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This article examines the extent to which U.S. outpatient substance abuse treatment (OSAT) facilities provide HIV counseling and testing (C&T) to clients between 1995 and 2005. We also examine organizational and client characteristics associated with OSAT facilities' provision of HIV C&T. Data were collected from a nationally representative sample of outpatient treatment facilities in 1995 (n = 618), 2000 (n = 571), and 2005 (n = 566). Results show that in 1995, 26.8% of OSAT clients received HIV C & T; by 2005, this proportion had increased, but only to 28.8%. Further, results from random-effects interval regression analysis show that C&T is especially widespread in public and nonprofit facilities, in methadone facilities, and in units that serve injection drug users and commercial sex workers. HIV C&T was also more widespread in units that employed formal intake protocols. Despite widespread efforts to increase HIV C&T services in OSAT care, only a small and stable minority of clients receive these services. Adoption of formal intake procedures may provide one vehicle to increase provision of C&T services. [ABSTRACT FROM AUTHOR]

Objective: To examine the extent to which U.S. methadone maintenance facilities meet established standards for minimum dosages, 1988-2005.Data Source: Data were collected from a nationally representative sample of outpatient treatment facilities in 1988 (n=172), 1990 (n=140), 1995 (n=116), 2000 (n=150), and 2005 (n=146).Study Design: Random-effects multiple regression analysis was used to examine unit characteristics associated with below recommended doses.Data Collection: Data regarding the proportion of patients who received maintenance dosages of <40, 60, and 80 mg/day were collected from unit directors and clinical supervisors.Principal Findings: Forty-four percent of patients receive doses of at least 80 mg/day--the threshold identified as recommended practice in recent work. Thirty-four percent of patients receive doses below 60 mg/day, while 17 percent receive doses below 40 mg/day. Units that serve a high proportion of African American or Latino clients were more likely to report low-dose care. Units managed by individuals who strongly favor abstinence models (e.g., Narcotics Anonymous) were more likely to provide low-dose care.Conclusions: One-third of methadone facilities provide doses below recommended levels. Managerial attitudes about abstinence and their relationship to low doses underscore the contested role of methadone in treatment of opiate disorders. [ABSTRACT FROM AUTHOR]

BACKGROUND: Many states recently have experimented with managed care as a way both to control costs and to enhance continuity of care in their publicly financed programs. A few states have applied managed care models to the care of chronically ill children. One marker for the effects of managed care is changes in use of the emergency department (ED). OBJECTIVE: We sought to determine whether a managed care program can reduce ED use for children with chronic health problems. SUBJECTS: We studied chronically ill children who were dually enrolled in Michigan's Title V program for children with special health care needs and Medicaid and who were enrolled in a managed care option at some time during the study period. The managed care model emphasized care coordination and did not include strong financial incentives for utilization and cost control. Sample consisted of 8580 person-months. METHOD: We used a fixed-effect negative binomial Poisson regression model to compare ED use before and after joining a managed care plan to test whether managed care use was associated with reduced likelihood of ED use. RESULTS: Managed care enrollment was associated with a 23% reduction in the incidence of ED use among children dually enrolled in Medicaid and Title V. CONCLUSIONS: A managed care model is associated with statistically significant and substantive reductions in observed use of ED care within an important population of children facing chronic illness. [ABSTRACT FROM AUTHOR]

OBJECTIVES: We explored changing relations between substance use, welfare receipt, and substance-abuse treatment among low-income mothers before and after welfare reform. METHODS: We examined annual data from mothers aged 18 to 49 years in the 1990-2001 National Household Survey of Drug Abuse and the 2002 National Survey of Drug Use and Health. Logistic regression was used to examine determinants of treatment receipt. RESULTS: Among low-income, substance-using mothers, the proportion receiving cash assistance declined from 54% in 1996 to 38% in 2001. The decline was much smaller (37% to 31%) among low-income mothers who did not use illicit substances. Low-income, substance-using mothers who received cash assistance were much more likely than other low-income, substance-using mothers to receive treatment services. Among 2002 National Survey of Drug Use and Health respondents deemed 'in need' of substance-abuse treatment, welfare recipients were significantly more likely than nonrecipients to receive such services (adjusted odds ratio=2.31; P<.05). Controlling for other factors, welfare receipt was associated with higher prevalence of illicit drug use. Such use declined among both welfare recipients and other mothers between 1990 and 2001. CONCLUSIONS: Welfare is a major access point to identify and serve low-income mothers with substance-use disorders, but it reaches a smaller proportion of illicit drug users than it did prereform. Declining welfare receipt among low-income mothers with substance abuse disorders poses a new challenge in serving this population. [ABSTRACT FROM AUTHOR]

The 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) changed the nature, purpose, and financing of public aid. Researchers, administrators, and policymakers expressed special concern about the act's impact on low-income mothers with substance use disorders. Before PRWORA's passage, however, little was known about the true prevalence of these disorders among welfare recipients or about the likely effectiveness of substance abuse treatment interventions for welfare recipients. Subsequent research documented that substance abuse disorders are less widespread among welfare recipients than was originally thought and are less common than other serious barriers to self-sufficiency. This research also showed significant administrative barriers to the screening, assessment, and referral of drug-dependent welfare recipients. This article summarizes current research findings and examines implications for welfare reform reauthorization. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Hepatitis C (HCV) has emerged as a major epidemic among injection drug users (IDUs), with observed prevalence exceeding 70% in many American and European cities. This article explores the potential of syringe exchange programs (SEPs) to reduce HCV incidence and prevalence. DESIGN: A random-mixing epidemiological model is used to examine the potential impact of harm reduction interventions. METHODS: Steady-state analysis is used to scrutinize the impact of SEP on HCV incidence and prevalence and to examine the accuracy of short-term incidence analysis in predicting long-run program effects. RESULTS: SEP is predicted to have little impact on HCV incidence and prevalence within realistic populations of IDUs. CONCLUSIONS: Short-term incidence analysis substantially overstates SEP effectiveness and cost-effectiveness in preventing HCV. More comprehensive harm reduction models, coupled with referral of active IDUs to treatment, must complement syringe exchange to successfully contain highly infectious blood-borne diseases. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This study analyzed the relationship between prenatal maternal smoking and sudden infant death syndrome (SIDS) and examined the cost-effectiveness of smoking cessation interventions. METHODS: All recorded US singleton SIDS deaths from the 1995 birth cohort with birthweight exceeding 500 g were investigated. Infants with available maternal smoking data were matched with controls who survived to 1 year. Conditional logistic regression was used to estimate SIDS risks and accompanying cost-effectiveness. RESULTS: A total of 23.6% of singleton SIDS deaths appear to be attributable to prenatal maternal smoking. Typical cessation services available to all pregnant smokers could avert 108 SIDS deaths annually, at an estimated cost of $210,500 per life saved. CONCLUSIONS: Typical prenatal smoking cessation programs are highly cost-effective but have limited impact on the population incidence of SIDS. [ABSTRACT FROM AUTHOR]

