The Medications for Opioid Use Disorder Study: Methods and Initial Outcomes From an 18-Month Study of Patients in Treatment for Opioid Use Disorder.

OBJECTIVE: Opioid use disorder (OUD) affects approximately 5.6 million people in the United States annually, yet rates of the use of effective medication for OUD (MOUD) treatment are low. We conducted an observational cohort study from August 2017 through May 2021, the MOUD Study, to better understand treatment engagement and factors that may influence treatment experiences and outcomes. In this article, we describe the study design, data collected, and treatment outcomes. METHODS: We recruited adult patients receiving OUD treatment at US outpatient facilities for the MOUD Study. We collected patient-level data at 5 time points (baseline to 18 months) via self-administered questionnaires and health record data. We collected facility-level data via questionnaires administered to facility directors at 2 time points. Across 16 states, 62 OUD treatment facilities participated, and 1974 patients enrolled in the study. We summarized descriptive data on the characteristics of patients and OUD treatment facilities and selected treatment outcomes. RESULTS: Approximately half of the 62 facilities were private, nonprofit organizations; 62% focused primarily on substance use treatment; and 20% also offered mental health services. Most participants were receiving methadone (61%) or buprenorphine (32%) and were predominately non-Hispanic White (68%), aged 25-44 years (62%), and female (54%). Compared with patient-reported estimates at baseline, 18-month estimates suggested that rates of abstinence increased (55% to 77%), and rates of opioid-related overdoses (7% to 2%), emergency department visits (9% to 4%), and arrests (15% to 7%) decreased. CONCLUSIONS: Our results demonstrated the benefits of treatment retention not only on abstinence from opioid use but also on other quality-of-life metrics, with data collected during an extended period. The MOUD Study produced rich, multilevel data that can lay the foundation for an evidence base to inform OUD treatment and support improvement of care and patient outcomes.

The School Environment and Physical and Social-Emotional Well-Being: Implications for Students and School Employees.

BACKGROUND: The school environment, consisting of the physical environment and social-emotional climate (SEC), plays a crucial role in both student and employee health; however, there is a lack of recent literature synthesizing school environment interventions in K-12 settings. We describe updated evidence about school environment interventions to support K-12 student and employee health in the United States. METHODS: A 2-phase search included a review of reviews (2010-2018), followed by a search for individual articles (2010-2020) that targeted school physical environment and/or SEC to address physical activity (PA) and/or nutrition. We also investigated how nutrition and PA interventions with an SEC component improves social-emotional and/or mental health outcomes. Because research on dietary and PA behaviors for school employees is limited; we included studies on other worksites (eg, hospitals and offices) to provide insight for school employees. FINDINGS: We identified 40 articles describing 40 unique studies and 45 interventions and grouped them by intervention type. Physical environment interventions demonstrated significant and positive nutrition and PA behavioral outcomes for students; outcomes among employees were mixed. Interventions with SEC components reported improvements in some mental health outcomes. IMPLICATIONS: The school environment can affect dietary and PA behaviors as well as mental health for students and employees. CONCLUSIONS: Establishing healthy school environments can support student and employee PA, dietary behaviors, and mental health.

Design and Implementation of an Innovative, Rapid Data-Monitoring Strategy for Public Health Emergencies: Pilot of the United States School COVID-19 Mitigation Strategies Project.

