Opioid-Related Overdose Deaths in Maryland (2018), by Industry and Occupation.

OBJECTIVES: Opioid-related overdose deaths (OROD) increase annually, yet little is known about workplace risk factors. This study assessed differences in OROD rates across industry and occupation in Maryland, in addition to demographic differences within industry and occupation. METHODS: The 2018 State Unintentional Drug Overdose Reporting System was used to compare OROD between industries and occupations. RESULTS: The leading industries in OROD included the following: construction, manufacturing, and transportation and warehousing. Occupational groups were similar: construction and extraction, production, and transportation and material moving. There were also differences by sex (greater rates in men), age (greater rates in older workers), and race/ethnicity (varied patterns in rates). CONCLUSIONS: Employers and state leaders should work collaboratively to target prevention and intervention for workplaces at highest risk for OROD. Construction was highest and needs supports that respond to the workplace culture.

Profiles and Predictors of Neurodevelopmental Functioning among Young Children Experiencing Family Homelessness.

In the context of family homelessness, children experience acute adversities related to loss of housing and residential mobility compounded with more chronic, poverty-related adversities and stressors. Among children in families experiencing homelessness, variability in experiences and outcomes warrant person-centered approaches to better delineate patterns of risk and resilience. Using latent profile analysis as a person-centered approach, we identified five distinct profiles of neurodevelopmental functioning within a sample of 231 children (ages 3-5 years old) staying in emergency homeless shelters with their families. Latent profiles were informed by indicators from parent-reported items for ten different domains of neurodevelopmental functioning. We examined whether demographic and ecological factors including age, ethnicity, adverse childhood experiences, parent mental health, and overreactive parenting would predict profile membership. Overall, half of the children in the sample demonstrated a profile of resilient functioning across developmental domains. Profiles of maladaptive functioning differed in areas of strength and challenge, with a small percentage of children showing poor functioning across all domains. Children whose parents had more mental health problems or overreactive parenting were significantly more likely to show profiles of poor functioning than to show resilient functioning. Implications for future research, practice, and policy are discussed.

Evolving Our Understanding: Housing Instability as an ACE for Young Children.

We investigated the conceptualization and impact of adverse childhood experiences (ACEs) in a sample of 231 children ages 3-5 living in poverty and experiencing homelessness, focusing specifically on caregiver well-being and housing instability. Data was collected using the Neurodevelopmental Ecological Screening Tool (NEST), which screens for developmental risk and resilience across three domains (neurodevelopmental, caregiver, and environment). We used structural equation modelling (SEM) to test the association between domains and ACE scores and assessed the impact on neurodevelopmental constructs. Fifty-five percent of the sample had high ACE scores (> 3), which were associated with lower attention, social skills, and emotional regulation. ACEs were strongly associated with 0.17 standard deviation units of higher levels of caregiver distress (p < .001), which was also associated with 0.26 standard deviation units of lower levels of child neurodevelopmental functioning (p = .001). For each unit increase in housing instability, there was a three-fourths increase in ACE (0.78 ACE at p = .004); four or more moves were associated with the worst neurodevelopmental outcomes (53% of the sample). We must use an ecological, developmental lens to understand how early adversity impacts children, at what age, and in what context. Housing stability plays a critical role in developmental well-being and should be accounted for in conceptualizations of child ACE scales. Caregiver and child relationships are reciprocal, and so the impacts of ACEs are also bidirectional. Our policies and practices at individual, community, and systemic levels should account for these dynamics to improve child well-being.

Item Response Theory Analysis: PROMIS® Anxiety Form and Generalized Anxiety Disorder Scale.

