Search

Adverse childhood experiences (ACEs), suicide and overdose are linked across the life course and across generations and share common individual-, interpersonal-, community- and societal-level risk factors. The purpose of this review is to summarise the shared aetiology of these public health issues, synthesise evidence regarding potential community- and societal-level prevention strategies and discuss future research and practice directions.Growing evidence shows the potential for community- and societal-level programmes and policies, including higher minimum wage; expanded Medicaid eligibility; increased earned income tax credits, child tax credits and temporary assistance for needy families benefits; Paid Family Leave; greater availability of affordable housing and rental assistance; and increased participation in the Supplemental Nutrition Assistance Program (SNAP), to contribute to ACEs, suicide and overdose prevention. Considerations for future prevention efforts include (1) expanding the evidence base through rigorous research and evaluation; (2) assessing the implications of prevention strategies for equity; (3) incorporating a relational health perspective; (4) enhancing community capacity to implement, scale and sustain evidenced-informed prevention strategies; and (5) acknowledging that community- and societal-level prevention strategies are longer-term strategies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Rates of death due to homicide, suicide and overdose during pregnancy and the first year postpartum have increased substantially in the USA in recent years. The aims of this study were to use 2018-2019 data on deaths identified for review by the North Carolina Maternal Mortality Review Committee (NC-MMRC), data from the North Carolina Violent Death Reporting System (NC-VDRS) and data from the Statewide Unintentional Drug Overdose Reporting System (NC-SUDORS) to examine homicide, suicide and unintentional opioid-involved overdose deaths during pregnancy and the first year postpartum., Methods: We linked data from the 2018-2019 NC-MMRC to suicide and homicide deaths among women ages 10-50 years from the 2018-2019 NC-VDRS and to unintentional opioid-involved overdose deaths among women ages 10-50 years from the 2018-2019 NC-SUDORS. We conducted descriptive analyses to examine the prevalence of demographic characteristics and the circumstances surrounding each cause of death., Results: From 2018 to 2019 in North Carolina, there were 23 homicides, nine suicides and 36 unintentional opioid-involved overdose deaths (9.7, 3.8 and 15.1 per 100 000 live births, respectively) during pregnancy and the first year postpartum. Most homicide deaths (87.0%) were by firearm, and more than half (52.5%) were related to intimate partner violence. More than two-thirds of women who died by suicide had a current mental health problem (77.8%). Less than one-fourth (22.2%) of those who died by unintentional opioid-involved overdose had a known history of substance use disorder treatment., Conclusion: Our approach to quantifying and describing these causes of pregnancy-associated death can serve as a framework for other states to inform data-driven prevention., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Food insecurity is a risk factor for poor mental health and suicidal behaviors among adolescents. Prior research shows that states with policies that expand Supplemental Nutrition Assistance Program (SNAP) eligibility have a lower prevalence of food insecurity. The primary aim of this study was to compare the prevalence of feelings of sadness or hopelessness, suicidal ideation, and suicide attempts among adolescents in states that had the asset test eliminated and the income limit increased for SNAP eligibility to adolescents in states that did not have either policy., Methods: Using 2013-2021 data from state Youth Risk Behavior Surveys (N = 855,119) and the SNAP Policy Database, we conducted log-binomial regression with generalized estimating equations and adjusted for confounders., Results: The prevalence of persistent feelings of sadness or hopelessness was similar among adolescents in states that had the asset test eliminated only and among adolescents in states that had both the asset test eliminated and the income limit increased (i.e., both policies) compared to adolescents in states that did not have either policy. While the prevalence of suicidal thoughts was similar among adolescents in states that had the asset test eliminated only compared to adolescents in states that did not have either policy, the prevalence of suicidal thoughts (prevalence ratio = 0.91, 95% CI 0.88, 0.94) and suicide attempts (prevalence ratio = 0.82, 95% CI 0.78, 0.86) was lower among adolescents in states that had both policies compared to adolescents in states that did not have either policy., Discussion: States with policies that expand SNAP eligibility have a lower prevalence of suicidal behaviors among adolescents., (Copyright © 2024 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Restrictive housing for control purposes (RHCP, a form of solitary confinement) is used in prisons in response to disruptive behaviors, including violence. North Carolina prisons introduced the rehabilitative diversion unit (RDU) in 2016 as an alternative to and step-down from RHCP. We compared rates of psychiatric treatment and self-injury among men enrolled in the RDU and men eligible for the RDU but placed in RHCP. We used Poisson regression to calculate rate ratios (RRs) and 95% confidence intervals (CIs) for these outcomes, using inverse probability of treatment weights to adjust for confounders. The cohort included 1,225 men in the RDU group and 3,059 in the RHCP group. In RHCP, the adjusted psychiatric treatment rate was 2.6 times (95% CI: 1.8, 3.8) and the adjusted self-injury incident rate was 1.2 times (95% CI: 0.6, 2.8) that in RDU. Nearly all self-injury incidents in RDU occurred during "non-participating time" (i.e., in a restrictive housing setting and not actively participating in RDU). After excluding non-participating time from the RDU group's person time, the adjusted RR for self-injury incidents was 23.5 (95% CI: 8.6, 64.2). These results further knowledge of potential benefits of diversion from restrictive housing. Continued development, implementation, and evaluation is needed., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Importance: Households with children and minoritized racial and ethnic groups experience a disproportionate burden of food hardship. During the COVID-19 pandemic, the US federal government implemented emergency allotments in the Supplemental Nutrition Assistance Program (SNAP), increasing the amount of food purchasing assistance received by many participating households., Objective: To examine the association of implementing emergency allotments in SNAP with food hardship among households with children overall and for households with Black, Hispanic, and White children by comparing income-eligible households that did and did not participate in SNAP., Design, Setting, and Participants: This ecologic cross-sectional study used 2016-2022 National Survey of Children's Health data and a difference-in-differences approach to compare changes in the risk of food hardship from before implementation of emergency allotments in SNAP (2016-2019) to during implementation (2020-2022). Households with children younger than 18 years and incomes 130% or less of the federal poverty level (FPL) in all 50 states and Washington, DC, were included., Exposure: Implementation of emergency allotments in SNAP., Main Outcome and Measures: The primary outcome was caregiver report of household food hardship during the past 12 months., Results: Of 44 753 households with incomes 130% or less of the FPL, a weighted 23.4% had Black children, 56.7% had White children, and 19.9% had children of other races. More than one-third of households (37.8%) had Hispanic children, and 31.8% had young children aged 0 to 5 years. The percentage of households that experienced food hardship decreased from 2016 to 2021 (from 62.9% to 48.2% among SNAP-participating households and from 44.3% to 38.9% among income-eligible nonparticipating households) but increased in 2022 (to 58.0% among SNAP-participating households and to 47.5% among nonparticipating households). Adjusting for confounders, implementing emergency allotments in SNAP was associated with a decreased risk of food hardship among SNAP-participating compared with nonparticipating households (risk ratio [RR], 0.88; 95% CI, 0.81-0.96). Implementing emergency allotments in SNAP was associated with a decreased risk of food hardship among SNAP-participating households with Hispanic (RR, 0.86; 95% CI, 0.72-1.02) and White (RR, 0.85; 95% CI, 0.76-0.94) children compared with nonparticipating households but not among households with Black children (RR, 1.04; 95% CI, 0.87-1.23)., Conclusions and Relevance: In this ecologic cross-sectional study, implementing emergency allotments in SNAP was associated with a decreased risk of food hardship among households with children. Efforts are needed to ensure that all populations benefit from economic policies.

Importance: Controlled substances have regulatory requirements under the US Federal Controlled Substance Act that must be met before pharmacies can stock and dispense them. However, emerging evidence suggests there are pharmacy-level barriers in access to buprenorphine for treatment for opioid use disorder even among pharmacies that dispense other opioids., Objective: To estimate the proportion of Medicaid-participating community retail pharmacies that dispense buprenorphine, out of Medicaid-participating community retail pharmacies that dispense other opioids and assess if the proportion dispensing buprenorphine varies by Medicaid patient volume or rural-urban location., Design, Setting, and Participants: This serial cross-sectional study included Medicaid pharmacy claims (2016-2019) data from 6 states (Kentucky, Maine, North Carolina, Pennsylvania, Virginia, West Virginia) participating in the Medicaid Outcomes Distributed Research Network (MODRN). Community retail pharmacies serving Medicaid-enrolled patients were included, mail-order pharmacies were excluded. Analyses were conducted from September 2022 to August 2023., Main Outcomes and Measures: The proportion of pharmacies dispensing buprenorphine approved for opioid use disorder among pharmacies dispensing an opioid analgesic or buprenorphine prescription to at least 1 Medicaid enrollee in each state. Pharmacies were categorized by median Medicaid patient volume (by state and year) and rurality (urban vs rural location according to zip code)., Results: In 2016, 72.0% (95% CI, 70.9%-73.0%) of the 7038 pharmacies that dispensed opioids also dispensed buprenorphine to Medicaid enrollees, increasing to 80.4% (95% CI, 79.5%-81.3%) of 7437 pharmacies in 2019. States varied in the percent of pharmacies dispensing buprenorphine in Medicaid (range, 73.8%-96.4%), with significant differences between several states found in 2019 (χ2 P < .05), when states were most similar in the percent of pharmacies dispensing buprenorphine. A lower percent of pharmacies with Medicaid patient volume below the median dispensed buprenorphine (69.1% vs 91.7% in 2019), compared with pharmacies with above-median patient volume (χ2 P < .001)., Conclusions and Relevance: In this serial cross-sectional study of Medicaid-participating pharmacies, buprenorphine was not accessible in up to 20% of community retail pharmacies, presenting pharmacy-level barriers to patients with Medicaid seeking buprenorphine treatment. That some pharmacies dispensed opioid analgesics but not buprenorphine suggests that factors other than compliance with the Controlled Substance Act influence pharmacy dispensing decisions.

