The HEALing (Helping to End Addiction Long-term SM) Communities Study: Protocol for a cluster randomized trial at the community level to reduce opioid overdose deaths through implementation of an integrated set of evidence-based practices

BACKGROUND

Opioid overdose deaths remain high in the U.S. Despite having effective interventions to prevent overdose deaths, there are numerous barriers that impede their adoption. The primary aim of the HEALing Communities Study (HCS) is to determine the impact of an intervention consisting of community-engaged, data-driven selection, and implementation of an integrated set of evidence-based practices (EBPs) on reducing opioid overdose deaths.

METHODS

The HCS is a four year multi-site, parallel-group, cluster randomized wait-list controlled trial. Communities (n = 67) in Kentucky, Massachusetts, New York and Ohio are randomized to active intervention (Wave 1), which starts the intervention in Year 1 or the wait-list control (Wave 2), which starts the intervention in Year 3. The HCS will test a conceptually driven framework to assist communities in selecting and adopting EBPs with three components: 1) a community engagement strategy with local coalitions to guide and implement the intervention; 2) a compendium of EBPs coupled with technical assistance; and 3) a series of communication campaigns to increase awareness and demand for EBPs and reduce stigma. An implementation science framework guides the intervention and allows for examination of the multilevel contexts that promote or impede adoption and expansion of EBPs. The primary outcome, number of opioid overdose deaths, will be compared between Wave 1 and Wave 2 communities during Year 2 of the intervention for Wave 1. Numerous secondary outcomes will be examined.

DISCUSSION

The HCS is the largest community-based implementation study in the field of addiction with an ambitious goal of significantly reducing fatal opioid overdoses.

Alcohol Use and Harm to Children by Parents and Other Adults

This study used mixed methods to examine parent-reported harm to children (lack of supervision or physical harm) due to alcohol use by themselves or someone else as well as parent beliefs about alcohol, parenting, and harms to children. We conducted a cross-sectional general population survey of 1,599 parents who were primary caregivers to a child aged 10 or younger and follow-up interviews with 23 parents who responded "yes" to one of the questions about alcohol use causing harm their child. Survey data were analyzed using multilevel logistic models. Compared to abstainers, parents who drank at least once a year were less likely to report that someone else's drinking caused a lack of supervision or physical harm to their child. Higher continued volumes of drinking were related to fewer reports of not watching a child closely enough. Social companionship support (having people to go out with) was related to greater odds that a parent's drinking would cause physical harm to his or her child(ren). In the qualitative analysis, four relevant themes emerged: perceived effects of alcohol use, tangible support and child supervision, immediate and distal harm, and turning points in drinking behaviors.

Opioid Misuse and the Availability of Medical Marijuana Through Dispensaries

OBJECTIVE

In this study we assess whether changes in ZIP code-level density of medical marijuana facilities are related to changes in rates of opioid poisonings and opioid use disorder hospitalizations in California.

METHOD

A panel study using California hospital discharge data was conducted to assess the relationship between density of medical marijuana dispensaries and opioid poisonings and use disorder. There were 8,536 space-time units at the ZIP code level. Outcome measures included ZIP code counts of opioid poisonings and opioid use disorder; independent variables were local- and adjacent-area medical marijuana dispensaries and demographic and economic characteristics.

RESULTS

Independent of effects for covariates, densities of medical marijuana dispensaries were positively related to opioid use disorder (RR = 1.05, CI [1.03, 1.06]) and opioid poisonings (RR = 1.04, CI [1.02, 1.05]) in local areas, but negatively related to opioid misuse in spatially adjacent areas (RR = 0.91, CI [0.88, 0.94] for opioid use disorder, RR = 0.89, CI [0.86, 0.93] for opioid poisonings).

