High-Dose Opioid Prescribing in Individuals with Acute Pain: Assessing the Effects of US State Opioid Policies.

BACKGROUND: How state opioid policy environments with multiple concurrent policies affect opioid prescribing to individuals with acute pain is unknown. OBJECTIVE: To examine how prescription drug monitoring programs (PDMPs), pain management clinic regulations, initial prescription duration limits, and mandatory continued medical education affected total and high-dose prescribing. DESIGN: A county-level multiple-policy difference-in-difference event study framework. SUBJECTS: A total of 2,425,643 individuals in a large national commercial insurance deidentified claims database (aged 12-64 years) with acute pain diagnoses and opioid prescriptions from 2007 to 2019. MAIN MEASURES: The total number of acute pain opioid treatment episodes and number of episodes containing high-dose (> 90 morphine equivalent daily dosage (MEDD)) prescriptions. KEY RESULTS: Approximately 7.5% of acute pain episodes were categorized as high-dose episodes. Prescription duration limits were associated with increases in the number of total episodes; no other policy was found to have a significant impact. Beginning five quarters after implementation, counties in states with pain management clinic regulations experienced a sustained 50% relative decline in the number of episodes containing > 90 MEDD prescriptions (95 CIs: (Q5: - 0.506, - 0.144; Q12: - 1.000, - 0.290)). Mandated continuing medical education regarding the treatment of pain was associated with a 50-75% relative increase in number of high-dose episodes following the first year-and-a-half of enactment (95 CIs: (Q7: 0.351, 0.869; Q12: 0.413, 1.107)). Initial prescription duration limits were associated with an initial relative reduction of 25% in high-dose prescribing, with the effect increasing over time (95 CI: (Q12: - 0.967, - 0.335). There was no evidence that PDMPs affected high-dose opioids dispensed to individuals with acute pain. Other high-risk prescribing indicators were explored as well; no consistent policy impacts were found. CONCLUSIONS: State opioid policies may have differential effects on high-dose opioid dispensing in individuals with acute pain. Policymakers should consider effectiveness of individual policies in the presence of other opioid policies to address the ongoing opioid crisis.

Recent tapering from long-term opioid therapy and odds of opioid-related hospital use.

PURPOSE: The number of patients tapered from long-term opioid therapy (LTOT) has increased in recent years in the United States. Some patients tapered from LTOT report improved quality of life, while others face increased risks of opioid-related hospital use. Research has not yet established how the risk of opioid-related hospital use changes across LTOT dose and subsequent tapering. Our objective was to examine associations between recent tapering from LTOT with odds of opioid-related hospital use. METHODS: Case-crossover design using 2014-2018 health information exchange data from Indiana. We defined opioid-related hospital use as hospitalizations, and emergency department (ED) visits for a drug overdose, opioid abuse, and dependence. We defined tapering as a 15% or greater dose reduction following at least 3 months of continuous opioid therapy of 50 morphine milligram equivalents (MME)/day or more. We used conditional logistic regression to estimate odds ratios (OR) with 95% confidence intervals (CI). RESULTS: Recent tapering from LTOT was associated with increased odds of opioid-related hospital use (OR: 1.50, 95%CI: 1.34-1.63), ED visit (OR: 1.52; 95%CI: 1.35-1.72), and inpatient hospitalization (OR: 1.40; 95%CI: 1.20-1.65). We found no evidence of heterogeneity of the effect of tapering on opioid-related hospital use by gender, age, and race. Recent tapering among patients on a high baseline dose (>300 MME) was associated with increased odds of opioid-related hospital use (OR: 2.95, 95% CI: 2.12-4.11, p < 0.001) compared to patients on a lower baseline doses. CONCLUSIONS: Recent tapering from LTOT is associated with increased odds of opioid-related hospital use.

Impacts of state COVID-19 reopening policy on human mobility and mixing behavior.