Introduction: We assessed awareness of the maternal health benefits of lactation among a sample of nulliparous pregnant individuals in the United States, identified variables associated with awareness of these benefits, and examined whether awareness of these benefits impacts breastfeeding attitudes or intentions., Methods: We administered a web-based survey to nulliparous U.S.-born individuals carrying a singleton gestation of at least 28 weeks. We assessed awareness of the maternal health benefits of lactation using 10 items to create a summative score. We examined variation in awareness of these benefits by demographic characteristics, health insurance, and personal or family health history and used multivariable models to estimate associations between awareness of the maternal health benefits of lactation and breastfeeding intentions., Results: Of the 675 individuals invited to complete surveys, 451 (67%) responded. Only 50% were aware that breastfeeding lowers maternal risk of breast cancer; fewer were aware that breastfeeding lowers the risk of ovarian cancer (35%), diabetes (27%), and hypertension and heart disease (26%). Awareness of the maternal benefits of lactation did not vary by age or race/ethnicity. However, significant regional variation was noted. In multivariable models, scores of awareness of the maternal health benefits of breastfeeding were significantly associated with intentions to breastfeed for at least 12 months (adjusted odds ratio, 1.23; 95% confidence interval, 1.11, 1.37)., Conclusions: Efforts to increase awareness of the maternal health benefits of lactation are still needed. Increasing awareness of the maternal health benefits of lactation may strengthen intentions to breastfeed as recommended., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Chronic pain in the context of certain factors may be associated with potential for nonmedical prescription opioid use; however, identifying this risk can be challenging and complex. Several variables alone have been associated with non-prescribed opioid use, including depression, anxiety, pain interference, and trauma exposure. Prior research has often failed to integrate these assessments together, which is important as these factors may cluster together in important and complex ways. The current study aimed to identify classes of patients with chronic pain who have differential risk for use of nonmedical prescription opioid use, depression and anxiety, and pain severity, interference, and catastrophizing, and interpersonal violence exposure., Methods: Self-report and medical record data from patients (N = 211; Mage = 48, 69.0% women, 69.0% white) at a pain management center were collected., Results: Latent class analysis revealed 3 classes with (1) low probability of clinically significant depression, anxiety, pain, and nonmedical prescription opioid use (44.7%), (2) high probability of clinically significant depression, anxiety, pain, pain catastrophizing, trauma, and nonmedical prescription opioid use (41.3%), and (3) high probability of severe pain and nonmedical prescription opioid use (14.0%)., Conclusions: High-risk classes had either high levels of depression and anxiety, pain catastrophizing, and interpersonal violence exposure, or pain severity and interference. Future research should continue to explore these classes in large, diverse samples, and prospective study designs. Finally, results underscore that opioid use is complex, not easily identified by a single factor, and may be motivated by complex unmet clinical needs., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Scabies infections of the breast in lactating individuals are not well described, especially how maternal infection can impact human milk feeding of hospitalized infants in the intensive care setting. Methods: This case report presents a critically ill female infant with a complex surgical history whose mother had an active scabies infection around the breast postpartum and wished to provide expressed human milk. Results: In this case report, human milk was recommended despite maternal scabies infection. Conclusion: Given the limited information that is known about the risk of scabies transmission in human milk for critically ill infants, this case adds to the knowledge base and supports the call for further research.

Introduction: The United States continues to experience an opioid overdose crisis. As a key social determinant of health, housing insecurity may contribute to initiation of substance use and can threaten outcomes for those with substance use disorders by increasing stress, risky substance use, discontinuity of treatment, and return to use, all of which may increase the risk of overdose. The Low-Income Housing Tax Credit (LIHTC) program supports access to rental housing for low-income populations. By facilitating access to affordable housing, this program may improve housing security, thereby reducing overdose risk., Methods: We used data from LIHTC Property Data and the State Emergency Department Database (SEDD) to identify the number of LIHTC units available and opioid overdoses discharged from the emergency department (ED) in 13 states between 2005 and 2014., Results: Between 2005 and 2014, mean opioid overdose ED visits were higher in states with fewer LIHTC units (<28 LIHTC units per 100,000 population) at 26.5 per 100,000 population as compared to states with higher LIHTC units (≥28 LIHTC units per 100,000 population) at 21.1 per 100,000. We find that greater availability of LIHTC units was associated with decreased rates of opioid overdose ED visits (RR 0.94; CI 0.90, 1.00)., Conclusions: Given the importance of housing as a key social determinant of health, the provision of affordable housing may mitigate substance misuse and prevent nonfatal opioid overdose., Competing Interests: Declaration of competing interest All authors: No conflicts declared., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Food insecurity is associated with the development of substance misuse and use disorders (SUD). This study sought to estimate associations between state Supplemental Nutrition Assistance Program (SNAP) eligibility policies and substance-related outcomes., Methods: 2014-2017 SNAP Policy Database and 2015-2019 National Survey on Drug Use and Health state-level estimates were used to estimate associations between state SNAP eligibility policies and alcohol use disorder (AUD), opioid misuse, illicit drug use disorder (IDUD), SUD, and needing but not receiving SUD treatment. State SNAP policies included those that (1) do not disqualify individuals with a felony drug conviction from SNAP and/or (2) expand SNAP eligibility by increasing the income limit or removing the asset test. Analyses were conducted January-May 2023., Results: States that adopted both SNAP eligibility policies had reduced rates of AUD (adjusted rate ratio (aRR): 0.92; 95% CI 0.86, 0.99), opioid misuse (aRR: 0.94; 95% CI 0.89, 0.98), IDUD (aRR: 0.91; 95% CI 0.85, 0.98), SUD (aRR: 0.91; 95% CI 0.85, 0.97), and needing but not receiving SUD treatment (aRR: 0.92; 95% CI 0.87, 0.98) compared to states with neither policy. Among states that did not adopt increases to the income limit or removal of the asset test, those that removed the felony drug disqualification had lower rates of IDUD, SUD, and needing but not receiving SUD treatment, compared to those that maintained a disqualification., Conclusions: Expanded SNAP eligibility could help reduce rates of substance misuse and SUD. Opting out of the federal disqualification on SNAP participation for those with felony drug convictions may be particularly beneficial., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Prior research suggests that physicians' personal experience with breastfeeding may influence their attitudes toward breastfeeding. This phenomenon has not been explored in well-newborn care physician leaders, whose administrative responsibilities often include drafting and approval of hospital breastfeeding and formula supplementation policies., Methods: We conducted a mixed-methods study, surveying physicians in the Better Outcomes through Research for Newborns (BORN) network. We examined physician attitudes toward recommending breastfeeding and their breastfeeding experience. Qualitative analysis was conducted on responses to the question: "How do you think your breastfeeding experience influences your clinical practice?", Results: Of 71 participants, most (92%) had a very positive attitude toward breastfeeding with 75% of respondents reporting personal experience with breastfeeding. Of these, 68% had a very positive experience, 25% had a somewhat positive experience, and 6% had a neutral experience. Four themes emerged with respect to the effect of breastfeeding experience on practice: (1) empathy with breastfeeding struggles, (2) increased knowledge and skills, (3) passion for breastfeeding benefits, and (4) application of personal experience in lieu of evidence-based medicine, particularly among those who struggled with breastfeeding., Conclusions: Well-newborn care physician leaders reported positive attitudes about breastfeeding, increased support toward breastfeeding persons, and a perception of improved clinical lactation skills. Those who struggled with breastfeeding reported increased comfort with recommending formula supplementation to their own patients. Medical education about evidence-based breastfeeding support practices and provision of lactation support to physicians has the potential to affect public health through improved care for the patients they serve., (© 2023 Wiley Periodicals LLC.)

