Barriers to Buprenorphine Dispensing by Medicaid-Participating Community Retail Pharmacies.

Importance: Controlled substances have regulatory requirements under the US Federal Controlled Substance Act that must be met before pharmacies can stock and dispense them. However, emerging evidence suggests there are pharmacy-level barriers in access to buprenorphine for treatment for opioid use disorder even among pharmacies that dispense other opioids. Objective: To estimate the proportion of Medicaid-participating community retail pharmacies that dispense buprenorphine, out of Medicaid-participating community retail pharmacies that dispense other opioids and assess if the proportion dispensing buprenorphine varies by Medicaid patient volume or rural-urban location. Design, Setting, and Participants: This serial cross-sectional study included Medicaid pharmacy claims (2016-2019) data from 6 states (Kentucky, Maine, North Carolina, Pennsylvania, Virginia, West Virginia) participating in the Medicaid Outcomes Distributed Research Network (MODRN). Community retail pharmacies serving Medicaid-enrolled patients were included, mail-order pharmacies were excluded. Analyses were conducted from September 2022 to August 2023. Main Outcomes and Measures: The proportion of pharmacies dispensing buprenorphine approved for opioid use disorder among pharmacies dispensing an opioid analgesic or buprenorphine prescription to at least 1 Medicaid enrollee in each state. Pharmacies were categorized by median Medicaid patient volume (by state and year) and rurality (urban vs rural location according to zip code). Results: In 2016, 72.0% (95% CI, 70.9%-73.0%) of the 7038 pharmacies that dispensed opioids also dispensed buprenorphine to Medicaid enrollees, increasing to 80.4% (95% CI, 79.5%-81.3%) of 7437 pharmacies in 2019. States varied in the percent of pharmacies dispensing buprenorphine in Medicaid (range, 73.8%-96.4%), with significant differences between several states found in 2019 (χ2 P < .05), when states were most similar in the percent of pharmacies dispensing buprenorphine. A lower percent of pharmacies with Medicaid patient volume below the median dispensed buprenorphine (69.1% vs 91.7% in 2019), compared with pharmacies with above-median patient volume (χ2 P < .001). Conclusions and Relevance: In this serial cross-sectional study of Medicaid-participating pharmacies, buprenorphine was not accessible in up to 20% of community retail pharmacies, presenting pharmacy-level barriers to patients with Medicaid seeking buprenorphine treatment. That some pharmacies dispensed opioid analgesics but not buprenorphine suggests that factors other than compliance with the Controlled Substance Act influence pharmacy dispensing decisions.

State expansion of Supplemental Nutrition Assistance Program eligibility and rates of firearm-involved deaths in the United States.

INTRODUCTION: Poverty is a consistent correlate of firearm-involved mortality, yet little work has considered the effects of social and economic policies on these deaths. This study examined associations of state elimination of the asset test and increases in the income limit for Supplemental Nutrition Assistance Program (SNAP) eligibility with rates of firearm-involved suicide and homicide deaths in the United States. METHODS: This ecological repeated cross-sectional study used 2015-2019 data from the SNAP Policy Database and death certificate data from the National Vital Statistics System. The exposures were (1) state elimination of the asset test for SNAP eligibility and (2) state elimination of the asset test and increases in the income limit for SNAP eligibility, compared with (3) state adoption of neither policy. The outcomes were firearm-involved suicide deaths and firearm-involved homicide deaths. The research team conducted mixed-effects regressions to estimate associations. RESULTS: State elimination of the asset test for SNAP eligibility (incidence rate ratio (IRR), 0.67; 95% CI, 0.48 to 0.91) and state adoption of both eliminating the asset test and increasing the income limit for SNAP eligibility (IRR, 0.68; 95% CI, 0.49 to 0.92) were associated with decreased rates of firearm-involved suicide deaths compared with state adoption of neither policy. There were no associations with state firearm-involved homicide rates. CONCLUSIONS: SNAP is an important social safety net programme that addresses food insecurity, and the present results suggest it may also contribute to reducing firearm-involved suicide.

"My Goal is to get Through the Day Without Pain": A Qualitative Study on Chronic Pain Experiences and Treatment Needs Among Child Caregiving Women.

