County-level factors associated with a mismatch between opioid overdose mortality and availability of opioid treatment facilities.

BACKGROUND: Opioid overdose deaths in the United States remain a major public health crisis. Little is known about counties with high rates of opioid overdose mortality but low availability of opioid use disorder (OUD) treatment facilities. We sought to identify characteristics of United States (US) counties with high rates of opioid overdose mortality and low rates of opioid treatment facilities. METHODS: Rates of overdose mortality from 3,130 US counties were compared with availability of opioid treatment facilities that prescribed or allowed medications for OUD (MOUD), from 2018-2019. The outcome variable, "risk-availability mismatch" county, was a binary indicator of a high rate (above national average) of opioid overdose mortality with a low (below national average) rate of opioid treatment facilities. Covariates of interest included county-level sociodemographics and rates of insurance, unemployment, educational attainment, poverty, urbanicity, opioid prescribing, depression, heart disease, Gini index, and Theil index. Multilevel logistic regression, accounting for the clustering of counties within states, was used to determine associations with being a "risk-availability mismatch" county. RESULTS: Of 3,130 counties, 1,203 (38.4%) had high rates of opioid overdose mortality. A total of 1,098 counties (35.1%) lacked a publicly-available opioid treatment facility in 2019. In the adjusted model, counties with an additional 1% of: white residents (odds ratio, OR, 1.02; 95% CI, 1.01-1.03), unemployment (OR, 1.11; 95% CI, 1.05-1.19), and residents without insurance (OR, 1.04; 95% CI, 1.01-1.08) had increased odds of being a mismatch county. Counties that were metropolitan (versus non-metropolitan) had an increased odds of being a mismatch county (OR, 1.85; 95% CI, 1.45-2.38). CONCLUSION: Assessing mismatch between treatment availability and need provides useful information to characterize counties that require greater public health investment. Interventions to reduce overdose mortality are unlikely to be effective if they do not take into account diverse upstream factors, including sociodemographics, disease burden, and geographic context of communities.

Association of COVID-19 Vaccination Rates and Facility Characteristics on COVID-19 Cases, Hospitalizations, and Deaths in US Nursing Homes.

OBJECTIVES: Nursing home residents have been disproportionately affected by the COVID-19 pandemic. Despite recognition as a priority group for receipt of the COVID-19 vaccine, vaccine uptake and COVID-19 cases, hospitalizations, and deaths in nursing home facilities were variable across nursing homes. This study has 2 objectives: (1) to describe nursing facility characteristics associated with higher vs lower vaccination rates and (2) to estimate facility characteristics associated with COVID-19 cases, hospitalizations, and deaths, stratified by vaccination rate. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: Facility-level data from 12,811 US nursing home facilities. METHODS: Using the CMS's Nursing Home COVID-19 Public File, we analyzed nursing home COVID-19 vaccination rates and outcomes from June 13, 2021, to September 19, 2021. We performed multivariable logistic regressions and identified facility characteristics associated with increased vaccination uptake and COVID-19 outcomes. RESULTS: Nursing homes with average vaccination rates ≤80% experienced higher total average COVID-19 cases, hospitalizations, and deaths compared to facilities with >80% average vaccination rates during the Delta surge. Moreover, facility factors, such as higher average age of residents, proportion of non-white residents, nurse staffing hours, and occupancy rates, were variably associated with increased risk of COVID-19 outcomes. CONCLUSIONS AND IMPLICATIONS: Facilities with higher resident vaccination rates experienced lower average COVID-19 cases, hospitalizations, and deaths in US nursing homes. Access to vaccines may play a role in mitigating harm associated with infectious diseases. Additionally, facility factors associated with increased adverse outcomes were variably associated with increased odds of COVID-19 outcomes, often, irrespective of vaccination level. As the COVID-19 pandemic continues to evolve and as the possibility of other infectious disease variants emerge, this research provides insight into facility factors, including vaccine uptake, that may mitigate adverse outcomes.

Unintended impacts of a national antipsychotic reduction initiative among nursing facility residents with and without Alzheimer's disease.

