In recent years, policy makers, payers, and providers have increasingly focused on resolving health-related social needs (HRSNs). The authors evaluated a private payer-led program, Community Connected Care (CCC), which integrates screening and addressing of social needs to enhance members' overall health, and assessed the impact on health care costs among referred Medicaid beneficiaries with high clinical risks. The authors used adjusted difference-in-differences analyses with generalized estimating equation regression models to estimate the average effect of the CCC program intervention on per-member per-month (PMPM) total allowed health care costs among referred high clinical risk Medicaid beneficiaries from January 1, 2022 to December 31, 2022. Differences in average PMPM cost outcomes between an intervention group (referred members who were successfully reached and assessed by program staff) and a control group (referred members who could not be reached) across pre- and postintervention periods (6 months before to 6 months after the index referral date) were compared after baseline covariate adjustment. Additional stratified subgroup analyses were conducted based on additional presence or absence of high social risk. There was a statistically significant decline in PMPM total allowed costs across all high clinical risk Medicaid beneficiaries referred to the CCC model (-US$85 [95% confidence interval (CI), -US$167 to -US$3], P=0.0421). In subgroup analysis, there was a larger and statistically significant decline in total allowed costs (PMPM reduction of -US$181 [95% CI, -US$329 to -US$33], P=0.0163) among the subset of high clinical risk Medicaid beneficiaries with known high social risk at the time of referral. In addition, there were statistically significant reductions in emergency department allowed costs and increases in primary care costs for this high clinical and high social risk Medicaid cohort after referral. By contrast, there was no statistically significant impact on PMPM total allowed costs for Medicaid members who only had high clinical risks without having additional high social risk (-US$40 [95% CI, -US$139 to US$59], P=0.4284). This study suggests that addressing HRSNs among Medicaid members with high clinical needs can lead to lower health care allowed costs. However, the health care industry should adopt a broader framework beyond medical cost reduction when evaluating the returns on addressing HRSNs. Metrics should also reflect nonmonetary values such as improved patient experience, enhanced quality of life, and the potential to reduce health disparities.

Importance:Transportation barriers have long been associated with poorer health outcomes; this burden is especially acute for individuals with opioid use disorder (OUD), a chronic disease often associated with low socioeconomic status. Conventional travel time analyses may not fully account for experiential components of travel, thereby understating the true travel burden and overstating treatment accessibility to opioid treatment programs (OTPs). Objective:To develop a metric of feels-like accessibility for those using public transit to access OTPs that accounts for the realistic travel burden on individuals with OUD. Design, Setting, and Participants:This cross-sectional study integrated high-resolution transit schedules and operating hours of OTPs to measure feels-like accessibility. Feels-like accessibility considers the differential outcomes of out-of-vehicle travel components and more realistically reflects individuals' transportation burden than conventional accessibility measures. Gini indices and spatial regression models were used to investigate inequities in accessibility. Geocoded data for residential addresses of 1018 overdose fatalities in Connecticut in 2019 were used as a proxy for the treatment needs of individuals with OUD. Data were analyzed between May and August 2023. Main Outcomes and Measures:Conventional and feels-like accessibility scores. Exposures:Fluctuations in public transit frequencies over the course of the day and the limited operating hours of the OTPs. Results:Of the 1018 individuals in the study, the mean (SD) age at death was 43.7 (12.6) years, 784 individuals (77%) were men, 111 (11%) were African American, and 889 (87%) were White, with other racial and ethnic categories including 18 individuals (2%). A total of 264 individuals in the sample (26%) could not access an OTP within 180 minutes. For those who could access these facilities, the average 1-way travel time was 45.6 minutes, with individuals spending approximately 70% of their trip duration on out-of-vehicle travel components. The conventional accessibility metric underestimates individuals' travel burden to OTPs as well as the inequity in accessibility compared with the feels-like accessibility metric. For example, the median (range) conventional accessibility score, defined as the number of OTPs within 120 minutes of transit travel time, was 5.0 (0.0-17.0); the median (range) feels-like accessibility score, defined as the number of OTPs within 120 minutes of transit travel time weighted to account for in- and out-of-vehicle segments, was 1.0 (0.0-10.0). There is a considerable temporal variation in travel time and accessibility depending on the departure times. Conclusions and Relevance:In this cross-sectional study of travel burdens, the calculated feels-like accessibility scores, which consider the differential outcomes of out-of-vehicle travel components (eg, walking and waiting), could better and more realistically reflect passengers' transportation burden. Policy recommendations derived from the conventional accessibility metric could be misleading, and decision-makers should use feels-like accessibility metrics that adequately capture individuals' travel burdens. In the context of access to OTPs, the findings from this study suggest that opening new OTP sites to address gaps in access due to distance to services or extending hours of operation at existing sites may ameliorate the travel burden for individuals.