INTRODUCTION: We aimed to understand connections between pain, caregiving, physical and behavioral health treatment needs, and motivations for prescription opioid use among child caregiving women with chronic pain. METHODS: We conducted in-depth, semi-structured interviews with 12 women (average age 48 years; 58% Black) in child caregiving roles, including women who were pregnant or trying to become pregnant and were caring for children or grandchildren < 18 years, and who received treatment at an outpatient pain management clinic. We used thematic text analysis to identify qualitative themes related to caregiving, pain, treatment, substance use, coping strategies, and sources of support. RESULTS: A diverse sample of women reported high levels of stress and pain, substance use, interpersonal violence, depression, and financial strain. Most described difficulties at work, interacting with children or grandchildren, and engaging routine, daily activities due to their pain. Most indicated that they spent less time with family and friends due to their pain and had limited sources of support to help them navigate both caregiving and pain. Many described barriers to receiving appropriate healthcare, including prescription opioids, due to stigma or logistics, though most also reported positive healthcare experiences. Women also reported added daily-life, physical, mental health, and interpersonal stressors and difficulty navigating the healthcare system to receive needed care. DISCUSSION: For women with chronic pain in child caregiver roles, results highlight the importance of care tailored to the physical needs of child caregiving and of trauma-informed approaches given the prevalence of comorbid conditions and trauma.

Pregnancy-associated homicide, suicide and unintentional opioid-involved overdose deaths, North Carolina 2018-2019.

OBJECTIVE: Rates of death due to homicide, suicide and overdose during pregnancy and the first year postpartum have increased substantially in the USA in recent years. The aims of this study were to use 2018-2019 data on deaths identified for review by the North Carolina Maternal Mortality Review Committee (NC-MMRC), data from the North Carolina Violent Death Reporting System (NC-VDRS) and data from the Statewide Unintentional Drug Overdose Reporting System (NC-SUDORS) to examine homicide, suicide and unintentional opioid-involved overdose deaths during pregnancy and the first year postpartum. METHODS: We linked data from the 2018-2019 NC-MMRC to suicide and homicide deaths among women ages 10-50 years from the 2018-2019 NC-VDRS and to unintentional opioid-involved overdose deaths among women ages 10-50 years from the 2018-2019 NC-SUDORS. We conducted descriptive analyses to examine the prevalence of demographic characteristics and the circumstances surrounding each cause of death. RESULTS: From 2018 to 2019 in North Carolina, there were 23 homicides, nine suicides and 36 unintentional opioid-involved overdose deaths (9.7, 3.8 and 15.1 per 100 000 live births, respectively) during pregnancy and the first year postpartum. Most homicide deaths (87.0%) were by firearm, and more than half (52.5%) were related to intimate partner violence. More than two-thirds of women who died by suicide had a current mental health problem (77.8%). Less than one-fourth (22.2%) of those who died by unintentional opioid-involved overdose had a known history of substance use disorder treatment. CONCLUSION: Our approach to quantifying and describing these causes of pregnancy-associated death can serve as a framework for other states to inform data-driven prevention.

Affordable housing through the Low-Income Housing Tax Credit program and opioid overdose emergency department visits.

INTRODUCTION: The United States continues to experience an opioid overdose crisis. As a key social determinant of health, housing insecurity may contribute to initiation of substance use and can threaten outcomes for those with substance use disorders by increasing stress, risky substance use, discontinuity of treatment, and return to use, all of which may increase the risk of overdose. The Low-Income Housing Tax Credit (LIHTC) program supports access to rental housing for low-income populations. By facilitating access to affordable housing, this program may improve housing security, thereby reducing overdose risk. METHODS: We used data from LIHTC Property Data and the State Emergency Department Database (SEDD) to identify the number of LIHTC units available and opioid overdoses discharged from the emergency department (ED) in 13 states between 2005 and 2014. RESULTS: Between 2005 and 2014, mean opioid overdose ED visits were higher in states with fewer LIHTC units (<28 LIHTC units per 100,000 population) at 26.5 per 100,000 population as compared to states with higher LIHTC units (≥28 LIHTC units per 100,000 population) at 21.1 per 100,000. We find that greater availability of LIHTC units was associated with decreased rates of opioid overdose ED visits (RR 0.94; CI 0.90, 1.00). CONCLUSIONS: Given the importance of housing as a key social determinant of health, the provision of affordable housing may mitigate substance misuse and prevent nonfatal opioid overdose.

