Impacts of State-Level Opioid Review Programs on Injured Workers and Their Health Care Providers: A Qualitative Study in Washington and Ohio.

Policy Points Workers' compensation agencies have instituted opioid review policies to reduce unsafe prescribing. Providers reported more limited and cautious prescribing than in the past; both patients and providers reported collaborative pain-management relationships and satisfactory pain control for patients. Despite the fears articulated by pharmaceutical companies and patient advocates, opioid review programs have not generally resulted in unmanaged pain or reduced function in patients, anger or resistance from patients or providers, or damage to patient-provider relationships or clinical autonomy. Other insurance providers with broad physician networks may want to consider similar quality-improvement efforts to support safe opioid prescribing. CONTEXT: Unsafe prescribing practices have been among the central causes of improper reception of opioids, unsafe use, and overdose in the United States. Workers' compensation agencies in Washington and Ohio have implemented opioid review programs (ORPs)-a form of quality improvement based on utilization review-to curb unsafe prescribing. Evidence suggests that such regulations indeed reduce unsafe prescribing, but pharmaceutical companies and patient advocates have raised concerns about negative impacts that could also result. This study explores whether three core sets of problems have actually come to pass: (1) unmanaged pain or reduced function among patients, (2) anger or resistance to ORPs from patients or providers, and (3) damage to patient-provider relationships or clinical autonomy. METHODS: In-depth semistructured interviews were conducted with 48 patients (21 from Washington, 27 from Ohio) and 32 providers (18 from Washington, 14 from Ohio) who were purposively sampled to represent a range of injury and practice types. Thematic coding was conducted with codebooks developed using both inductive and deductive approaches. FINDINGS: The consequences of opioid regulations have been generally positive: providers report more limited prescribing and a focus on multimodal pain control; patients report satisfactory pain control and recovery alongside collaborative relationships with providers. Participants attribute these patterns to a broad environment of opioid caution; they do not generally perceive workers' compensation policies as distinctly impactful. Both patients and providers comment frequently on the difficult aspects of interacting with workers' compensation agencies; effects of these range from simple inconvenience to delays in care, unmanaged pain, and reduced potential for physical recovery. CONCLUSIONS: In general, the three types of feared negative impacts have not come to pass for either patients or providers. Although interacting with workers' compensation agencies involves difficulties typical of interacting with other insurers, opioid controls seem to have generally positive effects and are generally perceived of favorably.

Development and maturation of the occupational health services research field in the United States over the past 25 years: Challenges and opportunities for the future.

Work is an important social determinant of health; unfortunately, work-related injuries remain prevalent, can have devastating impact on worker health, and can impose heavy economic burdens on workers and society. Occupational health services research (OHSR) underpins occupational health services policy and practice, focusing on health determinants, health services, healthcare delivery, and health systems affecting workers. The field of OHSR has undergone tremendous expansion in both definition and scope over the past 25 years. In this commentary, focusing on the US, we document the historical development and evolution of OHSR as a research field, describe current doctoral-level OHSR training, and discuss challenges and opportunities for the OHSR field. We also propose an updated definition for the OHSR field: Research and evaluation related to the determinants of worker health and well-being; to occupational injury and illness prevention and surveillance; to healthcare, health programs, and health policy affecting workers; and to the organization, access, quality, outcomes, and costs of occupational health services and related health systems. Researchers trained in OHSR are essential contributors to improvements in healthcare, health systems, and policy and programs to improve worker health and productivity, as well as equity and justice in job and employment conditions. We look forward to the continued growth of OHSR as a field and to the expansion of OHSR academic training opportunities.

Examining the Association of Billed Advance Care Planning With End-of-Life Hospital Admissions Among Advanced Cancer Patients in Hospice.

