Substance use disorders and self- and other-directed violence among adults: Results from the National Survey on Drug Use And Health

Associations of cannabis use, use frequency, and cannabis use disorder with violent behavior among young adults in the United States

BACKGROUND

Most violent crimes (52 %) are committed by adults aged 18-34, who account for 23 % of the US population and have the highest prevalence of cannabis use and cannabis use disorder (CUD). We examined whether and how associations of cannabis use, use frequency, and CUD with violent behavior (i.e., attacking someone with the intent to harm seriously) vary by sex in U.S. young adults.

METHODS

Data were from 113,454 participants aged 18-34 in the 2015-2019 US National Surveys on Drug Use and Health, providing nationally representative data on cannabis use, CUD (using DSM-IV criteria), and violent behavior. Descriptive analyses and bivariate and multivariable logistic regression analyses were conducted.

RESULTS

Among U.S. adults aged 18-34, 28.9 % (95 % CI = 28.5-29.2 %) reported past-year cannabis use (with/without CUD), including 20.5 % (95 % CI = 20.2-20.8 %) with non-daily cannabis without CUD, 4.7 % (95 % CI = 4.5-4.8 %) with daily cannabis use without CUD, 2.1 % (95 % CI = 1.9-2.2 %) with non-daily cannabis use and CUD, and 1.7 % (95 % CI = 1.5-1.8 %) with daily cannabis use and CUD. Past-year adjusted prevalence of violent behavior was higher among males with daily cannabis use but without CUD (2.9 %, 95 % CI = 2.4-2.7 %; adjusted prevalence ratio (PR) = 1.7, 95 % CI = 1.3-2.2) and males with daily cannabis use and CUD (3.1 %, 95 % CI = 2.3-4.0 %; adjusted PR = 1.8, 95 % CI = 1.3-2.4) than males without past-year cannabis use (1.7 %, 95 % CI = 1.6-1.9 %). Adjusted prevalence of violent behavior was higher among females with cannabis use regardless of daily cannabis use/CUD status (adjusted prevalence = 1.6-2.4 %, 95 % CIs = 0.9-3.2 %; adjusted PRs = 1.6-2.4, 95 % CI = 1.3-3.2) than females without past-year cannabis use (1.0 %, 95 % CI = 0.9-1.1 %).

CONCLUSIONS

Research is needed to ascertain the directionality of the associations between cannabis use and violent behavior and underlying sex-specific mechanism(s). Our results point to complex sex-specific relationships between cannabis use frequency, CUD, and violent behavior and highlight the importance of early screening for and treatment of CUD and of preventive interventions addressing cannabis misuse.

Substance use typologies among young people experiencing homelessness in seven cities across the United States: A latent class analysis

BACKGROUND

Substance use and other health-risk risk factors, including mental health, trauma, and sexual-risk behaviors, often co-occur among youth experiencing homelessness (YEH). The present study aimed to identify subgroups of YEH based on polysubstance use and the linkages to sociodemographic and health-risk characteristics.

METHODS

From June 2016 to July 2017, 1,426 YEH (aged 18-26 years) were recruited from seven cities (Houston, Los Angeles, Denver, Phoenix, New York City, St. Louis, San Jose). Participants provided information via a self-administered electronic survey on substance use, mental health, trauma, sexual risk behaviors, and sociodemographic characteristics. The majority of YEH identified as Black (37.3%), cisgender (92.8%), and heterosexual (69.2%). On average, YEH were 20.9 years (SD = 2.1). This study employed latent class analysis (LCA) to identify subgroups of YEH according to their substance use. Multinomial logistic regression analyses were conducted to identify sociodemographic and health-risk characteristics associated with class-membership.

RESULTS

Four latent classes of YEH substance use were identified: (1) high polysubstance use; (2) moderate stimulant and high marijuana, alcohol, and prescription drug use; (3) high marijuana, alcohol, and prescription drug use; (4) low/moderate marijuana and alcohol use. Multinomial logistic regression models indicated that geographic location, gender, race/ethnicity, mental health, trauma history, and sexual risk behaviors were significant correlates of substance use class membership among YEH.

CONCLUSIONS

These findings offer important implications for the prevention and treatment of substance use among YEH. Screening protocols should consider co-occurring risk factors such as traumatic experiences, sexual risk behaviors, and mental health history as indicators of polysubstance use.

