School- and intervention-related factors associated with institutionalization of health promotion interventions in elementary schools. / Facteurs liés aux écoles et facteurs liés aux interventions dans le contexte de l'institutionnalisation des interventions de promotion de la santé dans les écoles primaires.

INTRODUCTION: Long-term availability of health-promoting interventions (HPIs) in school settings can translate into health benefits for children. However, little is known about factors associated with HPI institutionalization in schools. In this study, we identified correlates of the institutionalization of HPIs offered in elementary schools in Quebec, Canada. METHODS: In two-part, structured telephone interviews over three academic years (2016-2019), elementary school principals (or their designees) throughout Quebec identified an index HPI offered at least once in their school during the previous three years, and were asked whether it was institutionalized (i.e. explicitly written in the school's educational project, e.g. in the form of educational objectives and means of achieving them). We examined associations between institutionalization and 10 school-related and 16 HPI-related characteristics in univariable and multivariable logistic regression analyses. RESULTS: School key informants (n = 163) reported on 147 different HPIs that had been available in their schools in the past three years, 56% of which were institutionalized. Three aspects of school culture-parent/community engagement with the school, school/teacher commitment to student health and school physical environment-were positively associated with HPI institutionalization. HPI-related characteristics positively associated with HPI institutionalization included number of competencies addressed by the HPI, number of teaching strategies employed, modifications made to the HPI prior to or during implementation and perceived success of the HPI. Inviting families or community groups to participate in the HPI was inversely associated with institutionalization. CONCLUSION: Better understanding of factors associated with HPI institutionalization may inform the development of school-based HPIs that have the potential for sustainability.

Availability of health-promoting interventions in high schools in Quebec, Canada, by school deprivation level. / Disponibilité des interventions de promotion de la santé dans des écoles secondaires du Québec (Canada) selon le niveau de défavorisation scolaire.

INTRODUCTION: School-based health-promoting interventions (HPIs) foster adolescent health and well-being. Access to HPIs may differ by the socioeconomic advantage of students at each school (school deprivation). We assessed the importance of health issues and availability of HPIs and extracurricular activities by school deprivation in high schools in Quebec, Canada. METHODS: In 2016/17, 2017/18 and 2018/19, we interviewed school principals or a designee in 48 public high schools classified as disadvantaged (33%) or advantaged (67%). Schools rated whether 13 common health-related issues were important (i.e. warranted intervention) in their student population and reported whether HPIs to address these or other health issues and/or sports or special interest extracurricular activities had been available in the past year. RESULTS: 84% of disadvantaged schools offered one or more HPIs in the past year compared to 73% of advantaged schools. Higher proportions of disadvantaged schools perceived most of 13 health-related issues as important. HPIs for bullying/exclusion, sex education and physical activity (issues subject to government mandates) were available in most schools. Higher proportions of disadvantaged schools offered non-mandated HPIs (i.e. for healthy eating, mental health/well-being and substance use). Higher proportions of advantaged schools offered extracurricular activities in all areas other than non-competitive sports, which was offered by equal proportions of advantaged and disadvantaged schools. CONCLUSION: Government mandates appear to facilitate universal availability of HPIs in schools, possibly boosting equity in school-based health promotion. Further investigation of possible differences in the content, implementation and/or effects of HPIs based on school deprivation is warranted.

A health-system-embedded deprescribing intervention targeting patients and providers to prevent falls in older adults (STOP-FALLS trial): study protocol for a pragmatic cluster-randomized controlled trial.

