The role of marijuana use disorder in predicting emergency department and inpatient encounters: A retrospective cohort study

Disproportionate increase in cannabis use among people with serious psychological distress and associations with psychiatric service use in the United States, 2009-2019

BACKGROUND

Cannabis use is on the rise, but it is unclear how use is changing among individuals with serious psychological distress (SPD) compared to the general population as well as what associations this may have with mental health service use.

METHODS

Retrospective cohort study using the National Survey on Drug Use and Health (NSDUH) 2009-19 public use files of 447,228 adults aged ≥ 18 years. Multivariable logistic regression and predictive margin methods were used to estimate linear time trends in any and greater-than-weekly levels of cannabis use by year and SPD status and rates of psychiatric hospitalization and outpatient mental health care.

FINDINGS

Rates of any and weekly-plus cannabis use increased similarly among individuals with SPD compared to those without from 200 to 2014 but more rapidly in SPD every year from 2015 to 2019 (p < 0.001). Among individuals with SPD, no use was associated with a 4.2 % probability of psychiatric hospitalization, significantly less than less-than-weekly (5.0 %, p = 0.037) and weekly-plus cannabis use (5.1 %, p = 0.028). For outpatient mental health care, no use was associated with a 27.4 % probability (95 % CI 26.7-28.1 %) of any outpatient care, significantly less than less than weekly use (32.6 % probability, p < 0.001) and weekly-plus use (29.9 % probability, p = 0.01).

CONCLUSIONS

Cannabis use is increasing more rapidly among individuals with SPD than the general population, and is associated with increased rates of psychiatric hospitalization and outpatient service use. These findings can inform policy makers looking to tailor regulations on advertising for cannabis and develop public health messaging on cannabis use by people with mental illness.

Acute care utilization and its associated determinants among patients with substance-related disorders: A worldwide systematic review and meta-analysis

INTRODUCTION

Identifying determinants of emergency department (ED) use and hospitalization among patients with substance-related disorders (SRDs) can improve health services to address unmet health needs.

AIM

The present study aimed to identify the prevalence rates of ED use and hospitalization, and their associated determinants among patients with SRDs.

METHODS

Studies in English published from January 1, 1995, to December 1, 2022, were searched on PubMed, Scopus, Cochrane Library, and Web of Science to identify primary studies.

RESULTS

The pooled prevalence rates of ED use and hospitalization among patients with SRDs were 36% and 41%, respectively. Patients with SRDs who were the most at risk of being both ED users and hospitalized were those (i) having medical insurance, (ii) having other drug and alcohol use disorders, (iii) having mental health disorders, and (iv) having chronic physical illnesses. A lower level of education increased the risk of ED use only.

DISCUSSION

To decrease ED use and hospitalization, more comprehensive services may be offered to these vulnerable patients with diversified needs.

IMPLICATIONS FOR PRACTICE

Chronic care integrating outreach interventions could be more provided for patients with SRDs after discharge from acute care units or hospitals.

Trends in Cannabis and Alcohol Use by Sexual Identity in the 2015-2019 National Survey on Drug Use and Health

OBJECTIVE

Sexual minority individuals are at substantially elevated risk for both cannabis use disorder (CUD) and alcohol use disorder (AUD). Although recent increases in the legalization of cannabis have been linked to increases in cannabis use among the general population, few studies have examined if changes in cannabis use and CUD vary by sexual identity. The purpose of the current study was to examine sexual identity differences in trends for CUD and compare them to trends for AUD.

METHOD

We used data from 2015-2019 National Survey on Drug Use and Health to examine annual prevalence and year-specific disparities in cannabis use, CUD, heavy episodic drinking, and AUD. We also examined sex-specific sexual identity differences in linear trends for these substance use outcomes over this 5-year period.

RESULTS

All groups except lesbian females experienced significant increases in cannabis use rates from 2015 to 2019. Heterosexual males, heterosexual females, and bisexual females also experienced significant increases in CUD rates. In contrast, no group exhibited significant increases in heavy episodic drinking or AUD rates. Bisexual women exhibited some of the largest year-specific disparities in cannabis use and CUD as well as the largest growth in disparities across time.

CONCLUSIONS

The few changes in heavy episodic drinking and AUD alongside numerous changes in cannabis use and CUD suggest that changes in cannabis use may be attributable to legalization of cannabis use in many states during this period. Given profound disparities and increasing rates of CUD affecting bisexual females, further research is needed to identify factors that may explain their disproportionate burden.

