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Objective: This study examined ethnic differences in accessing treatment for depression and substance use disorders (SUDs) among men and women in a large integrated health plan, and explored factors potentially contributing to health care disparities. Methods: Participants were 22,543 members ages 20 to 65 who responded to health surveys in 2002 and 2005. Survey questions were linked to provider-assigned diagnoses, electronic medication, psychiatry, and chemical dependency program records. Results: Among women diagnosed with depression, Latinas (p < .01) and Asian-Americans (p < .001) were less likely than Whites to fill an antidepressant prescription. Among men diagnosed with depression, African Americans (p < .01) were less likely than Whites to do so. Among women diagnosed with an SUD, African Americans (p < .05) were less likely than Whites to have one or more chemical dependency program visits. Conclusions: Results demonstrated ethnic differences in accessing depression and SUD treatment among patients diagnosed with these disorders, which persisted after controlling for education, income, having a regular health care provider and length of health plan enrollment. Findings highlight potential gender differences in ethnic disparities, lower antidepressant utilization among Asian Americans, and the effects of co-occurring disorders in accessing behavioral health care. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To examine associations between drinking patterns, medical conditions, and behavioral health risks among older adults. METHODS: Analyses compared survey participants (health plan members ages 65 to 90, N = 6662) who drank moderately to those who drank over recommended limits or did not drink. RESULTS: Overlimit drinking was associated with smoking; not trying to eat low-fat foods (in men), and lower BMI (in women). Predictors of not drinking during the prior 12 months included ethnicity, lower education, worse self-reported health, diabetes and heart problems. CONCLUSIONS: Significant relationships exist between health and alcohol consumption patterns, which vary by gender. [ABSTRACT FROM AUTHOR]

Introduction: Although addiction is recognized as a chronic, relapsing condition, few treatment studies, and none in a commercially insured managed care population, have measured long-term outcomes. We examined the relationship of 6-month treatment outcomes to abstinence 5 years post-treatment, and whether the predictors of abstinence at 5 years were different for those who were, and were not, abstinent at 6 months.Methods: The sample (N=784) is from an outpatient (day hospital and traditional outpatient) managed care chemical dependency program. Subjects were interviewed at baseline, 6 months, and 5 years. Logistic regression analysis was used to assess which individual, treatment and extra-treatment characteristics predicted alcohol and drug abstinence at 5 years.Results: Abstinence at 6 months was an important predictor of abstinence at 5 years. Among those abstinent at 6 months, predictors of abstinence at 5 years were older age, being female, 12-step meeting attendance, and recovery-oriented social networks. Among those not abstinent at 6 months, being alcohol dependent rather than drug dependent, 12-step meeting attendance, treatment readmission, and recovery-oriented social networks predicted abstinence at 5 years.Conclusion: Our findings demonstrate a clear association between short-term and long-term treatment success. In addition, these results strongly support the importance of recovery-oriented social networks for those with good short-term outcomes, and the beneficial impact of readmission for those not initially successful in treatment. [ABSTRACT FROM AUTHOR]

Background and Aims: Alcohol use is prevalent among hepatology clinic patients with chronic liver disease (CLD). We explored factors associated with the importance and confidence dimensions of motivation to reduce drinking., Methods: Participants (N = 121) with unhealthy alcohol use (i.e., over NIH guidelines) receiving care in hepatology clinics from a safety-net hospital (SN, N = 54) and two Veterans Affairs Healthcare Systems (VA, N = 67) were enrolled in an alcohol intervention trial from March 2022 through October 2023. Baseline assessments included Generalised Anxiety Disorder (GAD-7), Patient Health Questionnaire (PHQ-8), Alcohol Use Disorders Identification Test (AUDIT), COVID-19 stress; and measures of importance and confidence to decrease alcohol use (readiness rulers, scales of 1-10). Liver disease aetiology and severity were extracted from electronic health records. We performed multivariable linear regression models with forward selection to assess pre-specified variables' associations with importance and confidence., Results: The sample was 84% male, 40% Latino, 31% White, 18% Black and 11% other races; median age was 61 years. Median (Q1-Q3) AUDIT score was 16 (12-24), importance was 9 (6-10) and confidence was 8 (5-9). On multivariable analysis, VA site (vs. SN) participants had a 0.97-point lower importance score (p = 0.02); higher symptoms of depression (PHQ-8 score ≥ 10 vs. < 10) and AUDIT scores (for each point increase) were associated with higher importance score (estimates 1.2 and 0.08, p < 0.05, respectively). Liver disease aetiology and severity were not significantly associated with outcomes., Conclusions: Depression, alcohol problem severity and treatment site may influence motivation to reduce alcohol use and could inform future hepatology-based interventions., (© 2024 John Wiley & Sons Ltd.)

Introduction: Cannabis use among adolescents is prevalent, and clinicians who work with adolescents have unique insights about how to treat cannabis use in this population., Methods: This qualitative study interviewed 32 clinicians from addiction medicine recovery services (AMRS), the emergency department (ED), mental health (MH), and pediatrics in an integrated healthcare system to understand their perspectives and experiences regarding barriers and facilitators to treating adolescent cannabis use. The analysis was developed using thematic analysis of interviews., Results: Thirty-two clinicians (Mean age = 45.9, SD =7.6; 56.3 % Female; 56.3 % White) were recruited from AMRS (n = 13; 41.6 %), the ED (n = 7; 21.9 %), MH (n = 7; 21.9 %) and pediatrics (n = 5; 15.6 %). Clinicians discussed several key barriers and facilitators of treating adolescent cannabis use. Facilitators include the use of multiple screening tools for adolescent cannabis use (i.e., self-report and toxicology testing) which provide more comprehensive information; patient-centered treatment approaches; and discussing cannabis use in the context of adolescents' mental health. Barriers discussed included adolescents' and parents' minimization of adolescent cannabis use risks. Several factors were discussed as potential facilitators or barriers, depending on context, including the influence of peers, virtual treatment, and parental involvement or lack thereof in treatment., Conclusions: Interviews with clinicians who work with adolescents across settings highlighted factors that serve as barriers and facilitators to treating adolescent cannabis use. These findings have important implications for guiding future research and intervention efforts, including the inclusion of universal screening practices, addressing stigma, reducing adolescents' and parents' minimization of cannabis use-related harms, and improving adolescent and parent engagement in treatment., Competing Interests: Declaration of competing interest All authors report no conflict of interest., (Copyright © 2024. Published by Elsevier Inc.)

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

Objective: Individuals with unhealthy alcohol use and comorbid depression or anxiety may be vulnerable to alcohol use escalation in times of stress such as the COVID-19 pandemic. Among a cohort of individuals with pre-pandemic unhealthy drinking, we compared changes in alcohol use by whether people had a depression or anxiety diagnosis and examined whether mental health treatment was related to these changes., Method: Using electronic health record data from Kaiser Permanente Northern California, we analyzed drinking changes during the pandemic (3/1/2020-6/30/2022) among adults identified in primary care with unhealthy alcohol use (exceeding daily/weekly recommended limits) pre-pandemic (1/1/2019-2/29/2020). Outcomes were mean changes in number of heavy drinking days (prior 3 months), drinks/week, drinks/day, and drinking days/week. Multivariable linear regression models were fit to (a) compare outcomes of patients with depression or anxiety diagnoses to those without, and (b) among patients with depression or anxiety, estimate associations between mental health treatment and outcomes., Results: The sample included 62,924 adults with unhealthy alcohol use, of whom 12,281 (19.5%) had depression or anxiety. On average, alcohol use significantly decreased across all measures during the pandemic; however, patients with depression or anxiety had greater decreases in drinks/week (adjusted mean difference [aMD] [CI] = -0.34 [-0.55, -0.12]) and drinking days/week (-0.15 [-0.20, -0.10]). No associations were found between mental health treatment and changes in drinking., Conclusions: Contrary to expectations, patients with unhealthy alcohol use and depression or anxiety decreased alcohol use more than those without depression or anxiety during COVID-19, regardless of whether they accessed mental health services.