Little research has compared item functioning of the Patient-Reported Outcomes Measurement Information System (PROMIS®) anxiety short form 6a and the generalized anxiety disorder 7-item scale using item response theory models. This was a secondary analysis of self-reported assessments from 67 at-risk U.S. military veterans. The two measures performed comparably well with data fitting adequately to models, acceptable item discriminations, and item and test information curves being unimodal and symmetric. The PROMIS® anxiety short form 6a performed better in that item difficulty estimates had a wider range and distributed more evenly and all response categories had less floor effect, while the third category in most items of the generalized anxiety disorder 7-item scale were rarely used. While both measures may be appropriate, findings provided preliminary information supporting use of the PROMIS® anxiety short form 6a as potentially preferable, especially for veterans with low-to-moderate anxiety. Further testing is needed in larger, more diverse samples.

Systematic review and meta-analysis of retention in treatment using medications for opioid use disorder by medication, race/ethnicity, and gender in the United States.

BACKGROUND AND AIMS: There is mounting evidence that opioid use disorder is experienced differently by people of different genders and race/ethnicity groups. Similarly, in the US access to specific medications for opioid use is limited by gender and race/ethnicity. This study aims to evaluate if gender or race/ethnicity is associated with different rates of treatment retention in the US, for each of three medications used to treat opioid use disorder. METHODS: A systematic search was conducted using PubMed, CINHAL, and PsychINFO, databases. All studies that provided a ratio of those retained in treatment at a specified time in terms of gender and/or race/ethnicity and medication were included. Variables were created to assess the effects of time in treatment, recruited sample, required attendance at concurrent psychosocial treatment, and adherence to strict rules of conduct for continuation in treatment on retention. Meta-analytical and meta-regression methods were used to compare studies on the ratio of those who completed a specific time in treatment by race/ethnicity group and by gender. RESULTS: Nineteen articles that provided the outcome variable of interest were found (11 buprenorphine, six methadone, and two naltrexone). Meta-analyses found that treatment retention was similar for all gender and racial/ethnic groups for all three medications. Meta-regression found that those of the African American group who were recruited into buprenorphine treatment were retained significantly longer than African Americans in buprenorphine treatment who were studied retrospectively. Also, both genders had significantly lower retention in methadone treatment when there was the additional requirement of psychosocial therapy.

Developing a Screening Tool for Young Children Using an Ecological Framework.

Young children from impoverished backgrounds experience high levels of family and environmental stress, adversely impacting developmental functioning. Early identification provides a pathway to solutions, but many children are never assessed. In addition, the child-serving workforce lacks resources and expertise to use traditional measures. Furthermore, existing measures do not account for the substantial influence of a child's ecology. To bridge these gaps, we developed the Neurodevelopmental Ecological Screening Tool (NEST) and conducted a pilot study (n=60) to test its feasibility for use with caregivers of children ages 3-5 in low-resource settings. We developed an item pool across three domains (child, caregiver, environment), vetted it with experts, and conducted cognitive interviewing with parents (n=15) and case managers (n-10). Simultaneously, we built an online, user-friendly delivery platform. We used a one parameter Item Response Model and a Rasch-based Rating Scale Model (RSM) and fit confirmatory factor analytic (CFA) models to test for unidimensional and construct validity. The results support the feasibility of screening children from low SES populations within low-resource settings using an ecological perspective and supports the work of child-serving paraprofessionals in identifying and addressing risks in the lives of young children.

Featured Article: Bidirectional Effects of Sleep and Sedentary Behavior Among Toddlers: A Dynamic Multilevel Modeling Approach.

OBJECTIVE: To examine the bidirectional effects of objectively measured nighttime sleep and sedentary activity among toddlers. METHOD: Actical accelerometer data were analyzed for 195 toddlers participating in an obesity prevention trial (mean age = 27 months). Toddlers wore the accelerometers for up to 7 consecutive days. Nighttime sleep was defined as the number of minutes asleep between the hours of 8 pm and 8 am the following morning. Sedentary behavior (in minutes) was defined using previously established Actical cut points for toddlers. Variables were lagged and parsed into latent within- and between-person components, using dynamic structural equation modeling (DSEM). RESULTS: Toddlers spent an average of 172 min (∼3 hr) in sedentary activity and slept an average of 460 min (∼8 hr) per night. An autoregressive cross-lagged multilevel model revealed significant autoregression for both sleep and sedentary activity. Cross-lagged values revealed that decreased sleep predicted increased next-day sedentary activity, and sedentary activity predicted that night's sleep. For 89% of the sample, the within-person standardized cross-lagged effects of sleep on sedentary were larger than the cross-lagged effects of sedentary on sleep. CONCLUSIONS: Results suggest that, on average, nighttime sleep is a stronger predictor of subsequent sedentary behavior (compared with the reverse), and this is the case for the majority of toddlers. Findings highlight the importance of interindividual associations between sleep and sedentary activity. The present study is an example of how DSEM methods can be used to ask questions about Granger-causal cross-lagged relations between variables, both within and between individuals.

