Marcus A. Bachhuber

Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010

IMPORTANCE Opioid analgesic overdose mortality continues to rise in the United States, driven by increases in prescribing for chronic pain. Because chronic pain is a major indication for medical cannabis, laws that establish access to medical cannabis may change overdose mortality related to opioid analgesics in states that have enacted them. OBJECTIVE To determine the association between the presence of state medical cannabis laws and opioid analgesic overdose mortality. DESIGN, SETTING, AND PARTICIPANTS A time-series analysis was conducted of medical cannabis laws and state-level death certificate data in the United States from 1999 to 2010; all 50 states were included. EXPOSURES Presence of a law establishing a medical cannabis program in the state. MAIN OUTCOMES AND MEASURES Age-adjusted opioid analgesic overdose death rate per 100 000 population in each state. Regression models were developed including state and year fixed effects, the presence of 3 different policies regarding opioid analgesics, and the state-specific unemployment rate. RESULTS Three states (California, Oregon, and Washington) had medical cannabis laws effective prior to 1999. Ten states (Alaska, Colorado, Hawaii, Maine, Michigan, Montana, Nevada, New Mexico, Rhode Island, and Vermont) enacted medical cannabis laws between 1999 and 2010. States with medical cannabis laws had a 24.8% lower mean annual opioid overdose mortality rate (95% CI, -37.5% to -9.5%; P = .003) compared with states without medical cannabis laws. Examination of the association between medical cannabis laws and opioid analgesic overdose mortality in each year after implementation of the law showed that such laws were associated with a lower rate of overdose mortality that generally strengthened over time: year 1 (-19.9%; 95% CI, -30.6% to -7.7%; P = .002), year 2 (-25.2%; 95% CI, -40.6% to -5.9%; P = .01), year 3 (-23.6%; 95% CI, -41.1% to -1.0%; P = .04), year 4 (-20.2%; 95% CI, -33.6% to -4.0%; P = .02), year 5 (-33.7%; 95% CI, -50.9% to -10.4%; P = .008), and year 6 (-33.3%; 95% CI, -44.7% to -19.6%; P < .001). In secondary analyses, the findings remained similar. CONCLUSIONS AND RELEVANCE Medical cannabis laws are associated with significantly lower state-level opioid overdose mortality rates. Further investigation is required to determine how medical cannabis laws may interact with policies aimed at preventing opioid analgesic overdose.

Increasing Benzodiazepine Prescriptions and Overdose Mortality in the United States, 1996-2013.

OBJECTIVES To describe trends in benzodiazepine prescriptions and overdose mortality involving benzodiazepines among US adults. METHODS We examined data from the Medical Expenditure Panel Survey and multiple-cause-of-death data from the Centers for Disease Control and Prevention. RESULTS Between 1996 and 2013, the percentage of adults filling a benzodiazepine prescription increased from 4.1% (95% confidence interval [CI] = 3.8%, 4.5%) to 5.6% (95% CI = 5.2%, 6.1%), with an annual percent change of 2.5% (95% CI = 2.1%, 3.0%). The quantity of benzodiazepines filled increased from 1.1 (95% CI = 0.9, 1.2) to 3.6 (95% CI = 3.0, 4.2) kilogram lorazepam equivalents per 100 000 adults (annual percent change = 9.0%; 95% CI = 7.6%, 10.3%). The overdose death rate increased from 0.58 (95% CI = 0.55, 0.62) to 3.07 (95% CI = 2.99, 3.14) per 100 000 adults, with a plateau seen after 2010. CONCLUSIONS Benzodiazepine prescriptions and overdose mortality have increased considerably. Fatal overdoses involving benzodiazepines have plateaued overall; however, no evidence of decreases was found in any group. Interventions to reduce the use of benzodiazepines or improve their safety are needed.

The emerging public discourse on state legalization of marijuana for recreational use in the US: Analysis of news media coverage, 2010–2014

OBJECTIVES US states have begun to legalize marijuana for recreational use. In the absence of clear scientific evidence regarding the likely public health consequences of legalization, it is important to understand how the risks and benefits of this policy are being discussed in the national dialogue. To assess the public discourse on recreational marijuana policy, we assessed the volume and content of US news media coverage of the topic. METHOD We analyzed the content of a 20% random sample of news stories published/aired in high circulation/viewership print, television, and Internet news sources from 2010 to 2014 (N=610). RESULTS News media coverage of recreational marijuana policy was heavily concentrated in news outlets from the four states (AK, CO, OR, WA) and DC that legalized marijuana for recreational use during the study period. Overall, 53% of news stories mentioned pro-legalization arguments and 47% mentioned anti-legalization arguments. The most frequent pro-legalization arguments posited that legalization would reduce criminal justice involvement/costs (20% of news stories) and increase tax revenue (19%). Anti-legalization arguments centered on adverse public health consequences, such as detriments to youth health and well-being (22%) and marijuana-impaired driving (6%). Some evidence-informed public health regulatory options, like marketing and packaging restrictions, were mentioned in 5% of news stories or fewer. CONCLUSION As additional states continue to debate legalization of marijuana for recreational use, it is critical for the public health community to develop communication strategies that accurately convey the rapidly evolving research evidence regarding recreational marijuana policy.

