Generating real-world data from health records: design of a patient-centric study in multiple sclerosis using a commercial health records platform.

OBJECTIVE: The FlywheelMS study will explore the use of a real-world health record data set generated by PicnicHealth, a patient-centric health records platform, to improve understanding of disease course and patterns of care for patients with multiple sclerosis (MS). MATERIALS AND METHODS: The FlywheelMS study aims to enroll 5000 adults with MS in the United States to create a large, deidentified, longitudinal data set for clinical research. PicnicHealth obtains health records, including paper charts, electronic health records, and radiology imaging files from any healthcare site. Using a large-scale health record processing pipeline, PicnicHealth abstracts standard and condition-specific data elements from structured (eg, laboratory test results) and unstructured (eg, narrative) text and maps these to standardized medical vocabularies. Researchers can use the resulting data set to answer empirical questions and study participants can access and share their harmonized health records using PicnicHealth's web application. RESULTS: As of November 24, 2020, more than 4176 participants from 49 of 50 US states have enrolled in the FlywheelMS study. A median of 200 pages of records have been collected from 14 different doctors over 8 years per participant. Abstraction precision, established through inter-abstractor agreement, is as high as 97.8% when identifying and mapping data elements to a standard ontology. CONCLUSION: Using a commercial health records platform, the FlywheelMS study is generating a real-world, multimodal data set that could provide valuable insights about patients with MS. This approach to data collection and abstraction is disease-agnostic and could be used to address other clinical research questions in the future.

Cigarette Smoking Progression Among Young Adults Diagnosed With ADHD in Childhood: A 16-year Longitudinal Study of Children With and Without ADHD.

INTRODUCTION: Children with attention-deficit/hyperactivity disorder (ADHD) are at increased risk for smoking cigarettes, but there is little longitudinal research on the array of smoking characteristics known to be prognostic of long-term smoking outcomes into adulthood. These variables were studied into early adulthood in a multisite sample diagnosed with ADHD combined type at ages 7-9.9 and followed prospectively alongside an age- and sex-matched local normative comparison group (LNCG). METHODS: Cigarette smoking quantity, quit attempts, dependence, and other characteristics were assessed in the longitudinal Multimodal Treatment Study of Children with ADHD (MTA) eight times to a mean age of 24.9 years: ADHD n = 469; LNCG n = 240. RESULTS: In adulthood, the ADHD group had higher rates of daily cigarette smoking, one or more quit attempts, shorter time to first cigarette of the day, and more severe withdrawal than the LNCG. The ADHD group did not appear to have better smoking cessation rates despite a higher proportion quitting at least once. Smoking quantity and nicotine dependence did not differ between groups. The ADHD group reported younger daily smoking onset and faster progression from smoking initiation to daily smoking across assessments. Finally, ADHD symptom severity in later adolescence and adulthood was associated with higher risk for daily smoking across assessments in the ADHD sample. CONCLUSIONS: This study shows that ADHD-related smoking risk begins at a young age, progresses rapidly, and becomes resistant to cessation attempts by adulthood. Prevention efforts should acknowledge the speed of uptake; treatments should target the higher relapse risk in this vulnerable population. IMPLICATIONS: Although childhood ADHD predicts later smoking, longitudinal studies of this population have yet to fully characterize smoking behaviors into adulthood that are known to be prognostic of long-term smoking outcome. The current study demonstrates earlier and faster progression to daily smoking among those with a childhood ADHD diagnosis, as well as greater risk for failed quit attempts. Prevention efforts should address speed of smoking uptake, while treatments are needed that address smoking relapse risk. The current study also demonstrates ADHD symptom severity over development increases daily smoking risk, implicating the need for continuous ADHD symptom management.

How Substance Users With ADHD Perceive the Relationship Between Substance Use and Emotional Functioning.