BACKGROUND: In July 2012, the Centers for Medicare & Medicaid services launched an antipsychotic reduction initiative (ARI) to improve care for nursing facility residents with Alzheimer's disease and related dementias (ADRD). We examined the impact of this policy on antipsychotic and psychotropic medication (PM) utilization and diagnosis patterns in long-stay nursing facility residents with ADRD and other conditions in which antipsychotics are indicated. METHODS: Using an 80% sample of fee-for-service Medicare beneficiaries with Part D, we conducted a retrospective cohort study of nursing facility residents with ADRD, bipolar disorder, psychosis, Parkinson's disease, and residents exempt from the policy due to diagnoses of schizophrenia, Tourette syndrome, and/or Huntington's disease. We used interrupted time-series analyses to compare changes in diagnoses, antipsychotic use, and PM utilization before (January 1, 2011-June 30, 2012) and after (July 1, 2012-September 30, 2015) ARI implementation. RESULTS: We identified 874,487 long-stay nursing facility residents with a diagnosis of ADRD (n = 358,518), exempt (n = 92,859), bipolar (n = 128,298), psychosis (n = 93,402), and Parkinson's disease (n = 80,211). In all cohorts, antipsychotic use declined prior to the ARI; upon policy implementation, antipsychotic use reductions were sustained throughout the study period, including statistically significant ARI-associated accelerated declines in all cohorts. PM changes varied by cohort, with ARI-associated increases in non-benzodiazepine sedatives and/or muscle relaxants noted in ADRD, psychosis, and Parkinson's cohorts. Although anticonvulsant use increased throughout the study period in all groups, with the exception of the bipolar cohort, these increases were not associated with ARI implementation. Findings are minimally explained by increased post-ARI membership in the psychosis and Parkinson's cohorts. CONCLUSIONS: Our study documents antipsychotic use significantly declined in non-ADRD clinical and exempt cohorts, where such reductions may not be clinically warranted. Furthermore, ARI-associated compensatory increases in PMs do not offset these reductions. Changes in PM utilization and diagnostic make-up of residents using PMs require further investigation to assess the potential for adverse clinical and economic outcomes.

Traumatic Brain Injury and Risk of Long-Term Nursing Home Entry among Older Adults: An Analysis of Medicare Administrative Claims Data.

Traumatic brain injury (TBI) is a leading cause of injury-related disability among older adults, and there is increasing interest in post-discharge management as this population grows. We evaluated the association between TBI and long-term nursing home (NH) entry among a nationally representative sample of older adults. We identified 207,355 adults aged ≥65 years who received a diagnosis of either a TBI, non-TBI trauma, or were uninjured between January 2008 and June 2015 from a 5% sample of Medicare beneficiaries. The NH entry was operationalized as the first NH admission that resulted in a stay ≥100 days. Time to NH entry was calculated as the difference between the NH entry date and the index date (the date of TBI, non-TBI trauma, or inpatient/outpatient visit in the uninjured group). We used cause-specific Cox proportional hazards models with stabilized inverse probability of exposure weights to model time to NH entry as a function of injury in the presence of death as a competing risk and generated hazard ratios (HR) and 95% confidence intervals (CI). After excluding beneficiaries living in a NH at index, there were 60,600 TBI, 63,762 non-TBI trauma, and 69,893 uninjured beneficiaries in the sample. In weighted models, beneficiaries with TBI entered NHs at higher rates relative to the non-TBI trauma (HR 1.15; 95% CI 1.10, 1.20) and uninjured (HR 1.67; 95% CI 1.60, 1.74) groups. Future research should focus on interventions to retain older adult TBI survivors within the community.

Racial Disparities in Nursing Home Resident and Staff COVID-19 Vaccination Rates.

OBJECTIVES: To determine whether staff and resident COVID-19 vaccination rates varied by racial heterogeneity of nursing homes, defined as proportion of residents who are White. METHODS: Cross-sectional study using data from the Medicare COVID-19 Nursing Home Database and LTCFocus.org to examine facility-level resident and staff vaccination status. General linear regression models assessed analyses of variance and tests for trend on proportion of residents and staff fully vaccinated as of June 13, 2021 by proportion of White residents in each facility. RESULTS: Over 12,000 (n=12,278) nursing homes provided resident measures and 8,838 reported staff measures. The mean (standard deviation [SD]) resident vaccination rate of nursing homes in the lowest and highest quantiles of White residents was significantly different at 72.74% (20.59%) and 85.65% (16.70%), respectively. Staff vaccination rates of nursing homes in the lowest and highest quantiles of White residents were not significantly different at 58.34% (25.09%) and 56.06% (19.32%), respectively. CONCLUSIONS: A higher proportion of White residents per facility was associated with higher resident COVID-19 vaccination rates reflecting continued disparities in quality of care during the pandemic.

