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Background. Etiologic research on complex disorders including alcohol dependence requires informative phenotypes. Information is lost when categorical variables represent inherently dimensional conditions. We investigated the validity of DSM-IV alcohol dependence as a dimensional phenotype by examining evidence for linearity and thresholds in associations with validating variables.Method. Current drinkers in the National Longitudinal Alcohol Epidemiologic Survey (NLAES) (n=18352) and National Epidemiologic Survey of Alcohol and Related Conditions (NESARC) (n=20836) were analyzed. Validating variables included family alcoholism, early-onset drinking, and alcohol treatment. Logistic or Poisson regression modeled the relationships between the validating variables and dependence in categorical, dimensional or hybrid forms, with severity defined as number of current DSM-IV alcohol-dependence criteria. Wald tests assessed differences between models.Results. No evidence was found for boundaries between categories. Instead, the association of alcohol dependence with the validating variables generally increased in linear fashion as the number of alcohol-dependence criteria increased. For NLAES models of family alcoholism, early-onset drinking and treatment, the lines had zero intercepts, with slopes of 0.18, 0.27, 0.70, respectively. For NESARC models of family history and early-onset drinking, the zero intercept lines had slopes of 0.20, 0.33, and 0.77, respectively. Wald tests indicated that models representing alcohol dependence as a dimensional linear predictor best described the association between dependence criteria and the validating variables.Conclusions. The sample sizes allowed strong tests. Diagnoses are necessary for clinical decision-making, but a dimensional alcohol-dependence indicator should provide more information for research purposes. [ABSTRACT FROM AUTHOR]

OBJECTIVE: For patients who are actively using a substance and experience psychotic symptoms, determining whether the psychotic symptoms are due to a primary psychotic disorder or are substance induced is challenging, especially in emergency departments, where historical information is limited. This study examined the accuracy and subsequent treatment implications of emergency department diagnoses among substance-using patients who were having their first psychotic episode. METHODS: Emergency department diagnoses for 302 patients were compared with best-estimate longitudinal diagnoses (BELDs) based on research assessments at three time points (baseline, six months, and 12 months). RESULTS: Of the 223 patients whose symptoms were diagnosed in the emergency department as a primary psychotic disorder, one-quarter were determined by the BELD to have substance-induced psychosis or no psychosis. Overall, the diagnostic agreement was only fair (kappa=.32). Patients with an emergency department diagnosis of primary psychosis were significantly more likely than those with an emergency department diagnosis of substance-induced psychosis to be hospitalized, started on antipsychotic medication, and referred to mental health services instead of treatment for substance use (p<.001). Patients given an emergency department diagnosis of primary psychosis who were found by the BELD to have substance-induced psychosis or no psychosis were significantly more likely to be treated for a psychotic disorder rather than for substance-induced psychosis (p<.001) CONCLUSIONS: Clinicians in psychiatric emergency departments appear to have a tendency to attribute psychotic symptoms to a primary psychotic disorder rather than to concurrent substance use. Given that the diagnosis has significant implications for future management, it is important to improve diagnostic approaches in the emergency department. [ABSTRACT FROM AUTHOR]

Background. To examine sex differences in DSM-IV subclinical and pathological gambling in nationally representative data of the US population.Method. Data come from a large (n=43093) representative sample of the adult US population.Results. The lifetime prevalence rate of DSM-IV pathological gambling was 0.64% (95% CI 0.50-0.78) for men and 0.23% (95% CI 0.17-0.29) for women, whereas the lifetime prevalence of subclinical pathological gambling was 6.79% (95% CI 6.32-7.26) for men and 3.26% (95% CI 2.93-3.59) for women. For subclinical pathological gambling, men were significantly (p<0.01) more likely than women to have smoked more than two packs of cigarettes a day, to be classified as heavy drinkers and to have lifetime diagnoses of alcohol and drug use disorders. Women with subclinical and pathological gambling were significantly more likely than men to have lifetime mood and anxiety disorders. With respect to pathological gambling, women had later ages of onset of the disorder, and were significantly more likely than men to report gambling to relieve depressed mood and to prefer casino gambling. Rates of treatment-seeking for DSM-IV pathological gambling were low for both men and women.Conclusions. There are important sex differences in the prevalence, symptom pattern, sociodemographic and clinical correlates and course of DSM-IV subclinical and pathological gambling. Results underscore the need to investigate sex differences in the social determinants, neurobiology and treatment response of DSM-IV subclinical and pathological gambling. [ABSTRACT FROM AUTHOR]

Background. This study addressed the prevalences, correlates, co-morbidity and disability of DSM-IV generalized anxiety disorder (GAD) and other psychiatric disorders in a large national survey of the general population, the National Institute on Alcohol Abuse and Alcoholism's (NIAAA) National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). The study presents nationally representative data, for the first time, on prevalence, correlates, co-morbidity, and comparative disability of DSM-IV GAD.Method. Data are taken from a large (n=43093) representative sample of the adult USA population.Results. Prevalences of 12-month and lifetime GAD were 2·1% and 4·1%. Being female, middle-aged, widowed/separated/divorced, and low income increased risk, while being Asian, Hispanic, or Black decreased risk. GAD was highly co-morbid with substance use, and other anxiety, mood, and personality disorders. Co-morbidity in GAD was not substantially greater than for most other Axis I and II disorders. Disability and impairment in pure GAD were equivalent to pure mood disorders, but significantly greater than in pure substance use, and other anxiety and personality disorders. Individuals co-morbid for GAD and each mood disorder were more disabled than those with pure forms of GAD or each mood disorder. When co-morbid with GAD, nicotine dependence and other anxiety and personality disorders were not associated with increased disability over that associated with pure GAD, but GAD did show increased disability over that due to each of these disorders in pure form.Conclusions. Associations between GAD and Axis I and II disorders were strong and significant, with variation among specific disorders. Results strongly support GAD as an independent disorder with significant impairment and disability. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This study sought to test the relationships between relative body weight and clinical depression, suicide ideation, and suicide attempts in an adult US general population sample. METHODS: Respondents were 40,086 African American and White participants interviewed in a national survey. Outcome measures were past-year major depression, suicide ideation, and suicide attempts diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The primary predictor was relative body weight, treated both continuously (i.e., body mass index [BMI]) and categorically in logistic regression analyses. Covariates included age, income and education, disease status, and drug and alcohol use. RESULTS: Relative body weight was associated with major depression, suicide attempts, and suicide ideation, although relationships were different for men and women. Among women, increased BMI was associated with both major depression and suicide ideation. Among men, lower BMI was associated with major depression, suicide attempts, and suicide ideation. There were no racial differences. CONCLUSIONS: Differences in BMI, or weight status, were associated with the probability of past-year major depression, suicide attempts, and suicide ideation. Longitudinal studies are needed to differentiate the causal pathways and mechanisms linking physical and psychiatric conditions. [ABSTRACT FROM AUTHOR]

Background: Desire for death is not generally considered a harbinger of more severe suicidal behavior and is not routinely included in suicide research and assessment interviews. We aimed to compare desire for death and suicidal ideation as clinical markers for suicide attempts.Methods: Using data from two nationally representative surveys (n=42,862 and n=43,093 respectively), we examined whether desire for death predicts suicide attempts. We compared the odds ratio (OR) and "Number Needed to be Exposed for one additional person to be Harmed" [NNEH] for lifetime suicide attempts among those with desire for death but no suicidal ideation; those with suicidal ideation but no desire for death, and those with both desire for death and suicidal ideation, compared to those with neither desire for death nor suicidal ideation.Results: The risk for lifetime suicide attempt was similar among those with lifetime desire for death with no suicidal ideation and those with lifetime suicidal ideation with no desire for death. Respondents with both lifetime desire for death and suicidal ideation had the highest risk for lifetime suicide attempts.Limitations: Cross-sectional design and self-reported suicidal ideation/attempts are viewed as limitations of this study.Conclusions: Querying individuals on desire for death has the same value as assessing suicidal ideation to examine risk for suicide attempt. A combination of desire for death and suicidal ideation is the best predictor for suicide attempts. This is of high clinical relevance since we suggest that desire for death should be included as a potential clinical marker of suicidality in clinical assessments. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine changes in the prevalence of non-medical prescription drug use and DSM-IV non-medical prescription abuse and dependence in the United States between 1991-1992 and 2001-2002. METHOD: Comparison of the prevalence of past-year non-medical prescription drug use and drug use disorders in the total sample and among lifetime non-medical users in two large national surveys conducted 10 years apart. RESULTS: From 1991-1992 to 2001-2002, the prevalence of DSM-IV non-medical prescription drug use increased by 53%, from 1.5% to 2.3% (p<0.001), and the prevalence of drug use disorders increased by 67% from 0.3% to 0.5% (p<0.001). The conditional prevalence of a disorder among users increased numerically from 19.9% to 23.6%, but this increase was not statistically significant (p=0.15). CONCLUSIONS: There have been substantial increases in the prevalence of prescription drug non-medical use and prescription drug use disorders in the United States. Given the clinical utility of prescription drugs, urgent action is needed to find approaches that balance the need for access to these medications among those who need them, against their potential for abuse and dependence in subgroups of vulnerable individuals. [ABSTRACT FROM AUTHOR]

