Xylazine, a veterinary analgesic sedative, is circulating in the illicit drug markets of at least 23 states including Illinois. We conducted a geographic analysis to better identify the spatial ...distribution of xylazine-involved fatal overdoses in Cook County, IL.
Cook County Medical Examiner Office’s (CCMEO) publicly available data was used to identify xylazine-involved fatal overdoses from January 1, 2019, to June 30, 2022. Xylazine-positive (cases) to xylazine-negative groups with drug mixtures involving fentanyl, alcohol and stimulants (controls) were matched on age, race, sex, and year of death. Ripley’s K-function was used to examine the likelihood of case clustering compared to controls with the Bernoulli spatial scan deployed to identify specific geographic clusters.
Almost all (94.4%) xylazine-positive overdoses contained fentanyl. Using coordinate-based matching, we found that approximately 3% of xylazine overdose incidents were co-located with other overdoses. Xylazine cases clustered to from 0 to 16.1 miles (max=10.6 miles). Results of the Bernoulli spatial scan varied by control group with two high-risk clusters found relative to alcohol and stimulants and a low-risk cluster relative to fentanyl. Differences in co-occurring drugs were found between xylazine and fentanyl groups like the absolute number of drugs (4.6v 3.4, p<0.0001) and fentanyl analog types.
Xylazine fatal overdose incident locations exhibited localized clustering relative to fentanyl overdoses but clusters were not precisely detected at these scales. Even so, our results, especially relative to repeat overdose micro “hot spots”, offer insight on targeting harm reduction and other services at the neighborhood-level.
•Xylazine in fentanyl overdoses more than doubled in Cook County, IL from 2019 to 2022.•Xylazine overdoses occurred in closer proximity than fentanyl overdoses.•A southern area of the county with lower xylazine risk was identified.•Providing street addresses enables localized spatial analyses for overdose epidemiology.
Background/Objectives: Concurrent opioid (OPI) and benzodiazepine (BZD) use may exacerbate injurious fall risk (e.g., falls and fractures) compared to no use or use alone. Yet, patients may need ...concurrent OPI-BZD use for co-occurring conditions (e.g., pain and anxiety). Therefore, we examined the association between longitudinal OPI-BZD dosing patterns and subsequent injurious fall risk. Methods: We conducted a retrospective cohort study including non-cancer fee-for-service Medicare beneficiaries initiating OPI and/or BZD in 2016–2018. We identified OPI-BZD use patterns during the 3 months following OPI and/or BZD initiation (i.e., trajectory period) using group-based multi-trajectory models. We estimated the time to first injurious falls within the 3-month post-trajectory period using inverse-probability-of-treatment-weighted Cox proportional hazards models. Results: Among 622,588 beneficiaries (age ≥ 65 = 84.6%, female = 58.1%, White = 82.7%; having injurious falls = 0.45%), we identified 13 distinct OPI-BZD trajectories: Group (A): Very-low OPI-only (early discontinuation) (44.9% of the cohort); (B): Low OPI-only (rapid decline) (15.1%); (C): Very-low OPI-only (late discontinuation) (7.7%); (D): Low OPI-only (gradual decline) (4.0%); (E): Moderate OPI-only (rapid decline) (2.3%); (F): Very-low BZD-only (late discontinuation) (11.5%); (G): Low BZD-only (rapid decline) (4.5%); (H): Low BZD-only (stable) (3.1%); (I): Moderate BZD-only (gradual decline) (2.1%); (J): Very-low OPI (rapid decline)/Very-low BZD (late discontinuation) (2.9%); (K): Very-low OPI (rapid decline)/Very-low BZD (increasing) (0.9%); (L): Very-low OPI (stable)/Low BZD (stable) (0.6%); and (M): Low OPI (gradual decline)/Low BZD (gradual decline) (0.6%). Compared with Group (A), six trajectories had an increased 3-month injurious falls risk: (C): HR = 1.78, 95% CI = 1.58–2.01; (D): HR = 2.24, 95% CI = 1.93–2.59; (E): HR = 2.60, 95% CI = 2.18–3.09; (H): HR = 2.02, 95% CI = 1.70–2.40; (L): HR = 2.73, 95% CI = 1.98–3.76; and (M): HR = 1.96, 95% CI = 1.32–2.91. Conclusions: Our findings suggest that 3-month injurious fall risk varied across OPI-BZD trajectories, highlighting the importance of considering both dose and duration when assessing injurious fall risk of OPI-BZD use among older adults.
Early recognition and treatment are critical to improving sepsis outcomes. We sought to identify the frequency and types of encounters that patients have with the healthcare system in the week prior ...to a sepsis hospitalization.
PubMed, Cumulative Index to Nursing and Allied Health Literature, Scopus, and the Cochrane Library.
