Alcohol Use Disorder Visits and Suicide Ideation Diagnosis: Racial/Ethnic Differences at Emergency Departments.

INTRODUCTION: Nationally, suicide ideation prevalence is comparable among White, American Indian/Alaska Native, Black, and Hispanic adults experiencing alcohol use disorder. This study examines whether such comparability extends to the probability of receiving a suicide ideation diagnosis when presenting with alcohol use disorder at emergency departments. The probability of hospitalization following such diagnosis is examined as well. METHODS: National Emergency Department Sample (2019) data were used. Logistic and multilevel logistic regression analyses were performed in 2022-2023 with suicide ideation diagnosis and subsequent hospitalization as the outcome variables. Control variables included demographics, payor, alcohol use disorder level, comorbidities, and emergency department facility. Adjusted probabilities were computed. RESULTS: Age-adjusted probabilities of suicide ideation diagnoses for American Indian/Alaska Native, Black, and Hispanic patients with alcohol use disorder were 5.4%, 6.7%, and 4.9% (95% CIs=3.7, 7.1; 6.0, 7.4; 4.4, 5.4), respectively; all less than that for White counterparts (8.7%; 95% CI=8.2, 9.2). Among patients with alcohol use disorder plus suicide ideation diagnoses, the age-adjusted probability of hospitalization for American Indians/Alaska Natives (32.4%; 95% CI=20.9, 44.0) was less than that for Whites, Blacks, and Hispanics (49.8%, 52.3%, and 49.9%; 95% CIs=46.7, 52.8; 47.1, 57.5; and 43.9, 55.8, respectively). In regressions with multiple control variables, the racial/ethnic differences remained statistically significant (p<0.05). CONCLUSIONS: Diagnosis of suicide ideation, a key step in emergency department suicide prevention care, occurred significantly less often for patients of color with alcohol use disorder than for White counterparts. American Indians/Alaska Natives, the racial/ethnic group known to have the nation's highest suicide rate, had the lowest probability of being hospitalized after a diagnosis of alcohol use disorder plus suicide ideation.

Writing Support Group for Medical School Faculty-A Simple Way to Do It.

Problem: Writing for publication is a core activity for many medical school faculty, but faculty report numerous challenges to publication. To help address these challenges, some medical schools establish writing support programs, but those programs are often resource-intensive, involving didactic courses, accountability groups, formal mentorships, and even assistance from professional writers. Not all medical schools, however, provide resources for such programs, and many faculty members, especially clinicians, lack time needed to participate. Furthermore, success of these programs is typically judged by the total number of papers published. However, many clinicians would judge success as publication of the occasional papers they decide to write, not the total number of papers they or the group publish. With these issues in mind, we established a low-resource writing program focused on individual acceptance rates rather than total publications. Intervention: Our writing program is an informal group that meets monthly. Members bring their ideas for papers and drafts of papers, and other members provide critique and suggestions for improvement. Members then revise their papers to address that critique prior to journal submission. There are no formal or assigned mentors, courses, lectures, or writing assistants. Context: The program takes place in our family medicine department, in which faculty have various roles. Some group members are clinician-educators seeking to publish occasional clinical reviews or research articles; others are PhDs seeking to publish on aspects of their work. Impact: During the six years of the program, 86% of papers reviewed by the group were accepted for publication and 94% of those were accepted by the journal to which they were first submitted. Publication success rate of individual members averaged 79%. This exceeds the 30-40% acceptance rate for scholarly journals worldwide. Group members published an average of 5.2 papers per member, with some publishing as few as 2-3 papers and others as many as 10-11. Lessons Learned: An informal, low-resource writing program in medical school departments can help faculty reach their publication goals. We found that members were satisfied by having the group help them publish whatever number of papers they decided to write. The program's simple, informal approach fostered a culture of respectful and collegial interactions, in which members learned to depend on and accept critiques from colleagues. Finally, an unexpected benefit of our program resulted from membership of both clinicians and non-clinicians. This provided feedback from individuals with different perspectives, which enhanced development of manuscripts.

Services and Challenges at a Native American Residential Substance Use Disorder Treatment Center during the COVID-19 Pandemic.

During the COVID-19 pandemic, challenges arose for a Native American residential substance use disorder treatment program in California (e.g., insufficient housing for quarantining, inadequate telehealth bandwidth, food shortages, client skepticism regarding safety needs). These challenges were addressed, culturally appropriate services continued, no clients tested positive for COVID-19, and unexpected benefits arose.