Identifying patterns of pain, depression, anxiety, interpersonal trauma exposure, and nonmedical prescription opioid use: Latent class analysis among patients with chronic pain.

BACKGROUND: Chronic pain in the context of certain factors may be associated with potential for nonmedical prescription opioid use; however, identifying this risk can be challenging and complex. Several variables alone have been associated with non-prescribed opioid use, including depression, anxiety, pain interference, and trauma exposure. Prior research has often failed to integrate these assessments together, which is important as these factors may cluster together in important and complex ways. The current study aimed to identify classes of patients with chronic pain who have differential risk for use of nonmedical prescription opioid use, depression and anxiety, and pain severity, interference, and catastrophizing, and interpersonal violence exposure. METHODS: Self-report and medical record data from patients (N = 211; Mage = 48, 69.0% women, 69.0% white) at a pain management center were collected. RESULTS: Latent class analysis revealed 3 classes with (1) low probability of clinically significant depression, anxiety, pain, and nonmedical prescription opioid use (44.7%), (2) high probability of clinically significant depression, anxiety, pain, pain catastrophizing, trauma, and nonmedical prescription opioid use (41.3%), and (3) high probability of severe pain and nonmedical prescription opioid use (14.0%). CONCLUSIONS: High-risk classes had either high levels of depression and anxiety, pain catastrophizing, and interpersonal violence exposure, or pain severity and interference. Future research should continue to explore these classes in large, diverse samples, and prospective study designs. Finally, results underscore that opioid use is complex, not easily identified by a single factor, and may be motivated by complex unmet clinical needs.

NKG2D receptor signaling shapes T cell thymic education.

The role of natural killer group 2D (NKG2D) in peripheral T cells as a costimulatory receptor is well established. However, its contribution to T cell thymic education and functional imprint is unknown. Here, we report significant changes in development, receptor signaling, transcriptional program, and function in T cells from mice lacking NKG2D signaling. In C57BL/6 (B6) and OT-I mice, we found that NKG2D deficiency results in Vß chain usage changes and stagnation of the double-positive stage in thymic T cell development. We found that the expression of CD5 and CD45 in thymocytes from NKG2D deficient mice were reduced, indicating a direct influence of NKG2D on the strength of T cell receptor (TCR) signaling during the developmental stage of T cells. Depicting the functional consequences of NKG2D, peripheral OT-I NKG2D-deficient cells were unresponsive to ovalbumin peptide stimulation. Paradoxically, while αCD3/CD28 agonist antibodies led to phenotypic T cell activation, their ability to produce cytokines remained severely compromised. We found that OT-I NKG2D-deficient cells activate STAT5 in response to interleukin-15 but were unable to phosphorylate ERK or S6 upon TCR engagement, underpinning a defect in TCR signaling. Finally, we showed that NKG2D is expressed in mouse and human thymic T cells at the double-negative stage, suggesting an evolutionarily conserved function during T cell development. The data presented in this study indicate that NKG2D impacts thymic T cell development at a fundamental level by reducing the TCR threshold and affecting the functional imprint of the thymic progeny. In summary, understanding the impact of NKG2D on thymic T cell development and TCR signaling contributes to our knowledge of immune system regulation, immune dysregulation, and the design of immunotherapies.

State Supplemental Nutrition Assistance Program Policies and Substance Use Rates.

INTRODUCTION: Food insecurity is associated with the development of substance misuse and use disorders (SUD). This study sought to estimate associations between state Supplemental Nutrition Assistance Program (SNAP) eligibility policies and substance-related outcomes. METHODS: 2014-2017 SNAP Policy Database and 2015-2019 National Survey on Drug Use and Health state-level estimates were used to estimate associations between state SNAP eligibility policies and alcohol use disorder (AUD), opioid misuse, illicit drug use disorder (IDUD), SUD, and needing but not receiving SUD treatment. State SNAP policies included those that (1) do not disqualify individuals with a felony drug conviction from SNAP and/or (2) expand SNAP eligibility by increasing the income limit or removing the asset test. Analyses were conducted January-May 2023. RESULTS: States that adopted both SNAP eligibility policies had reduced rates of AUD (adjusted rate ratio (aRR): 0.92; 95% CI 0.86, 0.99), opioid misuse (aRR: 0.94; 95% CI 0.89, 0.98), IDUD (aRR: 0.91; 95% CI 0.85, 0.98), SUD (aRR: 0.91; 95% CI 0.85, 0.97), and needing but not receiving SUD treatment (aRR: 0.92; 95% CI 0.87, 0.98) compared to states with neither policy. Among states that did not adopt increases to the income limit or removal of the asset test, those that removed the felony drug disqualification had lower rates of IDUD, SUD, and needing but not receiving SUD treatment, compared to those that maintained a disqualification. CONCLUSIONS: Expanded SNAP eligibility could help reduce rates of substance misuse and SUD. Opting out of the federal disqualification on SNAP participation for those with felony drug convictions may be particularly beneficial.

