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Objectives. To examine whether local cannabis policies and retail availability are associated with cannabis use and problematic cannabis use (PCU) among adolescents in Northern California. Methods. The sample comprised adolescents aged 13 to 17 years screened for past-year cannabis use during well-child visits in 2021. Exposures included local bans on cannabis storefront retailers, policy protectiveness, and retail proximity and density. Outcomes included self-reported past-year cannabis use and PCU diagnoses. Modified Poisson regression models adjusted for sociodemographics. Results. The sample (n = 103 134) was 51.1% male with a median age of 15 years (interquartile range [IQR] = 14–16 years); 5.5% self-reported cannabis use, and 0.3% had diagnosed PCU. Adolescents had a lower prevalence of cannabis use in jurisdictions that banned storefront retailers (adjusted prevalence rate [APR] = 0.857; 95% confidence interval [CI] = 0.814, 0.903 vs allowed), banned delivery (APR = 0.751; 95% CI = 0.710, 0.795 vs allowed), or had more policy protections (APR range = 0.705–0.800). Lower PCU prevalence was also found among those in jurisdictions that banned (vs allowed) storefront retailers (APR = 0.786; 95% CI = 0.629, 0.983) or delivery (APR = 0.783; 95% CI = 0.616, 0.996). Longer drive time and lower density of storefront retailers were associated with a lower cannabis use prevalence. Conclusions. More protective cannabis policies and less retail availability were associated with a lower prevalence of adolescent cannabis use and PCU. (Am J Public Health. 2024;114(S8):S654–S663. https://doi.org/10.2105/AJPH.2024.307787) [ABSTRACT FROM AUTHOR]

Aims: To estimate the strength of association between psychiatric disorders and substance use disorders (SUD), and cannabis use and cannabis use disorder (CUD) during early pregnancy. Design: Observational study. Setting: Kaiser Permanente Northern California, USA. Participants: 299 496 pregnancies from 227 555 individuals screened for cannabis use by self‐report and a urine toxicology test at entrance to prenatal care in Kaiser Permanente Northern California during January 2011–December 2021 (excepting year 2020). The sample was 62.5% non‐White, with a mean (standard deviation) age of 31.1 (5.5) years; 6.8% used cannabis; 0.2% had a CUD. Measurements: Exposure variables included electronic health record‐based psychiatric diagnoses of attention deficit hyperactivity, anxiety, bipolar, depressive, personality, posttraumatic stress and psychotic disorders; and alcohol, opioid, stimulant and tobacco use disorders, during the two years prior to pregnancy up to the day before the prenatal substance use screening date. Outcome variables were any cannabis use, frequency of self‐reported cannabis use and CUD during early pregnancy. Findings Psychiatric disorder prevalence ranged from 0.2% (psychotic) to 14.3% (anxiety), and SUD ranged from 0.3% (stimulant/opioid) to 3.8% (tobacco). Psychiatric disorders were associated with cannabis use and CUD, with the strongest association for any use found for bipolar disorder (adjusted odds ratio [aOR] = 2.83; 95% confidence interval [CI] = 2.53–3.17) and the strongest association for CUD found for psychotic disorders (aOR = 10.01, 95% CI = 6.52–15.37). SUDs were associated with cannabis use and CUD, with the strongest association for any use found for tobacco use disorder (aOR = 4.03, 95% CI = 3.82–4.24) and the strongest association for CUD found for stimulant use disorder (aOR = 21.99, 95% CI = 16.53–29.26). Anxiety, bipolar, depressive disorders and tobacco use disorder were associated with greater odds of daily than monthly or less cannabis use. Conclusions: Psychiatric disorders and substance use disorders appear to be associated with elevated odds of any and frequent cannabis use as well as cannabis use disorder during early pregnancy. In most cases, the associations with cannabis outcomes were stronger for substance use disorders than other psychiatric disorders. [ABSTRACT FROM AUTHOR]

BACKGROUND: Screening for adverse childhood experiences (ACEs) and resilience in pregnancy is a promising practice for mitigating ACEs-related health complications. Yet, the best follow-up for pregnant patients with high ACEs and/or low resilience has not been established. OBJECTIVE: This study evaluates referrals to and participation in an embedded health psychologist (EHP) intervention for pregnant patients with ACEs and/or low resilience. MATERIALS AND METHODS: Patients in 3 Kaiser Permanente Northern California medical centers with ACEs who had also received resilience screening during standard prenatal care and who were participating in an EHP intervention were included (N = 910). The authors used multivariable logistic regression to examine whether ACEs (0, 1-2, 3+) and resilience (high vs low) were associated with referrals to and participation in EHP intervention. They also evaluated the impact of EHP intervention through clinician (N = 53) and patient (N = 51) surveys. RESULTS: Patients with 3+ vs 0 ACEs were more likely to receive an EHP referral (adjusted odds ratio [aOR] = 2.89, 95% confidence interval [CI]: 1.93-4.33) and were more likely to participate in EHP intervention (aOR = 2.85, 95% CI: 1.87-4.36). Those with low vs high resilience were also more likely to receive an EHP referral (aOR = 1.86, 95% CI: 1.32-2.62) and participate in EHP (aOR = 1.71, 95% CI: 1.19-2.44). When ACEs and resilience were combined, those with high ACEs and low resilience had the greatest odds of referrals and participation. Patients and clinicians reported positive experiences with EHP intervention. CONCLUSION: Patients with higher ACEs and lower resilience scores were more likely to be referred to and participate in EHP intervention, suggesting that at-risk patients can be successfully linked with a health psychologist when accessible within obstetric care. [ABSTRACT FROM AUTHOR]