Competency Status and Desire for Training in Core Public Health Domains: An Analysis by Job Level.

CONTEXT: Although trainings on core public health domains are widely available, and experts concur that competency in multiple core domains (analysis/assessment, leadership, communication, etc) is desirable for public health professionals, many still lack such competency. Employee job level could be a factor, as organizational research indicates that broad skill sets often hold importance mainly for higher-level employees. OBJECTIVE: This study examines whether the association between competency and desire for training in core public health domains depends on job level. DESIGN: A training preferences and domain competency survey of public health professionals: nonmanagers (n = 790), middle managers (n = 332), and upper managers (n = 69). The association of competency in domains overall with number of related training topics desired was examined using median tests. The association of competency in individual domains with desire for specific related training topics was assessed using logistic regressions adjusted for education. SETTINGS: Public health departments in the US Southwest (2013-2019). MAIN OUTCOME MEASURES: Competence in core domains: Financial Planning and Management, Analysis/Assessment, Communication, Cultural Competency, Leadership/Systems Thinking, Policy Development/Program Planning, Public Health Sciences, and Community Dimensions of Practice. Desire for training (yes/no) in 25 domain-related topics. RESULTS: Upper managers lacking overall competence in core domains desired more training topics than their competent counterparts (median of 12 topics vs 5, P = .02). In contrast, nonmanagers lacking overall competence desired fewer topics than their competent counterparts (4 vs 6, P < .001). Upper managers with lesser competency in an individual domain often had significantly higher odds of desiring training related to the domain, but the opposite was found for nonmanagers. Among middle managers, little association between competency and training desire was found. CONCLUSIONS: Ideally, lesser competence in core domains would be accompanied by greater desire for ameliorative training, but only upper managers exhibited this pattern. Efforts are needed to better connect domain competency status and training desire among nonmanagers and middle managers.

Gender, psychiatric disability, and dropout from peer support specialist training.

Although research indicates that the prevalence of psychiatric disability differs depending on gender, a paucity of information exists as to whether men and women with psychiatric disability also differ regarding service program outcomes. For a United States Southwest peer support specialist training program, this study examines whether gender moderates the association between psychiatric disability and a key outcome-training dropout. Data were collected for 78 men and 157 women with psychiatric disability and 137 men and 203 women with mental illness only. Logistic regression was used to examine the association between psychiatric disability and dropout, with gender as a moderator variable, and age, education, race/ethnicity, and substance use disorder as control variables. Of trainees with psychiatric disability, dropout was greater among men than women (34.6% and 20.4%, respectively; p < .05). Dropout was also greater among men with psychiatric disability than among men with mental illness only (34.6% and 15.3%; p < .01). In contrast, dropout was similar for women with psychiatric disability and mental illness only (20.4% and 18.7%; p > .05), and dropout was comparable among men and women with mental illness only (15.3% and 18.7%; p > .05). In summary, risk of dropout was substantially higher among men with psychiatric disability than women with psychiatric disability. Gender tailoring of the program's services should be considered to better support training completion. This study's findings also raise questions as to possible underrepresentation of men with psychiatric disability in the peer support workforce training pipeline. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Dual Diagnosis and Alcohol/Nicotine Use Disorders: Native American and White Hospital Patients in 3 States.

