A qualitative study on opportunities to improve research engagement and inclusion of Black adults with systemic lupus erythematosus.

In response to racial inequities in systemic lupus erythematosus (SLE), we aimed to identify practical recommendations for increasing engagement and inclusion of Black adults in SLE research. We used a qualitative, interpretive description approach and recruited 30 Black adults diagnosed with SLE in Michigan to participate in semi-structured interviews. Theme development focused on what factors influenced research perceptions and how research did not meet participant needs and expectations. We developed five main themes: (1) Ethical and equitable research. Participants shared how the impacts of past and present-day racism impacted their willingness to participate in research. (2) Trusting researchers to conduct studies and translate findings to health care. Participants had concerns related to researcher intentions and expressed the importance of communicating research outcomes to participants and translating findings to health care. (3) Drug trial beneficence. When considering drug trials, several people did not consider the potential benefits worth the risk of side effects, and some said they would need to consult with their doctor before agreeing to participate. (4) Altruism. Participants explained how the desire to help others was a motivating factor for participating in research and donating biological samples. (5) Research priorities. Participants described a need for better treatments that value their overall health and well-being. Findings indicate that researchers can center the perspectives of Black people with SLE across the research life cycle-beyond a focus on adequate racial diversity among study participants.

'I'm still here, I'm alive and breathing': The experience of Black Americans with long COVID.

AIMS AND OBJECTIVES: In this study, we aimed to characterize the impact of long COVID on quality of life and approaches to symptom management among Black American adults. BACKGROUND: As a novel condition, qualitative evidence concerning long COVID symptoms and their impact on quality of life can inform the refinement of diagnostic criteria and care plans. However, the underrepresentation of Black Americans in long COVID research is a barrier to achieving equitable care for all long COVID patients. DESIGN: We employed an interpretive description study design. METHODS: We recruited a convenience sample of 15 Black American adults with long COVID. We analysed the anonymized transcripts from race-concordant, semi-structured interviews using an inductive, thematic analysis approach. We followed the SRQR reporting guidelines. RESULTS: We identified four themes: (1) The impact of long COVID symptoms on personal identity and pre-existing conditions; (2) Self-management strategies for long COVID symptoms; (3) Social determinants of health and symptom management; and (4) Effects on interpersonal relationships. CONCLUSION: Findings demonstrate the comprehensive ramifications of long COVID on the lives of Black American adults. Results also articulate how pre-existing conditions, social risk factors, distrust due to systemic racism, and the nature of interpersonal relationships can complicate symptom management. RELEVANCE TO CLINICAL PRACTICE: Care approaches that support access to and implementation of integrative therapies may be best suited to meet the needs of long COVID patients. Clinicians should also prioritize eliminating patient exposure to discrimination, implicit bias, and microaggressions. This is of particular concern for long COVID patients who have symptoms that are difficult to objectively quantify, such as pain and fatigue. NO PATIENT OR PUBLIC CONTRIBUTION: While patient perspectives and experiences were the focus of this study, patients were not involved with the design or conduct of the study, data analysis or interpretation, or writing the manuscript.

Social determinants of depression in systemic lupus erythematosus: A systematic scoping review.

Social determinants of health (SDOH) influence inequities in systemic lupus erythematosus (SLE). While these inequities contribute to overall disease experience, there is little consensus guiding our understanding of the psychological implications of SDOH in SLE. Given the paucity of evidence in this area, the aim of this scoping review was to systematically assess the volume and features of available research literature on associations of SDOH with depression in SLE over the past 20 years, from 1 January 2000 to 16 November 2021. We developed a search strategy for PubMed and EMBASE that included keywords for depression and lupus. After screening 2188 articles, we identified 22 original articles that met our inclusion criteria. At least one SDOH was associated with depression in two of the six studies with unadjusted estimates and 13 of the 16 studies with adjusted estimates. Results provide consistent but sparse evidence that SDOH are associated with depression in SLE. Additionally, depression epidemiology in SLE may differ from the general population such that depression risk is more similar across genders and racial/ethnic groups. More work is needed to identify the SDOH that have the greatest impact on depression and mental health among SLE patients, as well as how and when to intervene.

