Partner incarceration, maternal substance use, and the mediating role of social support: A longitudinal analysis using the future of families and child wellbeing study.

INTRODUCTION: The United States is responsible for the highest incarceration rate globally. This study aimed to explore the impact of partner incarceration on maternal substance use and whether social support mediates the relationship between partner incarceration and maternal substance use. METHODS: Using data from the Future of Families and Child Wellbeing Study, a longitudinal cohort following new parents and children, this analysis quantifies the relationship between paternal incarceration and maternal substance use (N = 2823). We analyzed maternal responses in years 3 (2001-2003), 5 (2003-2006), 9 (2007-2010), and 15 (2014-2017). We explored the role of financial support and emergency social support as potential mediators. Confirmatory factor analysis (CFA) was employed to construct support-related mediators. We modeled the impact of partner incarceration and maternal substance use using generalized estimating equations (GEE) to account for repeated measures, adjusting for appropriate confounders (age of mother at child's birth, race, education, employment, and history of intimate partner violence). RESULTS: Nearly half (44.2%, N = 1247) of participants reported partner incarceration. Among mothers who experienced partner incarceration, the odds of reporting substance use were 110% greater than those who reported no partner incarceration (adjusted Odds Ratio [aOR]: 2.10; 95% Confidence Interval (CI):1.67-2.63). Financial support at year 5 accounted for 19.5% (95% CI: 6.03-33.06%) of the association between partner incarceration at year 3 and substance use at year 9; emergency social support at year 5 accounted for 6.4% (95% CI: 0.51-12.25%) of the association between partner incarceration and substance use at year 9. Neither financial nor emergency social support at year 9 were significant mediators between partner incarceration at year 3 and substance use at year 15. CONCLUSIONS: These findings demonstrate that partner incarceration impacts maternal substance use. Financial and emergency support may partially mediate this relationship in the short term, which has important implications for families disrupted by mass incarceration.

Associations between cannabis policies and state-level specialty cannabis use disorder treatment in the United States, 2004-2019.

BACKGROUND: Cannabis use disorder (CUD) treatment prevalence decreased in the US between 2002 and 2019, yet structural mechanisms for this decrease are poorly understood. We tested associations between cannabis laws becoming effective and self-reported CUD treatment. METHODS: Restricted-use 2004-2019 National Surveys on Drug Use and Health included people ages 12+ classified as needing CUD treatment (i.e., past-year DSM-5-proxy CUD or last/current specialty treatment for cannabis). Time-varying indicators of medical cannabis laws (MCL) with/without cannabis dispensary provisions differentiated state-years before/after laws using effective dates. Multi-level logistic regressions with random state intercepts estimated individual- and state-adjusted CUD treatment odds by MCLs and model-based changes in specialty CUD treatment state-level prevalence. Secondary analyses tested associations between CUD treatment and MCL or recreational cannabis laws (RCL). RESULTS: Using a broad treatment need sample definition in 2004-2014, specialty CUD treatment prevalence decreased by 1.35 (95 % CI = -2.51, -0.18) points after MCL without dispensaries and by 2.15 points (95 % CI = -3.29, -1.00) after MCL with dispensaries provisions became effective, compared to before MCL. Among people with CUD in 2004-2014, specialty treatment decreased only in MCL states with dispensary provisions (aPD = -0.91, 95 % CI = -1.68, -0.13). MCL were not associated with CUD treatment use in 2015-2019. RCL were associated with lower CUD treatment among people classified as needing CUD treatment, but not among people with past-year CUD. CONCLUSIONS: Policy-related reductions in specialty CUD treatment were concentrated in states with cannabis dispensary provisions in 2004-2014, but not 2015-2019, and partly driven by reductions among people without past-year CUD. Other mechanisms (e.g., CUD symptom identification, criminal-legal referrals) could contribute to decreasing treatment trends.

Trends in Prevalence of Cannabis Use Disorder Among U.S. Veterans With and Without Psychiatric Disorders Between 2005 and 2019.