Background: Gender and sex can influence cannabis behaviors and consequences (Cannabis Use Disorder [CUD]). Research typically examines sex and gender independently. Gender analyses often exclude transgender and gender diverse (TGD) populations. The objectives of this study were to (a) replicate less frequent cannabis use among TGD young adults compared to cisgender counterparts (b) compare severity of CUD, and (c) examine the role of sex on cannabis outcomes. Method: Online survey participants between 18 and 34 ( N =1213) from the United States who reported past-week cannabis consumption provided information on cannabis practices and CUD from February to April 2022. Bivariate analyses explored gender differences across frequency (daily frequency across routes of administration [ROAs]; daily use of 2+ ROAs, use throughout the day) and CUD. Adjusted regression models provided model-estimated marginal probabilities and means to examine differences across four gender-by-sex categories (cisgender men: n =385; cisgender women: n =681; male-at-birth TGD: n =26; female-at-birth TGD: n =121). Benjamini-Hochberg adjustments (10% false discovery rate) were applied. Results: Among past-week consumers, female-at-birth TGD participants demonstrated lower probability of daily flower smoking compared to cisgender men (0.54 vs. 0.67). Cisgender men reported greater probability of daily concentrate vaping (0.55) compared to cisgender women (0.45) and female-at-birth TGD participants (0.27); they were also more likely to report daily use of 2+ ROAs (cisgender men: 0.51 vs. cisgender women: 0.39 and female at-birth TGD: 0.27). TGD participants reported greater CUD severity compared to cisgender counterparts, t (1096)=-3.69, p =0.002. Model-estimated means found lower severity among cisgender women compared to cisgender men and female-at-birth TGD participants. Stratified regression models support positive associations between daily cannabis use and CUD in both TGD in cisgender groups. Among cisgender participants, greater severity was predicted by male sex, younger age, and younger age of onset. Conclusions: The present study replicates and extends a prior finding that among past-week cannabis consumers, TGD young adults report less frequent use than cisgender counterparts. Despite this, TGD participants demonstrated greater severity of CUD. While analyses were limited by the small sample of male-at-birth TGD participants, the article highlights the importance of expanding sex- and gender-focused analyses. Future work is expanding efforts to target hard-to-reach consumers.

Background: 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: Data came from two national surveys conducted in 2001-2002 ( n  = 43,093) and 2012-2013 ( n  = 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: 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: 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.

Background and Aims: Amid escalating cannabis legalization and daily consumption in the United States (US), determining the risk of cannabis use disorder (CUD) and relevant consequences among daily consumers has become a public health priority. Understanding these risks requires valid assessment of the daily quantity of delta-9-tetrahydrocannabinol (THC) consumed and its relation to consequences. This study characterized daily cannabis consumption using a new method for estimating milligrams of THC (mgTHC), and examined the relationship between daily mgTHC and CUD severity in a large national sample of daily consumers., Design, Setting and Participants: US adult (aged 18+ years) daily cannabis consumers (n = 4134) completed a comprehensive online survey of cannabis consumption patterns (e.g. frequency, quantity, product types, potencies, administration methods) and Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) CUD criteria., Measurements: The primary exposure was past-week daily mgTHC consumption, calculated from survey responses to queries about product type, amount and potency consumed and including adjustments for puff size and loss of THC from specific methods of administration. The primary outcomes were (1) number of CUD criteria (range = 0-11) and (2) CUD severity categories: none, mild, moderate, severe., Findings: Median daily consumption was ~130 mgTHC, with substantial variability (25% ≤ 50 mg and 25% ≥ 290 mg). On average, participants endorsed 2.5 CUD criteria, and 65% met criteria for CUD (39% mild, 18% moderate, 8% severe). Greater daily mgTHC predicted higher CUD criteria count [beta log(mgTHC)  = 0.50, 95% confidence interval (CI) = 0.267-0.734] and higher odds of mild [log odds ratio (logOR) = 0.238, 95% CI = 0.184-0.292], moderate (logOR = 0.303, 95% CI = 0.232-0.374) or severe (logOR = 0.335, 95% CI = 0.236-0.435) CUD., Conclusions: Among daily consumers of cannabis, there appears to be a positive relationship between the daily quantity of cannabis consumed (measured in milligrams of delta-9-tetrahydrocannabinol) and both the risk and severity of cannabis use disorder., (© 2024 Society for the Study of Addiction.)

Background: U.S. state electronic prescription drug monitoring programs (PDMPs) are associated with reduced opioid dispensing among people with chronic pain and may impact use of other chronic pain treatments. In states with medical cannabis laws (MCLs), patients can use cannabis for chronic pain management, reducing their need for chronic-pain related treatment visits and moderating effects of PDMP laws., Objective: Given high rates of chronic pain among Medicaid enrollees, we examined associations between PDMP enactment in the presence or absence of MCL on chronic pain-related outpatient and emergency department (ED) visits., Design: We created annual cohorts of Medicaid enrollees with chronic pain diagnoses using national Medicaid claims data from 2002-2013 and 2016. Negative binomial hurdle models produced adjusted odds ratios (aOR) for the likelihood of any chronic pain-related outpatient or ED visit and incident rate ratios (IRR) for the rate of visits among patients with ≥ 1 visit., Participants: Medicaid enrollees aged 18-64 years with chronic pain (N = 4,878,462)., Main Measures: A 3-level state-year variable with the following categories: 1) no PDMP, 2) PDMP enactment in the absence of MCL, or 3) PDMP enactment in the presence of MCL. Healthcare codes for chronic pain-related outpatient and ED visits each year., Key Results: The sample was primarily female (67.2%), non-Hispanic White (51.2%), and ages 40-55 years (37.2%). Compared to no-PDMP states, PDMP enactment in the absence of MCL was not associated with chronic pain-related outpatient visits but PDMP enactment in the presence of MCL was associated with lower odds of chronic pain-related outpatient visits (aOR = 0.81, 95% CI:0.71-0.92). PDMP enactment was not associated with ED visits, irrespective of MCL., Conclusions: During a period of PDMP and MCL expansion, our findings suggest treatment shifts for persons with chronic pain away from outpatient settings, potentially related to increased use of cannabis for chronic pain management., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Aim: Standardized survey measures that capture diverse cannabis consumption patterns are needed to inform public health and policy. Our team is developing a flexible, personalized, low-burden survey item inventory to measure cannabis use patterns and estimate milligrams of THC (mgTHC) consumption in large samples. This study aimed to identify measurement gaps and analysis implications associated with an initial pool of candidate items that assessed use of cannabis flower and concentrate products (smoked and/or vaporized). Methods: Adult cannabis consumers ( n =4247) completed an online survey assessing cannabis use frequency, quantity, product types, product potencies (%THC), and methods of administration. Participants chose to report their consumption quantities using one of three units: "hits per day," "grams per week," or "joints per week." Respondents also indicated whether their past 7-day consumption pattern represented their typical pattern. Results: Eighty-one percent had used cannabis daily in the past week. Thirty-two percent, 53%, and 15% chose to report flower and concentrate consumption quantity in hits, grams, and joints, respectively. Approximately 80-90% of responses for the number of hits, grams, and joints consumed were less than the maximum response option-suggesting that response options captured the full range of potential cannabis consumption behaviors. Those who chose grams or joints units were generally more likely to endorse higher risk cannabis use (e.g., morning use, high %THC products) in the past week than those who chose the hits unit (adjusted Odds Ratio range: 1.2-3.9). Among those who reported that the past week represented their typical behavior (83%), past 30-day and past 7-day frequencies were highly correlated (Spearman's Rho=0.77)-supporting the feasibility of using lower burden "typical week" items to extrapolate patterns beyond a 1-week time frame. Conclusion: Results from this online convenience sample of frequent cannabis consumers suggest that the current items yield coherent and expected response patterns. Although additional testing is required, a standardized, flexible survey instrument for large-scale assessment of cannabis patterns and calculation of mgTHC seems within reach.

Background: Cannabis use disorder (CUD) treatment prevalence decreased in the US between 2002 and 2019, yet structural mechanisms for this decrease are poorly understood. We tested associations between cannabis laws becoming effective and self-reported CUD treatment., Methods: Restricted-use 2004-2019 National Surveys on Drug Use and Health included people ages 12+ classified as needing CUD treatment (i.e., past-year DSM-5-proxy CUD or last/current specialty treatment for cannabis). Time-varying indicators of medical cannabis laws (MCL) with/without cannabis dispensary provisions differentiated state-years before/after laws using effective dates. Multi-level logistic regressions with random state intercepts estimated individual- and state-adjusted CUD treatment odds by MCLs and model-based changes in specialty CUD treatment state-level prevalence. Secondary analyses tested associations between CUD treatment and MCL or recreational cannabis laws (RCL)., Results: Using a broad treatment need sample definition in 2004-2014, specialty CUD treatment prevalence decreased by 1.35 (95 % CI = -2.51, -0.18) points after MCL without dispensaries and by 2.15 points (95 % CI = -3.29, -1.00) after MCL with dispensaries provisions became effective, compared to before MCL. Among people with CUD in 2004-2014, specialty treatment decreased only in MCL states with dispensary provisions (aPD = -0.91, 95 % CI = -1.68, -0.13). MCL were not associated with CUD treatment use in 2015-2019. RCL were associated with lower CUD treatment among people classified as needing CUD treatment, but not among people with past-year CUD., Conclusions: Policy-related reductions in specialty CUD treatment were concentrated in states with cannabis dispensary provisions in 2004-2014, but not 2015-2019, and partly driven by reductions among people without past-year CUD. Other mechanisms (e.g., CUD symptom identification, criminal-legal referrals) could contribute to decreasing treatment trends., Competing Interests: Conflict of interest Dr. H. Samples has received consulting fees from the American Society of Addiction Medicine and The Pew Charitable Trusts; other authors report no potential conflicts of interest., (Copyright © 2024. Published by Elsevier B.V.)

