Suicide Mortality Among Formerly Incarcerated People Compared With the General Population in North Carolina, 2000-2020.

We aimed to compare rates and characteristics of suicide mortality in formerly incarcerated people with those of the general population in North Carolina. We conducted a retrospective cohort study of 266,400 people released from North Carolina state prisons between January 1, 2000, and March 1, 2020. Using direct and indirect standardization by age, sex, and calendar year, we calculated standardized suicide mortality rates and standardized mortality ratios comparing formerly incarcerated people with the North Carolina general population. We evaluated effect modification by race/ethnicity, sex, age, and firearm involvement. Formerly incarcerated people had approximately twice the overall suicide mortality of the general population for 3 years after release, with the highest rate of suicide mortality being observed in the 2-week period after release. In contrast to patterns in the general population, formerly incarcerated people had higher rates of non-firearm-involved suicide mortality than firearm-involved suicide mortality. Formerly incarcerated female, White and Hispanic/Latino, and emerging adult people had a greater elevation of suicide mortality than their general-population peers compared with other groups. These findings suggest a need for long-term support for formerly incarcerated people as they return to community living and a need to identify opportunities for interventions that reduce the harms of incarceration for especially vulnerable groups. This article is part of a Special Collection on Mental Health.

Matching study design to prescribing intention: The prevalent new-user design for studying abuse-deterrent formulations of opioids.

PURPOSE: In drug studies, research designs requiring no prior exposure to certain drug classes may restrict important populations. Since abuse-deterrent formulations (ADF) of opioids are routinely prescribed after other opioids, choice of study design, identification of appropriate comparators, and addressing confounding by "indication" are important considerations in ADF post-marketing studies. METHODS: In a retrospective cohort study using claims data (2006-2018) from a North Carolina private insurer [NC claims] and Merative MarketScan [MarketScan], we identified patients (18-64 years old) initiating ADF or non-ADF extended-release/long-acting (ER/LA) opioids. We compared patient characteristics and described opioid treatment history between treatment groups, classifying patients as traditional (no opioid claims during prior six-month washout period) or prevalent new users. RESULTS: We identified 8415 (NC claims) and 147 978 (MarketScan) ADF, and 10 114 (NC claims) and 232 028 (MarketScan) non-ADF ER/LA opioid initiators. Most had prior opioid exposure (ranging 64%-74%), and key clinical differences included higher prevalence of recent acute or chronic pain and surgery among patients initiating ADFs compared to non-ADF ER/LA initiators. Concurrent immediate-release opioid prescriptions at initiation were more common in prevalent new users than traditional new users. CONCLUSIONS: Careful consideration of the study design, comparator choice, and confounding by "indication" is crucial when examining ADF opioid use-related outcomes.

Twenty-five year occupational homicide mortality trends in North Carolina: 1992-2017.

INTRODUCTION: Determining industry of decedents and victim-perpetrator relationships is crucial to inform and evaluate occupational homicide prevention strategies. In this study, we examine occupational homicide rates in North Carolina (NC) by victim characteristics, industry and victim-perpetrator relationship from 1992 to 2017. METHODS: Occupational homicides were identified from records of the NC Office of the Chief Medical Examiner system and the NC death certificates. Sex, age, race, ethnicity, class of worker, manner of death, victim-perpetrator relationship and industry were abstracted. Crude and age-standardised homicide rates were calculated as the number of homicides that occurred at work divided by an estimate of worker-years (w-y). Rate ratios and 95% CIs were calculated, and trends over calendar time in occupational homicide rates were examined overall and by industry. RESULTS: 456 homicides over 111 573 049 w-y were observed. Occupational homicide rates decreased from 0.82 per 100 000 w-y for the period 1992-1995 to 0.21 per 100 000 w-y for the period 2011-2015, but increased to 0.32 per 100 000 w-y in the period 2016-2017. Fifty-five per cent (252) of homicides were perpetrated by strangers. Taxi drivers experienced an occupational homicide rate that was 110 times (95% CI 76.52 to 160.19) the overall occupational homicide rate in NC; however, this rate declined by 76.5% between 1992 and 2017. Disparities were observed among workers 65+ years old, racially and ethnically minoritised workers and self-employed workers. CONCLUSION: Our findings identify industries and worker demographics that experienced high occupational homicide fatality rates. Targeted and tailored mitigation strategies among vulnerable industries and workers are recommended.