Observational cohort studies of patients hospitalized with sepsis or septic shock that were assessed for an outpatient or emergency department encounter with the healthcare system in the week prior to hospital admission.
The primary outcome was the proportion of patients with a healthcare encounter in the time period assessed (up to 1 week) prior to a hospitalization with sepsis.
Six retrospective observational studies encompassing 6,785,728 sepsis admissions were included for evaluation, ranging from a 263-patient single-center cohort to a large database evaluating 6,731,827 sepsis admissions. The average (unweighted) proportion of patients having an encounter with the healthcare system in the week prior to a sepsis hospitalization was 32.7% and ranged from 10.3% to 52.9%. These encounters commonly involved presentation or potential symptoms of infectious diseases, antibiotic prescriptions, and appeared to increase in frequency closer to a sepsis hospitalization admission. No consistent factors were identified that distinguished a healthcare encounter as more or less likely to precede a sepsis hospitalization in the subsequent week.
Patients that present to the hospital with sepsis are frequently evaluated in the healthcare system in the week prior to admission. Further research is necessary to understand if these encounters offer earlier opportunities for intervention to prevent the transition from infection to sepsis, whether they merely reflect the comorbidities of sepsis patients with a high baseline rate of healthcare encounters, or the declining trajectory of a patient's overall health in response to infection.
To evaluate changes in monthly buprenorphine dispensation associated with federal prescribing policies in Washington State from 2012 to 2022.
We conducted an interrupted time series analysis ...comparing monthly buprenorphine prescriptions dispensed per 1000 population after the Comprehensive Addiction and Recovery Act (CARA), Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT), and new prescribing rules during the COVID-19 pandemic. Buprenorphine formulated for opioid use disorder was included from the Washington State Prescription Monitoring Program. A log-linear autoregressive model measured linear trend changes.
Physician prescribing increased by 1.63% (95% confidence interval CI = 1.41%, 1.85%) per month after CARA with sustained declines after SUPPORT. Nurse practitioner (NP) prescribing increased by 19.48% (95% CI = 18.8%, 20.16%) per month after CARA with physician assistants (PAs) showing similar trends. Following the implementation of SUPPORT, NP and PA trends continued to increase at a reduced growth rate of 3.96% (95% CI = 2.01%, 5.94%) and 1.87% (95% CI = 0.56%, 3.19%), respectively. No prescribers experienced increases during the COVID-19 pandemic.
CARA nearly tripled the buprenorphine prescribing rate. The SUPPORT Act initiated sustained declines for physician prescribing, and the COVID-19 period reversed gains for PAs and NPs. The current opioid crisis requires expanded efforts in Washington State. (
. Published online ahead of print May 2, 2024:e1-e9. https://doi.org/10.2105/AJPH.2024.307649).
Nearly every U.S. state operates a prescription drug monitoring program (PDMP) to monitor dispensing of controlled substances. These programs are often considered key policy levers in the ongoing ...polydrug epidemic. Recent years have seen rapid growth of peer-reviewed literature examining PDMP consultation and the impacts of these programs on diverse patient populations and health outcomes. This literature synthesis presents a review of studies published from June 2018 to December 2019 and provides relevant updates from the perspective of three researchers in this field.
The analyzed studies were primarily distributed across three overarching research focus areas: outcome evaluations (n = 29 studies), user surveys (n = 23), and surveillance (n = 22). Identified themes included growing awareness of the unintended consequences of PDMPs on access to opioids, effects on benzodiazepines and stimulant prescribing, challenges with workflow integration across multiple specialties, and new opportunities for applied data science.
There is a critical gap in existing PDMP literature assessing how these programs have impacted psychiatrists, their prescribing behaviors, and their patients. Although PDMPs have improved population-level monitoring of controlled substances from medical sources, their role in responding to a drug epidemic shifting to illicitly manufactured drugs is under scrutiny.
An important effect of the current opioid epidemic is on children whose parents are unable to provide appropriate care. We employ quarterly, county-level data for California for 2009–2016 to study ...the relationship between foster care entries and opioid misuse by their parents. Our linear regression analysis includes both county and time fixed effects and controls related to child removal risk. We improve on the limited existing research in the area by analyzing higher frequency data, examining a proximal measure of opioid abuse, and allowing for differential associations by urbanicity. We found a positive association between the rate of child removals and the rate of residents who were cumulatively prescribed a high dose of opioids (>90 morphine milligram equivalents (MMEs) per day) during the quarter. A one standard deviation in this rate is associated with a roughly 9% increase in the overall removal rate. We further found that the association between removals and high MMEs is especially pronounced in rural areas and largely not existent in urban areas. Our results provide a more precise estimate of the relationship between the potential for opioid misuse and child welfare.