BACKGROUND: Central nervous system (CNS) active medications have been consistently linked to falls in older people. However, few randomized trials have evaluated whether CNS-active medication reduction reduces falls and fall-related injuries. The objective of the Reducing CNS-active Medications to Prevent Falls and Injuries in Older Adults (STOP-FALLS) trial is to test the effectiveness of a health-system-embedded deprescribing intervention focused on CNS-active medications on the incidence of medically treated falls among community-dwelling older adults. METHODS: We will conduct a pragmatic, cluster-randomized, parallel-group, controlled clinical trial within Kaiser Permanente Washington to test the effectiveness of a 12-month deprescribing intervention consisting of (1) an educational brochure and self-care handouts mailed to older adults prescribed one or more CNS-active medications (aged 60 + : opioids, benzodiazepines and Z-drugs; aged 65 + : skeletal muscle relaxants, tricyclic antidepressants, and antihistamines) and (2) decision support for their primary health care providers. Outcomes are examined over 18-26 months post-intervention. The primary outcome is first incident (post-baseline) medically treated fall as determined from health plan data. Our sample size calculations ensure at least 80% power to detect a 20% reduction in the rate of medically treated falls for participants receiving care within the intervention (n = 9) versus usual care clinics (n = 9) assuming 18 months of follow-up. Secondary outcomes include medication discontinuation or dose reduction of any target medications. Safety outcomes include serious adverse drug withdrawal events, unintentional overdose, and death. We will also examine medication signetur fields for attempts to decrease medications. We will report factors affecting implementation of the intervention. DISCUSSION: The STOP-FALLS trial will provide new information about whether a health-system-embedded deprescribing intervention that targets older participants and their primary care providers reduces medically treated falls and CNS-active medication use. Insights into factors affecting implementation will inform future research and healthcare organizations that may be interested in replicating the intervention. TRIAL REGISTRATION: ClinicalTrial.gov NCT05689554. Registered on 18 January 2023, retrospectively registered.

Understanding the Relationship Between Social Risk Factors and COVID-19 Contacts.

Introduction Social risks are associated with increased risk of COVID-19 transmission by limiting patients' ability to practice precautions and access care. Researchers need to understand the prevalence of patients' social risk factors during the pandemic and recognize how social risks may exacerbate COVID-19. Methods The authors conducted a national survey among Kaiser Permanente members between January and September 2020 and restricted analyses to those who responded to a set of COVID-19 items. The survey asked if they experienced social risks, knew of people with COVID-19, and if COVID-19 affected their emotional and mental health, and their preferred type of assistance. Results Social risks were reported by 62% of respondents, with 38% reporting having 2 or more social risks. Respondents most commonly reported financial strain (45%). One or more contact types with COVID-19 were reported by one-third of the respondents. Those with 2 or more COVID-19 contact types reported higher housing instability, financial strain, food insecurity, and social isolation than those with fewer contacts. Overall, 50% of respondents reported that COVID-19 negatively affected their emotional, mental health, and 19% noted that it affected their ability to maintain a job. Discussion People with any COVID-19 contacts reported more social risks compared to those who did not know anyone with COVID-19. This suggests that those with higher social risks during this time may have faced higher risk for COVID-19, or the converse may be true. Conclusion These findings highlight patients' social health during the pandemic and suggest that health systems develop interventions to assess social health and link patients to appropriate resources.

Identifying high school smokers likely to persist in smoking at age 31.

OBJECTIVE: Quitting smoking by the mid-30 s conveys important health benefits. Yet, although many smokers attempt to quit, few succeed. Identification of the characteristics of adolescent smokers most likely to continue smoking between ages 30 and 40 could help target early cessation efforts. Our objectives in this study were to (i) describe the course of smoking in a population-based sample of high school smokers into their 20 s and 30 s, and (ii) identify distal predictors of past-year cigarette smoking at age 31. METHODS: Data at ages 17 (in 11th grade), 20, 24 and 31 were drawn from a 20-year longitudinal study of students ages 12-13 at inception, from 10 high schools in Montréal, Canada. Associations between 11 smoking-related characteristics measured in 11th grade and past-year smoking at age 31 were estimated in multivariable logistic regression models. RESULTS: Among 244 11th grade smokers (67.4% female; 41% daily smokers), past-year smoking was reported by 71% at age 20, 68% at age 24, and 52% at age 31. Only 12% reported abstinence at ages 20, 24 and 31. Females were less likely than males to smoke at age 31. Parental smoking while the smoker was in 11th grade, use of other tobacco products, longer time since smoking onset, weekly or daily smoking, monthly cigarette consumption, and perceived nicotine addiction predicted past-year smoking at age 31. CONCLUSIONS: In addition to preventive interventions, cessation programs targeting novice smokers in high school as soon as they begin smoking, are warranted.

Acupuncture for chronic low back pain in older adults: Design and protocol for the BackInAction pragmatic clinical trial.

