Association of a novel restrictive housing diversion program with rates of mental health and self-injury in prison.

Restrictive housing for control purposes (RHCP, a form of solitary confinement) is used in prisons in response to disruptive behaviors, including violence. North Carolina prisons introduced the rehabilitative diversion unit (RDU) in 2016 as an alternative to and step-down from RHCP. We compared rates of psychiatric treatment and self-injury among men enrolled in the RDU and men eligible for the RDU but placed in RHCP. We used Poisson regression to calculate rate ratios (RRs) and 95% confidence intervals (CIs) for these outcomes, using inverse probability of treatment weights to adjust for confounders. The cohort included 1,225 men in the RDU group and 3,059 in the RHCP group. In RHCP, the adjusted psychiatric treatment rate was 2.6 times (95% CI: 1.8, 3.8) and the adjusted self-injury incident rate was 1.2 times (95% CI: 0.6, 2.8) that in RDU. Nearly all self-injury incidents in RDU occurred during "non-participating time" (i.e., in a restrictive housing setting and not actively participating in RDU). After excluding non-participating time from the RDU group's person time, the adjusted RR for self-injury incidents was 23.5 (95% CI: 8.6, 64.2). These results further knowledge of potential benefits of diversion from restrictive housing. Continued development, implementation, and evaluation is needed.

Racial and ethnic disparities in motor vehicle crash-related outcomes in North Carolina surrounding the COVID-19 pandemic.

Long-term impacts of the COVID-19 pandemic on racial and ethnic disparities in motor vehicle crash (MVC) injuries and death are poorly understood. This study aimed to characterize trends and investigate the heterogeneity of MVC-related disparities in North Carolina across several data sources. Crash reports, emergency department visit records, and death certificates from 2018 to 2021 were used to calculate monthly population-rates of MVC-related public health outcomes. We estimated trendlines using joinpoint regression and compared outcomes across racial and ethnic classifications. MVC and MVC-related injury rates declined in conjunction with NC's stay-at-home order, while rates of severe outcomes remained unimpacted. By December 2021 rates of MVC-related outcomes met or exceeded pre-pandemic levels, with the highest rates observed among non-Hispanic Black individuals. Racial and ethnic disparities in MVC-related outcomes remained prevalent throughout the COVID-19 pandemic. These results highlight the importance of a holistic approach to traffic injury surveillance when assessing the impact of MVCs.

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

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

Public Health Involvement in United States' Vision Zero Initiatives: A Mixed-Methods Study.

CONTEXT: Vision Zero (VZ) aims to reduce fatalities and serious injuries from road traffic crashes to zero through multidisciplinary coordination. While public health officials are often recognized as critical to VZ, their involvement in VZ across the United States has not been quantified. OBJECTIVE: To explore how United States public health officials were involved in VZ development and implementation. DESIGN: We used a mixed-method design including a quantitative assessment of VZ plans and in-depth interviewing with VZ coordinators. SETTING: United States. PARTICIPANTS: Twenty-two in-depth interviews with municipal (n = 12) and regional (n = 10) VZ coordinators and 43 VZ plans were reviewed. MAIN OUTCOME MEASURE: Public health involvement in VZ development and implementation. RESULTS: In the United States, 64 municipalities and 21 regional entities had first-time VZ plans published between 2014 and 2022. We abstracted a sample of municipal (n = 22) and all (n = 21) regional plans. Most plans described key groups involved in plan development (municipal 81.8%, regional 100%). About two-thirds (67.4%; 59.1% municipal, 76.2% regional) of the plans noted public health officials in the plan development. Most plans described the principles forming the foundation of their plan (83.7%), but few mentioned public health as part of the plan principles (22.7% municipal, 14.3% regional). Public health officials were involved in engaging the community (9.1% municipal, 33.3% regional) and providing data (22.7% municipal, 52.4% regional) for plan development, as documented in the plans. For proposed implementation, public health officials were identified as involved in: community engagement (31.8% municipal, 42.9% regional), sharing/analyzing data (40.9% municipal, 33.3% regional), and identifying/providing funding sources (13.6% municipal, 4.8% regional). The in-depth interviews provided further context and a more detailed understanding of public health involvement in VZ. CONCLUSIONS: Evidence from the VZ plans and interviews provided examples of how public health officials engaged in the development and implementation of VZ initiatives.

