Etiologic mechanisms in an adapted family-based preventive intervention for underage alcohol use in Mexico: Results of an exploratory pilot study.

Alcohol use represents a global health problem, especially for Latin American youth. As part of the Global Smart Drinking Goals campaign, a family-based preventive intervention was adapted and piloted in Mexico based on an existing evidence-based program, Guiding Good Choices. In this study, we explored the malleability and session-specific mean-level changes in protective and risk factors targeted by the adapted family intervention as related to the prevention of underage alcohol use and abuse. The sample consisted of 177 parents working at four private local companies who had children between the ages of 8 and 16. Data were collected before and after each program session. Linear mixed-effects models were used to examine growth trajectories and session-specific mean differences for selected etiologic factors. Significant effects on protective and risk factors were found. Among protective factors, positive family involvement showed the most considerable linear growth over time, while clear standards for youth showed the largest within-session increase. The greatest linear decrease in risk was observed for family conflict, which also showed the greatest pre-, and post-session reduction. Our findings suggest that the adapted program helped families develop protection against, and reduce risk of, alcohol use in their adolescent children. Results from this exploratory pilot study provide support for further rigorous evaluation and dissemination of the adapted intervention for Hispanic families.

Screening and brief intervention for alcohol use disorder risk in three middle-income countries.

BACKGROUND: This study examined the prevalence of screening and brief intervention (SBI) for alcohol use disorder (AUD) risk in samples of adult drinkers in three middle-income countries (Brazil, China, South Africa), and the extent to which meeting criteria for AUD risk was associated with SBI. METHODS: Cross-sectional survey data were collected from adult samples in two cities in each country in 2018. Survey measures included past-year alcohol use, the CAGE assessment for AUD risk, talking to a health care professional in the past year, alcohol use screening by a health care professional, receiving advice about drinking from a health care professional, and sociodemographic characteristics. The prevalence of SBI was determined for past-year drinkers in each country and for drinkers who had talked to a health care professional. Logistic regression analyses were conducted to examine whether meeting criteria for AUD risk was associated with SBI when adjusting for sociodemographic characteristics. RESULTS: Among drinkers at risk for AUD, alcohol use screening rates ranged from 6.7% in South Africa to 14.3% in Brazil, and brief intervention rates ranged from 4.6% in South Africa to 8.2% in China. SBI rates were higher among drinkers who talked to a health care professional in the past year. In regression analyses, AUD risk was positively associated with SBI in China and South Africa, and with brief intervention in Brazil. CONCLUSION: Although the prevalence of SBI among drinkers at risk for AUD in Brazil, China, and South Africa appears to be low, it is encouraging that these drinkers were more likely to receive SBI.

Predictors of Engagement and Attendance of a Family-Based Prevention Program for Underage Drinking in Mexico.

Underage drinking represents a major global health problem. Given the crisis that underage drinking represents, Tomando Buenas Decisiones, a family-based prevention program, was adapted and piloted in Mexico based on the existing Guiding Good Choices program. Although family-based interventions in the USA are promising for preventing underage drinking, little is known about how adapted versions of these interventions may work in low-middle income countries, such as in Latin America. The present study examined whether baseline individual, familial, and cultural factors predict participants' engagement and attendance in an adapted program for preventing underage drinking in Zacatecas, Mexico. The study was conducted with a sample of 178 parents who participated in the adapted program and were employed at local private companies. Latent growth curve modeling was used to analyze (a) change in engagement, (b) predictors of engagement, and (c) predictors of attendance. Results indicated that perceived engagement evidenced a significant linear increase throughout the intervention. Participants' familism values, such as perceived family as referents and family support, at baseline predicted both initial levels of and change in engagement. Perceived familial obligation also predicted change in engagement. Attendance was negatively predicted by male gender, by perceived stress, and by perceived familial obligations among women only. Poor family management, and perceived familial obligations among men, positively predicted attendance. Our findings have important implications for the conceptualization of engagement and attendance in family-based preventive interventions for underage drinking among Hispanics. Researchers interested in implementing interventions in Latin America can use these findings to better comprehend how and for whom adapted family-based preventive interventions work.

