Alcohol Screening During US Primary Care Visits, 2014-2016.

BACKGROUND: Unhealthy alcohol use is a significant health issue for the US population. The US Preventive Services Task Force (USPSTF) recommends screening adults 18 years or older for unhealthy alcohol use during primary care visits. OBJECTIVES: To evaluate alcohol screening among ambulatory visits made by US adult primary care patients and identify characteristics predictive of alcohol screening. DESIGN: A series of cross-sectional analysis of the National Ambulatory Medical Care Survey (NAMCS) data collected from 2014 to 2016 was used to examine US primary care providers' use of alcohol screening questionnaires and delivery of counseling on alcohol use. PARTICIPANTS: A total of 19,213 visits made by patients aged 18 years or older to a US primary care physician trained in family medicine or internal medicine. MAIN MEASURES: Administration of a validated alcohol screening questionnaire and counseling/education on alcohol use. Variation in alcohol screening by patient demographic characteristics, reason for office visit, length of office visit, chronic medical conditions, evaluation by assigned primary care physician, new patient to practice, and region. KEY RESULTS: Alcohol screening with a validated questionnaire occurred during 2.6% (95% Cl: 0.9%, 4.3%) of visits. Alcohol counseling, provided either by the physician or by referral, was documented in 0.8% (95% Cl: 0.3%, 1.3%) of visits. Screening was significantly more likely if patients were seen by their assigned primary care physician (adjOR 4.38 (95% Cl: 1.41, 13.61)), a new patient to the practice (adjOR 4.18 (95% Cl: 2.30, 7.79)), or had several chronic medical conditions (adjOR 3.40 (95% Cl: 1.48, 7.78)). Patients' sex, race/ethnicity, age group, or length of appointment time was not associated with screening for unhealthy alcohol use. CONCLUSIONS: Screening for unhealthy alcohol use using a validated questionnaire is uncommonly performed during US primary care visits. Interventions or incentives may be needed to increase uptake of USPSTF alcohol screening recommendations.

Talking about firearm injury prevention with patients: a survey of medical residents.

BACKGROUND: Firearm injury and death are significant public health problems in the U.S. and physicians are uniquely situated to help prevent them. However, there is little formal training in medical education on identifying risk for firearm injury and discussing safe firearm practices with patients. This study assesses prior education, barriers to counseling, and needs for improved training on firearm safety counseling in medical education to inform the development of future education on clinical strategies for firearm injury prevention. METHOD: A 2018 survey administered to 218 residents and fellows at a large, academic medical center asked about medical training on firearm injury prevention, frequency of asking patients about firearm access, and perceived barriers. RESULTS: The most common barriers cited were not knowing what to do with patients' answers about access to firearms (72.1%), not having enough time (66.2%), not feeling comfortable identifying patients at-risk for firearm injury (49.2%), and not knowing how to ask patients about firearm access (48.6%). Prior education on firearm injury prevention was more strongly associated with asking than was personal exposure to firearms: 51.5% of respondents who had prior medical education reported asking compared with who had not received such education (31.8%, p=0.004). More than 90% of respondents were interested in further education about interventions, what questions to ask, and legal mechanisms to separate dangerous people from their firearms. CONCLUSIONS: Education on assessing risk for firearm-related harm and, when indicated, counseling on safe firearm practices may increase the likelihood clinicians practice this behavior, though additional barriers exist.

Association between Opioid Overdose and Health Plan Disenrollment with Mitigating Impact of Buprenorphine Initiation.