Heat-related fatalities in North Carolina 1999-2017.

OBJECTIVES: Research shows the highest rates of occupational heat-related fatalities among farm laborers and among Black and Hispanic workers in North Carolina (NC). The Hispanic population and workforce in NC have grown substantially in the past 20 years. We describe the epidemiology of heat-related fatal injuries in the general population and among workers in NC. METHODS: We reviewed North Carolina death records and records of the North Carolina Office of the Chief Medical Examiner to identify heat-related deaths (primary International Classification of Diseases, Tenth Revision diagnosis code: X30 or T67.0-T67.9) that occurred between January 1, 1999, and December 31, 2017. Decedent age, sex, race, and ethnicity were extracted from both the death certificate and the medical examiner's report as well as determinations of whether the death occurred at work. RESULTS: In NC between 1999 and 2017, there were 225 deaths from heat-related injuries, and 25 occurred at work. The rates of occupational heat-related deaths were highest among males, workers of Hispanic ethnicity, workers of Black, multiple, or unknown race, and in workers aged 55-64. The highest rate of occupational heat-related deaths occurred in the agricultural industry. CONCLUSIONS: Since the last report (2001), the number of heat-related fatalities has increased, but fewer were identified as workplace fatalities. Rates of occupational heat-related deaths are highest among Hispanic workers. NC residents identifying as Black are disproportionately burdened by heat-related fatalities in general, with a wider apparent disparity in occupational deaths.

Forty-year trends in fatal occupational injuries in North Carolina.

BACKGROUND: We describe progress in the control of deaths on-the-job due to fatal occupational injury in North Carolina over the period 1978-2017. METHODS: Forty years of information on fatal occupational injuries in North Carolina has been assembled from medical examiners' reports and death certificates, supplemented by newspaper and police reports. Cases were defined as unintentional fatal occupational injuries among adults. Annual estimates of the population at risk were derived from US Census data, and rates were quantified using Poisson regression methods. RESULTS: There were 4434 eligible deaths. The unintentional fatal occupational injury rate at the beginning of the study period was more than threefold the rate at the end of the study. The fatal occupational injury rate among men declined from 9.6 per 100,000 worker-years in the period 1978-1982 to 3.1 per 100,000 worker-years in the period 2013-2017. The fatal occupational injury rate among women declined from 0.3 per 100,000 worker-years in the period 1978-1981 to 0.1 per 100,000 worker-years in the period 2013-2017. Declines in rates were observed for young adults as well as older workers and were observed across all major industry categories. Average annual declines in rates were greatest in those industries and occupations that had the highest fatal injury rates at the start of the study period. CONCLUSIONS: The substantial decline in fatal injury rates underscores the importance of injury prevention and demonstrates the ability to make meaningful reductions in unintentional fatal injury.

Forty years of struggle in North Carolina: Workplace segregation and fatal occupational injury rates.

OBJECTIVE: To assess workplace segregation in fatal occupational injury from 1992 to 2017 in North Carolina. METHODS: We calculated occupational fatal injury rates within categories of occupation, industry, race, age, and sex; and estimated expected numbers of fatalities among Black and Hispanic male workers had they experienced the rates of White male workers. We also estimated the contribution of workforce segregation to disparities by estimating the expected number of fatalities among Black and Hispanic male workers had they experienced the industry and occupation patterns of White male workers. We assessed person-years of life-lost, using North Carolina life expectancy estimates. RESULTS: Hispanic workers contributed 32% of their worker-years and experienced 58% of their fatalities in construction. Black workers were most overrepresented in the food manufacturing industry. Hispanic males experienced 2.11 (95% CI: 1.86-2.40) times the mortality rate of White males. The Black-White and Hispanic-White disparities were widest among workers aged 45 and older, and segregation into more dangerous industries and occupations played a substantial role in driving disparities. Hispanic workers who suffered occupational fatalities lost a median 47 life-years, compared to 37 among Black workers and 36 among White workers. CONCLUSIONS: If Hispanic and Black workers experienced the workplace safety of their White counterparts, fatal injury rates would be substantially reduced. Workforce segregation reflects structural racism, which also contributes to mortality disparities. Root causes must be addressed to eliminate disparities.