OBJECTIVE: Cannabis use disorder diagnoses are increasing among U.S. adults and are more prevalent among people with comorbid psychiatric disorders. Recent changes in cannabis laws, increasing cannabis availability, and higher-potency cannabis may have placed people with cannabis use and psychiatric disorders at disproportionately increasing risk for cannabis use disorder. The authors used Veterans Health Administration (VHA) data to examine whether trends in cannabis use disorder prevalence among VHA patients differ by whether they have psychiatric disorders. METHODS: VHA electronic health records from 2005 to 2019 (N range, 4,332,165-5,657,277) were used to identify overall and age-group-specific (<35, 35-64, and ≥65 years) trends in prevalence of cannabis use disorder diagnoses among patients with depressive, anxiety, posttraumatic stress, bipolar, or psychotic spectrum disorders and to compare these to corresponding trends among patients without any of these disorders. Given transitions in ICD coding, differences in trends were tested within two periods: 2005-2014 (ICD-9-CM) and 2016-2019 (ICD-10-CM). RESULTS: Greater increases in prevalence of cannabis use disorder diagnoses were observed among patients with psychiatric disorders compared to those without (difference in prevalence change, 2005-2014: 1.91%, 95% CI=1.87-1.96; 2016-2019: 0.34%, 95% CI=0.29-0.38). Disproportionate increases in cannabis use disorder prevalence among patients with psychiatric disorders were greatest among those under age 35 between 2005 and 2014, and among those age 65 or older between 2016 and 2019. Among patients with psychiatric disorders, the greatest increases in cannabis use disorder prevalences were observed among those with bipolar and psychotic spectrum disorders. CONCLUSIONS: The findings highlight disproportionately increasing disparities in risk of cannabis use disorder among VHA patients with common psychiatric disorders. Greater public health and clinical efforts are needed to monitor, prevent, and treat cannabis use disorder in this population.

Economic Cost of the HealthCall Smartphone Intervention to Reduce Heavy Alcohol Drinking in Adults With HIV.

OBJECTIVE: Alcohol use among people living with HIV (PLWH) can reduce adherence and worsen health outcomes. We evaluated the economic cost of an effective smartphone application (HealthCall) to reduce drinking and improve antiretroviral adherence among heavy-drinking PLWH participating in a randomized trial. METHOD: Participants were randomized to receive a brief drinking-reduction intervention, either (a) the National Institute on Alcohol Abuse and Alcoholism (NIAAA) Clinician's Guide (CG-only, n = 37), (b) CG enhanced by HealthCall to monitor daily alcohol consumption (CG+HealthCall, n = 38), or (c) motivational interviewing delivered by a nonclinician enhanced by HealthCall (MI+HealthCall, n = 39). We used micro-costing techniques to evaluate start-up costs and incremental costs per participant incurred from the health care sector perspective in 2018 U.S. dollars. We also investigated potential cost offsets using participant-reported health care utilization. RESULTS: Participants attended three intervention visits, and each visit cost on average $29 for CG-only, $32 for CG+HealthCall, and $15 for MI+HealthCall. The total intervention cost per participant was $94 for CG-only, $114 for CG+HealthCall, and $57 for MI+HealthCall; the incremental cost of CG+HealthCall compared with CG-only was $20 per participant, and the incremental savings of MI+HealthCall compared with CG-only was $37 per participant. No significant differences in health care utilization occurred among the three groups over 12 months. CONCLUSIONS: The cost of enhancing CG with the HealthCall application for heavy-drinking PLWH was modestly higher than using the CG alone, whereas MI enhanced with HealthCall delivered by a nonclinician had a lower cost than CG alone. HealthCall may be a low-cost enhancement to brief interventions addressing alcohol use and antiretroviral adherence among PLWH.

Recreational cannabis legislation and binge drinking in U.S. adolescents and adults.

BACKGROUND: Recreational cannabis laws (RCLs) may have spillover effects on binge drinking. Our aims were to investigate binge drinking time trends and the association between RCLs and changes in binge drinking in the United States (U.S.). METHODS: We used restricted National Survey on Drug Use and Health data (2008-2019). We examined trends in the prevalence of past-month binge drinking by age groups (12-20, 21-30, 31-40, 41-50, 51+). Then, we compared model-based prevalences of past-month binge drinking before and after RCL by age group, using multi-level logistic regression with state random intercepts, an RCL by age group interaction term, and controlling for state alcohol policies. RESULTS: Binge drinking declined overall from 2008 to 2019 among people aged 12-20 (17.54% to 11.08%), and those aged 21-30 (43.66% to 40.22%). However, binge drinking increased among people aged 31+ (ages 31-40: 28.11% to 33.34%, ages 41-50: 25.48% to 28.32%, ages 51+: 13.28% to 16.75%). When investigating model-based prevalences after versus before RCL, binge drinking decreased among people aged 12-20 (prevalence difference=-4.8%; adjusted odds ratio (aOR)=0.77, [95% confidence interval (CI) 0.70-0.85]), and increased among participants aged 31-40 (+1.7%; 1.09[1.01-1.26]), 41-50 (+2.5; 1.15[1.05-1.26]) and 51+ (+1.8%; 1.17[1.06-1.30]). No RCL-related changes were noted in respondents ages 21-30. CONCLUSIONS: Implementation of RCLs was associated with increased past-month binge drinking in adults aged 31+ and decreased past-month binge drinking in those aged < 21. As the cannabis legislative landscape continues to change in the U.S., efforts to minimize harms related to binge drinking are critical.

