Associations among drug acquisition and use behaviors, psychosocial attributes, and opioid-involved overdoses.

AIMS: This study sought to develop and assess an exploratory model of how demographic and psychosocial attributes, and drug use or acquisition behaviors interact to affect opioid-involved overdoses. DESIGN: We conducted exploratory and confirmatory factor analysis (EFA/CFA) to identify a factor structure for ten drug acquisition and use behaviors. We then evaluated alternative structural equation models incorporating the identified factors, adding demographic and psychosocial attributes as predictors of past-year opioid overdose. SETTING AND PARTICIPANTS: We used interview data collected for two studies recruiting opioid-misusing participants receiving services from a community-based syringe services program. The first investigated current attitudes toward drug-checking (N = 150). The second was an RCT assessing a telehealth versus in-person medical appointment for opioid use disorder treatment referral (N = 270). MEASUREMENTS: Demographics included gender, age, race/ethnicity, education, and socioeconomic status. Psychosocial measures were homelessness, psychological distress, and trauma. Self-reported drug-related risk behaviors included using alone, having a new supplier, using opioids with benzodiazepines/alcohol, and preferring fentanyl. Past-year opioid-involved overdoses were dichotomized into experiencing none or any. FINDINGS: The EFA/CFA revealed a two-factor structure with one factor reflecting drug acquisition and the second drug use behaviors. The selected model (CFI = .984, TLI = .981, RMSEA = .024) accounted for 13.1% of overdose probability variance. A latent variable representing psychosocial attributes was indirectly associated with an increase in past-year overdose probability (ß = .234, p = .001), as mediated by the EFA/CFA identified latent variables: drug acquisition (ß = .683, p < .001) and drug use (ß = .567, p = .001). Drug use behaviors (ß = .287, p = .04) but not drug acquisition (ß = .105, p = .461) also had a significant, positive direct effect on past-year overdose. No demographic attributes were significant direct or indirect overdose predictors. CONCLUSIONS: Psychosocial attributes, particularly homelessness, increase the probability of an overdose through associations with risky drug acquisition and drug-using behaviors. Further research is needed to replicate these findings with populations at high-risk of an opioid-related overdose to assess generalizability and refine the metrics used to assess psychosocial characteristics.

Current attitudes toward drug checking services and a comparison of expected with actual drugs present in street drug samples collected from opioid users.

BACKGROUND: The opioid epidemic continues to be associated with high numbers of fatalities in the USA and other countries, driven mainly by the inclusion of potent synthetic opioids in street drugs. Drug checking by means of various technologies is being increasingly implemented as a harm reduction strategy to inform users about constituent drugs in their street samples. We assessed how valued drug checking services (DCS) would be for opioid street drug users given the ubiquity of fentanyl and related analogs in the drug supply, the information they would most value from drug checking, and compared expected versus actual constituent drugs in collected samples. METHODS: A convenience sample of opioid street drug users (N = 118) was recruited from two syringe service exchange programs in Chicago between 2021 and 2022. We administered brief surveys asking about overdose history, whether fentanyl was their preferred opioid, and interest in DCS. We also collected drug samples and asked participants what drug(s) they expected were in the sample. Provided samples were analyzed using LC-MS technology and the results compared to their expected drugs. RESULTS: Participants reported an average of 4.4 lifetime overdoses (SD = 4.8, range = 0-20) and 1.1 (SD = 1.8, range = 0-10) past-year overdoses. A majority (92.1%) believed they had recently used drugs containing fentanyl whether intentionally or unintentionally. Opinions about the desirability of fentanyl were mixed with 56.1% indicating they did not and 38.0% indicating they did prefer fentanyl over other opioids, mainly heroin. Attitudes toward DCS indicated a general but not uniform receptiveness with a majority indicating interest in DCS though sizeable minorities believed DCS was "too much trouble" (25.2%) or there was "no point" in testing (35.4%). Participants were especially inaccurate identifying common cutting agents and potentiating drugs such as diphenhydramine in their samples (sensitivity = .17). CONCLUSIONS: Results affirmed street drug users remain interested in using DCS to monitor their drugs and such services should be more widely available. Advanced checking technologies that provide information on the relative quantities and the different drugs present in a given sample available at point-of-care, would be most valuable but remain challenging to implement.

A Latent Class Analysis of Chronic Health Conditions Among HIV-Positive Transgender Women of Color.

