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Caretakers provided informed consent and adolescents provided assent until age 17 and consent thereafter. We restricted analysis to adolescents at ages, as substance use by year was rare at younger ages: 93.9% and 84.5% did not use marijuana or alcohol, respectively, on any occasion between the ages of 7-12. Study procedures were approved by the Institutional Review Boards of the University of Pittsburgh School of Medicine and the Columbia University Mailman School of Public Health. Alcohol and marijuana use were assessed semi-annually by a 16-item Substance Use Scale adapted from the National Youth Survey. Adolescents were queried about timing, quantity, and frequency of alcohol and marijuana use. We defined “marijuana frequency” as the number of occasions of marijuana use in the past year. We defined “alcohol frequency” as the number of occasions of drinking in the past year. We defined “alcohol quantity” as the average number of drinks per occasion in the past year. For phases separated by only 6 months, past-year values were constructed by taking the average of the two semi-annual interviews. Affective, anxiety, and conduct problems were measured with items from the Child Behavior Checklist , Teacher Report Form , Youth Self-Report , and Young Adult Self Report from the Achenbach system of assessment.DSM-oriented problem domains were measured with items rated as very consistent with DSM-IV symptoms of affective disorders, anxiety disorders, and conduct disorder by a group of mental health professionals.The scales were administered to caregivers and teachers from age 7 to 16, and youth from age 10 to 19 .Items were scored as 0 = not true, 1 = somewhat or sometimes true, and 2 = very true or often true .In order to facilitate comparison across informants, total scores for each scale were converted to t-scores based on age- and gender-specific national norms .An average T-score was then calculated for years when multiple informants completed the scales. The average internal consistency coefficients for the caregiver, teacher, and youth depression scales were 0.82, 0.76, and 0.81, respectively. For the anxiety scales,rolling bench the internal consistency coefficients for caregiver, teacher and youth scales were 0.72, 0.73, and 0.67, respectively.

For the conduct disorder scale, the internal consistency coefficients were 0.91, 0.9, and 0.83 for caregiver, teacher, and youth scales, respectively.These scales have been shown to discriminate between clinic referred adolescents with depressive, anxiety, and conduct disorders and non-referred adolescents. All the scales used have previously shown acceptable concurrent and predictive validity in ROC analyses comparing the scales with official records of offense and delinquency or by assessing discrimination between adolescents referred to psychiatric clinics and non-referred adolescents.Several potential time-varying confounding factors were included in the current study to parse out the effect of psychiatric problems from the constellation of time-varying risk factors that could increase both psychiatric problems and substance use. The selection of confounders was based on theory and a review of the literature, as detailed below. “Family factors” included changes in socioeconomic status , assessed yearly by applying the Hollings head Index of Social Status to data provided by the primary caretaker or youth no longer living with family beginning at age 16; changes in parental supervision/involvement, a 43-question scale concerning caretakers’ knowledge of the youths’ whereabouts, the frequency of joint discussions, planning, and activities, and the amount of time that the youth is unsupervised; positive parenting, a scale measuring perception of frequency of positive responses to youth behavior; parental stress, a 14-item scale measuring perceived stress levels and caretakers’ abilities to cope with stress in the previous month 18; and parental use of physical punishment, drawn from a scale that measures parental discipline strategies. “Peer Variables” consisted of changes in youth peer delinquency and peer substance use, a 15-item scale that corresponds to a self-reported delinquency scale.Analyses were conducted in R version 3.0.2 and 3.0.3. Missing data in the covariates were imputed using R package ‘mice’ for “multivariate imputation by chained equations,” an implementation of fully conditional specified models for imputation. The fully conditional approach differs from the more traditional joint modeling approach by specifying a multivariate imputation model on a variable-by-variable basis. This fully conditional approach is used as an alternative to traditional joint modeling when no suitable multivariate distribution can be found. We imputed 20 datasets, and in subsequent analyses used the R package ‘mitools to pool the results of functions run on the 20 data sets using Rubin’s Rules.

We employed quasi-Poisson regression techniques to assess the fixed effects that one-yearlagged changes in psychiatric problems had on subsequent changes in alcohol use frequency/quantity and marijuana use frequency from ages 13 to 19. Quasi-Poisson models are an approach to dealing with over-dispersion, which was apparent in initial Poisson models. They use the mean regression function and the variance function from Poisson generalized linear models but leave the dispersion parameter unrestricted and estimate it from the data. Unlike negative binomial models, the variance is assumed to be a linear function of the mean.This strategy leads to the same coefficient estimates as a standard Poisson model but standard errors are adjusted for over dispersion. Following the “dummy variable method” for fixed effects in Poisson models 41 we included k – 1 dummy variables to represent the sample participants in each model. A series of models were fit sequentially to test the association of each one-year-lagged psychiatric problem domain with each substance use outcome. First, we regressed separately each one year-lagged shift in the average psychiatric problem T-scores on each substance use outcome. Within these models, age-related changes in substance use were controlled for using natural cubic splines. Natural cubic splines are a flexible smoothing approach for non-linear relationships, and are composed of piece wise polynomial functions that split the continuous age variable into separate line segments, each free to have its own shape. Segments are joined by “knots,” which we specified a priori to result in line segments for ages 13-14, 15-16, and 17-19. Slopes are constrained to converge at each knot. Second, we sequentially tested groups of potential confounders. All covariates were back-lagged two years, so that they would be modeled prior to the measurement of the exposure. This ensured that the estimated total effect of change in psychiatric problems on change in substance use included effects mediated through the covariates that occurred contemporaneous to changes in psychiatric problems. In our second set of models, we adjusted for age, SES, substance use variables that were not modeled as the outcome , and measures of psychiatric problems that were not the exposure of interest . In our third and fourth sets of models, we adjusted for age and parenting variables and age and peer variables, respectively.

In our fifth set of models,dry rack cannabis we adjusted for covariates that were significant in models. Third, we tested whether age modified the effect of our exposures by including a product term between exposure and each age spline. Significant effect measure modification was then probed to clarify how the association between psychiatric problems and substance use changed across the age splines. We conducted a sensitivity analysis to establish the directionality of the association between psychiatric problems and substance use. We thus estimated, with linear fixed effects models, the effect that changes in one-year-lagged substance use had on change in psychiatric problem domains in the following year. We followed the same modeling strategy for these models as we did with our primary models. We adjusted for groups of confounders as described above, first adjusting for SES, psychiatric problem domains that were not modeled as the outcome , and measures of substance use that were not the exposure of interest . Next we adjusted for parenting variables and peer variables, respectively. Finally, we adjusted for covariates that were significant in any of the previous groups of confounder models. Covariates were lagged one year prior to the exposure measure , to avoid blocking the causal Table 1 shows mean substance use and psychiatric problem counts over time, as well as demographic characteristics at baseline. The reports of particular informants in our psychiatric problem measures did not influence the associations between psychiatric problems and substance use . Table 2 displays the exponentiated coefficients and confidence intervals of quasiPoisson models, which can be interpreted as rate ratios. Table 2 shows the rate of substance use associated with a one-unit within-subject change in lagged psychiatric problems. Changes in lagged conduct problems were positively associated with changes in marijuana frequency. During years in which adolescents experienced a one-unit increase in conduct problems, the rate at which they smoked marijuana the following year increased 1.03 times : 1.01, 1.05. For a standard deviation change in conduct problems, this is equivalent to a 1.15 times higher rate of marijuana use frequency . The magnitude of this association did not change appreciably after adjusting for potential confounders, including alcohol quantity and frequency, SES, affective and anxiety problems, parenting, and peer deviance. Changes in lagged conduct problems were also associated with changes in alcohol quantity, only after adjusting for peer deviance. During years in which adolescents experienced a one-unit increase in conduct problems, the rate of their average alcohol consumption per occasion the following year increased by 1.01 . For a standard deviation change in conduct problems, this is equivalent to a 1.05 times higher rate of alcohol use . Associations of all covariates with substance use are presented in Appendix C, Table C1. Table 3 presents results for tests of effect measure modification of the association between conduct problems and marijuana frequency and alcohol quantity by age. Because splines are polynomial functions, there is no simple quantitative interpretation of individual effect modification terms; however, the significance of the coefficients implies that the associations between lagged conduct problems and marijuana frequency, and lagged conduct problems and alcohol quantity, differed by age. For ease of interpretation we present these results in Figure 1, which shows the predicted values of substance use outcomes associated with minimum, mean, and third-quartile levels of lagged conduct disorder T-scores, over time. Compared to minimal changes in lagged conduct problems, adolescents with mean or third-quartile levels of change in lagged conduct problems show markedly different marijuana frequency trajectories, which become the most disparate at ages 17-19. Compared to minimal changes in lagged conduct problems, adolescents with mean or third-quartile levels of change in lagged conduct problems show higher alcohol quantity in early adolescence but lower alcohol quantity in later adolescence. The results of our sensitivity analysis are presented in Table 4 and 5, and Figure 2. Table 4 displays the change in psychiatric problems associated with a one-unit change in lagged substance use in the prior year. There was one reverse association: while changes in lagged anxiety problems were not associated with changes in substance use, the opposite did occur: changes in lagged alcohol quantity in the past year were positively associated with changes in anxiety problems. During years in which adolescents experienced a one-unit increase in the average quantity of alcohol consumed when drinking, their anxiety problems T-score increased the following year by 0.12 . For a standard deviation change in average alcohol quantity, this is equivalent to an anxiety T-score increase of 0.3 .Associations of all lagged covariates with psychiatric problems are presented in Appendix C, Table C2. Table 5 presents results for tests of effect measure modification of the association between lagged alcohol quantity and anxiety problems by age, and Figure 2 shows the predicted values of anxiety problem T-scores associated with minimum, mean, and third-quartile levels of lagged alcohol quantity, over time. Adolescents show a decline in anxiety problems throughout adolescence, and little difference by the magnitude of fluctuations in lagged alcohol quantity. However, deviations arose at ages 13-14 and 17-19, where those who exhibited a mean or third-quartile level of increase in lagged alcohol quantity showed slower declines in anxiety problems compared to those who did not increase alcohol intake over time. This study focused on the longitudinal relationship between changes in psychiatric problems and changes in substance use one year later. However, the temporal resolution of this relationship may occur on a much shorter time frame – that is, changes in psychiatric problems may have immediate effects on substance use .

Notably, the correlations between cigarette demand indices and WSWS negative affect scores have not been previously reported. Although our participants were relatively satiated with smoking when they completed the CPT, these findings suggest that smokers’ withdrawal experience was positively associated with their demand for cigarettes. In contrast, we did not find alcohol demand indices and latent factors were correlated with alcohol-dependence measures except for the SAWS scores. Several studies have reported positive correlations, such as drinks per week , monthly binge drinking days , and AUDIT scores . Although the exact reasons for this discrepancy are unclear, we speculate that two factors may be relevant. The first is that the APT used in our study is different from other studies in terms of its instruction about framing the hypothetical drinking context, which will be discussed more in the study limitations later. Briefly, our generic description of the drinking situations may be insufficient to allow participants to imagine their typical drinking scenarios thus that they could not accurately report their alcohol demand. The other possible reason might be differences between study populations. Unlike previous studies , our participants were treatment seeking, and thus their motivation of quitting/reducing drinking and smoking may have changed how they responded in these purchase tasks. Besides the difference of motivations, our participants were more dependent on alcohol than the undergraduate samples tested previously —the average AUDIT score in our sample was almost twice that of theirs. Similarly, all of our participants had a diagnosis of AUD, while only about 50% who were dependent or abusing alcohol in the study by Amlung et al. . Additionally, our participants were also heavy smokers and importantly, several studies found that smoking resulted in higher demand for alcohol than nonsmoking . Thus, smoking may have resulted in a higher and more uniform alcohol use demand, masking a possible linear relationship between dependence and demand. Consistent with this possibility, we did not find any relationships between alcohol demand and alcohol misuse diagnoses. Although this possibility exists,cannabis square pot future studies evaluating this population will help address whether heavy smoking can indeed mask the relationship between alcohol dependence measures and alcohol demand indices.

