Maryland opioid overdose deaths from 2018 to 2022: occupational patterns and their sociodemographic variations.

INTRODUCTION: We aimed to describe the occupational pattern of opioid overdose deaths in Maryland between 2018 and 2022 and determine the occupations at higher risk of opioid overdose death. METHODS: The sample included undetermined or unintentional opioid overdose deaths among those aged 16 years or older in Maryland, drawn from the State Unintentional Drug Overdose Reporting System. We calculated population-based incidence overdose rates by occupation, stratified by sex and race. We further calculated the incidence rate ratios (IRRs) comparing each occupation with all other groups combined and estimated the IRRs among males versus females and non-Hispanic whites versus other racial/ethnic groups. RESULTS: The pooled sample included 11 455 opioid overdose decedents (72% male and 55% non-Hispanic whites) of whom 80% were employed. The three occupation groups with the highest incidence rates were 'construction and extraction', 'transportation and material moving' and 'installation/maintenance and repair' with 291, 137 and 133 deaths per 100 000 workers in these respective occupational groups. Incidence rates were significantly higher in males than females in all categories except those 'Not in Labour Force' (IRR=0.51, p<0.001). Non-Hispanic whites relative to other racial/ethnic groups had a lower incidence of opioid overdose death in 'Military-Specific' occupations (IRR=0.53, p=0.031). CONCLUSION: Opioid overdose deaths vary by type of occupation and certain occupations are at higher risk of overdose death. The findings highlight the need for priority setting in the implementation and expansion of existing strategies to target the workers most impacted by opioid overdose.

Ratio of emergency department visits to deaths for opioid overdose.

BACKGROUND: Data on fatal and non-fatal overdose provide important information about the magnitude of the overdose crisis. We consider these metrics in tandem and estimated the ratio of opioid overdose-related emergency department (ED) visits to opioid overdose deaths. A lower ratio could indicate more fatal overdoses, fewer overdose reversals with naloxone or a combination of both. METHODS: Data are from the Maryland Vital Statistics Administration (opioid overdose deaths), the Health Services Cost Review Commission (non-fatal ED visits for opioid overdose). We generated 2020 annual rates of fatal and non-fatal opioid overdose deaths for the state of Maryland and its 24 jurisdictions and estimated the ratio of opioid overdose-related ED visits to deaths. RESULTS: The 2020 visit-to-death ratio for Maryland was 1.7, and ranged from 0.9 to 3.8 across jurisdictions. We identified five counties that had above-median rates of opioid overdose-related ED visits and deaths, and low visit-to-death ratios. CONCLUSIONS: Our findings indicate that there were nearly two ED visits for each opioid overdose death in Maryland, and there was substantial variation across counties. The visit-to-death ratio enables a better understanding of the relationship between fatal and non-fatal opioid overdose and is essential to averting deaths and evaluating overdose prevention efforts.

Psychosocial and pharmacologic interventions to reduce harmful alcohol use in low- and middle-income countries.

