ABSTRACT
Purpose: Adolescent health surveillance systems are critical for understanding patterns of marijuana use and generating data to evaluate changes in use following marijuana legalization and during the COVID-19 pandemic. The wording of survey questions may be misaligned with adolescents’ language about marijuana use and the ways they consume it. Our objectives were to compare terminology and prevalence of marijuana use between data from a local surveillance system and from a participatory research study. Methods: To understand marijuana use trajectories over the course of adolescence/young adulthood, we conducted the “Model Building with Adolescents on Peers, Partners, and Substance Use” (MAPPS) study. MAPPS was IRB-approved and included participatory group model building (GMB) with youth in Baltimore City. MAPPS participants were recruited from a health clinic and through community partners. Participants’ marijuana use was assessed with the eligibility screener, an enrollment survey, and through GMB exercises that were conducted over the course of four two-hour workshops. GMB exercises included structured activities with youth, including behavior over time graphs and documenting their mental models in real time. Two independent reviewers interpreted youths’ graphed estimates of marijuana use. Lifetime and past 30-day marijuana use prevalence estimates from MAPPS were compared to estimates from the Baltimore Youth Risk Behavior Survey (YRBS), which is conducted in partnership with CDC’s National YRBS program. Results: MAPPS participants (n=20) had an average age of 18;7 (35%) were male and 19 (95%) were Black. MAPPS participants almost exclusively used the terms weed and blunts for marijuana, whereas the Baltimore YRBS used the term marijuana, and mentioned that it was also called “pot, weed, or cannabis.” Results from MAPPS revealed several discrepancies between different assessments of marijuana use;100% reported lifetime use during GMB activities, whereas 50% (n=10) reported lifetime use on the eligibility screener and 60% (n=12) reported lifetime use on the enrollment survey. Collectively, MAPPS participants estimated that 86% of Baltimore 16-year-olds use marijuana, whereas data from the Baltimore YRBS indicate that 30.2% of eleventh graders report past 30-day use. MAPPS participants perceived that there was a high frequency of use among youth who use and explained that youth who “hit a blunt” off someone else, but who do not buy marijuana themselves, would be unlikely to self report as having used marijuana. Conclusions: Our participatory research with urban, Black youth suggests that the terminology they use for marijuana (i.e., weed, blunt) differs from terms used in local surveillance (e.g., marijuana, pot). We also found that they would consider prevalence estimates from surveillance studies to be underestimated because youth who consume peers’ blunts would not characterize themselves as having used marijuana. Therefore, surveillance questionnaires may be misestimating marijuana use due to discrepancies in terminology in questions versus in spoken language, and because collective use is not considered. Misestimations of use limit effective prevention programming, and bias studies that quantify changes in marijuana use following policy changes or during the pandemic. A more comprehensive understanding of patterns of marijuana use is an important step for improving surveillance, evaluation, and clinical assessment. Sources of Support: NIH K01DA035387.
ABSTRACT
Purpose: Many individuals with opioid use disorder or opioid overdose do not receive the recommended life-saving medication for opioid use disorder (MOUD), particularly adolescents and young adults. During the COVID-19 pandemic, opioid overdoses have substantially increased and existing health disparities in treatment access have worsened. Initiating treatment with MOUD for individuals presenting with opioid overdose to the Emergency Department (ED) has been demonstrated to increase access and improve treatment retention, decrease opioid use, and is cost-effective. ED MOUD induction programs now exist throughout the US, though Massachusetts was the first state to pass legislation in 2018 mandating that all acute-care hospitals that provide emergency services must be able to provide opioid agonist MOUD for individuals presenting with opioid overdose. We sought to characterize the formulation and policymaking process for this groundbreaking legislation, with particular attention to the role of research, personal stories, economic and public health considerations, and whether and how the specific needs of youth were addressed. Methods: We conducted semi-structured qualitative interviews between August and November 2019 with 10 key stakeholders from Massachusetts involved in the policymaking process from multiple sectors including state government, hospitals, physicians, and related recovery and behavioral health organizations. Two coders analyzed transcripts using a hybrid inductive-deductive approach based on themes identified using an iterative process. The study was deemed exempt as non-human subjects research by the Johns Hopkins School of Public Health IRB. Results: Key themes identified regarding factors in the policymaking process included the pressing need for action amidst an opioid overdose crisis and the strong role of research. Stakeholders agreed that the evidence was unequivocal that ED inductions save lives: “The fact that there's clear research and data that makes MAT evidence-based was critical…if you're objective and you're really concerned about the people coming into your hospital and your ED and you look at the research, it's clear.” Additional themes including multiple stakeholders coming together to collaborate throughout the process, overcoming financing and feasibility concerns including the necessity of budget-neutral legislation, processes taken to move towards feasible implementation, and a complete lack of youth consideration during the policymaking and initial implementation planning process. Conclusions: These study results suggest that rather than personal stories, research supporting the effectiveness of ED MOUD induction was the driving factor in passing the Massachusetts legislation, and that the success of this legislation is attributable to diverse stakeholders collaborating towards a common goal of increasing access to evidence-based treatment in an attempt to respond to the opioid epidemic. The unique needs of youth were not addressed in this policymaking process, and should be considered in future implementation and policymaking. Policymakers and advocates in other states may look towards this legislative process in Massachusetts as a model for implementing similar legislation as states grapple with worsening opioid-related morbidity and mortality in the wake of the COVID-19 pandemic. Sources of Support: Alinsky, Silva: T32HD052459.