Medical marijuana access and prolonged opioid use among adolescents and young adults.

BACKGROUND AND OBJECTIVES: Laws liberalizing access to medical marijuana are associated with reduced opioid analgesic use among adults, but little is known about the impact of such policies on adolescents and young adults. METHODS: This retrospective cohort study used 2005 to 2014 claims from MarketScan® Commercial database, which covers all 50 states and Washington D.C. The sample included 195,204 adolescent and young adult patients (aged 12-25) who underwent one of 13 surgical procedures. RESULTS: Of the 195,204 patients, 4.8% had prolonged opioid use. Several factors were associated with a higher likelihood of prolonged opioid use, including being female (adjusted odds ratio [aOR], 1.27; 95% confidence interval [CI], 1.21-1.33), longer hospital stay (aOR, 1.04; 95% CI, 1.02-1.06), greater days of index opioid supply (8-14 days: aOR, 1.39, 95% CI, 1.33-1.45; greater than 14 days: aOR, 2.42, 95% CI, 2.26-2.59), rural residence (aOR, 1.07; 95% CI, 1.01-1.14), and cholecystectomy (aOR, 1.16; 95% CI, 1.08-1.25). There was not a significant association of medical marijuana dispensary laws on prolonged opioid use (aOR, 0.98; 95% CI, 0.81-1.18). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Medical marijuana has been suggested as a substitute for opioids, but our results focusing on adolescents and young adults provide new evidence that this particularly vulnerable population does not exhibit reductions in prolonged use of opioids after surgery when they have legal access to medical marijuana. These findings are the first to demonstrate potentially important age differences in sustained use of opioids, and point to the need for prescriber oversight and management with this vulnerable population.

The Implementation of the Tennessee Fetal Assault Law and Its Association With Out-of-State Births Among Residents of Tennessee.

INTRODUCTION: This study analyzed the association between the implementation of the Tennessee Fetal Assault Law (TFAL), which allowed prosecutors to incarcerate people who used substances during pregnancy, and out-of-state births among residents of Tennessee. METHODS: The main data source is vital records on singleton births in hospitals to people aged 15-44 years during the period January 2010 to June 2016. We include data from 33 states and the District of Columbia where birth certificate data are comparable over this time period. The statistical significance of the difference in outcomes observed before and after TFAL implementation was tested using a difference-in-differences analysis between Tennessee and the comparison group. RESULTS: After TFAL implementation, the odds of having an out-of-state birth increased by 13% for residents of Tennessee (odds ratio, 1.13; 95% confidence interval, 1.09-1.16) relative to residents of the comparison states. When we adopted different thresholds for travel distances to the birth hospital, the odds of residents of Tennessee having an out-of-state birth more than 75 miles away increased by 17% (odds ratio, 1.17; 95% confidence interval, 1.13-1.21) after TFAL implementation. CONCLUSION: The results of this study suggest that the implementation of a policy allowing incarceration of people who use substances during pregnancy is associated with an increase in out-of-state births, potentially putting pregnant people and their infants at greater risk.

Impact of a multipronged approach to reduce the incidence of Clostridioides difficile infections in hospitalized patients.

BACKGROUND: Effective approaches to reduce Clostridioides difficile infections (CDI) in hospitalized patients are needed. We report data from 3 years preceding and 3 years following interventions that proved successful, with detailed analysis of all cases the first year after implementation. METHODS: Interventions included a nursing protocol to identify cases present on admission by asking if the patient had 1 or more liquid stools in the last 24 hours, and a 2-step testing algorithm with samples positive by polymerase chain reaction (PCR) for the C. difficile toxin gene reflexing to an enzyme immunoassay (EIA) for the toxin antigen. RESULTS: Healthcare-associated infections due to CDI fell from ∼160 in each of the preceding 3 years to <65 in each of the subsequent 3 years (P < .001), while the ratio of observed-to-expected hospital-onset cases diminished to ∼0.50 (P < .02). In the first year, 395 samples were PCR(+), but only 118 (29.9%) of these were EIA(+). 55 (46.6%) of the PCR(+)/EIA(+) samples were from hospital day 1 or 2 and classified as present on admission. The mean time from stool collection to report of PCR results was ∼7.5 hours, and the EIA took on average only 68 additional minutes to be reported. CONCLUSIONS: The number of incident CDI cases can be dramatically decreased by implementing an admission screening question and a 2-step testing algorithm.

Spatial and temporal trends in the diagnosis of opioid-related problems in commercially-insured adolescents and young adults.

Little is known about the extent to which the prevalence of opioid-related problems (ORPs) varies among U.S. adolescents and young adults across geographic regions and over time, information that can help to guide policies that aim to curb the opioid epidemic. A retrospective, cross-sectional design was used to analyze longitudinal claims data from privately insured individuals aged 12-64 years who had an outpatient or inpatient diagnosis of an ORP in the years 2005-2018. The prevalence of opioid-related problem diagnoses (per 10,000) varied considerably across census divisions, both over time and between age groups. Knowledge of the origin of and variation in diagnosed opioid-related problems in terms of age group and census division is important so that interventions and policies can be more targeted and effective.