Introduction: Observational research is important for understanding the real-world benefits of advancements in lung cancer care. Integrated health care systems, such as Kaiser Permanente Northern California, have extensive electronic health records suitable for such research, but the generalizability of their populations is often questioned. Methods: Leveraging data from the California Cancer Registry, the authors compared distributions of demographic and clinical characteristics, in addition to neighborhood and environmental conditions, between patients diagnosed with lung cancer from 2015 through 2019 at Kaiser Permanente Northern California, National Cancer Institute-designated cancer centers (NCICCs), and all other non-N CICC hospitals within the same catchment area. Results: Of 20,178 included patients, 30% were from Kaiser Permanente Northern California, 8% from NCICCs, and 62% from other non-N CICC hospitals. Compared to NCICC patients, Kaiser Permanente Northern California patients were more similar to other non-N CICC patients on most characteristics. Compared to other non-N CICC patients, Kaiser Permanente Northern California patients were slightly older, more likely to be female, and less likely to be Hispanic or Asian/Pacific Islander and to reside in lower socioeconomic status (SES) neighborhoods. In contrast, NCICC patients were younger, less likely to be female or from non-A sian/Pacific Islander minoritized racial groups, and more likely to present with early-stage disease and adenocarcinoma and to reside in neighborhoods with higher SES and lower air pollution than Kaiser Permanente Northern California or other non-N CICC patients. Discussion: Patients from Kaiser Permanente Northern California, compared to NCICCs, are more broadly representative of the underlying patient population with lung cancer. Conclusion: Research using electronic health record data from integrated health care systems can contribute generalizable real-world evidence to benchmark and improve lung cancer care. [ABSTRACT FROM AUTHOR]

Despite well-documented associations between adverse childhood experiences (ACEs) and lifelong impairments in health and well-being, few studies have examined how to facilitate implementation of ACEs screening and referral programs in pediatric settings. We sought to identify facilitators and barriers related to screening for and addressing ACEs in a large integrated healthcare delivery system in Southern California. Using a developmental evaluation approach, we conducted twenty semi-structured interviews with pediatricians, nurses, social workers, and community referral organization staff. Interviews took place across six pediatric clinic pilot sites in Kaiser Permanente Southern California, where more than 7,000 pediatric patients were screened for ACEs between July 2018 and December 2019. Thematic analysis was conducted to identify themes. Key facilitators for screening and referrals for pediatric ACEs screening included providing clinician education to normalize conversations about ACEs, using screening data to provide more holistic and compassionate care, and collaborating across different types of clinicians. Key barriers included screening tool challenges related to patient confusion and cultural differences, capacity limitations, training issues, and care team silos. When used in the context of a trauma- and resilience-informed workforce, ACEs screening may be a powerful tool to support more collaborative and impactful care decisions that move away from symptom management to address root causes and promote prevention. [ABSTRACT FROM AUTHOR]

Objective: To examine plans for postpartum cannabis use among pregnant individuals who used cannabis during early pregnancy. Materials and Methods: Eighteen virtual focus groups were conducted from November 17, 2021, to December 17, 2021, with 23 Black and 30 White pregnant adults in Kaiser Permanente Northern California, who self-reported prenatal cannabis use during early pregnancy. Focus groups were recorded, transcribed, and analyzed using thematic analysis. Results: The sample (N = 53) had a mean age of 30.3 years (standard deviation = 5.2) at recruitment; 70% reported daily, 25% weekly, and 6% ≤ monthly cannabis use at entrance to prenatal care. Some participants viewed cannabis as critical for coping with postpartum mental and physical health challenges, while others questioned whether cannabis use would fit with their parental lifestyle, and some planned to abstain altogether. Most planned to use cannabis postpartum, but with lower frequency than before pregnancy, and in ways consistent with harm reduction (e.g., smoking outside to avoid secondhand or thirdhand smoke exposure). Many were motivated to abstain from cannabis while breastfeeding, and some desired more data on the safety of cannabis and breastfeeding, or intended to "pump and dump," believing it would reduce potential transfer of Δ9-tetrahydrocannabinol (THC) to their infant. Responses from Black and White participants were generally similar, but White participants were more likely to report plans to use cannabis while breastfeeding and to want information about cannabis and breastfeeding. Conclusions: Pregnant individuals with prenatal cannabis use had varied plans for cannabis use postpartum. Many were motivated to abstain or use cannabis less frequently than pre-pregnancy, especially during lactation. [ABSTRACT FROM AUTHOR]

BACKGROUND: Screening for adverse childhood experiences (ACEs) in prenatal and pediatric populations is recommended by the California ACEs Aware initiative and is a promising practice to interrupt ACEs in children and mitigate ACEs-related health complications in children and families. Yet, integrating ACEs screening into clinical practice poses several challenges. OBJECTIVE: The objective of this report was to evaluate the Kaiser Permanente Northern California and Kaiser Permanente Southern California pilots and implementation of ACEs screening into routine prenatal (Kaiser Permanente Northern California) and pediatric (Kaiser Permanente Southern California) care. MATERIALS AND METHODS: These pilots were evaluated and compared to identify common challenges to implementation and offer promising practices for negotiating these challenges. Evaluation methods included feedback from staff, clinicians, and patients, as well as comparisons of methods to overcome various barriers to screening implementation. RESULTS: Implementing ACEs screening, like implementation of any new component of clinical care, takes careful planning, education, creation of content and workflows, and continuous integration of feedback from both patients and staff. CONCLUSION: This evaluation can serve as support for care teams who are considering implementing ACEs screening or who are already screening for ACEs. More research is needed regarding the relationship between ACEs and preventable and treatable health outcomes to improve health for patients and their families. [ABSTRACT FROM AUTHOR]

