Derived psychoactive cannabis products and 4/20 specials: An assessment of popular brands and retail price discounts in Fort Worth, Texas, 2023

BACKGROUND

Retail sales of derived psychoactive cannabis products (DPCPs) have increased in the U.S. since passing the 2018 Farm Bill and is unregulated in most states. This study investigated the types and commonly sold brands of DPCPs as well as promotional pricing on April 20th, a day associated with cannabis use.

METHODS

On April 19-20, 2023, investigators conducted telephone surveys with 98 retail stores that sold DPCPs in Fort Worth, Texas (where the market was largely unregulated).

RESULTS

Delta-8, Delta-9, and Delta-10 THC products were widely available, with 97%, 72%, and 82% of stores selling each type, respectively. Fifteen additional DPCPs were identified, and selling blends containing multiple types of THC was common. Frequently sold brands included Cake, Medusa/Modus, Torch, Urb, Kik, Tyson, 3Chi, Casper, Hidden Hills, Esco Bars, Happi, Hometown Hero, STNR, Bomb Bars, Baked, Hi On Nature, Looper, and Space God. Overall, 45% reported having 4/20 specials discounting prices on DPCPs, smoking devices/accessories, or everything in the store. Several stores also sponsored 4/20 promotional events including free THC gummies and "live delta demos where people can test cartridges and try smoking flower in the store."

CONCLUSIONS

Findings highlight the growing complexity of the DPCP market, including numerous different intoxicating compounds and blends. Policymakers, researchers, and public health professionals should consider these complexities, as well as the commonly sold brands, when developing strategies to regulate DPCPs and protect consumer safety. Pricing policies may be an especially important form of harm reduction during events associated with heavy cannabis use, including 4/20.

Correlation of serum level of squamous cell carcinoma antigen with severity of cutaneous psoriasis, assessed using the simplified psoriasis index

BACKGROUND

Squamous cell carcinoma antigen (SCCA) is a biomarker of disease progression in squamous cell carcinoma but also contributes to the pathogenesis of psoriasis. Eight previous studies have shown a correlation between psoriasis severity, assessed using the Psoriasis Assessment Severity Index or body surface area, and serum level of SCCA, mainly SCCA2, assessed by means of non-commercial tests. We examined the correlation between serum SCCA level, measured with a commercial kit, and psoriasis severity assessed using the Simplified Psoriasis Index (SPI).

METHODS

We conducted a prospective, non-interventional, single-centre study at the University Hospital of Tours over 18 months. The primary endpoint was same-day measurement of serum SCCA level and the psoriasis severity score on the professional version of the SPI (proSPI-s) at both baseline and follow-up. Secondary endpoints were same-day measurement of serum SCCA level and the proSPI psychosocial score (proSPI-p), proSPI treatment score, Dermatology Life Quality Index (DLQI), and inflammation parameters (C-reactive protein level, neutrophil-to-lymphocyte ratio).

RESULTS

We included 50 psoriasis patients. Serum SCCA level was correlated with the proSPI-s at baseline and follow-up (Spearman r = 0.686 and r = 0.674, p < 0.0001) for both. It was correlated with the proSPI-p and DLQI. Serum SCCA level was not correlated with either neutrophil-to-lymphocyte ratio (r = 0.083) or C-reactive protein level (r = 0.192).

CONCLUSION

This study is the first to correlate serum SCCA level with proSPI-s. Moreover, SCCA was measured using a widely available kit. SCCA may be used to assess the severity of psoriasis.

