"Wanna cry this out real quick?": an examination of secondary traumatic stress risk and resilience among post-overdose outreach staff in Massachusetts.

BACKGROUND: Post-overdose outreach programs engage overdose survivors and their families soon after an overdose event. Staff implementing these programs are routinely exposed to others' trauma, which makes them vulnerable to secondary traumatic stress (STS) and compassion fatigue. The purpose of this study was to explore experiences of STS and associated upstream and downstream risk and protective factors among program staff. METHODS: We conducted a post-hoc analysis of semi-structured interviews with post-overdose outreach program staff in Massachusetts. Transcripts were analyzed using a multi-step hybrid inductive-deductive approach to explore approaches and responses to outreach work, factors that might give rise to STS, and compassion fatigue resilience. Findings were organized according to the three main constructs within Ludick and Figley's compassion fatigue resilience model (empathy, secondary traumatic stress, and compassion fatigue resilience). RESULTS: Thirty-eight interviews were conducted with staff from 11 post-overdose outreach programs in Massachusetts. Within the empathy construct, concern for others' well-being emerged as a motivator to engage in post-overdose outreach work - with staff trying to understand others' perspectives and using this connection to deliver respectful and compassionate services. Within the secondary traumatic stress construct, interviewees described regular and repeated exposure to others' trauma - made more difficult when exposures overlapped with staff members' personal social spheres. Within the compassion fatigue resilience construct, interviewees described the presence and absence of self-care practices and routines, social supports, and workplace supports. Job satisfaction and emotional detachment from work experiences also arose as potential protective factors. Interviewees reported inconsistent presence and utilization of formal support for STS and compassion fatigue within their post-overdose outreach teams. CONCLUSION: Post-overdose outreach program staff may experience secondary traumatic stress and may develop compassion fatigue, particularly in the absence of resilience and coping strategies and support. Compassion fatigue resilience approaches for post-overdose outreach staff warrant further development and study.

Implementing digital systems to facilitate genetic testing for hereditary cancer syndromes: An observational study of 4 clinical workflows.

PURPOSE: National efforts have prioritized the identification of effective methods for increasing case ascertainment and delivery of evidence-based health care for individuals at elevated risk for hereditary cancers. METHODS: This study examined the uptake of genetic counseling and testing following the use of a digital cancer genetic risk assessment program implemented at 27 health care sites in 10 states using 1 of 4 clinical workflows: (1) traditional referral, (2) point-of-care scheduling, (3) point-of-care counseling/telegenetics, and (4) point-of-care testing. RESULTS: In 2019, 102,542 patients were screened and 33,113 (32%) were identified as at high risk and meeting National Comprehensive Cancer Network genetic testing criteria for hereditary breast and ovarian cancer, Lynch syndrome, or both. Among those identified at high risk, 5147 (16%) proceeded with genetic testing. Genetic counseling uptake was 11% among the sites with workflows that included seeing a genetic counselor before testing, with 88% of patients proceeding with genetic testing after counseling. Uptake of genetic testing across sites varied significantly by clinical workflow (6% referral, 10% point-of-care scheduling, 14% point-of-care counseling/telegenetics, and 35% point-of-care testing, P < .0001). CONCLUSION: Study findings highlight the potential heterogeneity of effectiveness attributable to different care delivery approaches for implementing digital hereditary cancer risk screening programs.

Do Urine Drug Tests Reveal Substance Misuse Among Patients Prescribed Opioids for Chronic Pain?

BACKGROUND: Urine drug testing (UDT) is a recommended risk mitigation strategy for patients prescribed opioids for chronic pain, but evidence that UDT supports identification of substance misuse is limited. OBJECTIVE: Identify the prevalence of UDT results that may identify substance misuse, including diversion, among patients prescribed opioids for chronic pain. DESIGN: Retrospective cohort study. SUBJECTS: Patients (n=638) receiving opioids for chronic pain who had one or more UDTs, examining up to eight substances per sample, during a one 1-year period. MAIN MEASURES: Experts adjudicated the clinical concern that UDT results suggest substance misuse or diversion as not concerning, uncertain, or concerning. KEY RESULTS: Of 638 patients, 48% were female and 49% were over age 55 years. Patients had a median of three UDTs during the intervention year. We identified 37% of patients (235/638) with ≥1 concerning UDT and a further 35% (222/638) having ≥1 uncertain UDT. We found concerning UDTs due to non-detection of a prescribed substance in 24% (156/638) of patients and detection of a non-prescribed substance in 23% (147/638). Compared to patients over 65 years, those aged 18-34 years were more likely to have concerning UDT results with an adjusted odds ratio (AOR) of 4.8 (95% confidence interval [CI] 1.9-12.5). Patients with mental health diagnoses (AOR 1.6 [95% CI 1.1-2.3]) and substance use diagnoses (AOR 2.3 [95% CI 1.5-3.7]) were more likely to have a concerning UDT result. CONCLUSIONS: Expert adjudication of UDT results identified clinical concern for substance misuse in 37% of patients receiving opioids for chronic pain. Further research is needed to determine if UDTs impact clinical practice or patient-related outcomes.