Background: Given significant risks associated with long-term prescription opioid use, there is a need for non-pharmacological interventions for treating chronic pain. Activating patients to manage chronic pain has the potential to improve health outcomes. The ACTIVATE study was designed to evaluate the effectiveness of a 4-session patient activation intervention in primary care for patients on long-term opioid therapy. Methods: The two-arm, pragmatic, randomized trial was conducted in two primary care clinics in an integrated health system from June 2015—August 2018. Consenting participants were randomized to the intervention (n = 189) or usual care (n = 187). Participants completed online and interviewer-administered surveys at baseline, 6- and 12- months follow-up. Prescription opioid use was extracted from the EHR. The primary outcome was patient activation assessed by the Patient Activation Measure (PAM). Secondary outcomes included mood, function, overall health, non-pharmacologic pain management strategies, and patient portal use. We conducted a repeated measure analysis and reported between-group differences at 12 months. Results: At 12 months, the intervention and usual care arms had similar PAM scores. However, compared to usual care at 12 months, the intervention arm demonstrated: less moderate/severe depression (odds ratio [OR] = 0.40, 95%CI 0.18–0.87); higher overall health (OR = 3.14, 95%CI 1.64–6.01); greater use of the patient portal's health/wellness resources (OR = 2.50, 95%CI 1.42–4.40) and lab/immunization history (OR = 2.70, 95%CI 1.29–5.65); and greater use of meditation (OR = 2.72; 95%CI 1.61–4.58) and exercise/physical therapy (OR = 2.24, 95%CI 1.29–3.88). At 12 months, the intervention arm had a higher physical health measure (mean difference 1.63; 95%CI: 0.27–2.98). Conclusion: This trial evaluated the effectiveness of a primary care intervention in improving patient activation and patient-reported outcomes among adults with chronic pain on long-term opioid therapy. Despite a lack of improvement in patient activation, a brief intervention in primary care can improve outcomes such as depression, overall health, non-pharmacologic pain management, and engagement with the health system. Trial Registration: The study was registered on 10/27/14 on ClinicalTrials.gov (NCT02290223). [ABSTRACT FROM AUTHOR]

Introduction: Quantitative studies indicate that the COVID-19 pandemic has contributed to increased rates of prenatal cannabis use. However, little is known about how the pandemic has impacted cannabis use from the perspective of pregnant individuals themselves. Our objective was to characterize COVID-19- related changes in cannabis use among pregnant individuals who used cannabis during the pandemic. Methods: We conducted 18 focus groups (from 11/17/2021 to 12/17/2021) with Black and White pregnant individuals aged 18+ who self-reported prenatal cannabis use during universal screening at entrance to prenatal care (at ~8 weeks gestation) in Kaiser Permanente Northern California. Virtual focus groups were transcribed and analyzed using thematic analysis. Results: The sample of 53 pregnant individuals (23 Black, 30 White) was 30.3  years old (SD = 5.2) on average, and most (70%) self-reported daily versus weekly or monthly prenatal cannabis use. Major themes regarding the impact of the pandemic on cannabis use included increases in use (resulting from depression, anxiety, stress, boredom), and changes in social use (less sharing of smoked cannabis products), modes of use (from smoking to other modes due to respiratory concerns) and source (from storefront retailers to delivery). Conclusion: Coping with mental health symptoms and stress were identified drivers of perceived pandemic-related increases in prenatal cannabis use in 2021. Pregnant individuals adapted their use in ways consistent with public health recommendations to decrease social contact and reduce or quit smoking to mitigate COVID-19 transmission and harms. Proactive, mental health outreach for pregnant individuals during future pandemic waves may reduce prenatal cannabis use. [ABSTRACT FROM AUTHOR]

Introduction: The relationship between cigarette smoking status and SARS-CoV-2 infection and coronavirus disease 2019 (COVID-19) severity is highly debated. We conducted a retrospective cohort study of >2.4 million adults in a large healthcare system to evaluate whether smoking is associated with SARS-CoV-2 infection and disease severity.Methods: This retrospective cohort study of 2,427,293 adults in KPNC from 3/5/2020 (baseline) to 12/31/2020 (pre-vaccine) included smoking status (current, former, never), socio-demographics, and comorbidities from the electronic health record. SARS-CoV-2 infection (identified by a positive PCR test) and COVID-19 severity (hospitalization, ICU admission or death ≤30 days of COVID-19 diagnosis) were estimated in time-to-event analyses using Cox proportional hazard regression models adjusting for covariates. Secondary analyses examined COVID-19 severity among patients with COVID-19 using logistic regression.Results: During the study, 44,270 patients had SARS-CoV-2 infection. Current smoking was associated with lower adjusted rates of SARS-CoV-2 infection (aHR=0.64 95%CI:0.61-0.67), COVID-19-related hospitalization (aHR=0.48 95%CI:0.40-0.58), ICU admission (aHR=0.62 95%CI:0.42-0.87), and death (aHR=0.52 95%CI:0.27-0.89) than never-smoking. Former smoking was associated with a lower adjusted rate of SARS-CoV-2 infection (aHR=0.96 95%CI:0.94-0.99) and higher rates of hospitalization (aHR=1.10 95%CI:1.03-1.08) and death (aHR=1.32 95%CI:1.11-1.56) than never-smoking. Logistic regression analyses among patients with COVID-19 found lower odds of hospitalization for current versus never-smoking and higher odds of hospitalization and death for former versus never-smoking.Conclusions: In the largest US study to date on smoking and COVID-19, current and former smoking showed lower risk of SARS-CoV-2 infection than never-smoking, while a history of smoking was associated with higher risk of severe COVID-19.Implications: In this cohort study of 2.4 million adults, adjusting for socio-demographics and medical comorbidities, current cigarette smoking was associated with a lower risk of both COVID-19 infection and severe COVID-19 illness compared to never-smoking. A history of smoking was associated with a slightly lower risk of COVID-19 infection and a modestly higher risk of severe COVID-19 illness compared to never-smoking. The lower observed COVID-19 risk for current versus never-smoking deserves further investigation. Results support prioritizing individuals with smoking-related comorbidities for vaccine outreach and treatments as they become available. [ABSTRACT FROM AUTHOR]

