Community Health Worker Activities in Public Health Programs to Prevent Violence: Coding Roles and Scope.

In multiple and related forms, violence is a serious public health issue with lasting impacts on health and wellness in the United States. Community health workers (CHWs) are frontline public health workers and trusted members of communities. We aimed to analyze recent examples of CHW activities in violence prevention public health programs with a goal of informing future programs and research. We collected more than 300 documents published between 2010 and 2020 to identify public health programs to prevent violence including CHW activities. We used an iterative process to develop and apply a coding scheme to the CHW activities. We identified 20 public health programs to prevent violence which included CHW activities. CHWs most often addressed community violence, youth violence, and family violence and played an average of 8 of 10 core roles per program. Fewer than a third (i.e., 6 programs) reported community-focused CHW activities to address upstream and structural determinants of health inequities. This first examination, to our knowledge, of the intersection of the CHW and violence prevention literature shows that CHWs have played many of their core roles in public health programs to address multiple forms of violence. (Am J Public Health. 2022;112(8):1191-1201. https://doi.org/10.2105/AJPH.2022.306865).

A Randomized Controlled Trial of an Emergency Department Intervention for Patients with Chronic Noncancer Pain.

BACKGROUND: Emergency Departments (EDs) are beginning to notify their physicians of patients reporting chronic noncancer pain (CNCP) who frequent EDs, and are suggesting that the physicians not prescribe opioids to these patients. OBJECTIVES: We hypothesized that this intervention would reduce both the number of opioids prescribed to these patients by their ED physicians and the number of these patients' return visits to the ED. METHODS: We conducted a randomized controlled trial of this intervention in 13 electronically linked EDs. Patients eligible for the study were characterized by CNCP, lacked evidence of sickle cell anemia and suicide ideation, and made frequent (>10) visits to the EDs over a 12-month period. We randomly assigned 411 of these patients to either an intervention group or a control group. Our intervention comprised both an alert placed in eligible patients' medical files and letters sent to the patients and their community-based providers. The alert suggested that physicians decline requests for opioid analgesic prescriptions and instead refer these patients to community-based providers to manage their ongoing pain. RESULTS: During the 12 months after randomization, patients in the intervention and control groups averaged 11.9 and 16.6 return visits, and received prescriptions for opioids on 16% and 26% of those visits, respectively. Altogether, patients in the intervention group made 1033 fewer return visits to the EDs in the follow-up year than those in the control group. CONCLUSION: This intervention constitutes a promising practice that EDs should consider to reduce the number of visits made by frequent visitors with CNCP.

The effects of North Carolina's prescription drug monitoring program on the prescribing behaviors of the state's providers.

State-level prescription drug monitoring programs (PDMPs) show promise as a key strategy to respond to the epidemic of the misuse and abuse of controlled substances (CS), particularly opioid analgesics, in the United States. Undocumented concerns have been expressed that these PDMPs may have a "chilling effect" on providers' willingness to prescribe these substances to their patients. Using data from North Carolina's PDMP for the 3-year period from 2009 through 2011, we examined whether rapid increases in (1) the number of providers who queried the system, and (2) the number of days on which they queried it, would be related to their prescribing practices in regards to CS. We hypothesized that neither marker of PDMP utilization would be associated with a decrease in either patients receiving CS prescriptions or CS prescriptions filled. We found no association between either of these variables and the number of patients who filled prescriptions for CS or the number of prescriptions for CS filled. However, we did find a slight positive relationship between the growth in the utilization of the PDMP and the number of prescriptions filled for opioid analgesics. Concerns that PDMPs may constrain prescribing behavior with regards to CS are not supported.

North Carolina Medicaid recipient management lock-in program: the pharmacist's perspective.

BACKGROUND: The misuse and abuse of prescription opioids have become an urgent health issue in North Carolina (NC), particularly among Medicaid patients who suffer high rates of morbidity and mortality due to abuse and overdose. The NC Division of Medical Assistance (DMA) implemented a recipient management lock-in program, which limits identified patients for a 12-month period to 1 prescriber and 1 pharmacy for benzodiazepine, opiate, and certain anxiolytic prescriptions in order to prevent misuse and reduce overutilization of Medicaid benefits.  OBJECTIVES: To (a) evaluate pharmacists' perceptions of the implementation of the NC recipient management lock-in program (MLIP) and (b) determine how the beliefs and attitudes of pharmacists could promote or inhibit its success.  METHODS: We conducted 12 structured phone interviews with NC pharmacists serving lock-in patients. Interview responses were analyzed through construct analysis, which identified themes organized into 3 domains: organization and implementation, perceived effectiveness, and acceptability.  RESULTS: Most respondents reported a positive experience with the program but expressed doubt concerning its impact on prescription drug abuse. The program successfully utilized the pharmacist role as a gatekeeper of controlled substances, and the procedures of the program required no active effort on pharmacists' part. However, respondents suggested that the DMA improve communication and outreach to address pharmacists' lack of knowledge about the program's purpose and confusion over remediating problems that arise with lock-in patients. The DMA should also address the ways in which the program can interfere with access to health care and treatment, allow patients to see multiple physicians within the same clinic, and clarify procedures for patients whose complex health issues require multiple specialists.  CONCLUSIONS: Although possible improvements were identified, the NC MLIP has strong potential for success as it utilizes pharmacists' medication gate-keeping role, while minimizing the effort required for successful implementation.