Research on the health of transgender people has focused on the risk for and health consequences of HIV and other sexually transmitted infections with little known about the prevalence of a broader range of medical conditions experienced by transgender people. This study used latent class (LC) analysis to examine a range of chronic medical conditions among 223 HIV-positive transgender women of color receiving primary care and psychosocial services in Chicago. The best-fitting model had 2 classes: low and moderate/high multimorbidity with 26% of participants classified in the moderate/high multimorbidity LC. Age group (i.e., under 35 vs 35 and older; AOR 13.8, p < 0.001), ever having AIDS (AOR 4.0, p < 0.05) and psychological distress (AOR 5.1, p < 0.05) were associated with increased probability of moderate/high multimorbidity class membership. The results suggest focusing on HIV-related care or hormonal treatment and potential cardiovascular issues could result in sub-optimal treatment for a population dis-engaged from primary care but which has a broad spectrum of largely untreated medical conditions.

RESUMEN: La investigación sobre la salud de las personas transgénero se ha centrado en el riesgo y las consecuencias del VIH y otras infecciones de transmisión sexual, y se sabe poco acerca de la prevalencia de una gama más amplia de condiciones médicas experimentadas por las personas transgénero. Este estudio utilizó un análisis de clase latente (LC) para examinar una gama de condiciones médicas crónicas entre 223 mujeres transgénero VIH positivas que reciben atención primaria y servicios psicosociales en Chicago. El modelo que mejor se ajustó tuvo 2 clases: multimorbilidad baja y moderada/alta, con 26% de los participantes clasificados en la LC de multimorbilidad moderada/alta. Grupo de edad (es decir, menores de 35 contra 35 y más; AOR = 13.8, p < 0.001), con SIDA (AOR = 4.0, p < 0.05) y angustia psicológica (AOR = 5.1, p < 0.05) fueron asociado con una mayor probabilidad de membresía de clase de multimorbilidad moderada/alta. Los resultados sugieren que centrarse en la atención relacionada con el VIH o en el tratamiento hormonal y los posibles problemas cardiovasculares podrían resultar en un tratamiento subóptimo para una población que participa muy poco en la atención primaria, pero que tiene un amplio espectro de condiciones médicas en gran parte no tratadas.

Syringe service program-based telemedicine linkage to opioid use disorder treatment: protocol for the STAMINA randomized control trial.

BACKGROUND: A key strategy for mitigating the current opioid epidemic is expanded access to medications for treating opioid use disorder (MOUD). However, interventions developed to expand MOUD access have limited ability to engage opioid users at higher levels of overdose risk, such as those who inject opioids. This paper describes the study protocol for testing STAMINA (Syringe Service Telemedicine Access for Medication-assisted Intervention through NAvigation), an intervention that engages high-risk opioid users at community-based syringe service programs (SSP) and quickly links them to MOUD using a telemedicine platform. METHODS: This randomized control trial will be conducted at three SSP sites in Chicago. All participants will complete an initial assessment with a provider from a Federally Qualified Health Center who can prescribe or refer MOUD services as appropriate. The control arm will receive standard referral to treatment and the intervention arm will receive immediate telemedicine linkage to the provider and (depending on the type of MOUD prescribed) provided transportation to pick up their induction prescription (for buprenorphine or naltrexone) or attend their intake appointment (for methadone). We aim to recruit a total of 273 participants over two years to provide enough power to detect a difference in our primary outcome of MOUD treatment linkage. Secondary outcomes include treatment engagement, treatment retention, and non-MOUD opioid use. Data will be collected using structured interviews and saliva drug tests delivered at baseline, three months, and six months. Fixed and mixed effects generalized linear regression analyses and survival analysis will be conducted to compare the probabilities of a successful treatment linkage between the two arms, days retained in treatment, and post-baseline opioid and other drug use. DISCUSSION: If successful, STAMINA's telemedicine approach will significantly reduce the amount of time between SSP clients' initial indication of interest in the medication and treatment initiation. Facilitating this process will likely lead to stronger additional treatment- and recovery-oriented outcomes. This study is also timely given the need for more rigorous testing of telemedicine interventions in light of temporary regulatory changes that have occurred during the COVID-19 pandemic. TRIAL REGISTRATION: ClinicalTrials.gov (Clinical Trials ID: NCT04575324 and Protocol Number: 1138-0420). Registered 29 September 2020. The study protocol is also registered on the Open Science Framework (DOI 10.17605/OSF.IO/4853 M).

A Study of the Longitudinal Patterns of Stimulant and Amyl Nitrite Use and Sexual Behavior Pre- and Post-HIV Seroconversion Among MSM.