Background and Aims: Cannabis use is increasingly common among pregnant individuals and might be a risk factor for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection. We aimed to test whether prenatal cannabis use is associated with increased risk of SARS‐CoV‐2 infection during pregnancy. Design: This is a retrospective cohort study. Setting: The study was conducted in California, USA. Participants: A total of 58 114 pregnancies (with outcomes from 5 March 2020 to 30 September 2021) among 57 287 unique pregnant women aged 14–54 years who were screened for prenatal substance use, enrolled in Kaiser Permanente Northern California (KPNC) (a health‐care system) and had not tested positive for COVID‐19 prior to pregnancy onset. Measurements We utilized data from the KPNC electronic health record. Cannabis use status (current, recently quit and non‐user) was based on universal screenings during prenatal care (including urine toxicology testing and self‐reported use on a self‐administered questionnaire). SARS‐CoV‐2 infection [based on polymerase chain reaction (PCR) tests] was estimated in time‐to‐event analyses using Cox proportional hazard regression models adjusting for covariates. Secondary analyses examined differences in (a) SARS‐CoV‐2 testing rates and (b) SARS‐CoV‐2 infection rates among those tested. Findings We observed 348 810 person‐months of follow‐up time in our cohort with 41 064 SARS‐CoV‐2 PCR tests and 6% (n = 2414) of tests being positive. At the start of follow‐up, 7% of pregnant individuals had current use, 12% had recently quit and 81% did not use cannabis. Adjusting for covariates, current use was associated with lower rates of SARS‐CoV‐2 infection [adjusted hazard ratio (aHR) = 0.60, 95% confidence interval (CI) = 0.49–0.74 than non‐use. Those who had recently quit did not differ from non‐cannabis users in infection rates (aHR = 0.96, 95% CI = 0.86–1.08). Sensitivity analyses among patients who received a SARS‐CoV‐2 test also found lower odds of infection associated with current versus no cannabis use (aOR = 0.76, CI = 0.61–0.93). Conclusions: Current cannabis use appears to be associated with a reduced risk of SARS‐CoV‐2 infection among pregnant individuals. [ABSTRACT FROM AUTHOR]

Cannabis is the most commonly used federally illicit drug among pregnant women in the United States, and the prevalence and frequency of prenatal cannabis use are increasing. The preconception period – typically thought of as the 3-12 months immediately preceding pregnancy – is a distinct and critical period for women's health that has often been overlooked when examining prenatal cannabis use. Given that substance use behaviors typically develop before pregnancy, and risk factors associated with prenatal cannabis use are often present prior to conception, preventive approaches to addressing prenatal cannabis use would benefit from focusing on women who use cannabis prior to pregnancy. In order to ensure preconception cannabis use is brought to the forefront of cannabis prevention efforts, we recommend additional research, patient education, and clinician training focused on preconception cannabis use. [ABSTRACT FROM AUTHOR]

Given increases in cannabis use in pregnancy and animal model research showing effects of in‐utero cannabis exposure, high‐quality information on long‐term consequences of in‐utero cannabis exposure in humans is needed. While reviews have summarized findings from observational studies with humans, reviews have not focused on limitations of these studies and recommendations for future research. Therefore, we critically reviewed observational research on in‐utero cannabis exposure and psychiatric and neurodevelopmental outcomes measured at or after age 3 and provided recommendations for future research. We used Web of Science, Google Scholar, and work cited from relevant identified publications to identify 46 papers to include in our review. Our review includes two main sections. The first section highlights the extensive limitations of the existing research, which include small and nongeneralizable samples, reliance on self‐reported data, lack of detail on timing and amount of exposure, inclusion of older exposure data only, not accounting for important confounders, inclusion of potential mediators as covariates, not including outcome severity measures, and not assessing for offspring sex differences. The second section provides recommendations for future research regarding exposure and outcome measures, sample selection, confounder adjustment, and other methodological considerations. For example, with regard to exposure definition, we recommend that studies quantify the amount of cannabis exposure, evaluate the influence of timing of exposure, and incorporate biological measures (e.g., urine toxicology measures). Given that high‐quality information on long‐term consequences of in‐utero cannabis exposure in humans does not yet exit, it is crucial for future research to address the limitations we have identified. [ABSTRACT FROM AUTHOR]