Delta-8 THC Retail Availability, Price, and Minimum Purchase Age

Background: Retail sales of Delta-8 tetrahydrocannabinol (THC) products have increased in the U.S. market since the passing of the 2018 Farm Bill, and there is currently little regulation of marketing/sales and limited related safety standards in many states. After thousands of calls to poison control centers (40% for individuals under 18 years old and 70% requiring health care facility evaluation), the Food and Drug Administration issued warnings on Delta-8 THC products, stating their psychoactive effects and that some manufacturers may synthesize Delta-8 using unsafe household chemicals. The current study describes the Delta-8 THC retail sales environment in Fort Worth, Texas. Given its relatively inexpensive manufacturing and that low prices are a major determinant of cannabis use, the price of Delta-8 THC products was examined. This study also examined whether retail outlets in areas with greater socioeconomic deprivation had higher odds of selling Delta-8 THC products. This is important because if Delta-8 THC retailers are disproportionately located in more socioeconomically deprived communities, residents of these communities can more easily access these products and may have higher risk of adverse consequences. Methods: Potential Delta-8 THC retailers were selected by identifying lists of current retail locations with alcohol, cannabidiol, and/or tobacco licenses in Fort Worth. Trained research assistants called outlets in September and October 2021 to query about sales of products containing Delta-8 THC. The response rate was 69% (n=1,223). Outlets' 9-digit zip codes were merged with Area Deprivation Index scores. Products and purported minimum age were described. Chi-squared and Student's t-tests were used. Results: Eleven percent of outlets (n=133) reported selling Delta-8 THC. Ninety-six percent sold vapes and/or "flower" (i.e., hemp leaves coated with Delta-8 THC distillate) and 76% sold edibles. Among the least expensive products available, edibles cost, on average, $8.58 less than flower/vapes (p<0.001). Outlets that sold Delta-8 THC were located in areas with greater deprivation (p=0.02). Most reported a minimum purchase age of 21; however, 4% reported 18 years or no minimum age. Conclusions: Delta-8 THC retail outlets were disproportionately located in areas with more socioeconomic deprivation. Legal intervention such as zoning, minimum age, and tax laws may help reduce Delta-8 THC-related disparities.

The U.S. hemp-derived cannabinoid industry and the potential of self-regulation: Using social media to assess an evolving health risk

BACKGROUND

Facing statewide bans and increasing oversight in the U.S., representatives from the hemp-derived cannabinoid industry, product advocates, and consumers have been discussing self-policing and self-regulation. Prominent examples of these discussions are found online in Reddit groups.

METHODS

We conducted a qualitative thematic analysis of Reddit posts between September 2020 to August 2022, focusing on the conversations surrounding regulation and consumer safety. Approximately 3800 posts were collected and subject to initial analysis. Thematic analysis was guided by literature on self-regulation and consumer health, from the anthropology of pharmaceuticals and the commercial determinants of health.

RESULTS

The hemp-derived cannabinoid community is discussing self-regulation, shared standards, and transparency. Self-regulation is desired by many, in hopes to stave off prohibition or restrictive government regulation and simultaneously protect consumer health. However, there is little agreement as to what these standards should be, who should oversee them, or how basic concepts should be defined. Subreddit moderators note the ease at which unlicensed or untested products can enter retail store shelves or the informal market, thereby putting health at risk. Given the lack of collective agreement, the absence of state and federal oversight, and the possibilities for consumer deception, consumer frustration and confusion are rampant. With limited access to trustworthy and verifiable information about product safety, purchasers ultimately resort to experimenting on their own bodies to assess risks and benefits.

CONCLUSIONS

Reddit posts reflect the multiple existing tensions in the evolving industry between a genuine appeal among some for workable and consistent industry standards that could protect consumer health, a distrust of regulatory scrutiny from state or federal government, and a desire by others to maintain current profits within the existing unrestrictive free market. Our findings emphasize the urgency of developing coherent, collective, agreed upon policies structured by objective, transparent, scientifically informed regulation in order to develop a safe supply of cannabinoid products and protect consumer health.

Delta-8, Delta-10, HHC, THC-O, THCP, and THCV: What Should We Call These Products?

The 2018 U.S. Federal Agriculture Improvement Act ("Farm Bill") resulted in what some have called a "legal loophole" in cannabis regulation. As different types of cannabis products proliferate, so has the terminology used to attempt to categorize them. This article presents a variety of potential descriptors to encourage dialogue about the language used to classify the multitude of psychoactive cannabinoid products that have grown in popularity since the passage of the 2018 Farm Bill. Our recommended term for these products is derived psychoactive cannabis products. The term derived helps distinguish these products from naturally grown cannabis products. Psychoactive makes clear that these products can produce psychoactive effects. Finally, cannabis products balances accuracy and understandability regarding the substance while discouraging perpetuation of the word marijuana because of its racist inception. The resulting term, derived psychoactive cannabis products, is broad enough to encapsulate all related products while being specific enough to exclude other substances. Adopting accurate and consistent terminology will reduce confusion and help establish a more cohesive scientific literature base.