Organizational trauma-informed care: Associations with individual and agency factors.

In response to the growing awareness of the high rates of potentially traumatic experiences and their potential adverse impacts, health and human service providers have increasingly focused on implementing trauma-informed care (TIC). However, studies focusing on effective implementation have been limited. In this study, we explored the relationship of individual and agency characteristics to the level of organizational TIC. With data collected from a sample of 345 providers from 67 agencies, we used the TICOMETER, a brief measure of organizational TIC with strong psychometric properties, to determine these associations. We found weak relationships between individual factors and TICOMETER scores and stronger associations for agency-level factors. These included agency type, time since last trauma training, and involvement of service users. These findings highlight the importance of robust cultural changes, service user involvement at all levels of the organization, flattening power differentials, and providing ongoing experiential training. This analysis fills an important gap in our knowledge of how best to ensure agency-wide provision of TIC. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Language Barrier as a Risk Factor for Injuries From Patient Violence Among Direct Care Workers in Home Settings: Findings From a U.S. National Sample.

This study explored potential risk factors for injuries from patient violence among direct care workers in U.S. homes (DCWHs). A national probability sample of 3,377 DCWHs including home health and personal care aides was analyzed using complex sample analysis and generalized estimating equation. Injury from violence was defined as a workrelated injury sustained by aggression, violence, or abuse that was reported to the agency, required medical attention or resulted in absenteeism from work. An association between suffering an injury from patient violence and having a language barrier with patients was noted (OR = 4.44; 95% CI = 1.57, 12.56; p = .005). Findings illuminate the importance of homecare providers to match language between DCWHs and patients to reduce patient violence and improve quality of care in the home setting.

US regional and demographic differences in prescription opioid and heroin-related overdose hospitalizations.

BACKGROUND: US opioid overdose death rates have increased between 2000 and 2014. While, the increase in prescription opioid use has been linked to the increase in heroin use, there are reasons to view this relationship as a partial explanation for the recent increase in heroin-related harms. This study documents the differences in trends in prescription opioid overdose-related (POD) and heroin overdose-related (HOD) hospitalizations. METHODS: Data come from the National Inpatient Sample (NIS) for the years 2000 through 2014. POD and HOD hospitalizations were abstracted from ICD-9 codes. Rates of POD and HOD by census region and census division were constructed along with separate rates for age and race. Regression analysis analyzing trends across region were estimated along with graphs for documenting differences in POD and HOD rates. RESULTS: POD hospitalization rates were highest in the South and lowest in the Northeast. HOD hospitalization rates were highest in the Northeast region and grew the fastest in the Midwest. There was statistically significant heterogeneity in HOD trends but not POD trends across the four regions between 2000 and 2014. Between 2012 and 2014 POD rates decreased in eight of the nine census divisions, with only New England showing an increase. HOD hospitalization rates increased in all nine census divisions between 2012 and 2014. Both POD and HOD rates show different demographic patterns across the nine census divisions. CONCLUSION: Comparing POD and HOD hospitalization trends reveals significant disparities in geographic as well as demographic distributions. These epidemics are evolving and the simple opioid-to-heroin transition story is both supported and challenged by this paper. The opioid pill, heroin and fentanyl crises are intertwined yet increasingly have drivers and outcomes that support examining them as distinct. Addressing these complex and interrelated epidemics will require innovative public health research and interventions which need to consider local and regional contexts.