BACKGROUND: Back pain prevalence and burden increase with age; approximately one-third of U.S. adults 65 years of age and older experience lower back pain (LBP). For chronic low back pain (cLBP), typically defined as lasting three months or longer, many treatments for younger adults may be inappropriate for older adults given their greater prevalence of comorbidities with attendant polypharmacy. While acupuncture has been demonstrated to be safe and effective for cLBP in adults overall, few studies of acupuncture have either included or focused on adults ≥65 years old. METHODS: The BackInAction study is a pragmatic, multi-site, three-arm, parallel-groups randomized controlled trial designed to test the effectiveness of acupuncture needling for improving back pain-related disability among 807 older adults ≥65 years old with cLBP. Participants are randomized to standard acupuncture (SA; up to 15 treatment sessions across 12 weeks), enhanced acupuncture (EA; SA during first 12 weeks and up to 6 additional sessions across the following 12 weeks), and usual medical care (UMC) alone. Participants are followed for 12 months with study outcomes assessed monthly with the primary outcome timepoint at 6 months. DISCUSSION: The BackInAction study offers an opportunity to further understand the effectiveness, dose-dependence, and safety of acupuncture in a Medicare population. Additionally, study results may encourage broader adoption of more effective, safer, and more satisfactory options to the continuing over-reliance on opioid- and invasive medical treatments for cLBP among older adults. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04982315. Clinical trial registration date: July 29, 2021.

Complex modeling with detailed temporal predictors does not improve health records-based suicide risk prediction.

Suicide risk prediction models can identify individuals for targeted intervention. Discussions of transparency, explainability, and transportability in machine learning presume complex prediction models with many variables outperform simpler models. We compared random forest, artificial neural network, and ensemble models with 1500 temporally defined predictors to logistic regression models. Data from 25,800,888 mental health visits made by 3,081,420 individuals in 7 health systems were used to train and evaluate suicidal behavior prediction models. Model performance was compared across several measures. All models performed well (area under the receiver operating curve [AUC]: 0.794-0.858). Ensemble models performed best, but improvements over a regression model with 100 predictors were minimal (AUC improvements: 0.006-0.020). Results are consistent across performance metrics and subgroups defined by race, ethnicity, and sex. Our results suggest simpler parametric models, which are easier to implement as part of routine clinical practice, perform comparably to more complex machine learning methods.

Factors associated with cannabis use in early adolescence. / Facteurs associés à la consommation de cannabis au début de l'adolescence.

INTRODUCTION: We examined whether factors identified as associated with cannabis use at age 14 to 16 years are also associated with ever use at age 12. METHODS: Participants in the AdoQuest study (n = 1852) were recruited in 2005 from among Grade 5 students in 29 French-language elementary schools in Montréal, Canada. Self-report data were collected from participants in Grade 5 (spring 2005) and 6 (fall 2005 and spring 2006) and from parents/guardians in 2006/07. Inclusion in the analytic sample (n = 1076; mean age [SD] = 10.7 [0.5]) required data from participant and parental questionnaires and data on cannabis use in Grade 6 (mean age [SD] = 11.7 [0.4]). We estimated associations between ever use at age 12 with 33 potential correlates, separately in unadjusted and adjusted logistic regression models. RESULTS: Fifty-three participants (4.9%) reported ever use at age 12. Factors associated with higher odds of ever use included older age, identifying as male, lower household income, more weekly spending money, ever tried cigarettes or other tobacco products, ever drank alcohol or binge drank, ever gambled, friends or siblings smoke cigarettes, greater nicotine dependence, higher depressive symptoms and greater impulsivity. Protective factors included higher levels of parental/guardian monitoring and greater self-esteem and school connectedness. CONCLUSION: Factors associated with cannabis use at later ages are also associated with ever use at age 12. Our findings suggest that surveillance for and interventions to prevent cannabis use are warranted before age 12.

Provider knowledge, beliefs, and self-efficacy to deprescribe opioids and sedative-hypnotics.

