Medications for Alcohol Use Disorder: Rates and Predictors of Prescription Order and Fill in Outpatient Settings.

BACKGROUND: Alcohol use disorders (AUD) are prevalent and responsible for substantial morbidity and mortality; yet efficacious treatments are underused. Previous studies have identified demographic and clinical predictors of medication fills, yet these studies typically do not include patients who were prescribed a medication but did not fill it. OBJECTIVES: To examine rates of and factors associated with prescription order and prescription fill for medications for AUD (MAUD) among individuals diagnosed with AUD in outpatient settings. DESIGN: In a cross-sectional analysis, we used multivariate logistic regression to identify factors associated with prescription order and fill. PATIENTS: We used data from the Optum Labs Data Warehouse that linked 2016-2021 de-identified claims and electronic health record (EHR) data, allowing us to observe prescription orders and whether they were filled. We identified 14,674 patients aged ≥ 18 who had an index outpatient encounter with an AUD diagnosis in the EHR. KEY MEASURES: We computed the proportion for whom a MAUD prescription was ordered within 1 year of index visit, and for whom one was filled within 30 days of the order. KEY RESULTS: 5.8% of the sample had a MAUD prescription order within 1 year of their index visit. Among those with an order, 87% filled their MAUD prescription within 30 days of receipt (i.e., 5.1% of full sample). After multivariable adjustment, receipt of a MAUD prescription order was more likely for patients who were female (adjusted odds ratio (aOR) [95%CI] = 1.44 [1.24-1.67]), or had moderate or severe AUD (1.74 [1.50-2.01]). Patients receiving an order were more likely to fill it if they had a comorbid mental disorder (1.64 [1.09-2.49]). CONCLUSIONS: The low rate of prescription orders was notable. Low use of MAUD appears to result chiefly from prescription order decisions, rather than from prescription fill decisions made by patients.

Changes in Healthcare Spending Attributable to High Deductible Health Plan Offer Among Enrollees with Comorbid Substance Use Disorder and Cardiovascular Disease.

BACKGROUND: The rise in prevalence of high deductible health plans (HDHPs) in the United States may raise concerns for high-need, high-utilization populations such as those with comorbid chronic conditions. In this study, we examine changes in total and out-of-pocket (OOP) spending attributable to HDHPs for enrollees with comorbid substance use disorder (SUD) and cardiovascular disease (CVD). METHODS: We used de-identified administrative claims data from 2007 to 2017. SUD and CVD were defined using algorithms of ICD 9 and 10 codes and HEDIS guidelines. The main outcome measures of interest were spending measure for all non-SUD/CVD-related services, SUD-specific services, and CVD-specific services, for all services and medications specifically. We assessed both total and OOP spending. We used an intent-to-treat two-part model approach to model spending and computed the marginal effect of HDHP offer as both the dollar change and percent change in spending attributable to HDHP offer. RESULTS: Our sample included 33,684 enrollee-years and was predominantly white and male with a mean age of 53 years. The sample had high demonstrated substantial healthcare utilization with 94% using any non-SUD/CVD services, and 84% and 78% using SUD and CVD services, respectively. HDHP offer was associated with a 17.0% (95% CI = [0.07, 0.27] increase in OOP spending for all non-SUD/CVD services, a 21.1% (95% CI = [0.11, 0.31]) increase in OOP spending for all SUD-specific services, and a 13.1% (95% CI = [0.04, 0.23]) increase in OOP spending for all CVD-specific services. HDHP offer was also associated with a significant increase in OOP spending on non-SUD/CVD-specific medications and SUD-specific medications, but not CVD-specific medications. CONCLUSIONS: This study suggests that while HDHPs do not change overall levels of annual spending among enrollees with comorbid CVD and SUD, they may increase the financial burden of healthcare services by raising OOP costs, which could negatively impact this high-need and high-utilization population.

Anxiety and Depression Symptoms After the Dobbs Abortion Decision.

