Is peer support a tipping point for the opioid use disorder crisis in Appalachia? Research holds the answer.

BACKGROUND: The present commentary highlights the pressing need for systematic research to assess the implementation and effectiveness of medications for opioid use disorder, used in conjunction with peer recovery support services, to improve treatment outcomes for individuals with opioid use disorder in Central Appalachia. This region, encompassing West Virginia, Eastern Kentucky, Southwest Virginia, East Tennessee, and Western North Carolina, has long grappled with a disproportionate burden of the opioid crisis. Due to a complex interplay of cultural, socioeconomic, medical, and geographic factors, individuals in Central Appalachia face challenges in maintaining treatment and recovery efforts, leading to lower success rates. APPROACH: To address the issue, we apply an exploratory approach, looking at the intersection of unique regional factors with the utilization of medications for opioid use disorder, in conjunction with peer recovery support services. This combined treatment strategy shows promise in addressing crucial needs in opioid use disorder treatment and enhancing the recovery journey. However, there are significant evidence gaps that need to be addressed to validate the expected value of incorporating peer support into this treatment strategy. CONCLUSION: We identify nine obstacles and offer recommendations to address the gaps and advance peer recovery support services research. These recommendations include the establishment of specific partnerships and infrastructure for community-engaged, peer recovery support research; improved allocation of funding and resources to implement evidence-based practices such as peer support and medication-assisted treatment; developing a more precise definition of peer roles and their integration across the treatment and recovery spectrum; and proactive efforts to combat stigma through outreach and education.

Nonmedical Prescription Drug Use Among Female Adolescents: The Relative Influence of Maternal Factors, Social Norms, and Perceptions of Risk and Availability.

Increasing understanding of the risk and protective factors for adolescent nonmedical use of prescription drugs (NMUPD) could inform prevention efforts. Several correlates have been identified, including parental factors, perceptions about use and accessibility, social norms, and age. However, these constructs have rarely been simultaneously examined using paired data from parents and adolescents. We aimed to examine the relative influence of these correlates among dyads (N=349) of mothers and adolescent daughters. Using multiple logistic regression, daughters' past NMUPD and inclination for future NMUPD were regressed onto descriptive norms for friend use, perceived drug accessibility and risk of harm from use, daughter age, mothers' disapproval about use, mothers' past NMUPD and inclination for future NMUPD, and the mother-daughter relationship quality. Akaike weights and lasso regressions were also estimated to evaluate the relative importance of each correlate. Higher descriptive norms for friend use, older age, and mothers' inclination for NMUPD were risk factors for daughters' NMUPD, while a closer mother-daughter relationship and mothers' disapproving attitudes towards NMUPD were protective factors. The three analysis approaches were corroborative. Results suggest friend descriptive norms, mother-daughter relationship quality, and mothers' attitudes about NMUPD are important prevention targets.

Erythroblastic synartesis associated with lymphoproliferative disorder: There can be more than meets the eye.

Erythroblastic synartesis is a rare cause of acquired dyserythropoiesis. Only 9 cases have been previously reported. We hereby report 3 cases of patients diagnosed with erythroblastic synartesis associated with monoclonal immunoglobulin and an overt malignant lymphoid disorder. A different B-cell clone may produce the monoclonal immunoglobulin, forming a biclonal disorder. In light of these data and literature review, treatment targeting the paraprotein seems to be efficient to control synartesis and correct anemia. In the case of monoclonal gammapathy associated with chronic lymphocytic leukemia, therapeutics should be adapted to control both chronic lymphocytic leukemia and monitored monoclonal immunoglobulin titer.

Machine learning-based improvement of MDS-CBC score brings platelets into the limelight to optimize smear review in the hematology laboratory.

