Methadone dosing at New York State opioid treatment programs following initial revisions to federal regulations.

INTRODUCTION: In March 2020, a temporary federal regulatory exemption for opioid treatment programs (OTPs) was issued, allowing for a greater number of take-home methadone doses than was previously permitted. In the same month, to address financial sustainability, New York State (NYS) Medicaid also transitioned to a bundle reimbursement methodology for OTPs. We examined methadone dosing schedules in NYS before and after these regulatory and financing changes. METHODS: We conducted a retrospective cohort study using NYS OTP patient data from two sources: the client data system for a baseline period (February 2020) and survey data collected after regulatory and financing changes (May 2020 to August 2021, 64 weekly surveys). We compared methadone dosing schedules over time using chi-square tests and Poisson regression. RESULT: At baseline, data were available for 78% (n=77/99) of OTPs including 90.9% (n=26,225/28,839) of their enrolled patients. During the survey period, 99 OTPs completed 93.1% (n=5901/6336) of weekly surveys, with a mean statewide weekly patient census of 38,904 (SD=1214.5). Between February and May 2020, daily dosing significantly decreased from 55.4% to 16.3% of patients (-39.1 percentage points [95%CI: -39.8 to -38.4]), although it significantly increased subsequently (3.33%/4-weeks [95%CI: 3.28, 3.39]). In addition, weekly-to-monthly dosing significantly increased from 26.9% to 54.5% of patients (27.6 percentage points [95%CI: 26.9, 28.4]), although it significantly decreased subsequently (-1.19%/4-weeks [95%CI: -1.23, -1.15]). DISCUSSION: Despite large initial changes, we found a trend toward gradual return to more restrictive dosing schedules. OTPs need further support in leveraging new opportunities to improve methadone treatment and outcomes.

Examining Pre-Release Interventions on HIV Outcomes 12 Months After Release from Louisiana State Corrections.

Louisiana has the highest proportion of people living with HIV (PLWH) in state prison custody. Linkage to care programs minimize odds of HIV care drop-off after release. Louisiana has two pre-release linkage to HIV care programs, one implemented through Louisiana Medicaid and another through the Office of Public Health. We conducted a retrospective cohort study of PLWH released from Louisiana corrections from January 1, 2017 to December 31, 2019. We compared HIV care continuum outcomes within 12 months after release between intervention groups (received any vs. no intervention) using two proportion z-tests and multivariable logistic regression. Of 681 people, 389 (57.1%) were not released from a state prison facility and thus not eligible to receive interventions, 252 (37%) received any intervention, and 228 (33.5%) achieved viral suppression. Linkage to care within 30 days was significantly higher in people who received any intervention (v. no intervention, p = .0142). Receiving any intervention was associated with higher odds of attaining all continuum steps, though only significantly for linkage to care (AOR = 1.592, p = .0083). We also found differences in outcomes by sex, race, age, urbanicity of the return parish (county), and Medicaid enrollment between intervention groups. Receiving any intervention increased the odds of achieving HIV care outcomes, and was significantly impactful at improving care linkage. Interventions must be improved to enhance long-term post-release HIV care continuity and eliminate disparities in care outcomes.

Health services use among formerly incarcerated Louisiana Medicaid members within one year of release.

