The effect of combat deployments on veteran opioid abuse.

Grim national statistics about the U.S. opioid crisis are increasingly well known to the American public. Far less well known is that U.S. servicemembers are at ground zero of the epidemic, with veterans facing an overdose death rate of up to twice that of civilians. Exploiting a quasi-experiment in overseas deployment assignment, this study estimates the causal impact of combat exposure among the deployed in the Global War on Terrorism on opioid abuse. We find that exposure to war theater substantially increased the risk of prescription painkiller abuse and illicit heroin use among active duty servicemen. The magnitudes of our estimates imply lower-bound combat exposure-induced healthcare costs of $1.04 billion per year for prescription painkiller abuse and $470 million per year for heroin use.

Recreational cannabis and opioid distribution.

Twenty-one U.S. states have passed recreational cannabis laws as of November 2022. Cannabis may be a substitute for prescription opioids in the treatment of chronic pain. Previous studies have assessed recreational cannabis laws' effects on opioid prescriptions financed by specific private or public payers or dispensed to a unique endpoint. Our study adds to the literature in three important ways: by (1) examining these laws' impacts on prescription opioid dispensing across all payers and endpoints, (2) adjusting for important opioid-related policies such as opioid prescribing limits, and (3) modeling opioids separately by type. We implement two-way fixed-effects regressions and leverage variation from eleven U.S. states that adopted a recreational cannabis law (RCL) between 2010 and 2019. We find that RCLs lead to a reduction in codeine dispensed at retail pharmacies. Among prescription opioids, codeine is particularly likely to be used non-medically. Thus, the finding that RCLs appear to reduce codeine dispensing is potentially promising from a public health perspective.

The Effect of State-Level Sex Education Policies on Youth Sexual Behaviors.

Two types of sex education are generally offered in the U.S. abstinence-only and comprehensive sex education. There is no clear scientific consensus over which approach minimizes the risk of unintended pregnancy and sexually transmitted diseases for youth. While there have been many studies of specific programs in clinical or quasi-experimental settings, there are very few evaluations of how state-level sex education policies affect the youth population. We estimate the impact of various state-level sex education policies on youth sexual activity and contraceptive use using data from four waves of the Youth Risk Behavior Surveillance System from 39 states. We found that states that require sexuality (sex and/or HIV/STD) education and contraceptive content or states that mandate education but leave the actual content up to local districts have lower rates of sexually active youth and higher rates of contraception use when youth are sexually active. States that require sexuality education and require abstinence content increase the rate at which youth are sexually active, and youth in those states are less likely to use hormonal birth control if they are sexually active. In conclusion, we found that state policies regarding sex and HIV/STD education had statistically significant effects that are meaningful in magnitude from a public health perspective.

The effects of direct-to-consumer advertising on medication use among Medicaid children with asthma.

Asthma medication adherence is low, particularly among Medicaid enrollees. There has been much debate on the impact of direct-to-consumer advertising (DTCA) on health care use, but the impact on medication use among children with asthma has been unexamined. The study sample included 180,584 children between the ages of 5 and 18 with an asthma diagnosis from a combined dataset of Medicaid Analytic eXtract and national advertising data. We found that DTCA expenditure during the study period was significantly associated with an increase in asthma medication use. However, the effectiveness declined after a certain level.

Impact of FDA Actions, DTCA, and Public Information on the Market for Pain Medication.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the most important classes of prescription drugs used by primary care physicians to manage pain. The NSAID class of products has a somewhat controversial history, around which a complex regulatory and informational environment has developed. This history includes a boxed warning mandated by the Food and Drug Administration (FDA) for all NSAIDs in 2005. We investigate the impact that various information shocks have had on the use of prescription medications for pain in primary care in the USA. We accomplish this by extracting data on nearly 600,000 patients from a unique nationwide electronic medical record database and estimate the probability of any active prescription for the four types of pain medications as a function of FDA actions, advertising, media coverage, and patient characteristics. We find that even after accounting for multiple sources of information, the FDA label changes and boxed warnings had a significant effect on pain medication prescribing. The boxed warning did not have the same impact on the use of all NSAID inhibitors. We find that the boxed warning reduced the use of NSAID COX-2 inhibitor use, which was the focus of much of the press attention. In contrast, however, the warning actually increased the use of non-COX-2 NSAID inhibitors. Thus, the efficacy of the FDA's black box warning is clearly mixed.

A prescription for unemployment? Recessions and the demand for mental health drugs.