Increasing risk of cannabis use disorder among U.S. veterans with chronic pain: 2005-2019.

ABSTRACT: In the United States, cannabis is increasingly used to manage chronic pain. Veterans Health Administration (VHA) patients are disproportionately affected by pain and may use cannabis for symptom management. Because cannabis use increases the risk of cannabis use disorders (CUDs), we examined time trends in CUD among VHA patients with and without chronic pain, and whether these trends differed by age. From VHA electronic health records from 2005 to 2019 (∼4.3-5.6 million patients yearly), we extracted diagnoses of CUD and chronic pain conditions ( International Classification of Diseases [ ICD ]- 9-CM , 2005-2014; ICD-10-CM , 2016-2019). Differential trends in CUD prevalence overall and age-stratified (<35, 35-64, or ≥65) were assessed by any chronic pain and number of pain conditions (0, 1, or ≥2). From 2005 to 2014, the prevalence of CUD among patients with any chronic pain increased significantly more (1.11%-2.56%) than those without pain (0.70%-1.26%). Cannabis use disorder prevalence increased significantly more among patients with chronic pain across all age groups and was highest among those with ≥2 pain conditions. From 2016 to 2019, CUD prevalence among patients age ≥65 with chronic pain increased significantly more (0.63%-1.01%) than those without chronic pain (0.28%-0.47%) and was highest among those with ≥2 pain conditions. Over time, CUD prevalence has increased more among VHA patients with chronic pain than other VHA patients, with the highest increase among those age ≥65. Clinicians should monitor symptoms of CUD among VHA patients and others with chronic pain who use cannabis, and consider noncannabis therapies, particularly because the effectiveness of cannabis for chronic pain management remains inconclusive.

Associations between relative deprivation with opioid use among working-age adults during the great recession.

Recessions, poverty, and unemployment have been associated with opioid use. However, these measures of financial hardship may be imprecise, limiting our ability to understand this relationship. We tested associations between relative deprivation and non-medical prescription opioid use (NMPOU) and heroin use among working-age adults (ages 18-64) during the Great Recession. Our sample included working-age adults in the 2005-2013 United States National Survey of Drug Use and Health (n = 320,186). Relative deprivation compared the lowest limit of participants' income category to the national 25th percentile individual income for people with similar socio-demographic characteristics (race and ethnicity, gender, year). We distinguished the period before (1/2005-11/2007), during (12/2007-06/2009), and after (07/2007-12/2013) the Great Recession. We estimated odds of past-year NMPOU and heroin use for each past-year exposure (i.e., relative deprivation, poverty, unemployment) using separate logistic regressions adjusting for individual-level covariates (gender, age, race/ethnicity, marital status, and education) and national-level annual Gini coefficient. Our results show that NMPOU was higher among people experiencing relative deprivation (aOR = 1.13, 95% CI = 1.06-1.20), poverty (aOR = 1.22, 95% CI = 1.16-1.29), and unemployment (aOR = 1.42, 95% CI = 1.32-1.53) between 2005 and 2013, as was heroin use (aORs = 2.54, 2.09, 3.55, respectively). The association between relative deprivation and NMPOU was modified by recession timing, and was significantly higher after the Recession (aOR = 1.21, 95% CI = 1.11-1.33). Relative deprivation was associated with higher odds of NMPOU and heroin use, and higher odds of NMPOU after the Great Recession. Our findings suggest contextual-level factors may modify the relationship between relative deprivation and opioid use, and support the need for new measures of financial hardship.

Sex differences in Cannabis use disorder and associated psychosocial problems among US adults, 2012-2013.

While men show greater prevalence of cannabis use disorder (CUD) than women, whether cannabis use frequency drives this difference is unknown, and little is known about sex differences in problems associated with CUD. We therefore assessed the association of CUD with sex, adjusted for frequency of use, and compared the association of psychosocial and health-related problems with CUD between men and women. We included US adults age ≥ 18 who reported past-year cannabis use in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (n = 3701). Cannabis use frequency, DSM-5 CUD and problems (interpersonal, financial, legal, health-related) were assessed. Associations between psychosocial problems, sex and DSM-5 CUD were assessed using prevalence differences (PD) and 95% confidence intervals (CI) from logistic regression models, controlling for demographics and cannabis use frequency, and effect modification by sex was assessed. We found that the prevalence of CUD among men versus women was not significantly greater after adjusting for use frequency. Women had significantly higher prevalence of interpersonal, financial and health-related problems than men, adjusting for frequency of use. Women showed significantly greater association of CUD with interpersonal problems with a boss or co-workers (p < 0.05) and a neighbor, relative or friend (p < 0.05) compared to men. Lack of sex differences in CUD after adjusting for frequency of use suggests use frequency may be an important target of CUD prevention efforts. CUD showed stronger associations for interpersonal problems among women than men, suggesting the need for particular emphasis on treating interpersonal problems related to cannabis use among women.