The use of stimulant drugs alone or in combination with amyl nitrites (stimulant/nitrites) has been associated with higher rates of risky sexual behavior and predictive of HIV infection among men who have sex with men. However, the temporal pattern of stimulant/nitrite use pre- and post-seroconversion has not been well established. This study assessed changes in stimulant/nitrite use and risky sexual behavior among seroconverting MSM over time. Data were collected in the Baltimore-Washington, DC; Pittsburgh; Chicago; and Los Angeles sites of the Multicenter AIDS Cohort Study (MACS), a longitudinal study of the natural history of HIV infection among MSM. We used propensity scores to select 1044 MSM from 7087 MACS participants composed of 348 seroconverting, 348 seronegative, and 348 seroprevalent participants matched on demographics, recruitment cohort, and study visits. We centered up to four-years of semi-annual data around the seroconversion visit of the seroconverting case within each matched group of participants. Mixed effects regressions estimated the effects of serostatus, recruitment cohort, and time on self-reported stimulant/nitrite use, numbers of male intercourse partners, and numbers of unprotected receptive anal intercourse (URAI) partners. Covariates included demographics, binge drinking, and marijuana use. Seroconverters had the highest odds of stimulant/inhaled nitrite use (AOR 10.3, CI 4.8-22.0), incident rates of intercourse (IRR 1.6, CI 1.3-2.1), and URAI partners (IRR 5.1, CI 3.5-7.3). All participants decreased drug use and sexual risk behavior over time. However, the decreases were largest for seroconverters who nevertheless maintained the highest rates of stimulant/nitrite use and sexual risk. Cohort-related effects were associated with sharp reductions in stimulant/nitrite use and URAI in the early 1990s that rebounded considerably within the first decade of the 2000s. Although all participants decreased risky sexual behavior and stimulant and/or nitrite use over time, seroconverters had the largest decreases. There was no evidence for abrupt or substantial increases in drug use or risky sex post-seroconversion. However, there was substantial variation at the individual level, with the factors underlying this variation not well understood and worth further study. Moreover, stimulant/nitrite use and risky sexual behavior appear to have been strongly influenced by contextual historical and socio-cultural effects. The manner in which contextual factors influence individual behavior is also not well understood and also warrants further study.

A Multi-Group Latent Class Analysis of Chronic Medical Conditions Among Men Who Have Sex with Men.

Until recently, research on the health of gay and other men who have sex with men (MSM) has focused on risk for and the health consequences of HIV and other sexually transmitted infections. A multigroup latent class analysis examined a range of lifetime chronic medical conditions (CMCs) among MSM. Covariates included sociodemographics, substance use, psychological distress, and HIV serostatus. A two-class model best fit the medical condition data: a low probabilities class for most CMCs and a moderate to high probabilities (MHP) class. HIV serostatus was associated with increased within-class probabilities for some CMCs, particularly gastrointestinal and skin disorders. Only increasing age and use of erectile dysfunction drugs were directly associated with increased odds of being in the MHP class whereas methamphetamine use, identifying as gay, and lower alcohol use were indirectly associated. Implications of the findings for future research and the health care needs of MSM are discussed.

Association between nonspecific severe psychological distress as an indicator of serious mental illness and increasing levels of medical multimorbidity.

OBJECTIVES: We sought to determine whether severe psychological distress (SPD) and serious mental illnesses (SMIs) are associated with a specific set of chronic medical conditions (CMCs) and the association between SPD-SMIs and increasing levels of medical multimorbidity and complexity (i.e., from 1 to 3 or more CMCs). METHODS: We used data from 3 administrations (2008-2010) of the National Survey on Drug Use and Health collected from 110 455 adult participants. We used binary and ordinal logistic regressions adjusting for sociodemographics and substance abuse to examine the associations between SPD-SMIs and increasing levels of multimorbidity. RESULTS: SPD-SMI was associated with higher probabilities for many CMCs generally, but we found no specific pattern for any class of conditions for SPD-SMIs and multimorbidity. The association between SPD-SMIs and multimorbidity strengthened as the number of CMCs increased. CONCLUSIONS: The finding of no discernible risk pattern for any specific CMC grouping supports broad medical assessment strategies and closely coordinated primary and behavioral health care for those with SPD-SMIs, as called for in the Patient Protection and Affordable Care Act.

Latent class analysis of emergency department patients engaged in telehealth peer recovery support services and associations of identified classes with post-discharge outcomes.

