Evaluating the Effects of Opioid Prescribing Policies on Patient Outcomes in a Safety-net Primary Care Clinic.

BACKGROUND: After decades of liberal opioid prescribing, multiple efforts have been made to reduce reliance upon opioids in clinical care. Little is known about the effects of opioid prescribing policies on outcomes beyond opioid prescribing. OBJECTIVE: To evaluate the combined effects of multiple opioid prescribing policies implemented in a safety-net primary care clinic in San Francisco, CA, in 2013-2014. DESIGN: Retrospective cohort study and conditional difference-in-differences analysis of nonrandomized clinic-level policies. PATIENTS: 273 patients prescribed opioids for chronic non-cancer pain in 2013 at either the treated (n=151) or control clinic (n=122) recruited and interviewed in 2017-2018. INTERVENTIONS: Policies establishing standard protocols for dispensing opioid refills and conducting urine toxicology testing, and a new committee facilitating opioid treatment decisions for complex patient cases. MAIN MEASURES: Opioid prescription (active prescription, mean dose in morphine milligram equivalents [MME]) from electronic medical charts, and heroin and opioid analgesics not prescribed to the patient (any use, use frequency) from a retrospective interview. KEY RESULTS: The interventions were associated with a reduction in mean prescribed opioid dose in the first three post-policy years (year 1 conditional difference-in-differences estimate: -52.0 MME [95% confidence interval: -109.9, -10.6]; year 2: -106.2 MME [-195.0, -34.6]; year 3: -98.6 MME [-198.7, -23.9]; year 4: -72.6 MME [-160.4, 3.6]). Estimates suggest a possible positive association between the interventions and non-prescribed opioid analgesic use (year 3: 5.2 absolute percentage points [-0.1, 11.2]) and use frequency (year 3: 0.21 ordinal frequency scale points [0.00, 0.47]) in the third post-policy year. CONCLUSIONS: Clinic-level opioid prescribing policies were associated with reduced dose, although the control clinic achieved similar reductions by the fourth post-policy year, and the policies may have been associated with increased non-prescribed opioid analgesic use. Clinicians should balance the urgency to reduce opioid prescribing with potential harms from rapid change.

Engagement in HIV care and viral suppression following changes in long-term opioid therapy for treatment for chronic pain.

Chronic pain is common among persons living with HIV and changes in opioid prescribing practices may complicate HIV care management. Using medical record data from a retrospective cohort study conducted January 1, 2012 to June 30, 2019 for 300 publicly insured HIV-positive primary care patients prescribed opioids for chronic non-cancer pain in San Francisco, we examined associations between opioid dose changes and both time to disengagement from HIV care and experiencing virologic failure using logistic regression. Discontinuation of prescribed opioids was associated with increased odds of disengagement in care at 3, 6, and 9 months after discontinuation. There were no associations with virologic failure. Providers and policy makers must weigh impacts on HIV care when implementing necessary changes in opioid prescribing.

California's Mental Health Services Act and Mortality Due to Suicide, Homicide, and Acute Effects of Alcohol: A Synthetic Control Application.

California's Mental Health Services Act (MHSA) substantially expanded funding of county mental health services through a state tax, and led to broad prevention efforts and intensive services for individuals experiencing serious mental disorders. We estimated the associations between MHSA and mortality due to suicide, homicide, and acute effects of alcohol. Using annual cause-specific mortality data for each US state and the District of Columbia from 1976-2015, we used a generalization of the quasi-experimental synthetic control method to predict California's mortality rate for each outcome in the absence of MHSA using a weighted combination of comparison states. We calculated the association between MHSA and each outcome as the absolute difference and percentage difference between California's observed and predicted average annual rates over the postintervention years (2007-2015). MHSA was associated with modest decreases in average annual rates of homicide (-0.81/100,000 persons, corresponding to a 13% reduction) and mortality from acute alcohol effects (-0.35/100,000 persons, corresponding to a 12% reduction). Placebo test inference suggested that the associations were unlikely to be due to chance. MHSA was not associated with suicide. Protective associations with mortality due to homicide and acute alcohol effects provide evidence for modest health benefits of MHSA at the population level.