This study quantifies the effect of the 2020 state COVID economic activity reopening policies on daily mobility and mixing behavior, adding to the economic literature on individual responses to public health policy that addresses public contagion risks. We harness cellular device signal data and the timing of reopening plans to provide an assessment of the extent to which human mobility and physical proximity in the United States respond to the reversal of state closure policies. We observe substantial increases in mixing activities, 13.56% at 4 days and 48.65% at 4 weeks, following reopening events. Echoing a theme from the literature on the 2020 closures, mobility outside the home increased on average prior to these state actions. Furthermore, the largest increases in mobility occurred in states that were early adopters of closure measures and hard-hit by the pandemic, suggesting that psychological fatigue is an important barrier to implementation of closure policies extending for prolonged periods of time.

The effects of state rules on opioid prescribing in Indiana.

BACKGROUND: Prescription opioids have been linked to over half of the 28,000 opioid overdose deaths in 2014. High rates of prescription opioid non-medical use have continued despite nearly all states implementing large-scale prescription drug monitoring programs (PDMP), which points to the need to examine the impact of state PDMP's on curbing inappropriate opioid prescribing. In the short-term, PDMPs have been associated with short-term prescribing declines. Yet little is known about how such policies differentially impact patient subgroups or are interpreted by prescribing providers. Our objective was to compare volumes of prescribed opioids before and after Indiana implemented opioid prescribing emergency rules and stratify the changes in opioid prescribing by patient and provider subgroups. METHODS: An interrupted time series analysis was conducted using data obtained from the Indiana PDMP. Prescription level data was merged with census data to characterize patient socioeconomic status. Analyses were stratified by patients' gender, age, opioid dosage, and payer. The primary outcome indicator was the total morphine equivalent dose (MED) of dispensed opioids per day in the state of Indiana. Also considered were number of unique patients, unique providers, and prescriptions; MED per transaction and per day; and number of days supplied. RESULTS: After controlling for time trends, we found that total MED for opioids decreased after implementing the new emergency rules, differing by patient gender, age, and payer. The effect was larger for males than females and almost 10 times larger for 0-20 year olds as compared to the 60+ age range. Medicare and Medicaid patients experienced more decline in prescribing than patients with private insurance. Patients with prescriptions paid for by workers' comp experienced the most significant decline. The emergency rules were associated with decline in both the number of prescribers and the number of day supply. CONCLUSIONS: Although the Indiana opioid prescribing emergency rules impacted statewide prescribing behavior across all individual patient and provider characteristics, the emergency rules' effect was not consistent across patient characteristics. Further studies are needed to assess how individual patient characteristics influence the interpretation and application of state policies on opioid prescribing.

The evolving landscape of immunohistochemistry in cervical and uterine carcinoma in gynecologic oncology: current status and future directions.

Immunohistochemistry (IHC) has become an indispensable tool in routine gynecological pathology, particularly with the advancements in molecular understanding and histological classification of gynecological cancers. This evolution has led to new immunostainings for diagnostic and classification purposes. This review describes the diagnostic utility of IHC in gynecological neoplasms, drawing insights from literature reviews, personal experiences, and research findings. It delves into the application of IHC in resolving morphologically equivocal cases, emphasizing its role in achieving an accurate diagnosis. The selection of appropriate immunomarkers for common scenarios encountered in gynecological pathology aids pathologists in navigating complex cases. Specifically, we focus on cervical and endometrial malignancies, elucidating the molecular rationale behind the use of specific immunohistochemical markers. An updated overview of essential immunohistochemical markers provides knowledge for precise diagnosis and classification of gynecological cancers. This review serves as a valuable resource for clinicians and researchers involved in the management and study of gynecological malignancies, facilitating improved patient care and outcomes.

Vulval premalignant lesions: a review article.

Vulvar intraepithelial neoplasia (VIN) is a noninvasive squamous lesion that is a precursor of vulvar squamous cell cancer. Currently, no screening tests are available for detecting VIN, and a biopsy is performed to confirm the clinical diagnosis. Despite sharing many risk factors with cervical intraepithelial neoplasia, the diagnosis of VIN is poses challenges, contributing to its increasing prevalence. This study aimed to analyze the underlying risk factors that contribute to the development of VIN, identify specific populations at risk, and define appropriate treatment approaches. Differentiated VIN (dVIN) and usual VIN (uVIN) are the classifications of VIN. While dVIN is associated with other vulvar inflammatory disorders, such as lichen sclerosis, the more prevalent uVIN is associated with an underlying human papillomavirus infection. Patients with differentiated VIN have an increased risk of developing invasive malignancies. Few effective surveillance or management techniques exist for vulvar intraepithelial neoplasia, a preinvasive neoplasm of the vulva. For suspicious lesions, a thorough examination and focused biopsy are necessary. Depending on the specific needs of each patient, a combination of surgical and medical approaches can be used.

