Introduction:The American fentanyl epidemic has become the worst man-made epidemic the country has faced to date, claiming tens of thousands of lives each year. Methods:Using population-based data provided by the Centers for Disease Control and Prevention, we examined the increase in unintentional, fatal fentanyl overdose since 2005 and analyzed the geographic variation in fentanyl mortality among census divisions, states, and counties. Results:In 2022, 70 813 persons died of an unintentional fentanyl overdose, a 31-fold increase over the 2139 deaths that occurred in 2012; the age-adjusted mortality rate increased similarly. Fentanyl deaths resulted in ∼2.0-2.6 million estimated years of life lost. We estimated the economic loss to the nation resulting from premature mortality was on the order of $57-$67 billion. The impact of the fentanyl epidemic varied widely by geographic area. The mortality rate of West Virginia was 15 times greater than that of South Dakota. Conclusion:Containing the fentanyl epidemic will require new, data-driven preventive and treatment approaches, coordinated across sectors, including public health, health care, law enforcement, education, and social services. Interventions should be based upon the risk profile of geographic areas and include harm reduction activities as well as social marketing campaigns to improve public awareness of fentanyl's health risks.

What was the research about?Medicines called opioids can help ease acute pain caused by an injury.But long-term opioid use can lead to addiction, overdose, or death.One way to prevent these problems is to reduce unsafe prescribing.Unsafe prescribing can include taking high-dose opioids or taking opioids for longer than 60 days.In this study, the research team compared a workers' compensation program for injured workers in Washington State with a program in Ohio: PCORI identified unsafe opioid prescribing as an important research topic.Patients, clinicians, and others wanted to learn: How can primary care providers work with patients with noncancer pain to plan safe treatment and provide adequate pain management?To help answer this question, PCORI launched an initiative in 2016 on Strategies to Prevent Unsafe Opioid Prescribing in Primary Care among Patients with Acute or Chronic Noncancer Pain.The initiative funded this research project and others.

Background Few studies have assessed long-term opioid prescribing after a work-related injury. There is limited information about opioid prescriptions before an injury and how receipt of opioids before a work injury is associated with long-term opioid prescribing. We present patterns of long-term opioid prescription among workers after an injury, overall, and by pre-injury opioid use. Methods We used linked workers' compensation and prescription drug monitoring program (PDMP) data to identify workers injured between July 2019 and June 2020 with an opioid prescription dispensed within 6 weeks after injury. Opioid prescribing was assessed for the 3 months before injury and for 1 year after injury or claim closure, whichever came first. Results Among injured workers with an opioid in the first 6 weeks, 23% had opioids 6-12 weeks after injury, 19% had opioids 3-6 months, 14% had opioids 6-9 months, and 12% had opioids 9-12 months after injury; 19% had opioids in the 3 months before injury. For workers with opioid prescription prior to injury, the percentage with opioids 9-12 months after injury was 34%, versus 7% among workers with no opioids in the 3 months before injury (p < 0.001). Receipt of chronic opioids (for at least 60 days) 9-12 months after injury was substantially higher among those with prior opioid prescription (20%) than in those with no prior opioids (0.4%) (p < 0.001). Conclusions We found a strong relationship between opioid prescription in the 3 months before a work injury and opioid prescribing after an injury. Healthcare providers should be vigilant to the important relationship between prior opioid use and longer-term opioid use after work-related injuries.