Differential prescribing of opioid analgesics according to physician specialty for Medicaid patients with chronic noncancer pain diagnoses.

BACKGROUND: Despite >20 years of studies investigating the characteristics of patients seeking or receiving opioid analgesics, research characterizing factors associated with physicians' opioid prescribing practices has been inconclusive, and the role of practitioner specialty in opioid prescribing practices remains largely unknown. OBJECTIVE: To examine the relationships between physicians' and other providers' primary specialties and their opioid prescribing practices among patients with chronic noncancer pain (CNCP). METHODS: Prescriptions for opioids filled by 81,459 Medicaid patients with CNCP in North Carolina (USA), 18 to 64 years of age, enrolled at any point during a one-year study period were examined. χ2 statistics were used to examine bivariate differences in prescribing practices according to specialty. For multivariable analyses, maximum-likelihood logistic regression models were used to examine the effect of specialty on prescribing practices, controlling for patients' pain diagnoses and demographic characteristics. RESULTS: Of prescriptions filled by patients with CNCP, who constituted 6.4% of the total sample of 1.28 million individuals, 12.0% were for opioids. General practitioner/family medicine specialists and internists were least likely to prescribe opioids, and orthopedists were most likely. Across specialties, men were more likely to receive opioids than women, as were white individuals relative to other races/ethnicities. In multivariate analyses, all specialties except internal medicine had higher odds of prescribing an opioid than general practitioners: orthopedists, OR 7.1 (95% CI 6.7 to 7.5); dentists, OR 3.5 (95% CI 3.3 to 3.6); and emergency medicine physicians, OR 2.7 (95% CI 2.6 to 2.8). CONCLUSIONS: Significant differences in opioid prescribing practices across prescriber specialties may be reflective of differing norms concerning the appropriateness of opioids for the control of chronic pain. If so, sharing these norms across specialties may improve the care of patients with CNCP.

Development of a Set of Indicators to Evaluate Injury Control Research Centers.

BACKGROUND: Few methods have been defined for evaluating the individual and collective impacts of academic research centers. In this project, with input from injury center directors, we systematically defined indicators to assess the progress and contributions of individual Injury Control Research Centers (ICRCs) and, ultimately, to monitor progress of the overall injury center program. METHOD: We used several methods of deriving a list of recommended priority and supplemental indicators. This included published literature review, telephone interviews with selected federal agency staff, an e-mail survey of injury center directors, an e-mail survey of staff at the Centers for Disease Control and Prevention, a two-stage Delphi process (e-mailed), and an in-person focus group with injury center directors. We derived the final indicators from an analysis of ratings of potential indicators by center directors and CDC staff. We also examined qualitative responses to open-ended items that address conceptual and implementation issues. RESULTS: All currently funded ICRCs participated in at least one part of the process, resulting in a list of 27 primary indicators (some with subcomponents), 31 supplemental indicators, and multiple suggestions for using the indicators. CONCLUSION: Our results support an approach that combines standardized definitions and quantifiable indicators with qualitative reporting, which allows consideration of center distinctions and priorities. The center directors urged caution in using the indicators, given funding constraints and recognition of unique institutional environments. While focused on injury research centers, we suggest these indicators also may be useful to academic research centers of other types.

Statistical methods for designing and assessing the effectiveness of community-based interventions with small numbers.

Community-based interventions are, by their nature, tailored to the particular needs of the members and stakeholders of the community. In the area of safety promotion, the multifaceted aspects of violence and unintentional injuries necessitate complex intertwining of strategies and approaches. The evaluation of the effectiveness of any 'intervention' programme, either as a whole or of its discrete components, is thus challenging. In addition, standard experimental research designs involving controlled comparisons and the use of randomisation are often not practical. The evaluation is complicated further when the numbers of events in the community that constitute outcomes to be measured, before and after the interventions, are small. This manuscript reviews some of the statistical considerations that impact the evaluation of the effectiveness of such intervention approaches, and proposes a meta-regression methodology to address this complex issue. The application of the proposed methodology to the 'Safe Community' Model is provided as an example.

Physical and sexual violence among North Carolina women: associations with physical health, mental health, and functional impairment.

OBJECTIVE: This study examines links between women's experiences of violence during adulthood (including physical and sexual violence) and women's physical health, mental health, and functional status. METHODS: Data were analyzed from a representative sample of 9,830 North Carolina women surveyed by the North Carolina Behavioral Risk Factor Surveillance System (BRFSS). RESULTS: One-quarter of the women experienced violence as adults, with current or ex-partners being the most common perpetrators. Logistic regression analyses that controlled for the sociodemographic characteristics of the women found that women who experienced violence were significantly more likely than other women to have poor physical health, poor mental health, and functional limitations. Moreover, these negative health outcomes were most prevalent among the women who experienced a combination of both physical and sexual violence. CONCLUSIONS: These findings underscore the need for trauma-informed women's health services and policies.