Pathways to opioid use and implications for prevention: voices of young adults in recovery.

BACKGROUND: Opioid use remains a major public health issue, especially among young adults. Despite investment in harm reduction and supply-side strategies such as reducing overprescribing and safe medication disposal, little is known about demand-side issues, such as reasons for use and pathways to opioid use. Adolescents and young adults who struggle with opioid use disorder (OUD) are multifaceted individuals with varied individual histories, experiences, challenges, skills, relationships, and lives. METHODS: To inform the development of prevention strategies that hold promise for addressing opioid use, this study employs brief structured surveys and semi-structured in-depth interviews with 30 young adults (ages 18-29; 19 female, 23 White, 16 from Suburban areas) in recovery from OUD. For survey data, we used descriptive statistics to summarize the means and variance of retrospectively reported risk and protective factors associated with opioid use. For in-depth interview data, we used a combination of thematic analysis and codebook approaches to generate common themes and experiences shared by participants. RESULTS: Surveys revealed that the most endorsed risk factors pertained to emotions (emotional neglect and emotional abuse) followed by sexual abuse, physical abuse, and physical neglect. Themes generated from qualitative analyses reveal challenging experiences during adolescence, such as unaddressed mental health, social, and emotional needs, which were often reported as reasons for opioid initiation and use. Through surveys and interviews, we also identified positive assets, such as skills and social relationships that were present for many participants during adolescence. CONCLUSION: Implications include the need for universal prevention strategies that include emotion-focused interventions and supports alongside current harm reduction and environmental strategies to regulate prescriptions; the potential utility of more emotion-focused items being included on screening tools; and more voices of young people in recovery.

Treatment Referrals Post-prohibition of Alcohol Exclusion Laws: Evidence from Colorado and Illinois.

BACKGROUND: Individuals with alcohol-related disorders often encounter barriers to accessing treatment. One potential barrier is the state alcohol exclusion laws (AELs) that allow insurers to deny coverage for injuries or illnesses caused by alcohol intoxication. Several states have repealed AELs by prohibiting them completely, including banning exclusions in health and accident insurance policies, limiting their scope, or creating exemptions. OBJECTIVES: To examine whether prohibiting alcohol exclusions in health and accident insurance policies is associated with alcohol-related treatment admissions. DESIGN: We used the 2002 to 2017 Treatment Episode Data Set and obtained data from several sources to control for state-level factors. We employed a heterogeneous difference-in-differences method and an event study to compare the treatment admissions in Colorado and Illinois, two states that uniquely repealed AELs, with control states that allowed or had no AELs. MAIN MEASURES: We used aggregated alcohol treatment admission for adults by healthcare referral: (i) with alcohol as the primary substance and (ii) with alcohol as the primary, secondary, or tertiary substance. KEY RESULTS: We found a significant relationship between AEL repeal and increased referrals. AEL repeal in Colorado and Illinois was associated with higher treatment admissions from 2008 to 2011 (average treatment effect on the treated: 2008 = 653, 2009 = 1161, 2010 = 1388, and 2011 = 2020). We also found that a longer duration of exposure to AEL repeal was associated with higher treatment admissions, but this effect faded after the fourth year post-treatment. CONCLUSIONS: Our study reveals a potential positive association between the repeal and prohibition of AELs and increased alcohol-related treatment admissions. These findings suggest that states could enhance treatment opportunities for alcohol-related disorders by reconsidering their stance on AELs. While our study highlights the possible public health benefits of repealing AELs, it also paves the way for additional studies in this domain.

The Development and Testing of a Point-of-Sale E-Cigarette Health Communication Campaign.