OBJECTIVE: Although substance use (SU) is elevated in ADHD and both are associated with disrupted emotional functioning, little is known about how emotions and SU interact in ADHD. We used a mixed qualitative-quantitative approach to explore this relationship. METHOD: Narrative comments were coded for 67 persistent (50 ADHD, 17 local normative comparison group [LNCG]) and 25 desistent (20 ADHD, 5 LNCG) substance users from the Multimodal Treatment Study of Children with ADHD (MTA) adult follow-up (21.7-26.7 years-old). RESULTS: SU persisters perceived SU positively affects emotional states and positive emotional effects outweigh negative effects. No ADHD group effects emerged. Qualitative analysis identified perceptions that cannabis enhanced positive mood for ADHD and LNCG SU persisters, and improved negative mood and ADHD for ADHD SU persisters. CONCLUSION: Perceptions about SU broadly and mood do not differentiate ADHD and non-ADHD SU persisters. However, perceptions that cannabis is therapeutic may inform ADHD-related risk for cannabis use.

The Qualitative Interview Study of Persistent and Nonpersistent Substance Use in the MTA: Sample Characteristics, Frequent Use, and Reasons for Use.

OBJECTIVE: To evaluate participants' perceptions about frequent use and reasons for substance use (SU) in the qualitative interview study, an add-on to the multimodal treatment study of ADHD (MTA). METHOD: Using the longitudinal MTA database, 39 ADHD cases and 19 peers with Persistent SU, and 86 ADHD cases and 39 peers without Persistent SU were identified and recruited. In adulthood, an open-ended interview was administered, and SU excerpts were indexed and classified to create subtopics (frequent use and reasons for use of alcohol, marijuana, and other drugs). RESULTS: For marijuana, the Persistent compared with Nonpersistent SU group had a significantly higher percentage of participants describing frequent use and giving reasons for use, and the ADHD group compared with the group of peers had a significantly higher percentage giving "stability" as a reason for use. CONCLUSION: Motivations for persistent marijuana use may differ for adults with and without a history of ADHD.

Childhood ADHD Potentiates the Association Between Problematic Drinking and Intimate Partner Violence.

OBJECTIVE: Excessive alcohol consumption increases risk of perpetrating intimate partner violence (IPV). ADHD is associated with problematic drinking and IPV, but it is unclear whether problem drinkers with ADHD are more likely than those without ADHD to perpetrate IPV. METHOD: We compared the strength of association between problem drinking trajectories and IPV perpetration among 19- to 24-year-old men with ( n = 241) and without ( n = 180) childhood ADHD. RESULTS: Men with ADHD who reported higher heavy episodic drinking or alcohol use problems at age 19, and slower decreases in alcohol use problems from age 19 to 24, were more likely to perpetrate IPV than problem drinkers without ADHD, among whom the same associations were non-significant. Associations between problem drinking and IPV were not attenuated in adults with ADHD upon controlling for antisocial personality disorder. CONCLUSION: Study findings highlight the heightened risk of problem drinkers with ADHD perpetrating IPV.

Change over time in adolescent and friend alcohol use: Differential associations for youth with and without childhood attention-deficit/hyperactivity disorder (ADHD).

Individuals with attention-deficit/hyperactivity disorder (ADHD) are at increased risk for experiencing alcohol-related problems by adulthood. However, few studies have examined contextual factors that may contribute to this risk. The current study examined 1 widely investigated social-contextual risk factor, friend alcohol use, in a sample of adolescents with and without a history of ADHD. One hundred and 59 adolescents (14-17 years old) with childhood ADHD and 117 demographically similar youth without ADHD were interviewed annually in the Pittsburgh ADHD Longitudinal Study. Adolescents reported the frequency of their own alcohol use in the prior 12 months and the number of friends who used alcohol regularly or occasionally (perceived friend alcohol use). Multiple-group parallel process models indicated that increases in friend alcohol use were more strongly associated with increases in adolescent alcohol use over time for individuals with ADHD (r = .15, SE = 0.04; 95% confidence interval [CI] = [0.08, 0.22]) than for those without ADHD (r = .06, SE = 0.03; 95% CI [0.00, 0.11]). These results suggest that social factors are an important part of escalating alcohol use among adolescents with ADHD histories, and they highlight the possibility that interventions focused on the peer context could be important for these at-risk youth. Additional social network research on adolescent alcohol use within the larger context of other relationships (e.g., family and romantic relationships) is indicated.

Associations among trauma, posttraumatic stress disorder, cannabis use, and cannabis use disorder in a nationally representative epidemiologic sample.