Context: Health plan disenrollment has been associated with higher mortality in patients with opioid use disorder. Insurance loss and health plan disenrollment might be downstream social consequences of opioid misuse and overdose that may heighten patient mortality risks during a period of heightened need for professional assistance. Objective: To test hypotheses that: 1) overdose events in patients prescribed long-term opioids are associated with subsequent health plan disenrollment; and 2) buprenorphine initiation after overdose would attenuate this association. Study Design: Retrospective cohort study. Setting and Dataset: Data from the Optum Labs Data Warehouse which includes de-identified medical and pharmacy claims and enrollment records for commercial and Medicare Advantage enrollees. The database contains longitudinal health information on patients, representing a mixture of ages, ethnicities, and geographical regions across the United States. Population studied: Adults (aged ≥18 years) prescribed stable, opioid therapy for a 6-month baseline period (≥90% of days covered, <10% monthly fluctuation from 6-month average, average daily dose ≥10 morphine milligram equivalents). Outcome Measures: Health plan disenrollment during up to one year of follow-up. Negative binomial regression estimated adjusted incidence rate ratios of disenrollment by incident overdose and buprenorphine initiation after overdose. Results: We identified 556,676 patients who were followed up after 1,119,100 stable periods of opioid therapy. During follow-up, 17.5% of person-periods ended in health plan disenrollment. Overdose events during follow-up were associated with health plan disenrollment with a dose-response relationship [adjusted incidence rate ratio (aIRR) for 1 overdose event = 1.29 (95% CI: 1.24-1.35); aIRR for ≥2 overdose events = 1.51 (1.43-1.59)]. Among patients with overdose events, subsequent buprenorphine initiation was associated with substantially reduced risk of health plan disenrollment [aIRR 0.36 (0.17-0.74)]. Conclusions: Overdose events in patients prescribed long-term opioids may portend other social consequences, such as health insurance loss, which may exacerbate patient risk at a time of heightened need and vulnerability. Buprenorphine may mitigate the risk of health plan disenrollment in opioid-prescribed patients who overdose.

Longitudinal Dose Trajectory Among Patients Tapering Long-Term Opioids.

OBJECTIVE: To evaluate the dose trajectory of new opioid tapers and estimate the percentage of patients with sustained tapers at long-term follow-up. DESIGN: Retrospective cohort study. SETTING: Data from the OptumLabs Data Warehouse® which includes de-identified medical and pharmacy claims and enrollment records for commercial and Medicare Advantage enrollees, representing a diverse mixture of ages, ethnicities, and geographical regions across the United States. SUBJECTS: Patients prescribed stable, higher-dose opioids for ≥12 months from 2008 to 2018. METHODS: Tapering was defined as ≥15% relative reduction in average MME/day during any of six overlapping 60-day periods in the initial 7 months of follow-up after the period of stable baseline dosing. Average monthly dose was ascertained during consecutive 60-day periods up to 16 months of follow-up. Linear regression estimated the geometric mean relative dose by tapering status and follow-up duration. Poisson regression estimated the percentage of tapered patients with sustained dose reductions at follow-up and patient-level predictors of failing to sustain tapers. RESULTS: The sample included 113,618 patients with 203,920 periods of stable baseline dosing (mean follow-up = 13.7 months). Tapering was initiated during 37,170 follow-up periods (18.2%). After taper initiation, patients had a substantial initial mean dose reduction (geometric mean relative dose .73 [95% CI: .72-.74]) that was sustained through 16 months of follow-up; at which point, 69.8% (95% CI: 69.1%-70.4%) of patients who initiated tapers had a relative dose reduction ≥15%, and 14.2% (95% CI: 13.7%-14.7%) had discontinued opioids. Failure to sustain tapers was significantly less likely among patients with overdose events during follow-up (adjusted incidence rate ratio [aIRR]: .56 [95% CI: .48-.67]) and during more recent years (aIRR: .93 per year after 2008 [95% CI: .92-.94]). CONCLUSIONS: In an insured and Medicare Advantage population, over two-thirds of patients who initiated opioid dose tapering sustained long-term dose reductions, and the likelihood of sustaining tapers increased substantially from 2008 to 2018.

Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids.