Adolescents and young adults continue to use e-cigarettes, and communication campaigns are needed to decrease use among these populations. We developed and tested a point-of-sale communication campaign focused on e-cigarette chemical exposure. We developed messages based on formative research and tested them (versus text-only messages) in a nationally-representative online survey among adolescents and young adults (16-25) (Phase 1). Based on survey findings, we selected a message focused on nicotine and brain development for the point-of-sale trial (Phase 2). We then conducted a cluster-randomized trial at six gas stations with convenience stores, randomly assigned to the intervention (messages displayed) or no message control condition. We conducted intercept surveys with repeated cross-sectional samples of 50 participants (ages 16-25) per store, at baseline and a four-week follow-up. Phase 1 included 1,636 participants in the online study. Intervention messages were rated as more attention grabbing than plain text messages (p < .05), though were rated similarly on other outcomes. Exposure to intervention messages resulted in larger changes from pre- to posttest for beliefs about addiction and relative harms versus cigarettes (p < .05). Phase 2 included 586 participants in the point-of-sale study. Real-world campaign exposure was low (31.8%), and no differences were found between conditions. E-cigarette prevention messages focused on nicotine's impact on brain development show promise. However, garnering attention for communication campaigns in saturated point-of-sale environments, often dominated by tobacco advertising, is challenging. Future efforts should utilize additional communication channels to directly target adolescents and young adults.

Point-of-Sale Health Communication Campaigns for Cigarillos and Waterpipe Tobacco: Effects and Lessons Learned from Two Cluster Randomized Trials.

Many adolescents and young adults hold erroneous beliefs that cigarillos and waterpipe tobacco (WT) are safer than cigarettes, contributing to use. Communication campaigns can correct misperceptions and increase risk beliefs. We tested point-of-sale (POS) communication campaigns focused on chemical exposure for cigarillos and WT. We conducted two cluster randomized trials at 20 gas stations with convenience stores (10 stores for cigarillos, 10 for WT) in North Carolina between June and November 2017. Within each trial, stores were randomly assigned to either the intervention (campaign messages displayed) or a no message control condition. We conducted intercept surveys with repeated cross-sectional samples of 50 adolescents and young adults (ages 16-25) per store, at baseline and follow-up. There were 978 participants (mean age = 20.9 years) in the cigarillo trial, and 998 participants (mean age = 21.0 years) in the WT trial. Rates of campaign exposure were low (26% for cigarillos; 24.3% for WT). The cigarillo campaign increased knowledge that ammonia is in cigarillo smoke (p < .01). There were also significant increases in knowledge about ammonia and cyanide in cigarillo smoke and arsenic in WT smoke (p < .05) in the sub-sample who reported exposure to the campaign. No differences were found in outcome expectancies, product attitudes, worry about chemical exposure, or behavioral intentions in either campaign. Garnering attention for communication campaigns in saturated POS environments, often dominated by tobacco advertising, is challenging. Our study demonstrates the feasibility of anti-tobacco campaigns at the POS and points to several lessons learned for future POS campaigns.

Development and validation of an electronic health records-based opioid use disorder algorithm by expert clinical adjudication among patients with prescribed opioids.

BACKGROUND: In the US, over 200 lives are lost from opioid overdoses each day. Accurate and prompt diagnosis of opioid use disorders (OUD) may help prevent overdose deaths. However, international classification of disease (ICD) codes for OUD are known to underestimate prevalence, and their specificity and sensitivity are unknown. We developed and validated algorithms to identify OUD in electronic health records (EHR) and examined the validity of OUD ICD codes. METHODS: Through four iterations, we developed EHR-based OUD identification algorithms among patients who were prescribed opioids from 2014 to 2017. The algorithms and OUD ICD codes were validated against 169 independent "gold standard" EHR chart reviews conducted by an expert adjudication panel across four healthcare systems. After using 2014-2020 EHR for validating iteration 1, the experts were advised to use 2014-2017 EHR thereafter. RESULTS: Of the 169 EHR charts, 81 (48%) were reviewed by more than one expert and exhibited 85% expert agreement. The experts identified 54 OUD cases. The experts endorsed all 11 OUD criteria from the Diagnostic and Statistical Manual of Mental Disorders-5, including craving (72%), tolerance (65%), withdrawal (56%), and recurrent use in physically hazardous conditions (50%). The OUD ICD codes had 10% sensitivity and 99% specificity, underscoring large underestimation. In comparison our algorithm identified OUD with 23% sensitivity and 98% specificity. CONCLUSIONS AND RELEVANCE: This is the first study to estimate the validity of OUD ICD codes and develop validated EHR-based OUD identification algorithms. This work will inform future research on early intervention and prevention of OUD.