BACKGROUND: Myelodysplastic syndromes (MDS) are clonal hematopoietic diseases of the elderly characterized by chronic cytopenias, ineffective and dysplastic haematopoiesis, recurrent genetic abnormalities and increased risk of progression to acute myeloid leukemia. A challenge of routine laboratory Complete Blood Counts (CBC) is to correctly identify MDS patients while simultaneously avoiding excess smear reviews. To optimize smear review, the latest generations of hematology analyzers provide new cell population data (CPD) parameters with an increased ability to screen MDS, among which the previously described MDS-CBC Score, based on Absolute Neutrophil Count (ANC), structural neutrophil dispersion (Ne-WX) and mean corpuscular volume (MCV). Ne-WX is increased in the presence of hypogranulated/degranulated neutrophils, a hallmark of dysplasia in the context of MDS or chronic myelomonocytic leukemia. Ne-WX and MCV are CPD derived from leukocytes and red blood cells, therefore the MDS-CBC score does not include any platelet-derived CPD. We asked whether this score could be improved by adding the immature platelet fraction (IPF), a CPD used as a surrogate marker of dysplastic thrombopoiesis. METHODS: Here, we studied a cohort of more than 500 individuals with cytopenias, including 168 MDS patients. In a first step, we used Breiman's random forests algorithm, a machine-learning approach, to identify the most relevant parameters for MDS prediction. We then designed Classification And Regression Trees (CART) to evaluate, using resampling, the effect of model tuning parameters on performance and choose the "optimal" model across these parameters. RESULTS: Using random forests algorithm, we identified Ne-WX and IPF as the strongest discriminatory predictors, explaining 37 and 33% of diagnoses respectively. To obtain "simplified" trees, which could be easily implemented into laboratory middlewares, we designed CART combining MDS-CBC score and IPF. Optimal results were obtained using a MDS-CBC score threshold equal to 0.23, and an IPF threshold equal to 3%. CONCLUSIONS: We propose an extended MDS-CBC score, including CPD from the three myeloid lineages, to improve MDS diagnosis on routine laboratory CBCs and optimize smear reviews.

"It's Took Over This Region": Patient Perspectives of Prescription Drug Abuse in Appalachia.

Background: Prescription drug abuse is a public health problem in the United States and the region of Appalachia, specifically. Primary care and addiction medicine-as possible points of access for prescription drugs with abuse potential and points of intervention for prescription drug abuse-are among the medical fields at its forefront. Little is known, however, about perceptions of prescription drug abuse across the two patient populations. Objectives: The objective of this qualitative analysis was to explore perceptions of the scale and context of prescription drug abuse among primary care and addiction medicine patients in Appalachia. Methods: As part of a mixed methods study, semi-structured interviews were conducted with 20 patients from primary care and addiction medicine in Central and South Central Appalachia from 2014 to 2015. The interviews were audio-recorded and transcribed verbatim. Thematic analysis was used to identify themes. Results: Three themes were identified: (1) pervasiveness of prescription drug abuse, describing perceptions of its high prevalence and negative consequences; (2) routes and routine practices for prescription drug acquisition and distribution, describing perceptions of routes of access to prescription drugs and behaviors exhibited to acquire and distribute prescription drugs; and (3) rationales for prescription drug acquisition and distribution, describing perceptions of the two underlying reasons for these processes-tolerance/addiction and revenue source. Conclusions/Importance: Perceptions of prescription drug abuse among primary care and addiction medicine patients in Appalachia are multifaceted, especially regarding prescription drug acquisition and distribution. Clinical practice implications for mitigating prescription drug abuse are discussed.

Communication Experiences of DATA-Waivered Physicians with Community Pharmacists: A Qualitative Study.

