Changes in Opioid and Benzodiazepine Poisoning Deaths After Cannabis Legalization in the US: A County-level Analysis, 2002-2020.

BACKGROUND: Cannabis legalization for medical and recreational purposes has been suggested as an effective strategy to reduce opioid and benzodiazepine use and deaths. We examined the county-level association between medical and recreational cannabis laws and poisoning deaths involving opioids and benzodiazepines in the US from 2002 to 2020. METHODS: Our ecologic county-level, spatiotemporal study comprised 49 states. Exposures were state-level implementation of medical and recreational cannabis laws and state-level initiation of cannabis dispensary sales. Our main outcomes were poisoning deaths involving any opioid, any benzodiazepine, and opioids with benzodiazepines. Secondary analyses included overdoses involving natural and semi-synthetic opioids, synthetic opioids, and heroin. RESULTS: Implementation of medical cannabis laws was associated with increased deaths involving opioids (rate ratio [RR] = 1.14; 95% credible interval [CrI] = 1.11, 1.18), benzodiazepines (RR = 1.19; 95% CrI = 1.12, 1.26), and opioids+benzodiazepines (RR = 1.22; 95% CrI = 1.15, 1.30). Medical cannabis legalizations allowing dispensaries was associated with fewer deaths involving opioids (RR = 0.88; 95% CrI = 0.85, 0.91) but not benzodiazepine deaths; results for recreational cannabis implementation and opioid deaths were similar (RR = 0.81; 95% CrI = 0.75, 0.88). Recreational cannabis laws allowing dispensary sales was associated with consistent reductions in opioid- (RR = 0.83; 95% CrI = 0.76, 0.91), benzodiazepine- (RR = 0.79; 95% CrI = 0.68, 0.92), and opioid+benzodiazepine-related poisonings (RR = 0.83; 95% CrI = 0.70, 0.98). CONCLUSIONS: Implementation of medical cannabis laws was associated with higher rates of opioid- and benzodiazepine-related deaths, whereas laws permitting broader cannabis access, including implementation of recreational cannabis laws and medical and recreational dispensaries, were associated with lower rates. The estimated effects of the expanded availability of cannabis seem dependent on the type of law implemented and its provisions.

Metabolomics of head and neck cancer in biofluids: an integrative systematic review.

INTRODUCTION: Head and neck cancer (HNC) is the fifth most common cancer globally. Diagnosis at early stages are critical to reduce mortality and improve functional and esthetic outcomes associated with HNC. Metabolomics is a promising approach for discovery of biomarkers and metabolic pathways for risk assessment and early detection of HNC. OBJECTIVES: To summarize and consolidate the available evidence on metabolomics and HNC in plasma/serum, saliva, and urine. METHODS: A systematic search of experimental research was executed using PubMed and Web of Science. Available data on areas under the curve was extracted. Metabolic pathway enrichment analysis were performed to identify metabolic pathways altered in HNC. Fifty-four studies were eligible for data extraction (33 performed in plasma/serum, 15 in saliva and 6 in urine). RESULTS: Metabolites with high discriminatory performance for detection of HNC included single metabolites and combination panels of several lysoPCs, pyroglutamate, glutamic acid, glucose, tartronic acid, arachidonic acid, norvaline, linoleic acid, propionate, acetone, acetate, choline, glutamate and others. The glucose-alanine cycle and the urea cycle were the most altered pathways in HNC, among other pathways (i.e. gluconeogenesis, glycine and serine metabolism, alanine metabolism, etc.). Specific metabolites that can potentially serve as complementary less- or non-invasive biomarkers, as well as metabolic pathways integrating the data from the available studies, are presented. CONCLUSION: The present work highlights utility of metabolite-based biomarkers for risk assessment, early detection, and prognostication of HNC, as well as facilitates incorporation of available metabolomics studies into multi-omics data integration and big data analytics for personalized health.

Measuring Relationships Between Proactive Reporting State-level Prescription Drug Monitoring Programs and County-level Fatal Prescription Opioid Overdoses.

