Orphanhood and caregiver death among children in the United States due to all-cause mortality 2000-2021: A Modeling Study (preprint)

Importance: Deaths of parents and grandparent caregivers linked to social and health crises threaten child wellbeing due to losses of nurturance, financial support, physical safety, family stability, and care. Little is known about the full burden of all-causes and leading cause-specific orphanhood and caregiver death beyond estimates from select causes. Objective: To estimate 2000-2021 prevalence and incidence trends of all-cause orphanhood and caregiver death among children <18, by cause, age, race/ethnicity, and state. Data Sources: National Center for Health Statistics (NCHS) birth, death, race/ethnicity, and population data to estimate fertility rates and identify causes of death; 1983-1998 ICD-9 causes-of-death harmonized to ICD-10 classifications; 1999-2021 ICD-10 causes-of-death; CDC WONDER for state-specific estimates; and American Community Survey for grandparent population estimates. Data extraction and synthesis: We extracted U.S. population-level death, birth, population size, race, and ethnicity data from NCHS and attributed to each deceased individual the average number of children left behind according to subgroup-specific fertility rates in the previous 0-17 years. We examined prevalence and incidence of orphanhood by leading causes-of-death, including COVID-19, the leading 5 causes-of-death for 1983-2021, and additional leading causes for ages 15-44. We extended these to obtain state-level outcome estimates. Main outcome measures: National incidence and prevalence of orphanhood and caregiver death from 2000-2021, with orphanhood by year, parental cause-of-death and sex, child age, race/ethnicity, and state. Results: From 2000-2021, orphanhood and custodial/co-residing grandparent caregiver loss annual incidence and prevalence trends increased 49.2% and 8.3%, respectively. By 2021, 2.9 million children (4% of all children) had experienced prevalent orphanhood and caregiver death. Populations disproportionately affected by orphanhood included 5.0% of all adolescents; 6.5%, 4.8%, and 3.9% respectively of non-Hispanic American Indian/Alaska Native, non-Hispanic Black, and non-Hispanic White children; and children in New Mexico and Southern and Eastern States. Parental death due to drug overdose during 2020-2021 surpassed COVID-19 as the leading cause of incident and prevalent orphanhood during the COVID-19 pandemic. Conclusions and Relevance: Policies, programs, and practices aimed at orphanhood prevention, identification, and linkage to services and support of nearly 3 million bereaved children are needed, foremost prioritizing rapidly increasing overdose-linked orphanhood.

Impact of COVID-19 on Emergency Medical Services Utilization and Severity in the U.S. Upper Midwest (preprint)

The COVID-19 pandemic has claimed nearly one million lives and has drastically changed how patients interact with the healthcare system. Emergency medical services (EMS) are essential for emergency response, disaster preparedness, and responding to everyday emergencies. We therefore examined differences in EMS utilization and call severity in 2020 (pandemic period) compared to trends from 2015-2019 (pre-pandemic period) in a large, multi-state advanced life support EMS agency serving the U.S. Upper Midwest. Specifically, we analyzed all 911 calls made to Mayo Clinic Ambulance, the sole advanced life support EMS provider serving a large area in Minnesota and Wisconsin, in 2020 compared to those made between 2015-2019. We compared the number of emergency calls made in 2020 to the number of calls expected based on trends from 2015-2019. We similarly compared caller demographics, call severity, and proportions of calls made for overdose/intoxication, behavioral health, and motor vehicle accidents. Subgroup analyses were performed for rural vs. urban areas. We identified 262,232 emergent EMS calls in the pre-pandemic period and 53,909 calls in the pandemic period, corresponding to a decrease of 28.7% in call volume during the pandemic period. Caller demographics shifted towards older patients (mean age 59.7 [SD, 23.0] vs. 59.1 [SD, 23.7] years; p<0.001) and to rural areas (20.4% vs. 20.0%; p=0.007). Call severity increased, with 95.3% of calls requiring transport (vs. 93.8%; p<0.001) and 1.9% resulting in death (vs. 1.6%; p<0.001). The proportion of calls for overdose/intoxication increased from 4.8% to 5.5% (p<0.001), while the proportion of calls for motor vehicle collisions decreased from 3.9% to 3.0% (p<0.001). All changes were more pronounced in urban areas. These findings underscore the extent to which the COVID-19 pandemic impacted healthcare utilization, particularly in urban areas, and suggest that patients may have delayed calling EMS with potential implications on disease severity and risk of death.

