The Need to Rethink Harm Reduction for People Using Drugs Alone to Reduce Overdose Fatalities.

Background: During the ongoing opioid epidemic, Cuyahoga County (second largest in Ohio) reported overdose mortality rates (54/per 100,000) higher than the national average. Prior research demonstrates that people who use drugs often use alone but there is minimal research on people who died of overdose while using alone. The objective of this study is to examine sociodemographic, toxicologic, and injury characteristics, and emergency medical response to overdose decedents who died using drugs alone. Method: Data from the Cuyahoga County Medical Examiner's Office (2016-2020, N = 2944) on unintentional overdose deaths in adults was tabulated including socio-demographic, toxicologic, and injury-related information. Decedents using drugs alone were identified and compared to those not using alone via Chi-square and Fisher's exact tests. We further fit a multivariate logistic regression model to evaluate socio-demographic, toxicologic, and injury-related factors associated with increased odds of using alone. All results are reported with 95% confidence intervals. Result: Among decedents, 75% (n = 2205) were using drugs alone. Decedents using alone were more likely to be using drugs at home (p = 0.001) or be found dead at the scene (p < 0.001) and less likely to receive naloxone (p < 0.001) have other person/bystander, not using, present (p = 0.002). Using drugs at home (aOR = 1.61[1.19-2.20]) was associated with higher odds of using alone; and being married (aOR = 0.57[0.38-0.86]), having history of illicit drug use (aOR = 0.25[0.08-0.81]) and other person present, who was not using (aOR = 0.58[0.42-0.79]) were associated with lower odds of using alone. Conclusion: New harm reduction approaches targeting people using drugs alone are needed to reduce overdose deaths.

Bullying and School Violence.

Rates of traditional bullying have remained stable (30%) but rates of cyberbullying are increasing rapidly (46% of youth). There are significant long-term physical and mental health consequences of bullying especially for vulnerable youth. Multi-component school-based prevention programs that include caring adults, positive school climate, and supportive services for involved youth can effectively reduce bullying. While bullying has emerged as a legitimate concern, studies of surviving perpetrators to date suggest bullying is not the most significant risk factor of mass school shootings. Pediatricians play a critical role in identification, intervention, awareness, and advocacy.

A case study for local data surveillance in opioid overdose fatalities in Cuyahoga County, OH 2016-2020.

Introduction: Fentanyl and fentanyl analogs have increased the overdose mortality rates in the United States, significantly impacting states like Ohio. We examined carfentanil overdose deaths, other contributing Cause of Death (COD) drugs, and drug seizure trends from 2016 to 2020 in Northeast Ohio. Materials and methods: We studied death investigation data from the Cuyahoga County, Ohio Medical Examiner's Office (CCMEO) of all fatal accidental opioid overdoses as well as drug seizure data from Cuyahoga County Regional Forensic Science Laboratory (CCRFSL). We also compared decedents' race, gender, age, residential locality, drugs contributing to the COD in opioid cases, and for carfentanil, fentanyl, and cocaine seizures in Cuyahoga County from 2016 to 2020 (N = 2948). Results: Decedents' had an average of three different drugs contributing to their COD. A bimodal carfentanil spike was observed in fatal accidental overdoses in Cuyahoga County for the years 2017 and 2019. Decedents in urban residency, who were Non-Hispanic, White and younger, significantly predicted the presence of carfentanil contributing to the COD. In 2020, decedents who were Black and older were significantly associated with cocaine contributing to the COD. Carfentanil and carfentanil-related overdoses were significantly correlated. Discussion: The pervasiveness of illicitly manufactured fentanyl and fentanyl analog (e.g., carfentanil) mixtures with other drugs are changing the demographics of persons who fatally overdose in Cuyahoga County, OH. Significant trending shifts can also be observed for the presence of carfentanil in decedent and seizure county data. Conclusions: Local data of drug-related overdose deaths and drug seizures from a medical examiner's office and affiliated forensic laboratory lab can be used for timely public health surveillance, and informing prevention, and intervention at the county level.

The case for "investigate all": Assessing the cost-effectiveness of investigating no CODIS hit cases in a sexual assault kit initiative.