Supportive care needs for hematopoietic stem cell recipients have been studied. Less is known about the care needs of stem cell donors. Care challenges arise at donor selection, preparation for the donation, the donation procedure and the immediate and long-term after-care. Care needs were analyzed for 1,831 consecutive bone marrow and peripheral stem cell donors at MedStar Georgetown University Hospital between January 2018 and August 2023 in support of a review of the current literature. During the selection, related donors may experience psychological pressures affecting their motivation, while donation centers may be willing to accept co-morbidities in these donors which might preclude donation in unrelated peers. For bone marrow donations, it is important to select donors not only according to optimal genetic matching criteria but also according to suitable donor/recipient weight ratios, to facilitate sufficient stem cell yields. During the donation preparation phase, side effects and complications related to stem cell stimulation must be anticipated and managed for peripheral cell donors, while the pros and cons of autologous blood donation should be evaluated carefully for bone marrow donors. The stem cell donation procedure itself carries potential side effects and complications as well. Peripheral cell donors may require a central line and may encounter hypocalcemia, thrombocytopenia, and anemia. Bone marrow donors face risks associated with anesthesia, blood loss and pain. Post-procedure care focusses on pain management, blood cell recovery and the psychological support necessary to regain a high quality-of-life existence. Hematopoietic stem donors are giving part of themselves to save another's life. They deserve comprehensive supportive care to accompany them throughout the donation process.

Introduction: Poverty is a consistent correlate of firearm-involved mortality, yet little work has considered the effects of social and economic policies on these deaths. This study examined associations of state elimination of the asset test and increases in the income limit for Supplemental Nutrition Assistance Program (SNAP) eligibility with rates of firearm-involved suicide and homicide deaths in the United States., Methods: This ecological repeated cross-sectional study used 2015-2019 data from the SNAP Policy Database and death certificate data from the National Vital Statistics System. The exposures were (1) state elimination of the asset test for SNAP eligibility and (2) state elimination of the asset test and increases in the income limit for SNAP eligibility, compared with (3) state adoption of neither policy. The outcomes were firearm-involved suicide deaths and firearm-involved homicide deaths. The research team conducted mixed-effects regressions to estimate associations., Results: State elimination of the asset test for SNAP eligibility (incidence rate ratio (IRR), 0.67; 95% CI, 0.48 to 0.91) and state adoption of both eliminating the asset test and increasing the income limit for SNAP eligibility (IRR, 0.68; 95% CI, 0.49 to 0.92) were associated with decreased rates of firearm-involved suicide deaths compared with state adoption of neither policy. There were no associations with state firearm-involved homicide rates., Conclusions: SNAP is an important social safety net programme that addresses food insecurity, and the present results suggest it may also contribute to reducing firearm-involved suicide., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Economic stress, broadly defined, is associated with an increased likelihood of multiple forms of violence. Food insecurity is a distinct economic stressor and material hardship that is amenable to programmatic and policy intervention. To inform intervention and identify gaps in the current evidence base, we conducted a systematic review to synthesize and critically evaluate the existing literature regarding the association between food insecurity and five forms of interpersonal and self-directed violence: intimate partner violence (IPV), suicidality, peer violence and bullying, youth dating violence, and child maltreatment, in high-income countries. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and searched six electronic databases from their start date through February of 2022. We included studies that examined food insecurity as the exposure and an outcome measure of IPV, suicide, suicidality, peer violence, bullying, youth dating violence, or child maltreatment; were peer-reviewed and published in English; reported quantitative data; and took place in a high-income country. We identified 20 relevant studies. Nineteen studies found that food insecurity was associated with an increased likelihood of these forms of violence. Results highlight the potential for programs and policies that address food insecurity to function as primary prevention strategies for multiple forms of violence and underscore the importance of trauma-informed approaches in organizations providing food assistance. Additional theory-driven research with validated measures of food insecurity and clearly established temporality between measures of food insecurity and violence is needed to strengthen the existing evidence base., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To develop a nurse-to-family telehealth intervention for pediatric inter-facility transfers using the human-centered design approach., Methods: We conducted the inspiration and ideation phases of a human-centered design process from July 2022 to December 2022. For the inspiration phase, we conducted a qualitative cross-sectional case study design over 3 months. We used thematic analysis with the framework approach of parent and provider interviews. Five team members individually coded transcripts and then met to discuss memos, update a construct summary sheet, and identify emerging themes. The team adapted themes into "How Might We" statements. For the ideation phase, multidisciplinary stakeholders brainstormed solutions to the "How Might We" statements in a design workshop. Workshop findings informed the design of a nurse-to-family telehealth intervention, which was iteratively revised over 2 months based on stakeholder feedback sessions., Results: We conducted interviews with nine parents, 11 nurses, and 13 physicians. Four themes emerged supporting the promise of a nurse-to-family telehealth intervention, the need to effectively communicate the intervention purpose, the value of a user-friendly workflow, and the essentiality of ensuring that diverse populations equitably benefit from the intervention. "How Might We" statements were discussed among 22 total workshop participants. Iterative adaptations were made to the intervention until feedback from workshop participants and 67 other stakeholders supported no further improvements were needed., Conclusion: Human-centered design phases facilitated stakeholder engagement in developing a nurse-to-family telehealth intervention. This intervention will be tested in an implementation phase as a feasibility and pilot trial., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Background: To provide insight into the longitudinal dynamics of opioid use throughout the overdose crisis, this study estimated the separate influences of age, period and cohort on prescription opioid use during 1999-2018 in the USA., Methods: Data from 10 cycles of the cross-sectional National Health and Nutrition Examination Survey were used to conduct an age-period-cohort analysis of the prevalence of prescription opioid use (n=63 500 across 1999-2018). Temporal trends were graphically visualised. The median polish approach was used to estimate age, period and cohort-related effects on prescription opioid use., Results: Prescription opioid use broadly increased across the lifespan, with steeper prevalence increases observed from young adulthood to mid-adulthood. Period-related variation was consistent with recognised nationwide declines in opioid prescribing. While there was no evidence of systematic cohort effects, compared with individuals born in 1951-1954, those born during 1963-1966 had greater prescription opioid use (prevalence ratio (PR)=1.23, 95% CI: 1.05 to 1.43), whereas the 1991-1994 and 1999-2002 cohorts had lower prescription opioid use (PR 91-94 =0.70, 95% CI: 0.50 to 0.98; PR 99-02 =0.72, 95% CI: 0.63 to 0.81)., Conclusion: In the USA, longitudinal trends in prescription opioid use during 1999-2018 were predominantly driven by age and period influences. The cohort of youngest baby boomers experienced greater prescription opioid use, whereas recent-born cohorts have had lower use. As the overdose crisis continues evolving, such population-level characterisations of age, period and cohort dynamics are instrumental in understanding opioid use and can inform prevention and intervention approaches by identifying population groups more likely to use opioids who, thus, may also experience related outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: State expansion of Supplemental Nutrition Assistance Program (SNAP) eligibility under broad-based categorical eligibility (BBCE) is associated with decreases in household poverty and food insecurity, child protective services investigations, and mental health and substance use disorders among adults, key contributors to foster care entry., Objective: To examine the association of state expansion of SNAP eligibility under BBCE with rates of foster care entries., Participants: Foster care entries among children ages <18 years., Methods: We used 2005-2019 data from the SNAP Policy Database and the Adoption and Foster Care Analysis and Reporting System (AFCARS). We conducted difference-in-differences analyses and generated event study plots adjusting for state economic conditions (percent population unemployed, median household income) and policies (minimum wage, refundable Earned Income Tax Credits, maximum Temporary Assistance for Needy Families benefit for a family of 3)., Results: On average, there were 1.8 fewer foster care entries (95 % confidence interval (CI) -2.8, -0.8) per 1000 children per year in states that expanded SNAP eligibility than there would have been if they had not expanded eligibility. Average decreases in foster care entries were similar among young (-1.7 per 1000 children per year, 95 % -3.1, -0.3) and school-age (-1.8 per 1000 children per year, 95 % CI -2.7, -0.8) children and larger among Black non-Hispanic (-5.6 per 1000 children per year, 95 % CI -9.1, -2.0) than among White non-Hispanic (-1.4 per 1000 children per year, 95 % CI -2.2, -0.6) children. The magnitude of these decreases increased with greater time since policy adoption., Conclusions: Results add to growing evidence that programs and policies that support and stabilize household economic and material conditions may contribute to reductions in foster care entries at the population-level., Competing Interests: Declaration of competing interest None reported., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Introduction: Food insecurity is associated with an increased likelihood of interpersonal violence. The Supplemental Nutrition Assistance Program (SNAP) is the largest program addressing food insecurity in the U.S. States can eliminate the asset test and/or increase the income limit for SNAP eligibility, expanding the number of households receiving assistance. We examined the association of state elimination of the asset test and increases in the income limit with rates of interpersonal violence, including intimate partner violence (IPV), other relationship violence (violence by a parent, friend, etc.), and stranger violence., Methods: We used data from the SNAP Policy Database and state-level estimates of rates of interpersonal violence per 1000 population ages ≥12 years from the 2012-2014 to 2016-2018 National Crime Victimization Survey., Results: States that adopted both SNAP eligibility policies (eliminated the asset test and increased the income limit) had a lower rate of IPV (β = -0.4, 95% CI -0.9, 0.0) and other relationship violence (β = -2.4, 95% CI -3.8, -1.1) compared to states that did not adopt either policy. The rate of stranger violence (β = -0.5, 95% CI -2.3, 1.4) did not differ for states that adopted both policies compared to states that did not adopt either policy. Rates of IPV (β = -0.4, 95% CI -0.9, 0.2), other relationship violence (β = -1.2, 95% CI -3.2, 0.7), and stranger violence (β = -0.2, 95% CI -2.0, 1.6) did not differ for states that eliminated the asset test only compared to states that did not adopt either policy., Conclusion: Expanding SNAP eligibility may help prevent interpersonal violence at the population-level., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: To examine racial and ethnic differences and COVID-19 pandemic-related changes in key characteristics of drug overdose deaths in North Carolina., Methods: We used North Carolina State Unintentional Drug Overdose Reporting System data to describe specific drug-involvement, bystander presence, and naloxone administration for drug overdose deaths by race and ethnicity during pre-COVID-19 (May 2019-February 2020) and COVID-19 periods (March 2020-December 2020)., Results: For all racial and ethnic groups, drug overdose death rates and the percentage with fentanyl and alcohol involvement increased from the pre-COVID-19 to COVID-19 period, with fentanyl involvement highest among American Indian and Alaska Native (82.2%) and Hispanic (81.4%) individuals and alcohol involvement highest among Hispanic individuals (41.2%) during the COVID-19 period. Cocaine involvement remained high among Black non-Hispanic individuals (60.2%) and increased among American Indian and Alaska Native individuals (50.6%). There was an increase in the percentage of deaths with a bystander present from the pre-COVID-19 to COVID-19 period for all racial and ethnic groups, with more than half having a bystander present during the COVID-19 period. There was a decrease in the percentage of naloxone administered for most racial and ethnic groups, with the lowest percentage among Black non-Hispanic individuals (22.7%)., Conclusions: Efforts to address increasing inequities in drug overdose deaths, including expanded community naloxone access, are needed., Competing Interests: Declaration of Competing Interest None reported., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Treatment guidelines recommend regular urine drug testing (UDT) for persons initiating buprenorphine for opioid use disorder (OUD). However, little is known about UDT utilization. We describe state variation in UDT utilization and examine demographic, health, and health care utilization factors associated with UDT in Medicaid., Methods: We used Medicaid claims and enrollment data from persons initiating buprenorphine treatment for OUD during 2016-2019 in 9 states (DE, KY, MD, ME, MI, NC, PA, WI, WV). The main outcome was at least 1 UDT within 180 days of buprenorphine initiation, the secondary outcome was at least 3. Logistic regression models included demographics, pre-initiation comorbidities, and health service use. State estimates were pooled using meta-analysis., Results: The study cohort included 162,437 Medicaid enrollees initiating buprenorphine. The percent receiving ≥1 UDT varied from 62.1% to 89.8% by state. In the pooled analysis, enrollees with pre-initiation UDT had much higher odds of ≥1 UDT after initiation (aOR=3.83, 3.09-4.73); odds were also higher for enrollees with HIV, HCV, and/or HBV infection (aOR=1.25, 1.05-1.48) or who initiated in later years (2018 v 2016: aOR=1.39, 1.03-1.89; 2019 v 2016: aOR=1.67, 1.24-2.25). The odds of having ≥3 UDT were lower with pre-initiation opioid overdose (aOR=0.79, 0.64-0.96) and higher with pre-initiation UDT (aOR=2.63, 2.13-3.25) or OUD care (aOR=1.35, 1.04-1.74). The direction of associations with demographics varied by state., Conclusions: Rates of UDT increased over time and there was variability among states in UDT rates and demographic predictors of UDT. Pre-initiation conditions, UDT, and OUD care were associated with UDT., Competing Interests: Declaration of Competing Interest No conflict declared., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Individuals who commit acts of violence in prisons are often placed in highly controlled environments called restrictive housing (i.e., solitary confinement), which can have severe physical and mental health consequences and does not reduce violence. As such, North Carolina prisons have introduced the rehabilitative diversion unit (RDU) to reduce the use of restrictive housing and reduce violence in prison., Methods: We evaluated the effect of the RDU on prison infractions. We compared rates of infractions by type (including violent infractions) among men enrolled in the RDU and men who were eligible for the RDU but placed in restrictive housing for control purposes (RHCP). We also evaluated sustained program impacts by comparing the hazard of first infraction among these same two groups of men after program completion, when they had returned to the general prison population. Finally, we compared the hazard of first promotion to a less restrictive custody level (medium custody) when these men had returned to the general prison population., Results: The primary analytic cohort was made up of 3128 men contributing 897,822 person-days. Adjusted rates of violent infractions were lower in the RDU than in RHCP (adjusted rate ratio: 0.6; 95% CI: 0.4, 1.1). All other categories of infractions, including drug-related infractions, occurred at higher rates during RDU, as compared to RHCP. In analyses of sustained program impacts, for most categories of infractions, there were no differences in the hazard of first infraction post-RDU and post-RHCP. However, the hazard of violent infraction post-RDU was higher (adjusted hazard ratio: 2.1; 95% CI: 1.1, 4.0) than post-RHCP. The hazard of promotion to a less restrictive custody level was higher post-RDU (adjusted hazard ratio: 17.4; 95% CI: 7.2, 42.2) than post-RHCP., Conclusions: We found the RDU program may be effective in reducing violence for men enrolled in the program, but that these benefits were not sustained. Continued programming may be a useful tool to transition men from the programmatically intensive environment of the RDU to the general prison population. Additionally, we recommend the expansion of evidence-based treatment for substance use disorder., (© 2023. The Author(s).)