Reflections on 'Decolonizing' Big Data in Global Health.

While much has been written about the role of 'big data' in health services research and epidemiology, there has been less exploration of the imperative of data sovereignty on informing the ethics of health services research and global health more broadly, especially in the context of decoloniality in an era of 'big data.' In this viewpoint, epidemiologist and health services researcher Qato offers a brief exploration of some questions that may drive this effort: is 'decolonizing' health data necessary? If so, what are the stakes, and who sets the terms? What would a decolonized data infrastructure necessary for health systems equity globally look like?

Prediction of treatment nonadherence among older adults with chronic obstructive pulmonary disease using Medicare real-world data.

BACKGROUND: Suboptimal maintenance medication (MM) adherence remains a clinical problem among Medicare beneficiaries with chronic obstructive pulmonary disease (COPD). OBJECTIVE: To inform risk-based personalized decision-making, this study sought to develop and validate prediction models of nonadherence to COPD MMs for Medicare beneficiaries. METHODS: This was a retrospective cohort study of beneficiaries aged 65 years and older with COPD and inhaled MMs. Nonadherence (proportion of days covered < 0.8) was measured in 12 months following the first MM fill after COPD diagnosis. Logistic and least absolute shrinkage selector operator regressions were implemented, and area under the receiver operating characteristic curve (AUROC) evaluated model accuracy, as well as positive predictive values and negative predictive values. Our models evaluated different sets of predictors for two cohorts: those with an MM prescription before COPD diagnosis (prevalent users) and those without (new users). RESULTS: Among 16,157 prevalent and 40,279 new users of MMs, 11,271 (69.8%) and 34,009 (84.4%), respectively, were nonadherent. The best-performing logistic models achieved AUROCs of 0.8714 and 0.881, positive predictive values of 0.881 and 0.881, and negative predictive values of 0.559 and 0.578, respectively, for prevalent and new users. The least absolute shrinkage selector operator models had similar accuracy. Models with baseline-only predictors had average performance (AUROC < 0.72). The most important predictors were initial MM adherence, short-acting bronchodilator use, and asthma. CONCLUSIONS: To our knowledge, this study is the first to develop predictive models of nonadherence to COPD MMs. Generated models achieved good discrimination and underlined the importance of early adherence. Well-performed models can be useful for care decision-making and interventions to improve COPD medication adherence after the first critical few months following a treatment episode. DISCLOSURES: All authors declared no conflicts of interest.

Self-Reported Treatment Need and Barriers to Care for Adults With Opioid Use Disorder: The US National Survey on Drug Use and Health, 2015 to 2019.

Objectives. To explore barriers to care and characteristics associated with respondent-reported perceived need for opioid use disorder (OUD) treatment and National Survey on Drug Use and Health (NSDUH)‒defined OUD treatment gap. Methods. We performed a cross-sectional study using descriptive and multivariable logistic regression analyses to examine 2015-2019 NSDUH data. We included respondents aged 18 years or older with past-year OUD. Results. Of 1 987 961 adults, 10.5% reported a perceived OUD treatment need, and 71% had a NSDUH-defined treatment gap. There were significant differences in age distribution, health insurance coverage, and past-year mental illness between those with and without a perceived OUD treatment need. Older adults (aged ≥ 50 years) and non-White adults were more likely to have a treatment gap compared with younger adults (aged 18-49 years) and White adults, respectively. Conclusions. Fewer than 30% of adults with OUD receive treatment, and only 1 in 10 report a need for treatment, reflecting persistent structural barriers to care and differences in perceived care needs between patients with OUD and the NSDUH-defined treatment gap measure. Public Health Implications. Public health efforts aimed at broadening access to all forms of OUD treatment and harm reduction should be proactively undertaken. (Am J Public Health. 2022;112(2):284-295. https://doi.org/10.2105/AJPH.2021.306577).

