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They report challenges obtaining timely access to sick visits with primary care doctors and urgent visits with specialists and dentists. Additional barriers that make obtaining unscheduled care challenging include identifying clinics that offer comprehensive interpretation services, accept Refugee Medical Assistance, and are geographically convenient. Scheduling appointments over the phone, specifically automated services, is particularly challenging for refugees with limited English proficiency. On arrival to the ED, the same language barriers create challenges to understanding care received. In addition, the lack of trauma informed care can hinder the appropriate workup and treatment of symptoms. Finally, after obtaining care in any acute care setting, refugees face significant financial risk due to limited understanding of the health insurance system. It is important to highlight that some of the aforementioned barriers to acute outpatient care reported exist among U.S.-born individuals, including geographical and insurance barriers, and difficulty accessing mental and dental services. However, these challenges are exacerbated for refugees due to language and cultural barriers. The U.S. healthcare system is new and often quite different from health systems refugees have used in the past, adding an extra layer of complexity to understand. The lack of interpretation services limits already limited resources such as appointments with specialists, dentists, and mental health providers. Additionally, refugees have unique mental healthcare needs given their history of trauma that adds an additional challenge when identifying appropriate mental health services. There is limited existing data on the utilization of acute care services by refugees in the U. S.

In Australia a study evaluating the use of emergency services by refugees suggested that some refugees know how to call for emergency help,weed drying room yet have significant fear of calling for help because of security implications faced previously in their home countries.10 In our study, refugees identified knowing how to call 911 if they were ill but did not express fear as a barrier to using this service. It is possible that the study population perceived less fear because the resettlement employees recommended the use of 911. A qualitative study in the U.S. evaluating healthcare barriers of refugees one year post resettlement also identified individual and structural barriers to accessing health services. Barriers included challenges with language, acculturation processes, and cultural beliefs.Similarly, our study found that language and acculturation were significant barriers when accessing health services. Our study differed in that we were specifically focusing on barriers to acute care access and that we identified additional barriers related to health insurance and perceived poor access to prompt outpatient clinic options. Additionally, our results identified the important role of resettlement agencies in addressing these barriers. Notably, our study occurred early in the resettlement process, a time when resettlement agencies are typically more involved, as opposed to one year after resettlement. Respondents identified several areas for improvement to reduce barriers to accessing care for newly arrived refugees . Areas for improvement within the acute care system include establishing partnerships with resettlement/post resettlement agencies to assist with triage of refugees with acute conditions, and developing specific protocols that may help resettlement employees direct patients to appropriate levels of care. Finally, respondents recommended incorporating cultural competency and trauma-informed care training for providers. Trauma-informed care is based on the premise that past exposure to trauma can have long-lasting effects on the physical and mental health of patients. Thus, providers and organizations can respond by adopting trauma-informed models of care.

A trauma-informed organization acknowledges that trauma is pervasive, recognizes the signs and symptoms of trauma, and integrates knowledge about trauma into policies, procedures and practices with the goal of avoiding retraumatization.While it is challenging to accurately estimate the number of refugees who have experienced trauma prior to resettlement, estimates suggest that the prevalence rate may be as high as 35%.This does not account for trauma associated with the resettlement process. ED specific approaches of trauma-informed care have been suggested for violently injured patients who have been injured due to violence and are treated in the ED; and some components may be applicable to refugee populations.While more research is needed to establish trauma-informed models of care for refugees in the ED, providers should acknowledge a patient’s history of trauma, ongoing signs and symptoms, and avoid practices that may result in retraumatization. A major theme in our interviews was the importance of interpretation services. Refugees and resettlement employees describe challenges at all points of acute care access due to language barriers and a lack of appropriate interpretation services. Revisions to the Affordable Care Act in 2016 mandated that healthcare facilities must offer qualified interpreters to limited English proficient patients and the 2010 Joint Commission standards also require qualified interpreter services in hospital settings.However, patients with LEP have worse clinical outcomes and receive a lower quality of care.18 In the ED formal interpretation should be offered to all patients who do not identify English as their primary language, and operation teams should ensure interpretation services are embedded throughout a refugee’s ED course, and that all members of the ED team are routinely trained on how to use in-person and phone interpreters. Similarly, clinic teams can ensure that interpretation services are available during clinic visits, but also when refugees call to schedule appointments or ask questions. Another common barrier reported by resettlement employees and refugees is that refugees struggle to understand health insurance, which is also supported in prior studies.More education for refugees was suggested as a potential intervention to address this concern, and may be useful.

However, additional policy changes may be required to avoid insurance-related barriers to accessing care. For example, refugees who live in states without Medicaid expansion have a much smaller chance of enrolling in health insurance once Refugee Medical Assistance ceases.Additionally, it has been reported that in states where Medicaid requires reapplication annually, refugees often have a gap in insurance coverage.A study evaluating health coverage for immigrants suggests that expanding universal coverage may actually reduce net costs for LEP patients by increasing access to primary prevention and reducing emergency care for preventable conditions.For refugees, the cessation of Refugee Medical Assistance after eight months occurs at a difficult time of transition. At six to eight months, cash assistance from the government typically ends as does support from the resettlement agency based on the expectation that refugees are self-sufficient after six to eight months of support.A study evaluating unmet needs of refugees demonstrated that refugees in the U.S. for a longer period of time are more likely to report a lack of health insurance coverage and a delay in seeing a healthcare provider.Policymakers should consider extending Refugee Medical Assistance beyond the first eight months as an additional strategy to improve access to health insurance and ensure stable access to care. Finally, additional research is needed to understand networks of care for refugees. In order to understand ED utilization by refugees and barriers to acute care,drying rack for weed future studies should focus on prospectively following refugees after arrival to identify patterns of use and integration long term. This would then help guide types of interventions at locations where refugees most frequently seek acute care. Systematic identification of refugees in national datasets would assist with understanding variations in patterns of utilization between different regions and identifying areas of particular importance. We obtained the data from this study from one city. This limits the generalizability as results may be specific to the refugee experience in this location and healthcare system. However, our sample engaged refugees from a variety of countries, representing the current distribution of refugees resettled to locations throughout the country. This study did not specifically evaluate differences in access to acute care barriers for refugees based on country of origin, gender, educational, cultural, or economic background; however, all of these factors may influence experiences and are important to consider in future studies. Interviews with refugees occurred at a refugee clinic affiliated with a local resettlement agency and did not include refugees without acces to care and services.

Similarly, resettlement agency employees were recruited by the study team, largely consisting of physicians. Interviews with refugees were conducted mostly within three months of their arrival, thus only targeting newly arrived refugees. Barriers to access may differ at different stages of the resettlement process. However, this early period is likely to be the most vulnerable time with significant language, acculturation, and financial challenges. In addition, refugees typically see a physician within 30 days of arrival in the U.S. Many resettlement agencies work with specific clinics to meet this goal, making this the optimal time to capture a diverse population receiving care at one location. Some members of the study team had significant experience working at the refugee clinic and may have been influenced by potential biases from previous work with refugees, specifically when identifying themes. To counter these potential biases, members of the study team included individuals who did not work at the refugee clinic. Transcripts were double coded by both a clinic and non-clinic investigator and reviewed by a non-clinic investigator. Additionally, the use of interpreters may have altered responses from refugee patients. In some languages, a direct translation for specific words or meanings may not exist and as a result may be translated in a meaning that is different than what was intended. Finally, as with all qualitative studies, results generate hypotheses from the experience of the participants rather than testing or measuring a hypothesis. The Joint Commission, other medical governing agencies, and various hospital policies mandate that certain screening questions be asked of all patients who come through the emergency department for evaluation. Before a patient has even seen a physician, they have likely been asked dozens of screening questions as part of the triage or nursing assessment. Screening questions are often implemented with good intentions and some questions serve as public health screening where the ED acts as a safety net.The downstream consequences of adding on numerous questions to the ED stay are often not considered. There is the potential for a significant amount of nursing time to be used administering assessments. Additionally, the purpose of triage is to identify and prioritize patients who require immediate treatment over those who do not. The required screening questions often have an unclear benefit on determining triage acuity and on the care that the patient receives in the ED. In many instances the addition of screening questions is based on rudimentary studies that do not examine clinical outcomes or costs.4 Screening questions can add time to the triage process and ED wait time, and take nurses away from performing more direct patient care. While any individual question may not take long to ask, when you multiply it by the tens of thousands of patients who pass through the ED and the expanding number of screening questions, it quickly adds up to a significant amount of time. Our objective was to analyze the time nursing spent conducting standardized nursing screens and calculate the corresponding time cost.This is a cursory look at the potential monetary and time costs of standardized screening questions in the ED. The calculated values directly affect time and cost efficiency in the ED process and could potentially be redirected to more direct patient care. For just the five observed triage questions alone, we estimated the nursing time cost to our institution to be $20,675.50. This time cost would be significantly increased if we examined additional triage and nurse screening questions. Furthermore, this is just the time spent in a single ED. If all 136.9 million adult ED visits in the U.S. included the five studied questions the screening would take 964,354 hours to complete.5 This equates to $33.8 million in nursing costs annually. The required screening questions are often unrelated to the patient’s chief complaint and have a debatable impact on the medical management in the ED. Questions that may impact care, such as medication allergies, are typically asked by multiple medical providers during the ED visit, and redundancy leads to additional wasted time and cost. It is unclear whether the standardized questions are suitable for triage where the goal is to identify and prioritize patients who require immediate treatment over those who do not.

Moreover, many of those who participated in this survey reported being on treatment including methadone, and given high rates of relapse of substance use among those in treatment this suggests many in our survey were at high risk of substance use. When critical services that helped PWUD survive overdose and keep their use under control such as group therapy and MOUD became only virtual during the pandemic, the use of such services declined . Virtual access to care may be particularly challenging for individuals who are unemployed and older as fewer may own and have access to the technology needed for this than younger and employed people. What should also be noted is that fewest of those reporting intermittent use of substances were tested for COVID-19, with more of the daily users getting tested. This may be because reduced social interaction during the pandemic may have lessened situations in which some people use drugs particularly affecting those who used at bars or parties and thereby had less exposure to COVID-19. Some substances are often use for social enhancement particularly by YMSM, and the less social opportunities the less they may have felt like or had opportunities to use drugs reflected in their COVID testing rates. The reduction in social use of substances may also reflect the high rates of overdose that were noted during the pandemic as more people may have used drugs alone without someone to help them or call for help if they did overdose . Higher testing by those reporting daily use may be because these individuals may access services such as needle exchange or MOUD and may have been offered testing through these services.5Stimulant use disorders remain a significant public health concern . For example, cocaine was noted more often than any other illicit drug among emergency department visits in the United States . Currently,vertical cannabis there are no medications that have regulatory approval for cocaine addiction leading to an urgent need for novel therapeutic approaches.

Cocaine is a molecule that, by itself, is too small to elicit an antibody response. However, conjugation to larger, immunogenic protein carriers can enable production of antibodies specific to small molecules. The B subunit of cholera toxin is a highly immunogenic protein known to elicit a potent antibody response. TA-CD vaccine is designed to induce formation of anti-cocaine antibodies. This cocaine vaccine covalently links succinylnorcocaine to cholera toxin B , which has a worldwide safety record for cholera immunization . The anti-drug antibodies elicited by TA-CD bind to cocaine entering the bloodstream, forming antigen-antibody complexes too large to cross the blood-brain barrier. In sufficient quantity and appropriate affinity, such antibodies can therefore prevent high concentrations of cocaine from reaching the mid-brain. The absence of reward stimulus in the brain should reduce the reinforcing psychoactive effects of cocaine. By blocking the pleasurable response to cocaine, it is expected that cocaine usage could be reduced in subjects undergoing treatment for cocaine dependence. The concentration of anti-cocaine antibody in the blood must be sufficient to bind a significant amount of the drug in order to be effective. The peak plasma amount of cocaine that users need to experience pleasure in human laboratory studies is approximately 0.5 μM. , and to bind 90% of this amount of cocaine requires approximately 42 ug/ml of moderately high affinity antibody . We therefore compared reductions in cocaine use for the placebo group to two groups of vaccinated subjects: those with peak IgG antibody levels above versus below 42 ug/ml IgG. We also know from previous work that the window of optimal IgG levels would be after week 8 and that after week 16 these IgG levels would fall. . Thus, we hypothesized that subjects with high IgG levels above 42 ug/ml should have more cocaine-free urines, more sustained abstinence and greater treatment retention than the subjects getting placebo or having low IgG responses to the vaccine.

