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Background: The spread of illicitly manufactured fentanyl is driving steep increases in US overdose deaths. Fentanyl seizures are correlated with state-level opioid-related mortality; however, more granular seizure surveillance information has the potential to better inform overdose prevention and harm reduction efforts., Methods: Using data on fentanyl pill and powder seizures from High Intensity Drug Trafficking Areas (HIDTA), we tested associations between seizure prevalence and overdose mortality, from 2013 to 2020. The primary exposure-seizure burden-was constructed by identifying counties having high (above the median) prevalence of pill, powder, or combined pill/powder seizure burden per 100,000 population. Poisson models accounted for county demographic, law enforcement and time trends., Results: During the timeframe, there were 13,842 fentanyl seizures in 606 US counties. In adjusted models, counties with a high burden of pill or powder fentanyl seizures, or both (combined pills/powder) exhibited higher total overdose mortality than non-high burden counties (pills adjusted prevalence ratio [aPR]: 1.10 [95 % confidence interval [CI]: 1.08, 1.12]; powder aPR 1.12 [CI: 1.11, 1.13]; combined pills/powder aPR: 1.27 [CI: 1.25, 1.29]). A similar pattern of associations with fentanyl seizure burden was noted for overdose deaths involving synthetic opioids (pills [aPR]: 0.99 [CI: 0.96, 1.02]; powder aPR 1.29 [CI: 1.27, 1.30]; combined pills/powder aPR 1.55 [CI: 1.52, 1.58])., Conclusions: Law enforcement data on fentanyl seizures predicts drug overdose mortality at the county-level. Integrating these data with more traditional epidemiologic surveillance approaches has the potential to inform community overdose response efforts., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to disclose., (Copyright © 2024. Published by Elsevier B.V.)

Objectives: Overdose mortality rates in the United States remain critical to population health. Economic , such as unemployment, are noted risk factors for drug overdoses. The COVID-19 pandemic exacerbated economic hardship; as a result, the US government enacted income protection programs in conjunction with existing unemployment insurance (UI) to dampen COVID-19-related economic consequences. We investigate whether UI, operationalized as the weekly benefit allowance (WBA) replacement rate, is negatively associated with drug-related overdoses., Methods: Data from the pooled 2014-2020 Detailed Restricted Mortality files for all counties from the Centers for Disease Control and Prevention, restricted to people ≥18 years of age, aggregated at the county-quarter level (n = 89,914). We included any fatal drug, opioid, and stimulant overdose. We modeled the association between WBA replacement rate (e.g., a greater proportion of weekly earnings replaced by UI) on each county-level age-adjusted mortality outcome using separate linear regression models during 2014-2020, pre-COVID (2014-2018), and post-COVID (2019-2020). We conducted sensitivity analyses using multi-level linear regression models., Results: Results indicated that a more robust WBA replacement rate any drug (Risk Difference [RD]: -0.06, 95 % Confidence Interval [CI]: -0.08, -0.05), opioid (RD: -0.04, 95 % CI: -0.06, -0.03), and stimulant (RD: -0.03, 95 % CI: -0.04, -0.02) across the entire study period (2014-2020). A more robust WBA replacement rate was associated with fewer fatal drug, opioid and stimulant overdoses in the pre-COVID-19 period and on fatal any drug and stimulant overdoses in the COVID-19 period., Conclusions: Findings support the notion that income protection policies, such as robust UI, can have a supportive role in preventing fatal drug overdoses, calling for a broader discussion onthe role of the safety net programs to buffer drug-related harms., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Punitive legal responses to prenatal drug use may be associated with unintended adverse health consequences. However, in a rapidly shifting policy climate, current information has not been summarized. We conducted a survey of U.S. state policies that utilize criminal or civil legal system penalties to address prenatal drug use. We then systematically identified empirical studies evaluating these policies and summarized their potential public health impacts., Methods: Using existing databases and original statutory research, we surveyed current U.S. state-level prenatal drug use policies authorizing explicit criminalization, involuntary commitment, civil child abuse substantiation, and parental rights termination. Next, we systematically identified quantitative associations between these policies and health outcomes, restricting to U.S.-based peer-reviewed research, published January 2000-December 2022. Results described study characteristics and synthesized the evidence on health-related harms and benefits associated with punitive policies. Validity threats were described narratively., Results: By 2022, two states had adopted policies explicitly authorizing criminal prosecution, and five states allowed pregnancy-specific and drug use-related involuntary civil commitment. Prenatal drug use was grounds for substantiating civil child abuse and terminating parental rights in 22 and five states, respectively. Of the 16 review-identified articles, most evaluated associations between punitive policies generally (k = 12), or civil child abuse policies specifically (k = 2), and multiple outcomes, including drug treatment utilization (k = 6), maltreatment reporting and foster care entry (k = 5), neonatal drug withdrawal syndrome (NDWS, k = 4) and other pregnancy and birth-related outcomes (k = 3). Most included studies reported null associations or suggested increases in adverse outcome following punitive policy adoption., Conclusions: Nearly half of U.S. states have adopted policies that respond to prenatal drug use with legal system penalties. While additional research is needed to clarify whether such approaches engender overt health harms, current evidence indicates that punitive policies are not associated with public health benefits, and therefore constitute ineffective policy., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

Background: Cannabis use disorder (CUD) treatment prevalence decreased in the US between 2002 and 2019, yet structural mechanisms for this decrease are poorly understood. We tested associations between cannabis laws becoming effective and self-reported CUD treatment., Methods: Restricted-use 2004-2019 National Surveys on Drug Use and Health included people ages 12+ classified as needing CUD treatment (i.e., past-year DSM-5-proxy CUD or last/current specialty treatment for cannabis). Time-varying indicators of medical cannabis laws (MCL) with/without cannabis dispensary provisions differentiated state-years before/after laws using effective dates. Multi-level logistic regressions with random state intercepts estimated individual- and state-adjusted CUD treatment odds by MCLs and model-based changes in specialty CUD treatment state-level prevalence. Secondary analyses tested associations between CUD treatment and MCL or recreational cannabis laws (RCL)., Results: Using a broad treatment need sample definition in 2004-2014, specialty CUD treatment prevalence decreased by 1.35 (95 % CI = -2.51, -0.18) points after MCL without dispensaries and by 2.15 points (95 % CI = -3.29, -1.00) after MCL with dispensaries provisions became effective, compared to before MCL. Among people with CUD in 2004-2014, specialty treatment decreased only in MCL states with dispensary provisions (aPD = -0.91, 95 % CI = -1.68, -0.13). MCL were not associated with CUD treatment use in 2015-2019. RCL were associated with lower CUD treatment among people classified as needing CUD treatment, but not among people with past-year CUD., Conclusions: Policy-related reductions in specialty CUD treatment were concentrated in states with cannabis dispensary provisions in 2004-2014, but not 2015-2019, and partly driven by reductions among people without past-year CUD. Other mechanisms (e.g., CUD symptom identification, criminal-legal referrals) could contribute to decreasing treatment trends., Competing Interests: Conflict of interest Dr. H. Samples has received consulting fees from the American Society of Addiction Medicine and The Pew Charitable Trusts; other authors report no potential conflicts of interest., (Copyright © 2024. Published by Elsevier B.V.)

Background: The COVID-19 pandemic's impact on utilization of medications for opioid use disorder (MOUD) among patients with opioid use disorder (OUD) and chronic pain is unclear., Methods: We analyzed New York State (NYS) Medicaid claims from pre-pandemic (August 2019-February 2020) and pandemic (March 2020-December 2020) periods for beneficiaries with and without chronic pain. We calculated monthly proportions of patients with OUD diagnoses in 6-month-lookback windows utilizing MOUD and proportions of treatment-naïve patients initiating MOUD. We used interrupted time series to assess changes in MOUD utilization and initiation rates by medication type and by race/ethnicity., Results: Among 20,785 patients with OUD and chronic pain, 49.3% utilized MOUD (versus 60.3% without chronic pain). The pandemic did not affect utilization in either group but briefly disrupted initiation among patients with chronic pain (β=-0.009; 95% CI [-0.015, -0.002]). Overall MOUD utilization was not affected by the pandemic for any race/ethnicity but opioid treatment program (OTP) utilization was briefly disrupted for non-Hispanic Black individuals (β=-0.007 [-0.013, -0.001]). The pandemic disrupted overall MOUD initiation in non-Hispanic Black (β=-0.007 [-0.012, -0.002]) and Hispanic individuals (β=-0.010 [-0.019, -0.001])., Conclusions: Adults with chronic pain who were enrolled in NYS Medicaid before the COVID-19 pandemic had lower MOUD utilization than those without chronic pain. MOUD initiation was briefly disrupted, with disparities especially in racial/ethnic minority groups. Flexible MOUD policy initiatives may have maintained overall treatment utilization, but disparities in initiation and care continuity remain for patients with chronic pain, and particularly for racial/ethnic minoritized subgroups., Competing Interests: Declaration of Competing Interest The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the New York State Department of Health. Examples of analysis performed within this article are only examples. They should not be utilized in real-world analytic products. AP reports no conflicts of interest. KWM reports no conflicts of interest. DSH reports payments made to their institution for unrelated project work for Syneos Health on measurement of addiction in patients with chronic pain. KT reports no conflicts of interest. ZLM reports no conflicts of interest. VJ reports no conflicts of interest. TNT reports no conflicts of interest. JRP reports no conflicts of interest. SC reports no conflicts of interest. SSM reports no conflicts of interest. MC reports no conflicts of interest. NK receives compensation for expert testimony in ongoing opioid litigation., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Cannabis use disorder is associated with considerable comorbidity and impairment in functioning, and prevalence is increasing among adults with chronic pain. We aimed to assess the effect of introduction of medical cannabis laws (MCL) and recreational cannabis laws (RCL) on the increase in cannabis use disorder among patients in the US Veterans Health Administration (VHA)., Methods: Data from patients with one or more primary care, emergency, or mental health visit to the VHA in 2005-19 were analysed using 15 repeated cross-sectional VHA electronic health record datasets (ie, one dataset per year). Patients in hospice or palliative care were excluded. Patients were stratified as having chronic pain or not using an American Pain Society taxonomy of painful medical conditions. We used staggered-adoption difference-in-difference analyses to