Medications for Alcohol Use Disorder and Retention in Care in Medicaid-Enrolled Youth, 2014-2019.

PURPOSE: Alcohol use disorder (AUD) is a pediatric-onset condition needing timely, effective treatment. Medications for AUD are part of nationally recommended treatments for youth. This study measured receipt of medications and behavioral health services for AUD and subsequent retention in care. METHODS: This retrospective cohort study used claims data from > 4.7 million publicly insured youth aged 13-22 years in 15 states from 2014-2019. Timely treatment was defined as receipt of medication (naltrexone, acamprosate, or disulfiram) and/or behavioral health services within 30 days of incident AUD diagnosis. Associations of age and other characteristics with timely treatment were identified using modified Poisson regression. Retention in care (i.e., no period ≥ 60 days without claims) was studied using Cox regression. RESULTS: Among 14,194 youth with AUD, 10,851 (76.4%) received timely treatment. Only 2.1% of youth received medication (alone or in combination); nearly all (97.9%) received behavioral health services only. Older (aged 16-17 years) and younger adolescents (aged 13-15 years) were 0.13 (95% confidence interval [CI], 0.07-0.26) and 0.24 (95% CI, 0.11-0.51) times as likely, respectively, to receive medications than young adults aged ≥ 21 years. Median retention in care for youth receiving medications was 119 days (interquartile range, 54-321) compared with 108 days (interquartile range, 43-243) for behavioral health services alone (p = .126). Young adults aged ≥ 18 years were 1.12 (95% CI, 1.06-1.18) times as likely to discontinue treatment compared with adolescents aged < 18 years. DISCUSSION: This study found that more than seven in 10 youth received AUD treatment but only two in 100 received medications. Future studies should further characterize the effectiveness of medications and determine whether low rates of receipt represent underuse.

High levels of used syringe use and unsafe sex among people who inject drugs in Kumasi, Ghana: an urgent call for a comprehensive harm reduction approach.

BACKGROUND: Drug use is a growing concern in Ghana. People who inject drugs (PWID) are highly vulnerable to HIV and other infectious diseases. Ghana's National Strategic Plan for HIV/AIDS 2016-2020 identifies PWID as a key population, but efforts to address the needs of PWID have lagged behind those targeting sex workers and men who have sex with men. Lack of information about PWID is a critical barrier to implementing effective HIV prevention and treatment. We aimed to learn more about the vulnerability of the PWID population in order to inform much-needed harm reduction interventions. METHODS: From April to July 2018, we conducted a mixed methods study in Kumasi, Ghana, to identify all major drug using locations, count the numbers of PWID to obtain rough population size estimations, and administer anonymous surveys to 221 PWID regarding drug use and sexual behavior. We also tested for HIV, HCV, and HBV from syringes used by survey participants. RESULTS: Key informants identified five major drug using locations and estimated the total PWID population size to be between 600 and 2000. Enumerators counted between 35 and 61 individuals present at each of the five bases. Sharing syringes and reusing discarded syringes are common practices. Over half of survey participants (59%) reported past-month syringe sharing (34% used a used syringe and 52% gave away a used syringe). Individuals with higher injection frequency (≥ 21 times weekly) and who injected with four or more people had higher odds of syringe sharing. Of the survey participants reporting sex in the last month (23%), most reported having one partner, but only 12% used condoms. Nearly all women (11/13) reported exchanging sex for drugs and 6/13 reported exchanging sex for money in the last six months. Fifteen percent of participants (all men) reported paying for sex using drugs or money. Of the used syringes, prevalence estimates were 3% (HIV), 2% (HCV), and 9% (HBV). CONCLUSIONS: Our findings confirm the urgent need to implement harm reduction interventions targeting PWID and to build a strong and enabling legal and policy environment in Ghana to support these efforts.

Opioid use disorder and overdose among youth following an initial opioid prescription.

