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The intersecting crises of the COVID-19 pandemic, job losses, and concomitant loss of employer-sponsored health insurance may have disproportionately affected health care access within minorized and lower-socioeconomic status communities.To describe changes in access to care during the COVID-19 pandemic, stratified by race/ethnicity, household income, and state Medicaid expansion status.We used interrupted time series and difference-in-differences regression models, controlling for respondent characteristics and preexisting trends.Data were extracted for all adults aged 18-64 surveyed in the 2015-2020 Behavioral Risk Factor Surveillance System (N=1,731,699) from all 50 states and the District of Columbia.Our outcomes included indicators for whether respondents had any health insurance coverage or avoided seeking care because of cost within the prior year. The primary exposure was the onset of the COVID-19 pandemic in the United States in March 2020.The pandemic was associated with a 1.2 percentage point (pp) decline in uninsurance for Medicaid expansion states (95% CI, -1.8, -0.6); these reductions were concentrated among respondents who were Black, multiracial, or low income. The rates of uninsurance were generally stable in nonexpansion states. The rates of avoided care because of cost fell by 3.5 pp in Medicaid expansion states (95% CI, -3.9, -3.1), and by 3.6 pp (95% CI, 4.3-2.9) in nonexpansion states. These declines were concentrated among respondents who were Hispanic, Other Race, or low income.Our findings reinforce the value of Medicaid expansion as one tool to improve access to health insurance and care for marginalized and vulnerable populations.

State payers may face financial incentives to restrict use of high-cost medications. Yet, restrictions on access to high-value medications may have deleterious effects on population health. Direct-acting antivirals (DAAs), available since 2013, can cure chronic infection with hepatitis C virus (HCV). With prices upward of $90,000 for a treatment course, states have struggled to ensure access to DAAs for Medicaid beneficiaries and the incarcerated, populations with a disproportionate share of HCV. Advance purchase commitments (APCs), wherein a payer commits to purchase a certain quantity of medications at lower prices, offer payers incentives to increase access to high-value medications while also offering companies guaranteed revenue. This article discusses the use of subscription models, a type of APC, to support increased access to high-value DAAs for treating HCV. First, the authors provide background information about HCV, its treatment, and state financing of prescription medications. They then review the implementation of HCV subscription models in two states, Louisiana and Washington, and the early evidence of their impact. The article discusses challenges to evaluating state-sponsored subscription models, and it concludes by discussing implications of subscription models that target DAAs and other high-value, high-cost medicines.

Understanding differences in female pelvic medicine and reconstructive surgery (FPMRS) urology and gynecology-based fellowships is important because both are accredited by the American Board of Medical Subspecialties.The aim of the study was to characterize urology-based and gynecology-based FPMRS fellowships.An institutional review board-approved 21-item survey was emailed to Accreditation Council for Graduate Medical Education-accredited FPMRS fellowship program directors from January 8 through March 9, 2021. The survey aimed to characterize fellowships through a series of common and specialty-specific questions. Responses were collected with Qualtrics and analyzed using STATA/MP Version 16.1.The response rate was 75% (52/69). Many programs accept both gynecology- and urology-trained applicants (urology-based fellowships, 45.4%; gynecology-based fellowships, 68.3%) since the Accreditation Council for Graduate Medical Education accreditation in 2012. Within the gynecology-based cohort, there have been 10 urology-trained graduates among 7 programs (n = 1-2). Barriers to accepting urology applicants were limited gynecologic knowledge/experience (n = 14) and length of training (n = 11). Thirty-seven (94.8%) reported their graduates log more than 30 hysterectomies and 8.3% (n = 3) log 3 or more urinary diversions.Within the urology-based cohort, there have been 16 gynecology-trained graduates among 4 programs (n = 2-7). Lack of urologic clinical knowledge (n = 4) and training length (n = 2) were cited as barriers to accepting gynecology-trained applicants. Three (27%) reported that their graduates log more than 30 hysterectomies, while 8 (72.7%) reported that graduates log 3 or more urinary diversions.Despite many FPMRS programs stating that they accept gynecology or urology-trained applicants, few fellows graduate from outside specialty FPMRS training programs. Several barriers were identified that may prevent trainees acceptance outside of their residency specialty. Procedural training experience differs between urology- and gynecology-based fellowships.