Vaccine perceptions among Black adults with long COVID.

OBJECTIVES: Low uptake of COVID vaccines within Black communities is a concern given the stark racial inequities associated with the pandemic. Prior research details COVID vaccine perceptions within the general population and Black communities specifically. However, Black individuals with long COVID may be more or less receptive to future COVID vaccination than their peers without long COVID. The impact of COVID vaccination on long COVID symptoms is still controversial, since some studies suggest that vaccination can improve long COVID symptoms, whereas other studies report no significant change in symptoms or a worsening of symptoms. In this study, we aimed to characterize the factors influencing perceptions of COVID vaccines among Black adults with long COVID to inform future vaccine-related policies and interventions. DESIGN: We conducted 15 semi-structured, race-concordant interviews over Zoom with adults who reported physical or mental health symptoms that lingered for a month or more after acute COVID infection. We transcribed and anonymized the interviews and implemented inductive, thematic analysis to identify factors influencing COVID vaccine perceptions and the vaccine decision-making process. RESULTS: We identified five themes that influenced vaccine perceptions: (1) Vaccine safety and efficacy; (2) Social implications of vaccination status; (3) Navigating and interpreting vaccine-related information; (4) Possibility of abuse and exploitation by the government and scientific community; and (5) Long COVID status. Safety concerns were amplified by long COVID status and mistrust in social systems due to mistreatment of the Black community. CONCLUSIONS: Among the factors influencing COVID vaccine perceptions, participants reported a desire to avoid reinfection and a negative immune response. As COVID reinfection and long COVID become more common, achieving adequate uptake of COVID vaccines and boosters may require approaches that are tailored in partnership with the long COVID patient community.

Associations of mental health and chronic physical illness during childhood with major depression in later life.

OBJECTIVES: This study examined whether childhood chronic physical illness burden was associated with major depression in later life (>50 years) and whether this relationship was mediated by childhood mental health status. METHOD: Data came from the 2016 United States Health and Retirement Study (n = 18,483). Logistic regression tested associations of childhood chronic physical illness burden with childhood mental health status and major depression in later life. Path analysis quantified mediation of the association between chronic physical illness burden and major depression by childhood mental health status. RESULTS: One standard deviation increase in childhood chronic physical illness burden was associated with 1.34 (95% CI = 1.25, 1.43) times higher odds of major depression in later life. Childhood mental health status explained 53.4% (95% CI: 37.3%, 69.6%) of this association. In follow-up analyses of categorical diagnoses, having difficulty seeing, ear problems or infections, a respiratory disorder, asthma, an allergic condition, epilepsy or seizures, migraines or severe headaches, heart trouble, stomach problems, or a disability lasting ≥6 months was associated with major depression in later life with mediation by childhood mental health status. CONCLUSION: Findings of this study indicate that children with a higher chronic physical illness burden are more likely to have major depression in later life and poor mental health during childhood mediates this relationship. Further research is needed to determine whether increased screening and treatment of psychiatric symptoms in pediatrics can decrease the burden of major depression across the life course.

Short-term exposures to atmospheric evergreen, deciduous, grass, and ragweed aeroallergens and the risk of suicide in Ohio, 2007-2015: Exploring disparities by age, gender, and education level.

BACKGROUND: Seasonal trends in suicide mortality are observed worldwide, potentially aligning with the seasonal release of aeroallergens. However, only a handful of studies have examined whether aeroallergens increase the risk of suicide, with inconclusive results thus far. The goal of this study was to use a time-stratified case-crossover design to test associations of speciated aeroallergens (evergreen, deciduous, grass, and ragweed) with suicide deaths in Ohio, USA (2007-2015). METHODS: Residential addresses for 12,646 persons who died by suicide were linked with environmental data at the 4-25 km grid scale including atmospheric aeroallergen concentrations, maximum temperature, sunlight, particulate matter <2.5 µm, and ozone. A case-crossover design was used to examine same-day and 7-day cumulative lag effects on suicide. Analyses were stratified by age group, gender, and educational level. RESULTS: In general, associations were null between aeroallergens and suicide. Stratified analyses revealed a relationship between grass pollen and same-day suicide for women (OR = 3.84; 95% CI = 1.44, 10.22) and those with a high school degree or less (OR = 2.03; 95% CI = 1.18, 3.49). CONCLUSIONS: While aeroallergens were generally not significantly related to suicide in this sample, these findings provide suggestive evidence for an acute relationship of grass pollen with suicide for women and those with lower education levels. Further research is warranted to determine whether susceptibility to speciated aeroallergens may be driven by underlying biological mechanisms or variation in exposure levels.

