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A statewide evaluation of seven strategies to reduce opioid overdose in North Carolina.

ABSTRACT: BACKGROUND:In response to increasing opioid overdoses, US prevention efforts have focused on prescriber education and supply, demand and harm reduction strategies. Limited evidence informs which interventions are effective. We evaluated Project Lazarus, a centralised statewide intervention designed to prevent opioid overdose. METHODS:Observational intervention study of seven strategies. 74 of 100 North Carolina counties implemented the intervention. Dichotomous variables were constructed for each strategy by county-month. Exposure data were: process logs, surveys, addiction treatment interviews, prescription drug monitoring data. Outcomes were: unintentional and undetermined opioid overdose deaths, overdose-related emergency department (ED) visits. Interrupted time-series Poisson regression was used to estimate rates during preintervention (2009-2012) and intervention periods (2013-2014). Adjusted IRR controlled for prescriptions, county health status and time trends. Time-lagged regression models considered delayed impact (0-6 months). RESULTS:In adjusted immediate-impact models, provider education was associated with lower overdose mortality (IRR 0.91; 95%?CI 0.81 to 1.02) but little change in overdose-related ED visits. Policies to limit ED opioid dispensing were associated with lower mortality (IRR 0.97; 95%?CI 0.87 to 1.07), but higher ED visits (IRR 1.06; 95%?CI 1.01 to 1.12). Expansions of medication-assisted treatment (MAT) were associated with increased mortality (IRR 1.22; 95%?CI 1.08 to 1.37) but lower ED visits in time-lagged models. CONCLUSIONS:Provider education related to pain management and addiction treatment, and ED policies limiting opioid dispensing showed modest immediate reductions in mortality. MAT expansions showed beneficial effects in reducing ED-related overdose visits in time-lagged models, despite an unexpected adverse association with mortality.

SUBMITTER: Alexandridis AA

PROVIDER: S-EPMC5795575 | biostudies-literature | 2018 Feb

REPOSITORIES: biostudies-literature

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A statewide evaluation of seven strategies to reduce opioid overdose in North Carolina.

Alexandridis Apostolos A AA McCort Agnieszka A Ringwalt Christopher L CL Sachdeva Nidhi N Sanford Catherine C Marshall Stephen W SW Mack Karin K Dasgupta Nabarun N

Injury prevention : journal of the International Society for Child and Adolescent Injury Prevention 20170823 1

<h4>Background</h4>In response to increasing opioid overdoses, US prevention efforts have focused on prescriber education and supply, demand and harm reduction strategies. Limited evidence informs which interventions are effective. We evaluated Project Lazarus, a centralised statewide intervention designed to prevent opioid overdose.<h4>Methods</h4>Observational intervention study of seven strategies. 74 of 100 North Carolina counties implemented the intervention. Dichotomous variables were cons ...[more]

PMID: 28835443

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Project description:ImportanceResponding to the opioid crisis requires tools to identify individuals at risk of overdose. Given the expansion of illicit opioid deaths, it is essential to consider risk factors across multiple service systems.ObjectiveTo develop a predictive risk model to identify opioid overdose using linked clinical and criminal justice data.Design, setting, and participantsA cross-sectional sample was created using 2015 data from 4 Maryland databases: all-payer hospital discharges, the prescription drug monitoring program (PDMP), public-sector specialty behavioral treatment, and criminal justice records for property or drug-associated offenses. Maryland adults aged 18 to 80 years with records in any of 4 databases were included, excluding individuals who died in 2015 or had a non-Maryland zip code. Logistic regression models were estimated separately for risk of fatal and nonfatal opioid overdose in 2016. Model performance was assessed using bootstrapping. Data analysis took place from February 2018 to November 2019.ExposuresControlled substance prescription fills and hospital, specialty behavioral health, or criminal justice encounters.Main outcomes and measuresFatal opioid overdose defined by the state medical examiner and 1 or more nonfatal overdoses treated in Maryland hospitals during 2016.ResultsThere were 2 294 707 total individuals in the sample, of whom 42.3% were male (n = 970 019) and 53.0% were younger than 50 years (647 083 [28.2%] aged 18-34 years and 568 160 [24.8%] aged 35-49 years). In 2016, 1204 individuals (0.05%) in the sample experienced fatal opioid overdose and 8430 (0.37%) experienced nonfatal opioid overdose. In adjusted analysis, the factors mostly strongly associated with fatal overdose were male sex (odds ratio [OR], 2.40 [95% CI, 2.08-2.76]), diagnosis of opioid use disorder in a hospital (OR, 2.93 [95% CI, 2.17-3.80]), release from prison in 2015 (OR, 4.23 [95% CI, 2.10-7.11]), and receiving opioid addiction treatment with medication (OR, 2.81 [95% CI, 2.20-3.86]). Similar associations were found for nonfatal overdose. The area under the curve for fatal overdose was 0.82 for a model with hospital variables, 0.86 for a model with both PDMP and hospital variables, and 0.89 for a model that further added behavioral health and criminal justice variables. For nonfatal overdose, the area under the curve using all variables was 0.85.Conclusions and relevanceIn this analysis, fatal and nonfatal opioid overdose could be accurately predicted with linked administrative databases. Hospital encounter data had higher predictive utility than PDMP data. Model performance was meaningfully improved by adding PDMP records. Predictive models using linked databases can be used to target large-scale public health programs.