•Child welfare is an under-studied effect of opioid misuse.•We use quarterly, county-level data for California on child removals and opioid use.•We observe significant variation in opioid prescribing behavior across the state.•There is a positive association in rural counties adjacent to metropolitan areas.
Prescription drug monitoring programs (PDMPs) are a key component of the president's Prescription Drug Abuse Prevention Plan to prevent opioid overdoses in the United States.
To examine whether PDMP ...implementation is associated with changes in nonfatal and fatal overdoses; identify features of programs differentially associated with those outcomes; and investigate any potential unintended consequences of the programs.
Eligible publications from MEDLINE, Current Contents Connect (Clarivate Analytics), Science Citation Index (Clarivate Analytics), Social Sciences Citation Index (Clarivate Analytics), and ProQuest Dissertations indexed through 27 December 2017 and additional studies from reference lists.
Observational studies (published in English) from U.S. states that examined an association between PDMP implementation and nonfatal or fatal overdoses.
2 investigators independently extracted data from and rated the risk of bias (ROB) of studies by using established criteria. Consensus determinations involving all investigators were used to grade strength of evidence for each intervention.
Of 2661 records, 17 articles met the inclusion criteria. These articles examined PDMP implementation only (n = 8), program features only (n = 2), PDMP implementation and program features (n = 5), PDMP implementation with mandated provider review combined with pain clinic laws (n = 1), and PDMP robustness (n = 1). Evidence from 3 studies was insufficient to draw conclusions regarding an association between PDMP implementation and nonfatal overdoses. Low-strength evidence from 10 studies suggested a reduction in fatal overdoses with PDMP implementation. Program features associated with a decrease in overdose deaths included mandatory provider review, provider authorization to access PDMP data, frequency of reports, and monitoring of nonscheduled drugs. Three of 6 studies found an increase in heroin overdoses after PDMP implementation.
Few studies, high ROB, and heterogeneous analytic methods and outcome measurement.
Evidence that PDMP implementation either increases or decreases nonfatal or fatal overdoses is largely insufficient, as is evidence regarding positive associations between specific administrative features and successful programs. Some evidence showed unintended consequences. Research is needed to identify a set of "best practices" and complementary initiatives to address these consequences.
National Institute on Drug Abuse and Bureau of Justice Assistance.
The U.S. Centers for Disease Control and Prevention recommend clinicians use Prescription Drug Monitoring Program (PDMPs) as a risk assessment tool for opioid-related harms. This survey assessed ...perceptions of PDMPs for the purpose of Neonatal Abstinence Syndrome (NAS) prevention among a national sample of obstetricians-gynecologists (OB/GYNs) who are the primary care providers for most pregnancies.
A survey was emailed to a random sample of active American College of Obstetricians and Gynecologists (ACOG) members. Proxy data for the intensity of the opioid epidemic and state policies related to NAS were added to respondents survey answers. Chi-squared analyses were used to compare response frequencies.
Among 397 submitted responses, nearly 70% identified PDMPs having a role in preventing diversion and opioid use disorders but only 25.1% identified PDMPs as a tool to prevent NAS. States with stricter NAS policies (e.g. child abuse, mandatory testing) generally had higher positive responses for PDMPs’ role in preventing NAS. States with voluntary PDMP use versus mandatory reported higher positive responses for PDMPs with NAS but differences were not statistically significant (30.6% vs. 23.8%, p = 0.374). State-specific measures of the overall intensity of the opioid epidemic were not associated with perceptions of PDMP.
OB/GYNs do not associate PDMPs as a primary prevention tool against NAS despite endorsements. Tailored educational interventions to this practice environment are needed. Pharmacist engagement with pregnant patients and as champions of PDMP usage may help fill these gaps.
Public release of health data typically requires statistical disclosure limitation (SDL), but scant research demonstrates how real-world SDL affects data usability. Recent changes of federal data ...re-release policy allow a pseudo-counterfactual comparison of HIV and syphilis data suppression rules.
Incident counts (2019) of HIV and syphilis infections by county for Black and White populations were downloaded from the US Centers for Disease Control and Prevention. We quantified and compared suppression status by disease and county between Black and White populations and calculated incident rate ratios for counties with statistically reliable counts.
Approximately 50% of US counties have incident HIV counts suppressed for Black and White populations compared with only 5% for syphilis, which has an alternative suppression strategy. The county population sizes protected by a numerator disclosure rule (<4) spans several orders of magnitude. Calculations of incident rate ratios, used as a measure of health disparity, were impossible in the 220 counties most susceptible to an HIV outbreak.
Balancing tradeoffs between providing and protecting data are key to health initiatives worldwide. We encourage an increase in empirical research on the impact of SDL, especially in the context of health disparities, and recommend new approaches to avoid the "oppression of data suppression."
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