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Background12-step programs aim to address drug-related harms, like opioid overdose, via abstinence. However, abstaining from opioids can diminish tolerance, which increases risk for overdose death upon resumption. A recent study found that desire to abstain from drugs inhibited willingness to participate in take-home naloxone programming, which was linked to perceptions of harm reduction strategies being tied to drug use. In the present study, we uncovered a similar phenomenon occurring among newly-abstinent participants who were refusing to carry naloxone.MethodsThis study is an analysis of broader qualitative data collected throughout Southern California among persons who use opioids, including those recently abstinent. Preliminary analysis revealed that those newly abstinent refused to accept naloxone at the end of interviews, and so we began probing about this (N=44). We used thematic analysis and author positionality to explicate the emergent phenomenon and applied social identity theory to conceptualize findings.ResultsMechanisms underlying naloxone refusal included its tie to a drug-using identity that newly-abstinent participants were attempting to retire. Carrying naloxone was also viewed as pointless due to doubt of witnessing an overdose again. Furthermore, the thought of being equipped with naloxone was not believed to be congruent with an abstinent identity, e.g. "me carrying it [naloxone] is making me feel like I'm going to be hanging out with people that are doing it [using drugs]."ConclusionRecent detoxification heightens vulnerability to overdose, which other newly-abstinent peers might be positioned to respond to as bonds are formed through 12-step identity formation. However, naloxone is often refused by this group due to perceived 12-step identity clash. While some treatment spaces distribute naloxone, 12-step identity associated behavioral expectations appear to conflict with this strategy. Reframing these disconnects is essential for expanding the lifesaving naloxone community safety net.

While rates of opioid overdose deaths in North American have increased exponentially in recent years, most overdoses are not fatal, especially when witnesses are present and can intervene. Previous research has found that some people who use drugs [PWUDs] trained in overdose response might cut social ties with frequent overdosers, leading to more solitary opioid use and risk of death if someone overdoses alone. To examine the phenomenon of social distancing of people who overdose frequently, we used data from fifty-two in-depth qualitative interviews collected in Southern California with PWUDs who had recently witnessed an opioid overdose. Transcripts were reviewed and coded thematically, using the Integrated Threat Theory (ITT) to conceptualize the observed phenomenon. ITT outlines how realistic and symbolic threats are experienced by a group. We found that while some participants acknowledged the role of adulterated street drugs in overdoses, individualized blame was nonetheless imposed. Accusations of careless drug use practices fostered negative stereotyping towards frequent overdosers. This was attributed to the need to summon 911 for rescue, which often resulted in police dispatch. The intergroup relationship between police and PWUDs is precarious as police pose realistic threats onto PWUDs - such as incarceration, eviction, and manslaughter charges - leading to intragroup anxiety among PWUDs about future overdose events, and labelled frequent overdosers as liabilities. These threats, and inter/intra-group conflict, explained one reason how and why non-fatal overdoses led to social distancing events. People who overdose frequently were also accused of breaking the norm of drug user surreptitiousness; a symbolic threat that endangered the group due to police exposure. Social distancing might dampen exposure to the protective effect of peer-led interventions such as take-home naloxone programs, increasing risk of overdose death. This phenomenon highlights how intergroup dynamics are driving intragroup processes. Suggestions for tailoring public health interventions are discussed.

IntroductionResearch identifying pathways to heroin use has typically been conducted among urban populations. This study examined heroin initiation following pharmaceutical opioid use in three suburban/exurban Southern California counties.MethodsInterviewer-administered surveys collected data among 330 participants (65.9 % male; 63.9 % non-Hispanic white) whose initial use of any opioid was a pharmaceutical opioid. Retrospective discrete-time survival analysis identified predictors of heroin initiation, measured as self-reported age of first heroin use.ResultsMedian age of first pharmaceutical opioid use was 17 years; 50.6 % initially acquired pharmaceutical opioids from an illicit source, 56.7 % first used pharmaceutical opioids for recreational purposes, and 86 % initiated heroin use. Average time from first pharmaceutical opioid use to first heroin use was 8.2 years. Drug/alcohol treatment (adjusted Hazard Ratio [aHR]: 0.67, 95 % CI: 0.50, 0.88) was associated with delayed time to heroin initiation. Obtaining opioids from non-medical sources (aHR: 2.21, 95 % CI: 1.55, 3.14) was associated with accelerated time to heroin initiation. Reporting supply problems with obtaining pharmaceutical opioids (e.g., unable to acquire pharmaceutical opioids) was associated with accelerated time to heroin initiation, but the magnitude of this effect was dependent on one's history of methamphetamine use (p < 0.05).ConclusionsTime to heroin initiation following pharmaceutical opioid use was accelerated among those reporting supply problems and delayed among those with exposure to substance use treatment. Interventions interrupting supply of opioids might benefit from coordination with evidence-based medication-assisted treatment to minimize the risk of transitioning to heroin use, particularly among those with a long history of non-prescribed pharmaceutical opioid use.