BACKGROUND: Harmful alcohol use is defined as unhealthy alcohol use that results in adverse physical, psychological, social, or societal consequences and is among the leading risk factors for disease, disability and premature mortality globally. The burden of harmful alcohol use is increasing in low- and middle-income countries (LMICs) and there remains a large unmet need for indicated prevention and treatment interventions to reduce harmful alcohol use in these settings. Evidence regarding which interventions are effective and feasible for addressing harmful and other patterns of unhealthy alcohol use in LMICs is limited, which contributes to this gap in services. OBJECTIVES: To assess the efficacy and safety of psychosocial and pharmacologic treatment and indicated prevention interventions compared with control conditions (wait list, placebo, no treatment, standard care, or active control condition) aimed at reducing harmful alcohol use in LMICs. SEARCH METHODS: We searched for randomized controlled trials (RCTs) indexed in the Cochrane Drugs and Alcohol Group (CDAG) Specialized Register, the Cochrane Clinical Register of Controlled Trials (CENTRAL) in the Cochrane Library, PubMed, Embase, PsycINFO, CINAHL, and the Latin American and Caribbean Health Sciences Literature (LILACS) through 12 December 2021. We searched clinicaltrials.gov, the World Health Organization International Clinical Trials Registry Platform, Web of Science, and Opengrey database to identify unpublished or ongoing studies. We searched the reference lists of included studies and relevant review articles for eligible studies. SELECTION CRITERIA: All RCTs comparing an indicated prevention or treatment intervention (pharmacologic or psychosocial) versus a control condition for people with harmful alcohol use in LMICs were included. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We included 66 RCTs with 17,626 participants. Sixty-two of these trials contributed to the meta-analysis. Sixty-three studies were conducted in middle-income countries (MICs), and the remaining three studies were conducted in low-income countries (LICs). Twenty-five trials exclusively enrolled participants with alcohol use disorder. The remaining 51 trials enrolled participants with harmful alcohol use, some of which included both cases of alcohol use disorder and people reporting hazardous alcohol use patterns that did not meet criteria for disorder. Fifty-two RCTs assessed the efficacy of psychosocial interventions; 27 were brief interventions primarily based on motivational interviewing and were compared to brief advice, information, or assessment only. We are uncertain whether a reduction in harmful alcohol use is attributable to brief interventions given the high levels of heterogeneity among included studies (Studies reporting continuous outcomes: Tau² = 0.15, Q =139.64, df =16, P<.001, I² = 89%, 3913 participants, 17 trials, very low certainty; Studies reporting dichotomous outcomes: Tau²=0.18, Q=58.26, df=3, P<.001, I² =95%, 1349 participants, 4 trials, very low certainty). The other types of psychosocial interventions included a range of therapeutic approaches such as behavioral risk reduction, cognitive-behavioral therapy, contingency management, rational emotive therapy, and relapse prevention. These interventions were most commonly compared to usual care involving varying combinations of psychoeducation, counseling, and pharmacotherapy. We are uncertain whether a reduction in harmful alcohol use is attributable to psychosocial treatments due to high levels of heterogeneity among included studies (Heterogeneity: Tau² = 1.15; Q = 444.32, df = 11, P<.001; I²=98%, 2106 participants, 12 trials, very low certainty). Eight trials compared combined pharmacologic and psychosocial interventions with placebo, psychosocial intervention alone, or another pharmacologic treatment. The active pharmacologic study conditions included disulfiram, naltrexone, ondansetron, or topiramate. The psychosocial components of these interventions included counseling, encouragement to attend Alcoholics Anonymous, motivational interviewing, brief cognitive-behavioral therapy, or other psychotherapy (not specified). Analysis of studies comparing a combined pharmacologic and psychosocial intervention to psychosocial intervention alone found that the combined approach may be associated with a greater reduction in harmful alcohol use (standardized mean difference (standardized mean difference (SMD))=-0.43, 95% confidence interval (CI): -0.61 to -0.24; 475 participants; 4 trials; low certainty). Four trials compared pharmacologic intervention alone with placebo and three with another pharmacotherapy. Drugs assessed were: acamprosate, amitriptyline, baclofen disulfiram, gabapentin, mirtazapine, and naltrexone. None of these trials evaluated the primary clinical outcome of interest, harmful alcohol use.   Thirty-one trials reported rates of retention in the intervention. Meta-analyses revealed that rates of retention between study conditions did not differ in any of the comparisons (pharmacologic risk ratio (RR) = 1.13, 95% CI: 0.89 to 1.44, 247 participants, 3 trials, low certainty; pharmacologic in addition to psychosocial intervention: RR = 1.15, 95% CI: 0.95 to 1.40, 363 participants, 3 trials, moderate certainty). Due to high levels of heterogeneity, we did not calculate pooled estimates comparing retention in brief (Heterogeneity: Tau² = 0.00; Q = 172.59, df = 11, P<.001; I2 = 94%; 5380 participants; 12 trials, very low certainty) or other psychosocial interventions (Heterogeneity: Tau² = 0.01; Q = 34.07, df = 8, P<.001; I2 = 77%; 1664 participants; 9 trials, very low certainty). Two pharmacologic trials and three combined pharmacologic and psychosocial trials reported on side effects. These studies found more side effects attributable to amitriptyline relative to mirtazapine, naltrexone and topiramate relative to placebo, yet no differences in side effects between placebo and either acamprosate or ondansetron. Across all intervention types there was substantial risk of bias. Primary threats to validity included lack of blinding and differential/high rates of attrition. AUTHORS' CONCLUSIONS: In LMICs there is low-certainty evidence supporting the efficacy of combined psychosocial and pharmacologic interventions on reducing harmful alcohol use relative to psychosocial interventions alone. There is insufficient evidence to determine the efficacy of pharmacologic or psychosocial interventions on reducing harmful alcohol use largely due to the substantial heterogeneity in outcomes, comparisons, and interventions that precluded pooling of these data in meta-analyses. The majority of studies are brief interventions, primarily among men, and using measures that have not been validated in the target population. Confidence in these results is reduced by the risk of bias and significant heterogeneity among studies as well as the heterogeneity of results on different outcome measures within studies. More evidence on the efficacy of pharmacologic interventions, specific types of psychosocial interventions are needed to increase the certainty of these results.