Objective To evaluate the difference in odds of cesarean delivery in term, singleton, vertex pregnancies between the midwife and obstetrician-led services at the same rural tertiary care center. Methods A retrospective cohort study of term, singleton, and vertex deliveries in patients without a history of cesarean delivery was performed. Patients self-selected a delivery service. The primary outcome was the odds of cesarean delivery between midwife and obstetrician-led services. After propensity score matching, logistic regression was performed on the matched sample to assess the adjusted odds of cesarean delivery. Results From January 2015 to December 2017, 1,787 (80.2% of total) deliveries were analyzed with management of 956 (53.5%) by the midwife service and 831 (46.5%) by the obstetrician-led service. The rate of cesarean delivery was 20.7% (n=172) in the obstetrician-led service and 13.1% (n=125) in the midwife service. In the matched sample, the odds of cesarean delivery were lower in the midwife service compared with the obstetrician-led service in unadjusted and adjusted analyses (odds ratio [OR] 0.62, 95% CI 0.47-0.81; adjusted odds ratio [aOR] 0.58, 95% CI 0.44-0.80). Older maternal age (OR 1.02, 95% CI 1.00-1.06; aOR 1.07, 95% CI 1.04-1.10) and higher delivery body mass index (OR 1.06, 95% CI 1.04-1.08; aOR 1.07, 95% CI 1.04-1.09) were associated with higher odds of cesarean delivery. Increased parity was associated with decreased odds of cesarean delivery (OR 0.41, 95% CI 0.31-0.55; aOR 0.35, 95% CI 0.26-0.48). There were no differences in neonatal outcomes. Conclusion At a single rural tertiary care center, patients on the midwife service have significantly lower adjusted odds of cesarean delivery than patients on the obstetrician-led service.

The Veterans Health Administration (VHA) implemented the Stratification Tool for Opioid Risk Mitigation (STORM) to reduce the risk of serious adverse events (SAE) among patients with opioid analgesic prescriptions. VHA facilities were mandated to case review patients identified as high-risk by STORM. The aim of this study was to measure the effect of this mandate on all-cause mortality and SAEs among VHA patients newly-diagnosed with opioid use disorder (OUD).Secondary analysis of a stepped-wedged cluster randomized controlled trial conducted at all 140 VHA facilities, with facility as the unit of randomization, from 2018-2020. Setting and Participants United States VHA facilities were randomized to case review the top 1% or 5% of high-risk patients prescribed opioid analgesics identified by STORM. 28,251 patients were diagnosed with OUD during the trial, and were considered control or treatment depending on the status of the facility where they received their OUD diagnosis. Post-hoc analyses among patients who had at least one opioid analgesic prescription in the 90 days prior to diagnosis were conducted, and were then stratified by receipt of a prescription in the 90 days following diagnosis to assess the sensitivity of results to opioid discontinuation.All-cause mortality and opioid-related, drug-related, suicide-related, and other SAEs within 90-days of OUD diagnosis.Mandated case review increased the odds of 90-day mortality (odds ratio [OR] 1.74, 95% confidence interval [CI] 1.06, 2.87), but did not significantly change the odds of SAEs. Among patients who received an opioid prescription prior to but not after OUD diagnosis, the odds of all-cause mortality within 90 days was 5.87 (95% CI 1.85, 18.58) relative to control patients.Veterans Health Administration patients newly-diagnosed with opioid use disorder experienced increased all-cause mortality following expansion of a case-review mandate for high-risk patients prescribed opioids.

