Literature Collection

BACKGROUND: Prescription opioid misuse has become a leading cause of unintentional injury and death among adolescents and young adults in the United States. However, there is limited information on how adolescents and young adults obtain prescription opioids. There are also inadequate recent data on the prevalence of additional drug abuse among those misusing prescription opioids. In this study, we evaluated past-year prevalence of prescription opioid use and misuse, sources of prescription opioids, and additional substance use among adolescents and young adults. METHODS AND FINDINGS: This was a retrospective analysis of the National Survey on Drug Use and Health (NSDUH) for the years 2015 and 2016. Prevalence of opioid use, misuse, use disorder, and additional substance use were calculated with 95% confidence intervals (CIs), stratified by age group and other demographic variables. Sources of prescription opioids were determined for respondents reporting opioid misuse. We calculated past-year prevalence of opioid use and misuse with or without use disorder, sources of prescription opioids, and prevalence of additional substance use. We included 27,857 adolescents (12-17 years of age) and 28,213 young adults (18-25 years of age) in our analyses, corresponding to 119.3 million individuals in the extrapolated national population. There were 15,143 respondents (27.5% [95% CI 27.0-28.0], corresponding to 32.8 million individuals) who used prescription opioids in the previous year, including 21.0% (95% CI 20.4-21.6) of adolescents and 32.2% (95% CI 31.4-33.0) of young adults. Significantly more females than males reported using any prescription opioid (30.3% versus 24.8%, P < 0.001), and non-Hispanic whites and blacks were more likely to have had any opioid use compared to Hispanics (28.9%, 28.1%, and 25.8%, respectively; P < 0.001). Opioid misuse was reported by 1,050 adolescents (3.8%; 95% CI 3.5-4.0) and 2,207 young adults (7.8%; 95% CI 7.3-8.2; P < 0.001). Male respondents using opioids were more likely to have opioid misuse without use disorder compared with females (23.2% versus 15.8%, respectively; P < 0.001), with similar prevalence by race/ethnicity. Among those misusing opioids, 55.7% obtained them from friends or relatives, 25.4% from the healthcare system, and 18.9% through other means. Obtaining opioids free from friends or relatives was the most common source for both adolescents (33.5%) and young adults (41.4%). Those with opioid misuse reported high prevalence of prior cocaine (35.5%), hallucinogen (49.4%), heroin (8.7%), and inhalant (30.4%) use. In addition, at least half had used tobacco (55.5%), alcohol (66.9%), or cannabis (49.9%) in the past month. Potential limitations of the study are that we cannot exclude selection bias in the study design or socially desirable reporting among participants, and that longitudinal data are not available for long-term follow-up of individuals. CONCLUSIONS: Results from this study suggest that the prevalence of prescription opioid use among adolescents and young adults in the US is high despite known risks for future opioid and other drug use disorders. Reported prescription opioid misuse is common among adolescents and young adults and often associated with additional substance abuse, underscoring the importance of drug and alcohol screening programs in this population. Prevention and treatment efforts should take into account that greater than half of youths misusing prescription opioids obtain these medications through friends and relatives.

IMPORTANCE: Buprenorphine is an underused treatment for opioid use disorder (OUD) that can be prescribed in general medical settings. Founded in 2017, the Michigan Opioid Collaborative (MOC) is an outreach and educational program that aims to address clinician and community barriers to buprenorphine access; however, the association between the MOC and buprenorphine treatment is unknown. OBJECTIVE: To evaluate the association between MOC service use and county-level temporal trends of density of buprenorphine prescribers and patients receiving buprenorphine. DESIGN, SETTING, AND PARTICIPANTS: This cohort study exploited staggered implementation of MOC services across all Michigan counties. Difference-in-difference analyses were conducted by applying linear fixed-effects regression across all counties to estimate the overall association of MOC engagement with outcomes and linear regression for each MOC-engaged county separately to infer county-specific results using data from May 2015 to August 2020. Analyses were conducted from September 2021 to November 2023. EXPOSURES: MOC engagement. MAIN OUTCOMES AND MEASURES: County-level monthly numbers of buprenorphine prescribers and patients receiving buprenorphine (per 100 000 population). RESULTS: Among 83 total counties, 57 counties (68.7%) in Michigan were engaged by MOC by 2020, with 3 (3.6%) initiating engagement in 2017, 19 (22.9%) in 2018, 27 (32.5%) in 2019, and 8 (9.6%) in 2020. Michigan is made up of 83 counties with a total population size of 9 990 000. A total of 5 070 000 (50.8%) were female, 1 410 000 (14.1%) were African American or Black, 530 000 (5.3%) were Hispanic or Latino, and 7 470 000 (74.7%) were non-Hispanic White. The mean (SD) value of median age across counties was 44.8 (6.4). The monthly increases in buprenorphine prescriber numbers in the preengagement (including all time points for nonengaged counties) and postengagement periods were 0.07 and 0.39 per 100 000 population, respectively, with the absolute difference being 0.33 (95% CI, 0.12-0.53) prescribers per 100 000 population (P = .002). The numbers of patients receiving buprenorphine increased by an average of 0.6 and 7.15 per 100 000 population per month in preengagement and postengagement periods, respectively, indicating an estimated additional 6.56 (95% CI, 2.09-11.02) patients receiving buprenorphine per 100 000 population (P = .004) monthly increase after engagement compared with before. CONCLUSIONS AND RELEVANCE: In this cohort study measuring buprenorphine prescriptions in Michigan over time, counties' engagement in OUD-focused outreach and clinician education services delivered by a multidisciplinary team was associated with a temporal increase in buprenorphine prescribers and patients receiving buprenorphine.

