Contents Location Opioid dependence Opioid overdose deaths Cases of opioid dependence (1000s) (95%UI) Age-standardised rate per 100,000 (95%UI) Number of opioid deaths (1000s) (95%UI) Age-standardised overdose rate per 100,000 (95%UI)

Drs Green and Marshall had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Green, Clarke, Boss, Rich.

IMPORTANCE Treatment with methadone or buprenorphine is the current standard of care for opioid use disorder. Given the paucity of research identifying which patients will respond best to which medication, both medications should be accessible to all patients so that patients can determine which works best for them. However, given differences in the historical contexts of their initial implementation, access to each of these medications may vary along racial/ethnic lines. OBJECTIVE To examine the extent to which capacity to provide methadone and buprenorphine vary with measures of racial/ethnic segregation. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included all counties and county-equivalent divisions in the US in 2016. Data on racial/ethnic population distribution were derived from the American Community Survey, and data on locations of facilities providing methadone and buprenorphine were obtained from Substance Abuse and Mental Health Services Administration databases. Data were analyzed from August 22, 2018, to September 11, 2019. EXPOSURES Two county-level measures of racial/ethnic segregation, including dissimilarity (representing the proportion of African American or Hispanic/Latino residents who would need to move census tracts to achieve a uniform spatial distribution of the population by race/ethnicity) and interaction (representing the probability that an African American or Hispanic/Latino resident will interact with a white resident and vice versa, assuming random mixing across census tracts). MAIN OUTCOMES AND MEASURES County-level capacity to provide methadone or buprenorphine, defined as the number of facilities providing a medication per 100 000 population. RESULTS Among 3142 US counties, there were 1698 facilities providing methadone (0.6 facilities per 100 000 population) and 18 868 facilities providing buprenorphine (5.9 facilities per 100 000 population). Each 1% decrease in probability of interaction of an African American resident with a white resident was associated with 0.6 more facilities providing methadone per 100 000 population. Similarly, each 1% decrease in probability of interaction of a Hispanic/Latino resident with a white resident was associated with 0.3 more facilities providing methadone per 100 000 population. Each 1% decrease in the probability of interaction of a white resident with an African American resident was associated with 8.17 more facilities providing buprenorphine per 100 000 population. Similarly, each 1% decrease in the probability of interaction of a white resident with a Hispanic/Latino resident was associated with 1.61 more facilities providing buprenorphine per 100 000 population. CONCLUSIONS AND RELEVANCE These findings suggest that the racial/ethnic composition of a community was associated with which medications residents would likely be able to access when (continued) Key Points Question Does county-level capacity to provide methadone and buprenorphine vary with measures of racial/ethnic segregation? Findings In this cross-sectional s...

Calls for the adoption of complex systems approaches, including agent-based modeling, in the field of epidemiology have largely centered on the potential for such methods to examine complex disease etiologies, which are characterized by feedback behavior, interference, threshold dynamics, and multiple interacting causal effects. However, considerable theoretical and practical issues impede the capacity of agent-based methods to examine and evaluate causal effects and thus illuminate new areas for intervention. We build on this work by describing how agent-based models can be used to simulate counterfactual outcomes in the presence of complexity. We show that these models are of particular utility when the hypothesized causal mechanisms exhibit a high degree of interdependence between multiple causal effects and when interference (i.e., one person's exposure affects the outcome of others) is present and of intrinsic scientific interest. Although not without challenges, agent-based modeling (and complex systems methods broadly) represent a promising novel approach to identify and evaluate complex causal effects, and they are thus well suited to complement other modern epidemiologic methods of etiologic inquiry.

Importance Prescription opioids are involved in 40% of all deaths from opioid overdose in the United States and are commonly the first opioids encountered by individuals with opioid use disorder. It is unclear whether the pharmaceutical industry marketing of opioids to physicians is associated with mortality from overdoses. Objective To identify the association between direct-to-physician marketing of opioid products by pharmaceutical companies and mortality from prescription opioid overdoses across US counties. Design, Setting, and Participants This population-based, county-level analysis of industry marketing information used data from the Centers for Medicare & Medicaid Services Open Payments database linked with data from the Centers for Disease Control and Prevention on opioid prescribing and mortality from overdoses. All US counties were included, with data on overdoses from August 1, 2014, to December 31, 2016, linked to marketing data from August 1, 2013, to December 31, 2015, using a 1-year lag. Statistical analyses were conducted between February 1 and June 1, 2018. Main Outcomes and Measures County-level mortality from prescription opioid overdoses, total cost of marketing of opioid products to physicians, number of marketing interactions, opioid prescribing rates, and sociodemographic factors. Results Between August 1, 2013, and December 31, 2015, there were 434 754 payments totaling $39.7 million in nonresearch-based opioid marketing distributed to 67 507 physicians across 2208 US counties. After adjustment for county-level sociodemographic factors, mortality from opioid overdoses increased with each 1-SD increase in marketing value in dollars per capita (adjusted relative risk, 1.09; 95% CI, 1.05-1.12), number of payments to physicians per capita (adjusted relative risk, 1.18; 95% CI, 1.14-1.21, and number of physicians receiving marketing per capita (adjusted relative risk, 1.12; 95% CI, 1.08-1.16). Opioid prescribing rates also increased with marketing and partially mediated the association between marketing and mortality. Conclusions and Relevance In this study, across US counties, marketing of opioid products to physicians was associated with increased opioid prescribing and, subsequently, with elevated mortality from overdoses. Amid a national opioid overdose crisis, reexamining the influence of the pharmaceutical industry may be warranted.