INTRODUCTION: Nationally, mental illness prevalence is comparable among Native Americans and Whites experiencing alcohol and nicotine use disorders. However, authors are concerned that mental illness in Native Americans with substance use disorders may be disparately underdiagnosed in medical settings. For 3 states with large Native American populations, this study compares the prevalence of mental illness diagnoses among Native Americans and Whites hospitalized with alcohol/nicotine use disorders. METHODS: In 2021, hospital discharge data were used to compare non-Hispanic Native Americans with non-Hispanic Whites in Arizona and New Mexico (2016-2018) and (regardless of Hispanic ethnicity) Native Americans with Whites in Oklahoma (2016-2017). Differences in any mental illness, mood, and anxiety diagnoses were assessed using multilevel regressions (adjusted for demographics, payor, comorbidities, facility). Adjusted predicted probabilities were constructed. RESULTS: Among alcohol-related discharges, probabilities of non-Hispanic Native Americans and non-Hispanic Whites receiving any mental illness diagnoses in Arizona were 18.0% (95% CI=16.1, 19.9) and 36.8% (95% CI=34.1, 39.5), respectively; in New Mexico, they were 24.5% (95% CI=20.7, 28.3) and 43.4% (95% CI=38.7, 48.1). Oklahoma's probabilities for Native Americans and Whites were 30.7% (95% CI=27.4, 34.0) and 36.8% (95% CI=33.5, 40.2), respectively. Among nicotine-related discharges, any mental illness diagnosis probabilities for non-Hispanic Native Americans and non-Hispanic Whites in Arizona were 21.2% (95% CI=18.9, 23.5) and 33.1% (95% CI=30.3, 35.9), respectively; in New Mexico, they were 25.9% (95% CI=22.7, 29.1) and 37.4% (95% CI=33.8, 40.9). Oklahoma's probabilities for Native Americans and Whites were 27.3% (95% CI=25.1, 29.6) and 30.2% (95% CI=28.0, 32.4), respectively. Mood and anxiety diagnoses were also significantly lower for non-Hispanic Native Americans in Arizona/New Mexico and Native Americans in Oklahoma. CONCLUSIONS: Findings suggest disparate underdiagnosis of mental illness among Native Americans hospitalized with alcohol/nicotine use disorders in the examined states.

With socioeconomic status controlled, cigarette use is lower among American Indians/Alaska Natives than whites.

BACKGROUND: Higher crude prevalence of cigarette use among American Indians/Alaska Natives (AI/AN) than non-Hispanic whites (NHW) has helped engender an assumption that race/ethnicity explains the difference. This study examines whether being AI/AN versus NHW predicts greater use when socioeconomic status and demographics are controlled. METHODS: Data came from the National Survey on Drug Use and Health (2013-2017). Using logistic regressions with socioeconomic (income, education) and demographic (gender, age, marital status) controls, differences between AI/AN (n = 4,305) and NHW (n = 166,348) regarding heavier cigarette use (past month daily use, past month use of 300+ cigarettes, and nicotine dependence) and current cigarette use (past month use plus 100+ cigarettes in lifetime) were assessed. Adjusted predicted probabilities were also constructed. RESULTS: NHW, compared to AI/AN, had greater odds of daily use: adjusted odds ratio (AOR) = 1.23 (95% CI: 1.03-1.49); predicted probabilities-15.3% and 13.0%, respectively. NHW had greater odds of using 300+ cigarettes: AOR = 1.47 (CI: 1.19-1.83); predicted probabilities-13.6% and 9.9%. NHW had greater odds of being nicotine dependent: AOR = 1.57 (CI: 1.31-1.89); predicted probabilities-10.3% and 7.1%. A difference in current use was not found. As controls, income and education were especially impactful. CONCLUSIONS: With controls, particularly for socioeconomic status, heavier cigarette use was lower among AI/AN than NHW, and a current cigarette use difference was not indicated. This contradicts the idea that being AI/AN versus NHW independently predicts greater cigarette use, and it underscores the importance of socioeconomic status for understanding cigarette use among AI/AN.

Cigarette Use Among American Indians and Alaska Natives in Metropolitan Areas, Rural Areas, and Tribal Lands.

CONTEXT: Cigarette use among the US general population is significantly lower in metropolitan areas than in rural areas. OBJECTIVE: To assess whether cigarette use among American Indians and Alaska Natives (AI/AN) is lower in metropolitan areas than in rural areas and tribal lands (which are predominantly rural). DESIGN: Data came from the National Survey on Drug Use and Health (2012-2016). Regressions with adjustments for demographics were performed to assess whether cigarette use differed in association with type of place. SETTINGS: The AI/AN in tribal lands (n = 1569), nontribal large metropolitan (1+ million people) areas (n = 582), nontribal small metropolitan (<1 million) areas (n = 1035), and nontribal rural areas (n = 1043). MAIN OUTCOME MEASURES: Cigarette abstinence, current smoking, daily use, number of cigarettes used, and days of use-all in the past month. Nicotine dependence was also examined. RESULTS: Metropolitan (large or small) areas versus rural areas: no statistically significant differences in cigarette use were found. Metropolitan (large or small) areas versus tribal lands: days of cigarette use and daily use were significantly lower in tribal lands. Tribal lands were also lower than small metropolitan areas regarding number of cigarettes used and nicotine dependence. Rural areas versus tribal lands: cigarette measures were consistently lower in tribal lands. For example, the prevalence of current smokers, daily users and nicotine dependence, respectively, was 37.9%, 25.9%, and 16.3% in rural areas and 27.4%, 13.6%, and 8.9% in tribal lands. CONCLUSIONS: Differences in cigarette use between AI/AN in nontribal rural and metropolitan areas were not indicated. Instead, the place differences found were lower cigarette use in tribal lands than in nontribal rural areas and, to some extent, metropolitan areas. These findings can help inform policy makers working to develop context-sensitive anticommercial tobacco efforts for AI/AN.

