Sandra Fyfe

Prescription and illicit drug testing rates declined during the COVID-19 pandemic in 2020, according to a study published in the journal 

Many in-person health services were unavailable following pandemic stay-at-home orders, including in-person drug testing, to prevent the spread of the virus.

Harvey W Kaufman, MD, MBA, FCAP, senior medical director, information ventures and office of chief medical officer at Quest Diagnostics conducted the study along with colleagues. The authors analyzed changes in testing patterns for prescription and illicit drugs at Quest Diagnostics, a national clinical laboratory. Researchers compared data sets from before and during the COVID-19 pandemic by examining urine specimen results from Quest Diagnostics medMATCH® reporting method, which indicates whether provider-prescribed or other drugs are found in the samples.

Study authors used specimens collected between January 1, 2019 and May 16, 2020. Specimens that had no record of age, or that were collected from patients under 18 years of age were excluded. Researchers also excluded specimens with abnormal specimen validity testing results and those that tested negative for drugs. The authors noted that not all specimens were tested for all drugs as choice of test varied among medical providers. A total of 872,762 specimens were used in the study; specimens came from all 50 US States and the District of Columbia.

Kaufman and colleagues said the volume of weekly drug testing declined by 70% from the baseline of January 1, 2019 to March 29, 2020 before rebounding in the following weeks. Testing showed increases in substance use during the pandemic: positive tests for non-prescribed fentanyl rose by 35%, and positive tests for heroin rose by 44%. In addition, the authors reported that “Positivity for non-prescribed fentanyl increased significantly among patients positive for other drugs: by 89% for specimens positive for amphetamines; 48% for benzodiazepines; 34% for cocaine; and 39% for opiates (

for all comparisons).”1 There also was an increase in dangerous drug combination use, the authors said. Researchers suggested these rates are a direct result of the COVID-19 pandemic, and said that social distancing, stress, loneliness, depression, and job loss contributed to increases. They also said isolation makes drug use more dangerous during this time, as it decreases the chances of a bystander being present to call for help or administer naloxone in the event of an overdose.

Test positivity rates stayed the same for many other non-prescribed drugs or decreased when compared to patterns seen prior to COVID-19. “Models adjusting for potential confounding variables, including medication-assisted treatment and treatment at a substance use disorder facility indicated that the risk for non-prescribed fentanyl positivity rose by more than 50% during the pandemic,” study authors said.1

They also reported an increase in submissions to the Overdose Mapping Application Program (ODMAP); suspected overdose deaths rose 18% in March, 29% in April, and 42% in May when compared to the same period in 2019. ODMAP also reported an overall 11.4% increase in overdose deaths and an 18.6% increase in non-fatal overdoses in 2020.

® Kaufman said an important takeaway for providers is that “the pandemic and the associated social restrictions and stresses may have led many patients to engage in potentially dangerous drug behaviors.” He said that in June and September 2020 the American Society of Addiction Medicine (ASAM) issued guidance suggesting other ways of monitoring drug adherence that could be used instead of laboratory testing. “Predicting which patients are taking drugs can be challenging.Patient evaluation and drug testing, especially urine drug testing, are critical tools to help establish what drugs patients may be using,” Kaufman said.

For important steps that need to be taken following this study, Kaufman told 

® that providers “need to re-engage with patients who have skipped or delayed healthcare. Although this specific study focused on the epidemic of drug misuse, patients have postponed many healthcare visits.” He said that to get patients active in their care again, “we need to find creative ways, such as with telemedicine, to check in with patients who remain hesitant or in denial.”

in a separate Quest Diagnostics Health Trends

™ survey, researchers worked with the Harris Poll and found that 2 in 5 patients were concerned they had an undiagnosed medical condition. “With delayed care, some patients will present at more advanced stages of disease, will require more aggressive therapy, and have worse outcomes. We have observed decreases in cancer diagnoses, testing for sexually transmitted infections, and most other routine laboratory testing,” Kaufman explained in the interview.

“We recognize the role that women often have as the central caregiver in their immediate and extended families. Women are more likely to prioritize others’ health over their own. We need to address their needs so they can be healthy themselves and can continue to support their families and communities,” Kaufman told 

®. He said the pandemic has illuminated health inequities and collaboration is needed to find new ways to provide health care services to all who are in need.

"And we must not forget ourselves,” Kaufman stressed.“As healthcare providers, we need to take care of ourselves including addressing our personal needs for healthcare and need to take time to recuperate – to avoid burnout.”

