COVID-19 Mortality Rates in Los Angeles County Among People Experiencing Homelessness, March 2020-February 2021.

OBJECTIVE: Understanding COVID-19-related mortality among the large population of people experiencing homelessness (PEH) in Los Angeles County (LA County) may inform public health policies to protect this vulnerable group. We investigated the impact of COVID-19 on PEH compared with the general population in LA County. METHODS: We calculated crude COVID-19 mortality rates per 100 000 population and mortality rates adjusted for age, race, and sex/gender among PEH and compared them with the general population in LA County from March 1, 2020, through February 28, 2021. RESULTS: Among adults aged ≥18 years, the crude mortality rate per 100 000 population among PEH was 20% higher than among the general LA County population (348.7 vs 287.6). After adjusting for age, the mortality rate among PEH was 570.7 per 100 000 population. PEH had nearly twice the risk of dying from COVID-19 as people in the general LA County population; PEH aged 18-29 years had almost 8 times the risk of dying compared with their peers in the general LA County population. PEH had a higher risk of mortality than the general population after adjusting for race (standardized mortality ratio [SMR] = 1.4; 95% CI, 1.2-1.6) and sex/gender (SMR = 1.3; 95% CI, 1.1-1.5). CONCLUSIONS: A higher risk of COVID-19-related death among PEH compared with the general population indicates the need for public health policies and interventions to protect this vulnerable group.

Using Point-in-Time Homeless Counts to Monitor Mortality Trends Among People Experiencing Homelessness in Los Angeles County, California, 2015‒2019.

Objectives. To report trends in mortality rates, mortality rate ratios (MRRs), and causes of death among people experiencing homelessness (PEH) in Los Angeles County, California, by using annual point-in-time homeless counts and to compare findings to published longitudinal cohort studies of homeless mortality. Methods. We enumerated homeless deaths and determined causes by using 2015-2019 medical examiner‒coroner data matched to death certificate data. We estimated midyear homeless population denominators by averaging consecutive January point-in-time homeless counts. We used annual demographic surveys of PEH to estimate age- and gender-adjusted MRRs. We identified comparison studies through a literature review. Results. Mortality rates increased from 2015 to 2019. Drug overdose was the leading cause of death. Mortality was higher among White than among Black and Latino PEH. Compared with the general population, MRRs ranged from 2.8 (95% confidence interval [CI] = 2.7, 3.0) for all causes to 35.1 (95% CI = 31.9, 38.4) for drug overdose. Crude mortality rates and all-cause MRRs from comparison cohort studies were similar to those in the current study. Conclusions. These methods can be adapted by other urban jurisdictions seeking to better understand and reduce mortality in their homeless populations. (Am J Public Health. 2021;111(12):2212-2222. https://doi.org/10.2105/AJPH.2021.306502).

Prioritizing Surgical Services during on-Going Pandemic Response: Modification and Reliability of the Medically Necessary Time Sensitive Surgery (MeNTS) Scoring Tool.

Health systems are struggling to manage a fluctuating volume of critically ill patients with COVID-19 while continuing to provide basic surgical services and expand capacity to address operative cases delayed by the pandemic. As we move forward through the next phases of the pandemic, we will need a decision-making system that allows us to remain nimble as clinicians to meet our patient's needs while also working with a new framework of healthcare operations. Here, we present our quality improvement process for the adaptation and application of the Medically Necessary Time-Sensitive (MeNTS) toolto gynecologic surgical services beyond the initial COVID response and into recovery of surgical services; with analysis of the reliability of the modified-MeNTS tool in our multi-site safety net hospital network. This multicenter study evaluated the gynecology surgical case volume at three tertiary acute care safety net institutions within the LA County Department of Health Services: Harbor-UCLA (HUMC), Olive View Medical Center (OVMC), and Los Angeles County + University of Southern California (LAC+USC). We describe our modified-Delphi approach to adapt the MeNTS tool in a structured fashion and its application to gynecologic surgical services. Blinded reviewers engaged in a three-round iterative adaptation and final scoring utilizing the modified tool. The cohort consisted of 392 female consecutive gynecology patients across three Los Angeles County Hospitals awaiting scheduled procedures in the surgical queue.The majority of patients were Latina (74.7%) and premenopausal (67.1%). Over half (52.4%) of the patients had cardiovascular disease, while 13.0% had lung disease, and 13.8% had diabetes. The most common indications for surgery were abnormal uterine bleeding (33.2%), pelvic organ prolapse (19.6%) and presence of an adnexal mass (14.3%). Minimally invasive approaches via laparoscopy, robotic-assisted laparoscopy, or vaginal surgery was the predominant planned surgical route (54.8%). Modified-MeNTS scores assumed a normal distribution across all patients within our cohort (Median 33, Range 18-52). Overall, ICC across all three institutions demonstrated "good" interrater reliability (0.72). ICC within institutions at HUMC and OVMC were categorized as "good" interrater reliability, while LAC-USC interrater reliability was categorized as "excellent" (HUMC 0.73, OVMC 0.65, LAC+USC 0.77). The modified-MeNTS tool performed well across a range of patients and procedures with a normal distribution of scores and high reliability between raters. We propose that the modified-MeNTS framework be considered as it employs quantitative methods for decision-making rather than subjective assessments.

