Examining Racial/Ethnic Differences in Patterns of Opioid Prescribing: Results from an Urban Safety-Net Healthcare System.

Prescription opioids still account for a large proportion of overdose deaths and contribute to opioid use dependence (OUD). Studies earlier in the epidemic suggest clinicians were less likely to prescribe opioids to racial/ethnic minorities. As OUD-related deaths have increased disproportionately amongst minority populations, it is essential to understand racial/ethnic differences in opioid prescribing patterns to inform culturally sensitive mitigation efforts. The purpose of this study is to estimate racial/ethnic differences in opioid medication use among patients prescribed opioids. Using electronic health records and a retrospective cohort study design, we estimated multivariable hazard models and generalized linear models, assessing racial/ethnic differences in OUD diagnosis, number of opioid prescriptions, receiving only one opioid prescription, and receiving ≥18 opioid prescriptions. Study population (N=22,201) consisted of adult patients (≥18years), with ≥3 primary care visits (ensuring healthcare system linkage), ≥1 opioid prescription, who did not have an OUD diagnoses prior to the first opioid prescription during the 32-month study period. Relative to racial/ethnic minority patients, White patients, in both unadjusted and adjusted analyses, had a greater number of opioid prescriptions filled, a higher proportion received ≥18 opioid prescriptions, and a greater hazard of having an OUD diagnosis subsequent to receiving an opioid prescription (all groups p<0.001). Although opioid prescribing rates have declined nationally, our findings suggest White patients still experience a high volume of opioid prescriptions and greater risk of OUD diagnosis. Racial/ethnic minorities are less likely to receive follow-up pain medications, which may signal low care quality. Identifying provider bias in pain management of racial/ethnic minorities could inform interventions seeking balance between adequate pain treatment and risk of opioid misuse/abuse.

Examining Racial/Ethnic Disparities in Tobacco Dependence Treatment Among Medicaid Beneficiaries Using Fifty State Medicaid Claims, 2009-2014.

In the USA, low-income racial/ethnic minority groups experience higher smoking rates and greater smoking-related disease burden than their White counterparts. Despite the adverse effects, racial/ethnic minorities are less likely to access tobacco dependence treatment (TDT). Medicaid is one of the largest payers of TDT in the USA and covers predominantly low-income populations. The extent of TDT use among beneficiaries from distinct racial/ethnic groups is unknown. The objective is to estimate racial/ethnic differences in TDT use among Medicaid fee-for-service beneficiaries. Using a retrospective study design and 50 state (including the District of Columbia) Medicaid claims (2009-2014), we employed multivariable logistic regression models and predictive margin methods to estimate TDT use rates among adults (18-64) enrolled (≥ 11 months) in Medicaid fee-for-service programs (January 2009-December 2014) by race/ethnicity. The population included White (n = 6,536,004), Black (n = 3,352,983), Latinx (n = 2,264,647), Asian (n = 451,448), and Native American/Alaskan Native (n = 206,472) beneficiaries. Dichotomous outcomes reflected service use in the past year. Any TDT use was operationalized as any smoking cessation medication fill, any smoking cessation counseling visit, or any smoking cessation outpatient visit. In secondary analyses, we disaggregated TDT use into three separate outcomes. Results suggested that Black (10.6%; 95% CI = 9.9-11.4%), Latinx (9.5%; 95% CI = 8.9-10.2%), Asian (3.7%; 95% CI = 3.4-4.1%), and Native American/Alaskan Native (13.7%; 95% CI = 12.7-14.7%) beneficiaries had lower TDT use rates compared to White beneficiaries (20.6%). Similar racial/ethnic treatment disparities were identified across all outcomes. By identifying significant racial/ethnic disparities in TDT use between 2009 and 2014, this study provides a benchmark against which to measure recent interventions in state Medicaid programs improving equity in smoking cessation interventions.

Estimates of Major Depressive Disorder and Treatment Among Adolescents by Race and Ethnicity.