He said drug use may be in response to the stresses everyone faces, and the pandemic has exacerbated these stresses.“Medical evaluation, testing, and treatment are critical if we are to combat the drug epidemic now and moving forward as we continue to battle with COVID-19.”

Niles JK, Gudin J, Radcliff J, Kaufman HW. The opioid epidemic within the COVID-19 pandemic: drug testing in 2020. 

 2021;24(S1):S43-S51. doi:10.1089/pop.2020.0230

Articles

Lower levels of testing and higher positivity rates, higher rates of dangerous drug combination use, and increases in fatal and non-fatal overdoses during the coronavirus disease 2019 (COVID-19) pandemic reveal a need for more resources to address the opioid epidemic in the United States.

Reduced Testing, Higher Positivity Rates for Prescription and Illegal Drugs During the COVID-19 Pandemic in 2020

Patients with breast cancer who had 2 recent, consecutive mammography scans before receiving their diagnosis saw a 49% reduction in mortality and a 50% lower chance of death after 10 years than patients who did not have screenings, according to a study published in 

. Twice-screened women also had a 22% to 33% death reduction range compared with women who had a single screening prior to receiving a diagnosis of breast cancer.

The study was funded by the American Cancer Society. Previous studies had examined only the effect of a single screening on death rates following breast cancer diagnosis.

Investigators examined participation data from 549,091 Swedish women from 1992 to 2016 from 9 counties who were eligible for mammography. The participants ranged in age from 40 to 69 years, with mean age of 58.9 years. 

These data were connected to data from registries and regional cancer centers, which included breast cancer diagnosis, cause, and date of death, according to the authors. Breast cancer mortality data were obtained from the Swedish Cause of Death Register of the Swedish National Board of Health and Welfare.

During the study period, participants received a letter inviting them for mammography with a prebooked appointment. In Sweden, women aged 40 to 54 years are recommended to get a scan once every 18 months, and women aged 55 to 69 years are recommended to be screened once every 24 months. 

However, investigators noted that screening age ranges can vary by county. Urban screening participation rates in mammography screening are 70%, whereas in more rural areas there is a 90% participation rate, investigators said.

Investigators calculated breast cancer mortality based on the number of screenings and the timing of the scans. Participants were divided into 4 screening groups prior to receiving a diagnosis of breast cancer: serial participants (392,135), who had their last 2 scheduled screenings before receiving a diagnosis; intermittent participants (41,746), who went to their last scan but not the next-to-last screening; lapsed participants (30,945), who had their next-to-last scan but not the last scan; and serial nonparticipants (84,265), who did not have their last 2 screenings.

Investigators calculated rate data using Poisson regression and produced relative risks (RRs) and 95% CIs for 9 combined counties, according to the authors. A significant difference was considered to be 

 <.05. “The 2 end points were analyzed according to the different participation groups and were offset by the person-years of observation,” the study’s authors wrote.

Investigators reported 3995 deaths during the study period. Participants who attended both screenings had a 49% reduction in the risk of death and 50% lower risk of death after 10 years, according to the authors. “We found substantial and significant reductions for both mortality from breast cancer (relative risk [RR], 0.51; 95% CI: 0.48, 0.55; 

 <.001) and incidence of breast cancers proving fatal within 10 years (RR, 0.50; 95% CI: 0.46, 0.55; 

 <.001) for [those] who had participated in both of their previous 2 screening examinations (serial participants) compared with [those] who did not attend either of their last 2 screening examinations (serial nonparticipants),” the authors wrote.

 While reductions were smaller in intermittent (33%)and lapsed participants (28%), the investigators noted the decrease was still significant.

“Missing even 1 screening examination confers a significant increase in risk. This is an important message for women in the screening age groups, their referring physicians, and public health decision makers,” the authors concluded.

Duffy SW, Tabár L, Yen AMF, et al. Beneficial effect of consecutive screening mammography examinations on mortality from breast cancer: a prospective study. 

. March 2, 2021. doi:10.1148/radiol.2021203935

Tabár L, Dean PB, Chen THH, et al. The incidence of fatal breast cancer measures the increased effectiveness of therapy in women participating in mammography screening. 

 2019;125(4):515–523. doi:10.1002/cncr.31840

Duffy SW, Tabár L, Yen AMF, et al. Mammography screening reduces rates of advanced and fatal breast cancers: results in 549,091 women. 

 2020;126(13):2971-2979. doi:10.1002/cncr.32859

Missing just 1 screening can lead to significant increase in risk, investigators say.