Summary: Background: As the novel coronavirus (COVID-19) continues to impact the world at large, Veterans of the US Armed Forces are experiencing increases in both COVID-19 and non-COVID-19 mortality. Veterans may be more susceptible to the pandemic than the general population due to their higher comorbidity burdens and older age, but no research has examined if trends in excess mortality differ between these groups. Additionally, individual-level data on demographics, comorbidities, and deaths are provided in near-real time for all enrolees of the Veterans Health Administration (VHA). These data provide a unique opportunity to identify excess mortality throughout 2020 at a subnational level, and to validate these estimates against local COVID-19 burden. Methods: We queried VHA administrative data on demographics and comorbidities for 11.4 million enrolees during 2016-2020. Pre-pandemic data was used to develop and cross-validate eight mortality prediction models at the county-level including Poisson, Poisson quasi-likelihood, negative binomial, and generalized estimating equations. We then estimated county-level excess Veteran mortality during 2020 and correlated these estimates with local rates of COVID-19 confirmed cases and deaths. Findings: All models demonstrated excellent agreement between observed and predicted mortality during 2016-2019; a Poisson quasi-likelihood with county fixed effects minimized median squared error with a calibration slope of 1.00. Veterans of the U.S. Armed Forces faced an excess mortality rate of 13% in 2020, which corresponds to 50,299 excess deaths. County-level estimates of excess mortality were correlated with both COVID-19 cases (R2=0.77) and deaths per 1,000 population (R2=0.59). Interpretation: We developed sub-national estimates of excess mortality associated with the pandemic and shared our data as a resource for researchers and data journalists. Despite Veterans’ greater likelihood of risk factors associated with severe COVID-19 illness, their excess mortality rate was slightly lower than the general population. Consistent access to health care and the rapid expansion of VHA telemedicine during the pandemic may explain this divergence. Funding: This work was supported by grants from the Department of Veterans Affairs Quality Enhancement Research Initiative [PEC 16-001]. Dr. Griffith's effort was supported in part by the Agency for Healthcare Research & Quality [K12 HS026395].

This cross-sectional study assesses the prevalence and magnitude of state-level delivery event–triggered kick payments to Medicaid managed care plans and their association with delivery costs.

Background The COVID-19 pandemic caused disruptions in the delivery of health services, which may have adversely affected access to substance use disorder (SUD) treatment services. Medicaid expansion has been previously associated with increased access to SUD services for low-income adults. Thus, the pandemic may have differentially impacted overdose mortality depending on expansion status. This study examined trends in overdose mortality nationally and by state Medicaid expansion status from 2013 to 2020. Methods State-level data on overdose mortality were obtained from the Centers for Disease Control and Prevention’s WONDER database for 2013–2020 (N = 408 state-years). The primary outcomes were drug and opioid overdose deaths per 100,000 residents. The primary exposure was Medicaid expansion status as of January 1st, 2020. Difference-in-difference (DID) models were used to compare changes in outcomes between expansion and non-expansion states after the onset of the COVID-19 pandemic. Results The U.S. experienced 91,799 drug overdose deaths in 2020, a 29.9% relative increase from 2019. Expansion states experienced an adjusted increase of 7.0 drug overdose deaths per 100,000 residents (95% CI 3.3, 10.7) and non-expansion states experienced an increase of 4.3 deaths (95% CI 1.5, 8.2) from 2019 to 2020. Similar trends were observed in opioid overdose deaths. In DID models, Medicaid expansion was not associated with changes in drug (0.9 deaths, 95% CI −2.0, 3.7) or opioid overdose deaths (0.8 deaths, 95% CI −1.8, 3.5). Conclusions The increase in drug or opioid overdose deaths experienced during the first year of the COVID-19 pandemic was similar in states with and without Medicaid expansion.