Impacts of Canada's minimum age for tobacco sales (MATS) laws on youth smoking behaviour, 2000-2014.

BACKGROUND: Recently, the US Institute of Medicine has proposed that raising the minimum age for tobacco purchasing/sales to 21 years would likely lead to reductions in smoking behavior among young people. Surprisingly few studies, however, have assessed the potential impacts of minimum-age tobacco restrictions on youth smoking. OBJECTIVE: To estimate the impacts of Canadian minimum age for tobacco sales (MATS) laws on youth smoking behaviour. DESIGN: A regression-discontinuity design, using seven merged cycles of the Canadian Community Health Survey, 2000-2014. PARTICIPANTS: Survey respondents aged 14-22 years (n=98 320). EXPOSURE: Current Canadian MATS laws are 18 years in Alberta, Saskatchewan, Manitoba, Quebec, the Yukon and Northwest Territories, and 19 years of age in the rest of the country. MAIN OUTCOMES: Current, occasional and daily smoking status; smoking frequency and intensity; and average monthly cigarette consumption. RESULTS: In comparison to age groups slightly younger than the MATS, those just older had significant and abrupt increases immediately after the MATS in the prevalence of current smokers (absolute increase: 2.71%; 95% CI 0.70% to 4.80%; P=0.009) and daily smokers (absolute increase: 2.43%; 95% CI 0.74% to 4.12%; P=0.005). Average past-month cigarette consumption within age groups increased immediately following the MATS by 18% (95% CI 3% to 39%; P=0.02). There was no evidence of significant increases in smoking intensity for daily or occasional smokers after release from MATS restrictions. CONCLUSION: The study provides relevant evidence supporting the effectiveness of Canadian MATS laws for limiting smoking among tobacco-restricted youth.

Development and evaluation of the See Me Smoke-Free multi-behavioral mHealth app for women smokers.

Women face particular challenges when quitting smoking, especially those with weight concerns. A multi-behavioral smoking cessation intervention addressing these concerns and incorporating guided imagery may assist women to engage in healthy lifestyle behaviors. An mHealth app can easily disseminate such an intervention. The goals of this pilot study were to develop and test the feasibility and potential of the See Me Smoke-Free™ mHealth app to address smoking, diet, and physical activity among women smokers. We used pragmatic, direct-to-consumer methods to develop and test program content, functionality, and the user interface and conduct a pre-/post-test, 90-day pilot study. We enrolled 151 participants. Attrition was 52%, leaving 73 participants. At 90 days, 47% of participants reported 7-day abstinence and significant increases in physical activity and fruit consumption. Recruitment methods worked well, but similar to other mHealth studies, we experienced high attrition. This study suggests that a guided imagery mHealth app has the potential to address multiple behaviors. Future research should consider different methods to improve retention and assess efficacy.

Lessons learned in the development and evaluation of RxCoach™, an mHealth app to increase tobacco cessation medication adherence.

OBJECTIVE: In this project we developed and evaluated a mobile health app to improve adherence to tobacco cessation medication. METHODS: The study was conducted in three phases: (1) Create app with input from our consultant, focus groups and user testing; (2) Test feasibility of the app; and (3) Develop and user-test the barcode scanner. RESULTS: Focus group feedback was instrumental in developing content and creating the user interface. User testing helped to identify problems and refine the app. The feasibility trial provided "real world" testing. We experienced challenges in recruitment due to the inclusion criteria. We had high attrition due to technical issues, medication side effects, enrollment procedures, and lack of personal contact. Among the five retained participants, use of the app was associated with good medication adherence and high consumer satisfaction. CONCLUSION: The small sample size limits the generalizability of the findings and the conclusions that can be drawn from the study. However, the feasibility trial enabled the team to identify ways to improve the conduct of this and other mHealth studies. PRACTICAL IMPLICATIONS: We should expand RxCoach to include all prescription and over-the-counter tobacco cessation medications, and re-test for feasibility using lessons learned to improve recruitment and retention.

