Research

Deaths due to synthetic opioids have increased at far higher rates for Blacks and Hispanics than for Whites in the last decade. Meanwhile, Blacks and Hispanics experience lower opioid treatment rates and have less availability of medication-assisted treatment (MAT) via office-based buprenorphine in their counties compared to Whites. Racial/ethnic residential segregation is a recognized barrier to equal availability of MAT, but little is known about how such segregation is associated with opioid and substance use treatment availability over time and across Census regions and urban-rural lines. We combined data from the Substance Abuse and Mental Health Services Administration’s National Survey of Substance Abuse Treatment Services for 2009, 2014, and 2019 with the 5-year American Community Surveys of 2009, 2014, and 2019 to examine associations between residential segregation indices of dissimilarity and interaction and substance use treatment facilities per 100,000 population, including those providing MAT, in US counties. Estimating county-level two-way fixed effects models, controlling for county-level covariates, we find modest evidence of associations. Despite mostly null findings, an increased likelihood of exposure of Whites to Blacks in a county is associated with fewer substance use treatment facilities per 100,000, particularly those providing MAT via buprenorphine and located in Northeastern and Midwestern counties. Also, a more unequal distribution of Hispanics is associated with fewer facilities per 100,000 providing MAT, and this association is strongest in Southern and Western counties. These associations are driven by recent years (2014–2019) when synthetic opioids became the leading cause of opioid mortality and Blacks and Hispanics began dying at higher rates than Whites. Mixed evidence, however, tempers conclusions for how residential segregation drives racial/ethnic disparities in MAT availability.

Background: Local governments on the front lines of the opioid epidemic often collaborate across organizations to achieve a more comprehensive opioid response. Collaboration is especially important in rural communities, which can lack capacity for addressing health crises, yet little is known about how local collaboration in opioid response relates to key outputs like treatment capacity.

Purpose:  This cross-sectional study examined the association between local governments’ interorganizational collaboration activity and agonist treatment capacity for opioid use disorder (OUD), and whether this association was stronger for rural than for metropolitan communities.

Methods: Data on the location of facilities providing buprenorphine and methadone were merged with a 2019 survey of all 358 counties in 5 states (CO, NC, OH, PA, and WA) that inquired about their collaboration activity for opioid response. Regression analysis was used to estimate the effect of a collaboration activity index and its constituent items on the capacity to provide buprenorphine or methadone in a county and whether this differed by urbanicity.

Results: A response rate of 47.8% yielded an analytic sample of n = 171 counties, including 77 metropolitan, 50 micropolitan, and 44 rural counties. Controlling for covariates, a 1-unit increase in the collaboration activity index was associated with 0.155 (95% CI = 0.005, 0.304) more methadone facilities, ie, opioid treatment programs (OTPs), per 100 000 population. An interaction model indicated this association was stronger for rural (average marginal effect = 0.354, 95% CI = 0.110, 0.599) than for non-rural counties. Separate models revealed intergovernmental data and information sharing, formal agreements, and organizational reforms were driving the above associations. Collaboration activity did not vary with the capacity to provide buprenorphine at non-OTP facilities. Spatial models used to account for spatial dependence occurring with OUD treatment capacity showed similar results.

Conclusion: Rural communities may be able to leverage collaborations in opioid response to expand treatment capacity through OTPs.

Prescription central nervous system depressants, opioid pain relievers, and stimulants provide therapeutic value, but misuse for their recreational value is a growing problem in the United States. Because health insurance lowers the cost of purchasing prescription drugs, losing coverage may cause individuals to forgo treatment and decrease prescription drug consumption which could reduce health and increase the likelihood of overdose and death if individuals substitute to using illicit drugs. Using a regression discontinuity design, I estimate the effect of aging out of the federal dependent coverage mandate at age 26 on legal purchases of prescription central nervous system depressants, opioids, and stimulants. Individuals are 0.5-0.9 percentage points less likely to purchase a prescription central nervous system depressant and 0.8-1.5 percentage point less likely to purchase a prescription opioid after turning 26. These effects are strongest for women, while estimated effects for men are generally negative but imprecise. 

Objective

To determine the association between the abuse-deterrent reformulation of OxyContin and adolescent lifetime heroin use in the United States.

Methods

The quasi-experimental study uses individual survey data from the 1999–2019 Youth Risk Behavior Surveillance System to examine whether the reformulation of OxyContin in August 2010 affected adolescent lifetime heroin use, exploiting heterogeneity in state-level rates of OxyContin misuse before the reformulation. Multiple regression analysis adjusted for state and year fixed effects, adolescent demographics, and time-varying state characteristics and policies.

Results

The release of the abuse-deterrent reformulation of OxyContin was associated with a reduction in adolescents reporting ever using heroin. An adolescent in a state with a one percentage point higher state-level rate of pre-reformulation OxyContin misuse was 1.7% points less likely to report ever using heroin after the reformulation (95% confidence interval, [(CI) = −0.007, −0.027]). These effects are strongest for adolescent males (estimate: −0.028, [(CI) = −0.016, 0.040]) and non-whites (estimate: −0.021, [(CI) = −0.005, −0.037]).