The positive correlations between alcohol and cigarette demand indices suggest that those who had higher demand for alcohol tended to have higher demand for cigarettes too. This co-demand pattern is consistent with a recent study which revealed the same positive correlations among a similar sample of heavy drinking smokers . Moreover, by conducting hierarchical multiple regression analyses, their study found that smoking had a positive impact on the alcohol demand, but not the other way around . Their finding may help explain the relative higher demand for alcohol than for cigarettes among treatment-seeking smokers with AUD in the present study, because our participants were more dependent on nicotine than those non-treatment seeking heavy drinking smokers in their study —the relatively higher level of smoking in our sample may have resulted in greater alcohol demand in an asymmetric fashion. An important study factor that should be taken into account is the differential alcohol and smoking satiation statuses among the participants. Although our participants were instructed to complete the hypothetical purchase tasks in a general context, we cannot rule out the possibility that the reported demand patterns may have been influenced by their alcohol and smoking statuses. Previously, we speculated that the special characteristics may have caused the null correlations between alcohol demand and alcohol related measures. Unlike other alcohol-related measures, alcohol withdrawal scores were correlated with alcohol demand metrics, which support the possibility that alcohol deprivation status may have indeed increased the reported demand for alcohol among our participants who experienced more alcohol withdrawal, consistent with a previous study which showed the increased cigarette demand among nicotine-deprived smokers . In the current study, we also found that cigarette demand metrics were positively correlated with smoking withdrawal, which suggests an increased demand for cigarettes due to smoking deprivation. However, the exact effects of alcohol deprivation on alcohol demand are more speculative with the current study design , which can be examined in future studies that contrast the alcohol demand metrics between deprived and satiated patients with AUD. The study has the following limitations. First, the APT and CPT were administered separately, with each having no assumption of allocating limited resources to the other.

Although our findings suggested that alcohol had higher demand than cigarettes using the single-commodity tasks , we do not have direct evidence that alcohol is preferred if both drugs are considered in the same context. Such relative preference between two co-used drugs can be best captured by a cross-commodity task wherein the consumption patterns for both drugs are examined simultaneously. Using the cross-commodity paradigm, researchers have found a complex interplay between cannabis and alcohol use with nontrivial proportions of the study sample showing patterns of complementarity, substitution, and independence . However, in a different cross-commodity study involving marijuana and tobacco cigarettes, researchers found an independent demand pattern between these two drugs . These studies suggest the manipulation robustness of using the cross-commodity paradigm in substance use research to simultaneously study couse of drugs. More importantly, this paradigm provides a better ecological validity by placing participants in a more realistic context with their access to both drugs while having limited shared resources. Future studies should consider using this cross commodity paradigm to better capture the demand for alcohol and cigarettes among smokers with AUD, which may shed light on developing personalized treatments based on relative demand patterns between alcohol and cigarettes. Second, to make the participants have similar contexts for the APT and CPT, the APT’s instruction used the same contextual description as the CPT’s, and differences in the current APT’s instructions from previous studies may have affected participants’ ability to report their alcohol demand with ecological validity. Previous studies have generally assessed alcohol demand under contexts in which alcohol is likely to be consumed . Similarly, time parameters such as duration of access and weekend vs. weekday have been shown to impact alcohol demand. Third, per protocol requirements, participants were abstinent from alcohol to have proper cognitive functionality to complete the visits, but they could smoke ad libitum. Thus, differences in alcohol deprivation and smoking satiation may have affected the demand for alcohol and cigarettes. Alcohol appeared to have higher relative reinforcing efficacy than cigarettes among adult smokers with alcohol use disorder, as evidenced by their greater demand for alcohol than for cigarettes, although it is possible that acute substance status may play a role in modulating the demand for alcohol and cigarettes.

A two-factor structure was identified for both alcohol and cigarette demand curves, and the differential loadings of demand indices in the current population of heavy drinking smokers and other less dependent younger samples assessed previously suggest a distinct demand pattern for smokers with AUD. As an important future direction of the present study, hierarchical multiple regressions analyses of multiple purchase tasks should be conducted to provide a deeper understanding of cross substance demand for alcohol and cigarettes among treatment seeking smokers with AUD. Health care reform in the United States has had major implications for people with substance use disorders , including greater opportunities to enroll in private insurance coverage, increased access to services, and changes in health care costs . The Affordable Care Act established state insurance exchanges to promote and offer health coverage, and mandated SUD and psychiatric disorder treatment as essential benefits. Practitioners expected these ACA mandates,trim tray implemented in 2014, to increase access to care . Following ACA implementation in 2014, the overall number of individuals living without insurance dropped . Evidence suggests a positive impact of the ACA on both SUD and psychiatry coverage , including an increase in insurance choices . The number of individuals with identified SUDs enrolled in health plans increased . But access to services remains a major concern , and much is still unknown regarding how ACA-associated enrollment through insurance exchanges and cost-sharing structures are associated with access to and use of SUD treatment and other health services in this complex patient population.Specific characteristics of the ACA, such as enrollment via new state insurance exchanges and increased patient cost sharing via higher deductibles, may influence treatment differentially for people with SUDs who may be new enrollees . Patient cost sharing may adversely impact both initiation and retention. If SUD treatment and psychiatry services are viewed as discretionary and less essential than primary care, they may be especially vulnerable to cost-sharing mechanisms . A previous evaluation of SUD patients enrolled in the same California healthcare system found that compared to a pre-ACA enrollment cohort with SUDs, post-ACA SUD patients had more psychiatric and medical conditions and greater enrollment in high-deductible plans. Although this prior work did not examine patterns of health service utilization, the findings suggest that newly enrolled patients post-ACA may have greater clinical needs as well as increased financial obstacles to accessing services . It is important to not only evaluate SUD treatment initiation and retention over time following implementation of the ACA, but also to evaluate how factors related to the ACA may influence utilization of other health services. The current study aimed to extend what is currently known about the consequences of healthcare reform by examining the potential relationship of ACA exchange enrollment and high deductible health plans to trends in health service utilization in a cohort of individuals who were newly enrolled in a healthcare system and had a documented SUD.

We examined factors associated with utilization as conceptualized by the Andersen model of healthcare utilization , which proposes that utilization is determined by predisposing need and enabling factors . We hypothesized that psychiatric comorbidity would be associated with greater use of health services, and that members with higher deductibles would be less likely to initiate SUD and psychiatry treatment but would have higher emergency department and inpatient utilization than those without deductibles. As with earlier studies , which indicate that SUD diagnosis is often precipitated by a critical event such as an ED visit, we expected that post diagnosis utilization would be highest in the period immediately following diagnosis but would likely decrease over time, although trajectories would vary by type of utilization. Knowing how these factors are associated with use of healthcare can be highly informative to future healthcare reform and behavioral health services research. Kaiser Permanente Northern California is an integrated healthcare system serving approximately 4 million members . The membership is racially and socioeconomically diverse and representative of the demographic of the geographic area . SUD treatment is provided in specialty clinics within KPNC, which patients can access directly without a referral. The group based treatment model is similar to outpatient treatment programs nationwide. Treatment sessions take place daily or four times a week, depending on severity, for nine weeks . Treatment in psychiatry includes assessment, individual and group psychotherapy, and medication management . KPNC is not contracted to provide SUD care or intensive psychiatry treatment for Medicaid patients and those patients are referred to county providers. The University of California, San Francisco and Kaiser Permanente Northern California Institutional Review Boards approved the study and approved a waiver of informed consent.We identified common chronic medical conditions , many of which are known to be associated with SUDs using ICD-9/10 codes recorded within the first year after initial enrollment. Conditions included asthma, atherosclerosis, atrial fibrillation, chronic kidney disease, chronic liver disease, chronic obstructive pulmonary disease, coronary disease, diabetes mellitus, dementia, epilepsy, gastroesophageal reflux, heart failure, hyperlipidemia, hypertension, migraine, osteoarthritis, osteoporosis and osteopenia, Parkinson’s disease or syndrome, peptic ulcer, and rheumatoid arthritis. Patients with chronic medical conditions utilize more health services than patients without such conditions , which may influence their decision to choose a plan with a lower deductible if given an option , so we included this covariate to control for confounding. Deductibles are features across different benefit plans, including commercial plans, but are more common in ACA benefit plans. The individual deductible limit is the amount the individual must pay out of-pocket for health expenses before eligibility for health plan benefits. At KPNC, there are many types of benefit plans that include deductibles.

The participation of some participants can be interrupted due to drug-related police arrest or methadone treatment fatigue. This limitation can be minimized as we will select clinics with low drop-out rates. We have officially informed the local police on the study implementation and received approval from both national and local authorities. While this measure does not prevent participants from being arrested, especially when they are involved in illegal activities, it could reduce attrition. Furthermore, the COVID-19 pandemic and containment measures could pose challenges for the study implementation. With the response plan developed for potential interruption scenarios, we believe the study will be implemented safely and will maintain a high-level of data quality and intervention fidelity.Marijuana is one of the most widely used illicit substances world-wide. Although it has been reported that marijuana use rate has stabilized or even decreased in recent years in most high-income countries, the continuing high prevalence of use among adolescents and young adults is a cause for concern. Such emerging trends have heightened interest in the link between mental health problems and adolescent marijuana use to inform policy and prevention efforts. Understanding the comorbidity between psychopathology and marijuana use is complicated. Marijuana use is associated with numerous different psychiatric disorders, each of which tend to co-occur with one another. Additionally complicating matters is the potential bidirectional nature of this association,vertical grow system with evidence that marijuana use may both predict and result from poor zmental health. A parsimonious explanation of this comorbidity may be that a small set of transdiagnostic psychopathological vulnerabilities that give rise to numerous mental health conditions may also contribute to and result from marijuana use.

Such transdiagnostic vulnerabilities may account for the pervasive patterns of psychiatric comorbidity with use of marijuana and other substances. One such transdiagnostic vulnerability is anhedonia— diminished capacity to experience pleasure in response to rewards. As a subjective manifestation of deficient reward processing capabilities, anhedonia is believed to result from hypoactive brain reward circuitry. While anhedonia is a core feature in a DSM-defined major depressive episode, it has also been linked to other psychopathologies comorbid with drug use, including psychosis, borderline personality disorder, social anxiety, attention deficit hyperactivity disorder and post-traumatic stress disorder and has therefore been proposed to be a transdiagnostic process. Departing from its consideration as a ‘symptom’ of a disease state as in DSM-defined major depression, anhedonia has also been conceptualized as a continuous dimension, upon which there are substantial inter-individual differences. Individuals at the lower end of the anhedonic spectrum experience high levels of pleasure and experience robust affective responses to pleasurable events, whereas those at the upper end of this spectrum exhibit more prominent deficits in their pleasure experience. Anhedonia operates as a ‘traitlike’ dimension that is stable yet malleable, which is empirically and conceptually distinct from other emotional constructs, such as reward sensitivity , alexithymia and emotional numbing , sadness and negative affect. Recent literature documents a consistent association between anhedonia and substance use in adults. To the best of our knowledge, there has been only prior study of the association between anhedonia and marijuana use in youth, which found higher anhedonia levels among treatment-seeking marijuana users than healthy controls in a cross-sectional analysis of 62 French adolescents and young adults. Given the absence of longitudinal data, it is unclear whether anhedonia is a risk factor for or consequence of adolescent marijuana use. Because youth with higher anhedonia levels experience little pleasure from routine rewards they may seek out drugs of abuse, such as marijuana, which stimulate neural circuitry that underlie pleasure pharmacologically.

Alternatively, repeated tetrahydrocannabinol exposure during adolescence produces enduring deficits in brain reward system function and anhedonia-like behavior in rodent models. In observational studies of adults, heavy or problematic marijuana use is associated with subsequent anhedonia and diminished brain reward region activity during reward anticipation. Consequently, it is plausible that anhedonia may both increase risk of marijuana use and result from marijuana use. Because early adolescence is a period in which risk of marijuana use uptake is high and the developing brain may be vulnerable to cannabinoid-induced neuroadaptations, this study estimated the strength of bidirectional longitudinal associations between anhedonia and marijuana use among adolescents during the first 2 years of high school. The primary aim was to test the following hypotheses: greater baseline anhedonia would be associated with a faster rate of escalation in marijuana use across follow-up periods; and more frequent use of marijuana at baseline would be associated with increases in anhedonia across follow-ups. A secondary aim was to test whether these putative risk pathways were amplified or suppressed among pertinent sub-populations and contexts. Associations of affective disturbance and other risk factors with adolescent substance use escalation have been reported to be amplified among girls, early- onset substance users and those with substance-using peers.We therefore tested whether associations between anhedonia and marijuana use were moderated by gender, history of marijuana use prior to the study surveillance period at baseline and peer marijuana use at baseline.To characterize trajectories of anhedonia and marijuana use across time, latent growth curve modeling was applied to estimate a baseline level and linear slope for both anhedonia and marijuana use. Univariate latent growth curve models were first fitted for marijuana use and anhedonia separately to determine the shape and variance of trajectories. A two-process parallel latent growth curve model was then fitted, which simultaneously included growth factors for anhedonia and marijuana use after adjusting for covariates listed above and including within-construct level-to-slope associations.