BACKGROUND: People with substance use disorders (SUDs) frequently use emergency department (ED) services. Despite evidence demonstrating that post-discharge SUD treatment linkage effectively reduces the number of ED re-presentations, relatively few hospitals have implemented interventions to identify and connect patients with SUDs to appropriate care. ED-based peer recovery support specialist (PRSS) interventions have emerged as a promising approach for hospitals, but more research is needed to understand the extent to which these interventions meet the needs of patients who present to the ED for different reasons and with various underlying concerns. METHOD: A retrospective cohort analysis used data from a telehealth PRSS program in 15 EDs within one Indiana hospital system. The study included 2950 ED patients who engaged with telehealth PRSS services between September 2018 and September 2021. Latent class analysis identified patterns of patient characteristics associated with post-discharge PRSS engagement and ED re-presentations. Covariate predictors and distal outcomes were assessed to examine the associations between class membership, demographic factors, and patient outcomes. RESULTS: The study team selected a six-class model as the best fit for the data. Class 1, representing patients with opioid use disorder and mental health diagnoses who presented to the ED for an opioid overdose, was used as the reference class for all other statistical tests. Multinomial logistic regression analysis demonstrated significant associations between covariate predictors, outcomes, and class membership. Regression results also demonstrate PRSSs had greater success contacting patients with prior year ED use and patients with a successful post-discharge PRSS contact were less likely to re-present to the ED. CONCLUSION: Results highlight the heterogeneity of patients with SUDs and emphasize the need for tailored interventions to address patient-specific needs more effectively. They also provide support for the perceived utility of PRSS engagement for ED patients.

Associations among Drug Acquisition and Use Behaviors, Psychosocial Attributes, and Opioid-Involved Overdoses: A SEM Analysis.

Aims: This study sought to develop and assess an exploratory model of how demographic and psychosocial attributes, and drug use or acquisition behaviors interact to affect opioid-involved overdoses. Methods: We conducted exploratory and confirmatory factor analysis (EFA/CFA) to identify a factor structure for ten drug acquisition and use behaviors. We then evaluated alternative structural equation models incorporating the identified factors, adding demographic and psychosocial attributes as predictors of past-year opioid overdose. We used interview data collected for two studies recruiting opioid-misusing participants receiving services from a community-based syringe service program. The first investigated current attitudes toward drug-checking (N = 150). The second was an RCT assessing a telehealth versus in-person medical appointment for opioid use disorder treatment referral (N = 270). Demographics included gender, age, race/ethnicity, education, and socioeconomic status. Psychosocial measures were homelessness, psychological distress, and trauma. Self-reported drug-related risk behaviors included using alone, having a new supplier, using opioids with benzodiazepines/alcohol, and preferring fentanyl. Past-year opioid-involved overdoses were dichotomized into experiencing none or any. Results: The EFA/CFA revealed a two-factor structure with one factor reflecting drug acquisition and the second drug use behaviors. The selected model (CFI = .984, TLI = .981, RMSEA = .024) accounted for 13.1% of overdose probability variance. A latent variable representing psychosocial attributes was indirectly associated with an increase in past-year overdose probability (ß=.234, p = .001), as mediated by the EFA/CFA identified latent variables: drug acquisition (ß=.683, p < .001) and drug use (ß=.567, p = .001). Drug use behaviors (ß=.287, p = .04) but not drug acquisition (ß=.105, p = .461) also had a significant, positive direct effect on past-year overdose. No demographic attributes were significant direct or indirect overdose predictors. Conclusions: Psychosocial attributes, particularly homelessness, increase the probability of an overdose through associations with risky drug acquisition and drug-using behaviors. To increase effectiveness, prevention efforts might address the interacting overdose risks that span multiple functional domains.

Mental health and substance use disorder comorbidities among Medicaid beneficiaries: Associations with opioid use disorder and prescription opioid misuse.