We estimate the relationship between mental health drug prescriptions and the level of labor market activity in the USA. Based on monthly data from the National Ambulatory Medical Care Survey of physicians and aggregated by US census regions, we find that the number of mental health drug prescriptions (those aimed at alleviating depression and anxiety) rises by about 10% when employment falls by 1% and when unemployment rises by 100 basis points, but only for patients in the Northeast region. This paper is one of the first to look at compensatory health behavior in response to the business cycle.

The Cost of Implementing New Strategies (COINS): A Method for Mapping Implementation Resources Using the Stages of Implementation Completion.

OBJECTIVE: Illustrate the value of a strategy used for measuring the costs and resources used in the implementation process over and above the costs of the intervention itself in the context of a two-arm randomized controlled trial. METHODS: Counties in California and Ohio (sites) were invited to implement Multidimensional Treatment Foster Care (MTFC), an alternative to congregate care for youth. Participating sites (n=53) were randomized to one of two implementation = sites share information and move through the implementation process as a cohort facilitated by an MTFC purveyor or (2) Individual Implementation (IND: "as usual") where sites work individually with the MTFC purveyor. The implementations were monitored using the Stages of Implementation Completion (SIC) measure of a number of observable activities, developed as part of the trial to segment the implementation process into 8 stages of implementation. Resource data gathered from the implementation purveyors and site participants were used to map costs onto each of the 8 stages to generate total cost measures stratified by type of resource and stage of implementation for each of the study arms. RESULTS: The SIC provided a feasible costing template to map costs onto observable activities and to enable the examination of important differences in implementation strategies for an evidence-based practice. The average total implementation cost prior to program start-up of CDT was $133,106; IND cost $118,699. While CDT cost more in a number of stages, it resulted in fewer county staff hours being used and shorter mean times to implementation than IND. In cases where rapidity of implementation of reducing staff time required for implementation is valued, then CDT would be the preferable implementation approach. CONCLUSIONS: The SIC is a useful tool for determining implementation resources needed for new evidence-based practice programs for youth and particularly for comparing different implementation strategies that might be tried in pilot programs.

Higher Rates Of Homelessness Are Associated With Increases In Mortality From Accidental Drug And Alcohol Poisonings.

Alcohol and drug overdoses have multiple complex causes. In this article we contribute to the literature that links homelessness, the most extreme form of housing disruption, to accidental SUD-related poisonings. Using plausibly exogenous variation from a state's landlord-tenant policies that influence evictions, we estimated the causal impact of homelessness on SUD-related mortality. We found large effects of homelessness on SUD-related poisonings (for example, a 10 percent increase in homelessness led to a 3.2 percent increase in opioid poisonings in metropolitan areas). Our findings indicate that reducing local homelessness rates from the seventy-fifth to the fiftieth percentile levels could have saved more than 1,900 lives from opioid overdoses across all metropolitan localities in the final year of our study data. We conclude that strengthening the social safety net in terms of housing security could help curb the ongoing SUD-related poisoning epidemic in the US.

Buprenorphine Treatment For Opioid Use Disorder: Comparison Of Insurance Restrictions, 2017-21.

Buprenorphine is a treatment medication that decreases mortality risks among people with opioid use disorder (OUD). Despite its efficacy, buprenorphine is underused in the US. Insurance restrictions are commonly cited as barriers to buprenorphine prescribing. Using Medicaid, Medicare Advantage, and commercial insurance formulary files, we examined insurance-imposed utilization restrictions for buprenorphine for OUD for each year from 2017 to 2021 by insurance type. Almost all plans covered immediate-release buprenorphine in 2021, with a general trend of decreasing prior authorization requirements and quantity limits since 2017. In contrast, two payers had relatively low coverage of extended-release buprenorphine, with only 46 percent of commercial plans and only 19 percent of Medicare Advantage plans covering this formulation. Even though most Medicaid plans covered extended-release buprenorphine in 2021, 37 percent required prior authorization. Policy makers and researchers concerned with buprenorphine insurance barriers should shift their attention to extended-release buprenorphine. State lawmakers could help address these barriers by mandating that insurers include extended-release buprenorphine on their preferred drug lists.

Money Matters: Cost Effectiveness of Juvenile Drug Court with and without Evidence-Based Treatments.