BACKGROUND: Prescription drug monitoring programs (PDMPs) that collect and distribute information on dispensed controlled substances have been adopted by nearly all US states. We know little about program characteristics that modify PDMP impact on prescription opioid (PO) overdose deaths. METHODS: We measured associations between adoption of any PDMP and changes in fatal PO overdoses in 2002-2016 across 3109 counties in 49 states and D.C. We then measured changes related to the adoption of "proactive PDMPs," which report outlying prescribing/dispensing patterns and provide broader access to PDMP data by law enforcement. Comparisons were made within 3 time intervals that broadly represent the evolution of PDMPs (2002-2004, 2005-2009, and 2010-2016). We modeled overdoses using Bayesian space-time models. RESULTS: Adoption of electronic PDMP access was associated with 9% lower rates of fatal PO overdoses after three years (rate ratio [RR] = 0.91, 95% credible interval [CI]: 0.88-0.93) with well-supported effects for methadone (RR = 0.86,95% CI: 0.82-0.90) and other synthetic opioids (RR = 0.82, 95% CI: 0.77-0.86). Compared with states with no/weak PDMPs, proactive PDMPs were associated with fewer deaths attributed to natural/semi-synthetic opioids (2002-2004: RR = 0.72 [0.66-0.78]; 2005-2009: RR = 0.93 [0.90-0.97]; 2010-2016: 0.89 [0.86-0.92]) and methadone (2002-2004: RR = 0.77 [0.69-0.85]; 2010-2016: RR = 0.90 [0.86-0.94]). Unintended effects were observed for synthetic opioids other than methadone (2005-2009: RR = 1.29 [1.21-1.38]; 2010-2016: RR = 1.22 [1.16-1.29]). CONCLUSIONS: State adoption of PDMPs was associated with fewer PO deaths overall while proactive PDMPs alone were associated with fewer deaths related to natural/semisynthetic opioids and methadone, the specific targets of these programs. See video abstract at, http://links.lww.com/EDE/B619.

Limiting Alcohol Outlet Density to Prevent Alcohol Use and Violence: Estimating Policy Interventions Through Agent-Based Modeling.

Increasing alcohol outlet density is well-documented to be associated with increased alcohol use and problems, leading to the policy recommendation that limiting outlet density will decrease alcohol problems. Yet few studies of decreasing problematic outlets and outlet density have been conducted. We estimated the association between closing alcohol outlets and alcohol use and alcohol-related violence, using an agent-based model of the adult population in New York City. The model was calibrated according to the empirical distribution of the parameters across the city's population, including the density of on- and off-premise alcohol outlets. Interventions capped the alcohol outlet distribution at the 90th to the 50th percentiles of the New York City density, and closed 5% to 25% of outlets with the highest levels of violence. Capping density led to a lower population of light drinkers (42.2% at baseline vs. 38.1% at the 50th percentile), while heavy drinking increased slightly (12.0% at baseline vs. 12.5% at the 50th percentile). Alcohol-related homicides and nonfatal violence remained unchanged. Closing the most violent outlets was not associated with changes in alcohol use or related problems. Results suggest that focusing solely on closing alcohol outlets might not be an effective strategy to reduce alcohol-related problems.

Prescription Drug Monitoring Programs and Opioid Overdoses: Exploring Sources of Heterogeneity.

BACKGROUND: Prescription drug monitoring program are designed to reduce harms from prescription opioids; however, little is known about what populations benefit the most from these programs. We investigated how the relation between implementation of online prescription drug monitoring programs and rates of hospitalizations related to prescription opioids and heroin overdose changed over time, and varied across county levels of poverty and unemployment, and levels of medical access to opioids. METHODS: Ecologic county-level, spatiotemporal study, including 990 counties within 16 states, in 2001-2014. We modeled overdose counts using Bayesian hierarchical Poisson models. We defined medical access to opioids as the county-level rate of hospital discharges for noncancer pain conditions. RESULTS: In 2010-2014, online prescription drug monitoring programs were associated with lower rates of prescription opioid-related hospitalizations (rate ratio 2014 = 0.74; 95% credible interval = 0.69, 0.80). The association between online prescription drug monitoring programs and heroin-related hospitalization was also negative but tended to increase in later years. Counties with lower rates of noncancer pain conditions experienced a lower decrease in prescription opioid overdose and a faster increase in heroin overdoses. No differences were observed across different county levels of poverty and unemployment. CONCLUSIONS: Areas with lower levels of noncancer pain conditions experienced the smallest decrease in prescription opioid overdose and the faster increase in heroin overdose following implementation of online prescription drug monitoring programs. Our results are consistent with the hypothesis that prescription drug monitoring programs are most effective in areas where people are likely to access opioids through medical providers.

