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BACKGROUND: Alcohol use disorder (AUD) is underdiagnosed and undertreated in medical settings, in part due to a lack of AUD assessment instruments that are reliable and practical for use in routine care. This study evaluates the test-retest reliability of a patient-report Alcohol Symptom Checklist questionnaire when it is used in routine care, including primary care and mental health specialty settings. METHODS: We performed a pragmatic test-retest reliability study using electronic health record (EHR) data from Kaiser Permanente Washington, an integrated health system in Washington state. The sample included 454 patients who reported high-risk drinking on a behavioral health screen and completed two Alcohol Symptom Checklists 1–21 days apart. Subgroups who completed both checklists in primary care (n=271) or mental health settings (n=79) were also examined. The primary measure was an Alcohol Symptom Checklist on which patients self-report whether they have experienced each of the 11 AUD criteria within the past year, as defined by the Diagnostic and Statistical Manual of Mental Disorders-5(th) edition (DSM-5). RESULTS: Alcohol Symptom Checklists completed in routine care and documented in EHRs had excellent test-retest reliability for measuring AUD criteria counts (ICC=0.79, 95% CI: 0.76–0.82). Test-retest reliability estimates were also high and not significantly different for the subsamples of patients who completed both checklists in primary care (ICC=0.82, 95% CI: 0.77–0.85) or mental health settings (ICC=0.74, 95% CI: 0.62–0.83). Test-retest reliability was not moderated by having a past two-year AUD diagnosis, nor by the age or sex of the patient completing it. CONCLUSIONS: Alcohol Symptom Checklists can reliably and pragmatically assess AUD criteria in routine care among patients who screen positive for high-risk drinking. The Alcohol Symptom Checklist may be a valuable tool in supporting AUD-related care and monitoring AUD criteria longitudinally in routine primary care and mental health settings.

ImportanceSubstance use disorders (SUDs) are underrecognized in primary care, where structured clinical interviews are often infeasible. A brief, standardized substance use symptom checklist could help clinicians assess SUD.ObjectiveTo evaluate the psychometric properties of the Substance Use Symptom Checklist (hereafter symptom checklist) used in primary care among patients reporting daily cannabis use and/or other drug use as part of population-based screening and assessment.Design, Setting, and ParticipantsThis cross-sectional study was conducted among adult primary care patients who completed the symptom checklist during routine care between March 1, 2015, and March 1, 2020, at an integrated health care system. Data analysis was conducted from June 1, 2021, to May 1, 2022.Main Outcomes and MeasuresThe symptom checklist included 11 items corresponding to SUD criteria in the Diagnostic and Statistical Manual for Mental Disorders (Fifth Edition) (DSM-5). Item response theory (IRT) analyses tested whether the symptom checklist was unidimensional and reflected a continuum of SUD severity and evaluated item characteristics (discrimination and severity). Differential item functioning analyses examined whether the symptom checklist performed similarly across age, sex, race, and ethnicity. Analyses were stratified by cannabis and/or other drug use.ResultsA total of 23 304 screens were included (mean [SD] age, 38.2 [5.6] years; 12 554 [53.9%] male patients; 17 439 [78.8%] White patients; 20 393 [87.5%] non-Hispanic patients). Overall, 16 140 patients reported daily cannabis use only, 4791 patients reported other drug use only, and 2373 patients reported both daily cannabis and other drug use. Among patients with daily cannabis use only, other drug use only, or both daily cannabis and other drug use, 4242 (26.3%), 1446 (30.2%), and 1229 (51.8%), respectively, endorsed 2 or more items on the symptom checklist, consistent with DSM-5 SUD. For all cannabis and drug subsamples, IRT models supported the unidimensionality of the symptom checklist, and all items discriminated between higher and lower levels of SUD severity. Differential item functioning was observed for some items across sociodemographic subgroups but did not result in meaningful change (Conclusions and RelevanceIn this cross-sectional study, a symptom checklist, administered to primary care patients who reported daily cannabis and/or other drug use during routine screening, discriminated SUD severity as expected and performed well across subgroups. Findings support the clinical utility of the symptom checklist for standardized and more complete SUD symptom assessment to help clinicians make diagnostic and treatment decisions in primary care.

OBJECTIVE: The authors sought to characterize the 3-year prevalence of mental disorders and nonnicotine substance use disorders among male and female primary care patients with documented opioid use disorder across large U.S. health systems. METHODS: This retrospective study used 2014–2016 data from patients ages ≥16 years in six health systems. Diagnoses were obtained from electronic health records or claims data; opioid use disorder treatment with buprenorphine or injectable extended-release naltrexone was determined through prescription and procedure data. Adjusted prevalence of comorbid conditions among patients with opioid use disorder (with or without treatment), stratified by sex, was estimated by fitting logistic regression models for each condition and applying marginal standardization. RESULTS: Females (53.2%, N=7,431) and males (46.8%, N=6,548) had a similar prevalence of opioid use disorder. Comorbid mental disorders among those with opioid use disorder were more prevalent among females (86.4% vs. 74.3%, respectively), whereas comorbid other substance use disorders (excluding nicotine) were more common among males (51.9% vs. 60.9%, respectively). These differences held for those receiving medication treatment for opioid use disorder, with mental disorders being more common among treated females (83% vs. 71%) and other substance use disorders more common among treated males (68% vs. 63%). Among patients with a single mental health condition comorbid with opioid use disorder, females were less likely than males to receive medication treatment for opioid use disorder (15% vs. 20%, respectively). CONCLUSIONS: The high rate of comorbid conditions among patients with opioid use disorder indicates a strong need to supply primary care providers with adequate resources for integrated opioid use disorder treatment.

