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Changes in Opioid and Benzodiazepine Poisoning Deaths After Cannabis Legalization in the US: A County-level Analysis, 2002-2020

Castillo-Carniglia, Alvaro; Rivera-Aguirre, Ariadne; Santaella-Tenorio, Julian; Fink, David S; Crystal, Stephen; Ponicki, William; Gruenewald, Paul; Martins, Silvia S; Keyes, Katherine M; Cerdá, Magdalena
BACKGROUND:Cannabis legalization for medical and recreational purposes has been suggested as an effective strategy to reduce opioid and benzodiazepine use and deaths. We examined the county-level association between medical and recreational cannabis laws and poisoning deaths involving opioids and benzodiazepines in the US from 2002 to 2020. METHODS:Our ecologic county-level, spatiotemporal study comprised 49 states. Exposures were state-level implementation of medical and recreational cannabis laws and state-level initiation of cannabis dispensary sales. Our main outcomes were poisoning deaths involving any opioid, any benzodiazepine, and opioids with benzodiazepines. Secondary analyses included overdoses involving natural and semi-synthetic opioids, synthetic opioids, and heroin. RESULTS:Implementation of medical cannabis laws was associated with increased deaths involving opioids (rate ratio [RR] = 1.14; 95% credible interval [CrI] = 1.11, 1.18), benzodiazepines (RR = 1.19; 95% CrI = 1.12, 1.26), and opioids+benzodiazepines (RR = 1.22; 95% CrI = 1.15, 1.30). Medical cannabis legalizations allowing dispensaries was associated with fewer deaths involving opioids (RR = 0.88; 95% CrI = 0.85, 0.91) but not benzodiazepine deaths; results for recreational cannabis implementation and opioid deaths were similar (RR = 0.81; 95% CrI = 0.75, 0.88). Recreational cannabis laws allowing dispensary sales was associated with consistent reductions in opioid- (RR = 0.83; 95% CrI = 0.76, 0.91), benzodiazepine- (RR = 0.79; 95% CrI = 0.68, 0.92), and opioid+benzodiazepine-related poisonings (RR = 0.83; 95% CrI = 0.70, 0.98). CONCLUSIONS:Implementation of medical cannabis laws was associated with higher rates of opioid- and benzodiazepine-related deaths, whereas laws permitting broader cannabis access, including implementation of recreational cannabis laws and medical and recreational dispensaries, were associated with lower rates. The estimated effects of the expanded availability of cannabis seem dependent on the type of law implemented and its provisions.
PMID: 36943813
ISSN: 1531-5487
CID: 5524512

Global pain and aging: A cross-sectional study on age differences in the intensity of chronic pain among middle-aged and older adults in 20 countries

Calvo, Esteban; Córdova, Cynthia; Shura, Robin; Allel, Kasim; Castillo-Carniglia, Alvaro; Keyes, Katherine M; Mauro, Christine; Mauro, Pia M; Medina, José T; Mielenz, Thelma; Taramasco, Carla; Martins, Silvia S
OBJECTIVES/OBJECTIVE:This study aims to examine age differences in the intensity of chronic pain among middle-aged and older adults, where intensity is measured on a scale differentiating between chronic pain that is often troubling and likely requires intervention versus more endurable sensations. We aim to explore whether individual health and national gross domestic product (GDP) explain these differences as well. METHODS:Cross-nationally harmonized data from 20 countries on self-reported intensity of chronic pain (0=no, 1=mild, 2=moderate, 3=severe) in 104,826 individuals aged 50+ observed in 2012-2013. Two-level hierarchical ordinal linear models with individuals nested within countries were used to isolate estimations from heterogeneity explained by methodological differences across single-country studies. RESULTS:Overall, mean participant age was 66.9 (SD=9.9), 56.1% were women, and 41.9% of respondents reported any chronic pain. Chronic pain intensity rose sharply with age in some countries (e.g., Korea and Slovenia), but this association waned or reversed in other countries (e.g., the USA and Denmark). Cross-country variation and age differences in chronic pain were partly explained (85.5% and 35.8%, respectively) by individual-level health (especially arthritis), country-level wealth (as indicated by GDP per capita), and demographics. DISCUSSION/CONCLUSIONS:Chronic pain intensity is not an inevitable consequence of chronological age, but the consequence of potential selection effects and lower activity levels combined with individual-level health and country-level wealth. Our findings suggest further investigation of health conditions and country affluence settings as potential targets of medical and policy interventions aiming to prevent, reduce, or manage chronic pain among older patients and aging populations.
PMID: 36562345
ISSN: 1758-5368
CID: 5431902