During the COVID-19 pandemic, an urgent need existed for near-real-time data collection to better understand how individual beliefs and behaviors, state and local policies, and organizational practices influenced health outcomes. We describe the processes, methods, and lessons learned during the development and pilot testing of an innovative rapid data collection process we developed to inform decision-making during the COVID-19 public health emergency. We used a fully integrated mixed-methods approach to develop a structured process for triangulating quantitative and qualitative data from traditional (cross-sectional surveys, focus groups) and nontraditional (social media listening) sources. Respondents included students, parents, teachers, and key school personnel (eg, nurses, administrators, mental health providers). During the pilot phase (February-June 2021), data from 12 cross-sectional and sector-based surveys (n = 20 302 participants), 28 crowdsourced surveys (n = 26 820 participants), 10 focus groups (n = 64 participants), and 11 social media platforms (n = 432 754 503 responses) were triangulated with other data to support COVID-19 mitigation in schools. We disseminated findings through internal dashboards, triangulation reports, and policy briefs. This pilot demonstrated that triangulating traditional and nontraditional data sources can provide rapid data about barriers and facilitators to mitigation implementation during an evolving public health emergency. Such a rapid feedback and continuous improvement model can be tailored to strengthen response efforts. This approach emphasizes the value of nimble data modernization efforts to respond in real time to public health emergencies.

Witnessing Community Violence, Gun Carrying, and Associations with Substance Use and Suicide Risk Among High School Students - Youth Risk Behavior Survey, United States, 2021.

Community violence, including homicides involving firearms, is a significant public health concern. From 2019 to 2020, firearm-related homicides increased by 39% for youths and young adults aged 10-24 years, and rates of suicide by firearm increased by approximately 15% among the same age group. Findings from the nationally representative 2021 Youth Risk Behavior Survey were used to analyze disparities and correlates of witnessing community violence and gun carrying among a nationally representative sample of high school students. Chi-square tests and logistic regression accounting for the complex sampling of the survey were used to assess demographic differences by student sex, race and ethnicity, age, and sexual identity in ever witnessing community violence, gun carrying in the past 12 months, and their associations with substance use and suicide risk. Measures of substance use included current binge drinking and marijuana use and lifetime prescription opioid misuse and illicit drug use. Suicide risk included seriously considered attempting suicide and attempted suicide in the past 12 months. Overall, approximately 20% of students witnessed community violence and 3.5% of students carried a gun. American Indian or Alaska Native, Black, and Hispanic students were more likely to witness community violence and to report carrying a gun than their White peers. Males were more likely to witness community violence and carry a gun than females. Lesbian, gay, or bisexual students were more likely to witness community violence than their heterosexual peers. Also, witnessing community violence consistently was associated with increased odds of gun carrying, substance use, and suicide risk for both males and females and when comparing Black, White, and Hispanic students. These findings highlight the importance of comprehensive violence prevention strategies that incorporate health equity to mitigate the effects of violence exposure on substance use and suicide risk among youths.

Associations Between Exposure to School Violence and Weapon Carrying at School.

INTRODUCTION: Among U.S. high-school students, interpersonal violence and victimizations often occur on school property. The presence of a weapon can increase the potential for injury and death resulting from interpersonal conflict. This study examines the associations between exposure to school violence and weapon carrying on school property among U.S. high-school students. METHODS: Data from the 2017 and 2019 national Youth Risk Behavior Surveys were combined (N=28,442) and analyzed in 2022. Multivariable logistic regression models were used to calculate sex-stratified, adjusted (for race/ethnicity, grade, sexual identity, current substance use, suicidal thoughts, and history of concussion) prevalence ratios. Prevalence ratios were considered statistically significant if 95% CIs did not include 1.0. RESULTS: Male students (4.7%) were more likely than female students (1.8%) to report carrying a weapon at school during the 30 days preceding the survey. Weapon carrying at school was more prevalent among students who were threatened or injured with a weapon at school (male students, adjusted prevalence ratio=3.45; female students, adjusted prevalence ratio=3.90), among students who were involved in a physical fight at school (male students, adjusted prevalence ratio=3.44; female students, adjusted prevalence ratio=3.72), among students who missed school because they did not feel safe (male students, adjusted prevalence ratio=1.98; female students, adjusted prevalence ratio=2.97), and among male students who were bullied at school (adjusted prevalence ratio=1.72) than among students who did not experience school violence. CONCLUSIONS: Increased emphasis on safe and supportive school environments, where all types of interpersonal violence are less likely to occur, and increased access to programs and services to promote mental health, prevent violence, and deter weapon use are needed.