Policy Points Workers' compensation agencies have instituted opioid review policies to reduce unsafe prescribing. Providers reported more limited and cautious prescribing than in the past; both patients and providers reported collaborative pain-management relationships and satisfactory pain control for patients. Despite the fears articulated by pharmaceutical companies and patient advocates, opioid review programs have not generally resulted in unmanaged pain or reduced function in patients, anger or resistance from patients or providers, or damage to patient-provider relationships or clinical autonomy. Other insurance providers with broad physician networks may want to consider similar quality-improvement efforts to support safe opioid prescribing.ContextUnsafe prescribing practices have been among the central causes of improper reception of opioids, unsafe use, and overdose in the United States. Workers' compensation agencies in Washington and Ohio have implemented opioid review programs (ORPs)-a form of quality improvement based on utilization review-to curb unsafe prescribing. Evidence suggests that such regulations indeed reduce unsafe prescribing, but pharmaceutical companies and patient advocates have raised concerns about negative impacts that could also result. This study explores whether three core sets of problems have actually come to pass: (1) unmanaged pain or reduced function among patients, (2) anger or resistance to ORPs from patients or providers, and (3) damage to patient-provider relationships or clinical autonomy.MethodsIn-depth semistructured interviews were conducted with 48 patients (21 from Washington, 27 from Ohio) and 32 providers (18 from Washington, 14 from Ohio) who were purposively sampled to represent a range of injury and practice types. Thematic coding was conducted with codebooks developed using both inductive and deductive approaches.FindingsThe consequences of opioid regulations have been generally positive: providers report more limited prescribing and a focus on multimodal pain control; patients report satisfactory pain control and recovery alongside collaborative relationships with providers. Participants attribute these patterns to a broad environment of opioid caution; they do not generally perceive workers' compensation policies as distinctly impactful. Both patients and providers comment frequently on the difficult aspects of interacting with workers' compensation agencies; effects of these range from simple inconvenience to delays in care, unmanaged pain, and reduced potential for physical recovery.ConclusionsIn general, the three types of feared negative impacts have not come to pass for either patients or providers. Although interacting with workers' compensation agencies involves difficulties typical of interacting with other insurers, opioid controls seem to have generally positive effects and are generally perceived of favorably.

Work is an important social determinant of health; unfortunately, work-related injuries remain prevalent, can have devastating impact on worker health, and can impose heavy economic burdens on workers and society. Occupational health services research (OHSR) underpins occupational health services policy and practice, focusing on health determinants, health services, healthcare delivery, and health systems affecting workers. The field of OHSR has undergone tremendous expansion in both definition and scope over the past 25 years. In this commentary, focusing on the US, we document the historical development and evolution of OHSR as a research field, describe current doctoral-level OHSR training, and discuss challenges and opportunities for the OHSR field. We also propose an updated definition for the OHSR field: Research and evaluation related to the determinants of worker health and well-being; to occupational injury and illness prevention and surveillance; to healthcare, health programs, and health policy affecting workers; and to the organization, access, quality, outcomes, and costs of occupational health services and related health systems. Researchers trained in OHSR are essential contributors to improvements in healthcare, health systems, and policy and programs to improve worker health and productivity, as well as equity and justice in job and employment conditions. We look forward to the continued growth of OHSR as a field and to the expansion of OHSR academic training opportunities.

Background: Advance care planning (ACP), or the consideration and communication of care preferences for the end-of-life (EOL), is a critical process for improving quality of care for patients with advanced cancer. The incorporation of billed service codes for ACP allows for new inquiries on the association between systematic ACP and improved EOL outcomes. Objective: Using the IBM MarketScan® Database, we conducted a retrospective medical claims analysis for patients with an advanced cancer diagnosis and referral to hospice between January 2016 and December 2017. We evaluated the association between billed ACP services and EOL hospital admissions in the final 30 days of life. Design: This is a cross-sectional retrospective cohort study. Participants: A total of 3,705 patients met the study criteria. Main Measures: ACP was measured via the presence of a billed ACP encounter (codes 99497 and 99498) prior to the last 30 days of life; hospital admissions included a dichotomous indicator for inpatient admission in the final 30 days of life. Key Results: Controlling for key covariates, patients who received billed ACP were less likely to experience inpatient hospital admissions in the final 30 days of life compared to those not receiving billed ACP (OR: 0.34; p < 0.001). Conclusion: The receipt of a billed ACP encounter is associated with reduced EOL hospital admissions in a population of patients with advanced cancer on hospice care. Strategies for consistent, anticipatory delivery of billable ACP services prior to hospice referral may prevent potentially undesired late-life hospital admissions.