Food insecurity transitions and smoking behavior among older adults who smoke.

Cross-sectional data reveal that smoking cigarettes is highly prevalent among those who are food insecure. However, there is limited and conflicting evidence concerning whether causal factors may influence associations of food insecurity with smoking behavior. Additionally, temporality is a core feature of food insecurity that should be considered when examining linkages between food insecurity and health behaviors like smoking cessation. In 2019, data were extracted from waves 2012 and 2014 of the Health and Retirement Study-a representative sample of U.S. adults ≥50. Analyses were limited to those who smoked cigarettes in 2012 (n = 2197). Food insecurity was assessed in 2012 and 2014 to indicate food insecurity transitions: (1) initially food insecure (food insecure in 2012 only); (2) became food insecure (food insecure in 2014 only); (3) remained food insecure (food insecure in 2012 and 2014), and; (4) not food insecure (reference group). Multivariable logistic regression examined odds of smoking cessation in 2014 due to food insecurity transition. Becoming food insecure was associated with a 2.0 (95% confidence interval = 1.1-3.4) higher odds of smoking cessation. Employment loss or retirement (p < 0.020) and diagnosis of a new chronic condition (p = 0.026) were also associated with higher odds of smoking cessation. In older U.S. adults, smoking cessation was associated with decreased spending power and new health problems. Future studies should examine whether findings of this study may be similar among younger adults and; whether those who quit smoking due to food insecurity are more susceptible to relapse than those who quit due to other factors.

Response to a commentary on "Food insecurity transitions and smoking behavior among older adults who smoke".

Thank you for the opportunity to respond to the commentary by Kim-Mozeleski and colleagues on "Food insecurity transitions and smoking behavior among older adults who smoke". This study examined the influence of food insecurity transitions on smoking cessation and daily cigarette consumption in 2014 within a sample of older U.S. adults from the Health and Retirement Study (HRS) who indicated that they smoked in 2012. In particular, Kim-Mozeleski and colleagues highlight that findings of Bergmans (2019) contrast with results of a previous publication by Kim-Mozeleski and colleagues. In sum, it is not readily apparent why findings contradict those of Kim-Mozeleski et al. (2018). Moderation or confounding due to macroeconomic factors that influence health and behavior is a possibility. Bergmans (2019) examined associations over a recent 2-year period of U.S. economic growth. In contrast, data from Kim-Mozeleski et al. (2018) spanned 12 years and overlapped the Great Recession. A detailed response to the commentary is provided.

The association of dietary inflammatory potential with depression and mental well-being among U.S. adults.

Current treatment for depression is not considered effective among all cases and, thus far, nutritional protocols are minimal within depression treatment guidelines. Recently, there has been increasing interest in a possible protective and modifiable role of diet in common mental disorders, including depression, due to pro- and anti-inflammatory properties of nutrients. This study aims to investigate whether the Dietary Inflammatory Index (DII), designed to estimate the inflammatory potential of diet, is associated with depression and other measures of mental health. In a representative sample of U.S. adults (≥20years of age, N=11,592), the distribution of DII score is assessed. Multivariate logistic regression models determine the association between DII quintile and depression. Associations of DII quintile with frequent distress and frequent anxiety are also evaluated. In fully adjusted models, higher DII score is associated with over a two-fold higher odds of depression (OR (95% CI)=2.26 (1.60, 3.20) for highest vs. lowest quintile, Type III p-value≤0.0001). DII score is also associated with higher odds of frequent distress (OR (95% CI)=1.81 (1.20, 2.71) for highest vs. lowest quintile, Type III p-value=0.0167). This association was not significant for frequent anxiety (Type III p-value=0.12). Results of this study indicate that dietary inflammatory potential is associated with depression. These results are consistent with existing hypotheses that inflammatory pathways play a role in the etiology of depression. Further research examining the underlying biological and cellular mechanisms of depression is warranted.