Importance: The COVID-19 pandemic has contributed to poorer mental health and a greater need for treatment. Nationally representative estimates of major depressive disorder (MDD) and mental health treatment among US adolescents during the pandemic are needed. Objective: To estimate MDD prevalence among adolescents, evaluate mental health treatment use among adolescents with MDD, and assess differences by race and ethnicity. Design, Setting, and Participants: This cross-sectional analysis of the nationally representative 2021 National Survey on Drug Use and Health included noninstitutionalized US adolescents between the ages of 12 and 17 years (n = 10 743). Analytic weights were applied to all rates and model estimates to be nationally representative and account for sample design and survey nonresponse. Data were collected from January 14 to December 20, 2021, and analyzed from February 11 to April 3, 2023. Exposures: Self-reported race and ethnicity. Main Outcomes and Measures: Dichotomous outcomes of MDD as defined by the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition), MDD-specific mental health treatment, any type of mental health treatment, telehealth visits, and delays in mental health treatment. Results: The sample included 10 743 adolescents (51.1% male). Self-reported race and ethnicity included 5.1% Asian, 14.1% Black, 23.3% Latinx, 51.2% White, and 6.3% more than 1 race. Ages were evenly distributed: 34.0% aged 12 to 13 years; 33.3% aged 14 to 15 years; and 32.7% aged 16 to 17 years. Adolescents of more than 1 race or ethnicity had the highest MDD rate (26.5%). Compared with White adolescents, the lowest rates of any MDD treatment overall were found among Latinx adolescents (29.2% [95% CI, 22.2%-36.2%]) and those of more than 1 race or ethnicity (21.1% [95% CI, 11.6%-30.7%]). Similar results were found for treatment by any clinician (Latinx, 25.6% [95% CI, 18.8%-32.4%]; >1 race or ethnicity, 19.1% [95% CI, 9.7%-28.6%]), treatment by a mental health specialist (Latinx, 22.9% [95% CI, 16.9%-28.9%]; >1 race or ethnicity, 16.7% [95% CI, 7.1%-26.3%]), treatment by a nonspecialist clinician (Latinx, 7.3% [95% CI, 3.3%-11.3%]; >1 race or ethnicity, 4.8% [95% CI, 1.9%-7.7%]), and use of any psychotropic medication prescription (Latinx, 11.6% [95% CI, 7.3%-15.9%]; >1 race or ethnicity, 8.3% [95% CI, 2.8%-13.7]). Compared with White adolescents, Black adolescents had lower rates of MDD treatment by any clinician (31.7% [95% CI, 23.7%-39.8%]) and by nonspecialist clinicians (8.4% [95% CI, 3.8%-13.2%]) and experienced lower prescription rates for any psychotropic medication (12.6 [95% CI, 4.6%-20.6%]). Asian (16.0% [95% CI, 5.0%-27.2%]) and Latinx (17.8% [95% CI, 12.6%-23.0%]) adolescents had lower rates of virtual mental health treatment compared with White adolescents. Black (19.1% [95% CI, 14.1%-24.2%]) and Latinx (17.9% [95% CI, 15.0%-21.1%]) adolescents had lower rates of appointments transition to telehealth, while Black adolescents (14.1% [95% CI, 10.7%-17.4%]) experienced delays getting their prescriptions. Conclusions and Relevance: During the first full calendar year of the pandemic, approximately 1 in 5 adolescents had MDD, and less than half of adolescents who needed treatment had any mental health treatment. Adolescents in racial and ethnic minority groups, particularly Latinx, experienced the lowest treatment rates. Federal policy should target adolescents as a whole, and minority populations in particular, to ensure equitable treatment access. Efforts should consider the social, racial, ethnic, and cultural determinants of health.

Criminal Legal Involvement Among U.S. Adults With Serious Psychological Distress and Differences by Race-Ethnicity.

OBJECTIVE: The authors examined associations between criminal legal involvement (CLI) and serious psychological distress and how these associations differed by racial-ethnic group. METHODS: The authors conducted a retrospective analysis of multiple cross-sections of data from the National Survey on Drug Use and Health (2015-2019) and used multivariable linear probability regression models to assess lifetime CLI and past-year probation, parole, supervised release, or other conditional release in a nationally representative sample of noninstitutionalized U.S. adults, ages ≥18 years (N=214,505), with and without serious psychological distress. RESULTS: Adults with serious psychological distress had higher rates of CLI than adults without such distress (difference of 4.1 percentage points, 95% CI=3.3-4.8, p<0.001). The rate of CLI increased as distress severity increased, from mild (3.2 percentage-point difference, 95% CI=2.6-3.8, p<0.001) to high (7.2 percentage-point difference, 95% CI=6.4-8.0, p<0.001). The risk for CLI among those with serious psychological distress was even greater for Black and Latinx adults than for White adults (1.8 percentage-point difference, 95% CI=0.1-3.5, p<0.05, and 3.2 percentage-point difference, 95% CI=1.3-5.2, p<0.01, respectively). CONCLUSIONS: Rates of CLI were higher for adults with serious psychological distress. Efforts are needed to equitably triage individuals with acute mental health needs to timely psychiatric care instead of carceral settings. Collaborative models of care that commingle resources from mental health and law enforcement organizations are needed to prevent unnecessary incarceration of individuals experiencing mental health crises and to increase access to community-based treatment.