Infectious diseases prevention and control using an integrated health big data system in China.

BACKGROUND: The Yinzhou Center for Disease Prevention and Control (CDC) in China implemented an integrated health big data platform (IHBDP) that pooled health data from healthcare providers to combat the spread of infectious diseases, such as dengue fever and pulmonary tuberculosis (TB), and to identify gaps in vaccination uptake among migrant children. METHODS: IHBDP is composed of medical data from clinics, electronic health records, residents' annual medical checkup and immunization records, as well as administrative data, such as student registries. We programmed IHBDP to automatically scan for and detect dengue and TB carriers, as well as identify migrant children with incomplete immunization according to a comprehensive set of screening criteria developed by public health and medical experts. We compared the effectiveness of the big data screening with existing traditional screening methods. RESULTS: IHBDP successfully identified six cases of dengue out of a pool of 3972 suspected cases, whereas the traditional method only identified four cases (which were also detected by IHBDP). For TB, IHBDP identified 288 suspected cases from a total of 43,521 university students, in which three cases were eventually confirmed to be TB carriers through subsequent follow up CT or T-SPOT.TB tests. As for immunization screenings, IHBDP identified 240 migrant children with incomplete immunization, but the traditional door-to-door screening method only identified 20 ones. CONCLUSIONS: Our study has demonstrated the effectiveness of using IHBDP to detect both acute and chronic infectious disease patients and identify children with incomplete immunization as compared to traditional screening methods.

Associations between sociodemographic factors and receiving "ask and advise" services from healthcare providers in India: analysis of the national GATS-2 dataset.

BACKGROUND: India is home to about 12% of the world's tobacco users, with about 1.35 million tobacco-related deaths each year. The morbidity and mortality rates are socially patterned based on gender, rural vs. urban residence, education, and other factors. Following the World Health Organization's guidance, it is critical to offer tobacco users support for cessation as a complement to policy and environmental changes. Such guidance is typically unavailable in low-resource systems, despite the potential for population-level impact. Additionally, service delivery for tobacco control tends to be patterned by sociodemographic factors. To understand current activity in this area, we assessed the percentage of daily tobacco users being asked about tobacco use and advised to quit by a healthcare provider. We also examined social patterning of receipt of services (related to by rural vs. urban residence, age, gender, education, caste, and wealth). METHODS: We analyzed cross-sectional data from India's 2016-2017 Global Adult Tobacco Survey (GATS-2), a nationally representative survey. Among 74,037 respondents, about 25% were daily users of smoked and/or smokeless tobacco. We examined rates of being asked and advised about tobacco use overall and based on rural vs. urban residence, age, gender, education, caste, and wealth. We also conducted multivariate logistic regression to assess the association of demographic and socioeconomic conditions with participants' receipt of "ask and advise" services. RESULTS: Nationally, among daily tobacco users, we found low rates of individuals reporting being asked about tobacco use or advised to quit by a healthcare provider (22% and 19%, respectively). Being asked and advised about tobacco use was patterned by age, gender, education, caste, and wealth in our final regression model. CONCLUSIONS: This study offers a helpful starting point in identifying opportunities to address a critical service delivery gap in India. Given the existing burden on the public health and health systems, scale-up will require innovative, resource-appropriate solutions. The findings also point to the need to center equity in the design and scale-up of tobacco cessation supports so that marginalized and underserved groups will have equitable access to these critical services.

Time trends and disparities in anxiety among adolescents, 2012-2018.