25-Year fatal workplace suicide trends in North Carolina: 1992-2017.

BACKGROUND: Suicide is a serious public health problem in the United States, but limited evidence is available investigating fatal suicides at work. There is a substantial need to characterize workplace suicides to inform suicide prevention interventions and target high-risk settings. This study aims to examine workplace suicide rates in North Carolina (NC) by worker characteristics, means of suicide used, and industry between 1992 and 2017. METHODS: Fatal workplace suicides were identified from records of the NC Office of the Chief Medical Examiner system and the NC death certificate. Sex, age, race, ethnicity, class of worker, manner of death, and industry were abstracted. Crude and age-standardized homicide rates were calculated as the number of suicides that occurred at work divided by an estimate of worker-years (w-y). Rate ratios and 95% confidence intervals (CIs) were calculated, and trends over calendar time for fatal workplace suicides were examined overall and by industry. RESULTS: 81 suicides over 109,464,430 w-y were observed. Increased rates were observed in workers who were male, self-employed, and 65+ years old. Firearms were the most common means of death (63%) followed by hanging (16%). Gas service station workers experienced the highest fatal occupational suicide rate, 11.5 times (95% CI: 3.62-36.33) the overall fatal workplace suicide rate, followed by Justice, Public Order, and Safety workers at 3.23 times the overall rate (95% CI: 1.31-7.97). CONCLUSION: Our findings identify industries and worker demographics that were vulnerable to workplace suicides. Targeted and tailored mitigation strategies for vulnerable industries and workers are recommended.

"We adjusted for race": now what? A systematic review of utilization and reporting of race in American Journal of Epidemiology and Epidemiology, 2020-2021.

Race is a social construct, commonly used in epidemiologic research to adjust for confounding. However, adjustment of race may mask racial disparities, thereby perpetuating structural racism. We conducted a systematic review of articles published in Epidemiology and American Journal of Epidemiology between 2020 and 2021 to (1) understand how race, ethnicity, and similar social constructs were operationalized, used, and reported; and (2) characterize good and poor practices of utilization and reporting of race data on the basis of the extent to which they reveal or mask systemic racism. Original research articles were considered for full review and data extraction if race data were used in the study analysis. We extracted how race was categorized, used-as a descriptor, confounder, or for effect measure modification (EMM)-and reported if the authors discussed racial disparities and systemic bias-related mechanisms responsible for perpetuating the disparities. Of the 561 articles, 299 had race data available and 192 (34.2%) used race data in analyses. Among the 160 US-based studies, 81 different racial categorizations were used. Race was most often used as a confounder (52%), followed by effect measure modifier (33%), and descriptive variable (12%). Fewer than 1 in 4 articles (22.9%) exhibited good practices (EMM along with discussing disparities and mechanisms), 63.5% of the articles exhibited poor practices (confounding only or not discussing mechanisms), and 13.5% were considered neither poor nor good practices. We discuss implications and provide 13 recommendations for operationalization, utilization, and reporting of race in epidemiologic and public health research.

Disparities in Fatal Occupational Injury Rates in North Carolina, 1978-2017: Comparing Nonmanagerial Employees to Managers.

BACKGROUND: We examined fatal occupational injuries among private-sector workers in North Carolina during the 40-year period 1978-2017, comparing the occurrence of fatal injuries among nonmanagerial employees to that experienced by managers. METHODS: We estimated a standardized fatal occupational injury ratio by inverse probability of exposure weighting, taking nonmanagerial workers as the target population. When this ratio measure takes a value greater than unity it signals settings in which nonmanagerial employees are not provided as safe a work environment as that provided for managers. RESULTS: Across all industries, nonmanagerial workers in North Carolina experienced fatal occupational injury rates 8.2 (95% CI = 7.0, 10.0) times the rate experienced by managers. Disparities in fatal injury rates between managers and the employees they supervise were greatest in forestry, rubber and metal manufacturing, wholesale trade, fishing and extractive industries, and construction. CONCLUSIONS: The results may help focus discussion about workplace safety between labor and management upon equity, with a goal of providing a work environment for nonmanagerial employees as safe as the one provided for managers.

Fatal occupational injuries in North Carolina, 1992-2017.

