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The population of homeless older adults is growing and experiences premature mortality. Little is known about factors associated with mortality among homeless older adults.To identify the prevalence and factors associated with mortality in a cohort of homeless adults 50 years and older.In this prospective cohort study (Health Outcomes in People Experiencing Homelessness in Older Middle Age [HOPE HOME]), 450 adults 50 years and older who were homeless at baseline were recruited via venue-based sampling in Oakland, California. Enrollment occurred in 2 phases, from July 2013 to June 2014 and from August 2017 to July 2018, and participants were interviewed at 6-month intervals.Baseline and time-varying characteristics, including sociodemographic factors, social support, housing status, incarceration history, chronic medical conditions, substance use, and mental health problems.Mortality through December 31, 2021, based on state and local vital records information from contacts and death certificates. All-cause mortality rates were compared with those in the general population from 2014 to 2019 using age-specific standardized mortality ratios with 95% CIs.Of the 450 included participants, median (IQR) age at baseline was 58.1 (54.5-61.6) years, 107 (24%) were women, and 360 (80%) were Black. Over a median (IQR) follow-up of 55 (38-93) months, 117 (26%) participants died. Median (IQR) age at death was 64.6 (60.3-67.5) years. In multivariable analyses, characteristics associated with mortality included a first episode of homelessness at 50 years and older (adjusted hazard ratio [aHR], 1.62; 95% CI, 1.13-2.32), homelessness (aHR, 1.82; 95% CI, 1.23-2.68) or institutionalization (aHR, 6.36; 95% CI, 3.42-11.82) at any follow-up compared with being housed, fair or poor self-rated health (aHR, 1.64; 95% CI, 1.13-2.40), and diabetes (aHR, 1.55; 95% CI, 1.06-2.26). Demographic characteristics, substance use problems, and mental health problems were not independently associated. All-cause standardized mortality was 3.5 times higher (95% CI, 2.5-4.4) compared with adults in Oakland. The most common causes of death were heart disease (n = 17 [14.5%]), cancer (n = 17 [14.5%]), and drug overdose (n = 14 [12.0%]).The cohort study found that premature mortality was common among homeless older adults and associated factors included late-life homelessness and ongoing homelessness. There is an urgent need for policy approaches to prevent and end homelessness among older adults in the US.

IMPORTANCE: Chronic opioid use imposes a substantial burden in terms of morbidity and economic costs. Whether opioid-naive patients undergoing surgery are at increased risk for chronic opioid use is unknown, as are the potential risk factors for chronic opioid use following surgery. OBJECTIVE: To characterize the risk of chronic opioid use among opioid-naive patients following 1 of 11 surgical procedures compared with nonsurgical patients. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of administrative health claims to determine the association between chronic opioid use and surgery among privately insured patients between January 1, 2001, and December 31, 2013. The data concluded 11 surgical procedures (total knee arthroplasty [TKA], total hip arthroplasty, laparoscopic cholecystectomy, open cholecystectomy, laparoscopic appendectomy, open appendectomy, cesarean delivery, functional endoscopic sinus surgery [FESS], cataract surgery, transurethral prostate resection [TURP], and simple mastectomy). Multivariable logistic regression analysis was performed to control for possible confounders, including sex, age, preoperative history of depression, psychosis, drug or alcohol abuse, and preoperatice use of benzodiazepines, antipsychotics, and antidepressants. EXPOSURES: One of the 11 study surgical procedures. MAIN OUTCOMES AND MEASURES: Chronic opioid use, defined as having filled 10 or more prescriptions or more than 120 days’ supply of an opioid in the first year after surgery, excluding the first 90 postoperative days. For nonsurgical patients, chronic opioid use was defined as having filled 10 or more prescriptions or more than 120 days’ supply following a randomly assigned “surgery date” RESULTS: The study included 641 941 opioid-naive surgical patients (169 666 men; mean [SD] age, 44.0 [12.8] years), and 18 011137 opioid-naive nonsurgical patients (8 849107 men; mean [SD] age, 42.4 [12.6] years). Among the surgical patients, the incidence of chronic opioid in the first preoperative year ranged from 0.119% for Cesarean delivery (95% CI, 0.104%−0.134%) to 1.41% for TKA (95% CI, 1.29%−1.53%) The baseline incidence of chronic opioid use among the nonsurgical patients was 0.136% (95% CI, 0.134%−0.137%). Except for cataract surgery, laparoscopic appendectomy, FESS, and TURP, all of the surgical procedures were associated with an increased risk of chronic opioid use, with odds ratios ranging from 1.28 (95% CI, 1.12–1.46) for cesarean delivery to 5.10 (95% CI, 4.67–5.58) for TKA. Male sex, age older than 50 years, and preoperative history of drug abuse, alcohol abuse, depression, benzodiazepine use, or antidepressant use were associated with chronic opioid use among surgical patients. CONCLUSIONS AND RELEVANCE: In opioid-naive patients, many surgical procedures are associated with an increased risk of chronic opioid use in the postoperative period. A certain subset of patients (eg, men, elderly patients) may be particularly vulnerable.

Key Points Question Has the incidence of physicians seeking outpatient care for mental health and substance use changed during the COVID-19 pandemic? Findings In a cohort study of 34 055 physicians, the rate of outpatient visits for mental health and substance use increased on average by 13% per physician during the first 12 months of the pandemic compared with the prior 12 months. Meaning These findings suggest that the COVID-19 pandemic is associated with greater mental health services use among physicians., Importance Physicians self-report high levels of symptoms of anxiety and depression, and surveys suggest these symptoms have been exacerbated by the COVID-19 pandemic. However, it is not known whether pandemic-related stressors have led to increases in health care visits related to mental health or substance use among physicians. Objective To evaluate the association between the COVID-19 pandemic and changes in outpatient health care visits by physicians related to mental health and substance use and explore differences across physician subgroups of interest. Design, Setting, and Participants A population-based cohort study was conducted using health administrative data collected from the universal health system (Ontario Health Insurance Plan) of Ontario, Canada, from March 1, 2017, to March 10, 2021. Participants included 34 055 physicians, residents, and fellows who registered with the College of Physicians and Surgeons of Ontario between 1990 and 2018 and were eligible for the Ontario Health Insurance Plan during the study period. Autoregressive integrated moving average models and generalized estimating equations were used in analyses. Exposures The period during the COVID-19 pandemic (March 11, 2020, to March 10, 2021) compared with the period before the pandemic. Main Outcomes and Measures The primary outcome was in-person, telemedicine, and virtual care outpatient visits to a psychiatrist or family medicine and general practice clinicians related to mental health and substance use. Results In the 34 055 practicing physicians (mean [SD] age, 41.7 [10.0] years, 17 918 [52.6%] male), the annual crude number of visits per 1000 physicians increased by 27%, from 816.8 before the COVID-19 pandemic to 1037.5 during the pandemic (adjusted incident rate ratio per physician, 1.13; 95% CI, 1.07-1.19). The absolute proportion of physicians with 1 or more mental health and substance use visits within a year increased from 12.3% before to 13.4% during the pandemic (adjusted odds ratio, 1.08; 95% CI, 1.03-1.14). The relative increase was significantly greater in physicians without a prior mental health and substance use history (adjusted incident rate ratio, 1.72; 95% CI, 1.60-1.85) than in physicians with a prior mental health and substance use history. Conclusions and Relevance In this study, the COVID-19 pandemic was associated with a substantial increase in mental health and substance use visits among physicians. Physician mental health may have worsened during the pandemic, highlighting a potential greater requirement for access to mental health services and system level change., This cohort study examines the levels of mental health and substance use visits by physicians during the COVID-19 pandemic.