Among persons with HIV (PWH), unhealthy alcohol use and polypharmacy contribute to bothersome symptoms (e.g., fatigue, dizziness, memory loss). However, effective risk communication targeting these associations is challenging. The HIV and Alcohol Research center focused on Polypharmacy (HARP) is conducting a pilot study that will generate feasibility and acceptability data on a clinical pharmacist-delivered counseling intervention targeting the modification of unhealthy alcohol use and polypharmacy in PWH. Counseling is guided by the Information-Motivation-Behavioral Skills-Motivational Interviewing (IMB-MI) model. Herein, we describe the study protocol. This pilot uses a one-group pre-test/post-test design. We will recruit 50 participants from those who participated in the consented cohort of the Veterans Aging Cohort Study. Participants must be prescribed ≥ 5 long-term medications, have a self-reported Alcohol Use Disorders Identification Test score > 0, and be living with HIV. We will exclude those with moderate-severe alcohol use disorder as identified by an Alcohol Symptom Checklist score ≥ 4. Data are collected using three self-administered surveys (baseline, immediately after booster intervention, and 30-days post-intervention), two PEth blood tests (baseline, 30 days post-intervention), and medication data from the electronic health record (baseline). The intervention includes a 60-minute IMB-MI-based counseling session followed by a booster session 2 weeks later. Some participants will also be asked to participate in a qualitative interview to provide feedback on the intervention. The pilot investigates the impact of an intervention on alcohol consumption and the use of multiple medications among PWH, exploring how best to reduce bothersome symptoms, communicate risk, and support behavior change in this population., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Introduction: The COVID-19 pandemic changed the way healthcare providers delivered most health services, including treatment for alcohol use disorder (AUD). Specialty alcohol treatment remained available through the pandemic, and within some systems treatment use increased likely due to telehealth availability. However, the field knows little about the relationship between the pandemic's expanded access to specialty alcohol treatment and alcohol use outcomes., Methods: The sample included 14,712 patients from Kaiser Permanente Northern California who screened positive for unhealthy alcohol use in primary care and had an AUD diagnosis or risked developing an AUD by reporting 5 or more heavy drinking days in a 3-month period between 1/1/2019 and 2/29/2020 (pre-pandemic). The study examined the receipt of any specialty alcohol treatment (including at least one outpatient, inpatient, or telehealth specialty treatment encounter, or pharmacotherapy prescription) from 3/1/2020 (pandemic start) to either the first completed follow-up alcohol screening or 6/20/2022 (study period end). The outcomes of alcohol use included changes in heavy drinking days, drinks per week, drinking days per week, and drinks per drinking day between the pre- and post-pandemic periods., Results: On average patients significantly decreased alcohol use across all four alcohol use measures examined, regardless of whether they received treatment. However, those who received any treatment compared to those who did not had greater reductions in alcohol use, with an additional decrease of -3.55 heavy drinking days (95 % CI = -5.93, -1.17), -3.80 drinks per week (95 % CI = -5.18, -2.42), -0.72 drinks per drinking day (95 % CI = -1.14, -0.30), and - 1.01 drinking days per week (95 % CI = -1.30, -0.72). Treatment effects were greatest among patients who exceeded both daily and weekly limits pre-pandemic, with an additional decrease of -10.75 heavy drinking days (95 % CI = -15.28, -6.21), -12.83 drinks per week (95 % CI = -16.31, -9.35), -1.67 drinks per drinking day (95 % CI = -2.19, -1.14), and -2.02 drinking days per week (95 % CI = -2.41, -1.63)., Conclusions: On average, patients decreased alcohol use during the onset of the pandemic, however, those who had any specialty alcohol treatment had significantly greater decreases, suggesting that the hybrid in-person and telehealth treatment approach was effective during the pandemic., Competing Interests: Declaration of competing interest We have nothing to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: Despite recognition that people with HIV (PWH) are more vulnerable to sleep issues, there is limited understanding of clinically recognized sleep disorders in this population. Our objective was to evaluate the full spectrum of sleep disorder types diagnosed among PWH in care., Methods: We conducted a retrospective cohort study of PWH, and a comparator group of people without HIV (PWoH), in a large healthcare system. The incidence of clinically diagnosed sleep disorders was calculated using Poisson regression for three outcomes: any type of sleep disorder, insomnia, and sleep apnea. Incidence was compared between PWH and PWoH by computing the adjusted incidence rate ratio (aIRR), accounting for sleep disorder risk factors. Comparisons to PWoH were made for all PWH combined, then with PWH stratified by HIV management status (well-managed HIV defined as being on antiretroviral therapy, HIV RNA <200 copies/mL, and CD4 count ≥500 cells/μL)., Results: The study included 9076 PWH and 205 178 PWoH (mean age 46 years, 90% men). Compared with PWoH, sleep disorder incidence was greater among PWH overall [aIRR = 1.19, 95% confidence interval (CI): 1.12-1.26], particularly for insomnia (aIRR = 1.56, 95% CI: 1.45-1.67). Sleep apnea incidence was lower among PWH (aIRR = 0.90, 95% CI: 0.84-0.97). In HIV management subgroups, PWH without well-managed HIV had lower sleep apnea incidence (vs. PWoH: aIRR = 0.79, 95% CI: 0.70-0.89) but PWH with well-managed HIV did not (vs. PWoH: aIRR = 0.97, 95% CI: 0.89-1.06)., Conclusions: PWH have high sleep disorder incidence, and insomnia is the most common clinical diagnosis. Lower sleep apnea incidence among PWH may reflect underdiagnosis in those with sub-optimally treated HIV and will be important to investigate further., (© 2024 British HIV Association.)

Aims: This study examined differential changes in alcohol use during the COVID-19 pandemic among adults with unhealthy alcohol use., Methods: Among 62 924 adults identified with unhealthy alcohol use in primary care prepandemic (1 January 2019 to 29 February 2020), changes in alcohol use during the pandemic (1 March 2020 to 30 June 2022) were examined using electronic health record data from Kaiser Permanente Northern California. Outcomes were changes in heavy drinking days in the past three months (HDDs) and overall consumption (drinks/week), including continuous and categorical measures. Differences in outcomes by sex, age, race/ethnicity, and alcohol use disorder (AUD) were examined., Results: On average, drinking was reduced by 3.0 HDDs (in the past three months) (SD = 18.4) and 4.1 drinks/week (SD = 12.2), but women, certain age groups, White patients, and patients without AUD had smaller decreases than their counterparts. Overall, 9.1% increased, 34.4% maintained, and 56.5% decreased HDDs, and 20.2% increased, 19.8% maintained, and 60.1% decreased drinks/week. Women, patients aged ≥35 years, White patients, and patients with AUD had higher odds of increasing versus decreasing HDDs, and maintaining versus decreasing, compared to their counterparts. Patients aged 18-20 years, White patients, and patients without AUD had higher odds than their counterparts of increasing versus decreasing drinks/week. Women, patients aged 18-20 years, Asian/Pacific Islander, and Latino/Hispanic patients had higher odds of maintaining versus decreasing drinks/week., Conclusions: While alcohol use decreased overall among this sample of primary care patients with unhealthy drinking prepandemic, certain subgroups were more likely to increase drinking, suggesting a greater risk of alcohol-related problems., (© The Author(s) 2024. Medical Council on Alcohol and Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Hypertension is a major risk factor for dementia, but sustained blood pressure control is difficult to achieve. We evaluated whether inadequately controlled hypertension may contribute to excess dementia risk among people with HIV., Design: Retrospective cohort study., Methods: We studied demographically matched people with and without HIV between 7/1/2013 and 12/31/2021 who were ≥50 years old and had a hypertension diagnosis but no dementia diagnosis. Hypertension control was calculated using a disease management index (DMI) which captured degree and duration above the hypertension treatment goals of systolic blood pressure (SBP) <140 mmHg and diastolic blood pressure (DBP) <90 mmHg. DMI values ranged from 0% to 100% (perfect control); hypertension was considered "inadequately controlled" if DMI<80% (i.e., in control for <80% of the time). Annual, time-updated DMI was calculated for SBP and DBP. Associations of SPB and DPB control with incident dementia were evaluated using extended Cox regression models., Results: The study included 3,099 hypertensive people with HIV (mean age: 58.3 years, 90.2% men) and 66,016 people without HIV. Each year of inadequate SBP control was associated with greater dementia risk in both people with HIV (adjusted hazard ratio [aHR] = 1.26, 0.92-1.64) and people without HIV (aHR = 1.27 (1.21-1.33); p-interaction = 0.85). Similarly, inadequate DBP control was associated with greater dementia risk in both people with HIV (aHR = 1.43, 0.90-1.95) and people without HIV (aHR = 1.71, 1.50-1.93; p-interaction = 0.57)., Conclusions: Findings suggest the association of inadequate hypertension control with greater dementia risk is similar by HIV status. Stronger associations of DBP control with dementia merits further investigation., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Variation in specialty treatment utilization for alcohol use disorder (AUD) by patient subgroups is poorly understood. This study examined whether and how patient risk profiles predict receipt of specialty treatment and whether there are disparities by race and ethnicity., Methods: This cohort study included 206,956 adults with heavy alcohol use (that which exceeded National Institute on Alcohol Abuse and Alcoholism guidelines) between June 1, 2013 and December 31, 2014, using electronic health record data from Kaiser Permanente Northern California. Five risk profiles (characterized by daily or weekly heavy drinking and level of health risks) were identified in latent class analysis. Logistic regression models were fit to examine associations between risk profiles, race, ethnicity, and receipt of specialty treatment (including addiction medicine, psychiatry, or integrated behavioral health visits, and AUD pharmacotherapy), adjusting for other patient characteristics. Variation in the association between risk profiles and receipt of specialty treatment by race/ethnicity was also examined., Results: Overall, 4.0% of patients received specialty treatment. Latino/Hispanic and Asian/Pacific Islander patients had lower odds of receiving specialty treatment than White patients (adjusted odds ratio [aOR] [95% CI] = 0.80 [0.75, 0.85], and 0.64 [0.59, 0.70], respectively). The substance use disorder and mental health disorder (SUD/MH) risk profile had the highest odds of receiving specialty treatment (10.46 [9.65, 11.34]). Associations between risk profiles and receipt of specialty treatment significantly differed by race/ethnicity. Black patients in the SUD/MH risk profile, and Hispanic/Latino patients in the risk profile with heavy daily drinking and more health risks, had lower odds of receiving specialty treatment than their White counterparts (adjusted ratio of odds ratios [aROR] [95% CI] = 0.69 [0.50, 0.94], and 0.79 [0.67, 0.92], respectively)., Conclusions: This study provides new insights into racial/ethnic disparities in specialty treatment utilization for alcohol problems. Findings may help inform strategies for tailoring interventions to address heavy alcohol use., (© 2024 Research Society on Alcohol.)