The primary analysis compared the TA-CD group to placebo. With a two-sided t-test of the difference in the weekly fraction of cocaine-free urines between TA-CD and placebo with a common standard deviation of 0.40, the sample size needed with an 80% power is 113 for TA-CD and 113 for placebo, at a two-sided alpha of 0.05. Thus, the total sample size needed for the study would be 226 subjects in the efficacy evaluable sample. However, assuming approximately 20% of randomized subjects will drop out by the start of the efficacy evaluable period and be excluded from the efficacy evaluable population, a total of 300 subjects were randomized . Although the primary analysis did not use the t-test, it is anticipated that the primary analysis was more powerful than the t-test. The vaccine and placebo subjects were comparable in age, gender and ethnicity, but most were African American preventing ethnic sub-analysis . They had a long history of cocaine use and on average used 13 days in the month prior to treatment . Alcohol use was relatively low with an average of 4 days per month with few subjects reporting use to intoxication. Cannabis use was uncommon. We found no significant differences between the vaccine and placebo groups in an intention to treat analysis using generalized linear mixed modeling. Figure 3 shows the biweekly urine toxicology results for the placebo vs active vaccine groups.In addition to the cut-off of ≥42μg/ml we reanalyzed the data utilizing the 50th, 75th, and 90th percentiles of the whole sample as antibody titre cut-points, and similarly found no differences between the high and low antibody titer groups. Remaining abstinent from cocaine for at least two weeks of treatment occurred more often in the active than placebo vaccine group , but not significantly . Among the vaccinated patients those with the high antibody titer had a greater odds ratio of being cocaine-free for their final 2-weeks in treatment compared to the low antibody titer group , although only 15 patients attained abstinence for their last 2 weeks of treatment. Reanalyzing the data utilizing the 50th, 75th, and 90th percentiles as antibody titre cut-points yielded the same relative odds ratios between the high and low antibody groups.Table 3 shows the number of individuals reporting side-effects from specific body systems.

Also provided are raw p-values and False Discovery Rates evaluating these counts as a function of treatment condition. The only category showing differential reporting as a function of treatment condition is “General disorders and administration site conditions” . Further evaluation of preferred diagnostic terms occurring under “General disorders and administration site conditions” indicated differential reporting for an “Injection Site Reaction” . All these AEs were mild or moderate and none led to dropout from treatment. There were also no differences in side-effects related to peak antibody levels. Treatment-emergent severe AEs among randomized subjects included 29 hospitalizations: 14 in the active vaccine and 15 in the placebo group. Two in the placebo group were considered possibly related to the vaccine, but none in the active vaccine group were considered treatment related. Depression with suicidality was the most common event: 6 in the active vaccine and 5 in the placebo group. Cocaine use accounted for 3 in the vaccine and 2 in the placebo group. Other hospitalizations in the active vaccine group were for a leg ulcer, chronic obstructive lung disease, erectile dysfunction, and alcohol intoxication. Other hospitalizations in the placebo groups were for loss of consciousness, coronary vasospasm, foot pain, leg cellulitis, chest pain and a pelvic bone fracture. In contrast to our previous study with this cocaine vaccine TA-CD , we did not find a significant attenuation of outpatient cocaine use, even when adequate antibody levels were attained. Instead,cannabis drying racks the patients with higher antibody levels had more cocaine positive urines than those with the lower levels of 42 ug/ml or less throughout the first 16 weeks of the study. However, several findings suggested some efficacy for the vaccine. First, treatment dropout was significantly different and almost 3-times lower for the high IgG than for the low IgG or placebo groups . Second, the active vaccine group was more likely than placebo to attain sustained abstinence during the last two weeks of treatment, particularly those with the higher antibody levels . The odds ratio of 3.02 suggests that having more abstinent patients than the 5% obtained in this study or having a greater sample size of 466 would have demonstrated the vaccine efficacy for those attaining the higher antibody levels with a statistical power of 80%. Third, based on the mean antibody levels at weeks 9 and 16 the vaccine showed sufficient immunogenicity with two thirds of the patients attaining peak levels above 42 ug/ml. Thus, the vaccine may have therapeutic value for a portion of cocaine dependent patients, although many will try to override the partial blockade that is possible with this vaccine. Furthermore, it took us 17 months from multiple trial sites to recruit 300 cocaine addicted persons who were nominally motivated to cease using cocaine.

This suggests that even an effective vaccine may not be much more attractive to the cocaine abusing treatment population than are current psychosocial treatments. We are concerned that adequately immunized subjects may have increased their cocaine use to overcome the competitive anti-cocaine antibody blockade. As Haney and colleagues showed, these antibody levels were only sufficient to block modest doses of cocaine. Overall, this vaccine is designed to reduce relapse among cocaine dependent patients who are motivated to stop using cocaine. The high rate of cocaine use and low rate of sustained abstinence shown by these study patients clearly reflected a population that was using cocaine several times per week and rarely attempted abstinence during the clinical trial. In the previous study the high antibody level patients achieved 48% cocaine-free urines during weeks 9 to 16 compared to only 25% in the present study. Having only half the rate of cocaine-free urines in the present Phase III study compared to the previous Phase IIb study in methadone maintained patients may reflect several non-pharmacological differences in design and programmatic structure between the two studies. Some salient differences include first the study setting, which involved a daily methadone program with monitoring 6 days per week vs three times weekly monitoring in the current study. Second, delivery of Cognitive Behavioral Therapy was mandated in the Phase IIb methadone study and optional in this Phase III study. The participation rates in the therapy involved about two-thirds of the sessions in this study. Third, the single study site of opiate addicts who had secondary cocaine use was more homogenous than the primary cocaine users drawn from six sites in different regions of the country. Fourth, financial incentives of $55 per week plus $65 for each of the five vaccinations were approximately three times higher in this Phase III study than the compensation in the previous methadone based study, which may have made more funds available to purchase or trade for cocaine. In view of these differences future studies would benefit from a more structured study setting such as a day-treatment program that helps the patients become motivated for abstinence. This should lead to a more homogeneous population of patients who have been at least 2-weeks cocaine-free prior to starting the TA-CD vaccinations. In this way the study would shift from an abstinence initiation to a relapse-prevention design and potentially greater integration of CBT to facilitate the maintenance of abstinence. Future studies also may benefit from the development of high activity cholinesterase enzymes that will more rapidly metabolize the cocaine to inactive metabolites . Because these enzymes appear to act relatively slowly compared to the rapid entry of cocaine into the brain, the fast kinetics of antibody-drug interactions are ideally suited to being combined with these enhanced enzymes to produce extremely effective blockers of cocaine’s actions on all organ systems including both the brain and heart .The current generation of young people faces the worst labour market prospects in decades . The legacy of the Great Recession, as well as longer term structural changes to the global economy, have disproportionately affected young people . Disengagement from the labour market in young adulthood is particularly concerning because it may lead to long-term negative economic consequences for the individual as well as social problems such as criminal offending .

Findings on white matter micro-structure provide further evidence of different neuromaturational trajectories for boys and girls. In a whole-brain voxel wise DTI study of 106 children and adolescents 5–18 years of age, males had higher FA in bilateral frontal white matter areas, right arcuate fasciculus, and left parietal and occipito-parietal regions, while females showed higher FA in the splenium of the corpus callosum . Females displayed age-related increases in FA in all regions, whereas males did not. Other findings suggest higher FA in the genu in adolescent males compared to females , while fiber tract analysis of 31 children and adolescents documents no sex-related FA differences . It is possible that power differences in voxelwise versus tractography methods and in sample size contribute to discrepant findings. Different mechanisms of white matter growth, specifically, an increase in axonal diameter in males and a growth in myelin content in females, are implicated from magnetization-transfer ratio analysis . Indeed, higher levels of lutenizing hormone is associated with greater white matter content , and increasing testosterone levels may influence axonal diameter in males . Together, these findings suggest a role for sex hormones in developmental trajectories of cortical and white matter maturation.Brain regions with input from the neurotransmitter dopamine that comprise the reward system undergo pronounced developmental changes during adolescence . In particular, the density of dopaminergic connections to the prefrontal cortex increases in this phase of life . Activity of the dopamine degrading enzyme catechol-O-methyltransferase appears to increase in mid-adulthood based on post mortem studies ,hydroponic drain table but does not differ between infants, adolescents, and young adults.

This post-adolescent maturation may facilitate improved dopaminergic transmission to and within the prefrontal cortex. Dopamine synthesis and turnover in portions of the prefrontal cortex that project to sub-cortical regions increase from adolescence to adulthood , and this dopamine balance shift between prefrontal and sub-cortical structures may be due to pruning in the neocortex . In a study from Sweden, binding potential of the dopamine D1 receptor was evaluated in individuals spanning ages 10–30 using positron emission tomography. Binding potential declined non-linearly in all regions, most prominently in cortical regions including the dorsolateral prefrontal cortex during adolescence, with reductions of 26% from adolescence to young adulthood in frontal, anterior cingulate, and occipital cortex over one decade. A slower to flat decline in binding potential was seen for orbitofrontal and posterior cingulate and striatal regions . Expression of the dopamine D2 receptors in the prefrontal cortex peak in infancy then by adolescence reach adult levels . In contrast, prefrontal levels of the dopamine receptor D4 show little change with age . Overall, the development of dopaminergic transmission varies across particular receptor types, with some showing marked changes well into the third decade of life, past the stage typically considered adolescence. The inhibitory GABAergic system also shows development during adolescence. In rats, fibers from the basolateral amygdala continue to form connections with GABAergic interneurons in the prefrontal cortex throughout periadolescence . In non-human primates, GABAergic inputs to pyramidal cells undergo changes during the perinatal period and adolescence in concert with continued maturation of behaviors mediated by the prefrontal cortex . The timing of improved executive functioning and working memory performance appears to correspond with maturing GABAergic inhibitory circuits containing the protein parvalbumin .

In humans, the input to GABAergic interneurons in the prefrontal cortex appears to decrease strongly from adolescence to adulthood . Neurotransmission is influenced by activity in receptors for adrenal and gonadal hormones. Puberty-related hormonal development begins with changes in excitatory and inhibitory inputs to gonadotropin-releasing hormone neurons in the pituitary gland. This activity has clear influences on aggression and sexual behavior, but a less clear role concerning impulsivity and cognition . The neurotransmitter changes occurring during adolescence are in synchrony with the anatomical changes seen in the prefrontal cortex and other brain regions during this stage, as well as maturation of cognition and behavior and the emerging increased risk for psychopathology . Changes in dopamine and reward circuitry arecritical to assigning value and reinforcing behaviors, such as social interaction, food consumption, romantic behaviors, novelty seeking, and alcohol and other drug intake , while ongoing refinement of inhibitory neurotransmission has broad implications for information processing and modulation of impulses.Neuromaturation in the form of brain volume, structure, and neurochemistry changes during adolescence occurs along with numerous behavioral alterations. Among these, the acquisition and demonstration of advanced cognitive skills is particularly notable. Higher-order cognitive functions such as working memory, planning, problem solving, and inhibitory control are developing during adolescence and historically linked to maturation of the frontal lobes . The study of brain structure-function relationships has considerably burgeoned with the use of fiber tractography and fMRI, providing an appreciation for more distributed neural circuitry including frontosub-cortical networks as the seat of complex cognitive and executive skills . The correspondence between white matter development during adolescence and neurocognitive performance has been demonstrated in a number of recent studies. Intellectual functioning in youth is associated with the development of white matter circuitry in bilateral frontal, occipito-parietal, and occipito-temporoparietal regions .

The reading skills of children and adolescents improve with white matter changes in the internal capsule, corona radiata, and temporo-parietal regions , and greater left lateralization of the arcuate fasciculus fibers is associated with improved phonological processing and receptive vocabulary . Better visuospatial construction and psychomotor performance are associated with high corpus callosum FA . Visuospatial working memory capacity is linked to a fronto-intraparietal network , whereas delayed visual memory is linked to temporal and occipital FA . Verbal memory proficiency is related to decreased MD and decreased RD in left uncinate fasciculus and with parietal and cerebellar white matter integrity . As these studies are based on cross-sectional data, we examined whether the extent of white matter maturation during late adolescence would be linked to performance on measures of working memory, executive functioning, and learning and recall. Greater extent of FA increase and RD decrease in the right posterior limb of the internal capsule over time correlated with better complex attention and phonemic fluency in adolescents, and greater increase in MD and AD in the right inferior fronto-occipital fasciculus was associated with improved visuoconstruction ability and learning and recall .The social environment reaches heightened salience in adolescence when self-monitoring, sensitivity to evaluation, and awareness of others’ perspectives become increasingly apparent . Brain structures subserving socio-emotional processing continue to mature in this age group with demonstrable effects in blood-oxygenationlevel-dependent response. Amygdala, orbitofrontal cortex, and anterior cingulate cortex activation to facial affect processing is prominent in adolescence relative to adulthood with shifts toward more dorsolateral prefrontal activation with age . Differences in activation patterns, with girls showing bilateral and boys only right prefrontal response, may underlie sex-related nuances in behavioral response to affect and emotion. Nonetheless, adolescents as a group show elevated activity in bottom-up emotion processing centers ,rolling benches hydroponics suggesting that they are more likely to be influenced by emotional context than adults. As a result, poor decisions are often made in states of emotional reactivity. Although increased frontoamygdala activity during emotional processing habituates with repeated exposure, individuals with higher selfrated trait anxiety show less adaptation over time.Adolescents’ proclivity toward risk-taking behavior and susceptibility to poor decision-making may be related to unique neural characteristics that increase their sensitivity to rewarding outcomes. Two primary theories of reward processing in adolescence have received support, each purporting different functional trends in the striatum. One posits that hypoactivation of the striatal system leads adolescents to engage in reward seeking as a compensatory response. The other suggests that the striatum behaves in a contrasting manner; that its hyperactivity leads to greater reward-seeking behavior. Recent fMRI evidence lends support to the latter hypothesis and is reviewed in detail elsewhere . Briefly, greater ventral striatal activation has been shown in adolescents compared to children and adults in anticipation of reward and during reward receipt . During reward processing, BOLD signal showed attenuations in the ventral striatum when adolescents were required to assess an incentive cue, but showed elevations during reward anticipation , suggesting that adolescents may have limited capacity to assess potential reward outcomes and have exaggerated reactivity when anticipating reward compared with adults.