estimate the role of MCL and RCL enactment in the increases in prevalence of diagnosed cannabis use disorder and associations with presence of chronic pain, accounting for the year that state laws were enacted. We did this by fitting a linear binomial regression model stratified by pain, with time-varying cannabis law status, fixed effects for state, categorical year, time-varying state-level sociodemographic covariates, and patient covariates (age group [18-34 years, 35-64 years, and 65-75 years], sex, and race and ethnicity)., Findings: Between 2005 and 2019, 3 234 382-4 579 994 patients were included per year. Among patients without pain in 2005, 5·1% were female, mean age was 58·3 (SD 12·6) years, and 75·7%, 15·6%, and 3·6% were White, Black, and Hispanic or Latino, respectively. In 2019, 9·3% were female, mean age was 56·7 (SD 15·2) years, and 68·1%, 18·2%, and 6·5% were White, Black, and Hispanic or Latino, respectively. Among patients with pain in 2005, 7·1% were female, mean age was 57·2 (SD 11·4) years, and 74·0%, 17·8%, and 3·9% were White, Black, and Hispanic or Latino, respectively. In 2019, 12·4% were female, mean age was 57·2 (SD 13·8) years, and 65·3%, 21·9%, and 7·0% were White, Black, and Hispanic or Latino, respectively. Among patients with chronic pain, enacting MCL led to a 0·135% (95% CI 0·118-0·153) absolute increase in cannabis use disorder prevalence, with 8·4% of the total increase in MCL-enacting states attributable to MCL. Enacting RCL led to a 0·188% (0·160-0·217) absolute increase in cannabis use disorder prevalence, with 11·5% of the total increase in RCL-enacting states attributable to RCL. In patients without chronic pain, enacting MCL and RCL led to smaller absolute increases in cannabis use disorder prevalence (MCL: 0·037% [0·027-0·048], 5·7% attributable to MCL; RCL: 0·042% [0·023-0·060], 6·0% attributable to RCL). Overall, associations of MCL and RCL with cannabis use disorder were greater in patients with chronic pain than in patients without chronic pain., Interpretation: Increasing cannabis use disorder prevalence among patients with chronic pain following state legalisation is a public health concern, especially among older age groups. Given cannabis commercialisation and widespread public beliefs about its efficacy, clinical monitoring of cannabis use and discussion of the risk of cannabis use disorder among patients with chronic pain is warranted., Funding: NIDA grant R01DA048860, New York State Psychiatric Institute, and the VA Centers of Excellence in Substance Addiction Treatment and Education., Competing Interests: Declaration of interests DSH receives support from Syneos Health for an unrelated project. JLG reports consulting fees from Hoffman-La Roche, a patent pending (use of glecaprevir and pibrentasvir for the treatment of post-traumatic stress disorder), and participation on a data safety monitoring board or advisory board for National Institute of Mental Health (using machine learning to optimise user engagement and clinical response to digital mental health interventions). SSM serves on the Board of Directors for the College on Problems of Drug Dependence. AJS has received consulting fees from Indivior, travel support from Alkermes, research support from MedicaSafe, and royalties from UpTo-Date. KMK has served as an expert witness in litigation. All other authors declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Purpose: Adverse childhood experiences (ACEs) are common in Puerto Rican youths. Few large longitudinal studies of Latine youth examined what predicts co-use of alcohol and cannabis in late adolescence and young adulthood. We investigated the prospective association between ACEs with alcohol/cannabis co-use in Puerto Rican youth., Methods: Participants from a longitudinal study of Puerto Rican youth (n = 2,004) were included. Using multinomial logistic regressions to test associations between prospectively reported ACEs (11 types, reported by parents and/or children, categorized as 0-1, 2-3, and 4+ ACEs) with young adult alcohol/cannabis use patterns in the past month (i.e., no lifetime use, low-risk [no binge drinking and cannabis use < 10], binge-drinking only, regular cannabis use only, and alcohol/cannabis co-use). Models were adjusted for sociodemographic variables., Results: In this sample, 27.8% reported 4+ ACEs, 28.6% endorsed binge drinking, 4.9% regular cannabis use, and 5.5% alcohol/cannabis co-use. Compared to individuals with no lifetime use, those reporting 4+ (vs. 0-1) ACEs had greater odds of low-risk use (adjusted odds ratio [aOR] 1.60, 95% confidence interval [CI] = 1.04-2.45), regular cannabis use (aOR 3.13 95% CI = 1.44-6.77), and alcohol/cannabis co-use (aOR 3.57, 95% CI = 1.89-6.75). In relation to low-risk use, reporting 4+ ACEs (vs. 0-1) was associated with 1.96 odds (95% CI = 1.01-3.78) of regular cannabis use and 2.24 odds (95% CI = 1.29-3.89) of alcohol/cannabis co-use., Discussion: Exposure to 4+ ACEs was associated with the occurrence of adolescent/young adulthood regular cannabis use and alcohol/cannabis co-use. Importantly, ACEs exposure differentiated young adults who were co-using compared to those engaged in low-risk use. Preventing ACE or interventions for Puerto Rican youth experiencing 4+ ACEs may mitigate negative consequences associated with alcohol/cannabis co-use., (Copyright © 2023 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Recreational cannabis laws (RCLs) may have spillover effects on binge drinking. Our aims were to investigate binge drinking time trends and the association between RCLs and changes in binge drinking in the United States (U.S.)., Methods: We used restricted National Survey on Drug Use and Health data (2008-2019). We examined trends in the prevalence of past-month binge drinking by age groups (12-20, 21-30, 31-40, 41-50, 51+). Then, we compared model-based prevalences of past-month binge drinking before and after RCL by age group, using multi-level logistic regression with state random intercepts, an RCL by age group interaction term, and controlling for state alcohol policies., Results: Binge drinking declined overall from 2008 to 2019 among people aged 12-20 (17.54% to 11.08%), and those aged 21-30 (43.66% to 40.22%). However, binge drinking increased among people aged 31+ (ages 31-40: 28.11% to 33.34%, ages 41-50: 25.48% to 28.32%, ages 51+: 13.28% to 16.75%). When investigating model-based prevalences after versus before RCL, binge drinking decreased among people aged 12-20 (prevalence difference=-4.8%; adjusted odds ratio (aOR)=0.77, [95% confidence interval (CI) 0.70-0.85]), and increased among participants aged 31-40 (+1.7%; 1.09[1.01-1.26]), 41-50 (+2.5; 1.15[1.05-1.26]) and 51+ (+1.8%; 1.17[1.06-1.30]). No RCL-related changes were noted in respondents ages 21-30., Conclusions: Implementation of RCLs was associated with increased past-month binge drinking in adults aged 31+ and decreased past-month binge drinking in those aged < 21. As the cannabis legislative landscape continues to change in the U.S., efforts to minimize harms related to binge drinking are critical., Competing Interests: Declarations of Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Simultaneous alcohol and marijuana (SAM) use is associated with adverse consequences for youth. While SAM use is overall declining among youth, prior studies indicate increasing marijuana use among US adolescents who ever used cigarettes, suggesting possible moderation of the alcohol-marijuana relationship by cigarette use., Methods: We included 43,845 12-th grade students participating in Monitoring the Future data (2000-2020). A 5-level alcohol/marijuana measure was used, including past-year SAM, alcohol-only, marijuana-only, non-simultaneous alcohol and marijuana, or no use. Multinomial logistic regressions estimated associations between time periods (categorized based on sample size: 2000-2005, 2006-2009, 2010-2014, 2015-2020) and the 5-level alcohol/marijuana measure. Models adjusted for sex, race, parental education and survey mode and included interactions of time periods and lifetime cigarette or vaped nicotine use., Results: While overall SAM among 12th graders decreased from 23.65% to 18.31% between 2000 and 2020, SAM increased among students who never used cigarettes or vaped nicotine (from 5.42% to 7.03%). Among students who ever used cigarettes or vaped nicotine, SAM increased from 39.2% in 2000-2005-44.1% in 2010-2014 then declined to 37.8% in 2015-2020. Adjusted models controlling for demographics indicated that among students with no lifetime cigarette or vaped nicotine use, students in 2015-2020 had 1.40 (95% C.I. 1.15-1.71) times the odds of SAM, and 5.43 (95% C.I. 3.63-8.12) times the odds of marijuana-only (i.e., no alcohol use) compared to students who used neither in 2000-2005. Alcohol-only declined over time in both students who ever and never used cigarettes or nicotine vape products., Conclusion: Paradoxically, while SAM declined in the overall adolescent US population, the prevalence of SAM increased among students who have never smoked cigarettes or vaped nicotine. This effect arises because of a substantial decline in the prevalence of cigarette smoking; smoking is a risk factor for SAM, and fewer students smoke. Increases in vaping are offsetting these changes, however. Preventing adolescent use of cigarettes and nicotine vaped products could have extended benefits for other substance use, including SAM., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to disclose., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Naloxone distribution is central to ongoing efforts to address the opioid overdose crisis. Some critics contend that naloxone expansion may inadvertently promote high-risk substance use behaviors among adolescents, but this question has not been directly investigated., Methods: We examined relationships between naloxone access laws and pharmacy naloxone distribution with lifetime heroin and injection drug use (IDU), 2007-2019. Models generating adjusted odds ratios (aOR) and 95% confidence intervals (CI) included year and state fixed effects, controlled for demographics and sources of variation in opioid environments (e.g., fentanyl penetration), as well as additional policies expected to impact substance use (e.g., prescription drug monitoring). Exploratory and sensitivity analyses further examined naloxone law provisions (e.g., third-party prescribing) and applied e-value testing to assess vulnerability to unmeasured confounding., Results: Adoption of any naloxone law was not associated with changes in adolescent lifetime heroin or IDU. For pharmacy dispensing, we observed a small decrease in heroin use (aOR: 0.95 [CI: 0.92, 0.99]) and a small increase in IDU (aOR: 1.07 [CI: 1.02, 1.11]). Exploratory analyses of law provisions suggested that third-party prescribing (aOR: 0.80, [CI: 0.66, 0.96]) and non-patient-specific dispensing models (aOR: 0.78, [CI: 0.61, 0.99]) were associated with decreased heroin use but not decreased IDU. Small e-values associated with the pharmacy dispensing and provision estimates indicate that unmeasured confounding may explain observed findings., Conclusion: Naloxone access laws and pharmacy naloxone distribution were more consistently associated with decreases rather than increases in lifetime heroin and IDU among adolescents. Our findings therefore do not support concerns that naloxone access promotes high-risk adolescent substance use behaviors. As of 2019, all US states have adopted legislation to improve naloxone access and facilitate use. However, further removal of adolescent naloxone access barriers is an important priority given that the opioid epidemic continues to affect people of all ages., Competing Interests: Declarations of Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: D. Hasin has received funding from Syneos Health for an unrelated project. K. Keyes has received personal fees related to expert work in litigation. H. Samples has received consulting fees from the American Society of Addiction Medicine., (Copyright © 2023. Published by Elsevier B.V.)