Association of Food Insecurity With Multiple Forms of Interpersonal and Self-Directed Violence: A Systematic Review.

Economic stress, broadly defined, is associated with an increased likelihood of multiple forms of violence. Food insecurity is a distinct economic stressor and material hardship that is amenable to programmatic and policy intervention. To inform intervention and identify gaps in the current evidence base, we conducted a systematic review to synthesize and critically evaluate the existing literature regarding the association between food insecurity and five forms of interpersonal and self-directed violence: intimate partner violence (IPV), suicidality, peer violence and bullying, youth dating violence, and child maltreatment, in high-income countries. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and searched six electronic databases from their start date through February of 2022. We included studies that examined food insecurity as the exposure and an outcome measure of IPV, suicide, suicidality, peer violence, bullying, youth dating violence, or child maltreatment; were peer-reviewed and published in English; reported quantitative data; and took place in a high-income country. We identified 20 relevant studies. Nineteen studies found that food insecurity was associated with an increased likelihood of these forms of violence. Results highlight the potential for programs and policies that address food insecurity to function as primary prevention strategies for multiple forms of violence and underscore the importance of trauma-informed approaches in organizations providing food assistance. Additional theory-driven research with validated measures of food insecurity and clearly established temporality between measures of food insecurity and violence is needed to strengthen the existing evidence base.

State expansion of supplemental nutrition assistance program eligibility and rates of interpersonal violence.

INTRODUCTION: Food insecurity is associated with an increased likelihood of interpersonal violence. The Supplemental Nutrition Assistance Program (SNAP) is the largest program addressing food insecurity in the U.S. States can eliminate the asset test and/or increase the income limit for SNAP eligibility, expanding the number of households receiving assistance. We examined the association of state elimination of the asset test and increases in the income limit with rates of interpersonal violence, including intimate partner violence (IPV), other relationship violence (violence by a parent, friend, etc.), and stranger violence. METHODS: We used data from the SNAP Policy Database and state-level estimates of rates of interpersonal violence per 1000 population ages ≥12 years from the 2012-2014 to 2016-2018 National Crime Victimization Survey. RESULTS: States that adopted both SNAP eligibility policies (eliminated the asset test and increased the income limit) had a lower rate of IPV (ß = -0.4, 95% CI -0.9, 0.0) and other relationship violence (ß = -2.4, 95% CI -3.8, -1.1) compared to states that did not adopt either policy. The rate of stranger violence (ß = -0.5, 95% CI -2.3, 1.4) did not differ for states that adopted both policies compared to states that did not adopt either policy. Rates of IPV (ß = -0.4, 95% CI -0.9, 0.2), other relationship violence (ß = -1.2, 95% CI -3.2, 0.7), and stranger violence (ß = -0.2, 95% CI -2.0, 1.6) did not differ for states that eliminated the asset test only compared to states that did not adopt either policy. CONCLUSION: Expanding SNAP eligibility may help prevent interpersonal violence at the population-level.

State expansion of Supplemental Nutrition Assistance Program eligibility and rates of foster care entries.