Emergency Department Use, Hospitalization, and Their Sociodemographic Determinants among Patients with Substance-Related Disorders: A Worldwide Systematic Review and Meta-Analysis

Background: Identifying the determinants of emergency department (ED) use and hospitalization among patients with substance-related disorders (SRD) can help inform healthcare services and case management regarding their unmet health needs and strategies to reduce their acute care. Objectives: The present study aimed to identify sociodemographic characteristics, type of used drug, and risky behaviors associated with ED use and hospitalization among patients with SRD. Methods: Studies in English published from January 1st, 1995 to April 30th, 2022 were searched from PubMed, Scopus, Cochrane Library, and Web of Science to identify primary studies on ED use and hospitalization among patients with SRD. Results: Of the 17,348 outputs found, a total of 39 studies met the eligibility criteria. Higher ED use and hospitalization among patients with SRD were associated with a history of homelessness (ED use: OR = 1.93, 95%CI = 1.32-2.83; hospitalization: OR = 1.53, 95%CI = 1.36-1.73) or of injection drug use (ED use: OR = 1.34, 95%CI = 1.13-1.59; hospitalization: OR = 1.42, 95%CI = 1.20-1.69). Being female (OR = 1.24, 95%CI = 1.14-1.35), using methamphetamine (OR = 1.99, 95%CI = 1.24-3.21) and tobacco (OR = 1.25, 95%CI = 1.11-1.42), having HIV (OR = 1.70, 95%CI = 1.47-1.96), a history of incarceration (OR = 1.90, 95%CI = 1.27-2.85) and injury (OR = 2.62, 95%CI = 1.08-6.35) increased ED use only, while having age over 30  years (OR = 1.40, 95%CI = 1.08-1.81) and using cocaine (OR = 1.60, 95%CI = 1.32-1.95) increased hospitalization only among patients with SRD. Conclusions: The finding outline the necessity of developing outreach program and primary care referral for patients with SRD. Establishing a harm reduction program, incorporating needle/syringe exchange programs, and safe injection training with the aim of declining ED use and hospitalization, is likely be another beneficial strategy for patients with SRD.

Epidemiological associations of asthma status and tobacco use, substance use, and substance misuse among adults in the United States, 2015-2019

Objective: Adults with asthma have a higher prevalence of substance use. However, knowledge is scarce regarding the associations between adults with asthma and tobacco use, substance use, and substance misuse. This study aimed to use national samples of United States adults to assess the comprehensive use and misuse of substances in adults with asthma.Method: This cross-sectional study comprised data drawn from the 2015 to 2019 National Survey on Drug Use and Health. Weighted logistic regressions were used to measure the associations of asthma status (lifetime and current) with last month's tobacco use; substance use (alcohol, marijuana, cocaine, crack, heroin, hallucinogens, inhalants); and substance misuse (pain relievers, tranquilizers, stimulants, sedatives). All regression models were controlled for sociodemographic characteristics, comorbidity, last-month serious psychological distress, and co-substance use and misuse. Results: Adults with lifetime asthma (N_weighted = 115,600,887) were less likely to use cigarettes, cigars, smokeless tobacco, inhalants, and polyuse of any substance. In contrast, adults with current asthma (N_weighted = 765,096,31) were more likely to use pipe tobacco, cocaine, non-prescribed tranquilizers, and less likely to use polytobacco products. Adults with lifetime asthma were associated with fewer last-month tobacco and inhalant use than those without lifetime asthma. However, adults with current asthma were associated with greater last month's pipe tobacco, cocaine, and non-prescribed tranquilizers. Conclusion: Thus, further longitudinal studies are recommended among adults with asthma to effectively design tailored treatment and prevention interventions.

Cost-Effectiveness of Motivational Interviewing to Reduce Alcohol and Cannabis Use Among Patients With Depression

OBJECTIVE

Motivational interviewing (MI) is a promising intervention for helping patients with mental health problems reduce their substance use. Examining the cost-effectiveness of MI and associations between MI and the use of health services can inform appropriate intervention strategies for these patients.

METHOD

Kaiser Permanente adult patients with depression symptoms (Patient Health Questionnaire [PHQ-9] score > 5) seen in outpatient psychiatry (N = 302) who reported unhealthy alcohol use or other substance use (primarily cannabis) were randomized to three sessions of MI (intervention) or printed literature (control) with telephone follow-up interviews at 6 and 12 months. Cost-effectiveness analyses compared intervention costs associated with 30-day abstinence from unhealthy alcohol use (i.e., any days of ≥4/≥5 drinks for women/men) and cannabis use. Multivariable analyses examined associations between MI and healthcare utilization at 12 months (emergency department, primary care, psychiatry, and addiction treatment).

RESULTS

MI resulted in greater likelihood of abstaining from unhealthy alcohol use (70.0% vs. 60.2%, p < .01) and cannabis use (74.6% vs. 63.9%, p < .01) than the control at 6 months, but outcomes did not differ at 12 months. The 6-month incremental cost-effectiveness ratios were $1,207-$1,523 per abstinent patient for unhealthy drinking and $1,040-$1,313 per abstinent patient for cannabis. There were no differences between groups on health service utilization.