The parallel process model was constructed to test: bidirectional longitudinal associations by including directional paths from baseline anhedonia level to marijuana use slope as well as baseline marijuana use level to anhedonia slope; and non-directional correlations between baseline levels of anhedonia and marijuana use and between anhedonia slope and marijuana use slope. Significant directional longitudinal paths between anhedonia and marijuana use in the overall sample were tested subsequently in moderation analyses of differences in the strength of paths across sub-samples stratified by moderator status using a multi-group analysis. Analyses were performed using Mplus with the complex analysis function to adjust parameter standard errors due to clustering of the data by school. To address item- and wave-level missing data,grow cannabis in containers full information maximum likelihood estimation with robust standard errors was applied. Continuous and categorical ordinal scaled outcomes were applied for anhedonia and marijuana use, respectively. The Akaike information criterion and the Bayesian information criterion were used to gauge model fit in which lower values represent better-fitting models. For moderator analyses, χ2 differences were calculated using log-likelihood values and the number of free parameters contrasting the model fit with equality constraints on the anhedonia–marijuana use path of interest across groups stratified by the moderator variable. Standardized parameter estimates and 95% confidence intervals are reported. Significance was set at α = 0.05 .Youth with higher levels of anhedonia at baseline were at increased risk of marijuana use escalation during early adolescence in this study. In addition, levels of anhedonia and marijuana use reported at the beginning of high school were associated cross-sectionally with each other. To the best of our knowledge, the only prior study on this topic found higher levels of anhedonia in 32 treatment-seeking marijuana users than 30 healthy controls in a cross-sectional analysis of French 14–20-year-olds who did not adjust for confounders. The current data provide new evidence elucidating the nature and direction of this association in a large community-based sample, which advances a literature that has addressed the role of anhedonia predominately in adult samples. The association of baseline anhedonia with marijuana use escalation was observed after adjustment of numerous possible confounders, including demographic variables, symptom levels of three psychiatric syndromes linked previously with anhedonia and alcohol and tobacco use. Consequently, it is unlikely that anhedonia is merely a marker of these other psychopathological sources of marijuana use risk or a non-specific proclivity to any type of substance use. The temporal ordering of anhedonia relative to marijuana was addressed by the overarching bidirectional modeling strategy, which showed evidence of one direction of association and not the other direction . Ordering was confirmed further in moderator tests showing that the association of anhedonia with subsequent marijuana use did not differ by baseline history of marijuana use. Thus, differences in risk of marijuana use between adolescents with higher anhedonia may be observed in cases when anhedonia precedes the onset of marijuana use. Why might anhedonia be associated uniquely with subsequent risk of marijuana use escalation in early adolescence? Anhedonic individuals require a higher threshold of reward stimulation to generate an affective response and therefore may be particularly motivated to seek out pharmacological rewards to satisfy the basic drive to experience pleasure, as evidenced by prior work linking anhedonia to subsequent tobacco smoking escalation.Among the three most commonly used drugs of abuse in youth , marijuana may possess the most robust mood-altering psychoactive effects in young adolescents.

Consequently, marijuana may have unique appeal for anhedonic youth driven to experience pleasure that they may otherwise be unable to derive easily via typical non-drug rewards. The study results may open new opportunities for marijuana use prevention. Brief measures of anhedonia that have been validated in youth, such as the SHAPS scale used here, may be useful for identifying teens at risk who may benefit from interventions. If anhedonia is ultimately deemed a causal risk factor, targeting anhedonia may prove useful in marijuana use prevention. Interventions promoting youth engagement in healthy alternative rewarding behaviors without resorting to drug use have shown promise in prevention, and could be useful for offsetting anhedonia-related risk of marijuana use update. Moderator results raise several potential scientific and practical implications. The association was stronger among adolescents with friends who used marijuana, suggesting that expression of a proclivity to marijuana use may be amplified among teens in environments in which marijuana is easily accessible and socially normative. The association of anhedonia with marijuana use escalation did not differ by gender or baseline history of marijuana use. Thus, preventive interventions that address anhedonia may: benefit both boys and girls , aid in disrupting risk of onset as well as progression of marijuana use following initiation and be particularly valuable for teens in high-risk social environments. While anhedonia increased linearly over the first 2 years of high school on average, the rate of change in anhedonia was not associated with baseline marijuana use or changes in marijuana use across time. Given that anhedonia is a manifestation of defificient reward activity, this finding is discordant with pre-clinical evidence of THC induced dampening of brain reward activity and prior adult observational data, showing that heavy or problematic marijuana use is associated with subsequent anhedonia and diminished brain reward region activity during reward anticipation. Perhaps the typical level and chronicity of exposure to marijuana use in this general sample of high school students was insufficient for detecting cannabinoid-induced manifestations of reward deficiency. Longer periods of follow-up may be needed to determine the extent of marijuana exposure at which cannabinoid-induced reward functioning impairment and resultant psychopathological sequelae may arise. Strengths of this study include the large and demographically diverse sample, repeated-measures follow-up over a key developmental period, modeling of multi-directional associations, rigorous adjustment of potential confounders, high participation and retention rates and moderator tests to elucidate generalizability of the associations. Future work in which inclusion of biomarkers and objective measures is feasible may prove useful. Prevalence of heavy marijuana use was low in this sample, which precluded examination of clinical outcomes, such as marijuana use disorder. Students who did complete the final follow-up had lower baseline marijuana use and anhedonia, which might impact representativeness. Further evaluation of the impact of family history of mental health or substance use problems as well as use of other illicit substances, which was not addressed here, is warranted.Although researchers in sociology, cultural studies, and anthropology have attempted, for the last 20 years, to re-conceptualize ethnicity within post-modernist thought and debated the usefulness of such concepts as “new ethnicities,” researchers within the field of alcohol and drug use continue to collect data on ethnic groups on an annual basis using previously determined census formulated categories.

Raw scores for each of these component tests were converted to demographically-adjusted T-scores , including adjustments for age, education, gender, and ethnicity as available for each test. The demographically adjusted T-scores for each test were then converted into deficit scores, which reflect degree of impairment by setting performances within the normal range at zero with a range from 0 to 5 . Finally, the individual deficit scores were averaged to derive the domain deficit score, which reflects the severity of executive functioning deficit. Previous work has demonstrated that deficit scores achieve good diagnostic agreement with classifications made by blind clinical ratings. All neurocognitive testing and scoring was performed by trained psychometrists blinded to participants’ genotypes.A multiplex PCR technique designed using Sequenom SpectroDESIGNER software was employed by inputting a sequence containing 100 bp of flanking sequence on either side of the COMT Val158Met polymorphism. The SNP was then grouped into multiplexes so that the extended product would not overlap in mass with any other oligonucleotide present in the reaction mix, and where no primer-primer, primer-product, or nonspecific interactions would occur. The PCR was carried out in 384-well reaction plates in a volume of 5 μl using 10 ng genomic or whole-genome amplified DNA. All subsequent steps, up until the reaction, were spotted onto the SpectroCHIP and carried out in the same reaction plate. After PCR, any unincorporated dNTPs from the PCR were removed from the reaction by digestion with Shrimp alkaline phosphatase. dNTPs were removed so that they could not play any role in the extension of the oligonucleotide at the SNP site. The extension reaction was then carried out in the presence of the extension oligonucleotide and a termination mix containing mass-modified dideoxynucleotides which extended the oligonucleotide over the SNP site with one base. Before spotting onto the SpectroCHIP, the reaction was cleaned by incubation with a cation-exchange resin which removed any salts present.

The extension product was then spotted onto a 384-well spectroCHIP before being flown in the MALDI-TOF mass spectrometer. Data were collected, in real time,cannabis grow lights using SpectroTYPER Analyzer 3.3.0.15, SpectraAQUIRE 3.3.1.1 and SpectroCALLER 3.3.0.14 algorithms. All genotyping was performed by an accredited commercial laboratory .All statistical tests and procedures were conducted using SPSS 10.0 . Univariate comparisons across the three COMT genotypes were performed using one-way analysis of variance for continuous and chi-squared tests for categorical variables. In cases, where data violated normality assumptions medians were calculated and nonparametric tests performed. To examine the main and explore the interaction effects of executive functioning and COMT on sexual risk behaviors, hierarchical multiple linear regressions in accord with Barron and Kenny’s approach were conducted for each of the seven sexual risk behaviors under study. Prior to running each analysis, the executive functioning variable was centered and the COMT genotype contrast coded to reduce problems resulting from multi-collinearity . In addition, interaction terms were created by multiplying COMT genotype by the centered executive functioning variable. Next, multiple linear regressions were used to examine potential confounders based on univariate genotype comparisons described above. These confounders included: ethnicity, METH status, HIV status and age at first intercourse. We also included BDI scores based on inclusion of this measure in recent work testing a similar hypothesis. Results showed that METH status, HIV status, and age at first intercourse accounted for a significant unique variance for all sexual behaviors under investigation . Thus to control for these potential confounding effects, the residuals derived from each of the sexual behavior models were used as the dependent variables for all subsequent regression models. The centered executive functioning variable and COMT genotype as well as the new interaction term were then entered as independent variables into seven individual hierarchical multiple regression models using the residuals described above as the dependent variable. For models in which a significant interaction was observed, a final round of regressions were conducted stratified by COMT genotype to determine the nature of the interaction between executive functioning and COMT on the particular sexual risk behavior.

Due to the exploratory nature of the interaction analysis we selected a relaxed alpha threshold alpha < .10 to reduce Type II errors, albeit the traditional alpha threshold of .05 was used for all.To our knowledge this study is the first to examine main effects as well as explore the interaction effects of COMT genotype and executive functioning on sexual risk behavior. Our main findings suggest significant executive dysfunction main effects for number of sexual partners as well as frequency of oral sex and condom use. In addition, results of our exploratory interaction analyses provide evidence that COMT genotype and executive dysfunction interact in models of number of sexual partners, condom use, insertive and receptive anal sex, as well as oral sex. Stratified analyses further suggest that the strength of these associations is dependent on the number of Met alleles the individual was carrying, with the exception of oral sex in which Val/Val was the informative genotype. Our significant executive dysfunction main effects for sexual risk behaviors are discordant with the only other study, to our knowledge, that has examined the association between executive dysfunction and sexual risk behavior. In that study, no association was found between executivedys function and sexual risk behavior among an African American sample of men and women poly-substance abusers with and without HIV infection. However, three major methodological differences may explain our discordant findings. First, Gonzalez et al. estimated sexual risk behavior in the past 6 months compared to our window of 12 months and also utilized a composite score rather than individual sexual risk behaviors as their dependent variable. Second, executive dysfunction was assessed using the Iowa Gambling Task, delayed non-matching to sample paradigm, and Stroop task-reaction time version which, respectively, measure decision-making, working memory, and response inhibition. Although these tests are well justified, other components of executive functioning such as perseveration, cognitive sequencing, and concept formation which were assessed in the current study, were not examined. Third and finally, regression models were adjusted for sensation seeking, a factor shown in previous research to be associated with sexual risk behavior; however, in the current study sensation seeking data was not available and was not adjusted for.