Background: HIV sequence data can be used to reconstruct local transmission networks. Along international borders, like the San Diego-Tijuana region, understanding the dynamics of HIV transmission across reported risks, racial/ethnic groups, and geography can help direct effective prevention efforts on both sides of the border. Methods: We gathered sociodemographic, geographic, clinical, and viral sequence data from HIV infected individuals participating in ten studies in the San Diego-Tijuana border region. Phylogenetic and network analysis was performed to infer putative relationships between HIV sequences. Correlates of identified clusters were evaluated and spatiotemporal relationships were explored using Bayesian phylogeographic analysis. Findings: After quality filtering, 843 HIV sequences with associated demographic data and 263 background sequences from the region were analyzed, and 138 clusters were inferred (2-23 individuals). Overall, the rate of clustering did not differ by ethnicity, residence, or sex, but bisexuals were less likely to cluster than heterosexuals or men who have sex with men (p=0.043), and individuals identifying as white (p≤0.01) were more likely to cluster than other races. Clustering individuals were also 3.5 years younger than non-clustering individuals (p

© 2015 The New York Academy of Medicine Persons who inject drugs (PWID) are at increased risk for blood-borne virus (BBV) infections and overdose resulting from high-risk injecting practices. Studies of prefilled syringe use ([PFSU] using a syringe that already contained drug solution when it was obtained by the user), an injection practice previously described in Eastern Europe, suggest that it increases susceptibility to BBV. However, little is known about this practice in the USA. Data were obtained from an ongoing cohort study of PWID to determine the prevalence and assess correlates of PFSU in San Diego, CA. Baseline interviews assessed socio-demographics and drug use behaviors. Logistic regression was used to identify factors independently associated with ever using a prefilled syringe (yes/no). Participants (n = 574) were predominately males (73.9 %) and white (50.9 %) with a mean age of 43.4 years (range 18–80); 33.3 % reported ever using prefilled syringes, although only 4.9 % reported use in the past 6 months. In multivariable analyses, PFSU was independently associated with ever having a rushed injection due to police presence [adjusted odds ratio (AOR) = 2.51, 95 % CI 1.66, 3.79], ever being in prison (AOR = 1.80, 95 % CI 1.23, 2.63), injecting most often in public versus private places in the past 6 months (AOR = 1.66, 95 % CI 1.11, 2.48), and injecting drugs in Mexico (AOR = 1.70, 95 % CI 1.16, 2.49). Results indicate that a history of PFSU is common and associated with environmental factors that may also increase risk for adverse health outcomes. Studies are needed to better understand PFSU in order to develop interventions to prevent adverse outcomes associated with their use.

AimsIn 2009, Mexico passed legislation to decriminalize drug possession and improve access to addiction treatment. We undertook research to assess the implementation of the reform among a cohort of people who inject drugs (PWID) in Tijuana. This study specifically sought to determine whether discretionary policing practices like extortion impact access to methadone maintenance therapy (MMT) in Tijuana, a city characterized by high levels of drug-related harms.MethodsGeneralized estimating equation analyses were used to construct longitudinal confounding models to determine the association between paying a police bribe and MMT enrolment among PWID in Tijuana enrolled in a prospective cohort study. Outcome of interest was MMT enrolment in the past six months. Data on police interactions and MMT enrolment were also obtained.ResultsBetween October, 2011 and September, 2013, 637 participants provided 1825 observations, with 143 (7.8%) reports of MMT enrolment during the study period. In a final confounding model, recently reporting being forced to pay a bribe to police was significantly associated with an increased likelihood of accessing MMT (adjusted odds ratio=1.69, 95% confidence interval: 1.02-2.81, p=0.043). However, in 56 (39.2%) cases, MMT enrolment ceased within six months. The majority of participant responses cited the fact that MMT was too expensive (69.1%).DiscussionLevels of MMT access were low. PWID who experienced police extortion were more likely to access MMT at baseline, though this association decreased during the study period. Coupled with the costs of MMT, this may compromise MMT retention among PWID.