Importance: Opioid-related mortality and national prescribing guidelines have led to tapering of doses among patients prescribed long-term opioid therapy for chronic pain. There is limited information about risks related to tapering, including overdose and mental health crisis. Objective: To assess whether there are associations between opioid dose tapering and rates of overdose and mental health crisis among patients prescribed stable, long-term, higher-dose opioids. Design, Setting, and Participants: Retrospective cohort study using deidentified medical and pharmacy claims and enrollment data from the OptumLabs Data Warehouse from 2008 to 2019. Adults in the US prescribed stable higher doses (mean ≥50 morphine milligram equivalents/d) of opioids for a 12-month baseline period with at least 2 months of follow-up were eligible for inclusion. Exposures: Opioid tapering, defined as at least 15% relative reduction in mean daily dose during any of 6 overlapping 60-day windows within a 7-month follow-up period. Maximum monthly dose reduction velocity was computed during the same period. Main Outcomes and Measures: Emergency or hospital encounters for (1) drug overdose or withdrawal and (2) mental health crisis (depression, anxiety, suicide attempt) during up to 12 months of follow-up. Discrete time negative binomial regression models estimated adjusted incidence rate ratios (aIRRs) of outcomes as a function of tapering (vs no tapering) and dose reduction velocity. Results: The final cohort included 113 618 patients after 203 920 stable baseline periods. Among the patients who underwent dose tapering, 54.3% were women (vs 53.2% among those who did not undergo dose tapering), the mean age was 57.7 years (vs 58.3 years), and 38.8% were commercially insured (vs 41.9%). Posttapering patient periods were associated with an adjusted incidence rate of 9.3 overdose events per 100 person-years compared with 5.5 events per 100 person-years in nontapered periods (adjusted incidence rate difference, 3.8 per 100 person-years [95% CI, 3.0-4.6]; aIRR, 1.68 [95% CI, 1.53-1.85]). Tapering was associated with an adjusted incidence rate of 7.6 mental health crisis events per 100 person-years compared with 3.3 events per 100 person-years among nontapered periods (adjusted incidence rate difference, 4.3 per 100 person-years [95% CI, 3.2-5.3]; aIRR, 2.28 [95% CI, 1.96-2.65]). Increasing maximum monthly dose reduction velocity by 10% was associated with an aIRR of 1.09 for overdose (95% CI, 1.07-1.11) and of 1.18 for mental health crisis (95% CI, 1.14-1.21). Conclusions and Relevance: Among patients prescribed stable, long-term, higher-dose opioid therapy, tapering events were significantly associated with increased risk of overdose and mental health crisis. Although these findings raise questions about potential harms of tapering, interpretation is limited by the observational study design.

Poorer Physical and Mental Health Status Are Associated with Subsequent Opioid Prescriptions: a U.S. National Study.

BACKGROUND: How physical and mental health status relate to receipt of opioid prescription remains unclear, creating uncertainty in minimizing opioid harms while avoiding pain under-treatment. OBJECTIVE: To examine the associations of physical and mental health status with subsequent opioid prescriptions. DESIGN: Observational study of 2005-2015 United States (U.S.) Medical Expenditure Panel Survey data. PARTICIPANTS: Adult respondents (N = 78,563) participating for 2 years. The analyses focused on respondents reporting no opioid prescriptions in year 1 (N = 65,249). MAIN MEASURES: In the primary analysis, a negative binomial regression yielding adjusted incidence rate ratios (IRRs), the dependent variable was the number of opioid prescriptions in year 2. In two secondary analyses, both logistic regressions yielding adjusted odds ratios (ORs), the dependent variables were receipt of any opioid prescription (versus none) and receipt of ≥ 6 opioid prescriptions (versus 0-5) in year 2. The key independent variables in all analyses were the SF-12 Physical and Mental Component Summary scores (PCS-12 and MCS-12, respectively; higher scores = better health status). All models adjusted for socio-demographics, health-related variables, and year. KEY RESULTS: Primary analysis. With each 10-point decrement in year 1 PCS-12 or MCS-12 score, there were more opioid prescriptions received in year 2 (adjusted IRRs [95% CIs] 1.45 [1.39-1.52] and 1.22 [1.16-1.27], respectively). Secondary analyses. With each 10-point decrement in year 1 PCS-12 or MCS-12 score, there were higher odds in year 2 both of receiving any opioid prescription (adjusted ORs 1.23 [1.19-1.28] and 1.11 [1.08-1.15], respectively) and of receiving ≥ 6 opioid prescriptions (adjusted ORs 1.96 [1.75-2.17] and 1.37 [1.23-1.54], respectively). CONCLUSIONS: In a nationally representative U.S. sample, both poorer physical and mental health status independently predicted receiving more opioid prescriptions received in a subsequent year, as well as receiving ≥ 6 prescriptions during the year. Our findings may contribute to a more nuanced picture of the drivers of opioid prescription.

Opioid Prescriptions and Short-Term Mortality: a U.S. National Study.