Implementation of Overdose Prevention in Maryland: Implications for Resource Allocation, Program Scale-Up, and Evaluation.

Overdose mortality in the United States continues to climb, with Maryland being one of the hardest hit states. We summarized implementation of overdose prevention and response programs in Maryland and identified associations between opioid overdose deaths by jurisdiction in 2019 and implementation of overdose programs by 2021. Data on program implementation are from Maryland's Opioid Operational Command Center (OOCC) Program Inventory. OOCC coordinates the state's response to overdose, and their Program Inventory tracks implementation of 145 programs across 12 domains (e.g., public health, education, and judiciary), including 10 programs designed to broaden naloxone access. The level of program implementation was dichotomized as substantial implementation versus other levels (i.e., partial, planned, and none). We estimated associations between per capita opioid overdose deaths and substantial implementation of: all 145 programs in the Inventory, programs within each of 12 domains, and 10 naloxone programs. Data on program implementation and overdose mortality are summarized at the jurisdiction level. Across jurisdictions, the median proportion of programs with substantial implementation was 51% across all programs and 70% among naloxone programs. Overdose mortality was associated with subsequent substantial implementation of programs within the public health domain (p = .04), but not in the other 11 domains. We did not find evidence that per capita overdose deaths in 2019 spurred overdose program implementation by 2021, with the exception of public health programs. The OOCC Program Inventory is a novel way to track implementation across jurisdictions. Findings can inform the implementation and evaluation of overdose programs in other jurisdictions across the United States.

"I've smoked weed with my daughter": Cannabis Use within Families Affected by Parental Opioid Misuse.

Youth with parents who use opioids are more likely to engage in early substance use, especially cannabis use. The purpose of this study was to describe the context of cannabis use among families affected by parental opioid misuse. We conducted 25 in-depth interviews with families affected by parental opioid misuse. Participants were parents with a history of opioid misuse and young adults (ages 18-24) who had parents with a history of opioid misuse. Interviews were digitally recorded and professionally transcribed. Data were analyzed inductively using a qualitative content analytic approach. Familial cannabis use was common among young people and their parents. Participants described familial cannabis use as a bonding activity that felt safe and lightened the mood. Additional research is needed to understand the complex role that cannabis use may play in families affected by opioid misuse. Strategies for intergenerational substance use prevention are discussed.

Trends in heroin use and injection drug use among high school students in five urban school districts in the US (2005-2017).

Background. We describe the prevalence of and changes in heroin use and injection drug use (IDU) among high school students in five large, urban school districts in the US (2005-2017); nearly three-fourths of the students were Black and/or Hispanic/Latino.Methods. Data are from the Centers for Disease Control and Prevention's "Youth Risk Behavior Survey" program, which includes biennial surveys in urban school districts. We pooled data across districts and survey years, and then generated weighted prevalence estimates (and 95% CIs) for any lifetime heroin use and IDU. Joinpoint regression modeling was used to estimate changes in prevalence over the study period.Results. Biennial prevalence estimates (2005-2017) for heroin use and IDU were above 1.8% for all seven timepoints. In 2017, prevalence of heroin use and IDU were 2.9% and 2.5%, respectively. Both heroin use and IDU were higher among boys than girls. There were statistically significant increases in heroin use and IDU among girls from 2005-2009, whereas changes over time were stable among boys.Conclusions. High school students in large, urban school districts may have higher rates of heroin use and IDU than US high school students in general, and there is little evidence of increases since 2009. This study suggests that adolescence may be a critical period for initiation of heroin use among adolescents in large urban school districts, the majority of whom are Black and/or Latino.Supplemental data for this article is available online at https://doi.org/10.1080/15332640.2021.1992327 .

Area-level deprivation and adverse childhood experiences among high school students in Maryland.

