Increases in benzodiazepine prescribing for postpartum anxiety during COVID-19.

PURPOSE: Postpartum mood disorders affect many women following childbirth. Prescribing medication for depression and anxiety is one strategy for the effective treatment of postpartum mood disorders. Left untreated, mothers experiencing these disorders and their infants face increased risks of adverse health outcomes. Little is known about how diagnosis and treatment of postpartum mood disorders changed during COVID-19. METHODS: We used a retrospective pooled cross-sectional design in a sample of privately-insured postpartum women in U.S. claims data from January 1, 2016 to December 31, 2020. We measured changes in diagnoses of anxiety and depression and changes in prescription fills and days supplied of classes of medications used to treat these conditions (antidepressants, benzodiazepines, and z-drugs). We used ordinary least squares (OLS) regression for each outcome variable during the pre-pandemic period and forecast expected outcomes the observation period. Forecasted and actual values of the outcomes were then compared. RESULTS: Following the onset of the COVID-19 pandemic in March 2020, diagnoses of depression and anxiety were not significantly higher among privately insured postpartum women in the United States. The proportion of privately-insured postpartum women filling a benzodiazepine prescription increased by 15.2%. CONCLUSIONS: We find diagnosis of postpartum mood disorders did not increase after the onset of the COVID-19 pandemic, however, fills of benzodiazepines increased among privately-insured postpartum women. Given prior evidence of increased depressive and anxiety symptoms among postpartum women during COVID-19, this suggests increased barriers to appropriate diagnoses and treatment for depression during this period.

Concurrent Prescription Fills of Opioids and Benzodiazepines Among Postpartum Women During COVID-19.

Introduction: Concurrent prescribing of opioids and benzodiazepines is associated with increased risk of emergency department visits and overdose. Postpartum women commonly receive opioids for pain after delivery and are at risk for postpartum depression/anxiety. Although prior research finds increases in opioid prescribing and symptoms of depression/anxiety during COVID-19, concurrent prescribing among postpartum women has not been examined in the context of COVID-19. Methods: Using data from a large sample of privately insured postpartum women (N=514,120), the authors compared concurrent prescription fills of opioids and benzodiazepines before March 1, 2020, and after March 1, 2020. Primary outcome variables measured whether a patient ever filled concurrent opioid and benzodiazepine prescriptions and the number of concurrent prescription fills per patient in the 6 months after delivery. Results: Roughly 46.4% of postpartum women filled an opioid prescription, 2.4% filled a benzodiazepine prescription, and 1.2% of women filled a concurrent prescription. Among postpartum women filling a benzodiazepine prescription, 50.7% filled a concurrent opioid prescription. The number of concurrent fills among postpartum women significantly increased during the early period of COVID-19. On average, postpartum women filled 0.009 more concurrent prescriptions than expected on the basis of the preexisting trend, representing a 22.0% increase in the number of concurrent prescriptions relative to the sample mean. Conclusions: Concurrent prescribing of opioids and benzodiazepines places postpartum women at higher risk of emergency department visits and overdose. To reduce the harms associated with concurrent prescribing, clinicians should carefully consider whether opioids and/or benzodiazepines are clinically necessary for treatment and consult their state prescription drug monitoring program prior to prescribing these medications.

Medicaid Expansion and Availability of Opioid Medications in the Specialty Substance Use Disorder Treatment System.

OBJECTIVE: Research has examined the effect of Medicaid expansion on access to physicians with buprenorphine waivers, but less attention has been paid to Medicaid's impact on opioid use disorder medication availability within the specialty substance use disorder treatment system. To address this gap in the literature, this study examined the impact of Medicaid expansion on availability of opioid medications in specialty programs. METHODS: This study used data from the National Survey of the Substance Abuse Treatment Services (2002-2017), containing all known substance use disorder treatment programs in the United States, to examine the effect of Medicaid expansion on the availability of opioid use disorder medications by treatment program ownership type (publicly owned, private for profit, and private nonprofit) among opioid treatment programs (OTPs) and non-OTPs. RESULTS: The effects of Medicaid expansion were limited to nonprofit and for-profit OTPs. Medicaid expansion was associated with 135.1% and 57.5% increases in the number of nonprofit and for-profit OTPs offering injectable naltrexone, respectively, and with a 64.4% increase in the number of nonprofit OTPs offering buprenorphine. Nonprofit and for-profit OTPs compose <10% of the treatment system, indicating that improvements in opioid use disorder treatment associated with Medicaid expansion were limited to a small share of the specialty system. CONCLUSIONS: The limited impact of Medicaid expansion on the specialty treatment system may perpetuate disparities in the accessibility and quality of opioid use disorder treatment for Medicaid enrollees and fail to alleviate high rates of opioid use disorder and opioid overdose deaths in this vulnerable population.