Background: Patients engaged in evidence-based opioid use disorder (OUD) treatment can obtain prescriptions for buprenorphine containing products from specially trained physicians that are subsequently dispensed by community pharmacists. Despite the involvement of physicians and community pharmacists in buprenorphine prescribing and dispensing, respectively, our understanding of their interactions in this context is limited. Objective: To qualitatively describe the communication and collaborative experiences between Drug Addiction Treatment Act 2000 (DATA)-waivered physicians and community pharmacists from the perspective of the physician. Methods: Ten key informant interviews were conducted with DATA-waivered physicians practicing in Northeast Tennessee. A semi-structured interview guide was used to explore communication and collaborative experiences between the physicians and community pharmacists. Interviews were audio recorded and transcribed verbatim. A coding frame was developed using concepts from the scientific literature and emerging codes from physician interviews. Interviews were coded using NVivo 11, with the data subsequently organized and evaluated for themes. Results: Four themes were identified: (1) mechanics of communication; (2) role specification and expectations; (3) education and understanding; and (4) climate of clinical practice. Physician-pharmacist communication primarily occurred indirectly through patients or staff and perceived challenges to collaboration included; lack of trust, stigma, and fear of regulatory oversight. Physicians also indicated the two professionals may lack clear roles and responsibilities as well as common expectations for treatment plans. Conclusions: Communication between DATA-waivered physicians and community pharmacists is influenced by multiple factors. Further research is warranted to improve physician-community pharmacist collaboration (PCPC) in the context of OUD pharmacotherapy and addiction treatment.

Provider-patient communication about prescription drug abuse: A qualitative analysis of the perspective of prescribers.

Background: Provider-patient communication underpins many initiatives aimed at reducing the public health burden associated with prescription drug abuse in the United States. The purpose of this qualitative analysis was to examine the characteristics of provider-patient communication about prescription drug abuse from the perspective of prescribers. Methods: From 2014 to 2015, 10 semi-structured interviews were conducted with a purposive sample of prescribers from multiple professions and medical fields in Central and South Central Appalachia. The interviews were conducted using a guide informed by Social Cognitive Theory and community theory research, audio-recorded, and transcribed verbatim. Thematic analysis, facilitated by NVivo 10 software, was used to generate themes. Results: Prescribers described 3 primary communication patterns with patients related to prescription drug abuse-informative, counteractive, and supportive. Prescribers also reported multiple factors-personal (e.g., education, experiences, and feelings of tension) and environmental (e.g., relationship with a patient, clinical resources, and policies on controlled prescription drugs)-that affect provider-patient communication and, by association, delivery of patient care related to prescription drug abuse. Conclusions: The findings suggest that provider-patient communication about prescription drug abuse is multidimensional and dynamic, characterized by multiple communication patterns and contributory factors. They have implications for (1) research aimed at advancing theoretical understanding of prescriber prescription drug abuse communication behaviors with patients and (2) interventions aimed at strengthening prescriber prescription drug abuse communication behaviors with patients.

CD13 expression in B cell malignancies is a hallmark of plasmacytic differentiation.

The diagnosis of Waldenström Macroglobulinaemia (WM)/lymphoplasmacytic lymphoma (LPL) remains one of exclusion because other B-cell lymphoproliferative disorders (B-LPD), such as marginal zone lymphoma (MZL), can fulfil similar criteria, including MYD88 L265P mutation. It has been suggested that expression of the myeloid marker CD13 (also termed ANPEP) is more frequent in LPL than in other B-LPD and has also been described on normal and malignant plasma cells. Here, CD13 expression was tested in a cohort of 1037 B-LPD patients from 3 centres by flow cytometry. The percentage of CD13-expressing cells was found to be variable among B-LPD but significantly higher in WM/LPL (median 31% vs. 0% in non-WM/LPL, P < 0·001). In multivariate linear regression, CD13 expression remained significantly associated with a diagnosis of WM/LPL (P < 0·001). A cut-off value of 2% of CD19+ cells co-expressing CD13 yielded the best diagnostic performance for WM/LPL assertion. This was further improved by association with the presence or absence of IgM paraprotein. Finally, given that previously published transcriptomic data revealed no difference in CD13 (also termed ANPEP) mRNA between normal and pathological B-cells, the hypothesis of some post-transcriptional regulation must be favoured. These results suggest that testing for CD13 expression in routine flow cytometry panels could help to discriminate WM/LPL from other B-LPD.