Assessment of knowledge and behaviors of an opioid overdose education and naloxone distribution program during the Coronavirus disease 2019 pandemic. (preprint)

Background: The state of Louisiana ranked 4th in the US for per capita overdose rates as 56 out of 100,000 persons died due to overdose and 1,300 of those deaths involved opioids. Opioid involved deaths increased 131% between 2019–2022. A pharmacist-led OEND program was developed at a SSP in New Orleans during the COVID-19 pandemic in response to increased client enrolment during that time. The purpose of this research is to characterize the clients who participated in the OEND and to assess their learned knowledge and behaviors over time.Methods: A pharmacist led OEND program was created in April 2020 at a syringe access program in New Orleans, Louisiana. OEND was provided by a licensed pharmacist and student pharmacists. OEND coincided with the SSPs activities one time a week. Participants first received harm reduction supplies through the syringe access program and then had the option of receiving OEND. Patients' demographic information was collected. Participants who said they received opioid overdose education from our OEND program were verbally given a knowledge and behavior assessment. Participants knowledge and behaviors were scored using a rubric.Results: A total of 32 OEND sessions were held from July 2020 through February 2023 resulting in 1453 overall participant interactions. Repeat participants completed 269 visits and averaged 2.3 visits in three years. The average age of participants who received OEND was 40 years old. Additionally, participants who accessed OEND were primarily white (68.1%, n = 989/1453) and mostly male (59.1%, n = 859/1453). Among the participants who visited the OEND station more than once, 160 responses were collected for how helpful the previous education session had been. Of these responses, 75% (= 120/160) were “Very helpful”. Average scores on our knowledge assessment showed no significant change over time for repeat visitors showing participants retained at least basic knowledge.Conclusions: OEND programs established at SSPs play an important role in providing education to PWUD. Participants knowledge sustained over time; however, refresher education sessions may be valuable to ensure participants stay accurately informed. Participants find OEND helpful. As naloxone continues to become increasingly available, OEND is necessary in preventing opioid overdose deaths.

Heterogeneity in deaths of despair: excess mortality in the US during the Covid-19 pandemic (preprint)

The impact of Covid-19 on mortality includes both direct effects of the virus and indirect effects mediated through other causal pathways. In the United States, the indirect effects, particularly from suicides, overdoses and alcohol-induced causes (i.e. deaths of despair) (1) are understudied. Here, we estimated excess non-Covid deaths and deaths of despair, in the US overall, in each state and in 72 demographic strata. Nationally, 114,230 (127,597) excess non-Covid deaths, 19,074 (33,559) excess poisoning deaths and 8,746 (13,771) excess alcohol-induced deaths were estimated during 2020 (2021). Excess poisoning and alcohol-induced mortality were highest among the 35-44 and the 55-64 year groups, respectively. The Black and the American Indian/Alaskan Native populations had the highest excess poisoning and alcohol-induced mortality, respectively. Fewer suicides than expected occurred nationally, but excess suicides were estimated among Black youth. These findings suggest that additional resources need to be mobilized to limit increases in deaths of despair.

Early treatment with N-acetylcysteine reduces hepatotoxicity in acute acetaminophen poisoning.

During the outbreak of COVID19 measures taken to contain the spread of the virus have influenced the mental well-being of adults and adolescents. Acetaminophen overdose is the major cause of drug intoxication among children and adolescents. We reported a case of a 15-year- old girl referred to our Emergency Department 3 hours after ingestion of 10 g of paracetamol for suicidal purposes. She promptly started the administration of intravenous N-acetylcysteine (NAC) and the patient was discharged after 5 days of hospitalization in good clinical condition and with neuropsychiatric follow-up. Our case shows that the timing of the intravenous NAC administration is considered the most important factor in the prevention of acetaminophen-induced hepatic failure, despite high serum levels after acetaminophen ingestion.