Underlying the hyperactivation of the striatum is an increase in ventral striatal dopamine release during rewarding events . Greater dopamine release may lead adolescents to seek additional rewards, resulting in a reinforcing cycle of reward-seeking behavior. Pubertal maturation is associated with increases in sensation seeking and may play a role in reward sensitivity. Forbes et al. found less striatal and more medial prefrontal cortex activity in response to reward outcome in adolescents with more advanced pubertal maturation compared to similar-aged adolescents with less advanced pubertal maturation. Further, the putative role of the medial prefrontal cortex in self-processing and social cognition suggests that maturing adolescents may consider the social context and peer influences when responding to reward . Affective status may interact with neural response to reward, as low striatal and high prefrontal activity were linked to depressive symptoms. Indeed, adolescents show an increase in risky behavior when the situation evokes affective processing. Hormone levels may additionally influence reward sensitivity. Higher testosterone levels were associated with reduced reward outcome-related striatal activity for both males and females, implicating a unique contribution of this hormone to reward processing. Due to their neural profiles, adolescents may show a greater propensity for high stakes rewards that incline them toward risk-taking and sensation seeking .Alcohol is by far the most widely used intoxicant among adolescents in the U.S., and rates of use increase dramatically during the teenage years . By 8th grade, 37% of students have tried alcohol, increasing to 72% by 12th grade . Past-month rates of getting drunk increase from 5% to 27%, and having consumed 5 drinks in a row in the past 2 weeks expands from 8% to 25% from 8th to 12th graders. Nicotine is fairly widely used, with 6% of 8th graders reporting any use in the past month, compared to 20% of 12th graders. Marijuana is the second most used intoxicant, with 16% of 8th graders and 42% of 12th graders reporting use at least once in their lifetime , and 21% of high school seniors endorse past month use. Other drug use is not as widespread yet still concerning, with past month use among 12th graders of amphetamines and misused narcotic pain pills at 3% and 4%, respectively . Approximately 8% of those ages 12–17 meet criteria for substance abuse or dependence in the past year, but this peaks between ages 18–25, when 21% meet diagnostic criteria for a substance use disorder . Those with early substance use onset are more likely to continue use into adulthood; individuals who first used alcohol at age 14 or younger have a >5 time increased risk of lifetime alcohol use disorder as compared to those who first used alcohol after the U.S. legal limit of the 21st birthday . Adolescent alcohol and marijuana use has been linked to harmful effects on physiological, social, and psychological functioning . This includes increased delinquency , aggressivity, risky sexual behaviors, hazardous driving, and comorbid substance use .Given the extent of brain maturation occurring during this phase in life, adolescents who use substances appear to be vulnerable to alterations in brain functioning, cognition and behavior. Indication that alcohol and marijuana use may detrimentally influence the developing brain comes from studies showing diminutions in neurocognitive functioning, especially attention, visuospatial functioning, and learning and retrieval of verbal and nonverbal information ; morphological changes ; anisotropic differences in white matter ; and a more distributed functional network and recruitment of alternate brain regions . Heavy alcohol use is associated with a wide range of neural consequences in adults and similar sequelae are implicated in adolescent users. Hippocampal and prefrontal white matter volumes appear smaller in heavy alcohol using adolescents . Alterations in anisotropy in the genu and isthmus of the corpus callosum in alcohol-using teens and in frontal, cerebellar, temporal, and parietal regions in adolescent binge-drinkers lends further support to atypical developmental trajectories. White matter quality appears to relate to drinking in a dose dependent manner, where higher blood alcohol concentrations are associated with poorer tissue integrity in the corpus callosum, internal and external capsules, and superior corona radiata .

They even describe these methods to be responsible for externalization of the cannabinoid receptor in T cells. A phenomenon that we have never seen before. Previous studies have demonstrated that intracellular CB1 receptors located in lysosomes and mitochondria are able to induce intracellular signaling, suggesting that intracellular stores of CB1 receptor are functional [Kleyer 2012, Rozenfeld 2011]. Understanding CB2 receptor trafficking could help determine cell-type specific effects of cannabinoids and the regulation of the CB2 receptor in different immune cells. While GPCRs are integral membrane proteins, there has been increasing interest in their expression and function at sites other than the extracellular membrane [Jean-Alphonse 2011]. Relatively little is known about the expression and distribution of CB2 protein in human leukocytes. CB2 has been traditionally described as a cell membrane GPCR expressed primarily by B cells while CB2 mRNA has been identified in most leukocytes but with expression levels to also be the highest in B cells [Carayon 1998, Mackie 2006, Sanchez Lopez 2015]. However, experimental data supporting the expression of the CB2 receptor in human leukocytes has been limited and sometimes contradictory, mostly due to the lack of reliable tools for detecting CB2 protein in cells of interest. CB2 protein detection had been particularly difficult due to non-specific staining of primary antibodies and use of CB2 polyclonal antibodies that can be cross-reactive to other proteins [Graham 2010]. In contrast to our preliminary findings, Graham and associates have suggested that CB2 was highly expressed on all PBMC,flood tray but they used commercial polyclonal rabbit or goat antibodies from different companies without any controls.

Staining was different for every manufacturer, from batch to batch, and from subject to subject.Cannabinoids have also been variably described to promote or suppress B cell proliferation and to bias immunoglobulin class switching, suggesting cannabinoids might play a role in B cell activation, differentiation, and maturation [Agudelo 2008, Basu 2013, Newton 1994, Newton 2009, Ngaotepprutaram 2013]. Previous evidence from mouse studies has also suggested that exposure to cannabinoids can bias the response toward a Th2 response through a mechanism involving CB2 receptors [Agudelo 2008, Carayon 1998]. Detailed studies in CB2-knockout mice revealed deficient B cell subsets in several lymphoid organs [Buckley 2012, Ziring 2006]. The CB2 receptor has also been identified to have chemotactic effects, and cannabinoids have been described to have a role in B cell trafficking within mouse lymph nodes [Basu 2011]. The specific role of CB2 in the biologic function of B cells, especially in humans, remains to be studied in detail. The primary function of B cells is to secrete antibodies and thereby provide the humoral component of immunity. Additionally, B cells play important roles in presenting antigens and by secreting cytokines, therefore exerting an influence over the other arms of the immune system [Hoffman 2016]. However, in their naïve state, B cells exhibit limited function and must be activated by exposure to antigens and co-stimulatory signals. Activation in this manner promotes the naïve B cell to enlarge, clonally expand, differentiate, and eventually undergo isotype switching, which results in the production of mature antibodies and differentiation into memory or plasma B cells [Hoffman 2016]. Different antibody isotypes are elicited in response to different pathogens and directly influenced by the nature of cost imulatory signals and the local cytokine environment [Hoffman 2016]. Isotype switching in human B cells can be induced by CD40L when combined with IL-21 and modulated by several other cytokines including IL-2, IL-4, IL-10 [Avery 2008, Moens 2014].

The natural process of activation, expansion and differentiation is antigen- specific and directly enhances the capacity for a host to respond rapidly and effectively to future immune challenges by that same antigen [Hoffman 2016]. Dysregulated activation and isotype switching is also important as it can lead to autoimmune disorders or immunodeficiency [Hoffman 2016]. Some B cell activating signals can also promote allergic or suppressive immune reactions [Hoffman 2016, Taylor 2006]. Employing a mouse model where-in animals were infected with the legionella pneumophila organism, a number of studies were carried out to study the impact of cannabinoid exposure on the host antibody response to this infection [Cabral 2009, Newton 2004]. This approach demonstrated that exposure to THC and to other CB2-specific ligands during B cell activation is associated with Ig class switching and the generation of allergic or immunosuppressive responses [Agudelo 2008, Moens 2014, Newton 1994, Newton 2009]. IL- 4 is a potent B cell activating cytokine. In the presence of IL-4, CB2 message has been demonstrated to increase in B cells and to skew isotype switching. Carlisle and associates described that CB2 might be particularly responsive to agonists when in a responsive or activated state. The immunomodulatory activity of CB2 might be dependent on the activation of the target as well [Carlisle 2002]. Persidsky and associates found that activation of CB2 blocks monocyte migration and reduces secretion of pro-inflammatory cytokine, TNF-α [Persidsky 2015]. Further investigation regarding the effects of cannabinoids and the role of the CB2 receptor on B cell activation and isotype switching is vital in order to characterize potential mediators in controlling isotype switching and assuring the appropriate immune response is induced following antigen exposure. In conclusion, there are conflicting data regarding the effects of cannabinoids on B cell function.

These conflicting results can be attributed to inconsistencies in studies done with mixed immune cell populations versus isolated B cells, comparison of naïve versus activated cells, and peripheral blood B cells versus tonsillar or splenic B cells. Through the work of this dissertation, we hope to better understand how CB2 receptor location, the dynamic balance between extracellular and intracellular receptors, activation, and isotype switching link to the biologic effects of human leukocytes. We hypothesize that CB2 is an immunoregulatory molecule and its expression may be directly tied to the level and/or type of cell activation. Further research on the immunotoxic effects of marijuana and its effects on cannabinoid receptor biology are needed in order to develop a clear understanding of the balance between extracellular and intracellular CB2 receptors and the impact of intracellular location on cannabinoid-mediated signaling. These results will be of vital interest to the field of cannabinoid receptor biology and directly relevant to understanding the potential toxic effects of cannabinoids on immune function and how the cannabinoid/CB2 pathway can be exploited for immunotherapeutic purposes. Cannabinoids, the primary bioactive constituents of marijuana, activate CB1 and CB2 receptors and signal through an endogenous cannabinoid system to produce their biologic effects. Expression of the CB2 receptor predominates in cells from the immune system. However, there is little information known as to how the CB2 receptor influences human immunity and host defense, the specific location of CB2 receptors in human leukocytes, and the impact of cannabinoids on its distribution. While it is important to understand the immunotoxic effects that might result from marijuana smoking and exposure to cannabinoids, it is equally important to understand how the CB2 receptor might be exploited to control inflammation and regulate adaptive immunity from a therapeutic perspective. The CB2 receptor has traditionally been described as a cell membrane GPCR expressed primarily by B cells. However, as reliable methods for imaging the CB2 receptor did not exist, we hypothesized that a monoclonal antibody raised against the N-terminus of CB2 could be combined with conventional and imaging flow cytometry to study CB2 protein expression. Previous evidence suggested that T cells, which do not express surface CB2, can mediate the effects of cannabinoids through intracellular CB2 receptor expression. Therefore, this led us to also hypothesize that intracellular receptors must be able to mediate ligand-induced signaling and biological consequences. After employing a new approach with conventional and imaging flow cytometry, grow table we determined that B cells express CB2 on the cell surface and at intracellular locations, while T cells, monocytes, and dendritic cells only express CB2 at intracellular sites. Cell surface CB2 was responsive to THC by rapidly internalizing when exposed to the ligand. The distribution of this internalized CB2 did not appear to account for the pre-existing distribution of intracellular CB2. The reasons as to why CB2 is expressed on the cell surface of certain cells and not expressed on the cell surface in other cells remains unknown. After concluding with these findings, we hypothesize the cellular CB2 receptor location is a key feature that links location to specific biologic outcomes, and the expression of CB2 at extracellular versus intracellular sites may play an important function in mediating the biologic and toxic effects of cannabinoids. The expression of GPCRs at different cellular locations can promote functional heterogeneity with respect to downstream signaling and function. As such, we hypothesized that this differential expression of CB2 by leukocytes is likely a highly-regulated event and plays an important role in cannabinoid function. Activation of CB2 has been linked to many different signaling pathways and cellular events [Agudelo 2008, Carayon 1996, Ngaotepprutaram 2013].

