RESUMO
Importance: Transitions in insurance coverage may be associated with worse health care outcomes. Little is known about insurance stability for individuals with opioid use disorder (OUD). Objective: To examine insurance transitions among adults with newly diagnosed OUD in the 12 months after diagnosis. Design, Setting, and Participants: Longitudinal cohort study using data from the Massachusetts Public Health Data Warehouse. The cohort includes adults aged 18 to 63 years diagnosed with incident OUD between July 1, 2014, and December 31, 2014, who were enrolled in commercial insurance or Medicaid at diagnosis; individuals diagnosed after 2014 were excluded from the main analyses due to changes in the reporting of insurance claims. Data were analyzed from November 10, 2022, to May 6, 2024. Exposure: Insurance type at time of diagnosis (commercial and Medicaid). Main Outcomes and Measures: The primary outcome was the cumulative incidence of insurance transitions in the 12 months after diagnosis. Logistic regression models were used to generate estimated probabilities of insurance transitions by insurance type and diagnosis for several characteristics including age, race and ethnicity, and whether an individual started medication for OUD (MOUD) within 30 days after diagnosis. Results: There were 20â¯768 individuals with newly diagnosed OUD between July 1, 2014, and December 31, 2014. Most individuals with newly diagnosed OUD were covered by Medicaid (75.4%). Those with newly diagnosed OUD were primarily male (67% in commercial insurance, 61.8% in Medicaid). In the 12 months following OUD diagnosis, 30.4% of individuals experienced an insurance transition, with adjusted models demonstrating higher transition rates among those starting with Medicaid (31.3%; 95% CI, 30.5%-32.0%) compared with commercial insurance (27.9%; 95% CI, 26.6%-29.1%). The probability of insurance transitions was generally higher for younger individuals than older individuals irrespective of insurance type, although there were notable differences by race and ethnicity. Conclusions and Relevance: This study found that nearly 1 in 3 individuals experience insurance transitions in the 12 months after OUD diagnosis. Insurance transitions may represent an important yet underrecognized factor in OUD treatment outcomes.
Assuntos
Cobertura do Seguro , Seguro Saúde , Medicaid , Transtornos Relacionados ao Uso de Opioides , Humanos , Adulto , Masculino , Feminino , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Pessoa de Meia-Idade , Cobertura do Seguro/estatística & dados numéricos , Estudos Longitudinais , Estados Unidos/epidemiologia , Adolescente , Massachusetts/epidemiologia , Medicaid/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Adulto JovemRESUMO
Importance: Serious injection-related infections (SIRIs) cause significant morbidity and mortality. Medication for opioid use disorder (MOUD) improves outcomes but is underused. Understanding MOUD treatment after SIRIs could inform interventions to close this gap. Objectives: To examine rehospitalization, death rates, and MOUD receipt for individuals with SIRIs and to assess characteristics associated with MOUD receipt. Design, Setting, and Participants: This retrospective cohort study used the Massachusetts Public Health Data Warehouse, which included all individuals with a claim in the All-Payer Claims Database and is linked to individual-level data from multiple government agencies, to assess individuals aged 18 to 64 years with opioid use disorder and hospitalization for endocarditis, osteomyelitis, epidural abscess, septic arthritis, or bloodstream infection (ie, SIRI) between July 1, 2014, and December 31, 2019. Data analysis was performed from November 2021 to May 2023. Exposure: Demographic and clinical factors potentially associated with posthospitalization MOUD receipt. Main Outcomes and Measures: The main outcome was MOUD receipt measured weekly in the 12 months after hospitalization. We used zero-inflated negative binomial regression to examine characteristics associated with any MOUD receipt and rates of treatment in the 12 months after hospitalization. Secondary outcomes were receipt of any buprenorphine formulation, methadone, and extended-release naltrexone examined individually. Results: Among 8769 individuals (mean [SD] age, 43.2 [12.0] years; 5066 [57.8%] male) who survived a SIRI hospitalization, 4305 (49.1%) received MOUD, 5919 (67.5%) were rehospitalized, and 973 (11.1%) died within 12 months. Of those treated with MOUD in the 12 months after hospitalization, the mean (SD) number of MOUD initiations during follow-up was 3.0 (1.7), with 956 of 4305 individuals (22.2%) receiving treatment at least 80% of the time. MOUD treatment after SIRI hospitalization was significantly associated with MOUD in the prior 6 months (buprenorphine: adjusted odds ratio [AOR], 16.51; 95% CI, 13.81-19.74; methadone: AOR, 28.46; 95% CI, 22.41-36.14; or naltrexone: AOR, 2.05; 95% CI, 1.56-2.69). Prior buprenorphine (incident rate ratio [IRR], 1.17; 95% CI, 1.11-1.24) or methadone (IRR, 1.89; 95% CI, 1.79-2.01) use was associated with higher treatment rates after hospitalization, and prior naltrexone use (IRR, 0.86; 95% CI, 0.77-0.95) was associated with lower rates. Conclusions and Relevance: This study found that in the year after a SIRI hospitalization in Massachusetts, mortality and rehospitalization were common, and only half of patients received MOUD. Treatment with MOUD before a SIRI was associated with posthospitalization MOUD initiation and time receiving MOUD. Efforts are needed to initiate MOUD treatment during SIRI hospitalizations and subsequently retain patients in treatment.