PURPOSE: Prior studies have been inconclusive in documenting whether the prevalence of adolescent anxiety is increasing, given sampling and measurement limitations. This study adds new information on recent time trends in anxiety prevalence, specifically investigating trends among previously unexamined sociodemographic subgroups. METHODS: Weighted data of 37,360 youth respondents (51.1% female, 71.8% White, 91.3% heterosexual, 99.2% cisgender) from the 2012-2018 Dane County Youth Assessment, a county-wide survey administered to youth in participating school districts, were analyzed to estimate time trends in anxiety prevalence among the whole sample and by sociodemographic subgroups. RESULTS: The prevalence of youth meeting anxiety-screening criteria increased from 34.1% (95% CI 33.4-34.9) in 2012 to 44% (95% CI 43.2-44.7) in 2018 (OR for trend = 1.07, P for trend < 0.001). The trend remained significant after adjusting for known confounds (AOR for trend = 1.07, P for trend < 0.001). Anxiety increased significantly for several subgroups and widening disparities were documented among females relative to males (P < 0.001), and sexual minority youth relative to heterosexual youth (P = 0.003). In addition, Black youth did not increase at the same swift rate as White youth over the study period (P < 0.001). CONCLUSION: This study reports recent data on anxiety time trends and finds that among a geographically representative sample of adolescents, anxiety prevalence is rising. Findings provide new evidence documenting increased anxiety prevalence among sexual minority youth relative to their peers. Results highlight the need to bolster public health interventions focused on adolescent mental health, with tailored interventions for vulnerable groups.

Pharmacy on-site overdose protocols and prevention of overdose.

BACKGROUND: Opioid overdose is a preventable injury leading to high morbidity and premature mortality in communities across the United States. Overdoses take place where people use drugs, including commercial and public locations like community pharmacies, and necessitate swift detection and response to avoid harm and, even more seriously, death. The presence of emergency and safety protocols improves occupational health and safety for all in the workplace. The aim of this study was to assess the prevalence of experience with on-site pharmacy overdose and to explore pharmacist and site characteristics associated with having a known protocol for responding to on-site overdose emergencies.Methods: An anonymous, online survey about naloxone provision and opioid safety was delivered by email, through professional pharmacy associations and continuing education attendance lists, to 3,100 pharmacists in Massachusetts and Rhode Island between October 2017 and January 2018. Survey items gauged socio-demographics, practice site characteristics, safer opioid dispensing and naloxone provision. Summary statistics and bivariate analyses were conducted to describe characteristics associated with items pertaining to on-site overdose policy awareness.Results: Of the 357 respondents (11.5% response rate), 154 (5.0%) answered the questions of interest: 17.5% reported having at least one suspected overdose on-site at their practice location, while 42.9% reported that they were knowledgeable about and could locate at their practice location an on-site overdose protocol detailing how to respond to an overdose. Pharmacists who were knowledgeable about protocols were also more likely to offer naloxone to patients (p = 0.02) and did not practice at a chain pharmacy (p = 0.01).Conclusions: Community pharmacies that stock and distribute naloxone are key parts of community efforts to address the opioid crisis. Pharmacies and other healthcare settings should develop and implement on-site overdose response protocols and cultivate a norm of naloxone provision to patients.

Pharmacists' experiences with a statewide naloxone standing order program in Massachusetts: a mixed methods study.

OBJECTIVES: In a prior statewide naloxone purchase trial conducted in Massachusetts, we documented a high rate of naloxone dispensing under the state's standing order program. The purpose of this study was to understand the factors that facilitate naloxone access under the Massachusetts naloxone standing order (NSO) program and identify any remaining barriers amenable to intervention. DESIGN: Mixed methods design involving a pharmacist survey and 3 pharmacist focus groups. SETTING AND PARTICIPANTS: Focus groups were conducted at 3 separate professional conferences for pharmacists (n = 27). The survey was conducted among Massachusetts pharmacists (n = 339) working at a stratified random sample chain and independent retail pharmacies across Massachusetts. All data were collected between September 2018 and November 2019. OUTCOME MEASURES: Facilitators and barriers to NSO implementation and naloxone dispensing and pharmacists' attitudes and beliefs regarding naloxone and opioid use. RESULTS: Most pharmacists described NSO implementation as being straightforward, although differences were reported by pharmacy type in both the survey and focus groups. Facilitators included centralized implementation at chain pharmacies, access to Web-based resources, regularly stocking naloxone, and use of naloxone-specific intake forms. Barriers included patient confidentiality concerns and payment/cost issues. Only 31% of surveyed pharmacists reported always providing naloxone counseling; the most commonly cited barriers were perceived patient discomfort (21%) and time limitations (14%). Confidential space was also more of a concern for independent (vs. chain) pharmacists (18% vs. 6%, P = 0.008). A majority of pharmacists held supportive attitudes toward naloxone, although some reported having moral/ethical concerns about naloxone provision. CONCLUSION: We documented several facilitators to NSO implementation and naloxone dispensing. Areas for improvement include addressing stigma and misconceptions around opioids and naloxone use. These remain important targets for improving pharmacy-based naloxone dispensing, although our overall positive results suggest Massachusetts' experience with NSO implementation can inform other states' efforts to expand pharmacy-based naloxone access.

