Prior studies have found a substantial risk of persistent opioid use among adolescents and young adults undergoing surgical and dental procedures. It is unknown whether family-level factors, such as long-term opioid use in family members, is associated with persistent opioid use. OBJECTIVE To determine whether long-term opioid use in family members is associated with persistent opioid use among opioid-naive adolescents and young adults undergoing surgical and dental procedures. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from a commercial insurance claims database for January 1, 2010, to June 30, 2016, to study 346 251 opioid-naive patients aged 13 to 21 years who underwent 1 of 11 surgical and dental procedures and who were dependents on a family insurance plan. EXPOSURES Long-term opioid use in family members, defined as having 1 or more family members who (1) filled opioid prescriptions totaling a 120 days' supply or more during the 12 months before the procedure date or (2) filled 3 or more opioid prescriptions in the 90 days before the procedure date. MAIN OUTCOMES AND MEASURES The main outcome measure was persistent opioid use, defined as 1 or more postoperative prescription opioid fills between 91 and 180 days among patients with an initial opioid prescription fill. Generalized estimating equations with robust SEs clustered at the family level were used to model persistent opioid use as a function of long-term opioid use among family members, controlling for procedure, total morphine milligram equivalents of the initial fill, and patient and family characteristics. RESULTS A total of 346 251 patients (mean [SD] age, 17.0 [2.3] years; 175 541 [50.7%] female) were studied. Among these patients, 257 085 (74.3%) had an initial opioid fill. Among patients with an initial opioid fill, 11 016 (4.3%) had long-term opioid use in a family member. Persistent opioid use occurred in 453 patients (4.1%) with long-term opioid use in a family member compared with 5940 patients (2.4%) without long-term opioid use in a family member (adjusted odds ratio, 1.54; 95% CI, 1.39-1.71). CONCLUSION AND RELEVANCE The findings suggest that long-term opioid use among family members is associated with persistent opioid use among opioid-naive adolescents and young adults undergoing surgical and dental procedures. Physicians should screen young patients for long-term opioid use in their families and implement heightened efforts to prevent opioid dependence among patients with this important risk factor.

Objectives To assess the joint effects of water and sanitation infrastructure, whether they are redundant services preventing the same cases of diarrheal disease, act independently, or act synergistically; and to assess how these effects vary by country and over time. Methods We used data from 217 Demographic and Health Surveys conducted in 90 countries between 1986 and 2013. We used modified Poisson regression to assess the impact of water and sanitation infra-structure on the prevalence of diarrhea among children under five. Results The impact of water and sanitation varied across surveys, and adjusting for socioeconomic status drove these estimates towards the null. Sanitation had a greater effect than water infrastructure when all 217 surveys were pooled; however, the impact of sanitation diminished over time. Based on survey data from the past ten years, we saw no evidence for benefits in improving drinking water or sanitation alone, but we estimated a 6% reduction of both combined (prevalence ratio = 0.94, 95% confidence limit 0.91-0.98). Conclusions Water and sanitation interventions should be combined to maximize the number of cases of diarrheal disease prevented in children under five. Further research should identify the sources of variability seen between countries and across time. These national surveys likely include substantial measurement error in the categorization of water and sanitation, making it difficult to interpret the roles of other pathways.