Objective: To examine associations between passive exposure to opioid crisis information and public attitudes toward opioid use disorder (OUD) policies and stigma among United States (US) adults., Methods: A nationally representative survey of 6543 US adults was conducted from December 2023 to January 2024. Participants reported passive exposure to opioid crisis information from various sources. Outcome measures included preferences for national and local harm-reduction policies, discriminatory practices, carceral approaches, and OUD stigma. Multivariable regression analyses were performed, controlling for demographic factors., Results: Over half (n = 3863, 59.4 %) of participants reported passive exposure to opioid crisis information. Exposure from medical professionals (b = 0.143, p = 0.001), family/friends (b = 0.118, p = 0.013), print media (b = 0.135, p = 0.019), and web searches (b = 0.164, p = 0.002) was associated with increased support for local harm-reduction policies. Social media exposure was negatively associated with support for discriminatory practices (b = -0.101, p = 0.043). Exposure from medical professionals was negatively associated with OUD stigma (b = -0.090, p = 0.014). No significant associations were found between information exposure and support for national harm-reduction policies or carceral approaches., Conclusions: Despite widespread media coverage of the opioid crisis, passive information exposure was only associated with increased support for local, not national, harm-reduction policies. The modest exposure rate (59.4 %) suggests an attention gap between information availability and public engagement. The differential effectiveness of information channels suggests that communication strategies emphasizing community-level initiatives and leveraging specific sources like healthcare providers and interpersonal networks may be particularly important for building public support for evidence-based OUD prevention policies., Competing Interests: Declaration of competing interest None to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Recovery support workers (RSWs) who provide social support interventions for people who use drugs (PWUD) often face challenges that can jeopardize the well-being, efficacy and sustainability of this essential workforce. To date, little has been reported on the types of implementation strategies used to support RSWs. We describe and evaluate a multifaceted implementation strategy package to support Reducing Opioid Mortality in Illinois (ROMI), a paired peer recovery coach and case manager (PRC-CM) intervention for PWUD with recent criminal-legal involvement in urban and rural settings., Methods: ROMI utilized a remote, hub and spoke-administered multifaceted implementation strategy package to support PRCs-CMs to deliver evidence-based services to PWUD with criminal-legal involvement. The core strategies included: (a) comprehensive training; (b) individual clinical supervision; (c) group consultation; and (d) centralized technical assistance. We evaluated the implementation strategy package using a mixed-methods design including qualitative interviews with the intervention staff to explore their experiences with each strategy component, as well as a quantitative coding of topics discussed during supervision and group consultation meetings to estimate prioritization of issues and balance of topics between strategy type., Results: Between January 2019 and January 2024, the study interviewed 8 PRC-CMs and quantitatively coded 568 sessions (79 group consultations and 489 individual supervisory) for discussion themes. The hub-and-spoke model allowed for centralized access to highly skilled supervisory staff as well as knowledge sharing across geographically remote teams. The therapeutic space to process feelings and emotional support provided during individual supervision was noted to be an essential resource by PRC-CMs. Group consultation facilitated camaraderie, mutual support and continual learning through dynamic and responsive trainings. Frustrations around resource limitations and systemic barriers facing their clients remained a dominant concern for PRCs-CMs, and was incompletely addressed by the technical assistance strategy., Conclusion: Understanding the practical components and individual strengths of the implementation strategies required to support the implementers of complex interventions such as social support and navigation for PWUD with criminal-legal involvement elucidates the organizational and professional capacities that may be required for real world implementation., Trial Registration: NCT04925427., Competing Interests: Declaration of competing interest This work was supported by a grant from the National Institute on Drug AbuseUG1 DA050066. The funder had no role in the design, data collection, analysis, and interpretation of this study., (Copyright © 2024. Published by Elsevier Inc.)

Importance: Opioid-related overdose accounts for almost 80 000 deaths annually across the US. People who use drugs leaving jails are at particularly high risk for opioid-related overdose and may benefit from take-home naloxone (THN) distribution., Objective: To estimate the population impact of THN distribution at jail release to reverse opioid-related overdose among people with opioid use disorders., Design, Setting, and Participants: This study developed the agent-based Justice-Community Circulation Model (JCCM) to model a synthetic population of individuals with and without a history of opioid use. Epidemiological data from 2014 to 2020 for Cook County, Illinois, were used to identify parameters pertinent to the synthetic population. Twenty-seven experimental scenarios were examined to capture diverse strategies of THN distribution and use. Sensitivity analysis was performed to identify critical mediating and moderating variables associated with population impact and a proxy metric for cost-effectiveness (ie, the direct costs of THN kits distributed per death averted). Data were analyzed between February 2022 and March 2024., Intervention: Modeled interventions included 3 THN distribution channels: community facilities and practitioners; jail, at release; and social network or peers of persons released from jail., Main Outcomes and Measures: The primary outcome was the percentage of opioid-related overdose deaths averted with THN in the modeled population relative to a baseline scenario with no intervention., Results: Take-home naloxone distribution at jail release had the highest median (IQR) percentage of averted deaths at 11.70% (6.57%-15.75%). The probability of bystander presence at an opioid overdose showed the greatest proportional contribution (27.15%) to the variance in deaths averted in persons released from jail. The estimated costs of distributed THN kits were less than $15 000 per averted death in all 27 scenarios., Conclusions and Relevance: This study found that THN distribution at jail release is an economical and feasible approach to substantially reducing opioid-related overdose mortality. Training and preparation of proficient and willing bystanders are central factors in reaching the full potential of this intervention.