Background: As more states legalize cannabis, studies are needed to understand the potential impacts of recreational cannabis legalization (RCL) on adolescents from the perspective of clinicians who care for them., Methods: This qualitative study characterized clinician perspectives on whether cannabis legalization is associated with changes in adolescents' cannabis use beliefs, behaviors, and consequences. Semi-structured qualitative interviews were conducted with 32 clinicians in a large healthcare organization from 9/6/2022-12/21/2022. Video-recorded interviews were transcribed and analyzed using thematic analysis., Results: The 32 participants (56.3 % female, mean [SD] age, 45.9 [7.6] years; 65.3 % non-Hispanic White) were from Addiction Medicine (n = 13), Psychiatry/Mental Health (n = 7), Pediatrics (n = 5), and the Emergency Department (n = 7). Clinicians described post-RCL increases in adolescent cannabis use, use of non-combustible modes and high-potency products, and younger age of first use. Clinicians reported social, physical, and policy changes, including changes in social norms, appealing advertisements, marketing, and easier access. Many noted fewer perceived harms among adolescents and greater self-medication post-RCL. They described how RCL contributed to increased parental cannabis use and permissiveness around adolescent use. Finally, many described post-RCL increases in cannabis hyperemesis syndrome, and several noted increased cannabis-related psychosis and acute intoxication, and decreased court-mandated treatment., Conclusions: Clinicians from diverse specialties described post-RCL increases in adolescent cannabis use and cannabis-related consequences, alongside changes in social norms, access, marketing and advertisements, and decreased perceptions of harms. Findings can inform strategies to support adolescents in the context of increased cannabis availability and acceptability post-legalization and support the development of hypotheses for broader-scale quantitative work., 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 Ltd. All rights reserved.)

Background: People with HIV (PWH) are at elevated risk for suicidal ideation (SI), yet few studies have examined how substance use, clinical and sociodemographic factors are associated with SI among PWH., Method: We used substance use (Tobacco, Alcohol, Prescription Medication, and Other Substance Use [TAPS]) and depression (PHQ-9) data from computerized screening of adult PWH in primary care clinics in Northern California, combined with health record data on psychiatric diagnoses, HIV diagnosis, treatment, and control (HIV RNA, CD4), insurance, and neighborhood deprivation index (NDI) to examine factors associated with SI (PHQ-9 item 9 score > 0). Adjusted odds ratios (aOR) for SI were obtained from logistic regression models., Results: Among 2829 PWH screened (92 % male; 56 % white; mean (SD) age of 54 (13) years; 220 (8 %) reported SI. Compared with no problematic use, SI was higher among those reporting one (aOR = 1.65, 95 % CI = 1.17, 2.33), two (aOR = 2.23, 95 % CI = 1.42, 3.49), or ≥ 3 substances (aOR = 4.49, 95 % CI = 2.41, 8.39). SI risk was higher for those with stimulant use (aOR = 3.55, 95 % CI = 2.25, 5.59), depression (aOR = 4.18, 95 % CI = 3.04, 5.74), and anxiety diagnoses (aOR = 1.67, 95 % CI = 1.19, 2.34), or Medicaid (aOR = 2.11, 95%CI = 1.24, 3.60) compared with commercial/other insurance. SI was not associated with HIV-related measures or NDI., Limitations: SI was assessed with a single PHQ-9 item. Simultaneous SI and exposure data collection restricts the ability to establish substance use as a risk factor., Conclusions: HIV care providers should consider multiple substance use, stimulant use, depression or anxiety, and public insurance as risk factors for SI and provide interventions when needed., Competing Interests: Declaration of competing interest The authors report no competing of interest., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Posttraumatic stress disorder (PTSD) is highly comorbid with substance use disorders (SUDs), resulting in high prevalence of PTSD among individuals in residential SUD care. However, there is limited research on integrating trauma treatment into residential SUD care settings. The aim of the present project was to conduct an initial evaluation of the effects of group-based Written Exposure Therapy (WET) on PTSD and depressive symptoms that was integrated into programming for individuals in residential SUD treatment., Methods: Participants were 48 Veterans with comorbid PTSD-SUD from a 28-day residential SUD program at a Veterans Affairs Medical Center. Eligible participants were enrolled in 5 sessions of WET, delivered in twice-weekly in a group format. PTSD symptoms and depressive symptoms were assessed at each session with the Posttraumatic Stress Disorder Checklist, DSM-5 version (PCL-5) and the Patient Health Questionnaire (PHQ-9)., Results: Of the enrolled sample of 48 participants, 92% ( n = 44) completed 3 sessions, while 56% ( n = 28) completed 5 sessions. Dependent samples t-tests showed significant reductions from baseline in PTSD symptoms within-persons at both the 3-session ( t (43) = 4.77, p < .001, d = .72) and 5-session mark ( t (27) = 4.36, p < .001, d = .82). In addition, there were significant reductions in depressive symptoms after 3 sessions ( t (38) = 3.01, p < .01, d = .48) and after 5 sessions ( t (23) = 2.97, p < .01, d = .61)., Conclusion: Findings demonstrate that brief, group-delivered WET shows promise for addressing PTSD and depressive symptoms in residential SUD treatment. Results of the present evaluation could inform further efficacy testing and implementation of PTSD treatment into residential SUD settings., Competing Interests: Additional Declarations: No competing interests reported.

Background: While cannabis use is prevalent among people with HIV (PWH), factors associated with higher-risk use require further study. We examined factors associated with indicators risk for cannabis use disorder (CUD) among PWH who used cannabis., Methods: Participants included adult (≥18 years old) PWH from 3 HIV primary care clinics in Kaiser Permanente Northern California who reported past three-month cannabis use through the computerized Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) screening. Primary outcome was TAPS cannabis score (range 1-3), categorized as any use (1) and higher risk for CUD (≥2). Measures included sociodemographics (age, sex, race, neighborhood deprivation index [NDI]), Charlson Comorbidity Index (CCI), HIV RNA, CD4 cell counts, higher risk tobacco use (TAPS tobacco score≥2), depression, and anxiety symptoms. Unadjusted and multivariable logistic regression examined factors associated with higher risk for CUD., Results: Of the complete sample ( N =978; 94.1% Male; 58.3% White; Age Mode =51-60), 35.8% reported higher risk for CUD. Unadjusted models indicated younger age, Black race, higher CCI, depression, anxiety, and higher risk tobacco use were associated with higher risk, while only Black race (OR=1.84, 95% CI[1.29, 2.63]), anxiety (OR=1.91, 95% CI[1.22, 2.98]), and higher risk tobacco use (OR=2.27, 95% CI[1.47, 3.51]) remained significant in the multivariable model., Conclusions: Black race, anxiety and tobacco use, but not HIV clinical markers, were associated with higher risk for CUD among PWH. Clinical efforts to screen and provide interventions for preventing CUD alongside anxiety and tobacco use among PWH should be evaluated., Competing Interests: Conflict of interest: All authors report no conflict of interest.

Background: Management of hypertension, dyslipidemia, diabetes and other modifiable factors may mitigate the cardiovascular disease (CVD) risk in people with human immunodeficiency virus (HIV, PWH) compared with people without HIV (PWoH)., Methods: This was a retrospective cohort study of 8285 PWH and 170 517 PWoH from an integrated health system. Risk factor control was measured using a novel disease management index (DMI) accounting for amount/duration above treatment goals (0% to 100% [perfect control]), including 2 DMIs for hypertension (diastolic and systolic blood pressure), 3 for dyslipidemia (low-density lipoprotein, total cholesterol, triglycerides), and 1 for diabetes (HbA1c). CVD risk by HIV status was evaluated overall and in subgroups defined by DMIs, smoking, alcohol use, and overweight/obesity in adjusted Cox proportional hazards models., Results: PWH and PWoH had similar DMIs (80%-100%) except for triglycerides (worse for PWH) and HbA1c (better for PWH). In adjusted models, PWH had an elevated risk of CVD compared with PWoH (hazard ratio [HR], 1.18; 95% confidence interval [CI], 1.07-1.31). This association was attenuated in subgroups with controlled dyslipidemia and diabetes but remained elevated for PWH with controlled hypertension or higher total cholesterol. The strongest HIV status association with CVD was seen in the subgroup with frequent unhealthy alcohol use (HR, 2.13; 95% CI, 1.04-4.34)., Conclusions: Control of dyslipidemia and diabetes, but not hypertension, attenuated the HIV status association with CVD. The strong association of HIV and CVD with frequent unhealthy alcohol use suggests enhanced screening and treatment of alcohol problems in PWH is warranted., Competing Interests: Potential conflicts of interest. M. C. reports research grants from Gilead, MSD, and ViiV (paid to institution); payment for expert testimony from Gilead, MSD, and ViiV Healthcare (paid to institution); and support for attending meetings and/or travel from Gilead (paid to institution). C. B. H. reports grants or contracts from Gilead (payments to institution for unrelated research). All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Persons with HIV (PWH) experience high levels of pain. We examined the relationship of pain severity with use of cannabis and prescription opioids among PWH. This cross-sectional study evaluated associations between self-reported pain (moderate/severe vs mild/none) and cannabis and prescription opioid use in a primary care sample of PWH enrolled in an alcohol use treatment study at Kaiser Permanente, San Francisco. Prevalence ratios (PR) for moderate/severe pain associated with cannabis, opioid use, or both in the prior 30 days were obtained from Poisson regression models. Adjusted models included race/ethnicity, education, employment, HIV ribonucleic acid levels, depression, and anxiety. Overall, 614 PWH completed baseline questionnaires from May 2013 to May 2015, among whom 182/614 (29.6%) reported moderate/severe pain. The prevalence of moderate/severe pain varied by substances: 19.1% moderate/severe pain among study participants who reported neither cannabis or opioids, 30.2% for cannabis alone, 41.2% for opioids alone, and 60.9% for those reporting both substances. In adjusted models, compared with PWH who reported neither substance (reference), prevalence of moderate/severe pain was higher for those using cannabis alone (PR 1.54; 95% CI 1.13-2.09), opioids alone (PR 1.96; 95% CI 1.31-2.94), and those reporting both (PR 2.66; 95% CI 1.91-3.70). PWH who reported opioid and/or cannabis use were more likely to report moderate/severe pain compared with PWH who did not report use of these substances. To improve patient care, it is vital to assess patients' approaches to pain management including substance use and target appropriate interventions to reduce pain in PWH., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Adults over age 50 increasingly use cannabis, but few studies have examined co-occurring psychiatric and substance use disorders (SUDs) in this population. The current study utilized electronic health record (EHR) data to compare adults age 50 + with ICD-10 cannabis codes (cases) and matched controls on common psychiatric and SUDs from 2016 to 2020., Method: Patients age 50 + from an integrated healthcare system in Hawai'i were identified using ICD-10 codes for cannabis (use, abuse, and dependence) from 2016 to 2018. In a matched cohort design, we selected non-cannabis-using controls (matched on sex and age) from the EHR (n = 275) and compared them to cases (patients with an ICD-10 cannabis code; n = 275) on depressive and anxiety disorders and SUDs (i.e., tobacco, opioid, and alcohol use disorders) over a two-year follow-up period., Results: Participants were 62.8 years (SD = 7.3) old on average; and were White (47.8 %), Asian American (24.4 %), Native Hawaiian or Pacific Islander (19.3 %), or Unknown (8.5 %) race/ethnicity. Conditional multiple logistic regression was used to estimate odds ratios comparing cases vs controls. Participants with an ICD-10 cannabis code had a significantly greater risk of major depressive disorder (OR = 10.68, p < 0.0001) and any anxiety disorder (OR = 6.45, p < 0.0001), as well as specific anxiety or trauma-related disorders (e.g., generalized anxiety disorder, PTSD) and SUDs (ORs 2.72 - 16.00, p < 0.01 for all)., Conclusions: Over a two-year period, diverse adults age 50 + in Hawai'i with ICD-10 cannabis codes experienced higher rates of subsequent psychiatric and SUDs compared to controls. These findings can guide efforts to inform older adults about possible cannabis-related risks., 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 Elsevier Ltd. All rights reserved.)