US trends in the association of suicide ideation/behaviors with marijuana use among adolescents ages 12-17 and differences by gender and race/ethnicity.

Background: In the US over the past decade, there has been a steady increase in marijuana use rates among adolescents, in part due to marijuana legalization laws. It is unknown whether these greater marijuana use rates are associated with rising rates of adolescent suicide ideation and behaviors (plan and attempt) or whether these associations differ by gender or race/ethnicity. Objective: To determine whether marijuana use is associated with suicide ideation/behaviors among adolescents and if differences exist by gender and race/ethnicity. Materials and methods: Using the 2015-2019 National Surveys on Drug Use and Health, we assessed the relationship between marijuana use frequency and suicide ideation/behaviors among adolescents (12-17, n = 73,986). We also examined the association with marijuana use disorder (MUD) and assessed differences by gender and race/ethnicity. Marijuana use frequency in the past year was categorized as no use, non-weekly use, and weekly-plus use. We estimated multivariable logistic regression models, adjusting for sociodemographics, health status, common co-occurring behavioral health disorders, and criminal history. For interpretability, regression coefficients were converted into predicted probabilities using predictive margin methods. Results: In primary analyses, adolescents with non-weekly use and weekly-plus use had higher rates of any suicide ideation, 61.5% (+ 10.4 percentage-points; 95% CI: 7.0-13.8%) and 64.5% (+ 13.4 percentage-points; 95% CI: 9.1-17.7%), relative to no use (51.1%). Non-weekly and weekly-plus use was associated with higher rates of any suicide plan 58.2% (+ 11.8 percentage-points; 95% CI: 7.8-16.0%) and 59.0% (+ 12.6 percentage-points; 95% CI: 6.4-18.9%), and any suicide attempt, 42.0% (+ 11.6 percentage-points; 95% CI: 7.0-16.2%) and 47.3% (+ 16.9 percentage-points; 95% CI: 10.9-22.9%) compared to no use (46.4 and 30.4%, respectively). Similar results were found among adolescents with a MUD (all p < 0.05). Positive associations between marijuana use and suicide ideation/behaviors persisted among males and females as well as White, Black, and Latinx adolescents (all p < 0.05). Conclusion: Between 2015 and 2019, suicide ideation/behaviors increased for adolescents that used marijuana. As marijuana is legalized in more states, public health efforts are needed to curb increases in marijuana use among adolescents and to better understand the causal linkages between marijuana use and suicide ideation/behaviors.

Racial/Ethnic Disparity Trends in Children's Mental Health Care Access and Expenditures From 2010-2017: Disparities Remain Despite Sweeping Policy Reform.

OBJECTIVE: To examine trends in mental health care use for Black and Latinx children and adolescents. METHOD: Data from the Medical Expenditure Panel Survey for 2010-2017 were analyzed to assess trends among youth ages 5-17 in use and expenditures for any mental health care, outpatient mental health care, and psychotropic medication prescription fills. Unadjusted trends for all youth and the subpopulation of youth reporting need for mental health care and disparities adjusting for need were examined. RESULTS: Between 2010 and 2017, Black youth rates of any past year mental health care use decreased (from 9% to 8%), while White (from 13% to 15%) and Latinx (from 6% to 8%) youth rates increased. Among the subpopulation with need and in regression analysis adjusting for need, we identified significant Black-White and Latinx-White disparities in any mental health care use and any outpatient mental health care use in 2010-2011 and 2016-2017, with significant worsening of Black-White disparities over time. White youth were more than twice as likely as Latinx youth to use psychotropic medications, and Latinx-White and Black-White disparities in psychotropic medication prescription fills persisted over time. Black-White disparities existed in overall mental health expenditures (2016-2017) and outpatient mental health expenditures (2010-2011 and 2016-2017). CONCLUSION: Affordable, ubiquitous access to mental health care for Black and Latinx youth remains an elusive target. Significant disparities exist in receiving mental health care despite reforms and policies designed to increase mental health care access in the general population. Additional outreach and treatment strategies tailored to the cultural, linguistic, and structural needs of youth of color are required.

