Maryland opioid overdose deaths from 2018 to 2022: occupational patterns and their sociodemographic variations.

INTRODUCTION: We aimed to describe the occupational pattern of opioid overdose deaths in Maryland between 2018 and 2022 and determine the occupations at higher risk of opioid overdose death. METHODS: The sample included undetermined or unintentional opioid overdose deaths among those aged 16 years or older in Maryland, drawn from the State Unintentional Drug Overdose Reporting System. We calculated population-based incidence overdose rates by occupation, stratified by sex and race. We further calculated the incidence rate ratios (IRRs) comparing each occupation with all other groups combined and estimated the IRRs among males versus females and non-Hispanic whites versus other racial/ethnic groups. RESULTS: The pooled sample included 11 455 opioid overdose decedents (72% male and 55% non-Hispanic whites) of whom 80% were employed. The three occupation groups with the highest incidence rates were 'construction and extraction', 'transportation and material moving' and 'installation/maintenance and repair' with 291, 137 and 133 deaths per 100 000 workers in these respective occupational groups. Incidence rates were significantly higher in males than females in all categories except those 'Not in Labour Force' (IRR=0.51, p<0.001). Non-Hispanic whites relative to other racial/ethnic groups had a lower incidence of opioid overdose death in 'Military-Specific' occupations (IRR=0.53, p=0.031). CONCLUSION: Opioid overdose deaths vary by type of occupation and certain occupations are at higher risk of overdose death. The findings highlight the need for priority setting in the implementation and expansion of existing strategies to target the workers most impacted by opioid overdose.

Epidemiology of drug arrests in the United States: Evidence from the national survey on drug use and health, 2015-2019.

OBJECTIVE: Following changes to drug criminalization policies, we re-examine the epidemiology of drug arrests among people who use drugs (PWUD) in the U.S. METHODS: Serial cross-sectional data from the National Survey on Drug Use and Health (2015-2019) were utilized. Past-year illicit drug use (excluding cannabis) and drug arrests were described by year, area of residence, drug use characteristics and participant demographics. Adjusted associations between race and drug arrest were estimated using multivariable logistic regression. RESULTS: Past-year illicit drug use remained consistent over time and was highest among non-Hispanic (NH) white respondents. Of those reporting past-year illicit drug use (n = 25,429), prevalence of drug arrests remained stable over time overall and in metro areas while increasing in non-metro areas. Arrests were elevated among NH Black participants and those with lower income, unemployment, housing transience, non-metro area residence, polysubstance use, history of drug injection, substance use dependence and past-year drug selling. Adjusted odds of drug arrest remained significantly higher among NH Black individuals [aOR 1.92, 95% CI 1.30, 2.84]. CONCLUSION: Despite recent shifts away from punitive drug policies, we detected no reduction in drug arrests nationally and increasing prevalence in non-metro areas. Despite reporting the lowest level of illicit substance use and drug selling, NH Black individuals had significantly increased odds of arrest across years. Findings highlight the need for further examination of policy implementation and policing practices in different settings, with more research focused non-metro areas, to address enduring structural racism in drug enforcement and its consequences for health.

Implementation of Overdose Prevention in Maryland: Implications for Resource Allocation, Program Scale-Up, and Evaluation.

Overdose mortality in the United States continues to climb, with Maryland being one of the hardest hit states. We summarized implementation of overdose prevention and response programs in Maryland and identified associations between opioid overdose deaths by jurisdiction in 2019 and implementation of overdose programs by 2021. Data on program implementation are from Maryland's Opioid Operational Command Center (OOCC) Program Inventory. OOCC coordinates the state's response to overdose, and their Program Inventory tracks implementation of 145 programs across 12 domains (e.g., public health, education, and judiciary), including 10 programs designed to broaden naloxone access. The level of program implementation was dichotomized as substantial implementation versus other levels (i.e., partial, planned, and none). We estimated associations between per capita opioid overdose deaths and substantial implementation of: all 145 programs in the Inventory, programs within each of 12 domains, and 10 naloxone programs. Data on program implementation and overdose mortality are summarized at the jurisdiction level. Across jurisdictions, the median proportion of programs with substantial implementation was 51% across all programs and 70% among naloxone programs. Overdose mortality was associated with subsequent substantial implementation of programs within the public health domain (p = .04), but not in the other 11 domains. We did not find evidence that per capita overdose deaths in 2019 spurred overdose program implementation by 2021, with the exception of public health programs. The OOCC Program Inventory is a novel way to track implementation across jurisdictions. Findings can inform the implementation and evaluation of overdose programs in other jurisdictions across the United States.

Non-medical prescription opioid use among high school students in 38 U.S. States.

Background: Lifetime prevalence of non-medical prescription opioid use (NMPOU) among adolescents exceeds 10%. Building on that work, we estimate lifetime and recent (i.e., past 30-day) NMPOU and examine associations with alcohol and cannabis use. Methods: We used 2019 YRBS data from 38 states with a question on lifetime NMPOU (n = 151,910), a subsample of 8 states also inquired about recent NMPOU (n = 28,439). We estimated the prevalence and frequency of NMPOU for boys and girls in each state. Multivariable logistic regression was used to derive odds ratios (OR) and 95% confidence intervals (CIs) representing recent NMPOU in association with alcohol and cannabis use adjusting for state, race/ethnicity, and grade. Results: The prevalence of lifetime NMPOU ranged from 9.4% to 22.7% for girls and 8.6% to 23.2% for boys; significant sex difference in Florida. Recent NMPOU among lifetime users ranged from 33.0% to 50.7% for girls and 40.7% to 52.3% for boys, no significant sex differences. Students reporting recent NMPOU had significantly higher odds of recent alcohol (OR: 5.1, 95% CI: 4.3-6.1) and cannabis use (OR: 3.7, 95% CI: 2.8-4.8). Higher frequency (1-2 and ≥ 3 times vs. 0 times) of NMPOU had significantly greater odds of alcohol (3-9-fold) and cannabis use (3-5-fold). The magnitude of association was higher for boys compared to girls. Conclusion: The prevalence of recent NMPOU among lifetime users is high and is associated with alcohol and cannabis use. NMPOU can be a steppingstone towards other forms of opioid use therefore, opioid prevention programs should emphasize prescription drug misuse and consider socio-contextual and geographical variations.

