Faculty Bibliography

Violations of the positivity assumption (also called the common support condition) challenge health policy research and can result in significant bias, large variance, and invalid inference. We define positivity in the single- and multiple-timepoint (i.e., longitudinal) health policy evaluation setting, and discuss real-world threats to positivity. We show empirical evidence of the practical positivity violations that can result when attempting to estimate the effects of health policies (in this case, Naloxone Access Laws). In such scenarios, an alternative is to estimate the effect of a shift in law enactment (e.g., the effect if enactment had been delayed by some number of years). Such an effect corresponds to what is called a modified treatment policy, and dramatically weakens the required positivity assumption, thereby offering a means to estimate policy effects even in scenarios with serious positivity problems. We apply the approach to define and estimate the longitudinal effects of Naloxone Access Laws on opioid overdose rates.

Introduction/UNASSIGNED:Adolescent time use in recent cohorts is distinguished by large-scale changes, including shifts in parental monitoring, supervision, and adolescent activity patterns, that together may provide a more complete perspective on changing patterns of mental health than can be captured by single risk factors. Methods/UNASSIGNED:To determine whether patterns of adolescent time use explain recent increases in depressive and other internalizing symptoms, we first conducted latent profile analyses of 465,839 adolescents, grades 8/10, from annual, cross-sectional Monitoring the Future surveys, years:1991-2019, using twenty-one variables (e.g., frequency of attending parties) to identify groups based on patterns of time use. Most of the sample was female (51.0%), non-Hispanic white (58.8%), and in grade 8 (52.2%); mean age: 14.60 years (95% CI: 14.57, 14.64). We subsequently examined differences in depressive and other internalizing symptoms between these time use groups over time with survey-weighted logistic regressions producing odds ratios. Results/UNASSIGNED:Analyses derived six groups: part time workers, full time workers, and four groups based on levels of social activities (Low, medium, and high levels, with "High Social" split between those engaged in sports, academics, and community service and those who were not). Internalizing symptoms were predicted by lower socialization, low engagement in activities like sports, academics, and community service, and time spent at a paid job. Adolescents decreasingly engaged in social activities over time, though shifts in time use patterns did not account for much of the overall increase in depressive symptoms. Conclusion/UNASSIGNED:Shifts in adolescent time use do not explain increases in depressive and other internalizing symptoms, which increased across different patterns of time use. Levels of internalizing symptoms were highest among those with low socialization, low recreational engagement, and those working substantial hours. Encouraging socialization, engagement in recreational activities, and providing mental health resources for isolated adolescents may reduce internalizing symptom trends.

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.

OBJECTIVES:To compare the characteristics of individual overdose decedents in Rhode Island, 2016-2020 to the neighborhoods where fatal overdoses occurred over the same time period. METHODS:We conducted a retrospective analysis of fatal overdoses occurring between January 1, 2016 and June 30, 2020. Using individual- and neighborhood-level data, we conducted descriptive analyses to explore the characteristics of individuals and neighborhoods most affected by overdose. RESULTS:Most overdose decedents during the study period were non-Hispanic White. Across increasingly more White and non-Hispanic neighborhoods, rates of fatal overdose per 100,000 person-years decreased. An opposite pattern was observed across quintiles of average neighborhood poverty. CONCLUSIONS:Rates of fatal overdose were higher in less White, more Hispanic, and poorer neighborhoods, suggesting modest divergence between the characteristics of individuals and the neighborhoods most severely affected. These impacts may not be uniform across space and may accrue differentially to more disadvantaged and racially/ethnically diverse neighborhoods.