Health Care Provider Stigma Toward Patients With Substance Use Disorders: Protocol for a Nationally Representative Survey

BACKGROUND

The US overdose epidemic is an escalating public health emergency, accounting for over 100,000 deaths annually. Despite the availability of medications for opioid use disorders, provider-level barriers, such as negative attitudes, exacerbate the treatment gap in clinical care settings. Assessing the prevalence and intensity of provider stigma, defined as the negative perceptions and behaviors that providers embody and enact toward patients with substance use disorders, across providers with different specialties, is critical to expanding the delivery of substance use treatment.

OBJECTIVE

To thoroughly understand provider stigma toward patients with substance use disorders, we conducted a nationwide survey of emergency medicine and primary care physicians and dentists using a questionnaire designed to reveal how widely and intensely provider attitudes and stigma can impact these providers' clinical practices in caring for their patients. The survey also queried providers' stigma and clinical practices toward other chronic conditions, which can then be compared with their stigma and practices related to substance use disorders.

METHODS

Our cross-sectional survey was mailed to a nationally representative sample of primary care physicians, emergency medicine physicians, and dentists (N=3011), obtained by American Medical Association and American Dental Association licensees based on specified selection criteria. We oversampled nonmetropolitan practice areas, given the potential differences in provider stigma and available resources in these regions compared with metropolitan areas. Data collection followed a recommended series of contacts with participants per the Dillman Total Design Method, with mixed-modality options offered (email, mail, fax, and phone). A gradually increasing compensation scale (maximum US$250) was implemented to recruit chronic nonresponders and assess the association between requiring higher incentives to participate and providers stigma. The primary outcome, provider stigma, was measured using the Medical Condition Regard Scale, which inquired about participants' views on substance use and other chronic conditions. Additional survey measures included familiarity and social engagement with people with substance use disorders; clinical practices (screening, treating, and referring for a range of chronic conditions); subjective norms and social desirability; knowledge and prior education; and descriptions of their patient populations.

RESULTS

Data collection was facilitated through collaboration with the National Opinion Research Center between October 2020 and October 2022. The overall Council of American Survey Research Organizations completion rate was 53.62% (1240/2312.7; physicians overall: 855/1681.9, 50.83% [primary care physicians: 506/1081.3, 46.79%; emergency medicine physicians: 349/599.8, 58.2%]; dentists: 385/627.1, 61.4%). The ineligibility rate among those screened is applied to those not screened, causing denominators to include fractional numbers.

CONCLUSIONS

Using systematically quantified data on the prevalence and intensity of provider stigma toward substance use disorders in health care, we can provide evidence-based improvement strategies and policies to inform the development and implementation of stigma-reduction interventions for providers to address their perceptions and treatment of substance use.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47548.

A systematic review of the co-occurrence of self-harm and aggression: Is dual harm a unique behavioural construct?

Introduction

Dual harm is the co-occurrence of self-harm and aggression during an individual's lifetime. It is unclear whether sufficient evidence exists for dual harm as a unique clinical entity. This systematic review aimed to examine whether there are psychological factors that are uniquely associated with dual harm when compared to those who have engaged in sole harm (self-harm alone, aggression alone) and no harmful behaviours. Our secondary aim was to conduct a critical appraisal of the literature.

Methods

The review searched PsycINFO, PubMed, CINAHL, and EThOS on September 27, 2022, resulting in 31 eligible papers that represented 15,094 individuals. An adapted version of the Agency for Healthcare Research and Quality was used to assess risk of bias and a narrative synthesis was conducted.

Results

The included studies assessed differences in mental health problems, personality, and emotion related factors between the different behavioural groups. We found weak evidence that dual harm is an independent construct with unique psychological characteristics. Rather, our review suggests that dual harm results from the interaction of psychological risk factors that are associated with self-harm and aggression.

Discussion

The critical appraisal identified numerous limitations within the dual harm literature. Clinical implications and recommendations for future research are provided.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=197323, identifier CRD42020197323.

The role of mental health and substance use disorders on the relation of migraine with self-directed violence among women in the United States

OBJECTIVES

Migraine disproportionately affects women of reproductive age, and is associated with self-directed violence (SDV) which confers substantial risk for suicides. Mental health disorders (MHD) and substance use disorders (SUD) are higher among persons with migraines. However, there's limited information on the influence of these conditions on SDV among women. We evaluated the interplay of MHD and SUD on the relation of migraine with SDV among US women.

