International Journal of Drug Policy

AimsTo characterize decreases in overdose mortality in the United States between 2023 and 2024 by substance involvement, geography, race/ethnicity, demographic, and other key dimensions. DesignPopulation-based study of national death records. SettingUnited States. Participants/casesAll individuals who died from drug overdose between January 1999 and December 2024. MeasurementsAnnual or monthly (annualized) overdose deaths per 100,000 population. Year and month of occurrence of overdose death; substance involvement; census region and division; state; county; race/ethnicity, age, and sex. FindingsAfter over two decades of mostly exponential increases, monthly data show consistent decreases in overdose deaths between June 2023 and December 2024. Decreases reflected declining illicit fentanyl-involved deaths (with and without stimulants); however, increasing trends through 2024 were still seen in deaths involving stimulants without fentanyl, and those involving xylazine. Death rates in the Northeast, South and Midwest fell to 19.5, 19.4 and 17.3 per 100,000, respectively, in December 2024, but remained elevated in the West, compared with other regions, at 27.2 per 100,000. Non-Hispanic Black and African Americans had the largest decrease in death rates in 2023-2024 falling 29.3%, but remained elevated at 36.0 per 100,000, compared to the national average of 23.7 per 100,000. Non-Hispanic American Indian and Alaska Native individuals had the highest overdose mortality rate in 2024, at 50.8 per 100,000. ConclusionsRecent decreases in overdose deaths are encouraging and unprecedented. Racial gaps remained large but shrunk by a modest margin. The geography of the overdose crisis has shifted, with the West now the most affected region, which may have implications for the targeting of funding. The nature of the crisis is also shifting, as stimulants and xylazine continue to represent increasingly important public health challenges, and renewed attention to nonfatal aspects of addiction in the US is needed.

BACKGROUNDThis study evaluates the reach, scalability, and implementation of a large-scale, multi-site tele-buprenorphine program designed to treat opioid use disorder (OUD) within rural carceral settings. Given that individuals transition frequently between jails and the community, these facilities represent a critical window for OUD intervention, yet they often face significant provider shortages and logistical barriers. We conducted a retrospective chart review of 842 unique patients (1,321 treatment episodes) enrolled in the University of Marylands tele-buprenorphine program across six rural county jails between June 2020 and May 2025. Data extracted from jail records and electronic health records were used to analyze patient demographics, prescribing patterns, and program retention. RESULTSThe patient population was primarily male (71.1%) and White (75.7%), with a mean age of 35.4 years. Participants reported high-severity OUD, with an average of 12.6 years of opioid use. Reflecting broad admission criteria, 55.2% of participants were new treatment initiates not receiving MOUD prior to booking. Patients spent a mean of 35.6 days incarcerated before initiation and were retained in the program for an average of 66 days. Buprenorphine doses were titrated from a mean initiation dose of 8.8 mg to 16.2 mg at discharge. The program demonstrated a 99.5% adherence rate among retained patients. Only 3% of the total sample were discharged for medication diversion or hoarding. CONCLUSIONSTelemedicine is a highly feasible and scalable model for delivering evidence-based MOUD in rural jails. By utilizing a "liberal admission policy" that prioritizes both treatment initiation and maintenance, programs can successfully reach high-risk individuals who lack access to community-based care. These findings suggest that tele-buprenorphine can effectively bridge the treatment gap in underserved jurisdictions, potentially reducing the risk of overdose during the high-risk post-release period.