CONCLUSIONS

Although state-level studies suggest that more liberal marijuana policies may result in fewer opioid overdose deaths, our results within one state suggest that local availability of medical marijuana may not reduce those deaths. The relationship appears to be more complex, possibly based on socioeconomic conditions within and adjacent to areas with higher densities of medical marijuana dispensaries.

The spatio-temporal distribution of naloxone administration events in rural Ohio 2010-16

INTRODUCTION

In 2017, Ohio had the second highest rate of drug overdose deaths in the United States. Current opioid related epidemiologic literature has begun to uncover the environmental level influences on the opioid epidemic and how the end results may ultimately manifest over space and time. This work is still nascent however, with most clustering research conducted at a spatial unit such as county level, which (1) can obscure differences between urban and rural communities, (2) does not consider dynamics that cross county lines, and (3) is difficult to interpret directly into strategic and localized intervention efforts. We address this gap by describing, at the Census block level, the spatial-temporal clustering of opioid related events in rural Ohio.

METHODS

We use the outcome of the administration of naloxone emergency medical service (EMS) calls in rural Ohio Census blocks during 2010-16 in a Poisson model of spatial scan statistics.

RESULTS

We found that naloxone event clustering in rural Ohio in the recent decade was widely dispersed over time and space, with clusters that average 17 times the risk of having an event compared to areas outside the cluster. Many of the larger spatial clusters crossed administrative boundaries (i.e., county lines) suggesting that opioid misuse may be less responsive to county level policies than to other factors.

DISCUSSION

Timely identification of localized overdose event clustering can guide affected communities toward rapid interventions aimed at minimizing the morbidity and mortality resulting from contagious opioid misuse.

Activity Spaces: Assessing Differences in Alcohol Exposures and Alcohol Use for Parents

Parental alcohol use and alcohol outlet densities in residential areas are related to risk for child maltreatment. However, some parents spend significant time outside of their residential neighborhood. Thus, we may not be accurately assessing how alcohol environments are related to risks for problematic parenting. Here, we examine how residential environments and activity spaces are related to outlet density and whether drinking events in our sample of parents differ by location (e.g., routine vs. rare locations) and whether their children are present. We conducted semi-structured interviews with 60 parents living in four cities in the San Francisco Bay area who provided information on where they spent time, where they drank, and whether children were present. We constructed measures of activity spaces (e.g., convex hull polygons) and activity patterns (e.g., shortest network distance) and calculated outlet density in each. Density of alcohol outlets for residential Census tract was not related to density of the activity space and activity pattern measures. Alcohol use occurred more frequently (regardless of whether their children were present) inside activity spaces operationalized as convex hull polygons or two standard deviational ellipses. Measures that capture larger activity space areas (e.g., convex hull polygons, two standard deviational ellipses) may better model where people spend time, regardless of whether the location is routine or rare. By continuing to use activity spaces to explore relationships between outlet densities, drinking behaviors, and problems, we can start to ascertain those mechanisms by which outlets may affect local problems.

Child maltreatment and alcohol outlets in Spain: Does the country drinking culture matters?

BACKGROUND

Alcohol outlet density has been linked to rates of substantiated maltreatment both cross-sectionally and over time. Most of these studies have been conducted in Anglo-Saxon countries, especially in the U.S., but other countries, where alcohol outlets and alcohol consumption may have different social meanings, are clearly underrepresented in the literature.

OBJECTIVE

The aim of this study was to analyze whether alcohol outlet density is associated with neighborhood-level child maltreatment risk in a South-European city.

PARTICIPANTS AND SETTING

A longitudinal study was conducted in the city of Valencia (Spain). As spatial units, we used 552 census block groups. Family units with child maltreatment protection measures from 2004 to 2015 were geocoded (n = 1799).

METHODS

A Bayesian spatio-temporal autoregression model was conducted to model the outcome variable.

RESULTS

Results indicated that, once controlled for other neighborhood-level characteristics, the influence of off-premise density and restaurant/cafe density were not relevant, while bar density showed a negative relationship with child maltreatment risk. Spatially lagged alcohol outlet variables were also not relevant in the model.