Background: Medicaid presently insures about one-fourth of the US population and disproportionately insures about 38 % of non-elderly adults with an opioid use disorder (OUD). Owing to Medicaid's prominent role insuring persons with an OUD and that Medicaid coverage includes pharmaceutical benefits, there has been considerable interest in studying potential prescription opioid misuse among Medicaid beneficiaries and identifying subpopulations at higher risk for misuse and possible progression to an OUD. Methods: The study goals were to explore the associations among prescription opioid misuse, OUD, and co-occurring mental health and other substance use disorders (SUD). We analyzed Illinois Medicaid 2018 claims data for 1102479 adult beneficiaries 18 to 64 years of age. Using algorithms based on previous studies, we first determined either the presence or absence of nine SUDS (including OUD), nine mental health disorders and likely prescription opioid misuse. Then, we subdivided the beneficiary sample into five groups: those who were prescribed opioids and evidenced either no, possible, or probable misuse; those evidencing an OUD; and those evidencing no opioid use or misuse. Results: Bivariate analyses, upset plots, and multinomial logistic regressions were used to compare the five subgroups on the prevalence of co-occurring SUDS and mental health disorders. Those with an OUD or with probable prescription opioid misuse had the highest prevalence of most co-occurring conditions with beneficiaries with an OUD the most likely to evidence co-occurring SUDS, particularly tobacco use disorder, whereas those with probable misuse had elevated prevalence rates of co-occurring mental health disorders comparable to those with an OUD. Conclusion: The medical complexity of persons with an OUD or misusing prescription opioids are considered in light of recent attempts to expand buprenorphine provision as a medication for OUD among Medicaid beneficiaries. Additionally, we consider the possibility of gender, co-occurring mental health disorders, and tobacco use disorder as important risk factors for progressing to prescription opioid misuse and an OUD.

Development and validation of a liquid chromatography tandem mass spectrometry method for the analysis of 53 benzodiazepines in illicit drug samples.

An LC-MS/MS method for the analysis of 53 benzodiazepines, including various designer benzodiazepines, was developed. The developed method was applied to a total of 79 illicit street drug samples collected in Chicago, IL. Of these samples, 68 (84%) had detectable amounts of at least one benzodiazepine. Further, of the 53 benzodiazepines included in the developed method just 14 were measured in samples. Clonazolam, a potent designer benzodiazepine and derivative of clonazepam, was the most frequently measured benzodiazepine in 63% of samples and was measured in the highest concentrations. Other benzodiazepines measured in more than 10% of samples included clonazepam, alprazolam, flualprazolam, and oxazepam. Mixtures of benzodiazepines were frequently measured in samples, with just 24% of samples containing just one benzodiazepine. To determine the response of benzodiazepines on a rapid, point-of-use drug checking tool, all 53 benzodiazepine standards were screened on a lateral flow immunoassay benzodiazepine test strip. Sixty eight percent of standards gave a positive BTS response at a concentration of 20 µg/mL, demonstrating BTS have response to a wide variety of benzodiazepines, including many designer benzodiazepines. A comparison of this data to previous data reported for the same samples demonstrated all samples containing a benzodiazepine also had an opioid present, with fentanyl being present in 94% of benzodiazepine samples. These results highlight high rates of polysubstance drug presence in Chicago, IL illicit drug samples, posing an increased risk of drug overdoses in people who use drugs.

Feasibility Study of Using Mobile Phone-Based Experience Sampling to Assess Drug Checking by Opioid Street Drug Users.

Background: To date, evaluations of take-home fentanyl (and/or benzodiazepine) test strip use - the most common form of drug checking services - and potential effects on overdose risk have relied on retrospective accounts for some preceding time period, usually a week to several months. Such accounts, however, are subject to recall and memory biases. This pilot study assessed the feasibility of using experiential sampling to collect daily information in situ on drug checking and associated overdose risk reduction - the primary outcomes - among a sample of street opioid users and compared the results to retrospective reports. Methods: We recruited 12 participants from a Chicago-based syringe services program. Participants were 18 years of age or older, reported using opioids purchased on the street 3+ times per week in the past month, and had an available Android mobile phone. A phone-based app was programmed to collect daily drug checking information and provided to each participant along with a supply of fentanyl and benzodiazepine test strips and instructions for use over 21 days. Comparable retrospective data were collected via follow-up in-person surveys at the conclusion of daily report collection. Results: We found a reasonably high rate of daily reporting (63.5%) with participants submitting reports on 160 "person-days" out of 252 possible days. Participants submitted daily reports an average of 13 of 21 days. Reports of test strip use frequency varied between the retrospective and daily reports with a relatively higher percentage of days/time using test strips obtained from the daily reports. We also found higher proportions reporting overdose risk reduction behaviors on the daily reports compared with the retrospective reviews. Conclusions: We believe the results support using daily experience sampling to collect information on drug checking behaviors among street drug users. Although resource intensive in comparison to retrospective reports, daily reporting potentially provides more detailed information on test strip use and its association with overdose risk reduction and, ultimately, fewer overdoses. Needed are larger trials and validation studies of daily experience sampling to identify the optimum protocol for collecting accurate information on drug checking and overdose risk reduction behavior.