BACKGROUND: Most people with alcohol use disorder do not receive treatment, and primary care (PC)-based management of alcohol use disorder is a key strategy to close this gap. Understanding PC patients’ perspectives on changing drinking and receiving alcohol-related care is important for this goal, particularly those who decline alcohol-related care. This study examined perspectives on barriers and facilitators to changing drinking and receiving alcohol-related care among Veterans Health Administration (VA) PC patients who indicated interest but did not enroll in the Choosing Healthier drinking Options In primary CarE trial (CHOICE), which tested a PC-based alcohol care management intervention. METHODS: VA PC patients with frequent heavy drinking who indicated interest in CHOICE but did not enroll were invited to participate. Twenty-seven patients completed in-person, semi-structured interviews. Interview transcripts were analyzed using iterative deductive and inductive content analysis. RESULTS: Participants were mostly men (96%) and White (59%), and mean age was 48. Seventy-four percent met criteria for alcohol use disorder, and median number of past-week standard drinks was 41.5. Participants reported fewer alcohol-related problems, lower importance of/readiness to change drinking, and higher confidence in ability to change than patients who enrolled in the CHOICE trial. Barriers fell into 5 domains: drinking fulfills need(s); reducing drinking or treatment is not needed; treatment is not effective/not acceptable; alcohol-related stigma; and practical barriers. Facilitators fell into 4 domains: reasons to change drinking; social support; treatment is acceptable/meets patients’ needs; and practical facilitators. Participants discussed how Veteran identity and military experiences impacted drinking and willingness to receive care, which amplified multiple barriers/facilitators. CONCLUSIONS: This study identified barriers and facilitators to changing drinking and receiving alcohol-related care among VA PC patients who indicated interest but did not enroll in an alcohol care management trial. Findings can inform patient-centered interventions and support clinicians in engaging patients in care.

Background: The authors tested the efficacy of the “I-STAND” intervention for reducing sitting time, a novel and potentially health-promoting approach, in older adults with obesity. Methods: The authors recruited 60 people (mean age = 68 ± 4.9 years, 68% female, 86% White; mean body mass index = 35.4). The participants were randomized to receive the I-STAND sitting reduction intervention (n = 29) or healthy living control group (n = 31) for 12 weeks. At baseline and at 12 weeks, the participants wore activPAL devices to assess sitting time (primary outcome). Secondary outcomes included fasting glucose, blood pressure, and weight. Linear regression models assessed between-group differences in the outcomes. Results: The I-STAND participants significantly reduced their sitting time compared with the controls (–58 min per day; 95% confidence interval [–100.3, –15.6]; p = .007). There were no statistically significant changes in the secondary outcomes. Conclusion: I-STAND was efficacious in reducing sitting time, but not in changing health outcomes in older adults with obesity.

BACKGROUND: Most states have legalized medical cannabis, yet little is known about how medical cannabis use is documented in patients’ electronic health records (EHRs). We used natural language processing (NLP) to calculate the prevalence of clinician-documented medical cannabis use among adults in an integrated health system in Washington State where medical and recreational use are legal. METHODS: We analyzed EHRs of patients ≥18 years old screened for past-year cannabis use (11/1/2017–10/31/2018), to identify clinician-documented medical cannabis use. We defined medical use as any documentation of cannabis that was recommended by a clinician or described by the clinician or patient as intended to manage health conditions or symptoms. We developed and applied an NLP system that included NLP-assisted manual review to identify such documentation in encounter notes. RESULTS: Medical cannabis use was documented for 16,684 (5.6%) of 299,597 outpatient encounters with routine screening for cannabis use among 203,489 patients seeing 1,274 clinicians. The validated NLP system identified 54% of documentation and NLP-assisted manual review the remainder. Language documenting reasons for cannabis use included 125 terms indicating medical use, 28 terms indicating non-medical use and 41 ambiguous terms. Implicit documentation of medical use (e.g., “edible THC nightly for lumbar pain”) was more common than explicit (e.g., “continues medical cannabis use”). CONCLUSIONS: Clinicians use diverse and often ambiguous language to document patients’ reasons for cannabis use. Automating extraction of documentation about patients’ cannabis use could facilitate clinical decision support and epidemiological investigation but will require large amounts of gold standard training data.

ImportanceCannabis use is prevalent and increasing, and frequent use intensifies the risk of cannabis use disorder (CUD). CUD is underrecognized in medical settings, but a validated single-item cannabis screen could increase recognition.ObjectiveTo evaluate the Single-Item Screen–Cannabis (SIS-C), administered and documented in routine primary care, compared with a confidential reference standard measure of CUD.Design, Setting, and ParticipantsThis diagnostic study included a sample of adult patients who completed routine cannabis screening between January 28 and September 12, 2019, and were randomly selected for a confidential survey about cannabis use. Random sampling was stratified by frequency of past-year use and race and ethnicity. The study was conducted at an integrated health system in Washington state, where adult cannabis use is legal. Data were analyzed from May 2021 to March 2022.ExposuresThe SIS-C asks about frequency of past-year cannabis use with responses (none, less than monthly, monthly, weekly, daily or almost daily) documented in patients’ medical records.Main Outcomes and MeasuresThe Diagnostic and Statistical Manual, Fifth Edition (DSM-5) Composite International Diagnostic Interview–Substance Abuse Module (CIDI-SAM) for past-year CUD was completed on a confidential survey and considered the reference standard. The SIS-C was compared with 2 or more criteria on the CIDI-SAM, consistent with CUD. All analyses were weighted, accounting for survey design and nonresponse, to obtain estimates representative of the health system primary care population.ResultsOf 5000 sampled adult patients, 1688 responded to the cannabis survey (34% response rate). Patients were predominantly middle-aged (weighted mean [SD] age, 50.7 [18.1]), female or women (weighted proportion [SE], 55.9% [4.1]), non-Hispanic (weighted proportion [SE], 96.7% [1.0]), and White (weighted proportion [SE], 74.2% [3.7]). Approximately 6.6% of patients met criteria for past-year CUD. The SIS-C had an area under receiver operating characteristic curve of 0.89 (95% CI, 0.78-0.96) for identifying CUD. A threshold of less than monthly cannabis use balanced sensitivity (0.88) and specificity (0.83) for detecting CUD. In populations with a 6% prevalence of CUD, predictive values of a positive screen ranged from 17% to 34%, while predictive values of a negative screen ranged from 97% to 100%.Conclusions and RelevanceIn this diagnostic study, the SIS-C had excellent performance characteristics in routine care as a screen for CUD. While high negative predictive values suggest that the SIS-C accurately identifies patients without CUD, low positive predictive values indicate a need for further diagnostic assessment following positive results when screening for CUD in primary care.