Effects of constant and fluctuating incubation temperatures on hatching success and hatchling traits in the diamondback terrapin (Malaclemys terrapin) in the context of the warming climate.

As global temperatures continue to rise, so too will the nest temperatures of many species of turtles. Yet for most turtle species, including the estuarine diamondback terrapin (Malaclemys terrapin), there is limited information on embryonic sensitivity to elevated temperature. We incubated eggs of M. terrapin at three, mean temperatures (31, 34, 37 °C) under two thermal exposure regimes (constant or semi-naturally fluctuating temperature) and measured hatching success, developmental rate, and hatchling size. Hatching success was 100% at 31 °C and 67% at 34 °C, respectively; at 37 °C, all eggs failed early in the incubation period. These values were unaffected by exposure regime. The modeled LT50 (temperature that was lethal to 50% of the test population) was 34.0 °C in the constant and 34.2 °C in the fluctuating thermal regime, reflecting a steep decline in survival between 33 and 35 °C. Hatchlings having been incubated at a constant 34 °C hatched sooner than those incubated at 31 °C under either constant or fluctuating temperature. Hatchlings were smaller in straight carapace length (CL) and width after having been incubated at 34 °C compared to 31 °C. Larger (CL) hatchlings resulted from fluctuating temperature conditions relative to constant temperature conditions, regardless of mean temperature. Based upon recent temperatures in natural nests, the M. terrapin population studied here appears to possess resiliency to several degrees of elevated mean nest temperatures, beyond which, embryonic mortality will likely sharply increase. When considered within the mosaic of challenges that Maryland's M. terrapin face as the climate warms, including ongoing habitat losses due to sea level rise and impending thermal impacts on bioenergetics and offspring sex ratios, a future increase in embryonic mortality could be a critical factor for a population already experiencing ecological and physiological challenges due to climate change.

Metabolic rates are elevated and influenced by maternal identity during the early, yolk-dependent, post-hatching period in an estuarine turtle, the diamondback terrapin (Malaclemys terrapin).

Non-genetic maternal effects, operating through a female's physiology or behavior, can influence offspring traits and performance. Here we examined potential maternal influences on metabolic rates (MR) of offspring in an estuarine turtle, the diamondback terrapin (Malaclemys terrapin). Females and their eggs were collected from the field and the eggs incubated in the laboratory for subsequent measurement of MR of females, late-stage embryos, newly-hatched individuals that were nutritionally dependent on yolk, and older hatchlings that had depleted their yolk reserves and thus were independent of energetic contributions from the female. Female identity significantly affected MR of yolk-dependent hatchlings but, after yolk was depleted, MR of offspring converged and no longer reflected the maternal influence. Offspring from different females also differed in size, which influenced offspring MR and growth, but there was no correlation between female MR or size and offspring traits. MR of the older, yolk-independent hatchlings was lower overall than yolk-dependent hatchlings but correlated positively with growth rates and prior developmental rate (e.g. negatively correlated with time to hatching). Unlike another turtle species (snapping turtles), in which maternally-related differences in offspring MR were retained after yolk depletion, the maternal influence on offspring MR in diamondback terrapins is limited to early hatchling development and growth. The transient nature of the maternal effect, which was present only during the period that hatchlings were metabolizing yolk, suggests that variation among females in the composition of yolk deposited in eggs could be responsible for the differences observed in this study.

Dietary Accumulation of Inorganic Selenium by a Larval Amphibian (Hyla chrysoscelis) and Influence on Accumulation of Background Mercury.