Essential/precursor chemicals and drug consumption: impacts of US sodium permanganate and Mexico pseudoephedrine controls on the numbers of US cocaine and methamphetamine users.

BACKGROUND AND AIMS: In December 2006 the United States regulated sodium permanganate, a cocaine essential chemical. In March 2007 Mexico, the United States' primary source for methamphetamine, closed a chemical company accused of illicitly importing 60+ tons of pseudoephedrine, a methamphetamine precursor chemical. US cocaine availability and methamphetamine availability, respectively, decreased in association. This study tested whether the controls had impacts upon the numbers of US cocaine users and methamphetamine users. DESIGN: Auto-regressive integrated moving average (ARIMA) intervention time-series analysis. Comparison series-heroin and marijuana users-were used. SETTING: United States, 2002-14. PARTICIPANTS: The National Survey on Drug Use and Health (n = 723 283), a complex sample survey of the US civilian, non-institutionalized population. MEASUREMENTS: Estimates of the numbers of (1) past-year users and (2) past-month users were constructed for each calendar quarter from 2002 to 2014, providing each series with 52 time-periods. FINDINGS: Downward shifts in cocaine users started at the time of the cocaine regulation. Past-year and past-month cocaine users series levels decreased by approximately 1 946 271 (-32%) (P < 0.05) and 694 770 (-29%) (P < 0.01), respectively-no apparent recovery occurred through 2014. Downward shifts in methamphetamine users started at the time of the chemical company closure. Past-year and past-month methamphetamine series levels decreased by 494 440 (-35%) [P < 0.01; 95% confidence interval (CI) = -771 897, -216 982] and 277 380 (-45%) (P < 0.05; CI = -554 073, -686), respectively-partial recovery possibly occurred in 2013. The comparison series changed little at the intervention times. CONCLUSIONS: Essential/precursor chemical controls in the United States (2006) and Mexico (2007) were associated with large, extended (7+ years) reductions in cocaine users and methamphetamine users in the United States.

Alcohol use among Native Americans compared to whites: Examining the veracity of the 'Native American elevated alcohol consumption' belief.

BACKGROUND: This study uses national survey data to examine the veracity of the longstanding belief that, compared to whites, Native Americans (NA) have elevated alcohol consumption. METHODS: The primary data source was the National Survey on Drug Use and Health (NSDUH) from 2009 to 2013: whites (n=171,858) and NA (n=4,201). Analyses using logistic regression with demographic covariate adjustment were conducted to assess differences in the odds of NA and whites being alcohol abstinent, light/moderate drinkers (no binge/heavy consumption), binge drinkers (5+ drinks on an occasion 1-4 days), or heavy drinkers (5+ drinks on an occasion 5+ days) in the past month. Complementary alcohol abstinence, light/moderate drinking and excessive drinking analyses were conducted using Behavioral Risk Factor Surveillance System (BRFSS) data from 2011 to 2013: whites (n=1,130,658) and NA (n=21,589). RESULTS: In the NSDUH analyses, the majority of NA, 59.9% (95% CI: 56.7-63.1), abstained, whereas a minority of whites, 43.1% (CI: 42.6-43.6), abstained-adjusted odds ratio (AOR): 0.64 (CI: 0.56-0.73). Approximately 14.5% (CI: 12.0-17.4) of NA were light/moderate-only drinkers, versus 32.7% (CI: 32.2-33.2) of whites (AOR: 1.90; CI: 1.51-2.39). NA and white binge drinking estimates were similar-17.3% (CI: 15.0-19.8) and 16.7% (CI: 16.4-17.0), respectively (AOR: 1.00; CI: 0.83-1.20). The two populations' heavy drinking estimates were also similar-8.3% (CI: 6.7-10.2) and 7.5% (CI: 7.3-7.7), respectively (AOR: 1.06; CI: 0.85-1.32). Results from the BRFSS analyses generally corroborated those from NSDUH. CONCLUSIONS: In contrast to the 'Native American elevated alcohol consumption' belief, Native Americans compared to whites had lower or comparable rates across the range of alcohol measures examined.

