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Background: Timely evaluation of acute chest pain is necessary, although most evaluations will not find significant coronary disease. With employers increasingly adopting high-deductible health plans (HDHP), how HDHPs impact subsequent care after an emergency department (ED) diagnosis of nonspecific chest pain is unclear. Methods: Using a commercial and Medicare Advantage claims database, we identified members 19 to 63 years old whose employers exclusively offered low-deductible (≤$500) plans in 1 year, then, at an index date, mandated enrollment in HDHPs (≥$1000) for a subsequent year. We matched them with contemporaneous members whose employers only offered low-deductible plans. Primary outcomes included population rates of index ED visits with a principal diagnosis of nonspecific chest pain, admission during index ED visits, and index ED visits followed by noninvasive cardiac testing within 3 and 30 days, coronary revascularization, and acute myocardial infarction hospitalization within 30 days. We performed a cumulative interrupted time-series analysis, comparing changes in annual outcomes between the HDHP and control groups before and after the index date using aggregate-level segmented regression. Members from higher-poverty neighborhoods were a subgroup of interest. Results: After matching, we included 557 501 members in the HDHP group and 5 861 990 in the control group, with mean ages of 42.0 years, 48% to 49% female, and 67% to 68% non-Hispanic White individuals. Employer-mandated HDHP switches were associated with a relative decrease of 4.3% (95% CI, –5.9 to –2.7; absolute change, –4.5 [95% CI, –6.3 to –2.8] per 10 000 person-years) in nonspecific chest pain ED visits and 11.3% (95% CI, –14.0 to –8.6) decrease (absolute change, –1.7 per 10 000 person-years [95% CI, –2.1 to –1.2]) in visits leading to hospitalization. There was no significant decrease in subsequent noninvasive testing or revascularization procedures. An increase in 30-day acute myocardial infarction admissions was not statistically significant (15.9% [95% CI, –1.0 to 32.7]; absolute change, 0.3 per 10 000 person-years [95% CI, –0.01 to 0.5]) but was significant among members from higher-poverty neighborhoods. Conclusions: Employer-mandated HDHP switches were associated with decreased nonspecific chest pain ED visits and hospitalization from these ED visits, but no significant change in post-ED cardiac testing. However, HDHP enrollment was associated with increased 30-day acute myocardial infarction admission after ED diagnosis of nonspecific chest pain among members from higher-poverty neighborhoods.

This cross-sectional study assesses the availability of buprenorphine for opioid use disorder treatment at local pharmacies in the US by state and retail pharmacy chain.

Objectives To determine the effect of one-click integration of a state’s prescription drug monitoring program (PDMP) on the number of PDMP searches and opioid prescriptions, stratified by specialty. Methods Our large health system worked with the state department of public health to integrate the PDMP with the electronic health record (EHR), which enabled providers to query the data with a single click inside the EHR environment. We evaluated Schedule II or III opioid prescriptions reported to the Massachusetts PDMP 6 months before (November 15, 2017-May 15, 2018) and 6 months after (May 16, 2018, to November 16, 2018) integration. Search counts, prescriptions, patients, morphine milligram equivalents, as well as prescriber specialty were compared. Results There were 3,185 unique prescribers with a record of a Schedule II and/or III opioid prescription in both study periods that met inclusion criteria. After integration, the number of PDMP searches increased from 208,684 in the pre-integration phase to 298,478 searches in the post-integration phase (+43.0%). The number of opioid prescriptions dispensed decreased by 4.8%, the number of patients receiving a prescription decreased by 5.1%, and the mean morphine milligram equivalents (MMEs) per prescriber decreased by 5.4%. There were some notable specialty-specific differences in these measures. Conclusions Integration of the PDMP into the EHR markedly increased the number of searches but was associated with modest decreases in opioids prescribed and patients receiving a prescription. Single click EHR integration of the PDMP, if implemented broadly, may be a way for states to significantly increase PDMP utilization.