Acute fatigue predicts sickness absence in the workplace: A 1-year retrospective cohort study in paediatric nurses.

AIMS: To examine the relationship between fatigue and sickness absence in nurses from a paediatric hospital over 12 months of follow-up. A secondary aim was to identify other work and personal factors that predict sickness absence. BACKGROUND: Sickness absence is often related to worker-fatigue, yet few studies have explored this relationship in nurses despite documented high fatigue levels. DESIGN: The study used retrospective cohort design. METHODS: Baseline data on 40 nurses from an intervention study were linked to absence data using the hospital's attendance records (2012-2013). A total of 6,057 work shifts were studied of which 5.2% were absence episodes. Fatigue was measured by the Occupational Fatigue Exhaustion Recovery scale. The questionnaire included instruments assessing sleep disturbances, workload and personal characteristics. Generalized linear mixed models were used to test the associations between fatigue, work, personal factors and sickness absence, while accounting for non-independency of repeated measures. RESULTS: With 1SD increase in acute fatigue scores, nurses were 1.29 times more likely to be absent from work. Factors such as intershift recovery, perceived workload, obstructive sleep apnoea and marital status also predicted sickness absence, that is, with 1SD increase in workload scores, nurses were 1.23 times more likely to be absent from work. Nurses with obstructive sleep apnoea had two times higher odds of sickness absence. CONCLUSION: Sickness absence is related to acute fatigue in paediatric nurses and to workload. Nursing leaders can monitor these factors to reduce sickness absence and screen for sleep apnoea and assist nurses in receiving the appropriate treatments.

Predictors of Hospital Length and Cost of Stay in a National Sample of Adult Patients with Psychotic Disorders.

OBJECTIVE: This study examined effects of patient-level and hospital-level characteristics on length and cost of hospital stays among adult patients with psychotic disorders. METHODS: A subsample of 677,684 adult patients with a primary diagnosis of a psychotic disorder was drawn from the 2003-2011 Healthcare Cost and Utilization Project Nationwide Inpatient Sample. A nationally representative survey design and census data were used to calculate hospitalization rates. Multilevel models examined variation in length and cost of stay in relation to individual (age, sex, race-ethnicity, household income, payer source, and illness severity) and hospital (region, urban or rural location, ownership, teaching status, and size) characteristics. RESULTS: Admission rates differed dramatically by region, with higher rates in the Northeast. Compared with white patients, African Americans had higher admission rates but shorter stays and lower costs, and Asians/Pacific Islanders and Native Americans had longer stays. Longer stays were also associated with higher versus lower illness severity and use of Medicaid and Medicare versus private insurance. Length and cost of stays were greater in Northeast hospitals and in public hospitals. CONCLUSIONS: Strong differences were noted in use of hospitalization to treat psychotic disorders. Higher admission rates and longer stays in the Northeast were striking, as were differences in admission rates and length of stay for African-American patients compared with white patients. Future research should investigate the appropriateness of acute care use from an overuse (Northeast) and underuse (West) perspective. Findings raise questions about the effects of health reform on adult acute care use and have implications for mental health and hospital policy.

Nationwide increase in hospitalizations for heroin-related soft tissue infections: Associations with structural market conditions.

INTRODUCTION: Little is known about trends in national rates of injection-related skin and soft tissue infections (SSTI) and their relationship to the structural risk environment for heroin users. Use of Mexican-sourced "Black Tar" heroin, predominant in western US states, may have greater risk for SSTI compared with eastern US powder heroin (Colombian-sourced) due to its association with non-intravenous injection or from possible contamination. METHODS: Using nationally representative hospital admissions data from the Nationwide Inpatient Sample and heroin price and purity data from the Drug Enforcement Administration, we looked at rates of hospital admissions for opiate-related SSTI (O-SSTI) between 1993 and 2010. Regression analyses examined associations between O-SSTI and heroin source, form and price. RESULTS: Hospitalization rates of O-SSTI doubled from 4 to 9 per 100,000 nationally between 1993 and 2010; the increase concentrated among individuals aged 20-40. Heroin market features were strongly associated with changes in the rate of SSTI. Each $100 increase in yearly heroin price-per-gram-pure was associated with a 3% decrease in the rate of heroin-related SSTI admissions. Mexican-sourced-heroin-dominant cities had twice the rate of O-SSTI compared to Colombian-sourced-heroin-dominant cities. DISCUSSION: Heroin-related SSTI are increasing and structural factors, including heroin price and source-form, are associated with higher rates of SSTI hospital admissions. Clinical and harm reduction efforts should educate heroin users on local risk factors, e.g., heroin type, promote vein health strategies and provide culturally sensitive treatment services for persons suffering with SSTI.

