Local exposure to school shootings and youth antidepressant use.

While over 240,000 American students experienced a school shooting in the last two decades, little is known about the impacts of these events on the mental health of surviving youth. Using large-scale prescription data from 2006 to 2015, we examine the effects of 44 school shootings on youth antidepressant use. Our empirical strategy compares the number of antidepressant prescriptions written by providers practicing 0 to 5 miles from a school that experienced a shooting (treatment areas) to the number of prescriptions written by providers practicing 10 to 15 miles away (reference areas), both before and after the shooting. We include month-by-year and school-by-area fixed effects in all specifications, thereby controlling for overall trends in antidepressant use and all time-invariant differences across locations. We find that local exposure to fatal school shootings increases youth antidepressant use by 21.4% in the following 2 y. These effects are smaller in areas with a higher density of mental health providers who focus on behavioral, rather than pharmacological, interventions.

Enrollment Brokers Did Not Increase Medicaid Enrollment, 2008-18.

Between 2008 and 2018, six states and Washington, D.C., began contracting with enrollment brokers to facilitate enrollment into Medicaid, joining the eighteen states that already had such contracts in place as of 2008. Using newly collected data covering all contracts between state Medicaid agencies and independent enrollment brokers during this period, we compared changes in Medicaid participation following the initiation of contracts with enrollment brokers with contemporaneous changes in Medicaid participation in states that never contracted with brokers. We found that contract initiation had no statistically significant effects on state-level Medicaid participation. We further found no evidence of other enrollment-related benefits, such as improved application processing times.

Prescribing of Opioid Analgesics and Buprenorphine for Opioid Use Disorder During the COVID-19 Pandemic.

Importance: The COVID-19 pandemic disrupted medical care, impacting prescribing of opioid analgesics and buprenorphine for opioid use disorder. Understanding these patterns can help address barriers to care. Objective: To evaluate how prescribing of opioid analgesics and buprenorphine for opioid use disorder changed throughout the COVID-19 pandemic among both new and existing patients. Design, Setting, and Participants: In this cross-sectional study, use of opioid analgesics and buprenorphine for opioid use disorder from March 18 to September 1, 2020, was projected using a national database of retail prescriptions from January 1, 2018, to March 3, 2020. Actual prescribing was compared with projected levels for all, existing, and new patients. Exposures: The data include prescriptions to patients independent of insurance status or type and cover 90% of retail prescriptions, 70% of mail-order prescriptions, and 70% of nursing home prescriptions. Main Outcomes and Measures: Prescriptions for opioid analgesics and buprenorphine for opioid use disorder. Outcomes included total number of prescriptions, total morphine milligram equivalents, mean morphine milligram equivalents per prescription, mean dispensed units per prescription, and number of patients filling prescriptions. Results: A total of 452 691 261 prescriptions for opioid analgesics and buprenorphine for opioid use disorder were analyzed for 90 420 353 patients (50 921 535 female patients [56%]; mean [SD] age, 49 [20] years). From March 18 to May 19, 2020, 1877 million total morphine milligram equivalents of opioid analgesics were prescribed weekly vs 1843 million projected, a ratio of 102% (95% prediction interval [PI], 94%-111%; P = .71). The weekly number of opioid-naive patients receiving opioids was 370 051 vs 564 929 projected, or 66% of projected (95% PI, 63%-68%; P < .001). Prescribing of buprenorphine was as projected for existing patients, while the number of new patients receiving buprenorphine weekly was 9865 vs 12 008 projected, or 82% (95% PI, 76%-88%; P < .001). From May 20 to September 1, 2020, opioid prescribing for new patients returned to 100% of projected (95% PI, 96%-104%; P = .95), while the number of new patients receiving buprenorphine weekly was 10 436 vs 11 613 projected, or 90% (95% PI, 83%-97%; P = .009). Conclusions and Relevance: In this cross-sectional study, existing patients receiving opioid analgesics and buprenorphine for opioid use disorder generally maintained access to these medications during the COVID-19 pandemic. Opioid prescriptions for opioid-naive patients decreased briefly and then rebounded, while initiation of buprenorphine remained at a low rate through August 2020. Reductions in treatment entry may be associated with increased overdose deaths.

Just what the nurse practitioner ordered: Independent prescriptive authority and population mental health.

We examine whether relaxing occupational licensing to allow nurse practitioners (NPs)-registered nurses with advanced degrees-to prescribe medication without physician oversight improves population mental health. Exploiting time-series variation in independent prescriptive authority for NPs from 1990 to 2014, we find that broadening prescriptive authority leads to improvements in self-reported mental health and decreases in mental health-related mortality. These improvements are concentrated in areas that are underserved by physicians and among populations that have difficulty accessing physician-provided care. Our results demonstrate that extending independent prescriptive authority to NPs can help mitigate physician shortages and extend care to disadvantaged populations.

ADDRESSING THE OPIOID EPIDEMIC: IS THERE A ROLE FOR PHYSICIAN EDUCATION?

Using national data on opioid prescriptions written by physicians from 2006 to 2014, we uncover a striking relationship between opioid prescribing and medical school rank. Even within the same specialty and practice location, physicians who completed their initial training at top medical schools write significantly fewer opioid prescriptions annually than physicians from lower ranked schools. Additional evidence suggests that some of this gradient represents a causal effect of education rather than patient selection across physicians or physician selection across medical schools. Altering physician education may therefore be a useful policy tool in fighting the current epidemic.