Introduction Maternal thyroid disease is considered as a risk factor for abnormal thyroid function at birth, as well as for long-term morbidity in offspring. The potential harmful effects on the neonate had led to the clinical practice of thyroid function assessment in infants born to mothers with thyroid disease during pregnancy. In this study, we evaluated the usefulness of routine thyroid function tests for every newborn of a mother with thyroid dysfunction. Methods Data were collected retrospectively from the medical files of mothers diagnosed with thyroid disease and their infants (496 mother–neonate pairs). All mothers with diagnosed thyroid disease who gave birth in the years 2016–2019 at our medical center were included. Results Hypothyroidism was the most common maternal diagnosis (91.4%), among which 48.7% had Hashimoto’s thyroiditis. Hyperthyroidism was diagnosed in 8.6% of the cohort – 71.6% of them with Graves’ disease. None of the newborns was diagnosed with congenital hypothyroidism in the screening program. Thyroid-stimulating hormone was >10 mIU/L in 14.6% and >20 mUI/L in 2.2%; all had free thyroxine within normal range. Serum thyroid function test identified four infants with thyroid disease; two had congenital hypothyroidism not related to maternal thyroid disease, one had transient familial congenital hypothyroidism and one had neonatal Graves’ disease. Conclusions Thyroid function testing for all newborns of mothers with thyroid dysfunction seems redundant. However, in cases of congenital hypothyroidism in siblings, thyroid function test, in addition to newborn thyroid screening, is recommended, and more careful follow-up is indicated. In maternal Graves’ disease, thyroid function test on days 2–3 of life is recommended.

Synthesizes definitional debates to provide the reader with a comprehensive but useful understanding of kinship. Kinship is visible, especially in the Middle Eastern context, because an individual’s name indicates their kinship lineage. It is sticky because it gives an individual not only an in-group (member of family X), but also a specific orientation within that in-group (son of A, grandson of B, member of family X). As such, kinship is a useful social identity marker because it is easy to determine and difficult to falsify. The chapter shows how these kinship politics manifest in the Arab Gulf States.

Introduces the book’s theory that pre-state conditions affect kinship salience at the end of state building. Before state building, kinship groups accessed vital limited resources. Per the book’s model, access to vital limited resources can be either competitive or cooperative.Whether kinship groups had competitive or cooperative access to vital limited resources shaped the state building process. Where resource access was competitive, the state was forced to engage individual kinship groups during each of these three stages of state building to bring them under the purview of the bureaucratic state. As such, the importance of kinship authority was reified and at the end of state building, kinship authority had governing salience, meaning that it determined access to power (cabinet membership, elected office) and resources (monthly payouts, housing, healthcare). In contrast, where resource access was cooperative, the state could subsume proto-bureaucracies within its governing apparatus. Proto-bureaucracies remained staffed by kinship group members, but their authority was bureaucratic in that it was based on knowledge of how to administer and maintain resources. As such, at the end of state building, kinship authority had instrumentalized salience, meaning that it was used by governments for bureaucratic ends.

Compliments the analysis of Kuwait with an analysis of Qatar between 1905 and 1989. Since competitive access to resources before state building is the more common configuration in tribal societies, the Qatar case serves to illustrate the applicability of the model beyond the two major cases. In Qatar, access to vital limited resources was competitive before state building. During state building, the government attempted to consolidate power by building up public administration and engineering settlement patterns. However, kinship authority instrumentalized bureaucratic authority as a result of path dependent constraints on how the government conducted this state building process. Like in Kuwait, Qatar’s government engaged kinship groups as kinship groups, preserving the salience of kinship. As a result, kinship in Qatar at the end of state building had governing salience.

Highlights the model’s utility beyond the Arab Gulf states with a brief analysis of kinship politics in Somaliland and Iran. In Somaliland competitive resource access drove kinship to governing salience after state formation. In Iran cooperative access drove kinship to instrumentalized salience. The conclusion then highlights the importance of the book’s findings. First, it provides a rigorous political science conception of tribes and connects the construction of kinship identity generally to state-level outcomes. It does so by building upon Chandra’s (2004) well-established model of ethnic identity and extending it to model kinship. Second, it highlights the importance of pre-state conditions and connects them to post-state building outcomes. It does so in an empirically rigorous way, drawing on archival work, locally-produced histories, and interviews. This approach contrasts with earlier work which tends to discuss tribal politics without a given theoretical model (Kostiner and Khoury, 1991), or rigorously examine the politics of Arab Gulf societies but not link these politics directly to state-level outcomes (e.g. Limbert 2010). Ultimately, it shows that members of these societies were not passive actors during colonialism, oil booms, and the subsequent rapid acquisition of state capacity by governments.