Food insecurity and cardiovascular health: Findings from a statewide population health survey in Wisconsin.

BACKGROUND: The social and economic environment has become a major area of interest regarding the determinants of cardiovascular health. Among markers of economic distress, food insecurity has been found associated with metabolic disorders, dyslipidemia, and obesity, but no previous studies have examined its association with overall cardiovascular health. METHODS AND RESULTS: We conducted a cross-sectional analysis among 2935 participants in the Survey of the Health of Wisconsin (SHOW), a statewide population-based representative sample. The presence of food insecurity was determined by an affirmative answer to the question "In the last 12months, have you been concerned about having enough food for you or your family?" Cardiovascular health (CVH) was defined based on the American Heart Association Life's Simple 7 criteria and classified as "poor," "intermediate," or "ideal" using previously published criteria. "Good" CVH was defined as having no poor in any of the seven criteria (any amount of intermediate or ideal). Crude and adjusted odds ratios (OR) of good CVH according to presence of food insecurity were calculated using logistic regression models. Overall, food insecurity was associated with a decreased likelihood of good CVH (OR 0.53; 95% Confidence Interval 0.31 to 0.92; p=0.02). This association persisted in models controlling for age, gender, race, and urbanization. CONCLUSIONS: Participants who were food insecure were significantly less likely to have good CVH compared to participants who were food secure. Even though this study cannot confirm causality, these results suggest that food insecurity might be one of several socio-economic barriers contributing to poor CVH.

Chronic overlapping pain conditions increase the risk of long COVID features, regardless of acute COVID status.

ABSTRACT: Chronic overlapping pain conditions (COPCs) refer to conditions that have similar central nervous system pathophysiologic mechanisms driving widespread pain as well as common comorbid symptoms such as fatigue and problems with sleep, memory, and mood. If COPCs predict the onset of long COVID, this could offer a valuable orientation for long COVID-related research and clinical care. This retrospective cohort study aimed to determine whether having a COPC predicts the onset of long COVID features using US electronic health records and 1:1 propensity score matching without replacement. The study cohorts included (1) people with acute COVID (n = 1,038,402), (2) people with acute influenza (n = 262,092), and (3) a noninfected cohort comprising people with a routine healthcare encounter (n = 1,081,593). Having a COPC increased the risk of long COVID features in all 3 study cohorts. Among those with COVID, having a pre-existing COPC increased the risk by 1.47 (95% CI = 1.46, 1.47). In the influenza cohort, COPCs increased the risk by 1.39 (95% CI = 1.38, 1.40). In the noninfected cohort, COPCs increased the risk by 1.57 (95% CI = 1.56, 1.59). These findings reinforce the likelihood that nociplastic mechanisms play a prominent role in long COVID. Recognizing that this ubiquitous nonspecific syndrome occurs frequently in the population can inform precision medicine therapies that avoid the pitfalls of viewing long COVID exclusively in the framework of postinfectious disease.

Different types of greenspace within urban parks and depressive symptoms among older U.S. adults living in urban areas.

Access to greenspace in the form of urban parks is frequently used to study the mental health benefits of nature and may alleviate depression. However, there is a lack of research that considers the different types of vegetated and non-vegetated spaces that parks can provide. Our aim was to investigate whether different types of accessible park area, grassy; tree covered; and non-vegetated, were associated with depressive symptoms among older (≥50 years) urban US adults. We used interviews from the Health and Retirement Study spanning 2010 through 2016 as our primary data source. We calculated total grassy, tree covered, and non-vegetated park space accessible to participants using a comprehensive national database of US parks and a high resolution (10 m) landcover dataset. To measure depressive symptoms, we used the CESD-8 analyzed as a continuous scale. We used Poisson regression to estimate the percent difference in CESD-8 scores comparing quartiles of accessible park space. To control for confounding, we adjusted for sociodemographic characteristics, geography, and climate. Aggregated accessible park area was not substantively associated with depressive symptoms. However, having grassy park area near the home was associated with as much as 27 % fewer depressive symptoms. In contrast, non-vegetated park area was associated with up to 54 % more depressive symptoms. Our findings were robust to adjustment for air pollution, environmental noise, and artificial light at night. Different types of accessible park space may have disparate effects on mental health among older urban US adults.

