Shared Medical Appointment: A Novel Model for Incorporating Group Visits Into Residency Training for Substance Use Disorders.

BACKGROUND: Shared medical appointments (SMAs) are a novel modality for treating patients with similar conditions, together, by a team of interdisciplinary providers. SMAs benefit patients with substance use disorder (SUD), but no research has focused on the feasibility of implementation of SMAs in a teaching clinic. METHODS: Primary care residents rotated in a half-day ambulatory addiction clinic for 4 weeks where a third-year resident co-facilitated 4 SMAs. Confidence, knowledge, and attitudes about SUD care were assessed using web-based surveys at weeks 0, 4, and 8. Pre- and post-intervention scores were compared using a t test for paired samples. RESULTS: Ten residents were included in the analyses. Using a 10-point Likert scale, confidence in SUD knowledge (7.0-8.3, P = .003), confidence in counseling patients with SUD (7.1-8.2, P = .023), and confidence in facilitating an SMA (5.7-8.3, P = .007) showed statistically significant increases from baseline following exposure to the SMAs. Confidence that counseling and other treatments will make a difference for patients with illicit drug use increased (7.1-8.0, P = .142), but did not differ statistically. Furthermore, on a 4-point Likert scale, understanding of behavioral therapies for treating and preventing the relapse of SUD (2.9-3.2, P = .180) showed a similar increase. Attitudes toward patients with SUD (42.4-42.1, P = .303) and physician empathy (119.3-119.2, P = .963) did not change from pre- to post-intervention. CONCLUSIONS: SMAs are a feasible training tool in the education of primary care residents on an addiction medicine rotation. Residents develop confidence co-facilitating SMAs after 4 weeks. Overall, exposure to SMAs during residency can provide an opportunity to increase confidence in treating patients with SUD, as well as provide a training modality that may shift the way residents interact with patients receiving SUD treatment.

Cannabis use among youth who vape nicotine E-cigarettes: A qualitative analysis.

BACKGROUND: Nicotine vaping and cannabis use are common among youth. Among youth who use e-cigarettes, little is known about how and why they use cannabis and patterns of cannabis and nicotine co-use. Given the popularity of both products among youth, the study aim is to utilize qualitative data to better understand cannabis use among youth who use e-cigarettes. METHOD: Six focus groups of high schoolers who reported past-month e-cigarette use (N = 50; 52% male) were conducted to inform e-cigarette cessation programming. We conducted secondary data analysis examining report of cannabis use during focus groups. Transcripts were examined for report of cannabis use, reasons for use, and nicotine and cannabis co-use. RESULTS: In focus groups, cannabis was commonly discussed. Youth reported vaping cannabis, however other forms of cannabis delivery were common (e.g. blunts, joints). Themes related to reasons for simultaneous use of nicotine and cannabis were to experience stronger psychoactive effects than using either product alone and needing to use less nicotine product overall. Reasons for liking cannabis were positive psychoactive effects and stress relief. Reasons for disliking were related to health concerns. Notably, when youth reported disliking cannabis due to health concerns, a common discussion was strategies to acquire and continue cannabis use in ways that they perceived mitigated health concerns. CONCLUSION: Qualitative evidence identified associations between e-cigarette use and cannabis use among youth. Research and interventions targeting youth using e-cigarettes should consider how to address dual use of these products.

Saracatinib Fails to Reduce Alcohol-Seeking and Consumption in Mice and Human Participants.