BACKGROUND: Opioid-related mortality continues to rise. Though risks of prescription opioid misuse and abuse are well known, short-term mortality across a range of prescription opioid exposure is unclear. OBJECTIVE: This study was conducted in order to assess the short-term mortality associated with quantity of reported opioid prescriptions, DESIGN: An observational analysis was performed using data from the Medical Expenditure Panel Survey, years 2005-2015, a population-based, nationally representative household survey. PARTICIPANTS: This study included adults (age 18+) with prescription data and death status reported during their 2-year survey participation. MAIN MEASURES: Key exposure is the number of opioid prescriptions (0, 1-5, 6 or more) in year 1 of survey participation. The main outcome is all-cause mortality reported during the 2-year survey participation. KEY RESULTS: Of 90,622 participants, 14% reported at least 1 opioid prescription. There were 774 (0.9%) deaths during the survey period, 551 (0.7%) among those not reporting opioids, 127 (1.2%) among those reporting 1-5 opioid prescriptions, and 96 (3.9%) among those reporting 6 or more opioid prescriptions. After adjusting for sociodemographics, health status, and utilization, there was no significant association between category of opioid prescriptions and death during the study period; adjusted odds ratios = 0.86 (95% CI = 0.66, 1.22, p = 0.27) and 0.99 (95% CI = 0.74, 1.34, p = 0.96), respectively, for 1-5 prescriptions and 6 or more prescriptions. CONCLUSIONS: In a nationally representative sample, opioid prescriptions were associated with increased short-term mortality only without adjustment for sociodemographics, health status, or utilization. The relationship between prescription opioid use and mortality risk is more complex than previously reported, meriting further examination.

Cancer Screening Among Women Prescribed Opioids: A National Study.

PURPOSE: Prior work suggests that there are competing demands between addressing pain and other issues in primary care, potentially lessening delivery of evidence-based cancer screening. We assessed the association between opioid therapy and cancer screening among women in a nationally representative US sample. METHODS: We conducted an observational analysis of the 2005-2015 Medical Expenditure Panel Surveys. We included all women aged ≥18 years without cancer and with opioid prescription and preventive care services data. Logistic regression analyses examined associations between receipt of opioid prescription (any vs none) and receipt of breast, cervical, and colorectal cancer screenings. Analyses were adjusted for sociodemographic characteristics, health status, health conditions, and usual source of care, as well as health care utilization. RESULTS: Of 53,982 participants, 15.8% reported ≥1 opioid prescription. Compared with women not prescribed opioids, those prescribed opioids were more likely to visit their doctor (median number of visits per year = 5, vs 1). Without adjustment for number of visits, women prescribed opioids were more likely to receive all 3 cancer screenings; the adjusted odds ratio for breast cancer screening was 1.26 (95% CI, 1.16-1.38), that for cervical cancer screening was 1.22 (95% CI, 1.13-1.33), and that for colorectal cancer screening was 1.22 (95% CI, 1.12-1.33). With adjustment for number of visits, adjusted odds ratios decreased (breast 1.07 [95% CI, 0.98-1.18]; cervical 1.01 [95% CI, 0.93-1.09]; colorectal 1.04 [95% CI, 0.95-1.14]). CONCLUSIONS: In a nationally representative sample, receipt of opioid prescriptions was not associated with less recommended cancer screenings. Rather, women receiving opioids had greater adjusted odds of receiving breast, cervical, and colorectal cancer screening, although the associations were attenuated by adjusting for their more frequent office visits relative to women not receiving opioids.

Patient Satisfaction with Clinicians and Short-Term Mortality in a US National Sample: the Roles of Morbidity and Gender.

BACKGROUND: In a prior study, we found patient satisfaction was associated with mortality. However, that study included few deaths, yielding wide confidence intervals, was criticized for possible morbidity under-adjustment, and lacked power to explore sociodemographic moderation. OBJECTIVE: To revisit the satisfaction-mortality association in a larger national sample, allowing more precise risk estimates, sequential morbidity adjustment, and exploration of sociodemographic moderation. DESIGN: Prospective cohort study. PARTICIPANTS: 2000-2015 Adult Medical Expenditures Panel Surveys (MEPS) respondents (N = 92,952), each enrolled for 2 consecutive years. MAIN MEASURES: We used five Consumer Assessment of Health Plans Survey (CAHPS) items to assess patients' year 1 satisfaction with their clinicians. Death during the 2 years of MEPS participation was determined by proxy report. We modeled the satisfaction-mortality association in sequential regressions: model 1 included sociodemographics, model 2 added health status (approximating recommended CAHPS adjustment), and model 3 added smoking status, disease burden, and healthcare utilization. KEY RESULTS: Satisfaction was not associated with mortality in model 1. In model 2, higher satisfaction was associated with higher mortality (hazard ratios [95% CIs] for 2nd, 3rd, and 4th (top) quartiles vs. 1st quartile: 1.28 (1.01, 1.62), P = 0.04; 1.43 (1.12, 1.82), P = 0.004; and 1.57 (1.25, 1.98), P < 0.001, respectively). The associations were not attenuated in model 3. There was a significant interaction between gender and satisfaction (F[3, 443] = 3.62, P = 0.01). The association between satisfaction and mortality was significant in women only, such that their mortality advantage over men was eliminated in the highest satisfaction quartile. CONCLUSIONS: The association of higher patient satisfaction with clinicians with higher short-term mortality was evident only after CAHPS-recommended adjustment, was not attenuated by further morbidity adjustment, and was evident in women but not men. The findings suggest that characteristics among women who are more satisfied with their clinicians may be associated with increased mortality risk.