Insights from Drug Checking Programs: Practicing Bootstrap Public Health Whilst Tailoring to Local Drug User Needs.

The year 2021 was the most deadly year for overdose deaths in the USA and Canada. The stress and social isolation stemming from the COVID-19 pandemic coupled with a flood of fentanyl into local drug markets created conditions in which people who use drugs were more susceptible to accidental overdose. Within territorial, state, and local policy communities, there have been longstanding efforts to reduce morbidity and mortality within this population; however, the current overdose crisis clearly indicates an urgent need for additional, easily accessible, and innovative services. Street-based drug testing programs allow individuals to learn the composition of their substances prior to use, averting unintended overdoses while also creating low threshold opportunities for individuals to connect to other harm reduction services, including substance use treatment programs. We sought to capture perspectives from service providers to document best practices around fielding community-based drug testing programs, including optimizing their position within a constellation of other harm reduction services to best serve local communities. We conducted 11 in-depth interviews from June to November 2022 via Zoom with harm reduction service providers to explore barriers and facilitators around the implementation of drug checking programs, the potential for integration with other health promotion services, and best practices for sustaining these programs, taking the local community and policy landscape into account. Interviews lasted 45-60 min and were recorded and transcribed. Thematic analysis was used to reduce the data, and transcripts were discussed by a team of trained analysts. Several key themes emerged from our interviews: (1) the instability of drug markets amid an inconsistent and dangerous drug supply; (2) implementing drug checking services in dynamic environments in response to the rapidly changing needs of local communities; (3) training and ongoing capacity building needed to create sustainable programs; and (4) the potential for integrating drug checking programs into other services. There are opportunities for this service to make a difference in overdose deaths as the contours of the drug market itself have changed over time, but a number of challenges remain to implement them effectively and sustain the service over time. Drug checking itself represents a paradox within the larger policy context, putting the sustainability of these programs at risk and challenging the potential to scale these programs as the overdose epidemic worsens.

Racial, Ethnic, and Sex Differences in Methadone-Involved Overdose Deaths Before and After the US Federal Policy Change Expanding Take-home Methadone Doses.

Importance: In March 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) permitted states to relax restrictions on take-home methadone doses for treatment-adherent patients to minimize COVID-19 exposures. Objective: To assess whether the methadone take-home policy change was associated with drug overdose deaths among different racial, ethnic, and sex groups. Design, Setting, and Participants: Interrupted time series analysis from January 1, 2018, to June 30, 2022. Data analysis was conducted from February 18, 2023, to February 28, 2023. In this population-based cohort study of drug overdose mortality including 14 529 methadone-involved deaths, monthly counts of methadone-involved drug overdose deaths were obtained for 6 demographic groups: Hispanic men and women, non-Hispanic Black men and women, and non-Hispanic White men and women. Exposure: On March 16, 2020, in response to the first wave of the COVID-19 pandemic, SAMHSA issued an exemption to the states that permitted up to 28 days of take-home methadone for stable patients and 14 days for less stable patients. Main Outcome Measures: Monthly methadone-involved overdose deaths. Results: From January 1, 2018, to June 30, 2022 (54 months), there were 14 529 methadone-involved deaths in the United States; 14 112 (97.1%) occurred in the study's 6 demographic groups (Black men, 1234; Black women, 754; Hispanic men, 1061; Hispanic women, 520; White men, 5991; and White women, 4552). Among Black men, there was a decrease in monthly methadone deaths associated with the March 2020 policy change (change of slope from the preintervention period, -0.55 [95% CI, -0.95 to -0.15]). Hispanic men also experienced a decrease in monthly methadone deaths associated with the policy change (-0.42 [95% CI, -0.68 to -0.17]). Among Black women, Hispanic women, White men, and White women, the policy change was not associated with a change in monthly methadone deaths (Black women, -0.27 [95% CI, -1.13 to 0.59]; Hispanic women, 0.29 [95% CI, -0.46 to 1.04]; White men, -0.08 [95% CI, -1.05 to 0.88]; and White women, -0.43 [95% CI, -1.26 to 0.40]). Conclusions and Relevance: In this interrupted time series study of monthly methadone-involved overdose deaths, the take-home policy may have helped reduce deaths for Black and Hispanic men but had no association with deaths of Black or Hispanic women or White men or women.