Key Points Question What are the self-reported practices of frontline dispensary staff who interact with customers purchasing cannabis for medical purposes? Findings In this survey study of responses from 434 staff from 351 unique dispensaries, recommendations were most often based on experiences of the respondent, other customers, and other staff recommendations. Higher medicalization scores were associated with physician or clinician input as a basis for recommendation. Meaning The results of this survey study suggest a need for clinicians to be aware of dispensary staff practices and to engage in discussions about the benefits and harms of cannabis use with their patients., Importance Over the last decade, cannabis has become more accessible through the proliferation of dispensaries in states that have legalized its use. Most patients using cannabis for medical purposes report getting advice from dispensaries, yet there has been little exploration of frontline dispensary staff practices. Objective To describe the practices of frontline dispensary workers who interact with customers purchasing cannabis for medical purposes and assess whether dispensary practices are associated with medicalization of state cannabis laws (degree to which they resemble regulation of prescription or over-the-counter drugs) and statewide adult use. Design, Setting, and Participants This nationwide cross-sectional survey study was conducted from February 13, 2020, to October 2, 2020, using an online survey tool. Potential respondents were eligible if they reported working in a dispensary that sells tetrahydrocannabinol-containing products and interacting with customers about cannabis purchases. Main Outcomes and Measures Participant responses to questions about formulating customer recommendations and talking to customers about risks. Results The 434 survey responses from 351 unique dispensaries were most often completed by individuals who identified as budtenders (40%), managers (32%), and pharmacists (13%). Most respondents reported basing customer recommendations on the customer’s medical condition (74%), the experiences of other customers (70%), the customer’s prior experience with cannabis (67%), and the respondent’s personal experience (63%); fewer respondents relied on clinician input (40%), cost (45%), or inventory (12%). Most respondents routinely advised customers about safe storage and common adverse effects, but few counseled customers about cannabis use disorder, withdrawal, motor vehicle collision risk, or psychotic reactions. A higher state medicalization score was significantly associated with using employer training (odds ratio, 1.41; 95% CI, 1.18-1.67) and physician or clinician input (odds ratio, 1.23; 95% CI, 1.05-1.43) as a basis for recommendation. Medicalization score was not associated with counseling about cannabis risks. Conclusions and Relevance This survey study provides insight into how frontline dispensary staff base cannabis recommendations and counsel about risks. The findings may have utility for clinicians to counsel patients who purchase cannabis, customers who want to be prepared for a dispensary visit, and policy makers whose decisions affect cannabis laws., This survey study describes the practices of frontline dispensary staff who interact with customers purchasing cannabis for medical purposes and assesses whether dispensary practices vary according to state cannabis law medicalization.

BACKGROUND: Alcohol use disorder (AUD) is highly prevalent but underrecognized and undertreated in primary care settings. Alcohol Symptom Checklists can engage patients and providers in discussions of AUD-related care. However, the performance of Alcohol Symptom Checklists when they are used in routine care and documented in electronic health records (EHRs) remains unevaluated. OBJECTIVE: To evaluate the psychometric performance of an Alcohol Symptom Checklist in routine primary care. DESIGN: Cross-sectional study using item response theory (IRT) and differential item functioning analyses of measurement consistency across age, sex, race, and ethnicity. PATIENTS: Patients seen in primary care in the Kaiser Permanente Washington Healthcare System who reported high-risk drinking on the Alcohol Use Disorder Identification Test Consumption screening measure (AUDIT-C ≥ 7) and subsequently completed an Alcohol Symptom Checklist between October 2015 and February 2020. MAIN MEASURE: Alcohol Symptom Checklists with 11 items assessing AUD criteria defined in the Diagnostic and Statistical Manual for Mental Disorders, 5th edition (DSM-5), completed by patients during routine medical care and documented in EHRs. KEY RESULTS: Among 11,464 patients who screened positive for high-risk drinking and completed an Alcohol Symptom Checklist (mean age 43.6 years, 30.5% female), 54.1% reported ≥ 2 DSM-5 AUD criteria (threshold for AUD diagnosis). IRT analyses demonstrated that checklist items measured a unidimensional continuum of AUD severity. Differential item functioning was observed for some demographic subgroups but had minimal impact on accurate measurement of AUD severity, with differences between demographic subgroups attributable to differential item functioning never exceeding 0.42 points of the total symptom count (of a possible range of 0–11). CONCLUSIONS: Alcohol Symptom Checklists used in routine care discriminated AUD severity consistently with current definitions of AUD and performed equitably across age, sex, race, and ethnicity. Integrating symptom checklists into routine care may help inform clinical decision-making around diagnosing and managing AUD. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-021-07038-3.

Transgender persons are vulnerable to under-receipt of recommended health care due to chronic exposure to systemic stressors (e.g., discriminatory laws and health system practices). Scant information exists on receipt of alcohol-related care for transgender populations, and whether structural interventions to reduce transgender discrimination in health care improve receipt of recommended treatment. This study evaluated the effect of the Veteran Health Administration (VA) Transgender Healthcare Directive-a national policy to reduce structural discrimination-on receipt of evidence-based alcohol-related care for transgender VA patients with unhealthy alcohol use.The study used an interrupted time series with control design to compare monthly receipt of alcohol-related care among transgender patients with unhealthy alcohol use (Alcohol Use Disorders Identification Test Consumption ≥5) documented in their electronic health record before (10/1/2009-5/31/2011) and after (7/1/2011-7/31/2017) implementation of VA's Transgender Healthcare Directive. A propensity-score matched sample of non-transgender patients with unhealthy alcohol use served as a comparison group to control for concurrent secular trends. Mixed effects segmented logistic regression models estimated changes in level and slope (i.e., rate of change) in receipt of any evidence-based alcohol-related care, including brief intervention, specialty addictions treatment, and alcohol use disorder medications.The matched sample (mean age = 47.5 [SD = 15.0]; 75% non-Hispanic White race/ethnicity) included 2074 positive alcohol screens completed by 1377 transgender patients and 6,l99 positive alcohol screens completed by 6185 non-transgender patients. Receipt of alcohol-related care increased for transgender patients from 78.5% (95% CI: 71.3%-85.6%) at the start of study to 83.0% (75.9%-90.1%) immediately before the directive and decreased slightly from 81.6% (77.4%-85.9%) immediately after the directive to 80.1% (76.8-85.4) at the end of the study. Changes in level and slope comparing periods before and after the directive were not statistically significant, nor were they statistically significantly different from the matched sample of non-transgender patients.Health systems must urgently employ and evaluate policies to address structural stigma that produces and reproduces disparities in health and health care. Although VA's directive was not associated with increased receipt of alcohol-related care, that receipt of alcohol-related care among transgender patients is comparable to non-transgender patients is promising.