Comparing mental and physical health of U.S. veterans by VA healthcare use: implications for generalizability of research in the VA electronic health records.

OBJECTIVE: The Department of Veterans Affairs' (VA) electronic health records (EHR) offer a rich source of big data to study medical and health care questions, but patient eligibility and preferences may limit generalizability of findings. We therefore examined the representativeness of VA veterans by comparing veterans using VA healthcare services to those who do not. METHODS: We analyzed data on 3051 veteran participants age ≥ 18 years in the 2019 National Health Interview Survey. Weighted logistic regression was used to model participant characteristics, health conditions, pain, and self-reported health by past year VA healthcare use and generate predicted marginal prevalences, which were used to calculate Cohen's d of group differences in absolute risk by past-year VA healthcare use. RESULTS: Among veterans, 30.4% had past-year VA healthcare use. Veterans with lower income and members of racial/ethnic minority groups were more likely to report past-year VA healthcare use. Health conditions overrepresented in past-year VA healthcare users included chronic medical conditions (80.6% vs. 69.4%, d = 0.36), pain (78.9% vs. 65.9%; d = 0.35), mental distress (11.6% vs. 5.9%; d = 0.47), anxiety (10.8% vs. 4.1%; d = 0.67), and fair/poor self-reported health (27.9% vs. 18.0%; d = 0.40). CONCLUSIONS: Heterogeneity in veteran sociodemographic and health characteristics was observed by past-year VA healthcare use. Researchers working with VA EHR data should consider how the patient selection process may relate to the exposures and outcomes under study. Statistical reweighting may be needed to generalize risk estimates from the VA EHR data to the overall veteran population.

Trends in cannabis or cocaine-related dependence and alcohol/drug treatment in Argentina, Chile, and Uruguay.

BACKGROUND: In the context of changing cannabis and other drug policy and regulation, concerns may arise regarding drug treatment access and use. We assessed cannabis/cocaine-related dependence and treatment in Argentina, Chile, and Uruguay. METHODS: Nationally representative cross-sectional household surveys of people ages 15-64 in Argentina (4 surveys, 2006-2017), Chile (7 surveys, 2006-2018), and Uruguay (4 surveys, 2006-2018) were harmonized. We estimated weighted prevalences of cannabis or cocaine-related (cocaine or cocaine paste) dependence, based on meeting 3+ past-year ICD-10 dependence criteria. We estimated weighted prevalences of past-year alcohol/drug treatment use (Argentina, Chile) or use/seeking (Uruguay) among people with past-year cannabis/cocaine-related dependence. We tested model-based prevalence trends over time and described individual-level treatment correlates by country. RESULTS: Cannabis/cocaine dependence prevalence increased in the region starting in 2010-2011, driven by cannabis dependence. Adjusted cannabis dependence prevalence increased from 0.7% in 2010 to 1.5% in 2017 in Argentina (aPD=0.8, 95% CI= 0.3, 1.2), from 0.8% in 2010 to 2.8% in 2018 in Chile (aPD=2.0, 95% CI= 1.4, 2.6), and from 1.4% in 2011 to 2.4% in 2018 in Uruguay (aPD=0.9, 95% CI= 0.2, 1.6). Cocaine-related dependence increased in Uruguay, decreased in Argentina, and remained stable in Chile. Among people with past-year cannabis/cocaine dependence, average alcohol/drug treatment use prevalence was 15.3% in Argentina and 6.0% in Chile, while treatment use/seeking was 14.7% in Uruguay. Alcohol/drug treatment prevalence was lower among people with cannabis dependence than cocaine-related dependence. Treatment correlates included older ages in all countries and male sex in Argentina only. CONCLUSION: Alcohol/drug treatment use among people with cannabis/cocaine-related dependence remained low, signaling an ongoing treatment gap in the context of growing cannabis dependence prevalence in the region. Additional resources may be needed to increase treatment access and uptake. Future studies should assess contributors of low treatment use, including perceived need, stigma, and service availability.

Simultaneous Alcohol/Cannabis Use and Driving Under the Influence in the U.S.