Alcohol-Related Diagnoses in Hospital Admissions for All Causes Among Middle-Aged and Older Adults: Trends and Cohort Differences From 1993 to 2010.

OBJECTIVE: This aim of this study was to characterize trends in alcohol-related hospital admissions among middle-aged and older adults from 1993 to 2010 in relation to age, gender, race, and cohort membership. METHOD: This study utilized repeated cross-sectional data from the Nationwide Inpatient Sample. Using alcohol-related classified admissions, yearly rates and longitudinal trends of alcohol-related inpatient hospitalizations based on age, period, birth cohort, gender, and race were estimated. RESULTS: Among those aged 45 and older, admissions rose from an estimated 610,634 to more than 1,134,876, and rates of any alcohol-related diagnosis also increased from 1993 to 2010. Rates for men were consistently higher than women, and rates for Blacks were higher than Whites. Age was associated with decreasing rates, but post-World War II cohorts displayed higher rates over time. DISCUSSION: Rates of alcohol-related admissions are increasing among adults above age 45, which may be a function of cohort effects. Training the health care workforce is crucial to respond to this trend.

Hospital outcomes in major depression among older adults: differences by alcohol comorbidity.

OBJECTIVE: The prevalence of depression in older adults has been increasing over the last 20 years and is associated with economic costs in the form of treatment utilization and caregiving, including inpatient hospitalization. Comorbid alcohol diagnoses may serve as a complicating factor in inpatient admissions and may lead to overutilization of care and greater economic cost. This study sought to isolate the comorbidity effect of alcohol among older adult hospital admissions for depression. METHODS: We analyzed a subsample (N = 8,480) of older adults (65+) from the 2010 Nationwide Inpatient Sample who were hospitalized with primary depression diagnoses, 7,741 of whom had depression only and 739 of whom also had a comorbid alcohol disorder. To address potential selection bias based on drinking and health status, propensity score matching was used to compare length of stay, total costs, and disposition between the two groups. RESULTS: Bivariate analyses showed that older persons with depression and alcohol comorbidities were more often male (59.9% versus 34.0%, p <.001) and younger (70.9 versus 75.9 years, p <.001) than those with depression only. In terms of medical comorbidities, those with depression and alcohol disorders experienced more medical issues related to substance use (e.g., drug use diagnoses, liver disease, and suicidality; all p <.001), while those with depression only experienced more general medical problems (e.g., diabetes, renal failure, hypothyroid, and dementia; all p <.001). Propensity score matched models found that alcohol comorbidity was associated with shorter lengths of stay (on average 1.08 days, p <.02) and lower likelihood of post-hospitalization placement in a nursing home or other care facility (OR = 0.64, p <.001). No significant differences were found in overall costs or likelihood of discharge to a psychiatric hospital. CONCLUSIONS: In older adults, depression with alcohol comorbidity does not lead to increased costs or higher levels of care after discharge. Comorbidity may lead to inpatient hospitalization at lower levels of severity, and depression with alcohol comorbidity may be qualitatively different than non-comorbid depression. Additionally, increased costs and negative outcomes in this population may occur at other levels of care such as outpatient services or emergency department visits.

The relationship between US heroin market dynamics and heroin-related overdose, 1992-2008.