METHODS

We analyzed data from 96 million hospitalizations among women aged 15-49 years from the National Inpatient Sample (2004-2015). International Classification of Disease codes were used to identify hospitalizations for migraine and other health conditions. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

From 2004 to 2015 the prevalence (per 1000 hospitalizations) of migraine increased from 17.5 to 33.5, while SDV prevalence also increased from 10.5 to 38.9. A greater proportion of women hospitalized with migraine had epilepsy, suicidal ideations, SUD and MHD than women without migraine. In models adjusted for demographic and behavioral/lifestyle factors, menstrual disorders, pregnancy, health conditions and violent assault, hospitalization with migraine was positively associated with SDV (OR = 1.15, CI: 1.12-1.18). Women with migraine and either SUD (OR = 5.17, CI: 4.46-5.97) or MHD (OR = 14.13; CI: 12.1-16.47) had elevated odds of SDV, with the odds varying by type of MHD and SUD.

CONCLUSIONS

A significant relation between hospitalization with migraine and SDV was observed especially among reproductive-age women with SUD and MHD. Clinicians should consider monitoring women with these characteristics for suicide risk.

The association of prescription opioid use with suicide attempts: An analysis of statewide medical claims data

BACKGROUND

Suicides and opioid overdose deaths are among the most pressing public health concerns in the US. However direct evidence for the association between opioid use and suicidal behavior is limited. The objective of this article is to examine the association between frequency and dose of prescription opioid use and subsequent suicide attempts.

METHODS AND FINDINGS

This retrospective cohort study analyzed 4 years of statewide medical claims data from the Connecticut All-Payer Claims Database. Commercially insured adult patients in Connecticut (n = 842,773) who had any medical claims beginning in January 2012 were followed through December 2015. The primary outcome was suicide attempt identified using International Classification of Diseases (ICD 9) diagnosis codes. Primary predictor variables included frequency of opioid use, which was defined as the number of months with claims for prescription opioids per year, and strength of opioid dose, which was standardized using morphine milligram equivalent (MME) units. We also controlled for psychiatric and medical comorbidities using ICD 9 codes. We used Cox proportional hazards regression to examine the association between frequency, dose, and suicide attempts, adjusting for medical and psychiatric comorbid conditions. Interactions among measures of opioid use and comorbid conditions were analyzed. In this cohort study with follow-up time up to 4 years (range = 2-48 months, median = 46 months), the hazard ratios (HR) from the time-to-event analysis indicated that patients prescribed opioid medications for at least 6 months during the past year and at 20-50 MME levels or higher had 4.44 (95% CI: [3.71, 5.32]) to 7.23 (95% CI: [6.22, 8.41]) times the risk of attempted suicide compared to those not prescribed opioids. Risk of suicide attempt was sharply elevated among patients with psychiatric conditions other than anxiety who were prescribed more frequent and higher opioid doses. In contrast, more frequent and higher doses of prescription opioids were associated with lower risk of suicide attempts among patients with medical conditions necessitating pain management. This study is limited by its exclusive focus on commercially insured patients and does not include patients covered by public insurance. It is also limited to patients' receipt of prescription opioids and does not take into account opioids obtained through other means, nor does it include measures of actual patient opioid use.

CONCLUSIONS

This analysis provides evidence of a complex relationship among prescription opioids, mental health, pain and other medical comorbidities, and suicide risk. Findings indicate the need for proactive suicide surveillance among individuals diagnosed with affective or psychotic disorders who are receiving frequent and high doses of opioids. However, appropriate opioid treatment may have significant value in reducing suicide risk for those without psychiatric comorbidities.

Prevalence and Correlates of Illicit Substance Use Among Young Adults Experiencing Homelessness in Seven Cities Across the United States

Background

Young adults experiencing homelessness (YAEH) engage in substantially higher substance use rates than housed young adults. This current study builds on previous research by investigating the prevalence of and salient correlates of illicit substance use across a seven-city sample.

Methods

This study used the Homeless Youth Risk and Resiliency Survey (HYRRS) dataset, n=1426 Young adults experiencing homelessness to study patterns and correlates of illicit substance use.