Larval gray tree frogs (Hyla chrysoscelis) were exposed to inorganic Se (SeO2) added to the diet (10.2 and 86.3 ug/g dw) and monitored for accumulation and effect. Background concentrations of Hg were also measured in food and carcasses to assess possible effects of Se on Hg accumulation. Selenium was accumulated in a dose dependent manner, and life stages did not differ. No effects of Se exposure were observed on survival, growth, or time to metamorphosis. Mercury concentrations in carcasses, resulting from background concentrations in food, were significantly affected by the presence of Se. In the high Se treatment, Hg concentrations were significantly decreased relative to those in the low Se treatment and the control. Our study suggests that exposure to inorganic Se as SeO2 at the concentrations tested do not elicit adverse biological effects, but exposure to relatively high concentrations of Se may reduce accumulation of Hg from food.

Tracing maternal transfer of methylmercury in the sheepshead minnow (Cyprinodon variegatus) with an enriched mercury stable isotope.

Maternal transfer of methylmercury (MeHg) to eggs is an important exposure pathway for developing offspring. However, our understanding of this process is limited, particularly in estuarine fish. We conducted a 91-day chronic laboratory exposure of Cyprinodon variegatus to four concentrations of dietary MeHg ranging from 0.04 to 9.90 µg g(-1) dw. Juvenile fish were fed a preoogenesis MeHg diet for 28 days, after which the diet was switched to a diet enriched with Me(199)Hg, spanning the period of oogenesis, allowing us to differentiate between mercury stored in female tissues and mercury assimilated from the maternal diet during oogenesis. We found that both maternal body burden and clutch size were strong predictors of egg Hg content. A constant percentage of preoogenesis Hg was transferred to eggs in each treatment. Additionally, preoogenesis Hg and during-oogenesis Hg were transferred proportionally to eggs, suggesting that both female tissues and the maternal diet during oogenesis are significant sources of Hg.

Differential patterns of accumulation and retention of dietary trace elements associated with coal ash during larval development and metamorphosis of an amphibian.

We performed an experiment in which larval gray tree frogs (Hyla chrysoscelis) were raised through metamorphosis on diets increased with a suite of elements associated with coal combustion residues (silver [Ag], arsenic [As], cadmium [Cd], chromium [Cr], copper [Cu], mercury [Hg], lead [Pb], selenium [Se], vanadium [V], and zinc [Zn]) at "low" and "high" concentrations. We quantified accumulation of metals at three life stages (mid-larval development, initiation of metamorphosis, and completion of metamorphosis) as well as effects on survival, metabolic rate, size at metamorphosis, and duration and loss of weight during metamorphosis. Most elements were accumulated in a dose-dependent pattern by some or all life stages, although this was not the case for Hg. For most elements, larval body burdens exceeded those of later life stages in some or all treatments (control, low, or high). However for Se, As, and Hg, body burdens in control and low concentrations were increased in later compared with earlier life stages. A lack of dose-dependent accumulation of Hg suggests that the presence of high concentrations of other elements (possibly Se) either inhibited accumulation or increased depuration of Hg. The duration of metamorphosis (forelimb emergence through tail resorption) was lengthened in individuals exposed to the highest concentrations of elements, but there were no other statistically significant biological effects. This study shows that patterns of accumulation and possibly depuration of metals and trace elements are complex in animals possessing complex life cycles. Further study is required to determine specific interactions affecting these patterns, in particular which elements may be responsible for affecting accumulation or retention of Hg when organisms are exposed to complex mixtures of elements.

Pruritus in primary biliary cholangitis is under-recorded in patient medical records.