CONCLUSIONS

Our results suggest the importance of taking into account the cultural influences on the relationship between alcohol outlets and child maltreatment risk. Future cross-cultural research is needed for better understanding this relationship.

Types of Substance Use and Punitive Parenting: A Preliminary Exploration

Very little is known about how type of substance use is comparatively related to a range of parenting behaviors. We conduct a preliminary examination to ascertain effects of substance type on physical abuse compared with other child discipline tactics with data from a telephone survey in 2009 of 3,023 parents in 50 cities in California. Kruskal-Wallis tests and hierarchical generalized linear models are conducted to determine the relationship between substance type and frequency of nonviolent discipline, corporal punishment, and child physical abuse. Type of drug used is differentially related to use of discipline strategies in multivariate models. Nonviolent discipline and corporal punishment show a dose-response relationship when a parent who reported using more substances also reported using both types of discipline more frequently. We suggest that addiction professionals should consider partnering with a specialist in child development or child welfare to conduct in-depth assessments of parenting strategies among the highest-risk groups, such as those with past-year alcohol use or a history of polysubstance use or methamphetamine use.

Examination of Market Segmentation among Medical Marijuana Dispensaries

BACKGROUND

As medical marijuana legislation becomes more common, concerns arise about the overconcentration of dispensaries, raising questions about the number of medicinal marijuana dispensaries (MMD) needed to serve medicinal users.

OBJECTIVES

This paper applies niche-marketing theory-which suggests dispensaries market to specific types of people-to examine if MMDs might be targeting recreational users. Observed differences between dispensary populations and between dispensary clients and local residents may indicate that dispensaries are drawing in patients based on factors other than medical need.

METHODS

Data were collected via exit surveys with patients at four dispensaries in Long Beach, CA. A total of 132 patients were surveyed regarding demographic data, purchase information, medical condition, and nearest cross street for their home address. Census tract information was collected for every dispensary.

RESULTS

Chi-squared tests show significant associations between dispensary visited and race (χ² = 31.219, p < 0.001) and significant associations between medical condition and dispensary visited (χ² = 22.123, p < 0.05). Lastly, we found that all four of the dispensaries had patients who were different from community residents in some characteristics.

CONCLUSIONS

There were significant differences relating to race, medical condition, and distance traveled across dispensaries. Results suggest dispensary users do not necessarily reside in the same area in which dispensaries are located and do not necessarily reflect the local population. Taken together these results provide some support for market segmentation.

The emerging marijuana retail environment: Key lessons learned from tobacco and alcohol retail research

The emerging retail market for recreational marijuana use warrants research and surveillance as such markets are established in more US states. This research can be informed by the existing literature regarding tobacco and alcohol, which highlights the impact of spatial access to tobacco and alcohol retailers and exposure to tobacco and alcohol marketing on smoking and drinking among youth and young adults. Prior research indicates that tobacco and alcohol retailers, as well as medical marijuana dispensaries, are disproportionately located in neighborhoods characterized by socioeconomic disadvantage and by higher proportions of racial/ethnic minorities and young adults. Moreover, retail marketing or point-of-sale practices may differentially target subpopulations and differ by neighborhood demography and local policy. This literature and the methods employed for studying the tobacco and alcohol market could inform research on the retail environment for marijuana, as current gaps exist. In particular, much of the existing literature involves cross-sectional research designs; longitudinal studies are needed. Moreover, standardized measures are needed for systematic monitoring of industry marketing practices and to conduct research examining neighborhood differences in exposure to retail marketing for marijuana and its contribution to use modality and frequency, alone and in combination with nicotine and alcohol. The use of standardized measures for tobacco and alcohol marketing have been critical to develop an evidence base from cross-sectional and longitudinal studies that document the impact of retail marketing on substance use by adolescents and adults. Similar research is needed to establish an evidence base to inform federal, state, and local regulations of marijuana.

