Faculty Bibliography

BACKGROUND:Recreational cannabis use is increasing in Mexico, where legalization is a possibility. The current area-level socioeconomic context of cannabis use has not been studied in the country, limiting our understanding and public health response. We aimed to analyze the association between the municipal socioeconomic environment and recreational cannabis use in Mexico. METHODS:We used data from the National Survey of Drug, Alcohol and Tobacco Consumption 2016-17, the National Health and Nutrition Survey 2023, the 2015 intercensal survey and the 2020 census to study the association of municipal income and municipal education with past-year recreational cannabis use. We fitted Poisson models with robust variance to obtain prevalence ratios and assessed for effect modification by individual-level sex and age, and household-level education. RESULTS:For every unit increase in municipal education, we observed a 1.5 % increase in the prevalence of recreational cannabis use in 2016-17, and a 2.9 % increase in 2023. For each unit increase in municipal income, we observed a 1.5 % increase in the prevalence of recreational cannabis use in 2016-17, and a 1.8 % increase in 2023. We found no effect modification except for a single age group (20- to 29-year-olds vs to 12- to 19-year-olds). CONCLUSION/CONCLUSIONS:Recreational cannabis use in Mexico is currently higher in more socioeconomically advantaged municipalities. Recreational cannabis use through socioeconomic areas should be monitored closely. Further research of the modifiable causes of this association could help inform current and future public health policies.

BACKGROUND:Wider availability of cannabis through medical and recreational legalization (MCL alone and RCL+MCL) has been hypothesized to contribute to reductions in opioid use, misuse, and related harms. We examined whether state adoption of cannabis laws was associated with changes in opioid outcomes overall and stratified by cannabis use. METHODS:Using National Survey on Drug Use and Health (NSDUH) data from 2015 to 2019, we estimated cannabis law associations with opioid (prescription opioid misuse and/or heroin use) misuse and use disorder. All logistic regression models (overall models and models stratified by cannabis use), included year and state fixed effects, individual level covariates, and opioid-related state policies. Stratified analyses were restricted to individuals who reported lifetime cannabis use prior to law adoption to reduce potential for collider bias. Estimates accounted for multiple comparisons using false discovery rate (FDR) corrections and sensitivity to unmeasured confounding using e-values. RESULTS:Overall, MCL and RCL adoption were not associated with changes in the odds of any opioid outcome. After restricting to respondents reporting past-year cannabis use, we observed decreased odds of past year opioid misuse (adjusted odds ratio [AOR]: 0.57 [95 % confidence interval [CI]: 0.38, 0.85]; FDR p-value: 0.07), among individuals in states with MCL compared to those in states without cannabis laws. RCLs were not associated with changes in the odds of any opioid outcome beyond MCL adoption. CONCLUSION/CONCLUSIONS:Comparing individuals in MCL alone states to those in states without such laws, we found an inconsistent pattern of decreased odds of opioid outcomes, which were more pronounced among people reporting cannabis use. The pattern did not hold for individuals in RCL states. In line with a substitution-oriented perspective, findings suggests that MCLs may be associated with reductions in opioid use among people using cannabis but additional work to replicate and expand on these findings is needed.

INTRODUCTION/BACKGROUND:People who use drugs (PWUD) are at risk of HIV infection, but the frequency and distribution of transmission-associated behaviors within rural communities is not well understood. Further, while interventions designed to more explicitly affirm individuals' sexual orientation and behaviors may be more effective, descriptions of behavior variability by orientation are lacking. We sought to describe how disease transmission behaviors and overdose risk vary by sexual orientation and activity among rural PWUD. METHODS:From 01/2018-03/2020, rural PWUD participating in the Rural Opioid Initiative were surveyed across 8 sites. Collected data included: demographics; experiences with drug use, overdose, and healthcare; stigma; gender identity; and sexual orientation and partners. Participants were categorized as: monosexual by orientation and behavior (Mono-only), monosexual by orientation but behaviorally bisexual (Mono/Bi), and bisexual by orientation (Bi+). Analyses included descriptive summaries, bivariate examination (chi-square), and logistic regression (relative risk [RR] and 95 % confidence interval [CI]). RESULTS:The 1455 participants were 84.8 % Mono-only, 3.2 % Mono/Bi, and 12.0 % Bi+. Compared to Mono-only men, Mono/Bi and Bi+ men had greater risk of transactional sex (RR = 9.71, CI = 6.66-14.2 and RR = 5.09, CI = 2.79-9.27, respectively) and sharing syringes for injection (RR = 1.58, CI = 1.06-2.35 and RR = 1.85, CI = 1.38-2.47). Compared to Mono-only women, Mono-Bi and Bi+ women had greater risk of transactional sex (RR = 4.47, CI = 2.68-7.47 and RR = 2.63, CI = 1.81-3.81); and Bi+ women had greater risk of sharing syringes for injection (RR = 1.49, CI = 1.23-1.81), sharing syringes to mix drugs (RR = 1.44, CI = 1.23-1.69), and experiencing an overdose (RR = 1.32, CI = 1.12-1.56). Bi+ men and women both more frequently reported selling sex as a source of income (versus Mono-only, both p < 0.050) and measures of perceived stigma (all p < 0.050). CONCLUSIONS:Rural PWUD who are bisexual by orientation or behavior are significantly more likely to engage in behaviors associated with infectious disease transmission and to experience stigma and drug overdose. Given the growing recognition of bisexuality as a distinct orientation that warrants individualized consideration, interventions that are specifically acknowledging and affirming to the circumstances of this group are needed.