Effects of the Universal Prevention Curriculum for Schools on Substance Use Among Peruvian Adolescents: A Randomized Trial.

This group-randomized trial assessed the effects of a universal prevention training curriculum for school administrators and teachers that focused on effective strategies to prevent adolescent substance use and related problems. Twenty-eight schools in three regions of Peru were randomly assigned to either an intervention or control condition (14 schools per condition). Repeated cross-sectional samples of 11 to 19-year-old students participated in four surveys from May 2018 to November 2019 (N = 24,529). School administrators and teachers at intervention schools participated in a universal prevention training curriculum focusing on the development of a positive school climate as well as effective policies related to school substance use. All intervention and control schools were offered Unplugged, a classroom-based substance use prevention curriculum. Outcome measures included: lifetime drug use; past-year and past-month tobacco, alcohol, marijuana, and other drug use; awareness of school tobacco and alcohol use policies; perceived enforcement of school policies; school bonding; perceived friends' use of tobacco, alcohol, marijuana and other drugs; and personal problems in general and problems related to substance use. Multi-level analyses indicated significant reductions in past-year and past-month smoking, friends' substance use, and problems related to substance use and in general at intervention relative to control schools. Significant increases were found in intervention vs. control schools related to students' awareness of school substance use policies, perceived likelihood of getting caught for smoking, and school bonding. These findings suggest that the universal prevention training curriculum and the school policy and climate changes it promoted reduced substance use and related problems in the study population of Peruvian adolescents.

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.

The Contribution of Alcohol Beverage Types to Consumption, Heavy Drinking, and Alcohol-Related Harms: A Comparison across Five Countries.

BACKGROUND: This study examined the relative contribution of alcoholic beverage types to overall alcohol consumption and associations with heavy alcohol use and alcohol-related harms among adults. METHODS: Cross-sectional survey data were collected from adult samples in two cities involved in the Global Smart Drinking Goals (GSDG) initiative in each of five countries (Belgium, Brazil, China, South Africa, United States). Survey measures included past-30-day consumption of beer, wine, flavored alcoholic drinks, spirits, and homemade alcohol; past-30-day heavy drinking; 14 alcohol-related harms in the past 12 months; and demographic characteristics. Within in each country, we computed the proportion of total alcohol consumption for each beverage type. Regression analyses were conducted to estimate the relative associations between consumption of each alcoholic beverage type, heavy alcohol use, and alcohol-related harms, controlling for demographic characteristics. RESULTS: Beer accounted for at least half of total alcohol consumption in GSDG cities in Belgium, Brazil, the U.S., and South Africa, and 35% in China. Regression analyses indicated that greater beer consumption was associated with heavy drinking episodes and with alcohol-related harms in the cities in Belgium, Brazil, South Africa, and the U.S. Significant increases in heavy drinking and alcohol-related harms were also consistently observed for spirits consumption. CONCLUSIONS: Beer accounts for the greatest proportion of total alcohol consumption in most of the GSDG cities and was consistently associated with more heavy drinking episodes and alcohol-related harms. Reducing beer consumption through evidence-based interventions may therefore have the greatest impact on hazardous drinking and alcohol-related harms.

A Comparison of Chinese Adults Who Consume Homemade versus Commercial Alcohol.