An increasing number of US jurisdictions have begun to submit their previously untested sexual assault kits (SAKs) for DNA testing. However, best practices for what should happen after testing are not well established. Should all cases be investigated regardless of the testing outcome or only those that returned a DNA hit? We examine an early-adopter jurisdiction that has completed testing and investigating all 5165 previously never tested kits. We explore and compare the criminal justice outcomes and cost-effectiveness of investigating: all cases, those with CODIS hits, and those without CODIS hits. Findings indicate the SAK initiative produced a cost savings to the community: $26.48 million ($5127 p/kit) after the inclusion of tangible and intangible costs of future sexual assaults averted through convictions, of which $9.99 million ($1934 p/kit) was from also investigating no CODIS hit cases. When considering only the costs to law enforcement, investigating all cases cost $12,000 p/additional conviction. Findings also illustrate the cost-effectiveness of investigating no CODIS hits cases and support an "investigate all" approach. This study enhances our understanding of the economic value of what comes after testing kits and investigating cases and provides a framework for jurisdictions for prioritizing resources and maximizing outcomes from testing.

Examination of a New Brief Screener to Measure Trauma Symptoms and Violence Exposure Among Young Children.

The purpose of this study was to create a reliable, quick and easy to administer screening measure of violence exposure and trauma for children from infancy through age 7. In a sample of 6,676 children, caregivers completing a 22-item screener reported nearly one out of five youth had been exposed as witness or victim to at least one kind of violence. For trauma, caregivers reported that their children had trouble going to sleep at least sometimes (15.83%), had cried or had a tantrum to exhaustion (15.61%) and had difficulty concentrating or focusing (15.55%). Analyses showed reliable internal consistency for violence exposure (.74) and trauma (.85) scales. Factor analyses revealed a single trauma factor and two violence exposure factors, witnessing and victimization. These data provide support for a brief screening measure for trauma and violence exposure in children from birth through age seven that can be administered by minimally trained staff in public systems and community-based agencies who can then refer children and families to necessary assessment and treatment services.

Evaluation of Treatment and Other Factors That Lead to Drug Court Success, Substance Use Reduction, and Mental Health Symptomatology Reduction Over Time.

Adults presenting with substance use and mental health disorders in the criminal justice system is well documented. While studies have examined drug courts and medication-assisted treatment (MAT), few have examined social and behavioral health indicators, and even fewer have multiple study periods. This study employed a comprehensive approach to studying the MAT contribution to drug court success; reduce substance use, mental health symptoms, and risky behaviors; and the role that violence or trauma plays in mental health symptomatology. Using three time points, our findings indicated that MAT did not play a significant role in the reduction of substance use, risky behaviors, or mental health symptoms or increasing the odds of successful court graduation. However, there was an overall improvement from intake to termination in reduction of substance use, risky behaviors, and mental health symptomatology. Other factors, including social support, may play a role in drug court graduation. Policy implications are discussed.

Bullying Prevention: a Summary of the Report of the National Academies of Sciences, Engineering, and Medicine : Committee on the Biological and Psychosocial Effects of Peer Victimization: Lessons for Bullying Prevention.

Long tolerated as a rite of passage into adulthood, bullying is now recognized as a major and preventable public health problem. The consequences of bullying-for those who are bullied, the perpetrators of bullying, and the witnesses-include poor physical health, anxiety, depression, increased risk for suicide, poor school performance, and future delinquent and aggressive behavior. Despite ongoing efforts to address bullying at the law, policy, and programmatic levels, there is still much to learn about the consequences of bullying and the effectiveness of various responses. In 2016, the National Academies of Sciences, Engineering, and Medicine published a report entitled Preventing Bullying Through Science, Policy and Practice, which examined the evidence on bullying, its impact, and responses to date. This article summarizes the report's key findings and recommendations related to bullying prevention.

The impact of neighborhood disorganization on neighborhood exposure to violence, trauma symptoms, and social relationships among at-risk youth.

Previous research has demonstrated that exposure to violence (ETV) is a serious concern across the north-south socioeconomic divide. While studies have found that social support is a protective factor for youth exposed to violence and trauma, little is known about the impact of trauma symptoms on forming and maintaining social relationships which are key to accessing a vital social resource that fosters resilience in youth experiencing trauma symptomatology. Building on previous models that examine the impact of neighborhoods on exposure to violence and trauma, the current study examines the impact of neighborhood disorganization on ETV among youth and ETV's effects on trauma symptoms and social relationships. Data were collected on 2242 juvenile justice-involved youth with behavioral health issues in 11 urban and rural counties in the Midwestern United States. Using structural equation modeling (SEM), our data demonstrated that living in highly disorganized neighborhoods was associated with higher levels of ETV and that ETV was positively associated with trauma symptoms. Mediational analysis showed that trauma symptoms strongly mediated the effect of ETV on social relationships. Freely estimating structural paths by gender revealed that hypothesized associations between these variables were stronger for females than males. Findings here highlight the need to provide trauma-informed care to help youth to build and maintain social relationships. Identification and treatment of trauma symptoms that is culturally informed is a critical first step in ensuring that identified protective factors in local contexts, such as social relations and social support, have opportunities to minimize the impact of ETV among youth across northern and southern nations.

