Changing Prescribing Behavior in the United States: Moving Upstream in Opioid Prescription Education.

In the US, deaths from prescription opioids have quadrupled since 1999, prompting authorities to declare an "opioid abuse" crisis. Rising overdose deaths were attributed to trends in the overprescription of opioids, specifically the strength and duration of the initial prescription. We describe educational interventions designed to control healthcare professionals' (HCPs) opioid prescribing in the wake of this crisis. A review of relevant programs for practicing providers, medical residents, and medical students reveals a focus on educational interventions that we describe, borrowing from sociologist John McKinlay's metaphor for public health interventions, as "downstream." These downstream interventions concentrate on regulating and educating practicing HCPs rather than transforming the training environment for medical students and residents. We draw on theories of behavior change to call for the development of complementary "upstream" educational programs for future practitioners that focus on structural and psychosocial factors and may contribute to more sustainable behavior change outcomes.

Urban and rural differences in the relationship between substance use and violence.

This article examines the relationship between substance use and violence across rural-urban and Appalachian places of residence. The data come from a larger study on the health service use of 637 men who have a history of chronic substance abuse and who were incarcerated in four Kentucky prisons. The findings generally support previous research on substance use and violence but do not support Fischer's (1995) subculture theory of urbanism. Contrary to expectations, the population size of the prisoners' residence was not significantly associated with the prisoners' levels of violent victimization, violence toward others, violence toward intimate partners, or overall violence in the year prior to incarceration. Appalachian residency was also not associated with violence. Recognizing that the effect of substance use on violence perpetrated against others does not vary significantly by urban or rural residence may be helpful for designing violence prevention programs and planning law enforcement efforts.