Access to care for patients with chronic pain receiving prescription opioids, cannabis, or other treatments.

Changes in chronic noncancer pain treatment have led to decreases in prescribing of opioids and increases in the availability of medical cannabis, despite its federal prohibition. Patients may face barriers to establishing new care with a physician based on use of these treatments. We compared physician willingness to accept patients based on prescription opioid, cannabis, or other pain treatment use. This study of 36 states and Washington, DC, with active medical cannabis programs surveyed physicians who treat patients with chronic noncancer pain between July 13 and August 4, 2023. Of 1000 physician respondents (34.5% female, 63.2% White, 78.1% primary care), 852 reported accepting new patients with chronic pain. Among those accepting new patients with chronic pain, more physicians reported that they would not accept new patients taking prescription opioids (20.0%) or cannabis (12.7%) than those taking nonopioid prescription analgesics (0.1%). In contrast, 68.1% reported willingness to accept new patients using prescribed opioids on a daily basis. For cannabis, physicians were more likely to accept new patients accessing cannabis through medical programs (81.6%) than from other sources (60.2%). Access to care for persons with chronic noncancer pain appears to be the most restricted among those taking prescription opioids, although patients taking cannabis may also encounter reduced access.

Navigating addiction treatment during COVID-19: policy insights from state health leaders.

To mitigate pandemic-related disruptions to addiction treatment, US federal and state governments made significant changes to policies regulating treatment delivery. State health agencies played a key role in implementing these policies, giving agency leaders a distinct vantage point on the feasibility and implications of post-pandemic policy sustainment. We interviewed 46 state health agency and other leaders responsible for implementing COVID-19 addiction treatment policies across 8 states with the highest COVID-19 death rate in their census region. Semi-structured interviews were conducted from April through October 2022. Transcripts were analyzed using summative content analysis to characterize policies that interviewees perceived would, if sustained, benefit addiction treatment delivery long-term. State policies were then characterized through legal database queries, internet searches, and analysis of existing policy databases. State leaders viewed multiple pandemic-era policies as useful for expanding addiction treatment access post-pandemic, including relaxing restrictions for telehealth, particularly for buprenorphine induction and audio-only treatment; take-home methadone allowances; mobile methadone clinics; and out-of-state licensing flexibilities. All states adopted at least 1 of these policies during the pandemic. Future research should evaluate these policies outside of the acute COVID-19 pandemic context.

Trends in Opioid Use Disorder Outpatient Treatment and Telehealth Utilization Before and During the COVID-19 Pandemic.

OBJECTIVE: The authors examined trends in opioid use disorder treatment and in-person and telehealth modalities before and after COVID-19 pandemic onset among patients who had received treatment prepandemic. METHODS: The sample included 13,113 adults with commercial insurance or Medicare Advantage and receiving opioid use disorder treatment between March 2018 and February 2019. Trends in opioid use disorder outpatient treatment, treatment with medications for opioid use disorder (MOUD), and in-person and telehealth modalities were examined 1 year before pandemic onset and 2 years after (March 2019-February 2022). RESULTS: From March 2019 to February 2022, the proportion of patients with opioid use disorder outpatient and MOUD visits declined by 2.8 and 0.3 percentage points, respectively. Prepandemic, 98.6% of outpatient visits were in person; after pandemic onset, at least 34.9% of patients received outpatient care via telehealth. CONCLUSIONS: Disruptions in opioid use disorder outpatient and MOUD treatments were marginal during the pandemic, possibly because of increased telehealth utilization.

State Laws That Require Coprescribing Opioids and Naloxone and Codispensing Practices.