Results

Multivariate logistic regression analyses were used to assess correlates of substance use. Study site, age, gender identity, sexual orientation, history of suicidal ideation, use of specific substances, and trading sex for drugs were associated with five types of illicit substance use (ecstasy, cocaine, crack, methamphetamine, and injection drug use).

Conclusion

Findings indicate that substance use interventions for YAEH must be multifaceted, addressing illicit and multiple substance use, along with the myriad factors associated with substance use among this at-risk group.

The inter-connections between self-harm and aggressive behaviours: A general network analysis study of dual harm

Dual harm is the co-occurrence of self-harm and aggression during an individual's lifetime. This behaviour is especially prevalent within criminal justice and forensic settings. The forms of aggression that should be included in the definition of dual harm have not yet been established. This study aimed to use network analysis to inform an evidence-based definition of dual harm by assessing the relationship between self-harm and different forms of aggressive behaviour in young people (N = 3,579). We used data from the Avon Longitudinal Study of Parents and Children (ALSPAC). Results revealed low correlations between the variables, leading to sparse network models with weak connections. We found that when separated into their distinct forms, aggressive acts and self-harm are only weakly correlated. Our work provides preliminary evidence to assist in understanding and managing dual harm within clinical and forensic settings and informs recommendations for future research.

Improving suicide risk prediction via targeted data fusion: proof of concept using medical claims data

OBJECTIVE

Reducing suicidal behavior among patients in the healthcare system requires accurate and explainable predictive models of suicide risk across diverse healthcare settings.

MATERIALS AND METHODS

We proposed a general targeted fusion learning framework that can be used to build a tailored risk prediction model for any specific healthcare setting, drawing on information fusion from a separate more comprehensive dataset with indirect sample linkage through patient similarities. As a proof of concept, we predicted suicide-related hospitalizations for pediatric patients in a limited statewide Hospital Inpatient Discharge Dataset (HIDD) fused with a more comprehensive medical All-Payer Claims Database (APCD) from Connecticut.

RESULTS

We built a suicide risk prediction model for the source data (APCD) and calculated patient risk scores. Patient similarity scores between patients in the source and target (HIDD) datasets using their demographic characteristics and diagnosis codes were assessed. A fused risk score was generated for each patient in the target dataset using our proposed targeted fusion framework. With this model, the averaged sensitivities at 90% and 95% specificity improved by 67% and 171%, and the positive predictive values for the combined fusion model improved 64% and 135% compared to the conventional model.

DISCUSSION AND CONCLUSIONS

We proposed a general targeted fusion learning framework that can be used to build a tailored predictive model for any specific healthcare setting. Results from this study suggest we can improve the performance of predictive models in specific target settings without complete integration of the raw records from external data sources.

Higher Levels of Nicotine Dependence in Adolescence are Associated with Younger Onset Age of Violent Criminality: A Follow-Up Study of Former Adolescent Psychiatric Inpatients

OBJECTIVE

Earlier studies have reported that smoking is associated with violent behaviour. This study investigated nicotine dependence (ND), defined as already present in adolescence, and its relation to subsequent violent criminal offending.

METHOD

The baseline dataset is composed of 508 former adolescent inpatients, admitted to a psychiatric hospital between the ages of 13-17. Adolescent ND was assessed using the modified Fagerström Tolerance Questionnaire. Follow-up data on crimes up to young adulthood was acquired from the Legal Register Centre of Finland. The study analyzes the participants with violent offences (n = 78) and those without any criminal history (n = 368).

RESULTS

Over 80% of the violent offenders had ND already in adolescences. One third (32.2%) of those with high ND had committed their first violent crime before 18 years of age, the proportions being 15.2% in moderate and 7.1% in no-ND groups. The likelihood for committing first violent crimes at a younger age was increased in the participants with high (adjusted Hazard Ratio (aHR) = 2.66, p = .008) or moderate ND (aHR = 2.40, p = .011).

CONCLUSIONS

Adolescent psychiatric patients, showing moderate to high levels of addiction to nicotine, should be a target population for adolescent focused smoking cessation interventions and programs. Adolescents addicted to nicotine may benefit from intensive clinical attention in order to avoid more adverse and unfavorable outcomes in life, beyond merely physical health related problems.