More effective treatments to reduce pathological alcohol drinking are needed. The glutamatergic system and the NMDA receptor (NMDAR), in particular, are implicated in behavioral and molecular consequences of chronic alcohol use, making the NMDAR a promising target for novel pharmacotherapeutics. Ethanol exposure upregulates Fyn, a protein tyrosine kinase that indirectly modulates NMDAR signaling by phosphorylating the NR2B subunit. The Src/Fyn kinase inhibitor saracatinib (AZD0530) reduces ethanol self-administration and enhances extinction of goal-directed ethanol-seeking in mice. However, less is known regarding how saracatinib affects habitual ethanol-seeking. Moreover, no prior studies have assessed the effects of Src/Fyn kinase inhibitors on alcohol-seeking or consumption in human participants. Here, we tested the effects of saracatinib on alcohol consumption and craving/seeking in two species, including the first trial of an Src/Fyn kinase inhibitor to reduce drinking in humans. Eighteen male C57BL/6NCrl mice underwent operant conditioning on a variable interval schedule to induce habitual responding for 10% ethanol/0.1% saccharin. Next, mice received 5 mg/kg saracatinib or vehicle 2 h or 30 min prior to contingency degradation to measure habitual responding. In the human study, 50 non-treatment seeking human participants who drank heavily and met DSM-IV criteria for alcohol abuse or dependence were randomized to receive 125 mg/day saracatinib (n = 33) or placebo (n = 17). Alcohol Drinking Paradigms (ADP) were completed in a controlled research setting: before and after 7-8 days of treatment. Each ADP involved consumption of a priming drink of alcohol (0.03 mg%) followed by ad libitum access (3 h) to 12 additional drinks (0.015 g%); the number of drinks consumed and craving (Alcohol Urge Questionnaire) were recorded. In mice, saracatinib did not affect habitual ethanol seeking or consumption at either time point. In human participants, no significant effects of saracatinib on alcohol craving or consumption were identified. These results in mice and humans suggest that Fyn kinase inhibition using saracatinib, at the doses tested here, may not reduce alcohol consumption or craving/seeking among those habitually consuming alcohol, in contrast to reports of positive effects of saracatinib in individuals that seek ethanol in a goal-directed manner. Nevertheless, future studies should confirm these negative findings using additional doses and schedules of saracatinib administration.

Influence of menthol and green apple e-liquids containing different nicotine concentrations among youth e-cigarette users.

E-cigarettes are popular among adolescents. Given that flavors enhance e-cigarette appeal, this study examined the influence of flavors on nicotine in e-cigarettes. Youth e-cigarette users (average 26.2 days [SD = 3.6] in past 28 days) were randomized to use e-cigarettes containing 6 or 12 mg/mL of freebase nicotine and completed 4 test sessions. During the first 3 test sessions, participants completed 3 fixed puffing bouts (1 puffing bout = 10 puffs, 3 s each, 30-s interval), using menthol, green-apple, and unflavored e-liquids (50 propylene glycol [PG]/50 vegetable glycerin [VG]) with their assigned nicotine concentration in a random order using a ∼5.5-W V2 e-cigarette device. After each puffing bout, participants assessed subjective effects of nicotine and flavor. In the 4th test session, participants used any of the e-liquids they had tried in the earlier sessions, ad libitum for 60 min and the amount of e-liquid used for each flavor and the number of puffs was assessed. Participants (n = 49; 6 mg/mL [n = 24]; 12 mg/mL [n = 25]) were 63.3% male, 65.3% non-Hispanic White with an average age of 18.7 (SD = 0.9). Mixed models analysis revealed that green apple and 6 mg/mL of nicotine independently increased liking of e-cigarette taste. In addition, green apple produced higher ratings of fruitiness, sourness, sweetness, and menthol produced higher ratings of coolness. We did not observe any interactions between nicotine and flavor. Youth liked the taste of e-liquids containing green-apple flavor or low nicotine concentration which highlights the appeal of fruit flavors in e-cigarettes to adolescents. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Informing the development of adolescent e-cigarette cessation interventions: A qualitative study.