BACKGROUND: Nearly one-half of Americans have been exposed to at least one adverse childhood experience (ACE) before turning 18, contributing to a broad array of problems spanning physical health, mental and behavioral health, and psychosocial functioning. METHODS: This was a cross-sectional, survey research study, using 2018 data from a state adolescent health surveillance system, i.e., Maryland Youth Risk Behavior Survey/Youth Tobacco Survey. The population-based sample of Maryland high school students (n = 41,091) is representative at the state and county levels. The outcome variables included five binary measures of ACEs (i.e., food insecurity, parental substance use/gambling, parental mental illness, family member in jail/prison, and caregiver verbal abuse), and number of ACEs. The main exposure variable, area-level socioeconomic disadvantage, was assessed at the county level using a continuous measure of the area deprivation index (ADI). Additional covariates included: rural county status, age, race/ethnicity, sex, and sexual or gender minority (SGM) status. We used mixed-effect multivariate logistic regression to estimate the odds of ACEs in association with socioeconomic deprivation. Models were adjusted for all covariates. RESULTS: County-level ADI was associated with 3 of the 5 ACES [i.e., food insecurity (OR = 1.10, 95% CI: 1.07-1.13), parental substance use/gambling (OR = 1.05, 95% CI: 1.02-1.07), and incarceration of a family member (OR = 1.14, 95% CI: 1.09-1.19)]; and with having at least one ACE (i.e., OR = 1.08, 95% CI: 1.05-1.10). Odds of reporting at least one ACE were higher among girls, older adolescents (i.e., aged 16 and ≥ 17 relative to those aged ≤ 14 years), and among SGM, Black, and Latinx students (all ORs > 1.20). CONCLUSIONS: ACEs greatly increase risk for adolescent risk behaviors. We observed an increased likelihood of adversity among youth in more deprived counties and among Black, Latinx, or SGM youth, suggesting that social and structural factors play a role in determining the adversity that youth face. Therefore, efforts to address structural factors (e.g., food access, family financial support, imprisonment as a sanction for criminal behavior) could be a critical strategy for primary prevention of ACEs and promoting adolescent health.

Racial/Ethnic Inequities in Adverse Childhood Experiences and Selected Health-Related Behaviors and Problems Among Maryland Adolescents.

We examined racial/ethnic inequities in the prevalence of adverse childhood experiences (ACEs) and examined the association between ACEs and selected health-related behaviors and problems. Data for this cross-sectional study come from the 2018 Maryland Youth Risk Behavior Survey/Youth Tobacco Survey, a statewide survey of high school students (n = 40,188). ACEs included caregiver verbal abuse and household food insecurity, substance use or gambling, mental illness, and involvement with the criminal justice system. We estimated the prevalence of ACEs overall and by race/ethnicity, and then used multiple logistic regression to determine associations between ACEs and emotional/behavioral problems, adjusting for race/ethnicity. Outcome variables included emotional distress, poor school performance, suicidal ideation, fighting, alcohol use, and marijuana use. More than one fifth of students reported each individual ACE. Differences in the prevalence of ACEs by race/ethnicity were statistically significant (p < .001). More than one fourth (25.8%) reported one of the five ACEs, 15.1% reported two, and 15.4% reported three or more. For each ACE, reporting having experienced it (vs. not) was associated with a >30% higher prevalence for each of the outcome variables. Among students who reported three or more ACEs (relative to none), the odds of emotional distress and suicidal ideation were more than 8 times greater. Among Maryland adolescents, ACEs are common, are inequitably distributed by race/ethnicity, and are strongly linked to behavioral health. Findings suggest the need to monitor ACEs as a routine component of adolescent health surveillance and to refocus assessment and intervention toward "upstream" factors that shape adolescent health.

Trajectories of Mental Distress Among U.S. Adults During the COVID-19 Pandemic.

BACKGROUND: Cross-sectional studies have found that the coronavirus disease 2019 (COVID-19) pandemic has negatively affected population-level mental health. Longitudinal studies are necessary to examine trajectories of change in mental health over time and identify sociodemographic groups at risk for persistent distress. PURPOSE: To examine the trajectories of mental distress between March 10 and August 4, 2020, a key period during the COVID-19 pandemic. METHODS: Participants included 6,901 adults from the nationally representative Understanding America Study, surveyed at baseline between March 10 and 31, 2020, with nine follow-up assessments between April 1 and August 4, 2020. Mixed-effects logistic regression was used to examine the association between date and self-reported mental distress (measured with the four-item Patient Health Questionnaire) among U.S. adults overall and among sociodemographic subgroups defined by sex, age, race/ethnicity, household structure, federal poverty line, and census region. RESULTS: Compared to March 11, the odds of mental distress among U.S. adults overall were 1.84 (95% confidence interval [CI] = 1.65-2.07) times higher on April 1 and 1.92 (95% CI = 1.62-2.28) times higher on May 1; by August 1, the odds of mental distress had returned to levels comparable to March 11 (odds ratio [OR] = 0.80, 95% CI = 0.66-0.96). Females experienced a sharper increase in mental distress between March and May compared to males (females: OR = 2.29, 95% CI = 1.85-2.82; males: OR = 1.53, 95% CI = 1.15-2.02). CONCLUSIONS: These findings highlight the trajectory of mental health symptoms during an unprecedented pandemic, including the identification of populations at risk for sustained mental distress.