Lesbian, gay, bisexual, and transgender (LGBT) individuals have a high prevalence of substance use disorders (SUDs) and experience unique barriers to treatment. Little is known about the characteristics of SUD treatment facilities providing LGBT-tailored programs at the outpatient and residential levels of care. The purpose of this study is to examine the availability of LGBT-tailored programs in outpatient and residential SUD treatment facilities. Using the National Survey of Substance Abuse Treatment Services 2020, we conducted logistic regression to examine facility characteristics, including ownership, pay assistance, region, outreach, and telehealth services, associated with having an LGBT-tailored program among SUD treatment facilities. Outpatient facilities that were for-profit, had pay assistance, had community outreach services, and provided telemedicine/telehealth were more likely to have an LGBT-tailored program. Those that were government-owned, in the Midwest, and that accepted Medicaid were less likely to have an LGBT-tailored program. Residential facilities that were in the West, for-profit, and had community outreach services were more likely to have an LGBT-tailored program. This study offers a national examination of the availability of LGBT-tailored programs in SUD treatment facilities. Differences in availability based on ownership, region, pay assistance, and outreach highlight potential gaps in treatment availability., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Importance: Federal and state agencies granted temporary regulatory waivers to prevent disruptions in access to medication for opioid use disorder (MOUD) during the COVID-19 pandemic, including expanding access to telehealth for MOUD. Little is known about changes in MOUD receipt and initiation among Medicaid enrollees during the pandemic., Objectives: To examine changes in receipt of any MOUD, initiation of MOUD (in-person vs telehealth), and the proportion of days covered (PDC) with MOUD after initiation from before to after declaration of the COVID-19 public health emergency (PHE)., Design, Setting, and Participants: This serial cross-sectional study included Medicaid enrollees aged 18 to 64 years in 10 states from May 2019 through December 2020. Analyses were conducted from January through March 2022., Exposures: Ten months before the COVID-19 PHE (May 2019 through February 2020) vs 10 months after the PHE was declared (March through December 2020)., Main Outcomes and Measures: Primary outcomes included receipt of any MOUD and outpatient initiation of MOUD via prescriptions and office- or facility-based administrations. Secondary outcomes included in-person vs telehealth MOUD initiation and PDC with MOUD after initiation., Results: Among a total of 8 167 497 Medicaid enrollees before the PHE and 8 181 144 after the PHE, 58.6% were female in both periods and most enrollees were aged 21 to 34 years (40.1% before the PHE; 40.7% after the PHE). Monthly rates of MOUD initiation, representing 7% to 10% of all MOUD receipt, decreased immediately after the PHE primarily due to reductions in in-person initiations (from 231.3 per 100 000 enrollees in March 2020 to 171.8 per 100 000 enrollees in April 2020) that were partially offset by increases in telehealth initiations (from 5.6 per 100 000 enrollees in March 2020 to 21.1 per 100 000 enrollees in April 2020). Mean monthly PDC with MOUD in the 90 days after initiation decreased after the PHE (from 64.5% in March 2020 to 59.5% in September 2020). In adjusted analyses, there was no immediate change (odds ratio [OR], 1.01; 95% CI, 1.00-1.01) or change in the trend (OR, 1.00; 95% CI, 1.00-1.01) in the likelihood of receipt of any MOUD after the PHE compared with before the PHE. There was an immediate decrease in the likelihood of outpatient MOUD initiation (OR, 0.90; 95% CI, 0.85-0.96) and no change in the trend in the likelihood of outpatient MOUD initiation (OR, 0.99; 95% CI, 0.98-1.00) after the PHE compared with before the PHE., Conclusions and Relevance: In this cross-sectional study of Medicaid enrollees, the likelihood of receipt of any MOUD was stable from May 2019 through December 2020 despite concerns about potential COVID-19 pandemic-related disruptions in care. However, immediately after the PHE was declared, there was a reduction in overall MOUD initiations, including a reduction in in-person MOUD initiations that was only partially offset by increased use of telehealth.