BACKGROUND: Advance care planning (ACP), or the consideration and communication of care preferences for the end-of-life (EOL), is a critical process for improving quality of care for patients with advanced cancer. The incorporation of billed service codes for ACP allows for new inquiries on the association between systematic ACP and improved EOL outcomes. OBJECTIVE: Using the IBM MarketScan® Database, we conducted a retrospective medical claims analysis for patients with an advanced cancer diagnosis and referral to hospice between January 2016 and December 2017. We evaluated the association between billed ACP services and EOL hospital admissions in the final 30 days of life. DESIGN: This is a cross-sectional retrospective cohort study. PARTICIPANTS: A total of 3,705 patients met the study criteria. MAIN MEASURES: ACP was measured via the presence of a billed ACP encounter (codes 99497 and 99498) prior to the last 30 days of life; hospital admissions included a dichotomous indicator for inpatient admission in the final 30 days of life. KEY RESULTS: Controlling for key covariates, patients who received billed ACP were less likely to experience inpatient hospital admissions in the final 30 days of life compared to those not receiving billed ACP (OR: 0.34; p < 0.001). CONCLUSION: The receipt of a billed ACP encounter is associated with reduced EOL hospital admissions in a population of patients with advanced cancer on hospice care. Strategies for consistent, anticipatory delivery of billable ACP services prior to hospice referral may prevent potentially undesired late-life hospital admissions.

Preventing Adolescent and Young Adult Suicide: Do States With Greater Mental Health Treatment Capacity Have Lower Suicide Rates?

PURPOSE: Youth suicide is increasing at a significant rate and is the second leading cause of death for adolescents. There is an urgent public health need to address the youth suicide. The objective of this study is to determine whether adolescents and young adults residing in states with greater mental health treatment capacity exhibited lower suicide rates than states with less treatment capacity. METHODS: We conducted a state-level analysis of mental health treatment capacity and suicide outcomes for adolescents and young adults aged 10-24 spanning 2002-2017 using data from Centers for Disease Control and Prevention, U.S. Bureau of Labor Statistics, Federal Bureau of Investigation, and other sources. Multivariable linear fixed-effects regression models tested the relationships among mental health treatment capacity and the total suicide, firearm suicide, and nonfirearm suicide rates per 100,000 persons aged 10-24. RESULTS: We found a statistically significant inverse relationship between nonfirearm suicide and mental health treatment capacity (p = .015). On average, a 10% increase in a state's mental health workforce capacity was associated with a 1.35% relative reduction in the nonfirearm suicide rate for persons aged 10-24. There was no significant relationship between mental health treatment capacity and firearm suicide. CONCLUSIONS: Greater mental health treatment appears to have a protective effect of modest magnitude against nonfirearm suicide among adolescents and young adults. Our findings underscore the importance of state-level efforts to improve mental health interventions and promote mental health awareness. However, firearm regulations may provide greater protective effects against this most lethal method of firearm suicide.

Changes in early high-risk opioid prescribing practices after policy interventions in Washington State.

OBJECTIVE: To test associations between several opioid prescribing policy interventions and changes in early (acute/subacute) high-risk opioid prescribing practices. DATA SOURCES: Population-based workers' compensation pharmacy billing and claims data, Washington State Department of Labor and Industries (January 2008-June 2015). STUDY DESIGN: We used interrupted time series analysis to test associations between three policy intervention timepoints and monthly proportions of population-based measures of high-risk, low-risk, and any workers' compensation-related opioid prescribing. We also tested associations between the policy intervention timepoints and five high-risk opioid prescribing indicators among workers prescribed any opioids within 3 months after injury: (a) >7 cumulative (not necessarily consecutive) days' supply of opioids during the acute phase, (b) high-dose opioids, (c) concurrent sedatives, (d) chronic opioids, and (e) a composite high-risk opioid prescribing indicator. PRINCIPAL FINDINGS: Within 3 months after injury, 9 percent of workers were exposed to high-risk and 12 percent to low-risk workers' compensation-related opioid prescribing; 79 percent filled no workers' compensation-related opioid prescription. Among workers prescribed any early (acute/subacute) opioids, the indicator for >7 days' supply of opioids during the acute phase was present for 30 percent, high-dose opioids for 18 percent, concurrent sedatives for 3 percent, and chronic opioids for 2 percent. Beyond a general shift toward more infrequent and lower-risk workers' compensation-related opioid prescribing, each policy intervention timepoint was significantly associated with reductions in specific acute/subacute high-risk opioid prescribing indicators; each of the four specific high-risk opioid prescribing indicators had significant reductions associated with at least one policy. CONCLUSIONS: Several state-level opioid prescribing policies were significantly associated with safer workers' compensation-related opioid prescribing practices during the first 3 months after injury (acute/subacute phase), which should in turn reduce transition to chronic opioids and associated negative health outcomes.