Behavioral Intentions to Use Patient Portals to Disclose HIV and Other Sexually Transmitted Infection Testing Histories with Sexual Partners Among U.S. Sexual Minority Men.

Disclosure of HIV and other sexually transmitted infection (HIV/STI) testing history to sexual partners is low among gay, bisexual, and other U.S. sexual minority men (SMM). Patient portals (PP) could increase HIV/STI testing history disclosure. This study estimated the predictive validity of the Enhancing Dyadic Communication (EDC) latent construct for perceived behavioral intentions to use PP for HIV/STI test disclosures. A randomized subset of SMM completed the Patient Portal Sexual Health Instrument as part of the 2018 American Men's Internet Survey. Multivariable logistic regression models estimated associations between EDC and intentions to use PP for test disclosures. Among a sample of 1,509 SMM aged 15 to 77 years, EDC was associated with intentions to use PP to disclose test history with main partners (aOR 2.17; 95% CI 1.90 to 2.47) and non-main partners (aOR 2.39; 95%CI 2.07 to 2.76). Assessing EDC could be useful in clinical settings for interventions encouraging patients to communicate with partners about testing.

RESUMEN: La divulgación del historial de pruebas del VIH y otras infecciones de transmisión sexual (VIH / ITS) a las parejas sexuales es baja entre los homosexuales, bisexuales y otros hombres de minorías sexuales (SMM) de EE. UU. Los portales de pacientes (PP) podrían aumentar la divulgación del historial de pruebas de VIH / ITS. Este estudio estimó la validez predictiva del constructo latente Mejora de la comunicación diádica (EDC) para las intenciones conductuales percibidas de usar PP para las revelaciones de pruebas de VIH / ITS. Un subconjunto aleatorio de SMM completó el Instrumento de salud sexual del portal para pacientes como parte de la Encuesta de Internet de hombres estadounidenses de 2018. Los modelos de regresión logística multivariable estimaron asociaciones entre EDC e intenciones de usar PP para divulgaciones de pruebas. Entre una muestra de 1.509 SMM de entre 15 y 77 años, la EDC se asoció con las intenciones de utilizar PP para revelar el historial de pruebas con los socios principales (ORa = 2,17; IC del 95% = 1,90 a 2,47) y socios no principales (ORa = 2,39; IC del 95% = 2,07 a 2,76). La evaluación de EDC podría ser útil en entornos clínicos para intervenciones que alienten a los pacientes a comunicarse con sus socios sobre las pruebas.

Polytobacco use among a nationally-representative sample of black high school students.

BACKGROUND: Studies of the patterns of polytobacco use have increased. However, understanding the patterns of using multiple tobacco products among Black adolescents is minimal. This study identified the patterns of polytobacco use among U.S. Black adolescents. METHODS: Latent class analysis (LCA) was used to identify patterns of adolescent polytobacco use among a representative sample of Black youth from the 2017 Youth Risk Behavior Survey (n = 2782). Ever and recent (past 30 day) use of cigarettes, electronic cigarettes, cigars, and dip or chewing tobacco were used as latent class indicators. Multinomial regression was conducted to identify the association if smoking adjusting for sex, age, grade, and marijuana use. RESULTS: Most students were in the 9th grade (29%), e-cigarette users (21%) and were current marijuana users (25%). Three profiles of tobacco use were identified: Class 1: Non-smokers (81%), Class 2: E-cigarette Users (14%), and Class 3: Polytobacco Users (5%). Black adolescent Polytobacco users were the smallest class, but had the highest conditional probabilities of recent cigarette use, e-cigarette use, ever smoking cigars or chewing tobacco. Ever and current use of marijuana were associated with increased odds of being in the e-cigarette user versus non-smoker group, and current marijuana use was associated with increased odds of polytobacco use (aOR = 24.61, CI = 6.95-87.11). CONCLUSIONS: Findings suggests the need for targeted interventions for reducing tobacco use and examining the unique effects of polytobacco use on Black adolescents. Findings confirm a significant association of marijuana use with tobacco use.