Importance: In 2022, the US Supreme Court abolished the federal right to abortion in the Dobbs v Jackson Women's Health Organization decision. In 13 states, abortions were immediately banned via previously passed legislation, known as trigger laws. Objective: To estimate changes in anxiety and depression symptoms following the Dobbs decision among people residing in states with trigger laws compared with those without them. Design, Setting, and Participants: Using the nationally representative repeated cross-sectional Household Pulse Survey (December 2021-January 2023), difference-in-differences models were estimated to examine the change in symptoms of depression and anxiety after Dobbs (either the June 24, 2022, Dobbs decision, or its May 2, 2022, leaked draft benchmarked to the baseline period, prior to May 2, 2022) by comparing the 13 trigger states with the 37 nontrigger states. Models were estimated for the full population (N = 718 753), and separately for 153 108 females and 102 581 males aged 18 through 45 years. Exposure: Residing in states with trigger laws following the Dobbs decision or its leaked draft. Main Outcomes and Measures: Anxiety and depression symptoms were measured via the Patient Health Questionnaire-4 ([PHQ-4]; range, 0-12; scores of more than 5 indicate elevated depression or anxiety symptoms; minimal important difference unknown). Results: The survey response rate was 6.04% overall, and 87% of respondents completed the PHQ-4. The population-weighted mean age was 48 years (SD, 17 years), and 51% were female. In trigger states, the mean PHQ-4 scores in the baseline period and after the Dobbs decision were 3.51 (95% CI, 3.44 to 3.59) and 3.81 (95% CI, 3.75 to 3.87), respectively, and in nontrigger states were 3.31 (95% CI, 3.27 to 3.34) and 3.49 (95% CI, 3.45 to 3.53), respectively. There was a significantly greater increase in the mean PHQ-4 score by 0.11 (95% CI, 0.06 to 0.16; P < .001) in trigger states vs nontrigger states. From baseline to after the draft was leaked, the change in PHQ-4 was not significantly different for those in trigger states vs nontrigger states (difference-in-differences estimate, 0.09; 95% CI, -0.03 to 0.21; P = .15). From baseline to after the Dobbs opinion, there was a significantly greater increase in mean PHQ-4 scores for those in trigger states vs nontrigger states among females aged 18 through 45 years (difference-in-differences estimate, 0.23; 95% CI, 0.08 to 0.37; P = .002). Among males aged 18 through 45 years, the difference-in-differences estimate was not statistically significant (0.14; 95% CI, -0.08 to 0.36; P = .23). Differences in estimates for males and females aged 18 through 45 were statistically significant (P = .02). Conclusions and Relevance: In this study of US survey data from December 2021 to January 2023, residence in states with abortion trigger laws compared with residence in states without such laws was associated with a small but significantly greater increase in anxiety and depression symptoms after the Dobbs decision.

High-deductible Health Plans and Nonfatal Opioid Overdose.

OBJECTIVES: Opioid-related overdose is a public health emergency in the United States. Meanwhile, high-deductible health plans (HDHPs) have become more prevalent in the United States over the last 2 decades, raising concern about their potential for discouraging high-need populations, like those with opioid use disorder (OUD), from engaging in care that may mitigate the probability of overdose. This study assesses the impact of an employer offering an HDHP on nonfatal opioid overdose among commercially insured individuals with OUD in the United States. RESEARCH DESIGN: We used deidentified insurance claims data from 2007 to 2017 with 97,788 person-years. We used an intent-to-treat, difference-in-differences regression framework to estimate the change in the probability of a nonfatal opioid overdose among enrollees with OUD whose employers began offering an HDHP insurance option during the study period compared with the change among those whose employer never offered an HDHP. We also used an event-study model to account for dynamic time-varying treatment effects. RESULTS: Across both comparison and treatment groups, 2% of the sample experienced a nonfatal opioid overdose during the study period. Our primary model and robustness checks revealed no impact of HDHP offer on the probability of a nonfatal overdose. CONCLUSIONS: Our study suggests that HDHP offer was not associated with an observed increase in the probability of nonfatal opioid overdose among commercially insured person-years with OUD. However, given the strong evidence that medications for OUD (MOUD) can reduce the risk of overdose, research should explore which facets of insurance design may impact MOUD use.

Measurement Approaches to Estimating Methadone Continuity in Opioid Use Disorder Care.

