The International Cannabis Toolkit (iCannToolkit): a multidisciplinary expert consensus on minimum standards for measuring cannabis use.

BACKGROUND: The lack of an agreed international minimum approach to measuring cannabis use hinders the integration of multidisciplinary evidence on the psychosocial, neurocognitive, clinical and public health consequences of cannabis use. METHODS: A group of 25 international expert cannabis researchers convened to discuss a multidisciplinary framework for minimum standards to measure cannabis use globally in diverse settings. RESULTS: The expert-based consensus agreed upon a three-layered hierarchical framework. Each layer-universal measures, detailed self-report and biological measures-reflected different research priorities and minimum standards, costs and ease of implementation. Additional work is needed to develop valid and precise assessments. CONCLUSIONS: Consistent use of the proposed framework across research, public health, clinical practice and medical settings would facilitate harmonisation of international evidence on cannabis consumption, related harms and approaches to their mitigation.

Changes in opioid prescribing after implementation of mandatory registration and proactive reports within California's prescription drug monitoring program.

BACKGROUND: In 2016, California updated its prescription drug monitoring program (PDMP), adding two key features: automated proactive reports to prescribers and mandatory registration for prescribers and pharmacists. The effects of these changes on prescribing patterns have not yet been examined. We aimed to evaluate the joint effect of these two PDMP features on county-level prescribing practices in California. METHODS: Using county-level quarterly data from 2012 to 2017, we estimated the absolute change associated with the implementation of these two PDMP features in seven prescribing indicators in California versus a control group comprising counties in Florida and Washington: opioid prescription rate per 1000 residents; patients' mean daily opioid dosage in milligrams of morphine equivalents[MME]; prescribers' mean daily MME prescribed; prescribers' mean number of opioid prescriptions per day; percentage of patients getting >90 MME/day; percentage of days with overlapping prescriptions for opioids and benzodiazepines; multiple opioid provider episodes per 100,000 residents. RESULTS: Proactive reports and mandatory registration were associated with a 7.7 MME decrease in patients' mean daily opioid dose (95 %CI: -11.4, -2.9); a 1.8 decrease in the percentage of patients prescribed high-dose opioids (95 %CI: -2.3, -0.9); and a 6.3 MME decrease in prescribers' mean daily dose prescribed (95 %CI: -10.0, -1.3). CONCLUSIONS: California's implementation of these two PDMP features was associated with decreases in the total quantity of opioid MMEs prescribed, and indicators of patients prescribed high-dose opioids compared to states that had PDMP's without these features. Rates of opioid prescribing and other high-risk prescribing patterns remained unchanged.

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.

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.

Asociación entre variables demográficas y socioeconómicas y mortalidad por cirrosis y otras enfermedades del hígado / Association between demographic and socioeconomic variables and mortality due to cirrhosis and other liver diseases

Background Cirrhosis is a serious public health problem worldwide. There are geographical, socioeconomic and demographic differences in mortality due to the disease. Aim To establish an association between mortality from cirrhosis and other chronic liver diseases and socioeconomic and demographic indicators in communes of the two largest regions of Chile, the Metropolitan Region (RM) and Bíobío. Material and Methods Analysis of the mortality data from the Chilean Ministry of Health. Multiple regression models of smoothed standardized mortality ratios at the community level between 2001 and 2008, were carried out for men and women in relation to socioeconomic and demographic indicators. Results Quite dissimilar phenomena were observed in these two regions. In RM, the risk of death is associated with urban communes of lower educational level (R2 = 53.6% in men, R2 = 62.3% in women). In men of the Bíobío Region, the risk decreases along with the percentage of population belonging to originary populations (R2 = 9.1%). In women, the model also includes a variable that represents the service sector (R2 = 15.0%), that represents a greater risk. Conclusions The association of mortality due to liver disease with other variables, changes according to the territory in which it is studied. Therefore, specific local studies are required to address this problem in depth. These studies will contribute to the design of locally relevant public policies, aimed at addressing health inequities and the prevention of liver diseases.

Small area associations between social context and alcohol-attributable mortality in a middle income country.