A new measure of interpersonal exploitativeness.

Measures of exploitativeness evidence problems with validity and reliability. The present set of studies assessed a new measure [the Interpersonal Exploitativeness Scale (IES)] that defines exploitativeness in terms of reciprocity. In Studies 1 and 2, 33 items were administered to participants. Exploratory and Confirmatory Factor Analysis demonstrated that a single factor consisting of six items adequately assess interpersonal exploitativeness. Study 3 results revealed that the IES was positively associated with "normal" narcissism, pathological narcissism, psychological entitlement, and negative reciprocity and negatively correlated with positive reciprocity. In Study 4, participants competed in a commons dilemma. Those who scored higher on the IES were more likely to harvest a greater share of resources over time, even while controlling for other relevant variables, such as entitlement. Together, these studies show the IES to be a valid and reliable measure of interpersonal exploitativeness. The authors discuss the implications of these studies.

Violence and school shootings.

Multiple-homicide school shootings are rare events, but when they happen they significantly impact individuals, the school and the community. We focus on multiple-homicide incidents and identified mental health issues of shooters. To date, studies of school shootings have concluded that no reliable profile of a shooter exists, so risk should be assessed using comprehensive threat assessment protocols. Existing studies primarily utilize retrospective case histories or media accounts. The field requires more empirical and systematic research on all types of school shootings including single victim incidents, those that result in injury but not death and those that are successfully averted. We discuss current policies and practices related to school shootings and the role of mental health professionals in assessing risk and supporting surviving victims.

Displacement and suicide risk for juvenile justice-involved youth with mental health issues.

This article examined the relationship between suicide behaviors and displacement, as defined by out-of-home placement, in a sample of juvenile-justice-involved youth with mental health issues. Participants included boys and girls between the ages of 10 and 18 who were enrolled in a juvenile justice diversion program for children with mental or behavioral health problems. Data collected included youth-reported suicide and self-harm ideation, caregiver reports of previous suicide attempts, and whether the youth had been in an out-of-home placement in the year prior to enrollment in the program. Logistic regression analyses indicated that youth who had recently been in an out-of-home placement reported significantly less suicide ideation and marginally less self-harm ideation than youth who had not been in an out-of-home placement. Out-of-home placement status had no impact on caregiver reports of previous youth suicide attempts.

Understanding clinical complexity in delinquent youth: comorbidities, service utilization, cost, and outcomes.

This study describes the extent and severity of multiple comorbidities in ajuvenile detention center population, and explores how these numerous problems impact the utilization of treatment services, costs, and outcomes including those for substance abuse, mental illness, and criminal activity. Cluster analyses of the outcome scales at intake yielded two groups: youth high (42%) and youth lower (58%) on all factors. Girls experienced the most significant impairments across emotional problems, behavior complexity, internal mental distress, and victimization domains, utilized significantly more units of residential treatment,individual counseling and case management, and had the highest treatment costs. The total cost of services ($1,171,290, N = 114) was significantly related to substance problems in the past year (r = .219, p < .05), emotional problems (r = .237, p < .05), behavior complexity (r = .318, p < .05), internal mental distress (r = .263, p < .05), environmental risk (r = .205, p < .05), and conflict tactics (r = .240, p < .05). Despite initial differences in measures of baseline severity, high and low cluster youth, and boys and girls in general, achieved similar results on the key outcome variables 12 months later. Study implications include a need for co-occurring, integrated treatment efforts that address family, emotional, and mental health problems of delinquent youth (especially females) in order to improve their ability to successfully attend to substance abuse problems and interpersonal conflicts.

Profiles of behavioral problems in children who witness domestic violence.

Unlike previous investigations of shelter-based samples, our study examined whether profiles of adjustment problems occurred in a community-program-based sample of 175 school-aged children exposed to domestic violence. Cluster analysis revealed three stable profiles/clusters. The largest cluster (69%) consisted of children below clinical thresholds for any internalizing or externalizing problem. Children in the next largest cluster (18%) were characterized as having externalizing problems with or without internalizing problems. The smallest cluster (13%) consisted of children with internalizing problems only. Comparison across demographic and violence characteristics revealed that the profiles differed by child gender, mother's education, child's lifetime exposure to violence, and aspects of the event precipitating contact with the community program. Clinical and future research implications of study findings are discussed.

Predictors of internalizing symptoms among very low birth weight young women.