Pharmacy naloxone codispensing: A mixed methods study of practices and perspectives under a statewide standing order program.

BACKGROUND: In a previous statewide naloxone purchase trial conducted in Massachusetts, we documented high levels of naloxone accessibility, upon patient request, under the state's naloxone standing order (NSO) program. Equally important for reducing overdose mortality rates is expanding naloxone access via codispensing alongside opioid prescription and syringe purchases at pharmacies. OBJECTIVE: To understand naloxone codispensing from the perspective of pharmacists under the Massachusetts NSO program. METHODS: The study used a mixed methods design involving 3 focus groups and a quantitative survey. Participants in both the focus groups (N = 27) and survey (N = 339) were licensed Massachusetts pharmacists. Focus groups were conducted at 3 separate professional conferences for pharmacists. The survey was conducted using a stratified random sample of 400 chain and independent retail pharmacies across Massachusetts. All data were collected between September 2018 and November 2019. Quantitative and qualitative analyses examined current policies, practices, and attitudes regarding naloxone codispensing for patients at risk of opioid overdose. RESULTS: Most pharmacists (69%) reported that they, their pharmacy, or both promoted codispensing alongside opioid prescriptions. A majority promoting naloxone codispensing did so for patients prescribed high opioid dosages (80%); fewer promoted codispensing for patients also prescribed benzodiazepines (20%). Facilitators to codispensing were pre-existing relationships between pharmacists and prescribers, mandatory pharmacist consultation, and universal naloxone promotion to all patients meeting certain criteria. Barriers to codispensing were pharmacists' concerns about offending patients by initiating a conversation about naloxone, insufficient technician training, workflow and resource constraints, and misconceptions surrounding naloxone. We found no substantive differences in outcomes between chain and independent pharmacies. CONCLUSION: We documented several facilitators and barriers to naloxone codispensing in Massachusetts pharmacies. Areas amenable to intervention include increased training for front-line pharmacy technicians, mandatory pharmacist consultation for opioid-prescribed patients, workflow reorganization, and addressing stigma concerns on the pharmacist end.

The Effect of Integrating Primary Care and Mental Health Services on Diabetes and Depression: A Multi-site Impact Evaluation on the US-Mexico Border.

BACKGROUND: Health care delivery systems are increasingly integrating physical and mental health services to address patients' complex needs, contain costs, and improve satisfaction. Therefore, it is critical to understand whether adoption of integrated care models is effective in diverse settings. OBJECTIVE: This study examined the effect of integrated care on physical and mental health outcomes among low-income Latino participants on the US-Mexico border. RESEARCH DESIGN: In this quasi-experimental multisite study, individual-level data were pooled from 8 studies of locally adapted integrated care models. SUBJECTS: Participants were 18 years or older and had 1 or more chronic conditions: diabetes, depression, hypertension, or obesity. The study enrolled 4226 participants with 2254 participants in the intervention group and 1972 in the comparison group. MEASURES: Primary outcomes were depressive symptoms as measured by the Patient Health Questionnaire-9 score and blood glucose measured by hemoglobin A1c (HbA1c). Blood pressure, body mass index, and quality of life were secondary outcomes. RESULTS: Multivariable linear regression analyses indicated intervention participants had significantly lower Patient Health Questionnaire-9 scores (ß=-0.39, P=0.03) and HbA1c (ß=-0.14, P=0.02) at 12 months compared with comparison group participants. Stratified analyses showed improvements in HbA1c were even greater among intervention participants who had diabetes, depression, severe and persistent mental illness, were older or female compared with their counterparts in the comparison group. CONCLUSIONS: Health care is constantly transforming, making it critical to study these changes across populations and settings. Findings from this study indicate that integrated care can significantly improve mental and physical health in an underserved Latino population.

State Alcohol Policies, Binge Drinking Prevalence, Socioeconomic Environments and Alcohol's Harms to Others: A Mediation Analysis.