INTRODUCTION: Adolescents are using e-cigarettes at high rates and there is limited information on how to help them quit. We aimed to inform e-cigarette cessation interventions by understanding why adolescents use and dislike e-cigarettes and their quit experiences. METHODS: Six focus groups with current users (i.e., past-month use) and 2 focus groups with past users (i.e., no past-month use) were conducted in Fall 2019 in Connecticut (N = 62). We used a focus group guide and an iterative approach to identify themes. RESULTS: Adolescents used e-cigarettes because of social reasons and to relieve stress and reported disliking e-cigarettes due to the cost, negative health effects, and addiction. They reported both intentional and unintentional experiences with quitting e-cigarettes. Reasons for unintentional quitting included lack of access to e-cigarettes. Reasons for intentional quitting included short-term "tolerance breaks" and health concerns. Of those who tried to quit, common quitting methods were "cold turkey," giving away their device, and limiting interactions with peer users. The most common withdrawal symptom was negative mood. Notable barriers to quitting included exposure to social influences at school, easy access to e-cigarettes, and lack of motivation to quit. DISCUSSION: Our qualitative evidence suggests that e-cigarette cessation interventions need to motivate youth to quit, and teach them to manage social influences, stress and other negative mood, and withdrawal symptoms. Interventions that address social norms related to use of e-cigarettes in school and reduce cues related to e-cigarette use may also be beneficial.

E-cigarette devices used on school grounds.

INTRODUCTION: Preliminary evidence suggests adolescents use e-cigarettes in school. However, little is known about the types of devices that are used in schools, where they are used, and who uses them. Knowledge about these issues is critical to inform school regulations. METHODS: Cross-sectional surveys were conducted in 6 Connecticut high schools in 2019. Adolescents reported on current use (past 30-day use) of the following e-cigarette devices inschool: JUUL, any pod system other than JUUL, vape pens, disposables, mods, and on deviceuse in different locations: class, bathroom, hallways, outside on school grounds, and other school locations. Separate binary logistic regressions investigated predictors of use (demographics and past month use frequency of each device) in school for each device. RESULTS: Overall, 45.0% of current users (N = 1447) used e-cigarettes at school. Among users of each device, prevalence of current use at school varied by device with 45.7% reporting JUUL use, 41.3% other pod use, 34.6% vape pen use, 38.3% disposables use and 27.3% mod use. Current users used devices in bathrooms (75.1%), followed by outside on school grounds (52.2%), classrooms (45.7%), hallways (38.8%) and other school locations (11.7%). Greater e-cigarette past month use frequency for each device was associated with device use in school. CONCLUSIONS: This study is the first to examine use of specific e-cigarette devices in schools and demonstrates that e-cigarette use frequency predicts school use. Despite rules against vaping, e-cigarette use remains prevalent in many school locations, suggesting alternative strategies such as prevention and e-cigarette education are needed.

Computerized Cognitive Behavioral Therapy for Substance Use Disorders in a Specialized Primary Care Practice: A Randomized Feasibility Trial to Address the RT Component of SBIRT.

OBJECTIVES: Screening, Brief Intervention, and Referral to Treatment (SBIRT) has demonstrated efficacy for addressing unhealthy alcohol use in primary care, yet recent research indicates weaker efficacy for drug use as well as very limited success in referral to specialty care for patients with substance use disorder (SUD). Technology-based interventions for SUD delivered in primary care settings are a potential strategy of efficiently delivering treatment to those who need it. METHODS: We conducted a randomized clinical trial evaluating feasibility, satisfaction, and substance use outcomes for 58 individuals with SUD. Participants being treated in a primary care practice which provides integrated addiction treatment were randomized to standard care or standard care plus access to a web-based SUD intervention (computer-based training in cognitive behavioral therapy, or CBT4CBT). Self-reported substance use and urine toxicology screens were assessed at 8 weeks after randomization. RESULTS: Uptake of CBT4CBT in this setting was high; 77% of those assigned to this condition accessed the program at least once; of those, 77% completed all 7 modules. Satisfaction with the program was very high. Participants reported >90% days abstinent for all classes of drugs; with no significant differences between conditions. CONCLUSIONS: This study demonstrates feasibility of implementing technology-based treatments in primary care settings to address weak follow-through with the referral component of SBIRT. The overall positive outcomes in this specialized, integrated treatment setting may have undercut the ability to demonstrate differential effects on substance use; results suggest evaluation in less specialized primary care settings is warranted. TRIAL REGISTRATION: clinicaltrials.gov NCT03013478.

Querying About the Use of Specific E-Cigarette Devices May Enhance Accurate Measurement of E-Cigarette Prevalence Rates Among High School Students.