OBJECTIVE: Cholestatic pruritus in primary biliary cholangitis (PBC) reduces patients' health-related quality of life (HRQoL). Despite this, existing research suggests that pruritus is under-recorded in patients' health records. This study assessed the extent to which pruritus was recorded in medical records of patients with PBC as compared with patient-reported pruritus, and whether patients reporting mild itch were less likely to have pruritus recorded. We also evaluated clinico-demographic characteristics and HRQoL of patients with medical record-documented and patient-reported pruritus. DESIGN: This cross-sectional study used clinical information abstracted from medical records, together with patient-reported (PBC-40) data from patients with PBC in the USA enrolled in the PicnicHealth cohort. Medical record-documented pruritus was classified as 'recent' (at, or within 12 months prior to, enrolment) or 'ever' (at, or any point prior to, enrolment). Patient-reported pruritus (4-week recall) was assessed using the first PBC-40 questionnaire completed on/after enrolment; pruritus severity was classified by itch domain score (any severity: ≥1; clinically significant itch: ≥7). Patient clinico-demographic characteristics and PBC-40 domain scores were described in patients with medical record-documented and patient-reported pruritus; overlap between groups was evaluated. Descriptive statistics were reported. RESULTS: Pruritus of any severity was self-reported by 200/225 (88.9%) patients enrolled; however, only 88/225 (39.1%) had recent medical record-documented pruritus. Clinically significant pruritus was self-reported by 120/225 (53.3%) patients; of these, 64/120 (53.3%) had recent medical record-documented pruritus. Patients reporting clinically significant pruritus appeared to have higher mean scores across PBC-40 domains (indicating reduced HRQoL), versus patients with no/mild patient-reported pruritus or medical-record documented pruritus. CONCLUSION: Compared with patient-reported measures, pruritus in PBC is under-recorded in medical records and is associated with lower HRQoL. Research based only on medical records underestimates the true burden of pruritus, meaning physicians may be unaware of the extent and impact of pruritus, leading to potential undertreatment.

Dietary selenomethionine exposure induces physical malformations and decreases growth and survival to metamorphosis in an amphibian (Hyla chrysoscelis).

Selenium (Se) is an essential micronutrient with a narrow therapeutic concentration range. The relative toxicity of Se increases as it is biotransformed into organic compounds, primarily selenomethionine (SeMet), within the aquatic food chain. Effects of aquatic Se contamination are well quantified for many freshwater fish and aquatic bird species, but impacts on amphibians are not well known. This study investigated the responses of larval Cope's gray tree frogs (Hyla chrysoscelis) fed a diet enriched with one of two concentrations of SeMet (50.1 and 489.9 µg Se g(-1) dw [low and high groups, respectively]) by way of a food-limited (ration) or ad libitum (ad lib) feeding regimen. The high dose caused 100 % mortality during the larval period independent of resource provision levels. Regardless of feeding regimen, the low dose decreased larval survival and successful metamorphosis relative to control treatments. The low dose also induced rear limb deformities in ≤73 % of individuals initiating metamorphosis. Providing low-dose food by way of a rationed feeding regimen decreased observed toxicity, likely because of decreased dietary exposure to SeMet relative to the low ad lib treatment. Individuals from the low ration treatment had decreased wet mass at initiation and completion of metamorphic climax (Gosner stages 42 through 46) compared with those from the control ad lib treatment, indicating that resource limitation combined with Se exposure might negatively affect energy stores after metamorphosis. However, lipid content analyses of recently metamorphosed individuals did not reveal any influence of treatment or resource provision on energy stored as lipids. The mean tissue Se concentration of individuals that received the low dose and completed metamorphosis was significantly greater than that of control ad lib or ration individuals at the same developmental stage. This study demonstrates that larval exposure to dietary SeMet can decrease growth and survival and induce deformities in a developing amphibian. Furthermore, retention of Se body burdens through metamorphosis suggests that surviving individuals can transport Se accumulated from contaminated aquatic environments into terrestrial food webs.

California's Public Safety Realignment Act and prisoner mortality.