have little excess cardiovascular risk and do not typically require medication. ABPM can also be used to monitor the effectiveness of drug treatment and to detect the occasional patient with normal office blood pressures but elevated blood pressures out of the office ("masked hypertension"). Despite the availability of ambulatory monitors, policies that support reimbursement and current recommendations to use it routinely the use of ABPM in the United States remain quite low.Self-monitoring of blood pressure, however, has become quite common, and many clinicians and patients see it as a more practical approach to out-of-office monitoring than ABPM. Unfortunately, the practice of home blood pressure monitoring (HBPM) is even less standardized and less supported by evidence than ABPM. Correct HBPM requires patient training, correct equipment, and correct interpretation of results. The techniques that define best practice office measurement are also relevant at home but are rarely followed. HBPMs are also typically lower than office measurements but the relationship is not uniformly predictable. The exact timing of measurement is also important. Current guidelines suggest measurement in the morning before medications and before supper, but this is not uniform practice. The ability of HBPM to predict cardiovascular risk is less than ABPM, and the correlation of HBPM with ABPM to diagnose white coat hypertension is only 60% to 70%. Moreover, clinical trials of home monitoring alone to improve blood pressure control have shown little effect on BP at 6-month and 1-year follow-ups.What, then, is a reasonable approach to blood pressure measurement in 2018? Primary care practices should develop a clear strategy for best practice office measurement. Revisions of staff training, work flow, and physical settings may be needed. Blood pressure measurement should comply with the best practice check list. Practices may want to also consider implementing systems more similar to those used in clinical trials, in which unobserved automatic measurement is used. If an initial blood pressure measurement is high, a repeated measurement is indicated. Although this can be done by medical assistants, patients appreciate the primary care clinicians who retake the blood pressure measurement themselves. This may be the most important part of that day's physical examination. Practices also need to decide which measurement should be recorded in the medical record. Although most clinical trials and practice guidelines suggest averaging blood pressure measurements, quality improvement guidelines commonly use the final blood pressure recording.Home blood pressure monitoring can be a useful adjunct to care for some patients, but it, too, must be used carefully. It may identify white coat hypertension and may help adherence and control for individual patients. Multiple measurements over the course of an occasional single day (akin to ABPM) may be preferable to daily measurements at the same time of each day. This is especially true given the diurnal...

BackgroundIn 2016, drug overdose deaths exceeded 64,000 in the United States, driven by a sixfold increase in deaths attributable to illicitly manufactured fentanyl. Rapid fentanyl test strips (FTS), used to detect fentanyl in illicit drugs, may help inform people who use drugs about their risk of fentanyl exposure prior to consumption. This qualitative study assessed perceptions of FTS among young adults.MethodsFrom May to September 2017, we recruited a convenience sample of 93 young adults in Rhode Island (age 18–35 years) with self-reported drug use in the past 30 days to participate in a pilot study aimed at better understanding perspectives of using take-home FTS for personal use. Participants completed a baseline quantitative survey, then completed a training to learn how to use the FTS. Participants then received ten FTS for personal use and were asked to return 2–4 weeks later to complete a brief quantitative and structured qualitative interview. Interviews were transcribed, coded, and double coded in NVivo (Version 11).ResultsOf the 81 (87%) participants who returned for follow-up, the majority (n = 62, 77%) used at least one FTS, and of those, a majority found them to be useful and straightforward to use. Positive FTS results led some participants to alter their drug use behaviors, including discarding their drug supply, using with someone else, and keeping naloxone nearby. Participants also reported giving FTS to friends who they felt were at high risk for fentanyl exposure.ConclusionThese findings provide important perspectives on the use of FTS among young adults who use drugs. Given the high level of acceptability and behavioral changes reported by study participants, FTS may be a useful harm reduction intervention to reduce fentanyl overdose risk among this population.Trial registrationThe study protocol is registered with the US National Library of Medicine, Identifier NCT03373825, 12/24/2017, registered retrospectively. https://clinicaltrials.gov/ct2/show/NCT03373825?id=NCT03373825&rank=1

Background: The effect of lateral meniscal posterior root tear and repair-commonly seen in clinical practice in the setting of anterior cruciate ligament (ACL) reconstruction-is not known. Purpose/Hypothesis: This study evaluated the effect of tear and repair of the lateral meniscal posterior root on the biomechanics of the ACL-reconstructed knee. It was hypothesized that anterior tibial translation would increase under anterior loading and simulated pivot-shift loading with the root tear of the posterior lateral meniscus, while repair of the root tear would reduce it close to the noninjured state. Study Design: Controlled laboratory study. Methods: Thirteen fresh-frozen adult human knees were tested with a robotic testing system under 2 loading conditions: (1) an 89.0-N anterior tibial load applied at full extension and 15°, 30°, 60°, and 90°of knee flexion and (2) a combined 7.0-NÁm valgus and 5.0-NÁm internal tibial torque (simulated pivot-shift test) applied at full extension and 15°and 30°of knee flexion. The following knee states were tested: intact knee, ACL reconstruction and intact lateral meniscus, ACL reconstruction and lateral meniscal posterior root tear, and ACL reconstruction and lateral meniscal posterior root repair. Results: In the ACL-reconstructed knee, a tear of the lateral meniscal posterior root significantly increased knee laxity under anterior loading by as much as 1 mm. The transosseous pullout suture root repair improved knee stability under anterior tibial and simulated pivot-shift loading. Root repair improved the ACL graft force closer to that of the native ACL under anterior tibial loading. Conclusion: Lateral meniscal posterior root injury further destabilizes the ACL-reconstructed knee, and root repair improves knee stability. Clinical Relevance: This study suggests a rationale for surgical repair of the lateral meniscus, which can restore stability close to that of the premeniscal injury state.