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There has been a global surge in adolescents' use of electronic nicotine delivery systems (vaping), cannabis (vaped and edible), and prescription opioids, collectively termed ECPO. The nature of ECPO use can make it difficult to detect due to few obvious immediate physical and behavioural signs, as well as subtle long-term effects that allow adolescents to transition from initial exploration into hazardous ECPO use without easy detection by care providers. Here, we address the nature of the presentation of ECPO use in adolescents (roughly age 13-18 years), including challenges in detecting use and related complications, which affect screening, prevention, and intervention. We begin by reviewing empirical data on these difficult to detect effects in adolescents, including acute effects at cellular and neural levels and long-term neurocognitive and developmental changes that precede outwardly detectable physical signs. We then provide concrete approaches for providers to screen for ECPO use in adolescents even in the absence of overt physical and behavioural symptoms. Finally, we conclude with direct practice recommendations for prevention and intervention.

Two-thirds of veteran suicides are attributable to firearm injury. Although half of veterans who die by suicide are seen in primary care settings in the month prior to death, little is known about how to promote firearm safety within primary care. Describe veterans’ perspectives on discussing firearms storage safety (FSS) during primary care visits, and identify key strategies for primary care teams to use in discussing FSS with veterans at elevated risk for suicide. Qualitative analysis of transcripts and notes from four veteran focus groups and from individual semi-structured interviews with six veterans. Altogether, 68 veterans participated. Three of the groups were associated with one Veterans Health Administration facility. Groups were diverse in age, service era, and gender. The goals of the focus groups and interviews were to assess acceptance of FSS discussions during primary care visits, identify facilitators and barriers to conducting FSS discussions, and identify strategies for primary care teams to use to effectively conduct FSS discussions. Transcripts and meeting notes were analyzed using a grounded theory approach. There was general acceptance of having FSS discussions in primary care. Yet, most veterans did not support direct questioning about firearm ownership, which may trigger fears of having firearms taken away or limit access to firearms. Participants recommended primary care teams provide rationale for FSS discussions and be prepared to provide information on legal consequences of disclosing firearm ownership. Strategies suggested for primary care staff also included using a personalized, caring, and conversational approach rather than highly scripted or checklist approach, engaging veterans in a non-judgmental manner, and conveying respect for veterans’ knowledge of firearms. Discussing FSS with veterans in primary care settings is a promising upstream approach that can complement other suicide prevention efforts, but must be conducted in a veteran-centric manner.

Cannabis use peaks during adolescence and emerging adulthood, and cannabis use disorder (CUD) is associated with a wide range of adverse outcomes. This is particularly pertinent in youth, because the developing brain may be more vulnerable to adverse effects of frequent cannabis use. Combining evidence-based psychosocial interventions with safe and effective pharmacotherapy is a potential avenue to improve youth outcomes, but we lack approved CUD pharmacotherapies. Here, we review new potential avenues for helping youth with CUD, with a particular focus on cannabinoid-based treatments. Evidence from placebo-controlled RCTs suggests synthetic delta-9-tetrahydrocannabinol (THC) decreases withdrawal symptoms, but not cannabis use, in adults with daily cannabis use/CUD, while findings regarding formulations containing THC combined with cannabidiol (CBD) are mixed. Preliminary evidence from two placebo-controlled RCTs in adults with CUD suggests that both Fatty Acid Amide Hydrolase inhibitors and CBD can reduce cannabis use. However, larger trials are needed to strengthen the evidence. Findings from adults point to cannabinoid-based treatments as a potential strategy that should be examined in youth with CUD.

To examine the fit between core concepts of self-determination theory and patient experiences with health coaching, 18 participants at one large United States Veterans Affairs medical centre comple...