Key Points Question Did the use of direct-acting antiviral hepatitis C (HCV) medications change after these medications were carved out from Medicaid managed care organization (MCO) coverage and financed fee-for-service in 4 state Medicaid programs? Findings In this cross-sectional study, carve outs were associated with a mean quarterly increase of 22.1 HCV prescription fills per 100 000 Medicaid enrollees compared with synthetic control states, translating to a relative increase of 86%. Meaning This study suggests that carve outs of HCV medications from Medicaid MCO coverage may increase access to these medications, potentially improving the health of Medicaid enrollees with HCV and reducing the economic burden of untreated HCV on the US health care system., Importance Medicaid enrolls a disproportionate share of US adults with hepatitis C virus (HCV), and most receive Medicaid benefits through managed care organizations (MCOs). Medicaid MCOs often impose stricter requirements to access HCV medications than traditional fee-for-service Medicaid, which may inhibit use. Though Medicaid MCOs generally cover prescription drugs, several states have carved out direct-acting antiviral HCV medications from MCO coverage and opted to cover them under fee-for-service. Whether these carve outs were associated with changes in medication use is unknown. Objective To examine the association between Medicaid-covered HCV medication fills and carve outs of these medications from MCO coverage. Design, Setting, and Participants This cross-sectional study examined changes in fills of Medicaid-covered direct-acting antiviral HCV medications in 4 states (Indiana, Michigan, New Hampshire, and West Virginia) that carved out these drugs from Medicaid MCOs between 2015 and 2017. A synthetic control approach was used to compare changes in HCV prescription fills between states that did and did not carve out these medications from MCO prescription drug coverage. Data of direct-acting antiviral HCV prescription fills were obtained from the Medicaid State Drug Utilization Data files, January 2015 to June 2020. Data analysis was conducted from November 2020 to June 2021. Exposures Carve outs of direct-acting antiviral HCV medications from Medicaid MCO prescription drug coverage. Main Outcomes and Measures Direct-acting antiviral HCV prescriptions filled per 100 000 Medicaid enrollees. Results In this cross-sectional study, carve outs were associated with a mean quarterly increase of 22.1 (95% CI, 12.7-34.1) HCV prescriptions per 100 000 Medicaid enrollees, a relative increase of 86.3% compared with synthetic control states. Compared with each state’s respective synthetic control, HCV prescription fills were associated with an increase of 11.5 (95% CI, 5.1-19.0) HCV prescription fills per 100 000 Medicaid enrollees per quarter in Indiana, 36.6 (95% CI, 23.5-53.9) in Michigan, 20.7 (95% CI, 11.1-32.8) in West Virginia, and 43.6 (95% CI, 25.9-68.4) in New Hampshire. Conclusions and Relevance In this cross-sectional study of data from 39 states and the District of Columbia, carve outs of direct-acting antiviral HCV medications from Medicaid MCO prescription drug coverage were associated with significant increases in HCV medication use. Given their clinical benefits, greater uptake of HCV medication may help improve the health of Medicaid enrollees with HCV and reduce the economic burden of untreated HCV on the US health care system., This cross-sectional study assesses whether hepatitis C medication use would change in states that transitioned from carved-in to carved-out Medicaid coverage.

Purpose The legal landscape of cannabis availability and use in the United States is rapidly changing. As the heterogeneity of cannabis products and methods of use increases, more information is needed on how these changes affect use, especially in vulnerable populations such as youth. Methods A national sample of adolescents aged 14–18 years (N = 2,630) were recruited online through advertisements displayed on Facebook and Instagram to complete a survey on cannabis. The survey assessed patterns of edible use, vaping, and smoking cannabis, and the associations among these administration routes and use of other substances. Results The most frequent and consistent route of cannabis use was smoking (99% lifetime), with substantial numbers reporting vaping (44% lifetime) and edible use (61% lifetime). The majority of those who had experimented with multiple routes of cannabis administration continued to prefer smoking, and the most common pattern of initiation was smoking, followed by edibles and then vaping. In addition to cannabis use, adolescents reported high rates of nicotine use and substantial use of other substances. Adolescents who used more cannabis administration routes tended to also report higher frequency of other substances tried. Conclusions Additional work is needed to determine whether the observed adolescent cannabis administration patterns are similar across different samples and sampling methods as well as how these trends change over time with extended exposure to new products and methods. The combined knowledge gained via diverse sampling strategies will have important implications for the development of regulatory policy and prevention and intervention efforts.

Tobacco smoking among those seeking treatment for cannabis use disorder (CUD) is common and is a negative predictor of cannabis outcomes. Quitting tobacco may be beneficial for those seeking to quit cannabis use. This initial proof of concept, controlled trial was designed to compare a simultaneous versus sequential tobacco intervention among those seeking treatment for CUD. Sixty-seven adults received either a simultaneous (SIM) or sequential (SEQ) approach to tobacco cessation in the context of outpatient treatment for CUD. A tobacco intervention (TI) that combined web-based counseling with nicotine replacement therapy (NRT) was provided during weeks 1–12 for SIM and was delayed until weeks 13–24 for SEQ. During weeks 1–12, no between-condition significant differences were observed on treatment participation or cannabis use outcomes. The majority of SIM participants initiated TI counseling (62%), 50% made at least one quit attempt and 41% initiated NRT. Interestingly, 39% in SEQ made tobacco quit attempts and 18% initiated NRT on their own before the TI was offered to them. However, only 30% of those in SEQ continued treatment during weeks 13–24, which compromised between-condition comparisons following the TI, but illustrated a potential clinical concern with delaying the TI. Tobacco cessation outcomes generally were poor and did not differ between conditions. This initial controlled trial suggests that addressing tobacco use during CUD treatment is acceptable and generates action towards tobacco cessation. Additional trials testing more intensive TI models may be necessary to identify more efficacious interventions for co-use of cannabis and tobacco.