Introduction: Quantification of consumption patterns of the primary psychoactive compounds in cannabis, which cause euphoria or intoxication, is sorely needed to identify potential risks and benefits of use and to provide meaningful safety information to the public. The diversity of products available, multiple methods of administration, and lack of labeling of products have made such quantification challenging. Our group is developing a survey instrument for estimating the quantity of delta 9-tetrahydrocannabinol (THC) consumed in population samples, which is flexible and incorporates individualized reports of patterns of consumption. This study provides an illustration of a procedure for translating self-reported consumption into milligrams of THC (mgTHC), which may serve as a working model for future quantification efforts. Methods: Social media advertising was leveraged to enroll 5627 adults who use cannabis into an online, anonymous survey study. Only those who used cannabis in the past 7 days, used flower or concentrate products, and who chose to report their quantity of use in hits per day or grams per week ( n =3211) were included in this report. Formulas were used to estimate mgTHC used per day, in hits per day or grams per week; potency (%THC); constants for estimating the amount of material consumed for each hit; and a method of administration efficiency constant to account for THC loss due to the administration method. Results: The estimate for mgTHC used per day was M =92.8 mg/day (SD=97.2 mg; 1st-3rd quartile range=25-132 mg). The estimated quantity of use was much lower for those reporting in hits ( M =43.7 mg, SD=43.8) than for those reporting in grams ( M =115.1 mg, SD=107.0). The estimated rate of binge use in the past week, arbitrarily defined as more than 50 mgTHC within any one daily time quadrant, was 6.8%, which increased to 29.3% if 25 mgTHC was used. Conclusions: The approach illustrated in this study goes beyond existing cannabis measures by asking participants to provide highly detailed estimates of their past 7-day use patterns and then applying a logical formula to translate this information into mgTHC. This initial procedure has limitations and lacks generalization; however, we hope this demonstration stimulates testing of similar approaches and relevant laboratory experiments that will enhance the validity of cannabis consumption estimation procedures.

Background: The Veterans Health Administration tracks urine drug tests (UDTs) among patients on long-term opioid therapy (LTOT) and recommends discussing the health effects of cannabis use., Objective: To determine the occurrence of cannabis-related discussions between providers and patients on LTOT during six months following UDT positive for cannabis, and examine factors associated with documenting cannabis use., Design: We identified patients prescribed LTOT with a UDT positive for cannabis in 2019. We developed a text-processing tool to extract discussions around cannabis use from their charts., Subjects: Twelve thousand seventy patients were included. Chart review was conducted on a random sample of 1,946 patients., Main Measures: The presence of a cannabis term in the chart suggesting documented cannabis use or cannabis-related discussions. Content of those discussions was extracted in a subset of patients. Logistic regression was used to examine the association between patient factors, including state of residence legal status, with documentation of cannabis use., Key Results: Among the 12,070 patients, 65.8% (N = 7,948) had a cannabis term, whereas 34.1% (N = 4,122) of patients lacked a cannabis term, suggesting that no documentation of cannabis use or discussion between provider and patient took place. Among the subset of patients who had a discussion documented, 47% related to cannabis use for medical reasons, 35% related to a discussion of VA policy or legal issues, and 17% related to a discussion specific to medical risks or harm reduction strategies. In adjusted analyses, residents of states with legalized recreational cannabis were less likely to have any cannabis-related discussion compared to patients in non-legal states [OR 0.73, 95% CI 0.64-0.82]., Conclusions: One-third of LTOT patients did not have documentation of cannabis use in the chart in the 6 months following a positive UDT for cannabis. Discussions related to the medical risks of cannabis use or harm reduction strategies were uncommon., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background: Cannabis use is increasing among middle-aged and older US adults, populations that are particularly vulnerable to the adverse effects of cannabis. Risks for adverse effects differ by cannabis use patterns, which have become increasingly heterogeneous. Nevertheless, little is known about age differences in such patterns. Objective: To investigate age differences in cannabis use patterns, comparing younger (age 18-49), middle-aged (age 50-64), and older adults (age ≥65). Methods: A total of 4,151 US adults with past 7-day cannabis consumption completed an online survey (35.1% male; 60.1% female; 4.8% identified as "other"). Regression models examined age differences in cannabis use patterns. Results: Compared to younger adults, middle-aged and older adults were more likely to consume cannabis during evening hours (50-64: adjusted odds ratio [aOR] = 2.98, 95% CI 2.24-3.96; ≥65: aOR = 4.23, 95 CI 2.82-6.35); by only one method (50-64: aOR = 1.67, 95% CI 1.34-2.09; ≥65: aOR = 3.38, 95 CI 2.24-5.09); primarily by smoking as the only method (50-64: aOR = 1.52, 95% CI 1.29-1.78; ≥65: aOR = 2.12, 95 CI 1.64-2.74); but less likely to consume concentrated cannabis products (concentrates) with extremely high %THC (50-64: aOR = 0.71, 95% CI 0.54-0.93; ≥65: aOR = 0.30, 95 CI 0.16-0.55). Age differences in cannabis use patterns were also observed between middle-aged and older adults. Conclusion: Findings suggest that middle-aged and older adults may engage in less risky cannabis use patterns compared to younger groups (e.g. lower likelihood of consuming highly potent concentrates). However, findings also underscore the importance of recognizing risks unique to these older demographics, such as smoking-related health events. Consequently, prevention strategies targeting such use patterns are needed.

Objective: Cannabis use is associated with suicide-related outcomes in both adolescents and adults, and may be increasing amid shifting cannabis policies. However, little is known about the impact of medical marijuana legalization (MML) and recreational marijuana legalization (RML) policies on youth suicide. Using 20 years of national data, we examined associations between MML, RML, and suicide-related mortality among US individuals aged 12 to 25 years, and assessed whether they varied based on age and sex., Method: Suicide deaths (N = 113,512) from the 2000-2019 National Vital Statistics System Multiple Cause of Death files for age groups 12 to 13, 14 to 16, 17 to 19, 20 to 22, and 23 to 25 years were examined in relation to time-varying cannabis law status using a staggered adoption difference-in-difference (DiD) approach with a negative binomial regression to determine associations between MML, RML, and suicide rates, controlling for individual- and state-level covariates and accounting for the varying effective dates of MML and RML by state., Results: The overall unadjusted annual suicide rate was 10.93/100,000, varying from 9.76 (states without marijuana laws (ML)) to 12.78 (MML states) to 16.68 (RML states). In multivariable analysis, both MML (incidence rate ratio [IRR] = 1.10, 95% CI: 1.05-1.15) and RML (IRR = 1.16, 95% CI: 1.06-1.27) were associated with higher suicide rates among female youth compared to those in states without ML. Youth aged 14 to 16 years had higher rates of suicide in states with RML compared to states with MML (IRR = 1.14, 95% CI: 1.00-1.30) and states without ML (IRR = 1.09, 95% CI: 1.00-1.20). Findings were consistent across sensitivity analyses., Conclusion: MML and RML were associated with increased suicide-related mortality in female youth and 14- to- 16-year-old individuals of both sexes. Mechanisms through which cannabis policies are related to increased youth suicide warrant further study and should inform legislative reform., (Copyright © 2023 American Academy of Child and Adolescent Psychiatry. Published by Elsevier Inc. All rights reserved.)

Objective: Heavy drinking poses serious risks to individuals with HIV, hepatitis C virus (HCV), and especially HIV/HCV coinfection. We adapted the National Institute on Alcohol Abuse and Alcoholism Clinician's Guide to address HIV/HCV coinfection and paired this with the "HealthCall" smartphone app to create an intervention tailored to HIV/HCV. After formative work and pretesting with HIV/HCV coinfected heavy drinkers, we conducted a pilot trial to determine potential of this new intervention for decreasing drinking., Method: A sample of 31 HIV/HCV coinfected heavy drinkers were randomly assigned to either intervention ( n = 16) or control ( n = 15; psychoeducation and brief advice) conditions. All participants completed a 60-day program consisting of approximately 25-minute-long baseline sessions and brief 5-10-minute booster sessions at 30 and 60 days, as well as an assessment-only follow-up at 90 days. Outcomes were measured using the Timeline Followback at baseline, 30, 60, and 90 days. Generalized linear models were used for analysis., Results: Intervention participants drank fewer mean drinks per drinking day at 60 days (incidence rate ratio [IRR] = 0.43, p = .03) and 90 days (IRR = 0.34, p < .01). Intervention participants also reported fewer drinking days at 90 days (mean difference = 34.5%; p < .01). Self-efficacy differed between groups during intervention ( p < .05)., Conclusions: Although our sample was small, our results suggested lower drinking among participants who received a modified Clinician's Guide intervention plus use of the smartphone app HealthCall, in comparison with education and advice alone. A larger study is indicated to further examine this brief, disseminable intervention for HIV/HCV coinfected drinkers.