BACKGROUND: Long-term treatment with medications for opioid use disorder (OUD), including methadone, is lifesaving. There has been little examination of how to measure methadone continuity in claims data. OBJECTIVES: To develop an approach for measuring methadone continuity in claims data, and compare estimates of methadone versus buprenorphine continuity. RESEARCH DESIGN: Observational cohort study using de-identified commercial claims from OptumLabs Data Warehouse (January 1, 2017-June 30, 2021). SUBJECTS: Individuals diagnosed with OUD, ≥1 methadone or buprenorphine claim and ≥180 days continuous enrollment (N=29,633). MEASURES: OUD medication continuity: months with any use, days of continuous use, and proportion of days covered. RESULTS: 5.4% (N=1607) of the study cohort had any methadone use. Ninety-seven percent of methadone claims (N=160,537) were from procedure codes specifically used in opioid treatment programs. Place of service and primary diagnosis codes indicated that several methadone procedure codes were not used in outpatient OUD care. Methadone billing patterns indicated that estimating days-supply based solely on dates of service and/or procedure codes would yield inaccurate continuity results and that an approach incorporating the time between service dates was more appropriate. Among those using methadone, mean [s.d.] months with any use, days of continuous use, and proportion of days covered were 4.8 [1.8] months, 79.7 [73.4] days, and 0.64 [0.36]. For buprenorphine, the corresponding continuity estimates were 4.6 [1.9], 80.7 [70.0], and 0.73 [0.35]. CONCLUSIONS: Estimating methadone continuity in claims data requires a different approach than that for medications largely delivered by prescription fills, highlighting the importance of consistency and transparency in measuring methadone continuity across studies.

Prescribing Medications for Alcohol Use Disorder: A Qualitative Study of Primary Care Physician Decision Making.

PURPOSE: Over 29 million Americans have alcohol use disorder (AUD). Though there are effective medications for AUD (MAUD) that can be prescribed within primary care, they are underutilized. We aimed to explore how primary care physicians familiar with MAUD make prescribing decisions and to identify reasons for underuse of MAUD within primary care. METHODS: We conducted semistructured interviews with 19 primary care physicians recruited from a large online database of medical professionals. Physicians had to have started a patient on MAUD within the last 6 months in an outpatient setting. Inductive and deductive thematic analysis was informed by the theory of planned behavior. RESULTS: Physicians endorsed that it is challenging to prescribe MAUD due to several reasons, including: (1) somewhat negative personal beliefs about medication effectiveness and likelihood of patient adherence; (2) competing demands in primary care that make MAUD a lower priority; and, (3) few positive subjective norms around prescribing. To make MAUD prescribing a smaller component of their practice, physicians reported applying various rules of thumb to select patients for MAUD. These included recommending MAUD to the patients who seemed the most motivated to reduce drinking, those with the most severe AUD, and those who were also receiving other treatments for AUD. CONCLUSIONS: There is a challenging implementation context for MAUD due to competing demands within primary care. Future research should explore which strategies for identifying a subset of patients for MAUD are the most appropriate and most likely to improve population health and health equity.

Perspectives of U.S. harm reduction advocates on persuasive message strategies.

BACKGROUND: The messages used to communicate about harm reduction are critical in garnering public support for adoption of harm reduction interventions. Despite the demonstrated effectiveness of harm reduction interventions at reducing overdose deaths and disease transmission, the USA has been slow to adopt harm reduction to scale. Implementation of evidence-based interventions has been hindered by a historical framing of drug use as a moral failure and related stigmatizing attitudes among the public toward people who use drugs. Understanding how professional harm reduction advocates communicate to audiences about the benefits of harm reduction is a critical step to designing persuasive messaging strategies. METHODS: We conducted qualitative interviews with a purposively recruited sample of U.S. professional harm reduction advocates (N = 15) to examine their perspectives on which types of messages are effective in persuading U.S. audiences on the value of harm reduction. Participants were professionals working in harm reduction advocacy at national- or state-level organizations promoting and/or implementing harm reduction. Semi-structured interviews were audio-recorded, transcribed, and analyzed using a hybrid inductive/deductive approach. RESULTS: Interviewees agreed that messages about the scientific evidence demonstrating the effectiveness of harm reduction approaches are important but insufficient, on their own, to persuade audiences. Interviewees identified two overarching messaging strategies they perceived as persuasive: using messages about harm reduction that align with audience-specific values, for example centering the value of life or individual redemption; and positioning harm reduction as part of the comprehensive solution to current issues audiences are facing related to drug use and overdose in their community. Interviewees discussed tailoring messages strategies to four key audiences: policymakers; law enforcement; religious groups; and the family and friends of people who use, or have used, drugs. For example, advocates discussed framing messages to law enforcement from the perspective of public safety. CONCLUSIONS: Interviewees viewed messages as most persuasive when they align with audience values and audience-specific concerns related to drug use and overdose death. Future research should test effectiveness of tailored messaging strategies to audiences using experimental approaches.

