IMPORTANCE Opioid use disorder (OUD) frequently begins in adolescence and young adulthood. Intervening early with pharmacotherapy is recommended by major professional organizations. No prior national studies have examined the extent to which adolescents and young adults (collectively termed youth) with OUD receive pharmacotherapy.OBJECTIVE To identify time trends and disparities in receipt of buprenorphine and naltrexone among youth with OUD in the United States. DESIGN, SETTING, AND PARTICIPANTSA retrospective cohort study was conducted using deidentified data from a national commercial insurance database. Enrollment and complete health insurance claims of 9.7 million youth, aged 13 to 25 years were analyzed, identifying individuals who received a diagnosis of OUD between January 1, 2001, and June 30, 2014, with final follow-up date December 31, 2014. Analysis was conducted from April 25 to December 31, 2016. Time trends were identified and multivariable logistic regression was used to determine sociodemographic factors associated with medication receipt.EXPOSURES Sex, age, race/ethnicity, neighborhood education and poverty levels, geographic region, census region, and year of diagnosis. MAIN OUTCOMES AND MEASURESDispensing of a medication (buprenorphine or naltrexone) within 6 months of first receiving an OUD diagnosis.RESULTS Among 20 822 youth diagnosed with OUD (0.2% of the 9.7 million sample), 13 698 (65.8%) were male and 17 119 (82.2%) were non-Hispanic white. Mean (SD) age was 21.0 (2.5) years at the first observed diagnosis. The diagnosis rate of OUD increased nearly 6-fold from 2001 to 2014 (from 0.26 per 100 000 person-years to 1.51 per 100 000 person-years). Overall, 5580 (26.8%) youth were dispensed a medication within 6 months of diagnosis, with 4976 (89.2%) of medication-treated youth receiving buprenorphine and 604 (10.8%) receiving naltrexone. Medication receipt increased more than 10-fold, from 3.0% in 2002 (when buprenorphine was introduced) to 31.8% in 2009, but declined in subsequent years (27.5% in 2014). In multivariable analyses, younger individuals were less likely to receive medications, with adjusted probability for age 13 to 15 years, 1.4% (95% CI, 0.4%-2.3%); 16 to 17 years, 9.7% (95% CI, 8.4%-11.1%); 18 to 20 years, 22.0% (95% CI, 21.0%-23.0%); and 21 to 25 years, 30.5% (95% CI, 30.0%-31.5%) (P < .001 for difference). Females (7124 [20.3%]) were less likely than males (13 698 [24.4%]) to receive medications (P < .001), as were non-Hispanic black (105 [14.8%]) and Hispanic (1165 [20.0%]) youth compared with non-Hispanic white (17 119 [23.1%]) youth (P < .001). CONCLUSIONS AND RELEVANCEIn this first national study of buprenorphine and naltrexone receipt among youth, dispensing increased over time. Nonetheless, only 1 in 4 commercially insured youth with OUD received pharmacotherapy, and disparities based on sex, age, and race/ethnicity were observed.

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...

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.

Purpose Gay, lesbian and bisexual youth may experience significant body dissatisfaction. We examined sexual orientation differences in self-perceived weight status and prevalence of potentially dangerous weight control behaviors in a representative sample of adolescents. Methods Data were obtained from 12,984 youth between 2003–2009 over four cycles of the Massachusetts Youth Risk Behavior Survey, a statewide survey of 9th–12th grade students. Self-perceived weight status and past-month unhealthy weight control behaviors (fasting >24 hours, using diet pills, and vomiting/using laxatives) were compared among gay/lesbian, bisexual, self-identified heterosexual youth with same-sex partners, unsure youth, and exclusively heterosexual youth using logistic regression, adjusting for age and race/ethnicity. Results Compared to exclusively heterosexual males, heterosexual males with prior same-sex partners and bisexual males were more likely to self-perceive as overweight despite being of healthy weight/underweight (respectively, adjusted odds ratio [AOR], 2.61; 95% confidence interval [CI], 1.68–4.05; and AOR, 2.56; 95% CI, 1.64–4.00). Compared to exclusively heterosexual females, lesbians and bisexual females were more likely to self-perceive as being of healthy weight/underweight despite being overweight/obese (respectively, AOR, 3.17; 95% CI, 1.15–8.71; and AOR, 2.00; 95% CI, 1.20–3.33). Unhealthy weight control behaviors were significantly more prevalent among sexual minority males (32.5%; AOR, 4.38; 95% CI, 3.38–5.67) and females (34.7%; AOR, 2.27; 95% CI, 1.85–2.78) when considered together relative to exclusively heterosexual males (9.7%) and females (18.8%). Conclusions One-third of sexual minority youth engage in hazardous weight control behaviors. Future research should investigate underlying mechanisms and determine whether clinicians should routinely screen for these behaviors.

Importance: Retention in care for individuals with opioid use disorder (OUD) is one of the single greatest predictors of reduced mortality. Although clinical trials support use of OUD medications among adolescents and young adults (“youth”), data on timely receipt of buprenorphine, naltrexone, and methadone and its association with retention in care in real-world treatment settings are lacking. Objective: To identify the proportion of youth who receive timely addiction treatment, and to determine whether timely receipt of OUD medications is associated with retention in care. Design: Retrospective cohort. Setting: Enrollment and complete health insurance claims of 2.4 million Medicaid-enrolled youth from 11 states, January 1, 2014 to December 31, 2015. Participants: Youth of age 13–22 years diagnosed with OUD. Exposures: Receipt of OUD medication (buprenorphine, naltrexone, or methadone) within three months of diagnosis, compared to receipt of behavioral health services alone. Main Outcome and Measures: Retention in care, with attrition defined as ≥60 days without any treatment-related claims. Results: Among 4,837 youth diagnosed with OUD, 56.9% were female and 76.0% were non-Hispanic white. Median age was 20 years (interquartile range [IQR], 19–22). Overall, 3,654 (75.5%) youth received any treatment within three months. Most received only behavioral health services (n=2,515; 52.0%), with fewer receiving OUD medications (n=1,139; 23.5%). Only 4.7% (95% confidence interval [CI], 3.1–6.2%) of adolescents <18 years and 24.7% (95% CI, 23.4–26.0%) of young adults ≥18 years received timely OUD medications. Median retention in care among youth who received timely buprenorphine, naltrexone, or methadone was 123 days (IQR, 33–434), 150 days (IQR, 50–670), and 324 days (IQR, 115–670), respectively, compared to 67 days (IQR, 14–206) among youth who received only behavioral health services. Timely receipt of buprenorphine (adjusted hazard ratio [aHR], 0.58; 95% CI, 0.52–0.64), naltrexone (aHR, 0.54; 95% CI, 0.43–0.69), and methadone (aHR, 0.32; 95% CI, 0.22–0.47) were each independently associated with lower attrition from treatment compared to receiving behavioral health services alone. Conclusions and Relevance: Timely receipt of buprenorphine, naltrexone, or methadone is associated with greater retention in care among youth with OUD. Strategies to address the underutilization of evidence-based medications for youth are urgently needed.

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...

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Collaborative on Countering the US Opioid Epidemic [8] has been focusing on comprehensive and collaborative efforts to fundamentally address the opioid epidemic crisis. All of these major initiatives emphasize pain education as a key component in the fight against the dual crises of chronic pain and the opioid epidemic. I am honored to represent the AAPM on the HHS Pain Management Task Force and the NAM Action Collaborative and contribute to these important initiatives of our nation on your behalf.