See Me Smoke-Free: Protocol for a Research Study to Develop and Test the Feasibility of an mHealth App for Women to Address Smoking, Diet, and Physical Activity.

BACKGROUND: This paper presents the protocol for an ongoing research study to develop and test the feasibility of a multi-behavioral mHealth app. Approximately 27 million women smoke in the US, and more than 180,000 women die of illnesses linked to smoking annually. Women report greater difficulties quitting smoking. Concerns about weight gain, negative body image, and low self-efficacy may be key factors affecting smoking cessation among women. Recent studies suggest that a multi-behavioral approach, including diet and physical activity, may be more effective at helping women quit. Guided imagery has been successfully used to address body image concerns and self-efficacy in our 3 target behaviors-exercise, diet and smoking cessation. However, it has not been used simultaneously for smoking, diet, and exercise behavior in a single intervention. While imagery is an effective therapeutic tool for behavior change, the mode of delivery has generally been in person, which limits reach. mHealth apps delivered via smart phones offer a unique channel through which to distribute imagery-based interventions. OBJECTIVE: The objective of our study is to evaluate the feasibility of an mHealth app for women designed to simultaneously address smoking, diet, and physical activity behaviors. The objectives are supported by three specific aims: (1) develop guided imagery content, user interface, and resources to reduce weight concern, and increase body image and self-efficacy for behavior change among women smokers, (2) program a prototype of the app that contains all the necessary elements of text, graphics, multimedia and interactive features, and (3) evaluate the feasibility, acceptability, and preliminary efficacy of the app with women smokers. METHODS: We created the program content and designed the prototype application for use on the Android platform in collaboration with 9 participants in multiple focus groups and in-depth interviews. We programmed and tested the application's usability with 6 participants in preparation for an open, pre- and posttest trial. Currently, we are testing the feasibility and acceptability of the application, evaluating the relationship of program use to tobacco cessation, dietary behaviors, and physical activity, and assessing consumer satisfaction with approximately 70 women smokers with Android-based smart phones. RESULTS: The study was started January 1, 2014. The app was launched and feasibility testing began in April 1, 2015. Participants were enrolled from April 1-June 30, 2015. During that time, the app was downloaded over 350 times using no paid advertising. Participants were required to use the app "most days" for 30 days or they would be dropped from the study. We enrolled 151 participants. Of those, 78 were dropped or withdrew from the study, leaving 73 participants. We have completed the 30-day assessment, with a 92% response rate. The 90-day assessment is ongoing. During the final phase of the study, we will be conducting data analyses and disseminating study findings via presentations and publications. Feasibility will be demonstrated by successful participant retention and a high level of app use. We will examine individual metrics (eg, duration of use, number of screens viewed, change in usage patterns over time) and engagement with interactive activities (eg, activity tracking). CONCLUSIONS: We will aggregate these data into composite exposure scores that combine number of visits and overall duration to calculate correlations between outcome and measures of program exposure and engagement. Finally, we will compare app use between participants and non-participants using Google Analytics.

Considerations for practice-based research: a cross-sectional survey of chiropractic, acupuncture and massage practices.

BACKGROUND: Complementary and alternative medicine (CAM) use has steadily increased globally over the past two decades and is increasingly playing a role in the healthcare system in the United States. CAM practice-based effectiveness research requires an understanding of the settings in which CAM practitioners provide services. This paper describes and quantifies practice environment characteristics for a cross-sectional sample of doctors of chiropractic (DCs), licensed acupuncturists (LAcs), and licensed massage therapists (LMTs) in the United States. METHODS: Using a cross-sectional telephone survey of DCs (n = 32), LAcs (n = 70), and LMTs (n = 184) in the Tucson, AZ metropolitan area, we collected data about each location where practitioners work, as well as measures on practitioner and practice characteristics including: patient volume, number of locations where practitioners worked, CAM practitioner types working at each location, and business models of practice. RESULTS: The majority of practitioners reported having one practice location (93.8% of DCs, 80% of LAcs and 59.8% of LMTs) where they treat patients. Patient volume/week was related to practitioner type; DCs saw 83.13 (SD = 49.29) patients/week, LAcs saw 22.29 (SD = 16.88) patients/week, and LMTs saw 14.21 (SD =10.25) patients per week. Practitioners completed surveys for N = 388 practice locations. Many CAM practices were found to be multidisciplinary and/or have more than one practitioner: 9/35 (25.7%) chiropractic practices, 24/87 (27.6%) acupuncture practices, and 141/266 (53.0%) massage practices. Practice business models across CAM practitioner types were heterogeneous, e.g. sole proprietor, employee, partner, and independent contractor. CONCLUSIONS: CAM practices vary across and within disciplines in ways that can significantly impact design and implementation of practice-based research. CAM research and intervention programs need to be mindful of the heterogeneity of CAM practices in order to create appropriate interventions, study designs, and implementation plans.