BACKGROUND AND AIMS: Heroin-related overdose is linked to polydrug use, changes in physiological tolerance and social factors. Individual risk can also be influenced by the structural risk environment including the illicit drug market. We hypothesized that components of the US illicit drug market, specifically heroin source/type, price and purity, will have independent effects on the number of heroin-related overdose hospital admissions. METHODS: Yearly, from 1992 to 2008, Metropolitan Statistical Area (MSA) price and purity series were estimated from the US Drug Enforcement Administration data. Yearly heroin overdose hospitalizations were constructed from the Nationwide Inpatient Sample. Socio-demographic variables were constructed using several databases. Negative binomial models were used to estimate the effect of price, purity and source region of heroin on yearly hospital counts of heroin overdoses controlling for poverty, unemployment, crime, MSA socio-demographic characteristics and population size. RESULTS: Purity was not associated with heroin overdose, but each $100 decrease in the price per pure gram of heroin resulted in a 2.9% [95% confidence interval (CI) = 4.8%, 1.0%] increase in the number of heroin overdose hospitalizations (P = 0.003). Each 10% increase in the market share of Colombian-sourced heroin was associated with a 4.1% (95% CI = 1.7%, 6.6%) increase in number of overdoses reported in hospitals (P = 0.001) independent of heroin quality. CONCLUSIONS: Decreases in the price of pure heroin in the United States are associated with increased heroin-related overdose hospital admissions. Increases in market concentration of Colombian-source/type heroin is also associated with an increase in heroin-related overdose hospital admissions. Increases in US heroin-related overdose admissions appear to be related to structural changes in the US heroin market.

Urban segregation and the US heroin market: a quantitative model of anthropological hypotheses from an inner-city drug market.

BACKGROUND: We hypothesize that the location of highly segregated Hispanic and in particular Puerto Rican neighborhoods can explain how Colombian-sourced heroin, which is associated with a large-scale decade long decline in heroin price and increase in purity, was able to enter and proliferate in the US. METHODS: Our multidisciplinary analysis quantitatively operationalizes participant-observation ethnographic hypotheses informed by social science theory addressing complex political economic, historical, cultural and social processes. First, we ethnographically document the intersection of structural forces shaping Philadelphia's hypersegregated Puerto Rican community as a regional epicenter of the US heroin market. Second, we estimate the relationship between segregation and: (a) the entry of Colombian heroin into the US, and (b) the retail price per pure gram of heroin in 21 Metropolitan Statistical Areas. RESULTS: Ethnographic evidence documents how poverty, historically-patterned antagonistic race relations, an interstitial socio-cultural political and geographic linkage to both Caribbean drug trafficking routes and the United States and kinship solidarities combine to position poor Puerto Rican neighborhoods as commercial distribution centers for high quality, low cost Colombian heroin. Quantitative analysis shows that heroin markets in cities with highly segregated Puerto Rican communities were more quickly saturated with Colombian-sourced heroin. The level of Hispanic segregation (specifically in cities with a high level of Puerto Rican segregation) had a significant negative association with heroin price from 1990 to 2000. By contrast, there is no correlation between African-American segregation and Colombian-sourced heroin prevalence or price. CONCLUSION: Our iterative mixed methods dialogue allows for the development and testing of complex social science hypotheses and reduces the limitations specific to each method used in isolation. We build on prior research that assumes geographic proximity to source countries is the most important factor in determining illicit drug prices and purity, while we find more complex, potentially modifiable determinants of geographic variation in retail drug markets. We show that specific patterns of ethnic segregation, racism, poverty and the political economy of socio-cultural survival strategies combined to facilitate the entry of pure, inexpensive Colombian-sourced heroin.

The entry of Colombian-sourced heroin into the US market: the relationship between competition, price, and purity.