BACKGROUND: Little is known about adults in China who drink homemade alcohol, and whether they are at elevated risk of harms relative to those who drink alcohol from commercial sources. Purpose: We describe and contrast adults in China who regularly consume either homemade or commercially available alcohol, or both. Methods: Household-based in-person interviews were conducted in 2018 with adults in Jiangshan and Lanxi. We examined the characteristics of 833 adults who had consumed alcohol within the previous 30 days, comparing those who drank commercial alcohol only with those who drank homemade alcohol only and alcohol from both sources. Results: Regression analyses revealed that drinkers of both homemade and commercial alcohol consumed more drinks and were more likely to report heavy drinking than did drinkers of commercial or homemade alcohol only and were also more likely to meet criteria for alcohol use disorder. We also found that homemade-only alcohol drinkers were at elevated risk for this disorder. Conclusions: Drinkers of both homemade and commercial alcohol in China may be at risk for alcohol-related problems and constitute a little understood population for whom further research is needed. The AB InBev Foundation supported this study.

Evaluation of a Mystery Shopper Intervention to Reduce Sales of Alcohol to Minors in Zacatecas and Guadalupe, Mexico.

We report the results of a quasi-experimental evaluation of a mystery shopper intervention in Zacatecas and Guadalupe, Mexico. Underage youth attempted to purchase beer at 50 Modelorama stores and 32 Oxxo stores (intervention groups), and at 19 comparison convenience stores in March, July, and August 2018. After each attempt, intervention store operators were informed if a sale was made. Modelorama operators also received training and were warned that repeated sales to minors could jeopardize their franchise. Average sales rates to minors were 63.8% at Modeloramas, 86.5% at Oxxo stores, and 98.2% at comparison stores. The findings suggest that mystery shopper interventions with training, feedback to store operators, and sanctions after repeated sales to underage youth may reduce sales to minors in low- and middle-income countries.

Alcohol Availability, Use, and Harms Among Adolescents in Three Mexican Cities.

Alcohol remains readily available to youth in most countries. We examined the associations between both the on- and off-premises commercial availability of alcohol to youth and their alcohol use, heavy episodic drinking, and alcohol-related harms. We conducted the study using data from a survey of a sample of 594 students in central Mexico between 12 and 17 years of age in 2016. Both the perceived availability of alcohol and the purchasing of alcohol at an off-premises establishment were positively related to past-30-day alcohol use and heavy episodic drinking, as well as to alcohol-related harms in the past year. Consumption at on-premises establishments was also positively associated with alcohol-related harms. Preventive efforts to reduce the availability of alcohol at off- and on-premises establishments, by such strategies as mystery shopper and responsible beverage service programs, are imperative.

Trajectories of dispensed prescription opioids among beneficiaries enrolled in a Medicaid controlled substance "lock-in" program.

PURPOSE: "Lock-in" programs (LIPs) are used by health insurers to address potential substance (eg, opioid) misuse among beneficiaries. We sought to (1) examine heterogeneity in trajectories of dispensed opioids (in average daily morphine milligram equivalents (MMEs)) over time: prior to, during, and following release from a LIP, and (2) assess associations between trajectory patterns and beneficiary characteristics. METHODS: Medicaid claims were linked to Prescription Drug Monitoring Program records for a cohort of beneficiaries enrolled in the North Carolina Medicaid LIP (n = 2701). Using latent class growth analyses, we estimated trajectories of average daily MMEs of opioids dispensed to beneficiaries across specific time periods of interest. RESULTS: Five trajectory patterns appeared to sufficiently describe underlying heterogeneity. Starting values and slopes varied across the 5 trajectory groups, which followed these overall patterns: (1) start at a high level of MMEs, end at a high level of MMEs (13.1% of cohort); (2) start medium, end medium (13.2%); (3) start medium, end low (21.5%); (4) start low, end medium (22.6%); and (5) start low, end low (29.6%). We observed strong associations between patterns and beneficiaries' demographics, substance use-related characteristics, comorbid conditions, and healthcare utilization. CONCLUSIONS: In its current form, the Medicaid LIP appeared to have limited impact on beneficiaries' opioid trajectories. However, strong associations between trajectory patterns and beneficiary characteristics provide insight into potential LIP design modifications that might improve program impact (eg, LIP integration of substance use disorder assessment and referral to treatment, assessment and support for alternate pain therapies).