INTRODUCTION: Prevalence estimates of electronic cigarette (e-cigarette) use may underestimate actual use in youth. Confusion resulting from the fact that a multitude of devices (eg, vape pens, JUULs) fall under the umbrella term "e-cigarettes," the use of different names to refer to e-cigarettes (eg, vapes, electronic vaping devices), and the use of different terminology to refer to e-cigarette use (eg, "vaping," "JUULing"), may lead some young e-cigarette users to incorrectly indicate nonuse. Therefore, we compared rates of endorsing lifetime e-cigarette use when adolescents were asked about lifetime e-cigarette use in two different ways. METHODS: In May to June 2018, a total of 1960 students from two high schools in Connecticut completed a computerized, school-based survey. Participants first reported on lifetime "e-cigarette" use and, subsequently, on lifetime use of five different e-cigarette devices: disposables, cig-a-likes, or E-hookahs; vape pens or Egos; JUULs; pod systems other than JUULs such as PHIX or Suorin; and advanced personal vaporizers or mods. RESULTS: In total, 35.8% of students endorsed lifetime "e-cigarette" use, whereas 51.3% endorsed lifetime use of at least one e-cigarette device. The kappa statistic indicated only 66.6% agreement between the methods of assessing e-cigarette use. Overall, 31.5% of adolescents who endorsed lifetime device use did not endorse lifetime "e-cigarette" use, although rates of discordant responding varied across subgroups of interest (eg, sex, race). CONCLUSIONS: Assessing adolescents' use of specific e-cigarette devices likely yields more accurate results than assessing the use of "e-cigarettes." If these findings are replicated in a nationally representative sample, regulatory efforts requiring all e-cigarette devices to be clearly labeled as "e-cigarettes" may help to reduce confusion. IMPLICATIONS: Different prevalence estimates of lifetime e-cigarette use were obtained depending on the way that prevalence was assessed. Specifically, fewer adolescents (35.8%) endorsed lifetime e-cigarette use when they were asked "Have you ever tried an e-cigarette, even one or two puffs?" than when they were queried about lifetime use of five different e-cigarette devices (51.3%). Among those who endorsed lifetime use of at least one specific e-cigarette device, 31.5% did not endorse lifetime "e-cigarette" use. These findings suggest that when assessing adolescents' lifetime e-cigarette use, using of terms referring to specific devices likely produces more accurate prevalence estimates than using the term "e-cigarettes."

Influence of combined treatment with naltrexone and memantine on alcohol drinking behaviors: a phase II randomized crossover trial.

Glutamate and opioid systems play important roles in alcohol drinking behaviors. We examined if combined treatment with the NMDA antagonist memantine and the opioid antagonist naltrexone, when compared with naltrexone alone, would have a greater influence on alcohol drinking behaviors. Fifty-six, non-treatment-seeking heavy drinkers, with alcohol dependence and a positive family history (FHP) of alcoholism, participated in a randomized, double-blind, crossover trial, including two 6-8 days treatment periods, separated by a 6-day washout, and 3 alcohol drinking paradigm (ADP) sessions. After the first baseline (BAS) ADP1 session, participants were randomized to receive either naltrexone (NTX; 50 mg/day) + placebo memantine, or NTX (50 mg/day) + memantine (MEM; 20 mg/day), during the first treatment period, following which they completed ADP2. After a 6-day washout, participants were crossed over to the treatment they did not receive during the first treatment period, following which they completed ADP3. During each ADP, participants received a priming drink of alcohol followed by 3 1-hour, self-administration periods during which they had ad-lib access to 12 drinks. Individually, both NTX and NTX + MEM, when compared to BAS ADP1, significantly reduced the number of drinks consumed (p's < 0.001) and craving (p's < 0.001). When comparing NTX + MEM vs. NTX on number of drinks consumed, there was a significant treatment* sequence interaction (p = 0.004). Specifically, when NTX + MEM followed NTX alone, NTX + MEM resulted in a further reduction in drinking (mean: -1.94; 95% CI: -2.6, -0.8, p = 0.0005). However, when NTX alone followed NTX + MEM, NTX alone did not lead to further reduction in drinking (mean: 0.59; 95% CI: -0.67, 1.43, p = 0.47). Similar patterns were observed for alcohol craving; specifically, a significant reduction in craving was observed when NTX + MEM followed NTX alone (p = 0.009), but craving reduction was maintained when NTX + MEM was followed by NTX alone. Neither treatment condition significantly influenced alcohol-induced stimulation or sedation. Memantine (at a dose of 20 mg/day) enhances the efficacy of naltrexone (50 mg/day) in reducing alcohol drinking and craving among FHP drinkers with beneficial effects that appear to carryover after discontinuation of memantine treatment.