Importance: Male gender expressivity (MGE), which reflects prevalent sociocultural pressures to convey masculinity, has been associated with health. Yet, little is known about associations of MGE with the diagnosis and treatment of modifiable cardiovascular disease (CVD) risks., Objective: To investigate associations of MGE with modifiable CVD risk diagnoses and treatment in men., Design, Setting, and Participants: This population-based cohort study included data from waves I (1994-1995), IV (2008-2009), and V (2016-2018) of the US National Longitudinal Study of Adolescent to Adult Health (Add Health). Participants were male adolescents (age 12-18 years) followed up longitudinally through younger adulthood (age 24-32 years) and adulthood (age 32-42 years). Data were analyzed from January 5, 2023, to August 28, 2024., Exposure: Male gender expressivity was quantified in adolescence and younger adulthood using an empirically-derived and validated measurement technique that incorporates participants' responses to existing Add Health survey items to capture how similarly participants behave to same-gendered peers., Main Outcomes and Measures: Outcomes included self-reported diagnoses of CVD risk conditions (hypertension, diabetes, or hyperlipidemia) in adult men with elevated blood pressure, hemoglobin A1c, or non-high-density lipoprotein cholesterol levels, and self-reported treatment with antihypertensive, hypoglycemic, or lipid-lowering medications in adults reporting hypertension, diabetes, or hyperlipidemia. Multivariable regression was used to examine associations of adolescent and younger adult MGE with adult CVD risk diagnoses and treatment, adjusting for sociodemographic covariates., Results: Among 4230 eligible male participants, most were non-Hispanic White (2711 [64%]) and privately insured (3338 [80%]). Their mean (SD) age was 16.14 (1.81) years in adolescence, 29.02 (1.84) years in younger adulthood, and 38.10 (1.95) years in adulthood. Compared with participants whose younger adult MGE was below average, those with higher younger adult MGE were overall less likely to report hypertension (22% vs 26%; P < .001), diabetes (5% vs 8%; P < .001), and hyperlipidemia (19% vs 24%; P < .001) diagnoses and diabetes treatment (3% vs 5%; P = .02) as adults. In multivariable models, every SD increase in adolescent MGE was associated with lower probabilities of adult hypertension treatment (MGE,-0.11; 95% CI, -0.16 to -0.6) and diabetes diagnoses (MGE, -0.15; 95% CI, -0.27 to -0.03). Higher younger adult MGE was associated with lower probabilities of adult hypertension diagnoses (MGE, -0.04; 95% CI, -0.07 to -0.01), hypertension treatment (MGE, -0.07; 95% CI, -0.13 to -0.01), and diabetes treatment (MGE, -0.10; 95% CI, -0.20 to -0.01). Adolescent and younger adult MGE outcomes were not associated with other adult CVD outcomes., Conclusions and Relevance: In this cohort study of US males, higher adolescent and younger adult MGE was associated with lower adult hypertension and diabetes diagnoses and treatment. These findings suggest that males with high MGE may bear distinctive risks and correspondingly benefit from tailored public health efforts to prevent downstream CVD.

Importance: In 2023, more than 80 000 individuals died from an overdose involving opioids. With almost two-thirds of the US jail population experiencing a substance use disorder, jails present a key opportunity for providing lifesaving treatments, such as medications for opioid use disorder (MOUD)., Objectives: To examine the prevalence of MOUD in US jails and the association of jail- and county-level factors with MOUD prevalence using a national sample., Design, Setting, and Participants: This survey study used a nationally representative cross-sectional survey querying 1028 jails from June 2022 to April 2023 on their provision of substance use disorder treatment services. The survey was conducted via mail, phone, and the internet. County-level data were linked to survey data, and binary logistic regressions were conducted to assess the probability that a jail offered any treatment and MOUD. A stratified random sample of 2791 jails identified by federal lists of all jails in the US was invited to participate. Staff members knowledgeable about substance use disorder services available in the jail completed the survey., Exposures: US Census region, urbanicity, jail size, jail health care model (direct employees or contracted), county opioid overdose rate, county social vulnerability (measured using the Centers for Disease Control and Prevention 2020 Social Vulnerability Index summary ranking, which ranks counties based on 16 social factors), and access to treatment in the county were assessed., Main Outcomes and Measures: Availability of any type of substance use disorder treatment (eg, self-help meetings), availability of MOUD (ie, buprenorphine, methadone, and naltrexone) to at least some individuals, and availability of MOUD to any individual with an OUD were assessed., Results: Of 2791 invited jails, 1028 jails participated (36.8% response rate). After merging the sample with county data, 927 jails were included in analysis, representative of 3157 jails nationally after weighting; most were from nonmetropolitan counties (‭1756 jails [55.6%; 95% CI, 52.3%-59.0%]) and had contracted health care services (1886 jails [59.7%; 95% CI, 56.5%-63.0%]); fewer than half of these jails (1383 jails [43.8%; 95% CI, 40.5%-47.1%]) offered MOUD to at least some individuals, and 405 jails (12.8%; 95% CI, 10.7% to 14.9%) offered MOUD to anyone with an OUD. Jails located in counties with lower social vulnerability (adjusted odds ratio per 1-percentile increase = 0.28; 95% CI, 0.19-0.40) and shorter mean distances to the nearest facility providing MOUD (adjusted odds ratio per 1-SD increase, 0.80; 95% CI, 0.72-0.88) were more likely to offer MOUD., Conclusions and Relevance: In this study, few jails indicated offering frontline treatments despite being well positioned to reach individuals with an OUD. These findings suggest that efforts and policies to increase MOUD availability in jails and the surrounding community may be associated with helping more individuals receive treatment.