Examining injury trends in parcel delivery drivers in the United States: Challenges and opportunities.

INTRODUCTION: Growth of e-commerce has caused a vast increase in parcel delivery, which raises concern for safety of drivers and other road users as more deliveries take place. METHODS: This project analyzes injury/illness and fatality trends among workers with delivery-related NAICS codes using three major sources of occupational hazard data in the United States: the Survey of Occupational Illnesses and Injuries, the Census of Fatal Occupational Injuries, and the Industrial Tracking Application. Descriptive statistics were employed to illustrate trends over time as well as to highlight opportunities for improved data collection and dissemination. RESULTS: The number of injuries to drivers has risen sharply over the past decade. Some of this increase appears due to growth of this industry, but increasing overall rates suggest the industry is becoming more hazardous. While nonfatal injuries were typically caused by continuous workplace exposures (e.g., repetitive strain, contact with object/equipment), fatalities were almost exclusively caused by transportation incidents. Additionally, crucial aspects of these trends are difficult or impossible to analyze given the current data landscape. CONCLUSIONS: Observed trends reinforce earlier calls for additional scrutiny of working conditions that threaten drivers. Injuries caused by transportation incidents are likely more severe than others and highlight the danger the transportation system poses to drivers and others. Current data collection and dissemination processes offer room to improve in terms of understanding how to prevent future injuries.

Association Between Medical Diagnoses and Suicide in a Medicaid Beneficiary Population, North Carolina 2014-2017.

BACKGROUND: Firearms are used in about half of U.S. suicides. This study investigated how various medical diagnoses are associated with firearm and nonfirearm suicide. METHODS: We used a case-control design including n = 691 North Carolina Medicaid beneficiaries who died from suicide between 1 January 2014 and 31 December 2017 as cases. We selected a total of n = 68,682 controls (~1:100 case-control ratio from North Carolina Medicaid member files using incidence density sampling methods). We linked Medicaid claims to the North Carolina Violent Death Reporting System to ascertain suicide and means (firearm or nonfirearm). We matched cases and controls on number of months covered by Medicaid over the past 36 months. Analyses adjusted for sex, race, age, Supplemental Security Income status, the Charlson Comorbidity Index, and frequency of health care encounters. RESULTS: The case-control odds ratios for any mental health disorder were 4.2 (95% confidence interval [CI]: 3.3, 5.2) for nonfirearm suicide and 2.2 (95% CI: 1.7, 2.9) for firearm suicide. There was effect measure modification by sex and race. Behavioral health diagnoses were more strongly associated with nonfirearm suicides than firearm suicide in men but did not differ substantially in women. The association of mental health and substance use diagnoses with suicides appeared to be weaker in Blacks (vs. non-Blacks), but the estimates were imprecise. CONCLUSION: Behavioral health diagnoses are important indicators of risk of suicide. However, these associations differ by means of suicide and sex, and associations for firearm-related suicide are weaker in men than women.

Sustained impacts of North Carolina prison therapeutic diversion units on behavioral outcomes, mental health, self-injury, and restrictive housing readmission.

Therapeutic Diversion Units (TDUs) in North Carolina prisons are intended to reduce cycling of individuals with mental health conditions through restrictive housing (i.e., solitary confinement). This paper investigates if previously identified benefits of TDU are sustained when individuals return to the general prison population. Using administrative data on 3170 people, we compare individuals placed in TDUs to TDU-eligible individuals (i.e., individuals with mental health needs) placed in restrictive housing. We use survival analysis methods to estimate hazard ratios (HRs) with confidence intervals (CIs), controlling for confounders. Compared to restrictive housing placement, TDU placement reduced the hazard of infractions (HR: 0.66; 95% CI: 0.52, 0.84) and subsequent restrictive housing placement (HR: 0.64; 95% CI: 0.55, 0.73) but increased the hazard of self-harm (HR: 2.67; 95% CI: 1.66, 4.29) upon program release to the general prison population. These findings suggest a need for additional investments and research on restrictive housing diversion programming, including post-diversion program supports.

