ABSTRACT
BACKGROUND
There is limited data on the extent to which indicated alcohol interventions are delivered in U.S. ambulatory care settings.
OBJECTIVE
To assess the receipt of alcohol-related ...services, including assessment of use, advice to reduce drinking, and information about alcohol treatment, during ambulatory care visits.
DESIGN
Secondary data analysis of the 2013 National Survey on Drug Use and Health, a cross-sectional, nationally representative survey of civilians in the non-institutionalized U.S. general population (response rate 71.7 %).
PARTICIPANTS
Adult ambulatory care users in the public use data file who did not obtain emergency or inpatient services (
n
= 17,266).
MAIN MEASURES
Measurements included respondents’ alcohol consumption, heavy episodic drinking, alcohol use disorder, healthcare use, and receipt of alcohol-related interventions.
KEY RESULTS
Approximately 71.1 % of ambulatory care users received an alcohol assessment. Among past-month heavy episodic drinkers without an alcohol use disorder who reported receiving an alcohol assessment, 4.4 % were advised to cut back. Among individuals with alcohol abuse and alcohol dependence who reported receiving an alcohol assessment, 2.9 % and 7.0 %, respectively, were offered information about treatment.
CONCLUSIONS
Rates of alcohol screening and assessment were relatively high among adults who attended healthcare visits, but rates of intervention were low, even when individuals were assessed for use. Efforts are needed to expand delivery of interventions when patients are identified as positive for risky drinking, hazardous alcohol use, and alcohol use disorders during ambulatory care visits.
Compared to civilians, little is known about cannabis use among Veterans in the general United States (US) population. This study aimed to examine the prevalence and correlates of recent medical and ...non-medical cannabis use among this important US sub-population.
Data came from the 2014 National Survey on Drug Use and Health. Bivariate and multivariable analyses were conducted that were weighted to account for the complex survey design.
Approximately 9% of Veterans in the US reported past year cannabis use. Older, and female, Veterans had lower odds of past year cannabis use. Veterans who were unmarried, out of the work force, had greater functioning disability, nicotine dependence, heavy episodic alcohol use, alcohol use disorder, and drug use had greater odds of past year cannabis use. In states where medical cannabis was legal in 2014, approximately 41% of Veterans who used cannabis in the past year used medically. Those who used medically were older and less likely to engage in recent heavy episodic drinking or to meet criteria for alcohol abuse/dependence, compared to Veterans using non-medically.
Compared to non-Veterans in the US general population, recent cannabis use was similar or slightly lower among Veterans. However, among those with past year use, the proportion of those using medically was more than double that of the general population. Because only non-medical cannabis use was associated with higher rates of heavy episodic alcohol use and alcohol use disorder, it may be important to address problematic alcohol consumption among this high-risk group.
•9% of US Veterans reported past year cannabis use.•Heavy episodic alcohol use is related to non-medical cannabis use.•Alcohol use disorder is also related to non-medical cannabis use.•41% of Veterans using cannabis reported that they used cannabis medically.
To investigate cannabis smoking and tobacco cigarette smoking in relation to adenomyosis risk.
We used data from a case-control study of adenomyosis conducted among enrollees ages 18-59 years of an ...integrated health care system in Washington State. The case-control study used 2 control groups given the challenge of selecting noncases when cases are diagnosed by hysterectomy.
Cases (n = 386) were enrollees with incident, pathology-confirmed adenomyosis diagnosed between April 1, 2001, and March 31, 2006. The 2 control groups comprised hysterectomy controls (n = 233) with pathology-confirmed absence of adenomyosis and population controls (n = 323) with an intact uterus selected randomly from the health care system population and frequency matched to cases on age.
Detailed data on cannabis and tobacco cigarette smoking history were ascertained through in-person structured interviews, allowing estimation of joint-years of cannabis smoking and pack-years of tobacco cigarette smoking.
Odds ratios (ORs) and 95% confidence intervals (CIs) for the associations between cannabis smoking, tobacco cigarette smoking, and adenomyosis were estimated using multivariable unconditional logistic regression. Analyses were adjusted for age, reference year, menarche age, education, and pack-years of cigarette smoking (or joint-years of cannabis smoking).