Health-Risk Behaviors and Experiences Among Asian American and Native Hawaiian/Pacific Islander Adolescents in the United States, 2011-2019.

OBJECTIVES: Understanding the health-risk behaviors of racial and ethnic groups when disaggregated is an important step in improving the health outcomes of racial and ethnic minority groups. We compared national prevalence estimates for selected health-risk behaviors and experiences of Asian American and Native Hawaiian/Pacific Islander (NHPI) students with those of non-Hispanic White, non-Hispanic Black, and Hispanic students. METHODS: We analyzed data from the Youth Risk Behavior Survey, a nationally representative survey of US high school students. To generate a sufficient sample of Asian American and NHPI students for analyses, we combined data from 5 survey administrations, conducted in 2011, 2013, 2015, 2017, and 2019 (N = 73 074). We calculated the prevalence and 95% CIs; we analyzed data on Asian American and NHPI adolescents separately to unmask important differences. RESULTS: Compared with students of other races and ethnicities, Asian American students had the lowest prevalence of alcohol use (16.7%) and marijuana use (10.3%). In contrast, NHPI students were more likely than Asian American students to participate in several health-risk behaviors and experiences, such as substance use (ranging from 4.8% for ever injecting an illegal drug to 31.5% for current alcohol use), having been in a physical fight (15.4%), and having been threatened or injured with a weapon (11.6%). Differential patterns in the prevalence of ever having missed school due to feeling unsafe among NHPI and Asian American students were observed among male and female students. CONCLUSION: Further disaggregating racial subgroups within broad categories of Asian American and NHPI populations may reveal differences from overall group prevalence, and additional strategies to identify these differences should be investigated.

Family Economics and Mental Health Among High-School Students During COVID-19.

INTRODUCTION: The COVID-19 pandemic has had unprecedented socioeconomic and health impacts in the U.S. This study examined racial/ethnic and school poverty status differences in the relationship between parent job loss, experiences with hunger, and indicators of mental health problems among public high-school students nationwide during the COVID-19 pandemic. METHODS: The study analyzed data from the Adolescent Behaviors and Experiences Survey, conducted in January-June 2021. The Adolescent Behaviors and Experiences Survey was a 1-time, cross-sectional, online survey that used a stratified, 3-stage cluster sample to obtain a nationally representative sample of high-school students in the U.S. This study was limited to public-school students (n=7,379). RESULTS: Among public high-school students nationwide, 36.9% experienced poor mental health during the pandemic, and during the past year, 43.9% experienced persistent feelings of sadness or hopelessness, 19.8% seriously considered attempting suicide, and 9.1% attempted suicide. Parent job loss and having gone hungry were associated with indicators of mental health problems overall and across racial/ethnic groups and school poverty status levels. CONCLUSIONS: Students who experience parent job loss and hunger are likely to also experience poor mental health and may be at higher risk for suicide.

Adolescent Mental Health, Connectedness, and Mode of School Instruction During COVID-19.

BACKGROUND: Because COVID-19 was declared a pandemic in March 2020, nearly 93% of U.S. students engaged in some distance learning. These school disruptions may negatively influence adolescent mental health. Protective factors, like feeling connected to family or school may demonstrate a buffering effect, potentially moderating negative mental health outcomes. The purpose of the study is to test our hypothesis that mode of school instruction influences mental health and determine if school and family connectedness attenuates these relationships. METHODS: The COVID Experiences Survey was administered online or via telephone from October to November 2020 in adolescents ages 13-19 using National Opinion Research Center's AmeriSpeak Panel, a probability-based panel recruited using random address-based sampling with mail and telephone nonresponse follow-up. The final sample included 567 adolescents in grades 7-12 who received virtual, in-person, or combined instruction. Unadjusted and adjusted associations among four mental health outcomes and instruction mode were measured, and associations with school and family connectedness were explored for protective effects. RESULTS: Students attending school virtually reported poorer mental health than students attending in-person. Adolescents receiving virtual instruction reported more mentally unhealthy days, more persistent symptoms of depression, and a greater likelihood of seriously considering attempting suicide than students in other modes of instruction. After demographic adjustments school and family connectedness each mitigated the association between virtual versus in-person instruction for all four mental health indicators. CONCLUSION: As hypothesized, mode of school instruction was associated with mental health outcomes, with adolescents receiving in-person instruction reporting the lowest prevalence of negative mental health indicators. School and family connectedness may play a critical role in buffering negative mental health outcomes.