Mutational and cytogenetic analyses of 188 CLL patients with trisomy 12: A retrospective study from the French Innovative Leukemia Organization (FILO) working group.

Trisomy 12 (tri12) is the second most frequent chromosomal aberration (15%-20%) in chronic lymphocytic leukemia (CLL). Tri12 confers an intermediate prognosis but is a heterogeneous entity. We examined whether additional mutational or chromosomal alterations might impact tri12 patient outcomes. This retrospective study, carried out by the French Innovative Leukemia Organization, included 188 tri12 patients with comprehensive information on immunoglobulin heavy chain (IGHV) gene status, karyotypic/FISH abnormalities, and NOTCH1, TP53, SF3B1, and MYD88 mutations. The main cytogenetic abnormalities associated with tri12 were del(13q) (25%), additional trisomies (14%) (including tri19 (10%) and tri18 (4%)), 14q32 translocations (10%), del(17p) (6.5%), del(14q) (4%), and del(11q) (4%). Unmutated (UM) IGHV, NOTCH1, and TP53, mutations were identified in respectively 66%, 25%, and 8.5% of cases. Multivariate analyses showed that additional trisomies (HR = 0.43, 95% CI = 0.23-0.78, P = .01) were associated with a significantly longer time to first treatment in Binet stage A patients and with a lower risk of relapse (HR = 0.37, 95% CI = 0.15-0.9, P = .03) in the overall tri12 population. Binet stage B/C, TP53 disruption, and UM IGHV status were associated with a shorter time to next treatment, while Binet stage B/C (HR = 4, 95% CI = 1.6-4.9, P = .002) and TP53 disruption (HR = 5, 95% CI = 1.94-12.66, P = .001) conferred shorter overall survival in multivariate comparisons. These data indicate that additional cytogenetic and mutational abnormalities, and particularly additional trisomies, IGHV status, and TP53 disruption, influence tri12 patient outcomes and could improve risk stratification in this population.

A Dissemination and Implementation Science Approach to the Epidemic of Opioid Use Disorder in the United States.

PURPOSE OF REVIEW: This review aims to (1) conceptualize the complexity of the opioid use disorder epidemic using a conceptual model grounded in the disease continuum and corresponding levels of prevention and (2) summarize a select set of interventions for the prevention and treatment of opioid use disorder. RECENT FINDINGS: Epidemiologic data indicate non-medical prescription and illicit opioid use have reached unprecedented levels, fueling an opioid use disorder epidemic in the USA. A problem of this magnitude is rooted in multiple supply- and demand-side drivers, the combined effect of which outweighs current prevention and treatment efforts. Multiple primary, secondary, and tertiary prevention interventions, both evidence-informed and evidence-based, are available to address each point along the disease continuum-non-use, initiation, dependence, addiction, and death. If interventions grounded in the best available evidence are disseminated and implemented across the disease continuum in a coordinated and collaborative manner, public health systems could be increasingly effective in responding to the epidemic.

HIV/HCV Co-infection: Burden of Disease and Care Strategies in Appalachia.

PURPOSE OF REVIEW: The purpose of this review is to address infection with HIV and hepatitis C in the Appalachian region of the USA and the driving forces underlying this epidemic. We seek to discuss epidemiology of disease and the possible interventions to reduce incidence and burden of disease in this resource-limited area. RECENT FINDINGS: The rise of the opioid crisis has fueled a rise in new hepatitis C infection, and a rise in new HIV infection is expected to follow. Injection drug use has directly contributed to the epidemic and continues to remain a risk factor. Men who have sex with men remains a significant risk factor for HIV acquisition as well. Progress has been made in the battle against HIV and, to a lesser extent, hepatitis C, but much more can be done. Limited data on co-infection with HIV/HCV are currently available for this at-risk region, but it is clear that Appalachia is highly vulnerable to co-infection outbreaks. A multipronged approach that includes advances in assessment of co-infection and education for both patients and clinicians can help to recognize, manage, and ideally prevent these illnesses.