Objective: The purpose of this article is to describe the effects of the pediatric antidepressant controversy on the Treatment of Serotonin-Selective Reuptake Inhibitor (SSRI) Resistant Depression in Adolescents (TORDIA) trial.Method: Adolescents, ages 12-18 years, with SSRI resistant depression were randomized to one of four treatments for a 12 week trial: Switch to different SSRI, switch to an alternate antidepressant (venlafaxine), switch to an alternate SSRI plus cognitive behavior therapy (CBT), or switch to venlafaxine plus CBT.Results: The health advisories and "black box" warnings regarding suicidality and antidepressants in adolescents occurred during the course of the TORDIA trial. Revisions to the protocol, multiple-consent form changes, and re-consenting of patients were necessary. Recruitment of participants was adversely affected.Conclusion: Despite a cascade of unforeseen events that delayed the completion of the study, the TORDIA trial resulted in clinically important information about treatment-resistant depression in adolescents. [ABSTRACT FROM AUTHOR]

Acculturation discrepancy theory predicts that conflicting cultural preferences between adolescents and their parents will increase the adolescents' risk for behavior problems such as substance use. This study evaluated this hypothesis in a sample of 1683 Hispanic students in Southern California who completed surveys in 9th and 10th grade. Measures included the students' own cultural orientations and their perceptions of their parents' preference for their cultural orientations ("Perceived Parental Cultural Expectations"--PPCE). Hispanic PPCE in 9th grade was a risk factor for lifetime, but not past-month, cigarette, alcohol, and marijuana use in 10th grade. The adolescents' own Hispanic orientation in 9th grade was protective against lifetime and past-month smoking and marijuana use and lifetime alcohol use in 10th grade. The effects of the acculturation variables did not vary according to generation in the U.S. Change in acculturation between 9th and 10th grade was statistically significant but small in magnitude. Increases in parent-child Hispanic acculturation discrepancy (i.e., the difference between the adolescents' own cultural orientations and their PPCE, with adolescents perceiving that their parents wanted them to be more Hispanic oriented than they actually were) from 9th to 10th grade were associated with an increased risk of substance use. Family-based interventions for acculturating Hispanic families may be useful in decreasing the likelihood of substance use among Hispanic adolescents. [ABSTRACT FROM AUTHOR]

Context: Only about 60% of adolescents with depression will show an adequate clinical response to an initial treatment trial with a selective serotonin reuptake inhibitor (SSRI). There are no data to guide clinicians on subsequent treatment strategy.Objective: To evaluate the relative efficacy of 4 treatment strategies in adolescents who continued to have depression despite adequate initial treatment with an SSRI.Design, Setting, and Participants: Randomized controlled trial of a clinical sample of 334 patients aged 12 to 18 years with a primary diagnosis of major depressive disorder that had not responded to a 2-month initial treatment with an SSRI, conducted at 6 US academic and community clinics from 2000-2006.Interventions: Twelve weeks of: (1) switch to a second, different SSRI (paroxetine, citalopram, or fluoxetine, 20-40 mg); (2) switch to a different SSRI plus cognitive behavioral therapy; (3) switch to venlafaxine (150-225 mg); or (4) switch to venlafaxine plus cognitive behavioral therapy.Main Outcome Measures: Clinical Global Impressions-Improvement score of 2 or less (much or very much improved) and a decrease of at least 50% in the Children's Depression Rating Scale-Revised (CDRS-R); and change in CDRS-R over time.Results: Cognitive behavioral therapy plus a switch to either medication regimen showed a higher response rate (54.8%; 95% confidence interval [CI], 47%-62%) than a medication switch alone (40.5%; 95% CI, 33%-48%; P = .009), but there was no difference in response rate between venlafaxine and a second SSRI (48.2%; 95% CI, 41%-56% vs 47.0%; 95% CI, 40%-55%; P = .83). There were no differential treatment effects on change in the CDRS-R, self-rated depressive symptoms, suicidal ideation, or on the rate of harm-related or any other adverse events. There was a greater increase in diastolic blood pressure and pulse and more frequent occurrence of skin problems during venlafaxine than SSRI treatment.Conclusions: For adolescents with depression not responding to an adequate initial treatment with an SSRI, the combination of cognitive behavioral therapy and a switch to another antidepressant resulted in a higher rate of clinical response than did a medication switch alone. However, a switch to another SSRI was just as efficacious as a switch to venlafaxine and resulted in fewer adverse effects.Trial Registration: clinicaltrials.gov Identifier: NCT00018902. [ABSTRACT FROM AUTHOR]