Thus, future work examining the association between executive dysfunction and sexual risk behaviors are warranted; particularly research utilizing larger samples with diverse measures of executive functioning and models adjusting for sensation seeking and other personality covariates. Novel to the current study, we demonstrated several genotype by endophenotype interactions for sexual risk behaviors. A relaxed significance criterion produced significant interactions for number of sexual partners, condom use, insertive and receptive anal sex, as well as oral sex. These interactions collectively advocate for further investigation of genotypeendophenotype interactions for sexual risk behavior. However, due to the exploratory nature of these interactions our discussion will be confined to interactions observed for number of sexual partners, frequency of insertive anal sex and condom use,cannabis grow tent as interactions observed in these models met the traditional significance criterion . We observed both a main and interaction effect for number of sexual partners, albeit only within the model including the composite executive functioning deficit score. In this model we found that among carriers of the Met allele , a positive association between executive functioning deficit and number of sexual partners was present. Thus, among Met allele carriers those with greater deficit scores reported greater number of sexual partners; whereas among Val/Val carriers this association was not significant. Similar to results for number of sexual partners, stratified analysis showed that among carriers of the Met/Met but not Val/Met or Val/Val genotype an positive association between executive dysfunction and frequency of insertive anal sex was present, although only statistically significant for models including the Trails B test. Thus, individuals with lower T-scores on Trails B reported greater frequency of insertive anal sex only if they were carriers of the Met/Met genotype. Finally, the strongest interaction observed was between COMT and the Halstead Category Test for frequency of condom use. Contrary to the expected association, results suggest a negative association among carriers of the Met/Met genotype in which lower T-scores on the Category Test was associated with an increased frequency of condom use. This unexpected finding may be a result of several factors. First, the psychometric properties of the questionnaire used to measure sexual risk behaviors in our study have not been reported and thus measurement error may be influencing our reported associations. Although there is no agreed upon “gold-standard” for measuring sexual risk behavior, recommendations from a review of 56 sexual risk behavior measures in the literature have been developed and future studies should be encouraged to adopt these measurement strategies to improve accuracy of sexual risk behavior characterization. Second, recall deficits may result in sexual risk behavior reporting errors. This is particularly a concern when measuring sexual risk behavior retrospectively over large spans of time as was done in the current study. Post-hoc analysis within our sample showed no significant difference in recall deficit by COMT genotype, albeit there did appear to be a trend = 2.89; P = .058 in which carriers of the Val/Val genotype had greater deficits than that of Val/Met and Met/Met genotypes . Thus, it is possible that recall deficits within the Val/Val group biased our findings toward those in the Met/Met group and should be interpreted with caution. Finally and most speculative, harm reduction campaigns have long aimed to increase condom use within both HIV-infected and METH using populations and our finding may be an artifact of their success.

Collectively, these findings provide a preliminary model of differential susceptibility to sexual risk behavior via executive dysfunction, dependent on COMT genotype, particularly the Met/Met genotype . Although the role of the Met/Met genotype is contrary to our hypothesis, our findings, when placed in the context of previous research are informative. Recent research has linked the COMT Met/Met genotype to novelty seeking behavior in healthy and methamphetamine using populations. In addition, work by Gonzalez et al. on executive functioning and sexual risk behavior demonstrated that sensation seeking was independently associated with sexual risk, particularly among HIV-seropositive individuals. Thus, it appears that individuals with the Met/Met genotype may have a lower tolerance for monotony and may seek and participate in higher risk behaviors such as METH use or unprotected sex. Furthermore, work by our group and others have suggested that possession of the Met allele enhances executive functioning in healthy controls;however, this neuroprotective effect is significantly reduced among individuals exposed to methamphetamine. Thus, it is probable that in our sample, of which approximately half were methamphetamine dependent, the putative protective effect of the Met/Met genotype is diminished and propensity to sexual risk behavior enhanced. It is apparent that the associations between COMT, executive dysfunction, and sexual risk behavior are highly complex and context dependent. The current study provides preliminary evidence of these complex relationships and advocates for larger investigations that improve upon and consider several of the limitations that have been presented. Future work should also attempt to address independent and interaction effects of other putative polymorphisms particularly those involved in dopamine synthesis , metabolism , and reception . In addition, future transdisciplinary work that combines genetic and neurocognitive factors with psychosocial factors will provide valuable insights and elucidate a clearer picture of sexual risk behavior. Completion of such work in combination with the current as well as others previous work will further our understanding of the genotypic and endophenotypic factors involved in the phenotypic expression of sexual risk behaviors and potentially assist with risk identification, prevention, and treatment efforts in the future.These interruptions are a result of both widespread closure of services deemed nonessential in order to reduce social interactions and slow the spread of the novel coronavirus that causes COVID-19, and voluntary avoidance of situations perceived to be high risk for contracting COVID-19. These non-pharmaceutical interventions reduced the incidence of COVID-19 , allowing time for the development of effective vaccines and preventing potentially tens of thousands of deaths. However, interventions also led to substantial disruption of health and healthcare services , possibly at the expense of the health of people who relied on this medical care.

If the link between inflammation and depression is causal, our results suggest that treatment with selected anti-inflammatory medications might benefit mood and life quality in some PWH. Depressed mood was specifically associated with a factor loading on d-dimer, IL-6 and CRP. Factor analysis is a statistical method used to describe variability among observed, correlated variables in terms of a potentially lower number of unobserved variables called factors. Thus,factor analysis is a method for dimensionality reduction and can help control false discovery. Additionally, however, it is important to check the identified factors against known physiological relationships. Several prior reports link these specific markers with each other, particularly in the context of HIV, suggesting that they represent a physiologically congruent aspect of the inflammatory cascade. For example, the pro-inflammatory cytokine IL-6 stimulates the production of C-reactive protein in the liver . In one study, higher pre-ART CRP, D-dimer, and IL-6 levels were associated with new AIDS events or death . Also, in HIV patients, IL-6, hsCRP and D-dimer were intercorrelated and each was associated with an increased risk of cardiovascular disease independent of other CVD risk factors . In another report, baseline IL-6 and D-dimer were strong predictors of coronary risk in non-HIV-infected individuals and were associated with each other and with CRP . Additional support for the coherence of Factor 2 is that its components in this dataset demonstrate robust and statistically significant intercorrelations, while their correlations with other biomarkers are typically weaker and not statistically significant . Previous studies have demonstrated the importance for depression of the specific biomarkers identified in Factor 2. Thus, cognitive symptoms of depression at follow-up were associated with higher baseline plasma levels of CRP and IL-6 at baseline.In a clinical,mobile grow system high CRP was also shown to predict response to the anti-inflammatory drug infliximab, an inhibitor of TNF .

BDI-II scores at baseline and follow-up were highly correlated. Together with the finding that higher inflammatory markers at 12-year follow-up also were associated with depressed mood at baseline, these findings suggest that depressed mood is an enduring phenotype. A novel finding in this study was that although women had worse depressive symptoms, the association with inflammatory markers was seen only in men. While perhaps reflecting limited power due to the small number of women, this suggests that the underlying pathophysiology of depression is different in men and women with HIV. Of note, women tended to have higher markers of inflammation than men, consistent with a previous report . We found worse depression in non-Hispanic whites than in other ethnicities. This is consonant with higher rates of depressive disorders in whites in previous studies .Inflammation was not related to CD4 or viral load in this cohort of mostly virally suppressed PWH. Unlike other studies, elevations in inflammatory biomarkers were not associated with substance use disorders. Higher inflammatory biomarkers also were associated with greater disability , motor impairment, poor physical health , poorer general health, physical function, role function, social function, pain function, and worse health distress, emphasizing the importance of this phenotype. Inferences are limited by several factors in this study. There were relatively few women, However, inspection of the scatter plot reveals that there was no suggestion of a trend for an association between inflammation and depression in women. The panel of soluble biomarkers studied was limited, and important associations may have been missed. We did not characterize cellular markers of inflammation in these participants. The absence of a control group precludes consideration of whether effects of inflammation on depression are mediated or otherwise influenced by HIV infection itself. As noted previously, anti-inflammatory medications have shown promise for treatment-resistance depression.

Future studies might evaluate the effectiveness of anti-inflammatory medications for the treatment of depression in PWH selected for the presence of inflammation and treatment resistance.Public health measures to contain the spread of COVID-19, the disease caused by the novel coronavirus SARS-CoV-2, have affected billions of people worldwide. In March 2020, approximately 1.7 billion people were under orders to remain at home or shelter-in-place . Such orders, which mandate remaining at home except for essential activities and outdoor exercise with social distance , are crucial to slowing transmission of COVID-19, preserving healthcare systems’ capacities, and limiting deaths . However, successes in mitigating the spread of COVID-19 are paired with devastating economic, social, and psychological effects . Stress management strategies are needed to preserve well-being during this abrupt isolation period. Physical activity decreases emotional stress and improves physical and psychological health . Yet, engaging in regular PA can be challenging under even normal circumstances. In 2018, 54.2% of American adults engaged in light or moderate activity for 150+ minutes/week or vigorous activity for 75+ minutes per week . SIP orders may further reduce activity levels by decreasing incidental daily PA and exercise opportunities . As such, the World Health Organization issued recommendations for engaging in PA at home . Many people face serious challenges to being physically active during SIP. Many neighborhoods may not be conducive to safe, socially distant outdoor exercise. Moreover, many individuals have increased demands on their time during SIP, such as essential work, caring for family members, and standing in long lines to buy necessities. Vulnerable communities, particularly communities of color, have been disproportionately affected by COVID-19 . On the other hand, SIP may facilitate greater PA for some individuals. Those who transitioned from commuting to working from home may have more free time for PA. Additionally, individuals and families may spend time outside to combat boredom and stress.

Some stress management strategies that may be used during COVID-19 involve physical activity ,cannabis grow tray while others are mostly sedentary . We hypothesized that adults who met PA guidelines during COVID-19 SIP would be less likely to report increased stress during SIP and would be more likely to report use of physically active stress management strategies. We also explored whether increased stress would be associated with PA pattern or associated with use of specific stress management strategies. Participants were recruited from the U.S. component of the Stanford WELL for Life initiative , a cohort of adults residing mostly in Northern California. Eligible participants for the WELL for Life cohort were age 18 or older, residing in the U.S., and able to complete the online survey in English. Participants were recruited through research registries, Stanford listservs, social media, and through existing community partnerships . WELL for Life cohort participants who had indicated willingness to participate in other studies were invited to participate in the present study examining well-being during COVID-19. Participants completed surveys in early SIP and mid-SIP . Participants provided informed consent and the study was approved by the Stanford University Institutional Review Board. The majority of participants resided in the San Francisco Bay Area, where a regional SIP order on 17 March 2020 affecting 6 Bay Area counties and the city of Berkeley mandated closure of indoor and outdoor recreation venues such as gyms, climbing walls, playgrounds, golf courses, basketball and tennis courts, and pools . Additionally, the state of California closed many state parks and beaches and instructed residents to stay close to home for recreation . Most restrictions remained in place through the end of May 2020 . Past-month PA was measured with the Stanford Leisure-Time Activity Categorical Item , a validated measure with excellent sensitivity to change in PA over time . Participants selected one of six descriptions that best matched their past month leisure time physical activity. Scoring was based on adherence to the 2007 American College of Sports Medicine/American Heart Association guideline of: a) 30+ minutes of moderate-intensity aerobic physical activity 5 days/week, b) 20+ minutes of vigorous-intensity aerobic physical activity 3 days/week, or c) a combination of the above . Responses were categorized as meeting/exceeding or not meeting PA guidelines. Stress during SIP In early SIP, participants were asked, “Since the Shelter in Place Order, how stressed do you feel?” . At mid-SIP, participants were asked, “In the last two weeks, how stressed did you feel?” . Responses were categorized as “increase in stress” or “no increase in stress.” Coping strategies Participants responded to, “What are you currently doing to manage your stress?”. In early SIP, the question was open-ended. Participant responses from early SIP informed the 10 response options provided in mid-SIP: outdoor physical activities , indoor physical activities , yoga/meditation/prayer, calling/video-chatting with friends and family, watching TV/movies at home, reading, listening to music, gardening, sleeping more, and eating more. Participant characteristics Participants reported their age, gender, race, education, total combined family income, marital status, employment status, and the number of people living in their household. Participants also reported the number of days they drank alcohol in the past month and whether they used cannabis in the past two weeks . Current smoking status was derived from two items; participants were considered current smokers if they reported 100+ lifetime cigarettes and currently smoking “some days” or “every day” . Differences in participant characteristics by mid-SIP PA were tested using independent-samples t-tests and chi-square tests. PA pattern from early SIP to mid-SIP was coded as “remaining inactive” , “remaining active” , “becoming inactive” , or “becoming active” . Logistic regressions examined differences by mid-SIP PA in likelihood of increased stress at mid-SIP and use of each stress management strategy at mid-SIP, adjusting for age, race, education, income, employment, and past-month alcohol use . Chisquare tests examined the association between mid-SIP stress and PA pattern, and between midSIP stress and mid-SIP use of stress management strategies.