Substituting Medical Cannabis for Medications Among Patients with Rheumatic Conditions in the United States and Canada.

OBJECTIVE: There are numerous reports of people substituting medical cannabis (MC) for medications. Our obejctive was to investigate the degree to which this substitution occurs among people with rheumatic conditions. METHODS: In a secondary analysis from a cross-sectional survey conducted with patient advocacy groups in the US and Canada, we investigated MC use and medication substitution among people with rheumatic conditions. We subgrouped by whether participants substituted MC for medications and investigated differences in perceived symptom changes and use patterns, including methods of ingestion, cannabinoid content (cannabidiol vs delta-9-tetrahydrocannabinol [THC]), and use frequency. RESULTS: Among 763 participants, 62.5% reported substituting MC products for medications, including nonsteroidal anti-inflammatory drugs (54.7%), opioids (48.6%), sleep aids (29.6%), and muscle relaxants (25.2%). Following substitution, most participants reported decreases or cessation in medication use. The primary reasons for substitution were fewer adverse effects, better symptom management, and concerns about withdrawal symptoms. Substitution was associated with THC use and significantly higher symptom improvements (including pain, sleep, anxiety, and joint stiffness) than nonsubstitution, and a higher proportion of substitutors used inhalation routes than those who did not. CONCLUSION: Although the determination of causality is limited by our cross-sectional design, these findings suggest that an appreciable number of people with rheumatic diseases substitute medications with MC for symptom management. Inhalation of MC products containing some THC was most commonly identified among those substituting, and disease characteristics did not differ by substitution status. Further study is needed to better understand the role of MC for symptom management in rheumatic conditions.

Protocol for a pragmatic trial of Cannabidiol (CBD) to improve chronic pain symptoms among United States Veterans.

BACKGROUND: Chronic pain affects over 100 million Americans, with a disproportionately high number being Veterans. Chronic pain is often difficult to treat and responds variably to medications, with many providing minimal relief or having adverse side effects that preclude use. Cannabidiol (CBD) has emerged as a potential treatment for chronic pain, yet research in this area remains limited, with few studies examining CBD's analgesic potential. Because Veterans have a high need for improved pain care, we designed a clinical trial to investigate CBD's effectiveness in managing chronic pain symptoms among Veterans. We aim to determine whether CBD oral solution compared to placebo study medication is associated with greater improvement in the Patient Global Impression of Change (PGIC). METHODS: We designed a randomized, double-blind, placebo-controlled, pragmatic clinical trial with 468 participants. Participants will be randomly assigned in a 1:1 ratio to receive either placebo or a CBD oral solution over a 4-week period. The trial is remote via a smartphone app and by shipping study materials, including study medication, to participants. We will compare the difference in PGIC between the CBD and placebo group after four weeks and impacts on secondary outcomes (e.g., pain severity, pain interference, anxiety, suicide ideation, and sleep disturbance). DISCUSSION: Once complete, this trial will be among the largest to date investigating the efficacy of CBD for chronic pain. Findings from this clinical trial will contribute to a greater knowledge of CBD's analgesic potential and guide further research. Given the relative availability of CBD, our findings will help elucidate the potential of an accessible option for helping to manage chronic pain among Veterans. TRIAL REGISTRATION: This protocol is registered at clinicaltrials.gov under study number NCT06213233.

Medicinal Cannabis Use for Rheumatic Conditions in the US Versus Canada: Rationale for Use and Patient-Health Care Provider Interactions.