Background: Medication for opioid use disorder (MOUD) is evidence-based treatment during pregnancy and postpartum. Prior studies show racial/ethnic differences in receipt of MOUD during pregnancy. Fewer studies have examined racial/ethnic differences in MOUD receipt and duration during the first year postpartum and in the type of MOUD received during pregnancy and postpartum., Methods: We used Medicaid administrative data from 6 states to compare the percentage of women with any MOUD and the average proportion of days covered (PDC) with MOUD, overall and by type of MOUD, during pregnancy and four postpartum periods (1-90 days, 91-180 days, 181-270 days, and 271-360 days postpartum) among White non-Hispanic, Black non-Hispanic, and Hispanic women diagnosed with OUD., Results: White non-Hispanic women were more likely to receive any MOUD during pregnancy and all postpartum periods compared to Hispanic and Black non-Hispanic women. For all MOUD types combined and for buprenorphine, White non-Hispanic women had the highest average PDC during pregnancy and each postpartum period, followed by Hispanic women and Black non-Hispanic women (e.g., for all MOUD types, 0.49 vs. 0.41 vs. 0.23 PDC, respectively, during days 1-90 postpartum). For methadone, White non-Hispanic and Hispanic women had similar average PDC during pregnancy and postpartum, and Black non-Hispanic women had substantially lower PDC., Conclusions: There are stark racial/ethnic differences in MOUD during pregnancy and the first year postpartum. Reducing these inequities is critical to improving health outcomes among pregnant and postpartum women with OUD., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to report., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Limited information exists about testing for human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) among Medicaid enrollees after starting medication for opioid use disorder (MOUD), despite guidelines recommending such testing. Our objectives were to estimate testing prevalence and trends for HIV, HBV, and HCV among Medicaid enrollees initiating MOUD and examine enrollee characteristics associated with testing., Methods: We conducted a serial cross-sectional study of 505 440 initiations of MOUD from 2016 to 2019 among 361 537 Medicaid enrollees in 11 states. Measures of MOUD initiation; HIV, HBV, and HCV testing; comorbidities; and demographics were based on enrollment and claims data. Each state used Poisson regression to estimate associations between enrollee characteristics and testing prevalence within 90 days of MOUD initiation. We pooled state-level estimates to generate global estimates using random effects meta-analyses., Results: From 2016 to 2019, testing increased from 20% to 25% for HIV, from 22% to 25% for HBV, from 24% to 27% for HCV, and from 15% to 19% for all 3 conditions. Adjusted rates of testing for all 3 conditions were lower among enrollees who were male (vs nonpregnant females), living in a rural area (vs urban area), and initiating methadone or naltrexone (vs buprenorphine). Associations between enrollee characteristics and testing varied across states., Conclusions: Among Medicaid enrollees in 11 US states who initiated medications for opioid use disorder, testing for human immunodeficiency virus, hepatitis B virus, hepatitis C virus, and all 3 conditions increased between 2016 and 2019 but the majority were not tested., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Children presenting to emergency departments of community hospitals may require transfer to a children's hospital for more definitive care, but the transfer process can be distressing and burdensome to patients, families, and the healthcare system. Using telehealth to bring the children's hospital nurse virtually to the bedside of the child in the emergency department has the potential to promote family-centered care and minimize triage issues and other transfer-associated burdens. To explore the feasibility of the nurse-to-family telehealth intervention, we are conducting a pilot study., Methods: This parallel cluster randomized controlled feasibility and pilot trial will randomize six community emergency departments to use either nurse-to-family telehealth (intervention) or usual care (control) for pediatric inter-facility transfers. All eligible children presenting to a participating site during the study period who require inter-facility transfer will be included. Eligibility requires that there be an English-speaking adult parent or guardian at the emergency department bedside. We will examine feasibility objectives that assess protocol assignment adherence, fidelity, and survey response rates. We will measure subject-level exploratory outcome data to test feasibility of data collection and to obtain effect size estimates; exploratory outcomes include family-centered care, family experience, parent acute stress, parent distress, and change in level of care. Additionally, we will conduct a mixed methods implementation evaluation using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework., Discussion: The findings from this trial will increase our understanding about nurse-to-family telehealth during pediatric transfers. The mixed methods implementation evaluation will provide relevant insight about the contextual factors that influence the implementation and rigorous evaluation of our intervention., Trial Registration: ClinicalTrials.gov Identifier: NCT05593900. First Posted: October 26, 2022. Last Update Posted: December 5, 2022., (© 2023. The Author(s).)

Importance: Food insecurity is associated with an increased likelihood of poor mental health and suicidality. The Supplemental Nutrition Assistance Program (SNAP) is the largest program addressing food insecurity in the US; under broad-based categorical eligibility (BBCE), states have the option to expand SNAP eligibility to a greater number of households by eliminating the asset test or increasing the income limit for eligibility., Objectives: To examine the association of state elimination of the asset test and increases in the income limit for SNAP eligibility with rates of mental health and suicidality outcomes among adults., Design, Setting, and Participants: This ecological cross-sectional study used 2014 to 2017 data on US adults from the National Vital Statistics System and 2015 to 2019 data on US adults from the National Survey on Drug Use and Health (NSDUH) State-Level Small Area Estimates. Analyses were conducted between September and November 2022., Exposures: State elimination of the asset test only and state adoption of both SNAP eligibility policies (ie, state elimination of the asset test and increases in the income limit) for 2014 to 2017 from the SNAP Policy Database., Main Outcomes and Measures: Number of adults with a past-year major depressive disorder, mental illness, serious mental illness, or suicidal ideation and number of adults who died by suicide., Results: Analyses included 407 391 adult NSDUH participants and 173 085 adults who died by suicide. State elimination of the asset test only was associated with decreased rates of past-year major depressive episodes (rate ratio [RR], 0.92; 95% CI, 0.87-0.98) and mental illness (RR, 0.91; 95% CI, 0.87-0.97) among adults. State adoption of both SNAP eligibility policies (ie, state elimination of the asset test and increases in the income limit) was associated with decreased rates of past-year major depressive episodes (RR, 0.92; 95% CI, 0.86-0.99), mental illness (RR, 0.92; 95% CI, 0.87-0.98), serious mental illness (RR, 0.91; 95% CI, 0.84-0.99), and suicidal ideation (RR, 0.89; 95% CI, 0.82-0.96). Results suggested a decreased rate of suicide death (RR, 0.93; 95% CI, 0.84-1.02) in states with both policies compared with states with neither policy, although this result was not statistically significant., Conclusions and Relevance: State adoption of policies that expand SNAP eligibility may contribute to decreased rates of multiple mental health and suicidality outcomes at the population level.

