Anna E. Austin

Observed transition from opioid analgesic deaths toward heroin

BACKGROUND In the United States, overdose mortality from controlled substances has increased over the last two decades, largely involving prescription opioid analgesics. Recently, there has been speculation on a transition away from prescription opioid use toward heroin, however the impact on overdose deaths has not been evaluated. METHODS Time series study of North Carolina residents, 2007 through 2013. Monthly ratio of prescription opioid-to-heroin overdose deaths. Non-parametric local regression models used to ascertain temporal shifts from overdoses involving prescription opioids to heroin. RESULTS There were 4332 overdose deaths involving prescription opioids, and 455 involving heroin, including 44 where both were involved (total n = 4743). A gradual 6-year shift toward increasing heroin deaths was observed. In January, 2007, for one heroin death there were 16 opioid analgesic deaths; in December, 2013 there were 3 prescription opioid deaths for each heroin death. The transition to heroin appears to have started prior to the introduction of tamper-resistant opioid analgesics. The age of death among heroin decedents shifted toward younger adults. Most heroin and opioid analgesic deaths occurred in metropolitan areas, with little change between 2007 and 2013. CONCLUSIONS The observed increases in heroin overdose deaths can no longer be considered speculation. Deaths among younger adults were noted to have increased in particular, suggesting new directions for targeting interventions. More research beyond vital statistics is needed to understand the root causes of the shift from prescription opioids to heroin.

Adverse Childhood Experiences Related to Poor Adult Health Among Lesbian, Gay, and Bisexual Individuals

OBJECTIVES We explored the association of sexual orientation with poor adult health outcomes before and after adjustment for exposure to adverse childhood experiences (ACEs). METHODS Data were from the 2012 North Carolina, 2011 Washington, and 2011 and 2012 Wisconsin Behavioral Risk Factor Surveillance System (BRFSS) surveys regarding health risks, perceived poor health, and chronic conditions by sexual orientation and 8 categories of ACEs. There were 711 lesbian, gay, and bisexual (LGB) respondents and 29,690 heterosexual respondents. RESULTS LGB individuals had a higher prevalence of all ACEs than heterosexuals, with odds ratios ranging from 1.4 to 3.1. After adjustment for cumulative exposure to ACEs, sexual orientation was no longer associated with poor physical health, current smoking, and binge drinking. Associations with poor mental health, activity limitation, HIV risk behaviors, current asthma, depression, and disability remained, but were attenuated. CONCLUSIONS The higher prevalence of ACEs among LGB individuals may account for some of their excess risk for poor adult health outcomes.

Characteristics of self-inflicted drug overdose deaths in North Carolina

BACKGROUND Drug overdose mortality is a major public health concern in the United States, with prescription opioids contributing substantially to recent increases in drug overdose deaths. Compared to unintentional drug overdose deaths, relatively little data describes intentional self-inflicted drug overdose deaths (i.e., suicide by drug overdose). The aim of this study was to examine the characteristics of self-inflicted drug overdose deaths, overall and in comparison to unintentional drug overdose deaths. METHODS We linked vital statistics, prescription drug monitoring program, and toxicology data for self-inflicted and unintentional drug overdose deaths among North Carolina residents in 2012. RESULTS Most self-inflicted (79.2%) and unintentional (75.6%) drug overdose decedents had a prescription for a controlled substance within one year of death. Toxicology results revealed that antidepressants contributed to a significantly higher percent of self-inflicted compared to unintentional drug overdose deaths (45.0% vs. 8.1%). Among deaths in which commonly prescribed opioids (oxycodone, hydrocodone) or benzodiazepines (alprazolam, clonazepam) contributed to death, a significantly higher percent of self-inflicted drug overdose decedents had a prescription for the substance within 30days of death compared to unintentional drug overdose decedents. CONCLUSIONS The results highlight the use of prescription opioids, benzodiazepines, and antidepressants among self-inflicted drug overdose decedents. Importantly, the results indicate that self-inflicted drug overdose decedents were more likely than unintentional drug overdose decedents to have potential contact with the health care system in the weeks preceding death, offering an opportunity for professionals to identify and intervene on risk factors or signs of distress and potential for self-harm.