The 12-month cost effectiveness of juvenile drug court and evidence-based treatments within Court were compared with traditional Family Court for 128 substance abusing/dependent juvenile offenders participating in a four-condition randomized trial. Intervention conditions included Family Court with community services (FC), Drug Court with community services (DC), Drug Court with Multisystemic Therapy (DC/MST), and Drug Court with MST enhanced with a contingency management program (DC/MST/CM). Average cost effectiveness ratios for substance use and criminal behavior outcomes revealed that economic efficiency in achieving outcomes generally improved from FC to DC, with the addition of evidence-based treatments improving efficiency in obtaining substance use outcomes.

Opting into the Public List of DATA-Waivered Practitioners: Variations by Specialty, Treatment Capacity, and Practitioner Characteristics.

OBJECTIVES: Although increased access to buprenorphine treatment for opioid use disorder is a central policy objective in addressing the US opioid overdose crisis, insufficient capacity for buprenorphine treatment exists relative to treatment need. Little is known about the characteristics of practitioners who opt into the public listing, an online list of Drug Addiction Treatment Act (DATA)-waivered practitioners provided by the US government, as compared to those who do not. In this cross-sectional study, we examined the association of public listing with practitioner demographic data, specialty, and treatment capacity. METHODS: We combined comprehensive prescriber databases including the National Plan and Provider Enumeration System, data on DATA-waivered practitioners, and an online list waivered practitioners in January 2020 using matching algorithms. We used nonadjusted group mean comparisons and multivariate logistic regressions for the statistical analyses of 60,113 US DATA-waivered practitioners. RESULTS: Publicly listed waivered practitioners tended to have higher patient limits than non-listed practitioners. The proportions of psychiatrists among publicly listed practitioners were significantly lower than those of non-listed practitioners (6.6%, P < 0.001). Nonphysician prescribers, rural practitioners, male practitioners, and practitioners with fewer years of practice are overrepresented among publicly listed waivered practitioners. CONCLUSIONS: As it is easier for patients to find buprenorphine treatment providers who are on this list, the list serves to expand buprenorphine utilization. SAMHSA should encourage providers to opt into the public list, focusing on psychiatrists and prescribers with lower patient limits, consider requiring inclusion in the list, or make inclusion an "opt out" rather than an "opt in" decision.

Trends in Buprenorphine Coverage and Prior Authorization Requirements in US Commercial Formularies, 2017-2021.

This cross-sectional study assesses buprenorphine coverage and prior authorization requirements in US commercial formulary data from 2017 to 2021.

Spillover of Medicaid Expansion to Prescribing of Opioid Use Disorder Medications in Medicare Part D.

OBJECTIVE: The authors examined whether there were positive spillovers in opioid use disorder medication prescribing to Medicare Part D beneficiaries in Medicaid expansion states. Although prior studies have shown several positive benefits of Medicaid expansion for Americans with opioid use disorder, research has not examined potential spillovers to Medicare beneficiaries who have been hit hard by the opioid crisis. METHODS: Prescribing data were taken from the Medicare Part D Prescription Public Use File (2010-2017). A difference-in-differences linear regression framework was used to identify spillovers in prescribing of buprenorphine and injectable naltrexone to Medicare Part D beneficiaries in Medicaid expansion states. Three sets of dependent variables measured medication prescribing at the county-year level (N=24,850). All models included county and year fixed effects, with standard errors clustered at the state level to address within-state serial correlation. RESULTS: Medicaid expansion was associated with an increase in the probability of a county having an injectable naltrexone provider (p<0.01). After expansion, the number of buprenorphine providers in expansion states increased by 5.6% (p<0.05), and the number of injectable naltrexone providers increased by 3.3% (p<0.01), relative to nonexpansion states. Expansion was associated with a 23.1% (p<0.01) increase in the number of daily doses of injectable naltrexone, relative to nonexpansion states. CONCLUSIONS: Medicaid expansion states may be better equipped to address the opioid crisis because of direct benefits to Medicaid beneficiaries and availability of opioid use disorder medications for Medicare Part D beneficiaries. However, additional efforts are likely needed to close the opioid use disorder treatment gap for Medicare beneficiaries.

The Association Between Scope of Practice Regulations and Nurse Practitioner Prescribing of Buprenorphine After the 2016 Opioid Bill.

