Comparison of Postpartum Opioid Prescriptions Before vs During the COVID-19 Pandemic.

Importance: The COVID-19 pandemic substantially disrupted routine health care and exacerbated existing barriers to health care access. Although postpartum women frequently experience pain that interferes with activities of daily living, which is often successfully treated with prescription opioid analgesics, they are also at high risk for opioid misuse. Objective: To compare postpartum opioid prescription fills after the onset of the COVID-19 pandemic in March 2020 with fills before the pandemic. Design, Setting, and Participants: In this cross-sectional study of 460 371 privately insured postpartum women who delivered a singleton live newborn between July 1, 2018, and December 31, 2020, postpartum opioid fills before March 1, 2020, were compared with fills after March 1, 2020. Statistical analysis was performed from December 1, 2021, to September 15, 2022. Exposure: COVID-19 pandemic onset in March 2020. Main Outcomes and Measures: The main outcome was postpartum opioid fills, defined as patient fills of opioid prescriptions during the 6 months after birth. Opioid prescriptions were explored in terms of 5 measures: mean number of fills per person, mean filled morphine milligram equivalents (MMEs) per day, mean days supplied, percentage of patients filling a prescription for a schedule II opioid, and percentage of patients filling a prescription for a schedule III or higher opioid. Results: Among 460 371 postpartum women (mean [SD] age at delivery, 29.0 [10.8] years), those who gave birth to a single, live newborn after March 2020 were 2.8 percentage points more likely to fill an opioid prescription than expected based on the preexisting trend (forecasted, 35.0% [95% CI, 34.0%-35.9%]; actual, 37.8% [95% CI, 36.8%-38.7%]). The COVID-19 period was also associated with an increase in MMEs per day (forecasted mean [SD], 34.1 [2.0] [95% CI, 33.6-34.7]; actual mean [SD], 35.8 [1.8] [95% CI, 35.3-36.3]), number of opioid fills per patient (forecasted, 0.49 [95% CI, 0.48-0.51]; actual, 0.54 [95% CI, 0.51-0.55]), and percentage of patients filling a schedule II opioid prescription (forecasted, 28.7% [95% CI, 27.9%-29.6%]; actual, 31.5% [95% CI, 30.6%-32.3%]). There was no significant association with days' suppy of opioids per prescription or percentage of patients filling a prescription for a schedule III or higher opioid. Results stratified by delivery modality showed that the observed increases were larger for patients who delivered by cesarean birth than those delivering vaginally. Conclusions and Relevance: This cross-sectional study suggests that the onset of the COVID-19 pandemic was associated with significant increases in postpartum opioid fills. Increases in opioid prescriptions may be associated with increased risk of opioid misuse, opioid use disorder, and opioid-related overdose among postpartum women.

Spillover of Medicaid Expansion to Prescribing of Opioid Use Disorder Medications in Medicare Part D.

OBJECTIVE: The authors examined whether there were positive spillovers in opioid use disorder medication prescribing to Medicare Part D beneficiaries in Medicaid expansion states. Although prior studies have shown several positive benefits of Medicaid expansion for Americans with opioid use disorder, research has not examined potential spillovers to Medicare beneficiaries who have been hit hard by the opioid crisis. METHODS: Prescribing data were taken from the Medicare Part D Prescription Public Use File (2010-2017). A difference-in-differences linear regression framework was used to identify spillovers in prescribing of buprenorphine and injectable naltrexone to Medicare Part D beneficiaries in Medicaid expansion states. Three sets of dependent variables measured medication prescribing at the county-year level (N=24,850). All models included county and year fixed effects, with standard errors clustered at the state level to address within-state serial correlation. RESULTS: Medicaid expansion was associated with an increase in the probability of a county having an injectable naltrexone provider (p<0.01). After expansion, the number of buprenorphine providers in expansion states increased by 5.6% (p<0.05), and the number of injectable naltrexone providers increased by 3.3% (p<0.01), relative to nonexpansion states. Expansion was associated with a 23.1% (p<0.01) increase in the number of daily doses of injectable naltrexone, relative to nonexpansion states. CONCLUSIONS: Medicaid expansion states may be better equipped to address the opioid crisis because of direct benefits to Medicaid beneficiaries and availability of opioid use disorder medications for Medicare Part D beneficiaries. However, additional efforts are likely needed to close the opioid use disorder treatment gap for Medicare beneficiaries.