Assessing the Retail Environments of Licensed and Unlicensed Cannabis Dispensaries: Adapting the Marijuana Retail Surveillance Tool to Inform Cannabis Regulation in Los Angeles County.

CONTEXT: After statewide legalization of recreational cannabis in California, the Los Angeles (LA) County Board of Supervisors requested a health equity impact assessment to inform its decisions on whether and how to regulate cannabis dispensaries in unincorporated areas of LA County. OBJECTIVE: As part of this assessment, the LA County Department of Public Health compared the retail environments of licensed and unlicensed cannabis dispensaries in different parts of the county, using the Marijuana Retail Surveillance Tool (MRST), a validated instrument piloted in Colorado and Washington. DESIGN: Two waves of observational surveys were conducted, one comparing licensed and unlicensed dispensaries within and near unincorporated areas of LA County and another comparing licensed dispensaries across LA County in areas with varying levels of health advantage according to a neighborhood index measuring social determinants of health. MAIN OUTCOME MEASURES: Dispensaries were compared on measures of product types, promotional activities, security measures, regulatory compliance, and neighborhood context. RESULTS: Unlicensed dispensaries were more likely than licensed dispensaries to sell products in packaging designed to be attractive to children (71.8% vs 10.8%, P < .001) and in non-child-resistant packaging (98.9% vs 15.6%, P < .001) and were more likely allow on-site consumption (60.9% vs 0%, P < .001). Licensed dispensaries showed high compliance with regulations, regardless of whether they were in areas of high or low health advantage. CONCLUSIONS: The study points to the importance of efforts to eliminate illicit businesses as part of an overall strategy for regulating cannabis. It also demonstrates that the MRST is a flexible tool for regulatory surveillance and for continuing to study the relationships between cannabis retail environments and potential risks to public health.

The Andrews' Principles of Risk, Need, and Responsivity as Applied in Drug Abuse Treatment Programs: Meta-Analysis of Crime and Drug Use Outcomes.

OBJECTIVES: The purpose of the present meta-analysis was to answer the question: Can the Andrews principles of risk, needs, and responsivity, originally developed for programs that treat offenders, be extended to programs that treat drug abusers? METHODS: Drawing from a dataset that included 243 independent comparisons, we conducted random-effects meta-regression and ANOVA-analog meta-analyses to test the Andrews principles by averaging crime and drug use outcomes over a diverse set of programs for drug abuse problems. RESULTS: For crime outcomes, in the meta-regressions the point estimates for each of the principles were substantial, consistent with previous studies of the Andrews principles. There was also a substantial point estimate for programs exhibiting a greater number of the principles. However, almost all of the 95% confidence intervals included the zero point. For drug use outcomes, in the meta-regressions the point estimates for each of the principles was approximately zero; however, the point estimate for programs exhibiting a greater number of the principles was somewhat positive. All of the estimates for the drug use principles had confidence intervals that included the zero point. CONCLUSIONS: This study supports previous findings from primary research studies targeting the Andrews principles that those principles are effective in reducing crime outcomes, here in meta-analytic research focused on drug treatment programs. By contrast, programs that follow the principles appear to have very little effect on drug use outcomes. Primary research studies that experimentally test the Andrews principles in drug treatment programs are recommended.