Assuntos
Transtornos Relacionados ao Uso de Opioides , Humanos , Massachusetts/epidemiologia , Masculino , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Feminino , Adulto , Estudos Retrospectivos , Pessoa de Meia-Idade , Buprenorfina/uso terapêutico , Tratamento de Substituição de Opiáceos/estatística & dados numéricos , Abuso de Substâncias por Via Intravenosa/complicações , Abuso de Substâncias por Via Intravenosa/epidemiologia , Metadona/uso terapêutico , Adolescente , Adulto Jovem , Readmissão do Paciente/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Naltrexona/uso terapêuticoRESUMO
BACKGROUND: Little is known about how use patterns of medications for opioid use disorder (MOUDs) evolve from pre-incarceration to post-incarceration among incarcerated individuals with opioid use disorder. This article describes pre- and post-incarceration MOUD receipt during a period when naltrexone was the only type of MOUD offered in a state prison system, the Massachusetts Department of Correction (MADOC). METHODS: A retrospective cohort study of individuals with opioid use disorder who had an incarceration episode in MADOC during January 2015 to March 2019. The data source was the Massachusetts Public Health Data Warehouse, a multi-sector data platform that links individual-level data from multiple statewide datasets. We described patterns of MOUD receipt during the four weeks prior to and after an incarceration episode. Multivariable logistic regression models characterized predictors of post-incarceration MOUD receipt. RESULTS: In the male sample (n=691 incarcerations), from the pre- to post-incarceration periods, receipt of buprenorphine increased (14.3 % to 18.3 %), naltrexone increased (5.0 % to 10.5 %), and methadone decreased (4.7 % to 1.7 %). Similarly, in the female sample (n=892 incarcerations), from the pre- to post-incarceration periods, receipt of buprenorphine increased (10.3 % to 12.3 %, naltrexone increased (4.5 % to 9.3 %), and methadone decreased (5.0 % to 2.9 %). Much of the post-release naltrexone receipt occurred among participants in MADOC's pre-release naltrexone program. CONCLUSIONS: MOUD receipt was low but increased slightly in the post-incarceration period. This change was driven by increases in buprenorphine and naltrexone and despite decreases in methadone.
RESUMO
Medications for opioid use disorder (MOUD) increase retention in care and decrease mortality during active treatment; however, information about the comparative effectiveness of different forms of MOUD is sparse. Observational comparative effectiveness studies are subject to many types of bias; a robust framework to minimize bias would improve the quality of comparative effectiveness evidence. This paper discusses the use of target trial emulation as a framework to conduct comparative effectiveness studies of MOUD with administrative data. Using examples from our planned research project comparing buprenorphine-naloxone and extended-release naltrexone with respect to the rates of MOUD discontinuation, we provide a primer on the challenges and approaches to employing target trial emulation in the study of MOUD.
Assuntos
Combinação Buprenorfina e Naloxona , Pesquisa Comparativa da Efetividade , Naltrexona , Antagonistas de Entorpecentes , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides , Humanos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Antagonistas de Entorpecentes/uso terapêutico , Combinação Buprenorfina e Naloxona/uso terapêutico , Naltrexona/uso terapêutico , Tratamento de Substituição de Opiáceos/métodos , Buprenorfina/uso terapêutico , Estudos Observacionais como Assunto , Preparações de Ação Retardada , Projetos de Pesquisa , Naloxona/uso terapêuticoRESUMO
BACKGROUND: Post-overdose outreach programs engage overdose survivors and their families soon after an overdose event. Staff implementing these programs are routinely exposed to others' trauma, which makes them vulnerable to secondary traumatic stress (STS) and compassion fatigue. The purpose of this study was to explore experiences of STS and associated upstream and downstream risk and protective factors among program staff. METHODS: We conducted a post-hoc analysis of semi-structured interviews with post-overdose outreach program staff in Massachusetts. Transcripts were analyzed using a multi-step hybrid inductive-deductive approach to explore approaches and responses to outreach work, factors that might give rise to STS, and compassion fatigue resilience. Findings were organized according to the three main constructs within Ludick and Figley's compassion fatigue resilience model (empathy, secondary traumatic stress, and compassion fatigue resilience). RESULTS: Thirty-eight interviews were conducted with staff from 11 post-overdose outreach programs in Massachusetts. Within the empathy construct, concern for others' well-being emerged as a motivator to engage in post-overdose outreach work - with staff trying to understand others' perspectives and using this connection to deliver respectful and compassionate services. Within the secondary traumatic stress construct, interviewees described regular and repeated exposure to others' trauma - made more difficult when exposures overlapped with staff members' personal social spheres. Within the compassion fatigue resilience construct, interviewees described the presence and absence of self-care practices and routines, social supports, and workplace supports. Job satisfaction and emotional detachment from work experiences also arose as potential protective factors. Interviewees reported inconsistent presence and utilization of formal support for STS and compassion fatigue within their post-overdose outreach teams. CONCLUSION: Post-overdose outreach program staff may experience secondary traumatic stress and may develop compassion fatigue, particularly in the absence of resilience and coping strategies and support. Compassion fatigue resilience approaches for post-overdose outreach staff warrant further development and study.