Don't Rush with Your Brush: An In Vitro Study on Toothbrush Hygiene.

Aim: To evaluate the effectiveness of audiovisual (AV) aids in creating awareness of toothbrush hygiene. Materials and methods: This randomized trial study was conducted on 40 children aged 6-11 years. Children were given soft toothbrushes and then collected after brushing for 14 days. The toothbrushes were collected and sent to the laboratory for microbial culture evaluation. A questionnaire consisting of various questions regarding daily toothbrush hygiene practices was filled by the parents at the same time. After 14 days, brushes were collected, and the parents were shown an AV aid regarding toothbrush decontamination, parental awareness, and supervision. Those children were given new sets of toothbrushes and instructed to decontaminate them with chlorhexidine solution. After 14 days, the same questionnaire was filled out by the parents and toothbrushes were collected and immediately sent to the laboratory for microbial culture evaluation. Results: All the sampled toothbrushes had significant (p < 0.001) bacterial growth after 14 days of use. The use of disinfectant led to a 99.98% reduction in microbial colony counts. Hence, showed a significant result. Questionnaire analysis showed a positive parental approach toward maintaining toothbrush hygiene. Conclusion: Cleaning and disinfection of toothbrushes is crucial to stop the spread of disease since bacterial contamination cannot be 100% eliminated. AV aids can be effective tools for increasing awareness. Clinical significance: Through this study, we want to emphasize toothbrush hygiene and create awareness for the same through AV aid because a healthy toothbrush leads to healthy oral health. How to cite this article: Sharma S, Tandon S, Rai TS, et al. Don't Rush with Your Brush: An In Vitro Study on Toothbrush Hygiene. Int J Clin Pediatr Dent 2024;17(2):162-167.

Palatogingival Groove: The Known-unknown Devourer.

Aim: This case report aims to describe the management of a maxillary lateral incisor with a palatogingival groove (PGG) associated with a complex lesion. Background: The PGG is a rare developmental anomaly that involves the lingual surface of the maxillary incisors and extends for varying distances and depths on the root surface. This anomaly is usually inconspicuous and funnel-shaped, which forms a niche where bacterial plaque and calculus can accumulate to levels significant for pathological changes resulting in endodontic and periodontal lesions. These grooves are easily overlooked as etiologic factors, as they are concealed by the periodontal tissues. Case description: This paper describes the successful management of a rare case of maxillary lateral incisor with an accessory root, two canals, and a complex or type III PGG with a endodontic-periodontic lesion using a multidisciplinary approach. Conclusion: Recognizing PGG as the initiator of pathology is critical for the successful treatment and favorable prognosis of the affected tooth. Clinical significance: This case report highlights the importance of three-dimensional (3D) imaging using cone beam computed tomography (CBCT) that can provide accurate and sensitive information to assess and plan the treatment of the teeth with PGG. It also emphasizes that with the development of newer materials and diagnostic tools, clinicians need a detailed understanding of the characteristics, treatment, and prognosis of PGG to successfully manage the condition. How to cite this article: Gupta S, Tandon S, Rathore AS, et al. Palatogingival Groove: The Known-unknown Devourer. Int J Clin Pediatr Dent 2024;17(S-1):S95-S99.

Martian atmospheric hydrogen and deuterium: Seasonal changes and paradigm for escape to space.

Mars' water history is fundamental to understanding Earth-like planet evolution. Water escapes to space as atoms, and hydrogen atoms escape faster than deuterium giving an increase in the residual D/H ratio. The present ratio reflects the total water Mars has lost. Observations with the Mars Atmosphere and Volatile Evolution (MAVEN) and Hubble Space Telescope (HST) spacecraft provide atomic densities and escape rates for H and D. Large increases near perihelion observed each martian year are consistent with a strong upwelling of water vapor. Short-term changes require processes in addition to thermal escape, likely from atmospheric dynamics and superthermal atoms. Including escape from hot atoms, both H and D escape rapidly, and the escape fluxes are limited by resupply from the lower atmosphere. In this paradigm for the escape of water, the D/H ratio of the escaping atoms and the enhancement in water are determined by upwelling water vapor and atmospheric dynamics rather than by the specific details of atomic escape.