Background: This study aimed to identify racial and ethnic disparities in prenatal mental health and identify COVID-19 pandemic-related health/healthcare and economic contributors to these disparities, using an established framework for disparity investigation. Methods: This cross-sectional study includes 10,930 pregnant people at Kaiser Permanente Northern California who completed an online survey between June 22, 2020 and April 28, 2021 on COVID-19 pandemic-related health/healthcare and economic stressors, depression, and anxiety. Self-reported race and ethnicity were extracted from electronic health records. Weighted analyses were used to evaluate the association between racial and ethnic category and prenatal depression and anxiety; the prevalence of each stressor by race and ethnicity; and the relationship between each stressor and prenatal depression and anxiety in each racial and ethnic category. Results: The sample was 22% Asian, 3% Black, 20% Hispanic, 5% Other/Multiracial/Unknown, and 49% White. Compared to White people, Black and Hispanic people had a higher prevalence of prenatal depression (aPR: 1.85, 95% CI: 1.45, 2.35 and aPR: 1.17, 95% CI: 1.00, 1.37, respectively) and anxiety (aPR: 1.71, 95% CI: 1.34, 2.18 and aPR: 1.10, 95% CI: 0.94, 1.29, respectively). Compared to White people, Black and Hispanic people had a higher prevalence of moderate/severe distress due to changes in prenatal care (24 vs. 34 and 31%), and food insecurity (9 vs. 31 and 24%). Among Black and Hispanic people, distress due to changes in prenatal care was associated with a greater prevalence of prenatal depression (aPR: 2.27, 95% CI: 1.41, 3.64 and aPR: 2.76, 95% CI: 2.12, 3.58, respectively) and prenatal anxiety (aPR: 3.00, 95% CI: 1.85, 4.84 and aPR: 2.82, 95% CI: 2.15, 3.71, respectively). Additionally, among Hispanic people, high-risk employment and food insecurity were associated with a greater prevalence of prenatal depression and anxiety. Conclusions: This study identified racial and ethnic disparities in mental health for pregnant Black and Hispanic people. Distress due to prenatal care changes contributed to the observed disparities in prenatal depression and anxiety for Black and Hispanic people and food insecurity additionally contributed to the observed disparities for Hispanic people. Addressing distress due to changes to prenatal care and food insecurity specifically in Black and Hispanic people may help reduce the high burden of poor mental health and reduce observed disparities in these communities. [ABSTRACT FROM AUTHOR]

Cannabis is the most commonly used federally illicit drug among pregnant women in the United States, and the prevalence and frequency of prenatal cannabis use are increasing. The preconception period – typically thought of as the 3-12 months immediately preceding pregnancy – is a distinct and critical period for women’s health that has often been overlooked when examining prenatal cannabis use. Given that substance use behaviors typically develop before pregnancy, and risk factors associated with prenatal cannabis use are often present prior to conception, preventive approaches to addressing prenatal cannabis use would benefit from focusing on women who use cannabis prior to pregnancy. In order to ensure preconception cannabis use is brought to the forefront of cannabis prevention efforts, we recommend additional research, patient education, and clinician training focused on preconception cannabis use. [ABSTRACT FROM AUTHOR]

Background: Research on COVID-19 during pregnancy has mainly focused on women hospitalized for COVID-19 or other reasons during their pregnancy. Little is known about COVID-19 in the general population of pregnant women. Objective: To describe the prevalence of COVID-19, symptoms, consequent healthcare use, and possible sources of COVID-19 exposure among a population-based sample of pregnant women residing in Northern California. Methods: We analyzed data from 19,458 members of Kaiser Permanente Northern California who were pregnant between January 2020 and April 2021 and responded to an online survey about COVID-19 testing, diagnosis, symptoms, and their experiences during the COVID-19 pandemic. Medical diagnosis of COVID-19 during pregnancy was defined separately by self-report and by documentation in electronic health records (EHR). We examined relationships of COVID-19 with sociodemographic factors, underlying comorbidities, and survey measures of COVID-19-like symptoms, consequent healthcare utilization, and possible COVID-19 exposures. Results: Among 19,458 respondents, the crude prevalence of COVID-19 was 2.5% (n = 494) according to self-report and 1.4% (n = 276) according to EHR. After adjustment, the prevalence of self-reported COVID-19 was higher among women aged <25 years compared with women aged ≥35 years (prevalence ratio [PR], 1.75, 95% CI: 1.23, 2.49) and among Hispanic women compared with White women (PR, 1.91, 95% CI: 1.53, 2.37). Prevalence of self-reported COVID-19 was higher among women affected by personal or partner job loss during the pandemic (PR, 1.23, 95% CI: 1.02, 1.47) and among women living in areas of high vs. low neighborhood deprivation (PR, 1.74, 95% CI: 1.33, 2.27). We did not observe differences in self-reported COVID-19 between women with and without underlying comorbidities. Results were similar for EHR-documented COVID-19. Loss of smell or taste was a unique and common symptom reported among women with COVID-19 (42.3% in self-reported; 54.0% in EHR-documented). Among women with symptomatic COVID-19, approximately 2% were hospitalized, 71% had a telehealth visit, and 75% quarantined at home. Over a third of women with COVID-19 reported no known exposure to someone with COVID-19. Conclusions: Observed COVID-19 prevalence differences by sociodemographic and socioeconomic factors underscore social and health inequities among reproductive-aged women. Women with COVID-19 reported unique symptoms and low frequency of hospitalization. Many were not aware of an exposure to someone with COVID-19. [ABSTRACT FROM AUTHOR]

Amidst a rapidly changing legal landscape, cannabis use in the United States has become increasingly common in the past several years. There is strong evidence to suggest that chronic and early cannabis use increases the risk of developing a psychotic disorder, and there is at least moderate evidence that suggests ongoing cannabis use among individuals with a psychotic disorder worsens clinical outcomes (eg, decreased psychiatric medication adherence, more frequent psychiatric hospitalizations). In this Review Article, we provide a focused, clinically oriented overview of the epidemiology and characteristics of cannabis use among individuals with first-episode psychosis; evaluation of cannabis use; and treatment modalities, focusing on behavioral interventions suitable for outpatient primary care settings. We discuss the limited data supporting pharmacologic interventions for cannabis use disorder, specifically among individuals with first-episode psychosis, and the unique potential of cannabidiol to serve as a harm-reduction strategy for individuals who are not able or willing to achieve abstinence for cannabis. [ABSTRACT FROM AUTHOR]