How Are Retailers Describing Delta-8 THC?A Mixed-Methods Study in Fort Worth, Texas

OBJECTIVE

Delta-8 tetrahydrocannabinol (THC) is a largely unregulated psychoactive substance rising in popularity in the United States. This study aimed to understand how retailers explained Delta-8 THC to potential customers and if these descriptions were associated with socioeconomic deprivation surrounding the retail location.

METHOD

In Fort Worth, Texas, stores with retail alcohol, cannabidiol (CBD), or tobacco licenses were called. Among the 133 stores that sold Delta-8 THC, 125 retailers (94%) answered the question "What is Delta-8?" Qualitative methods were used to identify related themes; logistic regression models tested associations between themes and area deprivation index (ADI) scores, a measure of socioeconomic deprivation (1-10; 10 = most deprived areas).

RESULTS

Retailers often compared Delta-8 THC to other substances (49%). Although most often described as a type of cannabis (34%), several retailers likened Delta-8 to CBD (19%) or hemp (7%), which are nonpsychoactive. Retailers also described potential effects from use (35%). Some retailers reported that they were unsure of what Delta-8 was (21%), told surveyors to look it up themselves (6%), or withheld information (9%). Higher ADI scores were associated with higher odds of retailers communicating limited information (odds ratio = 1.21, 95% CI [1.04, 1.40], p = .011).

CONCLUSIONS

Study findings may inform the development of marketing regulations, as well as informational campaigns for both retailers and consumers.

COVID-19 has heightened tensions between and exposed threats to core values of emergency medicine

Background

Professional culture is a powerful influence in emergency departments, but incompletely understood. Disasters magnify cultural realities, and as such the COVID-19 pandemic offered a unique opportunity to better understand emergency medicine (EM) values, practices, and beliefs.

Methods

We conducted a collaborative ethnography at a tertiary care center during the acute phase of the response to the threat of COVID-19 (March–May 2020). Collaborative ethnography is a method that partners directly with communities during design, data gathering, and analysis to study culture. An ED-based research team gathered data including field notes from 300 h of participant observation and informal interviews, 42 semi-structured interviews, and 57 departmental documents. Data were deductively coded using a previously generated framework for understanding EM culture.

Results

Each of seven core values from the original framework were identified in the dataset and further contextualized understanding of EM culture. COVID-19 exacerbated pre-existing tensions and threats to the core values of EM. For example, the desire to provide patient-centered care was impeded by strict visitor restrictions; the ability to treat life-threatening illness was impaired by new resuscitation room layouts and infection control procedures; and subtle changes in protocols had downstream impact on flow and the ability to balance needs and resources at a system level. The cultural values related to teams were protective and strengthened during this time. The pandemic exposed problems with the status quo, underscored inherent tensions between ED values, and highlighted threats to self-identity.

Conclusion

COVID-19 has highlighted and compounded existing tensions and threats to the core values of EM, underscoring a critical mismatch between values and practice. Realignment of the realities of ED work with staff values is urgently needed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43678-022-00383-0.

Doing our work better, together: a relationship-based approach to defining the quality improvement agenda in trauma care

Background

Trauma care represents a complex patient journey, requiring multidisciplinary coordinated care. Team members are human, and as such, how they feel about their colleagues and their work affects performance. The challenge for health service leaders is enabling culture that supports high levels of collaboration, co-operation and coordination across diverse groups. We aimed to define and improve relational aspects of trauma care at Gold Coast University Hospital.

Methods

We conducted a mixed-methods collaborative ethnography using the relational coordination survey—an established tool to analyse the relational dimensions of multidisciplinary teamwork—participant observation, interviews and narrative surveys. Findings were presented to clinicians in working groups for further interpretation and to facilitate co-creation of targeted interventions designed to improve team relationships and performance.

Findings

We engaged a complex multidisciplinary network of ~500 care providers dispersed across seven core interdependent clinical disciplines. Initial findings highlighted the importance of relationships in trauma care and opportunities to improve. Narrative survey and ethnographic findings further highlighted the centrality of a translational simulation programme in contributing positively to team culture and relational ties. A range of 16 interventions—focusing on structural, process and relational dimensions—were co-created with participants and are now being implemented and evaluated by various trauma care providers.

Conclusions

Through engagement of clinicians spanning organisational boundaries, relational aspects of care can be measured and directly targeted in a collaborative quality improvement process. We encourage healthcare leaders to consider relationship-based quality improvement strategies, including translational simulation and relational coordination processes, in their efforts to improve care for patients with complex, interdependent journeys.