OBJECTIVE: Understanding how medical cannabis (MC) use is integrated into medical practice for rheumatic disease management is essential. We characterized rationale for MC use, patient-physician interactions around MC, and MC use patterns among people with rheumatic conditions in the US and Canada. METHODS: We surveyed 3406 participants with rheumatic conditions in the US and Canada, with 1727 completing the survey (50.7% response rate). We assessed disclosure of MC use to health care providers, MC authorization by health care providers, and MC use patterns and investigated factors associated with MC disclosure to health care providers in the US versus Canada. RESULTS: Overall, 54.9% of US respondents and 78.0% of Canadians reported past or current MC use, typically because of inadequate symptom relief from other medications. Compared to those in Canada, fewer US participants obtained MC licenses, disclosed MC use to their health care providers, or asked advice on how to use MC (all P values <0.001). Overall, 47.4% of Canadian versus 28.2% of US participants rated their medical professionals as their most trusted information source. MC legality in state of residence was associated with 2.49 greater odds of disclosing MC use to health care providers (95% confidence interval: 1.49-4.16, P < 0.001) in the US, whereas there were no factors associated with MC disclosure in Canada. Our study is limited by our convenience sampling strategy and cross-sectional design. CONCLUSION: Despite widespread availability, MC is poorly integrated into rheumatic disease care, with most patients self-directing use with minimal or no clinical oversight. Concerted efforts to integrate MC into education and clinical policy is critical.

Recommendations for Improving Systemic Lupus Erythematosus Care From Black Adults: A Qualitative Study.

Importance: Racial inequities in incidence, morbidity, and mortality are a defining feature of systemic lupus erythematosus (SLE). Health care systems are integral to addressing these inequities. However, qualitative evidence that highlights Black SLE care experiences is limited. Objective: To identify opportunities for improving SLE care based on the experiences and perspectives of Black adults with SLE. Design, Setting, and Participants: In this qualitative study, an interpretive description approach was used and data were analyzed using inductive thematic analysis. Semistructured interviews with Black adults in Michigan who were diagnosed with SLE were conducted. Interviews occurred from November 2, 2021, to July 19, 2022, and data analysis occurred from May 6, 2022, to April 12, 2023. Main Outcomes and Measures: Deidentified transcripts from the interviews were analyzed to develop themes that focused on opportunities to improve quality of care and symptom management. Results: The participants included 30 Black adults with SLE (97% women; mean age, 41 years; range, 18-65 years). Four main themes were identified: (1) awareness of SLE signs and symptoms before diagnosis (participants emphasized delays in diagnosis and how knowledge concerning SLE could be limited in their families and communities); (2) patient-clinician interactions (participants faced discrimination in health care settings and talked about the value of coordinated and supportive health care teams); (3) medication adherence and health effects (participants experienced a range of adverse effects from medications that treat SLE and described how monitoring medication use and efficacy could inform tailored care approaches); and (4) comprehensive care plans after diagnosis (participants reported persistent pain and other symptoms despite treatment). In the context of disease management, participants emphasized the importance of behavioral change and the negative impact of social risk factors. Conclusions and Relevance: The findings of this qualitative study suggest how limited information about SLE, experiences of racism, treatment regimens, and social risk factors may affect Black people with SLE. Future research should further engage and include Black communities within the context of treatment and intervention development to reduce racial inequities.

Musculoskeletal Components of Post-Acute Sequelae of SARS-CoV-2 Infections.

➢: Musculoskeletal (MSK) sequelae of severe acute respiratory syndrome coronavirus 2 infections seem to be common. ➢: Mechanisms of such effects are becoming clear. ➢: There is a complex interplay of biopsychosocial effects associated with MSK symptoms after acute coronavirus disease 2019. ➢: Additional research should focus on completely describing the breadth of these MSK sequelae and related psychosocial symptoms.

Healthy Debate: Major Depression among Older Immigrants and the United States 2016 Election.

This study investigated whether anti-immigrant sentiment leading up to the 2016 election increased risk of major depression among older U.S. immigrants. Drawing data from the Health and Retirement Study, we tested whether there was a disproportionate increase in major depression among U.S. immigrants than non-immigrants from 2014 to 2016 using a Difference in Difference approach. Older immigrants had a higher relative change in major depression from 2014 to 2016 than non-immigrants (RRR 1.35; 95% CI 1.06, 1.73). This relationship was driven by associations among those who are White (RRR 2.07; 95% CI 1.26, 3.41) or Hispanic (RRR 1.55; 95% CI 0.99, 2.40). Anti-immigrant sentiment leading up to the 2016 election was associated with an increase in major depression among older U.S. immigrants. Findings may help identify high-risk groups in future election years and inform treatment strategies for major depression that consider the influence of sociopolitical factors.