AIMS: Alcohol policy effects on alcohol's harms due to others' drinking (AHTO) and contextual factors that may mediate such policy effects have been understudied. This study examines state binge drinking prevalence as a mediator of the relationship between state alcohol policy and socioeconomic environments and individual-level AHTO. METHODS: A nationally representative sample of US adults (N = 32,401; 13,873 males, 18,528 females) from the 2000, 2005, 2010 and 2015 National Alcohol Surveys and the 2015 National Alcohol's Harm to Others Survey, administered in telephone interviews and based on random digit dialed sampling, were linked with state-level Alcohol Policy Scale (APS) scores, binge drinking prevalence and socioeconomic status (SES) data. Three 12-month AHTO measures were family/marriage difficulties, assault or vandalism and riding with drunk driver or having traffic accident. Three-level mediation analyses were conducted, controlling for gender, race, education, marital status, family problem-drinking history and state policing rate. RESULTS: The effects of the APS on reduced risks for assault/vandalism and drinking-driving harms were significantly mediated by reduced state binge drinking prevalence. The APS had no direct or indirect effect on family/marital trouble. State SES had significant indirect effects on increased risks for assault/vandalism and driving-related harm through increased state binge drinking prevalence and a direct effect on reduced family/marital problems. CONCLUSIONS: A more stringent alcohol policy environment could reduce assault/vandalism and driving-related harm due to another drinker by lowering state binge drinking rates. Alcohol policies may not be effective in reducing family problems caused by another drinker more prevalent in low-SES states.

The association of community and individual parental social capital with behavior problems among children in Japan: results from A-CHILD longitudinal study.

PURPOSE: The purpose of this study was to determine the association of individual-level and community-level parental social capital with childhood behavior problems using population-based longitudinal data in Japan. METHODS: We analyzed data from a population-based longitudinal survey study which followed first-grade elementary school children (6-7 years old) in Adachi City, Tokyo, Japan. At baseline, the parents of first-grade students from all 69 elementary schools in Adachi City were asked to respond to a questionnaire assessing behavior problems and prosocial behavior (using the Strengths and Difficulties Questionnaire) and parental social capital in the community (N = 5494). Data on follow-up questionnaires on behavior problems were collected when children were second grade. Among both surveys, 3656 parents returned valid responses. The association between individual-level and community-level parental social capital and children's behavior problems were analyzed using multilevel analyses adjusting for covariates. RESULTS: Community-level social capital was positively associated with prosocial behaviors, but not for total difficulties, after adjustment for covariates (coefficient = 0.19, 95% CI 0.03 to 0.36). Individual-level parental social capital was also positively associated with prosocial behaviors (coefficient = 0.27, 95% CI 0.12 to 0.41) and negatively associated with total difficulties (coefficient = - 0.54, 95% CI - 0.89 to - 0.19). CONCLUSIONS: This study showed that greater community-level social capital can benefit children with increased prosocial behaviors. Individual-level parental social capital can be protective of youth by increasing prosocial behaviors and reducing difficult behaviors. Boosting both community and individual social capital can be a promising means to enhance children's well-being.

Evaluation of the One Love Escalation Workshop for Dating Abuse Prevention: a Randomized Controlled Trial Pilot Study with a Sample of US Navy Sailors.

The purpose of this study was to evaluate the efficacy of the Escalation Workshop with a sample of US Navy sailors. Escalation is a one-session workshop designed to promote bystander behavior related to dating abuse. We conducted a two-arm RCT with follow-up at 4 and 8 months. Participants were 335 Navy sailors, recruited from two comparable ships based in the USA. The unit of randomization was the ship. The primary outcomes were as follows: (a) attitudes related to intervening as a bystander in dating abuse situations, (b) injunctive norms about dating abuse, (c) dating abuse-related prevention-oriented behaviors (e.g., such as posting dating violence prevention messages online), and (d) bystander behaviors including acting as a bystander to prevent peer self-harm, peer bullying, peer intoxication, or peer dating abuse, or being a proactive bystander and initiating conversations about dating abuse prevention with friends and others. Hierarchal linear models (HLMs) indicated that, compared to participants in the control group, participants in the intervention group demonstrated improvement in attitudes [ß = .09, p < .001] and had more engagement than controls in prevention-oriented behavior at 8-month follow-up [ß = 0.11, p < .01]. Those in the intervention group also reported larger increases than controls in bystander behavior related to peer self-harm, peer bullying, peer intoxication, and starting conversations about dating abuse. Results for dating abuse bystander behavior were mixed. At 4 months, workshop participation was marginally associated with increased bystander behavior with peers who had perpetrated dating abuse (ß = 0.89, p = 0.06) and with peers experiencing physical or sexual dating abuse, or stalking or threats (ß = 1.11, p = .07). However, workshop participation was not associated with increased bystander behavior with peers experiencing only physical abuse. The Escalation Workshop may be a promising strategy to promote change in dating abuse-related attitudinal change and prevention-oriented behavior, and bystander behavior with peers related to self-harm, bullying, intoxication, and some aspects of dating abuse prevention.