This article examines the relationship between federal regulations, state scope-of-practice regulations on nurse practitioners (NPs), and buprenorphine prescribing patterns using pharmacy claims data from Optum's deidentified Clinformatics Data Mart between January 2015 and September 2018. The county-level proportion of patients filling prescriptions written by NPs was low even after the 2016 Comprehensive Addiction and Recovery Act (CARA), 2.7% in states that did not require physician oversight of NPs, and 1.1% in states that did. While analyses in rural counties showed higher rates of buprenorphine prescriptions written by NPs, rates were still considerably low: 3.7% in states with less restrictive regulations and 1.1% in other states. These results indicate that less restrictive scope-of-practice regulations are associated with greater NP prescribing following CARA. The small magnitude of the changes indicates that federal attempts to expand treatment access through CARA have been limited.

Time Preference for Immediate Gratification: Associations With Low Medication Adherence and Uncontrolled Blood Pressure.

BACKGROUND: In search of innovative approaches to the challenge of uncontrolled hypertension, we assessed the association between preference for immediate gratification (i.e., high discounting rate), low medication adherence, and uncontrolled blood pressure (BP) in adults with hypertension. METHODS: Using a probability discounting model and the Collier-Williams hypothetical discount rate framework, participants in this cross-sectional study reported their preference for a smaller amount of money available immediately (high discount rate; immediate gratification preference) vs. a larger amount available 1 year later (low discount rate; delayed gratification preference). Multivariable Poisson regression was used to test the association of high discounting rates with low antihypertensive medication adherence using the validated 4-item Krousel-Wood Medication Adherence Scale (K-Wood-MAS-4 score ≥1). Mediation of the association between high discounting rate and uncontrolled BP (systolic/diastolic BP ≥ 130/80 mm Hg) by low adherence was tested using the counterfactual approach. RESULTS: Among 235 participants (mean age 63.7 ± 6.7 years; 51.1% women; 41.9% Black), 50.6% had a high 1-year discount rate, 51.9% had low K-Wood-MAS-4 adherence, and 59.6% had uncontrolled BP. High discounting rates were associated with low adherence (adjusted prevalence ratio 1.58, 95% confidence interval (CI) 1.18, 2.12). Forty-three percent (95% CI 40.9%, 45.8%) of the total effect of high discount rate on uncontrolled BP was mediated by low adherence. CONCLUSIONS: Adults with preference for immediate gratification had worse adherence; low adherence partially mediated the association of high discount rate with uncontrolled BP. These results support preference for immediate gratification as an innovative factor underlying low medication adherence and uncontrolled BP.

Where did the specialty behavioral health workforce grow between 2011 and 2019? Evidence from census data.

IMPORTANCE: Given that mental health and substance use conditions are ongoing major public health problems in the United States, it is important for researchers to understand the behavioral health treatment workforce landscape and to assess whether increases in treatment capacity exist in areas with public health needs. OBJECTIVES: This study quantified national and county-level changes in specialty behavioral health (SBH) workforce outcomes and assessed associations between these measures and age-adjusted drug mortality rate. DESIGN: Using a novel longitudinal dataset from the U.S. Census Bureau, this study described SBH workforce outcomes in 3130 U.S. counties between 2011 and 2019. The study stratified workforce outcomes, including the number of establishments, likelihood of having establishments, mean number of workers, and average wage of workers per county, by service settings: outpatient, residential, and hospital. The study fitted outcome data at the county level to ordinary least squares regression models as a function of the country's previous year age-adjusted drug mortality rate and county sociodemographic characteristics. RESULTS: The number of SBH establishments, their workforce, and their wages have increased steadily between 2011 and 2019, with the largest increases occurring in the following settings: outpatient (number of establishments and employment) and residential (average wage). County-level growth of residential SBH establishments was positively and significantly associated with the county's previous year county age-adjusted drug mortality rate. We did not observe a similar positive association between either employment or wages and the mortality rate. CONCLUSIONS: The increase in the number of SBH establishments in recent years may indicate that the SBH workforce is responding to increased need for treatment; however, more work needs to be done to close behavioral health workforce gaps in areas with an elevated drug overdose mortality rate.

The effect of evictions on accidental drug and alcohol mortality.