Differences in overdose deaths by intent: Unintentional & suicide drug poisonings in North Carolina, 2015-2019.

Comprehensive fatal overdose prevention requires an understanding of the fundamental causes and context surrounding drug overdose. Using a social determinants of health (SDOH) framework, this descriptive study examined unintentional and self-inflicted (i.e., suicide) overdose deaths in North Carolina (NC), focusing on specific drug involvement and contextual factors. Unintentional and suicide overdose deaths were identified using 2015-2019 NC death certificate data. Specific drug involvement was assessed by searching literal text fields for drug mentions. County-level contextual factors were obtained from NC Institute of Medicine and County Health Rankings, encompassing five SDOH domains (economic stability, social/community context, health care access/quality, education access/quality, neighborhood/built environment). Descriptive statistics were calculated by intent for drug involvement and a variety of contextual factors. During 2015-2019, 9% of NC drug overdose deaths were self-inflicted and 89% were unintentional (2% other/undetermined). Unintentional overdoses largely involved illicit drugs [fentanyl (47%), cocaine (33%), heroin (29%)]. Suicide overdoses frequently involved prescription opioids [oxycodone (18%), hydrocodone (10%)] and antidepressants (32%). Overall, overdose deaths tended to occur in under-resourced counties across all SDOH domains, though unintentional overdoses occurred more often among residents of under-resourced counties than suicide overdoses, with differences most pronounced for economic stability-related factors. There are notable distinctions between unintentional and suicide overdose deaths in demographics and drug involvement, though the assessment of SDOH demonstrated that overdose mortality is broadly associated with marginalization across all domains. These findings highlight the value of allocating resources to prevention and intervention approaches that target upstream causes of overdose (e.g., housing first, violence prevention programs).

Suicide typologies among Medicaid beneficiaries, North Carolina 2014-2017.

BACKGROUND: There is a well-established need for population-based screening strategies to identify people at risk of suicide. Because only about half of suicide decedents are ever diagnosed with a behavioral health condition, it may be necessary for providers to consider life circumstances that may also put individuals at risk. This study described the alignment of medical diagnoses with life circumstances by identifying suicide typologies among decedents. Demographics, stressful life events, suicidal behavior, perceived and diagnosed health problems, and suicide method contributed to the typologies. METHODS: This study linked North Carolina Medicaid and North Carolina Violent Death Reporting System (NC-VDRS) data for analysis in 2020. For suicide decedents from 2014 to 2017 aged 25-54 years, we analyzed 12 indicators of life circumstances from NC-VDRS and 6 indicators from Medicaid claims, using a latent class model. Separate models were developed for men and women. RESULTS: Most decedents were White (88.3%), with a median age of 41, and over 70% had a health care visit in the 90 days prior to suicide. Two typologies were identified in both males (n = 175) and females (n = 153). Both typologies had similar profiles of life circumstances, but one had high probabilities of diagnosed behavioral health conditions (45% of men, 71% of women), compared to low probabilities in the other (55% of men, 29% of women). Black beneficiaries and men who died by firearm were over-represented in the less-diagnosed class, though estimates were imprecise (odds ratio for Black men: 3.1, 95% confidence interval: 0.8, 12.4; odds ratio for Black women: 5.0, 95% confidence interval: 0.9, 31.2; odds ratio for male firearm decedents: 1.6, 95% confidence interval: 0.7, 3.4). CONCLUSIONS: Nearly half of suicide decedents have a typology characterized by low probability of diagnosis of behavioral health conditions. Suicide screening could likely be enhanced using improved indicators of lived experience and behavioral health.