Opioid days' supply limits: an interrupted time-series analysis of opioid prescribing before and following a Massachusetts law.

Background: In 2016, Massachusetts passed the first-in-the-nation law limiting opioid naïve adults and all minors to a 7-day supply of opioids when prescribed in the outpatient setting.Objective: We hypothesized this policy would be associated with declines in the percent of opioid prescriptions with more than a 7-day supply among opioid naïve adults and minors for select prescriber groups.Methods: Interrupted time series analyses were conducted using measures from the Massachusetts Prescription Monitoring Program database for 2015 through 2017 (n = 13,672,325 opioid prescriptions; 54% to females). Outcomes were the monthly percent of opioid prescriptions greater than 7 days' supply in opioid naïve adults and in minors among select prescriber groups. Model estimates of the pre-policy trend, the average changes in the level pre/post-implementation, and the trend changes post-implementation were assessed.Results: Pre-policy trends showed significant monthly declines in the percent of opioid prescriptions greater than 7 days' supply for all prescriber groups. Policy implementation was associated with significant reduction in the level for opioid naïve adults among surgeons (-2.92%, p < .01), dentists (-0.23%, p < .01), and general medical providers (-2.22%, p = .04), and for minors among all-included prescribers (-2.97%, p < .01) and surgeons (-3.8%, p < .01). Post-implementation changes in trends were not significant except among opioid naïve adults for dentists (0.02%, p = .04).Conclusion: Within a context of significant reductions occurring in opioid prescriptions greater than 7 days' supply during this period, the Massachusetts policy was associated with further declines for opioid naïve adults and minors among select prescriber groups.

Examining nonprescription syringe sales in Massachusetts and Rhode Island community pharmacies.

BACKGROUND: The role pharmacies play in addressing the opioid crisis and drug-related risks such as injection drug use is evolving. Estimating the prevalence of injection drug use at the community level is challenging because of the stigma of drug use. Many community pharmacies sell nonprescription sterile syringes; thus, pharmacy-level sales of injection equipment may be an indicator of drug-related harms and unmet needs of high-risk populations. OBJECTIVES: To describe, compare, and assess the convergent validity of staff-reported nonprescription syringe (NPS) sales volume and NPS administrative sales data from community pharmacies in Massachusetts (MA) and Rhode Island (RI). METHODS: This study employed both prospective cross-sectional survey data collection and utilization of administrative pharmacy sales data. Between November 2017 and January 2018, we administered a telephone-based survey to estimate average weekly NPS type and volume for 191 chain pharmacies (CVS Health) located in communities experiencing fatal opioid overdoses above the state's 2015 annual median rate. For the same time period, we obtained NPS sales data from surveyed pharmacies and all CVS Health pharmacies in the 2 states. We calculated Spearman correlations to assess convergence of average weekly volume between pharmacy staff reports and sales data. RESULTS: All pharmacies responded to the survey. Most (98.4%) pharmacies surveyed sold NPS, but 42.0% reported running out of stock monthly or more frequently. Pharmacy staff tended to under-report syringe sales. Staff-reported weekly NPS sales volume was 67,922 versus 70,962 syringes from administrative pharmacy sales data. Spearman correlation between reported and actual NPS sales was 0.40 (95% CI 0.27-0.51). CONCLUSION: The counts of administrative pharmacy syringe sales data in MA and RI indicate high need, substantial volume, and notable access at community pharmacies. Future research should use NPS sales data rather than self-report data to track emerging trends and tailor local responses.

Randomized Trial of Reverse Colocated Integrated Care on Persons with Severe, Persistent Mental Illness in Southern Texas.