Trends in Abortion- and Contraception-Related Internet Searches After the US Supreme Court Overturned Constitutional Abortion Rights: How Much Do State Laws Matter?

Importance: The US Supreme Court ruling in Dobbs v Jackson Women's Health Organization on June 24, 2022, revealed immediate and distinct differences between states regarding abortion legality. Whether the ruling was associated with population-level changes in seeking information on reproductive health care-related information is unknown. Objective: To determine whether the US Supreme Court ruling on Dobbs v Jackson Women's Health Organization was associated with increased information seeking for reproductive health care access in the states with immediately effective (trigger and pre-Roe) abortion laws vs other states. Design, Setting, and Participants: This was a retrospective cross-sectional study of nationwide real-time internet search data by state-week from January 1, 2021, through July 16, 2022. Difference-in-difference event study estimates were used to evaluate abortion- and contraception-related internet searches after the Supreme Court draft majority decision was leaked on May 2, 2022, and the final ruling was issued on June 24, 2022, in states immediately affected vs other states. Data analyses were performed from July 18 to January 14, 2022. Exposures: The Supreme Court's draft majority decision leaked on May 2, 2022, and the final ruling on Dobbs v Jackson Women's Health Organization on June 24, 2022. Preexisting state trigger laws and pre-Roe bans that became effective immediately when Roe was overturned by the decision on Dobbs. Main Outcomes and Measures: Number of searches per 10 million Google queries in a state-week for terms related to abortion or contraception. Results: Searches for abortion-related terms increased from 16 302 to 75 746 per 10 million searches per state-week during the weeks before vs after the May 2, 2022, leak of the draft majority decision in states with trigger laws or abortion bans. This was a 42% (95% CI, 24%-59%) higher increase than in states with laws that protect abortion access. Searches for contraception also increased from 56 055 to 82 133 searches per state-week after the ruling in the states with abortion bans, 25% (95% CI, 13%-36%) higher than the increase in states protecting abortion access. Conclusions and Relevance: The findings of this retrospective cross-sectional study suggest that changes in internet searching for terms related to reproductive health care can capture immediate population-level changes in information-seeking behavior regarding reproductive health care access. These data are critical for shaping health policy discussions.

Competitive effects of federal and state opioid restrictions: Evidence from the controlled substance laws.

A significant concern in the policy landscape of the U.S. opioid crisis is whether supply-side controls can reduce opioid prescribing without harmful substitution. We consider an unstudied policy: the federal Controlled Substance Act (CSA) restrictions placed in August 2014 on tramadol, the second most popular opioid medication. This was followed seven weeks later by CSA restrictions for hydrocodone combination products, the leading opioids on the market. Using regression discontinuity design (RDD) models, based on the timing of the (up-)scheduling changes, to explore spillover effects, we find that tightening prescribing restrictions on one opioid reduces its use, but increases prescribing of close competitors, leading to no reduction in total opioid prescriptions.This suggests that supply restrictions are not effective in reducing opioid prescribing the presence of close substitutes that remain unrestricted.

Ductal Carcinoma in Situ: A Detailed Review of Current Practices.

Ductal carcinoma in situ is a challenge for breast surgeons, beginning with its difficult radiological detection and continuing with its contentious multimodal treatment and management. It is becoming more common as a result of widespread screening mammography and usually manifests as a cluster of calcifications. Patients are usually asymptomatic or present with a small, palpable lump. It is, however, a premalignant lesion that has the potential to progress to invasive carcinoma and is treated similarly with multimodal therapy. Treatment options currently include total or simple mastectomy with sentinel lymph node biopsy or lumpectomy with radiation. Tamoxifen and human epidermal growth factor receptor two suppression therapy are examples of adjuvant therapy. A review of consensus guidelines and literature was performed, in which we included the available online literature on the concerned topic from 2000-2022. This article is not a complete review of all the available literature; rather, it is a comprehensive review of the topic and its current management guidelines.