Background: Since the coronavirus disease 2019 (COVID-19) pandemic began, telemedicine use has transformed healthcare delivery. Yet there is concern that telemedicine may widen care disparities for vulnerable populations, and patient experience data are limited., Aims: We aimed to assess patient satisfaction with hepatology-related telemedicine (telehepatology) for delivery of fatty liver disease (FLD) care in a safety-net healthcare system., Methods: Adult patients with FLD were surveyed regarding satisfaction with telehepatology. Clinical, demographic, resources, and social determinants of health (SDoH) data were collected to identify factors associated with satisfaction through multivariable modeling., Results: From June 2020 to March 2022, 220 participants were enrolled: the median age was 52 years, 37% were men, and 68% were Hispanic. One hundred nineteen (54%) had prior telehepatology experience. Overall, satisfaction was high; 70% reported being somewhat or very satisfied. On univariate analysis, Hispanic ethnicity (versus non-Hispanic, OR 0.34, 95% CI 0.1-0.9, p = 0.03) and limited access to personal cellphone/internet (OR 0.16, 95% CI 0.04-0.6, p = 0.01) were associated with lower satisfaction. On multivariable logistic regression modeling adjusted for pandemic duration, age, sex, severity of liver disease, and coexisting liver disease, Hispanic ethnicity and lack of personal cellphone/internet remained independently associated with lower telehepatology satisfaction (OR 0.24, 95% CI 0.07-0.9, p = 0.03 and OR 0.2, 95% CI 0.04-0.9, p = 0.04, respectively). The association remained statistically significant after inclusion of various SDoH in the multivariable model., Conclusions: Satisfaction with telehepatology among FLD patients in a safety-net clinical setting was high overall. However, Hispanic ethnicity and lack of personal cellphone/internet were independently associated with lower telehepatology satisfaction. A better understanding of patients' experience with telehepatology is needed to identify reasons for dissatisfaction, and in-person visits should remain an option for patients to ensure equitable care., (© 2024. The Author(s).)

Background: Management of cirrhosis is challenging and has been complicated by the COVID-19 pandemic due to decreased access to care, increased psychological distress, and alcohol misuse. Recently, The National Institute on Alcohol Abuse and Alcoholism has broadened the definition of recovery from alcohol use disorder to include quality of life (QoL) as an indicator of recovery. This study examined the associations of alcohol-associated cirrhosis etiology and problematic drinking with liver disease QoL (LDQoL)., Methods: Patients with cirrhosis (N=329) were recruited from 3 sites (63% from 2 Veterans Affairs Health Care Systems and 37% from 1 safety net hospital) serving populations that are economically or socially marginalized. Cirrhosis etiology was ascertained by chart review of medical records. Problematic drinking was defined by ≥8 on the Alcohol Use Disorders Identification Test. Multivariable general linear modeling adjusting for age, sex, race/ethnicity, site, pandemic-related stress, and history of anxiety/depressive disorder were conducted. Sensitivity analyses further adjusted for indicators of liver disease severity., Results: Participants were on average 64.6 years old, 17% female, 58% non-White, 44% with alcohol-associated cirrhosis, and 17% with problematic drinking. Problematic drinking was significantly associated with worse LDQoL scores in the overall scale and in the memory/concentration and health distress subscales. These associations remained significant after adjusting for indicators of liver disease severity, including Model for End-Stage Liver Disease-Sodium score and decompensated cirrhosis status., Conclusions: Among patients with cirrhosis, problematic drinking was associated with worse LDQoL, especially in the domains of memory/concentration and health distress. Assessment and awareness of cognitive deficits and negative emotionality within the context of cirrhosis and problematic drinking may help clinicians provide better integrated care for this population., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Study of Liver Diseases.)

Objectives: Late life depression (LLD) and hoarding disorder (HD) are common in older adults and characterized by executive dysfunction and disability. We aimed to determine the frequency of co-occurring HD in LLD and examine hoarding severity as an additional contributor to executive dysfunction, disability, and response to psychotherapy for LLD., Design: Cross-sectional., Setting: Outpatient psychiatry program., Participants: Eighty-three community-dwelling adults ages 65-90 with LLD., Intervention: Problem-solving therapy., Measurements: Measures of executive function, disability, depression, and hoarding severity were completed at post-treatment. Pearson's chi-squared tests evaluated group differences in rates of cognitive impairment, disability, and depression treatment response between participants with HD (LLD+HD) and LLD only. Separate linear regressions assessed associations between hoarding severity and executive function, disability, and psychotherapy response. Covariates included age, education, gender, and depression severity., Results: 30.1% (25/83) of LLD participants met HD criteria. Relative to LLD, LLD+HD participants demonstrated greater impairment rates on measures of executive function (Letter-Number-Sequencing, X 2 (1)=4.0, p = 0.045; Stroop-Interference, X 2 (1) = 4.8, p = 0.028). Greater hoarding severity was associated with poorer executive functioning performance (Letter-Number-Sequencing (t[70] = -2.1, β = -0.05, p = 0.044), Digit-Span (t[71] = -2.4, β = -0.07, p = 0.019), Letter-Fluency (t[ 71] = -2.8, β = -0.24, p = 0.006)). Rates of disability were significantly higher for LLD+HD (88.0%) than LLD (62.3%), (X 2 [1] = 5.41, p = 0.020) and higher hoarding severity was related to greater disability (t[72] = 2.97, β = 0.13, p = 0.004). Depression treatment response rates were significantly lower for LLD+HD (24.0%) compared to LLD (48.3%), X 2 (1) = 4.26, p = 0.039, and HD status predicted psychotherapy response, t(67) = -2.15, β = -15.6, p = 0.035., Conclusions: We found 30.1% co-occurrence of HD in LLD, which was accompanied by greater executive dysfunction, disability, and poorer response to depression treatment. Results underscore the need for increased screening of hoarding behaviors in LLD and tailored interventions for this LLD+HD group., Competing Interests: DISCLOSURES The authors declare the following financial interests/personal relationships: Dr. Insel has served as a consultant for Roche; Dr. Nelson has been an advisor or consultant to Astellas, Axsome, Biohaven, Janssen, Johnson and Johnson, Novartis, Otsuka, Sunovion; Dr. Mathews serves on the Scientific Advisory Boards of the Family Foundation for OCD Research and the International OCD Foundation. Dr. Mackin has received research support from The National Institute of Mental Health and Johnson and Johnson. Drs. Kassel, Kryza-Lacombe, Rhodes, Satre, and Tosun report no conflicts to declare for this work. This manuscript is based on work supported, in part, by the Department of Veterans Affairs, but does not necessarily represent the views of the Department of Veterans Affairs or the United States Government., (Published by Elsevier Inc.)

Background: Heavy alcohol use is a growing risk factor for chronic disease, yet little is known about its co-occurrence with other risk factors and health problems. This study aimed to identify risk profiles of adults with heavy alcohol use and examined potential disparities by race and ethnicity., Methods: This cross-sectional study included 211,333 adults with heavy alcohol use (in excess of daily or weekly limits recommended by National Institute on Alcohol Abuse and Alcoholism) between June 1, 2013 and December 31, 2014 in Kaiser Permanente Northern California. Latent class analysis was used to examine how heavy drinking patterns clustered with other behavioral and metabolic risk factors and health problems to form risk profiles. Multinomial logistic regression models were fit to examine associations between race, ethnicity, and risk profiles., Results: A 5-class model was selected as best fitting the data and representing clinically meaningful risk profiles: (1) "heavy daily drinking and lower health risks" (DAILY, 44.3%); (2) "substance use disorder and mental health disorder" (SUD/MH, 2.3%); (3) "heavy weekly drinking and lower health risks" (WEEKLY, 19.6%); (4) "heavy daily drinking and more health risks" (DAILY-R, 18.5%); (5) "heavy weekly drinking and more health risks" (WEEKLY-R, 15.3%). American Indian or Alaska Native (AIAN) and Black patients had higher odds than White patients of being in the SUD/MH, DAILY-R, and WEEKLY-R profiles than the DAILY profile. AIAN, Black, and Latino/Hispanic patients had higher odds than White patients of being in the SUD/MH, DAILY-R, and WEEKLY-R profiles rather than the WEEKLY profile., Conclusions: AIAN, Black, and Latino/Hispanic patients with self-reported heavy drinking were more likely to be in risk profiles with greater alcohol consumption, more health risks, and higher morbidity. Targeted, culturally appropriate interventions for heavy alcohol use that may address other modifiable risk factors are needed to work towards health equity., (© 2023 Research Society on Alcohol.)