Process-of-care measures as predictors of client outcome among a methamphetamine-dependent sample at 12- and 36-month follow-ups.

This study examines the utility of several process-of-care performance measures (initiation, engagement, retention, and monitoring of drug use during treatment) as predictors of methamphetamine (MA) use outcomes at 12- and 36-month follow-ups. MA-dependent individuals (n = 871) participated in a randomized, controlled trial of outpatient psychosocial treatment from 1999-2002 and completed 12- and 36-month follow-up interviews. This sample included a treatment-as-usual group (n = 436) and a 16-week Matrix treatment (n = 435) group. Significant associations were observed between select process-of-care measures and MA use outcomes at both follow-ups. While correlational analyses showed an association between MA abstinence at follow-up and enhanced treatment engagement and retention, mixed logistic regression analyses indicated that sustained abstinence from MA during outpatient treatment was the strongest predictor of testing negative for MA use at both follow-ups. Results suggest that monitoring client drug use during treatment may be a useful process-of-care measure with MA-dependent users.

Meta-analyses of seven of the National Institute on Drug Abuse's principles of drug addiction treatment.

Of the 13 principles of drug addiction treatment disseminated by the National Institute on Drug Abuse (NIDA), 7 were meta-analyzed as part of the Evidence-based Principles of Treatment (EPT) project. By averaging outcomes over the diverse programs included in the EPT, we found that 5 of the NIDA principles examined are supported: matching treatment to the client's needs, attending to the multiple needs of clients, behavioral counseling interventions, treatment plan reassessment, and counseling to reduce risk of HIV. Two of the NIDA principles are not supported: remaining in treatment for an adequate period and frequency of testing for drug use. These weak effects could be the result of the principles being stated too generally to apply to the diverse interventions and programs that exist or unmeasured moderator variables being confounded with the moderators that measured the principles. Meta-analysis should be a standard tool for developing principles of effective treatment for substance use disorders.

A multi-site, randomized study of strengths-based case management with substance-abusing parolees.

OBJECTIVES: To test whether strengths-based case management provided during an inmate's transition from incarceration to the community increases participation in community substance abuse treatment, enhances access to needed social services, and improves drug use, crime, and HIV risk outcomes. METHODS: In a multi-site trial, inmates (men and women) in four states (n = 812) were randomly assigned (within site) to receive either Transitional Case Management (TCM group), based on strengths-based principles, or standard parole services (SR group). Data were collected at baseline and at 3 and 9 months following release from prison. Analyses compared the two groups with respect to services received and to drug use, crime, and HIV risk behavior outcomes. RESULTS: There were no significant differences between parolees in the TCM group and the SR group on outcomes related to participation in drug abuse treatment, receipt of social services, or drug use, crime, and HIV risk behaviors. For specific services (e.g., residential treatment, mental health), although significant differences were found for length of participation or for number of visits, the number of participants in these services was small and the direction of effect was not consistent. CONCLUSION: In contrast to positive findings in earlier studies of strengths-based case management with mental-health and drug-abuse clients, this study found that case management did not improve treatment participation or behavioral outcomes for parolees with drug problems. The discussion includes possible reasons for the findings and suggestions for modifications to the intervention that could be addressed in future research.

Effects of sexual orientation and gender on perceived need for treatment by persons with and without mental disorders.

OBJECTIVE: Research has shown that sexual minority groups have higher prevalence rates of psychiatric disorders (both mental and substance use disorders) and that they may seek treatment at higher rates than heterosexuals. However, relationships between treatment need and treatment use are not well understood. This study examined the relationship of sexual orientation and gender to perceived need for treatment and treatment use among individuals with and without mental or substance use disorders. METHODS: Data were obtained from a probability sample of California residents that oversampled for persons from sexual minority groups (unweighted N=2,079). Bivariate analyses compared perceived treatment need and treatment use among groups defined by sexual orientation, gender, and presence of a mood, anxiety, or substance use disorder. Logistic regression models that controlled for sociodemographic factors were used to predict no use of treatment among those who perceived a need for it (unmet need), testing the interactive effects of gender, disorder, and sexual orientation. RESULTS: Women from sexual minority groups had about half the odds of unmet treatment need as heterosexual women, but no interaction was found for men between sexual minority status and unmet need. Among individuals without any of the disorders assessed, men and women from sexual minority groups had lower odds of unmet need for treatment than heterosexual men and women. CONCLUSIONS: Sexual orientation and gender differentially influenced treatment utilization, particularly among those who did not have a diagnosed disorder but perceived a need for treatment. Diagnostic criteria appear to be less relevant to understanding treatment use in sexual minority populations.