INTRODUCTION: Coprescribing naloxone with opioids could reduce the risk of overdose. By the end of 2020, 8 U.S. states implemented coprescribing laws requiring the prescription of naloxone alongside certain opioid prescriptions. This study examined the impacts of state laws that require coprescribing opioids and naloxone on codispensing practices. METHODS: Data included opioid prescriptions for commercially insured adults between 2014 and 2020. Augmented synthetic control analyses were used to examine the impacts of 8 coprescribing requirement laws implemented between 2017 and 2020 on the proportion of opioid prescription fills with a naloxone coprescription fill. Analyses were completed in spring 2023. RESULTS: Changes in the proportion of opioid prescription fills with a naloxone coprescription fill attributable to the laws varied across states. In 4 states (New Jersey, New Mexico, Rhodes Island, and Virginia), laws were associated with 0.8 (95% CI=0.3, 1.3) to 4.4 (95% CI=3.4, 5.4) percentage point increases in the proportion of opioid prescriptions with a naloxone coprescription fill (p<0.05). There were no statistically significant changes attributable to the other state laws (Arizona, Florida, Vermont, Washington). CONCLUSIONS: Laws requiring coprescribing naloxone with certain opioid prescriptions are associated with small-in-magnitude increases in codispensing in some states. Broadening the categories of opioid prescriptions covered in naloxone coprescribing requirement laws and implementing health system strategies to encourage providers to coprescribe naloxone could help to magnify the impacts of these laws.

Effects of U.S. State Medical Cannabis Laws on Treatment of Chronic Noncancer Pain.

BACKGROUND: State medical cannabis laws may lead patients with chronic noncancer pain to substitute cannabis in place of prescription opioid or clinical guideline-concordant nonopioid prescription pain medications or procedures. OBJECTIVE: To assess effects of state medical cannabis laws on receipt of prescription opioids, nonopioid prescription pain medications, and procedures for chronic noncancer pain. DESIGN: Using data from 12 states that implemented medical cannabis laws and 17 comparison states, augmented synthetic control analyses estimated laws' effects on receipt of chronic noncancer pain treatment, relative to predicted treatment receipt in the absence of the law. SETTING: United States, 2010 to 2022. PARTICIPANTS: 583 820 commercially insured adults with chronic noncancer pain. MEASUREMENTS: Proportion of patients receiving any opioid prescription, nonopioid prescription pain medication, or procedure for chronic noncancer pain; volume of each treatment type; and mean days' supply and mean morphine milligram equivalents per day of prescribed opioids, per patient in a given month. RESULTS: In a given month during the first 3 years of law implementation, medical cannabis laws led to an average difference of 0.05 percentage points (95% CI, -0.12 to 0.21 percentage points), 0.05 percentage points (CI, -0.13 to 0.23 percentage points), and -0.17 percentage points (CI, -0.42 to 0.08 percentage points) in the proportion of patients receiving any opioid prescription, any nonopioid prescription pain medication, or any chronic pain procedure, respectively, relative to what we predict would have happened in that month had the law not been implemented. LIMITATIONS: This study used a strong nonexperimental design but relies on untestable assumptions involving parallel counterfactual trends. Statistical power is limited by the finite number of states. Results may not generalize to noncommercially insured populations. CONCLUSION: This study did not identify important effects of medical cannabis laws on receipt of opioid or nonopioid pain treatment among patients with chronic noncancer pain. PRIMARY FUNDING SOURCE: National Institute on Drug Abuse.

A pilot trial of behavioural activation with a contingency management component: Preliminary examination of changes in smoking and alternative rewards among low-income individuals.

The heaviest smoking and burden of tobacco-related illness occurs among low-income individuals. Using a behavioural economics framework, this non-randomised pilot study examined the preliminary efficacy of behavioural activation (BA) with a contingency management (CM) component designed to encourage continued use of BA skills and reductions in cigarettes smoked. Eighty-four participants were recruited from a community centre. Data were collected at the start of every other group and at four different follow-up time points. Domains assessed included number of cigarettes smoked, activity level, and environmental rewards (i.e. alternative environmental reinforcers). Over time, cigarette smoking decreased (p < .001), environmental reward increased (p = .03), and reward probability and activity level were associated over time with cigarette smoking (p ≤ .03) above and beyond the effect of nicotine dependence. The continued use of BA skills was associated with greater environmental rewards (p = .04). While further research is needed to replicate this work, results suggest initial evidence for the utility of this intervention in a traditionally underserved community.