Outlines the difference between governing and instrumentalized salience. Where kinship authority governs functions normally conducted by the state and compels political behavior by kinship group members, it has governing salience. Where it lacks both of these, it has instrumentalized salience. The chapter operationalizes these concepts using a table of observable outcomes that assesses, firstly, the governing function of kinship in the state and, secondly, kinship authority’s ability to compel behavior. The chapter then provides a comparison of each outcome in Kuwait and Qatar on the one hand, and Oman on the other. Ultimately, Kuwait and Qatar reflect the presence of key indicators of governing salience, while Oman reflects instrumentalized salience. This assessment demonstrates observable variation in the dependent variable and suggests, in the context of the previous empirical chapters, that differences in kinship group access to vital limited resources before state building explain why kinship plays a governing role in some Arab Gulf states but is itself instrumentalized by the state in others.

Contrasts Kuwait and Qatar to the case of Oman between 1871 and 1986. In Oman, access to vital limited resources was cooperative rather than competitive. In Oman, many tribes cooperated to obtain water from aquifers and similar sources through a system of water channels known as aflaj. Prior to state formation, these tribes established proto-bureaucracies that managed the physical aflaj. These proto-bureaucracies were staffed by tribe members but carried bureaucratic authority by virtue of controlling knowledge about the aflajsystem. As such, they acted as intermediaries between pre-existing kinship authority and the new bureaucratic authority of the state. During state building, Oman extended infrastructure and national water, road, and electricity networks to non-urban populations. It also subsumed existing bureaucratic infrastructure within the national state, and created buy-in for this project through a different nationalist idiom than Kuwait and Qatar had used. Whereas Kuwait and Qatar described citizens as those who had been in the country since a certain year (1920 in Kuwait, 1930 in Qatar) and their descendants, Oman defined citizenship territorially. For each of these three steps, the chapter contrasts Oman's experience with Kuwait’s showing how cooperative access impacted state building in different ways in each case.

Considers the case of Kuwait between 1899 and 1990 as an example of competitive access to vital limited resources before state building. In the periphery, British and Kuwaiti historic records illustrate in great detail the conflicts between kinship groups and the limited extent of water resources. In the center, Kuwait’s Emir and the predominantly Shi’a merchant families of Kuwait City enjoyed a mutually beneficial relationship in which the Emir provided security for merchants, and merchants provided financial resources through taxation for the Emir. The chapter also provides new details of how water was distributed in pre-oil Kuwait based largely on trust and personal relationships. It then shows how Kuwait created infrastructure, moved non-urban tribal populations based predominantly in the Nejd desert onto that infrastructure, imposed bureaucratic authority, and created buy-in for this authority through a nationalist idiom. Throughout state building, Kuwait engaged with kinship groups themselves, reifying the importance of kinship authority in the process. The result is that kinship in Kuwait has governing salience.

Gives an overview of the book’s theory that kinship group access to vital and limited resources before state building determines the salience of kinship authority at the end of state building. Existing models of state formation, often rooted in literature on the rentier state, cannot account for variation in the salience of kinship authority in the Arabian Gulf states. As an alternate explanation, the book introduces the hypothesis that a state’s capacity to provide infrastructure, bureaucracy, and a nationalist idiom shapes the salience of kinship authority. Finally, the chapter introduces a road map of the book and explains the importance of the puzzle for comparative politics and studies of the Arab Gulf states.

Describes the nature of kinship salience in Kuwait, Oman, and Qatar based on the evaluative framework outlined in the previous chapter. Drawing on interviews with students, NGO leaders, former members of parliament, and tribal leaders, it assesses the extent to which kinship in Kuwait, Qatar, and Oman governs functions otherwise conducted by the state, and compels behavior by members of kinship groups. The chapter shows that while in Kuwait and Oman, kinship has governing salience, in Oman it has instrumentalized salience. In both cases, kinship is an essential aspect of politics, governance, and public life. The chapter also describes kinship politics in each state in the current era.