This cross-sectional study estimates the prevalence of psychoactive substance use among middle-aged and older adults with visual impairment in the US.

This cross-sectional study investigates the national prevalence of tobacco, alcohol, cannabis, and nonmedical prescription stimulant use among Canadian medical students.

This study uses National Center for Health Statistics data to assess mortality rates and their annual percentage changes for pregnancy-related and other causes among pregnant and recently pregnant women from 2015 to 2019, compared with cause-specific mortality rates in the total US female population of childbearing age.

This quality improvement study examines US allopathic medical schools’ student handbook policies on substance use and assesses their adherence to current Association of American Medical Colleges guidelines.

Key Points Question Are online risk factors measured using real-world online activity data associated with youth suicide-related behavior? Findings In this case-control study of 227 youths, having a severe suicide/self-harm alert in a school-based online safety monitoring program was associated with multiple online risk factors (including cyberbullying, violence, drug-related content, hate speech, profanity, sexual content, depression, and low-severity self-harm content). However, the greatest risk was found among youth having multiple types of online risk factors. Meaning This case-control study provides information that may help guide youth suicide prevention activities related to online risk factors., Importance The association between online activities and youth suicide is an important issue for parents, clinicians, and policy makers. However, most information exploring potential associations is drawn from survey data and mainly focuses on risk related to overall screen time. Objective To evaluate the association between a variety of online risk factors and youth suicide-related behavior using real-world online activity data. Design, Setting, and Participants A matched case-control study was conducted from July 27, 2019, to May 26, 2020, with the sample drawn from more than 2600 US schools participating in an online safety monitoring program via the Bark online safety tool. For 227 youths having a severe suicide/self-harm alert requiring notification of school administrators, cases were matched 1:5 to 1135 controls on location, the amount of follow-up time, and general volume of online activity. Exposures Eight potential online risk factors (cyberbullying, violence, drug-related, hate speech, profanity, sexual content, depression, and low-severity self-harm) through assessment of text, image, and video data. Main Outcomes and Measures Severe suicide/self-harm alert requiring notification of school administrators; severe suicide alerts are statements by youths indicating imminent or recent suicide attempts and/or self-harm. Results The 1362 participants had a mean (SD) age of 13.3 (2.41) years; 699 (51.3%) were male. All 8 online risk factors studied exhibited differences between case and control populations and were significantly associated with subsequent severe suicide/self-harm alerts when examining total direct and indirect pathways. These associations ranged from an adjusted odds ratio (aOR) of 1.17 (95% CI, 1.09-1.26) for drug-related content to an aOR of 1.82 (95% CI, 1.63-2.03) for depression-related content. When considering the total number of different types of online risk factors among the 8 measured, there was an exponentially larger risk of severe suicide/self-harm alerts; youths with 5 or more of the 8 risk factors present in their online activity had a more than 70-fold increased odds of subsequently having a severe suicide/self-harm alert (aOR, 78.64; 95% CI, 34.39-179.84). Conclusions and Relevance The findings of this study suggest that many discrete types of risk factors are identifiable from online data and associated with subsequent youth suicide-related behavior. Although each risk factor carries a specific association with suicide-related behavior, the greatest risk is evident for youths demonstrating multiple types of online risk factors., This case-control study examines the association between online risk factors and suicide-related behaviors in youths using a school-based online safety monitoring program.

This cross-sectional study evaluates whether and how patients self-report firearm access information on a routine mental health monitoring questionnaire and examines sociodemographic and clinical associations of reported access., Key Points Question Did patients respond to a standard question about firearm access on a mental health questionnaire, and, if so, how did they respond? Findings In this cross-sectional study of 128 802 patients receiving care for mental health and substance use, 83% of primary care patients answered a standard question about firearm access and 21% reported access. In mental health clinics, 92% of patients answered the question and 15% reported access. Meaning In this study, most patients reported firearm access on standard questionnaires; this screening practice may improve efforts to identify and engage patients at risk of suicide in discussions about securing firearms., Importance Firearms are the most common method of suicide, one of the “diseases of despair” driving increased mortality in the US over the past decade. However, routine standardized questions about firearm access are uncommon, particularly among adult populations, who are more often asked at the discretion of health care clinicians. Because standard questions are rare, patterns of patient-reported access are unknown. Objective To evaluate whether and how patients self-report firearm access information on a routine mental health monitoring questionnaire and additionally to examine sociodemographic and clinical associations of reported access. Design, Setting, and Participants Cross-sectional study of patients receiving care for mental health and/or substance use in primary care or outpatient mental health specialty clinics of Kaiser Permanente Washington, an integrated health insurance provider and care delivery system. Main Outcomes and Measures Electronic health records were used to identify patients who completed a standardized self-reported mental health monitoring questionnaire after a single question about firearm access was added from January 1, 2016, through December 31, 2019. Primary analyses evaluated response (answered vs not answered) and reported access (yes vs no) among those who answered, separately for patients seen in primary care and mental health. These analyses also evaluated associations between patient characteristics and reported firearm access. Data analysis took place from February 2020 through May 2021. Results Among patients (n = 128 802) who completed a mental health monitoring questionnaire during the study period, 74.4% (n = 95 875) saw a primary care clinician and 39.3% (n = 50 631) saw a mental health specialty clinician. The primary care and mental health samples were predominantly female (63.1% and 64.9%, respectively) and White (75.7% and 77.0%), with a mean age of 42.8 and 51.1 years. In primary care, 83.4% of patients answered the question about firearm access, and 20.9% of patients who responded to the firearm question reported having access. In mental health, 91.8% of patients answered the question, and 15.3% reported having access. Conclusions and Relevance In this cross-sectional study of adult patients receiving care for mental health and substance use, most patients answered a question about firearm access on a standardized mental health questionnaire. These findings provide a critical foundation to help advance understanding of the utility of standardized firearm access assessment and to inform development of practice guidelines and recommendations. Responses to standard firearm access questions used in combination with dialogue and decision-making resources about firearm access and storage may improve suicide prevention practices and outcomes.