Purpose: Adolescent internalizing symptoms are increasing in the United States. Changes in parenting practices, including monitoring and communication, have been hypothesized to contribute to these increases. We aimed to estimate trends in parenting practices and understand whether shifts in such practices explain increases in internalizing symptoms., Methods: Using 1991-2019 Monitoring the Future data (N = 933,645), we examined trends in five parental practices (i.e., knowledge [three combined indicators], monitoring [four combined indicators], communication, weekend curfew, social permission) with ordinal regressions. We tested associations between parental practices and indicators of being in the top decile of depressive affect, low self-esteem, and self-derogation using survey-weighted logistic regressions, adjusted for gender, race/ethnicity, grade, and parental education., Results: The prevalences of parental practices have not changed over time, with the exception of increases in parental knowledge, specifically parents knowing where an adolescent is after school (1999-2019 mean increase: 4.34 to 4.61 out of 5) and knowing an adolescent's location (4.16-4.49) and company at night (4.26-4.51). Higher levels of each practice were associated with lower internalizing symptoms (e.g., adjusted odds ratio for a high depressive affect based on a one-unit increase in parental knowledge: 0.89, 95% confidence interval: 0.88, 0.90). Patterns were consistent across internalizing outcomes and decade., Discussion: Parental knowledge, monitoring, and other practices are stable protective factors for adolescent mental health. These factors are not changing in a manner that would plausibly underlie increases in internalizing symptoms. Future interventions should provide resources that support these parental practices which are tied to adolescent internalizing symptoms., (Copyright © 2022 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Suicidal behavior and bullying victimization are important indicators of adolescent psychological distress, and are patterned by sex, race/ethnicity and sexual identity. This study aimed to estimate trends and disparities in these factors along with key demographics., Method: Youth Risk Behavior Survey data (2015-2019, N = 44,066) were collected biennially through national cross-sectional surveys of US school-attending adolescents. Survey-weighted logistic regressions examined disparities in past-year bullying and suicidal behavior, overall and by demographics., Results: Bullying in 2019 was highest for female (vs male) students (odds ratio [OR] = 1.82, 95% CI = 1.62, 2.06), American Indian/Alaskan Native (vs White) students (OR = 1.48, 95% 0.91, 2.41, p > .05), and gay/lesbian (vs heterosexual) students (OR = 2.81, 95% CI = 2.07, 3.81). Suicidal behavior disparities affected similar groups. There was minimal evidence for shifts in disparities since 2015, with the exception of bullying for gay/lesbian adolescents. The prevalence of bullying victimization among gay and lesbian adolescents went from 31.6% to 44.5% between 2015 and 2019, surpassing the bisexual and "Not Sure" groups to be the sexual identity group with the highest rate of bullying victimization., Conclusion: Interventions that operate on multiple structural levels and empower marginalized youth are needed., (Copyright © 2022 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background: While housing is a critical social determinant of nonprescription opioid overdose, little is known about how place impacts fatal overdose for people experiencing homelessness (PEH) who use drugs beyond the public versus private domains. This study investigated patterns of neighborhood environment features at locations of fatal overdoses among PEH., Methods: We remotely visited locations of opioid-involved fatal overdoses provided by the New York City Office of the Chief Medical Examiner, 2017-2019 (n=3276), with Google Street View and used systematic social observation to assess characteristics of the street block related to drug exposures. We cross-referenced home address with city shelters and supportive housing to identify PEH (n=503). We used the differences of K functions from the spatial point patterns and kernel ratio function maps to identify geographic clusters. We then used logistic regression to identify significant individual-, block-, and neighborhood-level covariates (neighborhood deprivation, segregation, population density)., Results: Over half (55.9%, n=281) of fatal overdoses among PEH occurred in supportive housing or shelters, and 15.5% (n=78) occurred in public spaces (e.g., parks). Spatial analyses identified areas of significant concentrated fatal overdoses among PEH in Manhattan, the South Bronx, and Brooklyn. We identified several significant indicators of physical and social order and disorder associated with increased odds of experiencing homelessness at time of fatal overdose, including construction/renovation, graffiti, traffic calming features, and loitering., Conclusion: Harm reduction services should be co-located in facilities that serve PEH and targeted to street blocks with indicators of physical and social disorder. While supportive housing is a crucial step in preventing fatal opioid overdoses among PEH, identifying neighborhoods for intervention services delivery and harm reduction outreach for PEH is necessary., Competing Interests: Declarations of Interest The authors have no possible competing interests to declare, including any direct or indirect connections with the alcohol, gambling, tobacco, or pharmaceutical industries., (Copyright © 2022. Published by Elsevier B.V.)

Background: States have enacted multiple types of laws, with a variety of constituent provisions, in response to the opioid epidemic, often simultaneously. This temporal proximity and variation in state-to-state operationalization has resulted in significant challenges for empirical research on their effects. Thus, expert consensus can be helpful to classify laws and their provisions by their degree of helpfulness and impact., Methods: We conducted a four-stage modified policy Delphi process to identify the top 10 most helpful and 5 most harmful provisions from eight opioid-related laws. This iterative consultation with six types of opioid experts included a preliminary focus group (n=12), two consecutive surveys (n=56 and n=40, respectively), and a final focus group feedback session (n=5)., Results: On a scale of very harmful (0) to very helpful (4), overdose Good Samaritan laws received the highest average helpfulness rating (3.62, 95% CI: 3.48-3.75), followed by naloxone access laws (3.37, 95% CI: 3.22-3.51), and pain management clinic laws (3.08, 95% CI: 2.89-3.26). Drug-induced homicide (DIH) laws were rated the most harmful (0.88, 95% CI: 0.66-1.11). Impact ratings aligned similarly, although Medicaid laws received the second highest overall impact rating (3.71, 95% CI: 3.45, 3.97). The two most helpful provisions were naloxone standing orders (3.94, 95% CI: 3.86-4.02) and Medicaid coverage of medications for opioid use disorder (MOUD) (3.89, 95% CI: 3.82). Mandatory minimum DIH laws were the most harmful provision (0.73, 95% CI 0.53-0.93); followed by requiring prior authorization for Medicaid coverage of MOUD (1.00 95% CI: 0.72-1.27)., Conclusion: Overall, experts rated laws and provisions that facilitated harm reduction efforts and access to MOUD as most helpful. Laws and provisions rated as most harmful criminalized substance use and placed restrictions on access to MOUD. These ratings provide a foundation for evaluating the overall overdose policy environment for each state., Competing Interests: Declarations of Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Samples has received consulting fees from the American Society of Addiction Medicine., (Copyright © 2022. Published by Elsevier B.V.)

Background: In the context of changing cannabis and other drug policy and regulation, concerns may arise regarding drug treatment access and use. We assessed cannabis/cocaine-related dependence and treatment in Argentina, Chile, and Uruguay., Methods: Nationally representative cross-sectional household surveys of people ages 15-64 in Argentina (4 surveys, 2006-2017), Chile (7 surveys, 2006-2018), and Uruguay (4 surveys, 2006-2018) were harmonized. We estimated weighted prevalences of cannabis or cocaine-related (cocaine or cocaine paste) dependence, based on meeting 3+ past-year ICD-10 dependence criteria. We estimated weighted prevalences of past-year alcohol/drug treatment use (Argentina, Chile) or use/seeking (Uruguay) among people with past-year cannabis/cocaine-related dependence. We tested model-based prevalence trends over time and described individual-level treatment correlates by country., Results: Cannabis/cocaine dependence prevalence increased in the region starting in 2010-2011, driven by cannabis dependence. Adjusted cannabis dependence prevalence increased from 0.7% in 2010 to 1.5% in 2017 in Argentina (aPD=0.8, 95% CI= 0.3, 1.2), from 0.8% in 2010 to 2.8% in 2018 in Chile (aPD=2.0, 95% CI= 1.4, 2.6), and from 1.4% in 2011 to 2.4% in 2018 in Uruguay (aPD=0.9, 95% CI= 0.2, 1.6). Cocaine-related dependence increased in Uruguay, decreased in Argentina, and remained stable in Chile. Among people with past-year cannabis/cocaine dependence, average alcohol/drug treatment use prevalence was 15.3% in Argentina and 6.0% in Chile, while treatment use/seeking was 14.7% in Uruguay. Alcohol/drug treatment prevalence was lower among people with cannabis dependence than cocaine-related dependence. Treatment correlates included older ages in all countries and male sex in Argentina only., Conclusion: Alcohol/drug treatment use among people with cannabis/cocaine-related dependence remained low, signaling an ongoing treatment gap in the context of growing cannabis dependence prevalence in the region. Additional resources may be needed to increase treatment access and uptake. Future studies should assess contributors of low treatment use, including perceived need, stigma, and service availability., Competing Interests: Declarations of Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022. Published by Elsevier B.V.)

Background: Substance use disorders (SUD) elevate the risk for COVID-19 hospitalization, but studies are inconsistent on the relationship of SUD to COVID-19 mortality., Methods: Veterans Health Administration (VHA) patients treated in 2019 and evaluated in 2020 for COVID-19 (n=5,556,315), of whom 62,303 (1.1%) tested positive for COVID-19 (COVID-19+). Outcomes were COVID-19+ by 11/01/20, hospitalization, ICU admission, or death within 60 days of a positive test. Main predictors were any ICD-10-CM SUDs, with substance-specific SUDs (cannabis, cocaine, opioid, stimulant, sedative) explored individually. Logistic regression produced unadjusted and covariate-adjusted odds ratios (OR; aOR)., Results: Among COVID-19+ patients, 19.25% were hospitalized, 7.71% admitted to ICU, and 5.84% died. In unadjusted models, any SUD and all substance-specific SUDs except cannabis use disorder were associated with COVID-19+(ORs=1.06-1.85); adjusted models produced similar results. Any SUD and all substance-specific SUDs were associated with hospitalization (aORs: 1.24-1.91). Any SUD, cocaine and opioid disorder were associated with ICU admission in unadjusted but not adjusted models. Any SUD, cannabis, cocaine, and stimulant disorders were inversely associated with mortality in unadjusted models (OR=0.27-0.46). After adjustment, associations with mortality were no longer significant. In ad hoc analyses, adjusted odds of mortality were lower among the 49.9% of COVID-19+ patients with SUD who had SUD treatment in 2019, but not among those without such treatment., Conclusions: In VHA patients, SUDs are associated with COVID-19 hospitalization but not COVID-19 mortality. SUD treatment may provide closer monitoring of care, ensuring that these patients received needed medical attention, enabling them to ultimately survive serious illness., (Copyright © 2022. Published by Elsevier B.V.)