US federal cocaine essential ('precursor') chemical regulation impacts on US cocaine availability: an intervention time-series analysis with temporal replication.

BACKGROUND AND AIMS: Research shows that essential/precursor chemical controls have had substantial impacts on US methamphetamine and heroin availability. This study examines whether US federal essential chemical regulations have impacted US cocaine seizure amount, price and purity-indicators of cocaine availability. DESIGN: Autoregressive integrated moving average (ARIMA)-intervention time-series analysis was used to assess the impacts of four US regulations targeting cocaine manufacturing chemicals: potassium permanganate/selected solvents, implemented October 1989 sulfuric acid/hydrochloric acid, implemented October 1992; methyl isobutyl ketone, implemented May 1995; and sodium permanganate, implemented December 2006. Of these chemicals, potassium permanganate and sodium permanganate are the most critical to cocaine production. SETTING: Conterminous United States (January 1987-April 2011). MEASUREMENTS: Monthly time-series: purity-adjusted cocaine seizure amount (in gross weight seizures < 6000 grams), purity-adjusted price (all available seizures), and purity (all available seizures). DATA SOURCE: System to Retrieve Information from Drug Evidence. FINDINGS: The 1989 potassium permanganate/solvents regulation was associated with a seizure amount decrease (change in series level) of 28% (P < 0.05), a 36% increase in price (P < 0.05) and a 4% decrease in purity (P < 0.05). Availability recovered in 1-2 years. The 2006 potassium permanganate regulation was associated with a 22% seizure amount decrease (P < 0.05), 100% price increase (P < 0.05) and 35% purity decrease (P < 0.05). Following the 2006 regulation, essentially no recovery occurred to April 2011. The other two chemical regulations were associated with statistically significant but lesser declines in indicated availability. CONCLUSIONS: In the United States, essential chemical controls from 1989 to 2006 were associated with pronounced downturns in cocaine availability.

Hazardous birthday drinking among young people: population-based impacts on emergency department and in-patient hospital admissions.

BACKGROUND AND AIMS: There is growing concern about the possible adverse health impacts of binge drinking during birthday celebrations among adolescents and young adults. We estimate the impacts of birthday alcohol use on adolescent and young adult in-patient/emergency department (ED) hospital admissions. DESIGN: We employed Autoregressive Integrated Moving Average (ARIMA) intervention analysis to assess whether the rate of ICD-10 alcohol-use-disorder (AUD) events per 1000 in-patient/ED admissions increased significantly during birthday weeks. SETTING: All in-patient/ED admissions in Ontario, Canada from 1 April 2002 to 31 March 2007. PARTICIPANTS: Individuals aged 12-30 years. MEASUREMENTS: AUD events per 1000 in-patient/ED admissions by age in weeks. FINDINGS: Multiple increases were found. The largest occurred during the birthday week of 19 years of age, the beginning of the minimum legal drinking age (MLDA) in Ontario: AUD admission rates increased (spiked) by 38.30 per 1000 total admissions [95% confidence interval (CI) = 34.66-41.94] among males (a 114.3% increase over baseline), and by 28.13 (95% CI = 25.56-30.70) among females (a 164.0% increase). Among both genders, the second largest birthday-week spikes occurred during ages 20-22 years, followed by somewhat lower but still pronounced birthday-week spikes during ages 23-26 years and 30 years (all these spikes: P < 0.05). Birthday-week spikes occurred as early as age 16 years for males and 14 years for females (both spikes: P < 0.05). CONCLUSIONS: There appears to be an increase in alcohol-related adverse events from drinking around the time of one's birthday among young adults in Canada.

Effects of the minimum legal drinking age on alcohol-related health service use in hospital settings in Ontario: a regression-discontinuity approach.

