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Key Points Question What are the characteristics of US counties with high rates of opioid overdose mortality and low capacity to deliver medications for opioid use disorder? Findings In this cross-sectional study of data from 3142 US counties, counties in the South Atlantic, Mountain, and East North Central divisions had more than twice the odds of being at high risk for opioid overdose mortality and lacking in capacity to deliver medications for opioid use disorder. Higher density of primary care clinicians, a younger population, micropolitan status, and lower rates of unemployment were associated with lower risk of opioid overdose and lower risk of lacking in capacity to deliver medications for opioid use disorder. Meaning Strategies to address mortality from opioid overdose by increasing treatment for addiction should target urban counties in Appalachia, the Midwest, and the Mountain division and include efforts to increase primary care clinicians and employment opportunities.

Objective: Determine the prevalence of benzodiazepine use, including both use as-prescribed and misuse; characterize misuse; determine whether and how misuse varies by age. Methods: Cross-sectional analysis of the 2015 and 2016 National Survey on Drug Use and Health (NSDUH), a nationally-representative sample of U.S. adults (n=86,186). Measurements included past-year prescription benzodiazepine use and misuse (i.e., use "any way a doctor did not direct"), along with substance use and use disorders, mental illness, and demographic characteristics. Misuse was compared between younger (18-49) and older (≥50) adults. Results: 30.6 million adults (12.6%) reported past-year benzodiazepine use annually: 25.3 million (10.4%) as-prescribed and 5.3 million (2.2%) with misuse. Misuse accounted for 17.2% of benzodiazepine use overall. Adults 50-64 had the highest prescribed use (12.9%). Those 18-25 had the highest misuse (5.2%), while adults ≥65 had the lowest (0.6%). Misuse and abuse or dependence of prescription stimulants or opioids were strongly associated with benzodiazepine misuse. Misuse without a prescription was the most common type of misuse, while a friend or relative was the most common source. Adults ≥50 were more likely to use a benzodiazepine more often than prescribed and to help with sleep. Conclusions: Benzodiazepine use in the U.S. is higher than previously reported and misuse accounted for nearly 20% of use overall. Use among adults 50-64 has now exceeded use by those ≥65. Clinicians should monitor patients also prescribed stimulants or opioids for benzodiazepine misuse. Improved access to behavioral interventions for sleep or anxiety may reduce some misuse.

Background:The extent to which adults with mental health disorders in the United States receive opioids has not been adequately reported.Methods: We performed a cross-sectional study of a nationally representative sample of the noninstitutionalized U.S. adult population from the Medical Expenditure Panel Survey. We examined the relationship between mental health (mood and anxiety) disorders and prescription opioid use (defined as receiving at least 2 prescriptions in a calendar year).Results: We estimate that among the 38.6 million Americans with mental health disorders, 18.7% (

Objectives Cannabis has been legalized for medical use in almost half of the states in the U.S. Although laws in these states make the distinction between medical and recreational use of cannabis, the prevalence of people using medical cannabis and how distinct this group is from individuals using cannabis recreationally is unknown at a national level. Methods Data came from the 2013 National Survey on Drug Use and Health (NSDUH). All adults endorsing past year cannabis use who reported living in a state that had legalized medical cannabis were divided into recreational cannabis use only and medical cannabis use. Demographic and clinical characteristics were compared across these two groups. Results 17% of adults who used cannabis in the past year used cannabis medically. There were no significant differences between those who used medically versus recreationally in race, education, past year depression and prevalence of cannabis use disorders. In adjusted analyses, those with medical cannabis use were more likely to have poorer health and lower levels of alcohol use disorders and non-cannabis drug use. A third of those who reported medical cannabis use endorsed daily cannabis use compared to 11% in those who reported recreational use exclusively. Conclusions Adults who use medical and recreational cannabis shared some characteristics, but those who used medical cannabis had higher prevalence of poor health and daily cannabis use. As more states legalize cannabis for medical use, it is important to better understand similarities and differences between people who use cannabis medically and recreationally.