Assuntos
Fadiga de Compaixão , Overdose de Drogas , Recursos Humanos de Enfermagem Hospitalar , Resiliência Psicológica , Humanos , Fadiga de Compaixão/psicologia , Recursos Humanos de Enfermagem Hospitalar/psicologia , Empatia , Massachusetts , Inquéritos e Questionários , Qualidade de VidaRESUMO
Importance: Agonist medications for opioid use disorder (MOUD), buprenorphine and methadone, in carceral settings might reduce the risk of postrelease opioid overdose but are uncommonly offered. In April 2019, the Massachusetts Department of Correction (MADOC), the state prison system, provided buprenorphine for incarcerated individuals in addition to previously offered injectable naltrexone. Objective: To evaluate postrelease outcomes after buprenorphine implementation. Design, Setting, and Participants: This cohort study with interrupted time-series analysis used linked data across multiple statewide data sets in the Massachusetts Public Health Data Warehouse stratified by sex due to differences in carceral systems. Eligible participants were individuals sentenced and released from a MADOC facility to the community. The study period for the male sample was January 2014 to November 2020; for the female sample, January 2015 to October 2019. Data were analyzed between February 2022 and January 2024. Exposure: April 2019 implementation of buprenorphine during incarceration. Main Outcomes and Measures: Receipt of MOUD within 4 weeks after release, opioid overdose, and all-cause mortality within 8 weeks after release, each measured as a percentage of monthly releases who experienced the outcome. Segmented linear regression analyzed changes in outcome rates after implementation. Results: A total of 15â¯225 individuals were included. In the male sample there were 14â¯582 releases among 12â¯688 individuals (mean [SD] age, 35.0 [10.8] years; 133 Asian and Pacific Islander [0.9%], 4079 Black [28.0%], 4208 Hispanic [28.9%], 6117 White [41.9%]), a rate of 175.7 releases per month; the female sample included 3269 releases among 2537 individuals (mean [SD] age, 34.9 [9.8] years; 328 Black [10.0%], 225 Hispanic [6.9%], 2545 White [77.9%]), a rate of 56.4 releases per month. Among male participants at 20 months postimplementation, the monthly rate of postrelease buprenorphine receipt was higher than would have been expected under baseline trends (21.2% vs 10.6% of monthly releases; 18.6 additional releases per month). Naltrexone receipt was lower than expected (1.0% vs 6.0%; 8.8 fewer releases per month). Monthly rates of methadone receipt (1.4%) and opioid overdose (1.8%) were not significantly different than expected. All-cause mortality was lower than expected (1.9% vs 2.8%; 1.5 fewer deaths per month). Among female participants at 7 months postimplementation, buprenorphine receipt was higher than expected (31.6% vs 9.5%; 12.4 additional releases per month). Naltrexone receipt was lower than expected (3.4% vs 7.2%) but not statistically significantly different. Monthly rates of methadone receipt (1.1%), opioid overdose (4.8%), and all-cause mortality (1.6%) were not significantly different than expected. Conclusions and Relevance: In this cohort study of state prison releases, postrelease buprenorphine receipt increased and naltrexone receipt decreased after buprenorphine became available during incarceration.
Assuntos
Buprenorfina , Overdose de Opiáceos , Transtornos Relacionados ao Uso de Opioides , Feminino , Masculino , Humanos , Adulto , Prisões , Naltrexona , Estudos de Coortes , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Metadona/uso terapêutico , Buprenorfina/uso terapêuticoRESUMO
BACKGROUND: Public health-public safety partnerships for post-overdose outreach have emerged in many communities to prevent future overdose events. These efforts often identify overdose survivors through emergency call data and seek to link them with relevant services. The aim of this study was to describe how post-overdose outreach programs in Massachusetts manage the confidentiality of identifiable information and privacy of survivors. METHODS: In 2019, 138 Massachusetts programs completed surveys eliciting responses to questions about program operations. Descriptive statistics were calculated from the closed-ended survey responses. Thirty-eight interviews were conducted among outreach staff members during 2019-2020. Interview transcripts and open-ended survey responses were thematically analyzed using deductive and inductive approaches. RESULTS: Of programs that completed the survey, 90 % (n = 124/138) reported acting to protect the privacy of survivors following overdose events, and 84 % (n = 114/135) reported implementing a protocol to maintain the confidentiality of personal information. Interviews with outreach team members indicated substantial variation in practice. Outreach programs regularly employed discretion in determining actions in the field, sometimes undermining survivor privacy and confidentiality (e.g., by disclosing the overdose event to family members). Programs aiming to prioritize privacy and confidentiality attempted to make initial contact with survivors by phone, limited or concealed materials left behind when no one was home, and/or limited the number of contact attempts. CONCLUSIONS: Despite the establishment of privacy and confidentiality protocols within most post-overdose outreach programs, application of these procedures was varied, discretionary, and at times viewed by staff as competing with engagement efforts. Individual outreach overdose teams should prioritize privacy and confidentiality during outreach to protect overdose survivors from undesired exposure. In addition to individual program changes, access to overdose survivor information could be changed across all programs to bolster privacy and confidentiality protocols. For example, transitioning the management of overdose-related information to non-law enforcement agencies would limit officers' ability to disseminate such information at their discretion.