Background: Over 3 million Americans have an opioid use disorder (OUD), and only a fraction receive treatment. Public opinion is crucial in enacting evidence-based policies. Few studies have examined the public's perception of blame for the ongoing opioid overdose epidemic directed at distinct groups. We assessed US adults' perceived blameworthiness for the epidemic and examined factors that may influence the perceived blameworthiness., Methods: We conducted a national survey in 2022 using the AmeriSpeak® panel to assess US adults' perception of blame toward individuals with an OUD and external contributors. Of the 3335 eligible panel members invited to participate, 1233 (37%) completed the survey. We developed a measure of knowledge and understanding of OUD, with a higher value indicating a greater understanding of the nature of OUD and recovery-including knowledge and beliefs on evidence-based treatment and relapse. We analyzed the relationships between sources of blame, knowledge, and understanding of OUD, and individual-level correlates., Results: Higher score of knowledge and understanding of OUD was associated with lower odds of blaming individuals with OUD (odds ratio [OR] = 0.73, 95% confidence interval [CI] = [0.51, 1.05]) and greater odds of blaming external contributors: healthcare providers (OR = 1.49, 95% CI = [1.05, 2.12]), pharmaceutical companies (OR = 2.17, 95% CI = [1.50, 3.15]), and health insurance companies (OR = 1.42, 95% CI = [0.97, 2.09]). Those who are female, non-Hispanic White, Democrat, have higher education, or have friends or family who misused opioids tended to score higher in knowledge and understanding of OUD., Conclusions: Perceived blameworthiness for the opioid overdose epidemic is related to knowledge and understanding of OUD. Public health campaigns with a bipartisan agenda to increase evidence-informed knowledge about OUD targeting people of color and with lower education may help reduce the blame toward people with an OUD, which in turn may increase support for evidence-informed policies., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The COVID-19 pandemic, polarized politics, and heightened stigma and discrimination are salient drivers for negative mental health outcomes, particularly among marginalized racial and ethnic minoritized groups. Intersectionality of race, ethnicity, foreign-born status, and educational attainment may distinctively shape an individual's experience of discrimination and mental health during such unprecedented time. The present study examines the differential associations of racial discrimination and mental health based on an individual's race, ethnicity, foreign-born status, and educational attainment during the COVID-19 pandemic. Analyses were based on a nationally representative sample of U.S. adults collected between October and November 2021 (n = 6276). We utilized multivariable linear regressions to identify the multiplicative effects of race, ethnic, foreign-born status and self-reported racial discrimination on mental health, stratified by educational attainment. Among individuals with lower educational attainment, associations between racial discrimination and poor mental health were stronger among Asians (US-born: β = -2.07, p = 0.03; foreign-born: β = -3.18, p = 0.02) and US-born multiracial individuals (β = -1.96, p = 0.02) than their White counterparts. Among individuals with higher educational attainment, foreign-born Hispanics (β = -3.66, p < 0.001) and US-born Asians (β = -2.07, p = 0.01) reported worst mental health when exposed to racial discrimination out of all other racial, ethnic and foreign-born groups. Our results suggest that association of racial discrimination and mental health varies across racial, ethnic, foreign-born, and education subgroups. Using an intersectional approach to address the widening inequities in racial discrimination and mental health during the COVID-19 pandemic contextualizes unique experience of discrimination and provides crucial insight on the patterns of mental health among marginalized groups., 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.

Purpose: Male gender expression (MGE), which is shaped by sociocultural pressures around masculinity, has been previously associated with health. This study examines associations of adolescent social network variables and school gender norms with MGE changes from adolescence to young adulthood, and associations of these changes with young adult substance use., Methods: Analyzing data from Waves I (1994-95, adolescents, aged 12-18) and IV (2008-09, young adults, 24-32) of a nationally representative longitudinal cohort study, male participants' MGE was assessed in each wave using a validated, empirically derived measure. Linear regression was used to evaluate associations of adolescent-to-young adult MGE changes between waves with adolescent social network characteristics and school gender norms. Logistic regression was used to examine associations between adolescent-to-young adult MGE changes and young adult substance uses (cigarette, marijuana, heavy alcohol, and recreational drug use, and prescription drug misuse)., Results: Among 4,776 male participants, adolescent-to-young adult MGE changes were significantly associated with school gender norms such that adolescents whose MGE markedly departed from their schools' average exhibited greater MGE changes in the direction of their schools' average (β = -0.83, p < .01) relative to those who were more similar to school means. Adolescent-to-young adult increases in MGE were significantly associated with greater odds of all young adult substance use behaviors except prescription drug misuse., Discussion: Adolescents' MGE relative to other males at their school was associated with MGE changes toward school norms, with implications for young adult substance use. Adolescent gender norms may be an underexplored strategy for interventions to reduce substance misuse., (Copyright © 2023 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: A collective trauma like COVID-19 impacts individuals differently due to socio-contextual and individual characteristics. Younger adults, minorities, affiliates of certain political parties, and residents of some regions of the United States reported experiencing poorer mental health during the pandemic. Being diagnosed with COVID-19, or losing a friend/family to it, was related to more adverse mental health symptoms. While the negative impact of COVID-19 on health outcomes has been studied, mental health changes during this pandemic need further exploration., Methods: In a study of 8,612 U.S. households, using three surveys collected from a nationally representative panel between May 2020 and October 2021, using a repeated cross-sectional design, a linear mixed effect regression model was performed to investigate factors associated with the mental health status, based on the Mental Health Inventory-5, of individuals throughout different phases of the COVID-19 pandemic, and whether an improvement over time, especially after vaccines became available, was observed., Results: An overall improvement in mental health was observed after vaccines became available. Individuals with no COVID-related death in their household, those not wearing masks, those identifying as members of the Republican Party, race/ethnicities other than Asian, men, older adults, and residents of the South were less likely than others to report mental health challenges., Conclusions: Our results highlight the need for widespread mental health interventions and health promotion to address challenges during the COVID-19 pandemic and beyond. Due to the worse mental health observed among Asians, younger adults, women, low-income families, those with a higher level of concern for COVID-19, people who lost someone to COVID-19, and/or individuals with histories of opioid use disorder and criminal legal involvement, over the period of this study, targeted attention needs to be given to the mental health of these groups., (© 2024. The Author(s).)