OBJECTIVES: To determine the association between enrollment in Medicaid prior to release compared with post-release, and the use of health services and time to the first service use after release among Louisiana Medicaid members within one year of release from Louisiana state corrections custody. METHODS: We conducted a retrospective cohort study linking Louisiana Medicaid and Louisiana state corrections release data. We included individuals ages 19 to 64 years released from state custody between January 1, 2017 and June 30, 2019 and enrolled in Medicaid within 180 days of release. Outcome measures included receipt of general health services (primary care visits, emergency department visits, and hospitalizations), cancer screenings, specialty behavioral health services, and prescription medications. To determine the association between pre-release Medicaid enrollment and time to receipt of health services, multivariable regression models were used which accounted for significant differences in characteristics between the groups. RESULTS: Overall, 13283 individuals met eligibility criteria and 78.8% (n = 10473) of the population was enrolled in Medicaid pre-release. Compared with those enrolled in Medicaid prior to release, those enrolled post-release were more likely to have an emergency department visit (59.6% versus 57.5%, p = 0.04) and hospitalization (17.9% versus 15.9%, p = 0.01) and less likely to receive outpatient mental health services (12.3% versus 15.2%, p<0.001) and prescription drugs. Compared with those enrolled in Medicaid prior to release, those enrolled post-release had a significantly longer time to receiving many services including a primary care visit (adjusted mean difference: 42.2 days [95% CI: 37.9 to 46.5; p<0.001]), outpatient mental health services (42.8 days [95% CI: 31.3 to 54.4; p<0.001]), outpatient substance use disorder service (20.6 days [95% CI: 2.0 to 39.2; p = 0.03]), and medication for opioid use disorder (40.4 days [95% CI: 23.7 to 57.1; p<0.001]) as well as inhaled bronchodilators and corticosteroids (63.8 days [95% CI: 49.3 to 78.3, p<0.001]), antipsychotics (62.9 days [95% CI: 50.8 to 75.1; p<0.001]), antihypertensives (60.5 days [95% CI: 50.7 to 70.3; p<0.001]), and antidepressants (52.3 days [95% CI: 44.1 to 60.5; p<0.001]). CONCLUSION: Compared with Medicaid enrollment post-release, pre-release Medicaid enrollment was associated with higher proportions of, and faster access to, a wide variety of health services. Regardless of enrollment status, we found prolonged times between release and receipt of time-sensitive behavioral health services and prescription medications.

Characteristics and health service use of Medicaid-insured individuals filling naloxone under a standing order in Louisiana.

BACKGROUND: Naloxone distribution is a key intervention to reduce opioid overdose deaths. On January 23, 2017, Louisiana implemented a standing order that permits pharmacies to dispense naloxone to patients without a patient-specific prescription. OBJECTIVES: To examine the characteristics and health service use of Louisiana Medicaid members filling naloxone under the standing order. METHODS: We conducted a retrospective cohort study of Louisiana Medicaid members from January 23, 2017 to December 31, 2019. We extracted fee-for-service claims and managed care encounters for naloxone dispensed under the standing order. RESULTS: Overall, there were 2053 naloxone fills by 1912 unique individuals. The total number of naloxone fills increased from 22 in 2017 to 1218 in 2019. Most members (n = 1,586, 83.0%) received any type of health service and 20.4% (n = 391) received an opioid-related health service in the 30 days prior to filling naloxone. Additionally, 12.7% (n = 242) of members had received medication for opioid use disorder (MOUD), and 42.6% (n = 815) filled a prescription opioid analgesic within the 60 days prior to filling naloxone. Nineteen members (1.0%) had an emergency department visit for overdose within 90 days after filling naloxone. CONCLUSION: Standing orders play an important role in providing access to naloxone, even among Medicaid members who had recent encounters with health care providers. We identified multiple opportunities to improve naloxone prescribing among providers caring for Medicaid-insured people who use opioids, including prescribers of opioid analgesics or MOUD.

Reducing Opioid Analgesic Prescribing in Dentistry Through Prescribing Defaults: A Cluster-Randomized Controlled Trial.

