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BackgroundAdverse childhood experiences are prevalent robust risk factors for the development of substance use problems. However, less is known about the causal mechanisms that explain these relationships. While directly preventing adverse childhood experiences is ideal, it is not always possible. In such cases, the mechanisms themselves may be amenable to intervention, allowing for the effective prevention of problematic substance use among children exposed to adversity. Identifying such mechanisms is therefore a critical step for efforts aiming to reduce the high individual and societal burdens associated with substance use globally. ObjectiveThis study aims to systematically identify and synthesize evidence on the modifiable mediators and moderators of the relationship between adverse childhood experiences and substance use outcomes in young people (age 10-24 years). MethodsA systematic review will be conducted using PubMed, MEDLINE, PsycINFO, Web of Science, and CINAHL databases to determine the modifiable mediators and moderators of the relationship between adverse childhood experiences and substance use in young people. Data from the review will be qualitatively synthesized, unless we identify a sufficient number of studies (at least five) that examine the same type of adversity (eg, physical or sexual abuse) and the same mediator/moderator, in which case a quantitative synthesis (meta-analysis) will be conducted. If a quantitative synthesis is warranted, standardized effect estimates of the indirect (mediated) effect between adverse childhood experiences and substance use outcomes will be combined using a random-effects meta-analysis. Mediators/moderators will be grouped according to a socioecological perspective, using the four levels of individual, interpersonal, community, and public policy/culture. ResultsElectronic searches were completed in August 2019. A total of 4004 studies were included for screening after removing duplicates. After evaluating titles and abstracts against eligibility criteria, a further 3590 studies were excluded, leaving 415 studies for full-text screening. The results of the review are expected to be available by December 2020. ConclusionsThe mechanisms linking adverse childhood experiences and substance use outcomes in young people are vital targets for substance use prevention efforts. This review will provide evidence to inform the development of prevention strategies in order to interrupt the negative life trajectory that can begin with childhood adversity. Trial RegistrationPROSPERO International Prospective Register of Systematic Reviews CRD42020148773; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020148773 International Registered Report Identifier (IRRID)DERR1-10.2196/22368

OBJECTIVE: Cannabis use disorder diagnoses are increasing among U.S. adults and are more prevalent among people with comorbid psychiatric disorders. Recent changes in cannabis laws, increasing cannabis availability, and higher-potency cannabis may have placed people with cannabis use and psychiatric disorders at disproportionately increasing risk for cannabis use disorder. The authors used Veterans Health Administration (VHA) data to examine whether trends in cannabis use disorder prevalence among VHA patients differ by whether they have psychiatric disorders. METHODS: VHA electronic health records from 2005 to 2019 (N range, 4,332,165-5,657,277) were used to identify overall and age-group-specific (

In the United States, cannabis is increasingly used to manage chronic pain. Veterans Health Administration (VHA) patients are disproportionately affected by pain and may use cannabis for symptom management. Because cannabis use increases the risk of cannabis use disorders (CUDs), we examined time trends in CUD among VHA patients with and without chronic pain, and whether these trends differed by age. From VHA electronic health records from 2005 to 2019 (∼4.3-5.6 million patients yearly), we extracted diagnoses of CUD and chronic pain conditions ( International Classification of Diseases [ ICD ]- 9-CM , 2005-2014; ICD-10-CM , 2016-2019). Differential trends in CUD prevalence overall and age-stratified (

ObjectiveIn the United States, adult cannabis use has increased over time, but less information is available on time trends in cannabis use disorder. The authors used Veterans Health Administration (VHA) data to examine change over time in cannabis use disorder diagnoses among veterans, an important population subgroup, and whether such trends differ by age group (

As opioid prescribing has declined, it is unclear how the landscape of prescription pain treatment across the U.S. has changed. We used nationally-representative data from the Medical Expenditure Health Survey, 2014 to 2018 to examine trends in prescriptions for opioid and non-opioid pain medications, including acetaminophen, non-steroidal anti-inflammatory drugs, gabapentinoids, and antidepressants among U.S. adults with self-reported pain. Overall, from 2014 to 2018, the percentage of participants receiving a prescription for opioids declined, (38.8% vs 32.8%), remained stable for non-steroidal anti-inflammatory drugs (26.8% vs 27.7%), and increased for acetaminophen (1.6% vs 2.3%), antidepressants (9.6% vs 12.0%) and gabapentinoids (13.2% vs 19.0%). In this period, the adjusted odds of receiving an opioid prescription decreased (aOR = .93, 95% CI = .90-.96), while the adjusted odds of receiving antidepressant, gabapentinoid and acetaminophen prescriptions increased (antidepressants: aOR = 1.08, 95% CI = 1.03-1.13 gabapentinoids: aOR = 1.11, 95% CI = 1.06-1.17; acetaminophen: aOR = 1.10, 95% CI: 1.02-1.20). Secondary analyses stratifiying within the 2014 to 2016 and 2016 to 2018 periods revealed particular increases in prescriptions for gabapentinoids (aOR = 1.13, 95% CI = 1.05-1.21) and antidepressants (aOR = 1.23, 95% CI = 1.12-1.35) since 2016. PERSPECTIVE: These data demonstrate that physicians are increasingly turning to CDC-recommended non-opioid medications for pain management, particularly antidepressants and gabapentinoids. However, evidence for these medications' efficacy in treating numerous common pain conditions, including low back pain, remains limited.