Importance: States in the US have the option to eliminate the asset test and/or increase the income limit for Supplemental Nutrition Assistance Program (SNAP) eligibility under a policy called broad-based categorical eligibility (BBCE). Given associations of economic hardships, including food insecurity, with child protective services (CPS) involvement, state adoption of these policies may be associated with changes in rates of CPS-investigated reports., Objective: To examine the association of state elimination of the asset test and increases in the income limit for SNAP eligibility under BBCE with rates of CPS-investigated reports., Design, Setting, and Participants: This cross-sectional ecologic study used data from 2006 to 2019 obtained from the SNAP Policy Database and the National Child Abuse and Neglect Data System Child Files and difference-in-differences analyses. The data were analyzed from March to September 2022. The study used CPS-investigated reports for suspected child abuse and neglect from 37 US states to examine elimination of the asset test, from 36 states to examine increases in the income limit, and from 26 states to examine adoption of both policies., Exposures: State elimination of the asset test, increases in the income limit, and adoption of both policies to expand SNAP eligibility., Main Outcomes and Measures: Number of CPS-investigated reports, overall and specifically for neglect and physical abuse, per 1000 child population., Results: From 2006 to 2019 for all 50 states and the District of Columbia, there were a total of 29 213 245 CPS-investigated reports. By race and ethnicity, 19.8% of CPS-investigated reports were among non-Hispanic Black children and 45.7% among non-Hispanic White children (hereafter referred to as Black and White children). On average, there were 8.2 fewer CPS-investigated reports (95% CI, -12.6 to -4.0) per 1000 child population per year in states that eliminated the asset test, 5.0 fewer CPS-investigated reports (95% CI, -10.8 to 0.7) per 1000 child population per year in states that increased the income limit, and 9.3 fewer CPS-investigated reports (95% CI, -15.6 to -3.1) per 1000 child population per year in states that adopted both SNAP policies than there would have been if these states had not adopted these policies. There were decreases in CPS-investigated reports for neglect in states that adopted either or both policies, and small decreases in CPS-investigated reports for physical abuse in states that increased the income limit or adopted both policies. There were decreases in CPS-investigated reports among both Black and White children. For example, there were 6.5 fewer CPS-investigated reports among Black children (95% CI, -14.6 to 1.6) and 8.7 fewer CPS-investigated reports among White children (95% CI, -15.8 to -1.6) in states that adopted both SNAP policies than there would have been if these states had not adopted these policies., Conclusions and Relevance: Results from this cross-sectional study suggest that state expansion of SNAP eligibility through elimination of the asset test and increases in the income limit may contribute to decreases in rates of CPS-investigated reports. These results can inform ongoing debates regarding SNAP policy options, specifically BBCE, and prevention efforts for child abuse and neglect.

Background: There are complex associations between insomnia symptoms and misuse of prescription drugs. The aim of this study was to examine prospective associations between insomnia symptoms and prescription opioid and benzodiazepine misuse among a nationally representative sample of adults., Methods: Utilizing data from the National Longitudinal Study of Adolescent to Adult Health (N = 10,685), we conducted log-binomial regression to examine associations of insomnia symptoms at Wave IV (2008-2009; 24-32 years) with prescription opioid and benzodiazepine misuse at Wave V (2016-2018; 33-43 years). We adjusted analyses for prior insomnia symptoms and substance misuse, as well as potential demographic and health-related confounders., Results: Each unit increase in insomnia symptoms at Wave IV was associated with a small increase in the likelihood of prescription opioid (RR = 1.08, 95 % CI 1.01, 1.15) but not benzodiazepine (RR = 1.09, 95 % CI 0.99, 1.21) use at Wave V. Both prescription opioid (β = 0.20, 95 % CI 0.09, 0.031) and benzodiazepine (β = 0.21, 95 % CI 0.10, 0.33) misuse at Wave IV had small associations with elevated insomnia symptoms at Wave V., Conclusions: Results support associations between prescription opioid and benzodiazepine misuse and later insomnia symptoms. There was a small association between insomnia symptoms and later prescription opioid misuse worthy of future study. These results fit within a broad line of research suggesting that insomnia symptoms are associated with future substance use and vice versa. Future research is needed explore mechanisms (e.g., mental health, pain) underlying these associations., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Objectives: Low-income, first-time mothers generally breastfeed exclusively and, overall, for a shorter average duration than high-income, multiparous mothers. A potential barrier to breastfeeding success is access to a breast pump for home use. In this pilot study, we estimated the effect of providing a manual breast pump during birth hospitalization for home use on any/exclusive breastfeeding and investigated participant attitudes about manual pumps and their breastfeeding experiences., Methods: Sixty low-income, first-time mothers were enrolled in a pilot randomized controlled trial. One-half received a manual breast pump and the other half received an attention control. Breastfeeding exclusivity, duration, and use of the manual pump were assessed at 6 and 12 weeks. Qualitative interviews regarding the breastfeeding experience were completed. Thirty-one women answered 13 questions that were then transcribed, coded, and grouped into themes., Results: Participants who were randomized to manual breast pump receipt during birth hospitalization had increased manual pump use at 6 weeks (13/19 [68%] versus controls 5/17 [29%]), there was no effect of pump receipt on any nor exclusive breastfeeding at 12 weeks. In qualitative analysis of the overall breastfeeding experience, participants expressed a need for additional support and had conflicting attitudes regarding breastfeeding and the pumping experience., Conclusions: Manual breast pump receipt in hospital among low-income, first-time mothers did not affect breastfeeding exclusivity or duration. Participants reported that early and ongoing lactation support is essential. Strategies to improve breastfeeding outcomes low-income, first-time mothers are needed., (Copyright © 2023 by the American Academy of Pediatrics.)

Purpose: The purpose of this illustrative, thematic review was to demonstrate the utility of data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) for substance use research and to describe substance use-specific insights gained from Add Health research over the past 2 decades., Methods: We searched multiple electronic databases (PubMed, PsycInfo, and Web of Science) and selected an illustrative sample of 40 articles that used Add Health data and longitudinally examined a measure of alcohol, marijuana, or illicit drug use or prescription drug misuse as the exposure or outcome in association with diverse domains of additional factors assessed (social, emotional, behavioral, contextual, biological, and genetic)., Results: Included articles identified several key associations between substance use behaviors and additional factors from a wide range of domains. For example, results from several studies indicated that experiences of sexual violence, adolescent dating violence, and intimate partner violence are associated with an increased likelihood of later prescription opioid misuse, heavy drinking, and marijuana use, with some differences by biological gender and race/ethnicity. Results from other studies showed that bidirectional associations between substance use and mental health differ by specific type of substance and mental health condition., Discussion: Existing research using Add Health data has provided valuable insights regarding substance use by leveraging the study's longitudinal design, the prospective nature of data collection, the breadth and depth of substance use questions assessed from adolescence to adulthood, the size and diversity of the cohort, and the wide range of additional factors measured over time., (Copyright © 2022 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Importance: Some states have implemented policies that consider substance use during pregnancy as child abuse and require mandated reporting of substance use during pregnancy. Implications of these policies for health care receipt among pregnant people who engage in substance use are unknown., Objective: To examine the association of state child abuse policies and mandated reporting policies with prenatal and postpartum care among women who engaged in substance use during pregnancy., Design, Setting, and Participants: In this cross-sectional study, data from the 2016-2019 Pregnancy Risk Assessment Monitoring System survey were analyzed. The study population included 4155 women from 23 states who reported substance use during pregnancy. Data were analyzed between August and November 2021., Exposures: Delivery in a state with a child abuse policy only (n = 6), a mandated reporting policy only (n = 4), both policies (n = 7), or neither policy (n = 5). One state switched from a mandated reporting policy only to having both policies., Main Outcomes and Measures: Month of gestation at prenatal care initiation (ie, months 1-10, with a higher number of months indicating later initiation), receipt of adequate prenatal care, and receipt of a postpartum health care visit 4 to 6 weeks after delivery. Sample characteristics were calculated using unweighted frequencies and weighted percentages and means. Associations of state policies with the outcomes were examined using generalized linear regression with generalized estimating equations, adjusting for potential confounders and accounting for the complex sampling design of the Pregnancy Risk Assessment Monitoring System survey., Results: The study sample included 4155 women who reported substance use during pregnancy; 33.9% of these women delivered in states with a child abuse policy only, 16.4% in states with a mandated reporting policy only, 32.9% in states with both policies, and 16.8% in states with neither policy. Overall, 14.7% of women were Black, 69.0% were White, and 64.6% were aged 18 to 29 years at delivery. Women who delivered in states with a child abuse policy only, mandated reporting policy only, or both policies initiated prenatal care at a later month of gestation (β = 0.44 [95% CI, 0.10-0.78], 0.32 [95% CI, 0.04-0.59], and 0.40 [95% CI, 0.09-0.72], respectively) and had a lower likelihood of adequate prenatal care (risk ratio, 0.85 [95% CI, 0.79-0.91], 0.94 [95% CI, 0.87-1.01], and 0.95 [95% CI, 0.89-1.03], respectively) and a postpartum health care visit (risk ratio, 0.89 [95% CI, 0.82-0.96], 0.89 [95% CI, 0.80-0.98], and 0.92 [95% CI, 0.83-1.02], respectively) compared with women who delivered in states with neither policy., Conclusions and Relevance: The results indicate that state child abuse policies and mandated reporting policies are associated with reduced receipt of prenatal and postpartum care among women who engage in substance use during pregnancy.