Does state repeal of alcohol exclusion laws increase problem drinking?

BACKGROUND: For decades, alcohol exclusion laws (AELs) have allowed insurance companies to reject claims for physical injuries caused by alcohol consumption, including injuries from impaired driving. A central premise of AELs is that they function as a deterrent to risk-taking behaviors, such as excessive drinking. If this assumption is correct, state repeal of these laws should result in increased drinking. This study examines whether the repeal of AELs by some states affects drinking behaviors. METHODS: Data were obtained from the 1993 to 2017 Behavioral Risk Factor Surveillance System nationwide survey. Exploiting the natural experiment presented by state repeal of AELs, we assessed the impact on current drinking and binge drinking. We used a rigorous quasi-experimental difference-in-differences analysis and conducted a battery of sensitivity analyses to assure robust findings. RESULTS: Overall, the study found no discernable impact of state repeal of AELs on alcohol consumption. While the repeal of AELs significantly decreased the odds of reporting drinking in the past 30 days compared to those living in states with AELs or that never had AELs, the effects were small (aOR = 0.98, 95% CI = 0.96, 0.99). Likewise, there were higher odds of binge drinking among individuals living in states that repealed AELs compared to those living in states without AELs, yet with small effects (aOR = 1.03, 95% CI = 1.01, 1.05). After additionally adjusting for state-varying characteristics and state-specific time trends, no significant effects were identified regarding current and binge drinking. Findings from the sensitivity analyses were largely consistent with the main analysis. CONCLUSION: This study found no evidence supporting the idea that repealing AELs increased alcohol consumption or binge drinking. Future studies should consider other state-specific dimensions within the Uniform Accident and Sickness Policy Provision Law.

Longitudinal latent class analysis of tobacco use and correlates among young adults over a 10-year period.

INTRODUCTION: We assessed patterns and correlates, including demographic characteristics, psychological factors, and social role transitions, of young adults' tobacco use over time. METHODS: In the fall of 2010, we recruited a cohort of 3146 students from 11 colleges in North Carolina and Virginia. Participants completed baseline and at least two survey waves between 2010 and 2019. RESULTS: The sample was 49.8% female, 15.7% non-white, and 6.6% Hispanic. Longitudinal latent class analysis revealed a five-class model with distinct patterns and correlates of tobacco use. Limited Use (52.6% of sample) had minimal use. College-Limited Combustible Tobacco Users (18.6%) had moderate probability of cigarette, cigar, and waterpipe smoking, which decreased to no use post-college. Intermittent Sustained Polytobacco Users (10.9%) had low probability of use that continued post-college. College Polytobacco with Continued Cigarette and E-Cigarette Users (14.5%) had high probability of use of cigarette smoking and increasing probability of e-cigarette, both of which continued post-college. Sustained Polytobacco Users (5.7%) had moderate probability of use of tobacco products across all waves. CONCLUSIONS: Patterns of tobacco use varied considerably. In most classes, tobacco use was highest during freshman year and in three classes, use continued post-college. Prevention activities should focus on first-year students and target those at risk for post-college tobacco use.

Repeal of state laws permitting denial of health claims resulting from alcohol impairment: Impact on treatment utilization.