Impact of High Deductible Health Plans on Continuous Buprenorphine Treatment for Opioid Use Disorder.

BACKGROUND: Long-term, continuous treatment with medication like buprenorphine is the gold standard for opioid use disorder (OUD). As high deductible health plans (HDHPs) become more prevalent in the commercial insurance market, they may pose financial barriers to people with OUD. OBJECTIVE: To estimate the impact of HDHPs on continuity of buprenorphine treatment, concurrent visits for counseling/psychotherapy and OUD-related evaluation and management, and out-of-pocket spending. DESIGN: Difference-in-differences analysis comparing trends in outcomes among enrollees whose employers offer an HDHP (treatment group) to enrollees whose employers never offer an HDHP (comparison group). PARTICIPANTS: Enrollees with OUD from a national sample of commercial health insurance plans during 2007-2017 who initiate buprenorphine treatment. MAIN MEASURES: Number of days of continuous buprenorphine treatment; probabilities of continuous buprenorphine treatment ≥30, ≥90, ≥180, and ≥365 days; probability of concurrent (i.e., within the same month) behavioral therapy (i.e., counseling or psychotherapy); probability of concurrent OUD-related evaluation and management visits; proportions of buprenorphine treatment episodes with counseling/psychotherapy and evaluation and management visits; and out-of-pocket (OOP) spending on buprenorphine, behavioral therapy, and evaluation and management visits. KEY RESULTS: HDHPs were associated with an average increase of $98 (95% CI: $48, $150) on OOP spending on buprenorphine per treatment episode but no change in the number of days of continuous buprenorphine treatment or concurrent use of related services. CONCLUSIONS: HDHPs do not reduce continuity of buprenorphine treatment among commercially insured enrollees with OUD but may increase financial burden for this population.

Scaling Interventions to Manage Chronic Disease: Innovative Methods at the Intersection of Health Policy Research and Implementation Science.

Policy implementation is a key component of scaling effective chronic disease prevention and management interventions. Policy can support scale-up by mandating or incentivizing intervention adoption, but enacting a policy is only the first step. Fully implementing a policy designed to facilitate implementation of health interventions often requires a range of accompanying implementation structures, like health IT systems, and implementation strategies, like training. Decision makers need to know what policies can support intervention adoption and how to implement those policies, but to date research on policy implementation is limited and innovative methodological approaches are needed. In December 2021, the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness and the Johns Hopkins Center for Mental Health and Addiction Policy convened a forum of research experts to discuss approaches for studying policy implementation. In this report, we summarize the ideas that came out of the forum. First, we describe a motivating example focused on an Affordable Care Act Medicaid health home waiver policy used by some US states to support scale-up of an evidence-based integrated care model shown in clinical trials to improve cardiovascular care for people with serious mental illness. Second, we define key policy implementation components including structures, strategies, and outcomes. Third, we provide an overview of descriptive, predictive and associational, and causal approaches that can be used to study policy implementation. We conclude with discussion of priorities for methodological innovations in policy implementation research, with three key areas identified by forum experts: effect modification methods for making causal inferences about how policies' effects on outcomes vary based on implementation structures/strategies; causal mediation approaches for studying policy implementation mechanisms; and characterizing uncertainty in systems science models. We conclude with discussion of overarching methods considerations for studying policy implementation, including measurement of policy implementation, strategies for studying the role of context in policy implementation, and the importance of considering when establishing causality is the goal of policy implementation research.

Predictors of cancer screening among Black and White Maryland Medicaid enrollees with serious mental illness.