OBJECTIVES: After declining for several decades, fatal occupational injury rates have stagnated in the USA since 2009. To revive advancements in workplace safety, interventions targeting at-risk worker groups must be implemented. Our study aims to identify these at-risk populations by evaluating disparities in unintentional occupational fatalities occurring in North Carolina (NC) from 1992 to 2017. METHODS: Our retrospective cohort study drew on both the NC Office of the Chief Medical Examiner system and the NC death certificate data system to identify unintentional fatal occupational injuries occurring from 1992 to 2017. Unintentional fatal occupational injury rates were reported across industries, occupations and demographic groups, and rate ratios were calculated to assess disparities. RESULTS: Among those aged 18 and older, 2645 unintentional fatal occupational injuries were identified. Fatal occupational injury rates declined by 0.82 injuries/100 000 person-years over this period, falling consistently from 2004 to 2009 and increasing from 2009 to 2017. Fatal injury rates were highest among Hispanic workers, who experienced 2.75 times the fatal injury rate of non-Hispanic White workers (95% CI 2.42 to 3.11) and self-employed workers, who experienced 1.44 times the fatal injury rate of private workers (95% CI 1.29 to 1.60). We also observed that fatal injury rates increased with age group and were higher among male relative to female workers even after adjustment for differential distributions across occupations. CONCLUSIONS: The decline in unintentional fatal occupational injury rates over this period is encouraging, but the increase in injury rate after 2009 and the large disparities between occupations, industries and demographic groups highlight the need for additional targeted safety interventions.

Development and validation of an electronic health records-based opioid use disorder algorithm by expert clinical adjudication among patients with prescribed opioids.

BACKGROUND: In the US, over 200 lives are lost from opioid overdoses each day. Accurate and prompt diagnosis of opioid use disorders (OUD) may help prevent overdose deaths. However, international classification of disease (ICD) codes for OUD are known to underestimate prevalence, and their specificity and sensitivity are unknown. We developed and validated algorithms to identify OUD in electronic health records (EHR) and examined the validity of OUD ICD codes. METHODS: Through four iterations, we developed EHR-based OUD identification algorithms among patients who were prescribed opioids from 2014 to 2017. The algorithms and OUD ICD codes were validated against 169 independent "gold standard" EHR chart reviews conducted by an expert adjudication panel across four healthcare systems. After using 2014-2020 EHR for validating iteration 1, the experts were advised to use 2014-2017 EHR thereafter. RESULTS: Of the 169 EHR charts, 81 (48%) were reviewed by more than one expert and exhibited 85% expert agreement. The experts identified 54 OUD cases. The experts endorsed all 11 OUD criteria from the Diagnostic and Statistical Manual of Mental Disorders-5, including craving (72%), tolerance (65%), withdrawal (56%), and recurrent use in physically hazardous conditions (50%). The OUD ICD codes had 10% sensitivity and 99% specificity, underscoring large underestimation. In comparison our algorithm identified OUD with 23% sensitivity and 98% specificity. CONCLUSIONS AND RELEVANCE: This is the first study to estimate the validity of OUD ICD codes and develop validated EHR-based OUD identification algorithms. This work will inform future research on early intervention and prevention of OUD.

Hurricane Florence and suicide mortality in North Carolina: a controlled interrupted time-series analysis.

BACKGROUND: Natural disasters are associated with increased mental health disorders and suicidal ideation; however, associations with suicide deaths are not well understood. We explored how Hurricane Florence, which made landfall in September 2018, may have impacted suicide deaths in North Carolina (NC). METHODS: We used publicly available NC death records data to estimate associations between Hurricane Florence and monthly suicide death rates using a controlled, interrupted time series analysis. Hurricane exposure was determined by using county-level support designations from the Federal Emergency Management Agency. We examined effect modification by sex, age group, and race/ethnicity. RESULTS: 8363 suicide deaths occurred between January 2014 and December 2019. The overall suicide death rate in NC between 2014 and 2019 was 15.53 per 100 000 person-years (95% CI 15.20 to 15.87). Post-Hurricane, there was a small, immediate increase in the suicide death rate among exposed counties (0.89/100 000 PY; 95% CI -2.69 to 4.48). Comparing exposed and unexposed counties, there was no sustained post-Hurricane Florence change in suicide death rate trends (0.02/100 000 PY per month; 95% CI -0.33 to 0.38). Relative to 2018, NC experienced a statewide decline in suicides in 2019. An immediate increase in suicide deaths in Hurricane-affected counties versus Hurricane-unaffected counties was observed among women, people under age 65 and non-Hispanic black individuals, but there was no sustained change in the months after Hurricane Florence. CONCLUSIONS: Although results did not indicate a strong post-Hurricane Florence impact on suicide rates, subgroup analysis suggests differential impacts of Hurricane Florence on several groups, warranting future follow-up.