Key Points Question What do people living in communities with high prevalence of diseases of despair (suicidality, drug abuse, and alcoholism) believe is driving the crisis, and what are their potential solutions? Findings In this qualitative study, 60 participants from 3 communities identified factors associated with despair-related disease, including financial distress, lack of infrastructure or social services, deteriorating sense of community, and family fragmentation. Intervention strategies included building resilience through community-level coordination and state investments in social services and infrastructure. Meaning Common beliefs were observed in rural and urban communities, highlighting associations between political and economic decline and despair-related illness and suggesting health systems improve clinical processes to screen for despair and address the factors associated with it., Importance Diseases of despair (ie, mortality or morbidity from suicidality, drug abuse, and alcoholism) were first characterized as increasing in rural White working-class populations in midlife with low educational attainment and associated with long-term economic decline. Excess mortality now appears to be associated with working-class citizens across demographic and geographic boundaries, but no known qualitative studies have engaged residents of rural and urban locales with high prevalence of diseases of despair to learn their perspectives. Objective To explore perceptions about despair-related illness and potential intervention strategies among diverse community members residing in discrete rural and urban hotspots. Design, Setting, and Participants In this qualitative study, high-prevalence hotspots for diseases of despair were identified from health insurance claims data in Central Pennsylvania. Four focus groups were conducted with 60 community members in organizations and coalitions from 3 census block group hotspot clusters in the health system between September 2019 and January 2020. Focus groups explored awareness and beliefs about causation and potential intervention strategies. Main Outcomes and Measures A descriptive phenomenological approach was applied to thematic analysis, and a preliminary conceptual model was constructed to describe how various factors may be associated with perpetuating despair and with public health. Results In total, 60 adult community members participated in 4 focus groups (44 women, 16 men; 40 White non-Hispanic, 17 Black, and 3 Hispanic/Latino members). Three focus groups with 43 members were held in rural areas with high prevalence of diseases of despair, and 1 focus group with 17 members in a high-prevalence urban area. Four themes emerged with respect to awareness and believed causation of despair-related illness, and participants identified common associated factors, including financial distress, lack of critical infrastructure and social services, deteriorating sense of community, and family fragmentation. Intervention strategies focused around 2 themes: (1) building resilience to despair through better community and organizational coordination and peer support at the local level and (2) encouraging broader state investments in social services and infrastructure to mitigate despair-related illness. Conclusions and Relevance In this qualitative study, rural and urban community members identified common factors associated with diseases of despair, highlighting the association between long-term political and economic decline and public health and a need for both community- and state-level solutions to address despair. Health care systems participating in addressing community health needs may improve processes to screen for despair (eg, social history taking) and codesign primary, secondary, and tertiary interventions aimed at addressing factors associated with distress. Such actions have taken on greater urgency with the COVID-19 pandemic., This qualitative study explores the perceptions of people residing in rural and urban areas with high prevalence of diseases of despair regarding potential causes and intervention strategies.

Importance Although adults with schizophrenia have an increased risk of suicide, sample size limitations of previous research have hindered characterizations of suicide risk across the life span. Objective To describe suicide mortality rates and correlates among adults with schizophrenia across the life span and standardized mortality ratios (SMRs) for suicide compared with the general US population. Design, Setting, and Participants Five national retrospective longitudinal cohorts of patients with schizophrenia in the Medicare program from January 1, 2007, to December 31, 2016, were identified by age: 18 to 34, 35 to 44, 45 to 54, 55 to 64, and 65 years or older. Death record information was obtained from the National Death Index. The total cohort included 668 836 Medicare patients with schizophrenia, 2 997 308 years of follow-up, and 2218 suicide deaths. Data were analyzed from September 30, 2020, to March 10, 2021. Main Outcomes and Measures For each age group, suicide mortality rates per 100 000 person-years and adjusted hazard ratios (aHRs) with 95% CIs of suicide were determined. Suicide SMRs were estimated for the total cohort and by sex and age cohorts standardized to the general US population by age, sex, and race/ethnicity. Results The study population of adults 18 years and older included 668 836 Medicare recipients with schizophrenia (52.5% men, 47.5% women). The total suicide rate per 100 000 person-years was 74.00, which is 4.5 times higher than that for the general US population (SMR, 4.54; 95% CI, 4.35-4.73) and included a rate of 88.96 for men and 56.33 for women, which are 3.4 (SMR, 3.39; 95% CI, 3.22-3.57) and 8.2 (SMR, 8.16; 95% CI, 7.60-8.75) times higher, respectively, than the rates for the general US population. Suicide rates were significantly higher for men (aHR, 1.44; 95% CI, 1.29-1.61) and those with depressive (aHR, 1.32; 95% CI, 1.17-1.50), anxiety (aHR, 1.15; 95% CI, 1.02-1.30), drug use (aHR, 1.55; 95% CI, 1.36-1.76), and sleep disorders (aHR, 1.22; 95% CI, 1.07-1.39), suicidal ideation (aHR, 1.41; 95% CI, 1.22-1.63), and suicide attempts or self-injury (aHR, 2.48; 95% CI, 2.06-2.98). The adjusted hazards of suicide were lower for Hispanic patients (aHR, 0.66; 95% CI, 0.54-0.80) or Black patients (aHR, 0.29; 95% CI, 0.24-0.35) than White patients. The suicide rate declined with age, from 141.95 (SMR, 10.19; 95% CI, 9.29-11.18) for patients aged 18 to 34 years to 24.01 (SMR, 1.53; 95% CI, 1.32-1.77) for patients 65 years or older. The corresponding declines per 100 000 person-years were from 153.80 (18-34 years of age) to 34.17 (65 years or older) for men and from 115.70 (18-34 years of age) to 18.66 (65 years or older) for women. In the group aged 18 to 34 years, the adjusted hazards of suicide risk were significantly increased for patients with suicide attempt or self-injury (aHR, 2.57; 95% CI, 18.20-2.04) and with comorbid drug use disorders (aHR, 1.48; 95% CI, 1.17-1.88), but not with comorbid depressive disorders (aHR, 0.99; 95% CI, 0.38-1.26) during the year before the start of follow-up. Conclusions and Relevance In this cohort study of adult Medicare patients with schizophrenia, suicide risk was elevated, with the highest absolute and relative risk among young adults. These patterns support suicide prevention efforts with a focus on young adults with schizophrenia, especially those with suicidal symptoms and substance use.