There have been large structural changes in the US heroin market over the past 20 years. Colombian-sourced heroin entered the market in the mid-1990s, followed by a large fall in the price per pure gram and the exit of Asian heroin. By the 2000s, Colombian-sourced heroin had become a monopoly on the east coast and Mexican-sourced heroin a monopoly on the west coast with competition between the two in the middle. We estimate the relationship between these changes in competitive market structure on retail-level heroin price and purity. We find that the entry of Colombian-sourced heroin is associated with less competition and a lower price per pure gram of heroin at the national level. However, there is wide variation in changes in market concentration across the US. Controlling for the national fall in the heroin price, more competition in a region or city is associated with a lower price per pure gram.

Illness severity and psychiatric hospitalization rates among Asian Americans and Pacific Islanders.

OBJECTIVE The study objective was to fill research gaps about inpatient psychiatric service utilization among Asian Americans and Pacific Islanders (AA/PIs). METHODS Rates of psychiatric hospitalization, illness severity, and length of stay were compared among AA/PI adults overall and across diagnoses (schizophrenia, depression, bipolar, anxiety, and other psychiatric disorders identified by All Patient Refined Diagnosis Related Groups) by using discharge data from all hospitalizations in Hawaii from December 2006 to 2010. Multivariable models adjusted for gender, age, payer, and residence. RESULTS In multivariable analyses of total psychiatric hospitalizations, Chinese (rate ratio [RR]=.22), Japanese (RR=.23), Filipinos (RR=.30), and Native Hawaiians (RR=.37) had significantly lower rates than whites. Native Hawaiians had significantly higher hospitalization rates compared with other AA/PI groups. Length of stay was significantly longer for Chinese (length of stay ratio [LOSR]=1.53), Filipinos (LOSR=1.20), and Japanese (LOSR=1.19) compared with whites, whereas severity of illness was significantly higher for Japanese (odds ratio [OR]=1.36) and Filipinos (OR=1.30). Within specific diagnoses, Native Hawaiians had higher hospitalization rates than other AA/PI groups for depression, bipolar disorder, and anxiety disorder. Chinese, Japanese, and Filipinos had significantly higher illness severity or longer stays than whites for at least one diagnostic category. CONCLUSIONS AA/PI subgroups had lower psychiatric hospitalization rates than whites, but rates varied across AA/PI subgroups. Native Hawaiians had higher hospitalization rates for many diagnoses. Chinese, Japanese, and Filipinos had greater illness severity or longer stays than whites overall and for some diagnoses, whereas Native Hawaiians did not. Disaggregating AA/PI groups provides important insight into mental health services utilization and need.

Intertwined epidemics: national demographic trends in hospitalizations for heroin- and opioid-related overdoses, 1993-2009.

The historical patterns of opiate use show that sources and methods of access greatly influence who is at risk. Today, there is evidence that an enormous increase in the availability of prescription opiates is fuelling a rise in addiction nationally, drawing in new initiates to these drugs and changing the geography of opiate overdoses. Recent efforts at supply-based reductions in prescription opiates may reduce harm, but addicted individuals may switch to other opiates such as heroin. In this analysis, we test the hypothesis that changes in the rates of Prescription Opiate Overdoses (POD) are correlated with changes in the rate of heroin overdoses (HOD). ICD9 codes from the Nationwide Inpatient Sample and population data from the Census were used to estimate overall and demographic specific rates of POD and HOD hospital admissions between 1993 and 2009. Regression models were used to test for linear trends and lagged negative binomial regression models were used to model the interrelationship between POD and HOD hospital admissions. Findings show that whites, women, and middle-aged individuals had the largest increase in POD and HOD rates over the study period and that HOD rates have increased in since 2007. The lagged models show that increases in a hospitals POD predict an increase in the subsequent years HOD admissions by a factor of 1.26 (p<0.001) and that each increase in HOD admissions increase the subsequent years POD by a factor of 1.57 (p<0.001). Our hypothesis of fungibility between prescription opiates and heroin was supported by these analyses. These findings suggest that focusing on supply-based interventions may simply lead to a shift in use to heroin rather minimizing the reduction in harm. The alternative approach of using drug abuse prevention resources on treatment and demand-side reduction is likely to be more productive at reducing opiate abuse related harm.