Health Care Utilization and Comorbidity History of North Carolina Medicaid Beneficiaries in a Controlled Substance "Lock-in" Program.

BACKGROUND Medicaid "lock-in" programs (MLIPs) are a widely used strategy for addressing potential misuse of prescription drugs among beneficiary populations. However, little is known about the health care needs and attributes of beneficiaries selected into these programs. Our goal was to understand the characteristics of those eligible, enrolled, and retained in a state MLIP.METHODS Demographics, comorbidities, and health care utilization were extracted from Medicaid claims from June 2009 through June 2013. Beneficiaries enrolled in North Carolina's MLIP were compared to those who were MLIP-eligible, but not enrolled. Among enrolled beneficiaries, those completing the 12-month MLIP were compared to those who exited prior to 12 months.RESULTS Compared to beneficiaries who were eligible for, but not enrolled in the MLIP (N = 11,983), enrolled beneficiaries (N = 5,424) were more likely to have: 1) substance use (23% versus 14%) and mental health disorders, 2) obtained controlled substances from multiple pharmacies, and 3) visited more emergency departments (mean: 8.3 versus 4.2 in the year prior to enrollment). One-third (N = 1,776) of those enrolled in the MLIP exited the program prior to completion.LIMITATIONS Accurate information on unique prescribers visited by beneficiaries was unavailable. Time enrolled in Medicaid differed for beneficiaries, which may have led to underestimation of covariate prevalence.CONCLUSIONS North Carolina's MLIP appears to be successful in identifying subpopulations that may benefit from provision and coordination of services, such as substance abuse and mental health services. However, there are challenges in retaining this population for the entire MLIP duration.

A statewide evaluation of seven strategies to reduce opioid overdose in North Carolina.

BACKGROUND: In response to increasing opioid overdoses, US prevention efforts have focused on prescriber education and supply, demand and harm reduction strategies. Limited evidence informs which interventions are effective. We evaluated Project Lazarus, a centralised statewide intervention designed to prevent opioid overdose. METHODS: Observational intervention study of seven strategies. 74 of 100 North Carolina counties implemented the intervention. Dichotomous variables were constructed for each strategy by county-month. Exposure data were: process logs, surveys, addiction treatment interviews, prescription drug monitoring data. Outcomes were: unintentional and undetermined opioid overdose deaths, overdose-related emergency department (ED) visits. Interrupted time-series Poisson regression was used to estimate rates during preintervention (2009-2012) and intervention periods (2013-2014). Adjusted IRR controlled for prescriptions, county health status and time trends. Time-lagged regression models considered delayed impact (0-6 months). RESULTS: In adjusted immediate-impact models, provider education was associated with lower overdose mortality (IRR 0.91; 95% CI 0.81 to 1.02) but little change in overdose-related ED visits. Policies to limit ED opioid dispensing were associated with lower mortality (IRR 0.97; 95% CI 0.87 to 1.07), but higher ED visits (IRR 1.06; 95% CI 1.01 to 1.12). Expansions of medication-assisted treatment (MAT) were associated with increased mortality (IRR 1.22; 95% CI 1.08 to 1.37) but lower ED visits in time-lagged models. CONCLUSIONS: Provider education related to pain management and addiction treatment, and ED policies limiting opioid dispensing showed modest immediate reductions in mortality. MAT expansions showed beneficial effects in reducing ED-related overdose visits in time-lagged models, despite an unexpected adverse association with mortality.

Community Readiness to Prevent Opioid Overdose.

Effective community-based actions are urgently needed to combat the ongoing epidemic of opioid overdose. Community readiness (CR) has been linked to communities' support for collective action, which in turn has been associated with the success of community-wide prevention strategies and resulting behavior change. Our study, conducted in North Carolina, assessed the relationship between CR and two indices of opioid overdose. County-level data included a survey of health directors that assessed CR to address drug overdose prevention programs, surveillance measures of opioid overdose collected from death records and emergency departments, and two indicators of general health-related status. We found that counties' rates of CR were positively associated with their opioid-related mortality (but not morbidity) and that this relationship persisted when we controlled for health status. North Carolina counties with the highest opioid misuse problems appear to be the most prepared to respond to them.