BACKGROUND:As overdose deaths continue to rise, public health officials need comprehensive surveillance data to design effective prevention, harm reduction, and treatment strategies. Disparities across race and ethnicity groups, as well as trends in substance use, treatment, or overdose deaths, have been examined individually, but reports rarely compare findings across multiple substances or data sources. OBJECTIVE:To provide a broad assessment of the overdose crisis, we describe trends in substance use, treatment, and overdose mortality across racial and ethnic groups for multiple substances. RESEARCH DESIGN:We conducted a longitudinal, cross-sectional analysis comparing trends. SUBJECTS:We identified self-reported use from the National Survey on Drug Use and Health, substance use treatment admissions from the Treatment Episode Data Set-Admissions, and overdose deaths from the CDC's Multiple Cause of Death files. MEASURES:We measured rates of substance use, treatment, and deaths involving heroin, methamphetamine, and cocaine among United States adults from 2010 to 2019. RESULTS:Heroin, methamphetamine, and cocaine use increased, though not all changes were statistically significant. Treatment admissions indicating heroin and methamphetamine increased while admissions indicating cocaine decreased. Overdose deaths increased among all groups: methamphetamine (257%-1,115%), heroin (211%-577%), and cocaine (88%-259%). Changes in rates of use, treatment, and death for specific substances varied by racial and ethnic group. CONCLUSIONS:Substance use, treatment, and overdose mortality changed considerably, though not always equivalently. Identifying diverging trends in substance-related measures for specific substances and racial and ethnic groups can inform targeted investment in treatment to reduce disparities and respond to emerging changes in the overdose crisis.

INTRODUCTION:There is uncertainty about whether criminal legal involvement (CLI) impacts the effectiveness of medications for opioid use disorder (MOUD). We aimed to determine whether CLI modifies the association between buprenorphine-naloxone (BUP-NX) vs. extended-release naltrexone (XR-NTX) and MOUD treatment outcomes. METHODS:We conducted a secondary analysis of X:BOT, a 24-week multi-center randomized controlled trial comparing treatment outcomes between BUP-NX (n = 287) and XR-NTX (n = 283) in the general population. We used baseline Additional Severity-Index Lite responses to identify patients with recent CLI (n = 342), defined as active CLI and/or CLI in the past 30 days, and lifetime incarceration (n = 328). We explored recent CLI and lifetime incarceration as potential effect modifiers of BUP-NX vs. XR-NTX effectiveness on relapse, induction, and overdose. We conducted both intention-to-treat and per-protocol analyses for each outcome. RESULTS:In intention-to-treat analyses, recent CLI modified the effect of BUP-NX vs. XR-NTX on odds of successful induction (p = 0.03) and hazard of overdose (p = 0.04), but it did not modify the effect on hazard of relapse (p = 0.23). All participants experienced lower odds of successful induction with XR-NTX compared to BUP-NX, but the relative likelihood of successful induction with BUP-NX was lower than XR-NTX among individuals with recent CLI (OR: 0.25, 95 % CI: 0.13-0.47, p < 0.001) compared to those without recent CLI (OR: 0.04, 95 % CI: 0.01-0.19, p < 0.001). Participants with recent CLI experienced similar hazard of overdose with XR-NTX and BUP-NX (HR: 1.12, 95 % CI: 0.42-3.01, p = 0.82), whereas those without recent CLI experienced greater hazard of overdose with XR-NTX compared to BUP-NX (HR: 12.60, 95 % CI: 1.62-98.03, p = 0.02). In per-protocol analyses, recent CLI did not modify the effect of MOUD on hazard of overdose (p = 0.10) or relapse (p = 0.41). Lifetime incarceration did not modify any outcome. CONCLUSIONS:Compared to individuals without recent CLI, individuals with recent CLI experienced decreased relative effectiveness of BUP-NX compared to XR-NTX for induction and overdose outcomes. This highlights the importance of considering the impact of recent CLI on opioid use disorder treatment outcomes. Future research should explore the mechanisms through which recent CLI modifies MOUD effectiveness and aim to improve MOUD effectiveness for individuals with recent CLI.