Purpose: To estimate changes in self-reported health and psychosocial factors associated with a 12-week sedentary behavior intervention for older adults. Design: Exploratory secondary analysis of pilot randomized controlled trial. Setting: Kaiser Permanente Washington Subjects: Sixty adults aged 60 to 89 with body mass index ≥30 kg/m2. Intervention: Participants were randomized to the I-STAND intervention or control group. I-STAND involved 6 coaching sessions, a study workbook, Jawbone UP activity tracker to prompt breaks from sitting, and activPAL feedback on objective sitting time. Measures: At baseline and 12-week follow-up, participants completed a survey with validated measures of self-reported health outcomes (depression, stress, memory/concentration, sleep, pain, ability to do daily activities, energy, and quality of life) and modified scales measuring psychosocial factors (perceived benefits/barriers, social support, self-efficacy, and sedentary habit strength) regarding sedentary behavior. Analysis: Generalized linear models assessed associations between group assignment and change in each self-reported health and psychosocial score, adjusting for baseline scores. Results: I-STAND participants demonstrated improvements in self-efficacy (β = 0.35, 95% confidence interval [CI]: 0.10 to 0.60) and reduced habit strength (β= −0.23, 95% CI: −0.42 to −0.04) compared to control participants. There were no significant differences in self-reported health outcomes, although power was limited in this exploratory analysis. Conclusion: A sedentary behavior reduction intervention for older adults resulted in improvements for some psychosocial factors. Health outcomes may require longer than 12 weeks to observe improvements.

OBJECTIVE: Alcohol use is understudied among transgender persons—persons whose sex differs from their gender identity. We compare patterns of alcohol use between Veterans Health Administration (VA) transgender and nontransgender outpatients. METHOD: National VA electronic health record data were used to identify all patients’ last documented Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) screen (October 1, 2009–July 31, 2017). Transgender patients were identified using diagnostic codes. Logistic regression models estimated four past-year primary outcomes: (a) alcohol use (AUDIT-C > 0); (b) unhealthy alcohol use (AUDIT-C ≥ 5); (c) high-risk alcohol use (AUDIT-C ≥ 8); and (d) heavy episodic drinking (HED; ≥6 drinks on ≥1 occasion). Two secondary diagnostic-based outcomes, alcohol use disorder (AUD) and alcohol-specific conditions, were also examined. RESULTS: Among 8,872,793 patients, 8,619 (0.10%) were transgender. For transgender patients, unadjusted prevalence estimates were as follows: 52.8% for any alcohol use, 6.6% unhealthy alcohol use, 2.8% high-risk use, 10.4% HED, 8.6% AUD, and 1.3% alcohol-specific conditions. After adjustment for demographic characteristics, transgender patients had lower odds of patient-reported alcohol use but higher odds of alcohol-related diagnoses compared with nontransgender patients. Differences in alcohol-related diagnoses were attenuated after adjustment for comorbid conditions and utilization. CONCLUSIONS: This is the largest study of patterns of alcohol use among transgender persons and among the first to directly compare patterns to nontransgender persons. Findings suggest nuanced associations with patterns of alcohol use and provide a base for further disparities research to explore alcohol use within the diverse transgender community. Research with self-reported measures of gender identity and sex-at-birth and structured assessment of alcohol use and disorders is needed.

PURPOSE. Shared decision making is an important implementation “pull” strategy for increasing uptake of evidence-based mental health practices. In this qualitative study, we explored provider perspectives on implementing shared decision making at the point of mental health treatment initiation using a publicly available, patient-facing decision support tool for post-traumatic stress disorder (PTSD). METHODS. We conducted semi-structured interviews with 22 mental health providers (psychiatrists, nurses, psychologists, and social workers) working in one of five VA primary care clinics. Interviewed were analyzed using thematic analysis. RESULTS. Provider were enthusiastic about using decision aids as a source of high quality information that could improve patient experience and confidence in treatment. However, providers had concerns about decision aid accessibility, time constraints to conduct shared decision making in-session, and patient motivation to engage in shared decision making. Providers stated they would prefer to use shared decision making with patients that they felt were most likely to follow through with treatment. CONCLUSIONS. While providers believed that shared decision making could improve PTSD treatment planning, they thought it most appropriate for patients with the highest levels of motivation and fewest barriers to care. These beliefs may limit widespread adoption and reflect missed opportunities to reach difficult-to-engage patients.