Correction: Using the Patient Portal Sexual Health Instrument in Surveys and Patient Questionnaires Among Sexual Minority Men in the United States: Cross-sectional Psychometric Validation Study.

[This corrects the article DOI: 10.2196/18750.].

Using the Patient Portal Sexual Health Instrument in Surveys and Patient Questionnaires Among Sexual Minority Men in the United States: Cross-sectional Psychometric Validation Study.

BACKGROUND: Patient portal modules, including electronic personal health records, health education, and prescription refill ordering, may be leveraged to address the sexually transmitted infection (STI) burden, including HIV, among gay, bisexual, and other sexual minority men (SMM). Theoretical frameworks in the implementation sciences highlight examining constructs of innovation attributes and performance expectations as key determinants of behavioral intentions and the use of new web-based health technologies. However, behavioral intentions to use patient portals for HIV and other STI prevention and care among SMM is understudied. OBJECTIVE: The aim of this study is to develop a brief instrument for measuring attitudes focused on using patient portals for STI prevention and care among a nationwide sample of SMM. METHODS: A total of 12 items of the American Men's Internet Survey-Patient Portal Sexual Health Instrument (AMIS-PPSHI) were adapted from a previous study. Psychometric analyses of the AMIS-PPSHI items were conducted among a randomized subset of 2018 AMIS participants reporting web-based access to their health records (N=1375). Parallel analysis and inspection of eigenvalues in a principal component analysis (PCA) informed factor retention in exploratory factor analysis (EFA). After EFA, Cronbach α was used to examine the internal consistency of the scale and its subscales. Confirmatory factor analysis (CFA) was used to assess the goodness of fit of the final factor structure. We calculated the total AMIS-PPSHI scale scores for comparisons within group categories, including age, STI diagnosis history, recency of testing, serious mental illness, and anticipated health care stigma. RESULTS: The AMIS-PPSHI scale resulting from EFA consisted of 12 items and had good internal consistency (α=.84). The EFA suggested 3 subscales: sexual health engagement and awareness (α=.87), enhancing dyadic communication (α=.87), and managing sexual health care (α=.79). CFA demonstrated good fit in the 3-factor PPSHI structure: root mean square error of approximation=0.061, comparative fit index=0.964, Tucker-Lewis index=0.953, and standardized root mean square residual=0.041. The most notable differences were lower scores on the enhanced dyadic communication subscale among people living with HIV. CONCLUSIONS: PPSHI is a brief instrument with strong psychometric properties that may be adapted for use in large surveys and patient questionnaires in other settings. Scores demonstrate that patient portals are favorable web-based solutions to deliver health services focused on STI prevention and care among SMM in the United States. More attention is needed to address the privacy implications of interpersonal use of patient portals outside of traditional health settings among persons with HIV.

"People Don't Just Start Shooting Heroin on Their 18th Birthday": A Qualitative Study of Community Stakeholders' Perspectives on Adolescent Opioid Use and Opportunities for Intervention in Baltimore, Maryland.

Initiation of non-medical prescription opioid use (NMPO) during early adolescence is tightly linked to heroin and other drug use disorders and related sequelae in later adolescence and young adulthood. Few studies explore stakeholders' perspectives on the burden and determinants of youth opioid use and barriers and facilitators to engaging youth in opioid use prevention and treatment services in urban settings with longstanding opioid epidemics. In-depth interviews were conducted with 22 stakeholders representing health and social service agencies in Baltimore, Maryland from May 2018- February 2019, to examine their perspectives on the burden and context of adolescent opioid use and identify barriers and facilitators to preventing and responding to adolescent opioid use. Transcripts were analyzed using the constant comparison method to identify themes. Most respondents described a recent uptick in opioid use independently, and in combination with other substances. As compared to heroin, NMPO was perceived to be more frequently used and less stigmatized among youth. Stakeholders perceived the process of transitioning from using NMPO to heroin as more common among White vs. Black youth and was perceived as occurring faster among White vs. Black youth. Some stakeholders believed racial differences in internal stigma against heroin use, and differential health service use among Black youth and White youth may have influenced these differences. Trauma and poverty were noted determinants of youth opioid use. Barriers to service provision included youth cognitive development, stigma and structural factors (e.g., disinvestment, lack of youth-centered and integrated services). Stakeholders perceive prevalent NMPO among Baltimore youth and identify multilevel barriers to delivering prevention, treatment and harm reduction services to this population. These findings encourage further investigation of determinants and consequences of opioid use among diverse racial/ethnic groups of youth in urban settings, and development of multilevel, youth-driven and youth-centered approaches to prevention and treatment.