Research in community and clinical samples has documented elevated rates of cannabis use and cannabis use disorders (CUDs) among individuals with trauma exposure and posttraumatic stress disorder (PTSD). However, there is a lack of research investigating relations between, and correlates of, trauma and cannabis phenotypes in epidemiologic samples. The current study examined associations between trauma (i.e., lifetime trauma exposure and PTSD) and cannabis phenotypes (i.e., lifetime cannabis use and CUD) in a nationally representative sample. Participants were individuals who participated in Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (n = 34,396; 52.4% women; age, M = 48.0 years, SD = 16.9). Lifetime DSM-IV Criterion A trauma exposure was significantly associated with lifetime cannabis use (OR = 1.215) but was only marginally associated with CUD (OR = 0.997). Within the trauma-exposed sample, lifetime PTSD showed a significant association with CUD (OR = 1.217) but was only marginally associated with lifetime cannabis use (OR = 0.992). Partially consistent with hypotheses, lifetime trauma was associated with greater odds of lifetime cannabis use, whereas PTSD was associated with greater odds of CUD. Longitudinal research investigating patterns of onset of these events/disorders is needed.

Cannabis species and cannabinoid concentration preference among sleep-disturbed medicinal cannabis users.

INTRODUCTION: Individuals report using cannabis for the promotion of sleep, and the effects of cannabis on sleep may vary by cannabis species. Little research has documented preferences for particular cannabis types or cannabinoid concentrations as a function of use for sleep disturbances. METHODS: 163 adults purchasing medical cannabis for a physical or mental health condition at a cannabis dispensary were recruited. They provided self-report of (a) whether cannabis use was intended to help with sleep problems (e.g. insomnia, nightmares), (b) sleep quality (PSQI), (c) cannabis use (including preferred type), and (d) symptoms of DSM-5 cannabis dependence. RESULTS: 81 participants reported using cannabis for the management of insomnia and 14 participants reported using cannabis to reduce nightmares. Individuals using cannabis to manage nightmares preferred sativa to indica strains (Fisher's exact test (2) = 6.83, p < 0.05), and sativa users were less likely to endorse DSM-5 cannabis dependence compared with those who preferred indica strains (χ(2)(2) = 4.09, p < 0.05). Individuals with current insomnia (t(9) = 3.30, p < 0.01) and greater sleep latency (F(3,6) = 46.7, p < 0.001) were more likely to report using strains of cannabis with significantly higher concentrations of CBD. Individuals who reported at least weekly use of hypnotic medications used cannabis with lower THC concentrations compared to those who used sleep medications less frequently than weekly (t(17) = 2.40, p < 0.05). CONCLUSIONS: Associations between sleep characteristics and the type of cannabis used were observed in this convenience sample of individuals using cannabis for the management of sleep disturbances. Controlled prospective studies are needed to better characterize the impact that specific components of cannabis have on sleep.

Narrative review of the safety and efficacy of marijuana for the treatment of commonly state-approved medical and psychiatric disorders.

The present investigation aimed to provide an objective narrative review of the existing literature pertaining to the benefits and harms of marijuana use for the treatment of the most common medical and psychological conditions for which it has been allowed at the state level. Common medical conditions for which marijuana is allowed (i.e., those conditions shared by at least 80 percent of medical marijuana states) were identified as: Alzheimer's disease, amyotrophic lateral sclerosis, cachexia/wasting syndrome, cancer, Crohn's disease, epilepsy and seizures, glaucoma, hepatitis C virus, human immunodeficiency virus/acquired immunodeficiency syndrome, multiple sclerosis and muscle spasticity, severe and chronic pain, and severe nausea. Post-traumatic stress disorder was also included in the review, as it is the sole psychological disorder for which medical marijuana has been allowed. Studies for this narrative review were included based on a literature search in PsycINFO, MEDLINE, and Google Scholar. Findings indicate that, for the majority of these conditions, there is insufficient evidence to support the recommendation of medical marijuana at this time. A significant amount of rigorous research is needed to definitively ascertain the potential implications of marijuana for these conditions. It is important for such work to not only examine the effects of smoked marijuana preparations, but also to compare its safety, tolerability, and efficacy in relation to existing pharmacological treatments.