BACKGROUND: Many states in the U.S. still have Alcohol Exclusion Laws (AELs), which allow insurance companies to deny health claims resulting from alcohol impairment. There are concerns that this form of structural stigmatization affects alcohol treatment-seeking behaviors. We examined the effects of AEL repeal on treatment admissions for alcohol use disorder (AUD). METHODS: Data on alcohol treatment admissions from 1992 to 2017 were obtained from the Treatment Episode Data Set. The state-level aggregate number of treatment admissions was derived, including healthcare professional referrals only, self-referrals only, and both self-referral and healthcare professional referrals. The number of treatment admissions by health insurance status (private, public, and uninsured) was also calculated. The study used a difference-in-differences (DID) quasi-experimental design. RESULTS: The DID analysis showed that the number of admissions for alcohol treatment from healthcare professional referrals increased 16% in the AEL repeal states compared to states with AELs or that never had AELs (IRR=1.16, 95% CI=1.07, 1.25). These results were consistent for analysis by payment sources. In particular, treatment admissions from healthcare professional referrals for patients covered by private insurance increased about 38% in states with AEL repeal (IRR=1.38, 95% CI=1.17, 1.64) compared to states without AEL repeal. However, the findings were no longer significant when the state-specific time trends were taken into account. CONCLUSIONS: This study documented that AEL repeal may have had a significant impact on the number of treatment admissions for AUD. These findings suggest that AELs function as a barrier to treatment-seeking behavior.

Changing course: supporting a shift to environmental strategies in a state prevention system.

BACKGROUND: This study examines how the North Carolina state prevention system responded to a policy shift from individual-level prevention strategies to environmental strategies from the perspective of the organizations implementing the policy shift. METHODS: We use two data sources. First, we conducted interviews to collect qualitative data from key informants. Second, we used prevention provider agency expenditure data from the year the shift was announced and the following year. RESULTS: The interviews allowed us to identify effective features of policy change implementation in complex systems, such as the need for clear communication and guidance about the policy changes. Our interview and expenditure analyses also underscore variation in the level of guidance and oversight provided by implementing agencies to prevention providers. CONCLUSIONS: Our analyses suggest that more active monitoring and oversight may have facilitated more consistent implementation of the policy shift toward greater use of environmental prevention strategies.

Unemployment rate, opioids misuse and other substance abuse: quasi-experimental evidence from treatment admissions data.

BACKGROUND: The relationship between economic conditions and substance abuse is unclear, with few studies reporting drug-specific substance abuse. The present study examined the association between economic conditions and drug-specific substance abuse admissions. METHODS: State annual administrative data were drawn from the 1993-2016 Treatment Episode Data Set. The outcome variable was state-level aggregate number of treatment admissions for six categories of primary substance abuse (alcohol, marijuana/hashish, opiates, cocaine, stimulants, and other drugs). Additionally, we used a broader outcome for the number of treatment admissions, including primary, secondary, and tertiary diagnoses. We used a quasi-experimental approach -difference-in-difference model- to estimate the association between changes in economic conditions and substance abuse treatment admissions, adjusting for state characteristics. In addition, we performed two additional analyses to investigate (1) whether economic conditions have an asymmetric effect on the number of substance use admissions during economic downturns and upturns, and (2) the moderation effects of economic recessions (2001, 2008-09) on the relationship between economic conditions and substance use treatment. RESULTS: The baseline model showed that unemployment rate was significantly associated with substance abuse treatment admissions. A unit increase in state unemployment rate was associated with a 9% increase in treatment admissions for opiates (ß = 0.087, p < .001). Similar results were found for other substance abuse treatment admissions (cocaine (ß = 0.081, p < .001), alcohol (ß = 0.050, p < .001), marijuana (ß = 0.036, p < .01), and other drugs (ß = 0.095, p < .001). Unemployment rate was negatively associated with treatment admissions for stimulants (ß = - 0.081, p < .001). The relationship between unemployment rate and opioids treatment admissions was not statistically significant in models that adjusted for state fixed effects and allowed for a state- unique time trend. We found that the association between state unemployment rates and annual substance abuse admissions has the same direction during economic downturns and upturns. During the economic recession, the negative association between unemployment rate and treatment admissions for stimulants was weakened. CONCLUSION: These findings suggest that economic hardship may have increased substance abuse. Treatment for substance use of certain drugs and alcohol should remain a priority even during economic downturns.