Multimodal Treatment Options, Including Rotating to Buprenorphine, Within a Multidisciplinary Pain Clinic for Patients on Risky Opioid Regimens: A Quality Improvement Study.

Objectives: We aimed to evaluate a novel clinical program designed to address unsafe use of opioids prescribed for pain-the Opioid Reassessment Clinic (ORC)-to inform practice and health system improvement. Design: Controlled, retrospective cohort study. Setting: The ORC is a multidisciplinary clinic in a primary care setting in a Veterans Health Administration hospital designed to perform longitudinal treatment of patients with unsafe use of opioids prescribed for pain, including tapering or rotating to the partial opioid agonist buprenorphine. Subjects: We included patients referred to the ORC from March 1, 2016, to March 1, 2017, who had an intake appointment (intervention group) and who did not (control group). Methods: We compared a priori-defined metrics at the patient, clinic process, and health system levels and compared metrics between groups. Results: During the study period, 114 veterans were referred to the ORC, and 71 (62%) of these had an intake appointment. Those in the intervention group were more likely to trial buprenorphine (N = 41, 62% vs N = 1, 2%, P < 0.01) and had greater reductions in their full agonist morphine equivalent daily dose than those in the control group (30 mg [interquartile range {IQR} = 0-120] vs 0 mg [IQR = 0-20] decrease, P < 0.01). Of those engaging in the ORC, 20 (30%) had not transitioned chronic pain management back to their primary care providers (PCPs) by the end of follow-up. Only one patient transitioned the management of buprenorphine to the PCP. Conclusions: Results suggest the ORC was effective in reducing total prescribed opioid doses and in transitioning patients to partial-agonist therapy, but PCP adoption strategies are needed.

Patient centered medical homes did not improve access to timely follow-up after ED visit.

BACKGROUND: Patients newly insured through coverage expansion under the Affordable Care Act (ACA) may have difficulty obtaining timely primary care follow-up appointments after emergency department (ED) discharge. We evaluated the association between availability of timely follow-up appointment with practice access improvements, including patient-centered medical home (PCMH) designations or extended-hours appointments. METHODS: We performed a secret-shopper audit of primary care practices in greater New Haven, Connecticut. Two callers, posing as patients discharged from the ED, called these practices requesting follow-up appointments. They followed standardized scripts varying in ED diagnosis (uncontrolled hypertension, acute back pain) and insurance status (commercial, exchange, Medicaid). We linked our findings with data from a previously completed survey that assessed practice characteristics and examined the associations between appointment availability and practice access improvements. RESULTS: Of the 58 included primary care practices, 49 (84.5%) completed both the audit and the survey. Overall, 167/536 calls (31.2%) obtained an appointment in 7days. Practices with PCMH designation were less likely to offer appointments within 7days (23.4% vs. 33.1%, p=0.03). However, callers were more likely to obtain an appointment in 7days from practices offering after-hour appointments (36.3% vs. 27.8%, p=0.04). After adjusting for insurance type, there were no significant associations between practice improvements and 7-day appointment availability or appointment wait time. CONCLUSION: PCMH designation and extended-hours appointments were not associated with improved availability of timely primary care follow-up appointment for discharged ED patients. EDs should engage local clinicians and other stakeholders to strengthen linkage and care transition with outpatient practices.

Bridging the Response to Mass Shootings and Urban Violence: Exposure to Violence in New Haven, Connecticut.