Association Between Prescription Drug Monitoring Programs and Nonfatal and Fatal Drug Overdoses: A Systematic Review.

Background: Prescription drug monitoring programs (PDMPs) are a key component of the president's Prescription Drug Abuse Prevention Plan to prevent opioid overdoses in the United States. Purpose: To examine whether PDMP implementation is associated with changes in nonfatal and fatal overdoses; identify features of programs differentially associated with those outcomes; and investigate any potential unintended consequences of the programs. Data Sources: Eligible publications from MEDLINE, Current Contents Connect (Clarivate Analytics), Science Citation Index (Clarivate Analytics), Social Sciences Citation Index (Clarivate Analytics), and ProQuest Dissertations indexed through 27 December 2017 and additional studies from reference lists. Study Selection: Observational studies (published in English) from U.S. states that examined an association between PDMP implementation and nonfatal or fatal overdoses. Data Extraction: 2 investigators independently extracted data from and rated the risk of bias (ROB) of studies by using established criteria. Consensus determinations involving all investigators were used to grade strength of evidence for each intervention. Data Synthesis: Of 2661 records, 17 articles met the inclusion criteria. These articles examined PDMP implementation only (n = 8), program features only (n = 2), PDMP implementation and program features (n = 5), PDMP implementation with mandated provider review combined with pain clinic laws (n = 1), and PDMP robustness (n = 1). Evidence from 3 studies was insufficient to draw conclusions regarding an association between PDMP implementation and nonfatal overdoses. Low-strength evidence from 10 studies suggested a reduction in fatal overdoses with PDMP implementation. Program features associated with a decrease in overdose deaths included mandatory provider review, provider authorization to access PDMP data, frequency of reports, and monitoring of nonscheduled drugs. Three of 6 studies found an increase in heroin overdoses after PDMP implementation. Limitation: Few studies, high ROB, and heterogeneous analytic methods and outcome measurement. Conclusion: Evidence that PDMP implementation either increases or decreases nonfatal or fatal overdoses is largely insufficient, as is evidence regarding positive associations between specific administrative features and successful programs. Some evidence showed unintended consequences. Research is needed to identify a set of "best practices" and complementary initiatives to address these consequences. Primary Funding Source: National Institute on Drug Abuse and Bureau of Justice Assistance.

Repeal of Comprehensive Background Check Policies and Firearm Homicide and Suicide.

BACKGROUND: In 2016, firearms killed 38,658 people in the United States. Federal law requires licensed gun dealers, but not private parties, to conduct background checks on prospective firearm purchasers with the goal of preventing prohibited persons from obtaining firearms. Our objective was to estimate the effect of the repeal of comprehensive background check laws-requiring a background check for all handgun sales, not just sales by licensed dealers-on firearm homicide and suicide rates in Indiana and Tennessee. METHODS: We compared age-adjusted firearm homicide and suicide rates, measured annually from 1981 to 2008 and 1994 to 2008 in Indiana and Tennessee, respectively, to rates in control groups constructed using the synthetic control method. RESULTS: The average rates of firearm homicide and suicide in Indiana and Tennessee following repeal were within the range of what could be expected, given natural variation (differences = 0.7 firearm homicides and 0.5 firearm suicides per 100,000 residents in Indiana and 0.4 firearm homicides and 0.3 firearm suicides per 100,000 residents in Tennessee). Sensitivity analyses resulted in similar findings. CONCLUSION: We found no evidence of an association between the repeal of comprehensive background check policies and firearm homicide and suicide rates in Indiana and Tennessee. In order to understand whether comprehensive background check policies reduce firearm deaths in the United States generally, more evidence on the impact of such policies from other states is needed. See video abstract at, http://links.lww.com/EDE/B353.

Firearms, alcohol and crime: convictions for driving under the influence (DUI) and other alcohol-related crimes and risk for future criminal activity among authorised purchasers of handguns.