Association Between Medicaid Expansion and Suicide Mortality Among Nonelderly US Adults.

In 2014, the Affordable Care Act gave states the option to expand Medicaid coverage to nonelderly adults (persons aged 18-64 years) with incomes up to 138% of the federal poverty level. To our knowledge, the association of Medicaid expansion with suicide, a leading cause of death in the United States, has not been examined. We used 2005-2017 data from the National Violent Death Reporting System to analyze suicide mortality in 8 Medicaid expansion states and 7 nonexpansion states. Using a difference-in-differences approach, we examined the association between Medicaid expansion and the rate of suicide death (number of deaths per 100,000 population) among nonelderly adults. After adjustment for state-level confounders, Medicaid expansion states had 1.2 fewer suicide deaths (ß = -1.2, 95% confidence interval: -2.5, 0.1) per 100,000 population per year during the postexpansion period than would have been expected if they had followed the same trend in suicide rates as nonexpansion states. Medicaid expansion was associated with reductions in suicide rates among women, men, persons aged 30-44 years, non-Hispanic White individuals, and persons without a college degree. Medicaid expansion was not associated with a change in suicide rates among persons aged 18-29 or 45-64 years or among non-White or Hispanic individuals. Overall, Medicaid expansion was associated with reductions in rates of suicide death among nonelderly adults. Further research on inequities in Medicaid expansion benefits is needed.

Prenatal Use of Medication for Opioid Use Disorder and Other Prescription Opioids in Cases of Neonatal Opioid Withdrawal Syndrome: North Carolina Medicaid, 2016-2018.

Objectives. To estimate use of medication for opioid use disorder (MOUD) and prescription opioids in pregnancy among mothers of infants with neonatal opioid withdrawal syndrome (NOWS). Methods. We used linked 2016-2018 North Carolina birth certificate and newborn and maternal Medicaid claims data to identify infants with an NOWS diagnosis and maternal claims for MOUD and prescription opioids in pregnancy (n = 3395). Results. Among mothers of infants with NOWS, 38.6% had a claim for MOUD only, 14.3% had a claim for prescription opioids only, 8.1% had a claim for both MOUD and prescription opioids, and 39.1% did not have a claim for MOUD or prescription opioids in pregnancy. Non-Hispanic Black women were less likely to have a claim for MOUD than non-Hispanic White women. The percentage of infants born full term and normal birth weight was highest among women with MOUD or both MOUD and prescription opioid claims. Conclusions. In the 2016-2018 NC Medicaid population, 60% of mothers of infants with NOWS had MOUD or prescription opioid claims in pregnancy, underscoring the extent to which cases of NOWS may be a result of medically appropriate opioid use in pregnancy.

Congestion Pricing Policies and Safety Implications: a Scoping Review.

Congestion pricing policies (CPPs) are a common strategy for addressing urban traffic congestion. Research has explored several impacts of these policies (e.g., air quality, equity, congestion relief). The purpose of this review was to synthesize findings from publications examining CPP impacts on road user safety outcomes. We conducted a systematic search of relevant literature in four large research databases (Transport Research International Documentation, Web of Science, PubMed, and Scopus), searching from database inception through January 2021. We identified 18 eligible publications. Safety-related outcomes included overall crashes and injury crashes with stratification by injury severity and road user type (e.g., bicyclist, pedestrian). A majority of the publications examined zone-based CPPs (n = 13) and used observed data involving real policies (n = 10), as compared to a predicted or simulated analysis. Decreases in overall crashes and injuries for some road users were observed (e.g., car occupants). While some studies estimated short-term increases in injuries and crashes for bicyclists and motorcyclists (likely due to shifts from personal vehicle use to other transportation modes and increased exposure), most analyses focused on longer-term impacts and generally found a reversal and eventual decrease in injuries and crashes after a few years. The relative scarcity of safety outcomes in published literature, along with the wide breadth of CPP types, implementation contexts, and outcomes measured, demonstrates that more research on safety outcomes is needed. Cities and regions planning to implement CPPs should consider potential mode shifts and safety supports for all road users (e.g., bicycle and pedestrian infrastructure).