We have described self-reported exposure to gun violence in an urban community of color to inform the movement toward a public health approach to gun violence prevention. The Community Alliance for Research and Engagement at Yale School of Public Health conducted community health needs assessments to document chronic disease prevalence and risk, including exposure to gun violence. We conducted surveys with residents in six low-income neighborhoods in New Haven, Connecticut, using a neighborhood-stratified, population-based sample (n = 1189; weighted sample to represent the neighborhoods, n = 29 675). Exposure to violence is pervasive in these neighborhoods: 73% heard gunshots; many had family members or close friends hurt (29%) or killed (18%) by violent acts. Although all respondents live in low-income neighborhoods, exposure to violence differs by race/ethnicity and social class. Residents of color experienced significantly more violence than did White residents, with a particularly disparate increase among young Black men aged 18 to 34 years. While not ignoring societal costs of horrific mass shootings, we must be clear that a public health approach to gun violence prevention means focusing on the dual epidemic of mass shootings and urban violence.

Home alone or connected: Caregiver communication and training from health providers.

BACKGROUND: As care shifts from institutional to community settings, family caregivers are providing increasing support to older adults, including complex medical/nursing care. In the mid-late pandemic, technology advancements such as use of online patient portals present opportunities for communication and care delivery. This study aims to assess the association between caregiver medical/nursing tasks or patient portal use with contact, communication, and training of caregivers by healthcare providers. METHODS: We conducted a cross-sectional analysis of caregiver data from the 2021 National Study of Caregiving (NSOC), linked to the National Health and Aging Trends Study (NHATS). NHATS is nationally-representative, annual survey of Medicare enrollees; NSOC surveys family/unpaid caregivers of NHATS participants. Logistic regression tested association between whether the caregiver does medical/nursing tasks or uses an online patient portal to contact the medical team (independent variables), and communication with or training by the medical team (dependent variables). RESULTS: Participants were 1590 caregivers of living, community-dwelling older adults. More than half (54%) reported no contact with the care recipient's medical team in the past year. Caregivers who did medical/nursing tasks (OR = 3.10; 95% CI: 2.16, 4.46) or who used patient portals (OR = 3.28; 95% CI: 1.96, 5.51) had higher odds of contacting the older adult's medical team. Thirty percent of caregivers stated communication was either not at all or just a little helpful. Sixty-seven percent reported that providers rarely asked if they needed help managing the older adult's treatments. Just 6% of caregivers reported receiving any caregiver training in the last year. CONCLUSIONS: Both medical/nursing tasks and online patient portal use were independently associated with contact with health providers. Overall contact, communication, and training were limited or of variable value. Despite recent policy changes and technology advancement, there is still a need for improved integration of caregivers into health teams with ongoing assessment of their needs.

Impact of overdose on health plan disenrollment among patients prescribed long-term opioids: Retrospective cohort study.

CONTEXT: Health plan disenrollment may disrupt chronic or preventive care for patients prescribed long-term opioid therapy (LTOT). PURPOSE: To assess whether overdose events in patients prescribed LTOT are associated with subsequent health plan disenrollment. DESIGN: Retrospective cohort study. SETTING AND DATASET: Data from the Optum Labs Data Warehouse which includes de-identified medical and pharmacy claims and enrollment records for commercial and Medicare Advantage enrollees. The database contains longitudinal health information on patients, representing a mixture of ages and geographical regions across the United States. PATIENTS: Adults prescribed stable opioid therapy (≥10 morphine milligram equivalents/day) for a 6-month baseline period prior to an index opioid prescription from January 1, 2018 to December 31, 2018. MAIN MEASURES: Health plan disenrollment during follow-up. RESULTS: The cohort comprised 404,151 patients who were followed up after 800,250 baseline periods of stable opioid dosing. During a mean follow-up of 9.1 months, unadjusted disenrollment rates among primary commercial beneficiaries and Medicare Advantage enrollees were 37.2 and 13.9 per 100 person-years, respectively. Incident overdoses were associated with subsequent health plan disenrollment with a statistically significantly stronger association among primary commercial insurance beneficiaries [adjusted incidence rate ratio (aIRR) 1.48 (95% CI: 1.33-1.64)] as compared to Medicare Advantage enrollees [aIRR 1.15 (95% CI: 1.07-1.23)]. CONCLUSIONS: Among patients prescribed long-term opioids, overdose events were strongly associated with subsequent health plan disenrollment, especially among primary commercial insurance beneficiaries. These findings raise concerns about the social consequences of overdose, including potential health insurance loss, which may limit patient access to care at a time of heightened vulnerability.