AbstractObjectiveTo test associations between several opioid prescribing policy interventions and changes in early (acute/subacute) high‐risk opioid prescribing practices.Data SourcesPopulation‐based workers' compensation pharmacy billing and claims data, Washington State Department of Labor and Industries (January 2008‐June 2015).Study DesignWe used interrupted time series analysis to test associations between three policy intervention timepoints and monthly proportions of population‐based measures of high‐risk, low‐risk, and any workers’ compensation‐related opioid prescribing. We also tested associations between the policy intervention timepoints and five high‐risk opioid prescribing indicators among workers prescribed any opioids within 3 months after injury: (a) >7 cumulative (not necessarily consecutive) days‘ supply of opioids during the acute phase, (b) high‐dose opioids, (c) concurrent sedatives, (d) chronic opioids, and (e) a composite high‐risk opioid prescribing indicator.Principal FindingsWithin 3 months after injury, 9 percent of workers were exposed to high‐risk and 12 percent to low‐risk workers’ compensation‐related opioid prescribing; 79 percent filled no workers’ compensation‐related opioid prescription. Among workers prescribed any early (acute/subacute) opioids, the indicator for >7 days' supply of opioids during the acute phase was present for 30 percent, high‐dose opioids for 18 percent, concurrent sedatives for 3 percent, and chronic opioids for 2 percent. Beyond a general shift toward more infrequent and lower‐risk workers’ compensation‐related opioid prescribing, each policy intervention timepoint was significantly associated with reductions in specific acute/subacute high‐risk opioid prescribing indicators; each of the four specific high‐risk opioid prescribing indicators had significant reductions associated with at least one policy.ConclusionsSeveral state‐level opioid prescribing policies were significantly associated with safer workers’ compensation‐related opioid prescribing practices during the first 3 months after injury (acute/subacute phase), which should in turn reduce transition to chronic opioids and associated negative health outcomes.

PURPOSE:Youth suicide is increasing at a significant rate and is the second leading cause of death for adolescents. There is an urgent public health need to address the youth suicide. The objective of this study is to determine whether adolescents and young adults residing in states with greater mental health treatment capacity exhibited lower suicide rates than states with less treatment capacity. METHODS:We conducted a state-level analysis of mental health treatment capacity and suicide outcomes for adolescents and young adults aged 10-24 spanning 2002-2017 using data from Centers for Disease Control and Prevention, U.S. Bureau of Labor Statistics, Federal Bureau of Investigation, and other sources. Multivariable linear fixed-effects regression models tested the relationships among mental health treatment capacity and the total suicide, firearm suicide, and nonfirearm suicide rates per 100,000 persons aged 10-24. RESULTS:We found a statistically significant inverse relationship between nonfirearm suicide and mental health treatment capacity (p = .015). On average, a 10% increase in a state's mental health workforce capacity was associated with a 1.35% relative reduction in the nonfirearm suicide rate for persons aged 10-24. There was no significant relationship between mental health treatment capacity and firearm suicide. CONCLUSIONS:Greater mental health treatment appears to have a protective effect of modest magnitude against nonfirearm suicide among adolescents and young adults. Our findings underscore the importance of state-level efforts to improve mental health interventions and promote mental health awareness. However, firearm regulations may provide greater protective effects against this most lethal method of firearm suicide.

Firearm suicide receives relatively little public attention in the United States, however, the United States is in the midst of a firearm suicide crisis. Most suicides are completed using a firearm. The age-adjusted firearm suicide rate increased 22.6% from 2005 to 2017, and globally the US firearm suicide rate is 8 times higher than the average firearm suicide rate of 22 other developed countries. The debate over how to solve the firearm suicide epidemic tends to focus on reducing the firearm supply or increasing access to behavioral health treatment. Ineffectual federal firearm control policies and inadequate behavioral health treatment access has heightened the need for primary care physicians to play a more meaningful role in firearm suicide prevention. We offer suggestions for how individual physicians and the collective medical community can take action to reduce mortality arising from firearm suicide and firearm deaths.

Objective: To estimate associations between early high-risk opioid prescribing practices and long-term work-related disability. Methods: Washington State Fund injured workers with at least one opioid prescription filled within 6 weeks after injury (2002 to 2013) were included (N = 83,150). Associations between early high-risk opioid prescribing (longer duration, higher dosage, concurrent sedatives), and time lost from work, total permanent disability, and a surrogate measure for Social Security disability benefits were tested. Measures of early hospitalization, body part, and nature of injury were included to address confounding by indication concerns, along with sensitivity analyses controlling for injury severity. Results: In adjusted logistic models, early high-risk opioid prescribing was associated with roughly three times the odds of each outcome. Conclusion: Exposure to high-risk opioid prescribing within 90 days of injury was significantly and substantially associated with long-term temporary and permanent disability.

