Stephen Crystal

Background: Acute care encounters for opioid overdose are increasingly recognized as critical opportunities to connect patients to opioid use disorder (OUD) treatment. However, national data on receipt of medication for OUD (MOUD) after overdose events are limited, particularly for new MOUD initiation. Objective: To examine MOUD receipt and timing after emergency department or inpatient encounters for opioid overdose, including patient characteristics associated with new MOUD initiation. Design: Retrospective analysis of 2014–2019 national Medicaid claims data. Participants: Acute care opioid overdose events among non-dual eligible Medicaid enrollees aged 18–64 with continuous enrollment during the 180-day (6-month) baseline period preceding the overdose. Main Measures: The primary outcome was any MOUD (buprenorphine, methadone, naltrexone) receipt in the 180 days after discharge. Baseline MOUD receipt was categorized by the proportion of days covered (PDC): none (reference), very low (> 0 to < 20%), low (20 to < 50%), moderate (50 to < 80%), high (≥ 80%). Key Results: Of 318,536 opioid overdose events, 22.8% and 26.0% had MOUD in the 6 months before and after the event, respectively. Prior MOUD had the strongest association with follow-up MOUD, with a gradient by baseline exposure levels. In Cox models adjusting for patient sociodemographic and clinical covariates, overdose characteristics, and community-level factors, the likelihood of follow-up MOUD was 3.58 times higher for very low (95% CI = 3.50–3.66), 5.47 times higher for low (95% CI = 5.35–5.60), 7.36 times higher for moderate (95% CI = 7.17–7.56), and 16.35 times higher for high (95% CI = 15.92–16.80) baseline MOUD exposure compared to no prior MOUD. Timely follow-up MOUD within 30 days was also higher among those with (76.0%) than without (32.4%) prior MOUD. Conclusions: Substantial gaps in MOUD receipt after opioid overdose indicate an urgent need to expand acute care interventions for treatment initiation, engagement, and referral as well as broader efforts to increase MOUD prescribing and uptake.

Multiple federal policy changes since 2018 have been intended to increase buprenorphine prescribing in response to a persistent treatment gap for opioid use disorder in the US. Anticipated national increases did not occur, but highly variable state-level trends provide important insights. We used IQVIA data to examine all-payer and per payer prescribing across states during the period 2018-24. All-payer prescriptions per 1,000 residents increased by more than 60 percent in ten states while decreasing by more than 10 percent in eight states. States expanding Medicaid during this period increased all-payer prescribing by 27.3 percent; those that had expanded earlier increased prescribing by 11.6 percent, whereas in nonexpansion states, prescribing declined by 2.1 percent. All-payer rates ranged thirty-eight-fold in 2024 (varying from 9.3 to 355.5 per 1,000; lowest quintile, 15.7 per 1,000; highest quintile, 118.6 per 1,000). Medicaid prescribing changes were key drivers of all-payer changes. In 2024, Medicaid prescribing ranged from 0.50 per 1,000 to 217.26 per 1,000, and from 3.6 percent to 66.8 percent of all-payer buprenorphine prescriptions. The self-pay proportion ranged from 0.7 percent to 30.8 percent, and this proportion was strongly associated with the Medicaid proportion. Highly disparate state-level changes suggest that federal policy impacts were mediated by state-specific factors. Medicaid's key role in driving overall prescribing highlights the public health urgency of maintaining expansions and sustaining enrollment for the single adult population.

Background/Objective: Little is known about the rates of rheumatic disease diagnosis among children during the COVID-19 pandemic. We examined the impact of the pandemic on the diagnosis of juvenile idiopathic arthritis (JIA) in the United States. Methods: We performed a historical cohort study using US commercial insurance data (2016–2021) to identify children aged ICD-10-CM diagnosis codes, location, and timing of medical services. Crude rates with 95% confidence intervals (CIs) of JIA diagnosis per 100,000 enrolled children per quarter were estimated and stratified by age group, sex, region, JIA type, and uveitis. The incidence rate ratio (95% CI) for JIA diagnosis was estimated using Poisson regression, adjusted for various demographic variables. Results: From 2018–2021, 643 children were diagnosed with JIA. Crude new JIA diagnoses per 100,000 children per quarter dropped from 2.62 (95% CI, 2.39–2.87) prepandemic to 1.94 (95% CI, 1.66–2.25) during the pandemic. Declines in JIA diagnosis were more apparent in the US Northeast and West regions and among children aged 6–11 years. After adjustment for covariates, JIA diagnoses fell by 30% during the pandemic compared with the prior 3 years (IRR, 0.70; 95% CI, 0.59–0.83). Conclusions: Compared with the prepandemic period, JIA was diagnosed 30% less often during the early pandemic among commercially insured children in the United States. More research is needed to understand the underlying reasons for these changes in JIA diagnosis and more recent trends.