BACKGROUND AND AIMS: Some adolescents and young adults (termed "youth") prescribed an opioid will develop opioid use disorder or experience overdose. This study aimed to identify patient and prescription characteristics associated with subsequent risk of opioid use disorder or overdose during the year after an opioid is first dispensed. DESIGN: Retrospective cohort study. SETTING: Commercial health insurance claims in a large United States (US) database from 2006 to 2016. PARTICIPANTS: Youth age 11 to 25 years filling an initial opioid prescription (n = 3 278 990). MEASUREMENTS: The primary outcome was development of an 'opioid-related complication' (a diagnosis of opioid use disorder or opioid-related overdose) during the subsequent 12 months. Exposures of interest were patient (sociodemographic information, and physical and mental health diagnoses) and prescription characteristics (opioid formulation, dose, and duration). FINDINGS: Among youth filling an initial opioid prescription, median age was 18 years (interquartile range [IQR] = 16-21) and 56.1% were female. During the subsequent 12 months, 10 405 (0.3%) youth experienced an opioid-related complication. Conditions associated with increased risk included mood/anxiety disorders (adjusted relative risk [aRR] = 4.45; 95% CI = 4.25-4.66) and substance use (aRR = 20.77; 95% CI = 19.74-21.84). Comorbid substance use disorders were present among 72.8% of youth experiencing an opioid-related complication and included alcohol (33.4%), cannabis (33.0%), nicotine (43.2%), and other substance use disorders (75.5%). Long-acting opioids (aRR = 2.59; 95% CI = 2.18-3.09) and longer durations were associated with increased risk (7-14 days: aRR = 1.15; 95% CI = 1.08-1.22; ≥15 days: aRR = 1.96; 95% CI = 1.80-2.12) compared with short-acting formulations and durations ≤3 days, respectively. CONCLUSIONS: Among United States youth, complications after an initial opioid prescription appear to be relatively rare and appear to be associated with mood/anxiety disorders, substance use, comorbid substance use disorders, and prescriptions involving long-acting opioids or long durations.

"Health Is on the Back Burner:" Multilevel Barriers and Facilitators to Primary Care Among People Who Inject Drugs.

BACKGROUND: The estimated 2.2 million people who inject drugs (PWID) in the USA experience significant gaps in preventive healthcare and a high burden of infectious, psychiatric, and other chronic diseases. Many PWID rely on emergency medical services, which are costly and not designed to deliver preventive services, manage chronic conditions, or address social needs. OBJECTIVE: The objective of this study was to explore barriers and facilitators to primary care utilization from the perspectives of PWID in New England, a region highly affected by the overdose crisis. DESIGN: Participants completed semi-structured qualitative interviews exploring substance use and healthcare utilization patterns. PARTICIPANTS: We recruited 78 PWID through community-based organizations (e.g., syringe service programs) in 16 urban and non-urban communities throughout Massachusetts and Rhode Island. APPROACH: Thematic analysis identified barriers and facilitators to primary care utilization at the individual, interpersonal, and systemic levels. KEY RESULTS: Among 78 PWID, 48 described recent primary care experiences; 33 had positive experiences and 15 described negative experiences involving discrimination or mistrust. Individual-level barriers to primary care utilization included perceived lack of need and competing priorities (e.g., avoiding opioid withdrawal, securing shelter beds). Interpersonal-level barriers included stigma and perceived low quality of care for PWID. Systemic-level barriers included difficulty navigating healthcare systems, inadequate transportation, long wait times, and frequent provider turnover. Participants with positive primary care experiences explained how appointment reminders, flexible hours, addiction medicine-trained providers, case management services, and transportation support facilitated primary care utilization and satisfaction. CONCLUSIONS: Findings regarding the multilevel barriers and facilitators to accessing primary care among PWID identify potential targets for programmatic interventions to improve primary care utilization in this population. Based on these findings, we make recommendations for improving the engagement of PWID in primary care as a means to advance individual and public health outcomes.

High Prevalence of Indications for Pre-exposure Prophylaxis Among People Who Inject Drugs in Boston, Massachusetts.