INTRODUCTION: Alcohol and cannabis are commonly involved in motor vehicle crashes and fatalities. This study examines whether simultaneous use of alcohol/cannabis is associated with higher odds of reporting driving under the influence of alcohol and cannabis in the U.S. METHODS: Drivers aged ≥16 years with any past-year alcohol and cannabis use in the 2016-2019 National Survey on Drug Use and Health (N=34,514) reported any past-year driving under the influence of alcohol-only, cannabis-only, both alcohol/cannabis, or not driving under the influence. Survey-weighted associations between simultaneous alcohol/cannabis use and each of the driving under the influence outcomes were computed adjusting for sociodemographics and daily alcohol/cannabis use. Analyses were conducted from November 2020 to September 2021. RESULTS: In 2016-2019, 42% of drivers with past-year alcohol and cannabis use reported driving under the influence (8% alcohol-only, 20% cannabis-only, 14% alcohol/cannabis). Simultaneous alcohol/cannabis use was associated with 2.88-times higher adjusted odds of driving under the influence of cannabis-only (95% CI=2.59, 3.19) and 3.51-times higher adjusted odds of driving under the influence of both alcohol/cannabis (95% CI=3.05, 4.05), compared to not driving under the influence. Associations with driving under the influence of alcohol-only were unexpectedly in the opposite direction (adjusted conditional odds ratio=0.59, 95% CI=0.45, 0.79). CONCLUSIONS: Overall, 2 in 5 drivers who used alcohol and cannabis reported driving under the influence of alcohol and/or cannabis. People reporting simultaneous alcohol/cannabis use were more likely to report cannabis-related driving under the influence. Prevention strategies should target individuals reporting simultaneous alcohol/cannabis use to reduce the occurrence of driving under the influence.

Use of Medication for Opioid Use Disorder Among US Adolescents and Adults With Need for Opioid Treatment, 2019.

Importance: Medication for opioid use disorder (MOUD) is the criterion standard treatment for opioid use disorder (OUD), but nationally representative studies of MOUD use in the US are lacking. Objective: To estimate MOUD use rates and identify associations between MOUD and individual characteristics among people who may have needed treatment for OUD. Design, Setting, and Participants: Cross-sectional, nationally representative study using the 2019 National Survey on Drug Use and Health in the US. Participants included community-based, noninstitutionalized adolescent and adult respondents identified as individuals who may benefit from MOUD, defined as (1) meeting criteria for a past-year OUD, (2) reporting past-year MOUD use, or (3) receiving past-year specialty treatment for opioid use in the last or current treatment episode. Main Outcomes and Measures: The main outcomes were treatment with MOUD compared with non-MOUD services and no treatment. Associations with sociodemographic characteristics (eg, age, race and ethnicity, sex, income, and urbanicity); substance use disorders; and past-year health care or criminal legal system contacts were analyzed. Multinomial logistic regression was used to compare characteristics of people receiving MOUD with those receiving non-MOUD services or no treatment. Models accounted for predisposing, enabling, and need characteristics. Results: In the weighted sample of 2 206 169 people who may have needed OUD treatment (55.5% male; 8.0% Hispanic; 9.9% non-Hispanic Black; 74.6% non-Hispanic White; and 7.5% categorized as non-Hispanic other, with other including 2.7% Asian, 0.9% Native American or Alaska Native, 0.2% Native Hawaiian or Pacific Islander, and 3.8% multiracial), 55.1% were aged 35 years or older, 53.7% were publicly insured, 52.2% lived in a large metropolitan area, 56.8% had past-year prescription OUD, and 80.0% had 1 or more co-occurring substance use disorders (percentages are weighted). Only 27.8% of people needing OUD treatment received MOUD in the past year. Notably, no adolescents (aged 12-17 years) and only 13.2% of adults 50 years and older reported past-year MOUD use. Among adults, the likelihood of past-year MOUD receipt vs no treatment was lower for people aged 50 years and older vs 18 to 25 years (adjusted relative risk ratio [aRRR], 0.14; 95% CI, 0.05-0.41) or with middle or higher income (eg, $50 000-$74 999 vs $0-$19 999; aRRR, 0.18; 95% CI, 0.07-0.44). Compared with receiving non-MOUD services, receipt of MOUD was more likely among adults with at least some college (vs high school or less; aRRR, 2.94; 95% CI, 1.33-6.51) and less likely in small metropolitan areas (vs large metropolitan areas, aRRR, 0.41; 95% CI, 0.19-0.93). While contacts with the health care system (85.0%) and criminal legal system (60.5%) were common, most people encountering these systems did not report receiving MOUD (29.5% and 39.1%, respectively). Conclusions and Relevance: In this cross-sectional study, MOUD uptake was low among people who could have benefited from treatment, especially adolescents and older adults. The high prevalence of health care and criminal legal system contacts suggests that there are critical gaps in care delivery or linkage and that cross-system integrated interventions are warranted.

Non-pharmacological Treatment for Chronic Pain in US Veterans Treated Within the Veterans Health Administration: Implications for Expansion in US Healthcare Systems.