No association was observed between cannabis smoking history and adenomyosis risk. However, we did observe the suggestion of an association between ever tobacco cigarette smoking and adenomyosis risk, comparing cases to hysterectomy controls (OR, 1.3; 95% CI, 0.9-1.9) and population controls (OR, 1.2; 95% CI, 0.8-1.8). Our data suggested a 50% increased odds of adenomyosis with >15 pack-years of smoking (vs. never smoking), comparing cases to hysterectomy controls (OR, 1.5; 95% CI, 0.9-2.6; P
=.135). The suggestion of a 40% increased adenomyosis odds was observed with smoking >5-15 pack-years (vs. never smoking), comparing cases to population controls (OR, 1.4; 95% CI, 0.8-2.4; P
=0.136).
In the first study of cannabis smoking and adenomyosis risk, no association was observed. However, our data suggested an increased odds of adenomyosis with history of tobacco cigarette smoking. Further research is warranted to replicate our results given the substantial morbidity with adenomyosis and frequency of cigarette smoking and recreational and medical cannabis use.
Background and aims
Research from cohorts of individuals with recreational cannabis use indicates that cannabis withdrawal symptoms are reported by more than 40% of those using regularly. Withdrawal ...symptoms are not well understood in those who use cannabis for medical purposes. Therefore, we prospectively examined the stability of withdrawal symptoms in individuals using cannabis to manage chronic pain.
Design, Setting, Participants
Using latent class analysis (LCA) we examined baseline cannabis withdrawal to derive symptom profiles. Then, using latent transition analysis (LTA) we examined the longitudinal course of withdrawal symptoms across the time points. Exploratory analyses examined demographic and clinical characteristics predictive of withdrawal class and transitioning to more or fewer withdrawal symptoms over time.
A cohort of 527 adults with chronic pain seeking medical cannabis certification or re‐certification was recruited between February 2014 and June 2015. Participants were recruited from medical cannabis clinic waiting rooms in Michigan, USA. Participants were predominantly white (82%) and 49% identified as male, with an average age of 45.6 years (standard deviation = 12.8).
Measurements
Baseline, 12‐month and 24‐month assessments of withdrawal symptoms using the Marijuana Withdrawal Checklist–revised.
Findings
A three‐class LCA model including a mild (41%), moderate (34%) and severe (25%) symptom class parsimoniously represented withdrawal symptoms experienced by people using medical cannabis. Stability of withdrawal symptoms using a three‐class LTA at 12 and 24 months ranged from 0.58 to 0.87, with the most stability in the mild withdrawal class. Younger age predicted greater severity and worsening of withdrawal over time.
Conclusions
Adults with chronic pain seeking medical cannabis certification or re‐certification appear to experience mild to severe withdrawal symptoms. Withdrawal symptoms tend to be stable over a 2‐year period, but younger age is predictive of worse symptoms and of an escalating withdrawal trajectory.
•Cigarette and cannabis use in adults is changing across rural and urban America.•Rural geographic disparities in cigarette smoking are increasingly pronounced.•Cannabis use increased the most in ...rural non-cigarette smokers.•Cannabis users are no longer predominantly cigarette smokers.
Rural-urban differences in cigarette and cannabis use have traditionally shown higher levels of cigarette smoking in rural areas and of cannabis use in urban areas. To assess for changes in this pattern of use, we examined trends and prevalence of cigarette, cannabis, and co-use across urban-rural localities.
Urban-rural trends in current cigarette and/or cannabis use was evaluated using 11 cohorts (2007–2017) of the National Survey on Drug Use and Health (NSDUH; N = 397,542). We used logistic regressions to model cigarette and cannabis use over time, adjusting for demographics (age, gender, race/ethnicity, income, education), in addition to assessing patterns of cannabis use among cigarette smokers and nonsmokers.
Despite decreases in cigarette smoking overall, between 2007 and 2017, the urban-rural disparity in cigarette smoking increased (AOR = 1.17), with less reduction in rural as compared to urban cigarette smokers. Cannabis use increased in general (AOR = 1.88 by 2017), with greater odds in urban than rural regions. Cannabis use increased more rapidly in non-cigarette smokers than smokers (AOR = 1.37 by 2017), with 219% greater odds of cannabis use in rural non-cigarette smokers in 2017 versus 2007.