Firearm violence frequently involves alcohol, but there are no studies of misuse of alcohol and risk for future violence among firearm owners. We examined the association between prior convictions for alcohol-related crimes, chiefly driving under the influence (DUI), and risk of subsequent arrest among 4066 individuals who purchased handguns in California in 1977. During follow-up through 1991, 32.8% of those with prior alcohol-related convictions and 5.7% of those with no prior criminal history were arrested for a violent or firearm-related crime; 15.9% and 2.7%, respectively, were arrested for murder, rape, robbery or aggravated assault. Prior alcohol-related convictions were associated with a fourfold to fivefold increase in risk of incident arrest for a violent or firearm-related crime, a relative increase greater than that seen for age, sex or prior violence. Prior convictions for alcohol-related crime may be an important predictor of risk for future criminal activity among purchasers of firearms.

Comprehensive background check policy and firearm background checks in three US states.

BACKGROUND: Comprehensive background check (CBC) policies are hypothesised to reduce firearm-related violence because they extend background checks to private party firearm sales, but no study has determined whether these policies actually increase background checks, an expected intermediary outcome. We evaluate the association between CBC policies and the rates of firearm background checks in three states that recently implemented these policies: Delaware (July 2013), Colorado (July 2013) and Washington (December 2014). METHODS: We used the synthetic control group method to estimate the difference from estimated counterfactual postintervention trends in the monthly rate of background checks per 1 00 000 people for handguns, long guns and both types combined, using data for January 1999 through December 2016. Inference was based on results from permutation tests. We conducted multiple sensitivity analyses to assess the robustness of our results. RESULTS: Background check rates increased in Delaware, by 22%-34% depending on the type of firearm, following enactment of its CBC law. No overall changes were observed in Washington and Colorado. Our results were robust to changes in the comparison group and statistical methods. CONCLUSIONS: The enactment of CBC policies was associated with an overall increase in firearm background checks only in Delaware. Data external to the study suggest that Washington experienced a modest, but consistent, increase in background checks for private party sales, and Colorado experienced a similar increase in checks for sales not at gun shows. Non-compliance may explain the lack of an overall increase in background checks in Washington and Colorado.

[The harm to others from drinking: A population study]. / Daño a terceros producido por el alcohol: resultados de un estudio poblacional en Chile.

BACKGROUND: Alcohol can harm both drinkers and their human environment. Most of research in Chile has focused on the drinker. This work focuses on the damage to others. Governmental expenditures due to drinking are estimated to quadruple the income earned through taxation. AIM: To report the results of a population survey conducted in Chile in 2013 to assess the harm done to others from drinking by a known or unknown drinker. MATERIAL AND METHODS: A household survey of a sample of 1500 subjects living in urban areas, predominantly over 50.000 inhabitants, was conducted by trained interviewers. RESULTS: A significant number of respondents reported that the effect of alcohol consumption by third parties was somewhat (18.7%) or very negative (14.8%). The most frequent negative effects were verbal abuse (37.4%), being bullied (17.4%), feeling fearful at home or in a private meeting (19.6%) and family problems (16.9%). CONCLUSIONS: About one third of Chileans surveyed have suffered negative effects due to alcohol consumption of a known or unknown drinker. This finding signals the need of designing public policies addressed to minimize or prevent collateral effects of drinking.

[Alcohol use and self-reported violent events in Chile]. / Consumo de alcohol y autoinforme de eventos violentos en Chile.

The objective is to examine the association between binge drinking and frequency of alcohol consumption during the last month with self-reported episodes of violence committed by people under the influence of alcohol or other drugs. We carried out a cross-sectional study that uses data from the National Survey on Drug Use on the General Population of Chile of 2010. A sample of 16,000 subjects, from 12 to 64 years of age (mean 35.8 years), representing a population of 9,536,602 individuals (49.5% men and 50.5% women) was used. The dependent variables were: being a victim of assault, aggression or sexual violence. The independent variables were: binge drinking (six or more drinks on one occasion at least once in the month) and the monthly frequency of alcohol consumption. The adjusted prevalence ratio (PR) for men reporting binge drinking (vs. negative reporting) was of 1.85 (95% CI: 1.28 to 2.66) for assault, 2.0 for aggression (1.40 to 2.66), and 1.35 for sexual violence (0.43 to 4.23). Among women, the PR was 2.08 (0.97 to 4.50), 1.61 (0.78 to 3.35) and 1.37 times (0.48 to 3.91), respectively. Regarding the frequency of alcohol use, for each day a month of alcohol consumption the PR increases significantly for aggression among men and for the three victimization variables among women. Men and women who reported frequent alcohol consumption and/or binge drinking had significantly a higher prevalence of episodes of aggression, assault or sexual violence; compared to those who did not report these consumption patterns.