Purpose: The rise of fatal stimulant use among adults who use opioids is a public health problem. Internalized stigma is a barrier to substance use treatment, which is greater for women and populations with criminal justice involvement., Methods: Using a nationally representative sample of adults in the United States from a probability-based survey on household opinions in 2021, we examined characteristics of women (n = 289) and men (n = 416) who misuse opioids. In gender-stratified multivariable linear regression, we investigated factors associated with internalized stigma, and tested for the interaction of stimulant use and criminal justice involvement., Results: Compared to men, women reported greater mental health symptom severity (3.2 vs. 2.7 on a 1 to 6 scale, p < 0.001). Internalized stigma was similar between women (2.3 ± 1.1) and men (2.2 ± 0.1). Among women and not men, however, stimulant use was positively associated with internalized stigma (0.36, 95% CI [0.07, 0.65]; p = 0.02). Interaction between stimulant use and criminal justice involvement was negatively associated with internalized stigma among women (- 0.60, 95% CI [- 1.16, -0.04]; p = 0.04); among men, the interaction was not significant. Predictive margins illustrate among women, stimulant use eliminated the gap in internalized stigma such that women with no criminal justice involvement had a similar level of internalized stigma as women with criminal justice involvement., Conclusion: Internalized stigma between women and men who misuse opioids differed based on stimulant use and criminal justice involvement. Future research should assess whether internalized stigma influences treatment utilization among women with criminal justice involvement., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Criminal legal system involvement (CLI) is a critical social determinant of health that lies at the intersection of multiple sources of health disparities. The COVID-19 pandemic exacerbates many of these disparities, and specific vulnerabilities faced by the CLI population. This study investigated the prevalence of COVID-19-related misinformation, as well as its relationship with COVID-19 information sources used among Americans experiencing CLI. A nationally representative sample of American adults aged 18+ (N = 1,161), including a subsample of CLI individuals (n = 168), were surveyed in February-March 2021. On a 10-item test, CLI participants endorsed a greater number of misinformation statements (M = 1.88 vs. 1.27) than non-CLI participants, p < .001. CLI participants reported less use of government and scientific sources (p = .017) and less use of personal sources (p = .003) for COVID-19 information than non-CLI participants. Poisson models showed that use of government and scientific sources was negatively associated with misinformation endorsement for non-CLI participants (IRR = .841, p < .001), but not for CLI participants (IRR = .957, p = .619). These findings suggest that building and leveraging trust in important information sources are critical to the containment and mitigation of COVID-19-related misinformation in the CLI population., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Zhao et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

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.

Using data from the Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System, we analyzed trends in firearm suicide across the life course, comparing age-related trends over time (2015-20 versus 1999-2014) and stratified by differences in state firearm policy environments. Overall, we found stable trends in firearm suicide rates across the life course, although with higher overall rates across all age groups in 2015-20 versus in 1999-2014. Ages 14-16 was the only age group with an accelerating life-course trend in firearm suicide rates in 2015-20 versus in 1999-2014. The state policy environment was associated with significant differences in firearm suicide, with an average of 4.62 more deaths per 100,000 people per year in states with less- versus more-strict environments. This was in contrast to nonfirearm suicides, for which we observed no consistent differences between states. The largest overall differences in firearm suicide between states occurred in adulthood through middle age. These findings can inform further research on health care-based approaches to reducing firearm suicide, such as health care screening for firearm ownership, screening for suicide risk among firearm owners, and motivational interviewing to promote safe firearm storage.

Rationale: Misinformation is a major concern for public health, with its presence and impact strongly felt in the COVID-19 pandemic. Misinformation correction has drawn strong research interest. In contrast, relatively little attention has been given to the likelihood of favorable behavioral change post correction (i.e., openness to change)., Objective: This study seeks to identify the characteristics of COVID misinformation endorsers who are open to adopt more self-protective behaviors after misinformation correction., Methods: COVID misinformation endorsers (N = 1991) in a large, nationally representative survey (fielded in October and November 2021) were asked how likely they would adopt self-protective behaviors if a source they trusted debunked their prior misperceptions. Multiple linear regression estimated the relationships between openness to change and socio-demographics, health-related factors, and health information source usage patterns., Results: Less than half of the misinformation endorsers in the sample (41.3%) indicated any openness to change. Openness to change was positively associated with minority status and negatively associated with leaning Republican in political affiliation, higher income, being currently unvaccinated or unsure about vaccination status, better health, and a greater number of misinformation items endorsed. Past-month use of government, community, and personal sources for health information positively predicted openness. The use of online media was negatively associated with openness., Conclusions: Openness to change is not guaranteed after misinformation correction. Targeted interventions based on openness to change are needed to enhance the public health impact of misinformation correction efforts., (Copyright © 2023. Published by Elsevier Ltd.)