BACKGROUND AND AIMS/OBJECTIVE:The opioid crisis continues to exert a tremendous toll in North America, with existing interventions often falling short of addressing ongoing needs. Psychedelics are emerging as a possible alternative therapy for mental health and substance use disorders. This study aimed to gather insights on how people use or are considering using psychedelics to manage opioid use disorder (OUD), how these experiences are perceived to impact opioid use and what these lessons imply for future research and practice. METHODS:We conducted a qualitative study using the Reddit online community platform. We extracted posts that contained key psychedelic terms from the two most subscribed-to subreddits dedicated to discussions of OUD treatment (r/OpiatesRecovery and r/Methadone) from 2018 to 2021. We thematically analyzed content from 151 relevant posts and their respective comments. RESULTS:Two prominent themes identified in discussions were perspectives on the effectiveness of psychedelics in treating OUD, and mechanisms through which psychedelics were thought to impact use and desire to use opioids. For many, psychedelics were deemed to have a strong impact on opioid use via multiple mechanisms, including alleviating physical symptoms of dependence, shifting motivations around desire to use opioids and addressing underlying mental health problems and reasons for use. Others saw the potential promise around psychedelics as exaggerated, acknowledging many people eventually return to use, or even considered psychedelics dangerous. CONCLUSIONS:There appear to be diverse perspectives on the effects of using psychedelics to treat opioid use disorder and an urgent need for controlled studies to better understand the impact of different psychedelics on opioid use, how they may be used in the context of existing treatments and what strategies they must be combined with to ensure safety and effectiveness. Integrating the experiences of people who use drugs will help guide psychedelics research toward effective person-centered interventions to enhance health and wellness.

BACKGROUND:Medicaid expansion via the Affordable Care Act, more recent legislation and Medicaid 1115 waivers offer opportunity to increase health care access among individuals involved in the carceral system. Effective enrollment of new beneficiaries and temporary suspension and reactivation of existing Medicaid benefits upon release is key to the success of these efforts. This study aims to characterize how jails, prisons and Medicaid agencies are implementing Medicaid suspension and enrollment programs and identifies barriers and facilitators to implementation. METHODS:We conducted 19 semi-structured interviews with 36 multi-state leaders in carceral facilities, Medicaid agencies, local health departments and national policy experts from 2020 to 2021. Interviews covered 4 domains: (1) the role of policy in influencing carceral and reentry Medicaid practices, (2) implementation strategies to suspend and enroll incarcerated individuals into Medicaid, (3) barriers and facilitators to successful implementation, and (4) variation in implementation between jails and prisons. RESULTS:Participants identified logistical challenges with suspension and enrollment, including limited infrastructure for data sharing between carceral facilities and Medicaid agencies, burdensome bureaucratic requirements, and challenges with Medicaid renewal, particularly in the jail environment. They offered opportunities to overcome barriers, such as the creation of specialized incarcerated Medicaid benefit categories and provision of in-reach services via managed care organizations. Participants also called for improvements to Medicaid reactivation processes, as even when facilities successfully suspended benefits, individuals faced significant challenges and delays reactivating benefits upon release. Participants also called for further loosening of the Medicaid Inmate Exclusion Policy. DISCUSSION/CONCLUSIONS:Findings highlight the need to update data sharing infrastructure, which will be critical to the implementation of the 1115 waivers, as carceral facilities will be subject to Medicaid billing and reporting requirements. In addition to investing in the ability to newly enroll and suspend Medicaid benefits, attention towards improving timely reactivation practices is needed, particularly given the highly elevated risk of mortality immediately after release. Participants calls for further reforms to the Medicaid Inmate Exclusion Policy are consistent with proposed legislation. CONCLUSIONS:Findings can critically inform the successful implementation of Medicaid-based reforms to improve the health of incarcerated and formerly incarcerated people.