[Validity evidence of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in Chile]. / Evidencia de validez en Chile del Alcohol, Smoking and Substance Involvement Screening Test (ASSIST).

This study aims to psychometrically validate the Chilean version of the Alcohol, Smoking and Substance Involvement Screening Test ASSIST. Specifically, this study is interested in evaluating the reliability, consistency and concurrent and discriminant validity of this instrument. The sample was composed for a total of 400 people from four different settings: treatment centers (residential and ambulatories), primary health care, police stations and companies. The reliability of the ASSIST was high (α = .86 for Alcohol, α = .84 for marijuana and α = .90 for cocaine). The intra class correlation coefficient (ICC) with test-retest comparison was statistically significant for Alcohol (ICC = .66), marijuana (ICC = .74) and cocaine (ICC = .80). There were statistically significant correlations between the ASSIST and the AUDIT score (Pearson’s r = .85), the ASSIST and the ASI-Lite score (r between .66 and .83 for tobacco, alcohol, marijuana and cocaine), and the ASSIST and the SDS score (r = .65). The original cutoff point for high risk detection was 27 points, however, in order to have a better balance between sensitivity and specificity the cut was changed to 21 points. The ASSIST presents good psychometric properties and therefore is a reliable and valid instrument to be used as a mechanism to detect risk levels of substance use in the Chilean population.

Longitudinal trajectories of substance use disorder treatment use: A latent class growth analysis using a national cohort in Chile.

BACKGROUND AND AIMS: Longitudinal studies have revealed that substance use treatment use is often recurrent among patients; the longitudinal patterns and characteristics of those treatment trajectories have received less attention, particularly in the global south. This study aimed to disentangle heterogeneity in treatment use among adult patients in Chile by identifying distinct treatment trajectory groups and factors associated with them. DESIGN: National-level registry-based retrospective cohort. SETTING AND PARTICIPANTS: Adults admitted to publicly funded substance use disorder treatment programs in Chile from November 2009 to November 2010 and followed for 9 years (n = 6266). MEASUREMENTS: Monthly treatment use; type of treatment; ownership of the treatment center; discharge status; primary substance used; sociodemographic. FINDINGS: A seven-class treatment trajectory solution was chosen using latent class growth analysis. We identified three trajectory groups that did not recur and had different treatment lengths: Early discontinuation (32%), Less than a year in treatment (19.7%) and Year-long episode, without recurrence (12.3%). We also identified a mixed trajectory group that had a long first treatment or two treatment episodes with a brief time between treatments: Long first treatment, or immediate recurrence (6.3%), and three recurrent treatment trajectory groups: Recurrent and decreasing (14.2%), Early discontinuation with recurrence (9.9%) and Recurrent after long between treatments period (5.7%). Inpatient or outpatient high intensity (vs. outpatient low intensity) at first entry increased the odds of being in the longer one-episode groups compared with the Early discontinuation group. Women had increased odds of belonging to all the recurrent groups. Using cocaine paste (vs. alcohol) as a primary substance decreased the odds of belonging to long one-episode groups. CONCLUSIONS: In Chile, people in publicly funded treatment for substance use disorder show seven distinct care trajectories: three groups with different treatment lengths and no recurring episodes, a mixed group with a long first treatment or two treatment episodes with a short between-treatment-episodes period and three recurrent treatment groups.

Substance use treatment completion and criminal justice system contact in Chile: A retrospective, linked data cohort study.