In 2011, a historic Supreme Court decision mandated that the state of California substantially reduce its prison population to alleviate overcrowding, which was deemed so severe as to preclude the provision of adequate healthcare. To comply, California passed the Public Safety Realignment Act (Assembly Bill [AB] 109), representing the largest ever court-ordered reduction of a prison population in U.S. history. AB109 was successful in reducing the state prison population; however, although the policy was precipitated by inadequate healthcare in state prisons, no studies have examined its effects on prisoner health. As other states grapple with overcrowded prisons and look to California's experience with this landmark policy, understanding how it may have impacted prisoner health is critical. We sought to evaluate the effects of AB109 on prison mortality and assess the extent to which policy-induced changes in the age distribution of prisoners may have contributed to these effects. To do so, we used prison mortality data from the Bureau of Justice Statistics and the California Deaths in Custody reporting program and prison population data from the National Corrections Reporting Program to examine changes in overall prison mortality, the age distribution of prisoners, and age-adjusted prison mortality in California relative to other states before and after the implementation of AB109. Following AB109, California prisons experienced an increase in overall mortality relative to other states that attenuated within three years. Over the same period, California experienced a greater upward shift in the age distribution of its prisoners relative to other states, suggesting that the state's increase in overall mortality may have been driven by this change in age distribution. Indeed, when accounting for this differential change in age distribution, mortality among California prisoners exhibited a greater reduction relative to other states in the third year after implementation. As other states seek to reduce their prison populations to address overcrowding, assessments of California's experience with AB109 should consider this potential improvement in age-adjusted mortality.

Evaluating buprenorphine prescribing and opioid-related health outcomes following the expansion the buprenorphine waiver program.

AIMS: To evaluate associations between new types of buprenorphine waivers (nurse practitioner and physician assistant [NP/PA]; 275-patient limit [MD/DO-275]) and both buprenorphine prescribing and health outcomes. METHODS: Using comprehensive county-level data from California 2010-2018, we modeled quarterly associations between numbers of NP/PA and MD/DO-275 waivers and rates of buprenorphine prescribing, opioid-related deaths, emergency department (ED) visits, and hospitalizations among all counties and separately among metropolitan and nonmetropolitan counties using Poisson regression models with county and quarter fixed effects and adjusting for time-varying covariates. RESULTS: Each additional NP/PA and MD/DO-275 waiver was associated with a 2.6% (95%CI: 1.1-4.1%) and 5.8% (4.1-7.4%) increase in buprenorphine prescribing among nonmetropolitan counties, respectively. Each additional MD/DO-275 waiver was associated with a 2.8% (1.0%-4.6%) increase in buprenorphine among metropolitan counties. There were no statistically significant associations between NP/PA waivers and buprenorphine prescribing among metropolitan counties or among either waiver type and opioid-related health outcomes. CONCLUSIONS: NP/PA waivers were associated with increased buprenorphine prescribing among nonmetropolitan counties and MD/DO-275 waivers were associated with increased buprenorphine prescribing among both metropolitan and nonmetropolitan counties.

Inpatient Opioid Use Disorder Treatment by Generalists is Associated With Linkage to Opioid Treatment Programs After Discharge.

OBJECTIVES: Describe clinical and demographic associations with inpatient medication for opioid use disorder (MOUD) initiation on general medicine services and to examine associations between inpatient MOUD initiation by generalists and subsequent patient healthcare utilization. METHODS: This is a retrospective study using medical record data from general medicine services at an urban safety-net hospital before an inpatient addiction consultation service. The patients were adults hospitalized for acute medical illness who had an opioid-related ICD-10 code associated with the visit. Associations with MOUD initiation were assessed using multivariable logistic regression. Hospital readmission, emergency department use, linkage to opioid treatment programs (OTP), and mortality at 30- and 90-days postdischarge were compared between those with and without hospital MOUD initiation using χ2 tests. RESULTS: Of 1,284 hospitalized patients with an opioid-related code, 59.81% received MOUD and 31.38% of these were newly initiated in-hospital. In multivariable logistic regression, Black race, mood disorder, psychotic disorder, and alcohol use disorder were negatively associated with MOUD initiation, while being aged 25-34, having a moderate hospital severity of illness score, and experiencing homelessness were positively associated. There were no bivariate associations between MOUD initiation and postdischarge emergency department use, hospital readmission, or mortality at 30- and 90-days, but those initiated on MOUD were more likely to present to an OTP within 90 days (30.57% vs 12.80%, P < 0.001). CONCLUSIONS: MOUD prescribing by inpatient generalists may help to increase the number of patients on treatment for opioid use disorder after hospital discharge. More research is needed to understand the impact of inpatient MOUD treatment without addiction specialty consultation.