BACKGROUND: While many studies have assessed and measured patient attitudes toward deprescribing, less quantitative research has addressed the provider perspective. We thus sought to describe provider knowledge, beliefs, and self-efficacy to deprescribe, with a focus on opioids and sedative-hypnotics. METHODS: An electronic anonymous survey was distributed to primary care providers at Kaiser Permanente Washington. Two reminder emails were sent. The survey included 10 questions on general deprescribing, and six questions each specific to opioid and sedative-hypnotic deprescribing. Knowledge questions used a multiple-choice response option format. Questions addressing beliefs and self-efficacy (i.e., confidence) used a 0-10 Likert scale. Scales were dichotomized at ≥7 to define agreement (belief questions) or confidence (self-efficacy questions). We calculated descriptive statistics to summarize the responses. RESULTS: Of 370 eligible primary care providers, 95 (26%) completed the survey. For general deprescribing questions, a majority believed that lack of patient willingness, withdrawal symptoms and fear of symptom return, and time constraints impeded deprescribing. Approximately half chose the correct answers about opioid deprescribing, 21% were confident that they could alleviate patient concerns about opioid tapering, and 32% were confident managing chronic non-cancer pain without opioids. For sedative-hypnotics, 64%-87% of respondents correctly answered questions about risks and the relative effectiveness of alternatives, but only one-third correctly answered a question about sedative-hypnotic tapering. Roughly half were confident in their ability to successfully engage patients in sedative deprescribing conversations and select alternatives. Only 54% and 34% were confident in writing a tapering protocol for opioids and sedative-hypnotics, respectively. CONCLUSION: Results suggest that raising provider awareness of patient willingness to deprescribe, addressing knowledge gaps, and increasing self-efficacy for deprescribing are important targets for improving deprescribing. Support for writing tapering protocols and prescribing evidence-based drug and non-drug alternatives may be important to improve care.

Preoperative Depression Status and 5 Year Metabolic and Bariatric Surgery Outcomes in the PCORnet Bariatric Study Cohort.

OBJECTIVE: To examine whether depression status before metabolic and bariatric surgery (MBS) influenced 5-year weight loss, diabetes, and safety/utilization outcomes in the PCORnet Bariatric Study. SUMMARY OF BACKGROUND DATA: Research on the impact of depression on MBS outcomes is inconsistent with few large, long-term studies. METHODS: Data were extracted from 23 health systems on 36,871 patients who underwent sleeve gastrectomy (SG; n=16,158) or gastric bypass (RYGB; n=20,713) from 2005-2015. Patients with and without a depression diagnosis in the year before MBS were evaluated for % total weight loss (%TWL), diabetes outcomes, and postsurgical safety/utilization (reoperations, revisions, endoscopy, hospitalizations, mortality) at 1, 3, and 5 years after MBS. RESULTS: 27.1% of SG and 33.0% of RYGB patients had preoperative depression, and they had more medical and psychiatric comorbidities than those without depression. At 5 years of follow-up, those with depression, versus those without depression, had slightly less %TWL after RYGB, but not after SG (between group difference = 0.42%TWL, P = 0.04). However, patients with depression had slightly larger HbA1c improvements after RYGB but not after SG (between group difference = - 0.19, P = 0.04). Baseline depression did not moderate diabetes remission or relapse, reoperations, revision, or mortality across operations; however, baseline depression did moderate the risk of endoscopy and repeat hospitalization across RYGB versus SG. CONCLUSIONS: Patients with depression undergoing RYGB and SG had similar weight loss, diabetes, and safety/utilization outcomes to those without depression. The effects of depression were clinically small compared to the choice of operation.

Social risks and social needs in a health insurance exchange sample: a longitudinal evaluation of utilization.