Project description:BackgroundPolysubstance involvement is increasing among fatal drug overdoses. However, little is known about the epidemiology of polysubstance drug overdoses. This paper describes emerging trends in unintentional polysubstance overdose deaths in North Carolina (NC) and examines associations with individual and community factors.MethodsUsing 2009-2018 NC death certificate data, we identified unintentional drug overdose deaths and commonly involved substances (opioids, stimulants, benzodiazepines, alcohol, and antiepileptics). We examined polysubstance combinations, comparing opioid and non-opioid involved deaths. We examined individual level correlates from death certificate data and community level correlates from the American Community Survey and Robert Wood Johnson Foundation County Health Rankings to quantify associations.ResultsFrom 2009-2018, 53 % of opioid and 19 % of non-opioid overdose deaths involved multiple substances. During this period, polysubstance overdose death increased dramatically, from 2.9 to 12.1 per 100,000 persons, with the greatest increases among drug combinations involving stimulants. The most common polysubstance combinations were: opioids and stimulants (12.1 % of overdose deaths); opioids and benzodiazepines (9.0 %); opioids and alcohol (5.1 %); opioids, stimulants, and benzodiazepines (3.1 %); and opioids, benzodiazepines, and antiepileptics (2.2 %). Compared to overdoses involving opioids alone, overdoses involving combinations of opioids, stimulants, and benzodiazepines involved younger individuals (53.7 % in 15-34 years of age vs. 40.7 %). Men comprised two-thirds of overdoses involving opioids alone, however, overdoses involving opioids, benzodiazepines, and antiepileptics were predominantly among women (60.6 %).ConclusionsPolysubstance involvement has increased among overdose deaths in NC. These findings can be used to inform public health interventions addressing polysubstance deaths and associated individual and community level factors.

Project description:BACKGROUND:As several regulatory and environmental changes have occurred in North America, trends in overdose deaths were examined in the United States (US), Ontario and British Columbia (BC), including changes in consumption levels of prescription opioids (PO) and overdose deaths, changes in correlations between consumption levels of PO and overdose deaths and modeled differences between observed and predicted overdose deaths if no changes had occurred. METHODS:Consumption levels of PO included defined daily doses for statistical purposes per million inhabitants per day for the US and Canada (2001-2015). Overdose deaths included opioid overdose deaths for the US (2001-2017) and Ontario (2003-2017) and illicit drug overdose deaths for BC (2001-2017). The analytic techniques included structural break point analyses, Pearson product-moment correlations and multivariate Gaussian state space modeling. RESULTS:Consumption levels of PO changed in the US in 2010 and in Canada in 2012. Overdose deaths changed in the US in 2014 and in Ontario and BC in 2015. Prior to the observed changes in consumption levels of PO, there were positive correlations between consumption levels of PO and overdose deaths in the US (r?=?0.99, p?<?0.001) and Ontario (r?=?0.92, p?=?0.003). After the observed changes in consumption levels of PO, there was a negative correlation between consumption levels of PO and overdose deaths in the US (r?=?-?0.99, p?=?0.002). Observed overdose deaths exceeded predicted overdose deaths by 5.7 (95% Confidence Interval [CI]: 4.8-6.6), 3.5 (95% CI: 3.2-3.8) and 21.8 (95% CI: 18.6-24.9) deaths per 100,000 people in the US, Ontario and BC, respectively in 2017. These excess deaths corresponded to 37.7% (95% CI: 31.9-43.6), 39.2% (95% CI: 36.3-42.1) and 72.2% (95% CI: 61.8-82.6) of observed overdose deaths in the US, Ontario and BC, respectively in 2017. CONCLUSIONS:The opioid crisis has evolved in North America, as a sizeable proportion of overdose deaths are now attributable to the several regulatory and environmental changes. These findings necessitate substance use policies to be conceptualized more broadly as well as the continued expansion of harm reduction services and types of pharmacotherapy interventions.