Pregnancy, Opioid Use Disorder and COVID-19: An Evaluation of Acute Care Presentations During a Pandemic.

INTRODUCTION: The opioid epidemic has been exacerbated by the COVID-19 pandemic, resulting in increased acute care opioid-related and overdose visits. We sought to assess how the pandemic may have impacted an obstetric cohort impacted by opioid misuse in the acute care context. METHODS: A retrospective review of acute care presentations of patients with concomitant pregnancy (Z33.1) and opioid-related diagnostic codes (T10 codes and/or F11) was conducted over a 24-month period (pre-COVID = March 2019 through February 2020, post-COVID = March 2020 through February 2021). Descriptive statistics and χ2 analysis of pre- versus post-COVID presentations were performed. RESULTS: A total of 193 individuals, 104 (53.9%) pre- and 89 (46.1%) post-COVID, accounting for 292 total encounters, 160 (54.8%) pre- and 132 (45.2%) post-COVID, were seen for acute care visits ( P = 0.84). Age ( P = 0.15), race ( P = 0.59), and insurance status ( P = 0.17) were similar pre- versus post-COVID. The majority of presentations, pre- (40.4%) and post-COVID (44.9%), were for opioid withdrawal ( P = 0.74). Although post-COVID individuals were more likely to lack prenatal care (48.3% versus 39.4% pre-COVID), this trend was not significant ( P = 0.19). Similar proportions of individuals were affected by pregnancy complications (51.9% pre-, 44.9% post-COVID; P = 0.30). Similar proportions of individuals were affected by adverse pregnancy outcomes (44.2% pre-, 48.3% post-COVID; P = 0.64). CONCLUSION: The COVID-19 pandemic did not have a statistically significant effect on opioid-related acute care presentations or outcomes for obstetric patients. In this acute care cohort, however, opioid misuse had significant general impact on pregnancy complications and outcomes, suggesting unmet needs in this population.

"We do it ourselves": strengths and opportunities for improving the practice of harm reduction.

BACKGROUND: Unprecedented increases in substance-related overdose fatalities have been observed in Texas and the U.S. since the onset of the COVID-19 pandemic and have made clear there is considerable need to reduce harms associated with drug use. At the federal level, initiatives have called for widespread dissemination and implementation of evidence-based harm reduction practices to reduce overdose deaths. Implementation of harm reduction strategies is challenging in Texas. There is a paucity of literature on understanding current harm reduction practices in Texas. As such, this qualitative study aims to understand harm reduction practices among people who use drugs (PWUD), harm reductionists, and emergency responders across four counties in Texas. This work would inform future efforts to scale and spread harm reduction in Texas. METHODS: Semi-structured qualitative interviews were conducted with N = 69 key stakeholders (25 harm reductionists; 24 PWUD; 20 emergency responders). Interviews were transcribed verbatim, coded for emergent themes, and analyzed using Applied Thematic Analysis with Nvivo 12. A community advisory board defined the research questions, reviewed the emergent themes, and assisted with interpretation of the data. RESULTS: Emergent themes highlighted barriers to harm reduction at micro and macro levels, from the individual experience of PWUD and harm reductionists to systemic issues in healthcare and the emergency medical response system. Specifically, (1) Texas has existing strengths in overdose prevention and response efforts on which to build, (2) PWUD are fearful of interacting with healthcare and 911 systems, (3) harm reductionists are in increasing need of support for reaching all PWUD communities, and (4) state-level policies may hinder widespread implementation and adoption of evidence-based harm reduction practices. CONCLUSIONS: Perspectives from harm reduction stakeholders highlighted existing strengths, avenues for improvement, and specific barriers that currently exist to harm reduction practices in Texas.

Estimated Reductions in Opioid Overdose Deaths With Sustainment of Public Health Interventions in 4 US States.