P-values < 0.05 were considered statistically significant. Managing stress while complying with the uniquely disruptive COVID-19 SIP restrictions may require a variety of stress management strategies. In a sample of adults mostly residing in Northern California, we examined relationships between stress, physical activity, and other stress management strategies during SIP. Participants who were physically active during SIP were less likely to feel increased stress during SIP and were more likely to report use of physically active stress management strategies. Additionally, physically active participants were less likely to report managing stress by sleeping more or eating more. Participants who reported managing stress using outdoor PA, indoor PA, and reading were less likely to feel increased stress during SIP. Those who managed stress by watching TV/movies, sleeping more, and eating more were more likely to feel increased stress. The association between greater PA and lower stress was consistent with hypotheses and with the extensive literature on the positive effects of PA on stress reduction in non-COVID contexts . Engaging in PA may have significantly reduced stress incurred by COVID-19. Alternatively, participants with fewer stressors may have found it easier to be physically active. In this study, participants meeting PA guidelines were older, more likely to be White and to drink alcohol, had greater educational attainment and higher household income, and were less likely to be employed . These participants may represent a subset of adults with greater resources and fewer demands on their time during SIP, leading to lower stress and increased ability to engage in PA. Nonetheless, the association between PA and stress remained statistically significant after accounting for age, race, past-month alcohol use, education, household income, and employment status. Participants reported relative stress during SIP compared to their own previous stress level. Engaging in PA may have contributed to stress management, even for participants who already had many advantages. This study suggests that the well-documented positive effects of PA on stress management persist even in the highly unusual circumstances of SIP. Active and less active participants also differed in the stress management strategies they employed. A majority of active participants reported that they used PA—especially outdoor PA — to manage stress. Active participants were four times more likely than less active participants to report managing stress using outdoor PA than inactive participants. Active participants were also more likely to report use of indoor PA, yoga, meditation, or prayer, gardening, and reading. Most of these activities involve a physical activity component. Additionally, physically active participants were less likely to cope with stress by eating more or sleeping more.

Revenues, based on a 20% state tax on sales, are anticipated to be $52 million a year.Public lands advocates were, of course, up in arms against the government redirecting funds away from the protection of public lands as expressly dictated in the referendum that passed in November 2020. 8 Gianforte’s budget also proposed redirecting about $11 million to be saved from a two-month halt to paying into the fund that pays the state’s share of its employee’s health insurance, along with a similar pause in contributions to the retirement of Montana’s judges, citing surpluses in both. Roughly $11 million of the reductions Gianforte proposes come from a two-month pause in the money the state pays as its share of employees’ health insurance premiums. Another controversial proposal in the governor’s budget was the proposal to garner about $24 million in savings by cutting staffing across state agencies by about 4%. Opponents argued that many state agencies were already severely understaffed. The governor’s proposal to not spend down the current surplus, as proposed in Governor Bullock’s budget, also motivated significant opposition. Governor Gianforte has touted this as yet another good faith demonstration of his conservative fiscal credentials. Meanwhile, not to be outdone, the Republican Legislative Caucus was busy too during the 2020 campaign season, signaling their intentions. In September 2020, anticipating with good reason a Gianforte victory, and its continued legislative majority in both houses all but guaranteed, House Republicans released their plan that enumerated their priorities, including reducing the “property tax burden,” reducing the “income tax burden,” a flat budget , lowering Medicaid Reimbursement rate to primary care hospitals , increase taxes on renewable energy generation, weaken the renewable portfolio requirement , introduce a series of voter repression laws , “remove nonessential services” , lower state employee FTE, literally disallow state gas tax monies from being used on bike paths and trails , promote school choice, a variety of anti-choice abortion proposals ,cannabis drying racks undermine the ability of public health officials and the governor’s office from imposing restrictions during public health emergencies , undermine union rights and of course, strengthening law and order.

Hence, as Montana headed into the 67th Session, it was assumed that there would be a rightward tilt in taxation and spending, and in a host of other bills. However, the details of what would pass and in what form were not. What follows is a summary of what happened during the session, turning attention first to the budget, then tax policy, and then more briefly describing what is intended to be a representative sampling of other bills in an effort to provide “a sense of the session.” Montana’s Medicaid program provides coverage for one-in-four Montanans , of who 100,000 are covered as part of Medicaid Expansion. Medicaid expansion has been contentious in Montana since it first passed during the 2015 legislature. In 2019, its fate was once again in doubt as many Republicans were opposed to the expansion. However, in the end it survived when Democrats joined with a group of moderate Republicans to pass the legislation, this time with work requirements that were insisted upon by the moderate Republicans. While the Trump Administration encouraged states to pass work requirements, this has since been reversed by the Biden Administration. As reported by Andrea Halland of Kaiser Health News in August 2021, “CMS [Centers for Medicare & Medicaid Services] has communicated to [the Montana Department of Public Health and Human Services] that a five-year extension of the Medicaid expansion waiver will not include work/community engagement requirements,” health officials wrote in a Medicaid waiver amendment application out for public review.In other words, while the Trump Administration was friendly to state level work requirements, it never completed the approval process for Montana, and the Biden Administration has told Montana that it will not accept a work requirement. As of this writing, no work requirements have been imposed on Medicaid recipients, nor are they likely to be at least for the remainder of the Biden Administration Medicaid expansion has survived at least in part by virtue of the fact that so many Montana state legislators come from poor rural communities heavily enrolled in Medicaid Expansion.

While the will of the Republican legislative majority and governor is clearly in favor of imposing work requirements of 80 hours a month, at least for now, the state seems ready to continue expansion even without work requirements, at least until 2025, when the legislature and governor will again have to vote to extend the program. Another important and politically contentious issue related to Medicaid expansion is continuous coverage. At play here is whether or not a person can or cannot maintain continuous Medicaid coverage for 12 months even if their income fluctuates during that time period. The 2021 legislature voted to terminate continuous coverage despite concerns expressed by many advocates of low-income health care concerned this will adversely affect a large number of Montanans. Tax cuts advantageous for wealthy Montanans and the businesses they own are foundational to Gianforte’s Montana Comeback Plan and the Republican legislative majority. According to the Montana Budget & Policy Center, “the 2021 Legislature enacted 21 pieces of legislation to cut taxes ultimately costing the state $77 million in lost revenue in the next biennium. While the state also will see some new revenue from the taxation of recreational cannabis, the state projects a net loss of revenue of $19 million over the 2023 biennium.” The cost of these tax breaks over the course of the 2025 biennium is estimated to be 109 million dollars. And, absent unforeseen changes in Montana’s legislative make-up, forecasting additional tax cuts during the 2023 legislative session seems likely. Of the tax breaks, the most regressive and the most expensive was SB 159, which cut the top income tax rate in Montana from 6.9% to 6.75%. This one was important to the governor and his supporters. The governor’s vision is that it “will keep more money in the hands of those who earn it and attract more wealthy investors to live in Montana,” which of course, is a good thing from perspective of the proponents. The critique is that most of these benefits go to the wealthy, and is thus unfair, and also that it costs the state revenues. The two other most important tax cuts were in capital gains and the business equipment tax. Despite the highly party polarized tenor of most committee and floor debate over most of the tax cut proposals, some bills did generate bipartisan support. Notable amongst them was HB 191, which provided residential property tax credit for the elderly, with an anticipated fiscal impact of $5.8 million over the course of the 2023 Biennium and about the same for the 2025 Biennium; HB 340, which provided tax incentives to film companies to shoot in Montana, with an anticipated fiscal impact of 2.0 million over the course of the 2023 Biennium and twice that in the2025 Biennium; HB 629, which provided for job creation tax credits; HB 663, which directed state tax revenues from recreational marijuana to public schools in an effort to decrease school funding pressures placed on local property taxpayers. Only one of these bills was key sponsored by a Democrat. Democrats, of course, put forward a series of efforts at progressive tax reform,hydroponic cannabis system all of which were defeated. House Bill 631 would have increased the state Earned Income Tax Credit. It was tabled in House Taxation Committee on a party-line vote. Other examples included a bill that would have created an income tax credit to help lower-income Montanans pay property taxes.

Another one would have bumped up income taxes on high earners to expand the Earned Income Tax Credit. The value contrasts here are strikingly clear. Rs wanted tax breaks for businesses and wealthy individuals, and Ds wanted tax increases on the wealthy and tax breaks for middle class, working class, and low-income people. Self-cutting can be understood clinically as a symptomatic behavior, on the one hand, and as a bodily practice embedded in a cultural imaginary and identity on the other. It is present in a variety of ways including the 1993 memoir of Susanna Kaysen “Girl, Interrupted” , the 1995 acknowledgment by Princess Diana that she identified herself as a “cutter,” and the 2011 video “F**kin’ Perfect” by the pop music performer Pink. The Internet has become a massively popular resource for cutters to share information , and one study identified more than 400 message boards about cutting generated via five search engines . Youths may identify with “Emo” or “Goth” culture which lionize depression and cultivate self-cutting as a cultural practice . Popular concern about perceived dangers of self-cutting has at times been heightened to the point that one cultural historian suggested that “Cutting has become a new moral panic about the dangers confronting today’s youth” . Anthropology has not been disposed toward addressing cutting as a problematic cultural or clinical phenomenon given the disciplinary propensity to understand body mutilation and modification in terms of rituals and cultural practices. This is perhaps because ritual meaning is not so dependent on distinguishing whether harm is inflicted by others or by oneself or on differentiating cultural practice from psychopathology. One other anthropological observation has been provided by Lester, who notes that current explanations of self-harm can be grouped into four categories: communicating emotional pain, emotional or physiological self-regulation, interpersonal strategy, and cultural trend. She notes that these categories share the idea that self-harm manifests individual pathology or dysfunction, with the cultural assumption of the individual as a rational actor. In contrast, an anthropological perspective emphasizes the “cultural actor who embodies and responds to cultural systems of meaning to internal psychological or physiological states” . Emphasizing the powerful symbolic significance and long cross-cultural record of self-harm and blood shedding as ritual and even therapeutic practices, she suggests that contemporary cutting may be seen as privatized and decontextualized social rituals affecting transformation parallel to collective initiation rituals that operate in a cycle of self-harm and repair, especially in the case of adolescent girls struggling with the aftermath of sexual abuse and/or with contradictory gender messages . Sociocultural characteristics of a typical “self-cutter” emerged in the 1960s as Euro-American, attractive, intelligent, and possibly sexually adventurous teenage girls, that Brickman claimed was partially taken up in medical discourse in a manner that “pathologizes the female body, relying on the notion of ‘femininity as a disease’” . Gilman took exception to assumptions of pathology with the provocative claim that “self-cutting is a reasonable response to an irrational world” . From a clinical vantage point, self-cutting is often viewed as a type of injury or harm to the self. The historical backdrop to this development can be traced to Menninger’s attention to self-mutilation as distinguished from suicidality. The distinction between “delicate” and “coarse” self-cutting was made by Pao , with Weissman focusing on wrist-cutting syndrome and Pattison and Kahan proposing the existence of a deliberate self-harm syndrome. Favazza provided cases of extreme and highly unusual forms of self-mutilation in excruciating detail, with an attempt to classify types based on severity. With the provisional emergence of non-suicidal self-injury disorder criteria in the fifth version of the Statistical and Diagnostic Manual of Mental Disorders DSM-V ,the distinction between self-harm as within a normative or pathological range remains equivocal. This is illustrative of the manner in which conceptualizations of self-cutting continue to be embedded in a complex cultural history of changes in the incidence, popular awareness, and social conditions in which such phenomena occur.While it is possible to find clinical, psychometric, survey, and historical approaches to the phenomenon of self-cutting, we lack an ethnographic account with a substantive locus in the interactions of individuals, grounded in the specificity of bodily experience and the immediacy of struggle in the face of existential precarity . In this article, we take a step toward such an account with a discussion situated at the intersection of two anthropological concerns. First is the ethnographic understanding of experiential specificity through anthropological adaptation of phenomenological method .

We did not replicate the findings of our previous study with regard to differences in the same word categories, further adding to this concern. However, we are equally interested in the lack of a difference as we are in detecting differences. Although negative findings are often highlighted less than positive ones, this analysis did not find a difference in the majority of word categories . Finally, as the majority of letters do not denote letter-writer gender and most were composed by a group of authors, this group composition did not allow for any evaluation of the relationships between author gender and applicant gender with respect to language used in the SLOE.In the 1970s, priority emergency medical services dispatch systems were introduced to help triage 911 calls and resources. Since then, multiple versions of dispatch triage, including criteria-based dispatch, medical priority dispatch systems, and locally developed protocols have been used.Many studies suggest that priority dispatch systems lead to overtriage of Advanced Life Support units with <1% of low-acuity calls requiring ALS resources.For this reason, multiple large cities with accelerating EMS call volumes are re-evaluating their current dispatch systems. Multiple studies have attempted to identify low-acuity chief complaints and triage criteria at the 911-dispatch level to better optimize allocation of resources.Although abdominal pain is one of the most common reasons 911 is activated, few studies have specifically examined dispatch protocols for abdominal pain. The few studies that have been published suggest over triage and over utilization of ALS resources for abdominal pain with a range from 10-51%.Other retrospective reviews found that 84-98% of abdominal pain calls are low acuity and that less than 6-8% were considered true emergencies.Of note,planting table most ALS care was pulse oximetry and/or an intravenous placement, and when the analysis was restricted to IV fluid bolus, medication, intubation or defibrillation, the majority received ALS <10% of time.