Project description:Importance:X-linked adrenoleukodystrophy (X-ALD) is a peroxisomal genetic disorder in which an accumulation of very long-chain fatty acids leads to inflammatory demyelination in the central nervous system and to adrenal cortex atrophy. In 2016, X-ALD was added to the US Recommended Uniform Screening Panel. Objective:To evaluate the performance of a single-tier newborn screening assay for X-ALD in North Carolina. Design, Setting, and Participants:This diagnostic screening study was of all newborn dried blood spot specimens received in the North Carolina State Laboratory of Public Health between January 2 and June 1, 2018, excluding specimens of insufficient quantity or quality. A total of 52?301 specimens were screened for X-ALD using negative ionization high-performance liquid chromatography tandem mass spectrometry to measure C24:0- and C26:0-lysophosphatidylcholine concentrations. Sanger sequencing of the adenosine triphosphate-binding cassette subfamily D member 1 (ABCD1) gene was performed on screen-positive specimens. Exposures:A medical and family history, newborn physical examination, sequencing of ABCD1 on dried blood spot samples, and plasma analysis of very long-chain fatty acids were obtained for all infants with screen-positive results. Main Outcomes and Measures:The prevalence of X-ALD in North Carolina and the positive predictive value and false-positive rate for the first-tier assay were determined. Results:Of 52?301 infants tested (47.8% female, 50.6% male, and 1.7% other or unknown sex), 12 received screen-positive results. Of these 12 infants, 8 were confirmed with a genetic disorder: 3 male infants with X-ALD, 3 X-ALD-heterozygous female infants, 1 female infant with a peroxisome biogenesis disorder, and 1 female infant with Aicardi-Goutières syndrome. Four infants were initially classified as having false-positives results, including 3 female infants who were deemed unaffected and 1 male infant with indeterminate results on confirmatory testing. The positive predictive value for X-ALD or other genetic disorders for the first-tier assay was 67%, with a false-positive rate of 0.0057%. Conclusions and Relevance:This newborn screening pilot study reported results on 2 lysophosphatidylcholine analytes, identifying 3 male infants with X-ALD, 3 X-ALD-heterozygous female infants, and 3 infants with other disorders associated with increased very long-chain fatty acids. These results showed successful implementation in a public health program with minimal risk to the population. The findings will support other state laboratories planning to implement newborn screening for X-ALD and related disorders.

Project description:BackgroundRecent increases in state laws to reduce opioid prescribing have demonstrated a need to understand how they are interpreted and implemented in healthcare systems. The purpose of this study was to explore the systems, strategies, and resources that hospital administrators and prescribers used to implement the 2017 North Carolina Strengthen Opioid Prevention (STOP) Act opioid prescribing limits, which limited initial prescriptions to a five (for acute) or seven (for post-surgical) days' supply.MethodsWe interviewed 14 hospital administrators and 38 prescribers with degrees in medicine, nursing, pharmacy, business administration and public health working across North Carolina. Interview guides, informed by the Consolidated Framework for Implementation Research, explored barriers and facilitators to implementation. Interview topics included communication, resources, and hospital system support. Interviews were recorded and transcribed, then analyzed using flexible coding, integrating inductive and deductive coding, to inform analytic code development and identify themes.ResultsWe identified three main themes around implementation of STOP act mandated prescribing limits: organizational communication, prescriber education, and changes in the electronic medical record (EMR) systems. Administrators reflected on implementation in the context of raising awareness and providing reminders to facilitate changes in prescriber behavior, operationalized through email and in-person communications as well as dedicated resources to EMR changes. Prescribers noted administrative communications about prescribing limits often focused on legality, suggesting a directive of the organization's policy rather than a passive reminder. Prescribers expressed a desire for more spaces to have their questions answered and resources for patient communications. While hospital administrators viewed compliance with the law as a priority, prescribers reflected on concerns for adequately managing their patients' pain and limited time for clinical care.ConclusionsHospital administrators and prescribers approached implementation of the STOP act prescribing limits with different mindsets. While administrators were focused on policy compliance, prescribers were focused on their patients' needs. Strategies to implement the mandate then had to balance patient needs with policy compliance. As states continue to legislate to prevent opioid overdose deaths, understanding how laws are implemented by healthcare systems and prescribers will improve their effectiveness through tailoring and maximizing available resources.

Dataset Information

A statewide evaluation of seven strategies to reduce opioid overdose in North Carolina.

Publications

A statewide evaluation of seven strategies to reduce opioid overdose in North Carolina.

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