Disruptions to U.S. Local Public Health's Role in Population-Based Substance Use Prevention and Response During COVID-19

Journal: Substance Abuse Treatment, Prevention, and Policy, 2022, doi: 10.1186/s13011-022-00499-7

Authors: Kellie Hall, Francis Higgins, Karla Feeser Beach, Kabaye Diriba, Mandy Sladky & Timothy C. McCall


Background: COVID-19 dramatically limited the scale and scope of local health department (LHD) work, redirecting resources to the response. However, the need for essential public health services-including substance use prevention-was not reduced.

Methods: We examined six quantitative data sources, collected between 2016 and 2021, to explore the impact of the COVID-19 pandemic on LHD substance use-related services.

Results: Before the pandemic, the proportion of LHDs providing some level of substance use prevention services was increasing, and many were expanding their level of provision. During the pandemic, 65% of LHDs reduced their level of substance use-related service provision, but the proportion of LHDs providing some level of services remained steady from prior to COVID-19.

Conclusion: We discuss policy recommendations to mitigate the risk of service disruptions during future public health emergencies, including direct and flexible funding for LHDs and federal directives declaring substance use prevention services as essential.

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Nicotine Addiction and Intensity of e-Cigarette Use by Adolescents in the US, 2014 to 2021

Journal: JAMA Network Open, 2022, doi: 10.1001/jamanetworkopen.2022.40671

Authors: Stanton Glantz, Abra Jeffers & Jonathan P. Winickoff


Importance: As e-cigarettes have become more effective at delivering the addictive drug nicotine, they have become the dominant form of tobacco use by US adolescents.

Objective: To measure intensity of use of e-cigarettes, cigarettes, and other tobacco products among US adolescents and their dependence level over time.

Design, Setting, and Participants: This survey study analyzed the cross-sectional National Youth Tobacco Surveys from 2014 to 2021. Confirmatory analysis was conducted using Youth Behavioral Risk Factor Surveillance System from 2015 to 2019. The surveys were administered to national probability samples of US students in grades 6 to 12.

Exposures: Use of e-cigarettes and other tobacco products before and after the introduction of e-cigarettes delivering high levels of nicotine.

Main Outcomes and Measures: First tobacco product used, age at initiation of use, intensity of use (days per month), and nicotine addiction (measured as time after waking to first use of any tobacco product).

Results: A total of 151 573 respondents were included in the analysis (51.1% male and 48.9% female; mean [SEM] age, 14.57 [0.03] years). Prevalence of e-cigarette use peaked in 2019 and then declined. Between 2014 and 2021, the age at initiation of e-cigarette use decreased, and intensity of use and addiction increased. By 2017, e-cigarettes became the most common first product used (77.0%). Age at initiation of use did not change for cigarettes or other tobacco products, and changes in intensity of use were minimal. By 2019, more e-cigarette users were using their first tobacco product within 5 minutes of waking than for cigarettes and all other products combined. Median e-cigarette use also increased from 3 to 5 d/mo in 2014 to 2018 to 6 to 9 d/mo in 2019 to 2020 and 10 to 19 d/mo in 2021.

Conclusions and Relevance: The changes detected in this survey study may reflect the higher levels of nicotine delivery and addiction liability of modern e-cigarettes that use protonated nicotine to make nicotine easier to inhale. The increasing intensity of use of modern e-cigarettes highlights the clinical need to address youth addiction to these new high-nicotine products over the course of many clinical encounters. In addition, stronger regulation, including comprehensive bans on the sale of flavored tobacco products, should be implemented.

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Early Childhood Behavioral and Academic Antecedents of Lifetime Opioid Misuse among Urban

Journal: Journal of Clinical Child and Adolescent Psychology, 2022, doi: 10.1080/15374416.2021.187532

Authors: Jill A. Rabinowitz, Beth A. Reboussin, Johannes Thrul, Deborah A. G. Drabick, Geoffrey Kahn, Kerry M. Green, … Brion S. Maher


Objective: Opioid misuse has become an epidemic in the United States. In the present study, we examine potential malleable early childhood predictors of opioid misuse including whether childhood achievement, aggressive behavior, attention problems, and peer social preference/likability in first grade predicted opioid misuse and whether these relationships differed depending on participant sex.

Method: Data are drawn from three cohorts of participants (N = 1,585; 46.7% male) recruited in first grade as part of a series of elementary school-based, universal preventive interventions conducted in a Mid-Atlantic region of the US. In first grade, participants completed standardized achievement tests, teachers reported on attention problems, and peers nominated their classmates with respect to their aggressive behavior and social preference/likability. At approximately age 20, participants reported on their misuse of opioids defined as lifetime use of heroin or misuse of prescription opioids.

Results: Higher levels of peer nominations for aggressive behavior in first grade predicted a greater likelihood of opioid misuse. An interaction between participant sex and attention problems was observed such that females higher in attention problems were more likely to misuse opioids, particularly prescription opioids, than females lower in attention problems. An interaction was also found between participant sex and peer likability such that males lower in peer-nominated likability were more likely to misuse opioids relative to males higher in likability.