OBJECTIVES: We assessed the impact of the minimum legal drinking age (MLDA) on hospital-based treatment for alcohol-related conditions or events in Ontario, Canada. METHODS: We conducted regression-discontinuity analyses to examine MLDA effects with respect to diagnosed alcohol-related conditions. Data were derived from administrative records detailing inpatient and emergency department events in Ontario from April 2002 to March 2007. RESULTS: Relative to youths slightly younger than the MLDA, youths just older than the MLDA exhibited increases in inpatient and emergency department events associated with alcohol-use disorders (10.8%; P = .048), assaults (7.9%; P < .001), and suicides related to alcohol (51.8%; P = .01). Among young men who had recently crossed the MLDA threshold, there was a 2.0% increase (P = .01) in hospitalizations for injuries. CONCLUSIONS: Young adults gaining legal access to alcohol incur increases in hospital-based care for a range of serious alcohol-related conditions. Our regression-discontinuity approach can be used in future studies to assess the effects of the MLDA across different settings, and our estimates can be used to inform cost-benefit analyses across MLDA scenarios.

Essential ("precursor") chemical control for heroin: impact of acetic anhydride regulation on US heroin availability.

BACKGROUND: To reduce heroin availability, the United Nations (UN) has encouraged nations to control acetic anhydride, an essential ("precursor") chemical typically necessary to the drug's production. This effort, a major environmental prevention policy, has received little evaluation. The United States, per the UN's lead, implemented acetic anhydride regulation in 11/1989. The present study examines whether the US regulation impacted US heroin availability. METHODS: Monthly series of three heroin availability indicators-heroin purity, heroin price, and amount of heroin seized-were constructed for the conterminous United States, the US Southwest (supplied predominantly with Mexican-produced heroin), and the US Northeast (supplied predominantly, at the time, with Southeast Asian-produced heroin). Data came from the System to Retrieve Information from Drug Evidence (01/1987-04/2011). Impacts were assessed using ARIMA-intervention time series analysis. RESULTS: In each US area, heroin purity and amount seized rose and price decreased throughout the pre-intervention period. All of the indicators then reversed course at the time of the regulation. In the conterminous United States, the US Northeast, and the US Southwest, purity decreased (-40%, -25% and -50%, respectively); amount seized decreased (-27%, -37% and -39%, respectively); and price rose (+93%, +102% and +296%, respectively). Impacts lasted 2-5 years. CONCLUSION: US heroin availability decreased in association with the US acetic anhydride regulation. The impacts in the US Southwest and US Northeast suggest that heroin production in Mexico and Southeast Asia, respectively, was constrained. This study lends support to the contention that essential ("precursor") chemical control can be used to help address heroin.

Mexico's precursor chemical controls: emergence of less potent types of methamphetamine in the United States.

BACKGROUND: This study examines whether Mexico's controls on ephedrine and pseudoephedrine, the two precursor chemicals that yield the most potent form of methamphetamine, d-methamphetamine, impacted the prevalence/availability of less potent types of methamphetamine in the United States-types associated with the alternative precursor chemical P2P. METHOD: Using ARIMA-intervention time series analysis of monthly drug exhibits (a prevalence/availability indicator) from the System to Retrieve Information from Drug Evidence (STRIDE), we tested whether Mexico's controls, which began in 2005, were associated with growth/decline in d-methamphetamine and growth/decline in P2P-associated, less potent l-methamphetamine, racemic methamphetamine (a 50:50 ratio of d- and l-isomers), and mixed isomer methamphetamine (an unequal ratio of d- and l-isomers). Heroin, cocaine and marijuana exhibits were used for quasi-control (01/2000-04/2011). RESULTS: Mixed-isomer exhibits constituted about 4% of the methamphetamine exhibits before Mexico's controls, then rose sharply in association with them and remained elevated, constituting about 37% of methamphetamine exhibits in 2010. d-Methamphetamine exhibits dropped sharply; l-methamphetamine and racemic methamphetamine exhibits had small rises. d-Methamphetamine exhibits partially recovered in the US West, but little recovery occurred in the US Central/South. Quasi-control series were generally unaffected. CONCLUSION: The US methamphetamine market changed. Widespread emergence of less potent methamphetamine occurred in conjunction with Mexico's controls. And prevalence/availability of the most potent type of the drug, d-methamphetamine, declined, a partial recovery in the West notwithstanding. Granting that lower potency drugs typically engender less dependence and attendant problems, these findings suggest that, following Mexico's controls, the potential harm of a sizeable amount of the US methamphetamine supply decreased.