Quantifying cumulative anticholinergic and sedative drug load among US Medicare Beneficiaries.

PURPOSE: Medications with anticholinergic and sedative properties are widely used among older adults despite strong evidence of harm. The drug burden index (DBI), a pharmacological screening tool, measures these properties across drug classes, and higher DBI drug exposure (DBI > 1) has been associated with certain physical function-related adverse events. Our aim was to quantify mean daily DBI drug exposure among older adults in the United States (US). METHODS: We screened medications for DBI properties and operationalized the DBI for US Medicare claims. We then conducted a retrospective cohort study of a 20% random, nationwide sample of 4 137 384 fee-for-service Medicare beneficiaries aged 66+ years (134 757 039 person-months) from January 2013 to December 2016. We measured the monthly distribution based on mean daily DBI, categorized as (a) >0 vs 0 (any use) and (b) 0, 0 < DBI ≤ 1, 1 < DBI ≤ 2, and DBI > 2, and examined temporal trends. We described patient-level factors (eg, demographics, healthcare use) associated with high (>2) vs low (0 < DBI≤1) DBI drug exposure. RESULTS: The distribution of the mean daily DBI, aggregated at the month-level, was: 58.1% DBI = 0, 29.0% 0 < DBI≤1, 9.3% 1 < DBI≤2, and 3.7% DBI > 2. Predictors of high monthly DBI drug exposure (DBI > 2) included certain indicators of increased healthcare use (eg, high number of drug claims), white race, younger age, frailty, and a psychosis diagnosis code. CONCLUSIONS: The predictors of high DBI drug exposure can inform discussions between patients and providers about medication appropriateness and potential de-prescribing. Future Medicare-based studies should assess the association between the DBI and adverse events.

Adolescent and Adult Correlates of Prescription Opioid Use and Misuse in Adulthood: Associations Across Domains of Despair.

Objective: Given continued increases in "deaths of despair", there is a need to examine associations of factors across multiple domains of despair (i.e. cognitive, emotional, behavioral, biological) with opioid-related behaviors. An understanding of current and early life correlates of prescription opioid behaviors can help inform clinical care, public health interventions, and future life course research. Methods: Using data from Waves I (1994-1995; participants ages 12-18 years) and V (2016-2018; participants ages 34-42 years) of the National Longitudinal Study of Adolescent to Adult Health (N = 10,685), we examined adolescent and adult demographic, mental and physical health, substance use, and behavioral characteristics associated with past 30-day prescription opioid use only, misuse only, and both use and misuse to no recent use or misuse in adulthood. Results: Overall, 2.3% of adult participants reported past 30-day prescription opioid use only, 6.3% reported past 30-day misuse only, and 1.3% reported both prescribed use and misuse in the past 30 days. Physical health conditions in adolescence and adulthood were most common among those reporting use only and both use and misuse. Mental health conditions, other substance use, and delinquent behaviors in adolescence and adulthood were most common among those reporting misuse only and both use and misuse. Conclusions: Results from this nationally representative sample highlight the prevalence of specific prescription opioid behaviors and underscore the importance of targeting underlying drivers of prescription opioid use and misuse early in the life course. Continued implementation individual- and population-level approaches will be critical to addressing continued demand for opioids.

Integrating complex systems science into road safety research and practice, Part 2: applying systems tools to the problem of increasing pedestrian death rates.