Point-of-sale marketing and context of marijuana retailers: Assessing reliability and generalizability of the marijuana retail surveillance tool

As recreational marijuana expands, standardized surveillance measures examining the retail environment are critical for informing policy and enforcement. We conducted a reliability and generalizability study using a previously developed tool involving assessment of a sample of 25 randomly selected Seattle recreational marijuana retailers (20 recreational; 5 recreational/medical) in 2017. The tool assessed: 1) contextual/neighborhood features (i.e., facilities nearby); 2) compliance/security (e.g., age-of-sale signage, age verification); and 3) marketing (i.e., promotions, product availability, price). We found that retailers were commonly within two blocks of restaurants (n = 23), grocery stores (n = 17), liquor stores (n = 13), and bars/clubs (n = 11). Additionally, two were within two blocks of schools, and four were within two blocks of parks. Almost all (n = 23) had exterior signage indicating the minimum age requirement, and 23 verified age. Two retailers had exterior ads for marijuana, and 24 had interior ads. Overall, there were 76 interior ads (M = 3.04; SD = 1.84), most commonly for edibles (n = 28). At least one price promotion/discount was recorded in 17 retailers, most commonly in the form of loyalty membership programs (n = 10) or daily/weekly deals (n = 10). One retailer displayed potential health harms/warnings, while three posted some health claim. Products available across product categories were similar; we also noted instances of selling retailer-branded apparel/ paraphernalia (which is prohibited). Lowest price/unit across product categories demonstrated low variability across retailers. This study documented high inter-rater reliability of the surveillance tool (Kappas = 0.73 to 1.00). In conclusion, this tool can be used in future research and practice aimed at examining retailers marketing practices and regulatory compliance.

Do characteristics of marijuana use correspond to overall health levels for medical marijuana patients?

The current study assesses how characteristics of medical marijuana use are related to general health status and past year change in health. An analytic sample of 312 patients were recruited from 16 medical marijuana dispensaries across Los Angeles, California. Patients completed a short intercept survey and a longer patient survey. Surveys asked information about health, marijuana use behaviors, preferred ways to use marijuana, marijuana recommendation, and sociodemographic information. Data were analyzed using hierarchical linear modeling of patients nested within dispensaries. For general health status, patients who smoke marijuana, have more medical conditions for which they received their medical marijuana recommendation, and use marijuana more times per day report lower levels of general health. The number of days using marijuana per month was related to worse health in the past year. Medical marijuana use does not appear to improve overall health status according to the results presented here, but is limited by the cross-sectional nature of the study. As the legalization of medical marijuana use continues to grow across the United States, identifying how marijuana is related to health will allow physicians to better determine who may benefit from its use.

The development and pilot testing of the marijuana retail surveillance tool (MRST): assessing marketing and point-of-sale practices among recreational marijuana retailers

As recreational marijuana expands, it is critical to develop standardized surveillance measures to study the retail environment. To this end, our research team developed and piloted a tool assessing recreational marijuana retailers in a convenience sample of 20 Denver retailers in 2016. The tool assesses: (i) compliance and security (e.g. age-of-sale signage, ID checks, security cameras); (ii) marketing (i.e. promotions, product availability and price) and (iii) contextual and neighborhood features (i.e. retailer type, facilities nearby). Most shops (90.0%) indicated the minimum age requirement, all verified age. All shops posted interior ads (M = 2.6/retailer, SD = 3.4), primarily to promote edibles and other non-smoked products. Price promotions were common in shops (73.7%), 57.9% used social media promotions and 31.6% had take-away materials (e.g. menus, party promotions). Nearly half of the shops (42.1%) advertised health claims. All shops offered bud, joints, honey oil, tinctures, kief, beverages, edibles and topicals; fewer sold clones and seeds. Six shops (31.6%) sold shop-branded apparel and/or paraphernalia. Prices for bud varied within and between stores ($20-$45/'eighth', ∼3.5 g). Twelve were recreational only, and eight were both recreational and medicinal. Liquor stores were commonly proximal. Reliability assessments with larger, representative samples are needed to create a standardized marijuana retail surveillance tool.