BACKGROUND AND AIMS: Substance use treatment (SUT) has shown to be effective in reducing self-reported offending; however, the association between SUT completion and criminal justice system (CJS) contact has been underexplored, especially in Latin America. This study aimed to estimate the association between SUT completion status and (1) any subsequent CJS contact and (2) CJS contact leading to imprisonment, at 1, 3 and 5 years post-discharge, in Chile. DESIGN: Retrospective cohort study using multivariable survival analysis based on linked administrative data from 2010 to 2019. SETTING: This study took place in Chile, where SUT is available at no cost through Chile's publicly funded health-care, and is provided in outpatient and inpatient modalities in public and private centres. PARTICIPANTS: A total of 70 854 individuals received their first SUT from 2010 to 2019. They were mainly males (76.3%), and their main substance used at admission was cocaine paste (39.2%). MEASUREMENTS: SUT completion status included completion, late dropout (≥ 3 months) and early dropout (< 3 months). Outcomes were (1) any CJS contact and (2) CJS contact leading to imprisonment after baseline treatment. We estimated the association between treatment completion and CJS contact through flexible parametric Royston-Parmar models while adjusting for several covariates. FINDINGS: Those who completed SUT (27.2%) were less likely to have any CJS contact at 5 years post-SUT compared with those who dropped out late [with a gap of -9.5%, 95% confidence interval (CI) = -8.7, -10.3] and early (-11.2%, 95% CI = -10.1, -12.3). Also, those who completed SUT were less likely to have CJS contact leading to imprisonment at 5 years post-SUT compared with those who dropped out late (-2.6%, 95% CI = -2.2, -3.1) and early (-4.0%, 95% CI = -3.3, -4.6). These differences were also observed at 1 and 3 years post-SUT for each outcome. CONCLUSIONS: In Chile, completion of substance use treatment appears to be associated with lower probabilities of both any criminal justice system contact and contact leading to imprisonment.

Alcohol-attributable mortality and years of potential life lost in Chile in 2009.

AIMS: The aim of the study was to estimate mortality and years of potential life lost (YPLL) attributable to alcohol consumption in 2009 in Chile. METHODS: The population considered for this study included those 15 years and over. Exposure to alcohol in the population was estimated by triangulating the records of alcohol per capita consumption in Chile with information from the Eighth National Study of Drugs in the General Population (2008). The effect of alcohol consumption on each cause of death (relative risk) was extracted from previously published meta-analyses. With this information we estimated the alcohol-attributable fraction (AAF) and deaths and YPLL due to alcohol consumption. The confidence intervals for the AAF were estimated with Monte Carlo sampling using the estimated variances of the exposure prevalence and relative effect. RESULTS: The estimated total number of deaths attributable to alcohol consumption was 8753 (95% CI: 6257, 11,584) corresponding to 9.8% (95% CI: 7.01%, 12.98%) of all deaths in Chile in 2009. The total estimated YPLL attributable to alcohol were 195,475 (95% CI: 164,287, 227,726), corresponding to 21.5% (95% CI: 18.1%, 25.0%) of total YPLL for that year in Chile. CONCLUSION: Alcohol consumption is a major risk factor and accounts for nearly one of ten deaths in Chile. These results may be used to guide the design of public health policies and evaluations.

Does substance use disorder treatment completion reduce the risk of treatment readmission in Chile?

BACKGROUND: Recovery from substance use disorders (SUD) often entails multiple treatment episodes, which clashes with a context of a treatment system with limited resources and long waiting. Treatment retention and completion have been pointed out as key elements for sustainable achievement; however, most of the evidence generated focuses on opioids and injected substances, which is hardly transferable to the Latin American context. OBJECTIVES: This study aims to estimate the effect of SUD treatment completion on the risk of being readmitted to a SUD treatment in Chile. METHODS: We conducted a retrospective analysis on a database of 107,559 treatment episodes from 85,048 adult patients admitted to SUD treatment during 2010-2019 in Chile. We adjusted two separate Prentice Williams and Petersen Gap Time models, to explore the association between treatment completion (vs. non-completion) and up to the third treatment readmission among residential and ambulatory modalities while controlling for time-varying covariates. To examine whether the effect of treatment completion differs between events, we included an interaction term with the stratification variable. RESULTS: We found that completing the treatment cuts readmission risk for the first event by 17% (Average Hazard Ratio [95% CI] = 0.83 [0.78, 0.88]) and by 14% for the second entry (Average Hazard Ratio [95% CI] = 0.86 [0.78, 0.94]) in ambulatory treatments. We did not find evidence that completing a treatment reduces the readmission risk for residential treatments or third attempts in ambulatory ones. CONCLUSION: Treatment completion was associated with benefits in cutting readmission risk for the first and second episodes in ambulatory treatments among Chilean adults. It is important to explore different mechanisms than treatment retention for residential treatments.

Evidence-based policymaking: Lessons from the Chilean Substance Use Treatment Policy.