BACKGROUND: Health systems are increasingly attempting to intervene on social adversity as a strategy to improve health care outcomes. To inform health system efforts to screen for social adversity, we sought to explore the stability of social risk and interest in assistance over time and to evaluate whether the social risk was associated with subsequent healthcare utilization. METHODS: We surveyed Kaiser Permanente members receiving subsidies from the healthcare exchange in Southern California to assess their social risk and desire for assistance using the Accountable Health Communities instrument. A subset of initial respondents was randomized to be re-surveyed at either three or six months later. RESULTS: A total of 228 participants completed the survey at both time points. Social risks were moderate to strongly stable across three and six months (Kappa range = .59-.89); however, social adversity profiles that included participants' desire for assistance were more labile (3-month Kappa = .52; 95% CI = .41-.64 & 6-month Kappa = .48; 95% CI = .36-.6). Only housing-related social risks were associated with an increase in acute care (emergency, urgent care) six months after initial screening; no other associations between social risk and utilization were observed. CONCLUSIONS: This study suggests that screening for social risk may be appropriate at intervals of six months, or perhaps longer, but that assessing desire for assistance may need to occur more frequently. Housing risks were associated with increases in acute care. Health systems may need to engage in screening and referral to resources to improve overall care and ultimately patient total health.

Comparative Safety and Effectiveness of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy for Weight Loss and Type 2 Diabetes Across Race and Ethnicity in the PCORnet Bariatric Study Cohort.

Importance: Bariatric surgery is the most effective treatment for severe obesity; yet it is unclear whether the long-term safety and comparative effectiveness of these operations differ across racial and ethnic groups. Objective: To compare outcomes of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) across racial and ethnic groups in the National Patient-Centered Clinical Research Network (PCORnet) Bariatric Study. Design, Setting, and Participants: This was a retrospective, observational, comparative effectiveness cohort study that comprised 25 health care systems in the PCORnet Bariatric Study. Patients were adults and adolescents aged 12 to 79 years who underwent a primary (first nonrevisional) RYGB or SG operation between January 1, 2005, and September 30, 2015, at participating health systems. Patient race and ethnicity included Black, Hispanic, White, other, and unrecorded. Data were analyzed from July 1, 2021, to January 17, 2022. Exposure: RYGB or SG. Outcomes: Percentage total weight loss (%TWL); type 2 diabetes remission, relapse, and change in hemoglobin A1c (HbA1c) level; and postsurgical safety and utilization outcomes (operations, interventions, revisions/conversions, endoscopy, hospitalizations, mortality, 30-day major adverse events) at 1, 3, and 5 years after surgery. Results: A total of 36 871 patients (mean [SE] age, 45.0 [11.7] years; 29 746 female patients [81%]) were included in the weight analysis. Patients identified with the following race and ethnic categories: 6891 Black (19%), 8756 Hispanic (24%), 19 645 White (53%), 826 other (2%), and 783 unrecorded (2%). Weight loss and mean reductions in HbA1c level were larger for RYGB than SG in all years for Black, Hispanic, and White patients (difference in 5-year weight loss: Black, -7.6%; 95% CI, -8.0 to -7.1; P < .001; Hispanic, -6.2%; 95% CI, -6.6 to -5.9; P < .001; White, -5.9%; 95% CI, -6.3 to -5.7; P < .001; difference in change in year 5 HbA1c level: Black, -0.29; 95% CI, -0.51 to -0.08; P = .009; Hispanic, -0.45; 95% CI, -0.61 to -0.29; P < .001; and White, -0.25; 95% CI, -0.40 to -0.11; P = .001.) The magnitude of these differences was small among racial and ethnic groups (1%-3% of %TWL). Black and Hispanic patients had higher risk of hospitalization when they had RYGB compared with SG (hazard ratio [HR], 1.45; 95% CI, 1.17-1.79; P = .001 and 1.48; 95% CI, 1.22-1.79; P < .001, respectively). Hispanic patients had greater risk of all-cause mortality (HR, 2.41; 95% CI, 1.24-4.70; P = .01) and higher odds of a 30-day major adverse event (odds ratio, 1.92; 95% CI, 1.38-2.68; P < .001) for RYGB compared with SG. There was no interaction between race and ethnicity and operation type for diabetes remission and relapse. Conclusions and Relevance: Variability of the comparative effectiveness of operations for %TWL and HbA1c level across race and ethnicity was clinically small; however, differences in safety and utilization outcomes were clinically and statistically significant for Black and Hispanic patients who had RYGB compared with SG. These findings can inform shared decision-making regarding bariatric operation choice for different racial and ethnic groups of patients.

Social Risk Factors and Desire for Assistance Among Patients Receiving Subsidized Health Care Insurance in a US-Based Integrated Delivery System.