Purpose: To examine whether adverse childhood experiences (ACEs) are associated with breastfeeding behaviors. Methods: Women in three Kaiser Permanente Northern California medical centers were screened for ACEs during standard prenatal care (N = 926). Multivariable binary and multinomial logistic regression was used to test whether ACEs (count and type) were associated with early breastfeeding at the 2-week newborn pediatric visit and continued breastfeeding at the 2-month pediatric visit, adjusting for covariates. Results: Overall, 58.2% of women reported 0 ACEs, 19.2% reported 1 ACE, and 22.6% reported 2+ ACEs. Two weeks postpartum, 92.2% reported any breastfeeding (62.9% exclusive, 29.4% mixed breastfeeding/formula). Compared with women with 0 ACEs, those with 2+ ACEs had increased odds of any breastfeeding (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 1.3–5.6) and exclusive breastfeeding 2 weeks postpartum (OR = 3.0, 95% CI = 1.4–6.3). Among those who breastfed 2 weeks postpartum, 86.4% reported continued breastfeeding (57.5% exclusive, 28.9% mixed breastfeeding/formula) 2 months postpartum. ACE count was not associated with continued breastfeeding 2 months postpartum. Individual ACEs were not related to breastfeeding outcomes, with the exception that living with someone who went to jail or prison was associated with lower odds of continued breastfeeding 2 months postpartum. Conclusions: ACE count was associated with greater early breastfeeding, but not continued breastfeeding, among women screened for ACEs as part of standard prenatal care. Results reiterate the need to educate and assist all women to meet their breastfeeding goals, regardless of ACE score. [ABSTRACT FROM AUTHOR]

Background: Cannabis use is common among individuals of reproductive age. We examined publicly posted questions about perinatal cannabis use and licensed United States health care provider responses. Materials and Methods: Data were medical questions on perinatal cannabis use posted online from March 2011 to January 2017 on an anonymous digital health platform. Posters were able to "thank" health care providers for their responses and providers could "agree" with other provider responses. We characterized 364 user questions and 596 responses from 277 unique providers and examined endorsement of responses through provider "agrees" and user "thanks." Results: The most frequent questions concerned prenatal cannabis use detection (24.7%), effects on fertility (22.6%), harms of prenatal use to the fetus (21.3%), and risks of baby exposure to cannabis through breast milk (14.4%). Provider sentiment in responses regarding the safety of perinatal cannabis use were coded as 55.6% harmful, 8.8% safe, 8.8% mixed/unsure, and 26.8% safety unaddressed. Half of providers (49.6%) discouraged perinatal cannabis use, 0.5% encouraged use, and 49.9% neither encouraged nor discouraged use. Provider responses received 1,004 provider "agrees" and 583 user "thanks." Provider responses indicating that perinatal cannabis use is unsafe received more provider "agrees" than responses indicating that use is safe (B = 0.42, 95% CI 0.02–0.82, p = 0.04). User "thanks" did not differ by provider responses regarding safety or dis/encouragement. Conclusion: The data indicate public interest in cannabis use effects before, during, and after pregnancy. While most health care providers indicated cannabis use during pregnancy and breastfeeding is not safe, many did not address safety or discourage use, suggesting a missed educational opportunity. [ABSTRACT FROM AUTHOR]

Introduction: Primary care visits present an opportunity to reduce tobacco use and tobacco smoke exposure (TSE) among adolescents. To date, few studies have examined tobacco-related electronic health record (EHR) documentation in adolescent visits. The purpose of this study was to (1) describe tobacco-related EHR documentation practices in adolescent care clinics, including whether alternative tobacco products, parental use, and TSE were addressed; and (2) identify aspects of adolescent tobacco use that may inform EHR updates and counseling and documentation practices.Methods: Following a convergent mixed-methods design, we conducted an EHR review of 508 adolescent well-child visits, performed focus groups with pediatric providers and staff, and conducted in-depth interviews with adolescent patients. Record review data and interview transcripts were analyzed and interpreted concurrently.Results: In the EHR review, cigarette screening was documented in 92.3% of visits, smokeless tobacco screening in 51.4%, parental tobacco use in 23.2%, and home TSE in 33.1% of visits. Smoking status options were not mutually exclusive and did not include noncigarette products. No records documented assessment of e-cigarette use, despite nearly half of adolescent interview respondents citing these as the most popular products among adolescents. In interviews, adolescents discussed their experiences with alternative tobacco/nicotine products more than cigarettes.Conclusions: Tobacco use status prompts should be revised for clarity and include noncigarette tobacco products and TSE. Provider education on noncigarette products and TSE assessment is needed. Improvements in EHR systems, resources, and tools can lead to better tobacco screening, prevention, and treatment practices among primary care providers.Implications: Clinical guidelines call for pediatricians to assess and treat adolescent and parental tobacco use during primary care visits. The use of electronic health records (EHRs) can improve screening and counseling practices; however, few studies have examined tobacco-related EHR documentation practices in adolescent care settings. This mixed-methods study found low rates of EHR documentation related to noncigarette nicotine/tobacco products, parental tobacco use, and tobacco smoke exposure. These results demonstrate the need for increased provider training and EHR modifications to facilitate comprehensive tobacco control efforts in the adolescent population. [ABSTRACT FROM AUTHOR]

