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Gun-related deaths and gun purchases were at record highs in 2020. In light of the COVID-19 pandemic, public protests against police violence, and a tense political environment, which may influence policy preferences, we aimed to understand the current state of support for gun policies in the U.S. We fielded a national public opinion survey in January 2019 and January 2021 using an online panel to measure support for 34 gun policies among U.S. adults. We compared support over time, by gun ownership status, and by political party affiliation. Most respondents supported 33 of the 34 gun regulations studied. Support for seven restrictive policies declined from 2019 to 2021, driven by reduced support among non-gun owners. Support declined for three permissive policies: allowing legal gun carriers to bring guns onto college campuses or K-12 schools and stand your ground laws. Public support for gun-related policies decreased from 2019 to 2021, driven by decreased support among Republicans and non-gun owners., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: Although high-deductible health plans (HDHPs) reduce health care spending, higher deductibles may lead to forgone care. Our goal was to determine the effects of HDHPs on the use of and spending on substance use disorder (SUD) services., Study Design: We used difference-in-differences models to compare service use and spending for treating SUD among enrollees who were newly offered an HDHP relative to enrollees offered only traditional plan options throughout the study period., Methods: We used deidentified commercial claims data from OptumLabs (2007-2017) to identify a sample of 28,717,236 person-years (2.2% with a diagnosed SUD). The main independent measure was an indicator for being offered an HDHP. The main dependent measures were the probability of (and spending associated with) using SUD services and specific treatment types., Results: Enrollees were 6.6% (P < .001) less likely to use SUD services after being offered an HDHP relative to the comparison group. Reductions were concentrated in inpatient, intermediate, and ambulatory care, as well as medication use. Being offered an HDHP was associated with a decrease of 21% (P < .001) on health plan spending and an increase of 14% (P < .01) on out-of-pocket spending., Conclusions: Offering an HDHP was associated with a reduction in SUD service use and a shift in spending from the plan to the enrollee. In the context of the US drug epidemic, these study findings highlight a concern that the movement toward HDHPs may be exacerbating undertreatment of SUD.

Drug criminalization creates significant barriers to prevention and treatment of substance use disorders and racial equity objectives, and removal of criminal penalties for drug possession is increasingly being endorsed by health and justice advocates. We present empirical data estimating the share of U.S. adults who support eliminating criminal penalties for possession of all illicit drugs, and examine factors associated with public support. Data from the Johns Hopkins COVID-19 Civic Life and Public Health Survey, a probability-based nationally representative sample of 1222 U.S. adults, was collected from November 11-30, 2020. Support for decriminalizing drug possession was assessed overall and by sociodemographic factors and attitudes towards politics and race. Correlates of support were examined using multivariable logistic regression. Thirty-five percent of adults supported eliminating criminal penalties for drug possession in the U.S. In adjusted regression models, respondents who were younger or identified as politically liberal were more likely to support decriminalization relative to other groups, and respondents who were Hispanic or identified strongly with their religious beliefs were less likely to support decriminalization. Among white respondents, greater racial resentment was strongly associated with reduced support for drug decriminalization. Support for drug decriminalization varies considerably by beliefs about politics and race, with racial resentment among white Americans potentially comprising a barrier to drug policy reform. Findings can inform communication and advocacy efforts to promote drug policy reform in the United States., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:, (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To measure associations between surgeons' examination performance and obtaining American Board of Surgery certification with the likelihood of having medical malpractice payments., Background: Further research is needed to establish a broader understanding of the association of board certification and patient and practice outcomes., Methods: Retrospective analysis using propensity score-matched surgeons who attempted to obtain American Board of Surgery certification. Surgeons who completed residency between 2000 and 2019 (n=910) and attempted to become certified were categorized as certified or failing to obtain certification. In addition, groups were categorized as either passing or failing their first attempt on the qualifying and certifying examinations. Malpractice payment reports were dichotomized for surgeons who either had a payment report or not., Results: The hazard rate (HR) of malpractice payment reports was significantly greater for surgeons who attempted and failed to obtain certification [HR=1.87; 95% confidence interval (CI), 1.28-2.74] than for surgeons who were certified. Moreover, surgeons who failed either the qualifying (HR=1.64; 95% CI, 1.14-2.37) or certifying examination (HR=1.72; 95% CI, 1.14-2.60) had significantly higher malpractice payment HRs than those who passed the examinations on their first attempt., Conclusions: Failing to obtain board certification was associated with a higher rate of medical malpractice payments. In addition, failing examinations in the certification examination process on the first attempt was also associated with higher rates of medical malpractice payments. This study provides further evidence that board certification is linked to potential indicators for patient outcomes and practice quality., Competing Interests: The authors report no conflicts of interest.

Importance: The rise in attacks on public health officials has weakened the public health workforce and complicated COVID-19 mitigation efforts., Objective: To examine the share of US adults who believed harassing or threatening public health officials because of COVID-19 business closures was justified and the factors shaping those beliefs., Design, Setting, and Participants: The Johns Hopkins University COVID-19 Civic Life and Public Health Survey was fielded from November 11 to 30, 2020, and July 26 to August 29, 2021. A nationally representative cohort of 1086 US adults was included., Main Outcomes and Measures: Respondents were asked how much they believed that threatening or harassing public health officials for business closures to slow COVID-19 transmission was justified. Adjusted differences in beliefs regarding attacks on public health officials were examined by respondent sociodemographic and political characteristics and by trust in science., Results: Of 1086 respondents who completed both survey waves, 565 (52%) were women, and the mean (SE) age was 49 (0.77) years. Overall, 177 respondents (16%) were Hispanic, 125 (11%) were non-Hispanic Black, 695 (64%) were non-Hispanic White, and 90 (8%) were non-Hispanic and another race. From November 2020 to July and August 2021, the share of adults who believed harassing or threatening public health officials because of business closures was justified rose from 20% (n = 218) to 25% (n = 276) (P = .046) and 15% (n = 163) to 21% (n = 232) (P = .01), respectively. In multivariable regression analysis, respondents who trusted science not much or not at all were more likely to view threatening public health officials as justified compared with who trusted science a lot (November 2020: 35% [95% CI, 21%-49%] vs 7% [95% CI, 4%-9%]; P < .001; July and August 2021: 47% [95% CI, 33%-61%] vs 15% [95% CI, 11%-19%]; P < .001). There were increases in negative views toward public health officials between November 2020 and July and August 2021, among those earning $75 000 or more annually (threatening justified: 7 [95% CI, 1-14] percentage points; P = .03), those with some college education (threatening justified: 6 [95% CI, 2-11] percentage points; P = .003), those identifying as politically independent (harassing justified: 9 [95% CI, 3-14] percentage points; P = .01), and those trusting science a lot (threatening justified: 8 [95% CI, 4-13] percentage points; P < .001)., Conclusions and Relevance: While antagonism toward public health officials was concentrated among those doubting science and groups most negatively affected by the pandemic (eg, those with lower income and less education), the findings of this study suggest that there has been a shift toward such beliefs within more economically advantaged subgroups and those more trusting of science. Restoring public trust in public health officials will require nuanced engagement with diverse groups.