CONCLUSIONS

MI cost more than the control condition but yielded better outcomes at 6 months; MI had no relationship to health service utilization. Findings can inform implementation of substance use interventions through understanding MI's potential clinical and cost impact and its relationship to health services use.

Chronic health conditions, acute health events, and healthcare utilization among adults over age 50 in Hawai'i who use cannabis: A matched cohort study

BACKGROUND

Research on cannabis-related health outcomes in diverse older adults is limited. The current study utilized a matched cohort study design to compare older adults in Hawai'i with identified cannabis diagnoses and matched controls on chronic health conditions, acute health events, and healthcare utilization from 2016 to 2020.

METHOD

Patients age 50 + were identified using ICD-10 diagnostic codes for cannabis use, abuse, and dependence using electronic health record data from an integrated health system (Kaiser Permanente Hawai'i). Those with cannabis diagnoses (n = 275) were compared to matched non-using controls (n = 275; based on age, sex) on chronic health conditions (coronary heart disease, hypertension, COPD, chronic non-cancer pain), acute health events (myocardial infarction, respiratory symptoms, stroke, persistent or cyclic vomiting, injuries), and healthcare utilization (outpatient, inpatient, and emergency department visits) following case identification for two years.

RESULTS

Participants were 19.3% Native Hawaiian/Pacific Islander, 24.4% Asian, 47.8% White, and 8.5% Other/Unknown, with an average age of 62.8 years (SD=7.3). Adjusting for covariates as possible, participants with a cannabis diagnosis had significantly greater risk of coronary heart disease, chronic non-cancer pain, stroke, myocardial infarction, cyclic vomiting, and injuries, over time, compared to controls. Cannabis use was associated with any and greater frequency of outpatient, inpatient, and emergency department visits.

CONCLUSIONS

In a diverse sample, older adults who used cannabis had worse health conditions and events and used more health services over a two-year period. Future studies should evaluate cannabis-related health outcomes, effects of cannabis problem severity, as well as implications for healthcare in aging populations.

Predictors of no, low and frequent emergency department use for any medical reason among patients with cannabis-related disorders attending Quebec (Canada) addiction treatment centres

INTRODUCTION

Patients with substance-related disorders and mental disorders (MD) contribute substantially to emergency department (ED) overcrowding. Few studies have identified predictors of ED use integrating service use correlates, particularly among patients with cannabis-related disorders (CRD). This study compared predictors of low (1-2 visits/year) or frequent (3+ visits/year) ED use with no ED use for a cohort of 9836 patients with CRD registered at Quebec (Canada) addiction treatment centres in 2012-2013.

METHODS

This longitudinal study used multinomial logistic regression to evaluate clinical, sociodemographic and service use variables from various databases as predictors of the frequency of ED use for any medical reason in 2015-2016 among patients with CRD.

RESULTS

Compared to non-ED users with CRD, frequent ED users included more women, rural residents, patients with serious MD and chronic CRD, dropouts from programs in addiction treatment centres and with less continuity of physician care. Compared with non-users, low ED users had more common MD and there more workers than students.

DISCUSSION AND CONCLUSIONS

Multimorbidity, including MD, chronic physical illnesses and other substance-related disorders than CRD, predicted more ED use and explained frequent use of outpatient services and prior specialised acute care, as did being 12-29 years, after controlling for all other covariates. Better continuity of physician care and reinforcement of programs like assertive community or integrated treatment, and chronic primary care models may protect against frequent ED use. Strategies like screening, brief intervention and treatment referral, including motivational therapy for preventing treatment dropout may also be expanded to decrease ED use.

Profiles of individuals with cannabis-related disorders

Background: Profiles of individuals with cannabis-related disorders (CRD) in specialized addiction treatment centers serving high-need patients have not been identified. This longitudinal study developed a typology for 9,836 individuals with CRD attending Quebec (Canada) addiction treatment centers in 2012-2013. Methods: Data on sociodemographic, clinical and service use variables were extracted from several databases for the years 1996-1997 to 2014-2015. Individual profiles were produced using Latent Class Analysis and compared predicting health outcomes on emergency department (ED) use, hospitalizations and suicidal behaviors for 2015-2016. Results: Six profiles were identified: 1-Older individuals, many living in couples and working, with moderate health problems, receiving intensive general practitioner (GP) care and high continuity of physician care; 2-Older individuals with chronic CRD, multiple social and health problems, and low health service use (chronic CRD referred to experiencing CRD for several years; social problems related to homelessness, unemployment, having criminal records or living alone); 3-Students with few social and health problems, and low health service use; 4-Young adults, many working, with few health problems, least health service use and continuity of physician care; 5-Youth, many working but some criminal offenders, with 1 or 2 years of CRD, few health problems and high addiction treatment center use; and 6-Older individuals with chronic CRD and multiple social and health problems, high health service use and continuity of physician care. Profiles 6 and 2 had the worst health outcomes. Conclusions: For Profiles 2 to 5, outreach and motivational services should be prioritized, integrated health and criminal justice services for profile 5 and, for Profiles 2 and 6, assertive community treatments. Screening, brief intervention and referrals to addiction treatment centers may also be encouraged for individuals with CRD, particularly those in Profile 2. This cohort had high social and health needs relative to services received, suggesting continued need for care.