Association of childhood abuse and prescription opioid use in early adulthood

INTRODUCTION Previous research has examined the association of childhood abuse with opioid misuse and dependence in adulthood. However, little research has focused specifically on prescription opioids, and no studies have examined associations with prescription opioid use, a potential pathway to later opioid misuse and dependence. The aim of the present study was to examine the association of childhood emotional, physical, and sexual abuse with prescription opioid use in early adulthood. METHODS We used data from Waves I (12-18years) and IV (24-32years) of the National Longitudinal Study of Adolescent to Adult Health. At Wave IV, respondents reported experiences of childhood abuse occurring prior to age 18years and prescription opioid use in the last four weeks. We conducted multivariable logistic regression to examine associations of childhood abuse with recent prescription opioid use. RESULTS In multivariable models adjusted for respondent sex, race/ethnicity, age, and socioeconomic status, childhood emotional abuse (OR=1.57, 95% CI 1.29, 1.90), physical abuse (OR=1.46, 95% CI 1.14, 1.87), and any childhood abuse (OR=1.51, 95% CI 1.24, 1.82) were significantly associated with recent prescription opioid use. CONCLUSIONS Given continued increases in prescription opioid use and opioid-related morbidity and mortality in the U.S., understanding upstream social and environmental factors associated with prescription opioid use is important to strengthening and expanding current prevention and intervention strategies. Future research is needed to examine factors potentially mediating the association between childhood abuse and prescription opioid use in order to provide additional insights for prevention and intervention efforts.

A Systematic Review of Interventions for Women Parenting in the Context of Intimate Partner Violence

Intimate partner violence (IPV) victimization is widespread among women with children and has negative consequences for both women’s and children’s well-being. Despite mixed evidence regarding the effect of IPV on women’s parenting ability and behaviors, there is an increasing focus on mothering in the context of IPV, particularly among the child welfare and child protection systems. To help respond to this increasing focus, several interventions have been developed that specifically target parenting among IPV-affected women. Given the growing numbers of these interventions, a comprehensive review is needed to help elucidate the approaches that are most effective in meeting the needs of IPV-affected women and children. Therefore, we conducted an in-depth systematic review of the literature to examine the approaches and effects of interventions designed to address aspects of parenting among IPV-affected women. We identified 26 articles concerned with 19 distinct interventions for review. We found substantial heterogeneity in intervention delivery, format, length, and focus. We noted several limitations of the existing studies in terms of study sample, measures, design, and implementation. Given the heterogeneity of the existing interventions and the limitations of the current research base, it is not yet clear which interventions or intervention components are most effective in addressing the unique needs of women parenting in the context of IPV. Further research is needed to address these limitations, and professionals working with IPV-affected families should be aware that current services may not meet women’s and children’s needs.

Prescription Opioid Use Among Young Parents in the United States: Results from the National Longitudinal Study of Adolescent to Adult Health

Objectives No estimates exist regarding the extent of prescription opioid use among US adults who are the primary caregivers to children. Methods Data were from Wave IV of the National Longitudinal Study of Adolescent to Adult Health. Respondents were age 24 to 32 years. We compared the prevalence of prescription opioid use in the last four weeks and medical conditions with the potential to precipitate use among parents (i.e., one or more children living in the household) and nonparents. We then examined demographics and substance use behaviors among parents with and without recent prescription opioid use. Results A significantly higher percentage of parents (6.7%) compared with nonparents (3.9%) had taken a prescription opioid in the last four weeks, but a significantly lower percentage of parents compared with nonparents reported medical conditions with the potential to precipitate use such as an injury in the last four weeks (2.8% vs 4.0%). A higher percentage of parents with recent prescription opioid use reported financial hardship (44.1% vs 28.2%) and met criteria for risky substance use behaviors such as prescription opioid misuse (26.3% vs 11.8%) compared with parents without recent prescription opioid use. Conclusions Results suggest notable prescription opioid use among young parents in the United States and that parents with recent prescription opioid use are more likely to have a history of inappropriate use of substances. These results highlight the need for additional research regarding the effects of prescription opioid use on parenting behaviors.

Using time-to-event analysis to identify preconception and prenatal predictors of child protective services contact

We examined preconception and prenatal predictors of time to first child protective services (CPS) contact among Alaska children. Data were from the Alaska Longitudinal Child Abuse and Neglect Linkage (ALCANLink) project, a population-representative data source linking 2009-2011 Alaska Pregnancy Risk Assessment Monitoring System (PRAMS) data with administrative data sources through 2015. We examined the incidence CPS contact using the Kaplan-Meier method and predictors of CPS contact using Cox proportional hazards regression. Using data from the Alaska Permanent Fund Dividend and Child Death Review, we censored children who emigrated out-of-state or died during the study period. Significant predictors included low socioeconomic status (HR = 2.23, 95% CI 1.68, 2.96), maternal smoking during pregnancy (HR = 1.87, 95% CI 1.55, 2.24), unmarried maternal marital status (HR = 1.62, 95% CI 1.31, 1.99), urban residence (HR = 1.59, 95% CI 1.32, 1.92), lower maternal education (HR = 1.54, 95% CI 1.24, 1.92), maternal experience of intimate partner violence in the 12 months before childbirth(HR = 1.32, 95% CI 1.01, 1.74), Alaska Native/American Indian race (HR = 1.40, 95% CI 1.15, 1.71), a greater number of living children (HR = 1.20, 95% CI 1.13, 1.29), a greater number of stressful life eventsin the 12 months before childbirth (HR = 1.16, 95% CI 1.11, 1.21), and younger maternal age at childbirth (HR = 0.95, 95% CI 0.93, 0.97). Use of multiple linked data sources and time-to-event analysis methods adds to the growing literature regarding predictors of CPS contact. Results suggest that assessing for and addressing clinical, social, and environmental indicators during the prenatal period may aid prevention efforts in mitigating family need for involvement with CPS.