Factors associated with substance use disorder treatment completion: a cross-sectional analysis of justice-involved adolescents

Background

Substance use disorders (SUD) are prevalent among those in the juvenile justice system. SUD treatment programs implemented in correctional settings can prevent overdose and other health-related problems among an underserved health disparity population. However, only a fraction of justice-involved adolescents with SUDs complete a treatment program and the factors associated with treatment completion among adolescents in the criminal justice system have not been thoroughly investigated.

Methods

Using cross-sectional data on 25,587 adolescents from the Florida Department of Juvenile Justice (FLDJJ) who met the criteria for SUD treatment, the study investigated the factors associated with the completion of SUD treatment. Sociodemographic, mental health, and other variables were examined.

Results

Several factors were associated with an increased likelihood of SUD treatment completion: previous participation in treatment programs, prior drug and alcohol education class attendance, and involvement in court-directed programs. Additional factors included multiple incarcerations, and strong financial and support networks.

Conclusions

The strongest factors associated with a higher likelihood of SUD treatment completion among adolescents in the justice system are ones that can be translated into programs and practices. Repeated referrals to treatment, court-directed programs, and strong support networks may yield higher rates of completion.

Machine learning for suicide risk prediction in children and adolescents with electronic health records

Accurate prediction of suicide risk among children and adolescents within an actionable time frame is an important but challenging task. Very few studies have comprehensively considered the clinical risk factors available to produce quantifiable risk scores for estimation of short- and long-term suicide risk for pediatric population. In this paper, we built machine learning models for predicting suicidal behavior among children and adolescents based on their longitudinal clinical records, and determining short- and long-term risk factors. This retrospective study used deidentified structured electronic health records (EHR) from the Connecticut Children's Medical Center covering the period from 1 October 2011 to 30 September 2016. Clinical records of 41,721 young patients (10-18 years old) were included for analysis. Candidate predictors included demographics, diagnosis, laboratory tests, and medications. Different prediction windows ranging from 0 to 365 days were adopted. For each prediction window, candidate predictors were first screened by univariate statistical tests, and then a predictive model was built via a sequential forward feature selection procedure. We grouped the selected predictors and estimated their contributions to risk prediction at different prediction window lengths. The developed predictive models predicted suicidal behavior across all prediction windows with AUCs varying from 0.81 to 0.86. For all prediction windows, the models detected 53-62% of suicide-positive subjects with 90% specificity. The models performed better with shorter prediction windows and predictor importance varied across prediction windows, illustrating short- and long-term risks. Our findings demonstrated that routinely collected EHRs can be used to create accurate predictive models for suicide risk among children and adolescents.

Identifying risk factors for mortality among patients previously hospitalized for a suicide attempt

Age-adjusted suicide rates in the US have increased over the past two decades across all age groups. The ability to identify risk factors for suicidal behavior is critical to selected and indicated prevention efforts among those at elevated risk of suicide. We used widely available statewide hospitalization data to identify and test the joint predictive power of clinical risk factors associated with death by suicide for patients previously hospitalized for a suicide attempt (N = 19,057). Twenty-eight clinical factors from the prior suicide attempt were found to be significantly associated with the hazard of subsequent suicide mortality. These risk factors and their two-way interactions were used to build a joint predictive model via stepwise regression, in which the predicted individual survival probability was found to be a valid measure of risk for later suicide death. A high-risk group with a four-fold increase in suicide mortality risk was identified based on the out-of-sample predicted survival probabilities. This study demonstrates that the combination of state-level hospital discharge and mortality data can be used to identify suicide attempters who are at high risk of subsequent suicide death.

Contribution of Substance Use in Acute Injuries With Regards to the Intent, Nature and Context of Injury: A CHIRPP Database Study

Introduction

Using the Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) sentinel surveillance system, the objective of this study was to compare intent, circumstances, injury type and patient demographics in patients who used a substance prior to the injury versus those who did not use any substances.

Methods

Data were retrospectively collected from November 1^st 2016 to October 31^st 2017. All patients presenting to the Hôpital de l’Enfant-Jésus ED following trauma were included, aside from those who left without seeing a physician or had no physical injury (e.g., overdose without any trauma was excluded). Patients voluntarily completed a standardised form or agreed to be contacted later. Medical charts of all attendances were reviewed by the CHIRPP’s program coordinator. Substance use included illicit drugs, medications for recreational purposes, alcohol or other used either by the patient or another person involved.