OBJECTIVE: To determine the effect of a uniform, reduced, default dispense quantity for new opioid analgesic prescriptions on the quantity of opioids prescribed in dentistry practices. METHODS: We conducted a cluster-randomized controlled trial within a health system in the Bronx, NY, USA. We randomly assigned three dentistry sites to a 10-tablet default, a 5-tablet default, or no change (control). The primary outcome was the quantity of opioid analgesics prescribed in the new prescription. Secondary outcomes were opioid analgesic reorders and health service utilization within 30 days after the new prescription. We analyzed outcomes from 6 months before implementation through 18 months after implementation. RESULTS: Overall, 6,309 patients received a new prescription. Compared with the control site, patients at the 10-tablet-default site had a significantly larger change in prescriptions for 10 tablets or fewer (38.7 percentage points; confidence interval [CI]: 11.5 to 66.0), lower number of tablets prescribed (-3.3 tablets; CI: -5.9 to -0.7), and lower morphine milligram equivalents (MME) prescribed (-14.1 MME; CI: -27.8 to -0.4), which persisted in the 30 days after the new prescription despite a higher percentage of reorders (3.3 percentage points; CI: 0.2 to 6.4). Compared with the control site, patients at the 5-tablet-default site did not have a significant difference in any outcomes except for a significantly higher percentage of reorders (2.6 percentage points; CI: 0.2 to 4.9). CONCLUSIONS: Our findings further support the efficacy of strategies that lower default dispense quantities, although they indicate that caution is warranted in the selection of the default. TRIAL REGISTRATION: ClinicalTrials.org ID: NCT03030469.

A Policy Approach to Reducing Low-Value Device-Based Procedure Use.

Policy Points Low-value care is common in clinical practice, leading to patient harm and wasted spending. Much of this low-value care stems from the use of medical device-based procedures. We describe here a novel academic-policymaker collaboration in which evidence-based clinical coverage for device-based procedures is implemented through prior authorization-based policies for Louisiana's Medicaid beneficiary population. This process involves eight steps: 1) identifying low-value medical device-based procedures based on clinical evidence review, 2) quantifying utilization and reimbursement, 3) reviewing clinical coverage policies to identify opportunities to align coverage with evidence, 4) using a low-value device selection index, 5) developing an evidence synthesis and policy proposal, 6) stakeholder engagement and input, 7) policy implementation, and 8) policy evaluation. This strategy holds significant potential to reduce low-value device-based care.

U.S. state policies on opioid prescribing during the peak of the prescription opioid crisis: Associations with opioid overdose mortality.

BACKGROUND: In response to the opioid overdose crisis in the United States, many states implemented policies to guide opioid prescribing, but their impact on overdose mortality (prescription and non-prescription) remains poorly understood. We examined the impact of U.S. state opioid-prescribing policies on opioid overdose mortality following implementation. METHODS: We calculated opioid overdose mortality rates from 1999-2016 by U.S. state using the CDC WONDER database, overall and separately for overdose deaths from prescription and non-prescription opioids. For each state, policies active on 1/1/2014 were reviewed for the presence and strength of six provisions recommending judicious opioid prescribing practices; "strong" provisions used the words "should," "shall," or "must". Interrupted time series (ITS) tested the association of each strong provision with overdose mortality, overall and separately for prescription and non-prescription opioids, in the two years following implementation. Sensitivity analyses compared between states, used time-lagged analyses, and excluded synthetic opioids from non-prescription opioid deaths. RESULTS: All six provisions had consistent direction of effect in ITS and sensitivity analyses. Strong provisions for prescriber training and limits on opioid dose reduced the slope of overall and prescription opioid overdose mortality in both ITS and sensitivity analyses. Reduced non-prescription opioid overdose mortality was only associated with strong provision for prescriber training. Some provisions had a negative impact. In ITS, strong provision for prescriber response to misuse increased the slope of non-prescription opioid overdose mortality. Strong provision for mandatory prescription drug monitoring program use had no relationship with overdose mortality in ITS and was associated with increased overall, prescription and non-prescription opioid overdose mortality in between-state sensitivity analysis. CONCLUSION: Opioid prescribing policies in U.S. states at the peak of the prescription opioid epidemic had modest mortality benefit, and did not reduce non-prescription opioid overdose mortality. A strong provision for prescriber training was the only provision associated with reduced prescription and non-prescription opioid overdose mortality. These findings can inform future efforts addressing prescription drug epidemics.