By focusing on B cells, the only leukocyte discovered to express both CB2 at the cell surface and at intracellular locations, we hypothesize that B cell activation plays a key role in CB2 expression and in mediating the biologic function of B cells, such as isotype switching and antibody production. In order to investigate the impact of B cell activation on CB2 expression, we have designed an in vitro activation model where we can induce activation and differentiation in naïve mature B cells and track CB2 expression across the different stages of differentiation and maturation. We determined that cells found to be in an activated state and cells activated in vitro lacked cell surface CB2 and expressed high intracellular CB2. This finding allowed us to directly link the acquisition of an activated phenotype to the loss of surface CB2. The intracellular location of CB2 and the specific role of different receptors on biologic function remains to be determined but will likely be very informative in understanding cannabinoid biology. The experiments detailed in this dissertation are the first steps in determining what major factor controls the distribution of CB2 in human leukocytes and how this relates to biologic function. Ultimately, we hypothesize that CB2 receptor expression, location, and trafficking are all critical features that link cannabinoids to specific signaling and functional consequences on human leukocytes. Understanding how these features are linked to immune regulation could lead to the development of novel therapeutics by targeting specific biologic outcomes, such as apoptosis, cytokine production, and isotype switching. By the conclusion of these studies, we will have established a clear understanding of the differential expression patterns of CB2 by human B cells and how it relates biologic function. CB2 mRNA has been described to be expressed by most leukocytes, with expression levels to be greatest in B cells, less in monocytes, and low in T cells [Carayon 1998, Mackie 2006]. However, experimental data supporting this in humans has been limited. At the protein level, CB2 has traditionally been described as a cell membrane GPCR expressed primarily by B cells, but our recent findings challenge this description. Preliminary data from our laboratory suggests there is no CB2 receptor cell surface expression in T cells, but there is previous evidence that states that T cells have reduced T cell proliferation, activation, and cytokine production when exposed to THC [Cabral 2015, Roth 2002, Volkow 2014]. These findings led us to hypothesize that CB2 receptors must be present at intracellular locations, and these receptors must be capable of mediating ligand induced signaling and biologic function. The distribution of the CB2 receptor in human leukocytes and the reason as to why extracellular CB2 is not expressed in T cells is not known. It is not clear whether a difference in distribution of CB2 represents variable rates of internalization and recycling or whether cell-specific differences related to activation and maturation result in these differential expression patterns. It is also not clear what role these CB2 expression patterns have in mediating the biologic and toxic effects of cannabinoids on immune function. We hypothesize that the presence of CB2 at different cellular locations is an important feature that promotes functional heterogeneity with respect to downstream signaling and biologic responses. At this point in cannabinoid receptor biology, relatively little is known about the expression and distribution of CB2 protein.

One approach to do this would be to disseminate tailored messages through adolescent peer networks to modify norms favoring the concurrent use of these substances, and therefore alter peer influences condoning the use of one of these substances or the concurrent use of two these substances. Such messages could act as cues to action to halt peer influences facilitating the progression from use of one substance to using both, concurrently. Lastly, a policy-relevant implication of our finding that marijuana use appears to lead to more cigarette and alcohol use is that there may be unintended consequences for adolescent substance use from the legalization of marijuana in states. If such legalization leads to greater marijuana use among adolescents, our results suggest that more cigarette smoking and alcohol drinking behavior among adolescents might occur concurrently. This is a possibility that has received some research attention and should be given more consideration in future work.The opioid crisis has had a substantial effect on women who are pregnant and parenting, focusing both public health and policymaker attention on opioids and on other substance use in pregnancy and postpartum. The number of pregnant women with an opioid use disorder diagnosis at delivery quadrupled from 1999 to 2014,and the incidence of neonatal opioid withdrawal syndrome increased nearly seven-fold from 2000 to 2014.Alcohol use remains common, with 1 of 9 pregnant women endorsing past 30 day use, one third of whom reported binge drinking.Cannabis use is increasing, with daily or near-daily cannabis use in pregnancy increasing from <1% in 2002 to nearly 3.5% in 2017.Stimulant use, specifically methamphetamine, doubled in pregnancy from 2008 to 2015.These trends have contributed to an increase in drug-related deaths among women in general7 and during pregnancy and postpartum in particular,cannabis growing system with overdose among the leading causes of maternal death in the US today.Furthermore, the child welfare system response to substance use in pregnancy is straining already-limited resources.

From 2011 to 2017, the number of infants entering the U.S. foster care system grew by almost 10,000, and at least half of infant placements are associated with parental substance use.Below, we review the change over time in state-level policy environments around substance use in pregnancy and contrast the policy response with the principles and guidance from professional societies and federal agencies. As SUDs, particularly involving opioids, increasingly affects pregnant women and their families, it is important to better understand how state policy environments with respect to substance use in pregnancy have evolved and the nature of policies being enacted by states. Professional societies and federal agencies universally endorse supportive policies and oppose punitive policies. Statements from the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the Centers for Disease Control and Prevention, the Substance Abuse and Mental Health Services Administration, the American Nurses Association, and several others all warn that policies penalizing pregnant women and imposing negative consequences for disclosing substance use to health care providers increase the fear of legal penalties and discourage women from seeking prenatal care and addiction treatment during pregnancy. Guidance documents and professional society committee opinions further suggest that punitive policies may lead to disengagement from care and poor pregnancy outcomes, although few studies have examined this issue. Expert consensus is grounded in the view of substance misuse in pregnancy as a medical condition requiring integrated care for both the pregnancy and the SUD and the recognition that supportive policies reduce barriers to care. For example, punitive policies enacted, in part, to reduce neonatal opioid withdrawal syndrome , have the opposite effect. Infants born in states that implemented policies that punish pregnant women for substance use had higher rates of NOWS than those born in states without such policies.The change in state policy environments with respect to substance use in pregnancy from 2000 to 2015 are detailed in the maps in Figure 1.

Six types of relevant policies were examined: those that define substance use in pregnancy as child abuse or neglect, criminalize it, or consider it grounds for civil commitment, mandate testing of infants with suspected prenatal substance exposure or pregnant women with suspected substance use; require reporting of suspected prenatal substance use to officials at local health and human services departments; create or fund targeted programs for pregnant and postpartum women with SUDs; prioritize pregnant women’s access to SUD treatment programs; and prohibit discrimination against pregnant women in publicly funded SUD treatment programs. Consistent with prior work and others’ approach,policies imposing legal consequences for substance use or requiring health professionals to test for or report suspected substance use to authorities were considered punitive. Policies reducing barriers for pregnant women with SUD or those that expand treatment were considered supportive. If a state enacted a policy with both punitive and supportive components, it was considered to have a mixed policy environment. Enactment dates were obtained from the Guttmacher Institute and supplemented with information from the National Conference of State Legislatures, ProPublica, and published studies retrieved through a targeted literature review.In addition, state statutes were reviewed to capture language illustrative of policy categories. Box 1 shows an example punitive policy enacted in North Dakota in 2003 and Box 2 contains a supportive policy enacted in Kentucky in 2015. Figure 1 shows substantial state policy activity in this area, with more states adopting punitive policies than supportive policies. This increase, from 18 states with at least one punitive policy in 2000 to 33 states in 2015, was primarily driven by states adopting policies considering substance use in pregnancy to be child abuse, grounds for civil commitment, or a criminal act, as well as policies requiring healthcare professionals to report suspected prenatal drug use. By 2015, states with only punitive policies increased from six to eight, while states with only supportive policies declined from 17 to 8.

States with both types of policies doubled from 12 in 2000 to 25 by 2015, and only 10 states had no policies specific to substance use in pregnancy in 2015, down from 16 in 2000. While encouraging that 28 states had supportive policies in 2000, only 4 additional states adopted supportive policies in the subsequent 15 years. The maps in Figure 1 are consistent with a pattern described in 1998 of more states enacting punitive policies than policies expanding treatment for women with SUD and echo the punitive approaches taken towards women with crack cocaine use in the 1980s and 1990s.These policies disproportionately affected Black women and women living inpoverty,and continue to do so today.While the government’s current approach to substance use in the general population is “remarkably less punitive” than its approach a few decades ago, it has recently been observed that “…pregnancy may represent an exception to the overall national willingness to treat the opioid epidemic as an issue of public health and not of law enforcement.”In addition, as one journalist put it, “There’s a growing consensus in the U.S. that drug addiction is a public health issue, and sufferers need treatment, not prison time. But good luck if you are pregnant.”Despite overwhelming consensus on the principle of a non-punitive approach towards substance use in pregnancy , the increase in punitive policies over the past two decades suggests that the gap between principles and practice is widening. What is needed is a holistic, public health-and prevention-oriented approach to substance use in pregnancy, consistent with the statements in Table 1. Imagine for a moment that pregnant women with diabetes, or epilepsy, or major depressive disorder, all of which are chronic medical conditions that confer some level of risk to the fetus, faced criminal charges and imprisonment if convicted of harming their infants. These examples illustrate just how differently many in the public and medical community view addiction. Addiction is a chronic medical condition, but pregnancy is a temporary period in the life course of a woman dealing with the recurring and remitting illness of addiction. Yet, too often, policies, health systems, and health services are designed to engage individuals in treatment only during pregnancy which is insufficient. Instead, women with SUD should be engaged throughout their life course. Women with SUD need comprehensive, coordinated, evidence-based, trauma-informed,flood table family-centered care not only during the 40 or so weeks of pregnancy but in the preconception, postpartum, and inter-conception periods—as well as throughout the life course for those not able to or not choosing to have children. This care should be delivered in a compassionate and non-punitive environment, and clinicians, policymakers, and public health officials all have a role to play in achieving this goal. There are encouraging examples of sound policy at both the federal and state levels.For example, recent federal legislation takes a much-needed public health approach to this issue, building on prior efforts to address gaps in the continuum of care for women who are pregnant and postpartum and strengthening Plans of Safe Care for infants with prenatal substance exposure. There has been a slow but noticeable shift in federal policy language towards less stigmatizing terminology and “people-first” language, such as an “individual in recovery” as opposed to a “drug addict,” and replacing “NAS baby” with “infant experiencing withdrawal.” Certain states are taking a dyadic approach to the challenge of mothers and infants affected by opioids. Medicaid policy levers have also shown promise. In Virginia, the Addiction and Recovery Treatment Services program,launched in 2017 to increase access to services for Medicaid members with SUDs, increased residential treatment capacity and removed the 16-bed reimbursement limit, which was a barrier to children and mothers remaining together during the mother’s treatment.

ARTS successfully increased the percentage of pregnant women with SUDs receiving treatment from 2% to 18% a year after implementation. Further research is needed to examine factors that may influence state-level variation in both the implementation and impact of different policy responses to substance use among pregnant women, but these are promising models. It is also encouraging that both federal and state policymakers are testing innovative ways to expand SUD treatment for women who are pregnant and parenting, including through telehealth and through telementoring and remote capacity building, based on the Project ECHO model.Importantly, public health and health systems are collaborating to address the often-overlooked “fourth trimester” the vulnerable early postpartum period in which a lot of the support and services a pregnant woman was eligible for rapidly fall away. Finally, the recommendation by multiple professional societies to extend postpartum Medicaid coverage to one year postpartum is garnering much-needed attention from policymakers.In conclusion, effectively addressing SUD, including opioid misuse, among pregnant women is a pressing public health issue, given both the dramatic increase in NOWS2 as well as the deleterious effects of untreated maternal opioid use disorder on both mothers and young children.10 Policymakers are aware of this issue, given the rapid pace of enacting policies addressing substance use in pregnant women. However, the greater increase in punitive compared to supportive policies is a concern. Better understanding how policies related to prenatal substance use affect maternal and child outcomes is essential as decision makers seek to best support pregnant women with SUDs. Substance use during pregnancy is a critical public health concern with significant consequences to both mother and infant . Women who use substances during pregnancy are at increased risk for poor perinatal outcomes, including preterm labor, low birth weight, congenital abnormalities, and stillbirths, and there can be additional long lasting physical, mental, behavioral and neurodevelopmental consequences for their children . Recognizing prenatal substance use as a primary cause of preventable birth defects, US guidelines consider substance use screening and referral to be essential for prenatal care . Prenatal alcohol use is associated with structural impairments, increased risk for adverse birth outcomes , fetal alcohol spectrum disorder and fetal alcohol syndrome, and neurodevelopmental problems in childhood . Prenatal nicotine use is associated with pregnancy complications , poor infant outcomes , sudden infant death syndrome, birth defects, and long-term health issues in childhood . National data indicate that alcohol use is increasing over time, and nicotine use is decreasing over time, among US women of reproductive age . However, corresponding with growing awareness of the potential harms of alcohol and nicotine use during pregnancy, initial data suggest that prenatal alcohol and nicotine use are decreasing over time . For example, data from the National Survey of Drug Use and Health indicate that among US adult pregnant women, any past-month use of alcohol during pregnancy decreased non-significantly from 9.6% in 2002 to 8.4% in 2016, and any past month cigarette smoking decreased significantly from 17.5% in 2002 to 10.3% in 2016 .

Our research team conducted 100 interviews of youth aged 18 to 24 between May 2017 and April 2018, with written informed consent obtained before each interview. Our survey questionnaire was composed of the Government Performance and Results Act survey for adolescents, supplemented with validated measures for substance use, anxiety, depression, PTSD, adverse childhood experiences, and quality of life. Based on consultations with frontline service delivery staff at Larkin Street, it was considered most effective for the interviewer to sit with the participant while they were completing the questionnaire in order to answer any questions the participant might have. If the participant preferred to complete the questionnaire in private, the research team member left the interview room. All participants who initiated the survey were provided with a $30 gift card to thank them for participating in the survey. Participation in the questionnaire had no bearing on individuals’ ability to obtain services at Larkin Street. All of the above stages of data collection were approved by the University of California, San Francisco’s Institutional Review Board .Demographics. Participants reported on age, race, ethnicity, and highest level of education attained . To determine sexual orientation and gender identity, participants also reported on sex assigned at birth, gender identity, and sexual orientation in multiple-choice and open-field format. Options for gender identity included “male”, “female”, and “other”, which allowed participants to write answers into an open-field option. Options for sexual orientation included “straight or heterosexual”, “bisexual”, “gay or lesbian”, and “unsure”. Government Performance and Results ActQuestionnaire. Per federal mandate, all Substance Abuse and Mental Health Services Administration grantees are required to collect and report performance data using the GPRA questionnaire. Data collection for GPRA includes measures on demographics, substance use, and HIV infection.