Firearms account for most self-harm deaths, and many more Americans kill themselves with a firearm each year than are murdered with one. Mental illness is an important risk factor for firearm suicide. While the literature focuses on firearm safety, little is understood about how the supply of behavioral health treatment services can reduce firearm suicide. We evaluated whether states with greater behavioral health treatment capacity have lower firearm suicide rates, examining variation across the United States and over time. The mean adjusted firearm suicide rate rose from 6.74 per 100,000 people in 2005 to 7.89 per 100,000 in 2015-a 17.1 percent increase. We found a significant independent inverse relationship between greater behavioral health treatment capacity and the firearm suicide rate. We show that across all states, on average, a 10.0 percent relative increase in behavioral health workers per state was associated with a modest 1.2 percent relative reduction in the adjusted firearm suicide rate. Given this finding, we discuss whether firearm control initiatives might offer a greater protective effect for reducing firearm suicide, compared to the protective effect of increasing behavioral health treatment capacity.

Purpose: This study aimed to determine the impact of advanced care planning (ACP) on potentially avoidable hospital admissions at the end of life (EOL) among a sample of hospice-referred patients with cancer, in order to present actionable considerations for the practicing clinician. Methods: This study was designed as a retrospective cohort using electronic health record data that assessed likelihood of hospital admissions in the last 30 days of life for 1185 patients with a primary diagnosis of cancer, referred to hospice between January 1, 2014, and December 31, 2015, at a large academic medical center. Inverse probability treatment weighting based on calculated propensity scores balanced measured covariates between those with and without ACP at baseline. Odds ratios (ORs) were calculated from estimated potential outcome means for the impact of ACP on admissions in the last 30 days of life. Results: A verified do-not-resuscitate (DNR) order prior to the last 30 days of life was associated with reduced odds of admission compared to those without a DNR (OR = 0.30; P < .001). An ACP note in the problem list prior to the last 30 days of life was associated with reduced odds of admission compared to those without an ACP note (OR = 0.71, P = .042), and further reduced odds if done 6 months prior to death (OR = 0.35, P < .001). Conclusions: This study shows that dedicated ACP documentation is associated with fewer admissions in the last 30 days of life for patients with advanced cancer referred to hospice. Improving ACP processes prior to hospice referral holds promise for reducing EOL admissions.

BACKGROUND:Brief substance use screening questions for tobacco, alcohol, cannabis, and other drugs need further validation in adolescents. In particular, optimal age-specific screening cut-points are not known, and no study has been large enough to evaluate screening questions for noncannabis illicit drug use. METHODS:Adolescent respondents to an annual national household survey were included (2008 to 2014; n = 169,986). Days of tobacco use in the past month, and days of alcohol, cannabis, other illicit drug use in the past year, were assessed as brief screens for tobacco dependence and DSM-IV alcohol (AUD), cannabis (CUD), and other illicit drug use disorders (DUD). Areas under receiver operating characteristics curves (AUCs), sensitivity and specificity were estimated separately by age group (12-15-, 16-17-, and 18-20-year-olds) and cut-points that maximized combined values of sensitivity and specificity were considered optimal. RESULTS:The prevalence of tobacco dependence, AUD, CUD, and DUD was 5.8%, 7.1%, 4.5%, and 2.0%, respectively. AUCs ranged 0.84 to 0.99. The optimal cut-points for screening for tobacco dependence and DUDs was the same for all age groups: ≥1 day. The optimal cut-points for alcohol and cannabis varied by age: ≥3 days for 12-15-year-olds and ≥12 days for older adolescents. CONCLUSIONS:Brief measures of past-year use, or past-month use for tobacco, accurately identified adolescents with problematic substance use. However, health systems should use age-specific screening cut-points for alcohol and cannabis to optimize screening performance.