Methadone treatment and patient-directed hospital discharges among patients with opioid use disorder: Observations from general medicine services at an urban, safety-net hospital.

Introduction: People with opioid use disorder (OUD) have high rates of discharge against medical advice from the hospital. Interventions for addressing these patient-directed discharges (PDDs) are lacking. We sought to explore the impact of methadone treatment for OUD on PDD. Methods: Using electronic record and billing data from an urban safety-net hospital, we retrospectively examined the first hospitalization on a general medicine service for adults with OUD from January 2016 through June 2018. Associations with PDD compared to planned discharge were examined using multivariable logistic regression. Administration patterns of maintenance therapy versus new in-hospital initiation of methadone were examined using bivariate tests. Results: During the study time period, 1,195 patients with OUD were hospitalized. 60.6% of patients received medication for OUD, of which 92.8% was methadone. Patients who received no treatment for OUD had a 19.1% PDD rate while patients initiated on methadone in-hospital had a 20.5% PDD rate and patients on maintenance methadone during the hospitalization had a 8.6% PDD rate. In multivariable logistic regression, methadone maintenance was associated with lower odds of PDD compared to no treatment (aOR 0.53, 95% CI 0.34-0.81), while methadone initiation was not (aOR 0.89, 95% CI 0.56-1.39). About 60% of patients initiated on methadone received 30 mg or less per day. Conclusions: In this study sample, maintenance methadone was associated with nearly a 50% reduction in the odds of PDD. More research is needed to assess the impact of higher hospital methadone initiation dosing on PDD and if there is an optimal protective dose.

Differential patterns of accumulation and depuration of dietary selenium and vanadium during metamorphosis in the Gray Treefrog (Hyla versicolor).

Selenium (Se) and vanadium (V) are contaminants commonly found in aquatic systems affected by wastes derived from fossil fuels. To examine their effects on a widely distributed species of amphibian, we exposed gray tree frogs (Hyla versicolor) to Se (as SeO2) or V (as NaVO3) in their diet from the early larval period to metamorphosis. Concentrations of Se in Se-enriched food were 1.0 (Se control), 7.5 (Se low), and 32.7 (Se high) µg/g dw. Concentrations of V in V-enriched food were 3.0 (V control), 132.1 (V low), and 485.7 (V high) µg/g dw. Although we observed bioaccumulation of both metals throughout the larval period, no effects on growth, survival, metabolic rate, or lipid content were observed. Se concentrations in tissues did not vary among life stages, neither in Se low nor Se high treatments, such that maximum accumulation had occurred by the mid-larval period. In addition, there was no evidence of depuration of Se in either the Se low or the Se high treatments during metamorphosis. A strikingly different pattern of accumulation and depuration occurred in V-exposed individuals. In treatments V low and V high, maximum body burdens occurred in "premetamorphs" (i.e., animals with developed forelimbs but in which tail resorption had not begun), whereas body burdens in animals having completed metamorphosis were much lower and similar to those in larvae. These results suggest that compared with Se-exposed animals, V-exposed animals were able to depurate a substantial amount of accumulated V during the metamorphic period. In an ecologic context, it appears that amphibians exposed to Se during the larval period may serve as a vector of the metal to terrestrial predators, yet potential transfer of accumulated V to predators would largely be restricted to the aquatic habitat.

Nonfatal Assault Injury Trends in California, 2005 to 2015.