Patterns of opioid and benzodiazepine use with gabapentin among disabled Medicare beneficiaries - A retrospective cohort study.

BACKGROUND: Our goal was to describe specific patterns associated with co-prescriptions of gabapentin, opioids, and benzodiazepines among disabled Medicare beneficiaries. METHODS: Using 2013-2015 Medicare data, we conducted a retrospective cohort study among fee-for-service disabled beneficiaries continuously enrolled in Medicare Parts A, B, and D. The index date was defined as the earliest fill date for a gabapentin, opioid, or benzodiazepine prescription. Monotherapy, dual therapy, and tri-therapy were defined as utilization of one, two, and three medication classes, respectively. Augmentation was defined as a prescription for a different medication class in addition to prescription for initial medication; switching referred to a change in prescription for a different medication class with no subsequent fills of initial medication. We used descriptive statistics, Kaplan Meier analyses and Cox proportional hazards to examine the association between initial therapy and monotherapy, dual therapy, tri-therapy, switching and augmentation. RESULTS: Among 151,552 disabled beneficiaries, gabapentin initiators were more likely to augment therapy (50.1%) when compared to opioid (28.7%) and benzodiazepine (38.7%) users. When compared to opioid initiators, the risk of augmentation (HR[95%CI]: 1.85[1.82-1.89]) and switching (1.62 [1.51-1.73]) was significantly higher among gabapentin initiators. Risk of augmentation was also significantly higher among beneficiaries with co-morbid pain and mental health conditions (p < 0.01). Overall, the majority of beneficiaries augmented and switched within 2-months and 4-months after initiating therapy, respectively. CONCLUSIONS: Given safety concerns associated with gabapentin, opioids, and benzodiazepines, it is imperative that the benefits and risks of co-prescribing these medications be examined comprehensively, especially for those in vulnerable sub-groups.

Adverse outcomes associated with concurrent gabapentin, opioid, and benzodiazepine utilization: A nested case-control study.

Background: Gabapentin, opioids, and/or benzodiazepines are commonly prescribed for a variety of pain and psychiatric conditions. Despite the high likelihood of co-prescription of these medications, little is known about co-utilization of gabapentin (GABA), opioids (OP), and benzodiazepines (BZD) and associated public health outcomes. Methods: Using Medicare CCW Data, 2013-2016, we conducted a nested case-control study to examine the association between concurrent utilization of GABA, OP, and BZD and respiratory depression, opioid, and substance-related overdose among Medicare disabled beneficiaries. Cases and controls were Fee-for-service disabled beneficiaries who had a diagnosis of acute pain (AP), chronic pain (CP) or mental health conditions (MH) and received GABA, OP or BZD. Cases with respiratory depression, opioid or substance-related overdose were matched with up to 4 controls on socio-demographics, year of cohort entry and disease risk score. Primary exposure was concurrent medication utilization defined as an overlap of at least one day in prescriptions for GABA, OP and BZD. Findings: Across all cohorts, the majority of cases and controls were under 65, female, dually eligible and had prior histories of pain and mental health conditions. GABA+OP+BZD use was associated with increased odds of respiratory depression [AOR(95%CI)-AP: 1.35 (1.19-1.52), CP:1.24 (1.11-1.38) and MH: 1.16 (1.02-1.32) vs. OP only], opioid-related overdose [AP: 1.43 (1.04-1.98), CP: 1.47 (1.07-2.00) and MH: 1.44 (1.04-2.00) vs. OP only], and substance-related overdose [AP: 1.77 (1.26-2.50), CP: 1.70 (1.24-2.34) and MH: 1.92 (1.31-2.82) vs. GABA only]. While there were cohort differences in the association between GABA+OP and both respiratory depression and opioid-related overdose, GABA+OP and GABA+BZD use were associated with significantly higher odds of substance-related overdose across all clinical cohorts. Interpretation: Among Medicare disabled beneficiaries, concurrent utilization of gabapentin, opioids, and benzodiazepines is associated with multiple adverse outcomes. Given this, it is imperative that the benefits and risks of co-prescribing these medications be comprehensively examined. Funding: None.

Staffing and Protective Equipment Access Mitigated COVID-19 Penetration and Spread in US Nursing Homes During the Third Surge.