Impact of the COVID-19 pandemic on temporal patterns of mental health and substance abuse related mortality in Michigan: An interrupted time series analysis.

Background: The emergence of SARS-CoV2 (COVID-19) had wide impacts to health and mortality and prompted unprecedented containment efforts. The full impact of the COVID-19 pandemic and resulting responses on mental health and substance abuse related mortality are unknown. Methods: We obtained records for deaths from suicide, alcohol related liver failure, and overdose from the Michigan Department of Health and Human Services (MDHHS) for 2006 to 2020. We compared mortality within sex, age, marital, racial and urban/rural groups using basic statistical methods. We compared standardized mean daily mortality incidence before and after the onset of the pandemic using t-tests. We used an interrupted time series approach, using generalized additive Poisson regression models with smoothed components for time to assess differences in mortality trends before and after the onset of the pandemic within demographic groups. Findings: There were 19,365 suicides, 8,790 deaths from alcohol related liver failure, and 21,778 fatal drug overdoses. Compared with 2019, suicides in 2020 declined by 17.6%, overdose mortality declined by 22.5%-while alcohol deaths increased by 12.4%. Crude comparisons suggested that there were significant declines in suicides for white people, people 18 to 65 and increases for rural decedents, overdoses increased for Black people, females and married/widowed people, and alcohol mortality increased for nearly all groups. ITS models, however, suggested increased suicide mortality for rural residents, significantly increased alcohol related mortality for people ≥65 and increased overdose mortality in men. Interpretation: The onset of the pandemic was associated with mixed patterns of mortality between suicide, alcohol and overdose deaths. Patterns varied within demographic groups, suggesting that impacts varied among different groups, particularly racial and marital groups. Funding: This work was supported by the United States National Institute of Environmental Health Sciences [K99/R00ES026198] and their Michigan Center on Lifestage Environmental Exposures and Disease [grant number P30ES017885]; and the Institute for Global Biological Change at the University of Michigan.

Healthcare provider and medical cannabis patient communication regarding referral and medication substitution: the Canadian context.

BACKGROUND: Patients use medical cannabis for a wide array of illnesses and symptoms, and many substitute cannabis for pharmaceuticals. This substitution often occurs without physician oversight, raising patient safety concerns. We aimed to characterize substitution and doctor-patient communication patterns in Canada, where there is a mature market and national regulatory system for medical cannabis. METHODS: We conducted an anonymous, cross-sectional online survey in May 2021 for seven days with adult Canadian federally-authorized medical cannabis patients (N = 2697) registered with two global cannabis companies to evaluate patient perceptions of Primary Care Provider (PCP) knowledge of medical cannabis and communication regarding medical cannabis with PCPs, including PCP authorization of licensure and substitution of cannabis for other medications. RESULTS: Most participants (62.7%, n = 1390) obtained medical cannabis authorization from their PCP. Of those who spoke with their PCP about medical cannabis (82.2%, n = 2217), 38.6% (n = 857) reported that their PCP had "very good" or "excellent" knowledge of medical cannabis and, on average, were moderately confident in their PCP's ability to integrate medical cannabis into treatment. Participants generally reported higher ratings for secondary care providers, with 82.8% (n = 808) of participants rating their secondary care provider's knowledge about medical cannabis as "very good" or "excellent." Overall, 47.1% (n = 1269) of participants reported substituting cannabis for pharmaceuticals or other substances (e.g., alcohol, tobacco/nicotine). Of these, 31.3% (n = 397) reported a delay in informing their PCP of up to 6 months or more, and 34.8% (n = 441) reported that their PCP was still not aware of their substitution. Older, female participants had higher odds of disclosing cannabis substitution to their PCPs. CONCLUSION: Most of the surveyed Canadian medical cannabis patients considered their PCPs knowledgeable about cannabis and were confident in their PCPs' ability to integrate cannabis into treatment plans. However, many surveyed patients substituted cannabis for other medications without consulting their PCPs. These results suggest a lack of integration between mainstream healthcare and medical cannabis that may be improved through physician education and clinical experience.