Effects of state opioid prescribing cap laws on providers' opioid prescribing patterns among patients with chronic non-cancer pain.

Prior work suggests opioid prescribing cap laws are not associated with changes in opioid prescribing among patients with chronic pain. It is unknown how these effects differ by provider specialty, provider opioid prescribing volume, or patient insurer. This study assessed effects of state opioid prescribing cap laws on opioid prescribing among providers of patients with chronic non-cancer pain, by high volume prescribing, provider specialty, and patient insurer. We identified 224,290 providers of patients with low back pain, fibromyalgia, or headache from the IQVIA administrative database. Using a difference-in-differences approach, we examined impacts of opioid prescribing cap laws implemented between 2016 and 2018 on the annual proportion of a provider's patient panel who received any opioid prescription, as well as on dose and duration of opioid prescriptions. For providers overall, high volume prescribers, all specialties, and patient insurance categories, prescribing cap laws were associated with non-significant changes of <1.0, 1.5, and 3.5 percentage points in the proportion of chronic non-cancer patients receiving any opioid prescription, a prescription with 7 days' supply, or with >50 morphine milligram equivalents (MME)/day, per year, respectively. There were two exceptions with high dose prescribing: prescribing cap laws were associated with a 1.5 percentage point increase in the proportion of high-volume prescribers' patient panel receiving an opioid prescription with ≥50 MME/day, and a 3.0 percentage point decrease in the same measure among surgeons. Among nearly all measured subgroups of providers and patient insurers, opioid prescribing cap laws were not associated with changes in opioid prescribing.

Barriers and facilitators to primary care engagement for people who inject drugs: A systematic review.

INTRODUCTION: People who inject drugs (PWID) have a greater burden of multimorbid chronic diseases than the general population. However, little attention has been paid to the engagement in primary care for services related specifically to injection drug use and management of underlying chronic comorbid diseases for this population. This systematic review identified facilitators and barriers to healthcare engagement in the primary care setting among PWID. DESIGN AND METHODS: Studies were identified by a literature search of PubMed, CINAHL, and EMBASE, and by searching the references of retrieved articles. Studies were included if they measured active injection drug use, and outcomes related to primary care engagement characterized by: diagnosis of a health condition, linkage or retention in care, health condition-related outcomes, and reported patient-provider relationship. RESULTS: Twenty-three articles were included. Using the behavioral model, factors within predisposing, enabling, need, and health behavior domains were identified. Having co-located services and a positive patient-provider relationship were among the strongest factors associated with healthcare utilization and engagement while active injection drug use was associated with decreased engagement. CONCLUSIONS: To our knowledge, this is the only review of evidence that has examined factors related to primary care engagement for people who inject drugs. Most articles were observational studies utilizing descriptive designs. Although the assessment of the evidence was primarily rated 'Good', this review identifies a significant need to improve our understanding of primary care engagement for PWID. Future research and intervention strategies should consider these findings to better integrate the holistic care needs of PWID into primary care to reduce morbidity and mortality associated with injection drug use and chronic disease. CLINICAL RELEVANCE: Primary care engagement is important for preventative care, early diagnosis of disease, and management of chronic diseases, including addressing problems of substance use. This review highlights factors nurses can utilize to facilitate primary care engagement of PWID.

Effects of Opioid Prescribing Cap Laws on Opioid and Other Pain Treatments Among Persons with Chronic Pain.