Aims/hypothesis: The aim of this study was to investigate racial and ethnic disparities in the use of sodium–glucose cotransporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor antagonists (GLP-1RAs) among older adults with type 2 diabetes and cardiorenal conditions. Methods: Using Medicare fee-for-service data (2013–2019), this retrospective cohort study identified older adults (≥65 years) with type 2 diabetes initiating second-line therapies (SGLT2is, GLP1-RAs, dipeptidyl peptidase-4 inhibitors [DPP4is] and sulfonylureas [SUs]) with (1) heart failure (HF), (2) atherosclerotic cardiovascular disease (ASCVD), (3) chronic kidney disease (CKD) and (4) no recorded cardiorenal conditions. Participants were classified as non-Hispanic White, non-Hispanic Black and Hispanic. Multinomial regressions, adjusting for sociodemographic, clinical and county-level characteristics, were used to model the odds of initiating SGLT2is or GLP-1RAs within each cohort. Results: Black participants with HF, ASCVD, CKD or no recorded cardiorenal conditions had 35% (adjusted OR 0.65 [95% CI 0.61, 0.68]), 33% (0.67 [0.64, 0.69]), 32% (0.68 [0.64, 0.72]) and 24% (0.76 [0.74, 0.79]) lower odds of initiating SGLT2is, respectively, than White participants. Disparities ameliorated from 50–60% lower odds in 2013 to 17–18% in 2019. Similar patterns were observed for GLP-1RA uptake among Black participants. By contrast, Hispanic participants had similar odds of SGLT2i initiation in the HF and CKD cohorts as White participants, but 6% (0.94 [0.91, 0.98]) lower odds in the ASCVD cohort. Notable disparities for Hispanic participants compared with White participants were observed for GLP-1RA uptake in the HF, ASCVD, CKD and no cardiorenal conditions cohorts: 11% (0.89 [0.84, 0.94]), 16% (0.84 [0.81, 0.87]), 16% (0.84 [0.80, 0.89]) and 25% (0.75 [0.72, 0.78]) lower odds, respectively. Participants had greater odds than White participants of initiating DPP4is, which confer no cardiorenal benefits, across all cohorts (HF 1.25 [1.19, 1.31]; ASCVD 1.36 [1.32, 1.40]; CKD 1.32 [1.26, 1.38). Adjustment for social determinants of health did not meaningfully change the study findings. Conclusions/interpretation: Compared with White participants, disparities in the uptake of SGLT2is were evident for Black participants, and in the uptake of GLP-1RAs for both Black and Hispanic participants. This study highlights how type 2 diabetes management is evolving, while underscoring historical imbalances that have shown signs of abatement. Graphical

Mandatory prescription drug monitoring programs and cannabis legalization have been hypothesized to reduce overdose deaths. We examined associations between prescription monitoring programs with access mandates (must-query PDMPs), legalization of medical and recreational cannabis supply, and opioid overdose deaths in United States counties in 2013-2020. Using data on overdose deaths from the National Vital Statistics System, we fit Bayesian spatiotemporal models to estimate risk differences and 95% credible intervals (CrIs) in county-level opioid overdose deaths associated with enactment of these state policies. Must-query PDMPs were independently associated with on average 0.8 (95% CrI, 0.5-1.0) additional opioid-involved overdose deaths per 100 000 person-years. Legal cannabis supply was not independently associated with opioid overdose deaths in this time period. Must-query PDMPs enacted in the presence of legal (medical or recreational) cannabis supply were associated with 0.7 (95% CrI, 0.4-0.9) more opioid-involved deaths relative to must-query PDMPs without any legal cannabis supply. In a time when overdoses are driven mostly by nonprescribed opioids, stricter opioid prescribing policies and more expansive cannabis legalization were not associated with reduced overdose death rates. This article is part of a Special Collection on Mental Health.

Background: The association between cannabis use and HIV-1 RNA (viral load) among people with HIV (PWH) engaged in care is unclear. Methods: We used data collected from 2002 to 2018 on PWH receiving antiretroviral therapy (ART) enrolled in the Veterans Aging Cohort Study. Generalized estimating equations were used to estimate associations between self-reported past-year cannabis use and detectable viral load (≥500 copies/mL), with and without adjustment for demographics, other substance use, and adherence. Results: Among 2515 participants, 97% were male, 66% were Black, the mean age was 50 years, and 33% had detectable HIV viral load at the first study visit. In unadjusted analyses, PWH with any past-year cannabis use had 21% higher odds of a detectable viral load than those with no past-year use (OR = 1.21; 95% CI, 1.07–1.37). However, there was no significant association between cannabis use and viral load after adjustment. Conclusions: Among PWH engaged in care and receiving ART, cannabis use is associated with decreased adherence in unadjusted analyses but does not appear to directly impact viral control. Future studies are needed to understand other potential risks and benefits of cannabis use among PWH.