Mask wearing and social distancing have been essential public health guidelines throughout the COVID-19 pandemic, but faced resistance from skeptical subgroups in the United States, including Republicans and evangelicals. We examined the effects of participation in ideologically heterogeneous civic associations on attitudes toward public health measures during the COVID-19 pandemic, particularly among partisan and religious subgroups most resistant to public health guidelines. We analyzed panel survey data from a nationally representative cohort of 1222 U.S. adults collected in April, July, and November 2020, and July/August 2021. Data on the importance of social distancing and mask wearing were collected in November 2020. Evangelicals and Republicans who participated in ideologically diverse civic associations were more likely to support mask wearing compared to those participating in ideologically homogenous associations (difference in predicted policy support on a 0-1 scale: 0.084, p ≤ .05 and 0.020, p ≤ .05, respectively). Evangelicals in ideologically diverse associations were also more likely to support social distancing compared to those in ideologically homogenous associations (0.089, p ≤ .05). Participation in civic associations with ideologically heterogeneous members was associated with greater support for public health measures among skeptical subgroups. Encouraging exposure to diverse ideologies may bolster support for public health measures to mitigate COVID-19., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: U.S. residents had varying experiences of the COVID-19 pandemic and social safety net policy in 2020. Past research has suggested that partisanship, ideology, racial attitudes, and personal experience may each influence policy attitudes. In this study, we explore whether variation in support for social safety net policy in 2020 is predicted by negative experiences of the pandemic when controlling for racial attitudes, partisanship, and ideology., Methods: Support for 12 social safety net policies in 2020 was estimated using data from a nationally representative panel survey of U.S. adults conducted in 2020 (n=1,222). Logistic regression was used to examine differences in the predicted probability of supporting a majority of social safety net policies related to health, housing, and employment by partisanship, ideology, racial attitudes, and negative experiences of the pandemic. Analyses were conducted in 2021., Results: Higher levels of symbolic racism was a consistently strong predictor of lower social safety net policy support across health, housing, and employment policies; as was identifying as either Conservative or Republican. Negative experiences of the pandemic were generally unpredictive of support for the social safety net policy., Conclusions: Despite the pandemic's consequences as well as the potential for social safety net policy to address these consequences, negative experiences of the pandemic failed to predict policy support, even as racial attitudes, partisanship, and ideology strongly predicted these preferences in 2020. Building public support for social safety net policy requires communication strategies that identify the shared benefits of these policies., (Copyright © 2022 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

This study sought to examine public support for gun carrying-related policies from 2019 to 2021, a period encompassing the COVID-19 pandemic and increasing calls for racial and social justice. We conducted the National Survey of Gun Policy in January 2019 and 2021. The surveys were fielded using the NORC AmeriSpeak panel. Respondents indicated support for six policies regulating civilian gun carrying. Analyses, conducted in 2021, incorporated survey weights for nationally representative estimates. There were significant declines in support from 2019 to 2021 for two policies that would expand where civilians can lawfully carry guns: allowing concealed carry when on K-12 school grounds (23% in 2021 vs 31% in 2019) and college/university campuses (27% vs 36%). Support was also significantly lower for requiring concealed carry applicants to pass a test demonstrating safe and lawful use (74% in 2021 vs 81% in 2019). For the two new policies in the 2021 survey, more than half of respondents overall supported prohibiting open carry at demonstrations/rallies (54%) and prohibiting the carry of guns into government buildings (69%). There was lower support among gun owners (39% and 57%, respectively). Since 2019, there has been a decline in support for expanding locations for civilian gun carrying. Support remains high among U.S. adults, including the two-thirds of gun owners, for requiring concealed carry applicants to demonstrate competence in safe and lawful gun use. Our findings in support of a more regulated approach to concealed carry are in direct contrast to state-level shifts eliminating concealed gun carrying regulations., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Although health coverage facilitates service access to adults in the general population, uncertainty exists over the extent to which this relationship extends to low-income adults with substance use disorders., Methods: The health status and service use patterns of low-income adults with substance use disorders who had continuous, discontinuous, and no past year health coverage were compared using data from the 2015-2019 National Survey on Drug Use and Health (NSDUH). The NSDUH is a nationally representative survey of the civilian non-institutionalized population., Results: In the weighted sample (unweighted n = 9243), approximately 65.66% of low-income adults with substance use disorders had continuous coverage, 17.03% had discontinuous coverage, and 17.31% had no insurance coverage during the past year. Although few group differences were observed in self-reported health status, the uninsured group compared to the discontinously and continuously covered groups, respectively, was less likely to report a past year substance use treatment visit (11.03% vs. 14.83% vs. 15.61%), an outpatient care visit (53.39% vs. 71.27% vs. 79.04%), an emergency department visit (33.33% vs. 45.76% vs. 45.57%), or an inpatient admission (9.24% vs. 15.11% vs. 15.58%)., Conclusions: Although the cross sectional design limits causal inferences, the correlations between lacking health insurance and low rates of substance use treatment and healthcare use raise the possibility that increasing healthcare coverage might increase access to substance use treatment and other needed healthcare services for low-income adults with substance use disorders., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: To examine the relationship between civic association participation and psychological distress during the COVID-19 pandemic, particularly whether different forms of engagement mitigate the increased rates of psychological distress throughout 2020., Methods: Panel survey data collected from a nationally representative cohort of 1222 U.S. adults. Data was collected in three waves in April, July, and November 2020. Psychological distress was measured using the validated Kessler-6 instrument in November 2020., Results: Respondents belonging to political associations were more likely to experience psychological distress (difference in predicted level of psychological distress on a 0-1 scale: 0.098, p ≤ .05) relative to those in unknown associations. However, individuals in political associations who more frequently interacted with others had lower levels of psychological distress (-.065, p ≤ .05) compared to those in political associations with less frequent interactions., Conclusions: Civic engagement that facilitates interpersonal interactions may protect against psychological distress., (© 2022. The Author(s).)

Rapidly rising drug overdose rates in the United States during the past decade underscore the need to increase access to treatment among people with substance use disorders (SUDs). We analyzed trends in the use of treatment services among people with SUDs during the period 2010-19, using data from the National Survey on Drug Use and Health. Compared with 2013, outpatient visits for general health in the prior year increased 3.6 percentage points by the 2017-19 period. Use of any SUD treatment in the prior year remained unchanged, but treatment use among people involved in the criminal legal system increased by about 6.2 percentage points by the end of the study period. Among those receiving SUD treatment, there was a 14.9-percentage-point increase in having treatment paid for by Medicaid between 2010-13 and 2017-19. Although access to general medical care and insurance coverage have improved for people with SUD, our study findings underscore the importance of renewed efforts to increase the use of SUD treatment.