Association Between Medical Diagnoses and Suicide in a Medicaid Beneficiary Population, North Carolina 2014-2017.

BACKGROUND: Firearms are used in about half of U.S. suicides. This study investigated how various medical diagnoses are associated with firearm and nonfirearm suicide. METHODS: We used a case-control design including n = 691 North Carolina Medicaid beneficiaries who died from suicide between 1 January 2014 and 31 December 2017 as cases. We selected a total of n = 68,682 controls (~1:100 case-control ratio from North Carolina Medicaid member files using incidence density sampling methods). We linked Medicaid claims to the North Carolina Violent Death Reporting System to ascertain suicide and means (firearm or nonfirearm). We matched cases and controls on number of months covered by Medicaid over the past 36 months. Analyses adjusted for sex, race, age, Supplemental Security Income status, the Charlson Comorbidity Index, and frequency of health care encounters. RESULTS: The case-control odds ratios for any mental health disorder were 4.2 (95% confidence interval [CI]: 3.3, 5.2) for nonfirearm suicide and 2.2 (95% CI: 1.7, 2.9) for firearm suicide. There was effect measure modification by sex and race. Behavioral health diagnoses were more strongly associated with nonfirearm suicides than firearm suicide in men but did not differ substantially in women. The association of mental health and substance use diagnoses with suicides appeared to be weaker in Blacks (vs. non-Blacks), but the estimates were imprecise. CONCLUSION: Behavioral health diagnoses are important indicators of risk of suicide. However, these associations differ by means of suicide and sex, and associations for firearm-related suicide are weaker in men than women.

Opioid Overdose Deaths Among Formerly Incarcerated Persons and the General Population: North Carolina, 2000‒2018.

Objectives. To compare opioid overdose death (OOD) rates among formerly incarcerated persons (FIPs) from 2016 to 2018 with the North Carolina population and with OOD rates from 2000 to 2015. Methods. We performed a retrospective cohort study of 259 861 North Carolina FIPs from 2000 to 2018 linked with North Carolina death records. We used indirectly standardized OOD mortality rates and ratios and present 95% confidence intervals (CIs). Results. From 2017 to 2018, the OOD rates in the North Carolina general population decreased by 10.1% but increased by 32% among FIPs. During 2016 to 2018, the highest substance-specific OOD rate among FIPs was attributable to synthetic narcotics (mainly fentanyl and its analogs), while OOD rates for other opioids were half or less than that from synthetic narcotics. During 2016 to 2018, the OOD risk for FIPs from synthetic narcotics was 50.3 (95% CI = 30.9, 69.6), 20.2 (95% CI = 17.3, 23.2), and 18.2 (95% CI = 15.9, 20.5) times as high as that for the North Carolina population at 2-week, 1-year, and complete follow-up after release, respectively. Conclusions. While nationwide OOD rates declined from 2017 to 2018, OOD rates among North Carolina FIPs increased by about a third, largely from fentanyl and its analogs. (Am J Public Health. 2022;112(2):300-303. https://doi.org/10.2105/AJPH.2021.306621).

Suicide typologies among Medicaid beneficiaries, North Carolina 2014-2017.