Rurality remains an important risk factor for cigarette smoking in adults and the fastest-growing group of cannabis users is rural non-cigarette smokers; however, cannabis use is currently still more prevalent in urban areas. Improved reach and access to empirically-supported prevention and treatment, especially in rural areas, along with dissemination and enforcement of policy-level regulations, may mitigate disparities in cigarette use and slow the increase in rural cannabis use.
The authors sought to estimate the prevalence of past-12-month and lifetime cannabis use and cannabis use disorder among U.S. veterans; to describe demographic, substance use disorder, and ...psychiatric disorder correlates of nonmedical cannabis use and cannabis use disorder; and to explore differences in cannabis use and cannabis use disorder prevalence among veterans in states with and without medical marijuana laws.
Participants were 3,119 respondents in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) who identified as U.S. veterans. Weighted prevalences were calculated. Logistic regression analyses tested associations of nonmedical cannabis use and cannabis use disorder with demographic and clinical correlates and examined whether prevalence differed by state legalization status.
The prevalences of any past-12-month cannabis use and cannabis use disorder were 7.3% and 1.8%, respectively. Lifetime prevalences were 32.5% and 5.7%, respectively. Past-12-month and lifetime cannabis use disorder prevalence estimates among nonmedical cannabis users were 24.4% and 17.4%, respectively. Sociodemographic correlates of nonmedical cannabis use and use disorder included younger age, male gender, being unmarried, lower income, and residing in a state with medical marijuana laws. Nonmedical cannabis use and use disorder were associated with most psychiatric and substance use disorders examined.
Among veterans, the odds of nonmedical cannabis use and use disorder were elevated among vulnerable subgroups, including those with lower income or psychiatric disorders and among survey participants residing in states with medical marijuana laws. The study findings highlight the need for clinical attention (e.g., screening, assessment) and ongoing monitoring among veterans in the context of increasing legalization of cannabis.
Individuals with regular cannabis use demonstrate adverse health outcomes, yet infrequently seek treatment. Insomnia, a common co-occurring complaint, could be targeted to reduce cannabis use and ...improve functioning in these individuals. In an intervention development study, we refined and tested the preliminary efficacy of a telemedicine-delivered CBT for insomnia tailored to individuals with regular cannabis use for sleep (CBTi-CB-TM).
In this single-blind randomized trial, fifty-seven adults (43 women, mean age 37.6 ± 12.8 years) with chronic insomnia and cannabis use for sleep ≥3 times/week received CBTi-CB-TM (n = 30) or sleep hygiene education (SHE-TM, n = 27). Participants completed self-reported assessments of insomnia (Insomnia Severity Index ISI) and cannabis use (Timeline Followback TLFB and daily diary data) at pre-treatment, post-treatment, and 8-week follow-up.
ISI scores improved significantly more in the CBTi-CB-TM compared to SHE-TM condition (β = −2.83, se=0.84, P = 0.004, d=0.81). At 8-week follow-up, 18/30 (60.0 %) CBTi-CB-TM compared to 4/27 (14.8 %) SHE-TM participants were in remission from insomnia (X2 =12.8, P = 0.0003). The TLFB showed a small reduction in past 30-day cannabis use for both conditions (β = −0.10, se=0.05, P = 0.026); CBTi-CB-TM participants demonstrated greater post-treatment reductions in the % of days cannabis was used within 2 h of bedtime (−29.1 ± 7.9 % fewer days vs. 2.6 ± 8.0 % more days, P = 0.008).
CBTi-CB-TM is feasible, acceptable, and demonstrated preliminary efficacy for improving sleep and cannabis-related outcomes among non-treatment-seeking individuals with regular cannabis use for sleep. Although sample characteristics limit generalizability, these findings support the need for adequately powered randomized controlled trials with longer follow-up periods.
•Individuals who regularly use cannabis for sleep frequently have insomnia.•CBT for insomnia is feasible and acceptable in those who use cannabis for sleep.•CBT for insomnia may improve insomnia and reduce cannabis use before bedtime.
Purpose
To identify temporal patterns of emergency dispatches as initiated by Veteran Crisis Line (VCL) responders and among moderate‐ and high‐risk contacts.