Aims: Most information on the relationship between medical cannabis laws (MCL) and the risk for opioid overdose fatality has been based on studies with ecological designs. To contribute additional information, we used a novel case-control design and individual-level data from national surveys to assess whether state medical cannabis laws were associated with reduced risk of fatal opioid overdose between 2000-2011., Methods: Data from participants surveyed in the National Health Interview Survey (NHIS) between 1986-2011 were included. For those sampled between 1986-2009, detailed mortality follow-up data were available from the National Death Index up to 12/31/2011. Opioid overdose decedents (n = 791) were classified as cases. Between 2000-2011, all cases arising in a given year were matched to adult controls who were surveyed the same year and eligible for mortality follow-up (n = 723,920). The distribution of exposure to state MCL was contrasted between cases and controls, providing an approximation of the rate ratio of fatal opioid overdose associated with MCLs. Due to a NHIS sample redesign, we stratified analysis using timeframes before and after 2005., Results: Overall, compared to controls, cases were more likely to be male, middle-aged, non-Hispanic White, separated/divorced; less educated, and have a family income below the poverty threshold. No overall association between state MCLs and the rate of opioid overdose was observed between 2000-2005 (aOR = 1.22, 95% CI: 0.83-1.79) or between 2006-2011 (aOR = 0.87, 95% CI: 0.60-1.25). No significant difference between sampling timeframes was observed (ratio of aOR's = 0.71, 95% CI: 0.49-1.01)., Conclusions: We found no overall protective relationship between state MCLs and opioid overdose. Future research with more recent mortality data and more refined cannabis policy classifications would be useful. The importance of the study is two-fold. First, the findings provide an additional source of information countering claims of a protective effect of MCLs on opioid overdoses, suggesting that other solutions to the opioid overdose crisis are needed. Second, the study offers a potentially useful design to answer important population-level public health questions., (Copyright © 2021. Published by Elsevier B.V.)

Cannabis use and binge drinking are increasingly common in the United States, yet little is known about cannabis use patterns among people who engage in binge drinking. This study explored the relationship between several cannabis use outcomes and past-month binge drinking status. Pooled 2015-2018 National Surveys on Drug Use and Health data (N = 226,632) were used to explore the hypothesis that binge drinking is associated with higher prevalence of cannabis outcomes. Cannabis outcomes included past-month and past-year use, daily/almost daily use, and past-year DSM-IV/DSM-5 cannabis use disorder (CUD). Covariates included age, gender, race, total income, and study year. Separate weighted multivariable logistic regressions assessed associations between binge drinking and each cannabis outcome and provided adjusted prevalences of cannabis outcomes by binge drinking status. Past-month binge drinking was positively associated with past-month (OR: 3.72, 95 %CI: 3.56-3.93) and past-year (OR: 3.90, 95 %CI: 3.74-4.06) cannabis use in adjusted regressions. The adjusted odds of DSM-IV and DSM-5 CUD among people who used cannabis were 15 % and 12 % higher among people who engaged in binge drinking than those who did not, respectively (OR: 1.15, 95 %CI: 1.05, 1.26 and OR: 1.12, 95 %CI: 1.03, 1.21). Conversely, the odds of past-month daily cannabis use among people who used cannabis and reported binge drinking was 18 % lower than those who did not (OR: 0.82, 95 %CI: 0.74, 0.91). Our findings provide evidence of associations between binge drinking and cannabis use. Future studies should explore associations between cannabis and other alcohol use behaviors, including heavy drinking, and simultaneous alcohol and cannabis use., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Alcohol outlets have been associated with various forms of injury and may contribute to neighborhood disparities in drug overdose. Few studies have examined the associations between alcohol outlets and drug overdose. This study investigated whether alcohol outlets were associated with the neighborhood drug overdose rate and whether the sale of drug paraphernalia contributes to this association., Methods: A cross-sectional ecological spatial analysis was conducted within census block groups in Baltimore City (n = 653). Outcomes were counts of EMS calls for any drug overdose in 2015 (n = 3,856). Exposures of interest were counts of alcohol outlets licensed for off-premise and on-premise consumption and the proportion of off-premise outlets selling drug paraphernalia (e.g., blunt wrappers, baggies, pipes). Negative binomial regression was used to assess the relationship between outlet count and overdose rate, and if paraphernalia sales altered this relationship, controlling for other neighborhood factors. Spatial autocorrelation was assessed and regression inference adjusted accordingly., Results: Each additional off-premise alcohol outlet was associated with a 16.6% increase in the neighborhood overdose rate (IRR=1.17, 95%CI=(1.11, 1.23)), adjusted for other neighborhood variables. On-premise alcohol outlets were not significantly associated with overdose rate when adjusting for off-premise alcohol outlets (IRR=1.01, 95% CI=(0.97, 1.06)). The proportion of off-premise outlets that sold drug paraphernalia was negatively associated with overdose rate (IRR=0.55, 95% CI=(0.41, 0.74)) and did not alter the relationship between off-premise outlets and overdose., Conclusion: This study provides preliminary public health evidence for informing policy decisions about alcohol outlet licensing and zoning. Alcohol outlets could be potential community partners for harm reduction strategies such as health communication in identifying overdose symptoms or Good Samaritan Laws., Competing Interests: Declarations of Interest The authors have no possible competing interests to declare, including any direct or indirect connections with the alcohol, gambling, tobacco, or pharmaceutical industries., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Prior work suggests that perceived risk and perceived availability of cannabis independently affect cannabis use. However, perceived risk likely modifies the effect of perceived availability, and vice versa. This study explored trends in joint perceived risk and availability of cannabis from 2002 to 2018 and the relationship between combined perceptions and cannabis use, frequent use, and cannabis use disorder (CUD)., Methods: National Surveys on Drug Use and Health data (n = 949,285, ages 12+) were used to create combined categories of perceived risk of weekly cannabis use and perceived cannabis availability. Descriptive analyses compared joint perceived risk/availability trends (pre/post-2015 due to survey redesign) overall and stratified by age, gender, past-year cannabis use, frequent use, and CUD. Regression analysis estimated associations between perceived risk/availability and cannabis outcomes., Results: From 2002 to 2018, the prevalence of perceiving cannabis as low-risk doubled while perceiving cannabis as available remained unchanged. The proportion of individuals perceiving cannabis as Low-risk/Available increased by 86% from 2002 to 2014 (16.8%-31.2%) and 19% from 2015 to 2018 (30.1%-35.8%) while High-risk/Available and High-risk/Unavailable proportions declined. Differing patterns were observed by age and gender. Compared with individuals perceiving cannabis as High-risk/Unavailable, people in all other perception categories had greater risk of all cannabis outcomes. Results were consistent with additive interaction between perceived risk and availability in their effects on cannabis use., Conclusions: Trends and associations with cannabis outcomes differ when considering perceived risk and availability independently versus jointly. Longitudinal studies and cannabis policy evaluations would advance understanding of links between cannabis perceptions and use., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Benzodiazepine (BZD)-related overdose deaths have risen in the past decade and BZD misuse contributes to thousands of emergency department (ED) visits annually, with the highest rates in adolescents and young adults. Because there are gaps in understanding BZD poisoning in youth and whether differences occur by sex, we aimed to characterize BZD poisoning ED visits in young people by sex., Methods: BZD poisoning visits were identified in the Nationwide Emergency Department Sample, among adolescents (12-17 years) and young adults (18-29 years). Stratified by sex and age, we described ED visits for BZD poisonings in 2016, including poisoning intent, concurrent substances involved, and co-occurring mental health disorder diagnoses. With logistic regression we examined the association between intent and concurrent substance., Results: There were approximately 38,000 BZD poisoning ED visits by young people nationwide with annual population rates per 10,000 of 2.9=adolescents and 5.8=young adults. Depression was diagnosed in 40 % of female and 23 % of male BZD visits (p < 0.01). Over half of BZD poisonings in females and a third in males were intentional (p < 0.01). Male BZD visits were more likely to involve opioids or cannabis and less likely to involve antidepressants than females (p-values<0.01). In males and females, BZD poisonings concurrent with antidepressants and other psychotropic medications were more likely to be intentional than unintentional (OR range:2.1-6.3)., Conclusions: The high proportion of BZD poisonings that are intentional and include mental health disorder diagnoses, especially among young females, underscore the importance of ED mental health and suicide risk assessment with appropriate follow-up referral., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Introduction: The standard therapy for American cutaneous leishmaniasis (ACL) is intravenous meglumine antimoniate (IV-MA). However, treatment interruptions due to adverse events (AEs) and non-adherence are frequent. Consequently, intralesional MA (IL-MA) was proposed., Objective: This study examined the effectiveness of and AEs associated with IL-MA., Methods: We performed a retrospective cohort study of 240 patients with ACL. We excluded patients with mucous lesions and disseminated leishmaniasis and those who received treatment in the previous 6 months. We considered protocol treatments as the main risk factors. IL-MA was performed using a subcutaneous injection of MA in a volume sufficient to elevate the lesion base (approximately 1 mL/cm 2 of lesion area) once weekly for 1-8 weeks. IV-MA was performed via intravenous injections of MA at a dosage of 10-20 mg Sb 5+ /kg/day for 20 days. The primary outcome was defined as a lesion cure 3 months after treatment, and AEs were secondary outcomes., Results: Seventy-three patients were included. The IL-MA group consisted of 21 patients, and the IV-MA group consisted of 52 patients. The IL-MA group was older, had more comorbidities and more previous unsuccessful treatment of ACL. The antimonial dose was significantly lower in this group. The cure rate for IL-MA was 66.7%, which was lower than that in the IV-MA group (relative risk (RR) = 0.68, 95% CI: 0.50-0.92, p < 0.001), while the rate of AEs was similar. Female sex (RR = 1.16, 95% CI: 1.02-1.33), lesion diameter ≤1 cm (RR = 1.25, 95% CI: 1.00-1.56) and treatment with IV-MA (RR = 1.43, 95% CI: 1.06-1.93) were independently associated with achieving a cure. Comorbidities (RR = 1.7, 95% CI: 1.06-2.98) were independently associated with AEs., Conclusions: Patients of IL-MA group were older, had more comorbidities and more previous unsuccessful treatment of ACL. Nevertheless, IL-MA had a cure rate of 66.7%, and it was useful in this context. A prospective randomized trial is recommended., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Medical marijuana laws (MMLs) can impact marijuana and opioid use, but the relationship between MMLs and other drugs, such as prescription stimulants, remains unexamined. Because lesbian, gay and bisexual (LGB) individuals report higher levels of prescription stimulant use than heterosexuals, we explored the relationship between MMLs and past-year medical and non-medical stimulant use by sexual identity and gender., Methods: We pooled 2015-2017 National Survey on Drug Use and Health data for adults (n = 126 463), and used survey-weighted multinomial logistic regression to estimate odds of past-year (a) medical prescription stimulant use, (b) non-medical prescription stimulant use and (c) non-medical versus medical stimulant use. We stratified by gender, adjusted for sociodemographic characteristics, and tested the interaction between MML state residence and sexual identity., Results: Bisexual men had higher medical (6.4% versus 4.1%; aROR=1.93[1.29-2.88]) and non-medical stimulant use 6.6% versus 2.4%; aROR=2.23[1.44-3.44]) than heterosexual men. Bisexual women had higher non-medical stimulant use (6.8% versus 1.6%; aROR=1.54[1.23-2.93] than heterosexual women. Female (aROR=0.70[0.62-0.78]) and male (aROR=0.74[0.66-0.82]) heterosexuals in MML states had lower odds of medical stimulant use than in non-MML states. Bisexual men in MML states had lower odds of medical (aROR=0.36[0.21-0.61]) and non-medical stimulant use (aROR=0.48[0.29-0.81]) than bisexual men in non-MML states. Similar patterns emerged for bisexual women's non-medical use (aROR=0.57[0.40-0.81])., Conclusion: Prescription stimulant use was higher in non-MML states for most LGB subgroups. MMLs may differentially impact stimulant use, primarily for bisexual men and women. States enacting MMLs should consider potential impacts on drugs other than marijuana, especially among LGB populations., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Purpose: Identifying temporal pattern of associations between bullying perpetration and substance use among youth is useful for optimal targeting of intervention and prevention. We examined the mutual influences on bullying perpetration and substance use and test the cumulative effects of bullying perpetration and substance use over time., Methods: We used data from the Population Assessment of Tobacco and Health cohort study, a nationally representative sample of youth, on bullying perpetration and substance use at three points in time over 3 years. We analyzed the associations of bullying perpetration with alcohol, cannabis and cigarette use using binary logistic regressions. The 13,068 youths aged 12-17 years at baseline (2013-2014) were included in the analytical sample., Results: Cross-sectional associations between bullying perpetration and substance use were found at baseline (odds ratio [OR] alcohol  = 1.62, 95% confidence interval [CI] 1.33-1.97; OR marijuana  = 1.28, 95% CI .99-1.66; OR cigarette  = 1.86, 95% CI 1.44-2.39). Cumulative episodic and frequent bullying perpetration over three data waves predicted an increased likelihood of substance use at follow-up (ORs between 1.18, 95% CI 1.02-1.36 and 2.13, 95% CI 1.66-2.74). Conversely, both episodic and frequent substance use predicted an increased probability of bullying others at follow-up (ORs between 1.50, 95% CI 1.20-1.86, and 2.10, 95% CI 1.69-2.61)., Conclusions: Associations between bullying perpetration and substance use appears to be bidirectional. In addition, episodic bullying perpetrators displayed intermediate levels of risk, suggesting a graded association between bullying perpetration pattern and substance use., (Copyright © 2020 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Barriers to early childhood development (ECD) are a global concern. Limited research exists on prenatal smoking and ECD in vulnerable populations, especially as it relates to school readiness (SR)., Aims: To examine how maternal cigarette use during pregnancy is associated with SR in a sample of Brazilian preschool-age children., Study Design: We used the Brazilian Preschool Mental Health Study, a cross-sectional, epidemiological study of preschool-age children in Embu das Artes, São Paulo. SR was assessed using the Engle Scale of Child Development (ESCD). We restricted analyses to biological mothers, who represented 81.9% (n = 591) of the total 722 with ESCD data. Logistic regression models, adjusting for birth and child characteristics (year of preschool, sex, race, history of head trauma, coma, convulsions or epilepsy), sociodemographic factors and school environment, were used to estimate odds ratios and 95% confidence intervals., Results: Prenatal smoking was negatively associated with SR. Children of mothers who smoked during pregnancy were more likely to be in the lowest ESCD quartile (aOR = 1.26, 95%CI: [1.02-1.55]) compared to those of non-smoking mothers, and each cigarette resulted in additional risk (aOR = 1.03, 95%CI:[1.01-1.05]). Children of heavy smokers had worse ESCD scores compared to children of non-smokers (aOR = 1.69, 95%CI:[1.18-2.44]), as well as when compared to children of moderate and non-smokers combined (aOR = 1.77, 95%CI:[1.22-2.57]). This relationship was not seen when comparing children of moderate smokers to children of non-smokers. Inferences were robust when examining very heavy smoking., Conclusion: Maternal tobacco use during pregnancy may affect child SR. Additional studies in other populations are needed to corroborate these results., Competing Interests: Declaration of competing interest Sheila C. Caetano has received a consulting fee from Pfizer, and was a presenter for Lundbeck in 2019. The other authors have no competing interests to declare., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: Social media and other digital technology use facilitate connection among adolescents, but also may reinforce norms and substance-related content from peers and advertisers. We use nationally representative data to examine the association between digital technology and past 30-day use of alcohol, cannabis, and vaping., Methods: Data were drawn from the 2018 Monitoring the Future survey of US adolescents (N = 44,482). Poisson regressions estimated the association between hours/day of technology use and past 30-day use of alcohol, cannabis, and vaping adjusting for grade, sociodemographics, and other past-year drug use., Results: Across grades, mean hours of social media/day was 3.06 (standard deviation = 2.90), past 30-day alcohol, cannabis, flavor vaping, cannabis vaping, and nicotine vaping were 15.7 %, 12.6 %, 10.6 %, 4.9 %, and 11.2 %, respectively. Digital technology use that required interaction with others was associated with increased risk of past 30-day drinking, cannabis use, and vaping. For example, social media 3+ hours/day was associated with past 30-day drinking (adjusted relative risk [aRR]: 1.99, 95 % CI: 1.65, 2.41). The magnitude of association was consistent across texting, phone calls, and video chatting, which were all more strongly associated with substance use than with activities that do not require interaction such as gaming and watching videos., Conclusion: Digital technology that facilitates interaction among adolescents, such as texting and social media, is associated with past substance use. Magnitudes of association are consistent across substances, supporting the hypothesis that networks of adolescents are social drivers of substance use, rather than the technology itself., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: In 2013, Uruguay became the first country in the world to legalize recreational cannabis, instituting a non-commercial state regulatory model of production and supply. This study provides the first empirical evidence on its impacts on adolescent use of cannabis and related risks., Methods: We use a generalization of the synthetic control method (SCM) to estimate the impact of legalization in Uruguay on adolescent past year and month cannabis use, perceived availability of cannabis and perceived risk of cannabis use. We compare biennial high school student self-reported survey data from Montevideo and regions in the interior of Uruguay post-legalization (2014-2018) and post initial implementation (2015-2018) to a synthetic counterfactual constructed using a weighted combination of 15 control regions in Chile., Results: We find no evidence of an impact on cannabis use or the perceived risk of use. We find an increase in student perception of cannabis availability (58% observed vs. 51% synthetic control) following legalization., Conclusion: Our findings provide some support for the thesis that Uruguay's state regulatory approach to cannabis supply may minimize the impact of legalization on adolescent cannabis use. At the same time, our study period represents a period of transition: pharmacy access, by far the most popular means of access, was not available until the summer of 2017. Additional study will be important to assess the longer-term impacts of the fully implemented legalization regime on substance use outcomes., Competing Interests: Conflict of Interest Statement None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Introduction: The opioid overdose crisis in the United States has prompted an expansion of treatment services, including pharmacotherapy with buprenorphine. However, many people who use illicit opioids (PWUIO) self-treat their opioid-use disorder (OUD) with non-prescribed buprenorphine (NPB) in lieu of attending formal treatment. The present study aims to qualitatively understand motivations of people who are self-treating their OUD with NPB., Methods: Qualitative study designed to supplement and contextualize quantitative findings from natural history study of buprenorphine diversion, self-treatment, and use of substance use disorder treatment services. Interviews were audio-recorded, transcribed, systematically coded and analyzed via Iterative Categorization., Study Setting: The Dayton, Ohio metropolitan area in the midwestern United States; a site previously characterized as high impact in the national opioid overdose crisis., Participants: Sixty-five individuals (35 men and 30 women) who met the DSM-5 criteria for OUD (moderate or severe) and had used NPB at least one time in the six months prior to their intake interview., Results: Participants described four key motivators for self-treating with NPB: perceived demands of formal treatment, the desire to utilize non-prescribed buprenorphine in combination with a geographic relocation, to self-initiate treatment while preparing for formal services, and to bolster a sense of self-determination and agency in their recovery trajectory., Conclusions: Use of NPB is a recognized self-treatment modality among PWUIO, with some PWUIO transitioning into sustained recovery episodes or enrollment in formal treatment. Understanding the motivations for opting out of treatment is crucial for improving forms of care for people with OUD., Competing Interests: Declaration of Competing Interest No conflict declared., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Unintentional drug overdoses have reached epidemic levels in the U.S. This study tests the hypothesis that people who have used non-prescribed buprenorphine more frequently in the past six months were less likely to experience a drug overdose during that same time period., Methods: Participants age 18 years or older with opioid use disorder who reported use of non-prescribed buprenorphine in the last six months were recruited from the Dayton, Ohio, area using a combination of targeted and modified respondent-driven sampling. Participants completed a structured interview, including six-month timeline follow-back, after informed consent. Logistic regression was used to test the association between (log-transformed) frequency of non-prescribed buprenorphine use and overdose in the previous six months, adjusted for confounding due to sex, homelessness, incarceration, substance use treatment, previous overdose, heroin/fentanyl injection, psychiatric comorbidity, and (log-transformed) frequencies of other (non-opioid) drug use., Results: Almost 89% of 356 participants were white, 50.3% were male, and 78.1% had high school or greater education. Over 27% (n = 98) reported experiencing an overdose in the past six months. After adjusting for confounding, greater frequency of non-prescribed buprenorphine use was significantly associated with lower risk of overdose (AOR = 0.81, 95% CI = 0.66, 0.98; p = .0286). Experiencing an overdose more than six months ago (AOR = 2.19, 95% CI = 1.24, 3.97); injection as the most common route of administration of heroin/fentanyl (AOR = 2.49, 95% CI = 1.36, 4.71); and frequency of methamphetamine use (AOR = 1.13, 95% CI = 1.02, 1.27) were strongly associated with increased risk of recent overdose in multivariable analysis., Discussion: The findings support our hypothesis that higher frequency of non-prescribed buprenorphine use is associated with lower risk of drug overdose, a potential harm reduction consequence of diversion. Improving the availability of buprenorphine though standard substance use disorder treatment, primary care, and other innovative methods is urgently needed., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Copyright © 2020. Published by Elsevier B.V.)