INTRODUCTION: In Massachusetts, recent outbreaks of HIV have been fueled by injection and sexual exposures among people who inject drugs. Understanding pre-exposure prophylaxis need, knowledge, and use among people who inject drugs will help inform and evaluate interventions. METHODS: In 2019, investigators analyzed 2018 National HIV Behavioral Surveillance data from people who inject drugs in Boston, MA, who met eligibility criteria. Proportions of people who inject drugs with U.S. Preventive Services Task Force-based pre-exposure prophylaxis indication were estimated by types of HIV acquisition risk in the past year: injection exposure only, sexual exposure only, and overlapping injection and sexual exposures. Investigators then evaluated pre-exposure prophylaxis awareness, conversations with healthcare providers about pre-exposure prophylaxis, and self-reported pre-exposure prophylaxis use among those with and without pre-exposure prophylaxis indications. RESULTS: The prevalence of pre-exposure prophylaxis indication was 92% overall (389/423), with 290 (69%) participants indicated for injection exposures only, 3 (<1%) indicated for sexual exposures only, and 96 (23%) indicated for both injection and sexual exposures. Among those indicated for pre-exposure prophylaxis (n=389), 152 (39%) reported being aware of pre-exposure prophylaxis, 41 (11%) had discussed pre-exposure prophylaxis with a healthcare provider, and 8 (2%) had used pre-exposure prophylaxis in the past year. There were no statistically significant differences between pre-exposure prophylaxis‒indicated and ‒nonindicated people who inject drugs with respect to pre-exposure prophylaxis awareness, discussion with a healthcare provider, and pre-exposure prophylaxis use. CONCLUSIONS: Indication for pre-exposure prophylaxis was high, but awareness was low, conversations about pre-exposure prophylaxis with healthcare providers were uncommon, and pre-exposure prophylaxis use was extremely low. These findings highlight important areas for clinical and community-based interventions to improve pre-exposure prophylaxis uptake among and delivery to people who inject drugs.

Incidence and Characteristics of Nonfatal Opioid Overdose Among Youths Aged 11 to 24 Years by Sex.

Importance: Opioid-related overdose has substantially increased among adolescents and young adults in recent years. How overdose differs by age and sex among youths and the factors associated with overdose by sex remain poorly described. Objective: To compare the sociodemographic and clinical characteristics of female and male youths who have experienced a nonfatal opioid overdose (NFOD) and compare the incidence of NFOD by sex. Design, Setting, and Participants: This retrospective cohort study used data on US individuals aged 11 to 24 years with a diagnosis of NFOD from the IBM MarketScan Commercial Database from January 1, 2006, through December 31, 2017. Exposure: Sex. Main Outcomes and Measures: The primary outcome was NFOD stratified by sex; covariates included sociodemographic and clinical characteristics. Results: Among 20 312 youths aged 11 to 24 years who had a history of NFOD and met study eligibility criteria, the median age was 20 years (interquartile range, 18-22 years; mean [SD] age, 20.0 [2.9] years) and 56.7% were male. Compared with male youths, female youths had a higher baseline prevalence of mood or anxiety disorder (65.5% vs 51.9%, P < .001), trauma and stress-related disorders (16.4% vs 10.1%, P < .001), and history of suicide attempt or self-harm (14.6% vs 9.9%, P < .001). Male youths had a higher prevalence of opioid use disorder (44.7% vs 29.2%, P < .001), cannabis use disorder (18.3% vs 11.3%, P < .001), and alcohol use disorder (20.3% vs 14.4%, P < .001). The incidence rate ratio of NFODs in females vs males was greater than 1 for ages 11 to 16 years and was less than or equal to 1 after age 17 years. Conclusions and Relevance: This cohort study found differences between female and male youths in sociodemographic and clinical characteristics and incidence of NFOD. Although female and male youths who experience overdose appear to have different risk factors, many of these risk factors may be amenable to early detection through screening and intervention.