Influence of gender, sexual orientation, and need on treatment utilization for substance use and mental disorders: findings from the California Quality of Life Survey.

BACKGROUND: Prior research has shown a higher prevalence of substance use and mental disorders among sexual minorities, however, the influence of sexual orientation on treatment seeking has not been widely studied. We use a model of help-seeking for vulnerable populations to investigate factors related to treatment for alcohol or drug use disorders and mental health disorders, focusing on the contributions of gender, sexual orientation, and need. METHODS: Survey data were obtained from a population-based probability sample of California residents that oversampled for sexual minorities. Logistic regression was used to model the enabling, predisposing, and need-related factors associated with past-year mental health or substance abuse treatment utilization among adults aged 18-64 (N = 2,074). RESULTS: Compared with individuals without a diagnosed disorder, those with any disorder were more likely to receive treatment. After controlling for both presence of disorder and other factors, lesbians and bisexual women were most likely to receive treatment and heterosexual men were the least likely. Moreover, a considerable proportion of sexual orientation minorities without any diagnosable disorder, particularly lesbians and bisexual women, also reported receiving treatment. CONCLUSION: The study highlights the need to better understand the factors beyond meeting diagnostic criteria that underlie treatment utilization among sexual minorities. Future research should also aim to ascertain the effects of treatment provided to sexual minorities with and without diagnosable disorders, including the possibility that the provision of such treatment may reduce the likelihood of their progression to greater severity of distress, disorders, or impairments in functioning.

Influence of perceived coercion and motivation on treatment completion and re-arrest among substance-abusing offenders.

The effects of perceived coercion and motivation on treatment completion and subsequent re-arrest were examined in a sample of substance-abusing offenders assessed for California's Substance Abuse and Crime Prevention Act (SACPA) program. Perceived coercion was measured with the McArthur Perceived Coercion Scale; motivation was measured with the subscales of the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). At treatment entry, clients were more likely to believe that they had exercised their choice in entering treatment than that they had been coerced into treatment. SACPA clients scored relatively low on Recognition and Ambivalence regarding their drug use but relatively high on Taking Steps to address their drug problem. Correlations between perceived coercion and motivation measures at treatment entry indicated that these are separate constructs. In logistic regression models, the Recognition subscale of the SOCRATES significantly predicted "any re-arrest," and Ambivalence and Taking Steps predicted "any drug arrest."

Adherence to Scheduled Sessions in a Randomized Field Trial of Case Management: The Criminal Justice-Drug Abuse Treatment Studies Transitional Case Management Study.

The Transitional Case Management (TCM) study, one of the projects of the Criminal Justice Drug Abuse Treatment Studies (CJ-DATS) cooperative, was a multi-site randomized test of whether a strengths-based case management intervention provided during an inmate's transition from incarceration to the community increases participation in community substance abuse treatment, enhances access to needed social services, and improves drug use and crime outcomes. As in many intervention studies, TCM experienced a relatively large percentage of treatment-group participants who attended few or no scheduled sessions. The paper discusses issues with regard to participation in community case management sessions, examines patterns of session attendance among TCM participants, and analyzes client and case manager characteristics that are associated with number of sessions attended and with patterns of attendance. The average number of sessions (out of 12) attended was 5.7. Few client or case manager characteristics were found to be significantly related to session attendance. Clinical and research implications of the findings and of adherence in case management generally are discussed.

Diagnostic profiles of offenders in substance abuse treatment programs.