BACKGROUND: Cancer is the second leading cause of death for people with serious mental illness (SMI), such as schizophrenia and bipolar disorder. People with SMI receive cancer screenings at lower rates than the general population. AIMS: We sought to identify factors associated with cancer screening in a publicly insured population with SMI and stratified by race, a factor itself linked with differential rates of cancer screening. MATERIALS AND METHODS: We used Maryland Medicaid administrative claims data (2010-2018) to examine screening rates for cervical cancer (N = 40,622), breast cancer (N = 9818), colorectal cancer (N = 19,306), and prostate cancer (N = 4887) among eligible Black and white enrollees with SMI. We examined individual-level socio-demographic and clinical factors, including co-occurring substance use disorder, medical comorbidities, psychiatric diagnosis, obstetric-gynecologic and primary care utilization, as well as county-level characteristics, including metropolitan status, mean household income, and primary care workforce capacity. Generalized estimating equations with a logit link were used to examine the characteristics associated with cancer screening. RESULTS: Compared with white enrollees, Black enrollees were more likely to receive screening for cervical cancer (AOR: 1.18; 95% CI: 1.15-1.22), breast cancer (AOR: 1.27; 95% CI: 1.19-1.36), and colorectal cancer (AOR: 1.07; 95% CI: 1.02-1.13), while similar rates were observed for prostate cancer screening (AOR: 1.06; 95% CI: 0.96-1.18). Primary care utilization and longer Medicaid enrollment were positively associated with cancer screening while co-occurring substance use disorder was negatively associated with cancer screening. CONCLUSION: Improving cancer screening rates among populations with SMI should focus on facilitating continuous insurance coverage and access to primary care.

Relationship between Drug Overdose Mortality and Coverage of Drug-Related Issues in US Television Political Campaign Advertising in the 2012 and 2016 Election Cycles.

CONTEXT: Understanding the role of drug-related issues in political campaign advertising can provide insight on the salience of this issue and the priorities of candidates for elected office. This study sought to quantify the share of campaign advertising mentioning drugs in the 2012 and 2016 election cycles and to estimate the association between local drug overdose mortality and drug mentions in campaign advertising across US media markets. METHODS: The analysis used descriptive and spatial statistics to examine geographic variation in campaign advertising mentions of drugs across all 210 US media markets, and it used multivariable regression to assess area-level factors associated with that variation. FINDINGS: The share of campaign ads mentioning drugs grew from 0.5% in the 2012 election cycle to 1.6% in the 2016 cycle. In the 2016 cycle, ads airing in media markets with overdose mortality rates in the 95th percentile were more than three times as likely to mention drugs as ads airing in areas with overdose mortality rates in the 5th percentile. CONCLUSIONS: A small proportion of campaign advertising mentioned drug-related issues. In the 2016 cycle, the issue was more prominent in advertising in areas hardest hit by the drug overdose crisis and in advertising for local races.

Effects of Maryland's Affordable Care Act Medicaid Health Home Waiver on Quality of Cardiovascular Care Among People with Serious Mental Illness.

BACKGROUND: Nineteen US states and D.C. have used the Affordable Care Act Medicaid health home waiver to create behavioral health home (BHH) programs for Medicaid beneficiaries with serious mental illness (SMI). BHH programs integrate physical healthcare management and coordination into specialty mental health programs. No studies have evaluated the effects of a BHH program created through the Affordable Care Act waiver on cardiovascular care quality among people with SMI. OBJECTIVE: To study the effects of Maryland's Medicaid health home waiver BHH program, implemented October 1, 2013, on quality of cardiovascular care among individuals with SMI. DESIGN: Retrospective cohort analysis using Maryland Medicaid administrative claims data from July 1, 2010, to September 30, 2016. We used marginal structural modeling with inverse probability of treatment weighting to account for censoring and potential time-dependent confounding. PARTICIPANTS: Maryland Medicaid beneficiaries with diabetes or cardiovascular disease (CVD) participating in psychiatric rehabilitation programs, the setting in which BHHs were implemented. To qualify for psychiatric rehabilitation programs, individuals must have SMI. The analytic sample included BHH and non-BHH participants, N = 2605 with diabetes and N = 1899 with CVD. MAIN MEASURES: Healthcare Effectiveness Data and Information Set (HEDIS) measures of cardiovascular care quality including annual receipt of diabetic eye and foot exams; HbA1c, diabetic nephropathy, and cholesterol testing; and statin therapy receipt and adherence among individuals with diabetes, as well as HEDIS measures of annual receipt of cholesterol testing and statin therapy and adherence among individuals with CVD. KEY RESULTS: Relative to non-enrollment, enrollment in Maryland's BHH program was associated with increased likelihood of eye exam receipt among individuals with SMI and co-morbid diabetes, but no changes in other care quality measures. CONCLUSIONS: Additional financing, infrastructure, and implementation supports may be needed to realize the full potential of Maryland's BHH to improve cardiovascular care for people with SMI.

Reducing Health-Related Stigma Through Narrative Messages.