High school students' use of flavored e-cigarette e-liquids for appetite control and weight loss.

BACKGROUND: Although weight-related reasons for smoking and vaping have been examined in adults, research in adolescents is lacking. Thus, we examined the prevalence and correlates of using flavored e-liquids for appetite control or weight loss in high school adolescents. METHODS: The analytic sample included 529 students who completed a school-based survey in Connecticut in Spring 2017 (50.6% female, 79.5% White, mean age 16.27 [SD = 1.18], range 13-19 years). Inclusion criteria were past-30-day vaping, using ≥ 1 flavored e-liquid (past month), and having non-missing data on flavored e-liquid use for appetite control and weight loss. Participants reported on sex, age, race, past-30-day vaping and smoking frequency, nicotine e-liquid use, flavored e-liquid use (e.g., tobacco, mint, fruit, candy), and flavored e-liquid use for appetite control and/or weight loss. RESULTS: Adolescent e-cigarette users (past 30-days) reported vaping flavored e-liquids for appetite control (13.8%) and weight loss (9.3%). Using flavored e-liquids for appetite control or weight loss, respectively, was associated with more frequent vaping (OR = 1.21; 1.21) and using more flavored e-liquids (OR = 1.33; 1.28, p-values < 0.01). Vaping candy-flavored e-liquids (OR = 1.16, p = 0.02) uniquely was associated with vaping for appetite control. CONCLUSIONS: A subset of adolescents reported using flavored e-liquids for weight-related reasons. These adolescents reported vaping more frequently than their counterparts, raising concerns about increased nicotine exposure. Research is needed to understand where adolescents learn about weight-motivated vaping (e.g., friends, social media) and whether weight-related motives promote e-cigarette initiation among e-cigarette naïve individuals or continued/escalating use among current users.

Nicotine Use Disorders in Adolescents.

Rates of certain tobacco products have decreased over the past decade, but nicotine use disorder is still prevalent among adolescents. New trends in tobacco use, such as in the use of electronic cigarettes, are creating alarm. This article reviews nicotine addiction and measurement in adolescents, along with potential health risks and comorbidities. Various psychosocial and pharmacologic interventions are reviewed along with novel interventions that show promise for reducing tobacco use in this vulnerable population.

Adolescents' awareness of the nicotine strength and e-cigarette status of JUUL e-cigarettes.

BACKGROUND: JUUL e-cigarettes are popular among youth. However, it is unknown whether adolescents understand that 5% JUUL pods contain a high nicotine concentration or consider JUULs to be e-cigarettes. METHOD: 3170 students from 4 Connecticut high schools completed a school-based survey (May-October 2018). Students reported on lifetime and past-month JUUL use and perceived JUUL nicotine strength (low/medium/high/don't know) when no information about nicotine concentration was provided and, subsequently, when informed JUULs contain 5% nicotine. Students reported whether they believe JUULs are e-cigarettes (no/yes/don't know). RESULTS: Students were never JUUL users (56.6%), ever users (13.2%), and past-month users (30.2%). When no information was provided, students reported that JUULs contain low (10.5%), medium (26.9%), or high nicotine levels (31.1%); 31.4% did not know. When informed JUULs contain 5% nicotine, students were more likely to believe JUUL's nicotine strength was low (29.5%) or medium (29.3%) than high (21.3%) and less likely to report not knowing (19.9%). 39% of students believed JUULs are not e-cigarettes or did not know. DISCUSSION: Most students were unaware of JUUL's high nicotine concentration, with more believing that JUULs contain low or medium nicotine concentrations when informed JUULs contain 5% nicotine. Thus, youth may misinterpret the nicotine concentration printed on JUUL pod packaging, raising concerns about inadvertent exposure to high nicotine levels and dependence risk. Further, 39% of adolescents believed JUULs are not e-cigarettes or were unsure. Regulatory efforts are needed to establish understandable nicotine concentration labels, require products to be labeled accordingly, and clarify what products constitute e-cigarettes.