Assuntos
Overdose de Drogas , Privacidade , Humanos , Confidencialidade , Overdose de Drogas/prevenção & controle , Massachusetts , FamíliaRESUMO
BACKGROUND: Post-overdose outreach programs have proliferated in response to opioid overdose. Implementing these programs is associated with reductions in overdose rates, but the role of specific program characteristics in overdose trends has not been evaluated. METHODS: Among 58 Massachusetts municipalities with post-overdose outreach programs, we examined associations between five domains of post-overdose outreach program characteristics (outreach contact rate, naloxone distribution, coercive practices, harm reduction activities, and social service provision or referral) and rates of fatal opioid overdoses and opioid-related emergency medical system responses (i.e., ambulance activations) per calendar quarter from 2013 to 2019 using segmented regression analyses with adjustment for municipal covariates and fixed effects. For both outcomes, each domain was modeled: a) individually, b) with other characteristics, and c) with other characteristics and municipal-level fixed effects. RESULTS: There were no significant associations (p < 0.05) between outreach contact rate, naloxone distribution, coercive practices, or harm reduction activities with municipal fatal overdose trends. Municipalities with programs providing or referring to more social services experienced 21% fewer fatal overdoses compared to programs providing or referring to more social services (Rate Ratio (RR) 0.79, 95% Confidence Interval (CI) 0.66-0.93, p = 0.01). Compared to municipalities in quarters when programs had no outreach contacts, municipalities with some, but less than the median outreach contacts, experienced 14% lower opioid-related emergency responses (RR 0.86, 95% CI 0.78-0.96, p = 0.01). Associations between naloxone distribution, coercive practices, harm reduction practices, or social services and opioid-related emergency responses were not consistently significant across modeling approaches. CONCLUSION: Municipalities with post-overdose outreach programs providing or referring to more social services had lower fatal opioid overdose rates. Municipalities in quarters when programs outreached to overdose survivors had fewer opioid-related emergency responses, but only among programs with below the median number of outreach contacts. Social service linkage should be core to post-overdose programs. Evaluations should assess program characteristics to optimize program design.
RESUMO
OBJECTIVE: Accurate naloxone distribution data are critical for planning and prevention purposes, yet sources of naloxone dispensing data vary by location, and completeness of local datasets is unknown. We sought to compare available datasets in Massachusetts, Rhode Island, and New York City (NYC) to a commercially available pharmacy national claims dataset (Symphony Health Solutions). DATA SOURCES AND STUDY SETTING: We utilized retail pharmacy naloxone dispensing data from NYC (2018-2019), Rhode Island (2013-2019), and Massachusetts (2014-2018), and pharmaceutical claims data from Symphony Health Solutions (2013-2019). STUDY DESIGN: We conducted a descriptive, retrospective, and secondary analysis comparing naloxone dispensing events (NDEs) captured via Symphony to NDEs captured by local datasets from the three jurisdictions between 2013 and 2019, when data were available from both sources, using descriptive statistics, regressions, and heat maps. DATA COLLECTION/EXTRACTION METHODS: We defined an NDE as a dispensing event documented by the pharmacy and assumed that each dispensing event represented one naloxone kit (i.e., two doses). We extracted NDEs from local datasets and the Symphony claims dataset. The unit of analysis was the ZIP Code annual quarter. PRINCIPAL FINDINGS: NDEs captured by Symphony exceeded those in local datasets for each time period and location, except in RI following legislation requiring NDEs to be reported to the PDMP. In regression analysis, absolute differences in NDEs between datasets increased substantially over time, except in RI before the PDMP. Heat maps of NDEs by ZIP code quarter showed important variations reflecting where pharmacies may not be reporting NDEs to Symphony or local datasets. CONCLUSIONS: Policymakers must be able to monitor the quantity and location of NDEs in order to combat the opioid crisis. In regions where NDEs are not required to be reported to PDMPs, proprietary pharmaceutical claims datasets may be useful alternatives, with a need for local expertise to assess dataset-specific variability.