Background and Aims: Benzodiazepines (BZDs) carry a risk for drug overdose and are prescribed alone or simultaneously with selective-serotonin reuptake inhibitors (SSRIs) for the treatment of anxiety and depression in young adults. We aimed to measure risks of drug overdose following BZD treatment initiation, and simultaneous BZD and SSRI initiation, compared with SSRI treatment alone in young adults with depression or anxiety., Design, Setting, Participants: The cohort study used administrative databases covering privately (MarketScan, 1/1/2009-12/31/2018) and publicly (Medicaid, 1/1/2015-12/31/2016) insured young adults (18-29 years) in the United States. Those with depression or anxiety diagnoses newly initiating BZD or SSRI treatment (without BZD or SSRI prescriptions in prior year) were included. Simultaneous "BZD + SSRI" initiation was defined as starting BZD and SSRI treatment on the same day. The cohorts included 604 664 privately insured young adults (BZD = 22%, BZD + SSRI = 10%, SSRI = 68%) and 110 493 publicly insured young adults (BZD = 23%, BZD + SSRI = 5%, SSRI = 72%)., Measurements: Incident medically treated drug overdose events were identified from emergency department and inpatient encounters (ICD poisoning codes) within 6 months of treatment initiation. Crude and propensity-score adjusted cumulative incidence and hazard ratios (HR) were estimated. Sub-analyses evaluated drug overdose intent., Findings: Adjusted HRs of drug overdose for BZD vs. SSRI treatment was 1.36 (95% confidence interval [CI]:1.23-1.51) in privately and 1.59 (95%CI:1.37-1.83) in publicly insured young adults. The adjusted HRs of drug overdose for BZD + SSRI treatment vs. SSRI treatment were 1.99 (95%CI:1.77-2.25) in privately and 1.98 (95%CI:1.47-2.68) in publicly insured young adults., Conclusions: Among young adults in the United States, initiating benzodiazepine treatment for anxiety and depression, alone or simultaneously with selective-serotonin reuptake inhibitors (SSRI), appears to have an increased risk of medically treated drug overdose compared with SSRI treatment alone. These associations were observed in publicly and privately insured individuals., (© 2023 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Objective: Cannabis use disorder diagnoses are increasing among U.S. adults and are more prevalent among people with comorbid psychiatric disorders. Recent changes in cannabis laws, increasing cannabis availability, and higher-potency cannabis may have placed people with cannabis use and psychiatric disorders at disproportionately increasing risk for cannabis use disorder. The authors used Veterans Health Administration (VHA) data to examine whether trends in cannabis use disorder prevalence among VHA patients differ by whether they have psychiatric disorders., Methods: VHA electronic health records from 2005 to 2019 (N range, 4,332,165-5,657,277) were used to identify overall and age-group-specific (<35, 35-64, and ≥65 years) trends in prevalence of cannabis use disorder diagnoses among patients with depressive, anxiety, posttraumatic stress, bipolar, or psychotic spectrum disorders and to compare these to corresponding trends among patients without any of these disorders. Given transitions in ICD coding, differences in trends were tested within two periods: 2005-2014 (ICD-9-CM) and 2016-2019 (ICD-10-CM)., Results: Greater increases in prevalence of cannabis use disorder diagnoses were observed among patients with psychiatric disorders compared to those without (difference in prevalence change, 2005-2014: 1.91%, 95% CI=1.87-1.96; 2016-2019: 0.34%, 95% CI=0.29-0.38). Disproportionate increases in cannabis use disorder prevalence among patients with psychiatric disorders were greatest among those under age 35 between 2005 and 2014, and among those age 65 or older between 2016 and 2019. Among patients with psychiatric disorders, the greatest increases in cannabis use disorder prevalences were observed among those with bipolar and psychotic spectrum disorders., Conclusions: The findings highlight disproportionately increasing disparities in risk of cannabis use disorder among VHA patients with common psychiatric disorders. Greater public health and clinical efforts are needed to monitor, prevent, and treat cannabis use disorder in this population., Competing Interests: Dr. Saxon receives royalties from UpToDate. Dr. Hasin has received support from Syneos Health.The other authors report no financial relationships with commercial interests.

LGBT+ adults demonstrate greater cannabis-related problems (e.g., Cannabis Use Disorder [CUD]) compared to non-LGBT+ counterparts. No study has explored age-related disparities in cannabis problems across the adult lifespan, nor have studies identified specific CUD criteria that contribute to elevated CUD among LGBT+ adults. The purpose of this study was to examine associations between LGBT+ identity and age with endorsement of CUD criteria in a sample of regular cannabis consumers. An online sample of N = 4334 (25.1% LGBT+) adults aged 18-64 residing in the U.S. completed an online survey about cannabis use behaviors and CUD diagnostic criteria. Bivariate contrasts revealed significantly greater CUD criteria endorsement among LGBT+ respondents, largely driven by differences at younger ages. However, this effect disappeared in the majority of adjusted logistic regression models. LGBT+ identity was associated with greater probability of use in larger amounts (adjOR = 2.10, 95% CI: 1.22-3.60) and use despite physical/mental health problems (adjOR = 2.51, 95% CI:1.23-5.03). No age*LGBT+ identity interactions were detected. Plotted trends depict more pronounced disparities in outcomes among LGBT+ adults under 35 years. Several potential risk and protective factors including employment, education, and reasons for use were identified. There were age-related differences in these characteristics among LGBT+ and non-LGBT+ respondents. Initial findings highlight the need for LGBT+ research examining trends in health outcomes and sociodemographic and cannabis characteristics across the lifespan. The study also provides a substantive contribution regarding specific cannabis-related problems that young LGBT+ cannabis consumers may be more likely to endorse than their non-LGBT+ counterparts., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Importance: Renewed interest in the clinical potential of hallucinogens may lead people with depression to a generally more positive view of the use of lysergic acid diethylamide (LSD). Therefore, past-year LSD use among people with depression may be increasing in prevalence., Objective: To assess time trends in the prevalence of past-year nonmedical LSD use by past-year major depression status and the variation in this association by sociodemographic characteristics., Design, Setting, and Participants: This survey study used pooled publicly available data from 478 492 adults aged 18 years or older who were administered the National Survey on Drug Use and Health from 2008 through 2019. Statistical analysis was conducted from December 2022 to June 2023., Main Outcome and Measures: Past-year major depression diagnoses per criteria from the DSM-IV were analyzed. Logistic regression models examined whether time trends in past-year nonmedical LSD use differed between adults with vs without past-year depression, adjusting for sociodemographic characteristics. Secondary analyses examined whether the trends in LSD use by depression status differed between sociodemographic subgroups., Results: The analytic sample included 478 492 adults, of whom 51.8% were female, 56.1% were younger than 50 years, 11.7% were Black, 15.1% were Hispanic, 65.8% were White, and 7.5% were another race. Weighted interview response rates ranged from 64.9% to 75.6% during the study time frame. From 2008 to 2019, past-year use of LSD increased significantly more among adults with major depression (2008 prevalence, 0.5%; 2019 prevalence, 1.8%; prevalence difference [PD], 1.3% [95% CI, 1.0%-1.6%]) compared with adults without major depression (2008 prevalence, 0.2%; 2019 prevalence, 0.8%; PD, 0.6% [95% CI, 0.5%-0.7%]) (difference in difference, 0.8% [95% CI, 0.5%-1.1%]). This difference was particularly pronounced among young adults aged 34 years or younger (PD among those aged 18-25 years with depression, 3.3% [95% CI, 2.5%-4.2%]; PD among those aged 26-34 years with depression, 2.7% [95% CI, 1.6%-3.8%]) and individuals with incomes less than $75 000 per year (PD among those with income <$20 000, 1.9% [95% CI, 1.3%-2.6%]; PD among those with income $20 000-$49 999, 1.5% [95% CI, 1.0%-2.1%]; PD among those with income $50 000-$74 999, 1.3% [95% CI, 0.7%-2.0%])., Conclusions and Relevance: This study suggests that, from 2008 to 2019, there was a disproportionate increase in the prevalence of past-year LSD use among US adults with past-year depression. Among those with depression, this increase was particularly strong among younger adults and those with lower household incomes. Among individuals with depression who also report LSD use, clinicians should discuss potential strategies for mitigating harm and maximizing benefits in medically unsupervised settings.

Background: Common adolescent psychiatric symptoms cluster into two dominant domains: internalizing and externalizing. Both domains are linked to self-esteem, which serves as a protective factor against a wide range of internalizing and externalizing problems. This study examined trends in US adolescents' self-esteem and externalizing symptoms, and their correlation, by sex and patterns of time use., Methods: Using Monitoring the Future data ( N = 338 896 adolescents, grades:8/10/12, years:1991-2020), we generated six patterns of time use using latent profile analysis with 17 behavior items (e.g. sports participation, parties, paid work). Groups were differentiated by high/low engagement in sports and either paid work or high/low peer socialization. Within each group, we mapped annual, sex-stratified means of (and correlation between) self-esteem and externalizing factors. We also examined past-decade rates of change for factor means using linear regression and mapped proportions with top-quartile levels of poor self-esteem, externalizing symptoms, or both., Results: We found consistent increases in poor self-esteem, decreases in externalizing symptoms, and a positive correlation between the two across nearly all activity groups. We also identified a relatively constant proportion of those with high levels of both in every group. Increases in poor self-esteem were most pronounced for female adolescents with low levels of socializing, among whom externalizing symptoms also increased., Conclusions: Rising trends in poor self-esteem are consistent across time use groups, as is the existence of a group facing poor self-esteem and externalizing symptoms. Effective interventions for adolescents' poor self-esteem/co-occurring symptoms are needed broadly, but especially among female adolescents with low peer socialization.