On generating adequate counterfactuals for national policy evaluations. A response to Mundt et al [Letter]

Rivera-Aguirre, Ariadne; Castillo-Carniglia, Alvaro; Laqueur, Hannah S; Rudolph, Kara E; Martins, Silva S; Ramírez, Jessica; Queirolo, Rosario; Cerdá, Magdalena
PMID: 36239882
ISSN: 1360-0443
CID: 5361232

Does recreational cannabis legalization change cannabis use patterns? Evidence from secondary school students in Uruguay

Rivera-Aguirre, Ariadne; Castillo-Carniglia, Alvaro; Laqueur, Hannah S; Rudolph, Kara E; Martins, Silva S; Ramírez, Jessica; Queirolo, Rosario; Cerdá, Magdalena
BACKGROUND AND AIMS/OBJECTIVE:In 2013, Uruguay became the first country to legalize and regulate the production and distribution of cannabis for recreational use. We measured whether Uruguay's non-commercial model of recreational cannabis legalization was associated with changes in the prevalence of risky and frequent cannabis use among secondary school students. DESIGN/METHODS:We used data from repeated cross-sectional surveys of secondary students in Uruguay and Chile (2007-2018). Using a difference-in-difference approach, we evaluated changes in the prevalence of past-year, past-month, any risky and frequent cannabis use following enactment (2014) and implementation (2016) of cannabis legalization among the full sample of secondary students and among students who reported past-year/month use. We examined changes separately for students aged 12-17, and students for whom cannabis became legally accessible, ages 18-21. SETTING/METHODS:Uruguay and Chile (2007-2018). PARTICIPANTS/METHODS:grade (n=204,730). MEASUREMENTS/METHODS:Past-year and past-month cannabis use; any risky cannabis use measured with the Cannabis Abuse Screening Test (CAST); and frequent cannabis use (10+ days in the past-month). FINDINGS/RESULTS:We found a decrease in past-year and past-month use following enactment or implementation. Among students ages 18-21, post-enactment, we observed a transitory increase in 2014 that decreased thereafter for: any risky use among those who reported past-year use (prevalence difference [PD]=13.5%; 95% confidence interval [CI]: 2.0, 24.9), frequent use in the full sample (PD=4.5%; 95%CI: 1.0, 8.1), and frequent use among those who reported past-month use (PD=16.8%; 95%CI: 1.9, 31.8). CONCLUSION/CONCLUSIONS:The legalization of recreational cannabis in Uruguay was not associated with overall increases in either past-year/past-month cannabis use or with multi-year changes in any risky and frequent cannabis use among young people.
PMID: 35491741
ISSN: 1360-0443
CID: 5205142

Trends in cannabis or cocaine-related dependence and alcohol/drug treatment in Argentina, Chile, and Uruguay