Therapeutic Diversion Units (TDUs) in North Carolina prisons are intended to reduce cycling of individuals with mental health conditions through restrictive housing (i.e., solitary confinement). This paper investigates if previously identified benefits of TDU are sustained when individuals return to the general prison population. Using administrative data on 3170 people, we compare individuals placed in TDUs to TDU-eligible individuals (i.e., individuals with mental health needs) placed in restrictive housing. We use survival analysis methods to estimate hazard ratios (HRs) with confidence intervals (CIs), controlling for confounders. Compared to restrictive housing placement, TDU placement reduced the hazard of infractions (HR: 0.66; 95% CI: 0.52, 0.84) and subsequent restrictive housing placement (HR: 0.64; 95% CI: 0.55, 0.73) but increased the hazard of self-harm (HR: 2.67; 95% CI: 1.66, 4.29) upon program release to the general prison population. These findings suggest a need for additional investments and research on restrictive housing diversion programming, including post-diversion program supports., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Charles Mautz and Gary Junker are employed by the NC Department of Public Safety and were involved in the development and implementation of the TDU program evaluated here. No other financial disclosures were reported by the authors of this paper., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Prior studies are mixed regarding whether infants diagnosed with neonatal opioid withdrawal syndrome have a higher risk of mortality than other infants. However, these studies have not accounted for whether mothers of infants with neonatal opioid withdrawal syndrome received medication for opioid use disorder in pregnancy., Methods: Linked data from 2016‒2018 North Carolina birth certificates, maternal and infant Medicaid claims, and infant death certificates were analyzed in summer 2021 to compare mortality and causes of mortality before age 1 year among infants diagnosed with neonatal opioid withdrawal syndrome whose mothers did and did not have claims for medication for opioid use disorder in pregnancy (N=4,480)., Results: Compared with mothers with medication for opioid use disorder claims in pregnancy (45.5%), mothers without medication for opioid use disorder claims (55.5%) were younger, more likely to be Black non-Hispanic, less likely to have paternity established, and more likely to have no prenatal care. The proportion (1.3%, n=31 vs 1.0%, n=21) and rate (3.5 vs 2.9 deaths per 100,000 infant days) of mortality was higher among infants of mothers without medication for opioid use disorder claims than infants of mothers with medication for opioid use disorder claims. Sudden unexpected infant death syndrome was the primary cause of death for infants of mothers with (90.5%) and without (58.1%) medication for opioid use disorder claims., Conclusions: Results highlight the importance of assessing for potential differences in outcomes according to whether infants with neonatal opioid withdrawal syndrome were exposed to medication for opioid use disorder. Efforts to ensure equitable access to medication for opioid use disorder and other support services in pregnancy are needed to promote healthy maternal and infant outcomes., (Copyright © 2022 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Comprehensive fatal overdose prevention requires an understanding of the fundamental causes and context surrounding drug overdose. Using a social determinants of health (SDOH) framework, this descriptive study examined unintentional and self-inflicted (i.e., suicide) overdose deaths in North Carolina (NC), focusing on specific drug involvement and contextual factors. Unintentional and suicide overdose deaths were identified using 2015-2019 NC death certificate data. Specific drug involvement was assessed by searching literal text fields for drug mentions. County-level contextual factors were obtained from NC Institute of Medicine and County Health Rankings, encompassing five SDOH domains (economic stability, social/community context, health care access/quality, education access/quality, neighborhood/built environment). Descriptive statistics were calculated by intent for drug involvement and a variety of contextual factors. During 2015-2019, 9% of NC drug overdose deaths were self-inflicted and 89% were unintentional (2% other/undetermined). Unintentional overdoses largely involved illicit drugs [fentanyl (47%), cocaine (33%), heroin (29%)]. Suicide overdoses frequently involved prescription opioids [oxycodone (18%), hydrocodone (10%)] and antidepressants (32%). Overall, overdose deaths tended to occur in under-resourced counties across all SDOH domains, though unintentional overdoses occurred more often among residents of under-resourced counties than suicide overdoses, with differences most pronounced for economic stability-related factors. There are notable distinctions between unintentional and suicide overdose deaths in demographics and drug involvement, though the assessment of SDOH demonstrated that overdose mortality is broadly associated with marginalization across all domains. These findings highlight the value of allocating resources to prevention and intervention approaches that target upstream causes of overdose (e.g., housing first, violence prevention programs)., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Breast milk feeding is an essential component of safe and effective care of the hospitalized premature infant. There are numerous barriers that impact breast milk expression during a preterm infant's hospitalization. We aimed to explore the experience of using videoconferencing with one's hospitalized premature infant while expressing breast milk. Materials and Methods: We conducted a qualitative study using purposive sampling to recruit lactating parents of premature (<34 weeks) hospitalized infants. We conducted semistructured interviews using an interview guide with 14 open-ended questions regarding the breast milk expression experience. Data collection and analysis were performed iteratively and were analyzed using inductive thematic analysis with a constant comparative approach. Data were organized into themes. Interview recruitment was discontinued when thematic saturation was reached. Results: Seventeen participants completed the interviews and four themes were identified: (1) videoconferencing promotes bonding and connection with the hospitalized infant, (2) videoconferencing provides motivation to pump, (3) videoconferencing reminds participants of the realities of separation from their infant, and (4) videoconferencing connects the whole family to the hospitalized infant. Conclusions: Users of videoconferencing with their hospitalized neonate reported an improved pumping experience while expressing milk for their premature infant. Videoconferencing is also a tool that can connect the whole family to the infant. This study was registered at clinicaltrials.gov (clinicaltrials.gov Identifier: NCT03957941) under the title "FamilyLink and Breastfeeding."

The objective of this study was to build on existing qualitative research to estimate the association of prenatal substance use with prenatal and postpartum care. We used data from the 2016-2019 Pregnancy Risk Assessment Monitoring System for 9 states. We conducted adjusted linear regression to compare month of gestation of first prenatal visit and adjusted logistic regression to compare receipt of adequate prenatal care and a postpartum healthcare visit among women who reported prenatal use of any opioids, prescription opioids, marijuana, and illicit drugs to those who did not report use of each substance. Women who reported prenatal use of any opioids (Risk Difference(RD) = 0.16; 95% Confidence Interval (CI) = 0.04, 0.28), prescription opioids (RD = 0.16; 95% CI = 0.04, 0.28), marijuana (RD = 0.25; 95% CI = 0.10, 0.41) and illicit drugs (RD = 0.52; 95% CI = 0.09, 0.95) initiated prenatal care later than those who did not report use of each substance. Women who reported prenatal use of any opioid (Odds Ratio (OR) = 0.82; 95% CI = 0.68, 1.00), prescription opioids (OR = 0.84; 95% CI = 0.69, 1.02), marijuana (OR = 0.59; 95% CI = 0.48, 0.73) and illicit drugs (OR = 0.29; 95% CI = 0.20, 0.42) were less likely to receive adequate prenatal care. Women who reported prenatal use of any opioid (OR = 0.82, 95% CI = 0.65, 1.04), prescription opioids (OR = 0.83; 95% CI = 0.66, 1.05), marijuana (OR = 0.65; 95% CI = 0.51, 0.82) and illicit drugs (OR = 0.47; 95% CI = 0.30, 0.72) had a lower likelihood of a postpartum visit than those who did not report use of each substance. Results indicate potential intervention points for pregnant women who use substances., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Prior research has identified common injuries among children who experience child maltreatment; however, most of this work has focused on inpatient settings and has excluded many cases of neglect. This study examines the prevalence of injuries that occur prior to a diagnosis of child maltreatment, as well as the proportion of children with well-child visits prior to the injury and child maltreatment diagnosis. Based on a secondary analysis of Medicaid data from four states, we found that among infants with 12 months of continuous enrollment ( N = 4817), 30.6% of those diagnosed with maltreatment were previously diagnosed with an injury. Among infants diagnosed with child maltreatment, 88.4% had at least one well-child visit prior to the maltreatment diagnosis. Among children with a maltreatment diagnosis and a prior injury, 84% had at least one well-child visit preceding the injury. These results indicate that most children had at least one well-child visit prior to being diagnosed with child maltreatment or an injury, indicating opportunities for prevention.

State and federal policies regarding substance use in pregnancy, specifically whether a notification to child protective services is required, continue to evolve. To inform practice, policy, and future research, we sought to synthesize and critically evaluate the existing literature regarding the association of prenatal substance exposure with child maltreatment. We conducted a comprehensive electronic search of PubMed, Web of Science, PsycInfo, CHINAL, Social Work Abstracts, Sociological Abstracts, and Social Services Abstracts. We identified 30 studies that examined the association of exposure to any/multiple substances, cocaine, alcohol, opioids, marijuana, and amphetamine/methamphetamine with child maltreatment. Overall, results indicated that substance exposed infants have an increased likelihood of child protective services involvement, maternal self-reported risk of maltreatment behaviors, hospitalizations and clinic visits for suspected maltreatment, and adolescent retrospective self-report of maltreatment compared to unexposed infants. While study results suggest an association of prenatal substance exposure with child maltreatment, there are several methodological considerations that have implications for results and interpretation, including definitions of prenatal substance exposure and maltreatment, study populations used, and potential unmeasured confounding. As each may bias study results, careful interpretation and further research are warranted to appropriately inform programs and policy.