Multicentric study underlining the interest of adding CD5, CD7 and CD56 expression assessment to the flow cytometric Ogata score in myelodysplastic syndromes and myelodysplastic/myeloproliferative neoplasms.

Although numerous recent publications have demonstrated interest in multiparameter flow cytometry in the investigation of myelodysplastic disorders, it is perceived by many laboratory hematologists as difficult and expensive, requiring a high level of expertise. We report a multicentric open real-life study aimed at evaluating the added value of the technically simple flow cytometry score described by the Ogata group for the diagnosis of myelodysplastic syndromes. A total of 652 patients were recruited prospectively in four different centers: 346 myelodysplastic syndromes, 53 myelodysplastic/myeloproliferative neoplasms, and 253 controls. The Ogata score was assessed using CD45 and CD34 staining, with the addition of CD10 and CD19. Moreover, labeling of CD5, CD7 and CD56 for the evaluation of myeloid progenitors and monocytes was tested on a subset of 294 patients. On the whole series, the specificity of Ogata score reached 89%. Respective sensitivities were 54% for low-risk myelodysplastic syndromes, 68% and 84% for type 1 and type 2 refractory anemia with excess of blasts, and 72% for myelodysplastic/myeloproliferative neoplasms. CD5 expression was poorly informative. When adding CD56 or CD7 labeling to the Ogata score, sensitivity rose to 66% for low-risk myelodysplastic syndromes, to 89% for myelodysplastic/myeloproliferative neoplasms and to 97% for refractory anemia with excess of blasts. This large multicenter study confirms the feasibility of Ogata scoring in routine flow cytometry diagnosis but highlights its poor sensitivity in low-risk myelodysplastic syndromes. The addition of CD7 and CD56 in flow cytometry panels improves the sensitivity but more sophisticated panels would be more informative.

Sex chromosome loss may represent a disease-associated clonal population in chronic lymphocytic leukemia.

Whether sex chromosome loss (SCL) is an age-related phenomenon or a cytogenetic marker of hematological disease is unclear. To address this issue in chronic lymphocytic leukemia (CLL), we investigated 20 cases with X or Y chromosome loss detected by conventional cytogenetics (CC). The frequency of SCL was low in CLL (2.3%). It was the sole abnormality, as detected by CC, in 10/20 (50%) patients. Fluorescence in situ hybridization (FISH) analyses confirmed SCL in all patients tested, present in 5-88% of cells (median: 68%). Deletions of 13q were observed by FISH in 16/20 (80%) patients. Compared with CLL without SCL, SCL was significantly associated with 13q deletion, especially when bi-allelic (P = 0.04). Co-hybridization analyses showed that SCL could be a concomitant, primary or secondary change, or be present in an independent clone. FISH analyses were performed on blood sub-populations isolated by Ficoll or flow cytometry. Comparing mononuclear cells (including CLL cells) and polynuclear cells separated by Ficoll, a maximum of 2% of polynuclear cells were found with SCL, whereas mononuclear cells exhibited a significantly higher loss frequency (range: 6-87%) (P = 0.03). Comparing B-cells (including CLL cells) and T-cells sorted by flow cytometry, the proportion of B-CD19+ cells with SCL was significantly higher (range: 88-96%) than that observed in T-CD3+ cells (range: 2-6%) (P = 0.008). We conclude that SCL has to be considered as a clonal aberration in CLL that may participate in the oncogenic process.

Associations Between Drug Overdose Mortality and Recovery Ecosystems in the United States: A County-Level Analysis Using a Novel Index.