AIM/OBJECTIVE:To quantify the trends in frequent and occasional cannabis vaping, demographic differences and concurrent nicotine and alcohol use. DESIGN/METHODS:Observational study. Survey-weighted multinomial logistic regression models assessed trends and disparities in past 30-day cannabis use. Trends were assessed overall and by sex, race/ethnicity, parental education and urbanicity. Multinomial logistic regression models also estimated associations of cannabis use (none, use without vaping, use with vaping) with past 2-week binge drinking and past 30-day nicotine/tobacco use. SETTING/METHODS:United States, 2017-19. PARTICIPANTS/METHODS:Participants in the national Monitoring the Future (n = 51 052) survey. MEASUREMENTS/METHODS:Past 30-day frequent cannabis use (six or more times/30 days) and past 30-day occasional use (one to five times/30 days), with and without vaping. FINDINGS/RESULTS:Past 30-day frequent cannabis use with vaping and occasional use with vaping rose from 2017 to 2019. Past 30-day frequent and occasional cannabis use without vaping declined. Certain groups, such as Hispanic/Latino or lower socio-economic status adolescents, experienced particularly notable increases in frequent cannabis use with vaping (e.g. prevalence among Hispanic/Latino adolescents). Adolescents who reported smoking and vaping nicotine, and 10+ occasions of binge drinking, were 42.28 [95% confidence interval (CI) = 33.14-53.93] and 10.09 (95% CI = 4.51-22.53) times more likely to report past 30-day cannabis use with vaping, respectively, compared with no use. DISCUSSION/CONCLUSIONS:Cannabis use without vaping appears to be declining among adolescents in the United States, while cannabis use with vaping is accelerating; frequent cannabis vaping is especially increasing, with consistent increases across almost all adolescent demographic groups. Cannabis use among US adolescents remains highly associated with other substance use.

BACKGROUND AND AIM/OBJECTIVE:In Uruguay, residents age 18 and older seeking legal cannabis must register with the government and choose one of three supply mechanisms: self-cultivation, non-profit cannabis clubs or pharmacies. This is the first paper to measure the association between type of legal cannabis supply mechanism and traffic crashes involving injuries. DESIGN/METHODS:Ecological study using ordinary least squares regression to examine how department-level variation in registrations (overall and by type) is associated with traffic crashes involving injuries. SETTING/METHODS:Uruguay. CASES/METHODS:532 department-quarters. MEASUREMENTS/METHODS:Quarterly cannabis registration counts at the department level and incident-level traffic crash data were obtained from government agencies. The analyses controlled for department-level economic and demographic characteristics and, as a robustness check, we included traffic violations involving alcohol for departments reporting this information. Department-level data on crashes, registrations and alcohol violations were denominated by the number of residents ages 18 and older. FINDINGS/RESULTS:From 2013 to 2019, the average number of registrations at the department-quarter level per 10 000 residents age 18 and older for self-cultivation, club membership and pharmacy purchasing were 17.7 (SD = 16.8), 3.6 (SD = 8.6), and 25.1 (SD = 50.4), respectively. In our multivariate regression analyses, we did not find a statistically significant association between the total number of registrations and traffic crashes with injuries (β = -0.007; P = 0.398; 95% CI = -0.023, 0.01). Analyses focused on the specific supply mechanisms found a consistent, positive and statistically significant association between the number of individuals registered as self-cultivators and the number of traffic crashes with injuries (β = 0.194; P = 0.008; 95% CI = 0.058, 0.329). Associations for other supply mechanisms were inconsistent across the various model specifications. CONCLUSIONS:In Uruguay, the number of people allowed to self-cultivate cannabis is positively associated with traffic crashes involving injuries. Individual-level analyses are needed to assess better the factors underlying this association.