Although more than 85% of 911 incidents for abdominal pain require only Basic Life Support transport to the emergency department ,8 many dispatch systems continue to send ALS resources, sometimes in addition to the closest first responder units. In 2015, the Los Angeles Fire Department implemented an internally developed tiered dispatch system . Under LA-TDS, patients reporting a chief complaint of abdominal pain received the closest BLS ambulance dispatched alone emergency if located within three miles of the incident. If no BLS ambulance was available within three miles, then a closer paramedic ambulance was dispatched, and if no ambulance was available within three miles, a BLS fire company responded emergency along with the closest ambulance non-emergency. The purpose of this study was to evaluate the safety of this dispatch algorithm by determining the prevalence of 911 patients with abdominal pain and a documented time-sensitive event.The LAFD is a tiered, fire-based EMS provider system, and it is the sole provider of 911-EMS response for the City of Los Angeles. The department covers 480 square miles and serves a population of 4.2 million people. All 911-call takers are sworn members of the LAFD and are either firefighter/ paramedics or firefighter/emergency medicine technicians who are certified as emergency medical dispatchers. A resource is dispatched to all calls, and there is mandatory offer of ambulance transport to an ED. LAFD-TDS is a homegrown dispatch system that was implemented in 2015 with the goal of improving call processing times, cardiac arrest recognition, resource availability and response times. Under LAFD-TDS, patients reporting a chief complaint of abdominal pain receive the closest BLS ambulance dispatched alone emergency if located within three miles of the incident. While the dispatch protocol calls for a BLS ambulance, the dispatch protocol dictates that an ALS ambulance responds if no BLS ambulances are available within three miles. Of note, in this system, only ALS providers can perform prehospital electrocardiograms .

However, given that ALS providers may be dispatched to these calls, ECGs are occasionally performed on patients with non-traumatic abdominal pain who met our study inclusion criteria.This was a retrospective review of electronic health records for 911 incidents dispatched as non-traumatic abdominal pain from May 2015–May 2018. Cases were included if the patient’s chief complaint was abdominal pain, the patient was the caller or was in close proximity to the caller , the patient was over age 15, and the patient was awake and breathing normally. All calls that met this inclusion criteria regardless of resource dispatched or transport to an ED were included in the study. The primary outcome was the prevalence of documented, time-sensitive prehospital events that require emergent lifesaving interventions, defined as cardiopulmonary resuscitation , defibrillation, or airway management . Secondary outcomes were incidents that could potentially benefit from ALS resources and included the presence of hypotension or a prehospital 12-lead ECG that was read as ST-elevated myocardial infarction or wide complex arrhythmia by computer software. ECGs that were marked as STEMI or wide complex arrhythmia were reviewed and interpreted by the authors . Descriptive statistics are presented, including frequencies. We excluded all incidents that were the result of trauma. Audios from the 911 calls for cases involving CPR, defibrillation, or airway management were reviewed. We used qualitative analysis to identify any themes or key words in the calls. Additionally, dispatch protocol adherence was evaluated. This study was approved by the institutional review board of the University of Southern California .Abdominal pain is a common medical reason for 911 activation. In an environment with limited resources and increasing 911-call volumes, minimizing over triage is essential to ensure ALS resources are available for true, time-critical emergencies. By introducing a tiered-dispatch system that dispatches a BLS ambulance alone for non-traumatic abdominal pain in patients who are awake and breathing normally, there is a potential opportunity to free up more ALS and first-responder resources to respond to true, time-critical calls. Time-sensitive events were identified in only 0.021% of all cases meeting inclusion criteria, which is considerably lower than LAFD’s overall rate of 0.82% for time-sensitive events for all EMS 911 calls during the study period. The need for airway management or CPR was extraordinarily rare among the 33,000 abdominal pain dispatches under study.

Furthermore, in two of the seven cases, if dispatch protocol had been followed correctly, ALS resources would have been deployed, decreasing the frequency from 0.021% to 0.015%, ie, 1.5 in 10,000 patient dispatches. This underscores the importance of a robust, dispatch quality improvement program. Close monitoring, feedback,cannabis indoor grow system and education are necessary to ensure that the system is being properly used to protect the public and allow for effective and efficient dispatch protocols. Hypotension was the most common outcome of interest that was documented. However, it is difficult to infer the clinical significance of these numbers and whether a closer first responder or an ALS response with IV fluids would have been of benefit. ECGs that met STEMI criteria were also very uncommon events in this cohort. None of the patients with ECGs that met STEMI criteria were hypotensive upon EMS arrival nor did they require CPR, airway management, or defibrillation prior to ED arrival. Furthermore, 50% of them were deemed to be false positives by the software algorithm. Finally, there is an association between age and time sensitive outcomes. Patients who had time-sensitive events tended to be older and female . Additionally, patients with ECGs that met STEMI criteria also tended to be older . While patients over the age of 65 accounted for 21.9% of all included calls, they made up 85.7% of time-sensitive events.Median success rates for prehospital ETI in the United States are lower than those for extraglottic airway placement.Currently, the national emergency medical services educational standards for paramedics do not define intubation training requirements for paramedics.Also, paramedics have few requirements during training to adequately practice the skill of intubation,and few ongoing opportunities to maintain proficiency.Neonatal resuscitations that use EGAs have demonstrated safety, high placement success, and improved resuscitation rates when compared to bag-valve mask ventilation .Limited data exists across the entire pediatric age spectrum on the use of EGAs, especially in EMS. A National Association of EMS Physicians position statement recommends that EMS have at least one blindly inserted nonsurgical airway available.Likewise, the American Academy of Pediatrics Committee on Pediatric Emergency Medicine and the American College of Emergency Physicians Pediatrics Committee have recommended the inclusion of EGAs with supplies for difficult airway conditions in the emergency department.In 2014 the National Association of State EMS Officials published its Model Clinical EMS Guidelines, which included recommendations from an evidence-based guideline for pediatric airway management that was implemented as part of a separate project in several New England states and the City of Houston Fire Department . The guideline emphasized step-wise escalation in airway management from BVM to EGA to ETI, only if the less invasive method was not effective .We performed a retrospective cohort study of pediatric patients <16 years old cared for by the HFD EMS from January 1, 2013 – March 31, 2017. We compared the intubation rates, operational metrics, and clinical outcomes of pediatric patients with respiratory failure or in cardiac arrest two years before and after an airway management algorithm change that included addition and prioritization of the EGA device, i-gel, . We used recorded end-tidal waveform capnography as a marker of both EGA and endotracheal tube success, or paramedic-reported passage through the vocal cords for ETI success. Prehospital return of spontaneous circulation , as recorded from the patient care and records, was defined as presence of a pulse with cessation of cardiopulmonary resuscitation prior to hospital arrival.

We recorded survival outcomes from both hospital records and the EMS agency cardiac arrest database.HFD is a two-tiered 9-1-1 EMS system with Basic Life Support and Advanced Life Support units. HFD serves a geographic area totaling 2.3 million persons and 667 square miles in the greater Houston region. The agency receives 300,000 EMS calls annually. No other EMS agencies provide emergency 9-1-1 response within Houston city limits. HFD has 3500 prehospital providers, all of whom are trained as firefighters and have at least BLS emergency medical technician training. HFD also has 700 paramedics providing ALS care. Dispatch of the initial unit is determined based on the 9-1-1 call type and severity.The local EMS protocol for management of respiratory failure in pediatric patients changed to include the use of an EGA for pediatric patients – the i-gel – in addition to algorithmic progression from one device to a more advanced device. Prior to the protocol change no EGA device was available for pediatric airway management due to the size restrictions of the then-used King LT-D airway . Prior to the protocol change pediatric patients with respiratory failure or cardiac arrest were managed first with BVM followed by intubation. Both ALS and BLS providers were equipped with the i-gel EGA post-protocol change for both adults and pediatric patients. The King LT-D was not available post-protocol change. The airway management protocol directed members to use BVM first and then advance to an EGA for all patients requiring transport and continued assisted ventilation. If the EGA provided inadequate oxygenation or ventilation it could be removed, with intubation attempted by a paramedic. The new protocol inclusive of EGAs was implemented in conjunction with an in-person lecture and skills training described in a prior publication.All study patients received ALS care.We retrospectively reviewed electronic patient data to establish the baseline characteristics, incidence of airway procedures, and outcomes for patients meeting this study’s inclusion criteria . Prospective patients were electronically identified on a weekly basis via the patient care record and cardiac arrest quality-assurance databases. Records were reviewed by trained abstractors who were aware of the study design and outcomes in question. Hospital and outcome data were abstracted from the EMS agency’s cardiac arrest database and hospital inpatient medical records.In this observational study, we found that the establishment of an airway management algorithm paired with an EGA suitable for all ages of pediatric patients decreased the rate of ETI in an urban EMS system. No differences in survival to hospital admission or discharge were observed in all patients with cardiac arrest or respiratory failure. For cardiac arrest patients specifically, we observed no difference in rates of ROSC.

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.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,microgreen grow rack 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.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. Previous work has shown that triage assessments can have poor interrater and intra-rater agreement.Additional research could evaluate whether the additional screening questions distract the triage nurse from his or her primary goal of assessing acuity and contribute to inconsistency in triage assessments. If nurses were liberated from the mandated questions, they could potentially have more time for one-on-one patient care and other aspects of patient care, such as medication administration and lab draws. Although we suspect that reducing the number of required questions would free nurses to spend more time on direct patient care and improve efficiency of ED throughput, additional research will be required to study this hypothesis. Studies evaluating ED screening questions often praise their ability to detect at-risk groups without looking at patient oriented outcomes or cost. Cost-benefit analyses should be considered prior to mandating additional nurse screening questions as even a few seconds spent on a question adds up to a significant amount of time. A better research agenda is needed to assess the impact of triage questions on patient care.There is significant potential for future research related to this topic. Further studies are needed to determine cost effectiveness of required ED screenings, including questions included as public health screens. Other potential time saving measures, such as self-completed triage questionnaires on kiosks, could be researched as well. Dr. Roberts has delivered an excellent review of many medical aspects of cannabis use and the effect of cannabis legalization on emergency medicine in Colorado.As emergency physician researchers in Colorado, we echo many of his concerns.

As he notes, since legalization, we have identified an increase in accidental pediatric exposures, an increase in emergency department visits for hyperemesis ,an increased number of visits attributable to cannabis edibles,a disproportionate increase in adult and adolescent mental health visits related to cannabis, and an increased number of visits for cannabis toxicity.These effects are measurable, and while the direct attribution of these changes to cannabis legalization are limited to observational data that is subject to temporal trends, selection bias, and confounding, we believe the links between these changes and cannabis legalization are plausible, consistent and relevant. While much of the focus in Colorado has been on recreational cannabis, it is important to note that many of the issues identified began before recreational cannabis was available in 2014. In Colorado, medical cannabis was legalized in 2000 and has been widely available since 2009. In Colorado, the qualifying medical conditions for cannabis use include the following: cancer, glaucoma HIV, severe pain, seizures, nausea, muscle spasm, post-traumatic stress disorder , autism spectrum disorder, and cachexia.As of June 2019, almost 84,000 patients have an active medical marijuana registration, 337 less than 18 years of age.As with any therapy, the adverse effects we have identified must be balanced against the potential benefits to patients and society. However, there are few high-quality evidenced based studies to support these recommendations. Without clinical trials the measurement of the positive effects of cannabis remain largely anecdotal.The United States Food and Drug Administration has issued numerous warning letters to various cannabidiol manufacturers for false claims in relation to disease diagnosis and treatment.The medical utility of cannabis is further limited by insufficient training provided to medical professionals and trainees, in addition to the reliance of many users on non-medical providers to guide therapeutic choices. For example, many dispensaries will recommend cannabis to pregnant women despite various national guidelines cautioning against this practice.The medical benefits of cannabis should have been evaluated using accepted clinical standards prior to providing legal status as medical treatments.