Employer-Sponsored Coverage Stabilized And Uninsurance Declined In The Second Year Of The COVID-19 Pandemic.

The health risks of COVID-19, combined with widespread economic instability in the US, spurred Congress to pass temporary measures to improve access to health insurance. Using data from the Household Pulse Survey, a high-frequency, population-based survey, we examined trends in health coverage during 2021 and early 2022 among nonelderly adults. We estimated that eight million people gained coverage during this period, primarily because of increases in Medicaid and other public coverage. Despite rising employment, rates of employer-sponsored coverage remained flat. In Medicaid expansion states, employment rates increased significantly among Medicaid enrollees. Our results suggest that when the public health emergency ends, many people currently enrolled in Medicaid might no longer be eligible, particularly in Medicaid expansion states. Policy makers and employers should be prepared to help people who lose Medicaid eligibility identify and navigate enrollment in alternative sources of health insurance, including both Affordable Care Act Marketplace and employer-sponsored coverage.

Racial And Ethnic Disparities In Buprenorphine Receipt Among Medicare Beneficiaries, 2015-19.

We examined Medicare Part D claims from the period 2015-19 to identify state and national racial and ethnic disparities in buprenorphine receipt among Medicare disability beneficiaries with diagnosed opioid use disorder or opioid overdose. Racial and ethnic disparities in buprenorphine use remained persistently high during the study period, especially for Black beneficiaries, suggesting the need for targeted interventions and policies.

Racial/ethnic disparities in timely receipt of buprenorphine among Medicare disability beneficiaries.

BACKGROUND: Medicare disability beneficiaries (MDBs) have disproportionately high risk of opioid use disorder (OUD) and related harms given high rates of comorbidities and high-dose opioid prescribing. Despite this increased risk, little is known about timely receipt of medication for opioid use disorder (MOUD), including potential disparities by patient race/ethnicity or moderation by county-level characteristics. METHODS: National Medicare claims for a sample of MDBs with incident OUD diagnosis between March 2016 and June 2019 were linked with county-level data. Multivariable mixed effects Cox proportional hazards models estimated time (in days) to buprenorphine receipt within 180 days of incident OUD diagnosis. Primary exposures included individual-level race/ethnicity and county-level buprenorphine prescriber availability, percent non-Hispanic white (NHW) residents, and Social Deprivation Index (SDI) score. RESULTS: The sample (n=233,079) was predominantly White (72.3%), ≥45 years old (76.3%), and male (54.8%). Black (adjusted hazard ratio [aHR]=0.50; 95% CI, 0.47-0.54), Asian/Pacific Islander (aHR=0.54; 95% CI, 0.41-0.72), Hispanic/Latinx (aHR=0.81; 95% CI, 0.76-0.87), and Other racial/ethnic groups (aHR=0.75; 95% CI, 0.58-0.97) had a lower likelihood of timely buprenorphine than non-Hispanic white beneficiaries after adjusting for individual and county-level confounders. Timely buprenorphine receipt was positively associated with county-level buprenorphine prescriber availability (aHR=1.05; 95% CI, 1.04-1.07), percent non-Hispanic white residents (aHR=1.01; 95% CI, 1.00-1.01), and SDI (aHR=1.06; 95% CI, 1.01-1.10). CONCLUSIONS: Racial/ethnic disparities highlight the need to improve access to care for underserved groups. Implementing equity-focused quality and performance measures and developing interventions to increase office-based buprenorphine prescribing in predominantly minority race/ethnicity counties may reduce disparities in timely access to medication for OUD.

Effects of social distancing policy on labor market outcomes.

US workers receive unemployment benefits if they lose their job, but not for reduced working hours. In alignment with the benefits incentives, we find that the labor market responded to COVID-19 and related closure-policies mostly on the extensive (12 pp outright job loss) margin. Exploiting timing variation in state closure-policies, difference-in-differences (DiD) estimates show, between March 12 and April 12, 2020, employment rate fell by 1.7 pp for every 10 extra days of state stay-at-home orders (SAH), with little effect on hours worked/earnings among those employed. Forty percentage of the unemployment was due to a nationwide shock, rest due to social-distancing policies, particularly among "non-essential" workers.