BACKGROUND: Communities with robust recovery ecosystems could reduce negative outcomes associated with substance use disorders (SUDs) and facilitate the recovery process. This cross-sectional study examined the relationship between drug overdose mortality rates in the United States and the strength of county-level recovery ecosystems, as measured by the Recovery Ecosystem Index (REI). METHODS: The REI assesses the strength of county-level recovery ecosystems in the United States. Comprised of 14 indicators across 3 component classes, overall and component scores ranging from "one" (strongest) to "five" (weakest) were calculated for each county using standardized values of the indicators. County-level analyses included: (1) correlational analyses between drug overdose mortality rates (n = 2076) and REI scores (overall score and by component); and (2) quadrant analysis (n = 2076), dividing counties based on their drug overdose mortality rates and overall REI scores. RESULTS: Drug overdose mortality rates were inversely related to REI overall, SUD treatment component, and continuum of SUD support component scores, indicating that lower (stronger) scores corresponded to higher rates. Conversely, REI infrastructure and social component scores were positively related to rates. Counties were relatively evenly distributed across quadrants, with 26% (n = 537) with a strong REI score and high overdose mortality rate, 24% (n = 489) with a strong REI score and low overdose mortality rate, 20% (n = 409) with a weak REI and high overdose mortality rate, and 31% (n = 641) with a weak REI and low overdose mortality rate. CONCLUSIONS: REI scores were generally inversely associated with drug overdose mortality rates in US counties, suggesting that communities have stronger recovery systems and services as the burden of SUD increases. Given relative variation in the scale of drug overdose mortality and strength of recovery ecosystems among counties, results could guide the identification of communities where the need for expanded recovery systems and services may be particularly critical.

A theoretical explanation of naloxone provision among primary care physicians and community pharmacists in Tennessee.

BACKGROUND: Increasing access to naloxone reduces opioid-related morbidity and mortality. Primary care and community pharmacy settings are critical access points, yet limited theoretical research has examined naloxone prescribing and dispensing behaviors. OBJECTIVES: To determine if the theory of planned behavior (TPB) combined with theoretical constructs from communication science explains intentions to co-prescribe and discuss co-dispensing naloxone among primary care physicians and community pharmacists, respectively. METHODS: This cross-sectional study surveyed cohorts of licensed primary care physicians and community pharmacists in Tennessee in 2017. Intentions were measured using profession-specific case vignettes, whereby they were asked given 10 similar patients, how many times (0-10) would they co-prescribe or discuss co-dispensing naloxone. Bivariate and multivariable analyses were used. RESULTS: The analytic sample included 295 physicians (response rate = 15.6 %) and 423 pharmacists (response rate = 19.4 %). Approximately 65 % of physicians reported never intending to co-prescribe naloxone (0 out of 10 patients), while 47 % of pharmacists reported never intending to discuss co-dispensing. All TPB constructs-attitudes (AOR = 1.32, CI = 1.16-1.50), subjective norms (AOR = 1.17, CI = 1.06-1.30), and perceived behavioral control (AOR 1.16, CI = 1.02-1.33)-were associated with an increased likelihood of pharmacists always (versus never) discussing co-dispensing. Similarly, two TPB constructs-attitudes (AOR = 1.41, CI = 1.19-1.68) and subjective norms (AOR = 1.22, CI = 1.08-1.39)-were associated with an increased likelihood of physicians always co-prescribing. Among physicians only, one communication construct-self-perceived communication competence (AOR = 1.19, CI = 1.01-1.41)-was associated with an increased likelihood of always co-prescribing. CONCLUSION: Findings support the value of theory, particularly TPB, in explaining primary care physician intentions to co-prescribe and community pharmacist intentions to discuss co-dispensing naloxone.

Deciphering bone marrow engraftment after allogeneic stem cell transplantation in humans using single-cell analyses.