Mixed Method Evaluation of Louisiana's Prerelease Medicaid Enrollment Program, 2017-2019.

BACKGROUND: Over 600,000 people leave US prisons annually. Many are eligible for Medicaid upon release but may need support to enroll. Carceral facilities in nearly half of states have implemented systems to facilitate Medicaid access for those leaving incarceration, but there is limited information on program implementation models or outcomes. OBJECTIVES: To evaluate implementation and initial outcomes of Louisiana's prison-based Prerelease Medicaid Enrollment Program. METHODS: In this mixed-methods study, we assessed enrollment in Louisiana Medicaid at time of release from prison in the 2 years (2017-2018) after Program implementation, as well as reasons for Medicaid closure (ie, loss of coverage) and health services use 6 months postrelease. In May-June 2019, we conducted interviews statewide with program implementers (n=16) and focus groups in New Orleans, Louisiana with formerly incarcerated Program participants (n=16). RESULTS: A total of 4476 people were included in the quantitative analysis. There was a 34.3 (95% confidence interval: 20.7-47.9) percentage point increase in Medicaid enrollment upon release. Nearly all (98.6%) attended at least 1 outpatient visit and almost half (46.7%) had 1 emergency department visit within 6 months of release. Not responding to information requests was the most common reason for Medicaid closure. Program implementers and formerly incarcerated participants identified Program strengths, barriers, and suggestions for improvement. CONCLUSIONS: The program was successful in rapidly increasing Medicaid enrollment at the time of prison release and facilitating the use of health care services.

Effect of Changing Electronic Health Record Opioid Analgesic Dispense Quantity Defaults on the Quantity Prescribed: A Cluster Randomized Clinical Trial.

Importance: Interventions to improve judicious prescribing of opioid analgesics for acute pain are needed owing to the risks of diversion, misuse, and overdose. Objective: To assess the effect of modifying opioid analgesic prescribing defaults in the electronic health record (EHR) on prescribing and health service use. Design, Setting, and Participants: A cluster randomized clinical trial with 2 parallel arms was conducted between June 13, 2016, and June 13, 2018, in a large urban health care system comprising 32 primary care and 4 emergency department (ED) sites in the Bronx, New York. Data were analyzed using a difference-in-differences method from 6 months before implementation through 18 months after implementation. Data were analyzed from January 2019 to February 2020. Interventions: A default dispense quantity for new opioid analgesic prescriptions of 10 tablets (intervention) vs no change (control) in the EHR. Main Outcomes and Measures: The primary outcome was the quantity of opioid analgesics prescribed with the new default prescription. Secondary outcomes were opioid analgesic reorders and health service use within 30 days after the new prescription. Intention-to-treat analysis was conducted. Results: Overall, 21 331 patients received a new opioid analgesic prescription from 490 prescribers. Comparing the intervention and control arms, site, prescriber, and patient characteristics were similar. For the new prescription, compared with the control arm, patients in the intervention arm had significantly more prescriptions for 10 tablets or fewer (7.6 percentage points; 95% CI, 6.1-9.2 percentage points), a lower number of tablets prescribed (-2.1 tablets; 95% CI, -3.3 to -0.9 tablets), and lower morphine milligram equivalents (MME) prescribed (-14.6 MME; 95% CI, -22.6 to -6.6 MME). Within 30 days after the new prescription, significant differences remained in the number of tablets prescribed (-2.7 tablets; 95% CI, -4.8 to -0.6 tablets), but not MME (-15.8 MME; 95% CI, -33.8 to 2.2 MME). Within this 30-day period, there were no significant differences between the arms in health service use. Conclusions and Relevance: In this study, implementation of a uniform reduced default dispense quantity of 10 tablets for opioid analgesic prescriptions led to a modest reduction in the quantity prescribed initially, without significantly increasing health service use. However, during 30 days after implementation, the influence on prescribing was mixed. Reducing EHR default dispense quantities for opioid analgesics is a feasible strategy that can be widely disseminated and may modestly reduce prescribing. Trial Registration: ClinicalTrials.gov Identifier: NCT03003832.