Objective Back pain is one of the most common pain syndromes in the United States, but there has been limited recent description of the role of emergency departments (EDs) in caring for patients with back pain. We investigated trends in the evaluation and management of back pain in U.S. EDs from 2007 to 2016. Methods We performed a retrospective analysis of the National Hospital Ambulatory Medical Care Survey, a nationally representative annual survey of ED visits, which includes data on patient-, hospital-, and visit-level characteristics. We evaluated trends among adult ED visits for back pain, including demographics, resource utilization, and disposition. Trends were assessed through the use of survey-weighted analyses. Results Visit rates as a proportion of overall ED visits were stable from 2007 to 2016 (9.1% [95% confidence interval (CI): 8.5–9.6] vs. 9.3% [95% CI: 8.6–10.0]; P = 0.44). Admission rates declined from 6.4% (95% CI: 5.1–8.0) to 5.0% (95% CI: 3.5–6.9; P Conclusions Opioid utilization during ED visits for back pain decreased from 2007 to 2016, whereas tramadol use more than doubled. Care intensity increased significantly despite declining admission rates. Further research into optimal strategies for back pain management in the ED is needed.

BACKGROUND: The United States is currently facing 2 epidemics: sustained morbidity and mortality from substance use and the more recent COVID-19 pandemic. We tested the hypothesis that the pandemic has disproportionately affected individuals with substance use disorder by evaluating average daily 9-1-1 ambulance calls for substance use-related issues compared with all other calls. METHODS: This was a retrospective cross-sectional analysis of 9-1-1 ambulance calls before and after the start of COVID-19 in Massachusetts. We used consecutive samples of 9-1-1 ambulance calls, categorized into those which were substance-related or not. An interrupted time series analysis was performed to determine if there were changes in numbers of daily calls before a statewide declaration of emergency for COVID-19 (February 15–March 9, 2020), from the emergency declaration until a stay-at-home advisory (March 10–March 22, 2020) and following the stay-at-home advisory (March 23–May 15, 2020). RESULTS: Compared with prior to the statewide emergency, the post-statewide emergency average of daily ambulance calls decreased from 2,453.2 to 1,969.6, a 19.7% decrease. Similarly, calls for substance-related reasons decreased by 16.4% compared with prior to the statewide emergency. However, despite an initial decrease in calls, after the stay-at-home advisory calls for substance use began increasing by 0.7 (95% confidence interval (CI) 0.4–1.1) calls/day, while calls for other reasons did not significantly change (+1.2 (95% CI −0.8 to 3.1) calls/day). Refusal of transport for substance-related calls increased from 5.0% before the statewide emergency to 7.5% after the declaration (p < 0.001). CONCLUSIONS: After an initial decline in substance-related ambulance calls following a statewide declaration of emergency, calls for substance use increased to pre-COVID-19 levels, while those for other reasons remained at a lower rate. The results suggest that COVID-19 is disproportionately affecting individuals with substance use disorder.

Objective This study evaluated the characteristics of opioid prescriptions, including prescriber specialty, given to opioid-naïve patients and their association with chronic use. Design Cross-sectional analysis of the Ohio prescription drug monitoring program from January 2010 to November 2017. Setting Ohio, USA. Subjects Patients who had no opioid prescriptions from 2010 to 2012 and a first-time prescription from January 2013 to November 2016. Methods Chronic use was defined as at least six opioid prescriptions in one year and either one or more years between the first and last prescription or an average of ≤30 days not covered by an opioid during that year. Results A total of 4,252,809 opioid-naïve patients received their first opioid prescription between 2013 and 2016; 364,947 (8.6%) met the definition for chronic use. Those who developed chronic use were older (51.7 vs 45.6 years) and more likely to be female (53.6% vs 52.8%), and their first prescription had higher pill quantities (44.9 vs 30.2), higher morphine milligram equivalents (MME; 355.3 vs 200.0), and was more likely to be an extended-release formulation (2.9% vs 0.7%, all P Conclusions Eight point six percent of opioid-naïve individuals who received an opioid prescription developed chronic use. This rate varied depending on the specialty of the provider who wrote the prescription. The risk of chronic use increased with higher MME content of the initial prescription and use of extended-release opioids.