Importance: In 2021, more than 80 000 US residents died from an opioid overdose. Public health intervention initiatives, such as the Helping to End Addiction Long-term (HEALing) Communities Study (HCS), are being launched with the goal of reducing opioid-related overdose deaths (OODs). Objective: To estimate the change in the projected number of OODs under different scenarios of the duration of sustainment of interventions, compared with the status quo. Design, Setting, and Participants: This decision analytical model simulated the opioid epidemic in the 4 states participating in the HCS (ie, Kentucky, Massachusetts, New York, and Ohio) from 2020 to 2026. Participants were a simulated population transitioning from opioid misuse to opioid use disorder (OUD), overdose, treatment, and relapse. The model was calibrated using 2015 to 2020 data from the National Survey on Drug Use and Health, the US Centers for Disease Control and Prevention, and other sources for each state. The model accounts for reduced initiation of medications for OUD (MOUDs) and increased OODs during the COVID-19 pandemic. Exposure: Increasing MOUD initiation by 2- or 5-fold, improving MOUD retention to the rates achieved in clinical trial settings, increasing naloxone distribution efforts, and furthering safe opioid prescribing. An initial 2-year duration of interventions was simulated, with potential sustainment for up to 3 additional years. Main Outcomes and Measures: Projected reduction in number of OODs under different combinations and durations of sustainment of interventions. Results: Compared with the status quo, the estimated annual reduction in OODs at the end of the second year of interventions was 13% to 17% in Kentucky, 17% to 27% in Massachusetts, 15% to 22% in New York, and 15% to 22% in Ohio. Sustaining all interventions for an additional 3 years was estimated to reduce the annual number of OODs at the end of the fifth year by 18% to 27% in Kentucky, 28% to 46% in Massachusetts, 22% to 34% in New York, and 25% to 41% in Ohio. The longer the interventions were sustained, the better the outcomes; however, these positive gains would be washed out if interventions were not sustained. Conclusions and Relevance: In this decision analytical model study of the opioid epidemic in 4 US states, sustained implementation of interventions, including increased delivery of MOUDs and naloxone supply, was found to be needed to reduce OODs and prevent deaths from increasing again.

Community partner perspectives on the implementation of a novel safer supply program in Canada: a qualitative study of the MySafe Project.

BACKGROUND: The adulteration of the illicit drug supply with fentanyl and its analogues is driving the ongoing overdose crisis in North America. While various harm reduction interventions address overdose-related risks, there is growing interest in safer supply programs, including the MySafe Project which utilizes a biometric dispensing machine that provides pharmaceutical opioid alternatives to the toxic drug supply. However, the experiences and perspectives of professional community partners on program implementation remain unexplored. This study aims to examine professional community partner perspectives on the feasibility, as well as barriers and facilitators to the implementation of the MySafe program. METHODS: Semi-structured qualitative interviews were conducted with 17 professional community partners involved in program implementation across four pilot locations in Canada. Thematic analysis of interviews focused on perspectives on safer supply, barriers and facilitators faced during program implementation, and recommendations to inform future scale-up of low-barrier safer supply models across Canada. RESULTS: Participants identified a variety of barriers, including the dependence on clinician buy-in, coupled with regulatory and logistical constraints. In addition, some participants perceived hydromorphone to be an inadequate substitute to the increasingly toxic street opioid supply. Lastly, technical difficulties were described as barriers to service uptake and delivery. Conversely, having political and community buy-in, availability of wrap-around services, and collaborative communication from the MySafe team served as facilitators to program implementation. Though community partners preferred establishing MySafe machines into existing community organizations, they also discussed benefits of housing-based MySafe programs. The potential role of this program in mid-sized to rural cities was also emphasized. CONCLUSIONS: To address the overdose crisis, there is an urgent need to implement and evaluate novel solutions that address supply drivers of crisis. Community partner-informed research plays an integral role in ensuring program acceptability and proper implementation. Our findings identify current gaps and facilitators underlying the efficacy of one such model, together with future directions for improvement. Participant recommendations included a diversification of medications offered and types of locations for MySafe programs, a streamlined national approach to prescribing guidelines coupled with more robust training for healthcare professionals, and an emphasis on service delivery within an integrated services model. Our findings underscore a potential gap between the goals of healthcare providers in ensuring comprehensive care and the necessity for low-barrier models such as MySafe that can function both within and outside of integrated service models.