Frequencies of emergency department use and hospitalization comparing patients with different types of substance or polysubstance-related disorders

Background

This study measured emergency department (ED) use and hospitalization for medical reasons among patients with substance-related disorders (SRD), comparing four subgroups: cannabis-related disorders, drug-related disorders other than cannabis, alcohol-related disorders and polysubstance-related disorders, controlling for various clinical, sociodemographic and service use variables.

Methods

Clinical administrative data for a cohort of 22,484 patients registered in Quebec (Canada) addiction treatment centers in 2012-13 were extracted for the years 2009-10 to 2015-16. Using negative binomial models, risks of frequent ED use and hospitalization were calculated for a 12-month period (2015-16).

Results

Patients with polysubstance-related disorders used ED more frequently than other groups with SRD. They were hospitalized more frequently than patients with cannabis or other drug-related disorders, but less frequently than those with alcohol-related disorders. Patients with alcohol-related disorders used ED more frequently than those with cannabis-related disorders and underwent more hospitalizations than both patients with cannabis-related and other drug-related disorders. Co-occurring SRD-mental disorders or SRD-chronic physical illnesses, more years with SRD, being women, living in rural territories, more frequent consultations with usual general practitioner or outpatient psychiatrist, and receiving more interventions in community healthcare centers increased frequency of ED use and hospitalization, whereas both adverse outcomes decreased with high continuity of physician care. Behavioral addiction, age less than 45 years, living in more materially deprived areas, and receiving 1-3 interventions in addiction treatment centers increased risk of frequent ED use, whereas living in semi-urban areas decreased ED use. Patients 25-44 years old receiving 4+ interventions in addiction treatment centers experienced less frequent hospitalization.

Conclusion

Findings showed higher risk of ED use among patients with polysubstance-related disorders, and higher hospitalization risk among patients with alcohol-related disorders, compared with patients affected by cannabis and other drug-related disorders. However, other variables contributed substantially more to the frequency of ED use and hospitalization, particularly clinical variables regarding complexity and severity of health conditions, followed by service use variables. Another important finding was that high continuity of physician care helped decrease the use of acute care services. Strategies like integrated care and outreach interventions may enhance SRD services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-021-00421-7.

Cannabis-Induced Malignant Catatonia: A Medical Emergency and Review of Prior Case Series

Few case reports of catatonia associated with cannabis use are reported. Here, we describe a case of a 35-year-old African American male who developed malignant catatonia following heavy cannabis use. The patient was brought to the emergency department (ED) for altered mental status, hypertension, and erratic behavior. Before his ED presentation, he was smoking cannabis in heavy amounts, confirmed by positive urine toxicology in ED. Initial lab results showed leukocytosis, elevated creatine phosphokinase (CPK) levels. Head CT scans without contrast, including cerebrospinal fluid (CSF) analysis, were nonsignificant. In ED, the patient was agitated, combative, mute, and rigid. He was sedated using 2 mg of intramuscular (IM) midazolam. Psychiatric consultation services suspected catatonia, and the patient scored 12 points on Bush-Francis Catatonia Rating Scale (BFCRS). Although the patient’s symptoms responded to 2 mg of IM lorazepam, the patient later relapsed, became tachycardic with blood pressure fluctuations, and his repeat BFCRS score was 18. At this point, the patient was diagnosed as having malignant catatonia, and his lorazepam dosage was increased up to 6 mg IM per day. After a few days of waxing and waning of his symptoms, he finally started to show constant improvement and gradually reduced his symptoms. Our case highlights the first-ever reported case of malignant catatonia associated with cannabis use.