Public stigma characterizes three leading health issues: prescription opioid addiction, obesity, and cigarette smoking. Attributions of individual responsibility are often embedded in negative public attitudes around these issues and can be important to stigma's development and reduction. Research suggests that narrative messages may hold promise for influencing attributions and stigma in these health contexts. Using a national sample of American adults from an online panel (N = 5,007), we conducted a survey-embedded randomized experiment, assigning participants to read one of six messages about one of three health issues. All participants read a statement detailing the magnitude of their assigned health problem, after which some respondents received a short inoculation message (serving as a comparison group) or a narrative message emphasizing external factors while acknowledging personal responsibility for the issue. Some participants also read a counter message emphasizing personal responsibility for the health issue to replicate competitive messaging environments surrounding these issues. Relative to those who received only the magnitude of problem message (comparison group 1) or the magnitude of problem and inoculation messages (comparison group 2), the narrative message reduced prescription opioid addiction stigma and increased attributions of responsibility to groups beyond the individual. Narrative effects were mixed for obesity, had no effect on attributions or stigma around cigarette smoking, and were generally consistent whether or not respondents received a counter message. Narrative messages may be a promising approach for shifting responsibility attributions and reducing public stigma around prescription opioid addiction, and may have some relevance for obesity stigma-reduction efforts.

The Policy Ecology of Behavioral Health Homes: Case Study of Maryland's Medicaid Health Home Program.

Behavioral health homes, shown to improve receipt of evidence-based medical services among people with serious mental illness in randomized clinical trials, have had limited results in real-world settings; nonetheless, these programs are spreading rapidly. To date, no studies have considered what set of policies is needed to support effective implementation of these programs. As a first step toward identifying an optimal set of policies to support behavioral health home implementation, we use the policy ecology framework to map the policies surrounding Maryland's Medicaid behavioral health home program. Results suggest that existing policies fail to address important implementation barriers.

Care Coordination and Population Health Management Strategies and Challenges in a Behavioral Health Home Model.

OBJECTIVES: Behavioral health home (BHH) models have been developed to integrate physical and mental health care and address medical comorbidities for individuals with serious mental illnesses. Previous studies identified population health management capacity and coordination with primary care providers as key barriers to BHH implementation. This study examines the BHH leaders' perceptions of and organizational capacity to conduct these functions within the community mental health programs implementing BHHs in Maryland. METHODS: Interviews and surveys were conducted with 72 implementation leaders and 627 front-line staff from 46 of 48 Maryland BHH programs. In-depth coding of the population health management and primary care coordination themes identified subthemes related to these topics. RESULTS: BHH staff described cultures supportive of evidence-based practices, but limited ability to effectively perform population health management or primary care coordination. Tension between population health management and direct, clinical care, lack of experience, and state regulations for service delivery were identified as key challenges for population health management. Engaging primary care providers was the primary barrier to care coordination. Health information technology and staffing were barriers to both functions. CONCLUSIONS: BHHs face a number of barriers to effective implementation of core program elements. To improve programs' ability to conduct effective population health management and care coordination and meaningfully impact health outcomes for individuals with serious mental illness, multiple strategies are needed, including formalized protocols, training for staff, changes to financing mechanisms, and health information technology improvements.

Stigmatizing language in news media coverage of the opioid epidemic: Implications for public health.

Public stigma toward people who use illicit drugs impedes advancement of public health solutions to the opioid epidemic and reduces willingness to seek addiction treatment. Experimental studies show that use of certain terms, such as "addict" and "substance abuser," exacerbate stigma while alternative terms, such as "person with a substance use disorder," are less stigmatizing. We examine the frequency with which stigmatizing terms and less-stigmatizing alternatives are used in U.S. news media coverage of the opioid epidemic. We analyzed 6399 news stories about the opioid epidemic published/aired by high-circulation and high-viewership U.S. national and regional print and television news outlets from July 2008 through June 2018. We calculated the proportion of news stories mentioning terms shown to be stigmatizing, as well as terms shown to be less-stigmatizing alternatives, in randomized experiments. Data was collected during May through August 2018 and analyzed in September 2018. Over the 10-year study period, 49% of news stories about the opioid epidemic mentioned any stigmatizing term and 2% mentioned any less-stigmatizing alternative. The proportion of news stories mentioning stigmatizing terms over the 10-year study period increased from 37% in July 2008-June 2009 to 45% in July 2017-June 2018. The language included in U.S. news media coverage of the opioid epidemic may contribute to and reinforce widespread public stigma toward people with opioid use disorders. This stigma may be a barrier to implementation of evidence-based interventions to prevent opioid overdose deaths. Establishing journalistic standards to de-stigmatize the language of addiction is a public health priority.