Tolerancing and characterization of curved image sensor systems

Curved image sensors, not having to correct the field curvature, are considered a relevant solution for improving the vast majority of optical systems. They offer the possibility of designing compact aberration-free optical systems. In this work, we explain the advantage of the curved sensor system using the aberration theory. A complete procedure was developed to produce functional curved sensors and functional prototypes were carried out. This paper focuses on the tolerancing process of curved sensors and its inclusion in optical design. A compact objective prototype designed and produced demonstrates the advantage of curvature and the impact of tolerancing.

Selective RET kinase inhibition for patients with RET-altered cancers

Background

Alterations involving the RET kinase are implicated in the pathogenesis of lung, thyroid and other cancers. However, the clinical activity of multikinase inhibitors (MKIs) with anti-RET activity in RET-altered patients appears limited, calling into question the therapeutic potential of targeting RET. LOXO-292 is a selective RET inhibitor designed to inhibit diverse RET fusions, activating mutations and acquired resistance mutations.

Patients and methods

Potent anti-RET activity, high selectivity, and central nervous system coverage were confirmed preclinically using a variety of in vitro and in vivo RET-dependent tumor models. Due to clinical urgency, two patients with RET-altered, MKI-resistant cancers were treated with LOXO-292, utilizing rapid dose-titration guided by real-time pharmacokinetic assessments to achieve meaningful clinical exposures safely and rapidly.

Results

LOXO-292 demonstrated potent and selective anti-RET activity preclinically against human cancer cell lines harboring endogenous RET gene alterations; cells engineered to express a KIF5B-RET fusion protein -/+ the RET V804M gatekeeper resistance mutation or the common RET activating mutation M918T; and RET-altered human cancer cell line and patient-derived xenografts, including a patient-derived RET fusion-positive xenograft injected orthotopically into the brain. A patient with RET M918T-mutant medullary thyroid cancer metastatic to the liver and an acquired RET V804M gatekeeper resistance mutation, previously treated with six MKI regimens, experienced rapid reductions in tumor calcitonin, CEA and cell-free DNA, resolution of painful hepatomegaly and tumor-related diarrhea and a confirmed tumor response. A second patient with KIF5B-RET fusion-positive lung cancer, acquired resistance to alectinib and symptomatic brain metastases experienced a dramatic response in the brain, and her symptoms resolved.

Conclusions

These results provide proof-of-concept of the clinical actionability of RET alterations, and identify selective RET inhibition by LOXO-292 as a promising treatment in heavily pretreated, multikinase inhibitor-experienced patients with diverse RET-altered tumors.

On three-dimensional Gerstner-like equatorial water waves

This paper reviews some recent mathematical research activity in the field of nonlinear geophysical water waves. In particular, we survey a number of exact Gerstner-like solutions which have been derived to model various geophysical oceanic waves, and wave-current interactions, in the equatorial region. These solutions are nonlinear, three-dimensional and explicit in terms of Lagrangian variables.This article is part of the theme issue 'Nonlinear water waves'.

Prediction of the free-surface elevation for rotational water waves using the recovery of pressure at the bed

This paper considers the pressure-streamfunction relationship for a train of regular water waves propagating on a steady current, which may possess an arbitrary distribution of vorticity, in two dimensions. The application of such work is to both near shore and offshore environments, and in particular, for linear waves we provide a description of the role which the pressure function on the seabed plays in determining the free-surface profile elevation. Our approach is shown to provide a good approximation for a range of current conditions.This article is part of the theme issue 'Nonlinear water waves'.

Correlates and Racial/Ethnic Differences in Bareback Sex Among Men Who Have Sex with Men with Unknown or Negative HIV Serostatus

Men who have sex with men (MSM), particularly racial/ethnic minority MSM, are disproportionately affected by HIV in the United States and Texas. Bareback sex or condomless anal intercourse (CAI) can be a high HIV risk behavior. Despite this, a majority of MSM continues to engage in barebacking. Research suggests racial/ethnic differences in barebacking exist; however, these conclusions remain unclear due to insufficient sample sizes to compare racial/ethnic groups. Our cross-sectional correlational design explores barebacking correlates (substance use during sex, safe sex fatigue, and optimistic HIV treatment beliefs) within and between racial/ethnic groups among 366 MSM. Regression models are significant for Latino and African-American MSM alone and for all MSM combined, though not significant for European-American and Other Race/Ethnicity MSM alone. Our findings suggest motivations and behaviors underlying barebacking among MSM vary by racial/ethnic membership with clinical implications for informing culturally sensitive HIV interventions and prevention programs for target racial/ethnic groups.