BackgroundPrevalence of fentanyl-laced counterfeit prescription pills has been increasing in the US, possibly placing a wider population at risk for unintentional exposure. We aimed to determine whether there have been shifts in the number of fentanyl seizures and in the form of fentanyl seized in the US.MethodsWe examined quarterly national seizure data from High Intensity Drug Trafficking Areas to determine the number of drug seizures in the US containing fentanyl from January 2018 through December 2021. Generalized additive models were used to estimate trends in the number and weight of pill and powder seizures containing fentanyl.ResultsThere was an increase both in the number of fentanyl-containing powder seizures (from 424 in 2018 Quarter 1 [Q1] to 1539 in 2021 Quarter 4 [Q4], β = 0.94, p

BackgroundSubstance use disorders (SUD) elevate the risk for COVID-19 hospitalization, but studies are inconsistent on the relationship of SUD to COVID-19 mortality.MethodsVeterans 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).ResultsAmong 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.ConclusionsIn 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.

ObjectiveThe Department of Veterans Affairs' (VA) electronic health records (EHR) offer a rich source of big data to study medical and health care questions, but patient eligibility and preferences may limit generalizability of findings. We therefore examined the representativeness of VA veterans by comparing veterans using VA healthcare services to those who do not.MethodsWe analyzed data on 3051 veteran participants age ≥ 18 years in the 2019 National Health Interview Survey. Weighted logistic regression was used to model participant characteristics, health conditions, pain, and self-reported health by past year VA healthcare use and generate predicted marginal prevalences, which were used to calculate Cohen's d of group differences in absolute risk by past-year VA healthcare use.ResultsAmong veterans, 30.4% had past-year VA healthcare use. Veterans with lower income and members of racial/ethnic minority groups were more likely to report past-year VA healthcare use. Health conditions overrepresented in past-year VA healthcare users included chronic medical conditions (80.6% vs. 69.4%, d = 0.36), pain (78.9% vs. 65.9%; d = 0.35), mental distress (11.6% vs. 5.9%; d = 0.47), anxiety (10.8% vs. 4.1%; d = 0.67), and fair/poor self-reported health (27.9% vs. 18.0%; d = 0.40).ConclusionsHeterogeneity in veteran sociodemographic and health characteristics was observed by past-year VA healthcare use. Researchers working with VA EHR data should consider how the patient selection process may relate to the exposures and outcomes under study. Statistical reweighting may be needed to generalize risk estimates from the VA EHR data to the overall veteran population.

BackgroundFirearm violence remains a persistent public health threat. Comparing the impact of targeted high-risk versus population-based approaches to prevention may point to efficient and efficacious interventions. We used agent-based modeling to conduct a hypothetical experiment contrasting the impact of high-risk (disqualification) and population-based (price increase) approaches on firearm homicide in New York City (NYC).MethodsWe simulated 800,000 agents reflecting a 15% sample of the adult population of NYC. Three groups were considered and disqualified from all firearm ownership for five years, grouped based on prevalence: low prevalence (psychiatric hospitalization, alcohol-related misdemeanor and felony convictions, 0.23%); moderate prevalence (drug misdemeanor convictions, domestic violence restraining orders, 1.03%); and high prevalence (all other felony/misdemeanor convictions, 2.30%). Population-level firearm ownership was impacted by increasing the price of firearms, assuming 1% price elasticity.ResultsIn this hypothetical scenario, to reduce firearm homicide by 5% in NYC, 25% of the moderate prevalence group, or 12% of the high prevalence group needed to be effectively disqualified; even when all of the low prevalence group was disqualified, homicide did not decrease by 5%. An 18% increase in price similarly reduced firearm homicide by 5.37% (95% CI 4.43-6.31%). Firearm homicide declined monotonically as the proportion of disqualified individuals increased and/or price increased. A combined intervention that both increased price and effectively disqualified "high-risk" groups achieved approximately double the reduction in homicide as any one intervention alone. Increasing illegal firearm ownership by 20%, a hypothetical response to price increases, did not meaningfully change results.ConclusionA key takeaway of our study is that adopting high-risk versus population-based approaches should not be an "either-or" question. When individual risk is variable and diffuse in the population, "high-risk approaches" to firearm violence need to focus on relatively prevalent groups and be highly efficacious in disarming people at elevated risk to achieve meaningful reductions in firearm homicide, though countering issues of social justice and stigma should be carefully considered. Similar reductions can be achieved with population-based approaches, such as price increases, albeit with fewer such countering issues.