Health Beliefs and Preventive Behaviors Among Adults During the Early COVID-19 Pandemic in the United States: a Latent Class Analysis.

The objectives of this study are to (1) characterize patterns of preventive behaviors 3 months after the COVID-19 pandemic was declared a national emergency in the USA and (2) identify how health beliefs (e.g., perceived risk of infection, perceived risk of death upon infection, and perceived effectiveness of CDC-recommended preventive behaviors) and sociodemographic characteristics are associated with preventive behaviors. Data were obtained from two waves of the Understanding America Study (UAS) conducted in March (wave 1) and May to June of 2020 (wave 2) (n = 4445); UAS is a nationally representative panel of US adults. We conducted a latent class analysis (LCA) using wave 2 data to identify our outcome, patterns of 10 COVID-preventive behaviors (e.g., wearing a facemask, handwashing, social distancing), and then used a three-step regression (R3STEP) to test associations between the likelihood of class membership with (1) health beliefs and sociodemographic characteristics (age, sex, race/ethnicity, and educational attainment) in bivariate models and (2) health beliefs adjusted for sociodemographic characteristics in multivariate models. The LCA identified a three-class model of preventive behaviors characterized by high likelihood of engagement in the set of preventive behaviors ("high"), low likelihood of the preventive behaviors ("low"), or engagement in some behaviors ("mixed"). Respondents of older age (i.e., age 50 or older) and those with higher levels of educational attainment (i.e., a 4-year college degree or higher) were less likely to be in the low engagement versus the mixed engagement class compared to those who are younger (18-29) and have lower levels of educational attainment (i.e., high school), respectively. Women (compared to men) and respondents who were Black and/or Hispanic/Latinx (compared to White) were more likely to be in the high (vs. mixed) engagement class. In separate models adjusted for sociodemographic characteristics, respondents with a high perceived risk of infection, high perceived risk of death, and high perceived effectiveness of COVID-preventive behaviors were statistically significantly less likely to be in the low engagement relative to the mixed engagement class. Engagement in COVID-preventive behaviors varies by sociodemographic characteristics (i.e., age, sex, race/ethnicity and educational attainment) and health beliefs (i.e., perceived risk of infection, perceived risk of death, and perceived effectiveness of CDC-recommended behaviors). Our findings highlight the potential utility of using health beliefs to inform targeted prevention efforts to help reduce the spread of COVID-19 and future pandemics.

Medical marijuana laws (MMLs) and dispensary provisions not associated with higher odds of adolescent marijuana or heavy marijuana use: A 46 State Analysis, 1991-2015.

Background: States are rapidly moving to reverse marijuana prohibition, most frequently through legalization of medical marijuana laws (MMLs), and there is concern that marijuana legalization may affect adolescent marijuana use. Methods: This natural-experimental study used state Youth Risk Behavior Survey (YRBS) data collected from participants in grades 9-12 from 1991 to 2015 in 46 states (N = 1,091,723). Taking advantage of heterogeneity across states in MML status and MML dispensary design, difference-in-difference estimates compared states with enacted MMLs/dispensaries to non-MML/dispensaries states. Multivariable logistic regression modeling was used to adjust for state and year effects, and student demographics. The main outcome assessed was past 30-day adolescent marijuana use ["any" and "heavy" (≥20)]. Results: In the overall sample, the adjusted odds of adolescents reporting any past 30-day marijuana use was lower in states that enacted MMLs at any time during the study period (OR 0.94, 95% CI 0.89 to 0.99; p < .05), and in states with operational dispensaries in 2015 (OR 0.93, 95% CI 0.88 to 0.99; p < .05). Among grade cohorts, only 9th graders showed a significant effect, with lower odds of use with MML enactment. We found no effects on heavy marijuana use. Conclusions: This study found no evidence between 1991 and 2015 of increases in adolescents reporting past 30-day marijuana use or heavy marijuana use associated with state MML enactment or operational MML dispensaries. In a constantly evolving marijuana policy landscape, continued monitoring of adolescent marijuana use is important for assessing policy effects.

Healthcare system distrust and the breast cancer continuum of care.