To assess HIV status,weed trimming tray participants were asked if they have ever been tested for HIV and to estimate the date of their last HIV test and to self-identify their HIV status. Of note, concomitant testing was not performed to confirm self-reported serostatus. National Institute on Drug Abuse-Modified Alcohol, Smoking, and Substance Involvement Screening Test V2.0 . The NIDA-Modified ASSIST V2.0 is a screening test for individuals who may have been, or are currently, at risk of developing a substance use disorder. The ASSIST questionnaire assesses for use of tobacco, alcohol, cannabis, cocaine, stimulants, sedatives, hallucinogens, inhalants, opioids, and other drugs. Individuals are asked to report whether or not they have ever used each substance in their lifetime, and then how frequently they used each substance within the past three months. For each substance used in the past 3 months, the respondent then answers five additional questions to measure harmful use associated with each substance. Q3 asks about compulsion , Q4 asks about health, social, financial, or legal complications associated with substance use, Q5 asks whether participants have failed to fill responsibilities of a usual role due to use of that substance, Q6 asks whether close contacts have expressed concern about their substance use, and Q7 asks about prior failed attempts to cut down on substance use. Based on responses to these latter questions measuring harmful use, a Substance Involvement score can be calculated that correlates to the overall health risk level associated with use of each specific substance. An SI score of 0 to 3 is considered low risk of harmful use, 4 to 26 equates to moderate risk, and 27+ indicates high risk of harmful use. The tool is intended to help clinicians assess the level of health-related risks associated with an individual’s substance use habits. The NIDA ASSIST has been validated for use in both adolescents and adults, including individuals who use a number of substances and exhibit varying degrees of use across different substances.Center for Epidemiologic Studies-Depression . The CES-D is a 20-item validated measure that asks participants to describe symptoms that have been associated with depression over the past week. Scores range from 0 to 60, with higher scores indicating greater depressive symptoms.

A score greater than 15 indicates increased risk for clinical depression. PTSD Checklist for DSM-5 . The PCL-5 is a 20-item validated measure that screens for the presence of symptoms of post-traumatic stress disorder . Participants are asked to consider “a very stressful experience” and answer questions about symptoms of PTSD over the past month specifically in response to the stressful experience. Scores range from 0 to 80, with higher scores indicating more severe symptoms of PTSD. A PCL-5 cut-off score of 33 can be used to screen for symptoms consistent with clinical PTSD. Generalized Anxiety Disorder instrument . Participants are asked to respond to questions regarding different symptoms of anxiety over the past 2 weeks. A total score of 10 or above on a scale of 0 to 21 indicates symptoms of moderate anxiety, with increasing scores indicating greater functional impairment due to clinical symptoms.The research team conducted a total of 103 interviews; three participants were unable to complete the entirety of the questionnaire and their data was excluded from analysis. Our analysis defined homelessness as living in a supervised publicly- or privately-operated shelter designated to provide temporary living arrangement or living within a primary nighttime residence that is a public or private place not designed for as a regular sleeping accommodation including car parks, abandoned buildings, bus or train stations, airports, and camping grounds. Participants who identified as gay, lesbian, bisexual, unsure, or self-identified in write-in responses as “pansexual”, “transgender”, and “non-gender” were categorized as SGM youth in data analysis. Pearson’s Chi-square analysis, Fisher’s Exact Test, and independent t-tests were used to test associations between study participant demographics and anxiety, depression, PTSD, and SGM status. One-tailed independent t-tests were used to test associations between mean ASSIST scores by substance and SGM status, with the hypothesis that SGM youth would exhibit higher levels of substance use and associated risks than heterosexual cisgender participants.

All analyses were conducted using STATA Version 14.2.Of the 100 participants included in the analysis, the mean age was 21.7 years, with an age range from 18 to 24 years. Of these, 67% of participants identified as male, 28% as female, and 5% as another gender identity. 52% of participants identified as lesbian, gay, or bisexual. More than three-quarters of participants were people of color, including participants who identified as Black, American Indian or Alaska Native, Filipino, Pacific Islander, or Multiracial , which correlates closely to the overall demographics of youth served at Larkin Street . With regards to education, 91% of participants had completed at least a high school education. Overall, 23% of surveyed participants self-reported living with an HIV diagnosis, including 43% of surveyed SGM youth, compared to only 3% of their heterosexual cisgender peers .Data on current or recent substance use revealed that 35 SGM participants and 21 heterosexual cisgender participants had used at least one substance in the past three months. The four most commonly used substances among all 100 participants were cannabis , cocaine and crack cocaine , methamphetamine and hallucinogens . Of note, recent use within the past 3 months did not differ significantly by SGM status for any of the substance types surveyed . Using the NIDA-modified ASSIST tool, we also assessed whether service-seeking SGM youth reported higher risk levels for negative health outcomes from substance use. Across all nine substances surveyed, a significant difference in ASSIST SI scores by SGM status was only noted for methamphetamine use . Using the ASSIST tool, SGM participants reported higher mean health risk scores associated with methamphetamine use compared to heterosexual cisgender participants . For the eight other substances analyzed, no significant increase in health risks scores were observed among service-seeking SGM participants compared to heterosexual cisgender participants .In addition to assessing substance use, mental health measures were also analyzed by SGM identity. Overall,cannabis grow setup service-seeking SGM youth were noted to experience more severe symptoms of generalized anxiety compared to their heterosexual cisgender peers . On average, SGM youth scored 10.8 on the GAD-7 –a score which correlates to moderate clinical symptoms of anxiety–whereas heterosexual cisgender youth scored an average of 8.5, which correlates to mild symptoms of anxiety. Of note, nearly one-third of SGM youth had severe range anxiety symptoms, compared to only 16% of heterosexual cisgender youth . Notably, with respect to PTSD, no significant differences were found between PCL-5 scores for symptoms of PTSD between service-seeking SGM and heterosexual cisgender youth. However, high rates of PTSD symptoms were seen among participants overall, with 80% of participants with PCL-5 scores screening positive for symptoms of PTSD . Similarly, the CES-D depression screening tool revealed that 74% of participants scored at or above 16 , although similarly high rates were found among both SGM youth and their heterosexual cisgender peers . All mental health validated questionnaires demonstrated strong internal consistency among our study population, with Cronbach’s alpha values for the GAD-7, PCL-5, and CES-D of 0.90, 0.96, and 0.83, respectively.In our study, service-seeking SGM youth experiencing homelessness did not exhibit higher levels of recent substance use within the past three months compared to their heterosexual cisgender peers. Across all nine substances analyzed, SGM and heterosexual cisgender participants were equally likely to have reported use of the substance in question at least once within the past 3 months.

This finding differs from several existing studies which reported higher levels of substance use among SGM youth experiencing homelessness. Beyond strictly measuring frequency of recent use, our study also demonstrated that compared to heterosexual cisgender youth, service-seeking SGM youth reported comparable risk levels of harmful outcomes associated with substance use for all substances measured, with the exception of methamphetamine. In regards to methamphetamine use, our finding that SGM participants reported higher associated risk levels fits into the well-established body of literature describing the high prevalence and associated risks of methamphetamine among gay and bisexual men. Additionally, previous research has demonstrated that methamphetamine use disorder is uniquely difficult to treat, though contingency management programs provide the best evidence for efficacy. Thus, the increased risk specifically associated with methamphetamine use among SGM youth identified in our study may be an important indicator that SGM youth require more tailored interventions for substance use disorders compared to the general homeless youth population. It is unclear why our study did not find significant differences in frequency and harmful risks of substance use among SGM youth experiencing homelessness and their heterosexual cisgender counterparts, though several possibilities exist. One possible explanation is the relatively high availability of supportive services and communities for SGM youth in San Francisco. In a qualitative study of gay and transgender youth of color in San Francisco, participants described the Castro, a historically queer neighborhood of San Francisco, as a place “where they each spent time and sought safety, community, and identification”.Larkin Street, our partnering community organization, provides transitional housing in the Castro for clients who identify as LGBTQ, including housing specifically for transgender youth experiencing homelessness. While programs in other cities may similarly support the needs of youth experiencing homelessness, they may also be settings in which SGM youth experience discrimination. For example, homeless youth in Canada have reported experiences of discrimination due to their SGM status from both other clients and staff in emergency shelters. The relatively higher availability of SGM-friendly services for unstably housed youth in San Francisco, including our partnering organization Larkin Street Youth Services, may in turn have helped mitigate the underlying factors leading to higher prevalence and risk of substance use and mental health symptoms among SGM youth described in other studies, such as discrimination and stigma. For example, staff at Larkin Street create a welcoming environment for all youth by using SGM-supportive language and imagery on program materials. Additionally, all staff undergo LGBTQ cultural competency training, a core tenant of public health policy recommendations aimed at improving outcomes for SGM youth experiencing homelessness. Available resources at Larkin Street specifically for SGM youth include culturally competent case management, aforementioned housing in neighborhoods that are welcoming to LGBTQ+ residents, and SGM-specific services such as support with official name and gender changes, and providing material needs such as chest binders. Larkin Street also offers substance use interventions such as harm reduction supplies and support groups to help individuals manage the intersection of substance use, trauma, and PTSD.

Dual use of conventional and e-cigarettes is also common in adolescents , raising the possibility that some adolescents may use e-cigarettes to substitute for conventional cigarettes in situations where smoking is restricted. Indeed, school bathrooms and staircases are among the most common places adolescents report using e-cigarettes . Given that adolescents with mental health symptoms are more prone to nicotine dependence , these populations could be more likely to initiate use of e-cigarettes to bridge situations when they are not able to smoke, which ultimately could perpetuate the over-representation of smoking among individuals with mental health problems. While research has yet to characterize the psychiatric comorbidity with patterns of conventional and e-cigarette use in adolescents, a recent study of Hawaiian adolescents found that alcohol/marijuana use and other psychosocial risk factors were highest in dual users, moderate in e-cigarette only users, and lowest in non-users . Most pairwise comparisons involving conventional cigarette only users were not significant in that study, perhaps limited by reduced statistical power due to the smaller size of this group . Given these findings, stratification of psychiatric comorbidity across dual use, single-product use, and non-use in adolescents is plausible. The current study characterized the mental health of adolescents who reported ever using ecigarettes, conventional cigarettes, both, or neither. To provide a wide-ranging picture of psychiatric comorbidity, traditional syndrome-based indices of various depressive, manic, anxiety, and substance use disorders were administered. Consistent with NIMH’s Research Domain Criteria Initiative ,greenhouse benches we also assessed several transdiagnostic phenotypes implicated in multiple internalizing and externalizing psychopathologies and conventional cigarette use .

Up to this point, data on the psychiatric comorbidity associated with ecigarette and dual use is virtually absent, leaving unclear as to how the mental health of these two groups compare to conventional cigarette users and non-users. Given that conventional cigarettes and e-cigarettes have both similarities and differences , whether the patterns of psychiatric comorbidity are similar or different between e-cigarette only users and conventional cigarette users is unclear. As the first study to comprehensively characterize psychiatric comorbidity in adolescent e-cigarette and dual use, this study may yield data that is important to tobacco policy by identifying adolescent populations that are psychiatrically vulnerable and potentially at risk for use of traditional and emerging tobacco products. Such data could highlight the need to protect psychiatrically vulnerable adolescents from tobacco product use take via targeted tobacco product regulation and behavioral health prevention programming for this populations. This report is based on a cross-sectional survey of substance use and mental health among 9 th grade students enrolled in ten public high schools surrounding Los Angeles, CA, USA. The percentage of students eligible for free lunch within each school on average across the ten schools was 31.1% . Students not in special education or English as a Second Language programs were eligible . Of the students who assented to participate , 3,383 provided active parental consent and enrolled in the study. In-classroom paper-and-pencil surveys were administered across two 60-minute data collections during the fall of 2013, conducted less than two weeks apart. Some students did not complete all questionnaires within the time allotted or were absent for data collections , leaving a final sample of 3310.

The University of Southern California Institutional Review Board approved the protocol. Based on patterns of lifetime use, the sample was divided into: use of neither electronic nor conventional cigarettes ; use of conventional cigarettes only ; use of electronic cigarettes only ; use of electronic and conventional cigarettes . Primary analyses used generalized linear mixed models that accounted for clustering of data within school, in which the 4-level cigarette use group variable was a categorical regressor variable and a mental health indicator was the outcome variable, with separate models for each outcome. GLMM specified binary and continuous distributions for the lifetime substance use status and mental health quantitative outcomes, respectively. Because of skewed distributions on the three substance use problems measures, Poisson distributions were specified for these outcomes. For outcomes with omnibus groups differences, we conducted follow up pairwise contrasts using an adjusted p-value, correcting for study-wise false discovery rate of 0.05. GLMMs were adjusted for gender, age, ethnicity, and highest parental education; missing data on covariates were accounted for by dummy coding a ‘missingness’ variable to allow inclusion in analyses. Results are reported as standardized effect size estimates . As illustrated in Table 2, there were omnibus differences across the four groups for all outcomes. Pairwise contrasts indicated that adolescents who used conventional cigarettes only reported worse mental health than non-users and e-cigarette only users on multiple internalizing emotional syndromes and transdiagnostic phenotypes . On these internalizing emotional outcomes, the conventional cigarettes only and dual use groups did not significantly differ. For some internalizing outcomes , e-cigarette only users had higher elevations than non-users, but lower problem levels than conventional only or dual users. Relative to non-users, use of either product was related to the externalizing phenotypes of poorer inhibitory control and impulsivity.