Objective Emergency physicians are commonly compared by their patients' length of stay (LOS). We test the hypothesis that LOS is associated with patient characteristics and that accounting for these features impacts physician LOS rankings. Methods This was a retrospective observational study of all encounters at an emergency department in 2010 to 2015. We compared the characteristics of patients seen by physicians in different quartiles of LOS. Primary outcome was variation in patient characteristics at time of physician assignment (age, sex, comorbidities, Emergency Severity Index [ESI], and chief complaint) across LOS quartiles. We also quantified the change in LOS rankings after accounting for difference in characteristics of patients seen by different physicians. Results A total of 264,776 encounters seen by 62 attending physicians met inclusion criteria. Physicians in the longest LOS quartile saw patients who were older (age = 49.1 vs 48.6 years, difference = +0.5 years, 95% confidence interval [CI] = 0.3 to 0.7) with more comorbidities (Gagne score = 1.3 vs. 0.9, difference = +0.4, 95% CI = 0.4 to 0.4) and higher acuity (ESI = 2.8 vs. 2.9, difference = -0.1, 95% CI = 0.1 to 0.1) than physicians in the shortest LOS quartile. The odds ratio (OR) of physicians in the longest LOS quartile seeing patients over age 50 compared to the shortest LOS quartile was 1.1 (95% CI = 1.0 to 1.1); the OR of physicians in the longest LOS quartile seeing patients with ESI of 1 or 2 was also 1.1 (95% CI = 1.0 to 1.1). Accounting for variation in patient characteristics seen by different physicians resulted in substantial reordering of physician LOS rankings: 62.9% (39/62) of physicians reclassified into a different quartile with mean absolute percentile change of 25.8 (95% CI = 20.3 to 31.3). A total of 62.5% (10/16) of physicians in the shortest LOS quartile and 56.3% (9/16) in the longest LOS quartile moved into a different quartile after accounting for variation in patient characteristics. Conclusions Length of stay was significantly associated with patient characteristics, and accounting for variation in patient characteristics resulted in substantial reordering of relative physician rankings by LOS. Comparisons of emergency physicians by LOS that do not account for patient characteristics should be reconsidered.

STUDY OBJECTIVE: Prehospital use of naloxone for presumed opioid overdose has increased markedly in recent years because of the current opioid overdose epidemic. In this study, we determine the one-year mortality of suspected opioid overdose patients who were treated with naloxone by EMS and initially survived. METHODS: This was a retrospective observational study of patients using three linked statewide datasets in Massachusetts: emergency medical services (EMS), a master demographics file, and death records. We included all suspected opioid overdose patients who were treated with naloxone by EMS. The primary outcome measures were death within 3 days of treatment and between 4 days and 1 year of treatment. RESULTS: Between July 1, 2013 and December 31, 2015, there were 9,734 individuals who met inclusion criteria and were included for analysis. Of these, 807 (8.3% (95% confidence interval (CI) 7.7%-8.8%)) died in the first 3 days, 668 (6.9% (95% CI 6.4%-7.4%)) died between 4 days and 1 year, and 8,259 (84.8% (95% CI 84.1%-85.6%)) were still alive at one year. Excluding those who died within 3 days, 668 of the remaining 8,927 individuals (7.5% (95% CI 6.9%-8.0%)) died within one year. CONCLUSION: The one-year mortality of those who are treated with naloxone for opioid overdose by EMS is high. Communities should focus both on primary prevention and interventions for this patient population, including strengthening regional treatment centers and expanding access to medication for opioid use disorder.

BACKGROUND Prior studies have found conflicting effects of Medicaid expansion on emergency department (ED) utilization but have not studied the reasons patients go to EDs. OBJECTIVES Examine the changes in reasons for ED use associated with Medicaid expansion. RESEARCH DESIGN Difference-in-difference analysis. SUBJECTS We included sample adults from the 2012 to 2017 National Health Interview Survey who were US citizens and reported a total family income below 138% federal poverty level (n=30,259). MEASURES We examined changes in the proportion of study subjects reporting: (1) any ED visits; (2) ED visits due to perceived illness severity; (3) office not open; and (4) barriers to outpatient care, comparing expansion and nonexpansion states. RESULTS Overall, 30.6% of low-income adults reported ED use in the past year, of which 74.1% reported illness acuity, 12.4% reported office not open, 9.5% reported access barriers, and 4.0% did not report any reason. Medicaid expansion was not associated with statistically significant changes in overall ED use [-2.2% (95% confidence interval-CI), -5.5% to 1.2%), P=0.21], ED visits due to perceived illness severity [0.5% (95% CI, -2.4% to 3.5%), P=0.73], or office not open [-0.9% (95% CI, -2.3% to 0.5%); P=0.22], but was associated with significant decrease in ED visits due to access barriers [-1.4% (95% CI, -2.6% to -0.2%), P=0.022]. CONCLUSIONS Medicaid expansion was associated with a decrease in low-income adults who reported outpatient care barriers as reasons for ED visits. There were no significant changes in overall ED utilization, likely because the majority of respondent reported ED use due to concerns with illness severity or outpatient office was closed.

