Youth and Adult Arrests for Cannabis Possession After Decriminalization and Legalization of Cannabis.

IMPORTANCE: Civil liberty advocates typically support legalization of cannabis, which targets adult use, rather than decriminalization, which can affect both adults and youths. However, it is unknown how arrests of youths for cannabis possession change when adult use of cannabis is legalized. OBJECTIVE: To model changes in arrest rates of adults and youths after decriminalization and legalization of cannabis. DESIGN, SETTING, AND PARTICIPANTS: This quasi-experimental study used the publicly available Uniform Crime Reporting Program Data: Arrests by Age, Sex, and Race administrative data set to examine arrest rates in 38 states from January 1, 2000, to December 31, 2016. Adult (age, ≥18 years) and youth (age, <18 years) arrests for possession of cannabis were examined. States were excluded if they did not report complete arrest data or if a policy was implemented that reduced penalties for possession of cannabis but fell short of decriminalization. Fixed-effects regression was used in an extended difference-in-differences framework. The analyses in their final form were conducted between January 17 and February 28, 2019. EXPOSURE: Living in a state with a cannabis decriminalization policy (ie, making the penalty for cannabis possession similar to the small fine for a traffic violation) or legalization policy (ie, creating a legal supply of cannabis along with the removal of penalties for possession of a small amount of cannabis for recreational use). MAIN OUTCOME AND MEASURES: State cannabis possession arrest rate per 100 000 population. RESULTS: Data from 38 states were examined, including 4 states with cannabis legalization policies and 7 states with cannabis decriminalization policies. The adult arrest rate decreased by 131.28 (95% CI, 106.23-154.21) per 100 000 population after the implementation of decriminalization and 168.50 (95% CI, 158.64-229.65) per 100 000 population after the implementation of legalization. The arrest rate for youths decreased by 60 (95% CI, 42-75) per 100 000 population after decriminalization but did not significantly change after legalization in a state (7 per 100 000 population; 95% CI, -15 to 30). CONCLUSIONS AND RELEVANCE: Legalization, as implemented through 2016, did not appear to reduce arrests for cannabis possession among youths, despite having benefited adults. The study's findings suggest that decriminalization reduces youth arrests in most cases, but these findings also suggest that any benefit for youths could be lost when adult use has also been legalized. To address this problem, it appears that state decriminalization policies should take the additional step to explicitly describe when youths can be arrested for possession of small amounts of cannabis.

Preventing Opioid Overdose in the Clinic and Hospital: Analgesia and Opioid Antagonists.

Drawing from existing opioid prescribing guidelines, this article describes how medical providers can reduce the risk of overdose. Through primary prevention, providers can prevent initial exposure and associated risks by educating patients, using risk stratification, minimizing opioid dose and duration, and avoiding coprescribing with sedatives. Secondary prevention efforts include monitoring patients with urine toxicology and prescription monitoring programs, and screening for opioid use disorders. Tertiary prevention includes treating opioid use disorders and providing naloxone to prevent overdose death. Specific preventive strategies may be required for those with psychiatric disorders or substance use disorders, adolescents, the elderly, and pregnant women.

Is Preconception Substance Use Associated With Unplanned or Poorly Timed Pregnancy?

OBJECTIVE: Unplanned and poorly timed pregnancies are associated with adverse maternal and neonatal outcomes. Further understanding of preconception substance use with unplanned and poorly timed pregnancy is warranted. METHODS: Data were analyzed from a prospective study enrolling women early in pregnancy. Preconception tobacco, alcohol, marijuana, opioid, and cocaine use was ascertained. Participants reported whether their current pregnancy was planned and whether it was a good time to be pregnant. Multivariable logistic regression modeling generated risk estimates for preconception substance use, and pregnancy planning and timing, adjusting for confounders. RESULTS: Overall, 37.2% reported unplanned pregnancy, 13.0% poorly timed pregnancy, and 39.0% reported either unplanned and/or poorly timed pregnancy. Within 6 months preconception, one-fifth (20.2%) reported nicotine cigarette use. In the month before conception, 71.8% reported alcohol use, 6.5% marijuana, and approximately 1% opioid or cocaine use. Multivariable analysis demonstrated preconception opioid use was associated with increased odds of poorly timed pregnancy (odds ratio [OR] 2.87, 95% confidence interval [CI] 1.03-7.99). Binge drinking the month before conception was associated with increased odds of poorly timed pregnancy and unplanned pregnancy (OR 1.75, 95% CI 1.01-3.05; and OR 1.68, 95% CI 1.01-2.79, respectively). Marijuana use 2 to 3 times in the month preconception was associated with increased risk of unplanned pregnancy, and unplanned and/or poorly timed pregnancy compared with nonuse (OR 1.78, 95% CI 1.03-3.08; and OR 1.79, 95% CI 1.01-3.17, respectively). Preconception tobacco or cocaine use was not associated with unplanned or poorly timed pregnancy following adjustment. CONCLUSIONS: We demonstrate increased odds of unplanned or poorly timed pregnancy among women with preconception binge drinking, marijuana use, and opioid use; however, no association is observed with other substances after multivariable adjustment, including tobacco. Further research to evaluate high-level preconception substance use and substance disorders with pregnancy planning and timing is warranted. Focused efforts optimizing preconception health behaviors and reducing risk of unplanned or poorly timed pregnancy are needed.

Group Visits for Overdose Education and Naloxone Distribution in Primary Care: A Pilot Quality Improvement Initiative.