Early High-Risk Opioid Prescribing Practices and Long-Term Disability Among Injured Workers in Washington State, 2002 to 2013.

OBJECTIVE: To estimate associations between early high-risk opioid prescribing practices and long-term work-related disability. METHODS: Washington State Fund injured workers with at least one opioid prescription filled within 6 weeks after injury (2002 to 2013) were included (N = 83,150). Associations between early high-risk opioid prescribing (longer duration, higher dosage, concurrent sedatives), and time lost from work, total permanent disability, and a surrogate measure for Social Security disability benefits were tested. Measures of early hospitalization, body part, and nature of injury were included to address confounding by indication concerns, along with sensitivity analyses controlling for injury severity. RESULTS: In adjusted logistic models, early high-risk opioid prescribing was associated with roughly three times the odds of each outcome. CONCLUSION: Exposure to high-risk opioid prescribing within 90 days of injury was significantly and substantially associated with long-term temporary and permanent disability.

The Firearm Suicide Crisis: Physicians Can Make a Difference.

Firearm suicide receives relatively little public attention in the United States, however, the United States is in the midst of a firearm suicide crisis. Most suicides are completed using a firearm. The age-adjusted firearm suicide rate increased 22.6% from 2005 to 2017, and globally the US firearm suicide rate is 8 times higher than the average firearm suicide rate of 22 other developed countries. The debate over how to solve the firearm suicide epidemic tends to focus on reducing the firearm supply or increasing access to behavioral health treatment. Ineffectual federal firearm control policies and inadequate behavioral health treatment access has heightened the need for primary care physicians to play a more meaningful role in firearm suicide prevention. We offer suggestions for how individual physicians and the collective medical community can take action to reduce mortality arising from firearm suicide and firearm deaths.

Behavioral Health Care And Firearm Suicide: Do States With Greater Treatment Capacity Have Lower Suicide Rates?

Firearms account for most self-harm deaths, and many more Americans kill themselves with a firearm each year than are murdered with one. Mental illness is an important risk factor for firearm suicide. While the literature focuses on firearm safety, little is understood about how the supply of behavioral health treatment services can reduce firearm suicide. We evaluated whether states with greater behavioral health treatment capacity have lower firearm suicide rates, examining variation across the United States and over time. The mean adjusted firearm suicide rate rose from 6.74 per 100,000 people in 2005 to 7.89 per 100,000 in 2015-a 17.1 percent increase. We found a significant independent inverse relationship between greater behavioral health treatment capacity and the firearm suicide rate. We show that across all states, on average, a 10.0 percent relative increase in behavioral health workers per state was associated with a modest 1.2 percent relative reduction in the adjusted firearm suicide rate. Given this finding, we discuss whether firearm control initiatives might offer a greater protective effect for reducing firearm suicide, compared to the protective effect of increasing behavioral health treatment capacity.

Identifying Problematic Substance Use in a National Sample of Adolescents Using Frequency Questions.