OBJECTIVES: To provide a specific example of how systems dynamics tools can increase understanding of stakeholder 'mental models' and generate robust systems-based hypotheses about the escalating problem of rising pedestrian death rates in the USA. METHODS: We designed and facilitated two group model building (GMB) workshops. Participants generated causal loop diagrams (CLDs) individually and in small groups to explore hypotheses concerning time-dynamic interacting factors underlying the increasing rates of pedestrian deaths. Using a grounded theory approach, research team members synthesised the structures and hypotheses into a single CLD. RESULTS: CLDs from the 41 participants indicated four core factors hypothesised to have a direct impact on pedestrian fatalities: pedestrian-vehicle crashes, vehicle speed at the time of the crash, vehicle size/dimensions and emergency response time. Participants diagrammed how actions and reactions impacted these proximal factors over time and led to ripple effects throughout a larger system to generate an increase in pedestrian deaths. Hypothesised contributing mechanisms fell within the following broad categories: community responses; research, policy and industry influence; potential unintended consequences of responses to pedestrian deaths; and the role of sprawl. CONCLUSIONS: This application of systems science tools suggested several strategies for advancing injury prevention research and practice. The project generated robust hypotheses and advanced stakeholder communication and depth of understanding and engagement in this key issue. The CLD and GMB process detailed in this study provides a concrete example of how systems tools can be adopted and applied to a transportation safety topic.

Integrating complex systems science into road safety research and practice, part 1: review of formative concepts.

Many of our most persistent public health problems are complex problems. They arise from a web of factors that interact and change over time and may exhibit resistance to intervention efforts. The domain of systems science provides several tools to help injury prevention researchers and practitioners examine deep, complex and persistent problems and identify opportunities to intervene. Using the increase in pedestrian death rates as an example, we provide (1) an accessible overview of how complex systems science approaches can augment established injury prevention frameworks and (2) a straightforward example of how specific systems science tools can deepen understanding, with a goal of ultimately informing action.

Evaluation of a Medicaid Lock-in Program: Increased Use of Opioid Use Disorder Treatment but No Impact on Opioid Overdose Risk.

BACKGROUND: "Lock-in" programs (LIPs) identify beneficiaries demonstrating potential overutilization of opioids, and other controlled substances, and restrict their access to these medications. LIPs are expanding to address the opioid crisis and could be an effective tool for connecting people to opioid use disorder treatment. We examined the immediate and sustained effects of a Medicaid LIP on overdose risk and use of medication-assisted treatment (MAT) for opioid use disorder. METHODS: We analyzed North Carolina Medicaid claims from July 2009 through June 2013. We estimated daily risk differences and ratios of MAT use and overdose during lock-in and following release from the program, compared with periods before program enrollment. RESULTS: The daily probability of MAT use during lock-in and following release was greater, when compared with a period just before LIP enrollment [daily risk ratios: 1.50, 95% confidence interval (CI): 1.18-1.91; 2.27, 95% CI: 1.07-4.80; respectively]. Beneficiaries' average overdose risk while enrolled in the program and following release was similar to their risk just before enrollment (daily risk ratios: 1.01, 95% CI: 0.79-1.28; 1.12, 95% CI: 0.82-1.54; respectively). DISCUSSION: North Carolina's Medicaid LIP was associated with increased use of MAT during enrollment, and this increase was sustained in the year following release from the program. However, we did not observe parallel reductions in overdose risk during lock-in and following release. Identifying facilitators of MAT access and use among this population, as well as potential barriers to overdose reduction are important next steps to ensuring effective LIP design.

Methodologic limitations of prescription opioid safety research and recommendations for improving the evidence base.

PURPOSE: The ongoing opioid epidemic has claimed more than a quarter million Americans' lives over the past 15 years. The epidemic began with an escalation of prescription opioid deaths and has now evolved to include secondary waves of illicit heroin and fentanyl deaths, while the deaths due to prescription opioid overdoses are still increasing. In response, the Centers for Disease Control and Prevention (CDC) moved to limit opioid prescribing with the release of opioid prescribing guidelines for chronic noncancer pain in March 2016. The guidelines represent a logical and timely federal response to this growing crisis. However, CDC acknowledged that the evidence base linking opioid prescribing to opioid use disorders and overdose was grades 3 and 4. METHODS: Motivated by the need to strengthen the evidence base, this review details limitations of the opioid safety studies cited in the CDC guidelines with a focus on methodological limitations related to internal and external validity. RESULTS: Internal validity concerns were related to poor confounding control, variable misclassification, selection bias, competing risks, and potential competing interventions. External validity concerns arose from the use of limited source populations, historical data (in a fast-changing epidemic), and issues with handling of cancer and acute pain patients' data. We provide a nonexhaustive list of 7 recommendations to address these limitations in future opioid safety studies. CONCLUSION: Strengthening the opioid safety evidence base will aid any future revisions of the CDC guidelines and enhance their prevention impact.