BACKGROUND/OBJECTIVE: Evidence-based alcohol-related care–brief intervention for all patients with unhealthy alcohol use and specialty addictions treatment and/or pharmacotherapy for patients with alcohol use disorder (AUD)–should be routinely offered. Transgender persons may be particularly in need of alcohol-related care, given common experiences of social and economic hardship that may compound the adverse effects of unhealthy alcohol use. We examined receipt of alcohol-related care among transgender patients compared to non-transgender patients in a large national sample of Veterans Health Administration (VA) outpatients with unhealthy alcohol use. METHODS: We extracted electronic health record data for patients from all VA facilities who had an outpatient visit 10/1/09-7/31/17 and a documented positive screen for unhealthy alcohol use (AUDIT-C ≥5). We identified transgender patients with a validated approach using transgender-related diagnostic codes. We fit modified Poisson models, adjusted for demographics and comorbidities, to estimate the average predicted prevalence of brief intervention (documented 0–14 days following most recent positive screening), specialty addictions treatment for AUD (documented 0–365 days following screening), and filled prescriptions for medications to treat AUD (documented 0–365 days following screening) for transgender patients, and compared to that of non-transgender patients. RESULTS: Among transgender Veterans with unhealthy alcohol use (N=1,392), the adjusted prevalence of receiving brief intervention was 75.4% (95% CI 72.2 – 78.5), specialty addictions treatment for AUD was 15.7% (95% CI 13.7 – 17.7), and any AUD pharmacotherapy was 19.0% (95% CI 17.1 – 20.8). Receipt of brief intervention did not differ for transgender relative to non-transgender patients (Prevalence Ratio [PR] 1.01, 95% CI 0.98 – 1.04, p=0.574). However, transgender patients were more likely to receive specialty addictions treatment (PR 1.24, 95% CI 1.12 – 1.37, p

Patients who use cannabis for medical reasons may benefit from discussions with clinicians about health risks of cannabis and evidence-based treatment alternatives. However, little is known about the prevalence of medical cannabis use in primary care and how often it is documented in patient electronic health records (EHR).To estimate the primary care prevalence of medical cannabis use according to confidential patient survey and to compare the prevalence of medical cannabis use documented in the EHR with patient report.This study is a cross-sectional survey performed in a large health system that conducts routine cannabis screening in Washington state where medical and nonmedical cannabis use are legal. Among 108 950 patients who completed routine cannabis screening (between March 28, 2019, and September 12, 2019), 5000 were randomly selected for a confidential survey about cannabis use, using stratified random sampling for frequency of past-year use and patient race and ethnicity. Data were analyzed from November 2020 to December 2021.Survey measures of patient-reported past-year cannabis use, medical cannabis use (ie, explicit medical use), and any health reason(s) for use (ie, implicit medical use).Survey data were linked to EHR data in the year before screening. EHR measures included documentation of explicit and/or implicit medical cannabis use. Analyses estimated the primary care prevalence of cannabis use and compared EHR-documented with patient-reported medical cannabis use, accounting for stratified sampling and nonresponse.Overall, 1688 patients responded to the survey (34% response rate; mean [SD] age, 50.7 [17.5] years; 861 female [56%], 1184 White [74%], 1514 non-Hispanic [97%], and 1059 commercially insured [65%]). The primary care prevalence of any past-year patient-reported cannabis use on the survey was 38.8% (95% CI, 31.9%-46.1%), whereas the prevalence of explicit and implicit medical use were 26.5% (95% CI, 21.6%-31.3%) and 35.1% (95% CI, 29.3%-40.8%), respectively. The prevalence of EHR-documented medical cannabis use was 4.8% (95% CI, 3.45%-6.2%). Compared with patient-reported explicit medical use, the sensitivity and specificity of EHR-documented medical cannabis use were 10.0% (95% CI, 4.4%-15.6%) and 97.1% (95% CI, 94.4%-99.8%), respectively.These findings suggest that medical cannabis use is common among primary care patients in a state with legal use, and most use is not documented in the EHR. Patient report of health reasons for cannabis use identifies more medical use compared with explicit questions about medical use.

Alcohol use increases non-adherence to antiretroviral therapy (ART) among persons living with HIV (PLWH). Dynamic longitudinal associations are understudied. Veterans Aging Cohort Study (VACS) data 2/1/2008-7/31/16 were used to fit linear regression models estimating changes in adherence (% days with ART medication fill) associated with changes in alcohol use based on annual clinically-ascertained AUDIT-C screening scores (range - 12 to + 12, 0 = no change) adjusting for demographics and initial adherence. Among 21,275 PLWH (67,330 observations), most reported no (48%) or low-level (39%) alcohol use initially, with no (55%) or small (39% ≤ 3 points) annual change. Mean initial adherence was 86% (SD 21%), mean annual change was - 3.1% (SD 21%). An inverted V-shaped association was observed: both increases and decreases in AUDIT-C were associated with greater adherence decreases relative to stable scores [p 0.001, F (4, 21,274)]. PLWH with dynamic alcohol use (potentially indicative of alcohol use disorder) should be considered for adherence interventions.El consumo de alcohol aumenta el no-cumplimiento a la terapia antirretroviral (TARV) entre las personas que viven con VIH. No se han estudiado lo suficiente las dinámicas asociaciones longitudinales. Los datos del Estudio de la Envejecimiento de Cohorte de Veteranos (EECV) (1/2/2008–31/7/2016) fueron usados para encajar modelos de regresión lineal estimando los cambios en cumplimiento (% de días con medicaciones TARV surtidas) asociados con los cambios en el consumo de alcohol basado en los resultados anuales de las evaluaciones AUDIT-C, determinadas clínicamente, (una gama de -12 a + 12, 0 = cero cambio) adaptándose a las estadísticas demográficas y cumplimiento inicial. Entre 21,275 personas que viven con VIH (67,330 observaciones), la mayoría reportó ningún (48%) o bajos niveles del (39%) consumo de alcohol inicialmente, con ningún (55%) o muy pequeño (39% ≤ 3 puntos) cambio anual. la media inicial de cumplimiento fue 86% (DE 21%). La media de cambio anual fue -3.1% (DE 21%). Se observó una asociación de forma V invertida: tanto los aumentos como las disminuciones en AUDIT-C fueron asociados con mayor disminuciones de cumplimiento en comparación con resultados estables (p 0.001, F (4, 21,274)). Personas que viven con VIH con el consumo dinámico de alcohol (potencialmente indicativo de un trastorno por consumo de alcohol) deben ser considerados por intervenciones de cumplimiento.