We characterized polysubstance use burden and associations with mental health problems across demographic subgroups of PWH. In 2018-2020, as part of a primary care-based intervention study, PWH in care at three medical centers in Kaiser Permanente Northern California were screened for depression (PHQ-9≥10), anxiety (GAD-2≥3), and substance use (Tobacco, Alcohol, Prescription medication, and other Substance use [TAPS]≥1 per substance). We used Poisson regression to estimate prevalence ratios (PRs) comparing polysubstance use prevalence (TAPS≥1 for ≥2 substances) between PWH with positive screens for depression or anxiety vs. neither, among all PWH, and stratified by race/ethnicity and age (restricted to men), adjusting for sociodemographics, CD4, and HIV load. Screened PWH (N = 2865) included 92% men, 56% White, 19% Black, and 15% Hispanic PWH, with a median age of 55 years. Overall, polysubstance use prevalence was 26.4% (95% CI 24.9%-28.1%). PWH with depression or anxiety (n = 515) had an adjusted polysubstance use PR of 1.26 (1.09-1.46) vs. PWH with neither (n = 2350). Adjusted PRs were 1.47 (1.11-1.96), 1.07 (0.74-1.54), and 1.10 (0.85-1.41) among Black, Hispanic, and White men, respectively. Adjusted PRs did not differ by age group. Interventions should consider jointly addressing mental health and substance use problems and potential drivers, e.g. stigma or socioeconomic factors., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Davy-Mendez 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.)

Background and Aims: Telehealth has emerged as an important mode of cirrhosis care delivery, but its use and satisfaction among vulnerable populations (eg, racial/ethnic minorities, socioeconomically disadvantaged, substance use disorders) are unknown. We evaluated digital capacity, telehealth use, satisfaction and associated factors among patients receiving hepatology care via telehealth (telehepatology) across 2 Veterans Affairs and 1 safety-net Healthcare systems., Methods: English- and Spanish-speaking adults with cirrhosis (N = 256) completed surveys on telehealth use and satisfaction, quality of life, pandemic stress, alcohol use and depression. Logistic regression analyses assessed telehealth use and general linear models evaluated telehealth satisfaction., Results: The mean age was 64.5 years, 80.9% were male and 35.9% Latino; 44.5% had alcohol-associated cirrhosis; 20.8% had decompensated cirrhosis; 100% had digital (phone/computer) capacity; and 75.0% used telehepatology in the prior 6 months. On multivariable analysis, participants with alcohol-associated (vs not) cirrhosis were less likely and those with greater pandemic stress were more likely to use telehepatology (odds ratio = 0.46 and 1.41, respectively; P < .05). Better quality of life was associated with higher telehepatology satisfaction and older age was associated with lower satisfaction ( β  = 0.01 and -0.01, respectively; P < .05). Latinos had higher satisfaction, but alcohol use disorder was associated with less satisfaction with telehepatology visits ( β  = 0.22 and -0.02, respectively; P  < .05)., Conclusion: Participants had high telehepatology capacity, yet demographics and alcohol-related problems influenced telehepatology use and satisfaction. Findings underscore the need for interventions to enhance patient experience with telehepatology for certain vulnerable groups including those with alcohol-associated cirrhosis in order to optimize care delivery., (© 2024 The Authors.)

Objective: Rates of prenatal cannabis use are rising, yet little is known about modes of cannabis use during pregnancy. This focus group study with pregnant individuals aimed to examine use patterns and perceptions regarding common modes of prenatal cannabis use., Method: Kaiser Permanente Northern California pregnant adult patients who identified as White or Black and self-reported cannabis use during pregnancy were recruited to participate (N = 53; 40% Black, 60% White; Mean age  = 30.3, SD = 5.2). Eighteen focus groups with race-concordant facilitators followed a semi-structured format that queried participants on their prenatal cannabis use, including preferred modes of use (e.g., vapes, blunts, dabs, joints, edibles, topicals, pipes). Focus group discussions were coded and analyzed using a general inductive approach., Results: A range of modes were preferred, with no single mode predominant. Participants' preferences aligned with four themes: perceived effects and benefits of cannabis, health and safety, convenience and familiarity, and partner and friend influences. Participants sought modes that were accessible and familiar, provided consistent and quick relief for pregnancy-related symptoms, were aligned with partners or friends, and minimized perceived risks while also providing symptom relief. Participants desired evidence-based information about mode safety to better inform mode selection during pregnancy., Conclusions: A range of personal and social factors influenced mode preferences during pregnancy. Many participants desired to reduce harms and use cannabis more safely in pregnancy but received little mode-specific information to guide these preferences. Further research identifying mode-specific risks is needed to guide harm reduction approaches during pregnancy., 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 Elsevier Ltd. All rights reserved.)

Background: Understanding demographic disparities in hospitalisation is crucial for the identification of vulnerable populations, interventions, and resource planning., Methods: Data were from the Antiretroviral Therapy Cohort Collaboration (ART-CC) on people living with HIV in Europe and North America, followed up between January, 2007 and December, 2020. We investigated differences in all-cause hospitalisation according to gender and mode of HIV acquisition, ethnicity, and combined geographical origin and ethnicity, in people living with HIV on modern combination antiretroviral therapy (cART). Analyses were performed separately for European and North American cohorts. Hospitalisation rates were assessed using negative binomial multilevel regression, adjusted for age, time since cART intitiaion, and calendar year., Findings: Among 23 594 people living with HIV in Europe and 9612 in North America, hospitalisation rates per 100 person-years were 16·2 (95% CI 16·0-16·4) and 13·1 (12·8-13·5). Compared with gay, bisexual, and other men who have sex with men, rates were higher for heterosexual men and women, and much higher for men and women who acquired HIV through injection drug use (adjusted incidence rate ratios ranged from 1·2 to 2·5 in Europe and from 1·2 to 3·3 in North America). In both regions, individuals with geographical origin other than the region of study generally had lower hospitalisation rates compared with those with geographical origin of the study country. In North America, Indigenous people and Black or African American individuals had higher rates than White individuals (adjusted incidence rate ratios 1·9 and 1·2), whereas Asian and Hispanic people living with HIV had somewhat lower rates. In Europe there was a lower rate in Asian individuals compared with White individuals., Interpretation: Substantial disparities exist in all-cause hospitalisation between demographic groups of people living with HIV in the current cART era in high-income settings, highlighting the need for targeted support., Funding: Royal Free Charity and the National Institute on Alcohol Abuse and Alcoholism., Competing Interests: Declaration of interests SMR reports fellowship payments from the Royal Free Charity. FCL reports grants from the National Institute for Health and Care Research paid to their institution. JACS and SMI report grants from the National Institutes of Health paid to their institution. JACS also received grants from the UK National Institute for Health and Care Research paid to their institution. MvdV received grants and consulting fees from Gilead, ViiV, and MSD paid to their institution. GW reports grants from Gilead and Roche Diagnostics and honoraria from Gilead, ViiV, and MSD. MJG participated on advisory boards for Merck, Gilead, and ViiV. HMC and JC report separate grants from the National Institutes of Health paid to their institution. HMC received grants from ViiV and AHRQ paid to their institution. LW reports grants from ANRS MIE. All other authors declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Among persons with HIV (PWH), higher alcohol use and having hepatitis C virus (HCV) are separately associated with increased morbidity and mortality. We investigated whether the association between alcohol use and mortality among PWH is modified by HCV. Data were combined from European and North American cohorts of adult PWH who started antiretroviral therapy (ART). Self-reported alcohol use data, collected in diverse ways between cohorts, were converted to grams/day. Eligible PWH started ART during 2001-2017 and were followed from ART initiation for mortality. Interactions between the associations of baseline alcohol use (0, 0.1-20.0, >20.0 g/day) and HCV status were assessed using multivariable Cox models. Of 58,769 PWH, 29,711 (51%), 23,974 (41%) and 5084 (9%) self-reported alcohol use of 0 g/day, 0.1-20.0 g/day, and > 20.0 g/day, respectively, and 4799 (8%) had HCV at baseline. There were 844 deaths in 37,729 person-years and 2755 deaths in 443,121 person-years among those with and without HCV, respectively. Among PWH without HCV, adjusted hazard ratios (aHRs) for mortality were 1.18 (95% CI: 1.08-1.29) for 0.0 g/day and 1.84 (1.62-2.09) for >20.0 g/day compared with 0.1-20.0 g/day. This J-shaped pattern was absent among those with HCV: aHRs were 1.00 (0.86-1.17) for 0.0 g/day and 1.64 (1.33-2.02) for >20.0 g/day compared with 0.1-20.0 g/day (interaction p < .001). Among PWH without HCV, mortality was higher in both non-drinkers and heavy drinkers compared with moderate alcohol drinkers. Among those with HCV, mortality was higher in heavy drinkers but not non-drinkers, potentially due to differing reasons for not drinking (e.g. illness) between those with and without HCV., (© 2023 The Authors. Journal of Viral Hepatitis published by John Wiley & Sons Ltd.)