An ordered effect of dual use vs. e-cigarette use only vs. non-use was found for elevations in mania, positive urgency, and anhedonia. An ordered effect of dual use vs. either single product use vs. non-use was also found for lifetime use status and level of abuse/problems for all substances. Given the differences in patterns across internalizing and externalizing and positive-emotion seeking behaviors, syndromes, and traits, we plotted standardized T-scores of the outcomes by conventional/e-cigarette use status separately in the two domains. These figures respectively illustrate general trends of: differentiation of conventional and dual cigarette use from never and e-cigarette use on most internalizing outcomes , and tri-level ordered differentiation of never vs. single product vs. dual use on externalizing outcomes . Analyses of the substance problem outcomes utilizing the overall sample cannot distinguish between substance ever-users who report zero drug/alcohol-related problems and substance never-users. To identify whether e- and conventional-cigarette use status differentiates level of substance problems among substance ever-users, a supplementary analysis of the three substance problem outcomes was conducted that limited each analysis to ever-users of the respective substance using the same GLMM analytic strategy and covariates as the primary analyses with a continuous outcome distribution specified. As in the analysis in the primary sample, these analyses of substance ever-users generally showed an ordered pattern whereby dual tobacco product users reported the highest levels of alcohol, cannabis, and drug problems, followed by single tobacco product users , and then never-users of either tobacco product, respectively . This study is the first to comprehensively examine differences in psychiatric profiles between four different groups based on typologies of tobacco product use: non-users; e-cigarette only users; conventional cigarette only users; and dual users. This novel 4- group comparison is a critical innovation; with changes in the pattern of tobacco product use in the past several years, new typologies of adolescent tobacco product use have emerged, including both e-cigarette and dual use . Given the relative lack of data to suggest that additional psychiatric problems would be associated with e-cigarette vs. conventional cigarette or dual use, it was unclear whether e-cigarette only users would differ from the other user groups in psychiatric comorbidity. This study’s main findings were that: e-cigarette only users reported a level of internalizing mental health problems midway between non-use and conventional cigarette use; and externalizing/substance use comorbidity was extensive and followed an ordered pattern with dual users having the most severe and pervasive comorbidity, followed by single-product users and non-users, respectively. These results are novel and raise an important question as to whether e-cigarette use may be common in ‘lower-risk’ subgroups of the adolescent population who otherwise are not attracted to other tobacco products, like conventional cigarettes. These results are broadly consistent with recent data in adults as well as Wills et al.’s study of psychosocial risk factors and alcohol/marijuana use in Hawaiian 9th/10th graders, growers equipment which found that e-cigarette users were at an intermediate risk status in between non-users and dual users .

In the current sample of Los Angeles 9th graders, a similar pattern of differentiation by dual vs. e-cigarette only vs. non-use is seen that extends across a number of mental health syndromes and transdiangostic phenotypes. The current study also found that conventional cigarette only users have worse internalizing mental health problems than e-cigarette only users. Overall, it is clear that future research and intervention dedicated to comorbidity between use of tobacco products and mental health problems in adolescents should assess and distinguish between use of conventional cigarettes only, e-cigarettes only, and dual use. For eight internalizing emotional disorder symptoms and phenotypes, adolescents who used e-cigarettes only reported an intermediate level of problems which was lower than conventional cigarette only users on seven outcomes and higher than never-users on three outcomes. Prior research suggests that adolescents with better emotional health are more strongly deterred from initiating smoking due to concerns about smoking’s negative effects on health and social acceptability . Thus, emotionally-healthier adolescents may be more willing to use e-cigarettes, which are generally perceived to be more socially acceptable and less harmful than conventional cigarettes . The availability of tobacco products that are perceived as less harmful and more socially acceptable, like e-cigarettes, may lower the threshold of risk for tobacco product experimentation associated with certain mental health problems. Externalizing behavioral comorbidities and mania were elevated in adolescents who used e-cigarettes only versus those who use never used either tobacco product. Adolescents who used conventional cigarettes only also showed this pattern relative to those who never used either tobacco product, which extends prior research on tobacco-psychiatric comorbidity . Moreover, this study provides novel data indicating use of e-cigarettes per se is not universally linked with all types of mental health comorbidities; rather use of e-cigarettes alone is associated more prominently with externalizing problems and less prominently with internalizing problems. A clear gradient was observed in which substance use/problems, mania, and positive urgency that successively increased with the number of tobacco products used . One explanation for these findings is that adolescent cigarette smokers with these comorbidities may be more nicotine dependent and may therefore be motivated to also use e-cigarettes to alleviate withdrawal during times when they cannot smoke . Indeed, these disorders are linked with more severe conventional cigarette dependence . Another explanation is that adolescents with substance use and mania comorbidity who have experimented with ecigarette use may not derive enough reinforcement from e-cigarettes, which may be an important factor given prior evidence that conventional cigarette smokers with these comorbidities report stronger motivation to smoke for positive reinforcement . Because e-cigarettes have provided less reliable nicotine delivery and reinforcement than conventional cigarettes in novice users , adolescents with substance use and mania comorbidities who have tried e-cigarettes may be motivated to subsequently experiment with conventional cigarettes in an effort to find a product that provides stronger and more consistent rewarding effects. An additional perspective is that substance experimentation is driven by a drive for pleasure and means for rebelling against norms , and that teens with externalizing mental health problems are motivated to experiment with a wider array of multiple substances, including e-cigarettes, conventional cigarettes, and other drugs. Further longitudinal evaluation of these hypotheses is necessary and future research should explore whether there is a gradient in the intensity of intervention needed in preventing conventional cigarette smoking and dual use. This study had several strengths, including a comprehensive four-group comparison strategy that distinguished four unique patterns of tobacco product use, broad sampling of mental health syndromes and cross-cutting traits, and utilization of a large, diverse sample. The cross-sectional design does not permit an assessment of the temporal precedence of the mental health problems and the use of conventional/e-cigarettes. Accordingly, this study cannot speak to etiological mechanisms underpinning the link between mental health and tobacco product use. Because the survey did not assess past 30-day e-cigarette use, use frequency and progression in use, persistence of use, and nicotine strength , several aspects regarding the quality and profile of e-cigarette and conventional cigarette use are not addressed in this study. Furthermore, the focus on lifetime use leaves unclear whether findings generalize to brief experimentation or more persistent use patterns. To limit burden on students and class time, brief self-report measures were used.

Reported heavy workloads and a lack of dedicated time to integrate naloxone screening into the pharmacy workflow was cited by 6 of 8 respondents as making it difficult to prioritize furnishing naloxone. One respondent noted, “It’s really time. We don’t really have time here to initiate for those implementing naloxone […] unless patients request it.” . With respect to stigma, 5 respondents stated that it was difficult to suggest supplying naloxone to patients due to its association with drug abuse. They indicated that patients perceived offers of naloxone as accusations of opioid abuse. One stated, “[T]here’s always like that lash back from a patient, like oh, I don’t need it because I’m not abusing it. That’s the common phrase.” . Lastly, one respondent reported that the absence of a shared language was a barrier due to lack of understanding and miscommunication, noting that, “[W]e have to get a translator to […] communicate with the patients. Maybe the patient’s not understanding correctly even [as] it’s being translated.” . Examples of responses regarding barriers to furnishing are shown in Table 3. Although California Assembly Bill No. 2760, which passed in 2018, required medical prescribers to offer a naloxone or equivalent prescription to populations at higher risk of opioid overdose, out-of-pocket costs to the uninsured in the United rose 500 percent from 2014 to 2018 for certain brands of naloxone.Generic naloxone has an average wholesale price of $64.80-$75.00.Participants believed that reducing out-of-pocket costs could increase naloxone purchase and use. A chain community pharmacist stated that they went “out of their way to try to find GoodRx discount cards to help bring down the price for patients.” and that doing so reduced patient reluctance to purchase naloxone. Similarly, an independent community pharmacist suggested that “lower [ing] restrictions and mak[ing] it OTC [over the counter]” would increase the likelihood of visitors purchasing naloxone. Participants were also asked to identify facilitators to furnishing.

Responses included collaborating with other health professionals, closer proximity to pain clinics,cannabis grow supplies expanded scope of pharmacy practice in California, supportive corporatepolicies, education and training on naloxone furnishing, and higher demand for naloxone. With respect to collaboration, 2 respondents stated that closer proximity to pain clinics increased the likelihood of pharmacies furnishing naloxone. One pharmacist stated that, “some pharmacies are located in regions [with] higher potential [of] abuse …that can also drive up having … more Naloxone in that location.” . One pharmacist indicated that demand was higher in their region, stating that, “people started asking for it. We dispensed it” . Additional examples of responses regarding facilitators to furnishing are provided in Table 4.Since 2013, California has sought to expand access to care by authorizing pharmacists to furnish medications. Implementing naloxone furnishing by pharmacists in particular provides a potential opportunity to reduce opioid overdoses. These services are especially critical in rural areas like California’s Central Valley that have been disproportionately impacted by the opioid epidemic.We were unable to identify any prior studies that assessed the extent of pharmacist furnishing in rural, HPSAs such as the Central Valley, and our findings suggest that contrary to initial expectations, almost half of contacted pharmacies, including some mail-order pharmacies, furnished naloxone in the Central Valley. In contrast, a study of primarily urban pharmacies in California conducted in 2020 found that 42.4% furnished naloxone.Interviews with pharmacists who furnished naloxone suggested that pharmacies continued to face barriers to successful implementation, many of which have been identified in previous research. These included time restrictions, high out of-pocket costs for purchasers, stigma associated with opioid use, and in 1 case, language barriers. All respondents indicated that out-of-pocket costs were the most critical barrier and that prices varied depending on insurance coverage; this finding is consistent with prior research.

The findings regarding stigma as a barrier to offering and accepting naloxone are also consistent with previous research. This includes a study involving pharmacy students in Tennessee and their perceptions of naloxone use and opioid use disorder patients, which found that although pharmacy students are capable of and predisposed to furnish naloxone, successful furnishing is complicated by limited patient awareness and stigma, specifically the perception that naloxone is for “addicts” only.Another study examining undergraduates’ reactions to fictional vignettes about people with opioid use disorder found addiction was attributed to the opioid user’s character and varied by an user’s socioeconomic status.Studies examining perceptions of take-home naloxone conducted with both healthcare providers and opioid users have found that stigma influences both parties when providing education and seeking out information about naloxone and overdose prevention, respectively.These studies suggest that further interventions in pharmacy education to combat stigma against naloxone use and opioid use disorder might help facilitate increasing naloxone furnishing rates.Limitations to this study include generalizability, variable effects of coronavirus disease 2019, and self-reporting bias. The analysis only considered the 11 counties in the Central Valley, which may limit extrapolation outside of this region. The sample also did not include interview data from pharmacies that furnished but chose not to participate, which may have resulted in a biased sample. Another limitation is that this study was conducted 2 years after the most recent comparison study of naloxone furnishing in California. As a result, the higher furnishing rates observed in this study may have re- flected a time trend or effect of the coronavirus disease 2019 pandemic, such as difficulty securing appointments with physicians encouraging use of pharmacy services, rather than a difference in prevalence.One interview was done through e-mail, rather than a phone call, which limited the ability to probe for clarification and additional detail.

Pharmacies that did not furnish naloxone were not included in interviews on the grounds that they would be unable to provide information on facilitators to naloxone furnishing; future studies could investigate if these pharmacies furnish other medications. Additional research could also address potential differences in furnishing practices between independent and chain pharmacies, as well as furnishing rates for other medications in this region. Irrespective of these limitations, the findings provide new information regarding pharmacist furnishing in HPSAs, barriers that prevent the widespread provision of naloxone, and potential strategies that may help overcome those barriers.The American College of Obstetrics and Gynecologists and the American Academy of Pediatrics recommend avoiding cannabidiol and CBD-containing products during breastfeeding because of potential neurodevelopmental risks to the infant. Cannabidiol use is widespread and increasing among adults, especially for medical purposes. However, information on CBD risk to the breastfed infant is largely unknown owing to limited and variable existing evidence. To support the strength of recommendations, more knowledge is required on the dose–exposure–response relationship of CBD in breastfed infants. Such information would lead to a better understanding of whether observed CBD concentrations in milk consumed by infants lead to relevant systemic concentrations in breastfed infants associated with neurodevelopmental delays . Beginning in 2014, Mommy’s Milk Human Milk Biorepository investigators sought to improve the understanding of maternal exposure to various agents, including marijuana and its metabolites, during breastfeeding and the potential for infant exposure to specific agents and subsequent adverse infant outcomes. The HMB is a USAand Canada-wide study that collects human milk samples from mothers who were or were not taking medications and recreational drugs,grow lights for cannabis including marijuana, CBD, and CBDcontaining products. The HMB investigators continue to study breastfeeding exposures and potential infant outcomes through administration of neurodevelopmental questionnaires and face-to-face testing. In the present secondary data analysis, we seek to fill a gap by further defining CBD exposures to breastfed infants. In this work, we leverage real-world CBD concentrations in breastmilk from the HMB, knowledge of breast milk intake as a function of infant age, dose and type of administration, and physiologically based pharmacokinetic models to translate CBD dose through breastfeeding into neonatalexposures. Physiologically based pharmacokinetic modeling is a mathematical tool used to predict drug exposures based on the physicochemical properties of a compound, and the anatomy and physiology of organisms. We sought to answer, among breastfeeding mothers taking CBD based on real-world use, what is the predicted exposure and its associated variability in breastfed infants? The open-source PBPK modeling platform, PK-Sim version 11 was used to perform PBPK modeling. Plot Digitizer version 2.6.8 was used to digitize published pharmacokinetic profiles to obtain concentration–time data. R was used to curate the HMB dataset, analyze subgroups, and simulate infant daily doses.