The role of stigma in U.S. primary care physicians' treatment of opioid use disorder.

OBJECTIVES: To characterize primary care physicians' (PCPs) attitudes and beliefs about people with opioid use disorder (OUD) and to understand the association between PCPs' stigmatizing attitudes and their OUD treatment practices, beliefs about treatment effectiveness, and support for policies designed to improve access to OUD medications. METHODS: We conducted a national postal survey of U.S. PCPs from January to August 2019. Survey items measured respondents' attitudes, beliefs, and current treatment practices. Data were analyzed using descriptive statistics and logistic regression. RESULTS: Of the original 1000 PCPs in the survey sample, 668 were deemed eligible to participate in the study. The survey was completed by 361 PCPs for an adjusted response rate of 54 %. PCPs reported high levels of stigmatizing attitudes. Less than 30 % of PCPs reported that they were willing to have a person taking medication for OUD as a neighbor or marry into their family, even if that person was being treated with medication. Greater stigma was associated with an 11 percentage point lower likelihood that PCPs prescribed OUD medication and lower support for policies intended to increase access to OUD medication. CONCLUSIONS: Addressing OUD stigma among PCPs is a public health priority in addressing the ongoing opioid crisis.

Medical Marijuana and Opioids (MEMO) Study: protocol of a longitudinal cohort study to examine if medical cannabis reduces opioid use among adults with chronic pain.

INTRODUCTION: In the USA, opioid analgesic use and overdoses have increased dramatically. One rapidly expanding strategy to manage chronic pain in the context of this epidemic is medical cannabis. Cannabis has analgesic effects, but it also has potential adverse effects. Further, its impact on opioid analgesic use is not well studied. Managing pain in people living with HIV is particularly challenging, given the high prevalence of opioid analgesic and cannabis use. This study's overarching goal is to understand how medical cannabis use affects opioid analgesic use, with attention to Δ9-tetrahydrocannabinol and cannabidiol content, HIV outcomes and adverse events. METHODS AND ANALYSES: We are conducting a cohort study of 250 adults with and without HIV infection with (a) severe or chronic pain, (b) current opioid use and (c) who are newly certified for medical cannabis in New York. Over 18 months, we collect data via in-person visits every 3 months and web-based questionnaires every 2 weeks. Data sources include: questionnaires; medical, pharmacy and Prescription Monitoring Program records; urine and blood samples; and physical function tests. Using marginal structural models and comparisons within participants' 2-week time periods (unit of analysis), we will examine how medical cannabis use (primary exposure) affects (1) opioid analgesic use (primary outcome), (2) HIV outcomes (HIV viral load, CD4 count, antiretroviral adherence, HIV risk behaviours) and (3) adverse events (cannabis use disorder, illicit drug use, diversion, overdose/deaths, accidents/injuries, acute care utilisation). ETHICS AND DISSEMINATION: This study is approved by the Montefiore Medical Center/Albert Einstein College of Medicine institutional review board. Findings will be disseminated through conferences, peer-reviewed publications and meetings with medical cannabis stakeholders. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT03268551); Pre-results.

Comparing perspectives on medication treatment for opioid use disorder between national samples of primary care trainee physicians and attending physicians.