Problem drinking as intentional risky behavior: Examining the association between state health insurance coverage and excessive alcohol consumption.

The moral hazard theory asserts that having health insurance may increase individual risk-taking behaviors. We examined the association between state health insurance coverage and excessive alcohol use among U.S. adults. We used 2001-2017 Behavioral Risk Factor Surveillance System data to estimate annual binge and heavy drinking rates for each state. In a multivariable regression analysis, we used difference-in-difference (DID) models to assess the association between state-level insurance coverage and binge and heavy drinking. Additionally, we assess the potential asymmetric effect and whether economic recessions (2001, 2008-09) had a moderation effect. In the multivariable DID analysis, aggregate state insurance coverage was not significantly associated with binge drinking rates in baseline analysis with state-fixed effects (Model 1), and in the analysis that extends the baseline model to include state unique time trend (Model 2). A similar result was found for heavy drinking in Model 1. In contrast, the result showed a significant association between health insurance coverage and heavy drinking rates in Model 2. However, we found no significant association for binge and heavy drinking rates in both models in the analyses restricting data to periods before the methodological change in the BRFSS sampling frame. The results did not show asymmetric effects, and the association between health insurance and excessive alcohol use did not differ during economic recessions. These findings largely do not support assertions that health insurance may lead to moral hazards (risk-taking behaviors), especially binge drinking.

Developing a health communication campaign for disposal of unused opioid medications.

INTRODUCTION: Communities throughout the United States have implemented medicine disposal programs to prevent diversion of unused opioid analgesics from homes but a general lack of awareness may contribute to low rates of utilization. The objective of this study was to develop and test community-based campaign messages promoting appropriate disposal of unused opioids at disposal programs. METHODS: In Fall 2019, 491 residents (79% female, 97% White, mean age: 40 years) of five rural, Appalachian counties (3 in Kentucky and 2 in North Carolina) completed a web-based, experimental survey. Participants were randomly exposed to two of four messages and rated each message separately. A pretest-posttest design was utilized to assess change in beliefs about retaining unused prescription opioids in the home following exposure to message sets. RESULTS: All messages favorably influenced participants' perceptions related to concerns and risks of retaining unused prescription opioids and importance of - and self-efficacy in disposing of unused opioid medications. After controlling for social and demographic characteristics and baseline beliefs in generalized linear mixed models, Message 1 outperformed other messages in increasing participants' concern about retaining unused prescription opioids in the home and Message 3 was most effective in increasing self-efficacy to dispose of unused prescription opioids. CONCLUSIONS: Messages including young children and pictorially demonstrate how to dispose of medications may have the greatest impact on behavioral actions related to medication disposal. The findings from this study can be used to inform community-based campaigns to facilitate disposal of unused prescription opioids.

Are Waterpipe Café, Vape Shop, and Traditional Tobacco Retailer Locations Associated with Community Composition and Young Adult Tobacco Use in North Carolina and Virginia?

PURPOSE: We examined whether waterpipe café, vape shop, and traditional tobacco retailer (e.g. stores selling cigarettes, cigars, smokeless tobacco) locations were associated with census tract composition and tobacco use among young adults in North Carolina and Virginia. Methods: We identified waterpipe cafés, vape shops, and traditional tobacco retailers in North Carolina and Virginia and conducted multivariable analyses between community characteristics (gender, race, ethnicity, education, college enrollment, and poverty) and density per 1000 population. Using fall 2017 data from 1099 young adults residing in North Carolina and Virginia, we conducted logistic regression analyses to determine whether tobacco retailer density and proximity were associated with tobacco use. Results: Waterpipe café, vape shop, and traditional retailer density were higher in communities with more people who were Hispanic, college-educated, and college-enrolled (each p < .05). Waterpipe café and traditional retailer density were higher in communities with more people living below the poverty level (each p < .05). Waterpipe café density was higher in communities with more people who were male (p < .05), while traditional retailer density was lower (p < .05). Waterpipe café and vape shop proximity were associated with increased likelihood of waterpipe tobacco use in the past 6 months (each p < .05; unadjusted). Traditional retailer proximity and waterpipe café, vape shop, and traditional retailer density were not associated with tobacco use. Conclusions: Waterpipe cafés and vape shops are located in both impoverished and college-educated communities in North Carolina and Virginia, similar to where traditional tobacco retailers are located. Further research is needed to examine associations with tobacco use.