OBJECTIVE:To evaluate the completeness and quality of Medicaid comprehensive managed care (CMC) data in national MAX/TAF research files. STUDY SETTING AND DESIGN/METHODS:This observational study compared CMC with fee-for-service (FFS) enrollee data in 2001-2019 Medicaid MAX/TAF inpatient, outpatient, and pharmacy files. Completeness was assessed as the proportion of enrollees with any claim and mean claims per enrollee with any claim. Quality was assessed as the proportion of inpatient and outpatient claims with primary diagnosis and procedure codes and the proportion of prescription drug claims with fill dates, National Drug Codes (NDC), days supplied, and quantity dispensed. Acceptable ranges for each study measure were defined as the national FFS mean ± 2 standard deviations. DATA SOURCES AND ANALYTIC SAMPLE/UNASSIGNED:We analyzed secondary data on 45 states from 2001 to 2013 (MAX) and 50 states and DC from 2014 to 2019 (TAF). The sample included adults aged 18-64 with continuous calendar-year enrollment who were eligible for full Medicaid benefits and ineligible for Medicare. We determined CMC enrollment rates and assessed data completeness and quality among state-years with ≥10% CMC penetration, comparing CMC with FFS enrollees. PRINCIPAL FINDINGS/RESULTS:Across 891 state-years, 194,364,647 enrollees met inclusion criteria. Of 540 state-years (60.6%) with ≥10% CMC enrollment, CMC data were largely comparable to national FFS distributions for all inpatient (n = 430; 79.6%), outpatient (n = 467, 86.5%), and prescription (n = 459, 85.0%) completeness criteria and for all inpatient (n = 449, 83.1%), outpatient (n = 511, 94.6%), and prescription (n = 528, 97.8%) quality criteria. Overall completeness (92.3%) and quality (84.6%) improved substantially by 2019. CONCLUSIONS:Completeness and quality of CMC data were largely comparable to FFS data, with increasing state-years meeting criteria over time. Further research on national Medicaid populations should assess and address differences in data completeness and quality by plan type across states, over time, and in relation to specific study samples and measures of interest.

INTRODUCTION/UNASSIGNED:Homelessness in the United States increased every year since 2016, with a 38% increase from 2023 to 2024. Much of the increase is attributable to rising home and rent costs, economic hardship caused by the recent pandemic, and the ending of protective legislation. Notably, people who experience homelessness have an increased risk of substance use disorders, HIV infection and poorer HIV outcomes than people who are stably housed. The iHouse model aims to develop feasible, effective, and cost-effective tailored approaches to improve health outcomes in this population including life expectancy, overdose, and HIV. METHODS AND ANALYSIS/UNASSIGNED:The study will employ Group Model Building methods and use insights from that process to develop an agent-based model simulating the dynamic processes contributing to HIV incidence and treatment, overdose, and life expectancy among people along the housing and homelessness continuum in Denver, CO and San Francisco, CA. The model will evaluate multiple outcomes from 4 conceptual dimensions: (1) movement along the housing continuum, (2) population health (overdose and HIV incidence and life expectancy), (3) budgetary impact, (4) economic value. ETHICS AND DISSEMINATION/UNASSIGNED:This study has been approved by the Colorado Institutional Review Board at the University of Colorado under protocol 24-0878. The data generated by this protocol, the methodologies used, and the findings will be made available in a timely manner to other researchers. iHOUSE code and parameter values will be published in Git Hub, such that all model analyses can be reproduced by independent investigators. Documentation of all parameter estimates and model results will be published for independent review and confirmation. In addition, supplemental materials and appendices for the model will be shared on a publicly available website.