OBJECTIVES: During the last quarter of 2020-despite improved distribution of personal protective equipment (PPE) and knowledge of COVID-19 management-nursing homes experienced the greatest increases in cases and deaths since the pandemic's beginning. We sought to update COVID-19 estimates of cases, hospitalization, and mortality and to evaluate the association of potentially modifiable facility-level infection control factors on odds and magnitude of COVID-19 cases, hospitalizations, and deaths in nursing homes during the third surge of the pandemic. DESIGN: Cross-sectional analysis. SETTING AND PARTICIPANTS: Facility-level data from 13,156 US nursing home facilities. METHODS: Two series of multivariable logistic regression and generalized linear models to examine the association of infection control factors (personal protective equipment and staffing) on incidence and magnitude, respectively, of confirmed COVID-19 cases, hospitalizations, and deaths in nursing home residents reported in the last quarter of 2020. RESULTS: Nursing homes experienced steep increases in COVID-19 cases, hospitalizations, and deaths during the final quarter of 2020. Four-fifths (80.51%; n = 10,592) of facilities reported at least 1 COVID-19 case, 49.44% (n = 6504) reported at least 1 hospitalization, and 49.76% (n = 6546) reported at least 1 death during this third surge. N95 mask shortages were associated with increased odds of at least 1 COVID-19 case [odds ratio (OR) 1.21, 95% confidence interval (CI) 1.05-1.40] and hospitalization (1.26, 95% CI 1.13-1.40), as well as larger numbers of hospitalizations (1.11, 95% CI 1.02-1.20). Nursing aide shortages were associated with lower odds of at least 1 COVID-19 death (1.23, 95% CI 1.12-1.34) and higher hospitalizations (1.09, 95% CI 1.01-1.17). The number of nursing hours per resident per day was largely insignificant across all outcomes. Of note, smaller (<50-bed) and midsized (50- to 150-bed) facilities had lower odds yet higher magnitude of all COVID outcomes. Bed occupancy rates >75% increased odds of experiencing a COVID-19 case (1.48, 95% CI 1.35-1.62) or death (1.25, 95% CI 1.17-1.34). CONCLUSIONS AND IMPLICATIONS: Adequate staffing and PPE-along with reduced occupancy and smaller facilities-mitigate incidence and magnitude of COVID-19 cases and sequelae. Addressing shortcomings in these factors is critical to the prevention of infections and adverse health consequences of a next surge among vulnerable nursing home residents.

Serious psychological distress and cannabis use among pregnant women in the United States: Findings from the National Survey of Drug Use and Health, 2015-2018.

BACKGROUND: Cannabis use in pregnancy has been shown to be associated with a past diagnosis of mental health disorders. This study aimed to evaluate the association between serious psychological distress (SPD) and cannabis use in pregnant women in the United States. METHODS: Using cross-sectional data from the 2015-2018 National Survey on Drug Use and Health (NSDUH), we compared likelihood of cannabis use among pregnant women who reported acute, recent or no SPD based on the Kessler K-6 Distress Scale. Weighted analyses were conducted to describe study population and differences in cannabis use patterns in women with SPD compared to those without. Multivariate logistic regression models were fit to determine whether the relationship between SPD and cannabis use differed by acute, recent or no SPD status. RESULTS: Our final study sample consisted of 2,277,425 pregnant women. In adjusted analyses, pregnant women with any SPD (acute or recent) had 3.1 (95% confidence interval: 2.1, 4.5) times the odds of being current cannabis users compared to pregnant women without SPD. Compared to those with no SPD, pregnant women adjusted with acute SPD had 3.9 (2.5, 6.1) the adjusted odds and recent SPD had 2.4 (1.3, 4.4) times the odds of being current cannabis users. Cannabis use rates in each trimester were significantly higher in women with SPD compared to women without. CONCLUSION: Women who report recent or acute SPD are significantly more likely to use cannabis during all trimesters of pregnancy than those who report no SPD.

Prevalence and Newly Diagnosed Rates of Multimorbidity in Older Medicare Beneficiaries with COPD.