Background Cannabis and other drug use is associated with adverse health events, but little is known about the association of routine clinical screening for cannabis or other drug use and acute care utilization. This study evaluated whether self-reported frequency of cannabis or other drug use was associated with subsequent acute care. Method This retrospective cohort study used EHR and claims data from 8 sites in Washington State that implemented annual substance use screening. Eligible adult primary care patients (N = 47,447) completed screens for cannabis (N = 45,647) and/or other drug use, including illegal drug use and prescription medication misuse, (N = 45,255) from 3/3/15-10/1/2016. Separate single-item screens assessed frequency of past-year cannabis and other drug use: never, less than monthly, monthly, weekly, daily/almost daily. An indicator of acute care utilization measured any urgent care, emergency department visits, or hospitalizations ≤19 months after screening. Adjusted Cox proportional hazards models estimated risk of acute care. Results Patients were predominantly non-Hispanic White. Those reporting cannabis use less than monthly (Hazard Ratio [HR] = 1.12, 95 % CI = 1.03–1.21) or daily (HR = 1.24; 1.10–1.39) had greater risk of acute care during follow-up than those reporting no use. Patients reporting other drug use less than monthly (HR = 1.34; 1.13–1.59), weekly (HR = 2.21; 1.46–3.35), or daily (HR = 2.53; 1.86–3.45) had greater risk of acute care than those reporting no other drug use. Conclusion Population-based screening for cannabis and other drug use in primary care may have utility for understanding risk of subsequent acute care. It is unclear whether findings will generalize to U.S. states with broader racial/ethnic diversity.

ZrB2 and HfB2 with incorporation of SiC are being considered as structural materials for elevated temperature applications. We used high energy ball milling of micron-size powders to increase lattice distortion enhanced inter-diffusion to get uniform distribution of SiC and reduce grain growth during Spark Plasma Sintering (SPS). High-energy planetary ball milling was performed on ZrB2 or HfB2 with 20vol% SiC powders for 24 and 48 hrs. The particle size distribution and crystal micro-strain were examined using Dynamic Light Scattering Technique and x-ray diffraction (XRD), respectively. XRD spectra were analyzed using Williamson-Hall plots to estimate the crystal micro-strain. The particle size decreased, and the crystal micro-strain increased with the increasing ball milling time. The SPS consolidation was performed at 32 MPa and 2,000°C. The SEM observation showed a tremendous decrease in SiC segregation and a reduction in grain size due to high energy ball milling of the precursor powders. Flexural strength of the SPS consolidated composites were studied using Four-Point Bend Beam test, and the micro-hardness was measured using Vickers micro-indenter with 1,000 gf load. Good correlation is observed in SPS consolidated ZrB2+SiC with increased micro-strain as the ball milling time increased: grain size decreased (from 9.7 to 3.2 μm), flexural strength (from 54 to 426 MPa) and micro-hardness (from 1528 to 1952 VHN) increased. The correlation is less evident in HfB2+SiC composites, especially in micro-hardness which showed a decrease with increasing ball milling time.

OBJECTIVES To investigate whether gender is associated with three recommended stages of the HIV care continuum and whether gender modifies known associations between level of alcohol use and HIV care among US veterans. DESIGN Retrospective cohort. METHODS Veterans Aging Cohort Study data were used to identify Veterans Health Administration (VA) patients with HIV and AUDIT-C alcohol screening from 1 February 2008 to 30 September 2014. Modified Poisson regression models estimated the relative risk and predicted prevalences of engagement in HIV care (documented CD4 cells/μl or viral load copies/ml lab values), ART treatment (at least one prescription), and viral suppression (HIV RNA

Tantalum carbide ceramics with high volume fractions of the ζ-Ta4C3 phase have been shown to exhibit high fracture strength and toughness as compared to those in absence of this phase. In this work, we investigated how microcracks propagated in this these high toughness ceramics using Knoop and Vickers microindentation. The Knoop indentations demonstrated that cracking preferentially occurred parallel to the lath structure in ζ-Ta4C3; however shorter cracks did form between the laths when a sufficient driving force was present. The resulting crack path was tortuous providing direct evidence for toughening through crack deflection; however, the microscale nature of the work cannot rule out crack bridging as a toughening mechanism as well. Plasticity is also observed under the indents, but is likely a result of the high confining pressures that occurred during indentation allowing for plastic flow.

Fishery catch projection models play a central role in fishery management, yet are underrepresented in the literature. A wide range of statistical approaches are employed for the task, including multiple regression models, autoregressive methods, different classes of generalized linear models, mixed model approaches and many others. However, the applicability of these statistical approaches can be limited in specific cases of complex fisheries. We developed a new catch projection model for quota-based fisheries on the West Coast of the U.S. to forecast annual catch and landings for a variety of groundfish species in the Northeast Pacific Ocean. The model projects total and landed catch of each species by individual vessel and for the entire fishing fleet, using a combination of weighted mean vessel attainment rates and historical catch rates, and generates uncertainty intervals. It demonstrated an ability to produce highly accurate predictions at both fleet (R 2 = 0.9847) and vessel levels (R 2 = 0.8447). The model framework contains much built-in versatility, is generalizable enough to serve a variety of quota based applications, and the approach can be tailored to other fisheries around the world. With the proliferation of quota based management of commercial fisheries, tools such as this one are increasingly useful for sustainable management of fishery resources.

Marine fish populations exist in a complex environment, with oceanographic and fisheries factors affecting their dynamics. It has been shown that life history characteristics of marine fish vary in space and time. We examined spatial variability in growth of eight groundfish species in the Northeast Pacific Ocean to identify shared spatial patterns and hypothesize about common mechanisms behind them. Growth parameters were estimated in different areas over the latitudinal range of the species, and several hypotheses were tested as to how these parameters vary along the US west coast. Clear differences in spatial growth variability emerged among the species examined. Shelf species exhibit the highest growth rate between Cape Blanco and Cape Mendocino, which may, in part, be attributed to area-specific upwelling patterns in the California Current ecosystem, when nutrient-rich deep water is brought to the surface south of Cape Blanco and is uniquely distributed throughout this area, providing favourable conditions for primary productivity. Slope species showed a cline in asymptotic size (L∞), with L∞ increasing from south to north. This cline, previously attributed to fishery removals, also fits a specific case of the widely described Bergmann’s rule, and we explore specific potential ecological mechanisms behind this relationship.

