The net effects of prescribing initiatives that encourage dose reductions are uncertain. We examined whether rapid dose reduction after high-dose chronic opioid therapy (COT) associates with suicide, overdose, or other opioid-related adverse events. This retrospective cohort study included Oregon Medicaid recipients with high-dose COT. Claims were linked with prescription data from the prescription drug monitoring program and death data from vital statistics, 2014 to 2017. Participants were placed into 4 mutually exclusive dose trajectory groups after the high-dose COT period, and Cox proportional hazard models were used to examine the effect of dose changes on patient outcomes in the following year. Of the 14,596 high-dose COT patients, 4191 (28.7%) abruptly discontinued opioid prescriptions, 1648 (11.3%) reduced opioid dose before discontinuing, 6480 (44.4%) had a dose reduction but never discontinued, and 2277 (15.6%) had a stable or increasing dose. Discontinuation, whether abrupt (adjusted hazard ratio [aHR] 3.63; 95% confidence interval [CI] 1.42-9.25) or with dose reduction (aHR 4.47,) significantly increased risk of suicide compared with those with stable or increasing dose. By contrast, discontinuation or dose reduction reduced the risk of overdose compared with those with a stable or increasing dose (aHR 0.36-0.62, 95% CI 0.20-0.94). Patients with an abrupt discontinuation were more likely to overdose on heroin (vs. prescription opioids) than patients in other groups (P , 0.0001). Our study suggests that patients on COT require careful risk assessment and supportive interventions when considering opioid discontinuation or continuation at a high dose.

A c c e p t e d M a n u s c r i p t Background: The United States is currently facing two epidemics: sustained morbidity and mortality from substance use and the more recent COVID-19 pandemic. We tested the hypothesis that the pandemic has disproportionately affected individuals with substance use disorder by evaluating average daily 911 ambulance calls for substance use-related issues compared with all other calls. Methods: This was a retrospective cross-sectional analysis of 911 ambulance calls before and after the start of COVID-19 in Massachusetts. We used consecutive samples of 911 ambulance calls, categorized into those which were substance-related or not. An interrupted time series analysis was performed to determine if there were changes in numbers of daily calls before a statewide declaration of emergency for COVID-19 (February 15-March 9, 2020), from the emergency declaration until a stay-at-home advisory (March 10-March 22, 2020) and following the stay-at-home advisory (March 23-May 15, 2020). Results: Compared with prior to the statewide emergency, the post-statewide emergency average of daily ambulance calls decreased from 2,453.2 to 1,969.6, a 19.7% decrease. Similarly, calls for substance-related reasons decreased by 16.4% compared with prior to the statewide emergency. However, despite an initial decrease in calls, after the stay-at-home advisory calls for substance use began increasing by 0.7 (95% confidence interval (CI) 0.4-1.1) calls/day, while calls for other reasons did not significantly change (+1.2 (95% CI-0.8 to 3.1) calls/day). Refusal of transport for substance-related calls increased from 5.0% before the statewide emergency to 7.5% after the declaration (p<0.001). Conclusions: After an initial decline in substance-related ambulance calls following a statewide declaration of emergency, calls for substance use increased to pre-COVID-19 levels while those A c c e p t e d M a n u s c r i p t for other reasons remained at a lower rate. The results suggest that COVID-19 is disproportionately affecting individuals with substance use disorder.

Being married is associated with earlier diagnosis and a more favorable prognosis for cervical cancer among US women. Interventions to improve prognosis for unmarried women, including increasing use of cervical cancer screenings, are warranted.

This cohort study investigates patient- and prescription-related factors associated with opioid-related fatal or nonfatal overdose among opioid-naive individuals receiving an initial opioid prescription.

Objective This study evaluated the characteristics of opioid prescriptions, including prescriber specialty, given to opioid-naïve patients and their association with chronic use. Design Cross-sectional analysis of the Ohio prescription drug monitoring program from January 2010 to November 2017. Setting Ohio, USA. Subjects Patients who had no opioid prescriptions from 2010 to 2012 and a first-time prescription from January 2013 to November 2016. Methods Chronic use was defined as at least six opioid prescriptions in one year and either one or more years between the first and last prescription or an average of ≤30 days not covered by an opioid during that year. Results A total of 4,252,809 opioid-naïve patients received their first opioid prescription between 2013 and 2016; 364,947 (8.6%) met the definition for chronic use. Those who developed chronic use were older (51.7 vs 45.6 years) and more likely to be female (53.6% vs 52.8%), and their first prescription had higher pill quantities (44.9 vs 30.2), higher morphine milligram equivalents (MME; 355.3 vs 200.0), and was more likely to be an extended-release formulation (2.9% vs 0.7%, all P &lt; 0.001). When compared with internal medicine, the adjusted odds of chronic use were highest with anesthesiology (odds ratio [OR] = 1.46) and neurology (OR = 1.43) and lowest with ophthalmology (OR = 0.33) and gynecology (OR = 0.37). Conclusions Eight point six percent of opioid-naïve individuals who received an opioid prescription developed chronic use. This rate varied depending on the specialty of the provider who wrote the prescription. The risk of chronic use increased with higher MME content of the initial prescription and use of extended-release opioids.