Although school environments are thought to influence health behaviors, experimental data assessing causality are lacking, and which aspects of school environments may be most important for adolescent health are unknown.To test whether exposure to high-performing schools is associated with risky adolescent health behaviors.This natural experiment used admission lotteries, which mimic random assignment, to estimate the association of school environments and adolescent health. A survey of 1270 students who applied to at least 1 of 5 high-performing public charter schools in low-income minority communities in Los Angeles, California. Schools had an academic performance ranked in the top tertile of Los Angeles County public high schools, applicants outnumbered available seats by at least 50, and an admissions lottery was used. Participants included lottery winners (intervention group [n = 694]) and lottery losers (control group [n = 576]) from the end of 8th grade and beginning of 9th grade through the end of 11th grade. Intention-to-treat (ITT) and instrumental variable techniques estimated the association of winning the lottery and attending high-performing schools with health behaviors and whether the association varied by sex. Data were collected from March 11, 2013, through February 22, 2017, and analyzed from October 1, 2017, through July 1, 2018.Schools were considered high performing if they placed in the top tercile of public high schools in LA County on 2012 state standardized tests. Most students attended that same school for 3 years (9th-11th grades).Primary self-reported outcomes were 30-day and high-risk self-reported marijuana use. Additional health outcomes included 30-day alcohol use, alcohol misuse, ever being in a fight, ever having sex, and past-year delinquency. Potential intermediate factors (time studying, truancy, school mobility, school culture, school order, teacher support for college, and proportion of substance-using peers in students' social networks) were also examined.Among the 1270 participating students (52.6% female; mean [SD] age at enrollment, 14.3 [0.5] years), ITT analysis showed that the intervention group reported less marijuana misuse than the control group (mean marijuana misuse score, 0.46 vs 0.71), as well as fewer substance-using peers (9.6% vs 12.7%), more time studying (mean, 2.63 vs 2.49 hours), less truancy (84.3% vs 77.3% with no truancy), greater teacher support for college (mean scores, 7.20 vs 7.02), more orderly schools (mean order score, 7.06 vs 6.83), and less school mobility (21.4% vs 28.4%) (all P .05). Stratified analyses suggest that among boys, intervention participants had significantly lower marijuana use (mean misuse score, 0.43 vs 0.88; difference, -0.45; 95% CI, -0.78 to -0.13) and alcohol misuse (mean misuse score, 0.52 vs 0.97; difference, -0.44; 95% CI, -0.80 to -0.09) scores compared with control participants, whereas no significant health outcomes were noted for girls.This natural experiment provides evidence that school environments can improve risky behaviors for low-income minority adolescents.

Key Points Question Is participation in a family-centered prevention program, designed to enhance caregiving practices, associated with protection of Black adolescents from the effects of racial discrimination on their mental health? Findings This secondary analyses of data from 2 randomized clinical trials found that participation in a family-centered prevention program was associated with protection of Black adolescents from the effects of racial discrimination on conduct problems (in both trials) and on depression/anxiety symptoms (in 1 trial). These associations were partially explained by intervention-induced changes in protective parenting. Meaning These findings suggest that family-centered prevention programs reduce the effects of racial discrimination on subsequent increases in mental health problems among Black adolescents., This secondary analysis of 2 randomized clinical trials examines the effects of family-centered prevention programs in mediating the adverse mental health outcomes associated with experience of racial discrimination among Black youths., Importance Some Black adolescents who frequently experience racial discrimination develop mental health problems. Protective caregiving may buffer adolescents from the negative mental health outcomes associated with experiencing racial discrimination. Objective To examine if participation in programs that enhance protective caregiving will attenuate the positive association between Black adolescents’ encounters with discrimination and subsequent increases in mental health problems. Design, Setting, and Participants This secondary analysis used data from 2 randomized clinical trials testing family-centered prevention programs: the Strong African American Families–Teen (SAAF–T) program and the Adults in the Making (AIM) program. The programs were implemented in community locations convenient for participants in 12 rural Georgia counties. For the SAAF–T trial, Black adolescents and their primary caregivers were recruited from 2007 to 2008. In the AIM trial Black adolescents and their primary caregivers were recruited from 2006 to 2007. Data for this study were analyzed from June to August 2020. Exposures Adolescents provided data at baseline on the frequency of their encounters with racial discrimination. Treatment group participants in each trial took part in a family-centered prevention program designed to prevent substance use and mental health problems. SAAF–T is a 5-session, 10-hour psychosocial intervention for families with a Black adolescent aged 14 to 16 years. AIM is a 6-session, 12-hour psychosocial intervention for families with a Black youth who is a high school senior. Main Outcomes and Measures The primary outcomes were mental health problems, including conduct problems and depression or anxiety symptoms. Results The SAAF–T study included 502 Black adolescents (mean [SD] age, 16.0 [0.6] years; 281 [56.0%] girls), including 252 randomized to the intervention and 250 randomized to the control, and the AIM trial included 367 Black adolescents (mean [SD] age, 17.7 [0.8] years; 217 [59.1%] girls and women), including 187 randomized to the intervention and 180 randomized to the control. Adolescents assigned to the SAAF–T intervention group who frequently experienced discrimination at baseline evinced fewer subsequent increases in conduct problems (incident risk ratio, 0.530 [95% CI, 0.340 to 0.783]). Adolescents assigned to the AIM intervention group who frequently experienced discrimination at baseline evinced fewer subsequent increases in conduct problems (mean difference, −0.361 [95% CI, −0.577 to −0.144]) and fewer subsequent increases in depression or anxiety symptoms (mean difference, −0.220 [95% CI −0.402 to −0.038]). Moderated mediation analyses suggested that enhanced protective caregiving was partially responsible for all observed interaction effects (indirect effect: SAAF-T conduct problems, −0.063 [95% CI, −0.127 to −0.001]; AIM conduct problems, −0.048 [95% CI, −0.095 to −0.001]; AIM depression or anxious symptoms, −0.036 [95% CI, −0.074 to 0]). Conclusions and Relevance This secondary analysis of 2 randomized clinical trials found that participation in family-centered preventive interventions attenuated the association between frequent exposure to discriminatory behaviors and subsequent mental health problems. Notably, all but 1 of the treatment and moderated-mediation findings were reproduced across the SAAF–T and AIM trials. Trial Registrations ClinicalTrials.gov Identifiers: SAAF–T, NCT04501471; AIM, NCT04510116