High HCV cure rates for people who use drugs treated with direct acting antiviral therapy at an urban primary care clinic

BACKGROUND Though direct acting antivirals (DAAs) promise high cure rates, many providers and payers remain concerned about successful treatment for people who use drugs (PWUD), even among those engaged in opioid agonist treatment (OAT). The efficacy of DAAs among PWUD in real-world settings is unclear. METHODS We conducted a cohort study of patients initiating HCV treatment between January 2014 and August 2015 (n=89) at a primary care clinic in the Bronx, NY. Onsite HCV treatment with DAAs was performed by an HCV specialist, with support from a care coordinator funded by the NYC Department of Health. We identified four categories of drug use and drug treatment: (1) no active drug use/not receiving OAT (defined as non-PWUD); (2) no active drug use/receiving OAT; (3) active drug use/not receiving OAT; and (4) active drug use/receiving OAT. The primary outcome was SVR at 12 weeks post-treatment. RESULTS Overall SVR rates were 95% (n=41/43) for non-PWUD and 96% (n=44/46) for patients actively using drugs and/or receiving OAT [p=0.95]. There were no differences in SVR rates by drug use or drug treatment category. Compared to non-PWUD, those with no active drug use/receiving OAT had 100% SVR (n=15/15; p=1.0), those actively using drugs/not receiving OAT had 90% SVR (n=9/10; p=0.47), and those actively using drugs/receiving OAT had 95% SVR (20/21; p=1.0). CONCLUSION Regardless of active drug use or OAT, patients who received DAA therapy at an urban primary care clinic achieved high HCV cure rates. We found no clinical evidence to justify restricting access to HCV treatment for patients actively using drugs and/or receiving OAT.

Hospitalization rates of people living with HIV in the United States, 2009

Objectives. We determined hospitalization rates and disparities among people with HIV, which may have been underestimated in previous studies, as only those in medical care were included. Methods. We estimated the hospitalization rate of people with diagnosed HIV infection in the U.S. in 2009 using two nationally representative datasets. We took the number of hospitalizations from the Nationwide Inpatient Sample and searched each discharge for International Classification of Diseases, Ninth Revision codes for HIV infection and opportunistic infections (OIs). We divided the number of hospitalizations by the number of prevalent diagnosed HIV cases estimated by CDC to produce hospitalization rates, and then compared those rates using Z-tests. Results. The estimated nationwide hospitalization rate was 26.6 per 100 population. Women had a 51% higher rate than men (35.5 vs. 23.5 per 100 population, p=0.002). Black people (31.2 per 100 population, p=0.01) had a 42% higher rate, and Hispanic people (18.2 per 100 population, p=0.23) had an 18% lower rate than white people (22.1 per 100 population) of hospitalization for any illness. Of hospitalizations with an OI, females with HIV had a 50% higher rate than males with HIV (5.0 vs. 3.4 per 100 population, p=0.003). Black people with HIV (4.7 per 100 population, p<0.001) had a 72% higher rate and Hispanic people with HIV (2.9 per 100 population, p=0.78) had a similar rate of hospitalization with an OI compared with white people with HIV (2.7 per 100 population). Conclusions. Hospitalization rates among people living with HIV in the U.S. are higher than have been previously estimated. Substantial gender and racial/ethnic disparities in hospitalization rates exist, suggesting that the benefits of antiretroviral therapy have not been realized across all groups equally.

Insurance Coverage and Treatment Use Under the Affordable Care Act Among Adults With Mental and Substance Use Disorders

OBJECTIVE Many adults who have mental or substance use disorders or both experience insurance-related barriers to care, contributing to low treatment utilization. Expanded insurance under the Affordable Care Act (ACA) could improve coverage and access. The study identified changes in coverage and treatment use following 2014 ACA insurance expansions. METHODS Data from the National Survey on Drug Use and Health were used to identify individuals ages 18-64 screening positive for any mental disorder (N=29,962) or substance use disorder (N=19,243) for two periods: 2011-2013 and 2014. Regression-adjusted means were calculated for insurance rates and treatment used in each period overall and among individuals with household incomes ≤200% of the federal poverty level (FPL). RESULTS Compared with 2011-2013, in 2014 significant reductions were seen in the uninsured rate for individuals with mental disorders (-5.4 percentage points, p<.01) and substance use disorders (-5.1 percentage points, p<.01). Increases in insurance coverage occurred mostly through Medicaid. Insurance gains were larger for adults with incomes ≤200% of FPL compared with the overall sample. Use of mental health treatment increased by 2.1 percentage points (p=.04), but use of substance use disorder treatment did not change. No significant changes were noted in treatment settings for mental and substance use disorder treatments. Payment by Medicaid for substance use disorder treatment increased by 7.4 percentage points (p=.05). CONCLUSIONS Sizable increases in coverage for adults with mental disorders and adults with substance use disorders were identified in the year following the 2014 ACA expansions; however, low treatment rates among this population remain a concern. Initiatives to engage the newly insured in treatment are needed.