Feasibility study of using mobile phone-based experience sampling to assess drug checking by opioid street drug users.

BACKGROUND: To date, evaluations of take-home fentanyl (and/or benzodiazepine) test strip use - the most common form of drug checking services - and potential effects on overdose risk have relied on retrospective accounts for some preceding time period, usually a week to several months. Such accounts, however, are subject to recall and memory biases. This pilot study assessed the feasibility of using experiential sampling to collect daily information in situ on drug checking and associated overdose risk reduction - the primary outcomes - among a sample of street opioid users and compared the results to retrospective reports. METHODS: We recruited 12 participants from a Chicago-based syringe services program. Participants were 18 years of age or older, reported using opioids purchased on the street 3 + times per week in the past month, and had an available Android mobile phone. A phone-based app was programmed to collect daily drug checking information and provided to each participant along with a supply of fentanyl and benzodiazepine test strips and instructions for use over 21 days. Comparable retrospective data were collected via follow-up in-person surveys at the conclusion of daily report collection. RESULTS: We found a reasonably high rate of daily reporting (63.5%) with participants submitting reports on 160 "person-days" out of 252 possible days. Participants submitted daily reports an average of 13 of 21 days. Reports of test strip use frequency varied between the retrospective and daily reports with a relatively higher percentage of days/time using test strips obtained from the daily reports. We also found higher proportions reporting overdose risk reduction behaviors on the daily reports compared with the retrospective reviews. CONCLUSIONS: We believe the results support using daily experience sampling to collect information on drug checking behaviors among street drug users. Although resource intensive in comparison to retrospective reports, daily reporting potentially provides more detailed information on test strip use and its association with overdose risk reduction and, ultimately, fewer overdoses. Needed are larger trials and validation studies of daily experience sampling to identify the optimum protocol for collecting accurate information on drug checking and overdose risk reduction behavior.

Validated method for the analysis of 22 illicit drugs and their metabolites via liquid chromatography tandem mass spectrometry (LC-MS/MS) in illicit drug samples collected in Chicago, IL.

Drug checking services are being utilized worldwide to provide people who use drugs information on the composition and contents of their drugs as a tool for harm reduction and accidental overdose prevention. Existing drug checking services use a variety of techniques including immunoassay strips and spectroscopic techniques like FTIR and Raman. Few services utilize LC-MS based methods for primary or secondary analysis and few methods exist for direct analysis of illicit drugs. To address this, an LC-MS/MS method was developed for 22 illicit drugs and cutting agents using LC-MS/MS with application to 124 illicit drug samples that were collected from Chicago, IL. Samples were also analyzed using fentanyl and benzodiazepine immunoassay test strips. Fentanyl test strips gave a positive result for 86% of samples with only one sample showing a positive result on a benzodiazepine test strip. LC-MS/MS analysis of samples show that opioids were the most commonly quantified in 96% of samples, followed by stimulants at 12% and benzodiazepines at 1%. Fentanyl was measured in 91% of samples, co-occurring with heroin in 58% of opioid-containing samples. A comparison of the gold-standard LC-MS/MS results to fentanyl test strips shows a high level of accuracy for the fentanyl test strips, with just 5% of samples being classified as false negatives and no false positives. These results demonstrate the strengths and benefits of LC-MS/MS when incorporated as a secondary analysis tool for drug checking.

A measurement invariance analysis of selected Opioid Overdose Knowledge Scale (OOKS) items among bystanders and first responders.

The Opioid Overdose Knowledge Scale (OOKS) is widely used as an adjunct to opioid education and naloxone distribution (OEND) for assessing pre- and post-training knowledge. However, the extent to which the OOKS performs comparably for bystander and first responder groups has not been well determined. We used exploratory structural equation modeling (ESEM) to assess the measurement invariance of an OOKS item subset when used as an OEND training pre-test. We used secondary analysis of pre-test data collected from 446 first responders and 1,349 bystanders (N = 1,795) attending OEND trainings conducted by two county public health departments. Twenty-four items were selected by practitioner/trainer consensus from the original 45-item OOKS instrument with an additional 2 removed owing to low response variation. We used exploratory factor analysis (EFA) followed by ESEM to identify a factor structure, which we assessed for configural, metric, and scalar measurement invariance by participant group using the 22 dichotomous items (correct/incorrect) as factor indicators. EFA identified a 3-factor model consisting of items assessing: basic overdose risk information, signs of an overdose, and rescue procedures/advanced overdose risk information. Model fit by ESEM estimation versus confirmatory factor analysis showed the ESEM model afforded a better fit. Measurement invariance analyses indicated the 3-factor model fit the data across all levels of invariance per standard fit statistic metrics. The reduced set of 22 OOKS items appears to offer comparable measurement of pre-training knowledge on opioid overdose risks, signs of an overdose, and rescue procedures for both bystanders and first responders.