Adolescent mental health, COVID-19, and the value of school-community partnerships.

Newly released 2019 Youth Risk Behavior Surveillance System data and the Center for Disease Control and Prevention's (CDC)'2019 Youth Risk Behavior Survey Data Summary and Trends Report show that US adolescents continue to suffer from poor mental health and suicidality at alarming rates. These data alone would be cause for concern, but the COVID-19 pandemic has the potential to further erode adolescent mental health, particularly for those whose mental health was poor prior to the pandemic. Given the status of adolescent mental health prior to COVID-19 and the impact of COVID-19, health professionals and schools must partner together now to mitigate potentially deleterious health, mental health and education impacts for children and adolescents.

Associations Between Antibullying Policies and Bullying in 25 States.

IMPORTANCE: Bullying is the most widespread form of peer aggression in schools. In an effort to address school bullying, 49 states have passed antibullying statutes. Despite the ubiquity of these policies, there has been limited empirical examination of their effectiveness in reducing students' risk of being bullied. OBJECTIVE: To evaluate the effectiveness of antibullying legislation in reducing students' risk of being bullied and cyberbullied, using data from 25 states in the United States. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional observational study was conducted using a population-based survey of 63 635 adolescents in grades 9 to 12 from 25 states participating in the 2011 Youth Risk Behavior Surveillance System study (September 2010-December 2011). Data on antibullying legislation were obtained from the US Department of Education (DOE), which commissioned a systematic review of state laws in 2011. The report identified 16 key components that were divided into the following 4 broad categories: purpose and definition of the law, district policy development and review, school district policy components (eg, responsibilities for reporting bullying incidents), and additional components (eg, how policies are communicated). Policy variables from 25 states were linked to individual-level data from the Youth Risk Behavior Surveillance System on experiencing bullying and cyberbullying. Analyses were conducted between March 1, 2014, and December 1, 2014. EXPOSURE: State antibullying legislation. MAIN OUTCOMES AND MEASURES: Exposure to bullying and cyberbullying in the past 12 months. RESULTS: There was substantial variation in the rates of bullying and cyberbullying across states. After controlling for relevant state-level confounders, students in states with at least 1 DOE legislative component in the antibullying law had a 24% (95% CI, 15%-32%) reduced odds of reporting bullying and 20% (95% CI, 9%-29%) reduced odds of reporting cyberbullying compared with students in states whose laws had no DOE legislative components. Three individual components of antibullying legislation were consistently associated with decreased odds of exposure to both bullying and cyberbullying: statement of scope, description of prohibited behaviors, and requirements for school districts to develop and implement local policies. CONCLUSIONS AND RELEVANCE: Antibullying policies may represent effective intervention strategies for reducing students' risk of being bullied and cyberbullied in schools.

Media violence exposure and physical aggression in fifth-grade children.