OBJECTIVE: This study was conducted to determine whether there are changes in the cognitive factors of attributional style, hopelessness, and self-esteem when suicidal ideation fades in psychiatrically hospitalized children and adolescents. METHOD: The cognitive factors of attributional style, hopelessness, and self-esteem were assessed in subjects aged 7-17 years (50 with and 50 without suicidal ideation) at admission and discharge from a psychiatric hospital. RESULTS: For subjects with suicidal ideation, attributional style became significantly more positive and hopelessness was decreased from admission to discharge, by which time suicidal ideation had faded. There was no association between self-esteem and suicidal ideation after control for depression. These changes in cognitive factors were not seen in the group without suicidal ideation. There were no significant differences between children and adolescents in the pattern of results. CONCLUSIONS: Change in attributional style was shown to be a factor significantly related to the resolution of suicidal ideation in children and adolescents. This cognitive style could be specifically addressed in psychotherapy with depressed children and adolescents as a means of reducing suicidal ideation. These results may have an implication for reducing the length of psychiatric inpatient stays. [ABSTRACT FROM AUTHOR]

Context: The serotonin reuptake inhibitors are the treatment of choice for patients with obsessive-compulsive disorder; however, empirical support for this assertion has been weaker for children and adolescents than for adults.Objective: To evaluate the safety and efficacy of the selective serotonin reuptake inhibitor sertraline hydrochloride in children and adolescents with obsessive-compulsive disorder.Design: Randomized, double-blind, placebo-controlled trial.Patients: One hundred eighty-seven patients: 107 children aged 6 to 12 years and 80 adolescents aged 13 to 17 years randomized to receive either sertraline (53 children, 39 adolescents) or placebo (54 children, 41 adolescents).Setting: Twelve US academic and community clinics with experience conducting randomized controlled trials.Intervention: Sertraline hydrochloride was titrated to a maximum of 200 mg/d during the first 4 weeks of double-blind therapy, after which patients continued to receive this dosage of medication for 8 more weeks. Control patients received placebo.Main Outcome Measures: The Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), the National Institute of Mental Health Global Obsessive Compulsive Scale (NIMH GOCS), and the NIMH Clinical Global Impressions of Severity of Illness (CGI-S) and Improvement (CGI-I) rating scales.Results: In intent-to-treat analyses, patients treated with sertraline showed significantly greater improvement than did placebo-treated patients on the CY-BOCS (adjusted mean, -6.8vs -3.4, respectively; P=.005), the NIMH GOCS (-2.2 vs -1.3, respectively; P=.02), and the CGI-I (2.7 vs 3.3, respectively; P=.002) scales. Significant differences in efficacy between sertraline and placebo emerged at week 3 and persisted for the duration of the study. Based on CGI-I ratings at end point, 42% of patients receiving sertraline and 26% of patients receiving placebo were very much or much improved. Neither age nor sex predicted response to treatment. The incidence of insomnia, nausea, agitation, and tremor were significantly greater in patients receiving sertraline; 12 (13%) of 92 sertraline-treated patients and 3 (3.2%) of 95 placebo-treated patients discontinued prematurely because of adverse medical events (P=.02). No clinically meaningful abnormalities were apparent on vital sign determinations, laboratory findings, or electrocardiographic measurements.Conclusion: Sertraline appears to be a safe and effective short-term treatment for children and adolescents with obsessive-compulsive disorder. [ABSTRACT FROM AUTHOR]

Objective: To advance knowledge regarding strategies for treating selective serotonin reuptake inhibitor (SSRI)-resistant depression in adolescents, we conducted a randomized controlled trial evaluating alternative treatment strategies. In primary analyses, cognitive-behavioral therapy (CBT) combined with medication change was associated with higher rates of positive response to short-term (12-week) treatment than medication alone. This study examines predictors and moderators of treatment response, with the goal of informing efforts to match youths to optimal treatment strategies.Method: Youths who had not improved during an adequate SSRI trial (N = 334) were randomized to an alternative SSRI, an alternative SSRI plus CBT, venlafaxine, or venlafaxine plus CBT. Analyses examined predictors and moderators of treatment response.Results: Less severe depression, less family conflict, and absence of nonsuicidal self-injurious behavior predicted better treatment response status. Significant moderators of response to CBT + medication (combined) treatment were number of comorbid disorders and abuse history; hopelessness was marginally significant. The CBT/combined treatment superiority over medication alone was more evident among youths who had more comorbid disorders (particularly attention-deficit/hyperactivity disorder and anxiety disorders), no abuse history, and lower hopelessness. Further analyses revealed a stronger effect of combined CBT + medication treatment among youths who were older and white and had no nonsuicidal self-injurious behavior and longer prestudy pharmacotherapy.Conclusions: Combined treatment with CBT and antidepressant medication may be more advantageous for adolescents whose depression is comorbid with other disorders. Given the additional costs of adding CBT to medication, consideration of moderators in clinical decision making can contribute to a more personalized and effective approach to treatment. [ABSTRACT FROM AUTHOR]

