Racial Disparities in Newborn Drug Testing After Implementation of Question-Based Screening for Prenatal Substance Use.

OBJECTIVE: To examine the association of universal question-based screening for prenatal substance use on racial inequities in prenatal and newborn drug testing. METHODS: We conducted a retrospective cohort study of 32,802 live births of patients receiving prenatal care at an academic medical center in the midwestern United States from 2014 to 2022, before and after implementation of question-based screening in 2018. Primary outcomes included prenatal and newborn drug test orders. Logistic regression models using a generalized estimating equation framework assessed associations with question-based screening and results, birthing parent age, race, ethnicity, marital status, and insurance type. Charts of patients who indicated difficulties stopping substance use were audited for guideline-directed care. RESULTS: A total of 12,725 of 14,992 pregnant people (85.3%) received question-based screening. Implementation of question-based screening was associated with a decrease in prenatal urine test orders (5.0% [95% CI, 4.6-5.3%] before implementation, 3.1% [95% CI, 2.8-3.4%] after implementation; P<.001), with Black birthing parents having the largest reduction in prenatal urine drug testing (10.3% [95% CI, 9.0-11.7%] before implementation, 4.9% [95% CI, 3.9-5.9%] after implementation). However, rates of newborn drug testing did not change (4.7% [95% CI, 4.4-5.0%] before implementation, 4.5% [95% CI, 4.2-4.8%] after implementation; P=.46), and clinicians continued to order significantly more newborn drug tests for newborns of Black birthing parents compared with other race and ethnicity groups. CONCLUSION: Implementation of question-based screening for substance use in pregnancy was associated with decreased prenatal urine drug testing but no change in overall newborn drug testing or racial inequities in newborn drug testing for Black birthing people. Further policy efforts are warranted to improve substance use treatment and to eliminate racial inequities in punitive policies such as newborn drug testing and subsequent child protective services reporting.

Perspectives of adolescents and young adults on cannabis use during pregnancy.

PURPOSE: Rates of cannabis use during pregnancy are highest for adolescents and young adults (AYAs). This study aims to understand AYA perspectives regarding the medical and legal consequences of prenatal and parental cannabis use. METHODS: This study delivered five open-ended survey questions regarding prenatal cannabis use in May/June 2022 via a text message polling platform to the MyVoice cohort, a cohort of AYA aged 14-24 throughout the United States recruited from social media to target national benchmarks set by the American Community Survey. We used qualitative content analysis to analyze open-ended responses and summarized code frequency and demographic data with descriptive statistics. RESULTS: Of 826 AYAs, 666 responded to at least one question (response rate = 80.6 %) and the mean age of respondents was 19.9 years (SD = 2.3). We identified four themes from responses: (1) AYA believe cannabis is harmful during pregnancy, (2) they are divided on whether prenatal cannabis exposure should be considered child abuse or neglect, (3) they have mixed attitudes about safe parenting and regular cannabis use, and (4) they support counseling from health care professionals about prenatal cannabis use. CONCLUSIONS: AYAs were concerned about potential risks of prenatal cannabis exposure and want clinicians to counsel about cannabis use during pregnancy. More than one in three AYAs surveyed felt prenatal cannabis use should be classified as child abuse or neglect, in contrast to the declining perception of risk among pregnant people.

Detection of a Human Adenovirus Outbreak, Including Some Critical Infections, Using Multipathogen Testing at a Large University, September 2022-January 2023.

Background: Human adenoviruses (HAdVs) can cause outbreaks of flu-like illness in university settings. Most infections in healthy young adults are mild; severe illnesses rarely occur. In Fall 2022, an adenovirus outbreak was identified in university students. Methods: HAdV cases were defined as university students 17-26 years old who presented to the University Health Service or nearby emergency department with flu-like symptoms (eg, fever, cough, headache, myalgia, nausea) and had confirmed adenovirus infections by polymerase chain reaction (PCR). Demographic and clinical characteristics were abstracted from electronic medical records; clinical severity was categorized as mild, moderate, severe, or critical. We performed contact investigations among critical cases. A subset of specimens was sequenced to confirm the HAdV type. Results: From 28 September 2022 to 30 January 2023, 90 PCR-confirmed cases were identified (51% female; mean age, 19.6 years). Most cases (88.9%) had mild illness. Seven cases required hospitalization, including 2 critical cases that required intensive care. Contact investigation identified 44 close contacts; 6 (14%) were confirmed HAdV cases and 8 (18%) reported symptoms but never sought care. All typed HAdV-positive specimens (n = 36) were type 4. Conclusions: While most students with confirmed HAdV had mild illness, 7 otherwise healthy students had severe or critical illness. Between the relatively high number of hospitalizations and proportion of close contacts with symptoms who did not seek care, the true number of HAdV cases was likely higher. Our findings illustrate the need to consider a wide range of pathogens, even when other viruses are known to be circulating.

Social Determinants of Mental and Behavioral Health.

Both mental illness and overall mental health are determined by a complicated interplay of life experiences and genetic predisposition. While genetic predisposition is difficult to modify, many of the life experiences that worsen mental health and exacerbate serious mental illness are associated with social policies and cultural norms that are changeable. Now that we have identified these associations, it is time to rigorously test scalable interventions to address these risks. These interventions will need to focus on high-impact stages in life (like childhood) and will need to address risk beyond the individual by focusing on the family and community.