Background: Influenza vaccination is recommended for adults regardless of human immunodeficiency virus (HIV) status. There may be facilitators or barriers to vaccinating people with HIV (PWH) that differ from people without HIV (PWoH). We sought to describe the uptake of influenza vaccination by HIV status and identify factors associated with vaccination., Methods: We abstracted data from the electronic health records of PWH and PWoH in Kaiser Permanente Northern California during 6 influenza seasons (2013-2018). We determined vaccination uptake and used Poisson regression models to evaluate factors associated with vaccination in PWH and PWoH., Results: 9272 PWH and 194 393 PWoH matched by age, sex, and race/ethnicity were included (mean age: 48 vs 49 years; men: 91% vs 90%; White race: 53% for both groups). PWH were more likely to receive the influenza vaccine (65-69% across years for PWH and 37-41% for PWoH) with an adjusted risk ratio for all years of 1.48 (95% CI: 1.46-1.50). For PWH, lower vaccination uptake was associated with several factors that suggested more complex health needs, such as lower CD4 cell counts, higher HIV viral loads, prior depression diagnoses, having Medicare insurance, and having a higher number of comorbidities. Associations with vaccination uptake were attenuated in PWH, compared with PWoH, for smoking, alcohol, and demographic factors., Conclusions: PWH had an almost 50% higher uptake of influenza vaccination than PWoH, possibly reflecting greater engagement with the healthcare system. We also found that PWH with more complex health needs had reduced vaccination uptake. Findings may inform outreach strategies to increase influenza vaccination in PWH., Competing Interests: Potential conflicts of interest. The authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Bothersome symptoms potentially related to drinking are commonly reported by people with and without HIV (PWH/PWoH). However, the relationship between bothersome symptoms and level of alcohol use is often not appreciated by patients or providers. Therefore, among persons reporting prior-year alcohol use, we assessed whether alcohol use level (AUDIT-C score), HIV status, and demographic covariates influenced the likelihood of the patient reporting a bothersome symptom. We used the Veterans Aging Cohort Study (VACS) surveys (2002-2018), including a validated symptoms index. Among 3679 PWH and 3830 PWoH currently drinking alcohol, the most commonly reported symptoms were muscle/joint pain (52%), sleep disturbance (51%), and fatigue (50%). Level of alcohol use was independently associated with 18 of 20 bothersome symptoms, including seven symptoms more common among PWH. Results can help inform PWH/PWoH who drink alcohol about the strong relationship between level of alcohol use and bothersome symptoms, potentially motivating reduced use., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Little is known about the prevalence of undiagnosed cognitive impairment and its impact on instrumental activities of daily living (IADL) among people with HIV (PWH) in primary care., Methods: PWH were recruited from an integrated health care setting in the United States. PWH were eligible for recruitment if they were ≥50 years old, taking antiretroviral therapy (ie, ≥1 antiretroviral therapy [ART] prescription fill in the past year), and had no clinical diagnosis of dementia. Participants completed a cognitive screen (St. Louis University Mental Status exam) and a questionnaire on IADL (modified Lawton-Brody)., Results: Study participants (n = 47) were mostly male (85.1%), 51.1% White, 25.5% Black, 17.0% Hispanic, and the average age (SD) was 59.7 (7.0) years. Overall, 27 (57.5%) participants were categorized as cognitively normal, 17 (36.2%) as having mild cognitive impairment, and 3 (6.4%) as having possible dementia. Of the 20 participants with mild cognitive impairment or possible dementia, 85.0% were men, the average age (SD) was 60.4 (7.1) years; 45.0% were White, 40.0% were Black, 10.0% were Hispanic, and 30.0% reported difficulty with at least 1 IADL. Most (66.7%) attributed difficulty with IADL primarily (33.3%) or in part (33.3%) to cognitive problems., Conclusions: Undiagnosed cognitive impairment is frequent among ART-treated PWH, with possible elevated risk among Black PWH, and may be accompanied by difficulty with IADL. Efforts are needed to optimize identification of factors contributing to cognitive and IADL difficulties among ART-treated PWH in primary care., Competing Interests: Potential conflicts of interest. All authors: no reported conflicts., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Mental health and substance use disorders disproportionately affect people with HIV (PWH), and may have been exacerbated during COVID-19. The Promoting Access to Care Engagement (PACE) trial was designed to assess the effectiveness of electronic screening for mental health and substance use in HIV primary care and enrolled PWH from October 2018 to July 2020. Our objective here was to compare screening rates and results for PWH before (October 2018 - February 2020) and early in the COVID-19 pandemic (March-July 2020)., Methods: Adult (≥ 18 years) PWH from 3 large HIV primary care clinics in a US-based integrated healthcare system were offered electronic screening online or via in-clinic tablet computer every 6 months. Screening completion and results (for depression, suicidal ideation, anxiety, and substance use) were analyzed using logistic regression with generalized estimating equations to estimate prevalence ratios (PR) before and after the start of the regional COVID-19 shelter-in-place orders on March 17, 2020. Models adjusted for demographics (age, sex, race/ethnicity), HIV risk factors (men who have sex with men, injection drug use, heterosexual, other), medical center, and modality of screening completion (online or tablet). We conducted qualitative interviews with providers participating in the intervention to evaluate how the pandemic impacted patient care., Results: Of 8,954 eligible visits, 3,904 completed screenings (420 during COVID, 3,484 pre-COVID), with lower overall completion rates during COVID (38% vs. 44%). Patients completing screening during COVID were more likely to be White (63% vs. 55%), male (94% vs. 90%), and MSM (80% vs., 75%). Adjusted PRs comparing COVID and pre-COVID (reference) were 0.70 (95% CI), 0.92 (95% CI), and 0.54 (95% CI) for tobacco use, any substance use, and suicidal ideation, respectively. No significant differences were found by era for depression, anxiety, alcohol, or cannabis use. These results were in contrast to provider-reported impressions of increases in substance use and mental health symptoms., Conclusion: Findings suggest PWH had modest declines in screening rates early in the COVID-19 pandemic which may have been affected by the shift to telemedicine. There was no evidence that mental health problems and substance use increased for PWH in primary care., Trial Registration: NCT03217058 (First registration date: 7/13/2017); https://clinicaltrials.gov/ct2/show/NCT03217058., (© 2023. The Author(s).)

Objectives: People living with HIV (PWH) have seen reduction in HIV-associated morbidity and increase in near-normal life expectancy, yet unhealthy alcohol use poses substantial risks to older as well as younger adults. Further research regarding age-associated physical and mental health concerns among PWH who drink alcohol is needed to inform services, given the expanding age range of patients in care. Methods: We compared age group differences (18-34, 35-44, 45-54, ≥55 years old) in two-year patient-reported outcomes and HIV viral control among PWH enrolled in a primary care-based behavioral alcohol intervention trial; with 90% follow up from baseline. Results: Of 553 PWH, 50 (9%) were 18-34, 85 (15%) were 35-44, 197 (36%) were 45-54, and 221 (40%) were ≥55 years old. Most were men (97%) and White (64%). At two years, PWH ≥55 reported less substance use in the prior 30 days, fewer social contacts, and more pain; younger PWH had lower antiretroviral therapy (ART) adherence. In adjusted analyses, PWH ages 18-34 had higher odds of unhealthy alcohol use, tobacco, cannabis, or other substances compared to those ≥55; with higher odds of anxiety among PWH 35-44 compared with those ≥55; and physical quality of life was worse among those ≥55 compared with younger groups. Conclusions: While older PWH report less substance use than younger PWH and have better ART adherence post-treatment, they are more likely to experience limited social support and worse physical quality of life. Findings can inform interventions to address varying needs of PWH across the lifespan.