Messaging to Increase Public Support for Naloxone Distribution Policies in the United States: Results from a Randomized Survey Experiment.

Background Barriers to public support for naloxone distribution include lack of knowledge, concerns about potential unintended consequences, and lack of sympathy for people at risk of overdose. Methods A randomized survey experiment was conducted with a nationally-representative web-based survey research panel (GfK KnowledgePanel). Participants were randomly assigned to read different messages alone or in combination: 1) factual information about naloxone; 2) pre-emptive refutation of potential concerns about naloxone distribution; and 3) a sympathetic narrative about a mother whose daughter died of an opioid overdose. Participants were then asked if they support or oppose policies related to naloxone distribution. For each policy item, logistic regression models were used to test the effect of each message exposure compared with the no-exposure control group. Results The final sample consisted of 1,598 participants (completion rate: 72.6%). Factual information and the sympathetic narrative alone each led to higher support for training first responders to use naloxone, providing naloxone to friends and family members of people using opioids, and passing laws to protect people who administer naloxone. Participants receiving the combination of the sympathetic narrative and factual information, compared to factual information alone, were more likely to support all policies: providing naloxone to friends and family members (OR: 2.0 [95% CI: 1.4 to 2.9]), training first responders to use naloxone (OR: 2.0 [95% CI: 1.2 to 3.4]), passing laws to protect people if they administer naloxone (OR: 1.5 [95% CI: 1.04 to 2.2]), and passing laws to protect people if they call for medical help for an overdose (OR: 1.7 [95% CI: 1.2 to 2.5]). Conclusions All messages increased public support, but combining factual information and the sympathetic narrative was most effective. Public support for naloxone distribution can be improved through education and sympathetic portrayals of the population who stands to benefit from these policies.

Changes in Testing for Human Immunodeficiency Virus, Sexually Transmitted Infections, and Hepatitis C Virus in Opioid Treatment Programs

To the Editor Opioid dependence is a risk factor for human immunodeficiency virus (HIV), sexually transmitted infections (STIs), and hepatitis C virus (HCV) infection.1 Opioid treatment programs, which provide medication-assisted treatment to over 300 000 opioid-dependent Americans,2 are well-positioned to offer testing for these infectious diseases to a high-risk population. They were among the first venues to offer HIV testing and are more likely to offer HIV, STI, and HCV testing than other drug treatment programs.1 Private for-profit opioid treatment programs are increasingly widespread and such programs offer on-site HIV testing less often than nonprofit and public programs.3 However, with the 2006 national recommendations for routine opt-out HIV testing,4 we hypothesized that the percent of programs offering on-site testing for HIV, STIs, and HCV would increase.

Deaths From Unintentional Injury, Homicide, and Suicide During or Within 1 Year of Pregnancy in Philadelphia

OBJECTIVES To understand the effect of unintentional injuries (e.g., drug overdose), suicide, and homicide on pregnancy-associated death (death during or within 1 year of pregnancy). METHODS We analyzed all cases of pregnancy-associated death among Philadelphia, Pennsylvania, residents from 2010 to 2014, examining cause of death, contributing factors, and history of health care use. RESULTS Approximately half (49%; 42 of 85) of pregnancy-associated deaths were from unintentional injuries (n = 31), homicide (n = 8), or suicide (n = 3); drug overdose was the leading cause (n = 18). Substance use was noted during or around events leading to death in 46% (31 of 67) of nonoverdose deaths. A history of serious mental illness was noted in 39% (32 of 82) of nonsuicide deaths. History of intimate partner violence (IPV) was documented in 19% (15 of 77) of nonhomicide deaths. Regardless of cause of death, approximately half of all decedents had an unscheduled hospital visit documented within a month of death. CONCLUSIONS Unintentional injury, homicide, and suicide contribute to many deaths among pregnant and recently pregnant women. Interventions focused on substance use, mental health, and IPV may reduce pregnancy-associated and pregnancy-related deaths.

Availability of buprenorphine on the Internet for purchase without a prescription

BACKGROUND Use of illicit buprenorphine is increasingly recognized, but it is unknown if the Internet currently represents an accessible source. METHODS A series of Internet searches were conducted. Twenty searches were performed on two different search engines. The first 100 results of each search were classified into categories based on content. All Internet pharmacies were searched for buprenorphine preparations and if available, sites were examined to determine if a prescription was required for purchase, for the cost of buprenorphine, the geographical origin of the pharmacy, and evidence of validation by an online pharmacy verification service. RESULTS Of the 2000 links examined, 1422 were unique. Six percent of links were to illicit commercial sites, 2% were to legitimate commercial sites, and 2% were to illicit portal sites, which contained links to many illicit commercial sites. Twenty pharmacies offering buprenorphine for purchase without a prescription were identified. The monthly cost of a typical starting dose of 2 mg buprenorphine daily ranged between