Interpersonal violence is a major global public health problem, and the burden of nonfatal assault injuries is far greater than that of homicides. To understand trends and inform prevention priorities, we sought to describe nonfatal assault injury trends across demographic groups from 2005 to 2015 in California, USA. Comprehensive hospitalization and emergency department discharge records were used to estimate annual rates of nonfatal assault injury overall and by means and age group and age-standardized annual rates by race/ethnicity, gender, and county. The overall rate of assault injury was stable in California from 2005 to 2015 (mean = 364 per 100,000), but there was substantial heterogeneity across demographic groups, including increases among African Americans (900 to 1,194), American Indian/Alaskan Natives (423 to 572), older individuals (age 25-29 = 697 to 727; 30-39 = 495 to 557; 40-49 = 352 to 404; 50-59 = 194 to 313; 60+ = 66 to 106), and women (199 to 252). Assault injury rates increased among several demographic groups, warranting the attention of professionals involved in violence prevention efforts. Epidemiologic examination to better understand causes of increases can inform prevention efforts. Similar analyses should be applied to other settings to determine how broadly these patterns are observed.

Using ICD-10-CM codes to detect illicit substance use: A comparison with retrospective self-report.

BACKGROUND: Understanding whether International Classification of Disease, 10th Revision, Clinical Modification (ICD-10-CM) codes can be used to accurately detect substance use can inform their use in future surveillance and research efforts. METHODS: Using 2015-2018 data from a retrospective cohort study of 602 safety-net patients prescribed opioids for chronic non-cancer pain, we calculated the sensitivity and specificity of using ICD-10-CM codes to detect illicit substance use compared to retrospective self-report by substance (methamphetamine, cocaine, opioids [heroin or non-prescribed opioid analgesics]), self-reported use frequency, and type of healthcare encounter. RESULTS: Sensitivity of ICD-10-CM codes for detecting self-reported substance use was highest for methamphetamine (49.5 % [95 % confidence interval: 39.6-59.5 %]), followed by cocaine (44.4 % [35.8-53.2 %]) and opioids (36.3 % [28.8-44.2 %]); higher for participants who reported more frequent methamphetamine (intermittent use: 27.7 % [14.6-42.6 %]; ≥weekly use: 67.2 % [53.7-79.0 %]) and opioid use (intermittent use: 21.4 % [13.2-31.7 %]; ≥weekly use: 52.6 % [40.8-64.2 %]); highest for outpatient visits (methamphetamine: 43.8 % [34.1-53.8 %]; cocaine: 36.8 % [28.6-45.6 %]; opioids: 33.1 % [25.9-41.0 %]) and lowest for emergency department visits (methamphetamine: 8.6 % [4.0-15.6 %]; cocaine: 5.3 % [2.1-10.5 %]; opioids: 6.3 % [3.0-11.2 %]). Specificity was highest for methamphetamine (96.4 % [94.3-97.8 %]), followed by cocaine (94.0 % [91.5-96.0 %]) and opioids (85.0 % [81.3-88.2 %]). CONCLUSIONS: ICD-10-CM codes had high specificity and low sensitivity for detecting self-reported substance use but were substantially more sensitive in detecting frequent use. ICD-10-CM codes to detect substance use, particularly those from emergency department visits, should be used with caution, but may be useful as a lower-bound population measure of substance use or for capturing frequent use among certain patient populations.

Drug overdose mortality among residents of single room occupancy buildings in San Francisco, California, 2010-2017.