Few studies have quantified the multimorbidity burden in older adults with chronic obstructive pulmonary disease (COPD) using large and generalizable data. Such evidence is essential to inform evidence-based research, clinical care, and resource allocation. This retrospective cohort study used a nationally representative sample of Medicare beneficiaries aged 65 years or older with COPD and 1:1 matched (on age, sex, and race) non-COPD beneficiaries to: (1) quantify the prevalence of multimorbidity at COPD onset and one-year later; (2) quantify the rates [per 100 person-years (PY)] of newly diagnosed multimorbidity during in the year prior to and in the year following COPD onset; and (3) compare multimorbidity prevalence in beneficiaries with and without COPD. Among 739,118 eligible beneficiaries with and without COPD, the average number of multimorbidity was 10.0 (SD = 4.7) and 1.0 (SD = 3.3), respectively. The most prevalent multimorbidity at COPD onset and at one-year after, respectively, were hypertension (70.8% and 80.2%), hyperlipidemia (52.2% and 64.8%), anemia (42.1% and 52.0%), arthritis (39.8% and 47.7%), and congestive heart failure (CHF) (31.3% and 38.8%). Conditions with the highest newly diagnosed rates before and following COPD onset, respectively, included hypertension (39.8 and 32.3 per 100 PY), hyperlipidemia (22.8 and 27.6), anemia (17.8 and 20.3), CHF (16.2 and 13.2), and arthritis (12.9 and 13.2). COPD was significantly associated with increased odds of all measured conditions relative to non-COPD controls. This study updates existing literature with more current, generalizable findings of the substantial multimorbidity burden in medically complex older adults with COPD-necessary to inform patient-centered, multidimensional care.Supplemental data for this article is available online at https://doi.org/10.1080/15412555.2021.1968815 .

Opioid and benzodiazepine dispensing and co-dispensing patterns among commercially insured pregnant women in the United States, 2007-2015.

BACKGROUND: Little is known about benzodiazepine and opioid-benzodiazepine co-dispensing patterns among pregnant women. Understanding these patterns is necessary to mitigate high-risk medication use during pregnancy. Our objective in this analysis was to evaluate opioid and benzodiazepine dispensing and co-dispensing patterns among commercially insured pregnant women in the United States. METHODS: This retrospective study used a 10% random sample of commercially insured enrollees from the IQVIA™ Adjudicated Health Plan Claims Data from 2007 to 2015. The study included women (12-55 years of age) with completed pregnancies who had continuous medical and prescription drug coverage from 3 months prior to the date of conception through 3 months post-delivery. We estimated the prevalence of opioid and benzodiazepine dispensing and co-dispensing before, during, and after pregnancy, and evaluated trends in dispensing patterns across the study period (2007-2015) using Cochrane-Armitage tests. Chi-square tests were used to examine differences in demographic and clinical characteristics by dispensing and co-dispensing patterns. Among women that received an opioid or benzodiazepine during pregnancy, logistic regression models were used to quantify the association between sample characteristics and dispensing patterns (co-dispensing vs single dispensing). RESULTS: Of 168,025 pregnant women that met our inclusion criteria, 10.1% received at least one opioid and 2.0% received at least one benzodiazepine during pregnancy, while 0.5% were co-dispensed these drugs. During the study period (2007 vs 2015), prevalence of opioid dispensing during pregnancy decreased from 11.2 to 8.6% (p <  0.01); while benzodiazepine dispensing increased from 1.3 to 2.9% (p <  0.01), and the prevalence of co-dispensing, while low and stable, increased slightly from 0.39 to 0.44% (p <  0.01). Older age, a higher comorbidity burden, pain diagnosis, anxiety diagnosis, and alcohol, tobacco, and drug use disorders, were all associated with an increased odds of co-dispensing during pregnancy. CONCLUSIONS: This study provides evidence that while opioid dispensing during pregnancy has decreased in the past decade, benzodiazepine dispensing has increased. The prevalence of opioid-benzodiazepine co-dispensing was rare and remained fairly stable during our study period. Those co-dispensed both drugs had a higher prevalence of adverse birth outcomes. Further research to establish the potentially causal relationship between opioid and benzodiazepine co-dispensing and adverse birth outcomes should be undertaken.

Opioid use disorder in pregnancy: leveraging provider perceptions to inform comprehensive treatment.