This study examined the association of Axis I and Axis II disorders among offenders who were in prison-based substance abuse treatment in a national multi-site study. Participants (N = 280) received a psychosocial assessment and a structured diagnostic interview in two separate sessions. Logistic regression models examined the association between lifetime mood and anxiety disorders with two personality disorders, and the relationship of Axis I and Axis II disorders (alone and in combination) to pre-treatment psychosocial functioning. Over two-thirds of the sample met criteria for at least one mental disorder. Borderline personality disorder was strongly associated with having a lifetime mood disorder (odds ratio = 7.5) or lifetime anxiety disorder (odds ratio = 8.7). Individuals with only an Axis II disorder, or who had both Axis I and Axis II disorders, had more severe problems in psychosocial functioning than those without any disorder. Clinical treatment approaches need to address this heterogeneity in diagnostic profiles, symptom severity, and psychosocial functioning.

Early and middle adolescents' autonomy development: impact of maternal HIV/AIDS.

Progression toward autonomy is considered of central importance during the adolescent period. For young adolescents with an HIV-infected parent, there may be additional challenges. This study investigated current autonomy among early and middle adolescents affected by maternal HIV (N = 108), as well as examined longitudinally the children's responsibility taking when they were younger (age 6-11; N = 81) in response to their mother's illness and their current autonomy as early/middle adolescents. In analyses of self-care and family autonomy, children with greater attachment to their mothers had higher autonomy, and there was a trend for children who drink or use drugs alone to have lower autonomy. In analyses of management autonomy, attachment to peers was associated with higher autonomy. Trajectory group findings indicate that those children who had taken on more responsibility for instrumental caretaking roles directly because of their mother's illness showed better autonomy development as early and middle age adolescents. Therefore, 'parentification' of young children with a mother with HIV may not negatively affect later autonomy development.

The persistence of HIV risk behaviors among methamphetamine-using offenders.

Studies have shown that methamphetamine (MA) is rapidly becoming the drug of choice for a large number of substance-abusing offenders and is associated with significantly higher levels of HIV risk behaviors prior to their incarceration. Despite these findings, there has been little follow-up research to determine whether these patterns persist among recently paroled offenders after attendance in an in-prison treatment program. This study uses the self-reported data from 812 substance-abusing offenders in a multisite NIDA-funded project to determine whether, either before incarceration or nine months after release from an in-prison substance abuse program, MA use in the past 30 days was associated with increased HIV risk behaviors. The findings indicate that offenders who used MA prior to and after incarceration and treatment report higher levels of HIV risk behaviors compared with offenders with no MA use. Clinical and policy implications of the findings are discussed.

Applying classification and regression tree analysis to identify prisoners with high HIV risk behaviors.

Among prisoners, past research has associated several factors with HIV risk behaviors, including illicit drug use, engaging in sex trade, older age (for drug-related risk), younger age (for sex-related risk), low education, low income, type of offense, history of abuse, mental health disorders, vulnerability and low self-perceived efficacy. This study employs data collected through the Transitional Case Management study of the Criminal Justice Drug Abuse Treatment Studies collaborative to analyze characteristics of prisoners who engaged in high-risk behaviors prior to incarceration. For the first 787 participants of this study, we employed recursive partitioning techniques to better identify groups at varying levels of HIV risk behaviors. Those more likely to engage in risky needle use were White and either unemployed and less likely to justify their behavior, or employed with poor decision making capacity. Risky sexual behavior was associated with a general tendency toward risk-taking or a history of unstable housing. Those engaging in any type of HIV risk behavior were risk-takers in general and were aged 25 to 47 with a history of unstable housing. Recursive partitioning, a technique seldom used previously, offers a useful method for identifying subpopulations at elevated risk for HIV risk behaviors.

Treatment needs and completion of community-based aftercare among substance-abusing women offenders.