Recreational use has no demonstrated inherent health benefit. While some have suggested that it may increase relaxation and reduce stress, there are no clinical studies to support those claims. One plausible health benefit is the substitution of cannabis for other more dangerous recreational drugs; however, ebb and flow flood table this is also not studied. Unfortunately, in Colorado we see that cannabis is also often combined with alcohol and other drugs and the relative increase in adverse effects may outweigh this potential benefit. Despite the observed increase in cannabis related driving fatalities in Colorado, 55% of cannabis users believed it was safe to drive under the influence of cannabis.There have been mixed results on how marijuana legalization has affected medical and non-medical opioid use and prescribing.The discussion around the impact of cannabis on the healthcare system is not absolute. When we speak to cannabis supporters we often hear the justification that it is safer than alternatives, and there are no real adverse effects. We believe our work has clearly demonstrated that cannabis legalization has measurably impacted the delivery of emergency care in Colorado. However, it is important to put the magnitude of this impact in perspective. Since 2006, more than 2000 Coloradans have died from opioid overdose, and tobacco use-associated healthcare costs in Colorado are almost 2 billion dollars per year. While it is disingenuous to say that cannabis legalization has not impacted emergency medicine in Colorado, it is important to recognize that there are many greater threats to public health and to provide appropriate focus to each of these conditions. A legitimate discussion around the health effects of cannabis in Colorado requires a fair assessment of the risks and benefits by advocates and critics alike. Continued surveillance on both the positive and negative effects on marijuana legalization, and evidence based research is needed as more states continue to pass medical and recreational marijuana. The long-term effects of increased availability of high-THC-cannabis are still to be determined. It is critical for public health officials, healthcare providers and legislators, in conjunction with advocates and industry representatives, to work toward regulations aimed at minimizing the public health impact of cannabis legalization on society. Musculoskeletal injuries are a major cause of morbidity and mortality across the world that disproportionately affect those in low- and middle-income countries , which often lack trained healthcare providers who can properly treat such conditions.Approximately 90% of the five million annual deaths across the world due to injuries occur in LMICs such as Rwanda.The literature lacks an updated fund of knowledge regarding the prevalence, etiology, and treatment for MSIs in Rwanda to supplement previous studies. The growing number of Rwandan healthcare providers may incorporate this knowledge into educational programs when approaching MSI.Injuries in Rwanda are associated with significant morbidity and mortality.Past studies in Rwanda have shown that most trauma victims are young men.Road traffic accidents , especially those involving motorcycles, were the most common mechanism for adults, while children were frequently injured as pedestrians.Approximately one-quarter of injured patients suffered a fracture.The overall mortality prevalence was 5.5% with approximately half of the hospital deaths occurring in the emergency department.Yet, these mortality figures do not paint a comprehensive picture of the burdens posed by MSIs and fractures in particular. MSIs resulting from trauma are frequently undertreated, causing difficulty for patients to resume normal work and life activities.This is related both to cost and a shortage of technology and supplies.In addition to a dearth of supplies, achieving health outcome targets without securing the appropriate human resources is difficult.One team in Namibia found that three out of the eight Millennium Development Goals concerning healthcare required appropriate human resources for success.A recent interrupted time-series study found that building Rwanda’s emergency medicine training program resulted in an absolute reduction of overall facilities-based mortality by 4% overall, which was twice as great a decline as the national trend.Such investments are vital to improving health in this region. While Africa contains approximately one-quarter of the world’s burden of diseases, it possesses 4% of its health staff.A recent systematic review found that of 59 LMIC emergency care programs, very few incorporated specialist emergency care training.The largest share of facilities was staffed either by physicians-in-training or by physicians whose level of training was unspecified. Data showed high patient loads and mortality, specifically in Africa where a substantial proportion of total deaths occurred in EDs.Compared to other LMIC regions, ED mortality is highest in Africa, with a median mortality rate of 3.4% compared to the average of 1.8% across all studied LMICs.A minority of LMIC EDs incorporate specialty-trained emergency physicians into the staffing paradigm, but availability is limited.The high volume and urgency of treatment make emergency care an important area of focus for interventions aimed at reducing mortality in these settings. Within a short period of time, Rwanda has made significant improvements to its healthcare system. Rwanda’s transformation of its health sector since the 1990s has helped to raise life expectancy from 27 years to 63 years of age, and nearly all Rwandans have health insurance.Although there have been significant improvements, Rwanda has just 0.84 health providers per 1000 population, the majority of whom are generalists. This number falls below the minimum 2.3 providers per 1000 population set forth by the World Health Organization.In 2011, the Rwandan Ministry of Health began a seven-year partnership with a U.S. academic consortium to train Rwandan providers to become future educators through medical residencies, creating the Human Resources for Health Program. Among the new medical residencies is the first EMTP in Rwanda.These trainees have introduced new emergency skills, such as triage and resuscitation, along with improvements to local protocols and systems.The training curriculum was in line with the American Board of Emergency Medicine 2013 Model of the Clinical Practice of Emergency Medicine.International faculty practicing EM were hired to implement EM training through the HRH program, a collaboration between academic medical centers in the U.S. and the Rwandan Ministry of Health.

This study examined longitudinal patterns of healthcare utilization among SUD patients and their relationships to key aspects of ACA benefit plans, including enrollment mechanisms and deductible levels. We anticipated that the increase in coverage opportunities that the ACA provided would bring high-utilizing patients into health systems, driving up overall use of healthcare. Consistent with prior studies of SUD treatment samples that have found elevated levels of healthcare utilization either immediately before or after starting SUD treatment , results of our longitudinal analysis showed that utilization among people with SUDs was highest immediately after initial SUD diagnosis at KPNC, and declined to a stable level in subsequent years. This suggests that the initial high utilization may be temporary. Our sensitivity analysis suggested that this result was not due to high utilizers leaving the KPNC healthcare system. This overall trend in utilization is a welcome finding, and consistent with the intent of the ACA to increase access to care; however, the subsequent decrease in utilization could also signify that patients are disengaging from treatment. Although we cannot specifically attribute the initial levels of utilization to lack of prior insurance coverage, as we did not have data on prior coverage, we found that individuals with fewer than 6 months of membership before receiving an SUD diagnosis were more likely to utilize primary care and specialty SUD treatment than those who had 6–12 months of membership. This suggests that future healthcare reforms that expand insurance coverage for people with SUDs might also lead to short-term increases in utilization for a range of health services. Deductibles are a key area of health policy interest given the growing number of people enrolling in deductible plans post-ACA. As anticipated, higher deductibles had a generally negative association with utilizing healthcare in this population. We found that patients with high deductibles had lower odds of using primary care, psychiatry, inpatient, and ED services than those without deductibles. Additionally,flood tray we found the associations between high deductibles and likelihood of utilizing primary care and psychiatry were strongly negative among ACA Exchange enrollees.

Although it is somewhat difficult to gauge the clinical significance of these specific results, the strength of the odds ratios for primary care and psychiatry access gives some indication of the potential impact. The associations of high deductibles with primary care and psychiatry access is worrying given the extent of medical and psychiatric comorbidities among people with SUDs . Although we found more consistent associations for higher deductibles and less healthcare initiation, it is possible that even a modest deductible could deter patients from seeking treatment . From a public policy and health system perspective, the possibility that deductibles could prevent people with SUDs from accessing any needed medical care is a cause for concern. Consistent with prior findings , our results suggest that high deductibles have the potential to dissuade SUD patients from accessing needed health services, and that those who enroll via the ACA exchange may be more sensitive to them. This could be attributable to greater awareness of coverage terms due to the mandate that exchange websites offer clear, plain-language explanations to compare insurance options . In contrast, high deductibles were associated with a greater relative likelihood of SUD treatment utilization. However, this association existed only among patients who enrolled via mechanisms other than the ACA Exchange. It is possible that individuals with emerging or unrecognized substance use problems may have selected higher deductible plans at enrollment due to either not anticipating use of SUD treatment, which is often more price-sensitive relative to other medical care , or not being aware of the implications of deductibles. However, once engaged in treatment, individuals with high deductibles may have been motivated to remain there. A contributing factor could also be that such patients were required to remain in treatment either by employer or court mandates, which are common and are associated with retention . The varying associations between deductibles and different types of health service utilization by enrollment mechanisms highlight the need for future research in this area. Insurance exchanges provide access to tax credits, a broader range of coverage levels, and information to assist in healthcare planning that might be less easily accessible through other sources of coverage, e.g., through employers .

In our sample, Exchange enrollment was associated with greater likelihood of remaining a member of KPNC, did not demonstrate an adverse association with routine care, and was associated with lower ED use. However, primary care and psychiatric services use were similar across enrollment types, even within low and high deductible limits. Prior studies have found that health plans offered through the ACA Exchange are more likely to have narrow behavioral health networks compared to other non-Exchange plans and primary care networks , which raises concerns about treatment access. For this health system, that concern appears unfounded. Psychiatric comorbidity was associated with greater service use of all types. Several prior studies have also found that patients with psychiatric comorbidity use more health services than those with SUD alone . Similar to our results, a recent study based in California found that after controlling for patient-level characteristics, the strongest predictors of frequent ED use post-ACA included having a diagnosis of a psychiatric disorder or an SUD . While the ACA was not expected to alter this general pattern, the inclusion of mental health treatment as an essential benefit was intended to improve availability of care and to contribute to efforts to reduce unnecessary service utilization. Our investigation confirms the ongoing importance post-ACA of psychiatric comorbidity and suggests that future efforts in behavioral health reform must anticipate high demand for healthcare in this vulnerable clinical population.Race/ethnic disparities in access to care are a longstanding concern in the addiction field . Some expected these disparities to be mitigated postACA . Findings on race/ethnic differences are similar to what has been observed in other health systems ; although, few studies have examined associations post-ACA. One prior study among young adults with SUD and psychiatric conditions post-ACA found modest ethnic disparities in lack of coverage between whites and other ethnic groups ; although, another study of young people more broadly found larger gains in coverage among Hispanics and Blacks relative to whites . The race/ethnic disparities in SUD and psychiatry treatment initiation in this cohort, in which overall insurance coverage was not a barrier but specific mechanisms could be, highlight the importance of addressing this complicated challenge to health equity. This study used a large SUD patient cohort enrolled in health coverage post-ACA and included comprehensive data on diagnoses,grow table insurance coverage, and use of care over three years. KPNC data are well suited to examine ACA-related changes in health service utilization given the size and diversity of its membership. KPNC’s integrated model is becoming more common as other health plans and federally qualified health centers move toward providing integrated SUD treatment services and using EHRs . However, we should note that is an observational study based on EHR data.