Background: There is concern that state laws to curb opioid prescribing may adversely affect patients with chronic noncancer pain, but the laws' effects are unclear because of challenges in disentangling multiple laws implemented around the same time., Objective: To study the association between state opioid prescribing cap laws, pill mill laws, and mandatory prescription drug monitoring program query or enrollment laws and trends in opioid and guideline-concordant nonopioid pain treatment among commercially insured adults, including a subgroup with chronic noncancer pain conditions., Design: Thirteen treatment states that implemented a single law of interest in a 4-year period and unique groups of control states for each treatment state were identified. Augmented synthetic control analyses were used to estimate the association between each state law and outcomes., Setting: United States, 2008 to 2019., Patients: 7 694 514 commercially insured adults aged 18 years or older, including 1 976 355 diagnosed with arthritis, low back pain, headache, fibromyalgia, and/or neuropathic pain., Measurements: Proportion of patients receiving any opioid prescription or guideline-concordant nonopioid pain treatment per month, and mean days' supply and morphine milligram equivalents (MME) of prescribed opioids per day, per patient, per month., Results: Laws were associated with small-in-magnitude and non-statistically significant changes in outcomes, although CIs around some estimates were wide. For adults overall and those with chronic noncancer pain, the 13 state laws were each associated with a change of less than 1 percentage point in the proportion of patients receiving any opioid prescription and a change of less than 2 percentage points in the proportion receiving any guideline-concordant nonopioid treatment, per month. The laws were associated with a change of less than 1 in days' supply of opioid prescriptions and a change of less than 4 in average monthly MME per day per patient prescribed opioids., Limitations: Results may not be generalizable to non-commercially insured populations and were imprecise for some estimates. Use of claims data precluded assessment of the clinical appropriateness of pain treatments., Conclusion: This study did not identify changes in opioid prescribing or nonopioid pain treatment attributable to state laws., Primary Funding Source: National Institute on Drug Abuse.

Objective: High-deductible health plans (HDHPs) are increasingly common in the U.S. health insurance market and are intended to reduce the use of low-value services, but evidence suggests that HDHP enrollees also reduce the use of high-value services. This study examined the effects of HDHPs on enrollees with mental health conditions, a population with high levels of unmet treatment need, often because of financial barriers. Enrollees with a co-occurring substance use disorder have greater treatment needs and unique barriers to care, perhaps changing their response to an HDHP., Methods: Commercial health insurance claims data in a difference-in-differences design was used to evaluate the effect of an employer's offer of an HDHP on 6,627,128 enrollee-years among enrollees with mental health conditions, stratified by having a co-occurring substance use disorder or not., Results: Among enrollees without a co-occurring substance use disorder, an HDHP offer was associated with a 4.8% (95% confidence interval [CI]=2.4%-7.2%) reduction in overall spending on mental health care, despite an 11.3% (95% CI=1.0%-21.6%) increase in spending on mental health-related emergency department visits. Among enrollees with a co-occurring substance use disorder, no significant changes attributable to an HDHP offer were found in most categories of spending on combined mental health and substance use disorder care, apart from a 4.5% (95% CI=1.9%-7.2%) reduction in spending on psychotropic medications., Conclusions: HDHPs may reduce use of necessary care among enrollees with mental health conditions, which could exacerbate undertreatment in this population and result in adverse health outcomes.

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., (© 2021. Society of General Internal Medicine.)

Importance: Stigma toward people with opioid use disorder (OUD) is pervasive in clinical settings, impeding delivery of high-quality care. To date, no study has evaluated the effect of different stigma-reduction messages or messengers among health care professionals., Objective: To evaluate the effect of OUD-related messages delivered by different messengers on stigma and attitudes toward people with OUD among health care professionals., Design, Setting, and Participants: This randomized clinical trial examined the effects of OUD-related messages delivered by a visual campaign alone or in combination with a written narrative vignette from the perspective of 1 of 3 messengers. Health care professionals in the US were recruited from 2 national online survey panels (Ipsos KnowledgePanel and SurveyHealthcareGlobus). A total of 1842 participants completed a web-based survey measuring stigma toward people with OUD from November 13 to 30, 2020., Interventions: Eight groups were exposed to 1 of 2 message frames. One frame (Words Matter) emphasized the harm of stigmatizing language, and the other (Medication Treatment Works) focused on the effectiveness of medications approved by the US Food and Drug Administration for the treatment of OUD. Message frames were communicated through either a visual campaign alone or a visual campaign in combination with a written narrative vignette from the perspective of a simulated patient with OUD, a clinician, or a health care system administrator., Main Outcomes and Measures: Dimensions of stigma toward people with OUD were measured on 5-point Likert scales that included items about desire for social distance from people with OUD, perception of individual blame for OUD, perspective of OUD as a medical condition, and support for increased governmental spending on OUD treatment. The level of warmth felt toward people with OUD was measured by a feeling thermometer (range, 0-100 points)., Results: Among 1842 participants, the mean (SD) age was 47 (13) years; 1324 participants (71.9%) were female, 145 (7.9%) were Hispanic, 140 (7.6%) were non-Hispanic Black, 1344 (73.0%) were non-Hispanic White, and 213 (11.6%) were of other non-Hispanic race (ie, individuals who did not self-report race as Black or White and did not self-report ethnicity as Hispanic). Compared with nonexposure, exposure to the combination of visual campaign and narrative vignette communicating the importance of nonstigmatizing language from the perspective of a patient with OUD was associated with a lower probability (difference, -16.8 percentage points, 95% CI, -26.1 to -7.4; P < .001) of unwillingness to have a person with OUD marry into the family (a measure of social distance preference) and a 7.2-point (95% CI, 3.2-11.1; P < .001) higher warmth rating. Participants exposed to the combined visual campaign and patient vignette about the value of medication treatment for OUD also had significantly lower levels of stigma compared with those in the nonexposed control group (eg, unwillingness to have a person with OUD as a neighbor: difference, -15.3 percentage points; 95% CI, -24.6 to -6.0; P = .001)., Conclusions and Relevance: In this study, messages about nonstigmatizing language and effective medication for OUD reduced stigma among health care professionals. Stigma-reduction efforts targeting health care professionals may improve health care system capacity to serve people with OUD., Trial Registration: ClinicalTrials.gov Identifier: NCT05127707.