BACKGROUND: Little is known about the association between alcohol-attributable mortality and small area socioeconomic variables when considering causes both wholly and partially attributable to alcohol. METHODS: An ecological study was conducted of the entire Chilean population aged 15 and older in 345 municipalities nationwide between 2004 and 2009. Deaths were attributed to alcohol consumption either wholly or partially, along with the estimated attributable fractions for each specified cause. Each municipality was characterized according to its average income and educational attainment. Estimates of the ecological associations were produced using a hierarchical Bayesian model, separating out deaths caused by alcohol and dividing them into seven groups of causes. RESULTS: Alcohol-attributable mortality risk showed an inverse association with income and education at the ecological level. A one-quintile increase in income was associated with an average decrease in risk of 10% (CI 95%: 10-20%) for cardiovascular deaths, 8% (6-10%) for intentional injuries and 7% (3-11%) for unintentional injuries. No associations were found between deaths due to cancers and other causes with income and education. CONCLUSIONS: Municipalities with lower income and education have higher risk of alcohol-attributable mortality in Chile.

Associations between social vulnerability, employment conditions and hazardous alcohol consumption in Chile.

INTRODUCTION AND AIMS: Studies from many different countries have found associations between alcohol use, employment and social context. The aim of this study was to investigate associations between hazardous alcohol consumption (HAC), social vulnerability and employment conditions among Chilean adults. DESIGN AND METHODS: A cross-sectional study, involving analysis of the 2008 National Survey on Drugs in Chile, was conducted on 8316 economically active men and women aged between 18 and 65 years, who completed the alcohol section of the survey. The participants were selected randomly and data collected through face-to-face interviews. Multilevel analysis was used to achieve the study's objectives. The Alcohol Use Disorders Identification Test was used to define HAC. RESULTS: There were no significant associations between HAC and employment status or occupational category when controlling for potential confounders. Using the social services sector as a reference, the adjusted odds ratio (95% confidence interval) of HAC was 2.60 (1.96-3.46) for those who worked in construction, 2.03 (1.43-2.89) in mining, 1.74 in agriculture (1.16-2.63) and in industry (1.26-2.39), 1.73 (1.31-2.28) in trade, 1.67 (1.29-2.16) in other services and 1.42 (1.01-2.00) in transport. There was no association between the socioeconomic status of the participant's neighbourhood and HAC in the fully adjusted model. The perception of neighbourhood security (third quartile of insecurity) was associated with HAC (odds ratio 1.22; 95% confidence interval 1.02-1.46). DISCUSSION AND CONCLUSIONS: HAC was independently associated with the participant's economic sector and perception of neighbourhood security in Chilean adults. It is important to perform in-depth analyses of contextual effects on individual alcohol consumption.

Consumo y valoración social de la leche purita fortificada y cereal del Programa Nacional de Alimentación Complementaria (PNAC) en Chile / Consumption and social assessment of fortified milk delivered by the National Complementary Feeding Program in Chile

Introducción: El Programa Nacional de Alimentación Complementaria (PNAC), es considerado la mayor intervención nutricional en Chile. Objetivo: Evaluar el consumo y valoración social de "Leche-Purita-Fortificada®" (LPF) y "Leche-Purita-Cereal®" (LPC) en beneficiarios del PNAC. Sujetos y métodos: Estudio transversal. Se aplicó una encuesta de consumo a 544 ninos entre 11 y 72 meses de muestra representativa de las Regiones Metropolitana y Quinta de Chile. La valoración social fue evaluada en 11 grupos focales. Resultados: El 73% y 69% de las madres declaró alimentar a su hijo con LPF y LPC, respectivamente. Las madres declararon entregar una mediana de 60 (45-75)g de LPF y 50 (40-75)g de LPC; diluidas al 10 (8-10)% y 10 (10-10)%, respectivamente. Existe una buena valoración social de los alimentos. Discusión: Los alimentos LPF y LPC son ampliamente consumidos y bien valorados por la población beneficiaria. Sin embargo, el consumo y uso de estos productos puede ser mejorado.

Background: The National Complementary Feeding Program (NCFP) is a universal nutritional intervention in Chile. Objective: To evaluate the consumption and social assessment ofiron fortified milk "Leche-Purita-Fortificada® (LPF)" and "Leche-Purita-Cereal® (LPC)" in NCFP's beneficiaries. Subjects and methods: Cross-sectional study. A feeding questionnaire was conducted in 544 children aged 11 to 72 months in a representative sample from the Metropolitan and fifth Chilean Regions. The social assessment was evaluated through 11 focus groups. Results: Seventy three % and 69% ofbeneficiaries consumed LPF and LPC, respectively. The mothers claimed to deliver a median of 60 (45-75) g of LPF and 50 g of LPC (40-75) g, with a dilution of 10 (8-10) %% and 10 (10-10) %%, respectively. The perceived social value of these foods was positive. Discussion: LPF and LPC were consumed for most beneficiaries and well appreciated by the target population. However, the consumption of these milks can be improved.