Stability of a flow down an incline with respect to two-dimensional and three-dimensional disturbances for Newtonian and non-Newtonian fluids

Squire's theorem, which states that the two-dimensional instabilities are more dangerous than the three-dimensional instabilities, is revisited here for a flow down an incline, making use of numerical stability analysis and Squire relationships when available. For flows down inclined planes, one of these Squire relationships involves the slopes of the inclines. This means that the Reynolds number associated with a two-dimensional wave can be shown to be smaller than that for an oblique wave, but this oblique wave being obtained for a larger slope. Physically speaking, this prevents the possibility to directly compare the thresholds at a given slope. The goal of the paper is then to reach a conclusion about the predominance or not of two-dimensional instabilities at a given slope, which is of practical interest for industrial or environmental applications. For a Newtonian fluid, it is shown that, for a given slope, oblique wave instabilities are never the dominant instabilities. Both the Squire relationships and the particular variations of the two-dimensional wave critical curve with regard to the inclination angle are involved in the proof of this result. For a generalized Newtonian fluid, a similar result can only be obtained for a reduced stability problem where some term connected to the perturbation of viscosity is neglected. For the general stability problem, however, no Squire relationships can be derived and the numerical stability results show that the thresholds for oblique waves can be smaller than the thresholds for two-dimensional waves at a given slope, particularly for large obliquity angles and strong shear-thinning behaviors. The conclusion is then completely different in that case: the dominant instability for a generalized Newtonian fluid flowing down an inclined plane with a given slope can be three dimensional.

Staff attitudes towards people with intellectual disabilities in Japan and the United States

BACKGROUND

Staff attitudes may affect choices available to persons with intellectual disabilities (ID). This study examined attitudes towards people with ID among staff working with people with ID in Japan and the United States.

METHOD

Attitudes of staff working with people with ID in Japan and the United States were compared using the Community Living Attitudes Scale, Intellectual Disabilities Form. Responses were examined via multivariate analysis of variance.

RESULTS

In unadjusted analyses, Japanese staff exhibited a greater tendency towards Sheltering and Exclusion of people with ID and lower endorsement of Empowerment and Similarity of people with ID. After controlling for covariates, the country effect was no longer significant for Sheltering and Exclusion. Age and education were significantly associated with attitudes in the adjusted model.

CONCLUSIONS

While attitudes in Japan appeared less supportive of community inclusion of people with ID, some of the differences between countries were attributable to other staff characteristics such as age and education. Findings provide new information about how attitudes of staff in each country compare with each other.

Near-field acoustic streaming jet

A numerical and experimental investigation of the acoustic streaming flow in the near field of a circular plane ultrasonic transducer in water is performed. The experimental domain is a parallelepipedic cavity delimited by absorbing walls to avoid acoustic reflection, with a top free surface. The flow velocities are measured by particle image velocimetry, leading to well-resolved velocity profiles. The theoretical model is based on a linear acoustic propagation model, which correctly reproduces the acoustic field mapped experimentally using a hydrophone, and an acoustic force term introduced in the Navier-Stokes equations under the plane-wave assumption. Despite the complexity of the acoustic field in the near field, in particular in the vicinity of the acoustic source, a good agreement between the experimental measurements and the numerical results for the velocity field is obtained, validating our numerical approach and justifying the planar wave assumption in conditions where it is a priori far from obvious. The flow structure is found to be correlated with the acoustic field shape. Indeed, the longitudinal profiles of the velocity present a wavering linked to the variations in acoustic intensity along the beam axis and transverse profiles exhibit a complex shape strongly influenced by the transverse variations of the acoustic intensity in the beam. Finally, the velocity in the jet is found to increase as the square root of the acoustic force times the distance from the origin of the jet over a major part of the cavity, after a strong short initial increase, where the velocity scales with the square of the distance from the upstream wall.