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

OBJECTIVE/UNASSIGNED:In the United States, adult cannabis use has increased over time, but less information is available on time trends in cannabis use disorder. The authors used Veterans Health Administration (VHA) data to examine change over time in cannabis use disorder diagnoses among veterans, an important population subgroup, and whether such trends differ by age group (<35 years, 35-64 years, ≥65 years), sex, or race/ethnicity. METHODS/UNASSIGNED:VHA electronic health records from 2005 to 2019 (range of Ns per year, 4,403,027-5,797,240) were used to identify the percentage of VHA patients seen each year with a cannabis use disorder diagnosis (ICD-9-CM, January 1, 2005-September 30, 2015; ICD-10-CM, October 1, 2015-December 31, 2019). Trends in cannabis use disorder diagnoses were examined by age and by race/ethnicity and sex within age groups. Given the transition in ICD coding, differences in trends were tested within two periods: 2005-2014 (ICD-9-CM) and 2016-2019 (ICD-10-CM). RESULTS/UNASSIGNED:In 2005, the percentages of VHA patients diagnosed with cannabis use disorder in the <35, 35-64, and ≥65 year age groups were 1.70%, 1.59%, and 0.03%, respectively; by 2019, the percentages had increased to 4.84%, 2.86%, and 0.74%, respectively. Although the prevalence of cannabis use disorder was consistently higher among males than females, between 2016 and 2019, the prevalence increased more among females than males in the <35 year group. Black patients had a consistently higher prevalence of cannabis use disorder than other racial/ethnic groups, and increases were greater among Black than White patients in the <35 year group in both periods. CONCLUSIONS/UNASSIGNED:Since 2005, diagnoses of cannabis use disorder have increased substantially among VHA patients, as they have in the general population and other patient populations. Possible explanations warranting investigation include decreasing perception of risk, changing laws, increasing cannabis potency, stressors related to growing socioeconomic inequality, and use of cannabis to self-treat pain. Clinicians and the public should be educated about the increases in cannabis use disorder in general in the United States, including among patients treated at the VHA.

BACKGROUND:The United States overdose crisis continues unabated. Despite efforts to increase capacity for treating opioid use disorder (OUD) in the U.S., how actual treatment receipt compares to need remains unclear. In this cross-sectional study, we estimate progress in addressing the gap between OUD prevalence and OUD treatment receipt at the national and state levels from 2010 to 2019. METHODS:We estimated past-year OUD prevalence rates based on the U.S. National Survey on Drug Use and Health (NSDUH), using adjustment methods that attempt to account for OUD underestimation in national household surveys. We used data from specialty substance use treatment records and outpatient pharmacy claims to estimate the gap between OUD prevalence and number of persons receiving medications for opioid use disorder (MOUD) during the past decade. RESULTS:Adjusted estimates suggest past-year OUD affected 7,631,804 individuals in the U.S. in (2,773 per 100,000 adults 12+), relative to only 1,023,959 individuals who received MOUD (365 per 100,000 adults 12+). This implies approximately 86.6% of individuals with OUD nationwide who may benefit from MOUD treatment do not receive it. MOUD receipt increased across states over the past decade, but most regions still experience wide gaps between OUD prevalence and MOUD receipt. CONCLUSIONS:Despite some progress in expanding access to MOUD, a substantial gap between OUD prevalence and treatment receipt highlights the critical need to increase access to evidence-based services.

As opioid prescribing has declined, it is unclear how the landscape of prescription pain treatment across the US has changed. We used nationally-representative data from the Medical Expenditure Health Survey, 2014-2018 to examine trends in prescriptions for opioid and non-opioid pain medications, including acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), gabapentinoids, and antidepressants among US adults with self-reported pain. Overall, from 2014-2018, the percentage of participants receiving a prescription for opioids declined, (38.8% vs. 32.8%), remained stable for NSAIDs (26.8% vs. 27.7%), and increased for acetaminophen (1.6% vs. 2.3%), antidepressants (9.6% vs. 12.0%) and gabapentinoids (13.2% vs. 19.0%). In this period, the adjusted odds of receiving an opioid prescription decreased (aOR=0.93, 95% CI=0.90-0.96), while the adjusted odds of receiving antidepressant, gabapentinoid and acetaminophen prescriptions increased (antidepressants: aOR=1.08, 95% CI=1.03-1.13 gabapentinoids: aOR=1.11, 95% CI=1.06-1.17; acetaminophen: aOR=1.10, 95% CI: 1.02-1.20). Secondary analyses stratifiying within the 2014-2016 and 2016-2018 periods revealed particular increases in prescriptions for gabapentinoids (aOR=1.13, 95% CI=1.05-1.21) and antidepressants (aOR=1.23, 95% CI=1.12-1.35) since 2016.