Relationship of County Opioid Epidemic Severity to Changes in Access to Substance Use Disorder Treatment, 2009-2017.

OBJECTIVE: The study measured the association between local opioid problem severity and changes in the availability of substance use disorder treatment programs, including the distance required for travel to treatment. METHODS: A two-part, multivariable regression estimated the number of treatment facilities in the county (per 100,000 residents) and the number of miles to the nearest program (for all treatment programs, programs offering opioid use disorder medication, and programs accepting Medicaid) using data from the 2009-2017 National Directory of Drug and Alcohol Abuse Treatment Facilities. The unit of analysis was the county-year (N=28,270). RESULTS: The probability of having at least one treatment program meeting the established criteria was greater in counties with a high-severity opioid problem than in counties with a low-severity problem, and the probability improved over time. In counties with a high-severity problem, the probability of having a treatment program offering buprenorphine, methadone, or both was 60.3% higher than in counties with low-severity problems. Between 2009 and 2017, the likelihood of having a treatment program that accepts Medicaid grew by 25.3%. For counties without treatment programs, the distance to the nearest program improved markedly over time, but there were no differences between distance to treatment in high-, moderate-, and low-severity status counties. CONCLUSIONS: The treatment system has reduced structural barriers to treatment where it is most needed. However, these findings do not imply that the treatment system has sufficient capacity to address the present scope of the opioid crisis. Policy makers should leverage this responsiveness to incentivize additional improvements in access.

County-level access to opioid use disorder medications in medicare Part D (2010-2015).

OBJECTIVE: To identify geographic disparities in access to opioid use disorder (OUD) treatment medications and county demographic and economic characteristics associated with access to buprenorphine and oral naltrexone prescribers in Medicare Part D. DATA SOURCES/STUDY SETTING: We utilized data from the Medicare Part D Prescription Drug Event Standard Analytic File (2010-2015). STUDY DESIGN/DATA COLLECTION: We used logistic regression to examine county-level access to OUD medication prescribers. PRINCIPAL FINDINGS: There was a 5.6 percentage point increase in counties with access to an OUD prescriber over the study period. However, in 2015, 60 percent of US counties lacked access to a Medicare Part D buprenorphine prescriber and over 75 percent lacked access to an oral naltrexone prescriber. Increased access to OUD prescribers was largely concentrated in urban counties. Results of logistic regression indicate regional differences and potential racial disparities in access to OUD prescribers. CONCLUSIONS: To improve access to buprenorphine and naltrexone treatment for Medicare Part D enrollees, CMS may consider implementing educational and training initiatives focused on OUD treatment, offering training to obtain a buprenorphine waiver at no cost to providers, and sending targeted information to providers in low OUD treatment capacity areas.

An Empirical Analysis of the Association Between Cigarette Smoking and Participation in the Supplemental Nutrition Assistance Program.