Results

A total of 12,857 patients were included. Substance use was involved in 701 (5.5%) cases and was associated with injuries sustained by males (p < .001). The mean age of patients injured while using substances was 42.8 years, compared to 45.5 years in those who did not use substances (p < .001). Substance use was involved in 3.6% of unintentional injuries, compared to 26.2% of injuries intentionally inflicted by other and 38.9% for self-inflicted injuries (p < 0.0001). When substances were used, the odds of intentional injuries were 7.5 times greater compared to non-intentional injuries (95% CI 6.7, 8.5). Burns, head injuries and polytraumas were more prevalent when drugs or alcohol were involved.

Conclusion

This study outlines the significant contribution of substance use in intentional injuries, suggesting that it could potentially be beneficial to specifically target patients who present with deliberate physical injuries in preventive and therapeutic interventions offered in the ED.

Suicides Among Incarcerated Persons in 18 U.S. States: Findings From the National Violent Death Reporting System, 2003-2014

Using data from the National Violent Death Reporting System (2003-2014), this study examined the characteristics and contributing circumstances of suicides in correctional facilities. χ² and logistic regression analyses revealed that, compared to nonincarcerated suicide decedents, incarcerated suicide decedents had significantly lower odds of positive toxicology for substances but significantly higher odds of substance abuse problems. Descriptive subanalyses indicated that incarcerated suicide decedents often were incarcerated for personal crimes. They often died ≤ 1 week of incarceration, in a cell (frequently single-person or segregation), by hanging, using bedding material. Positive toxicology was more common for incarcerated decedents who died shortly after versus later in their incarceration. Findings highlight the need for enhanced detection and treatment of suicidal behavior, especially during early and vulnerable periods of incarceration.

Drug Use Disorders and Violence: Associations With Individual Drug Categories

We conducted a systematic review that examined the link between individual drug categories and violent outcomes. We searched for primary case-control and cohort investigations that reported risk of violence against others among individuals diagnosed with drug use disorders using validated clinical criteria, following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We identified 18 studies published during 1990–2019, reporting data from 591,411 individuals with drug use disorders. We reported odds ratios of the violence risk in different categories of drug use disorders compared with those without. We found odds ratios ranging from 0.8 to 25.0 for most individual drug categories, with generally higher odds ratios among individuals with polydrug use disorders. In addition, we explored sources of between-study heterogeneity by subgroup and meta-regression analyses. Cohort investigations reported a lower risk of violence than case-control reports (odds ratio =  2.7 (95% confidence interval (CI): 2.1, 3.5) vs. 6.6 (95% CI: 5.1, 8.6)), and associations were stronger when the outcome was any violence rather than intimate partner violence (odds ratio = 5.7 (95% CI: 3.8, 8.6) vs. 1.7 (95% CI: 1.4, 2.1)), which was consistent with results from the meta-regression. Overall, these findings highlight the potential impact of preventing and treating drug use disorders on reducing violence risk and associated morbidities.

Addiction counselors and suicide: Education and experience do not improve suicide knowledge, beliefs, or confidence in treating suicidal clients

Substance use disorders (SUDs) are strongly associated with suicide deaths. However, SUD treatment is associated with lower suicide risk. To this date, we know little about whether SUD counselors are sufficiently knowledgeable about suicide and feel prepared and comfortable with treating and assessing their suicidal clients. This study was designed to characterize SUD counselors' general knowledge and confidence in treating suicidal clients, which was measured by their self-report of general knowledge of suicide prevention and belief in common myths about suicide as well as their self-reported confidence in treating suicidal clients. We hypothesized that confidence would be greater for counselors with more years of education and experience, that degree of education would predict greater knowledge and fewer beliefs in suicide myths, and finally that those counselors with greater knowledge and fewer beliefs in myths would have more confidence when treating suicidal clients. A total of 118 SUD counselors from 15 sites in Western Washington State agreed to participate in the study and completed baseline assessments. They were consented in group setting, usually during a staff meeting, and they were administered surveys on tablet computers. On average, the SUD counselors answered more than half the knowledge questions correctly and disagreed or strongly disagreed with common suicide myths. Their confidence in treating suicidal clients scored across the entire range. Our hypotheses were not supported: Confidence was not greater for those with more education or with more years of experience; degree of education and experience did not predict fewer beliefs in suicide myths; degree of education and experience did not predict greater knowledge; and greater knowledge and fewer beliefs in myths did not predict more confidence. The surprising finding that neither general suicide knowledge nor confidence were associated with the years of their work experience as a SUD counselor nor the level of their education and neither was associated with the other suggests that SUD treatment leadership should not depend on experience, education, general suicide knowledge to assure counselors are confidently able to treat suicidal clients. New or more precise training methods should be considered and evaluated.