BACKGROUND: State expansion of Supplemental Nutrition Assistance Program (SNAP) eligibility under broad-based categorical eligibility (BBCE) is associated with decreases in household poverty and food insecurity, child protective services investigations, and mental health and substance use disorders among adults, key contributors to foster care entry. OBJECTIVE: To examine the association of state expansion of SNAP eligibility under BBCE with rates of foster care entries. PARTICIPANTS: Foster care entries among children ages <18 years. METHODS: We used 2005-2019 data from the SNAP Policy Database and the Adoption and Foster Care Analysis and Reporting System (AFCARS). We conducted difference-in-differences analyses and generated event study plots adjusting for state economic conditions (percent population unemployed, median household income) and policies (minimum wage, refundable Earned Income Tax Credits, maximum Temporary Assistance for Needy Families benefit for a family of 3). RESULTS: On average, there were 1.8 fewer foster care entries (95 % confidence interval (CI) -2.8, -0.8) per 1000 children per year in states that expanded SNAP eligibility than there would have been if they had not expanded eligibility. Average decreases in foster care entries were similar among young (-1.7 per 1000 children per year, 95 % -3.1, -0.3) and school-age (-1.8 per 1000 children per year, 95 % CI -2.7, -0.8) children and larger among Black non-Hispanic (-5.6 per 1000 children per year, 95 % CI -9.1, -2.0) than among White non-Hispanic (-1.4 per 1000 children per year, 95 % CI -2.2, -0.6) children. The magnitude of these decreases increased with greater time since policy adoption. CONCLUSIONS: Results add to growing evidence that programs and policies that support and stabilize household economic and material conditions may contribute to reductions in foster care entries at the population-level.

Evaluation of a prison violence prevention program: impacts on violent and non-violent prison infractions.

BACKGROUND: Individuals who commit acts of violence in prisons are often placed in highly controlled environments called restrictive housing (i.e., solitary confinement), which can have severe physical and mental health consequences and does not reduce violence. As such, North Carolina prisons have introduced the rehabilitative diversion unit (RDU) to reduce the use of restrictive housing and reduce violence in prison. METHODS: We evaluated the effect of the RDU on prison infractions. We compared rates of infractions by type (including violent infractions) among men enrolled in the RDU and men who were eligible for the RDU but placed in restrictive housing for control purposes (RHCP). We also evaluated sustained program impacts by comparing the hazard of first infraction among these same two groups of men after program completion, when they had returned to the general prison population. Finally, we compared the hazard of first promotion to a less restrictive custody level (medium custody) when these men had returned to the general prison population. RESULTS: The primary analytic cohort was made up of 3128 men contributing 897,822 person-days. Adjusted rates of violent infractions were lower in the RDU than in RHCP (adjusted rate ratio: 0.6; 95% CI: 0.4, 1.1). All other categories of infractions, including drug-related infractions, occurred at higher rates during RDU, as compared to RHCP. In analyses of sustained program impacts, for most categories of infractions, there were no differences in the hazard of first infraction post-RDU and post-RHCP. However, the hazard of violent infraction post-RDU was higher (adjusted hazard ratio: 2.1; 95% CI: 1.1, 4.0) than post-RHCP. The hazard of promotion to a less restrictive custody level was higher post-RDU (adjusted hazard ratio: 17.4; 95% CI: 7.2, 42.2) than post-RHCP. CONCLUSIONS: We found the RDU program may be effective in reducing violence for men enrolled in the program, but that these benefits were not sustained. Continued programming may be a useful tool to transition men from the programmatically intensive environment of the RDU to the general prison population. Additionally, we recommend the expansion of evidence-based treatment for substance use disorder.

Age, period and cohort-related trends in prescription opioid use in the USA, 1999-2018.

BACKGROUND: To provide insight into the longitudinal dynamics of opioid use throughout the overdose crisis, this study estimated the separate influences of age, period and cohort on prescription opioid use during 1999-2018 in the USA. METHODS: Data from 10 cycles of the cross-sectional National Health and Nutrition Examination Survey were used to conduct an age-period-cohort analysis of the prevalence of prescription opioid use (n=63 500 across 1999-2018). Temporal trends were graphically visualised. The median polish approach was used to estimate age, period and cohort-related effects on prescription opioid use. RESULTS: Prescription opioid use broadly increased across the lifespan, with steeper prevalence increases observed from young adulthood to mid-adulthood. Period-related variation was consistent with recognised nationwide declines in opioid prescribing. While there was no evidence of systematic cohort effects, compared with individuals born in 1951-1954, those born during 1963-1966 had greater prescription opioid use (prevalence ratio (PR)=1.23, 95% CI: 1.05 to 1.43), whereas the 1991-1994 and 1999-2002 cohorts had lower prescription opioid use (PR91-94=0.70, 95% CI: 0.50 to 0.98; PR99-02=0.72, 95% CI: 0.63 to 0.81). CONCLUSION: In the USA, longitudinal trends in prescription opioid use during 1999-2018 were predominantly driven by age and period influences. The cohort of youngest baby boomers experienced greater prescription opioid use, whereas recent-born cohorts have had lower use. As the overdose crisis continues evolving, such population-level characterisations of age, period and cohort dynamics are instrumental in understanding opioid use and can inform prevention and intervention approaches by identifying population groups more likely to use opioids who, thus, may also experience related outcomes.