BACKGROUND: Consensus guidelines recommend multimodal chronic pain treatment with increased use of non-pharmacological treatment modalities (NPM), including as first-line therapies. However, with many barriers to NPM uptake in US healthcare systems, NPM use may vary across medical care settings. Military veterans are disproportionately affected by chronic pain. Many veterans receive treatment through the Veterans Health Administration (VHA), an integrated healthcare system in which specific policies promote NPM use. OBJECTIVE: To examine whether veterans with chronic pain who utilize VHA healthcare were more likely to use NPM than veterans who do not utilize VHA healthcare. DESIGN: Cross-sectional nationally representative study. PARTICIPANTS: US military veterans (N = 2,836). MAIN MEASURES: In the 2019 National Health Interview Survey, veterans were assessed for VHA treatment, chronic pain (i.e., past 3-month daily or almost daily pain), symptoms of depression and anxiety, substance use, and NPM (i.e., physical therapy, chiropractic/spinal manipulation, massage, psychotherapy, educational class/workshop, peer support groups, or yoga/tai chi). KEY RESULTS: Chronic pain (45.2% vs. 26.8%) and NPM use (49.8% vs. 39.4%) were more prevalent among VHA patients than non-VHA veterans. After adjusting for sociodemographic characteristics, psychiatric symptoms, physical health indicators, and use of cigarettes or prescription opioids, VHA patients were more likely than non-VHA veterans to use any NPM (adjusted odds ratio [aOR] = 1.52, 95% CI: 1.07-2.16) and multimodal NPM (aOR = 1.80, 95% CI: 1.12-2.87) than no NPM. Among veterans with chronic pain, VHA patients were more likely to use chiropractic care (aOR = 1.90, 95% CI = 1.12-3.22), educational class/workshop (aOR = 3.02, 95% CI = 1.35-6.73), or psychotherapy (aOR = 4.28, 95% CI = 1.69-10.87). CONCLUSIONS: Among veterans with chronic pain, past-year VHA use was associated with greater likelihood of receiving NPM. These findings may suggest that the VHA is an important resource and possible facilitator of NPM. VHA policies may offer guidance for expanding use of NPM in other integrated US healthcare systems.

Cost of Hepatitis C care facilitation for HIV/Hepatitis C Co-infected people who use drugs.

BACKGROUND: Using data from a randomized trial, we evaluated the cost of HCV care facilitation that supports moving along the continuum of care for HIV/HCV co-infected individuals with substance use disorder. METHODS: Participants were HIV patients residing in the community, initially recruited from eight US hospital sites. They received HCV care facilitation (n = 51) or treatment as usual (n = 62) for up to six months. We used micro-costing methods to evaluate costs from the healthcare sector and patient perspectives in 2017 USD. We conducted sensitivity analyses varying care facilitator caseloads and examined offsetting savings using participant self-reported healthcare utilization. RESULTS: The average site start-up cost was $6320 (site range: $4320-$7000), primarily consisting of training. The mean weekly cost per participant was $20 (site range: $4-$30) for care facilitation visits and contacts, $360 (site range: $130- $700) for supervision and client outreach, and $70 (site range: $20-$180) for overhead. In sensitivity analyses applying a weekly caseload of 10 participants per care facilitator (versus 1-6 observed in the trial), the total mean weekly care facilitation cost from the healthcare sector perspective decreased to $110. Weekly participant time and travel costs averaged $7. There were no significant differences in other healthcare service costs between participants in the intervention and control arms. CONCLUSION: Weekly HCV care facilitation costs were approximately $450 per participant, but approximately $110 at a real-world setting maximum caseload of 10 participants per week. No healthcare cost offsets were identified during the trial period, although future savings might result from successful HCV treatment.

Costs of opioid overdose education and naloxone distribution in New York City.

Background: Naloxone is an opioid antagonist medication that can be administered by lay people or medical professionals to reverse opioid overdoses and reduce overdose mortality. Cost was identified as a potential barrier to providing expanded overdose education and naloxone distribution (OEND) in New York City (NYC) in 2017. We estimated the cost of delivering OEND for different types of opioid overdose prevention programs (OOPPs) in NYC. Methods: We interviewed naloxone coordinators at 11 syringe service programs (SSPs) and 10 purposively sampled non-SSPs in NYC from December 2017 to September 2019. The samples included diverse non-SSP program types, program sizes, and OEND funding sources. We calculated one-time start up costs and ongoing operating costs using micro-costing methods to estimate the cost of personnel time and materials for OEND activities from the program perspective, but excluding naloxone kit costs. Results: Implementing an OEND program required a one-time median startup cost of $874 for SSPs and $2,548 for other programs excluding overhead, with 80% of those costs attributed to time and travel for training staff. SSPs spent a median of $90 per staff member trained and non-SSPs spent $150 per staff member. The median monthly cost of OEND program activities excluding overhead was $1,579 for SSPs and $2,529 for non-SSPs. The costs for non-SSPs varied by size, with larger, multi-site programs having higher median costs compared to single-site programs. The estimated median cost per kit dispensed excluding and including overhead was $19 versus $25 per kit for SSPs, and $36 versus $43 per kit for non-SSPs, respectively. Conclusions: OEND operating costs vary by program type and number of sites. Funders should consider that providing free naloxone to OEND programs does not cover full operating costs. Further exploration of cost-effectiveness and program efficiency should be considered across different types of OEND settings.