The aim of this study was to examine relationships among trauma burden, post-traumatic stress disorder, and perceived social support in a large, diverse group of trauma-exposed children and adolescents followed longitudinally. Specifically, we tested the social erosion hypothesis (i.e., mental health challenges negatively affect the quality of social relationships and contribute to reduced social support over time) using a sample of 1,829 trauma-exposed youth (aged 8-21) recruited through the multi-site Texas Childhood Trauma Research Network. Youth who reported more trauma burden (i.e., a greater number of traumas) perceived significantly lower levels of social support from family and peers, and those with more interpersonal trauma perceived significantly lower levels of social support from all sources, after controlling for multiple demographic variables and psychiatric comorbidities. Notably, the negative associations between trauma and perceived social support were most prominent among individuals without a PTSD diagnosis. Trauma burden was not associated with declines in perceived social support over a 12-month period. Additionally, in these trauma-exposed youth, being assigned female at birth was positively associated with perceived support from family members and negatively associated with perceived social support from a close friend. These findings extend our understanding of how trauma and PTSD independently predict and interact to predict perceived social support., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Charles B. Nemeroff and Karen Dineen Wagner reports financial support was provided by the State of Texas through the Texas Child Mental Health Care Consortium. Paul J. Rathouz reports a relationship with Sunovion Pharmaceuticals that includes: board membership. Josh M. Cisler reports a relationship with National Institutes of Health (NIH) that includes: funding grants. D. Jeffrey Newport reports a relationship with Eli Lilly, Glaxo SmithKline (GSK), Janssen, the National Alliance for Research on Schizophrenia and Depression (NARSAD), Navitor, Sage Therapeutics, Takeda Pharmaceuticals, the Texas Health & Human Services Commission, and Wyeth that includes: funding grants. D. Jeffrey Newport reports a relationship with Astra-Zeneca, Eli Lilly, GSK, Pfizer and Wyeth. He has served on advisory boards for GSK, Janssen, Merck, and Sage Therapeutics that includes: speaking and lecture fees. D. Jeffrey Newport reports a relationship with Sage Therapeutics that includes: consulting or advisory. Karen Dineen Wagner reports a relationship with the state of Texas and the NIH that includes: funding grants. Charles B. Nemeroff reports a relationship with AbbVie, ANeuroTech (division of Anima BV), Signant Health, Magstim, Inc., Intra-Cellular Therapies, Inc., EMA Wellness, Sage, Silo Pharma, Engrail Therapeutics, that includes: consulting or advisory. Charles B. Nemeroff reports a relationship with Pasithea Therapeutic Corp., EcoR1, GoodCap Pharmaceuticals, Inc., Senseye, Clexio, EmbarkBio, SynapseBio, BioXcel Therapeutics that includes: consulting or advisory. Charles B. Nemeroff reports a relationship with Seattle Genetics, Antares, Inc., Corcept Therapeutics Pharmaceuticals Company, EMA Wellness, Precisement Health, Relmada Therapeutics that includes: equity or stocks. Charles B. Nemeroff reports a relationship with ANeuroTech (division of Anima BV), Brain and Behavior Research Foundation (BBRF), Anxiety and Depression Association of America (ADAA) that includes: board membership. Charles B. Nemeroff reports a relationship with Skyland Trail, Signant Health, Laureate Institute for Brain Research (LIBR), Inc., Heading Health, Pasithea Therapeutic Corp., and Sage that includes: board membership. Charles B. Nemeroff reports a relationship with Gratitude America, ADAA, Lucy Scientific Discovery, Inc. that includes: board membership. If there are other authors, they 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 © 2024 Elsevier B.V. All rights reserved.)