Smoking identified as preferred mode of opioid safe supply use; investigating correlates of smoking preference through a 2021 cross-sectional study in British Columbia.

BACKGROUND: The increasing number of illicit drug toxicity deaths in British Columbia (BC) has led to calls for a regulated (pharmaceutical grade) supply of substances ("safe supply"). In order to inform safe supply recommendations, we aimed to identify why people currently smoke opioids and assess the preferred mode of consumption if people who use opioids were provided with opioid safe supply. METHODS: The BC Harm Reduction Client Survey (HRCS) is an annual survey that gathers information about people who use drugs' (PWUD) substance use characteristic with the goal of contributing to evidence-based policy. This study utilized data from the 2021 HRCS. The outcome variable was "prefer smoking opioid safe supply" ('yes/no'). Explanatory variables included participants' demographics, drug use, and overdose characteristics. Bivariate and hierarchical multivariable logistic regressions were conducted to identify factors associated with the outcome. RESULTS: Of 282 total participants who indicated a preference for a mode of consumption for opioid safe supply, 62.4% preferred a smokable option and 19.9% preferred to inject if provided with opioid safe supply. Variables significantly associated with the outcome (preferred smoking) included: being 19-29 years old (AOR=5.95, CI =1.93 - 18.31) compared to >50 years old, having witnessed an overdose in the last 6 months (AOR=2.26, CI=1.20 - 4.28), having smoked opioids in the last 3 days (AOR=6.35, CI=2.98 - 13.53) and having a preference to smoke stimulants safe supply (AOR=5.04, CI=2.53 - 10.07). CONCLUSION: We found that over half of participants prefer smokable options when accessing opioid safe supply. Currently in BC, there are limited smokable opioid safe supply options as alternatives to the toxic street supply. To reduce overdose deaths, safe supply options should be expanded to accommodate PWUD that prefer smoking opioids.

Considerations for the design of overdose education and naloxone distribution interventions: results of a multi-stakeholder workshop.

INTRODUCTION: Opioid overdose epidemic is a public health crisis that is impacting communities around the world. Overdose education and naloxone distribution programs equip and train lay people to respond in the event of an overdose. We aimed to understand factors to consider for the design of naloxone distribution programs in point-of-care settings from the point of view of community stakeholders. METHODS: We hosted a multi-stakeholder co-design workshop to elicit suggestions for a naloxone distribution program. We recruited people with lived experience of opioid overdose, community representatives, and other stakeholders from family practice, emergency medicine, addictions medicine, and public health to participate in a full-day facilitated co-design discussion wherein large and small group discussions were audio-recorded, transcribed and analysed using thematic approaches. RESULTS: A total of twenty-four participants participated in the multi-stakeholder workshop from five stakeholder groups including geographic and setting diversity. Collaborative dialogue and shared storytelling revealed seven considerations for the design of naloxone distribution programs specific to training needs and the provision of naloxone, these are: recognizing overdose, how much naloxone, impact of stigma, legal risk of responding, position as conventional first aid, friends and family as responders, support to call 911. CONCLUSION: To create an naloxone distribution program in emergency departments, family practice and substance use treatment services, stigma is a central design consideration for training and naloxone kits. Design choices that reference the iconography, type, and form of materials associated with first aid have the potential to satisfy the need to de-stigmatize overdose response.

Public transport access to drug treatment before and during COVID-19: Implications for the opioid epidemic.

Public transport disruptions caused by the COVID-19 pandemic had wide-ranging impacts on the ability of individuals to access health care. Individuals with opioid use disorder represent an especially vulnerable population due to the necessity of frequent, supervised doses of opioid agonists. Focused on Toronto, a major Canadian city suffering from the opioid epidemic, this analysis uses novel realistic routing methodologies to quantify how travel times to individuals\220 nearest clinics changed due to public transport disruptions from 2019 to 2020. Individuals seeking opioid agonist treatment face very constrained windows of access due to the need to manage work and other essential activities. We find that thousands of households in the most materially and socially deprived neighbourhoods crossed 30 and 20-minute travel time thresholds to their nearest clinic. As even small changes to travel times can lead to missed appointments and heighten the chances of overdose and death, understanding the distribution of those most impacted can help inform future policy measures to ensure adequate access to care.