Mortality and Discharge Location of Intensive Care Patients With Alzheimer Disease and Related Dementia.

BACKGROUND: Intensive care unit (ICU) utilization has increased among patients with Alzheimer disease and related dementia (ADRD), although outcomes are poor. OBJECTIVES: To compare ICU discharge location and subsequent mortality between patients with and patients without ADRD enrolled in Medicare Advantage. METHODS: This observational study used Optum's Clinformatics Data Mart Database from years 2016 to 2019 and included adults aged >67 years with continuous Medicare Advantage coverage and a first ICU admission in 2018. Alzheimer disease and related dementia and comorbid conditions were identified from claims. Outcomes included discharge location (home vs other facilities) and mortality (within the same calendar month of discharge and within 12 months after discharge). RESULTS: A total of 145 342 adults met inclusion criteria; 10.5% had ADRD and were likely to be older, female, and have more comorbid conditions. Only 37.6% of patients with ADRD were discharged home versus 68.6% of patients who did not have ADRD (odds ratio [OR], 0.40; 95% CI, 0.38-0.41). Both death in the same month as discharge (19.9% vs 10.3%; OR, 1.54; 95% CI, 1.47-1.62) and death in the 12 months after discharge (50.8% vs 26.2%; OR, 1.95; 95% CI, 1.88-2.02) were twice as common among patients with ADRD. CONCLUSIONS: Patients with ADRD have lower home discharge rates and greater mortality after an ICU stay than patients without ADRD.

Racial and Ethnic Disparities in Buprenorphine and Extended-Release Naltrexone Filled Prescriptions During the COVID-19 Pandemic.

Importance: COVID-19 disrupted delivery of buprenorphine and naltrexone treatment for opioid use disorder (OUD), and during the pandemic, members of racial and ethnic minority groups experienced increased COVID-19 and opioid overdose risks compared with White individuals. However, whether filled buprenorphine and naltrexone prescriptions varied across racial and ethnic groups during the COVID-19 pandemic remains unknown. Objective: To investigate whether disruptions in filled buprenorphine and naltrexone prescriptions differed by race and ethnicity and insurance status or payer type. Design, Setting, and Participants: This cross-sectional study used retail pharmacy claims from May 2019 to June 2021 from the Symphony Health database, which includes 92% of US retail pharmacy claims, with race and ethnicity data spanning all insurance status and payer categories. Interrupted time series were used to estimate levels and trends of dispensed buprenorphine and naltrexone prescriptions before and after pandemic onset. Included individuals were those who filled buprenorphine and extended-release naltrexone prescriptions. Data were analyzed from July 2021 through March 2022. Main Outcomes and Measures: Weekly rates of dispensed buprenorphine and extended-release naltrexone prescription fills per 1000 patients and proportion of longer (ie, ≥14 days' supply) buprenorphine prescription fills were calculated. Analyses were stratified by patient race and ethnicity and further by insurance status and payer type for White and Black patients. Results: A total of 1 556 860 individuals who filled buprenorphine prescriptions (4359 Asian [0.3%], 94 657 Black [6.1%], 55 369 Hispanic [3.6%], and 664 779 White [42.7%]) and 127 506 individuals who filled extended-release naltrexone prescriptions (344 Asian [0.3%], 8186 Black [6.4%], 5343 Hispanic [4.2%], and 53 068 White [41.6%]) from May 6, 2019, to June 5, 2021, were analyzed. Prepandemic increases in buprenorphine fill rate flattened for all groups after COVID-19 onset (30.5 percentage point difference in trend; P < .001) compared with prepandemic trends. Significant level decreases in buprenorphine fills (ranging from 2.5% for Black patients; P = .009 to 4.0% for Hispanic patients; P = .009) at pandemic onset were observed for members of racial and ethnic minority groups but not White patients. At pandemic onset, rate of buprenorphine fills decreased in level for Medicare and cash-paying patients but with greater decreases for Black patients (Medicare: 10.0%; P < .001; cash: 20.0%; P < .001) than White patients (Medicare: 3.5%; P = .004; cash: 15.0%; P < .001). No decreases were found among Medicaid patients. Unlike buprenorphine, extended-release naltrexone had uniform level (from 10.0% for White patients with private insurance; P < .001 to 23.3% for Black patients with Medicare; P < .001) and trend (from 15.5 percentage points for White patients with Medicaid; P = .001 to 52.0 percentage points for Black patients with private insurance; P < .001) decreases across groups. Conclusions and Relevance: This study found that the COVID-19 pandemic was associated with immediate decreases in filled buprenorphine prescriptions by members of racial and ethnic minority groups but not White individuals. These findings suggest that members of racial and ethnic minority groups had larger losses in buprenorphine access during the pandemic across payer types.