OBJECTIVE: To examine the association of media violence exposure and physical aggression in fifth graders across 3 media types. METHODS: We analyzed data from a population-based, cross-sectional survey of 5,147 fifth graders and their parents in 3 US metropolitan areas. We used multivariable linear regression and report partial correlation coefficients to examine associations between children's exposure to violence in television/film, video games, and music (reported time spent consuming media and reported frequency of violent content: physical fighting, hurting, shooting, or killing) and the Problem Behavior Frequency Scale. RESULTS: Child-reported media violence exposure was associated with physical aggression after multivariable adjustment for sociodemographics, family and community violence, and child mental health symptoms (partial correlation coefficients: TV, 0.17; video games, 0.15; music, 0.14). This association was significant and independent for television, video games, and music violence exposure in a model including all 3 media types (partial correlation coefficients: TV, 0.11; video games, 0.09; music, 0.09). There was a significant positive interaction between media time and media violence for video games and music but not for television. Effect sizes for the association of media violence exposure and physical aggression were greater in magnitude than for most of the other examined variables. CONCLUSIONS: The association between physical aggression and media violence exposure is robust and persistent; the strength of this association of media violence may be at least as important as that of other factors with physical aggression in children, such as neighborhood violence, home violence, child mental health, and male gender.

Associations of school violence with physical activity among U.S. high school students.

BACKGROUND: This study investigated associations of violence-related behaviors with physical activity (PA)-related behaviors among U.S. high school students. METHODS: Data from the 2009 national Youth Risk Behavior Survey, a cross-sectional survey of a nationally representative sample of 9th-12th grade students, were analyzed. Sex-stratified, adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated for associations between violence-related behaviors and being physically active for ≥60 minutes daily, sports participation, TV watching for ≥3 hours/day, and video game/computer use for ≥3 hours/day. RESULTS: Among male students, at-school bullying victimization was negatively associated with daily PA (aOR: 0.72; 95% CI: 0.58-0.87) and sports participation; skipping school because of safety concerns was positively associated with video game/computer use (1.42; 1.01-2.00); and physical fighting was positively associated with daily PA. Among female students, at-school bullying victimization and skipping school because of safety concerns were both positively associated with video game/computer use (1.46; 1.19-1.79 and 1.60; 1.09-2.34, respectively), and physical fighting at school was negatively associated with sports participation and positively associated with TV watching. CONCLUSIONS: Bullying victimization emerged as a potentially important risk factor for insufficient PA. Schools should consider the role of violence in initiatives designed to promote PA.

Sexual orientation and suicide ideation, plans, attempts, and medically serious attempts: evidence from local Youth Risk Behavior Surveys, 2001-2009.

OBJECTIVES: We examined the associations between 2 measures of sexual orientation and 4 suicide risk outcomes (SROs) from pooled local Youth Risk Behavior Surveys. METHODS: We aggregated data from 5 local Youth Risk Behavior Surveys from 2001 to 2009. We defined sexual minority youths (SMYs) by sexual identity (lesbian, gay, bisexual) and sex of sexual contacts (same- or both-sex contacts). Survey logistic regression analyses controlled for a wide range of suicide risk factors and sample design effects. RESULTS: Compared with non-SMYs, all SMYs had increased odds of suicide ideation; bisexual youths, gay males, and both-sex contact females had greater odds of suicide planning; all SMYs, except same-sex contact males, had increased odds of suicide attempts; and lesbians, bisexuals, and both-sex contact youths had increased odds of medically serious attempts. Unsure males had increased odds of suicide ideation compared with heterosexual males. Not having sexual contact was protective of most SROs among females and of medically serious attempts among males. CONCLUSIONS: Regardless of sexual orientation measure used, most SMY subgroups had increased odds of all SROs. However, many factors are associated with SROs.

Linking dating violence, peer violence, and suicidal behaviors among high-risk youth.