Emergency Department Visits Involving Mental Health Conditions, Suicide-Related Behaviors, and Drug Overdoses Among Adolescents - United States, January 2019-February 2023.

The U.S. adolescent mental and behavioral health crisis is ongoing,* with high pre-COVID-19 pandemic baseline rates† (1) and further increases in poor mental health (2), suicide-related behaviors (3), and drug overdose deaths (4) reported during 2020-2021. CDC examined changes in U.S. emergency department (ED) visits for mental health conditions (MHCs) overall and for nine specific MHCs,§ suicide-related behaviors (including suspected suicide attempts), and drug-involved overdoses (including opioids) among children and adolescents aged 12-17 years (adolescents) during January 2019-February 2023, overall and by sex. Compared with fall 2021, by fall 2022, decreases in weekly ED visits were reported among all adolescents, and females specifically, for MHCs overall, suicide-related behaviors, and drug overdoses; weekly ED visits among males were stable. During this same period, increases in weekly ED visits for opioid-involved overdoses were detected. Mean weekly ED visits in fall 2022 for suicide-related behaviors and MHCs overall were at or lower than the 2019 prepandemic baseline, respectively, and drug overdose visits were higher. Differences by sex were observed; levels among females were at or higher than prepandemic baselines for these conditions. These findings suggest some improvements as of fall 2022 in the trajectory of adolescent mental and behavioral health, as measured by ED visits; however, poor mental and behavioral health remains a substantial public health problem, particularly among adolescent females. Early identification and trauma-informed interventions, coupled with expanded evidence-based, comprehensive prevention efforts, are needed to support adolescents' mental and behavioral health.

Acceptability of a Fentanyl Vaccine to Prevent Opioid Overdose and Need for Personalized Decision-Making.

BACKGROUND: The opioid epidemic worsened during the coronavirus disease 2019 (COVID-19) pandemic. Synthetic opioids (primarily fentanyl) comprise the most common drugs involved in overdose (OD) death. A vaccine that blocks fentanyl from reaching the brain to prevent OD is under development, and insight is needed into its acceptability. METHODS: Using a semi-structured interview guide, persons with opioid use disorder (OUD), family, professionals, and the public were interviewed about attitudes and concerns regarding a fentanyl vaccine. Reactions to fictional clinical vignettes of persons at risk of OUD because of pain and/or substance use histories were collected, analyzed, and quantified for favorability. Interviews were transcribed, coded, and analyzed thematically. RESULTS: Among N = 64 participants, (70.3% female, average age 32.4 years), attitudes were favorable toward a fentanyl vaccine, with preference for lifelong durability (76% of n = 55 asked). Perceived benefits centered on the potential for a life-saving intervention, suffering averted, healthcare dollars saved, and the utility of a passive harm reduction strategy. Concerns centered on uncertainty regarding vaccine safety, questions about efficacy, worry about implications for future pain management, stigma, and need for supportive counseling and guidance to personalize decision making. Reactions to vignettes revealed complex attitudes toward fentanyl vaccination when considering recipient age, health history, and future risks for addiction and pain. CONCLUSIONS: Positive responses to a fentanyl vaccine were found along with appreciation for the complexity of a vaccine strategy to prevent OD in the setting of pain and uncertain durability. Further research is needed to elucidate operational, ethical, and communications strategies to advance the model.