Place over traits? Purchasing edibles from medical marijuana dispensaries in Los Angeles, CA

OBJECTIVES

To examine discrete purchasing behaviors of marijuana-infused edibles from medical marijuana dispensaries with the aim to identify potential venue- and individual-level targets for prevention.

METHODS

Two-stage, venue-based sampling approach was used to randomly select patrons exiting 16 medical marijuana dispensaries in Los Angeles, California during Spring 2013. Hierarchical generalized linear modeling was used to examine the likelihood of purchasing edibles among 524 patrons reporting a discrete purchase regressed on characteristics of the sampled dispensaries and their patrons.

RESULTS

At a venue level, patrons were more likely to purchase edibles from dispensaries located within Census tracts with higher median incomes or in close proximity to a higher number of dispensaries. At an individual level, patrons who identified as Black or Hispanic were associated with a lower likelihood of purchasing edibles when compared to patrons who identified as other non-White, non-Hispanic race/ethnicity.

CONCLUSIONS

Place-based policies focused on regulating edible sales through dispensaries may be fruitful in influencing access to edibles. Additionally, social marketing campaigns may benefit from targeting both locations where edible purchases are more likely and populations who are more likely to purchase edibles.

Drug Use, the Drug Environment, and Child Physical Abuse and Neglect

Although drug use is considered a risk factor for child maltreatment, very little work has examined how the drug environment may affect physical abuse and neglect by parents. Utilizing information from a telephone survey with 2,597 respondents from 43 cities with valid police data on narcotics incidents, we analyzed the relationship between drug use, drug availability, and child maltreatment using multilevel models. City-level rates of drug abuse and dependence were related to more frequent physical abuse. Parents who use drugs in areas with greater availability of drugs reported more physical abuse and physical neglect. Emotional support was protective of all types of maltreatment. While most child welfare interventions focus on reducing parental drug use in order to reduce child abuse, these findings suggest environmental prevention or neighborhood strengthening approaches designed to reduce the supply of illicit drugs may also reduce child abuse through multiple mechanisms.

Environmental and individual attributes associated with child maltreatment resulting in hospitalization or death

Maltreatment continues to be a leading cause of death for young children. Researchers are beginning to uncover which neighborhood attributes may be associated with maltreatment outcomes. However, few studies have been able to explore these influences while controlling for individual family attributes, and none have been able to parse out the most severe outcomes-injuries resulting in hospitalization or death. This study utilizes a retrospective, case-control design on a dataset containing both individual and environmental level attributes of children who have been hospitalized or died due to maltreatment to explore the relative influence of attributes inside and outside the household walls. Binary conditional logistic regression was used to model the outcome as a function of the individual and environmental level predictors. Separate analyses also separated the outcome by manner of maltreatment: abuse or neglect. Finally, a sub-analysis included protective predictors representing access to supportive resources. Findings indicate that neighborhood attributes were similar for both cases and controls, except in the neglect only model, wherein impoverishment was associated with higher odds of serious maltreatment. Dense housing increased risk in all models except the neglect only model. In a sub-analysis, distance to Family Resource Centers was inversely related to serious maltreatment. In all models, variables representing more extreme intervention and/or removal of the victim and/or perpetrator from the home (foster care or criminal court involvement) were negatively associated with the risk of becoming a case. Medi-Cal insurance eligibility of a child was also negatively associated with becoming a case. Government interventions may be playing a critical role in child protection. More research is needed to ascertain how these interventions assert their influence.