PURPOSE OF REVIEW:To summarize the impact of financial hardship on children whose parents have been incarcerated, describe both existing cash transfer and guaranteed income programs, and highlight their impact on child and family well being. RECENT FINDINGS:Emerging data on guaranteed income programs for formerly incarcerated adults indicates that the funds improve recipient health and legal system outcomes and allow participants to spend funds on stabilizing themselves and their families. Guaranteed income programs in the broader population similarly highlight the use of funds to support families' basic needs and improved parent-child relationships, but more data are needed to understand the impact on child health and well being among families impacted by the criminal legal system. SUMMARY:Over 5 million children experience parental incarceration, which directly contributes to financial hardship and subsequent negative health outcomes. Cash transfers may assist these families, but policies and administrative burdens limit the ability of existing programs to fully address financial hardship. Guaranteed income programs may therefore serve a unique role in supporting the financial needs of families impacted by incarceration. More longitudinal data focusing on child health outcomes are necessary to fully understand the impact of guaranteed income of children and families impacted by parental incarceration.

OBJECTIVE:The opioid overdose crisis continues within the United States, and the role of prescribed opioids and prescribing patterns in overdose deaths remains an important area of research. This study investigated patterns of prescription opioids dispensed in the 12 months before opioid-detected overdose death in Connecticut between May 8, 2016, and January 2, 2018, considering differences by demographic characteristics. METHOD:The sample included decedents who had an opioid dispensed within 30 days preceding death. Using multilevel modeling, we estimated the slope of change in mean morphine equivalent (MME) daily dose over 12 months before death, considering linear and quadratic effects of time. We also estimated the main effects of age, sex, race, and ethnicity and their interactions with time on MME. A sensitivity analysis examined how excluding decedents who did not receive long-term (≥90 days) opioid therapy affected mean MME slopes. The secondary analysis explored differences according to toxicology results. RESULTS:Among 1,580 opioid-detected deaths, 179 decedents had prescribed opioids dispensed within 30 days preceding death. Decedents' mean age was 47.3 years (SD = 11.5), 65.5% were male, 81% were White non-Hispanic, 9.5% were Black non-Hispanic, and 9.5% were Hispanic. In the time-only model, linear (beta = 6.25, p < .01) and quadratic (beta = 0.49, p = .02) effects of time were positive, indicating exponentially increasing dose before death. Linear change in MME was significantly attenuated in men compared with women (beta = -4.87, p = .03); however, men were more likely to have nonprescription opioids in their toxicology results (p = .02). Sensitivity analysis results supported the primary findings. CONCLUSIONS:Rapid dose increases in dispensed opioids may be associated with opioid-detected overdose deaths, especially among women.

Objective: To determine the relative risk of death following exposure to treatments for OUD compared to no treatment. Methods: In this retrospective cohort study we compiled and merged state agency data on accidental and undetermined opioid overdose deaths in 2017 and exposures to OUD treatment in the prior six months to determine incidence rates following exposure to different treatment modalities. These rates were compared to the estimated incidence among those exposed to no treatment to determine relative risk of death for each treatment exposure.Results: Incidence rates for opioid poisoning deaths for those exposed to treatment ranged from 6.06 +/- 1.40 per 1000 persons exposed to methadone to 17.36 +/- 3.22 per 1000 persons exposed to any non-medication treatment. The estimated incidence rate for those not exposed to treatment was 9.80 +/- 0.72 per 1000 persons. With no exposure to treatment as referent, exposure to methadone or buprenorphine reduced the relative risk by 38% or 34%, respectively; the relative risk of non-medication treatments was equal to or worse than no exposure to treatment (RR = 1.27-1.77). Principal conclusions: Exposure to non-MOUD treatments provided no protection against fatal opioid poisoning whereas the relative risk was reduced following exposures to MOUD treatment, even if treatment was not continued. Population level efforts to reduce opioid overdose deaths need to focus on expanding access to agonist-based MOUD treatments and are unlikely to succeed if access to non-MOUD treatments is made more available.