BACKGROUND:Firearm violence remains a leading cause of death and injury in the United States. Prior research supports that alcohol exposures, including individual-level alcohol use and alcohol control policies, are modifiable risk factors for firearm violence, yet additional research is needed to support prevention efforts. OBJECTIVES/OBJECTIVE:This scoping review aims to update a prior 2016 systematic review on the links between alcohol exposure and firearm violence to examine whether current studies indicate causal links between alcohol use, alcohol interventions, and firearm violence-related outcomes. ELIGIBILITY CRITERIA/METHODS:Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines, a comprehensive search of published studies was conducted, replicating the search strategy of the prior review but focusing on studies published since 2015. The review included published studies of humans, conducted in general populations of any age, gender, or racial/ethnic group, that examined the relationship between an alcohol-related exposure and an outcome involving firearm violence or risks for firearm violence. Excluded were small studies restricted to special populations, forensic or other technical studies, non-original research articles such as reviews, and studies that relied solely on descriptive statistics or did not adjust for confounders. SOURCES OF EVIDENCE/METHODS:The review included published studies indexed in PubMed, Web of Science, and Scopus. Eligible articles were published on or after January 1, 2015. The latest search was conducted on December 15, 2023. CHARTING METHODS/METHODS:Using a structured data collection instrument, data were extracted on the characteristics of each study, including the dimension of alcohol exposure, the dimension of firearm violence, study population, study design, statistical analysis, source of funding, main findings, and whether effect measure modification was assessed and, if so, along what dimensions. Two authors independently conducted title/abstract screening, full-text screening, and data extraction until achieving 95% agreement, with discrepancies resolved through discussion. RESULTS:The search yielded 797 studies. Of these, 754 were excluded and 43 met the final inclusion criteria. Studies addressed a range of alcohol exposures and firearm violence-related outcomes, primarily with cross-sectional study designs; 40% considered effect measure modification by any population characteristic. Findings from the 21 studies examining the relationship of individual-level alcohol use or alcohol use disorder (AUD) with firearm ownership, access, unsafe storage, or carrying indicated a strong and consistent positive association. Seven studies examined associations of individual-level alcohol use or AUD with firearm injury or death; these also indicated a pattern of positive associations, but the magnitude and precision of the estimates varied. Eight studies examined the impact of neighborhood proximity or density of alcohol outlets and found mixed results that were context- and study design-dependent. Two studies linked prior alcohol-related offenses to increased risk of firearm suicide and perpetration of violent firearm crimes among a large cohort of people who purchased handguns, and two studies linked policies prohibiting firearm access among individuals with a history of alcohol-related offenses to reductions in firearm homicide and suicide. Finally, four studies examined alcohol control policies and found that greater restrictiveness was generally associated with reductions in firearm homicide or firearm suicide. CONCLUSIONS:Findings from this scoping review continue to support a causal relationship between alcohol exposures and firearm violence that extends beyond acute alcohol use to include AUD and alcohol-related policies. Policies controlling the availability of alcohol and prohibiting firearm access among individuals with alcohol-related offense histories show promise for the prevention of firearm violence. Additional research examining differential impacts by population subgroup, alcohol use among perpetrators of firearm violence, policies restricting alcohol outlet density, and randomized or quasi-experimental study designs with longitudinal follow-up would further support inferences to inform prevention efforts.

BACKGROUND/UNASSIGNED:Rates of cannabis use disorder (CUD) have increased disproportionately among Veterans Administration (VA) patients with psychiatric disorders compared to patients with no disorder. However, VA patient samples are not representative of all U.S. adults, so results on disproportionate increases in CUD prevalence could have been biased. To address this concern, we investigated whether disproportionate increases in the prevalence of cannabis outcomes among those with psychiatric disorders would replicate in nationally representative samples of U.S. adults. METHODS/UNASSIGNED: = 36,309). Outcomes were any past-year non-medical cannabis use, frequent non-medical use (≥3 times weekly), and DSM-IV CUD. Psychiatric disorders included mood, anxiety and antisocial personality disorders. Logistic regression was used to generate predicted prevalences of the outcomes, prevalence differences calculated and additive interactions compared differences between those with and without psychiatric disorders. RESULTS/UNASSIGNED:Cannabis outcomes increased more among those with psychiatric disorders. The difference in prevalence differences included any past-year non-medical cannabis use, 2.45% (95%CI = 1.29-3.62); frequent non-medical cannabis use, 1.58% (95%CI = 0.83-2.33); CUD, 1.40% (95%CI = 0.58-2.21). For most specific disorders, prevalences increased more among those with the disorder. CONCLUSIONS/UNASSIGNED:In the U.S. general population, rates of cannabis use and CUD increased more among adults with psychiatric disorders than other adults, similar to findings from VA patient samples. Results suggest that although VA patients are not representative of all U.S. adults, findings from this important patient group can be informative. Greater clinical and policy attention to CUD is warranted for adults with psychiatric disorders.