U.S. news media coverage of solutions to the opioid crisis, 2013-2017.

News media coverage of the U.S. opioid epidemic influences Americans' knowledge of and preferences for solutions to address the crisis. From 1998 to 2012, news media coverage of the opioid epidemic focused on criminal justice-oriented solutions. We examine whether and how news coverage of solutions has shifted in the recent years of the crisis. We analyzed a random sample of 600 U.S. news stories published/aired by high circulation/viewership national and local print and television news outlets from 2013 to 2017. We examined the proportion of news stories mentioning treatment, harm reduction, prevention, criminal justice, opioid prescribing, pharmaceutical manufacturer, insurer, and other solutions. News stories were coded using a structured coding instrument, and 200 news stories were double-coded to ensure interrater reliability. Data were collected and analyzed in 2018. Treatment (mentioned in 33% of news stories), harm reduction (30%), and prevention (24%) solutions were the most frequently mentioned types of solutions. Several evidence-based public health solutions received little news coverage: medication treatment for opioid use disorder was mentioned in 9% of news stories and the harm reduction solutions syringe services programs and safe consumption sites were mentioned in 5% and 2% of news stories. While news coverage showed a promising emphasis on public health-oriented solutions, efforts to increase news coverage of examples of effective opioid use disorder treatment and harm reduction solutions are needed.

The Differential Effects of Insurance Mandates on Health Care Spending for Children's Autism Spectrum Disorder.

OBJECTIVES: There is substantial variation in treatment intensity among children with autism spectrum disorder (ASD). This study asks whether policies that target health care utilization for ASD affect children differentially based on this variation. Specifically, we examine the impact of state-level insurance mandates that require commercial insurers to cover certain treatments for ASD for any fully-insured plan. METHODS: Using insurance claims between 2008 and 2012 from three national insurers, we used a difference-in-differences approach to compare children with ASD who were subject to mandates to children with ASD who were not. To allow for differential effects, we estimated quantile regressions that evaluate the impact of mandates across the spending distributions of three outcomes: (1) monthly spending on ASD-specific outpatient services; (2) monthly spending on ASD-specific inpatient services; and (3) quarterly spending on psychotropic medications. RESULTS: The change in spending on ASD-specific outpatient services attributable to mandates varied based on the child's level of spending. For those children with ASD who were subject to the mandate, monthly spending for a child in the 95th percentile of the ASD-specific outpatient spending distribution increased by $1460 (P<0.001). In contrast, the effect was only $2 per month for a child in the fifth percentile (P<0.001). Mandates did not significantly affect spending on ASD-specific inpatient services or psychotropic medications. CONCLUSIONS: State-level insurance mandates have larger effects for those children with higher levels of spending. To the extent that spending approximates treatment intensity and the underlying severity of ASD, these results suggest that mandates target children with greater service needs.

Public support for safe consumption sites and syringe services programs to combat the opioid epidemic.

We examine Americans' support for two evidence-based harm reduction strategies - safe consumption sites and syringe exchange programs - and their attitudes about individuals who use opioids. We conducted a web-based survey of a nationally representative sample of U.S. adults in July-August 2017 (N = 1004). We measured respondents' support for legalizing safe consumption sites and syringe services programs in their communities and their attitudes toward people who use opioids. We used ordered logistic regression to assess how stigmatizing attitudes toward people who use opioids, political party identification, and demographic characteristics correlated with support for the two harm reduction strategies. Twenty-nine percent of Americans supported legalizing safe consumption sites and 39% supported legalizing syringe services programs. Respondents reported high levels of stigmatizing attitudes toward people who use opioids: 16% of respondents were willing to have a person using opioids marry into their family and 28% were willing to have a person using opioids start working closely with them on a job, and 27% and 10% of respondents rated persons who use opioids as deserving (versus worthless) and strong (versus weak). Stigmatizing attitudes were associated with lower support for legalizing safe consumption sites and syringe services programs. Democrats and Independents were more likely than Republicans to support both strategies. Stigmatizing attitudes toward people who use opioids are a key modifiable barrier to garnering the public support needed to fully implement evidence-based harm reduction strategies to combat the opioid epidemic. Dissemination and evaluation of stigma reduction campaigns are a public health priority.