Urine drug testing among Medicaid enrollees initiating buprenorphine treatment for opioid use disorder within 9 MODRN states.

BACKGROUND: Treatment guidelines recommend regular urine drug testing (UDT) for persons initiating buprenorphine for opioid use disorder (OUD). However, little is known about UDT utilization. We describe state variation in UDT utilization and examine demographic, health, and health care utilization factors associated with UDT in Medicaid. METHODS: We used Medicaid claims and enrollment data from persons initiating buprenorphine treatment for OUD during 2016-2019 in 9 states (DE, KY, MD, ME, MI, NC, PA, WI, WV). The main outcome was at least 1 UDT within 180 days of buprenorphine initiation, the secondary outcome was at least 3. Logistic regression models included demographics, pre-initiation comorbidities, and health service use. State estimates were pooled using meta-analysis. RESULTS: The study cohort included 162,437 Medicaid enrollees initiating buprenorphine. The percent receiving ≥1 UDT varied from 62.1% to 89.8% by state. In the pooled analysis, enrollees with pre-initiation UDT had much higher odds of ≥1 UDT after initiation (aOR=3.83, 3.09-4.73); odds were also higher for enrollees with HIV, HCV, and/or HBV infection (aOR=1.25, 1.05-1.48) or who initiated in later years (2018 v 2016: aOR=1.39, 1.03-1.89; 2019 v 2016: aOR=1.67, 1.24-2.25). The odds of having ≥3 UDT were lower with pre-initiation opioid overdose (aOR=0.79, 0.64-0.96) and higher with pre-initiation UDT (aOR=2.63, 2.13-3.25) or OUD care (aOR=1.35, 1.04-1.74). The direction of associations with demographics varied by state. CONCLUSIONS: Rates of UDT increased over time and there was variability among states in UDT rates and demographic predictors of UDT. Pre-initiation conditions, UDT, and OUD care were associated with UDT.

Characteristics of Outpatient and Residential Substance Use Disorder Treatment Facilities with a Tailored LGBT Program.

Lesbian, gay, bisexual, and transgender (LGBT) individuals have a high prevalence of substance use disorders (SUDs) and experience unique barriers to treatment. Little is known about the characteristics of SUD treatment facilities providing LGBT-tailored programs at the outpatient and residential levels of care. The purpose of this study is to examine the availability of LGBT-tailored programs in outpatient and residential SUD treatment facilities. Using the National Survey of Substance Abuse Treatment Services 2020, we conducted logistic regression to examine facility characteristics, including ownership, pay assistance, region, outreach, and telehealth services, associated with having an LGBT-tailored program among SUD treatment facilities. Outpatient facilities that were for-profit, had pay assistance, had community outreach services, and provided telemedicine/telehealth were more likely to have an LGBT-tailored program. Those that were government-owned, in the Midwest, and that accepted Medicaid were less likely to have an LGBT-tailored program. Residential facilities that were in the West, for-profit, and had community outreach services were more likely to have an LGBT-tailored program. This study offers a national examination of the availability of LGBT-tailored programs in SUD treatment facilities. Differences in availability based on ownership, region, pay assistance, and outreach highlight potential gaps in treatment availability.

Trends in Use of Medication to Treat Opioid Use Disorder During the COVID-19 Pandemic in 10 State Medicaid Programs.