Introduction: Poverty broadly and financial stress owing to housing insecurity specifically are associated with an increased risk of child maltreatment. Therefore, it is possible that a program designed to increase access to affordable housing such as the Low-Income Housing Tax Credit program could reduce child maltreatment. The purpose of this study is to examine the association of the availability of housing units through the Low-Income Housing Tax Credit Program with the rates of child maltreatment reports, including reports for physical abuse and neglect, at the state and county levels., Methods: Data were from the 2005‒2015 National Child Abuse and Neglect Data System and the Low-Income Housing Tax Credit Program database. Generalized estimating equations were conducted in 2021 to calculate rate ratios and 95% CIs, adjusting for relevant confounders., Results: At the state level, ≥25 compared with <25 Low-Income Housing Tax Credit Program units per 100,000 population was associated with a lower rate of overall child maltreatment (i.e., neglect and physical abuse; rate ratio=0.96, 95% CI=0.93, 0.99), neglect (rate ratio=0.96, 95% CI=0.94, 0.99), and physical abuse (rate ratio=0.96, 95% CI=0.93, 1.00) reports. Similarly, at the county level, ≥1 compared with 0 Low-Income Housing Tax Credit Program units per 100,000 population was associated with a lower rate of overall child maltreatment (rate ratio=0.94, 95% CI=0.92, 0.97), neglect (rate ratio=0.96, 95% CI=0.93, 0.98), and physical abuse (rate ratio=0.94, 95% CI=0.91, 0.98) reports., Conclusions: Increasing access to affordable housing may be an effective strategy to reduce child maltreatment at both the state and county levels., (Copyright © 2022 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: "Lock-in" programs are used by health insurers to reduce the risk of adverse outcomes that can result from overutilization of opioids and other controlled substances. We estimated the association between North Carolina's Medicaid lock-in program and use of opioid use disorder treatment-related services and naloxone dispensing., Methods: A cohort study of individuals who became eligible for a Medicaid lock-in program between December 2016 and December 2019 (n = 21,220). We compared those enrolled in the program to those eligible but not enrolled. Outcomes included rate of medication for opioid use disorder (MOUD); rate of other substance use disorder treatment (e.g., detoxification); and naloxone dispensing., Results: The majority of beneficiaries enrolled in the program had recently received MOUD or other treatment prior to enrollment (59%). After controlling for several potential confounders, the program was associated with slight increases in MOUD use, compared to those eligible but not enrolled (adjusted rate ratio: 1.09, 95% CI: 1.04,1.14). Those enrolled in the program received, on average, 5.4 more days of MOUD per person per year than those eligible but not enrolled (adjusted risk difference: 5.43, 95% CI: 2.49,8.36). Naloxone dispensing was similar and low among those enrolled and not enrolled in the program (7-8%)., Conclusions: Enrollment in a Medicaid lock-in program was associated with a small increase in the number of days with substance use disorder treatment. However, given the high prevalence of opioid use disorder among beneficiaries in the program, findings highlighted considerable opportunity for improvement in treatment utilization and retention and a need for increased naloxone dispensing., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Child maltreatment is a significant public health issue in the United States. Understanding key risk factors for child maltreatment is critical to informing effective prevention. Poverty is an established risk factor for child maltreatment. However, recent research indicates that material hardship (i.e., difficulties meeting basic needs) may serve as a more direct measure of the way in which poverty affects daily life. One form of material hardship that is common among families is housing stress. Previous reviews have summarized the existing literature regarding the association of economic insecurity with child maltreatment, but no reviews have synthesized and critically evaluated the literature specific to the association of various types of housing stress with child maltreatment. We conducted a systematic search of multiple electronic databases to identify peer-reviewed studies conducted in the U.S. regarding the association of housing stress with child maltreatment. We identified 21 articles that used nine distinct measures of housing stress including homelessness or eviction, homeless or emergency shelter stays, foreclosure filing, housing instability, inadequate housing, physical housing risk, living doubled-up, housing unaffordability, and composite housing stress indicators. Overall, results from this body of literature indicate that housing stress is associated with an increased likelihood of caregiver or child self-reported maltreatment, child protective services (CPS) reports, investigated and substantiated CPS reports, out-of-home placements, and maltreatment death. Additional theory-driven research is needed to further our understanding of the contribution of specific types of housing stress to risk for specific types of maltreatment.

Study Objectives: Trauma exposure likely contributes to poor sleep, but relatively few studies have empirically tested this, instead focusing on posttraumatic stress disorder. Moreover, little is known about sex differences in sleep after trauma. The current study used a cross-sectional and retrospective design to test hypotheses that trauma exposure would be associated with subsequent insomnia symptoms, particularly among women, even after accounting for important covariates., Method: Data from Wave 3 (1993-1996) of the Baltimore Epidemiologic Catchment Area Study (N = 1920) were used to examine associations between remote (prior to past year) and recent (past year) trauma and current sleep disturbance (insomnia, hypersomnia symptoms) in the total sample (M age = 55, 63.2% women, 57.7% white), and separately in men and women. Sensitivity analyses were conducted among individuals with no pretrauma sleep disturbance to examine incident sleep disturbance., Results: Among all participants, both remote (odds ratio [OR] = 1.95, 95% confidence interval [CI] [1.34, 2.85]) and recent (OR = 1.94, 95% CI [1.31, 2.87]) trauma exposure were associated with increased odds of insomnia (OR = 2.41, 95% CI [1.54, 3.76]) but not hypersomnia. Associations between trauma and insomnia were particularly strong among women, but null among men. The relationship between trauma exposure and insomnia symptoms persisted among individuals with no pretrauma history of insomnia., Conclusion: Results suggest women may be vulnerable to insomnia symptoms as sequelae of trauma. Future research should examine prospective associations between trauma and sleep in larger samples and how assessment and treatment of insomnia among women trauma survivors reduces the public health impact of trauma and poor sleep., (Copyright © 2021 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: This population-representative study examined the association of Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) with postpartum depressive symptoms among low-income women., Methods: We used data from the 2009 - 2018 Pregnancy Risk Assessment Monitoring System (PRAMS) surveys for 13 Medicaid expansion and 7 non-expansion states. We used a generalized difference-in-differences approach and log-binomial regression models to calculate prevalence ratios (PRs) and 95% confidence intervals (CIs) comparing the likelihood of postpartum depressive symptoms among low-income women (≤138% of the federal poverty level) who delivered in expansion and non-expansion states., Results: Adjusting for state and year fixed-effects and individual- and state-level confounders, low-income women who delivered in Medicaid expansion states had a decreased likelihood of postpartum depressive symptoms compared to low-income women who delivered in non-expansion states (PR = 0.93, 95% CI 0.80, 1.07). Results were largely consistent across multiple sensitivity analysis specifications. Results were robust to falsification tests among women with incomes >138% of the federal poverty level., Conclusion: Our results indicate that Medicaid expansion may be associated with a small reduction in the likelihood of postpartum depressive symptoms. Future research should examine the potential for implementation of multiple supportive policies to achieve larger gains in treatment and prevention., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: An understanding of factors contributing to variation in child welfare outcomes in cases of prenatal substance exposure (PSE) can help identify gaps in research and practice and guide state and agency policy., Objective: To summarize the evidence base and identify critical gaps in the literature, we conducted a scoping review regarding individual- and institutional-level factors associated with child welfare decision-marking across the service continuum and caregivers' perceptions of child welfare involvement in cases of PSE., Participants and Setting: The sample included peer-reviewed studies based in the United States., Methods: We conducted a comprehensive search of four databases for studies investigating 1) sociodemographic, behavioral, policy, or other factors contributing to variation in child welfare outcomes and 2) maternal, family, or provider perceptions of the child welfare process in cases of PSE. We followed an established methodological framework for conducting scoping reviews., Results: Of the 23 articles included in the review, 20 explored variation in decision-making across the child welfare services continuum and three examined caregivers' perceptions of child welfare involvement. At the institutional level, provider characteristics, such as agency capacity, were linked to specific child welfare outcomes including reports and removals. At the individual level, factors such as socioeconomic status, race, and substance type were also associated with outcomes across the service continuum., Conclusions: Child welfare agencies use an unsystematic approach in addressing PSE, contributing to a variation in child welfare outcomes and potentially allowing for bias. This review highlights a need for increased resources and guidance for caseworkers., (Copyright © 2022 Elsevier Ltd. All rights reserved.)