Racial and Ethnic Disparities in Childhood ADHD Treatment Access and Utilization: Results From a National Study.

OBJECTIVE: The study examined racial-ethnic disparities in access to and utilization of treatment for attention-deficit hyperactivity disorder (ADHD) and other psychiatric diagnoses among children with ADHD. METHODS: Nationally representative, cross-sectional data from the Household Component of the Medical Expenditure Panel Survey 2011-2019 were used to examine racial-ethnic disparities in access to and utilization of treatment by children ages 5-17 with ADHD (N=5,838). Logistic regression models were estimated for access outcomes, and generalized linear models were estimated for utilization outcomes. Multivariable regression models adjusted for race-ethnicity, age, sex, and treatment need in accordance with the Institute of Medicine definition of health care disparities. RESULTS: In adjusted analyses, compared with White children with ADHD, Black, Hispanic, and Asian children with ADHD had significantly lower rates of any past-year treatment visit for ADHD or for other psychiatric diagnoses. They also had lower rates of having accessed ADHD medication. Compared with White children, Black and Asian children with ADHD used fewer ADHD medications, and Black and Hispanic children with ADHD had lower overall mental health treatment expenditures. CONCLUSIONS: Disparities in ADHD treatment among children from racial-ethnic minority populations may be driven primarily by disparities in access rather than in utilization. Once treatment had been accessed, disparities in utilization were largely accounted for by differences in socioeconomic status. These findings suggest that interventions targeting access to treatment among children from racial-ethnic minority populations may help close existing care gaps.

Family Stressors and Resources as Social Determinants of Health among Caregivers and Young Children.

Life course-informed theories of development suggest it is important to integrate information about positive and negative aspects of the social environment into studies of child and parental wellbeing, including both stressors that compromise health and resources that promote well-being. We recruited a sample of 169 pairs of caregivers and young children (birth to 5 years) from a community health clinic and administered survey questions to assess stressors and resources. We constructed inventories of stressors and resources and examined the relationships between these inventories and caregivers' depressive symptoms, anxiety symptoms, and sleep problems, and young children's medical diagnoses derived from electronic health records. Cumulative stressors and resources displayed bivariate and adjusted associations with caregivers' depressive symptoms, anxiety symptoms, and sleep problems. For depressive and anxiety symptoms, these associations were evident in models that included stressors and resources together. Caregivers with high stressors and low resources displayed the highest levels of depressive and anxiety symptoms and sleep problems. In terms of children's health outcomes, only modest trends were evident for developmental/mental health outcomes, but not other diagnostic categories. Future studies are needed to examine stressors and resources together in larger samples and in relation to prospectively assessed measures of child well-being.

Associations between neighborhood-level factors and opioid-related mortality: A multi-level analysis using death certificate data.

AIM: To identify associations between opioid-related mortality and neighborhood-level risk factors. DESIGN: Cross-sectional study. SETTING: Massachusetts, USA. PARTICIPANTS: Using 2011-14 Massachusetts death certificate data, we identified opioid-related (n = 3089) and non-opioid-related premature deaths (n = 8729). MEASUREMENTS: The independent variables consisted of four sets of neighborhood-level factors: (1) psychosocial, (2) economic, (3) built environment and (4) health-related. At the individual level we included the following compositional factors: age at death, sex, race/ethnicity, marital status, education, veteran status and nativity. The primary outcome of interest was opioid-related mortality. FINDINGS: Multi-level models identified number of social associations per 10 000 [odds ratio (OR) = 0.84, P = 0.002, 95% confidence interval (CI) = 0.75-0.94] and number of hospital beds per 10 000 (OR = 0.78, P < 0.001, 95% CI = 0.68-0.88) to be inversely associated with opioid-related mortality, whereas the percentage living in poverty (OR = 1.01, P = 0.008, 95% CI = 1.00-1.01), food insecurity rate (OR = 1.21, P = 0.002, 95% CI = 1.07-1.37), number of federally qualified health centers (OR = 1.02, P = 0.028, 95% CI = 1.02-1.08) and per-capita morphine milligram equivalents of hydromorphone (OR = 1.05, P = 0.003, 95% CI = 1.01-1.08) were positively associated with opioid-related mortality. CONCLUSIONS: Opioid-related deaths between 2011 and 2014 in the state of Massachusetts appear to be positively associated with the percentage living in poverty, food insecurity rate, number of federally qualified health centers and per-capita morphine milligram equivalents of hydromorphone, but inversely associated with number of social associations per 10 000 and number of hospital beds per 10 000.