Adolescent Cannabis Use Among Youth in ZIP Codes with Medical Dispensaries.

Introduction: In the United States, 19 states permit recreational use of cannabis, with 16 more permitting medical use (Marijuana Policy Project, 2021). Concerns remain about whether liberalized policies result in increased adolescent cannabis use. To date, limited evidence exists that the statewide prevalence of adolescent cannabis use increased in states with liberalized policies. However, analyses at local levels show some negative impacts. Thus, we analyzed if living in a ZIP code with a dispensary (ZCWD) was associated with adolescent cannabis use. Methods: Dispensary ZIP codes from public records were matched to self- reported ZIP codes on the Illinois Youth Survey (IYS). We compared past 30-day and past-year cannabis use among youth living in a ZCWD and not living in a ZCWD. Results: About one in eight adolescents (12.8%, n = 1,348) in the weighted sample (n=10,569) resided in a ZCWD. Overall, past 30-day use was lower among youth who lived in ZIP codes with dispensaries (OR = .69, p < .05), with variation by grade. For example, only 10th (OR = .62, p < .05) and 12th graders (OR = .59, p < .05) living in a ZCWD had lower odds of past 30-day cannabis use. Additionally, only 12th graders in a ZCWD had lower odds of past-year use (OR = .70, p < .05). Finally, suburban youth living in a ZCWD also had lower odds of cannabis use (OR = .54, p < .01). Conclusion/Discussion: Cannabis use was significantly lower among 10th and 12th graders living in a ZCWD. Additional research should continue to monitor evolving state policies and whether they are associated with adolescent cannabis use.

Chronic medical conditions among jail detainees in residential psychiatric treatment: a latent class analysis.

Studies of incarcerates with serious mental illnesses have found elevated rates of chronic medical conditions such as asthma and diabetes, and of infectious diseases such as tuberculosis compared with general population rates. This study explored the pattern of chronic medical conditions in a sample of adult detainees in psychiatric treatment in a large urban jail to develop a clinical profile encompassing the full range of medical conditions. A total of 431 male and female detainees were sampled with certainty from admissions to a residential psychiatric treatment program (overall recruitment rate = 67%). Interviews used the World Mental Health version of the Composite International Diagnostic Interview to assess psychiatric and substance use disorders per DSM-IV criteria and chronic medical conditions. Latent class analysis was conducted using 17 medical conditions as class indicators, yielding a 3-class model composed of: a latent class with a high to intermediate probability of multiple medical conditions (HMC; 12.5% of the sample); an intermediate class with a lower probability of having a smaller number of medical conditions (MMC; 43.2%); and a class with a low probability of any medical condition (44.3%). Those in the HMC class were more likely to report respiratory problems, severe headaches, musculoskeletal pain, hypertension, and arthritis, have greater functional impairment, and have a higher number of co-occurring psychiatric disorders. Being older (50+ years) and female were associated with higher odds of being in the HMC or MMC classes. The policy implications for providing medical care to incarcerates with complex mixtures of medical conditions and psychiatric disorders are considered.

A Comparative Analysis of Lifetime Medical Conditions and Infectious Diseases by Sexual Identity, Attraction, and Concordance among Women: Results from a National U.S. Survey.

There have been limited studies assessing the differences in chronic health conditions between sexual minority (those who identify as lesbian or bisexual) and sexual majority (heterosexual) women. Research has primarily focused on overall physical and mental health or behavioral issues and not on specific health conditions. The addition of sexual orientation and attraction questions to the National Survey on Drug Use and Health (NSDUH) now allows for research regarding health conditions using a national survey that identifies participant sexual orientation and attraction. This study sought to compare the prevalence/odds of having 10 medical conditions/infectious diseases among women, assessing for differences associated with sexual identity, sexual attraction, and the degree of concordance between sexual identity and attraction. Data from 67,648 adult female participants in the 2015-2017 NSDUH survey were analyzed using bivariate and multivariable logistic regression models to assess for differences in prevalence/odds of seven medical conditions. Multivariable models adjusted for demographics, substance abuse/dependence, and mental illness. We found significant differences by sexual identity, but not sexual attraction or concordance. Compared with heterosexually identified women, women who identified as bisexual had significantly higher odds of having three medical conditions and two infectious diseases than heterosexual or lesbian women. The findings generally support those based on studies using more limited geographical samples. There are a number of potential associated and underlying factors that contribute to bisexual women reporting overall poorer health than heterosexual or lesbian women. The factors discussed include stigma, delays in seeking care, lack of insurance and access, and sexual minority women receiving poorer health care generally.