Introduction: Screening and referral for substance use are essential components of prenatal care. However, little is known about barriers to participation in substance use interventions that are integrated within prenatal care. Methods: Our study examines demographic and clinical correlates of participation in an initial assessment and counseling intervention integrated into prenatal care in a large healthcare system. The sample comprised Kaiser Permanente Northern California pregnant women with a live birth in 2014 or 2015 who screened positive for prenatal substance use via a self-reported questionnaire and/or urine toxicology test given as part of standard prenatal care (at ~ 8 weeks gestation). Results: Of the 11,843 women who screened positive for prenatal substance use (median age = 30 years; 42% white; 38% screened positive for alcohol only, 20% for cannabis only, 5% nicotine only, 17% other drugs only, and 19% ≥ 2 substance categories), 9836 (83%) completed the initial substance use assessment and counseling intervention. Results from multivariable logistic regression analyses indicated that younger age, lower income, single marital status, and a positive urine toxicology test predicted higher odds of participation, while other/unknown race/ethnicity, greater parity, receiving the screening later in pregnancy, and screening positive for alcohol only or other drugs only predicted lower odds of participation (all Ps <.05). Discussion: Findings suggest that integrated substance use interventions can successfully reach vulnerable populations of pregnant women (e.g., younger, lower income, racial/ethnic minorities). Future research should address whether differences in participation are due to patient (e.g., type of substance used, perceived stigma) or provider factors (e.g., working harder to engage traditionally underserved patients). [ABSTRACT FROM AUTHOR]

Background: Diabetes prevalence is twice as high among people with severe mental illness (SMI) when compared to the general population. Despite high prevalence, care outcomes are not well understood.Objective: To compare diabetes health outcomes received by people with and without comorbid SMI, and to understand demographic factors associated with poor diabetes control among those with SMI.Design: Retrospective cohort study PARTICIPANTS: 269,243 adults with diabetes MAIN MEASURES: Primary outcomes included optimal glycemic control (A1c < 7) or poor diabetes control (A1c > 9) in 2014. Secondary outcomes included control of other cardiometabolic risk factors (hypertension, dyslipidemia, smoking) and recommended diabetes monitoring.Key Results: Among this cohort, people with SMI (N = 4,399), compared to those without SMI (N = 264,844), were more likely to have optimal glycemic control, adjusting for various covariates (adjusted relative risk (aRR) 1.25, 95% CI 1.21-1.28, p < .001) and less likely to have poor control (aRR 0.92, 95% CI 0.87-0.98, p = 0.012). Better blood pressure and lipid control was more prevalent among people with SMI when compared to those without SMI (aRR 1.03; 95% CI 1.02-1.05, p < .001; aRR 1.02; 95% CI 1.00-1.05, p = 0.044, respectively). No differences were observed in recommended A1c or LDL testing, but people with SMI were more likely to have blood pressure checked (aRR 1.02, 95% CI 1.02-1.03, p < .001) and less likely to receive retinopathy screening (aRR 0.80, 95% CI 0.71-0.91, p < .001) than those without SMI. Among people with diabetes and comorbid SMI, younger adults and Hispanics were more likely to have poor diabetes control.Conclusions: Adults with diabetes and comorbid SMI had better cardiometabolic control than people with diabetes who did not have SMI, despite lower rates of retinopathy screening. Among those with comorbid SMI, younger adults and Hispanics were more vulnerable to poor A1c control. [ABSTRACT FROM AUTHOR]

This study uses toxicology screening data from a health care delivery system to investigate whether rates of cannabis use increased among pregnant women during the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

While persons with HIV (PWH) have benefited from significant advances in treatment and resulting longevity, mental health problems remain elevated in this population. Adverse childhood experiences (ACEs) are common among PWH and may negatively affect mental health and HIV-related outcomes. We examined the association between ACEs, depression and anxiety symptoms, substance use, antiretroviral therapy (ART) adherence, and HIV-clinical indicators in a sample of 584 PWH at risk for unhealthy alcohol use enrolled in a primary care-based alcohol intervention study. The sample was 96.9% male, 63.0% non-Hispanic white, with an average age of 49.0 years. ACEs were highly prevalent: 82.5% reported ≥1 ACE, including 34.2% reporting 1–2 ACEs, 25.0% reporting 3–4 ACEs, and 23.3% reporting ≥5 ACEs. Adjusting for demographics, having 1–2, 3–4 or ≥5 ACEs was significantly associated with anxiety (ORs (95%CI): 3.41 (1.13–10.33), 4.36 (1.42–3.36), and 3.96 (1.28–12.19), respectively) and poorer mental health quality of life (Betas (SE): –3.21 (1.40), –6.23 (1.51), and –7.09 (1.54), respectively), but not with other outcomes. Trauma-informed interventions to reduce anxiety and improve mental health quality of life in PWH may reduce the negative health sequelae of ACEs. [ABSTRACT FROM AUTHOR]