ImportanceMedicaid insures a disproportionate share of adults with substance use disorder (SUD) and is thus uniquely positioned to facilitate access to care. Many enrollees receive coverage through Medicaid managed care (MMC) plans, which receive capitated payments in exchange for coverage of a defined set of benefits. Historically, coverage of substance use services has been carved out of MMC plans and financed fee-for-service (FFS) by state Medicaid programs, but in recent years, many states have opted to carve in this benefit. Little is known about whether MMC coverage of substance use services, relative to FFS coverage, is associated with changes in utilization.ObjectiveTo examine the association between changes in MMC coverage of substance use services and admissions for substance use treatment.Design, Setting, and ParticipantsThis cross-sectional study examined changes in admissions for substance use treatment in 2 states after coverage of substance use services was either carved into (Nebraska) or carved out of (Maryland) comprehensive MMC coverage. Synthetic control methods were used to compare changes in admissions between states that did and did not alter MMC coverage of substance use services. Data on substance use treatment admissions were obtained from the Treatment Episode Data Set—Admissions from 2010 to 2019.ExposuresCarve-outs or carve-ins of coverage for both inpatient and outpatient substance use services from comprehensive MMC coverage.Main Outcomes and MeasuresReported substance use treatment admissions per 100 000 residents and admissions by treatment type (ie, rehabilitation or residential, outpatient, and detoxification) per 100 000 residents.ResultsMaryland’s carve-out was associated with an additional mean 787.1 (95% CI, 624.6-1141.7) substance use admissions per 100 000 residents during 2015 and 2016, a relative increase of 104.4% (95% CI, 64.4%-154.1%) compared with its synthetic control. This increase was concentrated among changes in outpatient services utilization. In Nebraska, the carve-in was associated with a mean decrease of 97.2 (95% CI, −23.4 to 213.6) admissions per 100 000 residents, a relative decrease of 33.2% (95% CI, −54.1% to 29.6%) compared with its synthetic control and was concentrated primarily among admissions for detoxification services.Conclusions and RelevanceThe results of this cross-sectional study suggest that carving out coverage of substance use services and financing them through FFS coverage may be associated with overall increases in treatment utilization but with heterogeneous associations across states and treatment types.

Key Points Question Did the use of direct-acting antiviral hepatitis C virus (HCV) medications change after implementation of subscription-based payment models for these drugs in Washington and Louisiana? Findings In this cross-sectional study, Louisiana experienced a 534.5% increase in HCV prescription fills after implementation of a subscription-based payment model, but no significant change in prescription fills was observed in Washington. Meaning In this study, subscription-based payment models in Louisiana and Washington were differentially associated with use of Medicaid-covered HCV medications, which may reflect state-level differences in implementation, historical restrictions on access to these medications, and responses to the COVID-19 pandemic., This cross-sectional study evaluates whether the implementation of subscription-based Medicaid payment models for hepatitis C virus medications was associated with a change in use of these drugs in Washington and Louisiana., Importance Hepatitis C virus (HCV) can be cured with direct-acting antiviral medications, but state Medicaid programs often restrict access to these lifesaving medications owing to their high costs. Subscription-based payment models (SBPMs), wherein states contract with a single manufacturer to supply prescriptions at a reduced price, may offer a solution that increases access. Whether SBPMs are associated with changes in HCV medication use is unknown. Objective To estimate changes in Medicaid-covered HCV prescription fills after Louisiana and Washington implemented SBPMs on July 1, 2019. Design, Setting, and Participants This cross-sectional study examined trends in prescription fills of Medicaid-covered direct-acting antiviral HCV medications in Louisiana and Washington after implementation of SBPMs. A synthetic control approach was used to compare changes in HCV prescription fills between states that did and did not implement SBPMs. The unit of analysis was state-quarter. Outpatient direct-acting antiviral HCV prescription fills from the Medicaid State Drug Utilization Data files were obtained from all 50 US states and the District of Columbia from January 1, 2017, to June 30, 2020. Exposures Implementation of SBPMs for Medicaid-covered direct-acting antiviral HCV medications. Main Outcomes and Measures Direct-acting antiviral HCV prescriptions filled per 100 000 Medicaid enrollees. Results In the year preceding SBPM implementation, the mean (SD) rate of quarterly HCV prescription fills per 100 000 Medicaid enrollees was 43.1 (8.6) prescriptions in Louisiana and 50.1 (4.1) in Washington. After SBPM implementation, the mean (SD) rate of quarterly HCV prescription fills per 100 000 enrollees was 206.0 (51.2) prescriptions in Louisiana and 53.9 (11.0) in Washington. In synthetic control models, SBPM implementation in Louisiana was associated with an increase of 173.5 (95% CI, 74.3-265.3) quarterly prescription fills per 100 000 Medicaid enrollees during the following year, a relative increase of 534.5% (95% CI, 228.7%-1125.0%). Washington did not experience a significant change in prescription fills following SBPM implementation. Conclusions and Relevance In this cross-sectional study, Louisiana experienced substantial increases in HCV medication use among its Medicaid-enrolled population following SBPM implementation, whereas Washington did not. These differences may partially be explained by state-level variation in SBPM implementation, historical restrictions on access to HCV medications, and responses to the COVID-19 pandemic.