BACKGROUND: Brief substance use screening questions for tobacco, alcohol, cannabis, and other drugs need further validation in adolescents. In particular, optimal age-specific screening cut-points are not known, and no study has been large enough to evaluate screening questions for noncannabis illicit drug use. METHODS: Adolescent respondents to an annual national household survey were included (2008 to 2014; n = 169,986). Days of tobacco use in the past month, and days of alcohol, cannabis, other illicit drug use in the past year, were assessed as brief screens for tobacco dependence and DSM-IV alcohol (AUD), cannabis (CUD), and other illicit drug use disorders (DUD). Areas under receiver operating characteristics curves (AUCs), sensitivity and specificity were estimated separately by age group (12-15-, 16-17-, and 18-20-year-olds) and cut-points that maximized combined values of sensitivity and specificity were considered optimal. RESULTS: The prevalence of tobacco dependence, AUD, CUD, and DUD was 5.8%, 7.1%, 4.5%, and 2.0%, respectively. AUCs ranged 0.84 to 0.99. The optimal cut-points for screening for tobacco dependence and DUDs was the same for all age groups: ≥1 day. The optimal cut-points for alcohol and cannabis varied by age: ≥3 days for 12-15-year-olds and ≥12 days for older adolescents. CONCLUSIONS: Brief measures of past-year use, or past-month use for tobacco, accurately identified adolescents with problematic substance use. However, health systems should use age-specific screening cut-points for alcohol and cannabis to optimize screening performance.

Effectiveness of Medicare cost-sharing elimination for Cancer screening on utilization.

BACKGROUND: The Patient Protection and Affordable Care Act (ACA) eliminated the cost-sharing requirement for several preventive cancer screenings. This study examined the cancer screening utilization of mammogram, Pap smear and colonoscopy in Medicare fee-for-service (FFS) under the ACA. METHODS: The primary data were the 2007-2013 Medicare Current Beneficiary Survey linked to FFS claims. The effect of the cost-sharing removal on the probability of receiving a preventive cancer screening test was estimated using a logistic regression, separately for each screening test, adjusting for the complex survey design. The model was also separately estimated for different socioeconomic and race/ethnic groups. The study sample included beneficiaries with Part B coverage for the entire calendar year, excluding beneficiaries in Medicaid or Medicare Advantage plans. Beneficiaries with a claims-documented or self-reported history of targeted cancers, who were likely to have diagnostic tests or have surveillance screenings were excluded. The screening measures were constructed separately following Medicare coverage and U.S. Preventive Services Task Force (USPSTF) recommendations. We measured the screening utilization outcome drawing from claims data, as well as using the self-reported survey data. RESULTS: After the cost-sharing removal policy, we found no statistically significant difference in a beneficiary's probability of receiving a colonoscopy (transition period: OR = 1.08, 95% CI = 0.90-1.29; post-policy period: OR = 1.08, 95% CI = 0.83-1.42), a mammogram (transition period: OR = 1.03, 95% CI = 0.91-1.17; post-policy period: OR = 1.07, 95% CI = 0.88-1.30), or a biennial Pap smear (transition period: OR = 0.87, 95% CI = 0.69-1.09; post-policy period: OR = 0.72, 95% CI = 0.51-1.03) in claims-based measures following Medicare coverage. Similarly, we found null effects of the policy change on utilization of colonoscopy among enrollees 50-75 years old, biennial mammograms by women 50-74, and triennial Pap smear tests among women 21-65 in claims-based measures according to USPSTF. The findings from survey-based measures were consistent with the estimates from claims-based measures, except that the use of Pap smear declined since 2011. Further, the policy change did not increase utilization in patients with disadvantaged socioeconomic characteristics. Yet the disparate patterns in adjusted screening rates by socioeconomic status and race/ethnicity persisted over time. CONCLUSIONS: Removing out-of-pocket costs for screenings did not provide enough incentives to increase the screening rates among Medicare beneficiaries.

The Impact of Advance Care Planning on End-of-Life Care: Do the Type and Timing Make a Difference for Patients With Advanced Cancer Referred to Hospice?