PURPOSE: Because social conditions such as food insecurity and housing instability shape health outcomes, health systems are increasingly screening for and addressing patients' social risks. This study documented the prevalence of social risks and examined the desire for assistance in addressing those risks in a US-based integrated delivery system. METHODS: A survey was administered to Kaiser Permanente members on subsidized exchange health insurance plans (2018-2019). The survey included questions about 4 domains of social risks, desire for help, and attitudes. We conducted a descriptive analysis and estimated multivariate modified Poisson regression models. RESULTS: Of 438 participants, 212 (48%) reported at least 1 social risk factor. Housing instability was the most common (70%) factor reported. Members with social risks reported more discomfort being screened for social risks (14.2% vs 5.4%; P = .002) than those without risks, although 90% of participants believed that health systems should assist in addressing social risks. Among those with 1-2 social risks, however, only 27% desired assistance. Non-Hispanic Black participants who reported a social risk were more than twice as likely to desire assistance compared with non-Hispanic White participants (adjusted relative risk [RR] 2.2; 95% CI, 1.3-3.8). CONCLUSIONS: Athough most survey participants believed health systems have a role in addressing social risks, a minority of those reporting a risk wanted assistance and reported more discomfort being screened for risk factors than those without risks. Health systems should work to increase the comfort of patients in reporting risks, explore how to successfully assist them when desired, and offer resources to address these risks outside the health care sector.VISUAL ABSTRACT.

Interest in Mindfulness Training for Chronic Low-Back Pain: Results from a Vignette-driven, Web-based Survey of Patients.

Objectives: Mindfulness-based stress reduction (MBSR) has been found effective for improving chronic low-back pain (cLBP). However, little data exist regarding how attractive this technique is to Americans as a therapy for cLBP. Design: Survey of randomly selected persons with cLBP. Settings/Location: Respondents were recruited from Kaiser Permanente Washington and one-time surveys were completed online. Patients: Adults 18-80 years of age with cLBP. Surveys: The study was conducted between December 2019 and August 2020. Outcome measures: The survey described an evidence-based classic MBSR course and then asked respondents about their sociodemographic characteristics, their current back pain, previous back pain treatments, behavioral risk factors for back pain, and four outcomes indicative of intention to engage in MBSR. Results: Four-hundred fifty-seven respondents completed the survey. Respondents were primarily women, white, educated, and with back pain for more than 5 years. About half had previously used a mind-body therapy for their pain. Overall, they reported moderate to high intention to try mindfulness classes and practice at home (median of 5 with 50% of the observations between 4 and 6, and 5.7, 50% of the observations between 4.3 and 6.3, respectively, on a 7-point scale). They reported a willingness to spend a median of 3 h/week learning mindfulness and 3.5 h/week practicing mindfulness techniques (for both outcomes, 50% of the respondents reported between 2 and 5 h). Few patient characteristics predicted intention to engage in MBSR, with no variable predicting all outcomes. The magnitude of the effect associated with significant predictors was small. Conclusion: Classic MBSR appealed to many survey respondents, in that they reported high interest in learning MBSR and intention to practice at home. The amount of time they reported being willing to spend learning MBSR and practicing at home is consistent with the time commitment in the original course.

Depressive Symptoms, Alcohol Beliefs and Heavy Episodic Drinking in Adolescents.

Adolescents who engage in heavy episodic drinking (HED-i.e., 5+ drinks on a single occasion) increase risks for psychopathology, alcohol dependence, and similar negative consequences in adulthood. We explored associations among depressive symptoms, positive alcohol beliefs, and progression of heavy episodic drinking (HED) in 3021 German adolescents (M(SD) age at baseline = 12.4 (1.0)) followed for 30 months in 4 waves, using a conditional parallel process linear growth model, with full information maximum likelihood estimation. By wave 4, 40.3% of participants had engaged in HED more than once; 16.4% had done so ≥5 times. Depressive symptoms were indirectly related to baseline values of HED (through positive beliefs and wave 1 drinking frequency and quantity) and to the rate of growth in HED (through positive beliefs and wave 1 quantity). Adolescents with higher levels of depressive symptoms and positive alcohol beliefs drink more frequently and at greater quantities, which is associated with initiating HED at a higher level and escalating HED more rapidly than peers with similar depressive symptoms who lack those beliefs. This suggests that, to the extent that positive alcohol beliefs can be tempered through public health campaigns, education and/or counseling, HED among depressed adolescents might be reduced.