BACKGROUND: Persons with severe, persistent mental illness (SPMI) are at high risk for poor health and premature mortality. Integrating primary care in a mental health center may improve health outcomes in a population with SPMI in a socioeconomically distressed region of the USA. OBJECTIVE: To examine the effects of reverse colocated integrated care on persons with SPMI and co-morbid chronic disease receiving behavioral health services at a local mental health authority located at the US-Mexico border. DESIGN: Randomized trial evaluating the effect of a reverse colocated integrated care intervention among chronically ill adults. PARTICIPANTS: Participants were recruited at a clinic between November 24, 2015, and June 30, 2016. INTERVENTIONS: Receipt of at least two visits with a primary care provider and at least one visit with a chronic care nurse or dietician, compared with usual care (behavioral health only). MAIN MEASURES: The primary outcome was blood pressure. Secondary outcomes included HbA1c, BMI, total cholesterol, and depressive symptoms. Sociodemographic data were collected at baseline, and outcomes were measured at baseline and 6- and 12-month follow-ups. KEY RESULTS: A total of 416 participants were randomized to the intervention (n = 249) or usual care (n = 167). Groups were well balanced on almost all baseline characteristics. At 12 months, intent-to-treat analysis showed intervention participants improved their systolic blood pressure (ß = - 3.86, p = 0.04) and HbA1c (ß = - 0.36, p = 0.001) compared with usual care participants when controlling for age, sex, and other baseline characteristics. No participants withdrew from the study due to adverse effects. Per-protocol analyses yielded similar results to intent-to-treat analyses and found a significantly protective effect on diastolic blood pressure. Older and diabetic populations differentially benefited from this intervention. CONCLUSIONS: Colocation and integration of behavioral health and primary care improved blood pressure and HbA1c after 1-year follow-up for persons with SPMI and co-morbid chronic disease in a US-Mexico border community. TRIAL REGISTRATION: clinicaltrials.gov , Identifier: NCT03881657.

Laws Mandating Coprescription of Naloxone and Their Impact on Naloxone Prescription in Five US States, 2014-2018.

Objectives. To examine early impacts of laws that require naloxone to be prescribed to patients at increased overdose risk.Methods. Using data from 2014 to 2018 from a large pharmacy chain, CVS Pharmacy, we examined the effects of naloxone-prescribing mandates 90 days before and after they took effect in Arizona, Florida, Rhode Island, Vermont, and Virginia. We compared the number of naloxone doses initiated directly by prescribers and by pharmacy standing order, prescriber specialty, pharmacies dispensing, and payor type by applying linear models and the χ2 test.Results. Naloxone-prescribing mandates increased pharmacy naloxone provision 255% from 90 days before to after implementation. This approach appeared to engage more prescribers (1028 before to 4285 after), complement ongoing naloxone provision under pharmacy standing orders, expand geographic reach (from 40% to 80% of pharmacies dispensing), and broaden the naloxone payor mix in 4 (P < .05) of 5 states.Conclusions. Mandating the prescribing of naloxone quickly expands access to this life-saving medication for more people in more places. Other states should consider mandating the coprescription of naloxone to individuals at increased risk of overdose.

Race/Ethnicity, Underlying Medical Conditions, Homelessness, and Hospitalization Status of Adult Patients with COVID-19 at an Urban Safety-Net Medical Center - Boston, Massachusetts, 2020.

As of July 5, 2020, approximately 2.8 million coronavirus disease 2019 (COVID-19) cases and 130,000 COVID-19-associated deaths had been reported in the United States (1). Populations historically affected by health disparities, including certain racial and ethnic minority populations, have been disproportionally affected by and hospitalized with COVID-19 (2-4). Data also suggest a higher prevalence of infection with SARS-CoV-2, the virus that causes COVID-19, among persons experiencing homelessness (5). Safety-net hospitals,† such as Boston Medical Center (BMC), which provide health care to persons regardless of their insurance status or ability to pay, treat higher proportions of these populations and might experience challenges during the COVID-19 pandemic. This report describes the characteristics and clinical outcomes of adult patients with laboratory-confirmed COVID-19 treated at BMC during March 1-May 18, 2020. During this time, 2,729 patients with SARS-CoV-2 infection were treated at BMC and categorized into one of the following mutually exclusive clinical severity designations: exclusive outpatient management (1,543; 56.5%), non-intensive care unit (ICU) hospitalization (900; 33.0%), ICU hospitalization without invasive mechanical ventilation (69; 2.5%), ICU hospitalization with mechanical ventilation (119; 4.4%), and death (98; 3.6%). The cohort comprised 44.6% non-Hispanic black (black) patients and 30.1% Hispanic or Latino (Hispanic) patients. Persons experiencing homelessness accounted for 16.4% of patients. Most patients who died were aged ≥60 years (81.6%). Clinical severity differed by age, race/ethnicity, underlying medical conditions, and homelessness. A higher proportion of Hispanic patients were hospitalized (46.5%) than were black (39.5%) or non-Hispanic white (white) (34.4%) patients, a finding most pronounced among those aged <60 years. A higher proportion of non-ICU inpatients were experiencing homelessness (24.3%), compared with homeless patients who were admitted to the ICU without mechanical ventilation (15.9%), with mechanical ventilation (15.1%), or who died (15.3%). Patient characteristics associated with illness and clinical severity, such as age, race/ethnicity, homelessness, and underlying medical conditions can inform tailored strategies that might improve outcomes and mitigate strain on the health care system from COVID-19.