Prescription opioid availability and opioid overdose-related mortality rates in Medicaid expansion and non-expansion states.

AIMS: To determine whether, in the United States, higher opioid overdose-related mortality rates (OOMR) in Affordable Care Act (ACA) Medicaid expansion states relative to mortality rates in non-expansion states have been mediated by increased prescription opioid availability. DESIGN: Separate mixed-effect regression models examined difference-in-difference effects of time and expansion status on Medicaid-reimbursed opioids measured in morphine milligram (mg) equivalents on all OOMR and on prescription OOMR. We used generalized structural equation models to test whether increases in Medicaid-reimbursed prescription opioid availability mediated OOMR post-Medicaid expansion. SETTING AND PARTICIPANTS: This study used national, serial, cross-sectional data for Medicaid-reimbursed prescription opioids, Medicaid enrollment information and annual OOMR for any opioids and for prescription opioids from 49 states and the DC pre- (2008-13) and post-ACA Medicaid expansion (2014-16). MEASUREMENTS: The outcome measures were OOOMR and Medicaid-reimbursed prescription opioid availability. The main input variables were time and ACA Medicaid expansion status. FINDINGS: Medicaid expansion states had larger increases in prescription opioid availability (b = 480, 357.8, P = 0.001) compared with non-expansion states. However, the largest increases in prescription opioid availability in expansion states were between 2009 and 2011, well before the ACA Medicaid expansion. Whereas expansion states also had higher any OOMR compared with non-expansion states (b = 3.6, P = 0.011), significant differences in prescription OOMR between expansion and non-expansion states did not emerge until 2015 (b = 1.4, P = 0.014) and 2016 (b = 4.0, P = 0.004), and Medicaid-reimbursed prescription opioid availability was not a significant mediator. CONCLUSIONS: Increases in Medicaid-reimbursed prescription opioid availability in Affordable Care Act Medicaid expansion states in the United States do not appear to have mediated post-Affordable Care Act Medicaid expansion mortality rate differences, but there is still a possibility of lagged effects.

Adapting Andersen's Behavioral Model of Health Service Use to Examine Risk Factors for Hypertension Among U.S. MSM.

Hypertension affects nearly a third of U.S. adult males and is a leading risk factor for cardiovascular disease, but there is a paucity of hypertension research among men who have sex with men (MSM). Andersen's model of health service use was adapted to examine factors associated with hypertension among MSM. In 2008, 7,454 U.S. MSM completed an online survey. Overall, 16.5% of the sample reported a lifetime diagnosis of hypertension. In hierarchical logistic regression, Black MSM had increased odds of reporting hypertension (adjusted odds ratio [AOR] = 1.79, 95% confidence interval [CI] [1.24, 2.60]) compared with White MSM, as did men aged 30 years and older (age 30-39: AOR = 2.46, 95% CI [1.84, 3.29]; age 40-49: AOR = 3.76, 95% CI [2.85, 4.97]; age 50+: AOR = 6.40, 95% CI [4.78, 8.58]; Reference: 18-29 years). Health conditions associated with hypertension included diabetes (AOR = 3.62, 95% CI [2.81, 4.68]), heart disease (AOR = 5.19, 95% CI [3.99, 6.75]), depression (AOR = 1.38, 95% CI [1.17, 1.63]), anxiety (AOR = 1.30, 95% CI [1.09, 1.57]), and being overweight (AOR = 2.23, 95% CI [1.91, 2.59]). Having a primary care provider (AOR = 2.19, 95% CI [1.64, 2.93]) and residing in South Atlantic (AOR = 1.39, 95% CI [1.12, 1.74]) or South Central (AOR = 1.59, 95% CI [1.27, 2.00]) regions was also associated with reporting hypertension. Study findings are consistent with those in the literature for the general population. To address health care inequities, the Internet could serve as a potential access point for health screening and referral for care.