OBJECTIVE: To assess the relationship between county-level eviction rates and drug and alcohol mortality rates. DATA SOURCES: Eviction rates from 2003 to 2016 provided by the Princeton University Eviction Lab were merged with Multiple Cause-of-Death Mortality Files and aggregated to the county-year level. STUDY DESIGN: All opioid (prescription and heroin), cocaine, psychostimulant, benzodiazepine, antidepressant, and alcohol poisoning-related deaths per 100 000 people, eviction rates, and socioeconomic indicators were merged at the county-year level from 2003 to 2016. We estimated a series of mortality rate models with county and year fixed effects and used a control function (2SRI) method to adjust for the endogeneity of eviction rates. DATA COLLECTION/EXTRACTION METHODS: We matched retrospectively collected datasets. PRINCIPAL FINDINGS: Higher levels of eviction rates were consistently associated with higher rates of mortality across six of nine substance categories studied when all counties were combined. Subanalysis by USDA population density measures indicated this positive association was almost entirely driven by urban counties; few systematic associations between the eviction rate levels and mortality were observed for suburban or rural counties. CONCLUSIONS: Risk of eviction appears to exacerbate the current "deaths of despair" crisis associated with substance use. Proposed changes to Housing and Urban Development policy that are expected to substantially increase the risk of eviction may worsen an already-acute mortality crisis.

To attend or not to attend? The effect of school-immunization exemption policies on enrollment rates for prekindergarten, kindergarten and elementary aged youth.

There is no national immunization policy in the United States, and the strictness of regulations allowing vaccine exemption for school attendance varies greatly by state. Despite substantial evidence on the safety and health benefits of immunization, there has been a recent upsurge in skepticism amongst parents regarding vaccine safety and efficacy for their children. To measure the effect of strictness of immunization policy on enrollment rates for school aged children, we utilize fixed effects regression. We construct a panel of data on county level enrollment rate and county characteristics from the American Community Survey, and utilize a recently validated measure of state vaccination policy effectiveness to identify level of strictness amongst states. Given the positive effects early education has for a child's future, paired with the importance of public health, understanding these outcomes may be of interest to policymakers. We find that as children exit the 3-and 4-year-old age cohort and enter the 5-to 9-year-old cohort, stricter vaccination policy has a positive effect on overall enrollment and, specifically, public school enrollment. We also find that female 3-and 4-year-olds' enrollment is more negatively affected by policy strictness than their male counterpart's.

Better together: Coexistence of for-profit and nonprofit firms with an application to the U.S. hospice industry.

Many markets maintain a nontrivial mix of both nonprofit and for-profit firms, particularly in health care industries such as hospice, nursing homes, and home health. What are the effects of coexistence vs. dominance of one ownership type? We show how the presence of both ownership types can lead to greater diversity in consumer types served, even if both firms merely profit-maximize. This is the case where firms serve consumers for multiple consumption durations, but where donations are part of a nonprofit firm objective function and happen after services have been provided. This finding is strengthened if the good or service has value beyond immediate consumption or the direct consumer. We show these predictions empirically in the hospice industry, using data containing over 90 percent of freestanding U.S. hospices, 2000-2008. Nonprofit and for-profit providers split the patient market according to length of stay, leading to a wider range of patients being served than in the absence of this coexistence.

Provider-directed marketing may increase prescribing of medications for opioid use disorder.

BACKGROUND: Opioid use disorder (OUD) has become an increasingly grave public health concern, especially in the United States where approximately 80% of the global opioid supply is consumed. Despite greater awareness of the present overdose crisis, potentially life-saving OUD pharmacotherapy (medications for opioid use disorder or MOUD) utilization remains low. This study examines the extent of provider-directed marketing (detailing) for MOUD drugs and identifies any associations between a provider's receipt of detailing and their prescribing of MOUD drugs to Medicare Part D beneficiaries. METHOD: We combined Open Payments data on all provider-directed payments from pharmaceutical manufacturers with physician-level data on all MOUD prescriptions filled in Medicare Part D. We estimated the adjusted difference in Medicare days supply for all MOUD drugs (collectively) and separately for each MOUD drug that was associated with receipt of payments. RESULTS: The Open Payments data show that $7.0 million MOUD-specific promotional payments were made by pharmaceutical manufacturers to 12,056 US physicians from 2014 to 2016, which is <1/6th of the $50.3 million made in overall non-MOUD opioid-related promotional payments to 76,992 US physicians during that same period. Prescribers who received any MOUD-specific payments prescribed 1080 daily MOUD-related doses per year more than peers who did not receive any MOUD-specific payments (p < 0.001). The data also show the relatively greater association between receipt of detailing and Suboxone prescriptions compared to Vivitrol. CONCLUSIONS: Provider-directed marketing by MOUD manufacturers has been found to be significantly and positively associated with incidence of MOUD prescribing in Medicare Part D, as well as with the quantity of MOUD prescribed.