Pain Management in Trauma in the Age of the Opioid Crisis

It is imperative to find the balance between pain control and addressing the opioid epidemic. Opioids, although effective in the acute pain management, have multiple side effects and can lead to dependence, abuse, overdose, or death. Physicians should identify patients who abuse opioids, using their states' prescription drug-monitoring programs and use screening tools to identify patients at increased risk of developing opioid dependence. Multimodal analgesic plans, incorporating regional techniques, and nonopioid medications should be employed to reduce the amount of opioids received by patients.

Regional Anesthesia and Analgesia for Acute Trauma Patients

Regional anesthesia for the acute trauma patient is increasing due to the growing appreciation of its benefits, development of newer techniques and equipment, and more robust training. Block procedures are expanding beyond perioperative interventions performed exclusively by anesthesiologists to paramedics on scene, emergency medicine physicians, and nurse-led services using these techniques early in trauma pain management. Special considerations and indications apply to trauma victims compared with the elective patient and must be appreciated to optimize safety and clinical outcomes. This review discusses current literature and future directions in the growing role of regional anesthesia in acute trauma care.

Work intensity in men and work-related emotional demands in women are associated with increased suicidality among persons attending primary care

BACKGROUND

A large proportion of persons died by suicide are employed at the time of death and work-related factors partly contribute to suicide risk. Our aim was to examine the association between multiple aspects of work organization and suicidal ideation in a study conducted in primary care.

METHODS

Data came from a study of 2027 working patients attending a GP representative of patients in the Nord Pas-de-Calais region in France (April-August 2014). Suicidality was assessed using the MINI (Mini International Neuropsychiatric Interview). Six emergent worked-related factors were explored (work intensity, emotional demands, autonomy, social relationships at work, conflict of values, insecurity of work). Several covariates were considered: patient's and GP's characteristics, and area-level data (material and social deprivation, psychiatrist and GPs' density, suicide attempts and suicide rates).

RESULTS

8.0% of participants reported suicidal ideation in the preceding month (7.5% of men and 8.6% of women, p = .03). In multivariate analyses adjusted for covariates, suicidality was significantly associated with work intensity (OR = 1.65; 95%CI [1.18-2.31]) in men and with work-related emotional demands (OR = 1.35; 95%CI [1.01-1.80]) in women. Area-level data were not associated.

LIMITATIONS

Our cross-sectional study cannot assess the direction of the relationships under study.

CONCLUSION

Our results emphasise a central role for GPs in suicide prevention among workers and highlight the importance of work-related factors with regard to suicidality in primary care.

Coping and violence perpetration in a residential substance use disorder treatment sample

Background: Individuals in substance use disorder treatment report high rates of violence against partners and non-partners. There is growing interest in integrated coping-oriented treatment approaches for violence and substance use concerns, yet little is known about the relationship between specific coping responses and perpetration of partner and non-partner violence. Objective: This cross-sectional study evaluated relationships between coping responses and partner and non-partner physical assault perpetration in a substance use disorder treatment sample. Methods: Participants included 343 men (76%) and women (24%) who completed self-report survey measures of coping responses, violence perpetration, and substance use as part of screening for a randomized trial. Negative binomial regression was used to examine relationships between coping strategies and partner and non-partner violence perpetration, when accounting for substance use and demographic factors. Results: About one-third of participants reported partner violence perpetration (30%) and non-partner violence perpetration (34%). Frequency of partner violence and non-partner violence were both associated with more use of avoidant and emotion-focused strategies and less use of problem-focused coping in adjusted models. Discussion: Continued research is warranted to determine whether coping-oriented interventions decrease violence among people in substance use disorder treatment.