Association Between Opioid Tapering and Subsequent Health Care Use, Medication Adherence, and Chronic Condition Control.

Importance: Opioid tapering has been associated with negative consequences, such as increased overdoses and mental health needs. Tapering could also alter use of health care services and worsen care of comorbid conditions through disruption in primary care. Objective: To evaluate tapering of stable long-term opioid therapy (LTOT) and subsequent health care service use and chronic condition care. Design, Setting, and Participants: A retrospective cohort study was conducted from January 1, 2008, to December 31, 2019. Data analysis was performed from July 9, 2020, to December 9, 2022. Data from the Optum Labs Data Warehouse, which contains deidentified retrospective administrative claims data and linked electronic health record data for commercial and Medicare Advantage enrollees, were used. Adults aged 18 years or older prescribed stable doses of LTOT at 50 morphine milligram equivalents or more per day during a 12-month baseline period were included, including subcohorts with hypertension or diabetes. Exposures: Opioid tapering, with 15% or more relative reduction in mean daily dose in 6 overlapping periods during 6 months. Main Outcomes and Measures: Emergency department visits, hospitalizations, primary care and specialist visits, antihypertensive or antiglycemic medication adherence, and blood pressure and hemoglobin A1c levels during up to 12 months' follow-up. Covariates included sociodemographic characteristics, comorbidities, health care use, and chronic condition control. Results: Among 113 604 patients (60 764 [53.5%] women; mean [SD] age, 58.1 [11.8] years) prescribed LTOT, 41 207 had hypertension and 23 335 had diabetes; in all cohorts, approximately half were women, and half were aged 50 to 65 years. In the overall cohort, tapering was associated with more emergency department visits (adjusted incidence rate ratio [aIRR], 1.19; 95% CI, 1.16-1.21) and hospitalizations (aIRR, 1.16; 95% CI, 1.12-1.20), with similar magnitude associations in the hypertension and diabetes subcohorts. Tapering was associated with fewer primary care visits in the overall cohort (aIRR, 0.95; 95% CI, 0.94-0.96) and hypertension subcohort (aIRR, 0.98; 95% CI, 0.97-0.99). For the hypertension or diabetes subcohorts, tapering was associated with reduced medication adherence (hypertension: aIRR, 0.60; 95% CI, 0.59-0.62; diabetes: aIRR, 0.69; 95% CI, 0.67-0.71) and small increases in diastolic blood pressure and hemoglobin A1c level. Conclusions and Relevance: In this cohort study of patients prescribed LTOT, opioid tapering was associated with more emergency department visits and hospitalizations, fewer primary care visits, and reduced antihypertensive and antidiabetic medication adherence. These outcomes may represent unintended negative consequences of opioid tapering for policy makers and clinicians to consider.

Vaccination and treatment options for SARS-CoV2 infection affecting lactation and breastfeeding.

The COVID-19 pandemic has posed considerable challenges to the health of lactating individuals. Vaccination remains one of the most important strategies for prevention of moderate to severe COVID-19 infection and is associated with protective benefits for lactating individuals and their breastfed infants with overall mild side effects. The current recommendations for COVID-19 treatment in lactating individuals includes remdesivir and dexamethasone for hospitalized patients and Paxlovid® (nirmatrelavir + ritonavir) as outpatient treatment in those with mild disease. As the pandemic continues to evolve with new COVID-19 variants, alternative therapeutic options are potentially needed, and it is critical to include lactating individuals in research to evaluate the safety and efficacy of COVID-19 treatment options in this population.

Urine Drug Testing Among Patients Prescribed Long-Term Opioid Therapy: Patient and Clinician Factors.