Survival Rates Increase When Patients Have 2 Mammograms Prior to Receiving Breast Cancer Diagnosis 

Hypertensive disorders of pregnancy (HDPs), particularly gestational hypertension and preeclampsia, increase a woman’s risk of premature death, especially from cardiovascular disease, according to a study in the 

Journal of the American College of Cardiology

. The risk remained even for women who were not diagnosed with chronic hypertension.

HDPs are one of the most frequent health challenges in pregnant women, occurring in about 10% of pregnancies throughout the world. The four categories of HDPs are gestational hypertension (GHTN), preeclampsia, chronic hypertension, and chronic hypertension with superimposed preeclampsia. Of these, preeclampsia and GHTN that occur at or after 20 weeks are leading causes of perinatal and maternal morbidity and mortality.

Jorge E Chavarro, MD, ScD, of the department of nutrition and the department of epidemiology, both at the Harvard T.H. Chan School of Public Health in Boston, Massachusetts and of the Channing Division of Network Medicine in the department of medicine at Brigham and Women's Hospital, Harvard Medical School also in Boston, served as lead author on the study. Chavarro and colleagues performed the study to examine the association between HDPs, particularly GHTN and preeclampsia, and a subsequent link to chronic hypertension and risk of premature death.

They examined data from 88,395 parous nurses between the ages of 25 and 42 who participated in the 

 between 1989-2017. This study collected data about lifestyle, health conditions, and reproductive characteristics over a period of 30 years. It focused on HDPs, particularly gestational hypertension and preeclampsia. Researchers used Cox proportional hazards models that were adjusted for relevant confounders to estimate confidence intervals and hazard ratios for connections between premature mortality and HDPs.

Using the Nurse’s Health Study II, the authors divided the women into 4 groups: no HDPs and chronic hypertension, HDPs only, chronic hypertension only, or both HDPs and subsequent chronic hypertension.

Researchers said 14% of women (12,405) had HDPs in at least one pregnancy. Of the 88,395 women in the study, 2,387 (2.7%) died before age 70 in 28 years of follow-up. Cancer accounted for 1,141 deaths, while CVD accounted for 212 deaths. According to the authors, during follow-up HDPs, either preeclampsia or GHTN was associated with a 1.31 hazard ratio for early death (95% CI: 1.18 to 1.46) and a 42% increase in premature death. 

Researchers said the association remained even after adjusting for cofounders and for reproductive characteristics, diet, and lifestyle post-pregnancy. Women with preeclampsia and/or GHTN had a higher baseline BMI, chronic hypertension, gestational diabetes, and parental history of myocardial infarction/stroke.

“Relations were strongest for CVD-related mortality (HR: 2.26; 95% CI: 1.67 to 3.07). The association between HDPs and all-cause premature death persisted, regardless of the subsequent development of chronic hypertension (HR: 1.20 [95% CI: 1.02 to 1.40] for HDPs only and HR: 2.02 [95% CI: 1.75 to 2.33] for both HDPs and subsequent chronic hypertension),” researchers reported.

According to the authors, HDP had more than twice the risk of premature CVD mortality. For the development of chronic hypertension, researchers saw a higher risk of all-cause premature CVD mortality in HDPs-only patients, chronic hypertension alone, and both HDPs and subsequent chronic hypertension.

“Our results suggest that HDPs, either GHTN or preeclampsia, was associated with a greater risk of premature mortality, especially CVD-related deaths, even in the absence of chronic hypertension," Chavarro said in the 

. "Our results highlight the need for clinicians to screen for the history of HDPs when evaluating CVD morbidity and mortality risk of their patients."

This study adds to data that health conditions in pregnancy affect women throughout their lives. A study also published in the 

Journal of the American College of Cardiology 

found increased rates of cardiac complications in women with obesity versus women of normal weight.

Candice Silversides, MD, of the division of cardiology at the University of Toronto’s Pregnancy and Heart Disease Program at Mount Sinai and Toronto General Hospitals in Toronto, Ontario, and co-author of this additional study said in the same 

, "Pregnant women with heart disease and obesity should be educated about these risks, and health care providers should ensure that dietary advice, weight gain recommendations, and that obesity and other comorbidities are addressed as part of routine care.

"Postpartum surveillance is important in pregnant women with obesity because of the increased risk of complications during this time period," she added.

Wang YX, Arvizu M, Rich-Edwards JW, et al. Hypertensive disorders of pregnancy and subsequent risk of premature mortality

. 2021;77(10):1302-1312. doi:10.1016/j.jacc.2021.01.018

Pfaller B, Siu SC, D'Souza R, et al. Impact of obesity on outcomes of pregnancy in women with heart disease. 