Review of methodological challenges in comparing the effectiveness of neoadjuvant chemotherapy versus primary debulking surgery for advanced ovarian cancer in the United States

Randomized trials outside the U.S. have found non-inferior survival for neoadjuvant chemotherapy (NACT) versus primary debulking surgery (PDS) for advanced ovarian cancer (AOC). However, these trials reported lower overall survival and lower rates of optimal debulking than U.S. studies, leading to questions about generalizability to U.S. practice, where aggressive debulking is more common. Consequently, comparative effectiveness in the U.S. remains controversial. We reviewed U.S. comparative effectiveness studies of NACT versus PDS for AOC. Here we describe methodological challenges, compare results to trials outside the U.S., and make suggestions for future research. We identified U.S. studies published in 2010 or later that evaluated the comparative effectiveness of NACT versus PDS on survival in AOC through a PubMed search. Two independent reviewers abstracted data from eligible articles. Nine of 230 articles were eligible for review. Methodological challenges included unmeasured confounders, heterogeneous treatment effects, treatment variations over time, and inconsistent measurement of treatment and survival. Whereas some limitations were unavoidable, several limitations noted across studies were avoidable, including conditioning on mediating factors and immortal time introduced by measuring survival beginning from diagnosis. Without trials in the U.S., non-randomized studies are an important source of evidence for the ideal treatment for AOC. However, several methodological challenges exist when assessing the comparative effectiveness of NACT versus PDS in a non-randomized setting. Future observational studies must ensure that treatment is consistent throughout the study period and that treatment groups are comparable. Rapidly-evolving oncology data networks may allow for identification of treatment intent and other important confounders.

0018 Adverse childhood experiences, sexual orientation, and adult health: an analysis of north carolina, washington, and wisconsin behavioural risk factor surveillance system data

Statement of purpose Inclusion of questions regarding sexual orientation on population based surveys has helped begin to identify health disparities among individuals identifying as lesbian, gay, or bisexual (LGB). However, little research has explored the link between multiple forms of childhood adversity and a range of poor outcomes in adulthood among LGB individuals compared to heterosexuals. The purpose of this study was to utilise data from the North Carolina, Wisconsin, and Washington Behavioural Risk Factor Surveillance System (BRFSS) surveys to explore the association of sexual orientation with poor outcomes in adulthood before and after adjustment for exposure to adverse childhood experiences (ACEs). Methods/Approach The study sample included all 2012 N.C., 2011 WA, and 2011 and 2012 WI BRFSS participants who responded to the ACE module and a question regarding sexual orientation. Descriptive statistics were used to define the prevalence of ACE categories by sexual orientation. Using sexual orientation as the primary independent variable, separate multivariate logistic regression models were conducted for perceived health, health risks, and chronic conditions outcomes. Results Results revealed an increased prevalence of all ACE categories among LGB individuals compared to heterosexuals, particularly for sexual abuse, adult mental illness in the household, and an incarcerated household member. In multivariate analyses, after adjustment for demographics, sexual orientation was significantly associated with several outcomes. After additional adjustment for an ACE summary score, sexual orientation was no longer significantly associated with poor physical health, current smoking, and binge drinking while associations with poor mental health, activity limitation, HIV risk behaviours, current asthma, depression, and disability remained, but were attenuated. Conclusions This study builds upon existing research by examining multiple forms of childhood adversity experienced by LGB individuals and the association of such experiences and sexual orientation with poor outcomes in adulthood. Significance and contribution to the field Results provide additional insight into the potential effects of childhood adversity on previously identified health disparities among LGB individuals. As efforts continue in N.C. to incorporate assessment of ACEs and ACE prevention into primary care practice, these results reinforce the importance of culturally competent services that are sensitive to the unique needs and experiences of special populations.