PURPOSE: This study aimed to determine the impact of advanced care planning (ACP) on potentially avoidable hospital admissions at the end of life (EOL) among a sample of hospice-referred patients with cancer, in order to present actionable considerations for the practicing clinician. METHODS: This study was designed as a retrospective cohort using electronic health record data that assessed likelihood of hospital admissions in the last 30 days of life for 1185 patients with a primary diagnosis of cancer, referred to hospice between January 1, 2014, and December 31, 2015, at a large academic medical center. Inverse probability treatment weighting based on calculated propensity scores balanced measured covariates between those with and without ACP at baseline. Odds ratios (ORs) were calculated from estimated potential outcome means for the impact of ACP on admissions in the last 30 days of life. RESULTS: A verified do-not-resuscitate (DNR) order prior to the last 30 days of life was associated with reduced odds of admission compared to those without a DNR (OR = 0.30; P < .001). An ACP note in the problem list prior to the last 30 days of life was associated with reduced odds of admission compared to those without an ACP note (OR = 0.71, P = .042), and further reduced odds if done 6 months prior to death (OR = 0.35, P < .001). CONCLUSIONS: This study shows that dedicated ACP documentation is associated with fewer admissions in the last 30 days of life for patients with advanced cancer referred to hospice. Improving ACP processes prior to hospice referral holds promise for reducing EOL admissions.

Examining Age Inequalities in Operationalized Components of Advance Care Planning: Truncation of the ACP Process With Age.

CONTEXT: Opportunities for patients to receive unnecessary, costly, and potentially harmful care near the end of life abound. Advance care planning (ACP) can help to make this vulnerable period better for patients, caregivers, and providers. OBJECTIVE: The objective of this study was to determine whether older age predicted the presence of certain forms of retrievable ACP documentation in the electronic health record (EHR) in a large sample of hospice-referred patients. METHODS: This was a retrospective analysis of medical-record data on 3595 patients referred to hospice between January 1, 2013 and December 31, 2015. EHR documentation of an ACP note in the problem list, presence of a scanned advance directive, and the presence of a verified do-not-resuscitate order were the outcome measures. Logistic regression was used to assess the effect of age, education, race, gender, cancer diagnosis, dementia diagnosis, palliative encounter, and death on the outcome variables. RESULTS: Our results suggest that when we control for prognosis, patients over age 70 years may experience gaps in ACP communication. We found that as patients age, the odds of having documentation of a conversation (odds ratio [OR] = 0.56; P < 0.001) or scanned advance directive decreased (OR = 0.63; P < 0.001), while the odds of having a verified do-not-resuscitate order increased (OR = 1.42; P < 0.001). CONCLUSION: The results of this study may imply some degree of unilateral and physician-driven decision making for end-of-life care among older adults. Collaborative efforts between an interdisciplinary medical team should focus on developing policies to address this potential disparity between younger and older adults at the end of life.

Brief report: Population-based reversal of the adverse impact of opioids on disability in Washington State workers' compensation.

BACKGROUND: Evidence has associated opioid use initiated early in a workers' compensation claim with subsequent disability. In 2013, the Washington State Department of Labor and Industries (DLI) implemented procedures based on new regulations that require improvement in pain and function to approve opioids beyond the acute pain period. METHODS: We measured opioid prescriptions between 6 and 12 weeks following injury, an indicator of persistent opioid use. Actuarial data for the association of any opioid use versus no opioid use with development of lost time payments are reported. RESULTS: Prior authorization with hard stops led to a sustained drop in persistent opioid use, from nearly 5% in 2013 to less than 1% in 2017. This reduction was also associated with reversal of the increased lost work time patterns seen from 1999 to 2010. CONCLUSIONS: Prior authorization targeted at preventing transition to chronic opioid use can prevent and reverse adverse time loss development that has occurred on a population basis concomitant with the opioid epidemic.

Innovations in Occupational Health Care Delivery Can Prevent Entry into Permanent Disability: 8-Year Follow-up of the Washington State Centers for Occupational Health and Education.