Mauro, Pia M; Gutkind, Sarah; Rivera-Aguirre, Ariadne; Gary, Dahsan; Cerda, Magdalena; Santos, Erica Chavez; Castillo-Carniglia, Alvaro; Martins, Silvia S
BACKGROUND:In the context of changing cannabis and other drug policy and regulation, concerns may arise regarding drug treatment access and use. We assessed cannabis/cocaine-related dependence and treatment in Argentina, Chile, and Uruguay. METHODS:Nationally representative cross-sectional household surveys of people ages 15-64 in Argentina (4 surveys, 2006-2017), Chile (7 surveys, 2006-2018), and Uruguay (4 surveys, 2006-2018) were harmonized. We estimated weighted prevalences of cannabis or cocaine-related (cocaine or cocaine paste) dependence, based on meeting 3+ past-year ICD-10 dependence criteria. We estimated weighted prevalences of past-year alcohol/drug treatment use (Argentina, Chile) or use/seeking (Uruguay) among people with past-year cannabis/cocaine-related dependence. We tested model-based prevalence trends over time and described individual-level treatment correlates by country. RESULTS:Cannabis/cocaine dependence prevalence increased in the region starting in 2010-2011, driven by cannabis dependence. Adjusted cannabis dependence prevalence increased from 0.7% in 2010 to 1.5% in 2017 in Argentina (aPD=0.8, 95% CI= 0.3, 1.2), from 0.8% in 2010 to 2.8% in 2018 in Chile (aPD=2.0, 95% CI= 1.4, 2.6), and from 1.4% in 2011 to 2.4% in 2018 in Uruguay (aPD=0.9, 95% CI= 0.2, 1.6). Cocaine-related dependence increased in Uruguay, decreased in Argentina, and remained stable in Chile. Among people with past-year cannabis/cocaine dependence, average alcohol/drug treatment use prevalence was 15.3% in Argentina and 6.0% in Chile, while treatment use/seeking was 14.7% in Uruguay. Alcohol/drug treatment prevalence was lower among people with cannabis dependence than cocaine-related dependence. Treatment correlates included older ages in all countries and male sex in Argentina only. CONCLUSION/CONCLUSIONS:Alcohol/drug treatment use among people with cannabis/cocaine-related dependence remained low, signaling an ongoing treatment gap in the context of growing cannabis dependence prevalence in the region. Additional resources may be needed to increase treatment access and uptake. Future studies should assess contributors of low treatment use, including perceived need, stigma, and service availability.
PMID: 35939947
ISSN: 1873-4758
CID: 5286592

Effects of 2019's social protests on emergency health services utilization and case severity in Santiago, Chile: a time-series analysis

Gajardo, Abraham I.J.; Wagner, Thomas D.; Howell, Kristina Devi; González-Santa Cruz, Andrés; Kaufman, Jay S.; Castillo-Carniglia, Alvaro
Background: On October 18th, 2019, protestors gathered across Chile to call for social equity, resulting in widespread civil unrest and violent confrontation with the police. In this study, we quantify the effects of the 2019 Chilean protests on emergency health services utilization and inpatient admission in Santiago. Methods: We used weekly emergency department (ED) admissions (2015-2019) from three large public hospitals near the focal point of protests in Santiago. The exposure period was from October 18th to December 31st, 2019. The outcomes were the number of weekly consultations and hospitalizations by trauma and respiratory causes and the proportion of hospitalizations among consultants per 1,000. We implemented Bayesian structural time series models to calculate the absolute and relative effects and 95% credible intervals (CrI). Findings: During the first ten weeks of protests ED consultations declined on average by 14% for trauma (95%CrI: -40·2%, 11·5%) and 30% for respiratory causes (95%CrI: -89·4%, 30·2%), 7% for respiratory hospitalizations (95%CrI: -43·6%, 30·8%); however, none of these three results were statistically distinguishable from the null. Trauma hospitalizations, on the other hand, increased by 15% (95%CrI: 4·0%, 26·4%), and the proportion of hospitalizations per consultations increased by 40% for trauma (95%CrI: 13·1%, 68·0%) and 59% for respiratory causes (95%CrI: 29·4%, 87·9%). Interpretation: The 2019 Chilean protests affected the use of emergency health services by increasing the trauma hospitalizations and the case hospitalization ratio per 1,000 consultations for trauma and respiratory causes. Crowd-control protocols must be reviewed to prevent the negative effects of civil unrest.
SCOPUS:85126947199
ISSN: 2667-193x
CID: 5197902