Assuntos
Overdose de Drogas , Transtornos Relacionados ao Uso de Opioides , Farmácias , Farmácia , Humanos , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Rhode Island , Cidade de Nova Iorque , Estudos Retrospectivos , Fonte de Informação , Overdose de Drogas/prevenção & controle , Massachusetts , Preparações Farmacêuticas , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológicoRESUMO
Importance: Nonfatal opioid overdose is the leading risk factor for subsequent fatal overdose and represents a critical opportunity to reduce future overdose and mortality. Postoverdose outreach programs emerged in Massachusetts beginning in 2013 with the main purpose of linking opioid overdose survivors to addiction treatment and harm reduction services. Objective: To evaluate whether the implementation of postoverdose outreach programs among Massachusetts municipalities was associated with lower opioid fatality rates compared with municipalities without postoverdose outreach programs. Design, Setting, and Participants: This retrospective interrupted time-series analysis was performed over 26 quarters (from January 1, 2013, through June 30, 2019) across 93 municipalities in Massachusetts. These 93 municipalities were selected based on a threshold of 30 or more opioid-related emergency medical services (EMS) responses in 2015. Data were analyzed from November 2021 to August 2022. Exposures: The main exposure was municipality postoverdose outreach programs. Municipalities had various program inceptions during the study period. Main Outcomes and Measures: The primary outcome was quarterly municipal opioid fatality rate per 100â¯000 population. The secondary outcome was quarterly municipal opioid-related EMS response (ambulance trips) rates per 100â¯000 population. Results: The mean (SD) population size across 93 municipalities was 47â¯622 (70â¯307), the mean (SD) proportion of female individuals was 51.5% (1.5%) and male individuals was 48.5% (1.5%), and the mean (SD) age proportions were 29.7% (4.0%) younger than 25 years, 26.0% (4.8%) aged 25 to 44 years, 14.8% (2.1%) aged 45 to 54 years, 13.4% (2.1%) aged 55 to 64 years, and 16.1% (4.4%) aged 65 years or older. Postoverdose programs were implemented in 58 municipalities (62%). Following implementation, there were no significant level changes in opioid fatality rate (adjusted rate ratio [aRR], 1.07; 95% CI, 0.96-1.19; P = .20). However, there was a significant slope decrease in opioid fatality rate (annualized aRR, 0.94; 95% CI, 0.90-0.98; P = .003) compared with the municipalities without the outreach programs. Similarly, there was a significant slope decrease in opioid-related EMS response rates (annualized aRR, 0.93; 95% CI, 0.89-0.98; P = .007). Several sensitivity analyses yielded similar findings. Conclusions and Relevance: In this study, among Massachusetts municipalities with high numbers of opioid-related EMS responses, implementation of postoverdose outreach programs was significantly associated with lower opioid fatality rates over time compared with municipalities that did not implement such programs. Program components, including cross-sectoral partnerships, operational best practices, involvement of law enforcement, and related program costs, warrant further evaluation to enhance effectiveness.
Assuntos
Overdose de Drogas , Overdose de Opiáceos , Transtornos Relacionados ao Uso de Opioides , Humanos , Masculino , Feminino , Analgésicos Opioides/efeitos adversos , Overdose de Opiáceos/tratamento farmacológico , Estudos Retrospectivos , Cidades , Massachusetts/epidemiologia , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológicoRESUMO
Importance: Opioid dosage tapering has emerged as a strategy to reduce harms associated with long-term opioid therapy; however, evidence supporting this approach is limited. Objective: To identify the association of opioid tapering or abrupt discontinuation with opioid overdose and suicide events among patients receiving stable long-term opioid therapy without evidence of opioid misuse. Design, Setting, and Participants: This comparative effectiveness study with a trial emulation approach used a large US claims data set of individuals with commercial insurance or Medicare Advantage who were aged 18 years or older and receiving stable long-term opioid therapy without evidence of opioid misuse between January 1, 2010, and December 31, 2018. Statistical analysis was performed from January 17, 2020, through November 12, 2021. Interventions: Three opioid dosage strategies: stable dosage, tapering (dosage reduction ≥15%), or abrupt discontinuation. Main Outcomes and Measures: Time to opioid overdose or suicide event identified from International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes in medical claims over 11 months of follow-up. Inverse probability weighting was used to adjust for baseline confounders. The primary analysis used an intention-to-treat approach; follow-up after assignment regardless of changes in opioid dose was included. A per-protocol analysis was also conducted, in which episodes were censored for lack of adherence to assigned treatment. Results: A cohort of 199â¯836 individuals (45.1% men; mean [SD] age, 56.9 [12.4] years; and 57.6% aged 45-64 years) had 415â¯123 qualifying, long-term opioid therapy episodes; 87.1% of episodes were considered stable, 11.1% were considered a taper, and 1.8% were considered abrupt discontinuation. The adjusted cumulative incidence of opioid overdose or suicide events 11 months after baseline was 0.96% (95% CI, 0.92%-0.99%) with a stable dosage strategy, 1.10% (95% CI, 0.99%-1.22%) with a tapered dosage strategy, and 1.28% (95% CI, 0.93%-1.38%) with an abrupt discontinuation strategy. The risk difference between a taper and a stable dosage was 0.15% (95% CI, 0.03%-0.26%), and the risk difference between abrupt discontinuation and a stable dosage was 0.33% (95% CI, -0.03% to 0.74%). Results were similar using the per-protocol approach. Conclusions and Relevance: This study identified a small absolute increase in risk of harms associated with opioid tapering compared with a stable opioid dosage. These results do not suggest that policies of mandatory dosage tapering for individuals receiving a stable long-term opioid dosage without evidence of opioid misuse will reduce short-term harm via suicide and overdose.
Assuntos
Overdose de Opiáceos , Transtornos Relacionados ao Uso de Opioides , Prevenção do Suicídio , Idoso , Analgésicos Opioides/efeitos adversos , Feminino , Humanos , Masculino , Medicare , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Estados Unidos/epidemiologiaRESUMO
Referrals of hospitalized patients with opioid use disorder (OUD) to postacute medical care facilities are commonly rejected. We linked all electronic referrals from a Boston safety-net hospital in 2018 to clinical data and used multivariable logistic regression to examine the association between OUD diagnosis and rejection from postacute medical care. Hospitalized patients with OUD were referred to more facilities than patients without OUD (8.2 versus 6.6 per hospitalization), were rejected a greater proportion of the time (83.3 percent versus 65.5 percent), and in adjusted analyses had greater odds of rejection from postacute care (adjusted odds ratio, 2.2). In addition, people with OUD were referred disproportionately to a small subset of facilities with a higher likelihood of acceptance. Our findings document disparities in postacute care admissions for people with OUD. Efforts to ensure equitable access to medically necessary postacute medical care for people with OUD are needed.