Background: Being bullied online is associated with being bullied in school. However, links between online bullying and violence-related experiences are minimally understood. We evaluated potential disparities in these associations to illuminate opportunities to reduce school-based violence. Methods: We used five cohorts of Youth Risk Behavior Survey national cross-sectional data (2011-2019, N[subscript total] = 73 074). We used survey-weighted logistic and multinomial models to examine links between online bullying and five school-based violence-related experiences: offline bullying, weapon carrying, avoiding school due to feeling unsafe, being threatened/injured with a weapon, and physical fighting. We examined interactions by sex, race/ethnicity, and sexual identity. Results: Being bullied online was positively associated with all offline violence-related behaviors. Groups with stronger associations between online bullying and physical fighting, including boys, adolescents whose sexual identity was gay/lesbian or unsure, and many adolescents of color (Black, Hispanic/Latino, and Asian/Pacific Islander adolescents), had stronger associations between online bullying and either weapon carrying or avoiding school. Conclusions: Online bullying is not an isolated harmful experience; many marginalized adolescents who experience online bullying are more likely to be targeted in school, feel unsafe, get in fights, and carry weapons. Reduction of online bullying should be prioritized as part of a comprehensive school-based violence prevention strategy.

PurposeDepression is increasingly common among US adolescents; the extent to which social media exposure contributes to this increase remains controversial.MethodsWe used Monitoring the Future data from 8th and 10th grade students (n = 74,472), 2009-2017, to assess the relationship between daily social media use and depressive symptoms. Self-reported depressive symptom score (range: 4-20) was assessed continuously using a log-transformed outcome and at varying cut scores with logistic regression analyses. First, these outcomes were examined overall, comparing adolescents using social media daily to adolescents who were not. We then estimated predicted depressive symptom scores using 26 predictors in order to establish underlying depression risk. We partitioned students into depression risk quintiles to control for confounding due to underlying depression risk and examine heterogeneity in the association between social media use and depressive symptoms. Sensitivity analyses were used to test the robustness of results with different configurations of the predicted score model, and overall associations were examined in two-year groups to identify differences in effects.ResultsFor girls, in adjusted risk-stratified analysis, daily social media use was not associated with high (vs. low) depressive symptoms. For boys, results were inconsistent, suggesting a protective effect of daily social media use at some cut scores. Results were consistent across sensitivity analyses, and any potential harmful effects appear to be limited to 2009-2010, limiting the evidence supporting social media as a current risk factor for depressive symptoms.ConclusionsAmong US adolescents, daily social media use is not a strong or consistent risk factor for depressive symptoms.

Although historically cisgender women (i.e., women whose sex assigned at birth is consonant with their gender) in the United States have had lower levels of alcohol consumption than cisgender men, [...]

Sexual minority adolescents have worse sleep health than their peers. Adolescents who identify as heterosexual and report prior same-sex sexual contact (termed 'discordant heterosexuals') have elevated health risks, but little is known about this group's sleep health. This study examined 2015-2017 Youth Risk Behavior Survey data (n = 12,773 high school students) comparing discordant heterosexuals to their concordant (i.e. sexual identity is concordant with reported sex of sexual contact) heterosexual, bisexual, gay and lesbian peers on three sleep outcomes: sufficient ([greater than or equal to]8 hours), short ([less than or equal to]6 hours) and extremely limited sleep ([less than or equal to]4 hours). Both discordant heterosexual (aOR:0.64, 95% CI:0.47, 0.86) and bisexual students (aOR:0.69, CI:0.56, 0.85) had lower odds of sufficient sleep compared to concordant heterosexuals, even after adjustment for demographic factors and substance use. Discordant heterosexual (aOR:1.29, CI:1.01, 1.66) and bisexual (aOR:1.74, CI:1.54, 1.98) students have higher odds of short sleep. Discordant heterosexual (aOR:1.94, CI:1.36, 2.77) and bisexual students (aOR:2.72, CI:2.23, 3.31) also had higher odds of extremely limited sleep. Victimization may partially explain some of these associations. Sleep health is one factor that may drive health disparities, and efforts to ensure that adolescents are safe and secure in sexual behavior and identity is important to reducing these disparities.

PurposeThe purpose of this study was to estimate the effect of firearm involvement during violent victimization on the level of distress experienced and daily functioning within sociodemographic subgroups.MethodsWe used cross-sectional data from the National Crime Victimization Survey (n = 5698) and Targeted Maximum Likelihood Estimation. Sociodemographic subgroups were defined by age, race, sex, and socioeconomic position. Outcomes included experiencing the victimization as severely distressing and problems in the workplace or at school, or with peers or family.ResultsAmong people victimized with a firearm, nearly 40% experienced the victimization as severely distressing and 28% reported daily functioning problems as a result of the victimization, compared with 25% and 27% of those victimized without a firearm. In most of the subgroups examined, a greater proportion of people described the event as severely distressing when a firearm was involved in the victimization, ranging up to 19 percentage points higher among women and among black respondents (95% CI for women = 10%-28%; for blacks = 6%-31%).ConclusionsOur findings suggest an almost universal negative response to firearm involvement during a violent victimization as compared with violent victimizations involving other or no weapons. These findings highlight the need for efforts by medical and mental health practitioners to address the potential sequelae of experiencing severe distress during a firearm victimization.