BACKGROUND: Most people with opioid use disorder (OUD) are not treated with FDA-approved medications methadone, buprenorphine, or naltrexone. Expanding capacity for evidence-based OUD medication in primary care is a national priority. No studies have examined primary care trainee physicians' attitudes about these medications. This study surveyed a national sample of primary care trainee physicians and compared their views with those of primary care attending physicians (i.e., those who have completed training). METHODS: Random samples of 1,000 trainee physicians and 1,000 attending physicians specializing in family, internal, or general medicine were selected from the American Medical Association Masterfile. Surveys were mailed February-August 2019. 45 % of eligible trainee physicians and 54 % of eligible attending physicians responded. Chi-square tests were used to compare responses between the groups. RESULTS: Trainee physicians were more likely than attending physicians to agree that treating OUD with medication is more effective than treatment without medication (76 % versus 67 %, p = 0.03). Half of trainee physicians (51 %) expressed interest in treating patients with OUD compared to 20 % of attending physicians. Trainee physicians expressed greater support than attending physicians for policies that loosen restrictions on prescribing OUD medications. CONCLUSIONS: Relative to attending physicians, the emerging cohort of primary care physicians may be more receptive to working with patients with OUD and prescribing medication. Enhancing medical training on OUD and its treatment, exposing clinicians to individuals in recovery from OUD, and increasing support for clinicians that provide medication treatment for OUD may strengthen this group's capacity to respond to the opioid crisis.

Abstinence-reinforcing contingency management improves HIV viral load suppression among HIV-infected people who use drugs: A randomized controlled trial.

BACKGROUND: HIV-infected people who use drugs (PWUD) have poor HIV outcomes. Few studies tested interventions to improve HIV outcomes among PWUD. Abstinence-reinforcing contingency management (CM) reduces drug use and could also improve HIV outcomes. METHODS: From 2012-2017, we conducted a randomized controlled trial testing whether a 16-week abstinence-reinforcing CM intervention improved HIV viral load (VL) among HIV-infected adults using opioids or cocaine. In the CM intervention, drug-free urines led to escalating value of vouchers ($2.50-$80/voucher, $1320 total maximum). In intention-to-treat mixed-effects linear and logistic regression analyses, we examined whether the CM intervention improved log10 VL (primary outcome), abstinence and antiretroviral adherence (secondary outcomes). RESULTS: Thirty-seven participants were randomized to the CM intervention and 36 to control. Median age was 49.2 years; most were male (61.6%) and non-Hispanic black (46.6%). In CM (vs. control) participants, mean reduction in log10 VL was greater (-0.16 log10 VL copies/mL per 4-week period; 95% CI: -0.29 to -0.03, p < 0.05). Over 16 weeks, CM participants had a mean reduction of 0.64 copies/mL in log10 VL greater than control participants. The CM intervention was not significantly associated with abstinence or adherence. CONCLUSIONS: This is the first study to demonstrate improvements in HIV VL via an abstinence-reinforcing CM intervention. Because the CM intervention did not significantly affect abstinence or adherence, the mechanism of its effect is unclear. To end the HIV epidemic, innovative strategies must address individuals with poor HIV outcomes. Abstinence-reinforcing CM may be one potential strategy to improve HIV outcomes among a select group of PWUD.

How do state Medicaid programs determine what substance use disorder treatment medications need prior authorization? An overview for clinicians.

The process by which state Medicaid programs develop their preferred drug lists, and determine which medications require prior authorization, is opaque to many clinicians. This process is a synthesis of cost and clinical information. For cost, the federal Medicaid Drug Rebate Program establishes mandatory rebates that pharmaceutical manufacturers must pay state Medicaid programs. In addition, state Medicaid programs may also negotiate supplemental rebates whereby, in exchange for a preferred position on the preferred drug list, manufacturers pay an additional rebate. These supplemental rebates are most important in therapeutic classes with multiple brand competitors (e.g., medication treatments for opioid use disorder). For clinical information, state Medicaid programs convene pharmaceutical and therapeutics committees, drug utilization review boards, or both, composed of a variety of stakeholders such as practicing clinicians. Cost factors such as federal rebate calculations and supplemental rebate negotiations may lead to counterintuitive preferred drug lists, for example, a state Medicaid program requiring prior authorization for a generic medication but not for its brand equivalent (e.g., buprenorphine/naloxone products). Because of states' reliance on rebates, mandates to remove prior authorization may have the unintended consequence of increasing costs significantly through the loss of rebate negotiating power. In the face of high and rising medication costs, state Medicaid programs are also implementing innovative policy approaches to maintain access and control costs, such as targeted rebate negotiation and value-based pricing. Through participation in state Medicaid program clinical advisory committees, individual clinicians can have a powerful voice. Interested clinicians should consider joining to inform policy and help ensure their patients' needs are met.