Trajectories of dispensed prescription opioids among beneficiaries enrolled in a Medicaid controlled substance "lock-in" program.

PURPOSE: "Lock-in" programs (LIPs) are used by health insurers to address potential substance (eg, opioid) misuse among beneficiaries. We sought to (1) examine heterogeneity in trajectories of dispensed opioids (in average daily morphine milligram equivalents (MMEs)) over time: prior to, during, and following release from a LIP, and (2) assess associations between trajectory patterns and beneficiary characteristics. METHODS: Medicaid claims were linked to Prescription Drug Monitoring Program records for a cohort of beneficiaries enrolled in the North Carolina Medicaid LIP (n = 2701). Using latent class growth analyses, we estimated trajectories of average daily MMEs of opioids dispensed to beneficiaries across specific time periods of interest. RESULTS: Five trajectory patterns appeared to sufficiently describe underlying heterogeneity. Starting values and slopes varied across the 5 trajectory groups, which followed these overall patterns: (1) start at a high level of MMEs, end at a high level of MMEs (13.1% of cohort); (2) start medium, end medium (13.2%); (3) start medium, end low (21.5%); (4) start low, end medium (22.6%); and (5) start low, end low (29.6%). We observed strong associations between patterns and beneficiaries' demographics, substance use-related characteristics, comorbid conditions, and healthcare utilization. CONCLUSIONS: In its current form, the Medicaid LIP appeared to have limited impact on beneficiaries' opioid trajectories. However, strong associations between trajectory patterns and beneficiary characteristics provide insight into potential LIP design modifications that might improve program impact (eg, LIP integration of substance use disorder assessment and referral to treatment, assessment and support for alternate pain therapies).

Health Care Utilization and Comorbidity History of North Carolina Medicaid Beneficiaries in a Controlled Substance "Lock-in" Program.

BACKGROUND Medicaid "lock-in" programs (MLIPs) are a widely used strategy for addressing potential misuse of prescription drugs among beneficiary populations. However, little is known about the health care needs and attributes of beneficiaries selected into these programs. Our goal was to understand the characteristics of those eligible, enrolled, and retained in a state MLIP.METHODS Demographics, comorbidities, and health care utilization were extracted from Medicaid claims from June 2009 through June 2013. Beneficiaries enrolled in North Carolina's MLIP were compared to those who were MLIP-eligible, but not enrolled. Among enrolled beneficiaries, those completing the 12-month MLIP were compared to those who exited prior to 12 months.RESULTS Compared to beneficiaries who were eligible for, but not enrolled in the MLIP (N = 11,983), enrolled beneficiaries (N = 5,424) were more likely to have: 1) substance use (23% versus 14%) and mental health disorders, 2) obtained controlled substances from multiple pharmacies, and 3) visited more emergency departments (mean: 8.3 versus 4.2 in the year prior to enrollment). One-third (N = 1,776) of those enrolled in the MLIP exited the program prior to completion.LIMITATIONS Accurate information on unique prescribers visited by beneficiaries was unavailable. Time enrolled in Medicaid differed for beneficiaries, which may have led to underestimation of covariate prevalence.CONCLUSIONS North Carolina's MLIP appears to be successful in identifying subpopulations that may benefit from provision and coordination of services, such as substance abuse and mental health services. However, there are challenges in retaining this population for the entire MLIP duration.