BACKGROUND: Many states have adopted laws that limit the amount or duration of opioid prescriptions. These limits often focus on prescriptions for acute pain, but there may be unintended consequences for those diagnosed with chronic pain, including reduced opioid prescribing without substitution of appropriate non-opioid treatments. OBJECTIVE: To evaluate the effects of state opioid prescribing cap laws on opioid and non-opioid treatment among those diagnosed with chronic pain. DESIGN: We used a difference-in-differences approach that accounts for staggered policy adoption. Treated states included 32 states that implemented a prescribing cap law between 2017 and 2019. POPULATION: A total of 480,856 adults in the USA who were continuously enrolled in medical and pharmacy coverage from 2013 to 2019 and diagnosed with a chronic pain condition between 2013 and 2016. MAIN MEASURES: Among individuals with chronic pain in each state: proportion with at least one opioid prescription and with prescriptions of a specific duration or dose, average number of opioid prescriptions, average opioid prescription duration and dose, proportion with at least one non-opioid chronic pain prescription, average number of such prescriptions, proportion with at least one chronic pain procedure, and average number of such procedures. KEY RESULTS: State laws limiting opioid prescriptions were not associated with changes in opioid prescribing, non-opioid medication prescribing, or non-opioid chronic pain procedures among patients with chronic pain diagnoses. CONCLUSIONS: These findings do not support an association between state opioid prescribing cap laws and changes in the treatment of chronic non-cancer pain.

State prescribing cap laws' association with opioid analgesic prescribing and opioid overdose.

INTRODUCTION: In response to the role of opioid prescribing in the U.S. opioid crisis, states have enacted laws intended to curb high risk opioid prescribing practices. This study assessed the effects of state prescribing cap laws that limit the dose and/or duration of dispensed opioid prescriptions on opioid prescribing patterns and opioid overdose. METHODS: We identified 1,414,908 adults from a large U.S. administrative insurance claims database. Treatment states included 32 states that implemented a prescribing cap law between 2017 and 2019. Comparison states included 16 states and DC without a prescribing cap law by 2019. A difference-in-differences approach with staggered policy adoption was used to assess effects of these laws on opioid analgesic prescribing and opioid overdose. RESULTS: State opioid prescribing cap laws were not associated with changes in the proportion of people receiving opioid analgesic prescriptions, the dose or duration of opioid prescriptions, or opioid overdose. States with laws that imposed days' supply limits only versus days' supply and dosage limits, as well as with specific law provisions also showed no association with opioid prescribing or opioid overdose outcomes. CONCLUSIONS: State opioid prescribing cap laws did not appear to impact outcomes related to opioid analgesic prescribing or opioid overdose. These findings are potentially due to the limited scope of these laws, which often apply only to a subset of opioid prescriptions and include professional judgment exemptions.

Association Between State Opioid Prescribing Cap Laws and Receipt of Opioid Prescriptions Among Children and Adolescents.