Systematic review of cigars, cigarillos, and little cigars among adolescents: Setting research agenda to inform tobacco control policy.

INTRODUCTION: We conducted a systematic review of the literature on cigar research on youth to identify potential future research agenda to generate evidence to inform cigar regulations to prevent cigar use among youth. METHODS: We searched articles on Medline, EMBASE, and PsycINFO in April 2017 to identify articles relevant to cigars and adolescents. Two independent coders examined 48 articles to determine eligibility: (1) published between 2000-April 2017; (2) published in English; (3) conducted in the United States; (4) published in a peer-review journal; (5) examined cigars, cigarillos, or little cigars; (6) included youth (12-18 years old); and (7) included empirical data. Three independent coders reviewed the included articles (n = 48) to identify whether the studies addressed FDA's Research Priorities. RESULTS: The studies addressed FDA's Research Priorities of "behavior" (n = 48), "communications" (n = 4), "marketing influences" (n = 1), and "impact analysis" (n = 1). Studies on "behavior" underscored the need for improvements in measurement, such as using brand names and distinguishing cigar products. The review revealed the need for restrictions on cigar flavors, development of media campaigns and interventions, increasing the cost (via taxation), and evaluating the impact of cigar policies. CONCLUSIONS: The studies mostly focused on surveillance of behaviors and use patterns, which revealed cigar specific issues to address in policies to decrease cigar use among youth. The lack of studies addressing other FDA's research priorities highlighted the critical need for future studies that inform prevention of youth cigar use.

Youth generated prevention messages about electronic cigarettes.

Rates of e-cigarette use are high among youth, and there is little known about the long-term health effects of e-cigarettes. Since peer influence is a powerful determinant of tobacco use, we aimed to identify message themes about e-cigarettes that youth would use to encourage or discourage peers from using e-cigarettes. We conducted 10 focus groups (N = 69) with non-smokers and smokers from one middle school, high school and college in Connecticut. Participants engaged in a discussion about e-cigarettes, and each participant created one written message to encourage e-cigarette use and one to discourage use among peers. We content-analyzed the messages and identified three main themes and 12 encouraging and discouraging sub-themes. Encouraging themes included health benefits of e-cigarettes relative to cigarettes, attractive product characteristics (e.g. flavors) and social advantages (e.g. positive social image) of using e-cigarettes. Discouraging messages included health risks of e-cigarettes relative to cigarettes, unattractive product characteristics (e.g. cost) and social disadvantages (e.g. negative social image of using an e-cigarette). Overall, there were no differences by sex, age group or smoking status in generation of encouraging and discouraging message themes. This study identified youth-generated themes that may aid in e-cigarette prevention among youth.

E-cigarette devices used by high-school youth.