Prospective effects of loneliness on frequency of alcohol and marijuana use.

BACKGROUND: Loneliness is a widespread problem, with demonstrated negative health effects. However, prospective data on the relationship between loneliness and problematic substance use are lacking, and few studies have examined specific commonplace substances, such as alcohol and cannabis. This study used prospective data from a community sample of US adults with problematic alcohol or cannabis use to examine whether loneliness was a predictor of subsequent increased substance use. METHODS: Participants (N = 210) were recruited between 05/2016-06/2019 from a New York City medical center. At baseline, 3-month, and 6-month follow-ups, participants completed identical computerized questionnaires. We used generalized estimating equations to assess the average effect of past 2-week loneliness on subsequent number of days of alcohol or cannabis use, controlling for baseline days of use, demographic characteristics, and past 2-week DSM-5 depression. RESULTS: Compared with individuals who were never lonely, participants with moderate or severe loneliness had a significantly higher frequency of alcohol or cannabis use at the subsequent assessment (ß = 0.25 95% CI: 0.08-0.42). CONCLUSION: Individuals experiencing loneliness at least a few times in the past 2 weeks reported more days of subsequent alcohol or cannabis use compared with individuals who were not lonely. This is cause for concern, as national surveys of US adults indicate increasing rates of loneliness, depression and substance use during the COVID-19 pandemic. These results suggest the need for health care providers to screen for feelings of loneliness and potentially harmful coping behaviors such as substance use, and to offer healthier alternative coping strategies.

Psychosocial and health problems associated with alcohol use disorder and cannabis use disorder in U.S. adults.

BACKGROUND: Although the problems associated with alcohol use disorder (AUD) are well known, little is known about the psychosocial problems associated with cannabis use disorder (CUD), and the harmfulness of CUD relative to AUD. We compared the odds of psychosocial and health-related problems between individuals with DSM-5 AUD-only, CUD-only and co-occurring AUD+CUD. METHODS: The 2012-2013 NESARC-III, a nationally representative cross-sectional survey of non-institutionalized US adults (n = 36,309), assessed participants for DSM-5 AUD, CUD, and psychosocial (interpersonal, financial, legal) and health-related problems. Based on their responses, participants were categorized into mutually exclusive groups: no AUD/CUD, AUD-only, CUD-only, and AUD+CUD. Multivariable logistic regression models examined the associations between psychosocial problems and the four AUD/CUD groups, adjusting for sociodemographic characteristics. RESULTS: People with AUD-only, CUD-only, and AUD+CUD had higher odds of most interpersonal problems (adjusted odds ratio [aORs] 1.07-4.01), financial problems (aORs 1.53-4.28), legal problems (aORs 3.34-7.71), and health-related problems (aORs 1.29-1.92). The odds of psychosocial and health-related problems were similar for CUD-only and AUD-only in direct comparisons. Compared to those with AUD-only, those with AUD+CUD had higher odds of most problems examined (aORs 1.42-2.31). In contrast, there were few differences when comparing AUD+CUD with CUD-only. CONCLUSIONS: AUD and CUD were similarly associated with interpersonal, financial, and legal problems, emergency treatment and suicide attempt. People with AUD+CUD had higher odds of certain problems than individuals with either AUD-only or CUD-only. Although most people who use cannabis do not experience harms, our results indicate that CUD does not appear to be less harmful than AUD.

Mental health and economic stressors associated with high-risk drinking and increased alcohol consumption early in the COVID-19 pandemic in the United States.