Importance: High-dose and long-duration opioid prescriptions remain relatively common among children and adolescents, but there is insufficient research on the association of state laws limiting the dose and/or duration of opioid prescriptions (referred to as opioid prescribing cap laws) with opioid prescribing for this group. Objective: To examine the association between state opioid prescribing cap laws and the receipt of opioid prescriptions among children and adolescents. Design Setting and Participants: This repeated cross-sectional study used a difference-in-differences approach accounting for staggered policy adoption to assess the association of state opioid prescribing cap laws in the US from January 1, 2013, to December 31, 2019, with receipt of opioid prescriptions among children and adolescents. Analyses were conducted between March 22 and December 15, 2021. Data were obtained from the OptumLabs Data Warehouse, a national commercial insurance claims database. The analysis included 482 118 commercially insured children and adolescents aged 0 to 17 years with full calendar-year continuous insurance enrollment between 2013 and 2019. Individuals were included for every year in which they were continuously enrolled; they did not need to be enrolled for the entire 7-year study period. Those with any cancer diagnosis were excluded from analysis. Exposure: Implementation of a state opioid prescribing cap law between January 1, 2017, and July 1, 2019. This date range allowed analysis of the same number years for both pre-cap and post-cap data. Main Outcomes and Measures: Outcomes of interest included receipt of any opioid prescription and, among those with at least 1 opioid prescription, the mean number of opioid prescriptions, mean morphine milligram equivalents (MMEs) per day, and mean days' supply. Results: Among 482 118 children and adolescents (754 368 person-years of data aggregated to the state-year level), 245 178 (50.9%) were male, with a mean (SD) age of 9.8 (4.8) years at the first year included in the sample (data on race and ethnicity were not collected as part of this data set, which was obtained from insurance billing claims). Overall, 10 659 children and adolescents (2.2%) received at least 1 opioid prescription during the study period. Among those with at least 1 prescription, the mean (SD) number of filled opioid prescriptions was 1.2 (0.8) per person per year. No statistically significant association was found between state opioid prescribing cap laws and any outcome. After opioid prescribing cap laws were implemented, a -0.001 (95% CI, -0.005 to 0.002) percentage point decrease in the proportion of youths receiving any opioid prescription was observed. In addition, percentage point decreases of -0.01 (95% CI, -0.10 to 0.09) in high-dose opioid prescriptions (>50 MMEs per day) and -0.02 (95% CI, -0.12 to 0.08) in long-duration opioid prescriptions (>7 days' supply) were found after cap laws were implemented. Conclusions and Relevance: In this cross-sectional study, no association was observed between state opioid prescribing cap laws and the receipt of opioid prescriptions among children and adolescents. Alternative strategies, such as opioid prescribing guidelines tailored to youths, are needed.

Effects of state opioid prescribing cap laws on opioid prescribing after surgery.

OBJECTIVE: To evaluate the effects of state opioid prescribing cap laws on opioid prescribing after surgery. DATA SOURCES: OptumLabs Data Warehouse administrative claims data covering all 50 states from July 2012 through June 2019. STUDY DESIGN: We included individuals from 20 states that had implemented prescribing cap laws without exemptions for postsurgical pain by June 2019 and individuals from 16 control states plus the District of Columbia. We used a difference-in-differences approach accounting for differential timing in law implementation across states to estimate the effects of state prescribing cap laws on postsurgical prescribing of opioids. Outcome measures included filling an opioid prescription within 30 days after surgery; filling opioid prescriptions of specific doses or durations; and the number, days' supply, daily dose, and pill quantity of opioid prescriptions. To assess the validity of the parallel counterfactual trends assumption, we examined differences in outcome trends between law-implementing and control states in the years preceding law implementation using an equivalence testing framework. DATA COLLECTION/EXTRACTION METHODS: We included the first surgery in the study period for opioid-naïve individuals undergoing one of eight common surgical procedures. PRINCIPAL FINDINGS: State prescribing cap laws were associated with 0.109 lower days' supply of postsurgical opioids on the log scale (95% Confidence Interval [CI]: -0.139, -0.080) but were not associated with the number (Average treatment effect on the treated [ATT]: -0.011; 95% CI: -0.043, 0.021) or daily dose of postsurgical opioid prescriptions (ATT: -0.013; 95% CI: -0.030, 0.005). The negative association observed between prescribing cap laws and the probability of filling a postsurgical opioid prescription (ATT: -0.041; 95% CI: -0.054, -0.028) was likely spurious, given differences between law-implementing and control states in the pre-law period. CONCLUSIONS: Prescribing cap laws appear to have minimal effects on postsurgical opioid prescribing.