BACKGROUND Alcohol use influences HIV disease severity through multiple mechanisms. Whether HIV disease severity is sensitive to changes in alcohol use among people with HIV (PWH) is understudied. SETTING National Veterans Health Administration. METHODS Pairs of AUDIT-C screens within 9-15 months (February 1, 2008-September 30, 2014) were identified among PWH from the Veterans Aging Cohort Study (VACS). Initial and follow-up VACS Index 2.0 pairs obtained 0-270 days after initial and follow-up AUDIT-Cs, respectively, determined change in VACS Index 2.0, a composite HIV severity measure. Change in VACS Index 2.0 was regressed on AUDIT-C change scores (-12 to +12) adjusted for demographics, initial VACS Index 2.0, and days between VACS Index measures. RESULTS Among 23,297 PWH (76,202 observations), most had no (51%) or low-level (38%) alcohol use initially. Most (54%) had no subsequent change; 21% increased and 24% decreased drinking. Initial VACS Index 2.0 scores ranged from 0 to 134, change scores ranged from -65 to +73, with average improvement of 0.76 points (SD 9.48). AUDIT-C change was associated with VACS Index 2.0 change (P < 0.001). Among those with stable alcohol use (AUDIT-C change ≤ │1│ point), VACS Index 2.0 improvements ranged 0.36-0.60 points. For those with maximum AUDIT-C increase (change from 0 to 12), VACS Index 2.0 worsened 3.74 points (95% CI: -4.71 to -2.78); for those with maximum AUDIT-C decrease (change from 12 to 0), VACS Index 2.0 changed minimally [-0.60 (95% CI: -1.43 to 0.23)]. CONCLUSIONS In this national sample, improvement in HIV severity was generally greatest among those with stable alcohol use (primarily those with no use).

Key Points Question Among primary care patients, what is the prevalence of electronic health record documentation of medical cannabis use and health conditions for which cannabis use might have benefits and risks? Findings In this cross-sectional study of 185 565 patients, 2% had past-year medical cannabis use documented in their electronic health records. Among patients with documented medical cannabis use, 44.5% had documented health conditions for which cannabis use might confer benefits, and 54.5% had conditions for which it might confer risks. Meaning These findings suggest that primary care practitioners should be prepared to discuss potential risks as well as potential benefits of cannabis use with patients., Importance Many people use cannabis for medical reasons despite limited evidence of therapeutic benefit and potential risks. Little is known about medical practitioners’ documentation of medical cannabis use or clinical characteristics of patients with documented medical cannabis use. Objectives To estimate the prevalence of past-year medical cannabis use documented in electronic health records (EHRs) and to describe patients with EHR-documented medical cannabis use, EHR-documented cannabis use without evidence of medical use (other cannabis use), and no EHR-documented cannabis use. Design, Setting, and Participants This cross-sectional study assessed adult primary care patients who completed a cannabis screen during a visit between November 1, 2017, and October 31, 2018, at a large health system that conducts routine cannabis screening in a US state with legal medical and recreational cannabis use. Exposures Three mutually exclusive categories of EHR-documented cannabis use (medical, other, and no use) based on practitioner documentation of medical cannabis use in the EHR and patient report of past-year cannabis use at screening. Main Outcomes and Measures Health conditions for which cannabis use has potential benefits or risks were defined based on National Academies of Sciences, Engineering, and Medicine’s review. The adjusted prevalence of conditions diagnosed in the prior year were estimated across 3 categories of EHR-documented cannabis use with logistic regression. Results A total of 185 565 patients (mean [SD] age, 52.0 [18.1] years; 59% female, 73% White, 94% non-Hispanic, and 61% commercially insured) were screened for cannabis use in a primary care visit during the study period. Among these patients, 3551 (2%) had EHR-documented medical cannabis use, 36 599 (20%) had EHR-documented other cannabis use, and 145 415 (78%) had no documented cannabis use. Patients with medical cannabis use had a higher prevalence of health conditions for which cannabis has potential benefits (49.8%; 95% CI, 48.3%-51.3%) compared with patients with other cannabis use (39.9%; 95% CI, 39.4%-40.3%) or no cannabis use (40.0%; 95% CI, 39.8%-40.2%). In addition, patients with medical cannabis use had a higher prevalence of health conditions for which cannabis has potential risks (60.7%; 95% CI, 59.0%-62.3%) compared with patients with other cannabis use (50.5%; 95% CI, 50.0%-51.0%) or no cannabis use (42.7%; 95% CI, 42.4%-42.9%). Conclusions and Relevance In this cross-sectional study, primary care patients with documented medical cannabis use had a high prevalence of health conditions for which cannabis use has potential benefits, yet a higher prevalence of conditions with potential risks from cannabis use. These findings suggest that practitioners should be prepared to discuss potential risks and benefits of cannabis use with patients., This cross-sectional study describes the prevalence and clinical characteristics of primary care patients with cannabis use documented in their electronic health records.

Fisheries stock assessments rely heavily on historical catch information to understand how a stock responds to exploitation and make meaningful forecasts under alternative management and environmental scenarios. However, for many bycatch species historical removals are virtually unknown, as a large portion of the catch was discarded at sea. For example, historical discard of elasmobranch species such as skates and sharks have been reported as 95 percent of the total catch based on available data. The longnose skate is one the most abundant groundfishes on the continental slope of the U.S. Pacific Coast by biomass, and the most abundant skate species in the Northeast Pacific Ocean. We developed a method to estimate catch of longnose skate on the U.S. West Coast based on the catch of Dover sole, a co-occurring targeted species with which longnose skate is caught. This method allowed us to reconstruct historical longnose skate catches back to the beginning of the bottom trawl fisheries and improve stock assessment for this species. We also examined the impact of using our method versus other common methods of catch reconstruction to inform stock assessment models, and found that the target-based predictive method produced results that more accurately reflected the life history and typical stock dynamics of elasmobranch taxa. Our method is not limited to the specific case of longnose skate and could be easily adapted for other species and areas.