The HMB was established in 2014 at the University of California San Diego for research purposes. The HMB collects voluntary human milk samples from lactating women who are or are not exposed to any medication, recreational drug, or environmental chemical primarily in the 2 weeks prior to sample collection. Detailed information on recruitment, data collection, and sample preparation and analysis methods have been presented previously. Participants complete an interview to provide their demographics, maternal and child health history, breastfeeding habits, and all exposures focused in the previous 2 weeks prior to sample collection. Exposure information from women who reported marijuana use at any time since giving birth included type of administration, frequency of use, dose, and time since last use before milk sample collection. Milk samples were previously measured for metabolites, including CBD concentrations and the date and time of the milk collection were ascertained. Cannabidiol concentrations in human milk were determined by liquid chromatography with tandem mass spectrometry. The analytical range of the assay was 0.1–200 ng/mL. The method was validated in human milk by establishing the accuracy and precision of three sets of calibration curves and quality-control samples over 3 days. Acceptability criteria for accuracy was ±15% of nominal concentrations except ±20% at the lower limit of quantification . Acceptability criteria for precision was ±15% coefficient of variation, except ±20% coefficient of variation at LLOQ. This present study received ethics clearance from the parent study through the UC San Diego Human Research Protections Program, and for a secondary data analysis through the University of Waterloo Research Ethics Board . Information on maternal demographics, exposures, and measured CBD concentrations in milk collected and assayed by the parent study between 2015 and 2021 were extracted from the existing HMB dataset. The dataset was organized to describe: all concentrations in milk ; and concentrations by self-reported maternal frequency, dose, and type of administration . From the existing data for the sample on quantification of CBD, three methods were assessed to account for below the limit of quantification values: BLQ = LLOQ/2, BLQ are drawn from uniform distributions of 0 to LLOQ, and BLQ = LLOQ. For concentrations from samples with a maternal reported type of administration , only concentrations with one type of maternal administration were retained. Missing end time of exposure was replaced with the time of concentration sample collection and vice versa. The effects of administration type, time after last dose , and dose frequency on concentration were assessed. Administration type was a categorical variable defined as: edible, joint, oil, pipe, or other , and N/A categories. As a continuous variable, TAD was described as time in hours elapsed from the end of maternal administration to milk sample collection for concentration measurement. Time after last dose was calculated by subtracting the date and time of sample collection by date and time of the last reported date of maternal administration. To account for the varying ways in which dose and frequency of CBD and CBD-containing products were consumed , dose frequency was categorized as low, medium, and high based on the data of each week-normalized dose type. To compare these subgroups, the exposure-concentration subset was considered with and without BLQ values. A linear regression model to predict log-concentrations was obtained after testing the significance of subgroups on CBD in milk concentrations including TAD, administration type, and interactions between TAD and administration type, and administration type and dose frequency. Model goodness of fit was evaluated through a standard residual analysis. Post-hoc pairwise comparisons of estimated marginal means of the significant subgroups were performed using various p value adjustment methods owing to the lack of a gold standard method. The pediatric PBPK model was developed according to the workflow of Maharaj et al.. An adult oral CBD PBPK model established from our previous work was scaled to simulate CBD exposure in virtual breastfeeding infants.

Pain is a protective evolutionary function that involves “unpleasant sensory and emotional experiences associated with, or resembling that associated with, actual or potential tissue damage” . Acute pain is an adaptive and essential survival behavior. Chronic pain is a pathological condition that poses a significant clinical, economic and social burden . Chronic pain is the most common clinical complaint in the United States affecting ∼10–20% of the U.S. population with an estimated annual cost of $600 billion, the most significant economic cost of any disease to-date . Neuropathic pain is defined as pain that is “initiated or caused by a primary lesion or dysfunction in the nervous system” . Neuropathic pain can be divided into either having peripheral origin or central origin and can be further divided into acute or chronic pain, the latter defined as pain lasting for longer than 3 months .Pain is a subjective sensory experience that cannot be directly measured nor quantified. Although pain is subjective and influenced by many physiological and psychological factors, measuring biomarkers of neuropathic pain provides an opportunity to identify objective markers of peripheral nerve damage and other pathology contributing to neuropathic pain. If used in combination, biomarkers related to pain mechanisms offer the possibility to develop objective painrelated indicators that may improve diagnosis, treatment, and understanding of pain pathophysiology . The pursuit of pain biomarkers has followed two largely separate general directions: physiological vs. brain neuroimaging. Physiological pain biomarkers research has followed multiple lines of investigation including genetic, vesicular micro-RNA, metabolic/molecular, and stress markers. Neuroimaging biomarker research in neuropathic pain research was initially motivated by research into brain areas activated by painful stimuli and that vary with pain severity . Brain activity that occurs in response to pain can also be observed in the absence of pain,ebb and flow tray which has led to conflicting evidence regarding brain activity related to pain.

Thus, some researchers are developing biomarkers based on the mechanisms underlying pain and pain perception and biomarkers that may predict response to medication and pain treatments allowing for prediction of personalized treatment responses . Toward the goal of identifying composite biomarkers for investigating neuropathic pain mechanisms and improving diagnosis and treatment response, we present a review of non-imaging and imaging pain biomarkers related to various neuropathic pain mechanisms, including opiate, inflammation, endocannabinoid mechanisms. In this review, we review mechanisms for neuropathic pain in general, but we focus on pain biomarkers for different types of peripheral neuropathies. Although various reviews of pain biomarkers exist, we focus on creating composite biomarkers through machine learning approaches that can most accurately identify people with neuropathic pain. Blocking opioidergic transmission reduces dopamine release in the nucleus accumbens that accompanies pain relief . The endogenous opioid system consists of four opioid peptide families: β-endorphin, enkephalins, dynorphins, Abbreviations: 2-AG, 2-arachidonoylglycerol; AEA, anandamide; CBR, G protein-coupled ECB receptor; CSF, cerebral spinal fluid; CRPS, complex regional pain syndrome; CRP, c reactive protein; DMN, default mode network; DHEA, dehydroepiandrosterone; ECB, endocannabinoid; FAAH, fatty acid amide hydrolase; MAGL, cytosolic monoacylglycerol lipase; MPF, medial prefrontal cortex; NA, nucleus accumbens; QST, quantitative sensory testing; SFN, small fiber neuropathy; sICAM-1, soluble intercellular adhesion molecule-1; TNF, tumor necrosis factor; WBC, white blood cell. and nociceptin/orphanin and 4 families of receptors: mu, delta, kappa, and nociceptin . Opioid receptors are expressed by central and peripheral neurons, by neuroendocrine , immune, and ectodermal cells .

All opioid receptor types mediate analgesia but have differing side effects, mostly due to their variable regional expression and functional activity in different parts of central and peripheral organ systems. Endogenous opioids are particularly concentrated in circuits involved in pain modulation . Beta-endorphin levels in the CSF, blood and saliva have been investigated as possible pain biomarkers. Plasma Beta-endorphin has been used to investigate age responses to experimental pain . Patients with chronic neuropathic pain due to trauma or surgery have been shown to have lower levels of Beta endorphin in the CSF . Plasma and CSF Beta-endorphin have been investigated in patients with trigeminal neuralgia . Interestingly, Beta-endorphin in peripheral blood was related to levels in CSF; furthermore, the levels of Beta-endorphin were inversely correlated with the severity of pain symptoms . While chronic low back pain typically involves non-neuropathic pain mechanisms, it is interesting that plasma Beta-endorphin levels have been shown to be a promising biomarker for chronic back pain . In other non-neuropathic pain conditions, mu opioid receptors expressed on immune B cells was found to be a biomarker for chronic pain in fibromyalgia and osteoarthritis. In this study, the percentage of mu opioid receptors positive B cells was statistically lower in patients with moderate to severe pain than in pain-free subjects or mild pain subjects . In a heterogenous group of patients with pain, a composite biomarker was identified that uses emergent properties in genetics to separate patients with pain requiring extremely high opioid doses from controls . Negative studies for opiate mechanism pain biomarkers have shown that salivary Beta-endorphin is not a biomarker for neuropathic chronic pain propensity . Functional brain imaging performed on patients with nonneuropathic primary dysmenorrhea with mu-opioid receptor A118G polymorphism has been used to investigate pain sensitivity and opioid-analgesic treatment related to function in the descending pain modulatory system. Specifically, the functional connectivity of the descending pain modulatory system dependence upon mu-opioid receptor A118G polymorphisms was investigated. This study found that patient groups with different alleles for the A118G polymorphisms exhibited varying functional connectivity between the anterior cingulate cortex and periaqueductal gray .

Although magnetic resonance imaging provides information regarding structural and metabolic changes that provide insight into pain perception of the CNS, magnetic resonance imaging cannot image opioid function in cells in vivo at the molecular level. Such important opioid function information can be obtained through positron emission tomography and can be used to investigate pain opioid mechanisms . While the development of neuropathic pain has long been ascribed to the known contributors of central sensitization , the role of neuroinflammation regarding the initiation and maintenance of neuropathic pain has evolved tremendously over the last decade. Pro-inflammatory cytokines have been implicated in the generation of neuropathic pain states at both peripheral and central nervous system sites . Neuroinflammation of the peripheral nervous system is triggered by inciting damage to the peripheral nerves, either by trauma, metabolic disturbances , viral infection or surgical lesions leading to sprouting of new pain-sensitive fibers , excessive neuronal firing, and hypersensitization of primary afferent peripheral neurons. During a peripheral nerve injury, local cytokines recruits macrophages which secrete components of the complement cascade, coagulation factors, proteases, hydrolases, interferons, and other cytokines that ultimately facilitate degradation and phagocytosis of the pathogen and injured tissue. Peripheral neuroinflammatory mechanisms affect the damaged neuron and neighboring afferent neurons sharing the same innervation territory . Peripheral nerve injury causes neuroinflammation in the spinal cord . The neuroinflammation is triggered by hyperactivity of the injured primary afferent peripheral sensory neuron which increases neurotransmitters and neuromodulators, causing hyperactivity of postsynaptic nociceptive neuronal hyperactivity as well as the release of several inflammatory activators. A result of this lumbar spinal inflammation process is disruption of the blood-spinal cord barrier leading to increased permeability, which then leads to infiltration of immune cells such as T lymphocytes, macrophages, mast cells,4×8 flood tray and neutrophils from the periphery into the spinal cord and dorsal root ganglion . These mechanisms contribute to further release of inflammatory mediators which contribute to alterations in post-synaptic receptors. This neurotransmitter increase leads to hyperactivity of post-synaptic nociceptive neurons in the spinal cord and altered signaling up to the thalamus and cortex that may contribute to central sensitization and pain hypersensitivity . Nerve injury typically involves neuro-immune interaction involving glia . Glia are known to provide functional microenvironment modulating neuronal signal transduction, synaptic pruning, and neuroplasticity that contributes to central sensitization.