Conclusion: Given the malleable nature of attention problems, aggression, and social skills in early childhood, prevention programs that target these behaviors during this developmental period may attenuate risk for opioid misuse.

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Validity of the Single-Item Screen–Cannabis (SIS-C) for Cannabis Use Disorder Screening in Routine Care

Journal: JAMA Network Open, 2022, doi:10.1001/jamanetworkopen.2022.39772

Authors: Theresa E. Matson; Gwen T. Lapham, Jennifer F. Bobb, Malia Oliver, Kevin A. Hallgren, Emily C. Williams & Katharine A. Bradley


Importance: Cannabis use is prevalent and increasing, and frequent use intensifies the risk of cannabis use disorder (CUD). CUD is underrecognized in medical settings, but a validated single-item cannabis screen could increase recognition.

Objective: To evaluate the Single-Item Screen–Cannabis (SIS-C), administered and documented in routine primary care, compared with a confidential reference standard measure of CUD.

Design, Setting, and Participants: This diagnostic study included a sample of adult patients who completed routine cannabis screening between January 28 and September 12, 2019, and were randomly selected for a confidential survey about cannabis use. Random sampling was stratified by frequency of past-year use and race and ethnicity. The study was conducted at an integrated health system in Washington state, where adult cannabis use is legal. Data were analyzed from May 2021 to March 2022.

Exposures: The SIS-C asks about frequency of past-year cannabis use with responses (none, less than monthly, monthly, weekly, daily or almost daily) documented in patients’ medical records.

Main Outcomes and Measures: The Diagnostic and Statistical Manual, Fifth Edition (DSM-5) Composite International Diagnostic Interview–Substance Abuse Module (CIDI-SAM) for past-year CUD was completed on a confidential survey and considered the reference standard. The SIS-C was compared with 2 or more criteria on the CIDI-SAM, consistent with CUD. All analyses were weighted, accounting for survey design and nonresponse, to obtain estimates representative of the health system primary care population.

Results: Of 5000 sampled adult patients, 1688 responded to the cannabis survey (34% response rate). Patients were predominantly middle-aged (weighted mean [SD] age, 50.7 [18.1]), female or women (weighted proportion [SE], 55.9% [4.1]), non-Hispanic (weighted proportion [SE], 96.7% [1.0]), and White (weighted proportion [SE], 74.2% [3.7]). Approximately 6.6% of patients met criteria for past-year CUD. The SIS-C had an area under receiver operating characteristic curve of 0.89 (95% CI, 0.78-0.96) for identifying CUD. A threshold of less than monthly cannabis use balanced sensitivity (0.88) and specificity (0.83) for detecting CUD. In populations with a 6% prevalence of CUD, predictive values of a positive screen ranged from 17% to 34%, while predictive values of a negative screen ranged from 97% to 100%.

Conclusions and Relevance: In this diagnostic study, the SIS-C had excellent performance characteristics in routine care as a screen for CUD. While high negative predictive values suggest that the SIS-C accurately identifies patients without CUD, low positive predictive values indicate a need for further diagnostic assessment following positive results when screening for CUD in primary care.

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Gaps and Barriers in Drug and Alcohol Treatment Following Implementation of The Affordable Care Act

Journal: Drug and Alcohol Dependence Reports, 2022, doi.org/10.1016/j.dadr.2022.100115

Authors: Catherine Tomko, Mark Olfson & Ramin Mojtabai


Background: This study examines changes in the substance use disorder (SUD) treatment gap and barriers to treatment for low-income adults following Affordable Care Act (ACA) implementation.

Methods: National Survey on Drug Use and Health (NSDUH) data were pooled to assess pre-ACA (2009–2013) and post-ACA (2015–2019) implementation. The sample (n = 44,622) included respondents 18–64 years old, income <200% federal poverty level, and meeting SUD criteria for abuse or dependence of heroin, powdered cocaine, crack cocaine, marijuana, or alcohol. The primary outcome was NSDUH-defined past-year illicit drug or alcohol treatment gap (needing but not receiving SUD specialty treatment). A secondary analysis assessed barriers to SUD treatment including insurance-related barriers, stigma, barriers to access, priority of treatment, and no interest in stopping substance use.

Results: Ninety-three percent of respondents reported a drug or alcohol treatment gap before and after ACA implementation. No interest in stopping use was the greatest barrier (40%), followed by insurance-related barriers (39%) and stigma (20%). After adjusting for covariates, results did not show a significant change in SUD treatment gap post-ACA compared to pre-ACA (adjusted odds ratio [aOR]=1.11, 95% confidence interval [CI]=0.97, 1.28, p = 0.13). Compared to pre-ACA, odds of reporting stigma-related barriers (aOR=1.66, 95% CI=1.17, 2.37, p = 0.01) and access-related barriers (aOR=1.79, 95% CI=1.34, 2.38, p < 0.001) increased post-ACA.

Conclusions: There was no significant change in the prevalence of SUD treatment gap after ACA implementation. Increasing access to SUD treatment for low-income individuals will require intervening at multiple socioecological levels beyond reforming treatment financing.

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