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Objective: The opioid overdose crisis continues within the United States, and the role of prescribed opioids and prescribing patterns in overdose deaths remains an important area of research. This study investigated patterns of prescription opioids dispensed in the 12 months before opioid-detected overdose death in Connecticut between May 8, 2016, and January 2, 2018, considering differences by demographic characteristics. Method: The sample included decedents who had an opioid dispensed within 30 days preceding death. Using multilevel modeling, we estimated the slope of change in mean morphine equivalent (MME) daily dose over 12 months before death, considering linear and quadratic effects of time. We also estimated the main effects of age, sex, race, and ethnicity and their interactions with time on MME. A sensitivity analysis examined how excluding decedents who did not receive long-term (>= 90 days) opioid therapy affected mean MME slopes. The secondary analysis explored differences according to toxicology results. Results: Among 1,580 opioid-detected deaths, 179 decedents had prescribed opioids dispensed within 30 days preceding death. Decedents' mean age was 47.3 years (SD = 11.5), 65.5% were male, 81% were White non-Hispanic, 9.5% were Black non-Hispanic, and 9.5% were Hispanic. In the time-only model, linear (beta = 6.25, p < .01) and quadratic (beta = 0.49, p = .02) effects of time were positive, indicating exponentially increasing dose before death. Linear change in MME was significantly attenuated in men compared with women (beta =-4.87, p = .03); however, men were more likely to have nonprescription opioids in their toxicology results (p = .02). Sensitivity analysis results supported the primary findings. Conclusions: Rapid dose increases in dispensed opioids may be associated with opioid-detected overdose deaths, especially among women.

Objectives. To determine mortality risk among those recently released from a Minnesota jail or prison. Methods. Using linked prison, jail, and death records, our retrospective cohort study followed 99 065 people who were released from Minnesota jails and prisons between March 1, 2020, and December 31, 2021. We explored differences between jail and prison exposures regarding mortality using standardized mortality ratios. Results. Adjusting for age and gender, we estimated that the rate of overdose death for people released from jail was 15.5 times that of the Minnesota general population. Overdose death rates for people released from prison were even higher at 28.3 times the rate of the Minnesota general population. Conclusions. Drug overdose was the leading cause of death for people reentering their communities from both jail and prison in Minnesota-with opioids being the leading cause of overdoses. Overdose death relative to the general population was double the estimates from earlier studies among people leaving prison. Providing seamless access to medications for opioid use disorder during and after incarceration is important to lower the risk of death following release. (Am J Public Health. 2024;114(9):913-922. https://doi.org/10.2105/AJPH.2024.307723).

This Viewpoint explores the current barriers to implementing contingency management treatment for individuals experiencing both opioid use and stimulant use disorders in the context of high numbers of US overdoses.

Background: As overdose rates increase for multiple substances, policymakers need to identify geographic patterns of substance-specific deaths. In this study, we describe county-level opioid and psychostimulant overdose patterns and how they correlate with county-level social vulnerability measures. Methods: A cross-sectional observational study, we used nationwide 2016-2018 restricted access Centers for Disease Prevention and Control county-level mortality files for 1,024 counties. We estimated quartiles of opioid and psychostimulant overdose mortality and provided estimates of their association with county-level Social Vulnerability Index (SVI) percentile. Results: There was high opioid and psychostimulant overdose mortality in the Middle Atlantic, South Atlantic, East North Central, and Mountain regions. The Central US had the lowest opioid and psychostimulant overdose mortality rates. Counties with higher SVI scores (i.e. higher social vulnerability) were significantly more likely to experience high opioid and high psychostimulant overdose (high-high) mortality. A 10-percentile increase in SVI score was associated with a 3.1 percentage point increase in the likelihood of being a high-high county (p < 0.001) in unadjusted models and a 1.5 percentage point increase (p < 0.05) in models adjusting for region. Conclusion: Our results illustrated the heterogenous geographic distribution of the growing concurrent opioid and psychostimulant overdose crisis. The substantial regional variation we identified highlights the need for local data to guide policymaking and treatment planning. The association of opioid-psychostimulant overdose mortality with social vulnerability demonstrates the critical need in impacted counties for tailored treatment that addresses the complex medical and social needs of people who use both opioids and psychostimulants.

OBJECTIVE Individuals with criminal legal involvement have high rates of substance use and other mental disorders. Before implementation of the Affordable Care Act's Medicaid expansion, they also had low health insurance coverage. The objective of this study was to assess the impact of Medicaid expansion on health insurance coverage and use of treatment for substance use or other mental disorders in this population. METHODS The authors used restricted data (2010-2017) from the National Survey on Drug Use and Health (NSDUH). Using a difference-in-differences approach, the authors estimated the impact of Medicaid expansion on health insurance coverage and treatment for substance use or other mental disorders among individuals with recent criminal legal involvement. RESULTS The sample consisted of 9,910 NSDUH respondents who were ages 18-64 years, had a household income ≤138% of the federal poverty level, and reported past-year criminal legal involvement. Medicaid expansion was associated with an 18 percentage-point increase in insurance coverage but no change in receipt of substance use treatment among individuals with substance use disorder. Individuals with any other mental illness had a 16 percentage-point increase in insurance coverage but no change in receipt of mental health treatment. CONCLUSIONS Despite a large increase in health insurance coverage among individuals with criminal legal involvement and substance use or other mental disorders, Medicaid expansion was not associated with a significant change in treatment use for these conditions. Insurance access alone appears to be insufficient to increase treatment for substance use or other mental disorders in this population.