Trends in US Health Insurance Coverage During the COVID-19 Pandemic.

Importance: While most working-age adults in the US obtain health insurance through an employer, little is known about the implications of the massive pandemic-related job loss in March 2020 and subsequent rebound for rates of employer-sponsored coverage and uninsurance. Objective: To determine how health insurance coverage changed during the COVID-19 pandemic. Design Setting and Participants: Analysis of trends in insurance coverage based on repeated cross sections of the US Census Bureau's Household Pulse Survey data, using linear regression to adjust for respondent's demographic and socioeconomic characteristics and state of residence. More than 1.2 million US adults aged 18 to 64 years were surveyed from April 23 through December 21, 2020. Exposures: The COVID-19 pandemic, separated into spring and summer and fall and winter time periods during 2020, as well as state Medicaid expansion status. Main Outcomes and Measures: Regression-based estimates of the weekly percentage-point change in respondents' health insurance status, including having any health insurance, any employer-sponsored health insurance, or only nonemployer sponsored coverage. Nonemployer-sponsored coverage is categorized into private, Medicaid, and other public in some analyses. Results: The study population included 1 212 816 US adults (51% female; mean [SD] age, 42 [13] years) across all 50 US states and Washington DC. Among these respondents, rates of employer-sponsored coverage declined by 0.2 percentage points each week during the COVID-19 pandemic. Other types of coverage, particularly from public sources, increased by 0.1 and 0.2 percentage points in the spring and summer and fall and winter periods, respectively. Overall, health insurance coverage of any type declined, particularly during the spring and summer period, during which uninsurance increased by 1.4 percentage points, representing more than 2.7 million newly uninsured people, over a 12-week period. Conclusions and Relevance: In this cross-sectional study of data from the US Census Bureau's Household Pulse Survey, results showed that while public programs played an important role in protecting US adults from pandemic-driven declines in employment-sponsored coverage, many people became uninsured during 2020.

Long-term opioid therapy tapering: Trends from 2014 to 2018 in a Midwestern State.

BACKGROUND: The 2016 Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain (Guideline hereafter) emphasized tapering patients from long-term opioid therapy (LTOT) when the harms outweigh the benefits. METHODS: To examine tapering from LTOT before and after the Guideline release, we conducted a retrospective cohort study of adults with high-dose LTOT (mean of >50 Morphine Milligram Equivalents [MME]/day) from 2014 to 2018 from one Midwest state's Health Information Exchange. We identified tapering (dose reductions in mean MME/day greater than 15%, 30%, 50%) and rapid discontinuation episodes (reduction to zero MME/day) over a 6-month follow-up period relative to a 3-month baseline period. We used segmented regressions to estimate outcomes adjusted for time trends and relevant state laws limiting opioid prescribing. RESULTS: The Guideline release was associated with statistically significant immediate increase in the patient likelihood of experiencing tapering (15%: 1.8% point [95% confidence interval (CI): 1.2-2.6; 30%: 1.4% point, 95% CI: 0.7-2.2; 50%: 0.8% point, 95% CI: 0.2-1.4) and rapid discontinuation episodes (0.006% point, 95% CI: 0.001-0.01). After the Guideline release, the patient likelihood of tapering increased over time (15%: 0.4% point/month, 95% CI: 0.3-0.5; 30%: 0.3% point/month, 95% CI:0.2-0.4; 50%: 0.3% point/month, 95% CI: 0.2-0.3; rapid discontinuation: 0.01% point/month, 95% CI: 0.007-0.01). Tapering and rapid discontinuation trends was similar among gender and race categories. CONCLUSION: The Guideline may be a useful tool in altering opioid prescribing practices, particularly for patients on shorter durations of LTOT.