The places parents go: understanding the breadth, scope, and experiences of activity spaces for parents

Neighborhood environments are related to parenting behaviors, which in turn have a life-long effect on children's health and well-being. Activity spaces, which measure individual routine patterns of movement, may be helpful in assessing how physical and social environments shape parenting. In this study we use qualitative data and GIS mapping from 4 California cities to examine parental activity spaces. Parents described a number of factors that shape their activity spaces including caregiving status, the age of their children, and income. Parental activity spaces also varied between times (weekends vs. weekdays) and places (adult-only vs. child-specific places). Knowing how to best capture and study parental activity spaces could identify mechanisms by which environmental factors influence parenting behaviors and child health.

The temporal-spatial distribution of seriously maltreated children

This descriptive study utilized Bernoulli and Poisson spatial scan statistical models in SatScan v.9.4 to examine the distribution in space and time of residence of maltreatment cases-operationalized as families with serious maltreatment (resulting in death or hospitalization) of children under 6 years-for the presence of clusters ("hot spots"). In the Poisson model, a population dataset of serious maltreatment cases were non-randomly dispersed in four major areas, with these "hot spots" moving over time and space. Most cases were outside these clusters. In the Bernoulli model, the geographic distribution of a case-control dataset of families with serious maltreatment who were previously investigated by child welfare did not differ compared to controls previously investigated by child welfare with no serious maltreatment. Findings suggest that child fatality prevention efforts such as Back to Sleep and Never Shake a Baby campaigns should continue to be universal efforts, targeted to all parents.

Testing a Social Mechanism: Does Alcohol Outlet Density Moderate the Relationship Between Levels of Alcohol Use and Child Physical Abuse?

OBJECTIVES

Parental alcohol use and alcohol outlet density are both associated with child abuse. Guided by alcohol availability theory, this article examines whether alcohol outlet density moderates the relationship between parental alcohol use and child physical abuse.

METHODS

A general population telephone survey of 3,023 parents or legal guardians 18 years or older was conducted across 50 California cities, whereas densities of alcohol outlets were measured for by zip code. Data were analyzed via overdispersed multilevel Poisson models.

RESULTS

Ex-drinkers, light drinkers, and heavy drinkers use physical abuse more often than lifetime abstainers. Moderate drinking was not related to child physical abuse. Proportion of bars was negatively related to frequency of physical abuse. Moderating relationships between alcohol outlet density and drinking categories were found for all drinking patterns.

CONCLUSION

Different types of alcohol outlets may be differentially related to drinking patterns, indicating that the interaction of drinking patterns and the drinking environment may place children at greater risk for being physically abused.

Understanding the Roles of Context, Frequency, and Quantity of Alcohol Consumption in Child Physical Abuse: Risks for Mothers and Fathers

INTRODUCTION

Alcohol use is related to child physical abuse, although little is known about gender-specific risks factors. This study examines the relationships between alcohol outlets, context-specific drinking, dose-response drinking and child physical abuse for mothers and fathers.

METHOD

Telephone interviews were conducted with 1,973 female and 1,050 male respondents in 50 California cities. Weighted negative binomial models were used to calculate the frequency of physical abuse in the past year.

RESULTS

Drinking more often at restaurants was related to higher frequency of physical abuse for fathers, while mothers who drank more frequently at bars and parties used physical abuse more often. There were no significant dose-response drinking relationships for fathers. Drinking higher amounts at bars, parties, and restaurants was associated with less frequent physical abuse for mothers.

DISCUSSION

Our findings suggest that a focus on drinking contexts may reveal heightened risk for many mothers who do not consume large amounts of alcohol.

A micro-temporal geospatial analysis of medical marijuana dispensaries and crime in Long Beach, California

AIMS

To determine whether the density of marijuana dispensaries in California, USA, in 2012-13 was related to violent and property crimes, both locally and in adjacent areas, during a time in which local law enforcement conducted operations to reduce the number of storefront medical marijuana dispensaries.

DESIGN

Data on locations of crimes and medical marijuana dispensaries as well as other covariates were collected for a sample of 333 Census block groups.