Outcomes of PWH with unhealthy alcohol use, such as alcohol use reduction or progression to AUD, are not well-known and may differ by baseline patterns of unhealthy alcohol use. Among 1299 PWH screening positive for NIAAA-defined unhealthy alcohol use in Kaiser Permanente Northern California, 2013-2017, we compared 2-year probabilities of reduction to low-risk/no alcohol use and rates of new AUD diagnoses by baseline use patterns, categorized as exceeding: only daily limits (72% of included PWH), only weekly limits (17%), or both (11%), based on NIAAA recommendations. Overall, 73.2% (95% CI 70.5-75.9%) of re-screened PWH reduced to low-risk/no alcohol use over 2 years, and there were 3.1 (95% CI 2.5-3.8%) new AUD diagnoses per 100 person-years. Compared with PWH only exceeding daily limits at baseline, those only exceeding weekly limits and those exceeding both limits were less likely to reduce and likelier to be diagnosed with AUD during follow-up. PWH exceeding weekly drinking limits, with or without exceeding daily limits, may have a potential need for targeted interventions to address unhealthy alcohol use., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objectives: To evaluate associations between alcohol brief intervention (BI) in primary care and 12-month drinking outcomes and 18-month health outcomes among adults with hypertension and type 2 diabetes (T2D)., Design: A population-based observational study using electronic health records data., Setting: An integrated healthcare system that implemented system-wide alcohol screening, BI and referral to treatment in adult primary care., Participants: Adult primary care patients with hypertension (N=72 979) or T2D (N=19 642) who screened positive for unhealthy alcohol use between 2014 and 2017., Main Outcome Measures: We examined four drinking outcomes: changes in heavy drinking days/past 3 months, drinking days/week, drinks/drinking day and drinks/week from baseline to 12-month follow-up, based on results of alcohol screens conducted in routine care. Health outcome measures were changes in measured systolic and diastolic blood pressure (BP) and BP reduction ≥3 mm Hg at 18-month follow-up. For patients with T2D, we also examined change in glycohaemoglobin (HbA1c) level and 'controlled HbA1c' (HbA1c<8%) at 18-month follow-up., Results: For patients with hypertension, those who received BI had a modest but significant additional -0.06 reduction in drinks/drinking day (95% CI -0.11 to -0.01) and additional -0.30 reduction in drinks/week (95% CI -0.59 to -0.01) at 12 months, compared with those who did not. Patients with hypertension who received BI also had higher odds for having clinically meaningful reduction of diastolic BP at 18 months (OR 1.05, 95% CI 1.00 to 1.09). Among patients with T2D, no significant associations were found between BI and drinking or health outcomes examined., Conclusions: Alcohol BI holds promise for reducing drinking and helping to improve health outcomes among patients with hypertension who screened positive for unhealthy drinking. However, similar associations were not observed among patients with T2D. More research is needed to understand the heterogeneity across diverse subpopulations and to study BI's long-term public health impact., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Annual screening for bacterial sexually transmitted infections (STI), including gonorrhea/chlamydia (GC/CT) and syphilis, is recommended for persons with HIV (PWH). We used the prevention index to quantify the extent to which STI screening was completed at guideline-recommended frequency in African American and Latinx persons, women, persons with alcohol (AUD) and substance (SUD) use disorders. Data from PWH at Kaiser Permanente Northern California were collected from electronic health records. We defined receipt of GC/CT and syphilis screening consistent with recommendations as a prevention index score ≥ 75%. Among 9655 PWH (17.7% Latinx; 16.2% African American; 9.6% female; 12.4% AUD; 22.1% SUD), prevention index scores for GC/CT and syphilis increased from 2015 to 2019. African American PWH had lower odds of receiving an annual syphilis screen (aOR 0.87 [95% CI 0.79-0.97]). Female sex was associated with lower odds of GC/CT (aOR 0.30 [95% CI 0.27-0.34]) and syphilis (aOR 0.27 [95% CI 0.24-0.310) screening. AUD and SUD were not associated with differences in annual GC/CT or syphilis screening. Key PWH subgroups experience ongoing challenges to annual STI screening despite comparable healthcare access., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Alcohol use problems are associated with serious medical, mental health and socio-economic consequences. Yet even when patients are identified in healthcare settings, most do not receive treatment, and use of pharmacotherapy is rare. This study will test the effectiveness of the Alcohol Telemedicine Consult (ATC) Service, a novel, personalized telehealth intervention approach for primary care patients with alcohol use problems., Methods: This cluster-randomized pragmatic trial, supplemented by qualitative interviews, will include adults with a primary care visit between 9/10/21-3/10/23 from 16 primary care clinics at two large urban medical centers within Kaiser Permanente Northern California, a large, integrated healthcare system. Clinics are randomized to the ATC Service (intervention), including alcohol pharmacotherapy and SBIRT (screening, MI (Motivational Interviewing)-based brief intervention and referral to addiction treatment) delivered by clinical pharmacists, or the Usual Care (UC) arm that provides systematic alcohol SBIRT. Primary outcomes include a comparison of the ATC and UC arms on 1) implementation outcomes (alcohol pharmacotherapy prescription rates, specialty addiction treatment referrals); and 2) patient outcomes (medication fills, addiction treatment initiation, alcohol use, healthcare services utilization) over 1.5 years. A general modeling approach will consider clustering of patients/providers, and a random effects model will account for intra-class correlations across patients within providers and across clinics. Qualitative interviews with providers will examine barriers and facilitators to implementation., Discussion: The ATC study examines the effectiveness of a pharmacist-provided telehealth intervention that combines pharmacotherapy and MI-based consultation. If effective, the ATC study could affect treatment models across the spectrum of alcohol use problems., Clinical Trials Registration: This study has been registered on ClinicalTrials.gov (NCT05252221)., 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 © 2022 Elsevier Inc. All rights reserved.)

Importance: Substance use disorders are associated with high rates of emergency department (ED) use and challenges engaging with primary care services., Objective: To examine 5-year health care engagement and utilization outcomes for participants in the LINKAGE trial, given previously reported associations of LINKAGE with improved care engagement in the short term., Design, Setting, and Participants: In this post hoc analysis of a nonrandomized controlled trial, participants were assigned to the LINKAGE or usual care (UC) groups using a nonrandomized 3-month alternating off and on strategy over 30 months. Baseline through 5-year follow-up data were collected from April 2011 to October 2018. The trial was conducted at an urban outpatient addiction treatment clinic within a large health system among patients newly enrolled in addiction treatment. Data analysis was conducted from April 2021 to February 2022., Intervention: The LINKAGE intervention included 6 group-based sessions emphasizing patient agency, skill, and motivation in navigating health care services as well as a facilitated telephone or email connection with a primary care practitioner. The UC group received medical education., Main Outcomes and Measures: Substance use problem discussions with primary care practitioners (by patient self-report at 1-, 2-, and 5-year follow-up interview) and annual use of the electronic patient portal, primary care, and ED based on electronic health records., Results: A total of 503 participants, with a mean (SD) age of 42 (12) years, 346 (69%) male participants and 37 (7%) African American, 34 (7%) Asian, and 101 (20%) Hispanic participants, were assigned to LINKAGE (252 participants) or UC (251 participants). Compared with UC participants, LINKAGE participants were significantly more likely to discuss substance use problems with a primary care practitioner at 1-year follow-up (risk ratio [RR], 1.30; 95% CI, 1.03-1.65; P = .03) and use the electronic patient portal at 1- and 2-year follow-up (eg, messaging clinicians at 2 years: RR, 1.24; 95% CI, 1.04-1.47; P = .02). The LINKAGE group had small, statistically significant 5-year annual increases in primary care use (RR, 1.03; 95% CI, 1.003-1.07; P = .03) and significant annual decreases in substance-related ED use (RR, 0.79; 95% CI, 0.64-0.97; P = .03), relative to UC. The LINKAGE group did not significantly differ from the UC group on other types of ED utilization., Conclusions and Relevance: In this study, a patient activation intervention embedded in outpatient addiction treatment was associated with sustained improvements in health care engagement beyond previously reported 6-month outcomes and with long-term improvements in health care use patterns., Trial Registration: ClinicalTrials.gov Identifier: NCT01621711.

Helping people with HIV (PWH) and without HIV (PWoH) understand the relationship between physical symptoms and alcohol use might help motivate them to decrease use. In surveys collected in the Veterans Aging Cohort Study from 2002 to 2018, PWH and PWoH were asked about 20 common symptoms and whether they thought any were caused by alcohol use. Analyses were restricted to current alcohol users (AUDIT-C > 0). We applied generalized estimating equations. The outcome was having any Symptoms Attributed to Alcohol use (SxAA). Primary independent variables were each of the 20 symptoms and HIV status. Compared to PWoH, PWH had increased odds of SxAA (OR 1.54; 95% CI 1.27, 1.88). Increased AUDIT-C score was also associated with SxAA (OR 1.32; 95% CI 1.28, 1.36), as were trouble remembering, anxiety, and weight loss/wasting. Evidence that specific symptoms are attributed to alcohol use may help motive people with and without HIV decrease their alcohol use., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The combination of unhealthy alcohol use and depression is associated with adverse outcomes including higher rates of alcohol use disorder and poorer depression course. Therefore, addressing alcohol use among individuals with depression may have a substantial public health impact. We compared the effectiveness of a brief intervention (BI) for unhealthy alcohol use among patients with and without depression., Method: This observational study included 312,056 adult primary care patients at Kaiser Permanente Northern California who screened positive for unhealthy drinking between 2014 and 2017. Approximately half (48%) received a BI for alcohol use and 9% had depression. We examined 12-month changes in heavy drinking days in the previous three months, drinking days per week, drinks per drinking day, and drinks per week. Machine learning was used to estimate BI propensity, follow-up participation, and alcohol outcomes for an augmented inverse probability weighting (AIPW) estimator of the average treatment (BI) effect. This approach does not depend on the strong parametric assumptions of traditional logistic regression, making it more robust to model misspecification., Results: BI had a significant effect on each alcohol use outcome in the non-depressed subgroup (-0.41 to -0.05, all ps < .003), but not in the depressed subgroup (-0.33 to -0.01, all ps > .28). However, differences between subgroups were nonsignificant (0.00 to 0.11, all ps > .44)., Conclusion: On average, BI is an effective approach to reducing unhealthy drinking, but more research is necessary to understand its impact on patients with depression. AIPW with machine learning provides a robust method for comparing intervention effectiveness across subgroups., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Objective: Motivational interviewing (MI) is a promising intervention for helping patients with mental health problems reduce their substance use. Examining the cost-effectiveness of MI and associations between MI and the use of health services can inform appropriate intervention strategies for these patients., Method: Kaiser Permanente adult patients with depression symptoms (Patient Health Questionnaire [PHQ-9] score > 5) seen in outpatient psychiatry ( N = 302) who reported unhealthy alcohol use or other substance use (primarily cannabis) were randomized to three sessions of MI (intervention) or printed literature (control) with telephone follow-up interviews at 6 and 12 months. Cost-effectiveness analyses compared intervention costs associated with 30-day abstinence from unhealthy alcohol use (i.e., any days of ≥4/≥5 drinks for women/men) and cannabis use. Multivariable analyses examined associations between MI and healthcare utilization at 12 months (emergency department, primary care, psychiatry, and addiction treatment)., Results: MI resulted in greater likelihood of abstaining from unhealthy alcohol use (70.0% vs. 60.2%, p < .01) and cannabis use (74.6% vs. 63.9%, p < .01) than the control at 6 months, but outcomes did not differ at 12 months. The 6-month incremental cost-effectiveness ratios were $1,207-$1,523 per abstinent patient for unhealthy drinking and $1,040-$1,313 per abstinent patient for cannabis. There were no differences between groups on health service utilization., Conclusions: MI cost more than the control condition but yielded better outcomes at 6 months; MI had no relationship to health service utilization. Findings can inform implementation of substance use interventions through understanding MI's potential clinical and cost impact and its relationship to health services use., Competing Interests: The authors declare no conflicts of interest.