COVID-19 has stretched the U.S. social safety net and prompted federal legislation designed to ameliorate the pandemic's health and economic impacts. We surveyed a nationally representative cohort of 1222 U.S. adults in April 2020 and November 2020 to evaluate changes in public opinion about 11 social safety net policies and the role of government over the course of the pandemic. A majority of U.S. adults supported six policies at both time points, including policies guaranteeing two weeks of paid sick leave; enacting universal health insurance; increasing the federal minimum wage; and increasing government spending on construction projects, business tax credits, and employment education and training. From April to November 2020, public support was stable for nine of the 11 policies but declined nearly 10 percentage points for policies guaranteeing two weeks paid sick leave (from 76% support in April 2020 to 67% support in November 2020) and extending unemployment insurance benefits (51% to 42%). Declines in support for these two policies were concentrated among those with higher incomes, more education, in better health status, the employed, and those with health insurance. The share of respondents believing in a strong role of government also declined from 33% in April to 26% in November 2020 (p > 0.05). Despite these shifts, we observed consistent majority support for several policies enacted during the pandemic, including guaranteeing paid sick leave and business tax credits, as well as employment-related policies., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Travel distance to medication treatment for opioid use disorder (OUD) is a challenge for many patients, but little is known about how distance is associated with medication treatment utilization. This study examines the association between distance to the nearest physician waivered to prescribe buprenorphine and patient-level buprenorphine treatment among West Virginia Medicaid expansion enrollees with diagnosed OUD. Methods : We conducted a cross-sectional spatial analysis with 2016 Medicaid claims data, separately examining individuals living in metropolitan and non-metropolitan areas. We calculated the driving distance from the centroid of patients' residential ZIP codes to the street address of the nearest waivered physician derived from the 2015 Drug Enforcement Administration listing. Regression models examined the association between distance and initiation and duration of buprenorphine (among those initiating). Results : We focused on 8,008 individuals with OUD in 2016. The nearest waivered prescriber in metropolitan areas was an average of 7.13 miles away from patients' residential ZIP codes and 14.54 miles in non-metropolitan areas. The providers they actually visited were a mean of 33.63 miles away in metro areas and 46.36 in non-metropolitan areas. In multivariable analyses, compared to those living <10 miles from a waivered physician, living >20 miles from a waivered physician was associated with -32.13 fewer days of treatment (95% CI: -57.86, -6.40) in metro areas and -16.70 fewer days in non-metro areas (95% CI: -32.32, -1.08). Conclusions : Longer travel distance to buprenorphine treatment is associated with a shorter duration of care that is likely to be clinically meaningful.

Aims: To identify implementation barriers and facilitators to the adoption and implementation of programs that provide opioid agonist treatments (OAT) with methadone and buprenorphine to treat opioid use disorder in jails and prisons in the United States., Design: Qualitative analysis: semi-structured interviews were conducted and thematic analyses of transcripts and notes were performed using a hybrid inductive/deductive coding approach., Setting: Jails and prisons in the United States., Participants: From August 2019 to January 2020, we conducted 20 key informant interviews with 35 individuals representing 19 carceral systems that both initiate and maintain OAT., Measurements: Interviews covered four domains: (1) program adoption; (2) policy influence on implementation; (3) program structure; and (4) program outcomes., Findings: Stigma among staff, particularly medical staff, challenged program adoption, but reduced over time as staff were exposed to the program. Regulations on OAT dispensation, such as licensing requirements and prescribing limits, were key challenges to program implementation and shaped program structure. Dispensing medication required significant staff, time and space. Facilities were further challenged to overcome stigma and concerns about diversion, as OAT medication is often treated as contraband in carceral settings. Some systems deviated from evidence-based treatment by limiting OAT dosage to low levels, requiring counseling for participation and requiring detoxification before medication initiation. Despite these challenges, early adopters felt strongly that other jails and prisons in the United States should provide OAT and that legislation and litigation may soon force OAT expansion in these carceral settings., Conclusions: Despite identifying regulatory and logistical challenges, early adopters of opioid agonist treatment (OAT) programs in US jails and prisons demonstrate that OAT programs can successfully be implemented in carceral settings with tailoring to the specific context., (© 2021 Society for the Study of Addiction.)

Introduction: The COVID-19 pandemic has exacerbated longstanding housing precarity. This study measures the public support for policies designed to increase housing stability and gauges whether support levels are associated with views about the role of evictions in COVID-19 transmission and the existence of racial inequities in the housing market., Methods: A cross-sectional survey with a representative sample of U.S. adults in November 2020 assessed support for 4 housing policies. Logistic regression models estimated the adjusted levels of support for each policy, with separate models testing the association with whether or not a respondent recognized the role of evictions in increased COVID-19 transmission or acknowledged racial inequities in the housing market., Results: Most U.S. adults supported policies aimed to increase housing stability during the COVID-19 pandemic, including extending moratoriums on evictions (63%) and foreclosures (67%) and increasing emergency rental assistance (63%). In total, 54% supported increased government spending on housing vouchers. Adults who agreed that averting eviction would slow COVID-19 transmission had higher support for housing stability policies, as did those who agreed that it was easier for White families to find affordable, high-quality housing than Black families., Conclusions: Support for housing stability policies was strong among U.S. adults, particularly among those who agreed that preventing evictions slowed COVID-19 transmission and among those who acknowledged racial inequities in the housing market. Raising public awareness of the connections among unstable housing, infectious disease transmission, and racial inequity could broaden the support for policies to keep people in their homes through the pandemic., (Copyright © 2021. Published by Elsevier Inc.)

Purpose of Review: This review summarizes studies examining impacts of medical and recreational cannabis laws on opioid prescribing, opioid use, opioid use disorder, opioid-related service utilization, and opioid-involved mortality. We also discuss research challenges and recommendations for future work., Recent Findings: Twenty-one U.S. based studies published between 2014-2021 that assessed state cannabis laws' association with opioid-related outcomes were reviewed. Study results were largely inconclusive. We identified six challenges of existing work: 1) inability to directly measure cannabis/opioid substitution; 2) use of general population samples and lack of individual-level longitudinal studies; 3) challenges disentangling effects of cannabis laws from other state laws; 4) methodological challenges with staggered policy implementation; 5) limited consideration of cannabis law provisions; 6) lack of triangulation across data sources., Summary: While existing research suggests the potential for cannabis laws to reduce high-risk opioid prescribing and other opioid-related adverse outcomes, studies should be interpreted in light of limitations.

We sought to characterize gun and ammunition purchasing during the initial phase of the COVID-19 pandemic using a nationally representative sample of U.S. adults. We fielded a survey using NORC's Amerispeak Panel between 7 and 22 July 2020 (survey completion rate = 91.1%, N  = 1337). We used survey-weighted data to calculate the proportion of adults who purchased a gun during this time period and types of guns and amount of ammunition purchased. Between March and mid-July 2020, 6% of adults purchased a gun and 9% bought ammunition. Of those purchasing a gun, 34% were first-time purchasers. Among those purchasing ammunition, 19% reported purchasing more than usual in response to the COVID-19 pandemic while 27% purchased less than usual. An estimated 6,451,163 adults bought guns for the first time between March and mid-July 2020. Increases in gun purchasing, particularly among first-time gun owners, could pose significant short- and long-term implications for public health.