Trends in personal and family member opioid prescriptions prior to a diagnosis of an opioid-related problem among adolescents and young adults.

Background: Efforts to reduce the risk of opioid misuse are often focused on reducing unnecessary prescriptions for opioid medications or reducing the dose prescribed; however, not all misuse occurs in individuals with a personal prescription. This study examined trends in the proportion of adolescents and young adults (AYAs) who had an opioid-related problem (ORP) and who also had a personal opioid prescription drug claim or had a family member with an opioid prescription drug claim prior to the ORP diagnosis. Methods: A retrospective cohort design was used to analyze longitudinal claims data. We identified individuals aged 12 to 25 years who had a newly diagnosed ORP in the years 2006 to 2014. Trends over time in personal or family opioid prescription drug claims within 1 year prior to ORP diagnosis were examined. Results: We identified 53,560 AYAs with an ORP diagnosis. Over the entire study period, 40% of AYAs with an ORP diagnosis had a personal opioid prescription in the year prior to diagnosis, and 48% had a family member with an opioid prescription in the prior year. While the proportion of AYAs with a family prescription remained constant, the proportion with a personal prescription fell from 77.1% in 2006 to 27.3% in 2014. Conclusions: The number of AYAs with an ORP increased over time, yet the proportion with a personal opioid prescription claim prior to their diagnosis decreased over time. This suggests that providers are paying greater attention to prescribing opioids to AYAs directly, although prescriptions to family members may still remain a point of access.

Children Enrolled in Hospice Care Under Commercial Insurance: A Comparison of Different Age Groups.

BACKGROUND:: Although most children at end of life have commercial insurance, little is known about their demographic and clinical characteristics, what care they are receiving, and how much it costs. OBJECTIVES:: To describe commercially insured children who enrolled in hospice care during their last year of life and to examine differences across age-groups. METHODS:: A retrospective cohort study was conducted using 2005 to 2014 data from the MarketScan Commercial Claims and Encounters database from Truven Health Analytics. Variables were created for demographics, health, utilization, and spending. Analyses included χ2 and analysis of variance tests of differences. RESULTS:: Among the 17 062 children who utilized hospice, 49% had a preferred provider organization (PPO). Hospice length of stay averaged less than 5 days. Over 80% of children visited their primary care physician. Eight percent had hospital readmissions, and 38% had emergency department (ED) visits. Average expenditures were US$3686 per month or US$44 232 annually. The most common condition for children less than 1 year was cardiovascular (21.96%). Neuromuscular conditions were the most frequent (7.89%) in children aged 1 to 5 years, while malignancies (10.53% and 11.32%, respectively) were prevalent in ages 6 to 14 and 15 to 17. Children less than 1 year had the highest frequency of hospital readmissions (16.25%) with the lowest ED visits (28.67%) while incurring the highest expenses (US$11 211/month). CONCLUSIONS:: The findings suggest that commercially insured children, who enroll in hospice, have flexible coverage with a PPO. Hospital readmissions and ED visits were relatively low for a population who was seriously ill. There were significant age-group differences.

An economic examination of private insurance claims among adolescents and young adults who were enrolled in hospice during the last year of life.

PURPOSE: The purpose of this study was to generate baseline data on the health characteristics, health care utilization, and health care spending among privately insured adolescents and young adults (AYA), who were enrolled in hospice care during their last year of life. METHODS: A retrospective, nonexperimental design was used to collect and analyze longitudinal claims data from the Truven Health MarketScan™ database. The sample included AYA (aged 15-24 years) who utilized hospice during their last year of life. RESULTS: Totally, 17,408 AYA were included in this analysis. Mean hospice length of stay (LOS) was low overall, but there was a statistically significant difference in hospice LOS in ages 15-19 years (mean 3.56, SD 15.17 days) compared with those aged 20-24 years (mean 2.26, SD 8.24; P<0.001 days). More than a third (37%) of the AYAs used the emergency department during the last year of life and 83% sought care from a primary care visit. However, only 6% of the sample who were hospice enrollees used frequent inpatient hospital services. CONCLUSIONS: This study provides preliminary data for private insurance expenditures and clinical utilization for AYA who were enrolled in hospice. This analysis also provides initial evidence to suggest extremely short hospice LOS for AYAs prior to the end of life and represents an area of future research need.

Depression in Parents of Children Diagnosed with Autism Spectrum Disorder: A Claims-Based Analysis.

Previous studies showing that Autism Spectrum Disorder (ASD) in children can have secondary effects on the child's parents are limited by small sample sizes and parent self-report. We examined the odds of depression in parents of children with ASD compared to parents of children without ASD using a large national claims database. Mothers (OR 2.95, 95% CI 2.81-3.09) and fathers (OR 2.41, 95% CI 2.25-2.58) of children with ASD were more likely to have a diagnosis of depression than parents of children without ASD. Odds of depression also increased when there was more than one child with ASD in the family and with child age. Study results reinforce the benefits of support and education for parents of children with ASD.