BACKGROUNDDonor cell engraftment is a prerequisite of successful allogeneic hematopoietic stem cell transplantation. Based on peripheral blood analyses, it is characterized by early myeloid recovery and T and B cell lymphopenia. However, cellular networks associated with bone marrow engraftment of allogeneic human cells have been poorly described.METHODSMass cytometry and CITE-Seq analyses were performed on bone marrow cells 3 months after transplantation in patients with acute myelogenous leukemia.RESULTSMass cytometric analyses in 26 patients and 20 healthy controls disclosed profound alterations in myeloid and B cell progenitors, with a shift toward terminal myeloid differentiation and decreased B cell progenitors. Unsupervised analysis separated recipients into 2 groups, one of them being driven by previous graft-versus-host disease (R2 patients). We then used single-cell CITE-Seq to decipher engraftment, which resolved 36 clusters, encompassing all bone marrow cellular components. Hematopoiesis in transplant recipients was sustained by committed myeloid and erythroid progenitors in a setting of monocyte-, NK cell-, and T cell-mediated inflammation. Gene expression revealed major pathways in transplant recipients, namely, TNF-α signaling via NF-κB and the IFN-γ response. The hallmark of allograft rejection was consistently found in clusters from transplant recipients, especially in R2 recipients.CONCLUSIONBone marrow cell engraftment of allogeneic donor cells is characterized by a state of emergency hematopoiesis in the setting of an allogeneic response driving inflammation.FUNDINGThis study was supported by the French National Cancer Institute (Institut National du Cancer; PLBIO19-239) and by an unrestricted research grant by Alexion Pharmaceuticals.

State Priorities and Needs: The Role of Block Grants.

OBJECTIVES: Block grant funding provides federal financial support to states, with increased flexibility as to how those funds can be allocated at the community level. At the state level, block grant amounts and distributions are often based on outdated formulas that consider population measures and funding environments at the time of their creation. We describe variation in state-level funding allocations for 5 federal block grant programs and the extent to which funding aligns with the current needs of state populations. METHODS: We conducted an analysis in 2022 of state block grant allocations as a function of state-level characteristics for 2015-2019 for all 50 states. We provide descriptive statistics of state block grant allocations and multivariate regression models for each program. Models include base characteristics relevant across programs plus supplemental characteristics based on program-specific goals and state population needs. RESULTS: Mean state block grant allocations per 1000 population by program ranged from $618 to $21 528 during 2015-2019. Characteristics associated with state allocations varied across block grants. For example, for every 1-percentage-point increase in the percentage of the population living in nonmetropolitan areas, Preventive Health and Health Services Block Grant funding was approximately $7 per 1000 population higher and Community Services Block Grant funding was approximately $40 per 1000 population higher. Few supplemental characteristics were associated with allocations. CONCLUSIONS: Current block grant funding does not align with state characteristics and needs. Future research should consider how funds are used at the state level or allocated to local agencies or organizations and compare state block grant allocations with other types of funding mechanisms, such as categorical funding.

The association between grandparents as caregivers and overdose mortality in Appalachia and non-Appalachia counties.

Objective: To assess the association of drug overdose mortality with grandparents serving as caregivers of children in Appalachia and non-Appalachia in the U.S. Methods: This study used a cross-sectional design, with percent of grandparents as caregivers and overdose mortality rates being of primary interest. County-level data were combined, and descriptive, bivariate, and multivariable statistics were applied. Multiple sociodemographic and geographic variables were included: median age of the population, percent of the population that is uninsured, percent of the population that is non-Hispanic white, teen birth rate, percent of high school dropouts, and rurality. Results: The percent of grandparents as caregivers increased as the overdose mortality rate increased (p < 0.01). For every 1% increase in the overdose mortality rate, the percent of grandparents as caregivers increased by 56% in Appalachian counties compared to 24% in non-Appalachian counties. After adjusting for sociodemographic characteristics, the interaction between overdose mortality and Appalachian vs. non-Appalachian counties was no longer significant (p = 0.3). Conclusions: Counties with higher overdose mortality rates had greater rates of grandparents as caregivers, with Appalachian counties experiencing greater rates of grandparents as caregivers than non-Appalachian counties. Sociodemographic characteristics that are often more prevalent in Appalachia may be driving the observed differences. Policy implications: Policies and programs are needed to support grandparents providing caregiving for children impacted by substance use disorders including reform to federal child welfare financing to support children, parents, and grandparent caregivers such as kinship navigation, substance use treatment and prevention services, mental health services and in-home supports.