Background: Four million individuals in the U.S. criminal-legal system are supervised in the community under probation or parole. Sentences to community supervision often mandate participation in substance use treatment. Yet evidence-based treatment with medication (i.e., methadone, buprenorphine, or naltrexone) is rarely offered to people under community supervision with opioid use disorder (OUD). This qualitative study explores the structural and organizational factors shaping OUD medication treatment use in community supervision., Methods: We conducted in-depth interviews with 31 community supervision professionals. Thematic analysis characterized interview participants' perceptions of the key factors shaping use of OUD medications in community supervision., Findings: Findings indicate that authorities making decisions about OUD treatment include community supervision agencies, treatment providers, judges and courts, and jails and prisons. Agencies with more rehabilitative cultural orientations are more forgiving of relapse and supportive of OUD medications. Punishment/enforcement orientations align with an emphasis on surveillance and drug testing, which can inhibit medication treatment and interrupt continuity of care. Community supervision agencies generally reported deference to the recommendations of substance use treatment providers regarding the details of treatment, including the use of medication. Given that most treatment providers do not offer OUD medication, community supervision agencies must develop a sophisticated understanding of the various services offered by local treatment providers to tailor referrals accordingly, a responsibility for which they may be inadequately trained., Conclusions: Efforts to improve engagement with medication treatment in U.S. community supervision settings could have a significant impact on reincarceration, morbidity, and mortality among individuals with OUD under supervision., (Copyright © 2021. Published by Elsevier B.V.)

Objective: To Study the Outcomes of the First Virtual General Surgery Certifying Exam of the American Board of Surgery., Summary of Background Data: The ABS General Surgery CE is normally an in-person oral examination. Due to the COVID-19 outbreak, the ABS was required to reschedule these. After 2 small pilots, the CE's October administration represented the first large-scale remote virtual exam. The purpose of this report is to compare the outcomes of this virtual and the previous in-person CEs., Methods: CE candidates were asked to provide feedback on their experience via a survey. The passing rate was compared to the 1025 candidates who took the 2019-2020 in-person CEs., Results: Of the 308 candidates who registered for the virtual CE, 306 completed the exam (99.4%) and 188 completed the survey (61.4%). The majority had a very positive experience. They rated the virtual CE as very good/excellent in security (90%), ease of exam platform (77%), audio quality (71%), video quality (69%), and overall satisfaction (86%). Notably, when asked their preference, 78% preferred the virtual exam. There were no differences in the passing rates between the virtual or in-person exams., Conclusions: The first virtual CE by the ABS was completed using available internet technology. There was high satisfaction, with the majority preferring the virtual platform. Compared to past in-person CEs, there was no difference in outcomes as measured by passing rates. These data suggest that expansion of the virtual CE may be desirable., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: The authors report no conflicts of interest.

Objective: The authors assessed changes in health care coverage in nationally representative samples of low- and middle-income adults with and without substance use disorders following the 2014 Affordable Care Act marketplace launch and Medicaid expansion., Methods: Data from the 2012-2018 (N=407,985) National Survey on Drug Use and Health identified low- and middle-income nonelderly adults with alcohol, marijuana, cocaine, or heroin use disorders. A sociodemographically adjusted difference-in-differences analysis assessed the trends in Medicaid and individually purchased private insurance between adults with and without substance use disorders., Results: Between 2012-2013 and 2015-2016, the percentages without health insurance significantly declined for adults with substance use disorders (from 27.8% to 18.7%) and for those without these disorders (from 22.6% to 14.6%). These trends were related to gains in Medicaid and in individually purchased private insurance but not to gains in employer-based private insurance coverage. Between 2015-2016 and 2017-2018, however, the percentages without health insurance among adults with substance use disorders (18.7% to 18.4%) and without these disorders (14.7% to 14.7%) was little changed., Conclusions: With insurance gains having stalled and the downturn of the U.S. economy, there is renewed urgency to extend health care coverage to middle- and low-income adults with substance use disorders that meets their substance use and general health needs.

We sought to examine support for gun polices by race and ethnicity, and among gun owning subgroups. We combined two waves of the National Survey of Gun Policy (January 2017 and 2019 [N = 3804]). We used chi-square tests to assess whether support for gun policies differed by race or ethnicity overall and among subgroups of gun owners. Most U.S. adults supported 17 of 21 gun-related policies. Among gun owners, Blacks supported six policies at higher levels than whites, including minimum age requirements for gun ownership and assault weapon and ammunition-related restrictions. Hispanic gun owners supported safe storage requirements at higher levels than white gun owners. While support differed by race and ethnicity for some policies, majorities of U.S. adults supported nearly all gun policies examine regardless of race. One notable exception, carrying a concealed gun on K-12 school grounds did not reach majority support among any subgroup. While tailored messaging may be appropriate in certain circumstances, it is important to highlight the similarities in support for evidence-based gun polices across racial and ethnic groups., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Problems accessing affordable treatment are common among low-income adults with substance use disorders. A difference-in-differences analysis was performed to assess changes in insurance and treatment of low-income adults with common substance use disorders following the 2014 ACA Medicaid expansion, using data from the 2008-2017 National Surveys on Drug Use and Health. Lack of insurance among low-income adults with substance use disorders in expansion states declined from 34.8% (2012-2013) to 20.0% (2014-2015) to 13.5% (2016-2017) while Medicaid coverage increased from 24.8% (2012-2013) to 48.0% (2016-2017). In nonexpansion states, lack of insurance declined from 44.8% (2012-2013) to 34.2% (2016-2017) and Medicaid coverage increased from 14.3% (2012-2013) to 23.4% (2016-2017). Treatment rates remained low and little changed. Medicaid expansion contributed to insurance coverage gains for low-income adults with substance use disorders, although persistent treatment gaps underscore clinical and policy challenges of engaging these newly insured adults in treatment., (© 2020. National Council for Behavioral Health.)