BACKGROUND: There is a well-established need for population-based screening strategies to identify people at risk of suicide. Because only about half of suicide decedents are ever diagnosed with a behavioral health condition, it may be necessary for providers to consider life circumstances that may also put individuals at risk. This study described the alignment of medical diagnoses with life circumstances by identifying suicide typologies among decedents. Demographics, stressful life events, suicidal behavior, perceived and diagnosed health problems, and suicide method contributed to the typologies. METHODS: This study linked North Carolina Medicaid and North Carolina Violent Death Reporting System (NC-VDRS) data for analysis in 2020. For suicide decedents from 2014 to 2017 aged 25-54 years, we analyzed 12 indicators of life circumstances from NC-VDRS and 6 indicators from Medicaid claims, using a latent class model. Separate models were developed for men and women. RESULTS: Most decedents were White (88.3%), with a median age of 41, and over 70% had a health care visit in the 90 days prior to suicide. Two typologies were identified in both males (n = 175) and females (n = 153). Both typologies had similar profiles of life circumstances, but one had high probabilities of diagnosed behavioral health conditions (45% of men, 71% of women), compared to low probabilities in the other (55% of men, 29% of women). Black beneficiaries and men who died by firearm were over-represented in the less-diagnosed class, though estimates were imprecise (odds ratio for Black men: 3.1, 95% confidence interval: 0.8, 12.4; odds ratio for Black women: 5.0, 95% confidence interval: 0.9, 31.2; odds ratio for male firearm decedents: 1.6, 95% confidence interval: 0.7, 3.4). CONCLUSIONS: Nearly half of suicide decedents have a typology characterized by low probability of diagnosis of behavioral health conditions. Suicide screening could likely be enhanced using improved indicators of lived experience and behavioral health.

Innovations in suicide prevention research (INSPIRE): a protocol for a population-based case-control study.

BACKGROUND: Suicide deaths have been increasing for the past 20 years in the USA resulting in 45 979 deaths in 2020, a 29% increase since 1999. Lack of data linkage between entities with potential to implement large suicide prevention initiatives (health insurers, health institutions and corrections) is a barrier to developing an integrated framework for suicide prevention. OBJECTIVES: Data linkage between death records and several large administrative datasets to (1) estimate associations between risk factors and suicide outcomes, (2) develop predictive algorithms and (3) establish long-term data linkage workflow to ensure ongoing suicide surveillance. METHODS: We will combine six data sources from North Carolina, the 10th most populous state in the USA, from 2006 onward, including death certificate records, violent deaths reporting system, large private health insurance claims data, Medicaid claims data, University of North Carolina electronic health records and data on justice involved individuals released from incarceration. We will determine the incidence of death from suicide, suicide attempts and ideation in the four subpopulations to establish benchmarks. We will use a nested case-control design with incidence density-matched population-based controls to (1) identify short-term and long-term risk factors associated with suicide attempts and mortality and (2) develop machine learning-based predictive algorithms to identify individuals at risk of suicide deaths. DISCUSSION: We will address gaps from prior studies by establishing an in-depth linked suicide surveillance system integrating multiple large, comprehensive databases that permit establishment of benchmarks, identification of predictors, evaluation of prevention efforts and establishment of long-term surveillance workflow protocols.

Association Between Statewide Opioid Prescribing Interventions and Opioid Prescribing Patterns in North Carolina, 2006-2018.

OBJECTIVE: To examine the impact of three sequential statewide policy and legislative interventions on opioid prescribing practices among privately insured individuals in North Carolina. METHODS: An interrupted time series approach was used to examine level and trajectory changes of new and prevalent opioid prescription rates, days' supply, and daily morphine milligram equivalents before and after implementation of a 1) prescription drug monitoring program, 2) state medical board initiative, and 3) legislative action. Analyses were conducted using individual-level claims data from a large private health insurance provider serving North Carolina residents, ages 18-64 years, from January 2006 to August 2018. RESULTS: Rates of new and prevalent prescription opioid patients were relatively unaffected by the prescription monitoring program but sharply declined in the months immediately following both medical board (-3.7 new and -19.3 prevalent patients per 10,000 person months) and legislative (-14.1 new and -26.7 prevalent patients) actions. Among all opioid prescriptions, days' supply steadily increased on average over the study period but declined after legislative action (-1.5 days' supply per year). CONCLUSIONS: The voluntary prescription drug monitoring program launched in 2010 only marginally affected opioid prescribing patterns on its own, but its redeployment as an investigative and clinical tool in multifaceted public policy approaches by the state medical board and legislature later in the decade plausibly contributed to notable declines in prescription rates and days' supply. This study lends new emphasis to the importance of enforcement mechanisms for state and national policies seeking to reverse this critical public health crisis.

Implementation of mandatory opioid prescribing limits in North Carolina: healthcare administrator and prescriber perspectives.