Polydrug Use and Co-occurring Substance Use Disorders in a Respondent Driven Sampling of Cocaine Base Paste Users in Santiago, Chile

Olivari, Carla F; Gaete, Jorge; Rodriguez, Nicolás; Pizarro, Esteban; Del Villar, Paloma; Calvo, Esteban; Castillo-Carniglia, Alvaro
We characterized substance use patterns and co-occurring substance use disorders among active cocaine base paste (CBP) users in Santiago, Chile using data from respondent-driven sampling (RDS) in three areas of Metropolitan Santiago. Recruitment began with nine seeds, reaching 398 active CBP users (18% women; mean age 37.7 years), defined as persons consuming CBP at least twice per week in the last three months. Population proportions and uncertainty were estimated accounting for individuals' social network and homophily. The median CBP age of initiation was 21 years, and the median number of years using CBP was 7 for women and 15 for men. The median days of use in the past month was 25 days, with a median of 56 doses per week. The proportion of monthly income spent on CBP was 65%. The prevalence of substance use disorders (SUDs) were: 98% for CBP, 67% for alcohol, 60% for marijuana, and 41% for cocaine hydrochloride. Heavy polydrug use patterns and co-occurring SUDs are frequent among active CBP users in the metropolitan area of Santiago. Traditional surveillance strategies may have underestimated polysubstance use and co-occurring SUDs in active CBP users. RDS proved to be a feasible methodology that could be effectively used for substance use surveillance among hard-to-reach populations.
PMID: 34724873
ISSN: 2159-9777
CID: 5037902

Trends in the sequence of initiation of alcohol, tobacco, and marijuana use among adolescents in Argentina and Chile from 2001 to 2017

Schleimer, Julia P; Smith, Nathan; Zaninovic, ViniNatalie; Keyes, Katherine M; Castillo-Carniglia, Alvaro; Rivera-Aguirre, Ariadne; Cerdá, Magdalena
BACKGROUND:Variation in drug policies, norms, and substance use over time and across countries may affect the normative sequences of adolescent substance use initiation. We estimated relative and absolute time-varying associations between prior alcohol and tobacco use and adolescent marijuana initiation in Argentina and Chile. Relative measures quantify the magnitude of the associations, whereas absolute measures quantify excess risk. METHODS:We analyzed repeated, cross-sectional survey data from the National Surveys on Drug Use Among Secondary School Students in Argentina (2001-2014) and Chile (2001-2017). Participants included 8th, 10th, and 12th grade students (N = 680,156). Linear regression models described trends over time in the average age of first use of alcohol, tobacco, and marijuana. Logistic regression models were used to estimate time-varying risk ratios and risk differences of the associations between prior alcohol and tobacco use and current-year marijuana initiation. RESULTS:Average age of marijuana initiation increased and then decreased in Argentina and declined in Chile. In both countries, the relative associations between prior tobacco use and marijuana initiation weakened amid declining rates of tobacco use; e.g., in Argentina, the risk ratio was 19.9 (95% CI: 9.0-30.8) in 2001 and 11.6 (95% CI: 9.0-13.2) in 2014. The relative association between prior alcohol use and marijuana initiation weakened Chile, but not in Argentina. On the contrary, risk differences (RD) increased substantially across both relationships and countries, e.g., in Argentina, the RD for tobacco was 3% (95% CI: 0.02-0.03) in 2001 and 12% (95% CI: 0.11-0.13) in 2014. CONCLUSION/CONCLUSIONS:Diverging trends in risk ratios and risk differences highlight the utility of examining multiple measures of association. Variation in the strength of the associations over time and place suggests the influence of environmental factors. Increasing risk differences indicate alcohol and tobacco use may be important targets for interventions to reduce adolescent marijuana use.
PMID: 34666217
ISSN: 1873-4758
CID: 5043262

Treatment outcome and readmission risk among women in women-only versus mixed-gender drug treatment programs in Chile