Physical distancing measures to curb COVID-19 transmission introduced mental health and economic stressors, possibly impacting problematic drinking. This cross-sectional study examines mental health and economic stressors early in the COVID-19 pandemic which may be associated with heavy alcohol use and increased alcohol use. We administered an online survey of U.S. adults via social media April 5 to May 5, 2020. High-risk drinking was defined by WHO risk drinking levels, a daily average of ≥4 drinks for men and ≥3 drinks for women. Participants reported retrospective assessments of increased alcohol use if their past-week alcohol consumption exceeded their past-year average weekly alcohol consumption. We used logistic regression to assess possible covariates of high-risk drinking and increased alcohol use. Among 2175 participants, 10% (n = 222) reported high-risk drinking, and 36% (n = 775) reported increased alcohol consumption. In multivariable analysis, high-risk drinking was significantly associated with household job loss (OR = 1.41, 95%CI = (1.06, 1.88)) and depressive symptoms (OR = 1.05, 95% CI = (1.02, 1.07)), and women had higher odds of high-risk drinking than men (OR = 2.37, 95% CI = (1.32, 4.69)). Previous mental health diagnosis was not significantly associated with high-risk drinking during the pandemic (OR = 1.31, 95% CI = (0.98, 1.76)) in univariable analysis. High-risk drinkers were almost six times as likely to report retrospective assessments of increased alcohol consumption, controlling for mental health and economic stressors (OR = 5.97, 95% CI = (4.35, 8.32)). Findings suggest a need for targeted interventions to address the complex mental health and economic stressors that may increase alcohol consumption and high-risk drinking during and after the pandemic.

Predictors of iron consumption for at least 90 days during pregnancy: Findings from National Demographic Health Survey, Pakistan (2017-2018).

BACKGROUND: Iron supplementation is considered an imperative strategy for anemia prevention and control during pregnancy in Pakistan. Although there is some evidence on the predictors of iron deficiency anemia among Pakistani women, there is a very limited understanding of factors associated with iron consumption among Pakistani pregnant women. Thus, this study aimed to investigate the predictors of iron consumption for at least ≥90 days during pregnancy in Pakistan. METHODS: We analyzed dataset from the nationally representative Pakistan Demographic Health Survey 2017-2018. The primary outcome of the current study was the consumption of iron supplementation for ≥90 days during the pregnancy of the last birth. Women who had last childbirth 5 years before the survey and who responded to the question of iron intake were included in the final analysis (n = 6370). We analyzed the data that accounted for complex sampling design by including clusters, strata, and sampling weights. RESULTS: Around 30% of the women reported consumed iron tablets for ≥90 days during their last pregnancy. In the multivariable logistic regression analysis, we found that factors such as women's age (≥ 25 years) (adjusted prevalence ratio (aPR) = 1.52; 95% CI: 1.42-1.62)], wealth index (rich/richest) (aPR = 1.25; [95% CI: 1.18-1.33]), primary education (aPR = 1.33; [95% CI: 1.24-1.43), secondary education (aPR = 1.34; [95% CI: 1.26-1.43), higher education (aPR = 2.13; [95% CI: 1.97-2.30), women's say in choosing husband (aPR = 1.68; [95% CI: 1.57-1.80]), ≥ five antenatal care visits (aPR =2.65; [95% CI (2.43-2.89]), history of the last Caesarian-section (aPR = 1.29; [95% CI: 1.23-1.36]) were significantly associated with iron consumption for ≥90 days. CONCLUSION: These findings demonstrate complex predictors of iron consumption during pregnancy in Pakistan. There is a need to increase the number of ANC visits and the government should take necessary steps to improve access to iron supplements by targeting disadvantaged and vulnerable women who are younger, less educated, poor, and living in rural areas.

Impact of Removing Medicaid Fee-for-Service Hepatitis C Virus (HCV) Treatment Restrictions on HCV Provider Experience with Medicaid Managed Care Organizations in New York City.

Immediately after the approval of direct-acting antiviral medications for the treatment of hepatitis C virus (HCV) in 2013, state Medicaid programs limited access to these expensive treatments based on liver disease stage, absence of active alcohol or substance use, and prescriber limitations. New York State fee-for-service (FFS) Medicaid eliminated these requirements in May 2016, but the effect on providers and patients obtaining prior authorization (PA) from Medicaid managed care organizations (MCOs) was unknown. We used a mixed methods approach to assess whether the removal of HCV treatment restrictions was associated with changes in Medicaid MCOs' PA approval processes and length of time to treatment initiation at two large urban New York City provider organizations participating in Project INSPIRE, an HCV care coordination demonstration project. At baseline, the top criteria for clinic care coordinators ranking MCOs as being "most difficult" were liver staging criteria, delayed treatment, and requiring a urine toxicology test. At follow-up, liver staging criteria were replaced by medication formulary limitations. Univariate analysis of the Project INSPIRE participant data suggests a decrease in the percentage of participants with insurance/PA-related treatment delays pre- versus post-policy change (23% versus 15%, p value = 0.02). Interrupted time series analysis found a 2 percentage point decrease (p value = 0.02) in the proportion of PAs each month with insurance-related treatment delays that was attributable to policy change. These results from two urban clinics indicate New York State FFS Medicaid's policy change for HCV treatment may have been associated with some changes in Medicaid MCO PA decisions, but MCO PA denials and treatment delays were still observed "on the ground" by clinic staff.