The use of immunosuppressive drugs is a potential risk factor for infectious disease, including COVID-19 illness. 1 For instance, although dexamethasone improves survival among patients with severe COVID-19 infections, 2 long-term glucocorticoid use may increase the risk of hospitalization among patients who contract COVID-19. 3 A prior study relying on patient self-report estimated that 2.7% of US adults were immunosuppressed in 2013, but the study did not explore features associated with use of immunosuppressive medications. 4 In this cross-sectional study, we used direct pharmaceutical claims to describe the contemporary prevalence of drug-induced immunosuppression in a large cohort of US adults. MethodsDeidentified data from Clinformatics Data Mart (Optum, Inc), a national commercial claims database, were used in this cross-sectional study. Adults aged 18 through 64 years who had continuous commercial medical insurance coverage from January 1, 2017, through December 31, 2019, were included. We used 2017 data to establish baseline comorbid conditions; 2018 and 2019 data were used to determine drug-induced immunosuppression. We defined drug-induced immunosuppression as use of any of the following regimens in a 365-day period: (1) 1 dose or more of an antineoplastic immunosuppressive drug; (2) 30 days or more of oral glucocorticoids; (3) 90 days of any other oral or subcutaneous immunosuppressive drug; or (4) 2 doses of intravenous, noncorticosteroid immunosuppressive drugs. We excluded single-dose intravenous corticosteroids, which are often used as premedication for infusions. We classified immunosuppressive drugs into 6 categories as follows: oral corticosteroids, methotrexate, other disease-modifying antirheumatic drugs and transplant antirejection medications, tumor necrosis factor inhibitors, antineoplastic agents, and other biological product medications and Janus kinase inhibitors (eTable 1 in the Supplement). We used Agency for Healthcare Research and Quality Clinical Classifications Software Refined (CCSR) to group International Statistical Classification of Diseases and Related HealthProblems, Tenth Revision diagnosis codes for common medical conditions associated with druginduced immunosuppression and common primary diagnoses (eTable 2 in the Supplement). This study was granted exempt status, including a waiver of informed patient consent for use of deidentified secondary data, by the University of Michigan Institutional Review Board. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies. ResultsOf the 3 169 441 continuously enrolled patients, 89 925 (2.8%) met the criteria for drug-induced immunosuppression during the period January 1, 2018, through December 31, 2019. Table 1 shows baseline patient characteristics. Most recipients of immunosuppressive drugs were older (median age, 53 years; interquartile range, 50-59 years), and women (55 043 [61.2%]).The most commonly

IMPORTANCE Dentists commonly prescribe opioids to relieve pain after tooth extraction.Understanding the differences in patient-reported outcomes between opioid users and nonusers could encourage the adoption of more conservative and appropriate prescribing practices in dental medicine.OBJECTIVE To evaluate whether pain and satisfaction scores reported by patients who used opioids after tooth extraction were similar to the levels reported by patients with no opioid use. DESIGN, SETTING, AND PARTICIPANTSThis quality improvement study was conducted in the 14 dental clinics of the University of Michigan School of Dentistry. Eligible adult patients of these clinics who underwent routine or surgical extractions between June 1, 2017, and December 31, 2017, were contacted by telephone within 6 months of the procedure. Patients were surveyed about the type of extraction, use of prescription opioid (if given), use of nonopioid analgesics, pain levels, and satisfaction with care after the procedure. Data analysis was conducted from February 1, 2018, to July 31, 2018. MAIN OUTCOMES AND MEASURES The primary outcome was self-reported pain as assessed by the question, "Thinking back, how would you rate your pain in the first week after your dental procedure?" with a 4-point pain scale of no pain, minimal pain, moderate pain, or severe pain. Secondary outcomes included self-reported satisfaction with care as assessed by a Likert scale ranging from 1 to 10, in which 1 was extremely dissatisfied and 10 was extremely satisfied. RESULTS The final cohort comprised 329 patients, of whom 155 (47.1%) underwent surgical extraction (mean [SD] age, 41.8 [18.1] years; 80 [51.6%] were men) and 174 (52.9%) underwent routine extraction (mean [SD] age, 52.4 [17.9] years; 79 [45.4%] were men). Eighty patients (51.6%) with surgical extraction and 68 (39.1%) with routine extraction used opioids after their procedure. In both extraction groups, patients who used opioids reported higher levels of pain compared with those who did not use opioids (surgical extraction group: 51 [64.6%] vs 34 [45.3%], P < .001; routine extraction group: 44 [64.8%] vs 35 [33.1%], P < .001). No statistically significant difference in satisfaction was found between groups after surgical extraction (median [interquartile range] scores: 9 [7-10] for nonopioid group vs 9 [8-10] for opioid group) and routine extraction (median [interquartile range] scores: 10 [8-10] for nonopioid group vs 9 [7-10] for opioid group).CONCLUSIONS AND RELEVANCE This study found that patients who used opioids after tooth extraction reported significantly higher levels of pain compared with nonusers, but no difference in satisfaction was observed.

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