Background: Black cisgender gay, bisexual, and other sexual minority men (SMM) and transgender women (TW) continue to be heavily affected by HIV. Further research is needed to better understand HIV prevention and care outcomes in this population. In particular, there is a need for research examining the impact of substance use and sleep health on HIV prevention and treatment outcomes among Black SMM and TW., Objective: This paper outlines the study methods being used in the recently launched follow-up study to the Neighborhoods and Networks (N2) study, which we refer to as N2 Part 2 (N2P2). N2P2 aims to address this gap in the literature, build off the findings of the original N2 study, and identify socioenvironmental determinants of health, including whether neighborhood and network factors mediate and moderate these relationships., Methods: Building on the N2 cohort study in Chicago from 2018 to 2022, N2P2 used a prospective longitudinal cohort design and an observational-implementation hybrid approach. With sustained high levels of community engagement, we aim to recruit a new sample of 600 Black SMM and TW participants residing in the Chicago metropolitan statistical area. Participants are asked to participate in 3 study visits across an 18-month study period (1 visit every 9 months). Four different forms of data are collected per wave: (1) an in-person survey, (2) biological specimen collection, (3) a daily remote ecological momentary assessment for 14 days after each study visit, and (4) data from electronic health records. These forms of data collection continue to assess neighborhood and network factors and specifically explore substance use, sleep, immune function, obesity, and the implementation of potential interventions that address relevant constructs (eg, alcohol use and pre-exposure prophylaxis adherence)., Results: The N2P2 study was funded in August 2021 by the National Institute of Drug Abuse (R01DA054553 and R21DA053156) and National Heart, Lung, and Blood Institute (R01HL160325). This study was launched in November 2022. Recruitment and enrollment for the first wave of data collection are currently ongoing., Conclusions: The N2P2 study is applying innovative methods to comprehensively explore the impacts of substance use and sleep health on HIV-related outcomes among an HIV status-neutral cohort of Black SMM and TW in Chicago. This study is applying an observational-implementation hybrid design to help us achieve findings that support rapid translation, a critical priority among populations such as Black SMM and TW that experience long-standing inequities with regard to HIV and other health-related outcomes. N2P2 will directly build off the findings that have resulted from the original N2 study among Black SMM and TW in Chicago. These findings provide a better understanding of multilevel (eg, individual, network, and neighborhood) factors that contribute to HIV-related outcomes and viral suppression among Black SMM and TW., International Registered Report Identifier (irrid): DERR1-10.2196/48548., (©Justin R Knox, Brett Dolotina, Tyrone Moline, Isabella Matthews, Mainza Durrell, Hillary Hanson, Ellen Almirol, Anna Hotton, Jade Pagkas-Bather, Yen-Tyng Chen, Devin English, Jennifer Manuzak, Joseph E Rower, Caleb Miles, Brett Millar, Girardin Jean-Louis, H Jonathon Rendina, Silvia S Martins, Christian Grov, Deborah S Hasin, Adam W Carrico, Steve Shoptaw, John A Schneider, Dustin T Duncan. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 01.12.2023.)

Objective: The COVID-19 pandemic contributed to healthcare disruptions for patients with chronic pain. Following initial disruptions, national policies were enacted to expand access to long-term opioid therapy (LTOT) for chronic pain and opioid use disorder (OUD) treatment services, which may have modified risk of opioid overdose. We examined associations between LTOT and/or OUD with fatal and non-fatal opioid overdoses, and whether the pandemic moderated overdose risk in these groups., Methods: We analyzed New York State Medicaid claims data (3/1/2019-12/31/20) of patients with chronic pain (N = 236,391). We used generalized estimating equations models to assess associations between LTOT and/or OUD (neither LTOT or OUD [ref], LTOT only, OUD only, and LTOT and OUD) and the pandemic (03/2020-12/2020) with opioid overdose., Results: The pandemic did not significantly (ns) affect opioid overdose among patients with LTOT and/or OUD. While patients with LTOT (vs. no LTOT) had a slight increase in opioid overdose during the pandemic (pre-pandemic: aOR:1.65, 95% CI:1.05, 2.57; pandemic: aOR:2.43, CI:1.75,3.37, ns), patients with OUD had a slightly attenuated odds of overdose during the pandemic (pre-pandemic: aOR:5.65, CI:4.73, 6.75; pandemic: aOR:5.16, CI:4.33, 6.14, ns). Patients with both LTOT and OUD also experienced a slightly reduced odds of opioid overdose during the pandemic (pre-pandemic: aOR:5.82, CI:3.58, 9.44; pandemic: aOR:3.70, CI:2.11, 6.50, ns)., Conclusions: Findings demonstrated no significant effect of the pandemic on opioid overdose among people with chronic pain and LTOT and/or OUD, suggesting pandemic policies expanding access to chronic pain and OUD treatment services may have mitigated the risk of opioid overdose., Competing Interests: Declaration of Competing Interest This work was supported by the National Institute on Drug Abuse [grant numbers R01DA045872-01A1S2; T32DA031099] and the National Center for Complementary and Integrative Health [grant number 1K01AT012205-01A1]. DSH receives support from Syneos Health for an unrelated project on diagnosing opioid use disorder in patients with pain. Authors report no other conflicts of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The COVID-19 pandemic's impact on utilization of medications for opioid use disorder (MOUD) among patients with opioid use disorder (OUD) and chronic pain is unclear., Methods: We analyzed New York State (NYS) Medicaid claims from pre-pandemic (August 2019-February 2020) and pandemic (March 2020-December 2020) periods for beneficiaries with and without chronic pain. We calculated monthly proportions of patients with OUD diagnoses in 6-month-lookback windows utilizing MOUD and proportions of treatment-naïve patients initiating MOUD. We used interrupted time series to assess changes in MOUD utilization and initiation rates by medication type and by race/ethnicity., Results: Among 20,785 patients with OUD and chronic pain, 49.3% utilized MOUD (versus 60.3% without chronic pain). The pandemic did not affect utilization in either group but briefly disrupted initiation among patients with chronic pain (β=-0.009; 95% CI [-0.015, -0.002]). Overall MOUD utilization was not affected by the pandemic for any race/ethnicity but opioid treatment program (OTP) utilization was briefly disrupted for non-Hispanic Black individuals (β=-0.007 [-0.013, -0.001]). The pandemic disrupted overall MOUD initiation in non-Hispanic Black (β=-0.007 [-0.012, -0.002]) and Hispanic individuals (β=-0.010 [-0.019, -0.001])., Conclusions: Adults with chronic pain who were enrolled in NYS Medicaid before the COVID-19 pandemic had lower MOUD utilization than those without chronic pain. MOUD initiation was briefly disrupted, with disparities especially in racial/ethnic minority groups. Flexible MOUD policy initiatives may have maintained overall treatment utilization, but disparities in initiation and care continuity remain for patients with chronic pain, and particularly for racial/ethnic minoritized subgroups., Competing Interests: Declaration of Competing Interest The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the New York State Department of Health. Examples of analysis performed within this article are only examples. They should not be utilized in real-world analytic products. AP reports no conflicts of interest. KWM reports no conflicts of interest. DSH reports payments made to their institution for unrelated project work for Syneos Health on measurement of addiction in patients with chronic pain. KT reports no conflicts of interest. ZLM reports no conflicts of interest. VJ reports no conflicts of interest. TNT reports no conflicts of interest. JRP reports no conflicts of interest. SC reports no conflicts of interest. SSM reports no conflicts of interest. MC reports no conflicts of interest. NK receives compensation for expert testimony in ongoing opioid litigation., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objective: To assess whether chronic pain increases the risk of COVID-19 complications and whether opioid use disorder (OUD) differentiates this risk among New York State Medicaid beneficiaries., Design, Setting, and Subjects: This was a retrospective cohort study of New York State Medicaid claims data. We evaluated Medicaid claims from March 2019 through December 2020 to determine whether chronic pain increased the risk of COVID-19 emergency department (ED) visits, hospitalizations, and complications and whether this relationship differed by OUD status. We included beneficiaries 18-64 years of age with 10 months of prior enrollment. Patients with chronic pain were propensity score-matched to those without chronic pain on demographics, utilization, and comorbidities to control for confounders and were stratified by OUD. Complementary log-log regressions estimated hazard ratios (HRs) of COVID-19 ED visits and hospitalizations; logistic regressions estimated odds ratios (ORs) of hospital complications and readmissions within 0-30, 31-60, and 61-90 days., Results: Among 773 880 adults, chronic pain was associated with greater hazards of COVID-related ED visits (HR = 1.22 [95% CI: 1.16-1.29]) and hospitalizations (HR = 1.19 [95% CI: 1.12-1.27]). Patients with chronic pain and OUD had even greater hazards of hospitalization (HR = 1.25 [95% CI: 1.07-1.47]) and increased odds of hepatic- and cardiac-related events (OR = 1.74 [95% CI: 1.10-2.74])., Conclusions: Chronic pain increased the risk of COVID-19 ED visits and hospitalizations. Presence of OUD further increased the risk of COVID-19 hospitalizations and the odds of hepatic- and cardiac-related events. Results highlight intersecting risks among a vulnerable population and can inform tailored COVID-19 management., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: In the U.S. non-medical use of prescription opioids (NMOU) is prevalent and often accompanied by opioid withdrawal syndrome (OWS). OWS has not been studied using nationally representative data. Objectives: We examined the prevalence and clinical correlates of OWS among U.S. adults with NMOU. Methods: We used data from 36,309 U.S. adult participants in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III, 1,527 of whom reported past 12-month NMOU. Adjusted linear and logistic regression models examined associations between OWS and its clinical correlates, including psychiatric disorders, opioid use disorder (OUD; excluding the withdrawal criterion), medical conditions, and healthcare utilization among people with regular (i.e. ≥3 days/week) NMOU ( n  = 534). Results: Over half (50.4%) of the sample was male. Approximately 9% of people with NMOU met criteria for DSM-5 OWS, with greater prevalence of OWS (∼20%) among people with regular NMOU. Individuals with bipolar disorder, dysthymia, panic disorder, and borderline personality disorder had greater odds of OWS (aOR range = 2.71-4.63). People with OWS had lower mental health-related quality of life (β=-8.32, p  < .001). Individuals with OUD also had greater odds of OWS (aOR range = 26.02-27.77), an association that increased with more severe OUD. People using substance use-related healthcare services also had greater odds of OWS (aOR range = 6.93-7.69). Conclusion: OWS was prevalent among people with OUD and some psychiatric disorders. These findings support screening for OWS in people with NMOU and suggest that providing medication- assisted treatments and behavioral interventions could help to reduce the burden of withdrawal in this patient population.