Study objective Despite the increased availability of naloxone, death rates from opioid overdose continue to increase. The goal of this study is to determine the 1-year mortality of patients who were treated for a nonfatal opioid overdose in Massachusetts emergency departments (EDs). Methods This was a retrospective observational study of patients from 3 linked statewide Massachusetts data sets: a master demographics list, an acute care hospital case-mix database, and death records. Patients discharged from the ED with a final diagnosis of opioid overdose were included. The primary outcome measure was death from any cause within 1 year of overdose treatment. Results During the study period, 17,241 patients were treated for opioid overdose. Of the 11,557 patients who met study criteria, 635 (5.5%) died within 1 year, 130 (1.1%) died within 1 month, and 29 (0.25%) died within 2 days. Of the 635 deaths at 1 year, 130 (20.5%) occurred within 1 month and 29 (4.6%) occurred within 2 days. Conclusion The short-term and 1-year mortality of patients treated in the ED for nonfatal opioid overdose is high. The first month, and particularly the first 2 days after overdose, is the highest-risk period. Patients who survive opioid overdose should be considered high risk and receive interventions such as being offered buprenorphine, counseling, and referral to treatment before ED discharge.

Background: All Payer Claims Databases (APCD) are a rich source of health information, however, race and ethnicity (R&E) data are largely missing. Bayesian Improved Surname Geocoding (BISG) is a common R&E imputation method, yet, validation of BISG in APCDs is lacking. We used the BISG to impute missing R&E in the Oregon APCD. Methods: BISG imputed R&E for Asian Pacific Islanders (API), Blacks, Hispanics and Whites were contrasted to the gold standard (vital statistics) and sensitivity and specificity improvements were assessed. Logistic regression examined whether missing R&E was random across patient characteristics. Results: Among 85,857 individuals in the study, 32.1% (n=27,594) had missing R&E. Missing R&E was not randomly distributed. There were higher odds of missingness among males, Whites, those age 65 and older, and commercially insured individuals. Differences in the percent missing were also found by co-morbid conditions and mortality causes. Imputing the missing R&E with BISG method improved the sensitivity to identify White, Black, API, and Hispanics. Conclusions: APCDs can benefit from enhancing missing R&E with BISG imputation to perform more robust population-health level analyses and identify inequities according to R&E without losing power or dropping non-random records with missing R&E data.

ImportancePrevious studies that examined the role of household opioid prescriptions in opioid overdose risk were limited to commercial claims, did not include fatal overdoses, and had limited inclusion of household prescription characteristics. Broader research is needed to expand understanding of the risk of overdose.ObjectiveTo assess the role of household opioid availability and other household prescription factors associated with individuals’ odds of fatal or nonfatal opioid overdose.Design, Setting, and ParticipantsA retrospective cohort study assessing patient outcomes from January 1, 2015, through December 31, 2018, was conducted on adults in the Oregon Comprehensive Opioid Risk Registry database in households of at least 2 members. Data analysis was performed between October 16, 2020, and January 26, 2023.ExposuresHousehold opioid prescription availability and household prescription characteristics.Main Outcomes and MeasuresOpioid overdoses were captured from insurance claims, death records, and hospital discharge data. Household opioid prescription availability and prescription characteristics for individuals and households were modeled as 6-month cumulative time-dependent measures, updated monthly. To assess the association between household prescription availability, household prescription characteristics, and overdose, multilevel logistic regression models were developed, adjusting for demographic, clinical, household, and prescription characteristics.ResultsThe sample included 1 691 856 individuals in 1 187 140 households, of which most were women (53.2%), White race (70.7%), living in metropolitan areas (75.8%), and having commercial insurance (51.8%), no Elixhauser comorbidities (69.5%), and no opioid prescription fills in the study period (57.0%). A total of 28 747 opioid overdose events were observed during the study period (0.0526 per 100 person-months). Relative to individuals without personal or household opioid fills, the odds of opioid-related overdose increased by 60% when another household member had an opioid fill in the past 6 months (adjusted odds ratio [aOR], 1.60; 95% CI, 1.54-1.66) and were highest when both the individual and another household member had opioid fills in the preceding 6 months (aOR, 6.25; 95% CI, 6.09-6.40).Conclusions and RelevanceIn this cohort study of adult Oregon residents in households of at least 2 members, the findings suggest that household prescription availability is associated with increased odds of opioid overdose for others in the household, even if they do not have their own opioid prescription. These findings underscore the importance of educating patients about proper opioid disposal and the risks of household opioids.