BACKGROUND: Long-term work disability is known to have an adverse effect on the nation's labor force participation rate. To reduce long-term work disability, the Washington State Department of Labor and Industries established a quality improvement initiative that created 2 pilot Centers of Occupational Health and Education (COHE). OBJECTIVES: To document the level of work disability in a sample of injured workers with musculoskeletal injuries and to examine (8-y) work disability outcomes associated with the COHE health care model. RESEARCH DESIGN: Prospective nonrandomized intervention study with nonequivalent comparison group using difference-in-difference regression models. SUBJECTS: Intervention group represents 18,790 workers with musculoskeletal injuries treated by COHE providers. Comparison group represents 20,992 workers with similar injuries treated within the COHE catchment area by non-COHE providers. MEASURES: Long-term disability outcomes include: (1) on disability 5 years after injury; (2) received a state pension for total permanent disability; (3) received total disability income support through the Social Security Disability Insurance program; or (4) a combined measure including any one of the 3 prior measures. RESULTS: COHE patients had a 30% reduction in the risk of experiencing long-term work disability (odds ratio=0.70, P=0.02). The disability rate (disability days per 1000 persons) over the 8-year follow-up for the intervention and comparison groups, respectively, was 49,476 disability days and 75,832 disability days. CONCLUSIONS: Preventing long-term work disability is possible by reorganizing the delivery of occupational health care to support effective secondary prevention in the first 3 months following injury. Such interventions may have promising beneficial effects on reversing the nation's progressively worsening labor force participation rate.

Mental Health and Substance Use Care Among Young Adults Before and After Affordable Care Act (ACA) Implementation: A Rural and Urban Comparison.

PURPOSE: Rural young adults experience greater unmet need for mental health (MH) and alcohol or drug (AOD) treatment and lower health insurance coverage than urban residents. It is unknown whether Affordable Care Act (ACA) reforms in 2010 (dependent coverage extended to age 26) or 2014 (Medicaid expansion) closed rural/urban gaps in insurance and treatment. The present study compared changes in rates of health insurance, MH treatment, and AOD treatment for rural and urban young adults over a period of ACA reforms. METHODS: Young adult participants (18-25 years) in the National Survey on Drug Use and Health (2008-2014) with past-year psychological distress or AOD abuse were included. Difference-in-differences logistic regression models estimated rural/urban differences in insurance, MH, and AOD treatment pre- versus post-ACA reforms. Analyses adjusted for gender, race, marital status, and health status. RESULTS: Among 39,482 young adults with psychological distress or AOD, adjusted insurance rates increased from 72.0% to 81.9% (2008-2014), but a significant rural/urban difference (5.1%) remained in 2014 (P < .05). Among young adults with psychological distress (n = 23,470), MH treatment rates increased following 2010 reforms from 30.2% to 33.0%, but gains did not continue through 2014. Differences in MH treatment over time did not vary by rural/urban status and there were no significant changes in AOD treatment for either group. CONCLUSIONS: Although rates of insurance increased for all young adults, a significant rural/urban difference persisted in 2014. Meaningful increases in MH and AOD treatment may require targeted efforts to reduce noninsurance barriers to treatment.

Trends in Opioid Dosing Among Washington State Medicaid Patients Before and After Opioid Dosing Guideline Implementation.

UNLABELLED: By 2007, opioid-related mortality in Washington state (WA) was 50% higher than the national average, with Medicaid patients showing nearly 6 times the mortality of commercially-insured patients. In 2007, the WA Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain was released, which recommended caution in prescribing >120 mg morphine-equivalent dose per day for patients not showing clinically meaningful improvement in pain and function. We report on opioid dosing in the WA Medicaid fee-for-service population for 273,200 adults with a paid claim for an opioid prescription between April 1, 2006 and December 31, 2010. Linear regression was used to test for trends in dosing over that time period, with quarter-year as the independent variable and median daily dose as the dependent variable. Prescription opioid use among WA Medicaid adults peaked in 2009, as evidenced by the unique number of opioid users (105,232), the total number of prescriptions (556,712), and the total person-years of prescription opioid use (29,442). Median opioid dose was unchanged from 2006 to 2010 at 37.5 mg morphine-equivalent dose, but doses at the 75th, 90th, 95th, and 99th percentiles declined significantly (P < .001). These results suggest that opioid treatment guidelines with dosing guidance may be able to reduce high-dose opioid use without affecting the median dose used. PERSPECTIVE: Some fear that opioid dosing guidelines might restrict access to opioid therapy for patients who could benefit. However, there is evidence that high-dose opioid therapy entails significant risks without demonstrated benefit. These findings indicate that high-dose opioid therapy can be reduced without altering median opioid dose in a Medicaid population.