Background: Researchers need accurate measurements of cannabis consumption quantities to assess risks and benefits. Survey methods for measuring cannabis flower and concentrate quantities remain underdeveloped. Objective: We examined "grams" and "hits" units for measuring flower and concentrate quantities, and calculating milligrams of THC (mgTHC). Methods: Online survey participants ( n  = 2,381) reported preferred unit (hits or grams), past-week hits and grams for each product, and product %THC. Quantile regression compared mgTHC between unit-preference subgroups. Hits-based mgTHC calculations assumed a universal grams-per-hit ratio (GPHR). To examine individualized GPHRs, we tested a "two-item approach," which divided total grams by total hits, and "one-item approach," which divided 0.5 grams by responses to the question: "How many total hits would it take you to finish 1/2 g of your [product] by [administration method]?" Results: Participants were primarily daily consumers (77%), 50% female sex, mean age 39.0 (SD 16.4), 85% White, 49% employed full-time. Compared to those who preferred the hits unit, those who preferred the grams unit reported consuming more hits and grams, higher %THC products, and consequently, larger median mgTHC (flower-hits mgTHC: 32 vs. 91 (95%CI: 52-67); flower-grams mgTHC: 27 vs. 113 (95%CI: 73-95); concentrate-hits mgTHC: 29 vs. 59 (95%CI: 15-43); concentrate-grams mgTHC: 61 vs. 129 (95%CI: 43-94)). "Two-item" and "one-item" approach GPHRs were similar and frequently 50% larger or smaller than the universal GPHR. Conclusion: Allowing respondents to choose "hits" or "grams" when reporting cannabis quantities does not compromise mgTHC estimates. A low-burden, one-item approach yields individualized "hit sizes" that may improve mgTHC estimates.

Background: Cannabis use disorder is associated with considerable comorbidity and impairment in functioning, and prevalence is increasing among adults with chronic pain. We aimed to assess the effect of introduction of medical cannabis laws (MCL) and recreational cannabis laws (RCL) on the increase in cannabis use disorder among patients in the US Veterans Health Administration (VHA)., Methods: Data from patients with one or more primary care, emergency, or mental health visit to the VHA in 2005-19 were analysed using 15 repeated cross-sectional VHA electronic health record datasets (ie, one dataset per year). Patients in hospice or palliative care were excluded. Patients were stratified as having chronic pain or not using an American Pain Society taxonomy of painful medical conditions. We used staggered-adoption difference-in-difference analyses to estimate the role of MCL and RCL enactment in the increases in prevalence of diagnosed cannabis use disorder and associations with presence of chronic pain, accounting for the year that state laws were enacted. We did this by fitting a linear binomial regression model stratified by pain, with time-varying cannabis law status, fixed effects for state, categorical year, time-varying state-level sociodemographic covariates, and patient covariates (age group [18-34 years, 35-64 years, and 65-75 years], sex, and race and ethnicity)., Findings: Between 2005 and 2019, 3 234 382-4 579 994 patients were included per year. Among patients without pain in 2005, 5·1% were female, mean age was 58·3 (SD 12·6) years, and 75·7%, 15·6%, and 3·6% were White, Black, and Hispanic or Latino, respectively. In 2019, 9·3% were female, mean age was 56·7 (SD 15·2) years, and 68·1%, 18·2%, and 6·5% were White, Black, and Hispanic or Latino, respectively. Among patients with pain in 2005, 7·1% were female, mean age was 57·2 (SD 11·4) years, and 74·0%, 17·8%, and 3·9% were White, Black, and Hispanic or Latino, respectively. In 2019, 12·4% were female, mean age was 57·2 (SD 13·8) years, and 65·3%, 21·9%, and 7·0% were White, Black, and Hispanic or Latino, respectively. Among patients with chronic pain, enacting MCL led to a 0·135% (95% CI 0·118-0·153) absolute increase in cannabis use disorder prevalence, with 8·4% of the total increase in MCL-enacting states attributable to MCL. Enacting RCL led to a 0·188% (0·160-0·217) absolute increase in cannabis use disorder prevalence, with 11·5% of the total increase in RCL-enacting states attributable to RCL. In patients without chronic pain, enacting MCL and RCL led to smaller absolute increases in cannabis use disorder prevalence (MCL: 0·037% [0·027-0·048], 5·7% attributable to MCL; RCL: 0·042% [0·023-0·060], 6·0% attributable to RCL). Overall, associations of MCL and RCL with cannabis use disorder were greater in patients with chronic pain than in patients without chronic pain., Interpretation: Increasing cannabis use disorder prevalence among patients with chronic pain following state legalisation is a public health concern, especially among older age groups. Given cannabis commercialisation and widespread public beliefs about its efficacy, clinical monitoring of cannabis use and discussion of the risk of cannabis use disorder among patients with chronic pain is warranted., Funding: NIDA grant R01DA048860, New York State Psychiatric Institute, and the VA Centers of Excellence in Substance Addiction Treatment and Education., Competing Interests: Declaration of interests DSH receives support from Syneos Health for an unrelated project. JLG reports consulting fees from Hoffman-La Roche, a patent pending (use of glecaprevir and pibrentasvir for the treatment of post-traumatic stress disorder), and participation on a data safety monitoring board or advisory board for National Institute of Mental Health (using machine learning to optimise user engagement and clinical response to digital mental health interventions). SSM serves on the Board of Directors for the College on Problems of Drug Dependence. AJS has received consulting fees from Indivior, travel support from Alkermes, research support from MedicaSafe, and royalties from UpTo-Date. KMK has served as an expert witness in litigation. All other authors declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objectives: This study aimed to examine trends in cannabis-positive urine drug screens (UDSs) among emergency department (ED) patients from 2008 to 2019 using data from the Veterans Health Administration (VHA) health care system, and whether these trends differed by age group (18-34, 35-64, and 65-75 years), sex, and race, and ethnicity., Method: VHA electronic health records from 2008 to 2019 were used to identify the percentage of unique VHA patients seen each year at an ED, received a UDS, and screened positive for cannabis. Trends in cannabis-positive UDS were examined by age, race and ethnicity, and sex within age groups., Results: Of the VHA ED patients with a UDS, the annual prevalence positive for cannabis increased from 16.42% in 2008 to 27.2% in 2019. The largest increases in cannabis-positive UDS were observed in the younger age groups. Male and female ED patients tested positive for cannabis at similar levels. Although the prevalence of cannabis-positive UDS was consistently highest among non-Hispanic Black patients, cannabis-positive UDS increased in all race and ethnicity groups., Discussion: The increasing prevalence of cannabis-positive UDS supports the validity of previously observed population-level increases in cannabis use and cannabis use disorder from survey and administrative records. Time trends via UDS results provide additional support that previously documented increases in self-reported cannabis use and disorder from surveys and claims data are not spuriously due to changes in patient willingness to report use as it becomes more legalized, or due to greater clinical attention over time., (Copyright © 2023 American Society of Addiction Medicine.)

Background: The screening, brief intervention, and referral to treatment (SBIRT) model is recommended by the U.S. Preventive Services Task Force to improve recognition of and intervention for unhealthy alcohol use. How SBIRT implementation differs by demographic characteristics is poorly understood., Methods: We analyzed data from the 2015-2019 National Survey on Drug Use and Health from respondents ≥18 years old who used an outpatient clinic and had at least one alcoholic drink within the past year. Respondents were grouped into one of three mutually exclusive groups: "no binge drinking or alcohol use disorder (AUD)," "binge drinking without AUD," or "AUD." Outcome variables were likelihood of screening, brief intervention (BI), referral to treatment (RT), and AUD treatment. The demographic predictors on which outcomes were regressed included gender, age, race and ethnicity, sexual orientation, insurance status, and history of military involvement. Consistent with SBIRT guidelines, the entire sample was included in the screening model; screened persons with either binge drinking without AUD or with AUD were included in the BI model; screened persons with AUD were included in the RT model, and persons referred to treatment with AUD were included in the AUD treatment model., Results: Analyses included 120,804 respondents. Women were more likely than men to be screened, but less likely to receive BI or RT. When referred to treatment, women were more likely than men to receive it. Persons aged ≥50 were least likely to be screened about alcohol, but most likely to receive BI, while persons aged 18-25 were least likely to receive BI or AUD treatment. Racial and ethnic minorities were less likely than White persons to be screened; Asians were less likely to receive RT, and Black persons were less likely to receive treatment than White persons. Persons identifying as gay, lesbian, or bisexual were equally as likely or more likely to receive SBIRT or AUD treatment as those identifying as heterosexual. Persons without insurance were less likely to be screened than those with insurance. Persons with a history of military involvement were more likely to be screened and receive BI and RT than persons who had not served in the military., Conclusions: Demographic disparities in SBIRT implementation exist. Addressing the sources of these disparities and minimizing attrition from care could improve outcomes for persons with unhealthy alcohol use., (© 2023 Research Society on Alcohol.)

Purpose of Review: Veterans are a large population that is disproportionately affected by various physical and mental health conditions. The primary aim of this review is to provide a concise overview of recent literature on the prevalence of cannabis use and cannabis use disorder (CUD) among US Veterans, and associations with mental and physical health conditions. We also addressed gaps in the literature by investigating associations between CUD and mental and physical health conditions in 2019 data from the Veterans Health Administration (VHA; N=5,657,277)., Recent Findings: In total, 25 studies were reviewed. In 2019, the prevalence of Veteran cannabis use ranged from 11.9%-18.7%. Cannabis use and CUD were associated with bipolar disorders, psychotic disorders, suicidality, pain conditions, and other substance use, but less consistently associated with depressive disorders, anxiety disorders, and posttraumatic stress disorder. Analyses of 2019 VHA data indicated that CUD was strongly associated with a broad array of physical and mental health conditions and mortality., Summary: Cannabis use and CUD are prevalent and highly comorbid with other conditions among US Veterans. Harm reduction methods tailored to these populations are needed.