Objectives: Late Life Depression (LLD) is associated with persistent cognitive dysfunction even after depression symptoms improve. The present study was designed to examine cognitive outcomes associated with the pattern of depression severity change during psychotherapy intervention for LLD., Methods: 96 community-dwelling adults ages 65-91 with major depressive disorder completed 12 sessions of Problem-Solving Therapy at the University of California, San Francisco. Nonlinear trajectories of depression severity ratings using the Hamilton Depression Rating Scale were computed from multiple time points collected throughout the weekly psychotherapy intervention. Performance on measures of cognition (information processing speed, executive functioning, verbal learning, memory) was assessed at baseline and post-treatment. Linear mixed-effects models examined associations between nonlinear depression severity trajectories and post-treatment change in cognitive performance., Results: Broadly, different patterns of depression change during treatment were associated with improved cognition post-treatment. Greater and more consistent interval improvements in depression ratings were differentially associated with improvements in aspects of verbal learning, memory, and executive function post-treatment, while no associations were found with information processing speed., Conclusions: The heterogeneity of depression trajectories associated with improved cognitive outcomes suggests that the temporal pattern of depression response may impact specific cognitive processes distinctly. Results suggest that use of nonlinear depression severity trajectories may help to elucidate complex associations between the time course of depression response and cognitive outcomes of psychotherapy in LLD. These findings have important implications for identifying treatment targets to enhance clinical and cognitive outcomes of psychotherapy in LLD., (© 2022 John Wiley & Sons Ltd.)

Objectives: This cross-sectional study examined associations between prenatal cannabis use and prescribed psychotropic medication use among pregnant patients with depression or anxiety in a large, integrated healthcare system., Methods: Study patients had a confirmed pregnancy and a depressive or anxiety disorder defined by International Classification of Diseases codes between 2012 and 2018 at Kaiser Permanente Northern California. Patients were screened for prenatal substance use via a self-reported questionnaire and urine toxicology test as part of standard prenatal care. Generalized estimating equation models tested for associations between prenatal cannabis use and any dispensation of antidepressants, benzodiazepines, and hypnotics during gestation. Models were stratified by diagnosis (depression or anxiety) and depression symptom severity., Results: This study included 35,047 pregnancies (32,278 patients; 17.6% aged <25 years, 48.1% non-Hispanic White). Adjusting for patient age, income, race/ethnicity, and depression symptom severity, the 12.6% of patients who screened positive for prenatal cannabis use demonstrated higher odds of prenatal benzodiazepine (adjusted odds ratios [aOR] = 1.40; 95% confidence interval [CI] = 1.20-1.62) and hypnotic (aOR = 1.28; 95% CI = 1.11-1.48), but not antidepressants (aOR = 1.05, 95% CI = 0.96-1.14) use. This pattern persisted when diagnostic groups were examined separately. The odds of prenatal benzodiazepine and hypnotic use associated with prenatal cannabis use were higher among pregnancies with severe depression symptom severity (31.8% of the sample)., Conclusions: Among pregnant patients with depression or anxiety, prenatal cannabis use was associated with higher odds of prenatal benzodiazepine and hypnotic use. As patients may be using cannabis to address depression and anxiety, prescribers should remain vigilant for under- or untreated psychiatric symptoms among pregnant patients and provide evidence-based treatments., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 American Society of Addiction Medicine.)

Background: Alcohol screening, brief intervention and referral to treatment (SBIRT) in adult primary care is an evidence-based, public health strategy to address unhealthy alcohol use, but evidence of effectiveness of alcohol brief intervention (ABI) in real-world implementation is lacking., Methods: We fit marginal structural models with inverse probability weighting to estimate the causal effects of ABI on 12-month drinking outcomes using longitudinal electronic health records data for 312,056 adults with a positive screening result for unhealthy drinking between 2014 and 2017 in a large healthcare system that implemented systematic primary care-based SBIRT. We examined effects of ABI with and without adjusting for receipt of specialty alcohol use disorder (AUD) treatment, and whether effects varied by patient demographic characteristics and alcohol use patterns., Results: Receiving ABI resulted in significantly greater reductions in heavy drinking days (mean difference [95% CI] = -0.26 [-0.45, -0.08]), drinking days per week (-0.04 [-0.07, -0.01]), drinks per drinking day (-0.05 [-0.08, -0.02]) and drinks per week (-0.16 [-0.27, -0.04]). Effects of ABI on 12-month drinking outcomes varied by baseline consumption level, age group and whether patients already had an AUD, with better improvement in those who were drinking at levels exceeding only daily limits, younger, and without an AUD., Conclusions: Systematic ABI in adult primary care has the potential to reduce drinking among people with unhealthy drinking considerably on both an individual and population level. More research is needed to help optimize ABI, in particular tailoring it to diverse sub-populations, and studying its long-term public health impact., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Research on cannabis-related health outcomes in diverse older adults is limited. The current study utilized a matched cohort study design to compare older adults in Hawai'i with identified cannabis diagnoses and matched controls on chronic health conditions, acute health events, and healthcare utilization from 2016 to 2020., Method: Patients age 50 + were identified using ICD-10 diagnostic codes for cannabis use, abuse, and dependence using electronic health record data from an integrated health system (Kaiser Permanente Hawai'i). Those with cannabis diagnoses (n = 275) were compared to matched non-using controls (n = 275; based on age, sex) on chronic health conditions (coronary heart disease, hypertension, COPD, chronic non-cancer pain), acute health events (myocardial infarction, respiratory symptoms, stroke, persistent or cyclic vomiting, injuries), and healthcare utilization (outpatient, inpatient, and emergency department visits) following case identification for two years., Results: Participants were 19.3% Native Hawaiian/Pacific Islander, 24.4% Asian, 47.8% White, and 8.5% Other/Unknown, with an average age of 62.8 years (SD=7.3). Adjusting for covariates as possible, participants with a cannabis diagnosis had significantly greater risk of coronary heart disease, chronic non-cancer pain, stroke, myocardial infarction, cyclic vomiting, and injuries, over time, compared to controls. Cannabis use was associated with any and greater frequency of outpatient, inpatient, and emergency department visits., Conclusions: In a diverse sample, older adults who used cannabis had worse health conditions and events and used more health services over a two-year period. Future studies should evaluate cannabis-related health outcomes, effects of cannabis problem severity, as well as implications for healthcare in aging populations., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Objective: Screening, brief intervention, and referral to treatment (SBIRT) is a systematic approach to identification and intervention for individuals at risk for substance use disorders. Prior research indicates that SBIRT is underutilized in pediatric primary care. Yet few studies have examined procedures for identifying and addressing substance use in clinics that serve publicly insured adolescents (i.e., federally qualified health centers [FQHC]). This descriptive, multi-method study assessed adolescent substance use frequency and provider perspectives to inform SBIRT implementation in an urban pediatric FQHC in California., Methods: A medical record review assessed substance use frequency and correlates among publicly insured adolescents aged 12-17 years who completed a well-child visit in pediatric primary care between 2014 and 2017 (N = 2252). Data on substance use (i.e., alcohol, illicit drugs, and tobacco) were from a health assessment tool mandated by Medicaid. Semi-structured interviews with 12 providers (i.e., pediatricians, nurse practitioners, behavioral health clinicians) elicited information about the current clinic workflow for adolescent substance use and barriers and facilitators to SBIRT implementation., Results: Of 1588 adolescents who completed the assessment (70.5%), 6.8% reported current substance use. Self-reported use was highest among non-Hispanic Black (15.2%) adolescents and those with co-occurring depressive symptoms (14.4%). Provider-reported challenges to implementing SBIRT included a lack of space for confidential screening and a lack of referral options. Providers favored implementing technology-based tools such as tablets for adolescent pre-visit screening and electronic medical record-based decision support to facilitate brief intervention and treatment referrals., Conclusions: This study fills a substantial research gap by examining factors that impede and support SBIRT implementation in pediatric FQHC settings. Successful SBIRT implementation in these settings could significantly reduce the unmet need for substance use treatment among uninsured and publicly insured adolescents. Pediatric primary care and urgent care providers perceived SBIRT to be feasible, and health information and digital technologies may facilitate the integration of SBIRT into clinic workflows. Ensuring confidentiality for screening and expanding referral options for adolescents in need of community-based addiction treatment are also critical to increasing SBIRT uptake., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Competing Interests: We declare no competing interests. JCH is supported by a grant from the National Institutes of Health (T32 DA007250).

Objective: To compare dementia incidence and prevalence after age 50 years by HIV status., Design: Observational cohort, 2000-2016., Methods: People with HIV (PWH) on antiretroviral therapy (ART) and demographically similar people without HIV (PWoH), all aged 50 years and older, were identified from Kaiser Permanente healthcare systems in Northern California, Southern California, and Mid-Atlantic States (Maryland, Virginia, Washington DC). Dementia diagnoses were obtained from electronic health records. Incidence and prevalence of dementia, overall and by time period (i.e. 2000-2002, 2003-2004, …, 2015-2016), were calculated using Poisson regression. Trends were examined using Joinpoint regression. Rate ratios were used to compare dementia by HIV status with adjustment for sociodemographics, substance use, and clinical factors., Results: The study included 13 296 PWH and 155 354 PWoH (at baseline: for both, mean age = 54 years, 89% men; for PWH, 80% with HIV RNA <200 copies/ml). From 2000 to 2016, overall incidence of dementia was higher among PWH [adjusted incidence rate ratio (aIRR) = 1.80, 95% confidence interval (CI) = 1.60-2.04]. Dementia incidence decreased among both PWH and PWoH (-8.0 and -3.1% per period, respectively) but remained higher among PWH in the most recent time period, 2015-2016 (aIRR = 1.58, 95% CI = 1.18-2.12). The overall prevalence of dementia from 2000 to 2016 was higher among PWH [adjusted prevalence ratio (aPR) = 1.86, 95% CI = 1.70-2.04] and was also higher among PWH in 2015-2016 (aPR = 1.75, 95% CI = 1.56-1.97)., Conclusion: Reductions in dementia incidence are encouraging and may reflect ART improvement, but PWH are still more likely to have dementia than PWoH. Monitoring the burden of dementia among PWH is important as this population ages., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)