Disruptions to naloxone training among lay and occupational responders in Maryland during the emergence of COVID-19: early impacts, recovery, and lessons learned.

Background: : Opioid overdose death rates increased during the COVID-19 pandemic. Disruptions in community-based naloxone trainings could have reduced the likelihood of overdose reversal and increased the chances of a fatal overdose. We investigated changes in the number of people trained in naloxone administration and distribution in Maryland before, during, and after COVID-related stay-at-home orders. Methods: : Data on naloxone training are from the Maryland Department of Health. We used interrupted time series models to estimate changes in average monthly number of people trained: [1] pre-interruption (4/2019-3/2020), [2] 1-month post-interruption (4/2020-5/2020), and [3] 12-months post-interruption (4/2020-3/2021). Trainees were classified as lay (e.g., people who use drugs) or occupational (e.g., law enforcement officers and harm reduction workers) responders. Results: : There were 101,332 trainees; 54.1% lay, 21.5% occupational, and 23.4% unknown responder status. We observed a decrease in the average monthly number of trainees in the pre-interruption period (-235, p<0.001), a larger decrease of 93.2% during the 1-month post-interruption (-846, p=0.013), and an increase 12-months post-interruption (+217, p<0.001). There was a significant decrease among occupational responders 1-month post-interruption, and a significant increase among lay responders in the 12-month post-interruption period. Conclusions: : Findings suggest a marked decrease in naloxone trainees immediately after stay-at-home order, followed by a moderate rebound in the 12-months after stay-at-home order. The decrease in occupational responders trained may have limited access to naloxone, but would likely have been offset by increases in number of lay responders trained. Strengthening lay and occupational responder connections could maintain naloxone distribution during public health crises.

Perceived Risk of Harm Mediates the Effects of Primary Care Alcohol Use Screening and Brief Advice in Adolescents.

PURPOSE: A previous trial found lower alcohol use risk during follow-up among adolescent primary care patients receiving computer-facilitated Screening and provider Brief Advice (cSBA) compared to treatment-as-usual (TAU). We tested whether the effect was mediated by alcohol-related perceived risk of harm (PRoH). METHODS: We analyzed data from the cSBA trial on 12- to 18-year-old patients at 9 New England practices (n = 2,096, 58% females). The trial used a quasi-experimental pre-post design with practices being their own controls (TAU followed by cSBA). Because prior alcohol experience could modify effects, we stratified analyses by baseline past 12-month drinking. Among baseline nondrinkers, we tested baseline to 3-month trajectories in PRoH of "trying alcohol" as an effect mediator for drinking at 3- and 12-month follow-up. Similarly, among those with prior drinking, we examined baseline to 3-month trajectories in PRoH of "weekly binge drinking" as an effect mediator for drinking and binge drinking. We used the Hayes product of coefficients mediation approach. RESULTS: Among baseline nondrinkers (n = 1,449), cSBA had higher PRoH compared to TAU for "trying alcohol," and higher PRoH in turn was associated with lower follow-up drinking risk. PRoH mediated their cSBA effect at 12 months, but not 3 months. Among adolescents with prior drinking (n = 647), cSBA had higher PRoH for "weekly binge drinking," which was associated with lower drinking risk at both follow-ups, and lower binge drinking risk at 3 months. PRoH mediated their cSBA effect on drinking at both follow-ups, and binge drinking at 3 months. CONCLUSION: A computer-facilitated primary care intervention enhanced adolescents' perceived alcohol risks which in turn was associated with lower drinking risk.

Unsolicited reporting notifications (URNs) through Maryland's prescription drug monitoring program (PDMP): Characteristics of providers.

Objectives: Unsolicited reporting is the activity of analyzing Prescription Drug Monitoring Program (PDMP) data and then sending unsolicited reporting notifications (URNs) to prescribers to notify them of their outlier prescribing behavior. We aimed to describe information about prescribers who were issued URNs. Methods: A retrospective study of Maryland's PDMP data from Jan.2018-Apr.2021. All providers who were issued ≥ one URN were included in analyses. We summarized data on types of URNs issued by provider type and years in practice using basic descriptive measures. We also performed logistic regression analysis to provide odds ratio and estimated marginal probability of issuing ≥ one URN to providers in the Maryland health care workforce in comparison with physicians as reference group. Results: A total of 4,446 URNs were issued to 2,750 unique providers. Odds ratio (OR) and the population estimated probability of issuing URNs were higher among nurse practitioners [OR: 1.42, 95% Confidence Interval (CI): 1.26-1.59] followed by physician assistants [OR: 1.87, 95% CI: 1.69-2.08], compared to physicians. Physicians and dentists with >10 years in practice comprised the majority of providers who were issued URNs (65.1% and 62.6%, respectively), while majority of nurse practitioners had been in practice for <10 years (75.8%). Conclusion: Findings indicate a higher probability of issuing URN for Maryland's physician assistants and nurse practitioners, compared to physicians, and an overrepresentation of physicians and dentists with longer and nurse practitioners with shorter practice experience. The study suggests education programs on safer prescribing practices and management of opioids should target certain types of providers.