The use of a prescription drug monitoring program to develop algorithms to identify providers with unusual prescribing practices for controlled substances.

The misuse, abuse and diversion of controlled substances have reached epidemic proportion in the United States. Contributing to this problem are providers who over-prescribe these substances. Using one state's prescription drug monitoring program, we describe a series of metrics we developed to identify providers manifesting unusual and uncustomary prescribing practices. We then present the results of a preliminary effort to assess the concurrent validity of these algorithms, using death records from the state's vital records database pertaining to providers who wrote prescriptions to patients who then died of a medication or drug overdose within 30 days. Metrics manifesting the strongest concurrent validity with providers identified from these records related to those who co-prescribed benzodiazepines (e.g., valium) and high levels of opioid analgesics (e.g., oxycodone), as well as those who wrote temporally overlapping prescriptions. We conclude with a discussion of a variety of uses to which these metrics may be put, as well as problems and opportunities related to their use.

Reducing youth access to alcohol: findings from a community-based randomized trial.

Underage drinking continues to be an important public health problem and a challenge to the substance abuse prevention field. Community-based interventions designed to more rigorously control underage access to alcohol through retailer education and greater enforcement of underage drinking laws have been advocated as potentially effective strategies to help address this problem, but studies designed to evaluate such interventions are sparse. To address this issue we conducted a randomized trial involving 36 communities to test the combined effectiveness of five interrelated intervention components designed to reduce underage access to alcohol. The intervention was found to be effective in reducing the likelihood that retail clerks would sell alcohol to underage-looking buyers, but did not reduce underage drinking or the perceived availability of alcohol among high school students. Post hoc analyses, however, revealed significant associations between the level of underage drinking law enforcement in the intervention communities and reductions in both 30-day use of alcohol and binge drinking. The findings highlight the difficulty in reducing youth drinking even when efforts to curtail retail access are successful. Study findings also suggest that high intensity implementation of underage drinking law enforcement can reduce underage drinking. Any such effects of enhanced enforcement on underage drinking appear to be more directly attributable to an increase in perceived likelihood of enforcement and the resultant perceived inconveniences and/or sanctions to potential drinkers, than to a reduction in access to alcohol per se.

Intended and unintended consequences: Changes in opioid prescribing practices for postsurgical, acute, and chronic pain indications following two policies in North Carolina, 2012-2018 - Controlled and single-series interrupted time series analyses.

BACKGROUND: The potential misapplication of current opioid prescribing policies remains understudied and may have substantial adverse implications for patient safety. METHODS: We used autoregressive integrated moving average models to assess level and trend changes in monthly 1) prescribing rates, 2) days' supply, and 3) daily morphine milligram equivalents (MME) of incident opioid prescriptions relative to 1) a state medical board initiative to reduce high-dose and -volume opioid prescribing and 2) legislation to limit initial opioid prescriptions for acute and postsurgical pain. We examined outcomes by pain indication overall and by cancer history, using prescribing patterns for benzodiazepines to control for temporal trends. We used large private health insurance claims data to include North Carolina residents, aged 18-64, insured at any point between January 2012 and August 2018. RESULTS: After the medical board initiative, prescribing patterns for chronic pain patients did not change; conversely, acute and postsurgical pain patients experienced immediate declines in daily MME. Post-legislation prescription rates did not decline for those with acute, postsurgical, and non-cancer pain, but instead declined among cancer patients with chronic pain. Chronic pain patients experienced the largest days' supply declines post-legislation, instead of acute and postsurgical pain patients. CONCLUSIONS: We found mixed evidence on the potential impact of two opioid prescribing policies, with some observed declines in a group not intended to be impacted by the policy. This study provides evidence of the need for clearer opioid prescribing policies to ensure impacts on intended populations and avoid unintended consequences.