This qualitative semi-structured interview study explores how 64 family caregivers for older adults with Alzheimer's Disease and related dementias across eight states experienced and executed caregiving decisions before and during the COVID-19 pandemic. First, caregivers experienced challenges communicating with loved ones and healthcare workers in all care settings. Second, caregivers displayed resilient coping strategies in adapting to pandemic restrictions, finding novel strategies to balance risks while preserving communication, oversight, and safety. Third, many caregivers modified care arrangements, with some avoiding and others embracing institutional care. Finally, caregivers reflected on the benefits and challenges of pandemic-related innovations. Certain policy changes reduced caregiver burden and could improve care access if made permanent. Telemedicine's increasing use highlights the need for reliable internet access and accommodations for individuals with cognitive deficits. Public policies must pay greater attention to challenges faced by family caregivers, whose labor is both essential and undervalued.

Background: The US overdose epidemic is an escalating public health emergency, accounting for over 100,000 deaths annually. Despite the availability of medications for opioid use disorders, provider-level barriers, such as negative attitudes, exacerbate the treatment gap in clinical care settings. Assessing the prevalence and intensity of provider stigma, defined as the negative perceptions and behaviors that providers embody and enact toward patients with substance use disorders, across providers with different specialties, is critical to expanding the delivery of substance use treatment., Objective: To thoroughly understand provider stigma toward patients with substance use disorders, we conducted a nationwide survey of emergency medicine and primary care physicians and dentists using a questionnaire designed to reveal how widely and intensely provider attitudes and stigma can impact these providers' clinical practices in caring for their patients. The survey also queried providers' stigma and clinical practices toward other chronic conditions, which can then be compared with their stigma and practices related to substance use disorders., Methods: Our cross-sectional survey was mailed to a nationally representative sample of primary care physicians, emergency medicine physicians, and dentists (N=3011), obtained by American Medical Association and American Dental Association licensees based on specified selection criteria. We oversampled nonmetropolitan practice areas, given the potential differences in provider stigma and available resources in these regions compared with metropolitan areas. Data collection followed a recommended series of contacts with participants per the Dillman Total Design Method, with mixed-modality options offered (email, mail, fax, and phone). A gradually increasing compensation scale (maximum US$250) was implemented to recruit chronic nonresponders and assess the association between requiring higher incentives to participate and providers stigma. The primary outcome, provider stigma, was measured using the Medical Condition Regard Scale, which inquired about participants' views on substance use and other chronic conditions. Additional survey measures included familiarity and social engagement with people with substance use disorders; clinical practices (screening, treating, and referring for a range of chronic conditions); subjective norms and social desirability; knowledge and prior education; and descriptions of their patient populations., Results: Data collection was facilitated through collaboration with the National Opinion Research Center between October 2020 and October 2022. The overall Council of American Survey Research Organizations completion rate was 53.62% (1240/2312.7; physicians overall: 855/1681.9, 50.83% [primary care physicians: 506/1081.3, 46.79%; emergency medicine physicians: 349/599.8, 58.2%]; dentists: 385/627.1, 61.4%). The ineligibility rate among those screened is applied to those not screened, causing denominators to include fractional numbers., Conclusions: Using systematically quantified data on the prevalence and intensity of provider stigma toward substance use disorders in health care, we can provide evidence-based improvement strategies and policies to inform the development and implementation of stigma-reduction interventions for providers to address their perceptions and treatment of substance use., International Registered Report Identifier (irrid): DERR1-10.2196/47548., (©Carrigan Leigh Parish, Daniel J Feaster, Harold A Pollack, Viviana E Horigian, Xiaoming Wang, Petra Jacobs, Margaret R Pereyra, Christina Drymon, Elizabeth Allen, Lauren K Gooden, Carlos del Rio, Lisa R Metsch. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 26.09.2023.)

We report on a preliminary investigation into the relationship between partisan media consumption (PMC) among U.S. adults and their (1) opioid use disorder (OUD) stigma, (2) national OUD policy support (e.g., Medicaid coverage for OUD treatment), (3) local OUD policy support (e.g., safe injection sites), (4) discriminatory OUD policies (e.g., denying housing), and (5) carceral OUD policies (e.g., jailing people who use opioids). We performed a cross-sectional survey of a nationally-representative sample of U.S. adults ( n  = 6,515) from October 1-November 19, 2021. We surveyed a sample of U.S. adults ages 18 and older drawn from NORC's AmeriSpeak® Panel. AmeriSpeak is a probability-based ongoing panel of over 40,000 households designed to represent the U.S. household population. Cross-sectional analyses revealed significant relationships between PMC and OUD stigma ( b  = 0.29, p  <.001, CI 95  = 0.14,0.43), support for national ( b  = -0.31, p  <.01, CI 95  = -0.54,-0.09) and local policy responses ( b  = -0.38, p  <.001, CI 95  = -0.59,-0.17), and support for discriminatory opioid use disorder policies ( b  = 0.27, p  <.01, CI 95  = 0.07,0.45). After controlling for self-reported political affiliation and other potential covariates, Republican-leaning media consumption was significantly associated with increased OUD stigma, less support for national and local harm reduction or rehabilitative policies, and more support for discriminatory policies against individuals experiencing OUD. The opposite associations were observed for Democratic-leaning media consumption. Markers for racism mediated the relationship between PMC and support for carceral policies (indirect path b  = -0.41, p  <.001, CI 95  = -0.50,-0.31). Our results indicate that public health advocates must collaborate with conservative leaders to find bipartisan common ground for targeted communication campaigns., Competing Interests: 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., (© 2023 The Authors.)