Introduction: Emergency department (ED) peer-delivered interventions have been implemented across the country to improve outcomes for people who use drugs. In this study we describe what elements patients believe led to a positive interaction with a certified peer recovery support specialist (CPRSS) in the ED and discuss implications when those elements were missing., Methods: This is a qualitatively driven mixed methods study embedded within a larger longitudinal study. Using a close and open-ended question interview guide, we interviewed 26 participants from 2018 to 2023 who met with a CPRSS in a Nevada ED for a substance use related concern. Interviews were recorded and transcribed verbatim. Thematic analysis was used to code the transcripts and generate themes. Quantitative data (satisfaction, therapeutic alliance, and social support) were analyzed using student-t, Fisher's exact, and one-way ANOVA tests., Results: Participants described numerous elements that they believed contributed to being satisfied with their CPRSS interaction, which we grouped into three categories: 1) how the CPRSS interaction felt, 2) how the CPRSS services were delivered, and 3) patient factors that influenced the interaction with a CPRSS. Elements that contributed to their satisfaction, including whether the CPRSS adapted to their current circumstances, if they received personalized referrals, and how their own mental and physical state impacted their receptivity to services., Conclusions: Our findings highlight areas to optimize implementation and increase program uptake for future ED-based CPRSS-delivered interventions, including training CPRSS in the philosophy of harm reduction, following up with the patient post-ED, and tailoring services to the patients' immediate needs., Competing Interests: Declaration of competing interest None., (Copyright © 2024. Published by Elsevier Inc.)

Objective: The aim of this study was to compare past 12-month use of cigarette smoking cessation aids (e.g., Food and Drug Administration (FDA)-approved cessation products or e-cigarettes for smoking cessation) among people with substance use problems (PWSUPs) who currently smoke to people without substance use problems (SUPs) who currently smoke cigarettes in a nationally representative US sample., Methods: We used the Population Assessment of Tobacco and Health (PATH) Wave 6 Study [n = 30,516]. Our sample comprised adult (18+) established cigarette smokers (100+ lifetime-sticks with daily/non-daily use) [n = 5,895]. The independent variable was SUP status (no, moderate, and high). The dependent variables were past-year use of: nicotine replacement therapies (NRTs), cessation medications [i.e., varenicline or bupropion], or e-cigarettes [for cigarette cessation and reduction]. Weighted multivariable logistic regression models for each dependent variable examined the associations between SUP status and each cessation aid, adjusting for cigarette dependence, daily cigarette smoking, and demographic factors., Results: Among people who smoke, a higher proportion of respondents with high SUP severity used NRTs, cessation medications, and e-cigarettes for cigarette cessation, respectively (12.3%, 8.4%, 15.7%), compared to those with no/low SUP severity (9.8%, 6.0%, 8.9%). In the multivariable models, respondents with high SUPs had 63% (95% CI:1.16-2.29) higher odds of using e-cigarettes for cessation than those without SUPs. No significant differences were seen between high (vs. no/low SUPs) in the past-year use of NRTs and cessation medications., Conclusion: Our findings indicate that cigarette smokers with high SUPs had higher odds of using e-cigarettes for cessation and reduction compared to smokers without SUPs., 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 © 2024 Elsevier Ltd. All rights reserved.)

Background: Patients presenting to Emergency Departments (ED) with opioid use disorder may be candidates for buprenorphine treatment, making EDs an appropriate setting to initiate this underused, but clinically proven therapy. Hospitals are devoting increased efforts to routinizing buprenorphine initiation in the ED where clinically appropriate, with the greatest successes occurring in academic medical centers. Overall, however, clinician participation in these efforts is suboptimal. Hospitals need more information to inform the standardized implementation of these programs nationally. Using an implementation science framework, we investigated ED providers' concerns about ED buprenorphine programs and their willingness to prescribe buprenorphine in the ED., Methods: We conducted Consolidated Framework for Implementation Research (CFIR)-informed interviews with 11 ED staff in Nevada and analyzed the transcripts using a six-step thematic approach. Results were organized within the CFIR 1.0 domains of inner setting, outer setting, intervention characteristics, and individual characteristics; potential implementation strategies were recommended., Results: Physicians expressed that the ED is a suitable location for prescribing buprenorphine. However, they expressed concerns about: information gaps in the prescribing protocols (inner setting), patient outcomes beyond the ED, buprenorphine effectiveness and appropriate timing of treatment initiation (intervention characteristics), and their own competence in managing opioid withdrawal (individual characteristics). Some were anxious about patients' outcomes and continuity of care in the community (outer setting), others desired access to prospective data that demonstrate buprenorphine effectiveness. Additional concerns included a lack of availability of the required support to prescribe buprenorphine, a lack of physicians' experience and competence, and concerns about opioid withdrawal. Recommended implementation strategies to address these concerns include: designating personnel at the ED to bridge the information gap, engaging emergency physicians through educational meetings, creating a community of practice, facilitating mentorship opportunities, and leveraging existing collaborative learning platforms., Conclusion: Overall, physicians in our study believed that implementing a buprenorphine program in the ED is appropriate, but had concerns. Implementation strategies could be deployed to address concerns at multiple levels to increase physician willingness and program uptake., (© 2024. The Author(s).)