E-Cigarette Use and Transition in Adult Smoking Frequency: A Longitudinal Study.

INTRODUCTION: The relationship between e-cigarette use and cigarette smoking is the subject of ongoing debate. There is limited research on e-cigarette use and changes in the frequency of cigarette smoking. This study examines whether the frequency of e-cigarette use is associated with changes in cigarette smoking behavior among U.S. adults. METHODS: The study used data (n=20,558) from Waves 1 (2013-2014) and 2 (2014-2015) of the Population Assessment of Tobacco and Health, analyzed in 2019. Multivariable multinomial logistic regression assessed the association between e-cigarette use at Wave 1 and change in cigarette smoking frequency between Waves 1 and 2. RESULTS: Every day cigarette smokers who used e-cigarettes some days (OR=1.95, 95% CI=1.27, 2.98) and every day (OR=3.37, 95% CI=1.78, 6.36) in Wave 1 had significantly higher odds of switching to some days cigarette smoking in Wave 2. Every day smokers who used e-cigarettes every day in Wave 1 had higher odds of becoming former cigarette smokers in Wave 2. Likewise, e-cigarette use at baseline among former cigarette smokers was associated with higher odds of switching to some days cigarette smoking (experimental e-cigarette use: OR=5.43, 95% CI=2.13, 10.72; some days e-cigarette use: OR=4.78, 95% CI=2.13, 10.72). In addition, experimental smokers who were also some days e-cigarettes users in Wave 1 had significantly lower odds of switching to experimental former smokers. CONCLUSIONS: Although e-cigarette use may reduce cigarette smoking frequency among continuing smokers, findings suggest that e-cigarette use may be associated with cigarette smoking relapse among former smokers.

Longitudinal associations between marijuana and cigar use in young adults.

BACKGROUND: We assess the longitudinal associations between marijuana and cigar (little cigars and cigarillos [LCCs] and large cigars) use on subsequent initiation of marijuana and cigar use. METHODS: Data are from a cohort study of 2189 young adults recruited in fall 2010 from 11 colleges in the Southeast. We used discrete-time survival analysis to examine whether ever use of marijuana at baseline (spring 2011, freshman year) predicted initiation of LCCs and large cigars and whether ever use of these cigar products predicted initiation of marijuana use across 10 waves of data collection (2011-2018). RESULTS: The sample was 65.3 % female, 83.6 % White, 5.9 % Hispanic, and 61.8 % had college-educated mothers. At baseline, 70 % reported never using LCCs, 71 % reported never using large cigars, and 74 % reported never using marijuana. Ever use of marijuana at baseline was associated with an increased risk of LCC initiation (Incident rate ratio [IRR] = 1.6, 95 %CI = 1.0, 2.5) but not large cigar initiation. Ever use of LCCs (IRR = 1.4, 95 %CI = 1.1, 1.8) and ever use of large cigars (IRR = 1.3, 95 %CI = 1.1, 1.8) at baseline both predicted initiation of marijuana use. CONCLUSIONS: Our findings support growing evidence that marijuana and LCCs are strongly associated and use of one substance predicts use of the other. In contrast to studies of adults, we also found that young adults who have tried large cigars may be at increased risk for subsequent marijuana use. These findings highlight the need to consider each product as a potential gateway of the other when developing interventions for young adults.

Methods for Population Research on Substance Use and Consequences.