OBJECTIVE: Opioid prescribing for chronic pain significantly contributes to opioid overdose deaths in the United States. Naloxone as a take-home antidote to opioid overdose is underutilized and has not been evaluated in the high-risk chronic pain population. The objective was to increase overdose education and naloxone distribution (OEND) to high-risk patients on long-term opioid therapy for pain by utilizing group visits in primary care. DESIGN: Quality improvement intervention among two primary care clinics. SETTING: A large, academic facility within the Veterans Health Administration. SUBJECTS: Patients prescribed ≥100 mg morphine-equivalent daily dose or coprescribed opioids and benzodiazepines. METHODS: One clinic provided usual care with respect to OEND; another clinic encouraged attendance at an OEND group visit to all of its high-risk patients. RESULTS: We used attendance at group visits, prescriptions of naloxone issued, and patient satisfaction scores to evaluate this format of OEND. KEY RESULTS: Group OEND visits resulted in significantly more naloxone prescriptions than usual care. At these group visits, patients were engaged, valued the experience, and all requested a prescription for the naloxone kit. CONCLUSION: This quality improvement pilot study suggests that OEND group visits are a promising model of care.

Long-Term Outcomes After Residential Substance Use Treatment: Relapse, Morbidity, and Mortality.

A cohort of 207 veterans admitted to a residential substance use treatment program was followed for 5 years following discharge to determine factors associated with reduced relapse or mortality following discharge. Subsequent utilization of medical and psychiatric hospitalization and emergency room utilization was also examined. Retrospective chart review was conducted using demographic, diagnostic, and prior treatment as independent variables. Dependent variables included aftercare compliance and subsequent morbidity as measured by relapse, emergency room visits, subsequent hospitalizations, and mortality. Cox proportional hazards models were used to examine factors associated with relapse and mortality. Aftercare attendance was higher in those who completed treatment (p < 0.01). Factors associated with higher risk of relapse included comorbid disorders, failure to complete the index residential substance use treatment program, and psychiatric rehospitalization. Factors associated with higher mortality included failure to complete residential substance use treatment, longer medical rehospitalization, and nicotine dependence. Longer psychiatric rehospitalization was associated with a lower risk of mortality. Comorbid psychiatric conditions and failure to complete residential substance use treatment were associated with higher relapse. Limitations include that this population has severe substance use disorder, that subjective report of symptom severity was not assessed and that attendance at Alcoholics Anonymous aftercare was not surveyed.

Participation in a novel treatment component during residential substance use treatment is associated with improved outcome: a pilot study.

BACKGROUND: A person-centered substance use treatment component, the Natural Recovery Program, was developed. The Natural Recovery Program is comprised of small group therapy combined with pursuit of hobbies. METHODS: This was a pilot study of the program and was not randomized. A retrospective record review of 643 veterans in an inpatient mental health recovery and rehabilitation program was analyzed to determine if participants of Natural Recovery had a different rate of treatment completion than those who elected to participate in the core program alone. Univariate and multivariate analyses were conducted on: participation in the Natural Recovery Program; co-morbid psychiatric disorders; and legal, medical, and psychiatric issues. RESULTS: Participation in Natural Recovery was significantly associated with successful treatment completion when analyzed by univariate analysis (p = 0.01). Other significant variables associated with successful completion included: no co-morbid psychiatric diagnosis, fewer prior suicide attempts, and no homelessness prior to admission. Binary logistic regression demonstrated that participation in Natural Recovery was associated with improved treatment completion, even when other variables were considered (p = 0.01). Treatment retention was longer for patients who participated in Natural Recovery, even if they did not complete treatment. CONCLUSIONS: The Natural Recovery Program was associated with improved outcomes, as measured by treatment retention in the first 60 days and by treatment completion. Participants of Natural Recovery with co-morbid psychiatric disorders completed treatment at a higher rate than those with co-morbid psychiatric disorders who participated in the core program. Patients reported high satisfaction with the program. This program may be a valuable adjunct to residential treatment.

Allopurinol and xanthine oxidase inhibition in liver ischemia reperfusion.

INTRODUCTION: Allopurinol was first introduced, in 1963, as a xanthine oxidase inhibitor when it was investigated for concomitant use with cancer chemotherapy drugs. Today it is used in gout and hyperuricemia. Due to its additive benefit in preventing oxidative damage, attention has shifted towards the use of allopurinol in organ ischemia and reperfusion. CURRENT STATUS: Currently, the mechanism by which allopurinol exerts a protective benefit in ischemia reperfusion related events is not fully understood. There are various theories: it may act by inhibiting the irreversible breakdown of purine substrates, and/or by inhibiting the formation of reactive oxygen species, and/or by protecting against damage to the mitochondrial membrane. AIM: This work focuses on liver ischemia and reperfusion injury in an effort to better understand the mechanisms associated with allopurinol and with this pathological entity. REVIEW OF LITERATURE: The current research, mainly in animal models, points to allopurinol having a protective benefit, particularly if used pre-ischemically in liver ischemia reperfusion injury. Furthermore, after reviewing allopurinol dosing and administration, it was found that 50 mg/kg is statistically the most effective dose in attenuating liver ischemia reperfusion injury. Owing to the limited number of samples, the time of administration did not show statistical difference, but allopurinol was often beneficial when given around 1 h before ischemia. CONCLUSION: In conclusion, allopurinol, through its known xanthine oxidase inhibitory effect, as only one of the potential mechanisms, has demonstrated its potential application in protecting the liver during ischemia and reperfusion.