Cigarette Use and Cannabis Use Disorder Onset, Persistence, and Relapse: Longitudinal Data From a Representative Sample of US Adults

Objective: The current study prospectively investigated the relationship between cigarette use and the onset of, persistence of, and relapse to cannabis use disorder (CUD) 3 years later among adults in the United States. Methods: Analyses included respondents who completed Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (2001-2002 and 2004-2005, respectively) and responded to questions about cigarette use, cannabis use, and CUD (n = 34,653). CUDs were defined by DSM-IV criteria using the Alcohol Use Disorder and Associated Disabilities Interview Schedule-Diagnostic Version IV. Multivariable logistic regression models were used to calculate the odds of CUD onset, persistence, and relapse at Wave 2 by Wave 1 cigarette use status. Analyses were adjusted for sociodemographics, psychiatric disorders, nicotine dependence, and alcohol and other substance use disorders. Results: Cigarette use at Wave 1 was associated with onset of CUD at Wave 2 among those without Wave 1 cannabis use (adjusted odds ratio [AOR] = 1.62; 95% CI, 1.35-1.94) but not among those with Wave 1 cannabis use (AOR = 1.00; 95% CI, 0.83-1.19). Cigarette use at Wave 1 was also associated with persistence of CUD at Wave 2 among those with CUD at Wave 1 (AOR = 1.63; 95% CI, 1.30-2.00) and relapse to CUD at Wave 2 among those with remitted CUD at Wave 1 (AOR = 1.23; 95% CI, 1.09-1.45). Conclusions: Among adults, cigarette use is associated with increased onset and persistence of and relapse to CUD 3 years later. Additional attention to cigarette use in community prevention and clinical treatment efforts aimed at reducing CUD may be warranted.

Cannabis use, other drug use, and risk of subsequent acute care in primary care patients

BACKGROUND

Cannabis and other drug use is associated with adverse health events, but little is known about the association of routine clinical screening for cannabis or other drug use and acute care utilization. This study evaluated whether self-reported frequency of cannabis or other drug use was associated with subsequent acute care.

METHOD

This retrospective cohort study used EHR and claims data from 8 sites in Washington State that implemented annual substance use screening. Eligible adult primary care patients (N = 47,447) completed screens for cannabis (N = 45,647) and/or other drug use, including illegal drug use and prescription medication misuse, (N = 45,255) from 3/3/15-10/1/2016. Separate single-item screens assessed frequency of past-year cannabis and other drug use: never, less than monthly, monthly, weekly, daily/almost daily. An indicator of acute care utilization measured any urgent care, emergency department visits, or hospitalizations ≤19 months after screening. Adjusted Cox proportional hazards models estimated risk of acute care.

RESULTS

Patients were predominantly non-Hispanic White. Those reporting cannabis use less than monthly (Hazard Ratio [HR] = 1.12, 95 % CI = 1.03-1.21) or daily (HR = 1.24; 1.10-1.39) had greater risk of acute care during follow-up than those reporting no use. Patients reporting other drug use less than monthly (HR = 1.34; 1.13-1.59), weekly (HR = 2.21; 1.46-3.35), or daily (HR = 2.53; 1.86-3.45) had greater risk of acute care than those reporting no other drug use.

CONCLUSION

Population-based screening for cannabis and other drug use in primary care may have utility for understanding risk of subsequent acute care. It is unclear whether findings will generalize to U.S. states with broader racial/ethnic diversity.

Frequency of health-care utilization by adults who use illicit drugs: a systematic review and meta-analysis

AIMS

To summarize evidence on the frequency and predictors of health-care utilization among people who use illicit drugs.

DESIGN

Systematic search of MEDLINE, EMBASE and PsychINFO for observational studies reporting health-care utilization published between 1 January 2000 and 3 December 2018. We conducted narrative synthesis and meta-analysis following a registered protocol (identifier: CRD42017076525).

SETTING AND PARTICIPANTS

People who use heroin, powder cocaine, crack cocaine, methamphetamine, amphetamine, ecstasy/3,4-methyl​enedioxy​methamphetamine (MDMA), cannabis, hallucinogens or novel psychoactive substances; have a diagnosis of 'substance use disorder'; or use drug treatment services.

MEASUREMENTS

Primary outcomes were the cumulative incidence (risk) and rate of care episodes in three settings: primary care, hospital admissions (in-patient) and emergency department (ED).

FINDINGS

Ninety-two studies were included, 84% from North America and Australia. Most studies focused on people using heroin, methamphetamine or crack cocaine, or who had a diagnosis of drug dependence. We were able to conduct a meta-analysis of rates across 25 studies reporting ED episodes and 25 reporting hospital admissions, finding pooled rates of 151 [95% confidence interval (CI) = 114-201] and 41 (95% CI = 30-57) per 100 person-years, respectively; on average 4.8 and 7.1 times more often than the general population. Heterogeneity was very high and was not explained by drugs used, country of study, recruitment setting or demographic characteristics. Predictors of health-care utilization were consistent across studies and included unstable housing, drug injection and mental health problems. Opioid substitution therapy was consistently associated with reduced ED presentation and hospital admission. There was minimal research on health-care utilization by people using ecstasy/MDMA, powder cocaine, hallucinogens or novel psychoactive substances.