Wireless sensor networks to study, monitor and manage cattle in grazing systems

Monitoring and management of grazing livestock production systems can be enhanced with remote monitoring technologies collecting information with high temporal and spatial detail. However, the potential benefits of such technologies have yet to be realised and challenges still exist with hardware, and data analysis and interpretation. The objective of this paper was to propose analytical methods and demonstrate the value of remotely collected liveweight (LW) and behaviour of beef cattle grazing tropical pastures. Three remote weighing systems were set up at the water troughs to capture LW of three groups of 20 animals for 341 days. LW data reflected short-term effects following the first rain event (>50 mm) at the end of the dry season, which resulted in LW losses of 22 ± 8.8 kg of LW at a rate of –1.54 ± 0.46 kg/day (n = 60). This period was followed by a peak daily LW change (LWC) of +2 kg/day. The remote weighing system also captured longer environmental effects related to seasonal changes in forage quality and quantity with highest LWC during the wet season and weight loss during the dry season. Effects of management on LW and LWC were observed as a result of moving animals to paddocks with more edible forage during the dry season when the negative trend in LWC was reversed after rotating animals. Behavioural monitoring indicated that resting and ruminating took place at camping sites, and foraging resulted in grazing hotspots. Remotely collected LW data captured both short- and long-term temporal changes associated with environmental and management factors, whereas remote monitoring collars captured the spatial distribution of behaviours in the landscape. Wireless sensor networks have the ability to provide data with sufficient detail in real-time making it possible for increased understanding of animal biology and early management interventions that should result in increased production, animal welfare and environmental stewardship.

Three-dimensional continuation study of convection in a tilted rectangular enclosure

A continuation method developed from a three-dimensional spectral finite element code is used to study natural convection in a tilted rectangular cavity. The cavity has its length equal to two times the side of its square cross section and it contains a fluid with a Prandtl number Pr = 1. A detailed bifurcation diagram is first obtained in the case without inclination in order to get the sequence of the different branches of solutions and determine the stable solutions. The focus is then put on the stable solutions in the inclined cavity, when the tilt occurs around its longest axis. The subtle changes induced by the tilt on the convective system are clarified. Three different stable solutions are obtained: the longitudinal roll L- solution (with the same sense of rotation as the inclination angle), which develops smoothly from zero Rayleigh number on the leading branch; the longitudinal roll L+ solution (with a sense of rotation opposite to the inclination angle), which is on a disconnected branch and is stabilized beyond a secondary bifurcation point; the oblique roll O ± solutions (corresponding to transverse roll solutions perturbed by the longitudinal flow induced by the tilt), which quickly appear beyond saddle-node points on new disconnected branches. The domain of existence of these stable solutions is eventually obtained and described in the Rayleigh number-inclination parameter space. Finally, the Nusselt number is determined as a function of the inclination at a constant Rayleigh number for the different stable solutions. The Nusselt number is maximum at an inclination of 49.55° for the leading longitudinal roll L- solution.

Stability of two-layer shear-thinning film flows

The stability of a two-layer film flow of non-Newtonian fluids is studied with a linear temporal approach. Shear-thinning fluids are considered, which follow the four-parameter inelastic Carreau model. A modified Orr-Sommerfeld equation system is obtained, which is solved by using a spectral Tau collocation method based on Chebyshev polynomials. The effects of density and viscosity stratification are considered, as well as the influence of the shear-thinning properties of the fluid. It is found that, when the viscosity is stronger in the upper layer, the base flow and the stability properties are almost not influenced by the change of the shear-thinning properties in this upper layer. In the other situations, the shear-thinning properties have an influence on the different instabilities, the long-wave surface instability and the short- and long-wave interface instabilities.

Understanding patient responses to insomnia

To better gain insight into patient responses to insomnia, we take a medical anthropologically informed approach to patient beliefs and behaviors, particularly those related to self-diagnosis, management, help-seeking, and self-treatment of insomnia. We conducted 24 in-depth qualitative interviews in which participants were asked their beliefs about the origin of their insomnia, its anticipated course, their evaluation of symptoms, their responses, and their expectations surrounding treatment. Important and novel data were generated about patient beliefs and behaviors related to problem sleeping. Patients identified barriers to treatment, particularly those contextualized within a general social stigma and personal isolation, in which their problems sleeping were not taken seriously. The interview format was particularly conducive to making patients comfortable discussing the personal changes they made to their medically prescribed treatment plans, or supplanting their medical therapy with some kind of complimentary and alternative medicine (CAM) therapy. These are important issues in the long term management of chronic insomnia. We underscore concern about the need to evaluate the efficacy of therapies that so many people with insomnia are driven to try.