BACKGROUND: Medications for opioid use disorder (MOUD) are recommended with adjuvant behavioral therapies, counseling, and other services for comprehensive treatment of maternal opioid use disorder. Inadequate access to treatment, lack of prescribing providers and complex delivery models are among known barriers to care. Multi-disciplinary provider input can be leveraged to comprehend factors that facilitate or inhibit treatment. The objective of this study is to explore provider perceptions of MOUD and factors critical to comprehensive treatment delivery to improve the care of pregnant women with opioid use disorder. METHODS: A qualitative research approach was used to gather data from individual provider and group semi-structured interviews. Providers (n = 12) responded to questions in several domains related to perceptions of MOUD, treatment delivery, access to resources, and challenges/barriers. Data were collected, transcribed, coded (by consensus) and emerging themes were analyzed using grounded theory methodology. RESULTS: Emerging themes revealed persistent gaps in treatment and challenges in provider, health systems and patient factors. Providers perceived MOUD to be a "lifeline" to women. CONCLUSIONS: Inconsistencies in treatment provision, access and uptake can be improved by leveraging provider perceptions, direct experiences and recommendations for an integrated team-based, patient-centered approach to guide the care of pregnant women with opioid use disorder.

Patterns of Psychoactive Medication Use in Community-Dwelling Older Adults in the US in 2016: A Descriptive Cross-Sectional Study.

Objectives: We aim to quantify any use and long-term use patterns of psychoactive medications and explore differences in use by sociodemographic factors in older adults (60-85 years) using the 2016 Medical Expenditure Panel Survey. Methods: Prevalence estimates of any use and long-term use were calculated. Chi-square and crude odds ratios were calculated to estimate differences in any use and long-term use of psychoactive medication by sociodemographic characteristics of respondents. Results: Thirty percent of older adults in the US reported any use of psychoactive medications. Long-term use was significantly higher in women (28.3% [95% confidence interval: 26.5, 30.2]), white (27.8 [26.1, 29.7]), presently unmarried (27.5 [25.4, 29.7]), and low-income (30.3 [27.7, 32.9]) subgroups than in men (20.5 [18.4, 22.5]), Black (14.7 [12.3, 17.1]), presently married (22.8 [20.7, 24.9]), and high-income (21.1 [19.1, 23.1]) subgroups, respectively. Discussion: Despite continued risks associated with use, long-term use of psychoactive medications is prevalent in the older adult population in the US. Given the increased complexity of pharmacotherapy regimens in this population, enhanced efforts at improving use of psychoactive medications should be intensified.

Continuation of Opioid Therapy at Transitions of Care in Critically Ill Patients.

PURPOSE: Opioids are one of the high-risk medication classes that are administered to critically ill patients during their intensive care unit (ICU) stay. However, little attention has been given to inpatient opioid prescribing practices, especially in critically ill patients. The purpose of our study was to characterize opioid prescribing practices across 2 transitions of care during an inpatient hospital stay: medical ICU (MICU)/intermediate care unit (IMC) to floor and floor to hospital discharge and identify potential patient-specific factors that impact opioid continuation. METHODS: This is a retrospective cohort study evaluating opioid-naive adult patients with new opioid therapy initiated in MICU/IMC at a tertiary care academic medical center from December 1, 2016, to November 30, 2017. Opioid continuation rate was assessed twice: transition 1 (MICU/IMC to floor) and transition 2 (floor to hospital discharge). RESULTS: In total, 112 opioid-naive patients with initial opioid administration in the MICU/IMC were included. Opioid therapy was continued in 56.1% (37/66) at transition 1 and 56.8% of patients (21/37) at transition 2. Patients with opioids continued at transition 1 had a longer hospital length of stay compared to those not continued on opioids, 22 (interquartile range [IQR] 11-36) vs 8 (IQR 6-14; P = .0004). Among the patients continued on opioids at hospital discharge, intubation during hospital stay and cumulative opioid dosage were greater than those not continued on opioids (17 [80.9%] vs 7 [43.8%], P = .019; and 3482 mcg [IQR 1690-9530] vs 732.5 mcg [IQR 187.5-1360.9], P = .0018, respectively). CONCLUSIONS: Opioid-naive patients receiving opioid therapy in the MICU/IMC had a continuation rate of >56% during transitions of care, including hospital discharge. Factors that contributed to the continuation of opioids at transitions of care included longer hospital length of stay, intubation, and cumulative hospital opioid dosage. These findings may help to provide health systems with guidance on targeted opioid stewardship programs.