Federal law places no regulations on unlicensed, private firearm sellers. However, a majority of the firearms used in crime come from these unregulated markets. This study aims to characterize the demographics of gun owners who engage in private sales, determine how often these individuals engage in selling behaviors, and ascertain whether sellers' attitudes are associated with their reported behaviors in the private market. A nationally representative web-based survey of 1444 gun owners, fielded in Spring 2016, were asked about their participation in the private market. The 238 respondents who participated in the private market were asked about their behavior on their last sale and the extent to which they felt it was the responsibility of sellers to ensure purchasers were legally able to own a firearm. Less than half of private gun sellers agreed that it is the seller's responsibility to ensure purchasers are eligible to buy guns (46%). Among private sellers, only 44% checked purchasers for eligibility and 32% denied a sale due to concerns about whether the firearm would be used safely. Sellers who agreed it was their responsibility to ensure purchasers were eligible to buy a gun had 4.52 (95% CI:1.78 to 11.5) times greater odds of reporting checking for a permit or conduct a background check on their last sale. it. These findings suggest a need for strategies to increase gun sellers' perceptions of responsibility for ensuring only eligible purchasers purchase guns, potentially including communication campaigns or educational programs., (Copyright © 2021 Elsevier Inc. All rights reserved.)

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., (Copyright © 2021 by Duke University Press.)

Context: Prior research suggests the potential for political campaign advertisements to increase psychological distress among viewers. The current study tests relationships between estimated exposure to campaign advertising and the odds of respondents reporting that a doctor told them they have anxiety, depression, insomnia, or (as a negative control) cancer., Methods: A secondary analysis of U.S. data on televised campaign ad airings from January 2015 to November 2016 (n = 4,659,038 airings) and five waves of a mail survey on television viewing patterns and self-reported medical conditions from November 2015 to March 2017 (n = 28,199 respondents from n = 16,204 unique households in the U.S.)., Findings: A 1 percent increase in the estimated volume of campaign advertising exposure was associated with a 0.06 [95% CI 0.03-0.09] percentage point increase in the odds of a respondent being told by a doctor that they have anxiety in the past 12 months. We observed this association regardless of the political party of the ad sponsor, the political party of the respondent, or their statistical interaction. We also observed this association for both Presidential campaign ads and non-Presidential (including local, state, and U.S. congressional election) campaign ads, providing evidence that these relationships were not driven by the unique divisiveness of the race between Donald Trump and Hilary Clinton. Some topic-specific models offered additional evidence of association between estimated volume of campaign advertising exposure and the odds of being told by a doctor that they have depression or insomnia, but these patterns were less consistent across models that utilized different categories of campaign exposure. Campaign ad exposure was not associated with cancer, which served as a negative control comparison., Conclusions: There was a consistent positive association between the volume of campaign advertising exposure and a reported diagnosis of anxiety among American adults., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objectives. To examine how sociodemographic, political, religious, and civic characteristics; trust in science; and fixed versus fluid worldview were associated with evolving public support for social distancing, indoor mask wearing, and contact tracing to control the COVID-19 pandemic. Methods. Surveys were conducted with a nationally representative cohort of US adults in April, July, and November 2020. Results. Support for social distancing among US adults dropped from 89% in April to 79% in July, but then remained stable in November 2020 at 78%. In July and November, more than three quarters of respondents supported mask wearing and nearly as many supported contact tracing. In regression-adjusted models, support differences for social distancing, mask wearing, and contact tracing were most pronounced by age, partisanship, and trust in science. Having a more fluid worldview independently predicted higher support for contact tracing. Conclusions. Ongoing resistance to nonpharmaceutical public health responses among key subgroups challenge transmission control. Public Health Implications. Developing persuasive communication efforts targeting young adults, political conservatives, and those distrusting science should be a critical priority.

Objectives: To characterize primary care physicians' (PCPs) attitudes and beliefs about people with opioid use disorder (OUD) and to understand the association between PCPs' stigmatizing attitudes and their OUD treatment practices, beliefs about treatment effectiveness, and support for policies designed to improve access to OUD medications., Methods: We conducted a national postal survey of U.S. PCPs from January to August 2019. Survey items measured respondents' attitudes, beliefs, and current treatment practices. Data were analyzed using descriptive statistics and logistic regression., Results: Of the original 1000 PCPs in the survey sample, 668 were deemed eligible to participate in the study. The survey was completed by 361 PCPs for an adjusted response rate of 54 %. PCPs reported high levels of stigmatizing attitudes. Less than 30 % of PCPs reported that they were willing to have a person taking medication for OUD as a neighbor or marry into their family, even if that person was being treated with medication. Greater stigma was associated with an 11 percentage point lower likelihood that PCPs prescribed OUD medication and lower support for policies intended to increase access to OUD medication., Conclusions: Addressing OUD stigma among PCPs is a public health priority in addressing the ongoing opioid crisis., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Thirty-three US states and Washington, D.C., have enacted medical cannabis laws allowing patients with chronic non-cancer pain to use cannabis, when recommended by a physician, to manage their condition. However, clinical guidelines do not recommend cannabis for treatment of chronic non-cancer pain due to limited and mixed evidence of effectiveness. How state medical cannabis laws affect delivery of evidence-based treatment for chronic non-cancer pain is unclear. These laws could lead to substitution of cannabis in place of clinical guideline-discordant opioid prescribing, reducing risk of opioid use disorder and overdose. Conversely, state medical cannabis laws could lead to substitution of cannabis in place of guideline-concordant treatments such as topical analgesics or physical therapy. This protocol describes a mixed-methods study examining the implementation and effects of state medical cannabis laws on treatment of chronic non-cancer pain. A key contribution of the study is the examination of how variation in state medical cannabis laws' policy implementation rules affects receipt of chronic non-cancer pain treatments., Methods: The study uses a concurrent-embedded design. The primary quantitative component of the study employs a difference-in-differences design using a policy trial emulation approach. Quantitative analyses will evaluate state medical cannabis laws' effects on treatment for chronic non-cancer pain as well as on receipt of treatment for opioid use disorder, opioid overdose, cannabis use disorder, and cannabis poisoning among people with chronic non-cancer pain. Secondary qualitative and survey methods will be used to characterize implementation of state medical cannabis laws through interviews with state leaders and representative surveys of physicians who treat, and patients who experience, chronic non-cancer pain in states with medical cannabis laws., Discussion: This study will examine the effects of medical cannabis laws on patients' receipt of guideline-concordant non-opioid, non-cannabis treatments for chronic non-cancer pain and generate new evidence on the effects of state medical cannabis laws on adverse opioid outcomes. Results will inform the dynamic policy environment in which numerous states consider, enact, and/or amend medical cannabis laws each year.