CONTEXT:Opportunities for patients to receive unnecessary, costly, and potentially harmful care near the end of life abound. Advance care planning (ACP) can help to make this vulnerable period better for patients, caregivers, and providers. OBJECTIVE:The objective of this study was to determine whether older age predicted the presence of certain forms of retrievable ACP documentation in the electronic health record (EHR) in a large sample of hospice-referred patients. METHODS:This was a retrospective analysis of medical-record data on 3595 patients referred to hospice between January 1, 2013 and December 31, 2015. EHR documentation of an ACP note in the problem list, presence of a scanned advance directive, and the presence of a verified do-not-resuscitate order were the outcome measures. Logistic regression was used to assess the effect of age, education, race, gender, cancer diagnosis, dementia diagnosis, palliative encounter, and death on the outcome variables. RESULTS:Our results suggest that when we control for prognosis, patients over age 70 years may experience gaps in ACP communication. We found that as patients age, the odds of having documentation of a conversation (odds ratio [OR] = 0.56; P < 0.001) or scanned advance directive decreased (OR = 0.63; P < 0.001), while the odds of having a verified do-not-resuscitate order increased (OR = 1.42; P < 0.001). CONCLUSION:The results of this study may imply some degree of unilateral and physician-driven decision making for end-of-life care among older adults. Collaborative efforts between an interdisciplinary medical team should focus on developing policies to address this potential disparity between younger and older adults at the end of life.

The Patient Protection and Affordable Care Act (ACA) eliminated the cost-sharing requirement for several preventive cancer screenings. This study examined the cancer screening utilization of mammogram, Pap smear and colonoscopy in Medicare fee-for-service (FFS) under the ACA. The primary data were the 2007–2013 Medicare Current Beneficiary Survey linked to FFS claims. The effect of the cost-sharing removal on the probability of receiving a preventive cancer screening test was estimated using a logistic regression, separately for each screening test, adjusting for the complex survey design. The model was also separately estimated for different socioeconomic and race/ethnic groups. The study sample included beneficiaries with Part B coverage for the entire calendar year, excluding beneficiaries in Medicaid or Medicare Advantage plans. Beneficiaries with a claims-documented or self-reported history of targeted cancers, who were likely to have diagnostic tests or have surveillance screenings were excluded. The screening measures were constructed separately following Medicare coverage and U.S. Preventive Services Task Force (USPSTF) recommendations. We measured the screening utilization outcome drawing from claims data, as well as using the self-reported survey data. After the cost-sharing removal policy, we found no statistically significant difference in a beneficiary’s probability of receiving a colonoscopy (transition period: OR = 1.08, 95% CI = 0.90–1.29; post-policy period: OR = 1.08, 95% CI = 0.83–1.42), a mammogram (transition period: OR = 1.03, 95% CI = 0.91–1.17; post-policy period: OR = 1.07, 95% CI = 0.88–1.30), or a biennial Pap smear (transition period: OR = 0.87, 95% CI = 0.69–1.09; post-policy period: OR = 0.72, 95% CI = 0.51–1.03) in claims-based measures following Medicare coverage. Similarly, we found null effects of the policy change on utilization of colonoscopy among enrollees 50–75 years old, biennial mammograms by women 50–74, and triennial Pap smear tests among women 21–65 in claims-based measures according to USPSTF. The findings from survey-based measures were consistent with the estimates from claims-based measures, except that the use of Pap smear declined since 2011. Further, the policy change did not increase utilization in patients with disadvantaged socioeconomic characteristics. Yet the disparate patterns in adjusted screening rates by socioeconomic status and race/ethnicity persisted over time. Removing out-of-pocket costs for screenings did not provide enough incentives to increase the screening rates among Medicare beneficiaries.

BACKGROUND:Evidence has associated opioid use initiated early in a workers' compensation claim with subsequent disability. In 2013, the Washington State Department of Labor and Industries (DLI) implemented procedures based on new regulations that require improvement in pain and function to approve opioids beyond the acute pain period.METHODS:We measured opioid prescriptions between 6 and 12 weeks following injury, an indicator of persistent opioid use. Actuarial data for the association of any opioid use versus no opioid use with development of lost time payments are reported.RESULTS:Prior authorization with hard stops led to a sustained drop in persistent opioid use, from nearly 5% in 2013 to less than 1% in 2017. This reduction was also associated with reversal of the increased lost work time patterns seen from 1999 to 2010.CONCLUSIONS:Prior authorization targeted at preventing transition to chronic opioid use can prevent and reverse adverse time loss development that has occurred on a population basis concomitant with the opioid epidemic.

Carnide, Nancy MSc*; Hogg-Johnson, Sheilah PhD*,†,‡; Côté, Pierre DC, PhD†,‡,§; Irvin, Emma BA*; Van Eerd, Dwayne PhD*,∥; Koehoorn, Mieke PhD*,¶; Furlan, Andrea D. MD, PhD*,#,** Author Information