Purpose: Identification of the temporal pattern of associations between bullying perpetration and mental health problems among youth is needed for the optimal targeting of intervention and prevention. We examined the bidirectional association between bullying perpetration and internalizing problems among youth in the U.S., Methods: We used data from the prospective cohort study of the Population Assessment of Tobacco and Health waves 1 (September 12, 2013, to December 14, 2014) and 2 (October 23, 2014, to October 30, 2015), a nationally representative sample of youth. We analyzed the associations of bullying perpetration with internalizing problems using binary and multinomial logistic regressions. The 13,200 youths aged 12-17 years were included in the analytic sample., Results: There was a cross-sectional association between bullying perpetration and moderate/high lifetime internalizing problems (OR moderate vs. no/low  = 3.13, 95% CI 2.67-3.65; and OR high vs. no/low  = 8.77, 95% CI 7.53-10.20). In the prospective analyses, bullying perpetration was associated with increased likelihood of moderate/high internalizing problems at follow-up (OR moderate vs. no/low  = 1.49, 95% CI 1.15-1.94; and OR high vs. no/low  = 1.71, 95% CI 1.23-2.38), and youth with moderate/high internalizing problems had higher odds of bullying perpetration at follow-up (OR moderate  = 1.95, 95% CI 1.65-2.31; and OR high  = 3.21, 95% CI 2.74-3.76)., Conclusions: The association between bullying perpetration and internalizing problems appears to be bidirectional. Bullying behaviors prevention and intervention strategies among youth should consider how to take into account and handle negative feelings and mental health problems., (Copyright © 2019 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Criminal justice referral to treatment is associated with reduced odds of receiving opioid agonist treatment (OAT), the gold-standard treatment for opioid use disorder. States vary substantially in the extent of criminal justice system involvement in opioid treatment; however, the effects on treatment provision are not clear. We examined whether state-level criminal justice involvement in the substance use treatment system modified the association between criminal justice referral to treatment and OAT provision among opioid treatment admissions., Methods: We conducted a random effects logistic regression to investigate how the effects of criminal justice referral to treatment on OAT provision differed in states with high vs. low state-level criminal justice involvement in opioid treatment, adjusting for individual and state-level covariates, among 22 states in the 2015 Treatment Episode Dataset-Admissions., Results: Criminal justice referral to treatment was associated with an 85% reduction in the odds of receiving OAT, compared to other sources of treatment referral (OR = 0.15; 95% CI: 0.15, 0.16). Among opioid treatment admissions resulting from criminal justice referral in 2015, receiving treatment in high criminal justice involvement states was associated with a 63% reduction in the odds of OAT provision, compared to opioid treatment received in low criminal justice involvement states (interaction OR = 0.37, 95% CI: 0.11, 0.89)., Conclusion: The effects of criminal justice referral to treatment on OAT provision varied by criminal justice involvement in opioid treatment at the state level. Targeted interventions should increase access to OAT in states that rely on the criminal justice system for opioid treatment referrals., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Conducted in the Dayton Metropolitan area of Southwestern Ohio, this qualitative study explores the self-treatment practices of people who use illicit opioids (PWUIO) amidst the new risk environment produced by illicit, non-pharmaceutical fentanyl (NPF). We explore local perceptions of the presence of NPF in the Dayton area, and how this has both positively and negatively impacted practices of non-prescribed buprenorphine use among PWUIO., Methods: This study analyzes qualitative data from 63 interviews conducted between October 2018 and June 2019. Participants were selected from a larger longitudinal study on non-prescribed buprenorphine use among individuals with opioid use disorder. Qualitative interviews were transcribed in their entirety, and their transcriptions were analyzed using NVivo software, drawing on a mix of thematic and inductive coding., Results: Interview respondents ranged from 19 to 70 years old, with a mean age of 38.9 years. 54% of them were male, and 85.7% identified as non-Hispanic White. 98.4% of the sample had used heroin, and 93.7% of the sample reported use of NPF. Participants agreed NPF dominated the illicit opioids market in the area, and was perceived as both dangerous and desirable. The domination of NPF and associated overdose experiences prompted some to seek positive change and initiate self-treatment with non-prescribed buprenorphine. For others, NPF sabotaged established practices of harm reduction, as unanticipated experiences of precipitated withdrawals prompted some participants to give up non-prescribed buprenorphine use as a tactic of self-treatment., Discussion: The changing nature of heroin/NPF necessarily gives rise to new beliefs surrounding self-treatment attempts, treatment seeking behaviors, and harm reduction practices. While buprenorphine treatment continues to offer promising results for treating opioid use disorders, it is urgent to reconsider how the unpredictable biochemical mixture of NPFs circulating on the streets today may impact the initiation and success of treatment., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Cannabis use disorder (CUD) prevalence among people reporting past-year cannabis use declined from 2002-2016. We examined whether similar reductions in CUD were observed among people reporting daily/almost daily cannabis use. We expected that CUD prevalence among people reporting daily/almost daily use would not decrease., Methods: We used 2002-2016 National Survey on Drug Use and Health (NSDUH) data, including 22,651 individuals using cannabis 300+ days in the past year. CUD was defined using DSM-IV criteria for cannabis abuse and/or dependence. Age categories included: 12-17, 18-25, and 26 + . Annual prevalence of CUD, cannabis dependence, cannabis abuse, and each individual abuse/dependence items accounted for the complex survey design. Differences in trends over time were examined by age group., Results: From 2002-2016, the prevalence of CUD among people reporting daily/almost daily cannabis use decreased by 26.8% in adolescents, by 29.7% in ages 18-25, and by 37.5% in ages 26 + . Prevalence of DSM-IV cannabis dependence decreased significantly among adolescents (-43.9%) and young adults (-26.8%) but remained stable in adults 26 + . Reductions in most dependence items were observed in young adults, with less consistent patterns in adolescents and adults 26 + . Prevalence of DSM-IV cannabis abuse decreased overall and for each abuse item across all age groups., Conclusions: Contrary to expectations, CUD prevalence decreased significantly across all ages reporting daily/almost daily cannabis use between 2002-2016. Cannabis dependence prevalence decreased for adolescents and young adults and was stable only among adults ages 26+ reporting daily/almost daily cannabis use. Potential drivers of this decrease should be further explored., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Prescription drug monitoring programs (PDMP), by reducing access to prescribed opioids (POs), may contribute to a policy environment in which some people with opioid dependence are at increased risk for transitioning from POs to heroin/other illegal opioids. This study examines how PDMP adoption and changes in the characteristics of PDMPs over time contribute to changes in fatal heroin poisoning in counties within states from 2002 to 2016., Methods: Latent transition analysis to classify PDMPs into latent classes (Cooperative, Proactive, and Weak) for each state and year, across three intervals (1999-2004, 2005-2009, 2010-2016). We examined the association between probability of PDMP latent class membership and the rate of county-level heroin poisoning death., Results: After adjustment for potential county-level confounders and co-occurring policy changes, adoption of a PDMP was significantly associated with increased heroin poisoning rates (22% increase by third year post-adoption). Findings varied by PDMP type. From 2010-2016, states with Cooperative PDMPs (those more likely to share data with other states, to require more frequent reporting, and include more drug schedules) had 19% higher heroin poisoning rates than states with Weak PDMPs (adjusted rate ratio [ARR] = 1.19; 95% CI = 1.14, 1.25). States with Proactive PDMPs (those more likely to report outlying prescribing and dispensing and provide broader access to law enforcement) had 6% lower heroin poisoning rates than states with No/Weak PDMPs (ARR = 0.94; 95% CI = 0.90, 0.98)., Conclusion: There is a consistent, positive association between state PDMP adoption and heroin poisoning mortality. However, this varies by PDMP type, with Proactive PDMPs associated with a small reduction in heroin poisoning deaths. This raises questions about the potential for PDMPs to support efforts to decrease heroin overdose risk, particularly by using proactive alerts to identify patients in need of treatment for opioid use disorder. Future research on mechanisms explaining the reduction in heroin poisonings after enactment of Proactive PDMPs is merited., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Little is known about recent nonmedical prescription tranquilizer and stimulant use trends in Latin America. We tested whether recent trends among students in three South American countries differed by sex over time., Methods: Three countries independently collected National School Students Survey on Drugs. Students in 8th, 10th, and 12th grades were sampled in Argentina (2007-2014, N = 328,202), Chile (2007-2015, N = 136,379), and Uruguay (2007-2016, N = 32,371). Weighted linear regression models predicted the prevalences and trends over time of past-year nonmedical tranquilizer and stimulant use by country, and tested whether trends differed by sex, adjusting for school type and grade., Results: In Argentina from 2007 to 2014, past-year nonmedical prescription tranquilizer (girls: 2.8 to 2.6%, boys: 2.5 to 2.3%) and stimulant (girls: 1.7 to 1.3%, boys: 1.9 to 1.5%) use trends did not differ by sex. In Chile from 2007 to 2015, nonmedical prescription tranquilizer use trends significantly differed comparing girls (3.9 to 10%) with boys (3.2 to 6.9%); stimulant use trends did not differ comparing girls (1.6 to 2.0%) with boys (2.0 to 1.3%). In Uruguay from 2007 to 2014 and 2014-2016, past-year nonmedical prescription tranquilizer (girls: 5.1 to 6.6%; boys: 2.8 to 4.2%) and stimulant (girls: 1.8 to 0.7%; boys: 1.8 to 0.7%) use trends did not differ by sex., Conclusions: Trends of nonmedical prescription tranquilizer use recently increased in Chile and Uruguay, widening by sex over time in Chile only. The drivers of increasing tranquilizer use among girls in Chile and Uruguay merit further investigation., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Objectives: To report and analyze prevalence's of Benzodiazepines (BZDs) and Prescription Opioids (POs) use by insurance status and to investigate associations between insurance status and BZDs, POs and concurrent medical/non-medical use and use disorders., Methods: This study included 81,133 adults ages 18 and older from 2015 and 2016 National Survey on Drug Use and Health. Participants' self-reported past- year medical use, non-medical use and use disorders of BZDs and POs were assessed, along with their insurance status (Private/Military, Medicare, Medicaid, and Uninsured) and demographic characteristics., Results: In 2015-2016, 12.6% of adults reported using BZDs and 36.9% reported using POs in the past year. Among adults, 8.3% reported past-year use of both BZDs and POs; also, 1.9% and 