INTRODUCTION: National guidelines recommend that patients with chronic noncancer pain prescribed long-term opioid therapy (LTOT) undergo periodic urine drug testing (UDT), yet UDT is performed inconsistently, and little evidence supports the utility of this approach. We examined patient and prescriber factors associated with UDT. METHODS: A 1-year retrospective cohort study of 5690 patients prescribed LTOT by 689 clinicians in a network of 13 primary care and specialty clinics. Negative binomial regression examined patient and prescriber factors associated with the number of tests completed, and logistic regression examined prescriber and practice level testing likelihood. Analyses were adjusted for patient and clinician characteristics and accounted for patient clustering within prescribers. RESULTS: A total of 2256 patients (39.6%) had UDT completed at least once. More UDT completion was associated with Black patient race and receipt of more opioid prescriptions, as well as with clinician testing compliance. CONCLUSIONS: UDT was relatively infrequent in patients prescribed LTOT and associated with patient factors not known to confer greater opioid-related risk, such as race. In addition, there was significant clinician-driven variation in UDT. Given the uncertain clinical utility of such testing, these findings signal the need for strategies to address potential biases in the use of UDT.

Long-term Risk of Overdose or Mental Health Crisis After Opioid Dose Tapering.

Importance: Patients prescribed long-term opioid therapy are increasingly undergoing dose tapering. Recent studies suggest that tapering is associated with short-term risks of substance misuse, overdose, and mental health crisis, although lower opioid dose could reduce risks of adverse events over the longer term. Objective: To assess the longer-term risks of overdose or mental health crisis associated with opioid dose tapering. Design, Setting, and Participants: This is a cohort study using an exposure-crossover analysis. Data were obtained from the OptumLabs Data Warehouse, which includes deidentified medical and pharmacy claims and enrollment records for commercial insurance and Medicare Advantage enrollees, representing a diverse mixture of ages, races, ethnicities, and geographical regions across the US. Participants were US adults who underwent opioid dose tapering from 2008 to 2017 after a 12-month baseline period of stable daily dosing of 50 morphine milligram equivalents or higher and who had at least 1 month of long-term follow-up during a postinduction period beginning 12 months after taper initiation. Data analysis was performed from October 2021 to April 2022. Exposures: Opioid tapering, defined as 15% or more relative reduction in mean daily dose during any of 6 overlapping 60-day windows within a 7-month follow-up period after the stable baseline period. Main Outcomes and Measures: Emergency or hospital encounters for drug overdose or withdrawal and mental health crisis (depression, anxiety, or suicide attempt). Outcome counts were assessed in pretaper and postinduction periods (from 12 to 24 months after taper initiation). Results: The study included 21 515 tapering events among 19 377 patients with a mean (SD) of 9.1 (2.7) months of postinduction follow-up per event (median [IQR], 10 [8-11] months). Patients had a mean (SD) age of 56.9 (11.2) years, 11 581 (53.8%) were female, and 8217 (38.2%) had commercial insurance (vs Medicare Advantage). In conditional negative binomial regression analyses, adjusted incidence rate ratios for the postinduction period compared with the pretaper period were 1.57 (95% CI, 1.42-1.74) for overdose or withdrawal and 1.52 (95% CI, 1.35-1.71) for mental health crisis. Conclusions and Relevance: These findings suggest that opioid tapering was associated with increased rates of overdose, withdrawal, and mental health crisis extending up to 2 years after taper initiation.

Clinical Quality Measures: A Challenge for-and to-Family Physicians.

INTRODUCTION: Improving design, selection and implementation of appropriate clinical quality measures can reduce harms and costs of health care and improve the quality and experience of care delivery. These measures have not been evaluated for appropriateness for use in performance measurement in a systematic, reproducible, and widely accepted manner. METHODS: We defined 10 criteria for evaluation of measure appropriateness in 4 domains: Patient-centeredness of outcomes, specification of population measured and measure detail, reliable evidence that benefits likely outweigh harms, and independence from significant confounders. We applied these criteria to 24 measures under consideration for statewide use in Massachusetts in public and private incentive-based programs. We appraised each measure as Appropriate or Not Appropriate for such use. RESULTS: We rated 15 measures as Appropriate (62.5%). Three measures (12.5%) were considered Appropriate only if applied at a system level but not for patient-provider assessment and 6 measures (25%) were rated Not Appropriate. Reasons for designation as "Not Appropriate" included benefits not clearly outweighing harms, lack of preservation of patient autonomy, inappropriate specification of population and measure detail, confounding by locus of control, and confounding by social determinants of health. CONCLUSIONS: Using this consensus-driven, 10-criteria methodology we were able to evaluate appropriateness of clinical quality measures. This methodology may improve measure design and inform selection of the most appropriate measures for use in quality measurement, financial incentives, and reporting.