Assuntos
Transtornos Relacionados ao Uso de Opioides , Analgésicos Opioides/uso terapêutico , Hospitalização , Humanos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Encaminhamento e Consulta , Provedores de Redes de Segurança , Cuidados Semi-IntensivosRESUMO
BACKGROUND: Naloxone is a prescription medication that reverses opioid overdoses. Allowing naloxone to be dispensed directly by a pharmacist without an individual prescription under a naloxone standing order (NSO) can expand access. The community-level factors associated with naloxone dispensed under NSO are unknown. METHODS: Using a dataset comprised of pharmacy reports of naloxone dispensed under NSO from 70% of Massachusetts retail pharmacies, we examined relationships between community-level demographics, rurality, measures of treatment for opioid use disorder, and overdose deaths with naloxone dispensed under NSO per ZIP Code-quarter from 2014 until 2018. We used a multi-variable zero-inflated negative binomial model, assessing odds of any naloxone dispensed under NSO, as well as a multi-variable negative binomial model assessing quantities of naloxone dispensed under NSO. RESULTS: From 2014-2018, quantities of naloxone dispensed under NSO and the number of pharmacies dispensing any naloxone under NSO increased over time. However, communities with greater percentages of people with Hispanic ethnicity (aOR 0.91, 95% CI 0.86-0.96 per 5% increase), and rural communities compared to urban communities (aOR 0.81, 95% CI 0.73-0.90) were less likely to dispense any naloxone by NSO. Communities with more individuals treated with buprenorphine dispensed more naloxone under NSO, as did communities with more opioid-related overdose deaths. CONCLUSION: Naloxone dispensing has substantially increased, in part driven by standing orders. A lower likelihood of naloxone being dispensed under NSO in communities with larger Hispanic populations and in more rural communities suggests the need for more equitable access to, and uptake of, lifesaving medications like naloxone.
Assuntos
Overdose de Drogas , Prescrições Permanentes , Overdose de Drogas/tratamento farmacológico , Overdose de Drogas/epidemiologia , Humanos , Massachusetts/epidemiologia , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêuticoRESUMO
BACKGROUND AND AIMS: Opioid-related overdose death rates continue to rise in the United States, especially in racial/ethnic minority communities. Our objective was to determine if US municipalities with high percentages of non-white residents have equitable access to the overdose antidote naloxone distributed by community-based organizations. METHODS: We used community-based naloxone data from the Massachusetts Department of Public Health and the Rhode Island non-pharmacy naloxone distribution program for 2016-18. We obtained publicly available opioid-related overdose death data from Massachusetts and the Office of the State Medical Examiners in Rhode Island. We defined the naloxone coverage ratio as the number of community-based naloxone kits received by a resident in a municipality divided by the number of opioid-related overdose deaths among residents, updated annually. We used a Poisson regression with generalized estimating equations to analyze the relationship between the municipal racial/ethnic composition and naloxone coverage ratio. To account for the potential non-linear relationship between naloxone coverage ratio and race/ethnicity we created B-splines for the percentage of non-white residents; and for a secondary analysis examining the percentage of African American/black and Hispanic residents. The models were adjusted for the percentage of residents in poverty, urbanicity, state and population size. RESULTS: Between 2016 and 2018, the annual naloxone coverage ratios range was 0-135. There was no difference in naloxone coverage ratios among municipalities with varying percentages of non-white residents in our multivariable analysis. In the secondary analysis, municipalities with higher percentages of African American/black residents had higher naloxone coverage ratios, independent of other factors. Naloxone coverage did not differ by percentage of Hispanic residents. CONCLUSIONS: There appear to be no municipal-level racial/ethnic inequities in naloxone distribution in Rhode Island and Massachusetts, USA.
Assuntos
Overdose de Drogas , Overdose de Opiáceos , Transtornos Relacionados ao Uso de Opioides , Analgésicos Opioides/uso terapêutico , Overdose de Drogas/tratamento farmacológico , Overdose de Drogas/prevenção & controle , Minorias Étnicas e Raciais , Etnicidade , Humanos , Massachusetts/epidemiologia , Grupos Minoritários , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Rhode Island/epidemiologia , Estados UnidosRESUMO
BACKGROUND: Urine drug testing (UDT) is a recommended risk mitigation strategy for patients prescribed opioids for chronic pain, but evidence that UDT supports identification of substance misuse is limited. OBJECTIVE: Identify the prevalence of UDT results that may identify substance misuse, including diversion, among patients prescribed opioids for chronic pain. DESIGN: Retrospective cohort study. SUBJECTS: Patients (n=638) receiving opioids for chronic pain who had one or more UDTs, examining up to eight substances per sample, during a one 1-year period. MAIN MEASURES: Experts adjudicated the clinical concern that UDT results suggest substance misuse or diversion as not concerning, uncertain, or concerning. KEY RESULTS: Of 638 patients, 48% were female and 49% were over age 55 years. Patients had a median of three UDTs during the intervention year. We identified 37% of patients (235/638) with ≥1 concerning UDT and a further 35% (222/638) having ≥1 uncertain UDT. We found concerning UDTs due to non-detection of a prescribed substance in 24% (156/638) of patients and detection of a non-prescribed substance in 23% (147/638). Compared to patients over 65 years, those aged 18-34 years were more likely to have concerning UDT results with an adjusted odds ratio (AOR) of 4.8 (95% confidence interval [CI] 1.9-12.5). Patients with mental health diagnoses (AOR 1.6 [95% CI 1.1-2.3]) and substance use diagnoses (AOR 2.3 [95% CI 1.5-3.7]) were more likely to have a concerning UDT result. CONCLUSIONS: Expert adjudication of UDT results identified clinical concern for substance misuse in 37% of patients receiving opioids for chronic pain. Further research is needed to determine if UDTs impact clinical practice or patient-related outcomes.