Developmental progression to early adult binge drinking and marijuana use from worsening versus stable trajectories of adolescent attention deficit/hyperactivity disorder and delinquency.

AIMS: To examine the association between developmental trajectories of inattention, hyperactivity-impulsivity and delinquency through childhood and adolescence (ages 8-16 years) and subsequent binge drinking and marijuana use in early adulthood (age 21 years). DESIGN: Prospective naturalistic follow-up of children with attention deficit/hyperactivity disorder (ADHD) previously enrolled in a randomized controlled trial (RCT). Treatment-phase assessments occurred at 3, 9 and 14 months after randomization; follow-up assessments occurred at 24 months, 36 months, and 6, 8 and 12 years after randomization. SETTING: Secondary analysis of data from the Multimodal Treatment Study of ADHD (MTA), a multi-site RCT comparing the effects of careful medication management, intensive behavior therapy, their combination, and referral to usual community care. PARTICIPANTS: A total of 579 children with DSM-IV ADHD combined type, aged 7.0 and 9.9 years at baseline (mean = 8.5, SD = 0.80). MEASUREMENTS: Ratings of inattention, hyperactivity-impulsivity and delinquency were collected from multiple informants at baseline and through the 8-year follow-up. Self-reports of binge drinking and marijuana use were collected at the 12-year follow-up (mean age 21 years). FINDINGS: Trajectories of worsening inattention symptoms and delinquency (and less apparent improvement in hyperactivity-impulsivity) were associated with higher rates of early adult binge drinking and marijuana use, compared with trajectories of stable or improving symptoms and delinquency (of 24 comparisons, all P-values <0.05), even when symptom levels in stable trajectories were high. CONCLUSIONS: Worsening inattention symptoms and delinquency during adolescence are were associated with higher levels of early adult substance use; this pattern may reflect a developmental course of vulnerability to elevated substance use in early adulthood.

Treatment of Adolescent Substance Use Disorders.

Significant progress has been made in development and dissemination of evidence-based behavioral interventions for adolescents with substance use disorders (SUD). Medications have also shown promise in reducing substance use when used in conjunction with psychosocial treatment for adolescents with SUD, even in the context of co-occurring psychopathology. Although the efficacy or "probable efficacy" of the behavioral interventions discussed in this review have been established based on at least two randomized controlled trials, they produce relatively low abstinence rates and modest reductions in substance use that attenuate over time. Research has shown that abstinence rates may increase with the addition of abstinence-based incentives, however, post-treatment relapse rates remain high with few treated adolescents sustaining abstinence one year post-treatment. This may be due to the paucity of continuing care or post-treatment recovery support services and the lack of integrated or concurrent treatment for co-occurring psychiatric conditions that contribute to poorer treatment outcomes. Thus, despite significant progress, there is clearly room for improvement of existing treatment for adolescents with SUD. There is also critical need to increase the availability and access to substance and behavioral health treatment services for adolescents. Although 10-15% of U.S. high school students would currently meet diagnostic criteria for at least one SUD, only 10% of those who could benefit from substance treatment receive it. Five-year trends showing significant increases in the use of marijuana and nonmedical prescription drugs among U. S. high school students are evidence of the shortcomings of existing school-based interventions and poor access to community-based substance treatment for non-juvenile-justice involved youth. There is clearly a need to adapt or develop more effective prevention, early interventions, and treatment for youth who are "at risk" as well as the increasing number of adolescents who have progressed to more serious substance involvement.

Motorsports involvement among adolescents and young adults with childhood ADHD.