BACKGROUND: Recent increases in state laws to reduce opioid prescribing have demonstrated a need to understand how they are interpreted and implemented in healthcare systems. The purpose of this study was to explore the systems, strategies, and resources that hospital administrators and prescribers used to implement the 2017 North Carolina Strengthen Opioid Prevention (STOP) Act opioid prescribing limits, which limited initial prescriptions to a five (for acute) or seven (for post-surgical) days' supply. METHODS: We interviewed 14 hospital administrators and 38 prescribers with degrees in medicine, nursing, pharmacy, business administration and public health working across North Carolina. Interview guides, informed by the Consolidated Framework for Implementation Research, explored barriers and facilitators to implementation. Interview topics included communication, resources, and hospital system support. Interviews were recorded and transcribed, then analyzed using flexible coding, integrating inductive and deductive coding, to inform analytic code development and identify themes. RESULTS: We identified three main themes around implementation of STOP act mandated prescribing limits: organizational communication, prescriber education, and changes in the electronic medical record (EMR) systems. Administrators reflected on implementation in the context of raising awareness and providing reminders to facilitate changes in prescriber behavior, operationalized through email and in-person communications as well as dedicated resources to EMR changes. Prescribers noted administrative communications about prescribing limits often focused on legality, suggesting a directive of the organization's policy rather than a passive reminder. Prescribers expressed a desire for more spaces to have their questions answered and resources for patient communications. While hospital administrators viewed compliance with the law as a priority, prescribers reflected on concerns for adequately managing their patients' pain and limited time for clinical care. CONCLUSIONS: Hospital administrators and prescribers approached implementation of the STOP act prescribing limits with different mindsets. While administrators were focused on policy compliance, prescribers were focused on their patients' needs. Strategies to implement the mandate then had to balance patient needs with policy compliance. As states continue to legislate to prevent opioid overdose deaths, understanding how laws are implemented by healthcare systems and prescribers will improve their effectiveness through tailoring and maximizing available resources.

State firearm laws, race and law enforcement-related deaths in 16 US states: 2010-2016.

The aim of this study was to assess the association between state firearm legislation and law enforcement-related deaths (LEDs) and its modification by race. We used secondary data from an ecological cohort of 16 states (2010 to 2016), using the National Violent Death Reporting System (NVDRS), the State Firearm Law Database and additional public sources. Poisson regression with generalised estimating equations and inverse probability of exposure weights to account for time-varying confounding were used to quantify the association. LEDs were also disaggregated by race (Black vs non-Black). A total of 1593 LEDs took place during the 6-year study period. After adjusting for confounders, the IRR among non-Blacks was 0.48 (95% CI 0.26 to 0.89) and 1.53 (95% CI 0.93 to 2.54) among Blacks. Our findings highlight the fact that increased firearm provisions may decrease rates of LED among non-Black American individuals-an association not observed among Black Americans.

Intimate Partner Homicides in North Carolina: 2011-2015.

BACKGROUND Research on intimate partner homicide (IPH), when someone is killed by a current or former intimate partner, in North Carolina is limited, making it difficult to understand the magnitude of IPHs and identify strategies for prevention.METHOD We used North Carolina Violent Death Reporting System (NC-VDRS) data to assess IPHs among North Carolina residents between 2011 and 2015. Homicides were considered IPHs if intimate partner violence was identified and the victim was the suspect's current or former intimate partner. Proportions and rates of demographic characteristics and circumstances were assessed.RESULTS Of the 2,299 homicides that occurred between 2011 and 2015, 350 were IPHs (0.9 per 100,000 person-years). Most (72.3%) IPH victims were female (n = 253). Among all female homicides almost half (48.2%) were IPHs, while only 5.4% of all male homicides were IPHs. The highest rate of IPH occurred among women aged 20-44 (2.1 per 100,000 person-years). Most victims were non-Hispanic (NH) white (54.0%, n = 189), although rates for NH American Indians and NH blacks were 1.8 and 2.0 times those among NH whites respectively. Most victims, 86.6% male and 82.6% female, were the suspect's current partner. Firearms were the most common weapon used (62.6%, n = 219).LIMITATIONS NC-VDRS data are not representative of all IPHs in the United States. Circumstance data were sometimes incomplete and categories of circumstance variables restrictive, limiting available information on IPHs.CONCLUSION Future interventions focused on women aged 20-44, NH American Indian and NH Black communities, and firearm access could be effective in preventing IPHs in North Carolina.