3.8% reported non-medical use of BZDs and POs, respectively, and 0.9% reported non-medical use of both BZDs and POs. Medicaid-covered respondents had higher risk of BZDs (aRRR = 1.59, 95%CI = [1.45, 1.74]), POs (aRRR = 1.66, 95%CI = [1.54, 1.79]) and concurrent past-year medical use (aRRR = 2.11, 95%CI = [1.87, 2.38]), higher risk of BZDs non-medical use (aRRR = 1.40, 95%CI = [1.17, 1.68]) and BZD Use Disorders (aRRR = 2.60, 95%CI = [1.82, 3.72]), POs non-medical use (aRRR = 1.67, 95%CI = [1.45, 1.92]), PO use Disorders (aRRR = 4.12, 95%CI = [3.33, 5.11]) and concurrent non-medical use (aRRR = 1.52, 95%CI = [1.20, 1.92]) and Use Disorders (aRRR = 3.68, 95%CI = [1.93, 6.78]), compared to those with private insurance., Conclusions: Future health policies should focus on reducing individual and co-prescription of BZDs and POs and providing different strategies of pain management., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: The growing use of prescription opioids and benzodiazepines has become a major health threat in the United States, so it is important to document their use among adults to inform health policies or interventions., Methods: This study included 81,186 adults ages 18 and older from 2015 and 2016 National Survey on Drug Use and Health. Participants' self-reported medical and nonmedical use of prescription opioids and/or benzodiazepines in the past year was assessed along with their demographic characteristics., Results: In 2015-2016, 41.13% of adults reported using prescription opioids and/or benzodiazepines in the past year; 8.24% reported both, 28.59% reported prescription opioids only, and 4.30% reported benzodiazepines only. The majority of adults used the drugs for medical purposes, including 71.35% of participants who reported both drugs in the past year, 90.36% of those who reported prescription opioids only, and 86.24% of those who reported benzodiazepines only. Younger adults ages 18-34 were more likely to use prescription opioids and/or benzodiazepines for nonmedical purposes compared to adults ages 35 and over., Conclusions: In the United States, the proportion of adults who used prescription opioids and/or benzodiazepines in the past year was high; most of them reported using these drugs for medical purposes. Special attention is needed to prevent potentially unnecessary medical co-prescribing of these drugs, particularly among younger adults, who were more likely report nonmedical use of both drugs than older adults., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Research demonstrates an association between state-level medical marijuana laws (MMLs) and increased marijuana use (MU) and MU disorder (MUD) among adults, but has yet to explore this association among lesbian, gay and bisexual (LGB) individuals, including gender differences., Methods: We pooled the 2015-2017 National Survey on Drug Use and Health data for adults (n = 126,463) and used gender-stratified adjusted multivariable logistic regression to model the odds of past-year MU, past-year medical MU, daily/near-daily MU, and MUD; we also tested the interaction between MML state residence and sexual identity., Results: Bisexual women had higher past-year MU (40% versus 10.3%; aOR = 2.9[2.4-3.4]), daily/near-daily MU (9.8% versus 1.5%; aOR = 4.6[3.3-6.2]), and medical MU ((5.5% versus 1.2%) aOR = 5.5[3.8-8.1]) than heterosexual women. Gay/lesbian women also had higher past-year MU (26.1% versus 10.3%; aOR = 2.8[2.2-3.7]), daily/near-daily MU (5.6% versus 1.5%; aOR = 2.9[1.8-4.6]), and medical MU (4.7% versus 1.2%; aOR = 3.0(1.4-6.6]) than heterosexual women. Bisexual women in MML states had higher past-year MU ((44.4% vs. 34.1%); aOR = 1.8[1.5-2.1]) and medical use (7.1% vs. 3.3% (aOR = 2.5[1.5-3.9]) than bisexual women in non-MML states. The odds of any past-year medical MU for bisexual versus heterosexual women was different in MML versus non-MML states (Exponentiated β = 0.53, p = 0.01). Gay men in MML states had higher past year MU (31.2% versus 25.7%; aOR = 1.6[1.1-2.5] and medical MU (6.4% vs 1.7%; aOR = 5.0[4.2-6.1]) than gay men in non-MML states., Conclusions: Results suggest that MMLs may differentially impact MU for sexual minority individuals-particularly bisexual women. Findings demonstrate the need for states enacting MMLs to consider potential differential impacts on LGB populations., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Aims: Amid changing marijuana policies in the Southern Cone, we examined relationships between marijuana-related risk factors and marijuana use among adolescents in Argentina, Chile, and Uruguay from 2001 to 2016., Methods: Using cross-sectional surveys from 8 th , 10 th , and 12 th graders and weighted time-varying effect models, we estimated associations between perceived risk (no/low risk versus moderate/great risk) and perceived availability (easy/very easy versus difficult/very difficult/not able to obtain) of marijuana, and any past-month marijuana use., Results: In all countries, marijuana use increased over time and adolescents who perceived no/low risk and easy availability had higher odds of use. In Argentina, the bivariate risk/use association weakened from 2001 (OR = 15.24, 95%CI = 9.63, 24.12) to 2004 [OR = 3.86 (2.72, 5.48)] and strengthened until 2011 [OR = 8.22 (7.56, 10.30)]; the availability/use association strengthened from 2005 [OR = 5.32 (4.05, 6.98)] to 2009 [OR = 20.77 (15.57, 27.70)] and weakened until 2014 [OR = 11.00 (9.11, 13.27)]. In Chile, the risk/use association weakened from 2001 [OR = 7.22 (6.57, 7.95)] to 2015 [OR = 5.58 (4.82, 6.48)]; the availability/use association weakened from 2001 [OR = 5.92 (4.96, 7.06)] to 2015 [OR = 4.10 (3.15, 5.34)]. In Uruguay, the risk/use association weakened from 2003 [OR = 34.22 (22.76, 51.46)] to 2016 [OR = 6.23 (4.96, 7.83)]; the availability/use association weakened from 2005 [OR = 29.13 (13.39, 63.39) to 2007 [OR = 9.42 (3.85, 23.07)], and strengthened until 2016 [OR = 22.68 (12.03, 42.76)]., Conclusions: Overall, the association between risk and use weakened in all countries, suggesting risk perceptions became a weaker determinant of marijuana use. Perceived availability remained strongly associated with use and may become an increasingly important driver of use (particularly in Uruguay and Argentina)., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Introduction: There is a lack of information on illicitly manufactured fentanyl and fentanyl analogue-related (IMF) unintentional overdose death trends over time. The study analyzes IMF-related unintentional overdose fatalities that occurred between July 2015 and June 2017 in Montgomery County, Ohio, an area with the highest rates of unintentional overdose mortality in Ohio., Methods: LC-MS/MS-based method was used to identify fentanyl analogs and metabolites in 724 unintentional overdose death cases. The Chi-square statistic was used to assess differences over time in demographic and drug-related characteristics., Results: The number of unintentional overdose death cases testing positive for IMFs increased by 377% between second half of 2015 and first half of 2017. The majority of decedents were white (82.5%) and male (67.8%). The proportion of fentanyl-only (no other analogs) cases declined from 89.2%-24.6% (p < 0.001), while proportion of fentanyl analogue-containing cases increased from 9.8%-70.3% (p < 0.001) between the second half of 2015 and first half of 2017. The most commonly identified fentanyl analogs were carfentanil (29.7%), furanyl fentanyl (14.1%) and acryl fentanyl (10.2%). Proportion of IMF cases also testing positive for heroin declined from 21.6% to 5.4% (p < 0.001), while methamphetamine positive cases increased from 1.4%-17.8% (p < 0.001) over the same time period., Discussion: Emergence of fentanyl analogs contributed to substantial increases in unintentional overdose deaths. The data indicate a growing overlap between the IMF and methamphetamine outbreaks. Continuous monitoring of local IMF trends and rapid information dissemination to active users are needed to reduce the risks associated with IMF use., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Medical cannabis laws (MCL) have received increased attention as potential drivers of cannabis use (CU), but little work has explored how the broader policy climate, independent of MCL, may impact CU outcomes. We explored the association between state-level policy liberalism and past-year cannabis use (CU) and cannabis use disorder (CUD)., Methods: We obtained state-level prevalence of past-year CU and CUD among past year cannabis users for ages 12-17, 18-25, and 26+ from the 2004-2006 and 2010-2012 National Surveys on Drug Use and Health. States were categorized as liberal, moderate, or conservative based on state-level policy liberalism rankings in 2005 and 2011. Linear models with random state effects examined the association between policy liberalism and past-year CU and CUD, adjusting for state-level social and economic covariates and medical cannabis laws., Results: In adjusted models, liberal states had higher average past-year CU than conservative states for ages 12-17 (+1.58 percentage points; p = 0.03) and 18-25 (+2.96 percentage points; p = 0.01) but not for 26+ (p = 0.19). CUD prevalence among past year users was significantly lower in liberal compared to conservative states for ages 12-17 (-2.87 percentage points; p = 0.045) and marginally lower for ages 26+ (-2.45 percentage points; p = 0.05)., Conclusion: Liberal states had higher past-year CU, but lower CUD prevalence among users, compared to conservative states. Researchers and policy makers should consider how the broader policy environment, independent of MCL, may contribute to CU outcomes., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Benzodiazepine overdose rates have increased in the US, largely from concomitant use of other drugs such as opioids. Studies are needed to examine trends in prescription tranquilizer (e.g., benzodiazepine) use-with a particular focus on use of other drugs such as opioids-to continue to inform prevention efforts., Methods: We conducted a secondary analysis of the 2005-2014 National Survey on Drug Use and Health, a repeated cross-sectional, nationally representative probability sample. Trends in past-year nonmedical tranquilizer use and trends in demographic and other past-year substance use characteristics among nonmedical users were examined (N = 560,099)., Results: Prevalence of nonmedical tranquilizer use remained stable from 2005/06 through 2013/14 at 2%. Prevalence of past-year heroin use and heroin use disorder both more than doubled among nonmedical tranquilizer users between 2005/06 and 2013/14 (Ps<.001). Nonmedical opioid use decreased between 2005/06 and 2013/14 (P < .001); however, opioid use disorder increased from 13.4% to 16.7% (P = .019). Prevalence doubled among those age >50 between 2005/06 and 2013/14 from 7.9% to 16.5% (P < .001), and nonmedical tranquilizer use among racial minorities also increased (Ps<.01). Prevalence of nonmedical use also increased among those with health insurance (P = .031), and this increase appeared to be driven by a 190.6% increase in nonmedical use among those with Medicare (from 2.6% to 7.4%; P = .002)., Conclusions: Characteristics of nonmedical tranquilizer users are shifting, and many shifts are related to past-year nonmedical prescription opioid use and heroin use. Prevention needs to be geared in particular towards older individuals and to those who use opioids nonmedically., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Prescription opioid overdose (POD) and heroin overdose (HOD) rates have quadrupled since 1999. Community-level socioeconomic characteristics are associated with opioid overdoses, but whether this varies by urbanicity is unknown., Methods: In this serial cross-sectional study of zip codes in 17 states, 2002-2014 (n = 145,241 space-time units), we used hierarchical Bayesian Poisson space-time models to analyze the association between zip code-level socioeconomic features (poverty, unemployment, educational attainment, and income) and counts of POD or HOD