CONCLUSIONS

People who use illicit drugs are admitted to emergency department or hospital several times more often than the general population.

Cohort study of medical cannabis authorisation and healthcare utilisation in 2014-2017 in Ontario, Canada

BACKGROUND

The impact of medical cannabis on healthcare utilisation between 2014 and 2017 in Ontario, Canada. With cannabis legalisation in Canada and some states in the USA, high-quality longitudinal cohort research studies are of urgent need to assess the impact of cannabis use on healthcare utilisation.

METHODS

A matched cohort study of 9925 medical cannabis authorised adult patients (inhaled (smoked or vaporised) or orally consumed (oils)) at specialised cannabis clinics, and inclusion of 17 732 controls (not authorised) between 24 April 2014 and 31 March 2017 from Ontario, Canada. Interrupted time series and multivariate Poisson regression analyses were conducted. Medical cannabis impact on healthcare utilisation was measured over 6 months: all-cause physician visits, all-cause hospitalisation, ambulatory care sensitive conditions (ACSC)-related hospitalisations, all-cause emergency department (ED) visits and ACSC-related ED visits.

RESULTS

For medical cannabis patients compared with controls, there was an initial (within the first month) increase in physician visits (additional 4330 visits per 10 000 patients). However, a numerical reduction was noted over the 6-month follow-up, and no statistical difference was observed (p=0.126). Likewise, in hospitalisations and ACSC ED visits, there was an initial increase (44 per 10 000 people, p<0.05) but no statistical difference after follow-up (p=0.34). Conversely, no initial increase in all-cause ED visits was observed with a slight decrease (19 visits per 10 000 patients, p=0.014) in follow-up.

CONCLUSIONS

An initial increase (within first month) in healthcare utilisation may be expected among medical cannabis users that appears to wane over time. Proactive follow-up of patients using medical cannabis is warranted to minimise initial risks to patients and actively assess potential benefits/harms of ongoing use.

Homelessness and self-rated health: evidence from a national survey of homeless people in Spain

Background

Internationally, acute homelessness is commonly associated with complex health and social care needs. While homelessness can be understood as an outcome of structural housing exclusion requiring housing led solutions, the health care issues faced by homeless people equally require attention. A substantive evidence base on the health needs of homeless people exists, but relatively little is known about what influences the self-rated health of homeless people. This article presents new evidence on whether drug use (alcohol consumption, ever having used drugs), health variables (visiting a hospital once in the last year, visiting the doctor in the last month, having a health card, sleeping difficulties, and having a disabling impairment) and sociodemographic characteristics are significantly associated with Self-Rated Health (SRH) among Spanish homeless people.

Method

The approach applies secondary analysis to cross-sectional data from a sample of 2437 homeless adults in Spain (83.8% were male). Multinomial logistic regression modelling was used to analyse the relationships between drug use, other health variables and SRH.

Results

Being male, an abstainer, having a health card and being in the youngest age groups were significant factors associated with perceived good health. On the other hand, ever having used drugs, having been a night in hospital, having gone to the doctor in the last month, having sleeping difficulties, having a disabling impairment and being in the older age group were all significant risk factors associated with perceived poor health.

Conclusions

These results help to improve understanding of the key factors that influence the SRH among homeless people. The findings can contribute to development and delivery of preventive policies, suggesting that interventions to reduce drug consumption and ensure access to a health card/health services, as well as enhancing services for older, female and disabled homeless people are all measures which could improve health and well-being for those who face homelessness. Effective housing interventions (e.g. Housing First or Permanent Supported Housing programmes) are equally important to underpin the effectiveness of measures to improve the self-rated health of homeless people.

Time since first cannabis use and 12-month prevalence of cannabis use disorder among youth and emerging adults in the United States

AIM

This study estimated whether and how the 12-month prevalence of cannabis use disorder among US youth aged 12-17 and emerging adults aged 18-25 varied by time since first cannabis use.

DESIGN

Repeated cross-sectional survey data from the 2015-17 National Surveys on Drug Use and Health (NSDUH).

SETTING

United States.

PARTICIPANTS

A total of 101 000 NSDUH participants aged 12-25.

MEASUREMENTS

Past 12-month cannabis use disorder was assessed using DSM-IV criteria.