Key Points Question How much does substance use disorder cost each year in US hospitals? Findings In this economic evaluation of 124 573 175 hospital emergency department encounters and 33 648 910 hospital inpatient encounters, the annual medical cost associated with substance use disorder in US emergency departments and inpatient settings exceeded $13 billion in 2017. Meaning These findings suggest that costs associated with substance use disorder are high; costs of treatment and prevention could potentially be offset by reducing the direct medical cost of substance use disorder., This economic evaluation investigates the annual estimated medical cost of substance use disorder in US emergency departments and inpatient settings., Importance A persistently high US drug overdose death toll and increasing health care use associated with substance use disorder (SUD) create urgency for comprehensive estimates of attributable direct costs, which can assist in identifying cost-effective ways to prevent SUD and help people to receive effective treatment. Objective To estimate the annual attributable medical cost of SUD in US hospitals from the health care payer perspective. Design, Setting, and Participants This economic evaluation of observational data used multivariable regression analysis and mathematical modeling of hospital encounter costs, controlling for patient demographic, clinical, and insurance characteristics, and compared encounters with and without secondary SUD diagnosis to statistically identify the total attributable cost of SUD. Nationally representative hospital emergency department (ED) and inpatient encounters from the 2017 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample and National Inpatient Sample were studied. Statistical analysis was performed from March to June 2020. Exposures International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) principal or secondary SUD diagnosis on the hospital discharge record according to the Clinical Classifications Software categories (disorders related to alcohol, cannabis, hallucinogens, inhalants, opioids, sedatives, stimulants, and other substances). Main Outcomes and Measures Annual attributable SUD medical cost in hospitals overall and by substance type (eg, alcohol). The number of encounters (ED and inpatient) with SUD diagnosis (principal or secondary) and the mean cost attributable to SUD per encounter by substance type are also reported. Results This study examined a total of 124 573 175 hospital ED encounters and 33 648 910 hospital inpatient encounters from the 2017 Healthcare Cost and Utilization Project Nationwide Emergency Department Sample and National Inpatient Sample. Total annual estimated attributable SUD medical cost in hospitals was $13.2 billion. By substance type, the cost ranged from $4 million for inhalant-related disorders to $7.6 billion for alcohol-related disorders. Conclusions and Relevance This study’s results suggest that the cost of effective prevention and treatment may be substantially offset by a reduction in the high direct medical cost of SUD hospital care. The findings of this study may inform the treatment of patients with SUD during hospitalization, which presents a critical opportunity to engage patients who are at high risk for overdose. Aligning incentives such that prevention cost savings accrue to payers and practitioners that are otherwise responsible for SUD-related medical costs in hospitals and other health care settings may encourage prevention investment.

This survey study compared patterns of mental health concerns, substance use, and suicidal ideation during June and September 2020 of the COVID-19 pandemic and examined at-risk demographic groups.

Key Points Question What are the clinical manifestations of synthetic cannabinoid intoxication, and are they life threatening? Findings This case series of 30 adult patients describes the acute neurologic and cardiopulmonary complications of synthetic cannabinoid intoxication, including severe toxic encephalopathy, acute respiratory failure, and death. Meaning These findings suggest that synthetic cannabinoids are a continued public health threat, with potential for morbidity and mortality from acute intoxication., This case series describes the neurologic and cardiopulmonary complications associated with synthetic cannabinoid intoxication experienced by adult patients admitted to intensive care., Importance Synthetic cannabinoids (SCs), commonly known as K2, spice, or fake weed, are cheap, artificially manufactured recreational drugs that have emerged as a major public health threat in various regions of the US. Objective To describe the clinical manifestations of SC intoxication. Design, Setting, and Participants This case series assessed adults admitted to the intensive care unit from 2014 to 2016 with acute life-threatening complications of SC use. Data analysis was completed in October 2016. Exposures Use of SCs such as K2, spice, or other synthetic versions of cannabinoids. Main Outcomes and Measures Data collected included patient demographic data, medical history, presenting symptoms, physical findings, laboratory and imaging data, and intensive care unit and hospital course. Results Thirty patients (mean age, 41 years [range, 21-59 years]; 24 men [80%]) with SC ingestion were admitted to the intensive care unit over a 2-year period. Thirteen patients were undomiciled. The majority had a history of polysubstance abuse, psychiatric illness, or personality disorder. The admission diagnoses were coma (10 patients [33%]), agitation (10 patients [33%]), and seizure (6 patients [20%]). Eighteen patients (60%) had acute respiratory failure, and tracheal intubation was required in 21 patients (70%) for either airway protection or acute respiratory failure. Rhabdomyolysis was noted in 8 patients (26%). A man developed transient cerebral edema with loss of gray-white differentiation but had complete recovery. A woman with history of asthma died of acute respiratory distress syndrome. All patients underwent routine toxicology testing, which was unrevealing in 16 cases and revealed coingestion in the remainder. Sixteen patients (53%) left the hospital against medical advice. Conclusions and Relevance Ingestion of SCs can lead to life-threatening complications, including severe toxic encephalopathy, acute respiratory failure, and death. Synthetic cannabinoids are undetectable in routine serum and urine toxicology testing but can be suspected on the basis of history and clinical presentation, which may include extreme agitation or coma. Frontline clinicians must be aware of the presentation and be vigilant in suspecting SC intoxication.