PURPOSE: To identify and synthesize the literature on healthcare system distrust across the breast cancer continuum of care. METHODS: We searched CINAHL, Cochrane, EMBASE, PubMed, PsycINFO, and Web of Science from January 1, 1990 to December 31, 2018 for all peer-reviewed publications addressing the role of healthcare system trust, distrust or mistrust in the breast cancer continuum of care. RESULTS: We identified a total of 20 studies, seven qualitative studies and thirteen quantitative studies. Two studies assessed genetic testing, eleven assessed screening and seven assessed treatment and follow-up. Twelve studies evaluated mistrust, five evaluated distrust, and three evaluated trust. Study populations included African American, American Indian, Latina, Hispanic, and Asian American participants. CONCLUSION: Healthcare system distrust is prevalent across many different racial and ethnic groups and operates across the entire breast cancer continuum of care. It is an important yet understudied barrier to cancer. We hope that the knowledge garnered by this study will enable researchers to form effective and targeted interventions to reduce healthcare system distrust mediated disparities in breast cancer outcomes.

Mental Distress in the United States at the Beginning of the COVID-19 Pandemic.

Objectives. To assess the impact of the COVID-19 pandemic on mental distress in US adults.Methods. Participants were 5065 adults from the Understanding America Study, a probability-based Internet panel representative of the US adult population. The main exposure was survey completion date (March 10-16, 2020). The outcome was mental distress measured via the 4-item version of the Patient Health Questionnaire.Results. Among states with 50 or more COVID-19 cases as of March 10, each additional day was significantly associated with an 11% increase in the odds of moving up a category of distress (odds ratio = 1.11; 95% confidence interval = 1.01, 1.21; P = .02). Perceptions about the likelihood of getting infected, death from the virus, and steps taken to avoid infecting others were associated with increased mental distress in the model that included all states. Individuals with higher consumption of alcohol or cannabis or with history of depressive symptoms were at significantly higher risk for mental distress.Conclusions. These data suggest that as the COVID-19 pandemic continues, mental distress may continue to increase and should be regularly monitored. Specific populations are at high risk for mental distress, particularly those with preexisting depressive symptoms.

Mental distress during the COVID-19 pandemic among US adults without a pre-existing mental health condition: Findings from American trend panel survey.

Most individuals in the United States have no history of a mental health condition yet are at risk for psychological distress due to the COVID-19 pandemic. The objective of this study was to assess the frequency and risk and protective factors of psychological distress, during the beginning of the COVID-19 pandemic, in this group. Data comes from the Pew Research Center's American Trends Panel (ATP), a probability-based online survey panel representative of the US adult population. The analytic sample consisted of 9687 individuals with no prior history of a mental health condition who completed the survey between March 19-24, 2020. Explanatory variables included sociodemographic factors and items related to behavior, perceptions, and experiences surrounding the pandemic. The outcome was psychological distress, measured by five items on symptoms of anxiety, depression, loneliness, sleep difficulties, and hyperarousal. A multivariable linear regression model was used to identify risk and protective factors for psychological distress. Fifteen percent of the sample experienced 2 psychological distress symptoms for at least 3 days over the past week; 13% had three or more symptoms. Risk factors for higher distress included searching online or using social media to post about coronavirus, reporting that the outbreak caused major changes to personal life, and perception that the virus was a threat to the US economy, the individual's personal health or finances. This has important implications for mental health service delivery.

Adolescent Anabolic-Androgenic Steroid Use in Association with Other Drug Use, Injection Drug Use, and Team Sport Participation.

Introduction: The majority of epidemiologic research on adolescent non-medical anabolic-androgenic steroid (AAS) use was conducted in the 1990s and early 2000s, indicating a need to update evidence for the modern era. We aim to understand the prevalence of AAS use among US adolescents and assess associations between AAS use, sports participation, other drug use, and injection drug use (IDU). Methods: Using data from the 2017 National Youth Risk Behavior Survey, we estimated the prevalence of AAS use and tested for associations between AAS use, sports participation, and drug use, overall and by sex. Results: The prevalence of AAS use was 2.98%. The prevalence among boys (3.46%) was higher than among girls (2.41%). AAS use was high among youth with lifetime heroin use (64.41%) and IDU (64.42%). There was no association between AAS and team sport participation (p=0.61). Conclusions: Our results indicate that adolescent AAS use is an aspect of polysubstance use rather than a substance used solely for performance enhancement in sports. Research with adolescents should be mindful of the overlap of heroin and AAS use among youth with IDU.