Although children with attention-deficit/hyperactivity disorder (ADHD) are at risk for impulsive, health-endangering behavior, few studies have examined nonsubstance, use-related risk-taking behaviors. This study examined whether adolescents and young adults with ADHD histories were more likely than those without ADHD histories to report frequent engagement in motorsports, a collection of risky driving-related activities associated with elevated rates of physical injury. Path analyses tested whether persistent impulsivity, comorbid conduct disorder or antisocial personality disorder (CD/ASP), and heavy alcohol use mediated this association. Analyses also explored whether frequent motorsporting was associated with unsafe and alcohol-influenced driving. Two hundred twenty-one adolescent and young adult males (16-25 years old) diagnosed with ADHD in childhood and 139 demographically similar males without ADHD histories reported their motorsports involvement. Persistent impulsivity, CD/ASP, heavy drinking, and hazardous driving were also measured in adolescence/young adulthood. Adolescents and young adults with ADHD histories were more likely to report frequent motorsports involvement than those without childhood ADHD. Impulsivity, CD/ASP, and heavy drinking partially mediated this association, such that individuals with ADHD histories, who had persistent impulsivity or CD/ASP diagnoses, were more likely to engage in heavy drinking, which was positively associated with frequent motorsporting. Motorsports involvement was associated with more unsafe and alcohol-influenced driving, and this association was more often found among those with, than without, ADHD histories. Adolescents and young adults with ADHD histories, especially those with persisting impulsivity, comorbid CD/ASP and heavy drinking tendencies, are more likely to engage in motorsports, which may heighten risk of injury.

Parents' Readiness to Change Affects BMI Reduction Outcomes in Adolescents with Polycystic Ovary Syndrome.

Evidence supports the importance of parental involvement for youth's ability to manage weight. This study utilized the stages of change (SOC) model to assess readiness to change weight control behaviors as well as the predictive value of SOC in determining BMI outcomes in forty adolescent-parent dyads (mean adolescent age = 15 ± 1.84 (13-20), BMI = 37 ± 8.60; 70% white) participating in a weight management intervention for adolescent females with polycystic ovary syndrome (PCOS). Adolescents and parents completed a questionnaire assessing their SOC for the following four weight control domains: increasing dietary portion control, increasing fruit and vegetable consumption, decreasing dietary fat, and increasing usual physical activity. Linear regression analyses indicated that adolescent change in total SOC from baseline to treatment completion was not predictive of adolescent change in BMI from baseline to treatment completion. However, parent change in total SOC from baseline to treatment completion was predictive of adolescent change in BMI, (t(24) = 2.15, p = 0.043). Findings support future research which carefully assesses adolescent and parent SOC and potentially develops interventions targeting adolescent and parental readiness to adopt healthy lifestyle goals.

Racial differences in the development of impulsivity and sensation seeking from childhood into adolescence and their relation to alcohol use.

BACKGROUND: Pronounced differences in drinking behavior exist between African Americans and European Americans. Disinhibited personality characteristics are widely studied risk factors for alcohol use outcomes. Longitudinal studies of children have not examined racial differences in these characteristics and in their rates of change or whether these changes differentially relate to adolescent alcohol use. METHODS: Latent growth curve modeling was performed on 7 annual waves of data on 447 African American and European American 8- and 10-year-old children followed into adolescence as part of the Tween to Teen Project. Both mother and child data were examined. RESULTS: European Americans had higher initial levels of (ß = 0.22, p < 0.001) and greater growth in sensation seeking (ß = 0.16, p < 0.05) compared with African Americans. However, African American children had higher initial levels of impulsivity compared with European American children (ß = -0.27 and -0.16, p < 0.01). Higher initial levels of sensation seeking (ß = 0.18, p < 0.01) and greater growth in both sensation seeking (ß = 0.24, p < 0.01) and impulsivity (ß = 0.30 to 0.34, p < 0.01) related to subsequent frequency of alcohol use. The association between race and alcohol use was partially mediated by initial levels of sensation seeking (ß = 0.04, p < 0.05; 95% CI: 0.004 to 0.078). Additionally, sharper increases in sensation seeking predicted greater levels of subsequent alcohol use for European Americans (ß = 0.33, p < 0.001) but not for African Americans (ß = -0.15, ns). CONCLUSIONS: This study revealed different developmental courses and important racial differences for sensation seeking and impulsivity. Findings highlight the possibility that sensation seeking at least partly drives early alcohol use for European American but not for African American adolescents.

Familial loading for alcoholism and offspring behavior: mediating and moderating influences.