Two parallel public health epidemics affecting the United States include the COVID-19 pandemic and a rise in substance use disorders (SUDs). Limited research has examined the potential relationship between these two epidemics. Our objective was therefore to perform an exploratory study in order to examine the association between public stigma toward people with a past history of opioid, methamphetamine, cocaine, and alcohol use disorder and COVID-19 vaccine hesitancy. A national sample of U.S. adults (N = 6515) completed a survey which assessed the degree of negative perceptions toward individuals with a past history of substance use disorders (referred to as substance use stigma) and COVID-19 vaccine hesitancy, along with variables such as racial prejudice, source of health news, and other demographics. We evaluated four multivariable logistic regression models to predict COVID-19 vaccine hesitancy, utilizing substance use stigma toward opioids, methamphetamine, cocaine, and alcohol use as independent variables. We found that COVID-19 vaccine hesitancy was positively associated with substance use stigma toward opioid (AOR = 1.34, p < 0.05), methamphetamine (AOR = 1.40, p < 0.01), and cocaine (AOR = 1.28, p < 0.05) use, but not alcohol use (AOR = 1.06, n.s.). Predictive models that incorporate substance use stigma may therefore improve our ability to identify individuals that may benefit from vaccine hesitancy interventions. Future research to understand the underlying reasons behind the association between substance use stigma and COVID-19 vaccine hesitancy may help us to construct combined interventions which address belief systems that promote both substance use stigma and vaccine hesitancy.

This study explores whether a school-based group counseling program for adolescent girls, implemented at scale, can mitigate trauma-related mental health harms. In a randomized trial involving 3749 Chicago public high school girls, we find that participating in the program for 4 months induces a 22% reduction in posttraumatic stress disorder symptoms and find significant decreases in anxiety and depression. Results surpass widely accepted cost-effectiveness thresholds, with estimated cost-utility well below $150,000 per quality adjusted life year. We find suggestive evidence that effects persist and may even increase over time. Our results provide the first efficacy trial of such a program specifically designed for girls, conducted in America's third largest city. These findings suggest the promise of school-based programs to mitigate trauma-related harms.

Using a nationally representative household sample, we sought to better understand types of medical mistrust as a driver of COVID-19 vaccine hesitancy. We used survey responses to conduct a latent class analysis to classify respondents into categories and explained this classification as a function of sociodemographic and attitudinal variables using multinomial logistic regression models. We then estimated the probability of respondents agreeing to receive a COVID-19 vaccine conditional on their medical mistrust category. We extracted a five-class solution to represent trust. The high trust group (53.0 %) is characterized by people who trust both their doctors and medical research. The trust in own doctor group (19.0 %) trust their own doctors but is ambiguous when it comes to trusting medical research. The high distrust group (6.3 %) neither trust their own doctor nor medical research. The undecided group (15.2 %) is characterized by people who agree on some dimensions and disagree on others. The no opinion group (6.2 %) did not agree nor disagree with any of the dimensions. Relative to the high trust group, those who trust their own doctors are almost 20 percentage points less likely to plan to get vaccinated (average marginal effect (AME) = 0.21, p <.001), and those who have high distrust are 24 percentage points less likely (AME = -0.24, p <.001) to report planning to get the vaccine. Results indicate that beyond sociodemographic characteristics and political attitudes, people's trust archetypes on parts of the medical field significantly predict their probability of wanting to get vaccinated. Our findings suggest that efforts to combat vaccine hesitancy should focus on building capacity of trusted providers to speak with their patients and parents of their patients, to recommend COVID-19 vaccination and build a trusting relationship; and increase trust and confidence in medical research., 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 © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

We compare multiple machine learning algorithms and develop models to predict future hospitalization among Home- and Community-Based Services (HCBS) Users. Furthermore, we calculate feature importance, the score of input variables based on their importance to predict the outcome, to identify the most relevant variables to predict hospitalization. We use the 2012 national Medicaid Analytic eXtract data and Medicare Provider Analysis and Review data. Predicting any hospitalization, Random Forest appears to be the most robust approach, though XGBoost achieved similar predictive performance. While the importance of features varies by algorithm, chronic conditions, previous hospitalizations, as well as use of services for ambulance, personal care, and durable medical equipment were generally found to be important predictors of hospitalization. Utilizing prediction models to identify those who are prone to hospitalization could be useful in developing early interventions to improve outcomes among HCBS users.

Improving interactions between first responders and individuals experiencing behavioral crisis is a critical public health challenge. To gain insight into these interactions, key informant qualitative interviews were conducted with 25 Chicago stakeholders. Stakeholders included directors and staff of community organizations and shelters that frequently engage first responders. Interviews included granular depictions related to the expectations and outcomes of 911 behavioral crisis calls, and noted areas requiring improved response. Stakeholders called 911 an average of 2 to 3 times per month, most often for assistance related to involuntary hospitalization. Engagements with first responders included unnecessary escalation or coercive tactics, or conversely, refusal of service. While stakeholders lauded the value of police trained through the city's Crisis Intervention Team program, they emphasized the need for additional response strategies that reduce the role of armed police, and underscored the need for broader social and behavioral health services for individuals at-risk of such crises., (© 2022. The Author(s).)

Research Objective: Medication opioid use disorder (MOUD) treatment is the first-line approach to the treatment of opioid use disorder (OUD). This analysis seeks to identify "critical access" MOUD facilities that ensure geographic access for MOUD patients. Using public-source data and spatial analysis, we identify the top 100 "critical access" MOUD units across the continental U.S., Study Design: We use locational data from SAMHSA's Behavioral Health Treatment Services Locator and DATA 2000 waiver buprenorphine providers. We identify the closest MOUDs to each ZIP Code Tabulation Area (ZCTA)'s geographic centroid. We then construct a difference-in-distance metric by computing the difference in this distance measure between closest and second-closest MOUD, multiplied by ZCTA population, ranking MOUDs by difference-distance scores., Population Studied: All listed MOUD treatment facilities and all listed ZCTA's across the continental U.S., and all listed MOUD providers proximate to these areas., Principal Findings: We identified the top 100 critical access MOUD units in the continental United States. Many critical providers were in rural areas in the central United States, as well as a band extending east from Texas to Georgia. Twenty-three of the top 100 critical access providers were identified as providing naltrexone. Seventy-seven were identified as providing buprenorphine. Three were identified as providing methadone., Conclusions: Significant areas of the United States are dependent on a single critical access MOUD provider., Implications for Policy or Practice: Place-based supports may be warranted to support MOUD treatment access in areas dependent upon critical access providers., Competing Interests: No conflict declared., (© 2022 The Authors. Published by Elsevier B.V.)