FINDINGS

Among youth, the life-time prevalence of cannabis use was 15.3% [95% confidence interval (CI) = 14.86-15.65%]. Among emerging adults, the life-time prevalence of cannabis use was 52.4% (95% CI = 51.77-53.01%). The adjusted 12-month prevalence of cannabis use disorder among youth with life-time cannabis use was 10.9% (95% CI = 9.24-12.75%) in the first year after starting cannabis use, 15.3% (95% CI = 13.68-17.12%) in the second year, 17.7% (95% CI = 15.55-19.97%) in the third year and 20.6% (95% CI = 18.23-23.17%) in the fourth year and beyond, which was consistently higher after the first year (linear trend only: P < 0.0001). The adjusted 12-month prevalence of cannabis use disorder among emerging adults with life-time use ranged from 5.6% (95% CI = 4.26-7.23%) in the first year after starting cannabis use, 7.7% (95% CI = 6.45-9.17%) in the second year and 9.1% (95% CI = 7.81-10.57%) in the third year to 10.5% (95% CI = 9.87%-11.12%) in the fourth year and beyond, which was consistently higher after the first year (linear trend only: P < 0.0001). Within each time-frame since first cannabis use, the adjusted 12-month prevalence of cannabis use disorder was higher among youth life-time users than their emerging adult counterparts.

CONCLUSIONS

Among youth and emerging adults in the United States, the prevalence of cannabis use disorder appears to increase with time since initiation of use and is higher among youth than among emerging adults during each examined time-frame.

Predictors and Costs of 30-Day Readmissions After Index Hospitalizations for Alcohol-Related Disorders in U.S. Adults

BACKGROUND

In 2015, the Hospital Readmissions Reduction Program mandated financial penalties to hospitals with greater rates of readmissions for certain conditions. Alcohol-related disorders (ARD) are the fourth leading cause of 30-day readmissions. Yet, there is a dearth of national-level research to identify high-risk patient populations and predictors of 30-day readmission. This study examined patient- and hospital-level predictors for index hospitalizations with principal diagnosis of ARD and predicted the cost of 30-day readmissions.

METHODS

The 2014 Nationwide Readmissions Database was used to identify ARD-related index hospitalizations. Multivariable logistic regression was used to estimate patient- and hospital-level predictors for readmissions, and a 2-part model was used to predict the incremental cost conditional upon readmission.

RESULTS

In 2014, 285,767 index hospitalizations for ARD were recorded, and 18.9% of ARD-associated hospitalizations resulted in at least one 30-day readmission. Patients who were males, aged 45 to 64 years, Medicaid enrollees, living in urban and low-income areas, or with 1 to 2 comorbidities had high risk of readmission. Index hospitalization costs were higher among readmitted patients ($8,840 vs. $8,036, p < 0.01). Predicted mean costs for readmissions on index stay with ARD were greater among those aged 45 to 64 years ($1,908, p < 0.001), Medicare enrollees ($2,133, p < 0.001), rural residents ($1,841, p < 0.01), living in high-income areas ($1,876, p < 0.001), with 4 or more comorbidities ($2,415, p < 0.001), or admitted in large metropolitan hospitals ($2,032, p < 0.001), with large number of beds ($1,964, p < 0.001), with government ownership ($2,109, p < 0.001), or with low volume of ARD cases ($2,155, p < 0.001).

CONCLUSIONS

One in 5 ARD-related index hospitalizations resulted in a 30-day readmission. Overall, costs of index hospitalizations for ARD were $2.3 billion, of which $512 million were spent on hospitalizations that resulted in at least 1 readmission. There is a need to develop patient-centric health programs to reduce readmission rates and costs among ARD patients.

An update on cannabis use disorder with comment on the impact of policy related to therapeutic and recreational cannabis use

Confusion and controversy related to the potential for cannabis use to cause harm, or alternatively to provide benefit, continues globally. This issue has grown in intensity and importance with the increased recognition of the public health implications related to the escalation of the legalization of cannabis and cannabinoid products. This selective overview and commentary attempt to succinctly convey what is known about one potential consequence of cannabis use, the development of cannabis use disorder (CUD). Such knowledge may help guide a reasonable and objective public health perspective on the potential impact of cannabis use and CUD. Current scientific data and clinical observation strongly support the contention that cannabis use, like the use of other substances such as alcohol, opioids, stimulants, and tobacco, can develop into a use disorder (addiction) with important clinical consequences. Epidemiological data indicate that the majority of those who use cannabis do not have problems related to their use, but a substantial subset (10-30%) do report experiencing symptoms and consequences consistent with a CUD. Treatment seeking for CUD comprises a substantial proportion of all substance use treatment admissions, yet treatment response rates show much room for improvement. Changing cannabis policies related to its therapeutic and recreational use are likely to impact the development of CUD and its course; however, definitive data on such effects are not yet available. Clearly, the development of more effective prevention and treatment strategies is needed for those vulnerable to developing a CUD and for those with a CUD.