Objective To describe VHA primary care clinician and staff perspectives on conducting firearms storage safety (FSS) discussions in primary care, and to identify key approaches for primary care teams to facilitate FSS conversations. Method Qualitative analysis of transcripts and notes from focus groups with VA primary care staff and individual semi-structured interviews with primary care clinicians. One hundred-seven VHA primary care team members participated in one of four focus groups or individual semi-structured interviews (n = 5). Results FSS discussions are perceived as within the purview of primary care. Primary care staff also outlined five tools and processes needed to meaningfully implement FSS discussions in primary care: training on firearms and firearms culture; examining personal attitudes toward firearms; developing supplemental materials to normalize and support FSS discussions; increasing knowledge of firearms laws and regulations; and providing scripts to facilitate conversations. Conclusions Conducting FSS discussions in primary care settings is perceived as an acceptable practice, yet care teams identified barriers and suggestions for overcoming implementation challenges.

Background: Discussing safe storage of firearms, including access, during times of crisis with veterans in primary care settings may enhance suicide prevention efforts. However, veteran attitudes toward such discussions are not well understood. The goal of this study is to understand the perspectives of veterans on discussing firearms storage safety with staff during primary care visits. Methods: Individual semistructured interviews with veterans were conducted by telephone, qualitatively coded, and analyzed for themes. The sample was composed of veterans (n = 27) who had positive depression or post-traumatic stress disorder screens and who received care from Veterans Health Administration primary care team members trained to discuss firearms storage safety with patients. Results: Citing the urgent need to prevent veteran suicide, most veterans felt discussing firearms safety was acceptable and needed, even if discussions felt uncomfortable or they had concerns. Veterans identified the need for providers to be transparent in their purposes for asking about firearms and to respect veterans9 unique relationships with firearms. Discussion: Conducting firearms safety discussions in a primary care setting with veterans who are at elevated risk for suicide is acceptable to veterans when a respectful, veteran-centered, and transparent approach is used.

Emerging adulthood (EA; ages 18–25) is characterized by socioemotional and neurodevelopmental challenges. Cannabis is a widely used substance among EAs, and hazardous use may increase risk for sustained use patterns and related health consequences. Research shows differential increases in hazardous use by objective as well as subjective measures of social inequality, with more concerning trajectories for youth with greater experiences of social inequality. Learning how to flexibly monitor and modify emotions in proactive ways (i.e., emotion regulation) is a central developmental task navigated during the EA window. Challenges to and with emotion regulation processes can contribute to the emergence of mental health symptoms during EA, including hazardous cannabis use. In this perspective, we highlight emotion dysregulation and social inequality as two critical factors that interact to either buffer against or exacerbate cannabis use during the EA period, noting critical gaps in the literature that merit additional research. We recommend novel methods and longitudinal designs to help clarify how dynamic cognition-emotion interplay predicts trajectories of negative emotional experiences and cannabis use in EA.

The OpenNotes initiative encourages health care systems to provide patients online access to clinical notes. Some individuals have expressed concerns about use of OpenNotes in mental health care. This study evaluated changes in mental health clinicians' attitudes and communications with patients after participation in a Web-based course designed to reduce potential for unintended consequences and enhance likelihood of positive outcomes of OpenNotes.All 251 mental health clinicians (physicians, nurse practitioners, psychologists, and social workers) of a large U.S. Department of Veterans Affairs facility were invited to participate. Clinicians completed surveys at baseline and 3 months after course participation. Ten items were examined that addressed clinicians' concerns and communication behaviors with patients. Mixed-effects models with repeated measures were used to compare pre-post data.Of the 251 clinicians, 141 (56%) completed baseline surveys, and 113 (80%) completed baseline and postcourse surveys. Of the 141 clinicians, 63% were female, 46% were social workers, 34% were psychologists, 16% were psychiatrists, and 4% were nurse practitioners. In final adjusted models, pre-post item scores indicated significant increases in clinicians' ability to communicate with and educate patients (p.01) and in the frequency with which clinicians educated patients about OpenNotes access (p.001), advised patients to access and read notes (p.01), and asked patients about questions or concerns they have with notes (p=.04). There was also a significant reduction in clinicians' worry about negative consequences (p=.05).A Web-based course for mental health clinicians on use of OpenNotes resulted in self-reported improvements in some concerns and in aspects of patient-clinician communication.