Key Points Question Are alternative health care payment and delivery models (APMs) associated with changes in service delivery or outcomes for mental health and/or substance use disorders (MH/SUDs) in the United States? Findings This systematic review included 27 articles on 17 APM implementations in MH/SUD care. Some specific APMs (eg, pay-for-performance) have been associated with improved MH/SUD outcomes, while others (eg, APMs with shared savings) have not; broadly, clinical outcome data are lacking in evaluations of APMs. Meaning This systematic review identified some evidence for APM effectiveness in MH/SUD care; further research is needed to identify successful program components and associations with clinical outcomes., This systematic review summarizes the published literature on populations and mental health and/or substance use disorder conditions examined by alternative payment and delivery models as well as the associations of these models with mental health and/or substance use disorder outcomes., Importance Health care spending in the United States continues to grow. Mental health and substance use disorders (MH/SUDs) are prevalent and associated with worse health outcomes and higher health care spending; alternative payment and delivery models (APMs) have the potential to facilitate higher quality, integrated, and more cost-effective MH/SUD care. Objective To systematically review and summarize the published literature on populations and MH/SUD conditions examined by APM evaluations and the associations of APMs with MH/SUD outcomes. Evidence Review A literature search of MEDLINE, PsychInfo, Scopus, and Business Source was conducted from January 1, 1997, to May 17, 2019, for publications examining APMs for MH/SUD services, assessing at least 1 MH/SUD outcome, and having a comparison group. A total of 27 articles met these criteria, and each was classified according to the Health Care Payment Learning and Action Network’s APM framework. Strength of evidence was graded using a modified Oxford Centre for Evidence-Based Medicine framework. Findings The 27 included articles evaluated 17 APM implementations that spanned 3 Health Care Payment Learning and Action Network categories and 6 subcategories, with no single category predominating the literature. APMs varied with regard to their assessed outcomes, funding sources, target populations, and diagnostic focuses. The APMs were primarily evaluated on their associations with process-of-care measures (15 [88.2%]), followed by utilization (11 [64.7%]), spending (9 [52.9%]), and clinical outcomes (5 [29.4%]). Medicaid and publicly funded SUD programs were most common, with each representing 7 APMs (41.2%). Most APMs focused on adults (11 [64.7%]), while fewer (2 [11.8%]) targeted children or adolescents. More than half of the APMs (9 [52.9%]) targeted populations with SUD, while 4 (23.5%) targeted MH populations, and the rest targeted MH/SUD broadly defined. APMs were most commonly associated with improvements in MH/SUD process-of-care outcomes (12 of 15 [80.0%]), although they were also associated with lower spending (4 of 8 [50.0%]) and utilization (5 of 11 [45.5%]) outcomes, suggesting gains in value from APMs. However, clinical outcomes were rarely measured (5 APMs [29.4%]). A total of 8 APMs (47.1%) assessed for gaming (ie, falsification of outcomes because of APM incentives) and adverse selection, with 1 (12.5%) showing evidence of gaming and 3 (37.5%) showing evidence of adverse selection. Other than those assessing accountable care organizations, few studies included qualitative evaluations. Conclusions and Relevance In this study, APMs were associated with improvements in process-of-care outcomes, reductions in MH/SUD utilization, and decreases in spending. However, these findings cannot fully substitute for assessments of clinical outcomes, which have rarely been evaluated in this context. Additionally, this systematic review identified some noteworthy evidence for gaming and adverse selection, although these outcomes have not always been duly measured or analyzed. Future research is needed to better understand the varied qualitative experiences across APMs, their successful components, and their associations with clinical outcomes among diverse populations and settings.

This meta-analysis and systemic review assess combined cognitive behavioral therapy and pharmacotherapy for alcohol or other substance use disorders in adults., Key Points Question Is cognitive behavioral therapy associated with improved outcomes for alcohol and other substance use disorders in the context of pharmacotherapy for addiction? Findings This systemic review and meta-analysis including 30 studies found that combined cognitive behavioral therapy and pharmacotherapy was associated with increased benefit compared with usual care and pharmacotherapy. Cognitive behavioral therapy did not perform better than another evidence-based modality in this context or as an add-on to combined usual care and pharmacotherapy. Meaning These findings suggest that best practices in addiction treatment should include pharmacotherapy plus cognitive behavioral therapy or another evidence-based therapy, rather than usual clinical management or nonspecific counseling services., Importance Substance use disorders (SUDs) represent a pressing public health concern. Combined behavioral and pharmacological interventions are considered best practices for addiction. Cognitive behavioral therapy (CBT) is a first-line intervention, yet the superiority of CBT compared with other behavioral treatments when combined with pharmacotherapy remains unclear. An understanding of the effects of combined CBT and pharmacotherapy will inform best-practice guidelines for treatment of SUD. Objective To conduct a meta-analysis of the published literature on combined CBT and pharmacotherapy for adult alcohol use disorder (AUD) or other SUDs. Data Sources PubMed, Cochrane Register, MEDLINE, PsychINFO, and Embase databases from January 1, 1990, through July 31, 2019, were searched. Keywords were specified in 3 categories: treatment type, outcome type, and study design. Collected data were analyzed through September 30, 2019. Study Selection Two independent raters reviewed abstracts and full-text articles. English language articles describing randomized clinical trials examining CBT in combination with pharmacotherapy for AUD and SUD were included. Data Extraction and Synthesis Inverse-variance weighted, random-effects estimates of effect size were pooled into 3 clinically informative subgroups: (1) CBT plus pharmacotherapy compared with usual care plus pharmacotherapy, (2) CBT plus pharmacotherapy compared with another specific therapy plus pharmacotherapy, and (3) CBT added to usual care and pharmacotherapy compared with usual care and pharmacotherapy alone. Sensitivity analyses included assessment of study quality, pooled effect size heterogeneity, publication bias, and primary substance moderator effects. Main Outcomes and Measures Substance use frequency and quantity outcomes after treatment and during follow-up were examined. Results The sample included 62 effect sizes from 30 unique randomized clinical trials that examined CBT in combination with some form of pharmacotherapy for AUD and SUD. The primary substances targeted in the clinical trial sample were alcohol (15 [50%]), followed by cocaine (7 [23%]) and opioids (6 [20%]). The mean (SD) age of the patient sample was 39 (6) years, with a mean (SD) of 28% (12%) female participants per study. The following pharmacotherapies were used: naltrexone hydrochloride and/or acamprosate calcium (26 of 62 effect sizes [42%]), methadone hydrochloride or combined buprenorphine hydrochloride and naltrexone (11 of 62 [18%]), disulfiram (5 of 62 [8%]), and another pharmacotherapy or mixture of pharmacotherapies (20 of 62 [32%]). Random-effects pooled estimates showed a benefit associated with combined CBT and pharmacotherapy over usual care (g range, 0.18-0.28; k = 9). However, CBT did not perform better than another specific therapy, and evidence for the addition of CBT as an add-on to combined usual care and pharmacotherapy was mixed. Moderator analysis showed variability in effect direction and magnitude by primary drug target. Conclusions and Relevance The present study supports the efficacy of combined CBT and pharmacotherapy compared with usual care and pharmacotherapy. Cognitive behavioral therapy did not perform better than another evidence-based modality (eg, motivational enhancement therapy, contingency management) in this context or as an add-on to combined usual care and pharmacotherapy. These findings suggest that best practices in addiction treatment should include pharmacotherapy plus CBT or another evidence-based therapy, rather than usual clinical management or nonspecific counseling services.