PURPOSE: To examine the association between smoking and participation in Supplemental Nutrition Assistance Program (SNAP) among low-income families. DESIGN: A quasi-experimental design using pooled cross-sectional data from the Bureau of Labor Statistics' Consumer Expenditure Diary Survey. SETTING: A national, representative sample of US households from 2005 through 2012. PARTICIPANTS: A total of 19 395 low-income households. MEASURES: US poverty thresholds were used, in conjunction with household income, to create a sample of families at 130% of the federal poverty level and below. Expenditures on cigarettes and self-reported enrollment in SNAP were used to measure smoking behavior and program participation, respectively. ANALYSIS: Estimation of a maximum likelihood model was used to predict the probability of smoking given participation in SNAP. RESULTS: The SNAP participation among low-income households was associated with a 30% ( P < .01) increase in the likelihood of a household containing at least 1 smoker, relative to low-income non-SNAP households. Among smokers, SNAP households do not spend more money on tobacco products than non-SNAP households. CONCLUSION: Given the strong association found between SNAP participation and smoking, connecting program participants who smoke to effective smoking cessation programs could be an effective tool in reducing the prevalence of smoking among the low-income population. States have a unique opportunity to use SNAP-Education programs to integrate tobacco prevention and cessation into curriculum for direct client impact.

An empirical assessment of the relationship between Official Development Aid and child mortality, 2000-2015.

OBJECTIVES: To analyze the effect of Official Development Aid (ODA) dollars on child mortality over the course of the United Nation's Millennium Development Goals initiative. METHODS: The relationship between child mortality and Official Development Aid over the duration of the Millennium Development Goals (2000-2015) is examined here using a longitudinal panel of country-level data from the World Bank and the United Nations. An Ordinary Least Squares regression approach was used with country-level fixed effects. Models were estimated for the full sample and by Human Development Index development strata (high, medium, and low developed countries) with clustered standard errors. RESULTS: ODA appears to be most strongly associated with decreases in child mortality in Medium Developed Countries. Every one dollar per capita increase in ODA is associated with a 0.035 decrease in child deaths per 1000 births. CONCLUSIONS: Significant gains were made in decreasing child mortality over the last 15 years. The need for more progress remains. Allocation of ODA to developing countries can be an effective policy tool in achieving public health goals.

Offsetting the Effects of Medical Expenses on Older Adults' Household Food Budgets: An Analysis of the Standard Medical Expense Deduction.

The Supplemental Nutrition Assistance Program (SNAP) provides critical nutrition assistance to over 40 million Americans each month. Low-income older adults (60 and older) and disabled participants experience additional budgetary constraints because of high out-of-pocket medical expenses. In recent years, some states have adopted a "Standard Medical Expense Deduction" (SMED) for senior and disabled beneficiaries, making it easier to report medical expenses in the SNAP application process. We conduct a descriptive national analysis that shows increases in benefit levels and reporting of medical expenses for states that have implemented SMED. We then present descriptive findings from Medicare claims data among a sample of low-income older adults in need of food assistance in Georgia. Average medical expenses among this sample approach $200 per month, whereas those for persons diagnosed with multiple chronic conditions exceed $300 per month. Policy implications of this analysis include the need for more states to consider adoption of SMED or alternative estimating approaches, leading to increases in benefit levels for the neediest beneficiaries and decreases in administrative burden among state agencies. We present two possible policy approaches states might take to receive approval for these changes from U.S. Department of Agriculture.

Growth In SNAP Retailers Was Associated With Increased Client Enrollment In Georgia During The Great Recession.

Policies to improve food accessibility in underserved areas often use direct financial incentives to attract new food retailers. Our analysis of data on the Supplemental Nutrition Assistance Program (SNAP) in Georgia before and after the Great Recession suggests that increased program enrollment improves access to food for SNAP beneficiaries by acting as an indirect subsidy to retailers. We divided food stores into four categories: large, midsize, small, and specialty retailers. Between 2008 and 2011 the number of SNAP enrollees increased by 87 percent, and between 2007 and 2014 the number of SNAP retailers in Georgia increased by 82 percent, primarily because of growth in the number of authorized small retailers. Inside metropolitan Atlanta, changes in the numbers of SNAP enrollees and authorized retailers were positively and significantly associated for small retailers. For the areas outside of metropolitan Atlanta, the association between changes in numbers of enrollees and authorized retailers was strongest for small retailers; more modest associations were also seen for large and specialty retailers. Policy makers should consider how retailers' sensitivity to and reliance on SNAP funding can be leveraged to improve not only food availability, but also access to healthy foods.