Many states have enacted laws that may disincentivize treatment-seeking among pregnant people who use drugs and lead to family separation. To craft effective state laws and support their implementation, state policymakers and practitioners could benefit from a treatment-oriented approach to prenatal substance use and additional state and federal guidance.

Scaling Interventions to Manage Chronic Disease: Innovative Methods at the Intersection of Health Policy Research and Implementation Science.

Policy implementation is a key component of scaling effective chronic disease prevention and management interventions. Policy can support scale-up by mandating or incentivizing intervention adoption, but enacting a policy is only the first step. Fully implementing a policy designed to facilitate implementation of health interventions often requires a range of accompanying implementation structures, like health IT systems, and implementation strategies, like training. Decision makers need to know what policies can support intervention adoption and how to implement those policies, but to date research on policy implementation is limited and innovative methodological approaches are needed. In December 2021, the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness and the Johns Hopkins Center for Mental Health and Addiction Policy convened a forum of research experts to discuss approaches for studying policy implementation. In this report, we summarize the ideas that came out of the forum. First, we describe a motivating example focused on an Affordable Care Act Medicaid health home waiver policy used by some US states to support scale-up of an evidence-based integrated care model shown in clinical trials to improve cardiovascular care for people with serious mental illness. Second, we define key policy implementation components including structures, strategies, and outcomes. Third, we provide an overview of descriptive, predictive and associational, and causal approaches that can be used to study policy implementation. We conclude with discussion of priorities for methodological innovations in policy implementation research, with three key areas identified by forum experts: effect modification methods for making causal inferences about how policies' effects on outcomes vary based on implementation structures/strategies; causal mediation approaches for studying policy implementation mechanisms; and characterizing uncertainty in systems science models. We conclude with discussion of overarching methods considerations for studying policy implementation, including measurement of policy implementation, strategies for studying the role of context in policy implementation, and the importance of considering when establishing causality is the goal of policy implementation research.

Trends in opioid and non-opioid treatment for chronic non-cancer pain and cancer pain among privately insured adults in the United States, 2012-2019.

Recent clinical guidelines have emphasized non-opioid treatments in lieu of prescription opioids for chronic non-cancer pain, exempting cancer patients from these recommendations. In this study, we determine trends in opioid and non-opioid treatment among privately insured adults with chronic non-cancer pain (CNCP) or cancer. Using administrative claims data from IBM MarketScan Research Databases, we identified privately-insured adults who were continuously enrolled in insurance for at least one calendar year from 2012 to 2019. We identified individuals with CNCP diagnosis, defined as a diagnosis of arthritis, headache, low back pain, and/or neuropathic pain, and a individuals with cancer diagnosis in a calendar year. Outcomes included receipt of any opioid, non-opioid medication, or non-pharmacologic CNCP therapy and opioid prescribing volume, MME-per-day, and days' supply. Estimates were regression-adjusted for age, sex, and region. Between 2012 and 2019, the proportion of patients who received any opioid decreased across both groups (CNCP: 49.7 to 30.5%, p<0.01; cancer: 86.0 to 78.7%, p<0.01). Non-opioid pain medication receipt remained steady for individuals with CNCP (66.7 to 66.4%, p<0.01) and increased for individuals with cancer (74.4 to 78.8%, p<0.01), while non-pharmacologic therapy use rose among individuals with CNCP (62.4 to 66.1%, p<0.01). Among those prescribed opioids, there was a decrease in the receipt of at least one prescription with >90 MME/day (CNCP: 13.9% in 2012 to 4.9% in 2019, p<0.01; Cancer: 26.2% to 7.6%, p<0.01); >7 days of supply (CNCP: 56.3% to 30.7%, p <0.01; Cancer: 47.5% to 22.7%, p<0.01), the mean number of opioid prescriptions (CNCP: 5.2 to 3.9, p<0.01; Cancer: 4.0 to 2.7, p<0.01) and mean MME/day (CNCP: 49.9 to 38.0, p<0.01; Cancer: 62.4 to 44.7, p<0.01). Overall, from 2012-2019, opioid prescribing declined for CNCP and cancer, with larger reductions for patients with CNCP. For both groups, reductions in prescribed opioids outpaced increases in non-opioid alternatives.