Importance: The coronavirus disease 2019 (COVID-19) pandemic has caused major disruptions in the US health care system., Objective: To estimate frequency of and reasons for reported forgone medical care from March to mid-July 2020 and examine characteristics of US adults who reported forgoing care., Design, Setting, and Participants: This survey study used data from the second wave of the Johns Hopkins COVID-19 Civic Life and Public Health Survey, fielded from July 7 to July 22, 2020. Respondents included a national sample of 1337 individuals aged 18 years or older in the US who were part of National Opinion Research Center's AmeriSpeak Panel., Exposures: The initial period of the COVID-19 pandemic in the US, defined as from March to mid-July 2020., Main Outcomes and Measures: The primary outcomes were missed doses of prescription medications; forgone preventive and other general medical care, mental health care, and elective surgeries; forgone care for new severe health issues; and reasons for forgoing care., Results: Of 1468 individuals who completed wave 1 of the Johns Hopkins COVID-19 Civic Life and Public Health Survey (70.4% completion rate), 1337 completed wave 2 (91.1% completion rate). The sample of respondents included 691 (52%) women, 840 non-Hispanic White individuals (63%), 160 non-Hispanic Black individuals (12%), and 223 Hispanic individuals (17%). The mean (SE) age of respondents was 48 (0.78) years. A total of 544 respondents (41%) forwent medical care from March through mid-July 2020. Among 1055 individuals (79%) who reported needing care, 544 (52%) reported forgoing care for any reason, 307 (29%) forwent care owing to fear of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission, and 75 (7%) forwent care owing to financial concerns associated with the COVID-19 pandemic. Respondents who were unemployed, compared with those who were employed, forwent care more often (121 of 186 respondents [65%] vs 251 of 503 respondents [50%]; P = .01) and were more likely to attribute forgone care to fear of SARS-CoV-2 transmission (78 of 186 respondents [42%] vs 120 of 503 respondents [24%]; P = .002) and financial concerns (36 of 186 respondents [20%] vs 28 of 503 respondents [6%]; P = .001). Respondents lacking health insurance were more likely to attribute forgone care to financial concerns than respondents with Medicare or commercial coverage (19 of 88 respondents [22%] vs 32 of 768 respondents [4%]; P < .001). Frequency of and reasons for forgone care differed in some instances by race/ethnicity, socioeconomic status, age, and health status., Conclusions and Relevance: This survey study found a high frequency of forgone care among US adults from March to mid-July 2020. Policies to improve health care affordability and to reassure individuals that they can safely seek care may be necessary with surging COVID-19 case rates.

Introduction: This study examines whether differences exist by sex in support for specific gun policies aimed at reducing gun violence., Methods: Investigators combined 2 waves of the National Survey of Gun Policy administered in January 2017 and January 2019. Data were analyzed in 2020. Opinions on 21 gun policies were examined. Respondents rated their support on a 5-point Likert scale ranging from strongly favor to strongly oppose. Somewhat favor and strongly favor were combined to create a dichotomous measure to indicate the proportion in favor of each policy. Respondents were categorized by their answer on the demographic profile as male or female and whether they personally owned a gun., Results: Women had higher levels of support than men for 20 of 21 policies, with 7 policies having a ≥10 percentage point difference in support. Differences in support between women and men who own guns were less pronounced. Only 3 of 21 policies had a ≥10 percentage point difference in support. Among women and men who do not personally own guns, 4 of 21 policies had a ≥10 percentage point difference in support., Conclusions: This survey is the first to explore differences in public support for specific gun policies between women and men. Policy support was substantially higher among women than men and higher among gun owners who are women compared with men. These findings provide important context for understanding differences in public opinion and suggest the need to tailor messages that will resonate within demographic groups., (Copyright © 2020 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives. To examine public support for health insurance, income support, and unemployment policies during the initial phase of disease transmission and economic distress following the coronavirus disease 2019 (COVID-19) outbreak and to assess varying public support based on beliefs about the role of government. Methods. We fielded a nationally representative survey of US adults (n = 1468) from April 7, 2020, to April 13, 2020. Results. Of US adults, 77% supported paid sick leave, and a majority also supported universal health insurance, an increased minimum wage, and various unemployment support policies. Public support for an active government role in society to improve citizens' lives increased by 10 percentage points during this initial pandemic response relative to September 2019. Belief in a strong governmental role in society was associated with greater support for social safety-net policies. Conclusions. During the initial phase of the COVID-19 pandemic in early April 2020, most US adults favored a range of safety-net policies to ameliorate its negative health and economic consequences. For most safety-net policies, public support was highest among those favoring a stronger governmental role in society.

Background: Most people with opioid use disorder (OUD) are not treated with FDA-approved medications methadone, buprenorphine, or naltrexone. Expanding capacity for evidence-based OUD medication in primary care is a national priority. No studies have examined primary care trainee physicians' attitudes about these medications. This study surveyed a national sample of primary care trainee physicians and compared their views with those of primary care attending physicians (i.e., those who have completed training)., Methods: Random samples of 1,000 trainee physicians and 1,000 attending physicians specializing in family, internal, or general medicine were selected from the American Medical Association Masterfile. Surveys were mailed February-August 2019. 45 % of eligible trainee physicians and 54 % of eligible attending physicians responded. Chi-square tests were used to compare responses between the groups., Results: Trainee physicians were more likely than attending physicians to agree that treating OUD with medication is more effective than treatment without medication (76 % versus 67 %, p = 0.03). Half of trainee physicians (51 %) expressed interest in treating patients with OUD compared to 20 % of attending physicians. Trainee physicians expressed greater support than attending physicians for policies that loosen restrictions on prescribing OUD medications., Conclusions: Relative to attending physicians, the emerging cohort of primary care physicians may be more receptive to working with patients with OUD and prescribing medication. Enhancing medical training on OUD and its treatment, exposing clinicians to individuals in recovery from OUD, and increasing support for clinicians that provide medication treatment for OUD may strengthen this group's capacity to respond to the opioid crisis., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Many privately insured adults with drug use disorders in the United States do not have health care coverage for drug use treatment. The Affordable Care Act sought to redress this gap by including substance use treatments as essential health benefits under new plans offered. This study used data from 11,732 privately insured adult participants of the 2005-2018 National Survey on Drug Use and Health with drug use disorders to examine trends in drug use treatment coverage and the association of coverage with receiving treatment. 37.6% of the participants with drug use disorders did not know whether their plan covered drug use treatment, with little change over time. Among those who knew, coverage increased modestly between the 2005-2013 and 2014-2018 periods (73.5% vs. 77.5%, respectively, p = .015). Coverage was associated with receiving drug use treatment (adjusted odds ratio = 2.09, 95% confidence interval = 1.61-2.72, p < .001). However, even among participants with coverage, only 13.4% received treatment. Broader coverage of drug use treatment could potentially improve treatment rates., Competing Interests: The authors have declared that no competing interests exist.