Racial disparities for COVID19 mortality in Georgia: Spatial analysis by age based on excess deaths.

INTRODUCTION: This study uses multiple measures of excess deaths to analyze racial disparities in COVID-19 mortality across Georgia. METHODS: The Georgia Department of Public Health provided monthly mortality data for 2010-2020 stratified by race/ethnicity, age, county, and recorded cause of death. We first calculate crude mortality rates by health district during the time period for all groups for March through June for our historical period to identify significant time-series outliers in 2020 distinguishable from general trend variations. We then calculate the mean and standard deviation of mortality rates by age and racial subgroup to create historic confidence intervals that contextualize rates in 2020. Lastly, we use risk ratios to identify disparities in mortality between Black and White mortality rates both in the 2010-2019 period and in 2020. RESULTS: Time-series analysis identified three health districts with significant increases in mortality in 2020, located in metro Atlanta and Southwest Georgia. Mortality rates decreased sharply in 2020 for children in both racial categories in all sections of the state, but rose in a majority of districts for both categories in adult and older populations. Risk ratios also increased significantly in 2020 for children and older populations, showing rising disparities in mortality during the pandemic even as crude mortality rates declined for children classified as Black. CONCLUSIONS: Increased mortality during the COVID-19 outbreak disproportionately affected African-Americans, possibly due, in part, to pre-existing disparities prior to the pandemic linked to social determinants of health. The pandemic deepened these disparities, perhaps due to unequal resources to effectively shelter-in-place or access medical care. Future research may identify local factors underlying geographically heterogenous differences in mortality rates to inform future policy interventions.

Narrowing but persisting gender pay gap among employees of the US Department of Health and Human Services during 2010-2018.

BACKGROUND: The gender pay gap in the United States (US) has narrowed over the last several decades, with the female/male earnings ratio in the US increased from about 60% before the 1980s to about 79% by 2014. However, the gender pay gap among the healthcare workforce persists. The objective of this study is to estimate the gender pay gap in the US federal governmental public health workforce during 2010-2018. METHODS: We used an administrative dataset including annual pay rates and job characteristics of employees of the US Department of Health and Human Services. Employees' gender was classified based on first names. Regression analyses were used to estimate the gender pay gap using the predicted gender. RESULTS: Female employees of the DHHS earned about 13% less than men in 2010, and 9.2% less in 2018. Occupation, pay plan, and location explained more than half of the gender pay gap. Controlling for job grade further reduces the gap. The unexplained portion of the gender pay gap in 2018 was between 1.0 and 3.5%. Female employees had a slight advantage in terms of pay increase over the study period. CONCLUSIONS: While the gender pay gap has narrowed within the last two decades, the pay gap between female and male employees in the federal governmental public health workforce persists and warrants continuing attention and research. Continued efforts should be implemented to reduce the gender pay gap among the health workforce.

The mobility of food retailers: How proximity to SNAP authorized food retailers changed in Atlanta during the Great Recession.

Retailer mobility, defined as the shifting geographic patterns of retail locations over time, is a significant but understudied factor shaping neighborhood food environments. Our research addresses this gap by analyzing changes in proximity to SNAP authorized chain retailers in the Atlanta urban area using yearly data from 2008 to 2013. We identify six demographically similar geographic clusters of census tracts in our study area based on race and economic variables. We use these clusters in exploratory data analysis to identify how proximity to the twenty largest retail food chains changed during this period. We then use fixed effects models to assess how changing store proximity is associated with race, income, participation in SNAP, and population density. Our results show clear differences in geographic distribution between store categories, but also notable variation within each category. Increasing SNAP enrollment predicted decreased distances to almost all small retailers but increased distances to many large retailers. Our chain-focused analysis underscores the responsiveness of small retailers to changes in neighborhood SNAP participation and the value of tracking chain expansion and contraction in markets across time. Better understanding of retailer mobility and the forces that drive it can be a productive avenue for future research.