Methods
Incidence rate ratios (IRRs) ...were used to examine the incidence of emergency dispatches among all 1,437,543 VCL contacts across 2019–2020.
Results
Emergency dispatches were initiated in 57,077 (4.0%) contacts. IRRs were elevated during Labor Day, IRR (95% CI) = 1.33 (1.15–1.54), and Independence Day, IRR (95% CI) = 1.22 (1.05–1.43), weekends, Saturdays, IRR (95% CI) = 1.04 (1.01–1.08), Sunday (reference), and 6 pm to 11:59 pm, IRR (95% CI) = 1.06 (1.04–1.09). IRRs for moderate‐ and high‐risk contacts were higher on Memorial Day, IRR (95% CI) = 1.16 (1.00–1.33), Sunday (reference), and 6 pm to 11:59 pm (reference).
Conclusions
The initiation of emergency dispatches fluctuates over time and were highest during Labor Day and Independence Day, weekends, and evenings. Moderate‐ and high‐risk contact also fluctuate over time and were highest on Memorial Day, Sundays, and midnight to 5:59 am. VCL policy makers can use knowledge of temporal fluctuations to allocate public health resources for increased efficiency and greatest impact; however, additional research on temporal stability and generalizability is needed.
The study examined whether same-day integrated mental health services are associated with increased diagnosis and treatment initiation among primary care patients with positive posttraumatic stress ...disorder (PTSD) screens.
Data were from a national sample of Veterans Health Administration (VHA) primary care patients with a positive PTSD screen (N=21,427). Patients were assessed for PTSD diagnosis and treatment initiation on the screening day and ≤ 7 days, ≤ 12 weeks, ≤ 6 months, and ≤ 1 year after screening positive. The service setting on screening day was categorized as primary care only, same-day primary care-mental health integration (PC-MHI), or same-day specialty mental health care. Multivariable generalized estimating equations logistic regression was used to estimate associations between category of screening day services and diagnosis and treatment initiation, with adjustment for demographic characteristics, prior psychiatric diagnoses, prior VHA service utilization, and PTSD screen score.
Of the 21,427 patients with positive PTSD screens, 10,809 (50.4%) received a diagnosis within one year of screening positive. Same-day PC-MHI services were associated with greater odds of PTSD diagnosis, both on the same day as (odds ratio OR=2.23) and one year (OR=1.67) after screening positive compared with primary care-only services (p<.001). Among those who received a diagnosis on the same day as their positive screen, same-day PC-MHI services were associated with increased odds of initiating PTSD treatment (OR=3.39) within 12 weeks of diagnosis, compared with primary care only (p<.001).
Same-day integrated mental health services may help facilitate PTSD diagnosis and treatment initiation after a positive screen.
To evaluate national trends in incident varenicline and nicotine replacement therapy (NRT) prescribing among Department of Veterans Affairs (VA) beneficiaries before and after US Food and Drug ...Administration (FDA) warnings regarding neuropsychiatric side effects with varenicline use.
All adult VA patients identified as smokers from 2007 to 2019 (N = 3,600,947) were determined and monthly counts of new varenicline and NRT users were calculated. An interrupted time-series analysis estimated the effect of the FDA warnings on varenicline and NRT prescribing overall and among Veterans with and without mental health disorders.
The incident use rate of varenicline decreased from a peak of 6.2 per 1,000 veteran smokers in October 2007 to 1.0 by July 2009 following the first FDA warning (pre-warning monthly slope = -0.27;
= .03). New NRT use increased from 10.7 per 1,000 veteran smokers in October 2007 to a peak of 12.6 per 1,000 in July 2009 (slope change = 0.71;
= .01), suggesting potential substitution. Following removal of the FDA boxed warning in December 2016, varenicline prescribing increased but did not return to pre-warning levels by December 2019. Among veterans with and without mental health disorders, varenicline use decreased 90% and 88%, respectively, following the first FDA warning, and both groups had comparable rates of new NRT use.
Following the first FDA warning, incident use of varenicline declined significantly among veterans both with and without mental health disorders. Despite removal of the FDA boxed warning in December 2016, new use of varenicline had not returned to pre-warning levels 3 years following the removal.
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