Racial Inequities in Preventable Pregnancy-Related Deaths in Louisiana, 2011-2016.

OBJECTIVE: To examine preventable pregnancy-related deaths in Louisiana by race and ethnicity and maternal level of care to inform quality improvement efforts. METHODS: We conducted a retrospective observational descriptive analysis of Louisiana Pregnancy-Associated Mortality Review data of 47 confirmed pregnancy-related deaths occurring from 2011 to 2016. The review team determined cause of death, preventability, and contributing factors. We compared preventability by race-ethnicity and maternal level of care of the facility where death occurred (from level I: basic care to level IV: regional perinatal health center) using odds ratios (ORs) and 95% CIs. RESULTS: The rate of pregnancy-related death among non-Hispanic black women (22.7/100,000 births, 95% CI 15.5-32.1, n=32/140,785) was 4.1 times the rate among non-Hispanic white women (5.6/100,000, 95% CI 2.8-10.0, n=11/197,630). Hemorrhage (n=8/47, 17%) and cardiomyopathy (n=8/47, 17%) were the most common causes of pregnancy-related death. Among non-Hispanic black women who experienced pregnancy-related death, 59% [n=19] of deaths were deemed potentially preventable, compared with 9% (n=1) among non-Hispanic white women (OR 14.6, 95% CI 1.7-128.4). Of 47 confirmed pregnancy-related deaths, 58% (n=27) occurred at level III or IV birth facilities. Compared with those at level I or II birth facilities (n=2/4, 50%), pregnancy-related deaths occurring at level III or IV birth facilities (n=14/27, 52%) were not less likely to be categorized as preventable (OR 2.0, 95% CI 0.5-8.0). CONCLUSION: Compared with non-Hispanic white women, pregnancy-related deaths that occurred among non-Hispanic black women in Louisiana from 2011 to 2016 were more likely to be preventable. The proportion of deaths that were preventable was similar between lower and higher level birth facilities. Hospital-based quality improvement efforts focused on addressing hemorrhage, hypertension, and associated racial inequities may prevent pregnancy-related deaths in Louisiana.

Interventions for incarcerated adults with opioid use disorder in the United States: A systematic review with a focus on social determinants of health.

Incarceration poses significant health risks for people involved in the criminal justice system. As the world's leader in incarceration, the United States incarcerated population is at higher risk for infectious diseases, mental illness, and substance use disorder. Previous studies indicate that the mortality rate for people coming out of prison is almost 13 times higher than that of the general population; opioids contribute to nearly 1 in 8 post-release fatalities overall, and almost half of all overdose deaths. Given the hazardous intersection of incarceration, opioid use disorder, and social determinants of health, we systematically reviewed recent evidence on interventions for opioid use disorder (OUD) implemented as part of United States criminal justice system involvement, with an emphasis on social determinants of health (SDOH). We searched academic literature to identify eligible studies of an intervention for OUD that was implemented in the context of criminal justice system involvement (e.g., incarceration or parole/probation) for adults ages 19 and older. From 6,604 citations, 13 publications were included in final synthesis. Most interventions were implemented in prisons (n = 6 interventions), used medication interventions (n = 10), and did not include SDOH as part of the study design (n = 8). Interventions that initiated medication treatment early and throughout incarceration had significant, positive effects on opioid use outcomes. Evidence supports medication treatment administered throughout the period of criminal justice involvement as an effective method of improving post-release outcomes in individuals with criminal justice involvement. While few studies included SDOH components, many investigators recognized SDOH needs as competing priorities among justice-involved individuals. This review suggests an evidence gap; evidence-based interventions that address OUD and SDOH in the context of criminal justice involvement are urgently needed.