Researchers condemn the effects of news but have only recently turned their attention to determining the extent to which individuals engage with news. Within the context of online uncivil news, the current project investigates whether negativity always increases engagement with news. The results of two experiments demonstrate that civility in the news increased news engagement, especially compared to news with the most incivility. News articles that included multiple types of incivility and news articles that prompted individuals to perceive that an out-group political party was behaving uncivilly discouraged people from engaging with online news. The studies contribute theoretically to negativity bias and incivility research and signal that negativity does not always attract clicks.

We evaluated associations between levels of alcohol use and HIV care continuum components using national Veterans Aging Cohort Study data for all patients with HIV and AUDIT-C screening (2/1/2008-9/30/2014). Poisson regression models evaluated associations between alcohol use levels (non-drinking, low-, medium-, high-, and very high-level drinking) and: (1) engagement with care (documented CD4 cells/µl or viral load copies/ml labs), (2) ART treatment (≥ 1 prescription), and (3) viral suppression (HIV RNA

Background Alcohol use is risky for patients with hepatitis C virus (HCV) and/or human immunodeficiency virus (HIV) infection, but alcohol use disorder (AUD) treatment is underutilized in these populations. Comorbid drug use disorders (DUD) are common, but their influence on AUD treatment receipt is understudied. We evaluated the association between DUD and AUD treatment receipt in two national samples of patients with AUD, those with HIV and those with HCV, in the U.S. Veterans Health Administration. Methods Samples included patients with AUD and HCV and/or HIV among positive alcohol screens (AUDIT-C≥5) documented 10/01/09-5/30/13 in the national electronic health record. Poisson regression models estimated incidence rate ratios for receiving specialty treatment (stop codes) and pharmacotherapy (filled prescription for naltrexone, disulfiram, acamprosate, or topiramate) within 365 days of positive alcohol screening for patients with DUD versus those without. Models were clustered on patient and adjusted for potential confounders. Results Among 22,039 patients with HCV/AUD, 45.2% (N = 9,964) had DUD, which was associated with receiving specialty treatment [adjusted incidence rate ratio: 1.89 (95% confidence interval 1.82–1.96)] and pharmacotherapy [aIRR: 1.50 (1.37–1.65)]. Among 1,834 patients with HIV/AUD, 56.9% (N = 1,043) had DUD, which was associated with receiving specialty treatment [aIRR: 1.94 (1.68–2.24)], but not pharmacotherapy. Conclusions Rates of AUD treatment receipt among patients with AUD and HCV and/or HIV were low overall, but likelihood of treatment receipt was generally higher among those with comorbid DUD. Future research should investigate mechanisms underlying these associations, such as enhanced readiness for treatment or differential provider prescribing or referral practices.

The CHOICE care management intervention did not improve drinking relative to usual care (UC) for patients with frequent heavy drinking at high risk of alcohol use disorders. Patients with alcohol dependence were hypothesized to benefit most. We conducted preplanned secondary analyses to test whether the CHOICE intervention improved drinking relative to UC among patients with and without baseline DSM-IV alcohol dependence. A total of 304 patients reporting frequent heavy drinking from 3 VA primary care clinics were randomized (stratified by DSM-IV alcohol dependence, sex, and site) to UC or the patient-centered, nurse-delivered, 12-month CHOICE care management intervention. Primary outcomes included percent heavy drinking days (%HDD) using 28-day timeline follow-back and a “good drinking outcome” (GDO)—abstaining or drinking below recommended limits and no alcohol-related symptoms on the Short Inventory of Problems at 12 months. Generalized estimating equation binomial regression models (clustered on provider) with interaction terms between dependence and intervention group were fit. At baseline, 59% of intervention and UC patients had DSM-IV alcohol dependence. Mean drinking outcomes improved for all subgroups. For participants with dependence, 12-month outcomes did not differ for intervention versus UC patients (%HDD 37% versus 38%, p = 0.76 and GDO 16% versus 16%, p = 0.77). For participants without dependence, %HDD did not differ between intervention (41%) and UC (31%) patients (p = 0.12), but the proportion with GDO was significantly higher among UC participants (26% versus 13%, p = 0.046). Neither outcome was significantly modified by dependence (interaction p values 0.19 for %HDD and 0.10 for GDO). Among participants with frequent heavy drinking, care management had no benefit relative to UC for patients with dependence, but UC may have had benefits for those without dependence. ClinicalTrials.gov NCT01400581.

Background: Older adults have high rates of obesity and are prone to chronic health conditions. These conditions are in part due to high rates of sedentary time (ST). As such, reducing ST could be an innovative strategy for improving health outcomes among obese older adults. To test this theory, we developed a novel, technology-enhanced intervention to reduce sitting time (I-STAND) and pilot tested it to assess the feasibility, acceptability, and preliminary effects of the intervention on ST and biometric outcomes. Objective: The current paper aims to describe the rationale, design, and methods of the I-STAND sitting reduction pilot trial. Methods: Older adults with obesity (n=60) were recruited from a large health care system and randomized to receive I-STAND or a healthy living intervention. I-STAND combined personal coaching with a technology-enhanced intervention (Jawbone UP band) to cue breaks from sitting. Participants completed self-report and biometric assessments at baseline and 3 months. Additional qualitative results were collected from a subset of I-STAND participants (n=22) to further inform the feasibility and acceptability of the interventions. The primary outcome was total hours of daily sitting time measured by the activPAL device. Secondary outcomes included sit-to-stand transitions, bouts of sitting longer than 30 minutes, physical function, blood pressure, fasting glucose, cholesterol, and depressive symptoms. Results: Study enrollment has ended and data processing is underway. Conclusions: Data from randomized trials on sitting reduction are needed to inform novel approaches to health promotion among older adults with obesity. Our trial will help fill this gap. The methods used in our study can guide future research on using technology-based devices to assess or prompt sedentary behavior reduction, or those interested in behavioral interventions targeting obese older adults with novel approaches Trial Registration: ClinicalTrials.gov: NCT02692560; https://clinicaltrials.gov/ct2/show/NCT02692560 (Archived by WebCite at http://www.webcitation.org/6wppLTWAl)