Characteristics of US Counties With High Opioid Overdose Mortality and Low Capacity to Deliver Medications for Opioid Use Disorder
Characteristics of US Counties With High Opioid Overdose Mortality and Low Capacity to Deliver Medications for Opioid Use Disorder
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DOI：
10.1001/jamanetworkopen.2019.6373
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发表时间：
2019-06-01
影响因子：
13.8
通讯作者：
Goldstick, Jason E.
中科院分区：
文献类型：
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作者：
Haffajee, Rebecca L.;Lin, Lewei Allison;Goldstick, Jason E.
重要性：美国阿片类药物过量死亡人数继续增加，反映出对阿片类药物使用障碍（OUD）患者的治疗需求日益增加。人们对阿片类药物过量死亡率高但OUD治疗可用性低的县知之甚少。目的：了解美国阿片类药物过量死亡率持续高且OUD药物递送能力低的县的特征。设计、环境和参与者本横断面研究收集了2015年1月1日至2017年12月31日美国3142个县的数据，比较了阿片类药物过量死亡率与2017年OUD药物提供者的可用性（24851名丁丙诺啡豁免临床医生[医生、执业护士和医师助理]、1517个阿片类药物治疗项目[提供美沙酮]和5222名可以开具缓释纳曲酮处方的卫生保健专业人员）。统计分析时间为2018年4月20日至2019年5月8日。人口、劳动力、缺乏保险、道路密度、城市化、阿片类药物处方和区域划分县级特征。主要结局和测量结果变量“阿片类药物高风险县”是一个高（高于全国）阿片类药物过量死亡率和低（低于全国）提供OUD药物的提供者可用性的二元指标。使用空间逻辑回归模型来确定与阿片类药物高风险县的关系。结果3142个县中，751个县（23.9%）阿片类药物过量死亡率较高。2017年，共有1457个县（46.4%）和1328个农村县中的946个（71.2%）缺乏可公开获得的OUD药物提供者。在调整后的模型中，与西北西北中部分区相比，东北中部、山区和南大西洋分区的县成为阿片类药物高危县的几率增加（东北中部：优势比[OR]， 2.21; 95% CI, 1.19-4.12；山区：OR， 4.15; 95% CI, 1.34-12.89；南大西洋：OR， 2.99; 95% CI, 1.26-7.11）。失业率增加1%与该县成为阿片类药物高危县的几率增加相关（OR, 1.09; 95% CI, 1.03-1.15）。每10万人口增加10名初级保健临床医生的县成为阿片类药物高危县的风险降低（OR, 0.89; 95% CI, 0.85-0.93），小城市县（vs大城市）（OR, 0.67; 95% CI, 0.50-0.90）和25岁以下人口增加1%的县（OR, 0.95; 95% CI, 0.92-0.98）也是如此。结论和相关性：OUD药物提供者可得性低、阿片类药物过量死亡率高的县不太可能是小城市，初级保健临床医生密度较低，但更可能在东北、中部、南大西洋或山区，失业率较高。增加药物治疗的策略必须考虑到这些因素。
IMPORTANCE Opioid overdose deaths in the United States continue to increase, reflecting a growing need to treat those with opioid use disorder (OUD). Little is known about counties with high rates of opioid overdose mortality but low availability of OUD treatment.OBJECTIVE To identify characteristics of US counties with persistently high rates of opioid overdose mortality and low capacity to deliver OUD medications.DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study of data from 3142 US counties from January 1, 2015, to December 31, 2017, rates of opioid overdose mortality were compared with availability in 2017 of OUD medication providers (24 851 buprenorphine-waivered clinicians [physicians, nurse practitioners, and physician assistants], 1517 opioid treatment programs [providing methadone], and 5222 health care professionals who could prescribe extended-release naltrexone). Statistical analysis was performed from April 20, 2018, to May 8, 2019.EXPOSURES Demographic, workforce, lack of insurance, road density, urbanicity, opioid prescribing, and regional division county-level characteristics.MAIN OUTCOME AND MEASURES The outcome variable, "opioid high-risk county," was a binary indicator of a high (above national) rate of opioid overdose mortality with a low (below national) rate of provider availability to deliver OUD medication. Spatial logistic regression models were used to determine associations with being an opioid high-risk county.RESULTS Of 3142 counties, 751 (23.9%) had high rates of opioid overdose mortality. A total of 1457 counties (46.4%), and 946 of 1328 rural counties (71.2%), lacked a publicly available OUD medication provider in 2017. In adjusted models, compared with the West North Central division, counties in the East North Central, Mountain, and South Atlantic divisions had increased odds of being opioid high-risk counties (East North Central: odds ratio [OR], 2.21; 95% CI, 1.19-4.12; Mountain: OR, 4.15; 95% CI, 1.34-12.89; and South Atlantic: OR, 2.99; 95% CI, 1.26-7.11). A 1% increase in unemployment was associated with increased odds (OR, 1.09; 95% CI, 1.03-1.15) of a county being an opioid high-risk county. Counties with an additional 10 primary care clinicians per 100 000 population had a reduced risk of being opioid high-risk counties (OR, 0.89; 95% CI, 0.85-0.93), as did counties that were micropolitan (vs metropolitan) (OR, 0.67; 95% CI, 0.50-0.90) and those that had an additional 1% of the population younger than 25 years (OR, 0.95; 95% CI, 0.92-0.98).CONCLUSIONS AND RELEVANCE Counties with low availability of OUD medication providers and high rates of opioid overdose mortality were less likely to be micropolitan and have lower primary care clinician density, but were more likely to be in the East North Central, South Atlantic, or Mountain division and have higher rates of unemployment. Strategies to increase medication treatment must account for these factors.