Introduction: Little is known about how exposure to adverse childhood experiences (ACEs) and protective factors, such as resilience, influence prenatal mental and behavioral health. This study examined associations between exposure to ACEs and mental and behavioral health during pregnancy overall and among women with high versus low levels of resilience. Materials and Methods: Women in two Kaiser Permanente Northern California medical centers were screened for ACEs and resilience during prenatal care (∼14–23 weeks of gestation; N = 355). Multivariable logistic regression analyses examined associations between ACEs and prenatal mental and behavioral health conditions overall and for women with low (≤32) versus high (>32) resilience on the 10-item Connor-Davidson Resilience Scale. Results: Overall, 54% of women reported 0 ACEs, 28% 1–2 ACEs, and 18% 3+ ACEs. Relative to women with 0 ACEs, those with 1–2 ACEs had higher odds of an anxiety or depressive disorder and intimate partner violence (IPV) (odds ratios [ORs] 2.42–3.12, p < 0.05), and those with 3+ ACEs had higher odds of an anxiety or depressive disorder, depression symptoms, and IPV (ORs 3.08–4.71, p < 0.05). In stratified analyses by high (56%) and low (44%) resilience, having one or more ACEs (vs. 0 ACEs) was only associated with worse mental and behavioral health in women with low resilience. Conclusions: ACEs predicted mental and behavioral health conditions among pregnant women, and associations were the strongest among women with low levels of current resilience. Longitudinal research is needed to understand the causal mechanisms underlying these associations. [ABSTRACT FROM AUTHOR]

Introduction: Disparities in receiving advice to quit smoking and other tobacco use from health professionals may contribute to the continuing gap in smoking prevalence among priority populations. Under the Affordable Care Act (ACA), beginning in 2010, tobacco cessation services are currently covered in private and public health insurance plans. Providers and hospitals are also incentivized through the Meaningful Use of Electronic Health Records (EHRs) to screen and document patients' tobacco use and deliver brief cessation counseling. This study analyzes trends and correlates of receiving health professionals' advice to quit and potential disparities among US adult smokers from 2010 to 2015.Methods: Data were from the National Health Interview Survey in 2010 and 2015. We analyzed the weighted prevalence of smokers' receipt of advice to quit smoking and other tobacco use from a health professional in 2010 and 2015 and correlates of receiving advice to quit.Results: Prevalence of receiving advice to quit from a health professional increased from 51.4% in 2010 to 60.6% in 2015. This positive trend was observed across tobacco disparity population groups. Survey year (2015), age (older), ethnicity (non-Hispanic), region (Northeast), poverty level (above 100% poverty level), past quit attempt, daily smoking, cigarettes per day (11+ per day), and psychological distress were associated with higher odds of receiving advice to quit.Conclusion: Based on national level data, receipt of advice to quit from health professionals increased between 2010 and 2015. However, disparities in receiving advice to quit from health professionals persist in certain populations.Implications: This study provides important data on the national trends in receipt of health professional advice to quit smoking and other tobacco use in the context of the ACA and Meaningful Use implementation and whether these policies helped to narrow the gaps in receipt of health professional advice among vulnerable populations. [ABSTRACT FROM AUTHOR]

Introduction: Adverse childhood experiences (ACEs) are common among pregnant women and contribute to increased risk for negative perinatal outcomes, yet few clinicians screen prenatal patients for ACEs. The purpose of this study was to evaluate the feasibility and acceptability of screening for ACEs in standard prenatal care. Methods: We evaluated a 4-month pilot (March 2016–June 2016) to screen pregnant women (at ∼14–23 weeks of gestation) for ACEs and resiliency in two Kaiser Permanente Northern California medical centers ( N  = 480). We examined the acceptability of the screening to patients through telephone surveys ( N  = 210) and to clinicians through surveys and focus groups ( N  = 26). Results: Most eligible patients (78%) were screened. Patients who received the screening were significantly more likely to be non-Hispanic White, Asian, or of “Other” or “Unknown” race/ethnicity than African American or Hispanic race/ethnicity ( p  = 0.02). Among those screened, 88% completed the questionnaires; 54% reported 0 ACEs, 28% reported 1–2 ACEs, and 18% reported ≥3 ACEs. Most patients were somewhat or very comfortable completing the questionnaires (91%) and discussing ACEs with their clinician (93%), and strongly or somewhat strongly agreed that clinicians should ask their prenatal patients about ACEs (85%). Clinicians reported significant pre- to postpilot increases in comfort discussing ACEs, providing education, and offering resources ( p s < 0.01). Clinicians' willingness to screen for ACEs was contingent on adequate training, streamlined workflows, inclusion of resilience screening, and availability of mental health, parenting, and social work resources. Conclusion: ACEs screening as part of standard prenatal care is feasible and generally acceptable to patients. Women's health clinicians are willing to screen patients for ACEs when appropriately trained and adequate behavioral health referral resources are available. [ABSTRACT FROM AUTHOR]

The Affordable Care Act (ACA) was expected to benefit patients with substance use disorders, including opioid use disorders (OUDs). This study examined buprenorphine use and health services utilization by patients with OUDs pre- and post-ACA in a large health care system. Using electronic health record data, we examined demographic and clinical characteristics (substance use, psychiatric and medical conditions) of two patient cohorts using buprenorphine: those newly enrolled in 2012 ("pre-ACA," N = 204) and in 2014 ("post-ACA," N = 258). Logistic and negative binomial regressions were used to model persistent buprenorphine use, and to examine whether persistent use was related to health services utilization. Buprenorphine patients were largely similar pre- and post-ACA, although more post-ACA patients had a marijuana use disorder (p < .01). Post-ACA patients were more likely to have high-deductible benefit plans (p < .01). Use of psychiatry services was lower post-ACA (IRR: 0.56, p < .01), and high-deductible plans were also related to lower use of psychiatry services (IRR: 0.30, p < .01). The relationship between marijuana use disorder and prescription opioid use is complex, and deserves further study, particularly with increasingly widespread marijuana legalization. Access to psychiatry services may be more challenging for buprenorphine patients post-ACA, especially for patients with deductible plans. [ABSTRACT FROM AUTHOR]