 2021;77(10):1317-1326. doi:10.1016/j.jacc.2021.01.010

Women diagnosed with hypertensive disorders of pregnancy have an increased risk of premature mortality, particularly from cardiovascular disease.

Pregnancy Hypertensive Disorders Increase Risk of Premature Death

Young Black women increased safe sex practices and drank less following a series of workshops conducted on weekends that focused on preventing sexually transmitted infections (STIs) and reducing alcohol use, according to a study published in the 

Ralph DiClemente, PhD, of the department of social and behavioral sciences at the School of Global Public Health at New York University, New York, NY and colleagues conducted a randomly assigned, parallel-group comparative treatment efficacy trial. 

The study enrolled 560 African American or Black women from community settings outside night clubs, at public transit stops, and in malls in Atlanta, GA from January 2012 to February 2014. 

Women were between the ages of 18 and 24 who had reported drinking and having unprotected vaginal or anal sex.

DiClemente and colleagues used a previously established, culturally tailored program that addressed STI prevention called Horizons, a CDC-designated best practices HIV prevention program, as a framework to which they added curriculum regarding alcohol use.

Women were assigned to 1 of the following groups: the Horizons group that met for 5 hours on 2 consecutive Saturdays and had sexual health programming only; the Horizons+, which followed the Horizons group but also added a 1-hour session on alcohol use that used motivational enhancement therapy; and a control group that had a 1-hour session that included a video, a question-and-answer session, and a discussion group.

After the sessions, the Horizons and Horizons+ groups received calls and texts messages as reminders of what was learned.

Researchers used follow-up assessments to gather data on safe sex, STIs, and drinking, including binge drinking. Alcohol use saw a significant reduction according to the authors, with the Horizons group seeing a 48% decrease, and a 59% decrease in binge drinking in the Horizons+ group. 

While the Horizons group did not differ from the control group in terms of rates of safer sex, the Horizons+ group reported a 45% greater chance of safe sex. Researchers said STI incidence was not reduced, probably because the study population’s rates were low from the start.

“The expanded intervention focusing on risky drinking creates a framework for addressing challenges and problem-solving within sexual partnerships; our findings suggest that using a combined approach of sexual health promotion and alcohol reduction, which reinforce each other, can significantly reduce both risky sex and drinking,” DiClemente said in an 

Study co-author Janet E. Rosenbaum, PhD, of the department of epidemiology and biostatistics at the school of public health at SUNY Downstate Health Sciences University in Brooklyn, NY, told 

® that “gynecologists should address even moderate substance use as a risk factor for unprotected sex.” She said that many women in this study engaged in moderate alcohol use; the majority scored normally on alcohol use disorder screen (AUDIT). 

However, “the intervention that addressed both safe sex and alcohol use was effective in reducing unprotected sex and increasing condom use,” she explained. Rosenbaum recommended that women be advised to drink with friends rather than possible romantic partners. 

Rosenbaum said that because about half of STIs are asymptomatic, “outreach to young women in community settings that includes STI testing can identify infections that might otherwise be undiagnosed.” She added that when Black women do the outreach, the results are most effective.

“Many young Black women attending family planning clinics may seldom use alcohol, less than 3 times in 90 days,” Rosenbaum said. “After initial recruitment efforts at family planning clinics found few women who used alcohol 3 times in 90 days, the intervention team moved recruitment to community settings such as subway stops near local colleges, shopping areas, and by leaving flyers on windshields of cars parked outside dance clubs.” 

She noted that about 25% of the young women recruited in these community settings tested positive for an STI that may have otherwise gone undetected if the women had not received community outreach.

“This intervention was about 10 hours long, spread over 2 Saturdays,” Rosenbaum said. “Clinicians can encourage community groups, colleges, and public health departments to adopt effective interventions like this, in order to supplement the brief counseling in clinic.”

DiClemente RJ, Rosenbaum JE, Rose ES, et al. Horizons and group motivational enhancement therapy: HIV prevention for alcohol-using young black women, a randomized experiment [published online ahead of print, 2021 Feb 23]. 

. 2021;S0749-3797(21)00056-8. doi:10.1016/j.amepre.2020.11.014.

A weekend workshop with a group therapy intervention program promoted safe sex and reduced drinking.

Sandra Fyfe

Articles

Reduced Testing, Higher Positivity Rates for Prescription and Illegal Drugs During the COVID-19 Pandemic in 2020

Survival Rates Increase When Patients Have 2 Mammograms Prior to Receiving Breast Cancer Diagnosis

Pregnancy Hypertensive Disorders Increase Risk of Premature Death

Young Black Women Benefit from Combination Program that Addresses Sexual Health and Alcohol Use