Objectives: We described age, gender, race, and ethnicity associations with filling buprenorphine prescriptions post-emergency department (post-ED) visits., Methods: We analyzed 1.5 years (July 1, 2020-December 31, 2021) of encounter-level Medicaid ED and retail pharmacy claims data obtained from the Nevada Department of Health and Human Services. We studied ED patients with an opioid use disorder (OUD) diagnosis who did not fill a prescription for OUD medications within 6 months before the ED encounter. Using logistic regression, we modeled the associations between the patient's demographic characteristics and the outcome, filling a buprenorphine prescription at a community pharmacy within 14 or 30 days of the ED encounter., Results: Among 2781 ED visits, representing 2094 patients, the median age was 39 years, 54% were male, 18.5% were Black, 11.7% were Hispanic, and 62.3% were White. Only 4% of the ED visits were followed by a filled buprenorphine prescription. Increasing age (14-day window: adjusted odds ratio (aOR) = 0.965, 95% confidence interval [CI]: 0.948-0.983) and being a Black patient (14-day window: aOR: 0.114, 95% CI 0.036-0.361) were both associated with lower odds of filled buprenorphine prescriptions. These results were similar within 30 days of an ED visit., Conclusions: Initiation of buprenorphine following an ED visit remains low among Nevadan Medicaid patients and is less likely with increasing age and among Black patients, despite strong evidence supporting its use. Overburdened EDs, lack of attention from managers, and substance use stigma are among possible explanations. When ED clinicians do write buprenorphine prescriptions, peer recovery support could increase the fill rates., Competing Interests: The authors declare no conflicts of interest., (© 2024 The Author(s). Journal of the American College of Emergency Physicians Open published by Wiley Periodicals LLC on behalf of American College of Emergency Physicians.)

Background: Co-use of stimulants and opioids is often deliberate. However, the possibility remains that some people are unintentionally consuming fentanyl. To advance understanding of overdose risk, we examined the rate of concordance between self-reported fentanyl use and corresponding urine toxicology screen results., Methods: Between August 2022-August 2023, 411 participants (adults who reported any non-medical drug use in the past three months) in Nevada and New Mexico completed a cross-sectional survey, of whom 64% ( n  = 270; the analytical sample) also completed a urine toxicology screen, which detects fentanyl use in the past three days. Positive predictive value, negative predictive value, sensitivity, and specificity were calculated using self-reported past three-day fentanyl use (yes/no) and urine toxicology screen results for the presence of fentanyl (positive/negative)., Results: Of the 270 participants who provided a urine sample, 268 are included in the descriptive statistics (two with inconclusive urine toxicology screen results were excluded). Of the 268 participants, 146 (54.5%) had a fentanyl-positive urine toxicology screen result, 122 (45.5%) had a fentanyl-negative urine toxicology screen result, 137 (51.1%) reported past three-day fentanyl use, and 130 (48.5%) reported no past three-day fentanyl use. Only 6.9% of those with a fentanyl-positive urine toxicology screen did not report recent fentanyl use. The sensitivity of self-reported fentanyl use was 93%, specificity was 97%, positive predictive value was 97%, and negative predictive value was 92%., Discussion: The rate of unanticipated exposure to fentanyl (that is, positive urine screen and negative self-report) in this sample was low, at 6.9%. This runs counter to the national narrative that there is widespread unknown contamination of fentanyl in the drug supply., Conclusion: Future research is needed to further explore how people who use multiple substances interpret their overdose risk and what harm reduction methods they employ.