Drug Overdose Mortality Rates by Educational Attainment and Sex for Adults Aged 25 to 64 in the United States Before and During the COVID-19 Pandemic, 2015 to 2021 (preprint)

Introduction: Dramatic increases in U.S. drug overdose deaths involving synthetic opioids, most prominently fentanyl, beginning around 2014 have driven a marked progression in national rates of overall drug overdose deaths, which sharply rose to unprecedented levels amid the COVID-19 pandemic. Disparities in U.S. drug overdose mortality burden by educational attainment have not been widely scrutinized during the fentanyl era of the drug overdose epidemic and its intersection with the COVID-19 pandemic. Methods: Utilizing restricted-use mortality data from the National Vital Statistics System and population estimates from the American Community Survey, we estimated annual national age-adjusted drug overdose mortality rates jointly stratified by educational attainment and sex for adults aged 25-64 from 2015 to 2021. State-level age-adjusted mortality rates were estimated in 2015 and 2021 to examine geographic trends in the cumulative evolution of disparities in drug overdose deaths by educational attainment over the course of the analysis period. Results: Over 452,700 drug overdose deaths among U.S. adults aged 25-64 occurred from 2015 to 2021. For both men and women in this age range, age-adjusted mortality rates rose fastest among persons with at most a high school-level education, whereas little to no change in age-adjusted mortality rates was observed for Bachelors degree holders, widening pre-existing disparities in drug overdose mortality burden by educational attainment. During the analysis period, the difference in age-adjusted mortality rates between persons with at most a high school-level education and Bachelors degree holders, for both men and women, increased from less than 8-fold to approximately 13-fold. These disparities widened in nearly every state, and the widening accelerated after the onset of the COVID-19 pandemic. Among non-Bachelors degree holders, age-adjusted mortality rates increased markedly faster among men. Conclusions: The widening disparities in drug overdose deaths by educational attainment are a likely indicator of a rapidly-increasing socioeconomic divide in drug overdose mortality more broadly. Policy strategies should address the upstream socioeconomic drivers of drug use and overdose, especially among men, and tailor interventions accordingly.

Retention and Critical Outcomes Among New Methadone Maintenance Patients Following Extended Take-Home Reforms (preprint)

Background: Approximately 1,800 opioid treatment programs (OTPs) in the US dispense methadone to upwards of 400,000 patients with opioid use disorder (OUD) annually, operating under longstanding highly restrictive guidelines. OTPs were granted novel flexibilities beginning March 15, 2020 allowing for reduced visit frequency and extended take-home doses to minimize COVID exposure with great variation across states and sites. We sought to use electronic health records to compare retention in treatment, opioid use, and adverse events among patients newly entering methadone maintenance in the post-reform period in comparison with year-ago, unexposed, controls.Methods: Retrospective observational cohort study across 9 OTPs, geographically dispersed nationally, in the National Institute of Drug Abuse Clinical Trials Network. Newly enrolled OTP methadone maintenance patients for a new care episode between April 15-October 14, 2020 (post-COVID, reform period) v. March 15-September 14, 2019 (pre-COVID, unexposed controls) were assessed. The primary outcome was 6-month retention. Secondary outcomes were opioid use and critical outcomes including emergency department (ED) visits, hospitalizations, and overdose.Findings: 821 individuals were newly admitted in the post-COVID and year-ago control periods, average age 38·3 (SD 11·1), 58·9% male. The only difference across pre- and post-reform groups was the prevalence of psychostimulant use disorder (25·7%v·32·9%,p=0·02)· Six-month retention rates were equivalent between groups (60·0% vs 60·1%) and hazards of discontinuation (HR=1·02,95%CI=0·81-1·27) and adverse events in the aggregate (X2 (1)=0·55,p=0·46) were non-inferior in the post-COVID period. However rates of opioid use throughout care was higher among post-COVID intakes compared to pre-COVID controls (64·8% v 51·1%,p<0·001). Moderator analyses accounting for stimulant use and site-level variation in take-home schedules did not change findings·Interpretation: Meaningful increases in take-home schedules were not associated with worse retention or adverse events despite slightly elevated rates of measured opioid use. Relaxed guidelines were not associated with increased harms and findings could inform permanent system redesign.Funding: SDHHS NIDA CTN UG1 DA013035-15.Declaration of Interest: Dr. Williams receives equity, consulting fees, and travel expenses from Ophelia Health Inc. a telehealth company for the treatment of opioid use disorder. Other authors have no financial conflicts to disclose.Ethical Approval: In accordance with applicable federal regulations (45 CFR 46·116(d)), the study was approved for a waiver of informed consent by the New York University Institutional Review Board.