Olivari, Carla F; Gonzáles-Santa Cruz, Andrés; Mauro, Pia M; Martins, Silvia S; Sapag, Jaime; Gaete, Jorge; Cerdá, Magdalena; Castillo-Carniglia, Alvaro
INTRODUCTION/BACKGROUND:Traditional treatment programs for substance use disorder (SUD) tend to be male-dominated environments, which can negatively affect women's access to treatment and related outcomes. Women's specific treatment needs have led some providers to develop women-only SUD treatment programs in several countries. In Chile, women-only programs were only fully implemented in 2010. We compared treatment outcomes and readmission risk for adult women admitted to state-funded women-only versus mixed-gender SUD treatment programs in Chile. METHODS:We used a registry-based retrospective cohort design of adult women in women-only (N = 8200) and mixed-gender (N = 13,178) SUD treatment programs from 2010 to 2019. The study obtained data from the National Drug and Alcohol Service from Chile. We used a multistate model to estimate the probabilities of experiencing treatment completion, discharge without completion (i.e., patient-initiated discharge and administrative discharge), or readmission, as well as the likelihood of being readmitted, conditioned on prior treatment outcome. We adjusted models for multiple baseline characteristics (e.g., substance use, socioeconomic). RESULTS:Overall, 24% of women completed treatment and 54% dropped out of treatment. The proportion of patient-initiated discharges within the first three month was larger in women-only than in mixed-gender programs (19% vs. 12%). In both programs, women who completed treatment were more likely to experience readmission at three months, and one and three years. In the long term, women in the women-only programs were more likely to complete treatment than women in mixed-gender programs (34% vs. 23%, respectively). The readmission probability was higher among women who previously completed treatment than those who had a discharge without completion (40% vs 21% among women in women-only programs; 38% vs. 19% among women in mixed-gender programs, respectively); no differences occurred in the risk of readmission between women-only and mixed-gender programs. CONCLUSIONS:In terms of treatment outcomes and readmission risk, women-only programs had similar results to mixed-gender programs in Chile. The added value of these specialized programs should be addressed in further research.
PMID: 34483012
ISSN: 1873-6483
CID: 5011892

Cross-country differences in age trends in alcohol consumption among older adults: a cross-sectional study of individuals aged 50 years and older in 22 countries

Calvo, Esteban; Allel, Kasim; Staudinger, Ursula M; Castillo-Carniglia, Alvaro; Medina, José T; Keyes, Katherine M
BACKGROUND AND AIMS/OBJECTIVE:Age-related changes in physiological, metabolic and medication profiles make alcohol consumption likely to be more harmful among older than younger adults. This study aimed to estimate cross-national variation in the quantity and patterns of drinking throughout older age, and to investigate country-level variables explaining cross-national variation in consumption for individuals aged 50 years and older. DESIGN/METHODS:Cross-sectional observational study using previously harmonized survey data. SETTING/METHODS:Twenty-two countries surveyed in 2010 or the closest available year. PARTICIPANTS/METHODS:A total of 106 180 adults aged 50 years and over. MEASUREMENTS/METHODS:Cross-national variation in age trends were estimated for two outcomes: weekly number of standard drink units (SDUs) and patterns of alcohol consumption (never, ever, occasional, moderate and heavy drinking). Human Development Index and average prices of vodka were used as country-level variables moderating age-related declines in drinking. FINDINGS/RESULTS:Alcohol consumption was negatively associated with age (risk ratio = 0.98; 95% confidence interval = 0.97, 0.99; P-value < 0.001), but there was substantial cross-country variation in the age-related differences in alcohol consumption [likelihood ratio (LR) test P-value < 0.001], even after adjusting for the composition of populations. Countries' development level and alcohol prices explained 31% of cross-country variability in SDUs (LR test P-value < 0.001) but did not explain cross-country variability in the prevalence of heavy drinkers. CONCLUSIONS:Use and harmful use of alcohol among older adults appears to vary widely across age and countries. This variation can be partly explained both by the country-specific composition of populations and country-level contextual factors such as development level and alcohol prices.
PMID: 33241648
ISSN: 1360-0443
CID: 4702722