We are in a youth mental health crisis with unprecedented and staggeringly high rates of suicidal ideations and suicide behaviors in preteens. In the United States, 14.5% of children aged 9-10 have experienced suicidal thoughts and behaviors, including 1.3% with a suicide attempt. American Academy of Pediatrics guidelines call for universal suicide risk screening of youth aged 12 years and older during preventative health care visits and screening in preteens aged 8-11 years when clinically indicated. However, what constitutes a clinical indication at 8-11 years can be difficult to systematically detect, and pediatric practitioners may not be equipped with necessary age-specific assessment tools. This is compounded by the lack of emphasis on preteen suicide risk screening (and focus on adolescents), which leaves practitioners without age-appropriate resources to make clinical determinations for at-risk preteens. The objective of this project was to develop an evidence-informed suicide risk screening pathway for pediatric practitioners to implement with preteen patients in outpatient settings. Suicide risk assessment in younger children (<8 years) is also briefly addressed. We convened a group of researchers and practitioners with expertise in preadolescent suicide, pediatric medicine, behavioral health screening integration with primary care, and child development. They reviewed the empirical literature and existing practice guidelines to iterate on a multi-informant clinical suicide risk screening pathway for preteens that includes both caregivers and preteens in the screening process. We also developed tools and accompanying guidelines for a preteen suicide risk screening workflow and risk determination to aid practitioners in deciding who, when, and how to screen. Finally, we provide scripts for introducing suicide risk screening to caregivers and preteens and to discuss screening findings.

Firearm-related injuries remain the leading cause of mortality in children in the United States. It is not well-characterized how often clinicians perform firearms access screening and safety counseling. We examined documentation of these services in a cross-sectional study of well child exams (WCEs) at a tertiary academic center in Southeast Michigan. Overall, we found that clinicians documented screening in 25,469 of 32,582 WCE encounters due to categorical Pediatrics clinicians doing so in 73.8% of encounters; Family Medicine and Internal Medicine-Pediatrics clinicians documented some form of screening in nearly all (> 99%) encounters. Clinicians documented counseling in 21.8% of encounters with Family Medicine clinicians lagging the other two specialties (8.2% versus 23.9% and 18.4% for Pediatrics and Internal Medicine-Pediatrics, respectively). Multinomial logistic regression for screening (conducted only for Pediatrics given the near universal screening by Family Medicine and Internal Medicine-Pediatrics) and counseling (conducted for all specialties) showed decreased likelihood of both screening and counseling for certain age and sociodemographic groups; however, while there was decreased likelihood for non-attending physician clinicians (i.e. advanced practice providers and resident/fellow physicians) and high inter-clinic variability (77.1%) for screening, the opposite was true for counseling with decreased likelihood for attending physicians and inter-clinic variability of 16.7%. Findings suggest that quality improvement efforts and clinician training are needed to eliminate gaps in risk-stratified screening and counseling regarding firearm safety.

IMPORTANCE: The incidence of opioid use during pregnancy is increasing, and drug overdoses are a leading cause of postpartum mortality. Most women who are pregnant do not receive medications for treatment of opioid use disorder, despite the mortality benefit that these agents confer. Furthermore, buprenorphine is associated with milder symptoms of neonatal abstinence syndrome (NAS) compared with methadone. OBJECTIVE: To describe the prevalence and geographic distribution across the US of obstetrician-gynecologists who can prescribe buprenorphine (henceforth described as X-waivered) in 2019. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional, nationwide study linking physician-specific data to county- and state-level data was conducted from September 1, 2019, to March 31, 2020. Data were obtained on 31 211 obstetrician-gynecologists who accept Medicaid insurance through the Centers for Medicare & Medicaid Services Physician Compare data set and linked to the Drug Addiction Treatment Act buprenorphine-waived clinician list. EXPOSURES: State-level NAS incidence and county-level uninsured rates and rurality. MAIN OUTCOMES AND MEASURES: Prevalence and geographic distribution of obstetrician-gynecologists who are trained to prescribe buprenorphine. RESULTS: Among the 31 211 identified obstetrician-gynecologists, 18 710 (59.9%) were women. Most had hospital privileges (23 236 [74.4%]) and worked in metropolitan counties (28 613 [91.7%]). Only 560 of the identified obstetrician-gynecologists (1.8%) were X-waivered. Obstetrician-gynecologists in counties with fewer than 5% uninsured residents had nearly twice the odds of being X-waivered (adjusted odds ratio [aOR], 1.59; 95% CI, 1.04-2.44; P = .04) compared with those in counties with greater than 15% uninsured residents. Compared with those located in metropolitan counties, obstetrician-gynecologists in suburban counties (eg, urban population of ≥20 000 and adjacent to a metropolitan area) were more likely to be X-waivered (aOR, 1.85; 95% CI, 1.26-2.71; P = .002). Compared with states with an NAS rate of 5 per 1000 births or less, obstetrician-gynecologists in states with an NAS rate of 15 per 1000 births or greater had nearly 5 times the odds of being X-waivered (aOR, 4.94; 95% CI, 3.60-6.77; P < .001). Obstetrician-gynecologists without hospital privileges were more likely to be X-waivered (aOR, 1.32; 95% CI, 1.08-1.61; P = .007). CONCLUSIONS AND RELEVANCE: Fewer than 2% of obstetrician-gynecologists who accept Medicaid are able to prescribe buprenorphine, and their geographic distribution appears to be skewed in favor of suburban counties. This finding suggests that there is an opportunity for health systems and professional societies to incentivize X-waiver trainings among obstetrician-gynecologists to increase patients' access to buprenorphine, especially during pregnancy.