Who mixes tobacco with cannabis and does mixing relate to nicotine dependence?

BACKGROUND: Cannabis users who mix tobacco with cannabis are exposed to nicotine in the tobacco. We identified characteristics of young adult cannabis users who mix and investigated whether mixing frequency is associated with nicotine dependence (ND). METHODS: Data were collected in self-report questionnaires in 2017-20 from 788 young adults (44% male; mean (SD) age 30.6 (1.0) years) participating in a longitudinal investigation of the natural course of ND. Using multivariable logistic regression, we assessed whether any of 16 sociodemographic, lifestyle, psychosocial or other characteristics were associated with mixing among 313 past-year cannabis users. We also assessed whether mixing frequency was associated with ND among 289 past-year cannabis users who had ever smoked cigarettes controlling for age, sex, and other sources of nicotine (i.e., number of cigarettes smoked, other tobacco products, second-hand smoke exposure). RESULTS: Of 788 participants, 40 % (n = 313) reported past-year cannabis use. Of these, 150 (48 %) reported mixing. Younger age, lower education and income, past-year cigarette use, use of other tobacco products and illicit drugs, poor coping skills and gambling were associated with mixing. Number of ICD-10 ND criteria endorsed was associated with mixing < weekly (b(95 % CI) = 0.3(0.02,0.7)) and weekly/daily (0.5(0.1,0.9)) after controlling for other sources of nicotine. CONCLUSION: Mixing is associated with ND and therefore may threaten tobacco control efforts by rendering quitting cigarette smoking more difficult among smokers who mix tobacco with cannabis. Mixing tobacco with cannabis should be considered as an additional source of nicotine exposure in studies of ND in young people.

Cost-effectiveness of telephone cognitive behavioral therapy for osteoarthritis-related insomnia.

BACKGROUND: Osteoarthritis-related insomnia is the most common form of comorbid insomnia among older Americans. A randomized clinical trial found that six sessions of telephone-delivered cognitive behavioral therapy for insomnia (CBT-I) improved sleep outcomes in this population. Using these data, we evaluated the incremental cost-effectiveness of CBT-I from a healthcare sector perspective. METHODS: The study was based on 325 community-dwelling older adults with insomnia and osteoarthritis pain enrolled with Kaiser Permanente of Washington State. We measured quality-adjusted life years (QALYs) using the EuroQol 5-dimension scale. Arthritis-specific quality of life was measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Insomnia-specific quality of life was measured using the Insomnia Severity Index (ISI) and nights without clinical insomnia (i.e., "insomnia-free nights"). Total healthcare costs included intervention and healthcare utilization costs. RESULTS: Over the 12 months after randomization, CBT-I improved ISI and WOMAC by -2.6 points (95% CI: -2.9 to -2.4) and -2.6 points (95% CI: -3.4 to -1.8), respectively. The ISI improvement translated into 89 additional insomnia-free nights (95% CI: 79 to 98) over the 12 months. CBT-I did not significantly reduce total healthcare costs (-$1072 [95% CI: -$1968 to $92]). Improvements in condition-specific measures were not reflected in QALYs gained (-0.01 [95% CI: -0.01 to 0.01]); at a willingness-to-pay of $150,000 per QALY, CBT-I resulted in a positive net monetary benefit of $369 with substantial uncertainty (95% CI: -$1737 to $2270). CONCLUSION: CBT-I improved sleep and arthritis function without increasing costs. These findings support the consideration of telephone CBT-I for treating insomnia among older adults with comorbid OA. Our findings also suggest potential limitations of the general quality of life measures in assessing interventions designed to improve sleep and arthritis outcomes.

Long-term improvements in sleep, pain, depression, and fatigue in older adults with comorbid osteoarthritis pain and insomnia.