The dataset summarized in this article is a combination of several of U.S. federal data resources for the years 2006-2013, containing county-level variables for opioid pill volumes, demographics (e.g. age, race, ethnicity, income), insurance coverage, healthcare demand (e.g. inpatient and outpatient service utilization), healthcare infrastructure (e.g. number of hospital beds or hospices), and the supply of various types of healthcare providers (e.g. medical doctors, specialists, dentists, or nurse practitioners). We also include indicators for states which permitted opioid prescribing by nurse practitioners. This dataset was originally created to assist researchers in identifying which factors predict per capita opioid pill volume (PCPV) in a county, whether early state Medicaid expansions increased PCPV, and PCPV's association with opioid-related mortality. Missing data were imputed using regression analysis and hot deck imputation. Non-imputed values are also reported. Taken together, our data provide a new level of precision that may be leveraged by scholars, policymakers, or data journalists who are interested in studying the opioid epidemic. Researchers may use this dataset to identify patterns in opioid distribution over time and characteristics of counties or states which were disproportionately impacted by the epidemic. These data may also be joined with other sources to facilitate studies on the relationships between opioid pill volume and a wide variety of health, economic, and social outcomes.

Objectives: COVID-19 resulted in rapid implementation of telemedicine. It is critical to explore patient factors that drive telemedicine use to recognize any disparities in healthcare access that may emerge with remote healthcare. Our objective was to compare the characteristics and subsequent health care utilization of gynecologic oncology patients who had a scheduled telemedicine visit from 3/23/20-5/18/20. Methods: We conducted a retrospective study of women whose scheduled in-person office visits were converted to telemedicine. Video visits were encouraged and telephone visits were the default option. We compared patient factors between women who cancelled versus those who completed their telemedicine visits. Subsequent health care utilization included in-person office appointments, emergency department (ED) or operative care was compared between those who cancelled versus completed telemedicine visits. We also evaluated patient differences in completion of video vs telephone visits. Cancellation rates were compared to a historical control of in-person gynecologic oncology office visits (3/23- 5/18/19). Multivariate logistic regression analyses were performed to assess odds of completing a telehealth appointment. Results: Of the 185 women with scheduled telemedicine visits, 158 (85%) completed and 27 (15%) cancelled. Telemedicine had significantly higher cancellations compared to office visits a year ago, 15% vs. 3% (p

Background New Hampshire (NH) has had among the highest rates of fentanyl-related overdose deaths per capita in the United States for several years in a row—more than three times the national average in 2016. This mixed-methods study investigated drug-using practices and perspectives of NH residents who use opioids to inform policy in tackling the overdose crisis. Methods Seventy-six participants from six NH counties completed demographic surveys and semi-structured interviews focused on drug-using practices and perspectives, including use precursors, fentanyl-seeking behaviors, and experiences with overdose. Rigorous qualitative methods were used to analyze interview data including transcription, coding and content analysis. Descriptive statistics were calculated on quantitative survey data. Results Eighty-four percent of interviewees had knowingly used fentanyl in their lifetime, 70 % reported overdosing at least once, and 42 % had sought a batch of drugs known to have caused an overdose. The majority stated most heroin available in NH was laced with fentanyl and acknowledged that variability across batches increased overdose risk. Participants reported high availability of fentanyl and limited access to prevention, treatment, and harm reduction programs. There was widespread support for expanding education campaigns for youth, increasing treatment availability, and implementing needle exchange programs. Conclusions A confluence of factors contribute to the NH opioid overdose crisis. Despite consensus that fentanyl is the primary cause of overdoses, individuals continue to use it and affirm limited availability of resources to address the problem. Policies targeting innovative prevention, harm reduction, and treatment efforts are needed to more effectively address the crisis.