Abstract: In the United States, cannabis is increasingly used to manage chronic pain. Veterans Health Administration (VHA) patients are disproportionately affected by pain and may use cannabis for symptom management. Because cannabis use increases the risk of cannabis use disorders (CUDs), we examined time trends in CUD among VHA patients with and without chronic pain, and whether these trends differed by age. From VHA electronic health records from 2005 to 2019 (∼4.3-5.6 million patients yearly), we extracted diagnoses of CUD and chronic pain conditions ( International Classification of Diseases [ ICD ]- 9-CM , 2005-2014; ICD-10-CM , 2016-2019). Differential trends in CUD prevalence overall and age-stratified (<35, 35-64, or ≥65) were assessed by any chronic pain and number of pain conditions (0, 1, or ≥2). From 2005 to 2014, the prevalence of CUD among patients with any chronic pain increased significantly more (1.11%-2.56%) than those without pain (0.70%-1.26%). Cannabis use disorder prevalence increased significantly more among patients with chronic pain across all age groups and was highest among those with ≥2 pain conditions. From 2016 to 2019, CUD prevalence among patients age ≥65 with chronic pain increased significantly more (0.63%-1.01%) than those without chronic pain (0.28%-0.47%) and was highest among those with ≥2 pain conditions. Over time, CUD prevalence has increased more among VHA patients with chronic pain than other VHA patients, with the highest increase among those age ≥65. Clinicians should monitor symptoms of CUD among VHA patients and others with chronic pain who use cannabis, and consider noncannabis therapies, particularly because the effectiveness of cannabis for chronic pain management remains inconclusive., (Copyright © 2023 International Association for the Study of Pain.)

Background: Recreational cannabis laws (RCLs) may have spillover effects on binge drinking. Our aims were to investigate binge drinking time trends and the association between RCLs and changes in binge drinking in the United States (U.S.)., Methods: We used restricted National Survey on Drug Use and Health data (2008-2019). We examined trends in the prevalence of past-month binge drinking by age groups (12-20, 21-30, 31-40, 41-50, 51+). Then, we compared model-based prevalences of past-month binge drinking before and after RCL by age group, using multi-level logistic regression with state random intercepts, an RCL by age group interaction term, and controlling for state alcohol policies., Results: Binge drinking declined overall from 2008 to 2019 among people aged 12-20 (17.54% to 11.08%), and those aged 21-30 (43.66% to 40.22%). However, binge drinking increased among people aged 31+ (ages 31-40: 28.11% to 33.34%, ages 41-50: 25.48% to 28.32%, ages 51+: 13.28% to 16.75%). When investigating model-based prevalences after versus before RCL, binge drinking decreased among people aged 12-20 (prevalence difference=-4.8%; adjusted odds ratio (aOR)=0.77, [95% confidence interval (CI) 0.70-0.85]), and increased among participants aged 31-40 (+1.7%; 1.09[1.01-1.26]), 41-50 (+2.5; 1.15[1.05-1.26]) and 51+ (+1.8%; 1.17[1.06-1.30]). No RCL-related changes were noted in respondents ages 21-30., Conclusions: Implementation of RCLs was associated with increased past-month binge drinking in adults aged 31+ and decreased past-month binge drinking in those aged < 21. As the cannabis legislative landscape continues to change in the U.S., efforts to minimize harms related to binge drinking are critical., Competing Interests: Declarations of Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Cannabis use and cannabis use disorder (CUD) are associated with mental health disorders, however the extent of this matter among pregnant and recently postpartum (e.g., new moms) women in the US is unknown. Associations between cannabis use, DSM-5 CUD and DSM-5 mental health disorders (mood, anxiety, personality and post-traumatic stress disorders) were examined among a nationally representative sample of pregnant and postpartum women., Methods: The 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III was used to examine associations between past-year cannabis use, CUD and mental health disorders. Weighted logistic regression models were used to estimate unadjusted and adjusted odds ratios (aORs). The sample (N=1316) included 414 pregnant and 902 postpartum women (pregnant in the past year), aged 18-44 years old., Results: The prevalence of past-year cannabis use and CUD was 9.8% and 3.2%, respectively. The odds of cannabis use (aORs range 2.10-3.87, p-values<0.01) and CUD (aORs range 2.55-10.44, p-values< 0.01) were higher among women with versus without any past-year mood, anxiety or posttraumatic stress disorders or any lifetime personality disorder. aORs for the association of cannabis use with specific mood, anxiety or personality disorders ranged from 1.95 to 6.00 (p-values<0.05). aORs for the association of CUD with specific mood, anxiety or personality disorders ranged from 2.36 to 11.60 (p-values<0.05)., Conclusions: From pregnancy up to one year postpartum is a critical period where women may be particularly vulnerable to mental health disorders, cannabis use and CUD. Treatment and prevention are essential., Competing Interests: Declaration of Competing Interest No conflict declared., (Copyright © 2023 Elsevier B.V. All rights reserved.)

The DSM-5 criteria for cannabis use disorder (CUD) combine DSM-IV dependence and abuse criteria (without legal problems) and new withdrawal and craving criteria. Information on dimensionality, internal reliability, and differential functioning of the DSM-5 CUD criteria is lacking. Additionally, dimensionality of the DSM-5 withdrawal items is unknown. This study examined the psychometric properties of the DSM-5 CUD criteria among adults who used cannabis in the past 7 days (N = 5,119). Adults with frequent cannabis use were recruited from the US general population through social media and filled in a web-based survey about demographics and cannabis use behaviors. Factor analysis was used to assess dimensionality, and item response theory analysis models were used to explore relationships between the criteria and the underlying latent trait (CUD), and whether each criterion and the criteria set functioned differently by demographic and clinical characteristics: sex, age, state-level cannabis laws, reasons for cannabis use, and frequency of use. The DSM-5 CUD criteria showed unidimensionality and provided information about the CUD latent trait across the severity spectrum. The cannabis withdrawal items indicated one underlying latent factor. While some CUD criteria functioned differently in specific subgroups, the criteria set as a whole functioned similarly across subgroups. In this online sample of adults with frequent cannabis use, evidence supports the reliability, validity, and utility of the DSM-5 CUD diagnostic criteria set, which can be used for determining a major risk of cannabis use, i.e., CUD, to inform cannabis policies and public health messaging, and for developing intervention strategies., Competing Interests: Declaration of competing interest Alan Budney has served as a scientific consultant for Canopy Growth, Inc. and Jazz Pharmaceuticals. All other authors have no conflicts of interest to declare., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Simultaneous cannabis/alcohol use, using both substances within a short time interval so that their effects overlap, has a greater risk of potential negative consequences than single-substance use and is more common in younger age. Relationships between recreational cannabis laws (RCLs) and changes in simultaneous cannabis/alcohol use prevalence remain untested., Objective: To examine trends in simultaneous cannabis/alcohol use from 2008 to 2019, and investigate associations between implementation of RCLs (i.e., presence of active legal dispensaries or legal home cultivation) and simultaneous cannabis/alcohol use in the United States (U.S.)., Design: Repeated cross-sectional samples from the 2008-2019 U.S. National Survey on Drug Use and Health (NSDUH)., Participants: Respondents (51% female) aged 12 and older., Interventions: Changes in simultaneous cannabis/alcohol use before and after RCL implementation (controlling for medical cannabis law implementation) were compared in different age groups (12-20, 21-30, 31-40, 41-50, 51+), using adjusted multi-level logistic regression with state random intercepts and an RCL/age group interaction., Measurements: Self-reported simultaneous cannabis/alcohol use., Results: From 2008 to 2019, the overall prevalence of simultaneous cannabis/alcohol use declined among those aged 12-20 but increased in adults aged 21+. Model-based simultaneous cannabis/alcohol use prevalence increased after RCL implementation among respondents aged 21-30 years (+1.2%; aOR= 1.15 [95%CI = 1.04-1.27]), 31-40 years (+1.0; 1.15 [1.04-1.27]), and 41-50 years (+1.75; 1.63 [1.34-1.98]), but not in individuals aged <21 or 51+ years., Conclusions: Implementation of recreational cannabis policies resulted in increased simultaneous use of cannabis and alcohol, supporting the complementarity hypothesis, but only among adults aged 21+. Efforts to minimize harms related to simultaneous cannabis/alcohol use are critical, especially in states with RCLs. Future studies should investigate cultural norms, perceived harm, and motives related to simultaneous use., (© 2022. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: Compared to plant/flower cannabis products, cannabis concentrates have higher average potency of delta-9-tetrahydrocannabinol (Δ9-THC), which may be associated with greater likelihood of cannabis-related harms. Information on factors associated with use of cannabis concentrates is needed., Methods: Respondents were 4,328 adult past-7-day cannabis users from all 50 U.S. states and Washington DC (DC) who participated in an online 2021 survey. Using logistic regression to generate adjusted odds ratios (aOR), we investigated whether participants in states that enacted recreational cannabis laws (RCL, 12 states plus DC [treated as a state], n = 1,236) or medical cannabis laws (MCL-only, 23 states, n = 2,030) by December 31, 2020 were more likely than those in states without cannabis laws (no-CL, 15 states, n = 1,062) to use cannabis concentrate products in the prior 7 days., Results: Most participants (92.4%) used plant material in the prior 7 days; 57.0% used cannabis concentrates. In RCL, MCL and no-CL states, concentrate use was reported by 61.5%, 56.6%, and 52.5%, respectively. Compared to participants in no-CL states, odds of using cannabis concentrate products were greater among those in RCL states (aOR = 1.47; CI = 1.17-1.84) and MCL-only states (aOR = 1.29; CI = 1.08-1.55). Whether states had legally-authorized dispensaries had little effect on results., Conclusion: Results suggest that individuals in MCL-only and RCL states are more likely to use cannabis concentrate products. Determining mechanisms underlying these results, e.g., commercialization, could provide important information for prevention. Clinicians should be alert to patient use of concentrates, especially in MCL-only and RCL states. Continued monitoring is warranted as additional states legalize cannabis use., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: The diversity in characteristics of cannabis products and behavior patterns make evaluation of cannabis exposure in population-based, self-report surveys challenging. Accurate identification of cannabis exposure and related outcomes necessitates a thorough understanding of participants' interpretations of survey questions assessing cannabis consumption behaviors., Objectives: The current study utilized cognitive interviewing to gain insight on participants' interpretation of items in a self-reported survey instrument used to estimate the quantity of THC consumed in population samples., Methods: Cognitive interviewing was used to evaluate survey items assessing cannabis use frequency, routes of administration, quantity, potency, and perceived "typical patterns" of use. Ten participants ≥18 years ( n  = 4 cisgender-men; n  = 3 cisgender-women; n  = 3 non-binary/transgender) who had used cannabis plant material or concentrates in the past week were recruited to take a self-administered questionnaire and subsequently answer a series of scripted probes regarding survey items., Results: While most items presented no issues with comprehension, participants identified several areas of ambiguity in question or response item wording or in visual cues included in the survey. Generally, participants with irregular use patterns (i.e., non-daily use) reported more difficulty recalling the time or quantity of cannabis use. Findings resulted in several changes to the updated survey, including updated reference images and new quantity/frequency of use items specific to the route of administration., Conclusion: Incorporating cognitive interviewing into cannabis measurement development among a sample of knowledgeable cannabis consumers led to improvements in assessing cannabis exposure in population surveys, which may otherwise have been missed., Competing Interests: Alan Budney has served as a scientific consultant for Canopy Growth, Inc. and Jazz Pharmaceuticals., (© 2023 Published by Elsevier B.V.)