Family Adverse Experiences and Psychotropic Polypharmacy Among US Youth: 2009-2015.

OBJECTIVE: To determine if adverse family factors are associated with a higher likelihood of psychotropic polypharmacy among US youth with a mental health condition. METHODS: The 2009-2015 Medical Expenditure Panel Survey data were used to identify family characteristics of 5136 youth aged ≤18 years with an emotional or behavioral health condition. Family adversity was based on family size, number of parents in the household, parental education and income, and parent-reported physical and/or cognitive or mental health disability. Cluster analysis identified family adversity subgroups. Polypharmacy was defined as 3 or more psychotropic classes (eg, stimulants, antipsychotics, antidepressants, mood stabilizers, and sedatives) in at least 1 interview round in a calendar year. Weighted logistic regression evaluated associations between family adversity and psychotropic polypharmacy among youth. RESULTS: Nearly half (47.8%) of youth lived with parents who had a disability. Parents in the least socioeconomically disadvantaged cluster mainly had a mental illness, and 94% of parents in the most socioeconomically disadvantaged cluster had a parent-reported physical and/or cognitive disability and mental illness. Among youth, mood disorder (24.2%; 95% confidence interval [CI]: 12.6%-16.0%), antidepressant use (16.0%; 95% CI: 10.6%-21.5%), and antipsychotic use (7.5%; 95% CI: 5.4%-9.6%) were higher in the most socioeconomically disadvantaged cluster relative to the other clusters. Approximately 3% of youth received psychotropic polypharmacy. The odds of psychotropic polypharmacy were 2.7 (95% CI: 1.1-6.4) times greater among youth in the most relative to the least socioeconomically disadvantaged cluster. CONCLUSIONS: Higher use of psychotropic polypharmacy among youth with parents who have multiple disabilities raises concerns about oversight and monitoring of complex psychotropic treatment.

Current state of pharmacovigilance in the Arab and Eastern Mediterranean region: results of a 2015 survey.

OBJECTIVES: This study describes the current state of pharmacovigilance systems in Arab and Eastern Mediterranean countries. METHODS: A descriptive cross-sectional study was conducted between May and September 2015. Data were gathered from a standardized online survey sent to pharmacovigilance leadership identified as the official national contact for the WHO Programme for International Drug Monitoring. In countries with no specified pharmacovigilance programme or leadership, Ministry of Health officers responsible for drug safety policies were invited to participate in the survey. The survey measured three domains of pharmacovigilance performance using indicators that were defined and assigned scores a priori: 10 structural, 10 process, and seven impact indicators. Total scores were assigned to each domain of indicators, and countries were compared depending on their total performance score. KEY FINDINGS: Complete responses were received from 20 countries (of 24 total), representing an 83% response rate. Approximately 20% (n = 4) of respondents reported not having any pharmacovigilance programme in their country. In total, across the three primary pharmacovigilance performance domains, the mean score for the 20 countries in the survey was 28.9 [standard deviation(SD): 13.8] with a range from 4 to 48 (maximum possible score: 48). In the structural performance domain, which assessed the existence of key pharmacovigilance structures, systems and policies in each country, the mean score among respondents was 13.1 (SD: 5.7) and the scores ranged from 2 to 19 (maximum possible score: 19). In the process performance domain, which assessed the constellation of activities undertaken by pharmacovigilance programmes (including the collection, collation, analysis and evaluation of adverse drug event reports), the mean score among respondent countries was 9.1 (SD: 5.4) and the scores ranged from 0 to 17 (maximum possible score: 17). Finally, in the impact domain, which measured the scope of national efforts at promoting risk minimization and increasing awareness in use of potentially unsafe pharmaceutical products, the mean score was 6.8 (SD: 3.6) and scores ranged from 0 to 12 (maximum possible score: 12). CONCLUSIONS: The findings suggest wide disparities in pharmacovigilance systems in the region, underscoring the need for a multistakeholder effort in bolstering programme development and the necessity to build collaboration regionally and internationally to enhance capacity, improve public and healthcare provider awareness and assist in the development of pharmacovigilance systems still in their nascent stage.