The Veterans Health Administration (VHA) designed the Opioid Safety Initiative (OSI) to help decrease opioid prescribing practices associated with adverse outcomes. Key components included disseminating a dashboard tool that aggregates electronic medical record data to audit real-time opioid-related prescribing and identifying a clinical leader at each facility to implement the tool and promote safer prescribing. This study examines changes associated with OSI implementation in October 2013 among all adult VHA patients who filled outpatient opioid prescriptions. Interrupted time series analyses controlled for baseline trends and examined data from October 2012 to September 2014 to determine the changes after OSI implementation in prescribing of high-dosage opioid regimens (total daily dosages >100 morphine equivalents [MEQ] and >200 MEQ) and concurrent benzodiazepines. Across VHA facilities nationwide, there was a decreasing trend in high-dosage opioid prescribing with 55,722 patients receiving daily opioid dosages >100 MEQ in October 2012, which decreased to 46,780 in September 2014 (16% reduction). The OSI was associated with an additional decrease, compared to pre-OSI trends, of 331 patients per month (95% confidence interval [CI] -378 to -284) receiving opioids >100 MEQ, a decrease of 164 patients per month (95% CI -186 to -142) receiving opioids >200 MEQ, and a decrease of 781 patients per month (95% CI -969 to -593) receiving concurrent benzodiazepines. Implementation of a national health care system-wide initiative was associated with reductions in outpatient prescribing of risky opioid regimens. These findings provide evidence for the potential utility of large-scale interventions to promote safer opioid prescribing.

US health care systems are rapidly responding to coronavirus disease 2019 (COVID-19) by mobilizing resources to treat infected patients and prevent further transmission. Concurrently, patients with behavioral health conditions continue to need health care or they risk becoming silent casualties of the pandemic. National data indicate that 7.8% of adults met past-year criteria for a substance use disorder (SUD). 1 These patients, including those with co-occurring mental health disorders, are vulnerable to serious consequences, including overdose and suicide, if treatments and psychosocial services are disrupted by COVID-19. With COVID-19, it is imperative to minimize transmission while continuing SUD and mental health care in the context of rapidly evolving health care response and policies. This presents an urgent, unprecedented need for telemedicine and mobile health in SUD care and the need to understand how to implement these services now and continue them long term. Telehealth increases availability and reach of treatments, but it has been underused and understudied in patients with SUDs. 2 Telehealth encompasses a range of telecommunication platforms to support or provide health care at a distance. Here, telehealth encompasses (1) telemedicine or synchronous videoconferencing between clinicians and patients in separate locations; and (2) mobile health, involving telephone, text, or web-based interventions. In the age of COVID-19, telehealth uniquely supports health care delivery while preserving social distancing, reducing disease transmission. Prior to COVID-19, regulatory hurdles limited widescale adoption of telehealth for SUDs. Since COVID-19, 5 major changes have rapidly reduced barriers across the United States: 1. The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 imposed rules around telemedicine prescribing of controlled medications. With the federal declaration of a public health emergency, the US Drug Enforcement Administration (DEA) announced that DEA-registered clinicians may prescribe schedule II through V medications for patients they have not seen in person if they are using telemedicine prescribing for legitimate medical reasons under usual practice in concert with relevant state and federal laws. 3 This allows telemedicine and, more recently, telephone visits 3 to start buprenorphine treatment for opioid use disorder, without patients first coming to clinic in person. 2. The US Department of Health and Human Services announced it will waive Health Insurance Portability and Accountability Act penalties for "good faith use of telehealth." 4

Overdoses involving opioid analgesics represent a significant public health problem in the United States. We reviewed the literature on risk factors for overdose, with a focus on studies that examine clinical populations of patients receiving opioids for pain and potential risk factors for overdose in these populations. A structured review resulted in 15 articles published between 2007 and 2015 that examined risk factors for fatal and nonfatal overdose in patients receiving opioid analgesics. Opioid dosage was the factor most consistently analyzed and also associated with increased risk of overdose. Other risk factors include concurrent use of sedative-hypnotics, use of extended-release/long-acting opioids, and the presence of substance use and other mental health disorder comorbidities. Future research is needed to better characterize populations taking opioids for pain to help clarify discrepancies between existing studies and identify previously unexplored risk factors for overdose. Given that policy and clinical practice have shifted as a result of prior studies reviewed here, further efforts in understanding patient groups and opioid-related prescribing practices associated with overdose risk have great potential to impact policy and practice in the treatment of pain while improving the safety around opioid prescribing.