Key Points Question Are US national data measuring aspects of cannabis use consistently available across states and over time? Findings This case series study examining 7 state and US nationwide surveys found that limited data are available at the state or national level to monitor 8 key dimensions of cannabis use and perceptions. Meaning These findings suggest that despite growing public support for cannabis legalization, monitoring public health effects of state and national policies may be difficult owing to a lack of available data in existing population surveys., This case series study examines the types of survey data available on cannabis use among aming US adults and adolescents., Importance In response to increasing public support for cannabis legalization, understanding associations of state and federal policy changes related to cannabis legalization with patterns of cannabis use is important. A challenge for public health monitoring and research is significant variation in data availability related to cannabis use behaviors and perceptions across and within states and over time, including the availability of prelegalization vs postlegalization data. Objective To review data available on cannabis use and related behaviors over time in Massachusetts and the US. Design, Setting, and Participants This case series examined state and national surveys on public health and related behaviors and outcomes to review availability of cannabis-related data for Massachusetts for 8 key indicators over time. Additionally, the Behavioral Risk Factor Surveillance System (BRFSS) and Youth Risk Behavior Surveillance System for all states were reviewed. The analysis was conducted between February 1, 2019, and March 18, 2020. Exposures Surveys that enable state-level estimation of cannabis use and related behaviors. Main Outcomes and Measures Eight key indicators related to cannabis use behaviors and perceptions: lifetime cannabis use, age of initiation, frequency of use, location of use, method of use, source of cannabis, perceptions of cannabis, and reason for use (ie, medical vs nonmedical). Results There were 7 surveys that monitored cannabis use and related behaviors in Massachusetts for adolescents and adults. No surveys monitored all 8 indicators of interest, and availability over time was limited. In the most recent BRFSS, 24 states asked cannabis-related questions, meaning BRFSS data on cannabis use was lacking for more than half of the US adult population. In the Youth Risk Behavior Surveillance System, 36 states asked standard cannabis questions; most other states had at least 1 question related to cannabis use and frequency. Conclusions and Relevance These findings of limitations of existing surveys, and particularly the lack of national questions in the BRFSS and Youth Risk Behavior Surveillance System, suggest that available data have substantial limitations for monitoring cannabis use. As cannabis policy changes continue, there is a need to remain focused on the availability of high-quality data sources that allow for critical public health research.

This cross-sectional analysis assesses the prevalence and number of alcohol- or benzodiazepine-involved opioid overdose deaths by opioid subtypes in the United States from 1999 to 2017., Key Points Question What is the prevalence of alcohol or benzodiazepine co-involvement in opioid overdose deaths among the opioid subtypes currently and over time? Findings This repeated cross-sectional analysis of deaths attributed to opioid overdose identified the co-involvement of alcohol or benzodiazepines as common and increasing, reaching 14.7% for alcohol and 21.0% for benzodiazepines in 2017. Significant correlations occurred between state-level binge drinking rates and alcohol co-involvement and between state-level benzodiazepine prescribing rates and benzodiazepine co-involvement in opioid overdose deaths. Meaning Prevalence of respiratory-depressing drugs in opioid overdose deaths is common and increasing and represents a potential target for policy and practice efforts to reduce opioid-related harms., Importance The use of benzodiazepines or alcohol together with opioids increases overdose risk, but characterization of co-involvement by predominant opioid subtype is incomplete to date. Understanding the use of respiratory depressants in opioid overdose deaths (OODs) is important for prevention efforts and policy making. Objective To assess the prevalence and number of alcohol- or benzodiazepine-involved OODs by opioid subtypes in the United States from 1999 to 2017. Design and Setting This repeated cross-sectional analysis used data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (WONDER) database of all opioid-involved poisoning deaths from January 1, 1999, to December 31, 2017, for the United States. State-level binge drinking prevalence rates for 2015 to 2017 were obtained from the Behavior Risk Factor Surveillance System of the Centers for Disease Control and Prevention, and benzodiazepine prescribing rates for 2012 (most recent available data) were obtained from IMS Health, a commercial database. Data were analyzed from July 10, 2018, to May 16, 2019. Main Outcomes and Measures Prevalence of alcohol or benzodiazepine co-involvement for all OODs and by opioid subtype, nationally and by state. Results From 1999 to 2017, 399 230 poisoning deaths involved opioids, of which 263 601 (66.0%) were male, and 204 560 (51.2%) were aged 35 to 54 years. Alcohol co-involvement for all opioid overdose deaths increased nonlinearly from 12.4% in 1999 to 14.7% in 2017. By opioid subtype, deaths involving heroin and synthetic opioids (eg, fentanyl; excluding methadone) had the highest alcohol co-involvement at 15.5% and 14.9%, respectively, in 2017. Benzodiazepine co-involvement in all OODs increased nonlinearly from 8.7% in 1999 to 21.0% in 2017. Benzodiazepines were present in 33.1% of prescription OODs and 17.1% of synthetic OODs in 2017. State-level rates of binge drinking were significantly correlated with alcohol co-involvement in all OODs (r = 0.34; P = .02). State benzodiazepine prescribing rates were significantly correlated with benzodiazepine co-involvement in all OODs (r = 0.57; P

Key Points Question Can alcohol use screening scores provide clinically meaningful information and facilitate identification of adverse mental health conditions and other substance use? Findings This cohort study using data from 6431 US patients collected from 2003 to 2012 found that high alcohol use scores (Alcohol Use Disorders Identification Test score ≥20) were associated with depression, anxiety, crack or cocaine use, and other stimulant use, with likelihood ratios greater than 3.5. Meaning These findings suggest that alcohol screening can inform decisions about further screening and diagnostic assessment for depression, anxiety, and some drug use outcomes., This cohort study examines whether alcohol screening provides information regarding alcohol-clustering conditions, including depression, anxiety, and use of tobacco, marijuana, and illicit drugs among US adults., Importance Alcohol screening may be associated with health outcomes that cluster with alcohol use (ie, alcohol-clustering conditions), including depression, anxiety, and use of tobacco, marijuana, and illicit drugs. Objective To quantify the extent to which alcohol screening provides additional information regarding alcohol-clustering conditions and to compare 2 alcohol use screening tools commonly used for this purpose. Design, Setting, and Participants This longitudinal cohort study used data from the Veterans Aging Cohort Study. Data were collected at 8 Veterans Health Administration facilities from 2003 through 2012. A total of 7510 participants were enrolled, completed a baseline survey, and were followed up. Veterans with HIV were matched with controls without HIV by age, race, sex, and site of care. Data were analyzed from January 2019 to December 2019. Exposures The Alcohol Use Disorders Identification Test (AUDIT) and Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) were used to assess alcohol use, with 4 risk groups delineated for each test: score 0 to 7 (reference), score 8 to 15, score 16 to 19, and score 20 to 40 (maximum score) for the full AUDIT and score 0 to 3 (reference), score 4 to 5, score 6 to 7, and score 8 to 12 (maximum score) for the AUDIT-C. Main Outcomes and Measures Alcohol-clustering conditions, including self-reported symptoms of depression and anxiety and use of tobacco, marijuana, cocaine, other stimulants, opioids, and injection drugs. Results A total of 6431 US patients (6104 [95%] men; median age during survey years 2003-2004, 50 years [range, 28-86 years; interquartile range, 44-55 years]) receiving care in the Veterans Health Administration completed 1 or more follow-up surveys when the AUDIT was administered and were included in the present analyses. Of the male participants, 4271 (66%) were African American, 1498 (24%) were white, and 590 (9%) were Hispanic. The AUDIT and AUDIT-C scores were associated with each alcohol-clustering condition. In particular, an AUDIT score of 20 or higher (vs