Assuntos
Dor Crônica , Transtornos Relacionados ao Uso de Opioides , Analgésicos Opioides/uso terapêutico , Dor Crônica/tratamento farmacológico , Dor Crônica/epidemiologia , Feminino , Humanos , Masculino , Transtornos Relacionados ao Uso de Opioides/diagnóstico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Estudos Retrospectivos , Detecção do Abuso de Substâncias/métodosRESUMO
BACKGROUND: Post-overdose outreach programs engage survivors in harm reduction and treatment to prevent future overdoses. In Massachusetts, these emerging programs commonly deploy teams comprised of police and public health professionals based on 911 call information. Some teams use name/address data to conduct arrest warrant checks prior to outreach visits. We used mixed methods to understand approaches to outreach related to warrant checking, from the perspectives of police and public health outreach agencies and staff. METHODS: We analyzed a 2019 statewide survey of post-overdose outreach programs in Massachusetts to classify approaches to warrant checking and identify program and community factors associated with particular approaches. Ethnographic analysis of qualitative interviews conducted with outreach staff helped further contextualize outreach program practices related to warrants. RESULTS: A majority (57% - 79/138) of post-overdose outreach programs in Massachusetts conducted warrant checks prior to outreach. Among programs that checked warrants, we formulated a taxonomy of approaches to handling warrants: 1) performing outreach without addressing warrants (19.6% - 27/138), 2) delaying outreach until warrants are cleared (15.9% - 22/138), 3) arresting the survivor (11/138 - 8.0%), 4) taking a situational approach (10/138 - 7.2%), 5) not performing outreach (9/138 - 6.5%). Program characteristics and staff training did not vary across approaches. From police and public health outreach staff interviews (n = 38), we elicited four major themes: a) diverse motivations precede warrant checking, b) police officers feel tension between dual roles, c) warrants alter approaches to outreach, and d) teams leverage warrants in relationships. Findings from both analyses converged to demonstrate unintended consequences of warrant checking. CONCLUSION: Checking warrants prior to post-overdose outreach visits can result in arrest, delayed outreach, and barriers to obtaining services for overdose survivors, which can undermine the goal of these programs to engage overdose survivors. With the public health imperative of engaging overdose survivors, programs should consider limiting warrant checking and police participation in field activities.
Assuntos
Overdose de Drogas , Overdose de Drogas/prevenção & controle , Redução do Dano , Humanos , Aplicação da Lei , Massachusetts , PolíciaRESUMO
BACKGROUND: As a response to mounting overdose fatalities, cross-agency outreach efforts have emerged to reduce future risk among overdose survivors. We aimed to characterize such programs in Massachusetts, with focus on team composition, approach, services provided, and funding. METHODS: We conducted a two-phase cross-sectional survey of public health and safety providers in Massachusetts. Providers in all 351 municipalities received a screening survey. Those with programs received a second, detailed survey. We analyzed responses using descriptive statistics. RESULTS: As of July 2019, 44 % (156/351) of Massachusetts municipalities reported post-overdose outreach programs, with 75 % (104/138) formed between 2016-2019. Teams conducted home-based outreach 1-3 days following overdose events. Police departments typically supplied location information on overdose events (99 %, 136/138) and commonly participated in outreach visits (86 %, 118/138) alongside public health personnel, usually from community-based organizations. Teams provided or made referrals to services including inpatient addiction treatment, recovery support, outpatient medication, overdose prevention education, and naloxone. Some programs deployed law enforcement tools, including pre-visit warrant queries (57 %, 79/138), which occasionally led to arrest (11 %, 9/79). Many programs (81 %, 112/138) assisted families with involuntary commitment to treatment - although this was usually considered an option of last resort. Most programs were grant-funded (76 %, 104/136) and engaged in cross-municipal collaboration (94 %, 130/138). CONCLUSIONS: Post-overdose outreach programs have expanded, typically as collaborations between police and public health. Further research is needed to better understand the implications of involving police and to determine best practices for increasing engagement in treatment and harm reduction services and reduce subsequent overdose.