Trends in cannabis use among U.S. adults amid the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has had an impact on mental health and alcohol use in the US, however there is little research on its impacts on cannabis use. Considering the role of cannabis as a coping strategy or self-medicating behavior, there is a need to understand how individuals who use cannabis have adapted their use amid the pandemic. Therefore, this study examined changes in self-reported cannabis use among US adults in the context of COVID-19 pandemic by (1) describing trends of use during the first 8 months of the pandemic among adults who used cannabis in this period; and (2) characterizing trends of use within sociodemographic subgroups and by state cannabis policy status. METHODS: The sample consisted of 1,761 US adults who used cannabis at least once during the 8-month study period from the nationally representative Understanding America Study. Linear mixed-effect models were used to model changes in the number of days of past-week cannabis use across 16 waves from March 10, 2020, to November 11, 2020. RESULTS: Compared to early March, the number of days cannabis was used per week was significantly higher at the start of April (ß=0.11, 95% CI=0.03, 0.18) and May (ß=0.21,95% CI=0.05, 0.36). In subsequent months (June - November), the number of days of cannabis use attenuated to levels comparable to March. Trends of cannabis use across the study period generally did not differ across sociodemographic characteristics and state cannabis policy status. CONCLUSION: Though increases in use were marginal among many groups, the evolving pandemic and the growing concern for the mental health of segments of the U.S. population warrant close monitoring of coping behaviors, including substance use.

Studying how state health services delivery policies can mitigate the effects of disasters on drug addiction treatment and overdose: Protocol for a mixed-methods study.

BACKGROUND: The United States is experiencing a drug addiction and overdose crisis, made worse by the COVID-19 pandemic. Relative to other types of health services, addiction treatment and overdose prevention services are particularly vulnerable to disaster-related disruptions for multiple reasons including fragmentation from the general medical system and stigma, which may lead decisionmakers and providers to de-prioritize these services during disasters. In response to the COVID-19 pandemic, U.S. states implemented multiple policies designed to mitigate disruptions to addiction treatment and overdose prevention services, for example policies expanding access to addiction treatment delivered via telehealth and policies designed to support continuity of naloxone distribution programs. There is limited evidence on the effects of these policies on addiction treatment and overdose. This evidence is needed to inform state policy design in future disasters, as well as to inform decisions regarding whether to sustain these policies post-pandemic. METHODS: The overall study uses a concurrent-embedded design. Aims 1-2 use difference-in-differences analyses of large-scale observational databases to examine how state policies designed to mitigate the effects of the COVID-19 pandemic on health services delivery influenced addiction treatment delivery and overdose during the pandemic. Aim 3 uses a qualitative embedded multiple case study approach, in which we characterize local implementation of the state policies of interest; most public health disaster policies are enacted at the state level but implemented at the local level by healthcare systems and local public health authorities. DISCUSSION: Triangulation of results across methods will yield robust understanding of whether and how state disaster-response policies influenced drug addiction treatment and overdose during the COVID-19 pandemic. Results will inform policy enactment and implementation in future public health disasters. Results will also inform decisions about whether to sustain COVID-19 pandemic-related changes to policies governing delivery addiction and overdose prevention services long-term.

Co-Occurring Opioid Use and Depressive Disorders: Patient Characteristics and Co-Occurring Health Conditions.

OBJECTIVE: Among persons with opioid use disorder (OUD), co-occurring depression is linked to a greater risk of opioid misuse, overdose and suicide. Less is known about characteristics and other comorbid health conditions of persons with co-occurring opioid use and depressive disorders. METHODS: This study used electronic health record (EHR) encounters from the Geisinger Health System prior to the fall of 2019. Adult patients were recruited from a medication-based treatment clinic and had an OUD diagnosis (N = 692). Co-occurring depression was defined by a depression diagnosis in the EHR. Multivariable logistic regression was performed to assess differences in characteristics, behavioral health and medical diagnoses, as well as opioid overdose and suicide attempt or ideation between individuals with and without comorbid depression. RESULTS: Forty-seven percent of patients with OUD had a lifetime depression diagnosis. Individuals with co-occurring depression were more likely to be female and have comorbid chronic pain or other medical conditions. Co-occurring depression was associated with an increased likelihood of other mental health and substance use disorders, as well as opioid overdose and/or suicide attempt or ideation. CONCLUSIONS: While it is established that co-occurring depression is associated with increased risk of overdose and suicide, this study adds that other health conditions, including chronic pain and common medical conditions, are more prevalent among persons with co-occurring depressive disorders. Results highlight the need to consider these complex health needs when developing treatment plans and services.