Importance No empirically supported treatments have been evaluated to address co-occurring substance use problems (SUP) and posttraumatic stress disorder (PTSD) symptoms among adolescents in an integrative fashion. This lack is partially owing to untested clinical lore suggesting that delivery of exposure-based PTSD treatments to youth with SUP might be iatrogenic. Objective To determine whether an exposure-based, integrative intervention for adolescents with SUP and PTSD symptoms—risk reduction through family therapy (RRFT)—resulted in improved outcomes relative to a treatment-as-usual (TAU) control condition consisting primarily of trauma-focused cognitive behavioral therapy. Design, Setting, and Participants This randomized clinical trial enrolled 124 participants who were recruited from November 1, 2012, through January 30, 2017. Adolescents (aged 13-18 years) who engaged in nontobacco substance use at least once during the past 90 days, experienced at least 1 interpersonal traumatic event, and reported 5 or more PTSD symptoms were enrolled. Blinded assessments were collected at baseline and at 3, 6, 12, and 18 months after baseline. Recruitment and treatment took place in community-based child advocacy centers in the Southeastern United States. Data were analyzed from August 2 through October 4, 2018, and were based on intention to treat. Interventions Participants were randomized to receive RRFT (n = 61) or TAU (n = 63). Main Outcomes and Measures Primary outcomes focused on number of nontobacco substance–using days measured with the timeline follow-back method and PTSD symptom severity using the UCLA (University of California, Los Angeles) PTSD Reaction Index forDSM-IVcompleted by adolescents and caregivers. Secondary outcomes focused on marijuana, alcohol, and polysubstance use and PTSD criterion standard (re-experiencing, avoidance, and hyperarousal) symptom severity. Results In all, 124 adolescents (mean [SD] age, 15.4 [1.3] years; 108 female [87.1%]) were randomized. For primary outcomes relative to TAU, RRFT yielded significantly greater reductions in substance-using days from baseline to month 12 (event rate [ER], 0.28; 95% CI, 0.12-0.65) and month 18 (ER, 0.10; 95% CI, 0.04-0.24). Significant reductions in PTSD symptoms were observed within groups for RRFT from baseline to months 3 (β = −9.25; 95% CI, −12.95 to −5.55), 6 (β = −16.63; 95% CI = −20.40 to −12.87), 12 (β = −17.51; 95% CI, −21.62 to −13.40), and 18 (β = −19.02; 95% CI, −23.07 to −14.96) and for TAU from baseline to months 3 (β = −9.62; 95% CI, −13.16 to −6.08), 6 (β = −13.73; 95% CI, −17.43 to −10.03), 12 (β = −15.53; 95% CI, −19.52 to −11.55), and 18 (β = −13.88; 95% CI, −17.69 to −10.09); however, between-group differences were not observed. Conclusions and Relevance In this study, RRFT and TAU demonstrated within-group improvements in SUP and PTSD symptoms, with greater improvement for substance use and PTSD avoidance and hyperarousal symptoms among adolescents randomized to RRFT compared with TAU. No evidence of the worsening of SUP was observed in either condition. These results suggest that this exposure-based treatment is safe, feasibly delivered by community-based clinicians, and offers an effective approach to inform clinical practice. Trial Registration ClinicalTrials.gov Identifier:NCT01751035

Key Points Question After experimentation in adolescence, do risks of progression and persistence of cannabis use during a 12-month follow-up period differ among 5 cannabis products? Findings In this cohort study of 2685 adolescents with no history of heavy cannabis use, after accounting for polyuse of multiple products, the association of baseline experimental use with persistent use and progression of use of that product during a 12-month follow-up period was significantly stronger for cannabis concentrate than for other cannabis products. Meaning The rate of persistence and progression after experimentation among adolescents may be amplified with the use of cannabis concentrate compared with other cannabis products., This cohort study compares the relative risk of the status and frequency of use of 5 cannabis products following experimental use among adolescents during 12 months of follow-up., Importance While a diverse array of cannabis products that may appeal to youth is currently available, it is unknown whether the risk of persistent cannabis use and progression to higher frequency of use after experimentation differs among cannabis products. Objective To estimate the comparative relative risk of experimental use of 5 cannabis products on use status and frequency of use among adolescents during 12 months of follow-up. Design, Setting, and Participants In this cohort study, data were collected from 3065 adolescents at 10 high schools in southern California, with baseline data collected in spring 2016, when students were in 11th grade, and 6-month and 12-month follow-up surveys collected in fall 2016 and spring 2017, when students were in 12th grade. Analyses, conducted from April to June 2019, were restricted to 2685 participants who were light or nonusers of any cannabis product (ie, ≤2 days in the past 30 days) at baseline. Exposures Number of days of use of each cannabis product (ie, combustible, blunts, vaporized, edible, or concentrated) in the past 30 days at baseline (ie, 1-2 vs 0 days). Main Outcomes and Measures Past 6-month use (ie, yes vs no) and number of days of use in the past 30 days at 6-month and 12-month follow-ups for each product. Results Of 2685 individuals in the analytic sample, 1477 (55.0%) were young women, the mean (SD) age was 17.1 (0.4) years, and a plurality (1231 [46.6%]) were Hispanic individuals. Among them, 158 (5.9%) reported combustible cannabis use on 1 to 2 days of the past 30 days at baseline, 90 (3.4%) reported blunt use, 78 (2.9%) reported edible cannabis use, 17 (0.6%) reported vaping cannabis, and 15 (0.6%) reported using cannabis concentrates. In regression models adjusting for demographic characteristics and poly–cannabis product use, statistically stronger associations of baseline use with subsequent past 6-month use at the 6-month and 12-month follow-ups were observed for combustible cannabis use (odds ratio, 6.01; 95% CI, 3.66-9.85) and cannabis concentrate use (odds ratio, 5.87; 95% CI, 1.18-23.80) compared with use of blunts (OR, 2.77; 95% CI, 1.45-5.29) or edible cannabis (OR, 3.32; 95% CI, 1.86-5.95) (P for comparison