As such, we cannot attribute causal relationships to our findings. However, we have conducted sensitivity analyses to examine the robustness of our findings in the absence of a randomized clinical trial. These analyses supported our initial findings; e.g., indicating that service use decrease over time was not due to high utilizers leaving KPNC. Medicaid expansion has the potential to improve access to SUD treatment , but we were also not able to examine its relationship to services in the current analysis due to collinearity with deductible limits . Our study was set in a single nonprofit healthcare delivery system in Northern California, which enabled us to characterize post-ACA patterns of service utilization in depth but did not allow us to compare populations or implementation across systems . Nevertheless, our findings can inform future work on health reform and policy efforts to improve access to healthcare for similar clinically complex patients in other health systems. E-cigarette use, or vaping, among adolescents has become a public health concern, with 26.7% of high school seniors reporting past-month vaping in 2018, and 900,000 middle and high school students reporting daily or near-daily use. Adolescents’ use of e-cigarettes is associated with an increased risk of subsequent cigarette initiation and frequent use, an increased risk of nicotine dependence, and exposure to potentially toxic chemicals. Despite harm reduction claims by e-cigarette companies, in cross-sectional studies, e-cigarette use among adolescent and young adult dual users is associated with smoking a greater number of cigarettes per day , more frequent smoking, and fewer attempts to quit smoking. Notably little is known about the stability of adolescents’ use of e-cigarettes over time, such as whether non-daily use progresses into daily use and whether daily use is sustained. The potential for harm from exposure to nicotine and toxicants is likely to be greater with sustained and frequent use over time. Study of longitudinal patterns of adolescent e-cigarette use is needed to model the potential for harm from these products. Furthermore, research is needed to articulate adolescent patterns of dual product use over time and the resulting levels of nicotine and toxicant exposure. It remains unclear, for example, whether dual users succeed in reducing and stopping their cigarette use or whether they continue to dual use over time. The stability in adolescents’ e-cigarette preferred type or brand also has not been examined. E-cigarette brands that are popular today among adolescents can deliver nicotine from a single compact pod that equals that of a pack of cigarettes, in attractive flavors, and with easy concealment for use in settings where cigarettes may be forbidden . These characteristics may facilitate the progression from intermittent to frequent use and nicotine dependence. Alternatively, low nicotine content and/or low device appeal may result in adolescents losing interest in e-cigarettes over time, with diminishing frequency and dependence risk. Among adults, research indicates that evolving from a simpler e-cigarette device to a more complex modifiable device is a common pattern and is associated with greater dependence on e-cigarettes. Despite rapid growth in the e-cigarette market in recent years, research has not yet examined whether or how adolescents’ preferred devices change over time, particularly with regard to nicotine delivery and exposure. Finally, minimal research has examined changes in adolescents’ reasons for initiating, continuing, and/or quitting e-cigarette use over time. In cross-sectional survey studies, adolescents’ top reasons for experimenting with e-cigarettes include curiosity, appealing flavors, friends’ use, and perceived benefits compared with cigarettes. However, reasons may shift over time, as adolescents move from experimentation to sustained use. The literature on youth initiation and transition to regular use of combustible cigarettes shows that media/marketing and social influences motivate initiation, whereas the drive for nicotine due to addiction motivates regular use. These nicotine product use patterns observed with combustible cigarettes warrant investigation with e-cigarettes. With e-cigarettes, adolescents who begin experimenting because of curiosity or appealing flavors may subsequently use to alleviate withdrawal symptoms. The present study followed a cohort of adolescent e-cigarette users over 12 months’ time to examine patterns of e-cigarette use frequency, nicotine exposure, and dependence, product use and flavor preference, and motivators to use and cease use. The primary objectives were to determine persistence in e-cigarette and dual use and the stability in frequency and dependence measures of e-cigarette use. We also examined changes in device and e-liquid preferences and reasons for using e-cigarettes. This longitudinal study adds to the literature by providing an understanding of shifts in tobacco and nicotine product use over time among adolescents based on self-report and biomarkers of exposure.Adolescents from the San Francisco Bay Area who reported having used an e-cigarette at least once in the past 30 days and at least 10 times in their lives were recruited for a longitudinal study on teen vaping between May 2015 and April 2017. Advertisements were posted on social media and in the community around the Bay Area. Interested individuals were directed to the study Web site, where they could submit their information to be contacted by study staff to complete eligibility screening.

Nation states became more and more interested in representing their population along identity criteria, and the census then arose as the most visible means by which states could depict and even invent collective identities . In this way, previous ambiguous and context-dependent identities were, by the use of the census technology, ‘frozen’ and given political significance. “The use of identity categories in censuses was to create a particular vision of social reality. All people were assigned to a single category and hence conceptualized as sharing a common collective identity” , yet certain groups were assigned a subordinate position. In France, for example, the primary distinction was between those who were part of the nation and those who were foreigners, whereas British, American, and Australian census designers have long been interested in the country of origin of their residents. In the US, the refusal to enfranchise Blacks or Native Americans led to the development of racial categories, and these categories were in the US census from the beginning. In some of the 50 federated states of the US, there were laws, including the “one drop of blood” rule that determined that to have any Black ancestors meant that one was de jure Black . Soon a growing number of categories supplemented the original distinction between white and black. Native Americans appeared in 1820, Chinese in 1870, Japanese in 1890, Filipino, Hindu and Korean in 1920, Mexican in 1930, Hawaiian and Eskimo in 1960. In 1977, the Office of Management and Budget , which sets the standards for racial/ethnic classification in federal data collections including the US Census data, established a minimum set of categories for race/ethnicity data that included 4 race categories and two ethnicity categories . In 1997, OMB announced revisions allowing individuals to select one or more races,greenhouse growing racks but not allowing a multiracial category. Since October 1997, the OMB has recognized 5 categories of race and 2 categories of ethnicity .

In considering these classifications, the extent to which dominant race/ethnic characterizations are influenced both by bureaucratic procedures as well as by political decisions is striking. For example, the adoption of the term Asian-American grew out of attempts to replace the exoticizing and marginalizing connotations of the externally imposed pan-ethnic label it replaced, i.e. “Oriental”. Asian American pan-ethnic mobilization developed in part as a response to common discrimination faced by people of many different Asian ethnic groups and to externally imposed racialization of these groups. This pan-ethnic identity has its roots in many ways in a racist homogenizing that constructs Asians as a unitary group , and which delimits the parameters of “Asian American” cultural identity as an imposed racialized ethnic category . Today, the racial formation of Asian American is the result of a complex interplay between the federal state, diverse social movements, and lived experience.In fact, the OMB itself admits to the arbitrary nature of the census classifications and concedes that its own race and ethnic categories are neither anthropologically nor scientifically based . Issues of ethnic classification continue to play an important role in health research. However, some researchers working in public health have become increasingly concerned about the usefulness or applicability of racial and ethnic classifications. For example, as early as 1992, a commentary piece in the Journal of the American Medical Association, challenged the journal editors to “do no harm” in publishing studies of racial differences . Quoting the Hippocratic Oath, they urged authors to write about race in a way that did not perpetuate racism. However, while some researchers have argued against classifying people by race and ethnicity on the grounds that it reinforces racial and ethnic divisions; Kaplan & Bennett 2003; Fullilove, 1998; Bhopal, 2004, others have strongly argued for the importance of using these classifications for documenting health disparities . Because we know that substantial differences in physiological and health status between racial and ethnic groups do exist, relying on racial and ethnic classifications allows us to identify, monitor, and target health disparities .

On the other hand, estimated disparities in health are entirely dependent upon who ends up in each racial/ethnic category, a process with arguably little objective basis beyond the slippery rule of social convention . If the categorization into racial groups is to be defended, we, as researchers, are obligated to employ a classification scheme that is practical, unambiguous, consistent, and reliable but also responds flexibly to evolving social conceptions . Hence, the dilemma at the core of this debate is that while researchers need to monitor the health of ethnic minority populations in order to eliminate racial/ethnic health disparities, they must also “avoid the reification of underlying racist assumptions that accompanies the use of ‘race’, ethnicity and/or culture as a descriptor of these groups. We cannot live with ‘race’, but we have not yet discovered how to live without it” . Reinarman and Levine have argued that investigations of ethnicity in alcohol and drugs research have typically taken the form, whether intentionally or not, of linking “a scapegoated substance to a troubling subordinate group – working-class immigrants, racial or ethnic minorities, or rebellious youth” . Different minority ethnic groups have often been framed at one time or another by their perceived use of alcohol and illicit drugs, regardless of their actual substance using behaviors and regardless of their relative use in comparison with drug and alcohol use among whites . Such framing arguably has led to extensive stereotyping of minority cultures, their characters, and their behaviors. For example, in the 18th century, white settlers in the US used stereotypical portrayals of Native drinking to justify the confiscation and exploitation of Native lands . In the early part of the 19th century, Chinese immigrants were victimized and controlled for their supposed opium use, despite the fact that only 6% at the time used opium . In the early 1900s, cannabis was relatively plentiful along the Texas border brought to the US by Mexican migrants, and its popularity among ethnic minorities practically ensured that it would be classified as a narcotic and attributed with addictive qualities . By the early 1930s, cannabis had been prohibited in 30 states. In 1937 the Marijuana Tax Act was passed by Congress which banned cannabis at the Federal level . And, the most recent drug scare, which fueled the development of the War on Drugs, linked crack cocaine to impoverished African Americans and Latinos in inner city neighborhoods .

Since the War on Drugs, an exceptionally high rate of imprisonment of mainly poor ethnic minority people has occurred primarily for non-violent crimes and relatively minor drug offences. For example, in 2012, although African-Americans accounted for only 13% of the national population , nearly 40% of those incarcerated for drug offences in State or Federal prisons were African-Americans . Hispanic/Latinos, while accounting for 17% of the national population in 2013, represented 37% of all those in prison for drug offenses . These statistics lie in sharp contrast to the available empirical data on differential rates of alcohol and substance use between whites and non-whites . The evidence from Monitoring the Future – a longstanding and reliable source of data on drug use among youth in the US – suggests that crack cocaine cannot be considered a drug consumed primarily by Blacks in American nor can marijuana be considered a drug used primarily by Latino/as. Rather, white youth have higher rates of use for most drugs of abuse. For example, Terry McElrath and colleagues reviewing 30 years’ worth of data from MTF,vertical hydroponic garden found that for all drugs except heroin, past year prevalence rates were significantly higher among whites compared to blacks and Latinos . In spite of the backdrop, the vast majority of alcohol and drug research has failed to mention the injustices of drug laws and high rates of imprisonment of ethnic minority youth. Instead of situating research within a context of oppression and inequality, researchers have tended to ignore this situation and instead focus on risk factors associated with drug use among racial/ethnic groups, an approach that dominates alcohol and drugs research today.This trajectory in alcohol and drug research is unfortunate in light of recent debates in social epidemiology about the importance of examining health disparities within a framework that considers “social structures and social dynamics that encompass individuals” . Social epidemiologists have argued that mainstream research tends “to focus on the body, lifestyle, behaviour, sex/gender, race/ethnicity and perhaps the personality, emotional state or socioeconomic status of the single person” . Just as mainstream epidemiology has been criticized for having little regard for social structures, social dynamics, and social theory , most existing studies of ethnicity within drug and alcohol research can similarly be critiqued for failing to adopt a structural approach as well as neglecting contemporary social science theories of and debates about ethnicity. In mainstream drug and alcohol research, traditional ethnic group categories continue to be assessed in ways which suggest little critical reflection in terms of the validity of the measurement itself. This is surprising given that social scientists since the early 1990s have critiqued the propensity of researchers to essentialize identity as something ’fixed’ or ’discrete’ and to neglect to consider how social structure shapes identity formation. Recent social science literature on identity suggests that people are moving away from rooted identities based on place and towards a more fluid, strategic, positional, and context-reliant nature of identity. This does not mean, however, that there is an unfettered ability to freely choose labels or identities, as if off of a menu . An individual’s ability to choose an identity is constrained by social structure, context, and power relations.

Structural constraints on identity formation cannot be ignored, as people do not exist as free floating entities but instead are influenced and constrained in various ways by their socioeconomic and geographical environment . As such, an identity is not just claimed by an individual but is also recognized and validated by an audience, resulting in a dialectical relationship between an individual and the surrounding social structures . Similarly, a ‘new’ perspective on ethnic identity specifically has emphasized the fluidity and contextually-dependent nature of ethnicity, minimizing notions about ethnicity as a cultural possession or birthright and instead emphasizing ethnicity as a socially, historically, and politically located struggle over meaning and identity . Ethnicity or ethnic identity is not some immutable sense of one’s identity but rather something produced through the performance of socially and culturally determined boundaries . Hence, individuals are not passive recipients of acquired cultures but instead active agents who constantly construct and negotiate their ethnic identities within given social structural conditions . In spite of these sociological contributions, which have enriched our understanding of identity generally and ethnicity specifically, the alcohol and drugs fields have not adequately integrated these perspectives, thwarting our ability to understand the relationships between ethnicity and substance use. As such, the field is ripe with correlations between ethnic group categories and substance use problems, resulting in solutions to problems that focus on reifying questionable social group categorizations and revealing little about how drugs are connected to identities and shaped by broader social and cultural structures. It is important to note that we do not intend to argue that existing categories of ethnicity be disregarded in the alcohol and drugs fields. As Krieger and colleagues have noted in another context , surveillance data documenting health disparities, in our case in substance use, are exceedingly important in terms of identifying potential inequities in health. However, without understanding the complexity of ethnic identity and its relationship to substance use, these surveillance data may perpetuate stereotypes and the victimization of specific socially-delineated ethnic groupings, obfuscate the root causes of substance use and elated problems, and reify politicized categories of ethnicity which may have little meaning for the people populating those categories. While acknowledging that socially-deliented ethnic categories are important for documenting social injustices, we must also be vigilant about questioning the appropriateness of those categories . Conceptually this type of critical approach is important for considering how substance use is related to negotiations of ethnicity over time and place and bounded by structure.