In a primary care population of 327 older adults (age 60+) with chronic osteoarthritis (OA) pain and insomnia, we examined the relationship between short-term improvement in sleep or pain and long-term sleep, pain, depression, and fatigue by secondary analyses of randomized controlled trial data. Study participants, regardless of trial arm, were classified as Sleep or Pain Improvers with ≥30% baseline to 2-month reduction on the Insomnia Severity Index or the Brief Pain Inventory, respectively, or Sleep or Pain Non-Improvers. After controlling for trial arm and potential confounders, both Sleep and Pain Improvers showed significant (p < .01) sustained improvements across 12 months compared to respective Non-Improvers for the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index, Brief Pain Inventory-short form (total, Interference, and Severity subscales), Patient Health Questionnaire, and Flinders Fatigue Scale. The effect sizes (Cohen's f2) for the sustained benefits in both Sleep and Pain Improvers compared to their respective Non-Improvers for all variables were small (<0.15) with the exception of medium effect size for sustained reduction in insomnia symptoms for the Sleep Improvers. We conclude that short-term sleep improvements in pain populations with comorbid insomnia precede benefits not only for long-term improvement in sleep but also for reduced pain over the long-term, along with associated improvements in depression and fatigue. Short-term improvements in pain appear to have similar long-term sequelae. Successfully improving sleep in pain populations with comorbid insomnia may have the additional benefits of improving both short- and long-term pain, depression, and fatigue. Trial Registration: OsteoArthritis and Therapy for Sleep (OATS) NCT02946957: https://clinicaltrials.gov/ct2/show/NCT02946957.

Natural course of co-use of alcohol and cannabis in adolescents and young adults in Montréal, Canada.

OBJECTIVE: Little is known about changes in alcohol and cannabis co-use over time in adolescents and young adults. We sought to describe the natural course of alcohol and cannabis co-use from age 12 to 17 and 20 to 31 and to describe frequent (i.e., ≥ once/month) binge drinking (i.e., ≥ 5 drinks/occasion) and cannabis use from age 20 to 31. METHOD: Data were drawn from two longitudinal studies conducted in Montréal, Canada: AdoQuest (n = 1,852) and the Nicotine Dependence in Teens (NDIT) study (n = 1,293). Complete data on alcohol and cannabis were available for 620 12-17-year-olds (58% female) followed from 2005 to 2011 in AdoQuest, and 673 20-31-year-olds (56% female) followed from 2007 to 2020 in NDIT. We reported proportions of co-use, exclusive drinking ("drinking"), exclusive cannabis use ("cannabis use"), frequent co-use, frequent binge drinking, and frequent cannabis use by age and sex. RESULTS: Co-use rose from 2% at age 12-13 to 23% at age 17, was stable at 44% at age 20 and 24, and then decreased to 37% at age 31. Drinking rose from 20% to 51%, and cannabis use was consistently rare (< 2%). During young adulthood, frequent co-use declined from 21% at age 20 to 12% at age 31, and frequent binge drinking declined from 29% at age 20 to 22% at age 31. Frequent cannabis use increased from 6% at age 20 to 11% at age 31. CONCLUSIONS: Alcohol and cannabis use should be studied as time-varying behaviors. Co-use patterns should be monitored over time in this population. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Obstructive sleep apnea and risk of motor vehicle accident.

OBJECTIVE: To evaluate the association between obstructive sleep apnea (OSA) and risk of motor vehicle accident (MVA). METHODS: We conducted a cohort study at Kaiser Permanente Washington using electronic health plan data and linked Washington State Department of Transportation MVA records. We included persons 18-79 years of age during 2005-2014. OSA was ascertained via diagnosis codes. The primary outcome, first MVA during cohort follow-up, was ascertained from state MVA records. Risk factors for MVAs, including medical conditions and medication use, were ascertained from health plan data. Multivariable Cox proportional hazards models were used to estimate the adjusted hazard ratio (HR) and 95% confidence interval (CI) for the association between OSA and study outcomes. RESULTS: Among the 879,547 eligible persons, the unadjusted rate of MVA in those with and without OSA was 238 and 229 per 10,000 person-years, respectively. A diagnosis of OSA was associated with a 17% increased risk of MVA (adjusted HR = 1.17; 95% CI: 1.13 to 1.20). CONCLUSION: In this large population-based study, a diagnosis of OSA was associated with a modestly increased risk of MVA.