hospital discharges. We tested multiplicative interactions between each socioeconomic feature and zip code urbanicity measured with Rural-Urban Commuting Area codes., Results: Percent in poverty and of adults with ≤ high school education were associated with higher POD rates (Rate Ratio [RR], 5% poverty: 1.07 [95% credible interval: 1.06-1.07]; 5% low education: 1.02 [1.02-1.03]), while median household income was associated with lower rates (RR, $10,000: 0.88 [0.87-0.89]). Urbanicity modified the association between socioeconomic features and HOD. Poverty and unemployment were associated with increased HOD in metropolitan areas (RR, 5% poverty: 1.12 [1.11-1.13]; 5% unemployment: 1.04 [1.02-1.05]), and median household income was associated with decreased HOD (RR, $10,000: 0.88 [0.87-0.90]). In rural areas, low educational attainment alone was associated with HOD (RR, 5%: 1.09 [1.02-1.16])., Conclusions: Regardless of urbanicity, elevated rates of POD were found in more economically disadvantaged zip codes. Economic disadvantage played a larger role in HOD in urban than rural areas, suggesting rural HOD rates may have alternative drivers. Identifying social determinants of opioid overdoses is particularly important for creating effective population-level interventions., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objectives: To 1) estimate changes in the prevalence of daily and non-daily cigarette smoking among current (past 30-day) daily, non-daily, and non-cannabis users in the United States (U.S.) population; 2) examine time trends in current (past 30-day) cigarette smoking in daily, non-daily, and non-cannabis users ages 12+ from 2002 to 2015., Methods: Data collected annually from the 2002 to 2015 National Survey on Drug Use and Health (NSDUH) were employed. Linear time trends of daily and non-daily cigarette smoking were assessed using logistic regression with year as the predictor., Results: In 2015, the prevalence of current (past 30-day) cigarette smoking was highest among daily (54.57%), followed by non-daily (40.17%) and non-cannabis users (15.06%). The prevalence of non-daily cigarette smoking increased among daily cannabis users from 2002 to 2015, whereas non-daily cigarette smoking declined among non-daily cannabis users and non-cannabis users from 2002 to 2015. Daily cigarette smoking declined among both cannabis users and non-users; the most rapid decline was observed among daily cannabis users, followed by non-daily and then by non-cannabis users. However, the relative magnitude of the change in prevalence of daily cigarette smoking was similar across the three cannabis groups., Conclusions: Despite ongoing declines in cigarette smoking in the U.S., non-daily cigarette smoking is increasing among current cannabis users, a growing proportion of the U.S., Population: Daily and non-daily cigarette smoking continue to decline among those who do not use cannabis. Efforts to further tobacco control should consider novel co-use-oriented intervention strategies and outreach for the increasing population of cannabis users., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Aims: The purpose of this paper is to analyze characteristics of marijuana concentrate users, describe patterns and reasons of use, and identify factors associated with daily use of concentrates among U.S.-based cannabis users recruited via a Twitter-based online survey., Methods: An anonymous Web-based survey was conducted in June 2017 with 687 U.S.-based cannabis users recruited via Twitter-based ads. The survey included questions about state of residence, socio-demographic characteristics, and cannabis use including marijuana concentrates. Multiple logistic regression analyses were conducted to identify characteristics associated with lifetime and daily use of marijuana concentrates., Results: Almost 60% of respondents were male, 86% were white, and the mean age was 43.0 years. About 48% reported marijuana concentrate use. After adjusting for multiple testing, significant predictors of concentrate use included: living in "recreational" (AOR = 2.04; adj. p = .042) or "medical, less restrictive" (AOR = 1.74; adj. p = .030) states, being younger (AOR = 0.97, adj. p = .008), and daily herbal cannabis use (AOR = 2.57, adj. p = .008). Out of 329 marijuana concentrate users, about 13% (n = 44) reported daily/near daily use. Significant predictors of daily concentrate use included: living in recreational states (AOR = 3.59, adj. p = .020) and using concentrates for therapeutic purposes (AOR = 4.34, adj. p = .020)., Conclusions: Living in states with more liberal marijuana policies is associated with greater likelihood of marijuana concentrate use and with more frequent use. Characteristics of daily users, in particular, patterns of therapeutic use warrant further research with community-recruited samples., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Nearly half of marijuana users in the United States also smoke cigarillos, with many using the products as marijuana "blunts." The relationship between marijuana legalization and tobacco retail has not yet been examined. This study uses tobacco sales data to compare the cigarillo marketplace in states with legalized recreational marijuana to the overall U.S. marketplace in 2016., Methods: Cigarillo sales data from 2016 were obtained from the Nielsen Research Company in the following market regions: Denver, CO; Seattle, WA; Portland, OR; and the overall U.S. Descriptive statistics highlighted differences in the market share of various product features (e.g., flavors, brand, pack size) across regions., Results: Characteristics such as fruit flavors, single sticks, and 2-3 packs were more popular in legal marijuana regions compared to the overall U.S. Black & Mild, a brand not traditionally used for blunts, was the top brand nationally (32.8% market share), but Swisher was the top brand in legal marijuana regions. In Seattle and Portland, for example, over half of cigarillo sales were for Swisher products (59.1% and 52.1%, respectively). Cigarillo wraps (i.e., no tobacco filler) were particularly popular in Denver, constituting 11.4% all cigarillo sales versus 2.8% nationally., Conclusions: Cigarillo product characteristics traditionally associated with blunt use may shape the tobacco market in legal marijuana regions. As more states continue to legalize recreational marijuana, state and local governments should anticipate the potential impact on the tobacco marketplace and implement tobacco control policies (e.g., flavor bans, minimum pack sizes) that discourage product use., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: "Rosin tech" is an emerging solventless method consisting in applying moderate heat and constant pressure on marijuana flowers to prepare marijuana concentrates referred to as "rosin." This paper explores rosin concentrate-related Twitter data to describe tweet content and analyze differences in rosin-related tweeting across states with varying cannabis legal statuses., Method: English language tweets were collected between March 15, 2015 and April 17, 2017, using Twitter API. U.S. geolocated unique (no retweets) tweets were manually coded to evaluate the content of rosin-related tweets. Adjusted proportions of Twitter users and personal communication tweets per state related to rosin concentrates were calculated. A permutation test was used to analyze differences in normalized proportions between U.S. states with different cannabis legal statuses., Results: eDrugTrends collected 8389 tweets mentioning rosin concentrates/technique. 4164 tweets (49.6% of total sample) posted by 1264 unique users had identifiable state-level geolocation. Content analysis of 2010 non-retweeted tweets revealed a high proportion of media-related tweets (44.2%) promoting rosin as a safer and solventless production method. Tweet-volume-adjusted percentages of geolocated Twitter users and personal communication tweets about rosin were respectively up to seven and sixteen times higher between states allowing recreational use of cannabis and states where cannabis is illegal., Conclusion: Our results indicate that there are higher proportions of personal communication tweets and Twitter users tweeting about rosin in U.S. states where cannabis is legalized. Rosin concentrates are advertised as a safer, more natural form of concentrates, but more research on this emerging form of marijuana concentrate is needed., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: The opioid epidemic in the US is affecting pregnant women and their offspring, with rising numbers of maternal and neonatal treatment episodes. The aim of this study was to characterize pregnant drug users in order to inform intervention strategies based on sociodemographic, mental health, and substance use characteristics., Methods: Data on pregnant women aged 18-44 reporting past-year, nonmedical opioid use or use of non-opioid illegal drugs (other than marijuana) were analyzed from the National Survey on Drug Use and Health (2005-2014). Women (N = 818) were categorized into 3 groups: 1) use of opioids only (n = 281), 2) opioid-polydrug users (n = 241), and 3) other (non-opioid) illegal drug users (n = 296). Characteristics between the 3 groups of women were compared using bivariable analyses., Results: Most women were non-Hispanic White (67.6%), had a high school diploma or less education (61.0%), a household income <$20,000/year (72.2%), and health insurance coverage (84.3%). No significant differences between the three groups were found regarding sociodemographic characteristics. Past-30-day marijuana use was less prevalent among opioid-only users (10.9%) compared to opioid-polydrug users (43.6%) and other pregnant illegal drug users (27.6%) (P < 0.001) and past-year drug/alcohol treatment was less prevalent among opioid-only users (6.3%) compared to opioid-polydrug users (20.3%) and other illegal drug users (8.3%) (P = 0.002). Opioid-only users also reported lower prevalence of past-year depression (P < 0.001) and anxiety (P = 0.039)., Conclusions: Pregnant drug-using women were often of low socioeconomic status, with mental health and substance use patterns suggesting the need for targeted mental health/substance use screening and interventions before and during pregnancy, particularly for opioid-polydrug users., (Copyright © 2017. Published by Elsevier B.V.)

Background: Ecstasy/MDMA has been one of the most prevalent party drugs for decades, and powder ecstasy recently increased in popularity. We examined trends in use to determine who to best target for prevention and harm reduction., Methods: Secondary analysis of the 2007-2014 National Survey on Drug Use and Health, a repeated cross-sectional, nationally representative probability sample, was conducted. Linear trends in past-year ecstasy use and trends in demographic and other past-year substance use characteristics among ecstasy users were examined among participants ages 12-34 (N=332,560)., Results: Past-year prevalence of ecstasy use was stable across years at 2% (P=0.693). Over time, the proportion of ecstasy users with a college degree increased from 11.5% in 2007/08 to 24.5% in 2013/14 (P<0.001). The proportion of users who were age 12-17 decreased, as did proportions of users who are non-Hispanic black, and reported income <$20,000/year (Ps<0.001). Prevalence of past-year use of marijuana, LSD, ketamine, and DMT/AMT/Foxy increased among ecstasy users (Ps<0.05); DMT/AMT/Foxy use increased more than four-fold from 2.1% in 2007/08 to 8.7% in 2013/14. Perception of great risk associated with LSD use decreased among users and ease of obtaining LSD increased (Ps<0.05). Past-year use of 5 or more other substances also increased over time (P<0.05)., Conclusions: Ecstasy use in the US appears to be increasing among those with college degrees and use of other substances among ecstasy users is growing-particularly use of otherwise rare substances such as tryptamines. Results inform prevention and harm reduction strategies in this increasingly shifting group of ecstasy users., (Copyright © 2017 Elsevier B.V. All rights reserved.)