BACKGROUND: Gaps in the understanding of how different types of violent behavior are linked have limited the ability to design violence prevention efforts that can address multiple types of violence. The objective of this study was to quantify the associations among suicide attempts, and date and peer violence victimization and perpetration and to determine any differences in these associations by gender. METHODS: Analyses, computed in 2006 and 2007, used data from the Youth Violence Survey conducted in 2004. This survey was administered to over 80% of public school students in grades 7, 9, 11, and 12 (N=4131) in a high-risk, urban school district. Analyses were restricted to adolescents who dated in the past year (n=2888). Five forms of violent behaviors (i.e., dating violence perpetration, dating violence victimization, peer violence perpetration, peer violence victimization, and suicide attempts) were examined. RESULTS: Peer violence victimization was the most common type of violence reported (33.0%), followed by date violence victimization (30.7%), peer violence perpetration (29.9%), date violence perpetration (24.8%), and suicide attempts (11.2%). Among all students, 9.8% reported involvement in at least four of the five violent behaviors examined. All five forms of violent behaviors were associated. The highest ORs were observed for victimization and perpetration within either the dating or peer context. However, associations across contexts were also observed. CONCLUSIONS: There is a substantial overlap among different forms of violent behavior, suggesting that additional research is needed to better understand the factors that contribute to involvement in multiple forms of violence.

Healthy and safe school environment, Part I: Results from the School Health Policies and Programs Study 2006.

BACKGROUND: Policies set at the state, district, and school levels can support and enhance a healthy and safe school environment. METHODS: The Centers for Disease Control and Prevention conducts the School Health Policies and Programs Study every 6 years. In 2006, computer-assisted telephone interviews or self-administered mail questionnaires were completed by state education agency personnel in all 50 states plus the District of Columbia and among a nationally representative sample of school districts (n=461). Computer-assisted personal interviews were conducted with personnel in a nationally representative sample of elementary, middle, and high schools (n=1025). RESULTS: Most districts had adopted a policy on the inspection and maintenance of school facilities and equipment, and most schools had inspected and provided appropriate maintenance for each type of school facility and equipment during the 12 months preceding the study. Nearly all districts and schools had a comprehensive crisis preparedness, response, and recovery plan. Nearly all districts and schools prohibited tobacco, alcohol, and illegal drug use; fighting; weapons use; and weapon possession; but when students broke rules related to those behaviors, punitive measures were taken more often than provision of supportive services. Most schools did not reschedule outdoor activities to avoid times when the sun was at peak intensity, nor did they encourage the use of sunscreen before going outside. CONCLUSIONS: To provide students with a truly healthy and safe school environment in which learning can take place, more schools need to promote a positive school climate and reduce violence, injuries, and the use of tobacco, alcohol, and other substances. States and districts need to continue to provide policy and technical assistance in support of school efforts.

Health-related quality of life and behaviors risky to health among adults aged 18-24 years in secondary or higher education--United States, 2003-2005.

PURPOSE: To identify the demographic characteristics and behaviors risky to health contributing to health-related quality of life (HRQOL), defined as the perceived physical or mental health over time. METHODS: Information on students aged 18-24 years from the aggregated Behavioral Risk Factor Surveillance System survey (BRFSS) 2003, 2004, and 2005 data for the 50 states and District of Columbia was studied. Selected HRQOL measures, health care access, behaviors risky to health (i.e., leisure-time physical activity or exercise, cigarette smoking, binge drinking, and indicators of risky sex behaviors), and selected health conditions were analyzed. RESULTS: Overall, students aged 18-24 years reported more mentally unhealthy days than physically unhealthy days. Compared with students in secondary education, younger graduate students reported better mental health, self-rated health, and fewer behaviors risky to health. Regardless of educational level, reported physically or mentally unhealthy days differed by selected demographic characteristics, health care access, behaviors risky to health, and health conditions. CONCLUSIONS: Behaviors risky to health and their associations with mental health should be recognized and addressed in any health prevention or intervention program for student populations. Public health professionals should promote evidence-based health promotion programs to prevent young adults from initiating risky behaviors, continue to promote risk-reduction and cessation skills to those engaged in these behaviors, and incorporate mental health promotion into risk-reduction intervention programs.