"People Don't Just Start Shooting Heroin on Their 18th Birthday": A Qualitative Study of Community Stakeholders' Perspectives on Adolescent Opioid Use and Opportunities for Intervention in Baltimore, Maryland.

Initiation of non-medical prescription opioid use (NMPO) during early adolescence is tightly linked to heroin and other drug use disorders and related sequelae in later adolescence and young adulthood. Few studies explore stakeholders' perspectives on the burden and determinants of youth opioid use and barriers and facilitators to engaging youth in opioid use prevention and treatment services in urban settings with longstanding opioid epidemics. In-depth interviews were conducted with 22 stakeholders representing health and social service agencies in Baltimore, Maryland from May 2018- February 2019, to examine their perspectives on the burden and context of adolescent opioid use and identify barriers and facilitators to preventing and responding to adolescent opioid use. Transcripts were analyzed using the constant comparison method to identify themes. Most respondents described a recent uptick in opioid use independently, and in combination with other substances. As compared to heroin, NMPO was perceived to be more frequently used and less stigmatized among youth. Stakeholders perceived the process of transitioning from using NMPO to heroin as more common among White vs. Black youth and was perceived as occurring faster among White vs. Black youth. Some stakeholders believed racial differences in internal stigma against heroin use, and differential health service use among Black youth and White youth may have influenced these differences. Trauma and poverty were noted determinants of youth opioid use. Barriers to service provision included youth cognitive development, stigma and structural factors (e.g., disinvestment, lack of youth-centered and integrated services). Stakeholders perceive prevalent NMPO among Baltimore youth and identify multilevel barriers to delivering prevention, treatment and harm reduction services to this population. These findings encourage further investigation of determinants and consequences of opioid use among diverse racial/ethnic groups of youth in urban settings, and development of multilevel, youth-driven and youth-centered approaches to prevention and treatment.

Methods to Optimize Recruitment, Participation, and Retention Among Vulnerable Individuals Participating in a Longitudinal Clinical Trial.

Low-income and ethnic/racial minority adults do not often participate in research or may face unique barriers when participating in research, which delays and impedes medical advances for this vulnerable population. This article describes in detail the evidenced-based methods used to enhance recruitment, participation, and retention in a clinical trial at a center serving ethnic/racial minorities and low-income individuals. The article details the partnership with a community outreach center and describes the duties and impact of a community liaison to enhance recruitment, participation, and retention in a randomized controlled trial with a 6-month follow-up. Of the 246 individuals initially recruited for screening, 80 did not meet inclusion criteria with the most common reason for disqualification being meeting criteria for substance use disorder (n = 44). One hundred sixty-six participants qualified for participation. The majority of participants identified as African American (n = 127, 77.1%) and reported an annual individual income under $10,000 (n = 121 (74.2%). Forty-five percent of the sample completed the requested number of sessions (i.e., 12). Sixty-three percent of participants completed post intervention assessments and 42% completed 6-month follow-up data collection. The participation and retention numbers in this study appear higher than typical participation and retention rates in longitudinal studies with similar populations. The methods and lessons learned may be useful for other clinical trials that recruit vulnerable populations and wish to enhance participation, engagement, and retention.

Protocol: mixed-methods study of how implementation of US state medical cannabis laws affects treatment of chronic non-cancer pain and adverse opioid outcomes.