Background: Individuals with criminal legal involvement (CLI), housing instability, or Medicaid insurance may experience barriers accessing substance use treatment in certain settings. Previous research has found individuals in these groups are less likely to receive medications for opioid use disorder (MOUD), but the role treatment setting may play in low rates of MOUD is unclear. Methods: We conducted a cross-sectional study using nationally representative survey data from 2015 to 2021. We estimated the proportion of individuals who had CLI, housing instability, or Medicaid insurance who received substance use treatment in a variety of settings. We used multivariable logistic regressions to estimate the associations between group and the receipt of MOUD across treatment settings. Results: Individuals with CLI, housing instability, or Medicaid insurance were more likely to receive substance use treatment in hospitals, rehabilitation, and mental health facilities compared with individuals not in these groups. However, all groups accessed substance use treatment in doctors’ offices at similar rates. Treatment at a doctor's office was associated with the highest likelihood of receiving MOUD (aOR 4.73 [95% CI: 2.2.15-10.43]). Across multiple treatment settings, Individuals with CLI or housing instability were less likely to receive MOUD. Conclusions: Individuals with CLI, housing instability, or Medicaid insurance are more likely to access substance use treatment at locations associated with lower rates of MOUD use. MOUD access across treatment settings is needed to improve engagement and retention in treatment for patients experiencing structural disadvantage or who have low incomes.

Purpose Older adults who are or have been incarcerated constitute a growing population in the USA. The complex health needs of this group are often inadequately addressed during incarceration and equally so when transitioning back to the community. The purpose of this paper is to discuss the literature on challenges older adults (age 50 and over) face in maintaining health and accessing social services to support health after an incarceration and to outline recommendations to address the most urgent of these needs. Design/methodology/approach This study conducted a narrative literature review to identify the complex health conditions and health services needs of incarcerated older adults in the USA and outline three primary barriers they face in accessing health care and social services during reentry. Findings Challenges to healthy reentry of older adults include continuity of health care; housing availability; and access to health insurance, disability and other support. The authors recommend policy changes to improve uniformity of care, development of support networks and increased funding to ensure that older adults reentering communities have access to resources necessary to safeguard their health and safety. Originality/value This review presents a broad perspective of the current literature on barriers to healthy reentry for older adults in the USA and offers valuable system, program and policy recommendations to address those barriers.

Background: Opioid overdoses are a leading cause of preventable death in the United States. There is limited research linking decedents' receipt of controlled substances and presence of controlled substances on postmortem toxicology (PMT). Methods: We linked data on opioid-detected deaths in Connecticut between May 3, 2016, and December 31, 2017 from the Office of the Chief Medical Examiner, Department of Consumer Protection, and Department of Mental Health and Addiction Services. Exposure was defined as receipt of an opioid or benzodiazepine prescription within 90 days prior to death. Our primary outcome was concordance between medication received and metabolites in PMT. Results: Our analysis included 1412 opioid-detected overdose deaths. 47 % received an opioid or benzodiazepine 90 days prior to death; 36 % received an opioid and 27 % received a benzodiazepine. Concordance between receipt of an opioid or benzodiazepine and its presence in PMT was observed in 30 % of opioid-detected deaths. Concordance with an opioid was present in 17 % of opioid-detected deaths and concordance with a benzodiazepine was present in 21 % of opioid-detected deaths. Receipt of an opioid or benzodiazepine and concordance with PMT were less common in fentanyl or heroin-detected deaths and more common in pharmaceutical opioiddetected deaths. Discussion: Our results suggest medically supplied opioids and benzodiazepines potentially contributed to a substantial number, though minority, of opioid-detected deaths during the study period. Efforts to reduce opioid and benzodiazepine prescribing may reduce risk of opioid-detected deaths in this group, but other approaches will be needed to address most opioid-detected deaths that involved non-pharmaceutical opioids.