Background: Past studies show that illicit opioid use may impair parents' ability to care for their children. However, few studies have examined adverse outcomes in adolescent children of mothers who misuse opioids., Methods: Data come from the National Survey on Drug Use and Health's nationally representative matched sample of mothers and their adolescent children who resided in the same household. The outcome of interest was whether adolescents engaged in aggressive or antisocial behaviors in the past year. Using logistic regression, adolescent children whose mothers engaged in past-year opioid misuse were respectively compared to children whose mothers used other illicit drugs, had an alcohol use disorder, or had no misuse of substances. To control for confounding, propensity scores were used to match the three other maternal substance use groups to mothers who misused opioids on a number of measured confounding variables., Results: The odds of antisocial behaviors were 1.6 times higher among adolescent children whose mother engaged in past-year opioid misuse than matched adolescent children whose mothers reported no illicit substance use. There was no significant difference in antisocial behaviors between adolescents whose mothers misused opioids and either adolescents whose mothers used illicit drugs or had an alcohol use disorder., Conclusion: As the United States seeks to respond to the needs of families impacted by its ongoing opioid crisis, it is likely that services will be needed not only for parents who misuse opioids, but also for their children, who are at elevated risk for adverse behavioral outcomes., (Copyright © 2020. Published by Elsevier B.V.)

Objectives: To describe how the novel coronavirus (COVID-19) pandemic has affected opioid agonist treatment (OAT) programs in jails and prisons., Methods: In May 2020, we conducted an online survey of 19 carceral systems that provided methadone and/or buprenorphine treatment for incarcerated populations before COVID-19. Eleven survey items examined challenges and changes to these programs as a result of the pandemic. Sixteen of 19 programs (84%) responded to the survey., Results: Ten out of 16 systems reported downsizing their OAT programs. Seven of 16 systems made changes to medication dispensation processes. Half of systems report challenges implementing physical distancing (n = 8), and/or obtaining personal protective equipment (n = 8). In 13 out of 16 systems some OAT program participants were released early due to COVID-19 infection risk., Conclusions: Jails and prisons with existing OAT programs have curtailed their operations in the context of the COVID-19 pandemic. Given the robust evidence base around OAT for treating opioid use disorder and averting overdose deaths, guidance is needed on maintaining and ramping up medication access as carceral facilities grapple with implementing COVID-19 mitigation.

Introduction: This study aims to quantify out-of-pocket spending associated with respiratory hospitalizations for conditions similar to those caused by coronavirus disease 2019 and to compare out-of-pocket spending differences among those enrolled in consumer-directed health plans and in traditional, low-deductible plans., Methods: This study used deidentified administrative claims from the OptumLabs Data Warehouse (January 1, 2016-August 31, 2019) to identify patients with a respiratory hospitalization. It compared unadjusted out-of-pocket spending among consumer-directed health plan enrollees with that among traditional plan enrollees using difference of mean significance tests and repeated the analysis separately by age category and calendar year quarter. These data were collected on a rolling basis by OptumLabs and were analyzed in March 2020., Results: Commercially insured consumer-directed health plan enrollees had significantly higher out-of-pocket spending than traditional plan enrollees, and these differences were largest among younger populations. The largest difference in out-of-pocket spending occurred during the first half of the year., Conclusions: Consumer-directed health plan enrollees may experience differential financial burden from a hospitalization related to coronavirus disease 2019. Although some insurers are waiving cost-sharing payments for coronavirus disease 2019 treatment, self-insured employers remain exempt. As of now, policy responses may be insufficient to reduce the financial burden on consumer-directed health plans enrollees with respiratory hospitalizations related to coronavirus disease 2019., (Copyright © 2020 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Latinx adults, especially immigrants, face higher uninsurance and lower awareness of the Affordable Care Act's (ACA) provisions and resources compared to other racial/ethnic groups. Television advertising of ACA health plans has directed many consumers to application assistance and enrollment, but little is known about how ads targeted Latinx consumers. We used Kantar Media/CMAG data from the Wesleyan Media Project to assess Spanish- vs. English-language ad targeting strategies and to assess which enrollment assistance resources (in person/telephone vs. online) were emphasized across three Open Enrollment Periods (OEP) (2013-14, 2014-15, 2015-16). We examined differences in advertisement sponsorship and volume of Spanish- versus English-language ads across the three OEPs. State-based Marketplaces sponsored 47% of Spanish-language airings; insurance companies sponsored 55% of English-language airings. The proportion of Spanish-language airings increased over time (8.8% in OEP1, 11.1% in OEP2, 12.0% in OEP3, p <.001). Spanish-language airings had 49% lower (95%CI: 0.50,0.53) and 2.20 times higher odds (95%CI: 2.17,2.24) of mentioning online and telephone/in-person enrollment assistance resources, respectively. While there was a significant decrease in mention of telephone/in-person assistance over time for English-language airings, these mentions increased significantly in Spanish-language airings. Future research should examine the impact of the drastic federal cuts to ACA outreach and marketing.

Background: In response to the role overprescribing has played in the U.S. opioid crisis, in the past decade states have enacted four main types of laws to curb opioid prescribing: mandatory prescription drug monitoring program (PDMP) enrollment laws requiring clinicians to register with a PDMP; mandatory PDMP query laws requiring clinicians to check a PDMP prior to prescribing opioids; pill mill laws regulating pain management clinics; and opioid prescribing cap laws limiting the dose/duration of opioid prescriptions. While 47 states now have one or more of these laws in place, little is known about implementation and enforcement strategies, facilitators, and barriers., Methods: From November 2017 to February 2019, we interviewed 114 professionals involved in state opioid prescribing law implementation and enforcement in 20 states and identified common themes., Results: Implementation efforts focused on awareness campaigns and targeted training of key front-line implementers. Enforcement strategies included active, complaint-based, and automated strategies. Collaboration across agencies and stakeholders, particularly health agencies and law enforcement, was identified as an important facilitator of implementation and enforcement. Two key interrelated barriers were identified: the complexity of state opioid prescribing laws in terms of which providers, patients, and prescriptions they applied to, and IT infrastructure., Conclusion: Despite differing approaches, our findings suggest similar barriers to implementation and enforcement across state opioid prescribing laws. Strategies are needed to ease implementation and enforcement of laws that apply only to specific sub-sets of providers, patients, or prescriptions and address issues of access and data utilization of the PDMP., Competing Interests: Declaration of Competing Interests Dr. Bicket reports Axial Healthcare (past served on an advisory board, stock options) and Alosa Health (advisory board). These arrangements have been reviewed and approved by Johns Hopkins University in accordance with its conflict of interest policies. Dr. Alexander previously served as Chair of FDA’s Peripheral and Central Nervous System Advisory Committee; has served as a paid advisor to IQVIA; and is a consultant and holds equity in Monument Analytics, a health care consultancy whose clients include the life sciences industry as well as plaintiffs in opioid litigation; and is a member of OptumRx’s National P&T Committee. This arrangement has been reviewed and approved by Johns Hopkins University in accordance with its conflict of interest policies. The other co-authors have no conflicts of interest to disclose., (Copyright © 2020 Elsevier B.V. All rights reserved.)