BACKGROUND: Thirty-three US states and Washington, D.C., have enacted medical cannabis laws allowing patients with chronic non-cancer pain to use cannabis, when recommended by a physician, to manage their condition. However, clinical guidelines do not recommend cannabis for treatment of chronic non-cancer pain due to limited and mixed evidence of effectiveness. How state medical cannabis laws affect delivery of evidence-based treatment for chronic non-cancer pain is unclear. These laws could lead to substitution of cannabis in place of clinical guideline-discordant opioid prescribing, reducing risk of opioid use disorder and overdose. Conversely, state medical cannabis laws could lead to substitution of cannabis in place of guideline-concordant treatments such as topical analgesics or physical therapy. This protocol describes a mixed-methods study examining the implementation and effects of state medical cannabis laws on treatment of chronic non-cancer pain. A key contribution of the study is the examination of how variation in state medical cannabis laws' policy implementation rules affects receipt of chronic non-cancer pain treatments. METHODS: The study uses a concurrent-embedded design. The primary quantitative component of the study employs a difference-in-differences design using a policy trial emulation approach. Quantitative analyses will evaluate state medical cannabis laws' effects on treatment for chronic non-cancer pain as well as on receipt of treatment for opioid use disorder, opioid overdose, cannabis use disorder, and cannabis poisoning among people with chronic non-cancer pain. Secondary qualitative and survey methods will be used to characterize implementation of state medical cannabis laws through interviews with state leaders and representative surveys of physicians who treat, and patients who experience, chronic non-cancer pain in states with medical cannabis laws. DISCUSSION: This study will examine the effects of medical cannabis laws on patients' receipt of guideline-concordant non-opioid, non-cannabis treatments for chronic non-cancer pain and generate new evidence on the effects of state medical cannabis laws on adverse opioid outcomes. Results will inform the dynamic policy environment in which numerous states consider, enact, and/or amend medical cannabis laws each year.

The state of the evidence on the association between state cannabis laws and opioid-related outcomes: A review.

Purpose of Review: This review summarizes studies examining impacts of medical and recreational cannabis laws on opioid prescribing, opioid use, opioid use disorder, opioid-related service utilization, and opioid-involved mortality. We also discuss research challenges and recommendations for future work. Recent Findings: Twenty-one U.S. based studies published between 2014-2021 that assessed state cannabis laws' association with opioid-related outcomes were reviewed. Study results were largely inconclusive. We identified six challenges of existing work: 1) inability to directly measure cannabis/opioid substitution; 2) use of general population samples and lack of individual-level longitudinal studies; 3) challenges disentangling effects of cannabis laws from other state laws; 4) methodological challenges with staggered policy implementation; 5) limited consideration of cannabis law provisions; 6) lack of triangulation across data sources. Summary: While existing research suggests the potential for cannabis laws to reduce high-risk opioid prescribing and other opioid-related adverse outcomes, studies should be interpreted in light of limitations.

Uncommitted Commitment: Behavioral Strategy to Prevent Preference Reversals.

When both smaller-sooner (SS) and larger-later (LL) rewards are temporally distal, individuals frequently prefer the LL. However, because both outcomes become proximal, individuals frequently switch to preferring the SS. These preference reversals are predicted by hyperbolic delay discounting, and may model the essential challenge of self-control. Using smokers, a population known to have high rates of delay discounting, and thus more vulnerable to preference reversals, this pilot study sought to examine soft commitment as a strategy that may prevent preference reversals. Eleven smokers were assigned to an experimental commitment condition, operationalized as 3 weeks of daily commitment trials indicating preference between an SS and LL. Ten smokers were assigned to a control commitment condition. These 3 weeks were followed by 8 days of daily choice trials indicating preference between an impending SS and LL, for both experimental and control conditions. Though no overall difference of preference was observed between groups during the choice trials, hierarchical linear modeling revealed a decrease in preference for the LL over time by the control group (e.g., increasing trend of preference reversals) but no changes by the experimental group. This pilot study provides an initial indication that soft commitment can facilitate choice persistence and prevent preference reversals.