BACKGROUND: Single room occupancy (SRO) buildings, also known as residential hotels, are a form of affordable housing common to cities in North America, and residents of these buildings face elevated rates of substance use, physical and mental multimorbidity, and mortality. Identifying distinct populations at greater risk of overdose death is crucial to the planning of interventions aiming to reduce drug-related mortality, yet no studies have assessed the population burden of overdose mortality among SRO residents. The present study quantifies and characterizes drug overdose mortality among residents of SRO buildings in a large U.S. city. METHODS: We used mortality records and a database of SRO buildings to calculate rate ratios comparing overdose mortality due to opioids, cocaine, and methamphetamine among SRO residents and non-SRO residents in San Francisco, CA 2010-2017 and assessed bivariate differences in decedent and death location characteristics between SRO resident and other overdose decedents. RESULTS: There were 1,551 overdose deaths during the study period, with an overall rate of 21.3 per 100,000 residents (95%CI = 20.2-22.6). The rate among SRO residents (278.7, 95%CI = 252.9-306.5) was 19.3 (95%CI = 17.1-21.7) times that of non-SRO residents (21.3, 95%CI = 20.2-22.6). An additional 79 (5%) deaths among non-residents occurred in SRO buildings, and 86% of SRO resident decedents died at home compared to 64% of non-SRO residents (p < 0.05). CONCLUSIONS: Overdose mortality was substantially higher among SRO residents, who were also more likely to die from overdose at home, which highlights the need for resources and targeted interventions directed towards residents of SRO buildings.

Modeling effects of cadmium on population growth of Palaemonetes pugio: results of a full life cycle exposure.

In an 8-month laboratory experiment, Palaemonetes pugio (grass shrimp) were exposed to aqueous cadmium (free cadmium ion concentrations of 1.51 or 2.51 microg Cd(2+)/L) for an entire life cycle, from larva to reproductive adult and through to production of second-generation larva. Individual-level effects on survival, life stage duration, and reproduction were measured, and population growth was projected using two models: a stage-based matrix model and a z-transformed life cycle graph analysis. Adult survival was significantly reduced at 2.51 microg Cd(2+)/L, but cadmium exposure had no effects on survival or stage duration of embryos, larvae, or juveniles. Survival of second-generation larvae was unaffected by maternal exposure. Brood size was reduced by 27% at 1.51 microg Cd(2+)/L and by 36% at 2.51 microg Cd(2+)/L. The percent of females in the population that was gravid was approximately 50% lower at 2.51 microg Cd(2+)/L, compared to controls. Both population models projected a dose-dependent decrease in population growth rate (lambda), up to a 12% reduction at 2.51 microg Cd(2+)/L, which can be attributed mainly to contributions from reproductive effects. Elasticity analysis revealed that population growth rate was most sensitive to changes in survival of juveniles and adults. However, lethal effects of cadmium made only a small contribution to the effect on population growth rate. Even though both models project positive growth (lambda>1) of grass shrimp populations exposed to low concentrations of cadmium, the ability of populations to withstand predation pressure would be compromised.

Accumulation and maternal transfer of polychlorinated biphenyls in snapping turtles of the upper Hudson River, New York, USA.

We conducted field studies over three years to assess body burdens and maternal transfer of polychlorinated biphenyls (PCBs) as well as indices of sexual dimorphism in snapping turtles (Chelydra serpentina) of the upper Hudson River (NY, USA.) We collected adult turtles in areas known to be contaminated with PCBs and in nearby reference areas for measurement of body size, precloacal length, and penis size. We analyzed PCB concentrations in eggs collected over three years and in whole blood from adults in one year. Total PCB concentrations (mean +/- standard error) in eggs were 2,800 +/- 520 and 59 +/- 5 ng/g wet weight in the contaminated area and the reference area, respectively. Eggs from the contaminated area were significantly enriched in tri-, penta-, and hepta-PCBs relative to the reference area. Blood from adults in the contaminated area averaged 475 +/- 200 and 125 +/- 34 ng/g wet weight for males and females, respectively. In the reference area, blood PCB concentrations were 7 +/- 3 and 4 +/- 1 ng/g wet weight for males and females, respectively. Significant positive relationships were found between carapace length and blood PCB concentration for both sexes in the contaminated area; however, only a marginal relationship was found between female carapace length and concentration of PCBs in their eggs. Our results suggest that PCB contamination of the upper Hudson River presents risks of establishing high body burdens and of maternal transfer of PCBs to eggs, although our measures of gross morphology revealed no discernable expression of abnormal sexual development or reproduction.