Divergent conceptualization of posttraumatic stress disorder (PTSD) within the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) and International Statistical Classification of Diseases and Related Health Problems (11th ed..; ICD-11) significantly confounds both research and practice. Using a diverse sample of trauma-exposed youth (N = 1,542, age range: 8-20 years), we compared these two diagnostic approaches along with an expanded version of the ICD-11 PTSD criteria that included three additional reexperiencing symptoms (ICD-11+). Within the sample, PTSD was more prevalent using the DSM-5 criteria (25.7%) compared to the ICD-11 criteria (16.0%), with moderate agreement between these diagnostic systems, κ = .57. The inclusion of additional reexperiencing symptoms (i.e., ICD-11+) reduced this discrepancy in prevalence (24.7%) and increased concordance with DSM-5 criteria, κ = .73. All three PTSD classification systems exhibited similar comorbidity rates with major depressive episode (MDE) or generalized anxiety disorder (GAD; 78.0%-83.6%). Most youths who met the DSM-5 PTSD criteria also met the criteria for ICD-11 PTSD, MDE, or GAD (88.4%), and this proportion increased when applying the ICD-11+ criteria (95.5%). Symptom-level analyses identified reexperiencing/intrusions and negative alterations in cognition and mood symptoms as primary sources of discrepancy between the DSM-5 and ICD-11 PTSD diagnostic systems. Overall, these results challenge assertions that nonspecific distress and diagnostically overlapping symptoms within DSM-5 PTSD inflate comorbidity with depressive and anxiety disorders. Further, they support the argument that the DSM-5 PTSD criteria can be refined and simplified without reducing the overall prevalence of psychiatric diagnoses in youth., (© 2024 International Society for Traumatic Stress Studies.)

Introduction: In the United States, methamphetamine use is increasing and the context of its use has changed, with reports of illicitly manufactured fentanyl being mixed with methamphetamine (either deliberately or inadvertently). We explore risk-mitigating actions taken by people who use drugs to protect their health when using methamphetamine in that context., Methods: We conducted qualitative interviews with 48 adults (18+) who used methamphetamine in the past three months at two sites in Nevada, USA and two sites in New Mexico, USA. Interviews were recorded, transcribed, and analyzed using thematic analysis., Results: Respondents described two rationales for employing harm reduction strategies. First, to prevent harm from methamphetamine containing illicit fentanyl, and second, to maintain their general wellbeing while using methamphetamine. Regarding methamphetamine containing illicit fentanyl, our findings highlight how respondents employ primary strategies like buying from trusted sources and secondary strategies such as spotting and selective use of harm reduction tools (i.e., fentanyl test strips) to reduce risks. To maintain their general wellbeing, participants reduced their use of methamphetamine as reasonably as possible, and used other substances like marijuana and alcohol alongside methamphetamine to counter the unwanted side effects of methamphetamine (i.e., hallucinations and paranoia). Use of these harm reduction strategies varied within situational and social contexts, and respondents usually developed these strategies based on their lived experiences., Conclusion: Our findings uniquely demonstrate that people who use methamphetamine prioritize community driven, trust-based strategies within their social networks to mitigate risks in a fentanyl-contaminated drug environment. Additionally, our results indicate that harm reduction behaviors are influenced by multilevel risk environments, which include social, physical, economic, and political factors. Overall, these results highlight the potential for targeted interventions at the network level, which are responsive to complexities and shifts in drug market dynamics- such as illicit fentanyl in methamphetamine., Competing Interests: Declaration of competing interest All other authors have no conflict of interest., (Copyright © 2024 Elsevier B.V. All rights reserved.)

This investigation, conducted within the Texas Childhood Trauma Research Network, investigated the prospective relationships between resiliency and emergent internalizing symptoms among trauma-exposed youth. The cohort encompassed 1262 youth, aged 8-20, from twelve health-related institutions across Texas, who completed assessments at baseline and one- and six-month follow-ups for resiliency, symptoms of depression, generalized anxiety, posttraumatic stress disorder (PTSD), and other demographic and clinical characteristics. At baseline, greater resilience was positively associated with older age, male (vs female) sex assigned at birth, and history of mental health treatment. Unadjusted for covariates, higher baseline resilience was associated with greater prospective depression and PTSD symptoms but not anxiety symptoms. Upon adjusting for demographic and clinical factors, higher baseline resilience was no longer associated with depression, PTSD, or anxiety symptoms. Our analyses demonstrate that the predictive value of resilience on psychopathology is relatively small compared to more readily observable clinical and demographic factors. These data suggest a relatively minor prospective role of resilience in protecting against internalizing symptoms among trauma-exposed youth and highlight the importance of controlling for relevant youth characteristics when investigating a protective effect of resilience on internalizing symptoms., Competing Interests: Declaration of competing interest AVS has no conflicts of interest or financial disclosures., (Copyright © 2024. Published by Elsevier B.V.)