The prevalence of Healthcare Effectiveness Data and Information Set (HEDIS) initiation and engagement in treatment among patients with cannabis use disorders in 7 US health systems

Background: Cannabis use disorders (CUDs) have increased with more individuals using cannabis, yet few receive treatment. Health systems have adopted the Healthcare Effectiveness Data and Information Set (HEDIS) quality measures of initiation and engagement in alcohol and other drug (AOD) dependence treatment, but little is known about the performance of these among patients with CUDs. Methods: This cohort study utilized electronic health records and claims data from 7 health care systems to identify patients with documentation of a new index CUD diagnosis (no AOD diagnosis ≤60 days prior) from International Classification of Diseases, Ninth revision, codes (October 1, 2014, to August 31, 2015). The adjusted prevalence of each outcome (initiation, engagement, and a composite of both) was estimated from generalized linear regression models, across index identification settings (inpatient, emergency department, primary care, addiction treatment, and mental health/psychiatry), AOD comorbidity (patients with CUD only and CUD plus other AOD diagnoses), and patient characteristics. Results: Among 15,202 patients with an index CUD diagnosis, 30.0% (95% confidence interval [CI]: 29.2-30.7%) initiated, 6.9% (95% CI: 6.2-7.7%) engaged among initiated, and 2.1% (95% CI: 1.9-2.3%) overall both initiated and engaged in treatment. The adjusted prevalence of outcomes varied across index identification settings and was highest among patients diagnosed in addiction treatment, with 25.0% (95% CI: 22.5-27.6%) initiated, 40.9% (95% CI: 34.8-47.0%) engaged, and 12.5% (95% CI: 10.0-15.1%) initiated and engaged. The adjusted prevalence of each outcome was generally highest among patients with CUD plus other AOD diagnosis at index diagnosis compared with those with CUD only, overall and across index identification settings, and was lowest among uninsured and older patients. Conclusion: Among patients with a new CUD diagnosis, the proportion meeting HEDIS criteria for initiation and/or engagement in AOD treatment was low and demonstrated variation across index diagnosis settings, AOD comorbidity, and patient characteristics, pointing to opportunities for improvement.

Emergency Department Utilization for Substance Use-Related Disorders and Assessment of Treatment Facilities in New York State, 2011-2013

BACKGROUND

Annually, 1.8 million New York (NY) residents experience substance use disorders (SUDs). Even though emergency departments (EDs) continue to experience high numbers of SUD-related visits, only 15% receive treatment.

OBJECTIVES

This study estimates hospital-based EDs rates for SUDs in the State of New York. Also, the geographic distribution of substance use treatment centers and EDs are mapped to correlate utilization with access to care.

METHODS

The 2011-2013 Healthcare Cost and Utilization Project's NY State Emergency Department Database provided information on utilization of services in EDs, charges, diagnoses, and discharge, as well as patient demographic variables. All patients within NY who had visited the ED for SUDs comprised the study population. Geographic mapping of EDs and substance abuse treatment centers at the county-level is based on data from the National Emergency Department Inventory and National Survey of Substance Abuse Treatment Services, respectively.

RESULTS

A total of 492,419 ED visits for SUDs were reported through 2011-2013. Despite NY's Medicaid expansion in 2012, ED visits increased in 2013. About $856 million was spent in treating SUDs in EDs, with average charge of $1,764 per visit. Conclusions/Importance: Alcohol and drug-induced mental disorders are increasingly prevalent in New York's EDs. There is a need to develop health policies and programs to improve access to care for SUDs in urban states.

Adverse impact of marijuana use on clinical outcomes among psychiatry patients with depression and alcohol use disorder

This study examined whether marijuana use was associated with clinically problematic outcomes for patients with depression and alcohol use disorder (AUD). The sample consisted of 307 psychiatry outpatients with mild to severe depression and past 30-day hazardous drinking/drug use, who participated in a trial of substance use treatment. Participants were assessed for AUD based on DSM-IV criteria. Measures of marijuana use, depression symptoms, and functional status related to mental health were collected at baseline, 3, and 6 months. Differences in these outcomes were analyzed among patients with and without AUD using growth models, adjusting for treatment effects. Marijuana was examined as both an outcome (patterns of use) and a predictor (impact on depression and functioning). Forty percent used marijuana and about half the sample met AUD criteria. Fewer patients with AUD used marijuana than those without AUD at baseline. Over 6 months, the proportion of patients with AUD using marijuana increased compared to those without AUD. Patients with AUD using marijuana had greater depressive symptoms and worse functioning than those without AUD. These findings indicate that marijuana use is clinically problematic for psychiatry outpatients with depression and AUD. Addressing marijuana in the context of psychiatry treatment may help improve outcomes.