Purpose: Even with an efficacious vaccine, protective behaviors (social distancing, masking) are essential for preventing COVID-19 transmission and could become even more important if current or future variants evade immunity from vaccines or prior infection., Methods: We created an agent-based model representing the Chicago population and conducted experiments to determine the effects of varying adult out-of-household activities (OOHA), school reopening, and protective behaviors across age groups on COVID-19 transmission and hospitalizations., Results: From September-November 2020, decreasing adult protective behaviors and increasing adult OOHA both substantially impacted COVID-19 outcomes; school reopening had relatively little impact when adult protective behaviors and OOHA were maintained. As of November 1, 2020, a 50% reduction in young adult (age 18-40) protective behaviors resulted in increased latent infection prevalence per 100,000 from 15.93 (IQR 6.18, 36.23) to 40.06 (IQR 14.65, 85.21) and 19.87 (IQR 6.83, 46.83) to 47.74 (IQR 18.89, 118.77) with 15% and 45% school reopening. Increasing adult (age ≥18) OOHA from 65% to 80% of prepandemic levels resulted in increased latent infection prevalence per 100,000 from 35.18 (IQR 13.59, 75.00) to 69.84 (IQR 33.27, 145.89) and 38.17 (IQR 15.84, 91.16) to 80.02 (IQR 30.91, 186.63) with 15% and 45% school reopening. Similar patterns were observed for hospitalizations., Conclusions: In areas without widespread vaccination coverage, interventions to maintain adherence to protective behaviors, particularly among younger adults and in out-of-household settings, remain a priority for preventing COVID-19 transmission., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Price transparency is an ethical and policy imperative for American health care. More transparent pricing would allow patients and families to make better decisions and would allow clinicians to deliver care with greater simplicity and integrity. This article also considers transparency's real-world patient care limitations and the extent to which price transparency is a reliable pathway to service delivery efficiency and market discipline., (Copyright 2022 American Medical Association. All Rights Reserved.)

To explore the attitude towards COVID-19 vaccination among healthcare workers in the US, we surveyed three groups of individuals (essential non-healthcare workers, general healthcare workers, and correctional healthcare workers). We found surprisingly high portions of healthcare workers with COVID-19 vaccine hesitancy/resistance, with 23% of correctional healthcare workers and 17% general healthcare workers (as compared to 12%) refusing to be vaccinated against COVID-19. Multivariate regression models suggest that current season flu vaccination (aOR = 3.34), relying on employer for COVID-19 information (aOR = 3.69), and living in the Midwest (aOR = 5.04) to be strongly associated with COVID-19 vaccine acceptance among essential workers and general healthcare workers. Current season flu vaccination (aOR = 7.52) is also strongly associated with COVID-19 vaccine acceptance among correctional healthcare workers. Potential mechanisms of vaccine hesitancy/resistance among healthcare workers involves low health literacy and employer mistrust. Our findings are highly relevant as we try to reach COVID-19 vaccination goals in the US., Competing Interests: The authors have declared that no competing interests exist.

Policy Points In the preexpansion period, federally qualified health centers (FQHCs) in Medicaid expansion states were significantly different from those in nonexpansion states. This gap widened as revenues in expansion states continued to grow at a faster rate after the expansion. If Medicaid expansion had occurred nationwide, FQHCs' revenue and capacity could have increased substantially. Over time, Medicaid could play a bigger role as it becomes a more stable funding source to allow for capital investments. Section 330 grants appear to have a larger impact on access to care. Given the varying levels of reliance on Medicaid, investing through federal grants might be more effective and equitable., Context: The Health Resources and Services Administration's Health Center Program (HCP) plays a critical role as the national ambulatory safety net, delivering services to patients in medically underserved areas, regardless of their ability to pay. As the program has grown, health policy initiatives may have altered access to care for the underserved population. Understanding how federally qualified health centers (FQHCs) have been affected by past policies is important for anticipating the effects of future policies., Methods: By analyzing a national data set from the Uniform Data System, we examined, using two sets of random effects regressions, the potential impact of alternative policy actions affecting FQHCs. Our primary equation models the number of full-time equivalent staff, of patients served, and of visits provided in the subsequent year as a function of Medicaid revenues, Section 330 grants, and other revenues. Our secondary equation is a difference-in-differences analysis that models Medicaid revenues as a function of the states' status of Medicaid expansion., Findings: The expansion of Medicaid in nonexpansion states could have increased Medicaid revenues by 138%, staffing by 25%, and patients' visits by 24% in 2017. Compared to the impact of a "repeal" of Medicaid expansion, the percentage of reductions in staffing would be similar to those predicted by a 50% cut in Medicaid revenues or in Section 330 grants. On a dollar-for-dollar basis, the effects of one dollar of Section 330 grants were more than double that of one dollar of Medicaid revenue., Conclusions: Both Medicaid eligibility and Section 330 funding support are important to the HCP, and Section 330 grants are particularly closely related to staffing and the provision of services. States' decisions not to participate in or to repeal Medicaid expansion, to reduce Medicaid payment rates, and federal funding cuts all could have a negative impact on FQHCs, resulting in thousands of low-income patients losing access to primary care., (© 2022 The Authors. The Milbank Quarterly published by Wiley Periodicals LLC on behalf of The Millbank Memorial Fund.)