Locked Down: Economic and Health Effects of COVID-19 Response on Residents of a South African Township.

Background: Little research has examined how pandemics affect residents in under-resourced communities. This study investigated how COVID-19 and lockdown policies affected residents of Alexandra, one of Johannesburg, South Africa's lowest-income townships. Methods: We conducted a telephone survey May 11-22, 2020, while the lockdown and alcohol ban were in effect, of a spatially stratified sample of 353 adult Alexandra residents drawn randomly from voter registration, credit card application, and prior studies' sampling frames. We examined economic consequences; health experiences, including COVID-19 exposure and mental health symptoms; alcohol use; and personal experiences with violence. Results: Respondents were aged 18 to 89 and 47% female. About 70% of those employed before the lockdown were no longer working. Over half of households lost at least one source of income. About 50% of respondents reported stockpiling food. A majority reported price rises and declines in availability of food. Smaller percentages reported such changes for other items. Over 80% reported stress or anxiety, or depression due to the pandemic. The prevalence of past-week alcohol use fell from over 50% before the lockdown to less than 10% during the lockdown. Self-reported physical violence victimization increased. Discussion: COVID-19 and the lockdown disrupted Alexandra residents' lives through unemployment, lost income, mental health problems, and increased violence. The differences between these outcomes and those in more advantaged communities deserve investigation. Research should also seek to identify tailored responses to effectively address the challenges of marginalized communities that often have limited resources to deal with pandemics and policies to contain them.

Association of Opioid Dose Reduction With Opioid Overdose and Opioid Use Disorder Among Patients Receiving High-Dose, Long-term Opioid Therapy in North Carolina.

Importance: Rapid reduction or discontinuation of long-term opioid therapy may increase risk of opioid overdose or opioid use disorder (OUD). Current guidelines for chronic pain management caution against rapid dose reduction but are based on limited evidence. Objective: To characterize the association between rapid reduction or abrupt discontinuation of opioid therapy (vs maintained or gradual reduction) and incidence of opioid overdose and OUD among patients prescribed high-dose, long-term opioid therapy (HDLTOT). Design, Setting, and Participants: This retrospective cohort study was conducted among patients aged 18 to 64 years who were prescribed HDLTOT (≥90 daily morphine milligram equivalents for ≥90% of 90 days) from January 2006 to September 2018, with follow-up up to 4 years after cohort entry. Claims data were drawn from a large private health insurer in North Carolina and analyzed from March 1, 2006, to September 30, 2018. Exposures: Time-varying exposure of rapid dose reduction or discontinuation (>10% dose reduction/week) vs maintenance, increase, or gradual reduction or discontinuation. Main Outcomes and Measures: The main outcome was incident opioid overdose (fatal or nonfatal) or diagnosed OUD. Inverse probability-weighted cumulative incidence of outcomes were estimated using the cumulative incidence function and hazard ratios (HRs) using marginal structural Fine-Gray models as a function of rapid dose tapering or discontinuation (vs gradual reduction or discontinuation or maintained or increased), accounting for competing risks. Results: A total of 19 443 patients (median [IQR] age, 49 [41-55] years; 10 073 [51.8%] men) who received HDLTOT were identified. Rapid reduction or discontinuation was associated with higher risk of fatal and nonfatal overdoses compared with gradual reduction after the first year (year 1: HR, 1.43; 95% CI, 0.94-2.18; years 2-4: HR, 1.95; 95% CI, 1.31-2.90). There was no association between rapid reduction or discontinuation and diagnosed OUD through 2 years of follow-up; however, the hazard of incident OUD among patients exposed to rapid tapering or discontinuation was greater 25 to 48 months after the start of follow-up (HR, 1.28; 95% CI, 1.01-1.63). Conclusions and Relevance: In this cohort study, rapid dose reduction or discontinuation was associated with increased risk of opioid overdose and OUD during long-term follow-up. These findings reinforce prior concerns about safety of rapid dose reductions for patients receiving HDLTOT and highlight the need for caution when reducing opioid doses.