Incidence of Newborn Drug Testing and Variations by Birthing Parent Race and Ethnicity Before and After Recreational Cannabis Legalization.

Importance: Thirty-seven US states and the District of Columbia mandate reporting newborns with suspected prenatal substance exposure to the state, and punitive policies that link prenatal substance exposure to newborn drug testing (NDT) may lead to disproportionate reporting of Black parents to Child Protective Services. The impact of recreational cannabis legalization on racial disproportionality in NDT is unknown. Objectives: To examine variations in the incidence and results of NDT by birthing parent race and ethnicity, variables associated with variation, and changes after statewide legalization of recreational cannabis. Design, Setting, and Participants: This retrospective cohort study was conducted from 2014 to 2020 with 26 366 live births to 21 648 birthing people who received prenatal care at an academic medical center in the Midwestern United States. Data were analyzed from June 2021 to August 2022. Exposures: Variables included birthing parent age, race, ethnicity, marital status, zip code, insurance type, prenatal and newborn diagnoses codes, and prenatal urine drug test orders and results. Main Outcome and Measures: The primary outcome was an NDT order. Secondary outcomes were substances detected. Results: Among 26 366 newborns of 21 648 birthing people (mean [SD] age at delivery, 30.5 [5.2] years), most birthing parents were White (15 338 [71.6%]), were non-Hispanic (20 125 [93.1%]), and had private insurance coverage (16 159 [74.8%]). The incidence of NDT ordering was 4.7% overall (1237 newborns). Clinicians ordered more NDTs for Black compared with White newborns (207 of 2870 [7.3%] vs 335 of 17 564 [1.9%]; P < .001) when the birthing parent had no prenatal urine drug test, a presumably low-risk group. Overall, 471 of 1090 NDTs (43.3%) were positive for only tetrahydrocannabinol (THC). NDTs were more likely to be positive for opioids in White compared with Black newborns (153 of 693 [22.2%] vs 29 of 308 [9.4%]; P < .001) and more likely to be positive for THC in Black compared with White newborns (207 of 308 [67.2%] vs 359 of 693 [51.8%]; P < .001). Differences remained consistent after state recreational cannabis legalization in 2018. Newborn drug tests were more likely to be positive for THC after legalization vs before legalization (248 of 360 [68.9%] vs 366 of 728 [50.3%]; P < .001) with no significant interaction with race and ethnicity groups. Conclusions and Relevance: In this study, clinicians ordered NDTs more frequently for Black newborns when no drug testing was done during pregnancy. These findings call for further exploration of how structural and institutional racism contribute to disproportionate testing and subsequent Child Protective Services investigation, surveillance, and criminalization of Black parents.

Defining and supporting high-quality telehealth for patients with opioid use disorder: The promise and potential pitfalls of telehealth expansion.

Many patients with opioid use disorders do not receive evidence-based treatment. The COVID-19 pandemic expanded the use of telehealth for prescribing medications for opioid use disorder (OUD). The uptake of telehealth has been variable, and this uneven expansion has created natural experiments to test assumptions and answer key questions about what improves outcomes for patients with OUD. Many current quality of care measures are not patient centered and do not focus on the practical questions that clinicians face. What criteria should be met before prescribing buprenorphine? Are physical exams necessary? Does the frequency and type of drug testing predict clinical outcomes? Are short check-in visits by phone or video better than less frequent in-person visits? Answering these questions can help define the essential components of high-quality care for patients with OUD. Defining the features of high-quality care can help create guardrails that will help protect our patients from potentially exploitive and ineffective care. Telehealth will likely end up being one additional tool to deliver care, but the scientific questions that can be answered during this period of rapid change can help answer some of the fundamental questions about providing high-quality care-and that will help all our patients, no matter how care is delivered.

Mandatory Reporting of Fatal and Nonfatal Opioid Overdoses in a Rural Public Health Department.

In 2016, Clallam County became the first county in Washington State to mandate reporting of fatal and nonfatal opioid overdoses. This reporting improved our understanding of opioid overdoses in the community and allowed us to provide harm reduction and case management services after nonfatal overdoses. By using the Washington State Prescription Monitoring Program, we have been able to notify health care providers when their patients have experienced a fatal or nonfatal opioid overdose to help better guide their prescribing practices.

Regulation of telomere elongation by the cyclin-dependent kinase CDK1.

Telomere elongation is cell-cycle regulated and requires the coordinated activity of proteins involved in the DNA damage response. We used an assay that detects de novo telomere addition to examine the role of the cyclin-dependent kinase Cdk1 (Cdc28) in cell-cycle-specific telomere elongation. Inhibition of an ATP analog-sensitive allele of Cdk1 completely blocked the addition of telomere repeats. Mutations in Rif2 and DNA polymerase alpha that cause increased telomere elongation were unable to compensate for the loss of Cdk1 activity, suggesting Cdk1 activity is required for an early step in telomere addition. Mutations in DNA repair proteins that act with Cdk1 at double-strand breaks also prevented telomere elongation. Cdk1 activity was required for the generation of 3' single-strand overhangs at both native and de novo telomeres. We propose Cdk1 activity controls the timing of telomere elongation by regulating the single-strand overhang at chromosome ends.