Assuntos
Relações Comunidade-Instituição , Overdose de Opiáceos/terapia , Saúde Pública , Estudos Transversais , Overdose de Drogas/prevenção & controle , Redução do Dano , Humanos , Aplicação da Lei , Masculino , Massachusetts/epidemiologia , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Organizações , Polícia/educação , Inquéritos e QuestionáriosRESUMO
PURPOSE: We sought to obtain baseline statistics regarding the amount of opioid tablets prescribed by oral and maxillofacial surgeons (OMSs) in the New England area after office-based procedures and to identify factors that might be predictors of their prescription patterns. MATERIALS AND METHODS: An anonymous online survey was e-mailed to practicing OMSs in the New England area. The survey explored the quantity of opioid medications prescribed for various procedures, how opioid precautions were given, practitioners' attitude toward opioid dependency, and whether certain surgeon- or patient-related factors influenced prescription behavior. Statistical analyses were used to categorize the OMSs according to their prescription patterns and to identify the most common factors affecting their decision to prescribe opioids. RESULTS: Of 315 OMSs, 151 (43%) responded to the survey. Our analyses were of complete data obtained from 118 respondents. For procedures, such as extraction of 7 or more teeth, the placement of 4 or more implants, office-based sinus surgery, cortical block grafts, and removal of third molar teeth, respondents indicated they typically prescribed 8 to 12 opioid tablets. For all other procedures, they typically never or rarely prescribed opioid tablets. The respondents were grouped into low-, medium-, and high-quantity opioid prescribers. Regardless of their grouping status, the respondents showed general agreement regarding their roles in reducing opioid prescription-related issues. No group differences were found in terms of the demographic variables. Relative to the factors predicting increased prescribing habits, the results suggested that OMSs working either exclusively or primarily in academic settings tended to prescribe fewer opioid tablets than those working primarily in the private setting (ß = -2.73; P < .001). Additionally, 109 respondents (92.4%) reported that OMSs could play a role in decreasing opioid dependency. CONCLUSIONS: Most practicing OMSs in the New England area prescribed opioids after office-based surgery and are cognizant of the risks of opioid medications.
Assuntos
Analgésicos Opioides , Cirurgiões Bucomaxilofaciais , Humanos , Dente Serotino , Dor Pós-Operatória , Padrões de Prática Odontológica , Padrões de Prática Médica , Inquéritos e QuestionáriosRESUMO
One of the most fundamental and challenging questions in the cancer field is how immunity in patients with cancer is transformed from tumor immunosurveillance to tumor-promoting inflammation. Here, we identify the transcription factor STAT3 as the culprit responsible for this pathogenic event in lung cancer development. We found that antitumor type 1 CD4+ T-helper (Th1) cells and CD8+ T cells were directly counter balanced in lung cancer development with tumor-promoting myeloid-derived suppressor cells (MDSCs) and suppressive macrophages, and that activation of STAT3 in MDSCs and macrophages promoted tumorigenesis through pulmonary recruitment and increased resistance of suppressive cells to CD8+ T cells, enhancement of cytotoxicity toward CD4+ and CD8+ T cells, induction of regulatory T cell (Treg), inhibition of dendritic cells (DC), and polarization of macrophages toward the M2 phenotype. The deletion of myeloid STAT3 boosted antitumor immunity and suppressed lung tumorigenesis. These findings increase our understanding of immune programming in lung tumorigenesis and provide a mechanistic basis for developing STAT3-based immunotherapy against this and other solid tumors. Cancer Immunol Res; 5(3); 257-68. ©2017 AACR.
Assuntos
Transformação Celular Neoplásica/metabolismo , Vigilância Imunológica , Neoplasias Pulmonares/etiologia , Neoplasias Pulmonares/metabolismo , Células Mieloides/metabolismo , Fator de Transcrição STAT3/metabolismo , Animais , Antígenos CD8/deficiência , Movimento Celular/genética , Sobrevivência Celular/genética , Transformação Celular Neoplásica/genética , Citotoxicidade Imunológica , Modelos Animais de Doenças , Humanos , Vigilância Imunológica/genética , Vigilância Imunológica/imunologia , Inflamação/complicações , Inflamação/genética , Inflamação/metabolismo , Inflamação/patologia , Interferon gama/metabolismo , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/patologia , Macrófagos/imunologia , Macrófagos/metabolismo , Camundongos , Camundongos Knockout , Células Mieloides/imunologia , Células Supressoras Mieloides/imunologia , Células Supressoras Mieloides/metabolismo , Prognóstico , Fator de Transcrição STAT3/genética , Subpopulações de Linfócitos T/imunologia , Subpopulações de Linfócitos T/metabolismoRESUMO
Signal transducer and activator of transcription 3 (STAT3) is linked to multiple cancers, including pulmonary adenocarcinoma. However, the role of STAT3 in lung cancer pathogenesis has not been determined. Using lung epithelial-specific inducible knockout strategies, we demonstrate that STAT3 has contrasting roles in the initiation and growth of both chemically and genetically induced lung cancers. Selective deletion of lung epithelial STAT3 in mice before cancer induction by the smoke carcinogen, urethane, resulted in increased lung tissue damage and inflammation, K-Ras oncogenic mutations and tumorigenesis. Deletion of lung epithelial STAT3 after establishment of lung cancer inhibited cancer cell proliferation. Simultaneous deletion of STAT3 and expression of oncogenic K-Ras in mouse lung elevated pulmonary injury, inflammation and tumorigenesis, but reduced tumor growth. These studies indicate that STAT3 prevents lung cancer initiation by maintaining pulmonary homeostasis under oncogenic stress, whereas it facilitates lung cancer progression by promoting cancer cell growth. These studies also provide a mechanistic basis for targeting STAT3 to lung cancer therapy.