As part of a longitudinal study of the outcomes of very low birth weight children (<1.5 kg), we sought to examine the perinatal, childhood, and young adult predictors of internalizing symptoms among very low birth weight young women and their normal birth weight controls. The cohort included 125 very low birth weight and 124 normal birth weight 20-year-old subjects. Perinatal, childhood, and young adult predictors were examined via stepwise multivariate analyses. Results revealed very low birth weight to be a significant predictor of parent-reported internalizing symptoms of their daughters but only among white subjects who had mothers with high levels of psychological distress. Additional significant predictors of 20-year internalizing symptoms included child I.Q. and internalizing symptoms at age 8 years and family expressiveness. When the results were analyzed according to the young adult self-report, additional predictors of internalizing symptoms included a history of asthma and exposure to violence. Perinatal risk factors were not found to be predictive of internalizing symptoms at age 20 years. Future studies should prospectively examine social and environmental factors associated with the neonatal intensive care experience that might explain the effect of very low birth weight on later psychopathology.

Violence, coping, and mental health in a community sample of adolescents.

The current study examined the coping strategies, exposure to violence and psychological trauma symptoms of violent adolescents compared to less violent and nonviolent adolescents in a community sample. An anonymous self-report questionnaire was administered to students in six public high schools (grades 9-12). The 10% most violent adolescents were identified and compared to their less violent and nonviolent peers. A total of 3724 students represented 68% of adolescents in all targeted schools. Ages ranged from 14 to 19 years; 52% were female; and 35% were African-American, 34% Caucasian and 23% Hispanic. Analyses revealed that violent adolescents compared to their less violent and nonviolent peers employed more maladaptive coping strategies, were exposed to higher levels of violence and reported higher clinical levels of psychological trauma symptoms. Maladaptive coping was also significantly associated with psychological trauma symptoms and violent behavior, even after controlling for the influence of demographic factors. The findings support the importance of appropriate identification, assessment and referral services for adolescents in nonclinical settings, and the role that coping strategies play in contributing to adolescent mental health and well-being.

Initial behavior outcomes for the peacebuilders universal school-based violence prevention program.

PeaceBuilders is a universal, elementary-school-based violence prevention program that attempts to alter the climate of a school by teaching students and staff simple rules and activities aimed at improving child social competence and reducing aggressive behavior. Eight matched schools (N > 4,000 students in Grades K-5) were randomly assigned to either immediate postbaseline intervention (PBI) or to a delayed intervention 1 year later (PBD). Hierarchical linear modeling was used to analyze results from assessments in the fall and spring of 2 consecutive school years. In Year 1, significant gains in teacher-rated social competence for students in Grades K-2, in childself-reported peace-building behavior in Grades K-5, and reductions in aggressive behavior in Grades 3-5 were found for PBI but not PBD schools. Differential effects in Year 1 were also observed for aggression and prosocial behavior. Most effects were maintained in Year 2 for PBI schools, including increases in child prosocial behavior in Grades K-2. Implications for early universal school-based prevention and challenges related toevaluating large-scale prevention trials are discussed.

Outcomes in young adulthood for very-low-birth-weight infants.

BACKGROUND: Very-low-birth-weight infants (those weighing less than 1500 g) born during the initial years of neonatal intensive care have now reached young adulthood. METHODS: We compared a cohort of 242 survivors among very-low-birth-weight infants born between 1977 and 1979 (mean birth weight, 1179 g; mean gestational age at birth, 29.7 weeks) with 233 controls from the same population in Cleveland who had normal birth weights. We assessed the level of education, cognitive and academic achievement, and rates of chronic illness and risk-taking behavior at 20 years of age. Outcomes were adjusted for sex and sociodemographic status. RESULTS: Fewer very-low-birth-weight young adults than normal-birth-weight young adults had graduated from high school (74 percent vs. 83 percent, P=0.04). Very-low-birth-weight men, but not women, were significantly less likely than normal-birth-weight controls to be enrolled in postsecondary study (30 percent vs. 53 percent, P=0.002). Very-low-birth-weight participants had a lower mean IQ (87 vs. 92) and lower academic achievement scores (P<0.001 for both comparisons). They had higher rates of neurosensory impairments (10 percent vs. <1 percent, P<0.001) and subnormal height (10 percent vs. 5 percent, P=0.04). The very-low-birth-weight group reported less alcohol and drug use and had lower rates of pregnancy than normal-birth-weight controls; these differences persisted when comparisons were restricted to the participants without neurosensory impairment. CONCLUSIONS: Educational disadvantage associated with very low birth weight persists into early adulthood.