Characteristics and Receipt of Medication Treatment Among Young Adults Who Experience a Nonfatal Opioid-Related Overdose.

STUDY OBJECTIVE: Nonfatal opioid overdose represents an opportunity to engage young adults into using medication for opioid use disorder. We seek to describe characteristics of young adults who experience nonfatal overdose and estimate rates of and time to medication for opioid use disorder for young adults relative to those aged 26 to 45 years. METHODS: We conducted a cohort study using retrospective administrative data of 15,281 individuals aged 18 to 45 years who survived an opioid-related overdose in Massachusetts between 2012 and 2014, using deidentified, individual-level, linked data sets from Massachusetts government agencies. We described patient characteristics stratified by age (18 to 21, 22 to 25, and 26 to 45 years) and evaluated multivariable Cox proportional hazards models to compare rates of medication for opioid use disorder receipt, controlling for age, sex, history of mental health disorders, and addiction treatment. RESULTS: Among 4,268 young adults in the year after nonfatal overdose, 28% (n=336/1,209) of those aged 18 to 21, 36% (n=1,097/3,059) of those aged 22 to 25 years, and 36% (n=3,916/11,013) of those aged 26 to 45 years received medication for opioid use disorder. For individuals aged 18 to 21 and 22 to 25 years, median time to buprenorphine treatment was 4 months (interquartile range 1.7 to 1.8 months); to methadone treatment, 4 months (interquartile range 2.8 to 2.9 months); and to naltrexone treatment, 1 month (interquartile range 1 to 1 month). Individuals aged 18 to 21 years were less likely (adjusted hazard ratio 0.60 [95% confidence interval 0.45 to 0.70]) to receive methadone than those aged 22 to 25 and 26 to 45 years. Individuals aged 18 to 21 years and those aged 22 to 25 years were more likely to receive naltrexone (adjusted hazard ratio 1.65 [95% confidence interval 1.36 to 2.00] and 1.41 [95% confidence interval 1.23 to 1.61], respectively) than those aged 26 to 45 years. CONCLUSION: One in 3 young adults received medication for opioid use disorder in the 12 months after surviving an overdose. Type of medication for opioid use disorder received appeared to be age associated. Future research should focus on how medication choice is made and how to optimize the emergency department for medication for opioid use disorder initiation after nonfatal overdose.

The influence of a ban on outpatient intravenous antibiotic therapy among the secondary and tertiary hospitals in China.

BACKGROUND: Antimicrobial resistance (AMR) is a serious global public health challenge. Physicians' over-prescription of antibiotics is a major contributor, and intravenous (IV) antibiotic use has been a particular concern in China. To address the rapid fallout of antibiotic overuse, the Chinese government has piloted a ban of IV antibiotics in the outpatient department (OD) with the exemption of paediatrics, emergency department (ED), and inpatient ward of secondary and tertiary hospitals in several provinces. METHODS: To assess the potential impact of the policy, we conducted a mixed-methods study including 1) interviews about the ban of IV antibiotic use with 68 stakeholders, covering patients, health workers, and policy-makers, from two cities and 2) a hospital case study which collected routine hospital data and survey data with 207 doctors. RESULTS: Our analyses revealed that the ban of IV antibiotics in the OD led to a reduction in the total and IV antibiotic prescriptions and improved the rational antibiotic prescribing practice in the OD. Nevertheless, the policy has diverted patient flow from OD to ED, inpatient ward, and primary care for IV antibiotic prescriptions. We also found that irrational antibiotic use in paediatrics was neglected. Radical policy implementation, doctors circumvented the regulations, and lack of doctor-patient communication during patient encounters were barriers to the implementation of the ban. CONCLUSIONS: Future efforts may include 1) to de-escalate both oral and IV antibiotic therapy in paediatric and reduce oral antibiotic therapy among adults in outpatient clinics, 2) to reduce unnecessary referrals by OD doctors to ED, primary care, or inpatient services and better coordinate for patients who clinically need IV antibiotics, 3) to incorporate demand-side tailored measures, such as public education campaigns, and 4) to improve doctor-patient communication. Future research is needed to understand how primary care and other community clinics implement the ban.