Importance: Federal and state agencies granted temporary regulatory waivers to prevent disruptions in access to medication for opioid use disorder (MOUD) during the COVID-19 pandemic, including expanding access to telehealth for MOUD. Little is known about changes in MOUD receipt and initiation among Medicaid enrollees during the pandemic. Objectives: To examine changes in receipt of any MOUD, initiation of MOUD (in-person vs telehealth), and the proportion of days covered (PDC) with MOUD after initiation from before to after declaration of the COVID-19 public health emergency (PHE). Design, Setting, and Participants: This serial cross-sectional study included Medicaid enrollees aged 18 to 64 years in 10 states from May 2019 through December 2020. Analyses were conducted from January through March 2022. Exposures: Ten months before the COVID-19 PHE (May 2019 through February 2020) vs 10 months after the PHE was declared (March through December 2020). Main Outcomes and Measures: Primary outcomes included receipt of any MOUD and outpatient initiation of MOUD via prescriptions and office- or facility-based administrations. Secondary outcomes included in-person vs telehealth MOUD initiation and PDC with MOUD after initiation. Results: Among a total of 8 167 497 Medicaid enrollees before the PHE and 8 181 144 after the PHE, 58.6% were female in both periods and most enrollees were aged 21 to 34 years (40.1% before the PHE; 40.7% after the PHE). Monthly rates of MOUD initiation, representing 7% to 10% of all MOUD receipt, decreased immediately after the PHE primarily due to reductions in in-person initiations (from 231.3 per 100 000 enrollees in March 2020 to 171.8 per 100 000 enrollees in April 2020) that were partially offset by increases in telehealth initiations (from 5.6 per 100 000 enrollees in March 2020 to 21.1 per 100 000 enrollees in April 2020). Mean monthly PDC with MOUD in the 90 days after initiation decreased after the PHE (from 64.5% in March 2020 to 59.5% in September 2020). In adjusted analyses, there was no immediate change (odds ratio [OR], 1.01; 95% CI, 1.00-1.01) or change in the trend (OR, 1.00; 95% CI, 1.00-1.01) in the likelihood of receipt of any MOUD after the PHE compared with before the PHE. There was an immediate decrease in the likelihood of outpatient MOUD initiation (OR, 0.90; 95% CI, 0.85-0.96) and no change in the trend in the likelihood of outpatient MOUD initiation (OR, 0.99; 95% CI, 0.98-1.00) after the PHE compared with before the PHE. Conclusions and Relevance: In this cross-sectional study of Medicaid enrollees, the likelihood of receipt of any MOUD was stable from May 2019 through December 2020 despite concerns about potential COVID-19 pandemic-related disruptions in care. However, immediately after the PHE was declared, there was a reduction in overall MOUD initiations, including a reduction in in-person MOUD initiations that was only partially offset by increased use of telehealth.

STI Testing among Medicaid Enrollees Initiating PrEP for HIV Prevention in Six Southern States.

OBJECTIVES: The purpose of this study was to measure sexually transmitted infection (STI) testing among Medicaid enrollees initiating preexposure prophylaxis (PrEP) to prevent human immunodeficiency virus. Secondary data are in the form of Medicaid enrollment and claims data in six states in the US South. METHODS: Research partnerships in six states in the US South developed a distributed research network to accomplish study aims. Each state identified all first-time PrEP users in fiscal year 2017-2018 (combined N = 990) and measured the presence of STI testing for chlamydia, syphilis, and gonorrhea through 2019. Each state calculated the percentage of individuals with at least one STI test during 3-, 6-, and 12-month follow-up periods. RESULTS: The proportion of first-time PrEP users that received an STI test varied by state: 37% to 67% of all of the individuals in each state who initiated PrEP received a test within the first 6 months of PrEP treatment and 50% to 77% received a test within the first 12 months. CONCLUSIONS: Although the Centers for Disease Control and Prevention recommends STI testing at least every 6 months for PrEP users, our analysis of Medicaid data suggests that STI testing occurs less frequently than recommended in populations at elevated risk of syphilis, gonorrhea, and chlamydia.

Racial and ethnic differences and COVID-19 pandemic-related changes in drug overdose deaths in North Carolina.