BACKGROUND: Women offenders with substance abuse problems typically have many treatment needs on reentry to the community from prison. This paper explores the correlates of treatment needs among a sample of women offenders with substance-abuse problems (n = 1,404), and the relationship between their treatment needs and other background characteristics with completion of community-based treatment after parole. METHODS: Treatment needs were assessed at admission into prison-based substance abuse treatment; participants were admitted into community-based treatment upon parole. Descriptive statistics and multiple regression were used to examine their treatment needs; logistic regression analysis was used to determine the factors related to completion of the aftercare program. Analysis of variance was used to examine ethnic differences in treatment needs. RESULTS: Greater treatment needs were associated with unstable housing before incarceration, a history of sexual or physical abuse, mental health problems, alcohol or drug dependence, and first arrest at age <19; lower treatment needs were associated with having been mandated to prison-based treatment (versus volunteering). Mental health problems and earlier age at first arrest predicted treatment noncompletion. Drug dependence was associated with higher treatment needs and a greater likelihood of treatment completion, whereas African American and Hispanic ethnicity were both associated with lower treatment needs (compared with Whites) and a lower likelihood of treatment completion. CONCLUSIONS: Interventions are needed to engage substance-abusing women offenders in community treatment after parole to address their treatment needs, improve their retention in treatment, and reduce the likelihood of recidivism.

Organizational characteristics of drug abuse treatment programs for offenders.

This article examines the association between the organizational characteristics of drug abuse treatment programs for offenders and the provision of wraparound services and three types of treatment orientations. Data are from the National Criminal Justice Treatment Practices Survey, which was conducted with program directors (N = 217). A greater number of wraparound services provided were associated with inpatient treatment, specialized treatment facilities, community setting (vs. correctional), services provided for more types of client populations, college-educated staff, and planned treatment for > 180 days. Therapeutic community orientation was associated with prison-based treatment and specialized treatment facilities. Cognitive-behavioral therapy orientation was associated with higher perceived importance of community treatment, more perceived staff influence on treatment, and treatment for 91-180 days. The 12-step orientation was most strongly associated with having staff specialized in substance abuse. Study findings have implications for developing effective reentry programs for offenders that bridge correctional and community treatment.

Substance use pathways to methamphetamine use among treated users.

Considerable research has focused on patterns of substance use initiation among adolescents and for users of selected drugs; however, few data are available for methamphetamine (MA) users. This study describes substance initiation patterns for 352 MA users and assesses predictors of age of MA initiation and its sequencing. Subjects were randomly selected from treatment admissions in a large California county and interviewed using an extensive natural history protocol. Average age of MA initiation was 19 years. Nearly all (95%) had used alcohol, marijuana, and tobacco (average initiation age 13); inhalants, hallucinogens, and crack were also commonly used earlier in the drug sequence than MA. Earlier age of MA initiation was related to race/ethnicity (being non-African-American), younger age of first use of any substance, more types of early criminal behavior, and initiating MA use for sensation-seeking reasons. Following initiation of alcohol, marijuana, and/or tobacco, 27% initiated MA before other illicit drugs, 18% initiated another illicit drug before MA, and 56% initiated two or more other illicit drugs before MA. Later MA order in the initiation sequence was related to ethnicity (being African-American) and initiating MA to substitute for another drug. Results may support targeted prevention efforts and development of more effective interventions.

Physical health of mothers with HIV/AIDS and the mental health of their children.

A longitudinal study was conducted on the psychological well-being of 81 young children (mean age = 8.8 years) living with mothers with AIDS or HIV-infected mothers with symptomatic disease. The relationship between mothers' physical health and children's psychological well-being was investigated. The children were assessed at seven time points over approximately 6 years. Individual growth models were estimated for children's depression, anxiety, and aggressiveness in relation to: mothers' viral load (medical records) and physical functioning, number of HIV-related physical symptoms, and medical visits due to illness (self-report). Results showed significant linear declines in children's depression, anxiety, and aggressiveness over time. Lower levels of physical functioning and more physical symptoms among mothers were associated with higher levels of children's depression, anxiety, and aggressiveness at baseline. Lower levels of physical functioning and more physical symptoms among mothers were associated with initially high but more rapidly decreasing levels of depression among children. However, mothers who began the study in better health appear to have changed in health more quickly than mothers who began the study in poorer health. Thus, stability in mothers' health appears to be associated with a more rapid improvement in children's mental health over time. Our findings suggest that the measures representing observable levels of, and changes in, mothers' health that are most likely to be directly experienced by themselves and their children are the measures that are most predictive of changes in children's mental health over time.