State Medical Board Policy and Opioid Prescribing: A Controlled Interrupted Time Series.

INTRODUCTION: In March 2016, the Centers for Disease Control and Prevention issued opioid prescribing guidelines for chronic noncancer pain. In response, in April 2016, the North Carolina Medical Board launched the Safe Opioid Prescribing Initiative, an investigative program intended to limit the overprescribing of opioids. This study focuses on the association of the Safe Opioid Prescribing Initiative with immediate and sustained changes in opioid prescribing among all patients who received opioid and opioid discontinuation and tapering among patients who received high-dose (>90 milligrams of morphine equivalents), long-term (>90 days) opioid therapy. METHODS: Controlled and single interrupted time series analysis of opioid prescribing outcomes before and after the implementation of Safe Opioid Prescribing Initiative was conducted using deidentified data from the North Carolina Controlled Substances Reporting System from January 2010 through March 2017. Analysis was conducted in 2019-2020. RESULTS: In an average study month, 513,717 patients, including patients who received 47,842 high-dose, long-term opioid therapy, received 660,912 opioid prescriptions at 1.3 prescriptions per patient. There was a 0.52% absolute decline (95% CI= -0.87, -0.19) in patients receiving opioid prescriptions in the month after Safe Opioid Prescribing Initiative implementation. Abrupt discontinuation, rapid tapering, and gradual tapering of opioids among patients who received high-dose, long-term opioid therapy increased by 1% (95% CI= -0.22, 2.23), 2.2% (95% CI=0.91, 3.47), and 1.3% (95% CI=0.96, 1.57), respectively, in the month after Safe Opioid Prescribing Initiative implementation. CONCLUSIONS: Although Safe Opioid Prescribing Initiative implementation was associated with an immediate decline in overall opioid prescribing, it was also associated with an unintended immediate increase in discontinuations and rapid tapering among patients who received high-dose, long-term opioid therapy. Better policy communication and prescriber education regarding opioid tapering best practices may help mitigate unintended consequences of statewide policies.

Compliance with a law to reduce alcoholic beverage sales and service in Zacatecas, Mexico.

BACKGROUND: Research on the effects of restricting bar opening hours and alcohol sales in middle-income countries is very limited. We assessed compliance with and possible effects of a law enacted in Zacatecas, Mexico on December 30, 2017 and implemented in 2018 and 2019 that established a 2 AM bar closing time and 10 PM cut-off for alcohol sales by off-premises stores. METHODS: Monthly observations of bars and off-premises stores and alcohol mystery shopping visits from 2018 to early 2020 were conducted to assess compliance with the law. Breath tests were conducted in 2018 and 2019 with samples of pedestrians in the nighttime entertainment districts of Zacatecas and a comparison city (Aguascalientes). Surveys of bar owners/managers and staff, emergency medical personnel (EMP), and police officers were conducted in Zacatecas in 2018 and 2019 to assess awareness and support of the law and possible effects of the law on alcohol-related problems such as violence and injuries. RESULTS: Monthly observations indicated that a substantial percentage of bars and off-premises package stores did not comply with the law. Pedestrian breath tests in 2018 and 2019 indicated significant reductions in blood alcohol concentration and heavy drinking among pedestrians in Zacatecas from 11 PM to 2 AM compared to Aguascalientes, but not after 2 AM. Surveys of bar owners/managers indicated that most were aware and supportive of the law. EMP surveys indicated reductions in incidents of physical fighting and drunk or injured customers during the annual September fair in Zacatecas. CONCLUSIONS: This study suggests that restricting bar opening hours and alcohol sales may not result in full compliance by bars and off-premises stores, but may help to reduce excessive alcohol use and related harms in a middle-income country. A more rigorous evaluation with pre-intervention data is needed, however, to fully address this latter question.