Concentrations of CSF proinflammatory cytokines are increased in multiple neuropathic pain states . Most studies of pain syndromes have found elevations of proinflammatory and anti-inflammatory cytokines in painful conditions compared with healthy controls; furthermore, frequently higher levels of proinflammatory markers are associated with greater pain . Other markers such as soluble intercellular adhesion molecule- 1 , for example, have also been demonstrated to correlate with pain. sICAM-1 measured in serum correlates with patients’ self-reported pain levels in various pain conditions , distinguishing these patients from those with no or mild pain .Cytokines have also been demonstrated to be potent mediators of pain in peripheral neuropathy. In one peripheral neuropathy study, gene expression of pro- and anti-inflammatory cytokines was shown to be increased in patients compared to controls . Another study found neuropathic pain group was found to have higher serum levels of several markers including CReactive Protein and Tumor Necrosis Factor – α compared with two control groups. Furthermore, patients with painful neuropathy had higher sICAM-1 and CRP levels when compared to painless neuropathy . A meta-analysis comprehensively assessed the relationship between serum TNF- α levels and diabetic peripheral neuropathy in patients with type 2 diabetes, demonstrating increased serum TNF-α levels in patients with diabetic neuropathy compared to type 2 diabetic patients without neuropathy and compared with controls . Il- 17 is significantly upregulated in rat models of neuropathic pain, and mRNA expression levels of IL-1β and IL-6 are significantly enhanced in the spinal dorsal horn compared with controls . Moreover, functional recovery from neuropathic pain following a peripheral nerve injury relies on down regulation of IL-1 β and TNF- α responses .Another key pro-inflammatory neuropeptide, Substance P, is known to initiate biological inflammatory effects . In painful trigeminal neuralgia, levels of Substance P and other neuropeptides in the cerebrospinal fluid and blood of patients were found to have higher levels than that of controls; furthermore, blood levels of these markers correlated with those of the CSF . Another study investigating nonneuropathic experimental pain found altered substance P levels and dynamics when comparing older and younger adults . Compromised BBB can be identified with gadolinium-enhanced MRI as is seen in the setting of white matter lesions in multiple sclerosis. CNS-infiltration of circulating immune cells, such as monocyte infiltration into brain parenchyma, can be tracked with iron oxide nanoparticles and MRI. Pathological consequences of neuroinflammation such as apoptosis can be imaged with PET [99mTc] Annexin V or with iron accumulation with using MRI T2∗ relaxometry. These imaging techniques can be used to image human neuroinflammation which have potential to impact patient care in the foreseeable future . Integrated positron emission tomography-magnetic resonance imaging and the radioligand 11C-PBR28 for the translocator protein can be used to image regional brain volumes with glial activation. Given the putative role of activated glia in the establishment and or maintenance of persistent pain, pathophysiology, and management of a variety of persistent pain conditions the results from this technique are important to consider when considering imaging techniques for measuring CNS inflammatory effects of pain . There are three classifications of cannabinoids: phytocannabinoids , endocannabinoids , and synthetic cannabinoids. Similar to the opioid system, versions of the endocannabinoid system have been found in the vast majority of species with a nervous system . In particular, the ECB ligands 2-AG and AEA have been found throughout the animal kingdom . The ECB system regulates physiology across most organ systems and operates independently and interacts with the inflammatory system, the opiate system, the Vaniloid system, and with nuclear transcription factors . The ECB system works as a part of a negative feedback loop that regulates neurotransmitter and neuropeptide release in the nervous system. Endocannabinoid ligands are generated on-demand in response to high levels of activity and produce short-term inhibitory effects via their actions as retrograde transmitters at presynaptic inhibitory G protein-coupled receptors . The two most prevalent endocannabinoid ligands that bind endocannabinoid receptors are anandamide and 2- arachidonoylglycerol . The 2-AG basal level is ∼1,000 times greater than AEA in the brain . The enzyme acylphosphatidylethanolamine-phospholipase D is involved in the formation of AEA, and the enzyme diacylglycerol lipase is involved in 2-AG formation . Once synthesized and released, endocannabinoids are removed from the extracellular space through an endocannabinoid membrane transporter, subsequently AEA is hydrolyzed by the enzyme fatty acid amide hydrolase , and 2-AG is degraded by cytosolic monoacylglycerol lipase .

Furthermore, a significant relationship was found between GCS scores, sex, blood alcohol levels, and a history of substance abuse at the time of presentation in the ED. Older participants were found to have higher GCS scores, indicating a less serious brain injury. Study participants who had higher blood alcohol levels were found to have lower GCS scores, indicating a more serious brain injury. Age and higher blood alcohol levels were found to be associated, with higher blood alcohol levels noted in younger patients. A linear regression showed that the presence of THC was associated with lower GCS scores, which is a predictor of TBI severity. However, that finding was not statistically significant. Alternatively, being male, having elevated blood alcohol levels, having other drugs present on admission, and a history of substance abuse were all found to have a significant influence on GCS scores and TBI severity, with GCS scores being lower for all four variables, implying a more serious TBI. To effectively determine the relationship between the presence of THC and TBI severity, better data, or datasets, are needed. Perhaps, the American College of Surgeons can be empowered to employ strategies to acquire more consistent data as it pertains to drugs, so that clean data is abstracted and inputted, and clean data is analyzed and then interpreted. Another important implication to consider is the inclusion of different variables and outcome measures that can help provide a better dataset for analysis. This can include diagnostic tests such as CTs can findings, or mortality. However, the NTDB does not provide such data, therefore, the NTDB itself may not be the most ideal database to use to answer the research question posed. As expected,ebb and flow table and supported by other research studies, elevated blood alcohol levels, being male, presence of other drugs, and a diagnoses of substance abuse were found to have an influence on GCS scores.

This confirms that these variables need to be considered in the context of TBI research. While the presence of THC initially did show a hypothesized relationship to GCS score , the relationship became insignificant when adjusted for all the other covariates variables. As noted in the discussion section, and in the context of such large percentages of missing data in this study, validity of findings, such as THC prevalence rate in this TBI population, should be cautiously interpreted for all the included hypothesized explanatory variables. Further research with datasets that are larger and more complete are needed to fully understand and examine the relationship between marijuana and TBI severity. This study importantly underscores the need for better data to enable better research regarding the relationship between marijuana and TBI severity. This secondary analysis is based on data from a larger pilot, which aimed to measure the efficacy of an 8-week CM trial in treating MUD through behavioral and neuroimaging outcomes. Ethics approval for the larger pilot study, “Contingency Management, Neuroplasticity and Methamphetamines Abuse in South Africa” was obtained by the University of Cape Town’s Human Research Ethics Committee as well as the University of California, Los Angeles’ Institutional Review Board . Data were collected in Cape Town, South Africa, from August 2016 to January 2017. We report on how our sample size was determined, in addition to describing any data exclusions, manipulations, and all measures used in the study. The pilot trial aimed to select approximately 30 participants with MUD, in line with the pilot nature of the study containing a neuroimaging component, which is in line with samples sizes reported in neuroimaging studies of substance use disorder participants within a treatment setting . A total of 269 individuals were recruited via drug rehabilitation centers and then screened, of which 33 participants were eligible and consented to partake in the 8-week CM trial, in addition to completing a computerized risk-taking task and various self-report measures.

One participant was excluded due to missing baseline computerized decision-making task data, resulting in a final analytic sample size of 32. Participants were eligible to participate in the study if they were between the ages of 18 and 45 years, if they met the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria for current and primary MUD as assessed using the Structured Clinical Interview for DSM-5 , were able to attend several visits over a 2-week baseline period to complete screening tools, be available for CM pilot visits over a further 8 weeks, and tested positive for methamphetamine during the baseline phase. Exclusion criteria included meeting DSM-5 criteria for a substance other than MA, excluding secondary tobacco, marijuana, or methaqualone use disorder. Other psychiatric comorbidities were excluded for, including schizophrenia spectrum disorder, bipolar and related disorders, obsessive-compulsive related disorder, as well as depressive and anxiety disorder not induced by MUD. Currently receiving treatment for a substance other than MA, requiring inpatient treatment and/or current use of psychoactive medication, and scoring a subthreshold score on the Wechsler Abbreviated Scale of Intelligence was excluded for. Additional exclusion criteria included chronic physical or neurological illness, previous head injury, Human Immunodeficiency Virus -seropositive status based on pin-prick test, left-handedness, and exclusion criteria relating to the neuroimaging component of the study included current pregnancy, claustrophobia, pacemaker, or presence of any metal in the body.Participants attended thrice weekly clinic visits over an 8-week period to undergo drug urine testing, where urine collection was supervised and verified through urine cup temperature-sensitive strips. Urine was assessed for the presence of MA using radioimmunoassay strips , which detects MA in urine over the prior 48–73 hr. Participants were rewarded with cash vouchers for MA-negative urine tests, where the value of each subsequent cash voucher was incrementally increased by ZAR12.50 with sustained abstinence, starting at ZAR25 . A total of 24 cash vouchers could be obtained, worth a maximum of ZAR4850 . At every visit, abstinence was defined as either confirmed, with a MA-negative urine test, or as a relapse, with either a MA-positive urine test or missing test. A missing test was defined as an unattended scheduled visit with no attempt by the participant to reschedule it.

Where a MA-negative urine test was followed by a MA-positive test, the voucher for the next MA-negative urine sample was reset to ZAR25 . A “rapid reset” rule was applied to sustain motivation, which allowed a participant to return to their highest received voucher value after providing three consecutive MA-negative urine tests. In addition to testing for MA, participants were randomly tested on a weekly basis for barbiturates, cocaine, opiates, and cannabis. However, vouchers were exclusively contingent on MA nonusage. Spending during the CM trial was defined as the expenditure of a voucher on non-drug rewards following a MA-negative test, which was documented through retrieval of voucher expenditure receipts. At baseline, participants completed a sociodemographic questionnaire, the SCID-5, WASI, and Addiction Severity Index , as well as providing usage history of MA and other substances. Participants were administered the Psychology Experiment Building Language 0.14 computerized version of the Iowa Gambling Task at baseline, which has been demonstrated to capture deficits in real-world decision-making under conditions of uncertain reward and loss outcomes . The IGT has been extensively utilized to demonstrate risky decision-making among various clinical populations, including participants who use substances and those with lesions of the ventromedial prefrontal cortex . The IGT was designed to assess the extent to which individuals can learn to switch from short-term to greater long-term gains, what will be referred in this article as the “IGT Magnitude Effect,” as the metric has, in part, much to do with the size of rewards and losses. Lower “IGT Magnitude Effect” scores are more reflective of a riskier, maladaptive strategy that prioritizes immediate, large short-term rewards over long-term gains, whereas in contrast,flood table higher “IGT Magnitude Effect” scores typically illustrate a greater tendency to avoid short term rewards for larger long-term gains. Decision-making on the IGT can also be driven by the frequency with which rewards and losses are presented , where the preference for more frequent rewards will be referred to as the “IGT Frequency effect.” The IGT consists of four virtual decks, decks A, B, C, and D, each associated with a unique reward and loss probability, where participants were instructed to select decks over a series of 100 trials in a time unconstrained, quiet, and distraction-free room, after participants successfully passed a Snellen chart test for visual competence. The “IGT Magnitude Effect” is measured by a greater selection of riskier decks, A and B, where the score was calculated as the sum of deck selections –, where lower scores exhibit the “IGT Magnitude Effect.” In contrast, the “IGT Frequency effect” was demonstrated by a greater selection of decks associated with more frequency rewards, namely B and D, and was calculated as the sum of deck selections –, where a higher score reflects the “IGT Frequency effect.” Given that the objective of the IGT is to obtain a net positive payout, to promote optimal performance, participants received a flat rate of ZAR25 if they obtained an overall positive net payout following 100 trials.Participants were first described according to various sociodemographic and socioeconomic factors, including gender, ethnicity, age, education, employment, household income, and broad intellectual function. Participants were also described according to substance use characteristics, such as MA use quantity, history, and severity of use, in addition to use of other substances. Data were summarized using frequencies and percentages, for categorical variables, and median and interquartile range , for continuous variables.

A series of time-lagged counting process Cox Proportional Hazards models, computing standard errors using the grouped jacknife method, were conducted to assess whether baseline decision-making tendencies were associated with spending at future visits and whether these baseline decision-making tendencies and spending at visits were associated with future abstinence. Models controlled for recent and cumulative earnings, recent and cumulative expenditure, as well as baseline household income. Specific to Aim , adjusted models were first run, controlling only for recent and cumulative expenditure and baseline household income, and were then rerun to incorporate recent and cumulative earnings . All data analyses were conducted in R , using the survival package, version 3.2–13 . Hypotheses and methods were registered on the Open Science Framework . Participants were predominately males of mixed ancestry , with a median of 34 years old. Most participants were unemployed , had completed a median of 11 years of education, and obtained a median WASI score of 89. Participants used a median of 1 g of MA per day over a 12-year period, and 18 of participants used methaqualone and/or cannabis as a secondary substance/s alongside MA . During the trial, MA was the only substance detected in the urine of participants except for Tetrahydrocannabinol , which was detected in three participants.Overall, 30 out of the 32 participants provided all 24 urine samples , whereas one participant provided 18 urine samples and another provided 10 out of the 24 required urine samples before dropping out. Thirty-two percent of the total possible number of vouchers that could be received were missing due to MA-positive urine samples. Only “IGT Frequency Effect” was significantly associated with greater probability of spending at the current visit after controlling for last and cumulative earnings and expenditure . Obtaining a preceding MA-negative sample and greater cumulative past expenditure significantly predicted greater odds of spending at the current visit. In contrast, there was no association between “The Magnitude Effect” and spending. A higher baseline “IGT Magnitude Effect” score and recent voucher spending were linked to significantly greater odds of remaining abstinent at the current visit . In contrast, baseline “IGT Frequency Effect” was not associated with abstinence at the current visit. In both “IGT Magnitude and Frequency Effect” models, the most recent purchase significantly increased the likelihood of being abstinent at the current visit, whereas cumulative expenditure did not. Moreover, a higher baseline household income decreased the likelihood of being abstinent at the current visit. After incorporating the impact of prior abstinence in predicting current abstinence, recent expenditure no longer predicted current abstinence. In this secondary analysis, spending of CM rewards was associated with a higher chance of obtaining abstinence at the future visit, as was a baseline tendency to avoid short term rewards for larger long-term gains on the IGT. This spending result is consistent with findings from Krishnamurti et al. and Ling Murtaugh et al. , even after controlling for decision-making tendency.