SETTING

Long Beach, California, USA from January 2012 to December 2013.

OBSERVATIONS

A total of 7992 space-time observations (from 333 Census block groups over 24 time-points).

MEASUREMENTS

Outcome measures focused on block-group counts of violent and property crimes. Predictors were numbers of local and adjacent-area medical marijuana dispensaries. Covariates included markers of alcohol availability as well as area demographic and economic characteristics.

FINDINGS

After adjustment for covariates, density of medical marijuana dispensaries was unrelated to property and violent crimes in local areas but related positively to crime in spatially adjacent areas [incident rate ratio (IRR) = 1.0248, CI (1.0097, 1.0402) for violent crime, IRR = 1.0169, CI (1.0071, 1.0268) for property crime].

CONCLUSIONS

Using law enforcement to reduce medical marijuana dispensaries in California appears to have reduced crime in residential areas near to, but not in, these locations.

Assessing Sample Bias among Venue-Based Respondents at Medical Marijuana Dispensaries

Venue-based sampling is the identification of, and outreach to, locations visited by the population of interest for the purpose of collecting data. The method is frequently used to reach specific populations, commonly referred to as "hidden populations." Medical marijuana users represent a hidden population of persons who use marijuana for medicinal purposes. We examine whether venue-based procedures introduce selection or non-respondent bias into the study. The venue based sampling procedures employed for the UCLA Medical Marijuana Study used a two-stage, venue-based sampling approach. First, analyses were conducted to assess potential bias within dispensaries that agreed to participate in the surveys. Secondly, analyses were conducted to examine differences among patrons who responded to surveys. Overall, selection bias was generally absent among study results. Results also illuminated the minimal respondent bias observed among the survey respondents. Results suggest that the use of dispensaries to access and survey medical marijuana users is a viable option to gather patient information that adequately represents the greater population of medical marijuana users in Los Angeles. Thus, recommendations and conclusions based on findings from venue-based studies of medical marijuana users at dispensary sites serve to impartially inform meaningful research.

Correlates of Amount Spent on Marijuana Buds During a Discrete Purchase at Medical Marijuana Dispensaries: Results from a Pilot Study

Marijuana purchasing behaviors vary by the purchaser's individual characteristics; however, little is known about patients' purchasing behaviors when buying from medical marijuana dispensaries (MMDs). Our objective was to explore whether patient characteristics were associated with amount spent during one financial transaction at medical marijuana dispensaries. We conducted a pilot study of four purposively sampled MMD locations in Long Beach, California, in 2012. A total of 132 medical marijuana patients (33 patients per dispensary) participated in an exit survey about their demographic characteristics, conditions for their medical marijuana recommendation, amount spent at the dispensary, and cross-streets of where they lived. The sample reported amounts spent on discrete purchases of marijuana buds averaging $40.82 (ranging from $10 to $255). Multivariate regression analyses indicated average amount spent differed significantly by patient age and condition. An increase in 10 years of age was associated with a 10% higher amount spent. Receiving a recommendation for anxiety and/or sleeping problems or other nonspecified conditions was related to higher discrete purchase amounts than chronic pain. This pilot suggests that variations in patient purchasing behaviors from MMDs exist. These purchase behaviors can provide insight into variations in how patients use dispensaries, consume products, and allocate personal resources.

Where Are the Beds? Housing Locations for Transition Age Youth Exiting Public Systems

Transition age youth (TAY) from the child welfare and juvenile justice systems experience high rates of homelessness, but little is known about the neighborhoods to which they return after they exit these systems. This exploratory study investigates whether housing options are located in areas where TAY exit public systems and if the characteristics of areas surrounding these facilities support their transition to adulthood. Results show that housing is not related to areas where TAY exit public systems. Further, supportive housing and shelter density is related to low-income areas. Implications for practice and policy on housing locations for TAY are discussed.