BACKGROUND: Familial loading for alcoholism is an important marker of risk for early-onset alcohol problems, but the early expression of this risk in community samples of children is understudied. METHODS: This study tested, for 452 8- and 10-year-old children, whether the density of alcohol problems in their biological relatives was associated with externalizing behaviors that are risk factors for later alcohol problems. RESULTS: Density of alcohol problems in first- and second-degree biological relatives was associated with behavioral disinhibition (BD; e.g., poor inhibitory control, attentional shifting, ß = 0.10, p = 0.04) and conduct problems (CP; i.e., defiance, aggression, delinquency, ß = 0.18, p = 0.00). These relations were moderated by parenting practices (parental warmth, discipline consistency, and parental monitoring). The density-behavior association lost statistical significance when at least 2 of 3 parenting practices were rated above median levels for the sample (p = 0.67 to 0.36). The density-behavior association was mediated by current demographic advantage (p = 0.00 for BD, p = 0.00 for CP), current maternal mental health (p = 0.01 for BD, p = 0.00 for CP), and current maternal deviant behavior (for CP only, p = 0.01). CONCLUSIONS: Findings support previously proposed but untested pathways in etiologic models of alcoholism and show the potentially important role of active parenting in reducing the expression of inherited vulnerability to alcoholism in childhood.

Concordance of adolescent reports of friend alcohol use, smoking, and deviant behavior as predicted by quality of relationship and demographic variables.

OBJECTIVE: The strongest predictor of adolescent alcohol use is affiliation with friends who drink, use other drugs, or engage in deviant behavior. Most studies measure this variable using adolescent perceptions of friend problem behavior, but some research suggests these perceptions may be inaccurate. The current study's objective was to determine the concordance between adolescent perceptions of their friend's drinking, smoking, and deviant behavior and the friend's self-report. Relationship characteristics and demographic variables were explored as predictors of report concordance. METHOD: Participants (targets) were 232 adolescents ages 13 or 15 (53% girls) from Wave 9 of the Tween to Teen Project. At least one reciprocally endorsed friend participated for 59% of target adolescents (n = 232/390). Targets completed computer-assisted interviews. Friends completed telephone interviews. RESULTS: The relations between target perceptions of friend and friend self-reports of drinking and smoking were statistically significant (p < .001), but concordance was driven largely by agreement regarding the absence of behavior. Although 22% of friends drank and 8.6% smoked, fewer than 60% of targets perceived these behaviors. Deviant behavior reports correlated moderately (r = .45), with 51% of adolescents underreporting friend deviance. There were few predictors of report concordance. CONCLUSIONS: Adolescents and their friends generally provided concordant reports of one another's drinking and smoking behaviors, but most agreement concerned the absence of behavior; most targets provided underreports of their friend's engagement in deviant behaviors. These findings suggest that adolescent perceptions of friends' problem behavior do not exaggerate the involvement of their friends in these behaviors.

Hepatitis C and human immunodeficiency virus risk behaviors in polydrug users on methadone maintenance.

We examined the impact of methadone maintenance treatment (MMT) on risk behaviors for transmission of blood-borne diseases in polydrug users who had tested positive or negative for hepatitis C virus (HCV). At intake, HCV-positive participants (n=362) engaged in more human immunodeficiency virus (HIV) risk behaviors (as measured by the HIV Risk-Taking Behavior Scale) than HCV-negative participants (n=297; p< .001). This difference was specific to injection-related behaviors and decreased significantly within the first few weeks of MMT (p< .0001). Where needles continued to be used, HCV-positive participants became more likely over time to engage in safer injecting practices. Furthermore, HCV-positive participants became more likely to use condoms than HCV-negative participants. These findings demonstrate that both drug- and sex-related risk behaviors decrease during MMT and emphasize the benefits of methadone programs for public health and HIV/HCV prevention.

Assessing the concordance of measures used to diagnose adult ADHD.

OBJECTIVE: Recent evidence suggests that ADHD persists into adulthood, but the best means of diagnosis and the concordance of measures used to diagnose adult ADHD are unknown. METHOD: The current study explores the relationships of these measures in a sample of 69 mothers of children with ADHD. RESULTS: This study determines the concordance of (a) self- and collateral reports on diagnostic interviews and (b) diagnostic interviews and self-report paper-and-pencil ADHD symptom measures. CONCLUSION: Results suggest that self- and collateral reports of inattentive and hyperactive/impulsive symptoms are highly correlated, as are self-report measures and diagnostic interviews. Additionally, it was found that probands report more inattentive symptoms than collaterals in both childhood and currently. Potential implications for the assessment of adult ADHD are presented.