Background In parallel to a substantial increase in opioid overdose deaths in New Hampshire (NH), emergency personnel experienced an increase in opioid-related encounters. To inform public health responses to this crisis, insights into the experiences and perspectives of those emergency personnel who treat opioid-related overdoses are warranted. Aims Systematically examine emergency personnel’s experiences treating opioid overdoses and obtain their perspectives on policy-level responses to the opioid crisis in NH. Methods Semi-structured qualitative interviews were conducted with 18 first responders [firefighters (n = 6), police officers (n = 6), emergency medical service providers (n = 6)] and 18 emergency department personnel employed in six NH counties. Interviews focused on emergency personnel’s perspectives on fentanyl/heroin formulations, experiences treating overdoses, harm reduction strategies, and experiences with treatment referral. Interviews were audio recorded, transcribed verbatim, and analyzed using content analysis. Results Emergency personnel cited the potency and inconsistency of fentanyl-laced heroin as primary drivers of opioid overdose. Increases in overdose-related encounters took a substantial emotional toll on emergency personnel, who described a range of responses including feelings of burnout, exhaustion, and helplessness. While some emergency personnel felt conflicted about the implementation of harm reduction strategies like syringe services programs, others emphasized the necessity of these services. Emergency personnel expressed frustration with barriers to treatment referral in the state and recommended immediate treatment access after overdose events. Conclusions Findings suggest that interventions addressing trauma and burnout are necessary to support emergency personnel, while expanded harm reduction and treatment access are critical to support those who experience opioid overdose in NH.

Background Prescription opioids accounted for the majority of opioid-related deaths in the United States prior to 2010, and continue to contribute to opioid misuse and mortality. We used a novel dataset to investigate the distributional patterns of prescription opioids, whether opioid pill volume was associated with opioid-related mortality, and whether early state Medicaid expansions were associated with either pill volume or opioid-related mortality. Methods Data on opioid shipments to retail pharmacies for 2006–2013 were obtained from the U.S. Drug Enforcement Administration, and opioid-related deaths (ORDs) were obtained from the Centers for Disease Control and Prevention. We first compared characteristics of counties in the highest and lowest quartiles for per capita pill volume (PCPV). We used adjusted difference-in-differences regression models to identify factors associated with PCPV or ORDs, and whether early state Medicaid expansions were associated with either outcome. All models were estimated as linear regressions with standard errors clustered by county, and weighted by county population. Results We found large geographic variations in opioid distribution, and this variation appears to be driven by differences in demographics, healthcare access, and healthcare supply. In adjusted models, a one-pill increase in PCPV was associated with a 0.20 increase in ORDs per 100,000 population (95 % CI 0.11–0.30). Early Medicaid expansions were associated with lower PCPV (−2.20, 95 % CI −2.97 to −1.43). Conclusions Our findings validate the relationship between PCPV and ORDs, identify important environmental drivers of the opioid epidemic, and suggest early state Medicaid expansions were beneficial in reducing opioid pill volume.

BACKGROUND: Buprenorphine is an effective pharmacotherapy for the treatment of opioid use disorder (OUD), but recent increases in the rate of OUD in the U.S. have outpaced the supply of clinicians waivered to prescribe buprenorphine. To increase the supply of buprenorphine prescribers, the Comprehensive Addiction and Recovery Act expanded buprenorphine prescribing waiver eligibility beyond physicians to nurse practitioners (NP) and physician assistants (PA) in 2017. Little is known about patterns of waiver uptake among NPs and PAs. This study examined associations between the existing supply of waivered prescribers and waiver uptake among NPs and PAs in U.S. states. METHODS: NP and PA waiver uptake was evaluated as the number of NPs or PAs obtaining an initial buprenorphine prescribing waiver per 10,000 state residents from January 2017 to December 2018 using data from the Buprenorphine Waiver Notification System. NP and PA waiver uptake was estimated as a function of existing waivered prescriber supply, OUD treatment capacity, and other state characteristics using generalized least squares (GLS) regression. RESULTS: 28,010 NPs and PAs have become waivered to prescribe buprenorphine since January, 2017. GLS regressions indicated that waivered prescriber supply was significantly, positively associated with both NP (b = 0.101 p