Association Between US State Medical Cannabis Laws and Opioid Prescribing in the Medicare Part D Population.

Importance: Opioid-related mortality increased by 15.6% from 2014 to 2015 and increased almost 320% between 2000 and 2015. Recent research finds that the use of all pain medications (opioid and nonopioid collectively) decreases in Medicare Part D and Medicaid populations when states approve medical cannabis laws (MCLs). The association between MCLs and opioid prescriptions is not well understood. Objective: To examine the association between prescribing patterns for opioids in Medicare Part D and the implementation of state MCLs. Design, Setting, and Participants: Longitudinal analysis of the daily doses of opioids filled in Medicare Part D for all opioids as a group and for categories of opioids by state and state-level MCLs from 2010 through 2015. Separate models were estimated first for whether the state had implemented any MCL and second for whether a state had implemented either a dispensary-based or a home cultivation only-based MCL. Main Outcomes and Measures: The primary outcome measure was the total number of daily opioid doses prescribed (in millions) in each US state for all opioids. The secondary analysis examined the association between MCLs separately by opioid class. Results: From 2010 to 2015 there were 23.08 million daily doses of any opioid dispensed per year in the average state under Medicare Part D. Multiple regression analysis results found that patients filled fewer daily doses of any opioid in states with an MCL. The associations between MCLs and any opioid prescribing were statistically significant when we took the type of MCL into account: states with active dispensaries saw 3.742 million fewer daily doses filled (95% CI, -6.289 to -1.194); states with home cultivation only MCLs saw 1.792 million fewer filled daily doses (95% CI, -3.532 to -0.052). Results varied by type of opioid, with statistically significant estimated negative associations observed for hydrocodone and morphine. Hydrocodone use decreased by 2.320 million daily doses (or 17.4%) filled with dispensary-based MCLs (95% CI, -3.782 to -0.859; P = .002) and decreased by 1.256 million daily doses (or 9.4%) filled with home-cultivation-only-based MCLs (95% CI, -2.319 to -0.193; P = .02). Morphine use decreased by 0.361 million daily doses (or 20.7%) filled with dispensary-based MCLs (95% CI, -0.718 to -0.005; P = .047). Conclusions and Relevance: Medical cannabis laws are associated with significant reductions in opioid prescribing in the Medicare Part D population. This finding was particularly strong in states that permit dispensaries, and for reductions in hydrocodone and morphine prescriptions.

Availability of tobacco cessation services in substance use disorder treatment programs: Impact of state tobacco control policy.

OBJECTIVE: Given the high prevalence of smoking among substance use disorder (SUD) patients, the specialty SUD treatment system is an important target for adoption and implementation of tobacco cessation (TC) services. While research has addressed the impact of tobacco control on individual tobacco consumption, largely overlooked in the literature is the potential impact of state tobacco control policies on availability of services for tobacco cessation. This paper examines the association between state tobacco control policy and availability of TC services in SUD treatment programs in the United States. METHODS: State tobacco control and state demographic data (n=51) were merged with treatment program data from the 2012 National Survey of Substance Abuse Treatment Services (n=10.413) to examine availability of TC screening, counseling and pharmacotherapy services in SUD treatment programs using multivariate logistic regression models clustered at the state-level. RESULTS: Approximately 60% of SUD treatment programs offered TC screening services, 41% offered TC counseling services and 26% offered TC pharmacotherapy services. Results of multivariate logistic regression showed the odds of offering TC services were greater for SUD treatment programs located in states with higher cigarette excise taxes and greater spending on tobacco prevention and control. CONCLUSIONS: Findings indicate cigarette excise taxes and recommended funding levels may be effective policy tools for increasing access to TC services in SUD treatment programs. Coupled with changes to insurance coverage for TC under the Affordable Care Act, state tobacco control policy tools may further reduce tobacco use in the United States.