PURPOSE: To examine racial and ethnic differences and COVID-19 pandemic-related changes in key characteristics of drug overdose deaths in North Carolina. METHODS: We used North Carolina State Unintentional Drug Overdose Reporting System data to describe specific drug-involvement, bystander presence, and naloxone administration for drug overdose deaths by race and ethnicity during pre-COVID-19 (May 2019-February 2020) and COVID-19 periods (March 2020-December 2020). RESULTS: For all racial and ethnic groups, drug overdose death rates and the percentage with fentanyl and alcohol involvement increased from the pre-COVID-19 to COVID-19 period, with fentanyl involvement highest among American Indian and Alaska Native (82.2%) and Hispanic (81.4%) individuals and alcohol involvement highest among Hispanic individuals (41.2%) during the COVID-19 period. Cocaine involvement remained high among Black non-Hispanic individuals (60.2%) and increased among American Indian and Alaska Native individuals (50.6%). There was an increase in the percentage of deaths with a bystander present from the pre-COVID-19 to COVID-19 period for all racial and ethnic groups, with more than half having a bystander present during the COVID-19 period. There was a decrease in the percentage of naloxone administered for most racial and ethnic groups, with the lowest percentage among Black non-Hispanic individuals (22.7%). CONCLUSIONS: Efforts to address increasing inequities in drug overdose deaths, including expanded community naloxone access, are needed.

Association of State Supplemental Nutrition Assistance Program Eligibility Policies With Adult Mental Health and Suicidality.

Importance: Food insecurity is associated with an increased likelihood of poor mental health and suicidality. The Supplemental Nutrition Assistance Program (SNAP) is the largest program addressing food insecurity in the US; under broad-based categorical eligibility (BBCE), states have the option to expand SNAP eligibility to a greater number of households by eliminating the asset test or increasing the income limit for eligibility. Objectives: To examine the association of state elimination of the asset test and increases in the income limit for SNAP eligibility with rates of mental health and suicidality outcomes among adults. Design, Setting, and Participants: This ecological cross-sectional study used 2014 to 2017 data on US adults from the National Vital Statistics System and 2015 to 2019 data on US adults from the National Survey on Drug Use and Health (NSDUH) State-Level Small Area Estimates. Analyses were conducted between September and November 2022. Exposures: State elimination of the asset test only and state adoption of both SNAP eligibility policies (ie, state elimination of the asset test and increases in the income limit) for 2014 to 2017 from the SNAP Policy Database. Main Outcomes and Measures: Number of adults with a past-year major depressive disorder, mental illness, serious mental illness, or suicidal ideation and number of adults who died by suicide. Results: Analyses included 407 391 adult NSDUH participants and 173 085 adults who died by suicide. State elimination of the asset test only was associated with decreased rates of past-year major depressive episodes (rate ratio [RR], 0.92; 95% CI, 0.87-0.98) and mental illness (RR, 0.91; 95% CI, 0.87-0.97) among adults. State adoption of both SNAP eligibility policies (ie, state elimination of the asset test and increases in the income limit) was associated with decreased rates of past-year major depressive episodes (RR, 0.92; 95% CI, 0.86-0.99), mental illness (RR, 0.92; 95% CI, 0.87-0.98), serious mental illness (RR, 0.91; 95% CI, 0.84-0.99), and suicidal ideation (RR, 0.89; 95% CI, 0.82-0.96). Results suggested a decreased rate of suicide death (RR, 0.93; 95% CI, 0.84-1.02) in states with both policies compared with states with neither policy, although this result was not statistically significant. Conclusions and Relevance: State adoption of policies that expand SNAP eligibility may contribute to decreased rates of multiple mental health and suicidality outcomes at the population level.

Use of residential opioid use disorder treatment among Medicaid enrollees in nine states.

INTRODUCTION: Residential treatment is a key component of the opioid use disorder care continuum, but research has not measured well the differences in its use across states at the enrollee level. METHODS: This cross-sectional observational study used Medicaid claims data from nine states to document the prevalence of residential treatment for opioid use disorder and to describe the characteristics of patients receiving care. For each patient characteristic, chi-square and t-tests tested for differences in the distribution between individuals who did and did not receive residential care. RESULTS: Among 491,071 Medicaid enrollees with opioid use disorder, 7.5 % were treated in residential facilities in 2019, though this number ranged widely (0.3-14.6 %) across states. Residential patients were more likely to be younger, non-Hispanic White, male, and living in an urban area. Although residential patients were less likely than those without residential care to be eligible for Medicaid through disability, diagnoses for comorbid conditions were more frequently observed among residential patients. CONCLUSIONS: Results from this large, multi-state study add context to the ongoing national conversation around opioid use disorder treatment and policy, providing a baseline for future work.