This chapter reviews the array of methods used in contemporary research on population-level research on substance use and its consequences. We argue that there are critical questions that can best - or in some cases, only - be addressed at the level of a population. We then describe the major categories of data collection methods used in population research, including surveys, ecological momentary assessment, administrative data, audit methods, and unobtrusive assessment of substance use. Two categories of measures are then discussed: measures of an individual's use of substances and related problems and measures of harm to others caused by one's use. We then review factors that may be considered causes or correlates of substance use and consequences, including both individual and environmental factors. We close with a few thoughts on the accumulation of knowledge and its translation to policy and practice.

Encouraging Disposal of Unused Opioid Analgesics in Appalachia.

The Appalachian region has been disproportionately impacted by the opioid epidemic. This study, informed by the Health Belief Model (HBM), explored Appalachian community members' perspectives on prescription opioid misuse and community-based programs to dispose of unused opioid analgesics. In 2018, we conducted ten focus groups (n=94 participants) in 5 Appalachian counties. Thirteen themes across 5 of the HBM constructs emerged from our analysis. Participants perceived that their communities are susceptible to the harms associated with opioid misuse, these harms are serious, suggesting they could be motivated to change disposal behaviors. Many participants recognized the benefit to disposing of unused prescription opioids including protecting household members from misusing and protecting the home from robbery. Nevertheless, participants identified barriers to proper disposal, including keeping the medications "just in case" for future ailments and the location of drop boxes near law enforcement (due to deep-seated mistrust of law enforcement agencies). Self-efficacy was difficult to assess as many participants were completely unaware of the presence of dropboxes in the community and also expressed concerns about the inconvenience of proper disposal using dropboxes These findings have implications for developing community-based campaign messages promoting proper disposal of unused opioids.

Laws and Policies Related to the Health of US Immigrants: A Policy Scan.

OBJECTIVES: We conducted a policy scan of state and local laws and policies across the United States related to social determinants of health among immigrants. METHODS: We collected all state and municipal laws and policies in 10 domains that had potential to affect immigrant health from all 50 U.S. states and the 30 most populous U.S. metropolitan statistical areas. We coded these laws and policies and created an index of restrictiveness and supportiveness of immigrants. RESULTS: We identified 539 state and 322 municipal laws and policies. The most common restrictive state laws and policies were in the domains of identification requirements and driver's license access. The most common supportive state laws and policies were in the domains of health services and higher education access. The most common restrictive municipal laws and policies were in the domains of identification requirements and immigration policy enforcement. The most common supportive municipal laws and policies were in the domains of immigration policy enforcement and health services access. CONCLUSIONS: Most states had index scores reflecting policy environments that were primarily restrictive of immigrants, indicating potential negative impacts on social determinants of health. Further research examining the impact of these on health behaviors is warranted.

Trends in Opioid Misuse among Marijuana Users and Non-Users in the U.S. from 2007-2017.

Prescription-opioid misus e continues to be a significant health concern in the United States. The relationship between marijuana use and prescription-opioid misuse is not clear from the extant literature. This study examined national trends in prescription-opioid misuse among marijuana users and non-users using the 2007-2017 National Survey on Drug Use and Health. Cochran-Armitage tests were used to assess the statistical significance of changes in the yearly prevalence of prescription-opioid misuse and marijuana use. Multivariable logistic regression was used to examine the association between prescription-opioid and marijuana use adjusting for sociodemographic characteristics. From 2007 to 2017, marijuana use increased, while prescription-opioid misuse declined. Larger declines in prescription-opioid misuse were found among marijuana users than non-users. Marijuana ever-use was significantly associated with prescription-opioid misuse. Specifically, marijuana ever-users had higher odds of prescription-opioid misuse (ever-misuse [OR: 3.04; 95% CI, 2.68-3.43]; past-year misuse [OR: 3.44; 95% CI, 3.00-3.94]; and past-month misuse [OR: 4.50; 95% CI, 3.35-6.05]) compared to marijuana never-users. Similar results were found for the association of past-year and past-month marijuana use with prescription-opioid misuse. This study provides data on trends and associations about opioid misuse among marijuana users and non-users in a changing social environment of drug use in the United States. Future research should consider whether there is a causal relationship between marijuana use and prescription opioid misuse.