State-level prescription drug monitoring program mandates and adolescent injection drug use in the United States, 1995-2017: A difference-in-differences analysis.

BACKGROUND: Prescription opioid misuse is an ongoing crisis and a risk factor for injection drug use (IDU). Few studies have evaluated strategies for preventing opioid or IDU initiation among adolescents. We evaluated changes in the proportion of adolescents reporting IDU before and after prescription drug monitoring program (PDMP) mandates were implemented in 18 states compared to 29 states without such mandates. METHODS AND FINDINGS: This difference-in-differences analysis used biannual Youth Risk Behavioral Surveillance System (YRBSS) data representative of adolescents 17 to 18 years old across 47 states from 1995 to 2017. We compared changes in adolescent IDU in 18 states with and 29 states without PDMP mandates. Among 331,025 adolescents, 51.7% identified as male, 62.1% as non-Hispanic white, 17.4% as non-Hispanic black, and 14.6% as Hispanic. Overall, 3.5% reported IDU during the 2 years prior to PDMP mandates. In the final multivariable difference-in-differences model, we included individual age, sex, and race/ethnicity, as well as state and year as covariates from the YRBSS. We also included state- and year-specific poverty rates based on US Census Bureau data. Additionally, we controlled for state implementation of (non-mandated) PDMPs before states subsequently implemented mandates and pill mill laws. We conducted several sensitivity analyses, including repeating our main analysis using a logistic, rather than linear, model, and with a lead indicator on PDMP mandate implementation, a lag indicator, and alternative policy implementation dates. PDMP mandates were associated with a 1.5 percentage point reduction (95% CI -2.3 to -0.6 percentage points; p = 0.001) in adolescent IDU, on average over the years following mandate implementation, a relative reduction of 42.9% (95% CI -65.7% to -17.1%). The association of PDMP mandates with this reduction persisted at least 4 years beyond implementation. Sensitivity analyses were consistent with the main results. Limitations include the multi-stepped causal pathway from PDMP mandate implementation to changes in IDU and the potential for omitted state-level time-varying confounders. CONCLUSIONS: Our analysis indicated that PDMP mandates were associated with a reduction in adolescent IDU, providing empirical evidence that such mandates may prevent adolescents from initiating IDU. Policymakers might consider PDMP mandates as a potential strategy for preventing adolescent IDU.

Ecological momentary assessment of daily drug use and harm reduction service utilization among people who inject drugs in non-urban areas: A concurrent mixed-method feasibility study.

BACKGROUND: Ecological momentary assessments (EMA) can improve data accuracy and be useful for understanding the real-time co-occurrence of drug use and harm reduction service utilization among people who inject drugs (PWID); however, feasibility and acceptability of EMA in this population is unknown. METHODS: We conducted qualitative interviews (n = 45) and EMA surveys (n = 38) with PWID in cities and towns outside of Massachusetts' and Rhode Island's capital cities to 1) assess EMA feasibility and acceptability and 2) examine day-level correlations between drug use and harm reduction service utilization. RESULTS: Qualitative and quantitative data demonstrated that a 14-day EMA study was both feasible and acceptable. Interviews identified housing instability and related disruptions in cellphone access as challenges to consistent EMA participation. In the 14-day EMA study, EMA completion was high (mean = 10.1 days,SD = 5.3). High completion was associated with higher education (p = 0.005), receiving EMA via SMS text (vs. email, p = 0.017), and not having injected crack in the past month (p = 0.026). Of those who responded (n = 29), 100 % reported willingness to participate in a similar future study. Past 24 -h use of harm reduction services was positively associated with past 24 -h injection drug use (p = 0.013), but not past 24 -h syringe sharing (p = 0.197). CONCLUSION: Findings support the acceptability, feasibility, and potential utility of EMA for understanding daily experiences of PWID. Future studies should explore strategies to overcome structural barriers to maximize EMA participation, and assess how injection practices, syringe sharing, and use of harm reduction services interact to impact health risks in larger and diverse samples of PWID.