BACKGROUND: Evidence-based policymaking is a guiding paradigm of substance use treatment (SUT) policy, that seeks to prioritise scientific criteria over other concerns (e.g., economic, political) when addressing policy decisions. We provide a comprehensive analysis of the context and mechanisms that enable and constrain evidence to improve the Chilean SUT policy and draw some lessons that might be useful to other contexts, particularly low and middle-income countries. METHODS: This study relied on an interpretive case study design based on the principles of realist evaluation. We included interviews (N≈17) with international, national, regional, and local policymakers and experts, as well as technical and clinical teams from private and public care SUT providers in Chile. RESULTS: Complex sets of institutional realities and notions of 'evidence' shared by actors - between other elements- guide the SUT policy decisions and shape the specific type of evidence considered relevant. Evidence is understood in Chile in narrow terms, and national non-experimental research is often overlooked. This limits the possibility of studying other research questions that could contribute to improving and informing SUT policy. CONCLUSIONS: In contexts where addiction research resources are limited, it appears necessary to re-frame the notion of "evidence", to consider relevant national non-experimental knowledge to strengthen SUT policy and achieve its goals. Indeed, this study is an example of how methodological approaches, such as case analysis, can provide a powerful heuristic alternative contribution to the local and global mental health debate.

Does recreational cannabis legalization change cannabis use patterns? Evidence from secondary school students in Uruguay.

BACKGROUND AND AIMS: In 2013, Uruguay became the first country to legalize and regulate the production and distribution of cannabis for recreational use. We measured whether Uruguay's non-commercial model of recreational cannabis legalization was associated with changes in the prevalence of risky and frequent cannabis use among secondary school students. DESIGN: We used data from repeated cross-sectional surveys of secondary students in Uruguay and Chile (2007-2018). Using a difference-in-difference approach, we evaluated changes in the prevalence of past-year, past-month, any risky and frequent cannabis use following enactment (2014) and implementation (2016) of cannabis legalization among the full sample of secondary students and among students who reported past-year/month use. We examined changes separately for students ages 12 to 17, and students for whom cannabis became legally accessible, ages 18 to 21. SETTING: Uruguay and Chile (2007-2018). PARTICIPANTS: Secondary school students in 8th, 10th and 12th grade (n = 204 730). MEASUREMENTS: Past-year and past-month cannabis use; any risky cannabis use measured with the Cannabis Abuse Screening Test (CAST); and frequent cannabis use (10+ days in the past-month). FINDINGS: We found a decrease in past-year and past-month use following enactment or implementation. Among students ages 18 to 21, post-enactment, we observed a transitory increase in 2014 that decreased thereafter for: any risky use among those who reported past-year use (prevalence difference [PD] = 13.5%; 95% CI: 2.0, 24.9), frequent use in the full sample (PD = 4.5%; 95% CI: 1.0, 8.1), and frequent use among those who reported past-month use (PD = 16.8%; 95% CI: 1.9, 31.8). CONCLUSION: The legalization of recreational cannabis in Uruguay was not associated with overall increases in either past-year/past-month cannabis use or with multi-year changes in any risky and frequent cannabis use among young people.

The Epidemiology of Violent Deaths in Chile between 2001 and 2018: Prevalence, Trends, and Correlates.

BACKGROUND: Despite its enormous health and social burden, there are limited published studies describing the epidemiology of violent deaths in Chile. We described violent mortality rate trends in Chile between 2001 and 2018, its current spatial distribution and ecological level correlates. METHODS: A population-based study using publicly accessible data. We calculated age-adjusted mortality rates per 100,000 persons for sex, age, intention, and mechanism of death. Next, we used linear regression to estimate time trends for sex and intention. We then employed hierarchical Poisson analyses to model the spatial distribution across 345 municipalities and the influence of six ecological level variables. RESULTS: The average rate of violent death in Chile between 2001 and 2018 was 15.9 per 100,000 people, with the majority (70.3%) of these attributed to suicide. Suffocation was the most common mechanism of death for suicide (82.3%) and cut/pierce for homicide (43.1%), followed by firearm (33.2%). Violent deaths are trending downward in Chile across all categories except suicides by women, which have remained stable. Poverty rates and urban population were positively associated with violent mortality rates. CONCLUSIONS: Although violence-related deaths seem to be decreasing, disparities across gender, age group, and geographic location may have continuing effects on mortality rates.