Background Buprenorphine is a widely used treatment option for patients with opioid use disorder (OUD). Premature discontinuation from this treatment has many negative health and societal consequences. Objective To develop and evaluate a machine learning based two-stage clinical decision-making framework for predicting which patients will discontinue OUD treatment within less than a year. The proposed framework performs such prediction in two stages: (i) at the time of initiating the treatment, and (ii) after two/three months following treatment initiation. Methods For this retrospective observational analysis, we utilized Massachusetts All Payer Claims Data (MA APCD) from the year 2013 to 2015. Study sample included 5190 patients who were commercially insured, initiated buprenorphine treatment between January and December 2014, and did not have any buprenorphine prescription at least one year prior to the date of treatment initiation in 2014. Treatment discontinuation was defined as at least two consecutive months without a prescription for buprenorphine. Six machine learning models (i.e., logistic regression, decision tree, random forest, extreme-gradient boosting, support vector machine, and artificial neural network) were tested using a five-fold cross validation on the input data. The first-stage models used patients’ demographic information. The second-stage models included information on medication adherence during the early phase of treatment based on the proportion of days covered (PDC) measure. Results A substantial percentage of patients (48.7%) who started on buprenorphine discontinued the treatment within one year. The area under receiving operating characteristic curve (C-statistic) for the first stage models varied within a range of 0.55 to 0.59. The inclusion of knowledge regarding patients’ adherence at the early treatment phase in terms of two-months and three-months PDC resulted in a statistically significant increase in the models’ discriminative power (p-value Conclusion Machine learning models can predict which patients are most at-risk of premature treatment discontinuation with reasonable discriminative power. The proposed machine learning framework can be used as a tool to help inform a clinical decision support system following further validation. This can potentially help prescribers allocate limited healthcare resources optimally among different groups of patients based on their vulnerability to treatment discontinuation and design personalized support systems for improving patients’ long-term adherence to OUD treatment.

Background Hydrocodone and oxycodone are prescribed commonly to treat pain. However, differences in risk of opioid-related adverse outcomes after an initial prescription are unknown. This study aims to determine the risk of opioid-related adverse events, defined as either chronic use or opioid overdose, following a first prescription of hydrocodone or oxycodone to opioid naïve patients. Methods A retrospective analysis of multiple linked public health datasets in the state of Oregon. Adult patients ages 18 and older who a) received an initial prescription for oxycodone or hydrocodone between 2015–2017 and b) had no opioid prescriptions or opioid-related hospitalizations or emergency department visits in the year preceding the prescription were followed through the end of 2018. First-year chronic opioid use was defined as ≥6 opioid prescriptions (including index) and average ≤30 days uncovered between prescriptions. Fatal or non-fatal opioid overdose was indicated from insurance claims, hospital discharge data or vital records. Results After index prescription, 2.8% (n = 14,458) of individuals developed chronic use and 0.3% (n = 1,480) experienced overdose. After adjustment for patient and index prescription characteristics, patients receiving oxycodone had lower odds of developing chronic use relative to patients receiving hydrocodone (adjusted odds ratio = 0.95, 95% confidence interval (CI) 0.91–1.00) but a higher risk of overdose (adjusted hazard ratio (aHR) = 1.65, 95% CI 1.45–1.87). Oxycodone monotherapy appears to greatly increase the hazard of opioid overdose (aHR 2.18, 95% CI 1.86–2.57) compared with hydrocodone with acetaminophen. Oxycodone combined with acetaminophen also shows a significant increase (aHR 1.26, 95% CI 1.06–1.50), but not to the same extent. Conclusions Among previously opioid-naïve patients, the risk of developing chronic use was slightly higher with hydrocodone, whereas the risk of overdose was higher after oxycodone, in combination with acetaminophen or monotherapy. With a goal of reducing overdose-related deaths, hydrocodone may be the favorable agent.