Expanding vocational retraining options for injured workers: An experiment in worker choice.

BACKGROUND: An innovative self-directed vocational retraining alternative (Option 2) has been offered to eligible Washington State injured workers since 2008. OBJECTIVE: We aimed to describe: (1) how frequently Option 2 was selected and by whom, (2) the extent to which Option 2 workers used their reserved retraining funds, and (3) how worker satisfaction and employment outcomes for Option 2 workers compared with those of workers undergoing traditional vocational retraining. METHODS: Five-year cohort study involving workers' compensation data, state wage files, and two worker surveys. RESULTS: Fewer than 25% of Option 2 workers used their retraining funds. Retraining fund use was associated with better employment outcomes. Workers who were older, whose preferred language was not English, or who had lower pre-injury wages or less education, were least likely to use Option 2 retraining funds. Many workers chose Option 2 because they thought the approved traditional retraining plan was not a good fit for them. CONCLUSIONS: Self-directed retraining may benefit workers who have the ability, resources, and motivation to independently identify and complete retraining. Additional efforts may be needed to ensure that traditional retraining plans are well-suited to workers' circumstances, and to identify and remove barriers to use of reserved retraining funds.

Opioid poisonings in Washington State Medicaid: trends, dosing, and guidelines.

BACKGROUND: Opioid poisonings have increased as use of prescription opioid medications have increased. To reduce these poisonings, guidelines for chronic opioid use have been implemented. However, if opioid poisonings occur in individuals who do not have high prescribed doses and who are not chronic opioid users, the current guidelines may need revision. OBJECTIVES: To examine changes in rates of methadone and other opioid poisonings after implementation of the WA State Opioid Guideline in 2007 and to examine the prescription history before poisonings. METHODS: The study sample consisted of individuals who had at least 1 paid claim for an opioid prescription in the Medicaid fee-for-service system between April 2006 and December 2010 and had an emergency department or inpatient hospital claim for an opioid poisoning. RESULTS: Methadone poisonings occurred at 10 times the rate of other prescription opioid poisonings and increased between 2006 and 2010. Rates of other prescription opioid poisonings appeared to level off after implementation of the WA opioid guideline in 2007. Among individuals with nonmethadone opioid poisonings, only 44% had chronic opioid use, 17% had prescribed doses in the week before the poisoning >120 mg/d morphine-equivalent dose (MED), 28% had doses <50 mg/d MED, and 48% had concurrent sedative prescriptions. CONCLUSIONS: It may be prudent to revise guidelines to address opioid poisonings occurring at relatively low prescribed doses and with acute and intermittent opioid use. Research is needed to establish the best strategies to prevent opioid poisonings.

Does time pressure create barriers for people to receive preventive health services?

OBJECTIVE: Regular use of recommended preventive health services can promote good health and prevent disease. However, individuals may forgo obtaining preventive care when they are busy with competing activities and commitments. This study examined whether time pressure related to work obligations creates barriers to obtaining needed preventive health services. METHODS: Data from the 2002-2010 Medical Expenditure Panel Survey (MEPS) were used to measure the work hours of 61,034 employees (including 27,910 females) and their use of five preventive health services (flu vaccinations, routine check-ups, dental check-ups, mammograms and Pap smear). Multivariable logistic regression analyses were performed to test the association between working hours and use of each of those five services. RESULTS: Individuals working long hours (>60 per week) were significantly less likely to obtain dental check-ups (OR=0.81, 95% CI: 0.72-0.91) and mammograms (OR=0.47, 95% CI: 0.31-0.73). Working 51-60 h weekly was associated with less likelihood of receiving Pap smear (OR=0.67, 95% CI: 0.46-0.96). No association was found for flu vaccination. CONCLUSIONS: Time pressure from work might create barriers for people to receive particular preventive health services, such as breast cancer screening, cervical cancer screening and dental check-ups. Health practitioners should be aware of this particular source of barriers to care.