Background: Although the DSM-5 was adopted in 2013, the validity of the new substance use disorder (SUD) diagnosis and craving criterion has not been investigated systematically across substances., Methods: Adults ( N = 588) who engaged in binge drinking or illicit drug use and endorsed at least one DSM-5 SUD criterion were included. DSM-5 SUD criteria were assessed for alcohol, tobacco, cannabis, cocaine, heroin, and opioids. Craving was considered positive if "wanted to use so badly that could not think of anything else" (severe craving) or "felt a very strong desire or urge to use" (moderate craving) was endorsed. Baseline information on substance-related variables and psychopathology was collected, and electronic daily assessment queried substance use for the following 90 days. For each substance, logistic regression estimated the association between craving and validators, i.e. variables expected to be related to craving/SUD, and whether association with the validators differed for DSM-5 SUD diagnosed with craving as a criterion v. without., Results: Across substances, craving was associated with most baseline validators ( p values<0.05); neither moderate nor severe craving consistently showed greater associations. Baseline craving predicted subsequent use [odds ratios (OR): 4.2 (alcohol) - 234.3 (heroin); p 's ⩽ 0.0001], with stronger associations for moderate than severe craving ( p 's < 0.05). Baseline DSM-5 SUD showed stronger associations with subsequent use when diagnosed with craving than without ( p 's < 0.05)., Conclusion: The DSM-5 craving criterion as operationalized in this study is valid. Including craving improves the validity of DSM-5 SUD diagnoses, and clinical relevance, since craving may cause impaired control over use and development and maintenance of SUD.

Importance: Cannabis use disorder (CUD) is increasing among US adults. Few national studies have addressed the role of medical cannabis laws (MCLs) and recreational cannabis laws (RCLs) in these increases, particularly in patient populations with high rates of CUD risk factors., Objective: To quantify the role of MCL and RCL enactment in the increases in diagnosed CUD prevalence among Veterans Health Administration (VHA) patients from 2005 to 2019., Design, Setting, and Participants: Staggered-adoption difference-in-difference analyses were used to estimate the role of MCL and RCL in the increases in prevalence of CUD diagnoses, fitting a linear binomial regression model with fixed effects for state, categorical year, time-varying cannabis law status, state-level sociodemographic covariates, and patient age group, sex, and race and ethnicity. Patients aged 18 to 75 years with 1 or more VHA primary care, emergency department, or mental health visit and no hospice/palliative care within a given calendar year were included. Time-varying yearly state control covariates were state/year rates from American Community Survey data: percentage male, Black, Hispanic, White, 18 years or older, unemployed, income below poverty threshold, and yearly median household income. Analysis took place between February to December 2022., Main Outcomes and Measures: As preplanned, International Classification of Diseases, Clinical Modification, ninth and tenth revisions, CUD diagnoses from electronic health records were analyzed., Results: The number of individuals analyzed ranged from 3 234 382 in 2005 to 4 579 994 in 2019. Patients were largely male (94.1% in 2005 and 89.0% in 2019) and White (75.0% in 2005 and 66.6% in 2019), with a mean (SD) age of 57.0 [14.4] years. From 2005 to 2019, adjusted CUD prevalences increased from 1.38% to 2.25% in states with no cannabis laws (no CLs), 1.38% to 2.54% in MCL-only enacting states, and 1.39% to 2.56% in RCL-enacting states. Difference-in-difference results indicated that MCL-only enactment was associated with a 0.05% (0.05-0.06) absolute increase in CUD prevalence, ie, that 4.7% of the total increase in CUD prevalence in MCL-only enacting states could be attributed to MCLs, while RCL enactment was associated with a 1.12% (95% CI, 0.10-0.13) absolute increase in CUD prevalence, ie, that 9.8% of the total increase in CUD prevalence in RCL-enacting states could be attributed to RCLs. The role of RCL in the increases in CUD prevalence was greatest in patients aged 65 to 75 years, with an absolute increase of 0.15% (95% CI, 0.13-0.17) in CUD prevalence associated with RCLs, ie, 18.6% of the total increase in CUD prevalence in that age group., Conclusions and Relevance: In this study of VHA patients, MCL and RCL enactment played a significant role in the overall increases in CUD prevalence, particularly in older patients. However, consistent with general population studies, effect sizes were relatively small, suggesting that cumulatively, laws affected cannabis attitudes diffusely across the country or that other factors played a larger role in the overall increases in adult CUD. Results underscore the need to screen for cannabis use and CUD and to treat CUD when it is present.

Background: Naloxone distribution is central to ongoing efforts to address the opioid overdose crisis. Some critics contend that naloxone expansion may inadvertently promote high-risk substance use behaviors among adolescents, but this question has not been directly investigated., Methods: We examined relationships between naloxone access laws and pharmacy naloxone distribution with lifetime heroin and injection drug use (IDU), 2007-2019. Models generating adjusted odds ratios (aOR) and 95% confidence intervals (CI) included year and state fixed effects, controlled for demographics and sources of variation in opioid environments (e.g., fentanyl penetration), as well as additional policies expected to impact substance use (e.g., prescription drug monitoring). Exploratory and sensitivity analyses further examined naloxone law provisions (e.g., third-party prescribing) and applied e-value testing to assess vulnerability to unmeasured confounding., Results: Adoption of any naloxone law was not associated with changes in adolescent lifetime heroin or IDU. For pharmacy dispensing, we observed a small decrease in heroin use (aOR: 0.95 [CI: 0.92, 0.99]) and a small increase in IDU (aOR: 1.07 [CI: 1.02, 1.11]). Exploratory analyses of law provisions suggested that third-party prescribing (aOR: 0.80, [CI: 0.66, 0.96]) and non-patient-specific dispensing models (aOR: 0.78, [CI: 0.61, 0.99]) were associated with decreased heroin use but not decreased IDU. Small e-values associated with the pharmacy dispensing and provision estimates indicate that unmeasured confounding may explain observed findings., Conclusion: Naloxone access laws and pharmacy naloxone distribution were more consistently associated with decreases rather than increases in lifetime heroin and IDU among adolescents. Our findings therefore do not support concerns that naloxone access promotes high-risk adolescent substance use behaviors. As of 2019, all US states have adopted legislation to improve naloxone access and facilitate use. However, further removal of adolescent naloxone access barriers is an important priority given that the opioid epidemic continues to affect people of all ages., Competing Interests: Declarations of Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: D. Hasin has received funding from Syneos Health for an unrelated project. K. Keyes has received personal fees related to expert work in litigation. H. Samples has received consulting fees from the American Society of Addiction Medicine., (Copyright © 2023. Published by Elsevier B.V.)

Over 80% of National Football League (NFL) retirees experience daily pain. Pain acceptance is an important psychological construct implicated in the intensity of chronic pain, though these findings have not been extended to NFL retirees. Therefore, the current study examined the association between pain acceptance and pain intensity among former NFL athletes. NFL retirees ( N = 90) recruited from 2018 to 2019 completed questionnaires that assessed pain, substance use, and NFL career information. Multiple linear regression examined the association between current pain acceptance and pain intensity while adjusting for other risk factors of pain. NFL retirees reported average scores of 33.31 ( SD = 10.00), and 2.18 ( SD = 2.40) on measures of pain acceptance and pain intensity, respectively. After covariate adjustment, greater pain acceptance (β = -0.538, p < .001) was associated with lower pain intensity. These findings can further inform the behavioral and mental health care of retired NFL athletes.