Background E-cigarette use rates are high among youth, but there is limited information on the types of e-cigarette devices that are used by youth. Methods During Spring 2017, students from 4 high schools completed surveys on use of e-cigarette devices (cig-a-like, vape/hookah pen, modified devices or mods, and JUUL). Among youth who endorsed ever (lifetime) use of an e-cigarette and of at least one device (n = 875), we assessed 1) prevalence rates of ever and current (past-month) use of each device, 2) use of nicotine in each device, and 3) predictors [age, sex, race, socioeconomic status (SES), other tobacco use] of ever use of each device and of use of single versus multiple devices. Results Cig-a-likes were used least frequently (Ever use: cig-a-likes: 25.4%; vape/hookah pens: 60.6%; JUUL: 64.2%; mods: 71.2%; Current use: cig-a-likes: 7.3%; vape/hookah pens; 18.7%; mods: 33.1%; JUUL: 47.1%;). Nicotine use was highest for JUUL (JUUL: 80.3%; mods: 56.3%; cig-a-likes: 51.4%; vape/hookah pens: 46.8%). Among ever users of single devices, use of JUUL was highest (JUUL: 43%; mods: 32%; vape/hookah pens: 21%; cig-a-likes: 4%). Ever use of all devices, except JUUL, was associated with other tobacco product use. Ever use of JUUL was associated with higher SES. Ever use of multiple devices (two: 34.7%; three: 25.8%; four: 11.7%) compared with a single device (27.8%) was associated with other tobacco product use. Conclusions Targeted regulatory and prevention efforts that consider the use of multiple e-cigarette devices are needed to lower youth e-cigarette use rates.

Correction: Preferring more e-cigarette flavors is associated with e-cigarette use frequency among adolescents but not adults.

[This corrects the article DOI: 10.1371/journal.pone.0189015.].

Socioeconomic status and adolescent e-cigarette use: The mediating role of e-cigarette advertisement exposure.

Among adolescents, low socioeconomic status (SES) is associated with greater exposure to tobacco cigarette advertising and cigarette use. However, associations among SES, e-cigarette advertising and e-cigarette use are not well understood. This study examined exposure to e-cigarette advertisements as a mediator of the relationship between SES and adolescent e-cigarette use. Adolescents (N = 3473; 51% Female) from 8 high schools in Connecticut completed an anonymous survey in Spring 2015. Mediation analysis was used to examine whether the total number of sources of recent e-cigarette advertising exposure (e.g., TV, radio, billboards, magazines, local stores [gas stations, convenience stores], vape shops, mall kiosks, tobacco shops, social media) mediated the association between SES (measured by the Family Affluence Scale) and past-month frequency of e-cigarette use. We clustered for school and controlled for other tobacco product use, age, sex, race/ethnicity and perceived social norms for e-cigarette use in the model. Our sample recently had seen advertisements via 2.1 (SD = 2.8) advertising channels. Mediation was supported (indirect effect: ß = 0.01, SE = 0.00, 95% CI [0.001, 0.010], p = 0.02), such that higher SES was associated with greater recent advertising exposure, which, in turn, was associated with greater frequency of e-cigarette use. Our study suggests that regulations to reduce youth exposure to e-cigarette advertisement may be especially relevant to higher SES youth. Future research should examine these associations longitudinally and evaluate which types of advertisements target different SES groups.

Addressing discordant quantitative urine buprenorphine and norbuprenorphine levels: Case examples in opioid use disorder.

INTRODUCTION: Urine adulteration is a concern among patients treated for opioid use disorder. Quantitative urine testing for buprenorphine (B) and norbuprenorphine (NB), and the appropriate interpretation of B and NB levels, can facilitate constructive conversations with patients that may lead to modifications in the treatment plan, and strengthening of the patient-provider relationship. CASE SUMMARY: Three cases are presented in which discordant urine B and NB levels were recognized. Each patient was submerging buprenorphine/naloxone strips in their urine to mask ongoing illicit drug use. The authors used an approach to addressing intentional adulteration of urine samples that adheres to the principles of harm-reduction, the centrality of the patient-provider relationship, and the acknowledgment that ongoing illicit drug use and subsequent dishonesty about disclosure may be common among persons with substance use disorders. Each of the three patients ultimately endorsed diluting their urine, which allowed for strengthening of the patient-provider relationship and modifications to their treatment plans. Two of the three patients stabilized and achieved abstinence, while the third was eventually referred to a methadone treatment program. CONCLUSION: Providers should routinely monitor B and NB levels, rather than qualitative screening alone, and discordant levels should elicit a timely conversation with the patient. The authors use of a nonjudgmental approach to address urine adulteration, including giving patients an opportunity to reflect on potential solutions, has been effective at helping patients and providers to reestablish a therapeutic alliance and maintain retention in treatment.