Primary care engagement is associated with increased pharmacotherapy prescribing for alcohol use disorder (AUD).

BACKGROUND: Primary care provider skills such as screening, longitudinal monitoring, and medication management are generalizable to prescribing alcohol use disorder (AUD) pharmacotherapy. The association between primary care engagement (i.e., longitudinal utilization of primary care services) and prescribing of AUD pharmacotherapy is unknown. METHODS: We examined a 5-year (2010-2014) retrospective cohort of patients with AUD, 18 years and older, at an urban academic medical center in the Bronx, NY, USA. Our main exposure was level of primary care engagement (no primary care, limited primary care, and engaged with primary care) and our outcome was any AUD pharmacotherapy prescription within 2 years of AUD diagnosis. Using multivariable logistic regression, we examined the association between primary care engagement and pharmacotherapy prescribing, accounting for demographic and clinical factors. RESULTS: Of 21,159 adults (28.9% female) with AUD, 2.1% (n = 449) were prescribed pharmacotherapy. After adjusting for confounders, the probability of receiving an AUD pharmacotherapy prescription for patients with no primary care was 1.61% (95% CI 1.39, 1.84). The probability of AUD pharmacotherapy prescribing was 2.56% (95% CI 2.06, 3.06) for patients with limited primary care and 2.89% (95% CI 2.44, 3.34%) for patients engaged with primary care. CONCLUSIONS: The percentage of AUD patients prescribed AUD pharmacotherapy was low; however, primary care engagement was associated with a higher, but modest, probability of receiving a prescription. Efforts to increase primary care engagement among patients with AUD may translate into increased AUD pharmacotherapy prescribing; however, strategies to increase prescribing across health care settings are needed.

Early outcomes after implementation of treat all in Rwanda: an interrupted time series study.

INTRODUCTION: Nearly all countries in sub-Saharan Africa have adopted policies to provide antiretroviral therapy (ART) to all persons living with HIV (Treat All), though HIV care outcomes of these programmes are not well-described. We estimated changes in ART initiation and retention in care following Treat All implementation in Rwanda in July 2016. METHODS: We conducted an interrupted time series analysis of adults enrolling in HIV care at ten Rwandan health centres from July 2014 to September 2017. Using segmented linear regression, we assessed changes in levels and trends of 30-day ART initiation and six-month retention in care before and after Treat All implementation. We compared modelled outcomes with counterfactual estimates calculated by extrapolating baseline trends. Modified Poisson regression models identified predictors of outcomes among patients enrolling after Treat All implementation. RESULTS: Among 2885 patients, 1803 (62.5%) enrolled in care before and 1082 (37.5%) after Treat All implementation. Immediately after Treat All implementation, there was a 31.3 percentage point increase in the predicted probability of 30-day ART initiation (95% CI 15.5, 47.2), with a subsequent increase of 1.1 percentage points per month (95% CI 0.1, 2.1). At the end of the study period, 30-day ART initiation was 47.8 percentage points (95% CI 8.1, 87.8) above what would have been expected under the pre-Treat All trend. For six-month retention, neither the immediate change nor monthly trend after Treat All were statistically significant. While 30-day ART initiation and six-month retention were less likely among patients 15 to 24 versus >24 years, the predicted probability of both outcomes increased significantly for younger patients in each month after Treat All implementation. CONCLUSIONS: Implementation of Treat All in Rwanda was associated with a substantial increase in timely ART initiation without negatively impacting care retention. These early findings support Treat All as a strategy to help achieve global HIV targets.