Conclusions

These results suggest the release of abuse-deterrent OxyContin is associated with a decrease in the likelihood of adolescent lifetime heroin use in states with higher pre-reformulation rates of OxyContin misuse. Pharmaceutical innovations and policies that reduce the likelihood of prescription opioid misuse may be effective in reducing adolescent lifetime heroin use.

Shortages in healthcare labor markets were a major concern voiced by critics of the 2010 Patient Protection and Affordable Care Act (ACA). Using a difference‐in‐differences strategy, I find the 2014 ACA Medicaid expansions increased the average workweek by 30 min for registered nurses (RNs) and 50 min for licensed practical nurses (LPNs), driven by an increase in full‐time work. RNs and LPNs were three and five percentage points more likely to work full‐time, respectively, due to the Medicaid expansions. There is little evidence of increased nurse employment on the extensive margin. 

Obesity has become an increasingly important public health issue in the USA and many other countries. Hypothesized causes for this increase include declining relative cost of food and a decreasing share of the population working in labor-intensive occupations. In this paper, we suggest another factor: the Internet. Increasing Internet access could affect body weight through several channels. First, more time spent using the Internet, a sedentary activity, could lead to increases in body weight. Second, the prior literature has shown that economic activity (and income) increase with Internet access: given a positive health-income gradient, obesity rates could likewise increase, although the empirical evidence on the income-obesity gradient is mixed. Third, the Internet increases information and creates the possibility for online peer networks. Theoretically, increases in information should lead to more optimal consumer choices. At the same time, greater networking opportunities may result in peers having greater influence over positive or negative health behaviors. While we are unable to fully test these mechanisms, we are able to use the rollout of broadband Internet providers as a plausibly exogenous source of variation in Internet access to identify the reduced form effect of Internet use on body weight. We show that greater broadband coverage increases the body weight of white women and has both positive and negative effects on modifiable adult health behaviors including exercise, smoking, and drinking.

I examine how the substance use treatment sector responded to the abuse-deterrent reformulation of OxyContin, which contributed to a shift from prescription opioid misuse to heroin and synthetic opioids. First, I document a national increase in substance use treatment facilities after the reformulation and a shift toward outpatient-only care. Medication-assisted treatment with buprenorphine and naltrexone grew strongly throughout the first and second waves of the opioid crisis, while opioid treatment programs providing methadone increased relatively modestly after the reformulation. To isolate the role of exposure to OxyContin’s reformulation, I use variation in states’ pre-reformulation OxyContin misuse rates in a continuous difference-in-differences design. I find that pre-reformulation misuse rates are associated with larger increases in substance use treatment facilities after the reformulation, particularly outpatient-only facilities, with limited evidence misuse rates the availability of medication-assisted treatment services or inpatient care across states. Medicaid expansion under the Affordable Care Act was associated with more substance use treatment facilities and this effect was stronger in states with higher misuse rates, while the expansion of substance use treatment facilities was lower in states with certificate-of-need laws, highlighting the importance of insurance and regulatory barriers in treatment access. Back-of-the envelope estimates suggest the additional SUT facilities averted 2,700-7,800 overdose deaths between 2011 and 2019, corresponding to a value of $36-102 billion.

Background: Ivermectin is not approved to treat COVID-19 infections, but it was one of many substances used by United States (US) citizens with the intent to prevent and self-treat for COVID-19 infection. When used inappropriately, especially in large doses or when used in conjunction with other medication, ivermectin can put patients at risk for serious health harms. We examined whether urbanicity, sociodemographic, political, and healthcare infrastructure and access factors are associated with residential human ivermectin exposure reports per capita in US counties during the COVID-19 pandemic. 

Methods: We analyzed whether urbanicity, sociodemographic characteristics, political voting preference, percentage with health insurance coverage, and hospitals per 100,000 population were associated with America’s Poison Centers’ residential human ivermectin exposure reports per capita in 3113 US counties during 2020-2021 using Poisson regression. Such reports refer to the location of the incoming call and not necessarily where the person exposed lives.

Results: The average county had 0.60 (interquartile range = 0.0-1.0) ivermectin exposures reported from a caller’s own residence to US Poison Control Centers during 2020-2021.Counties with a lower percentage of Democratic voters in the 2020 presidential election (incident rate ratio [IRR] = 0.98, 95% CI: 0.97-0.995; P = 0.007), Asian Americans or Pacific Islanders (IRR = 0.97, 95% CI: 0.96-0.99; P = 0.001), and females (IRR = 0.96, 95% CI: 0.91-1.01; P = 0.09) reported more residential ivermectin exposures per capita. Counties with a higher percentage of residents with a bachelor’s degree or higher (IRR = 1.03, 95% CI: 1.01-1.06; P = 0.004) reported more exposures per capita. Reports per capita were not more likely in nonmetropolitan versus metropolitan counties, but rural counties (IRR = 1.24, 95% CI: 0.98-1.56; P = 0.07) were associated with a higher reporting rate compared to large metropolitan counties. The percentage with health insurance coverage and hospitals per 100,000 population did not vary with such reported exposures per capita. 

Conclusions: This study finds political, sociodemographic, and urbanicity correlates of residential ivermectin exposure reports per capita during 2020-2021. Understanding these correlates can inform a more comprehensive COVID-19 response strategy that considers use of non-evidenced-based treatments.

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