Background and AimsThe UK legalised medical cannabis in 2018, yet little is known about people accessing cannabis legally via prescription or those using cannabis for medical purposes without a prescription. This study aimed to estimate: 1) the percentage of people who use cannabis medically with and without a prescription; 2) the sources used to obtain cannabis; 3) the products used; and 4) the associations between monthly or more frequent (MMF) product use and medical cannabis use status. DesignNational repeat cross-sectional surveys conducted in September-November 2023 and 2024. SettingUK. ParticipantsPeople aged 16-65 who used cannabis in the past 12 months (n=4,414). MeasurementsInferential statistics compared outcomes by medical cannabis use status. Multivariable regression analyses estimated associations between MMF product use and medical cannabis use status. FindingsOverall, 13.0% of people reported receiving a medical cannabis prescription, 36.4% reported medical use without a prescription, and 50.6% reported no medical use. Cannabis was sourced through diverse routes; only 10.7% of people with prescriptions obtained all their cannabis from a legal medical prescription. People with a medical prescription had a higher probability of reporting MMF use of oils or liquid drops (aRR=3.51; 95% CI: 2.73-4.52), oil or liquid capsules (aRR=2.63; 1.99-3.47), vape oils (aRR=2.40; 2.03-2.84), edibles (aRR=2.41; 2.01-2.90), cannabis drinks (aRR=3.39; 2.69-4.26), solid concentrates (aRR=3.10; 2.29-4.21), hash or kief (aRR=1.82; 1.44-2.30), and topicals (aRR=3.42; 2.58-4.51) than people who did not report medical use, after adjusting for covariates. People who ever asked for a medical prescription and people with a medical prescription in the past year had a higher probability of screening positive for high-risk use. ConclusionOver one in ten people who use cannabis in the UK report a medical cannabis prescription, yet a third reported medical use without a prescription. With only a minority obtaining all their cannabis legally, many rely on illegal sources, suggesting prescriptions may not meet the needs of those reporting use for medical purposes. People with prescriptions show a higher probability of frequent use of processed, higher-potency products, and meeting a threshold for high-risk use. Healthcare encounters during medical cannabis prescribing should discuss risks related to potency, product type, and adverse effects such as cannabis use disorder.

IntroductionOpioid use continues to cause harm and fatalities worldwide, despite ongoing preventive efforts. Early administration of the antidote naloxone can reverse potentially fatal opioid overdoses. Naloxone distribution programs have increased survival across regions; however, additional efforts are needed to reduce opioid overdose mortality. One approach is to expand naloxone availability within communities. Methods and analysisThe feasibility trial RESPONDER (REgion Sk[a]ne Preventing Overdose through Naloxone Distribution with Emergency Runners) introduces a unique smartphone alerting system with community first responders (CFRs) dispatched to suspected opioid overdoses, in addition to dispatch of regular emergency medical services (EMS). The aim is to investigate if trained CFRs can successfully recognize and reverse overdoses caused by opioids, prior to EMS arrival. The CFRs will be equipped with nasal naloxone and introduced to a novel naloxone algorithm during a study-specific course prior to participation. The course will offer practical training in basic life support and first aid, and it will also assess competence in the low-arousal approach, as well as the legal and ethical aspects of being a CFR. Main outcomes of the trial are feasibility, acceptability and safety. The trial will be performed in the region of Sk[a]ne, Sweden, between September 1st, 2025, and August 31st, 2027, with every CFR followed for up to 12 months. Ethics and disseminationThe trial has been approved by The Swedish Ethical Review Authority (file number 2024-05887-01). Written informed consent is required from participating CFRs. This is also required of overdose survivors to allow the collection of clinical data from hospital records. Information regarding the project and recruitment will be disseminated via social media, news media, through the healthcare regions communication channels, and within public transportation hubs. Outcomes and analyses will be submitted to peer-reviewed journals. ConclusionSafe, early and effective management of opioid overdoses by trained CFRs prior to EMS arrival may reduce morbidity and mortality among people who use opioids. Findings from the current trial may contribute to further knowledge on how to implement and improve CFR systems for opioid overdoses globally. ClinicalTrials.gov-ID: NCT07079241. Article SummaryO_ST_ABSStrengths and limitations of this studyC_ST_ABS- The RESPONDER trial introduces a novel community first responder system for time-critical opioid overdose reversal in addition to out-of-hospital cardiac arrest. - The trial aims to enhance access to naloxone and raise community awareness, improving the likelihood of early and potentially life-saving overdose reversal. - A study-specific course introduces a novel naloxone algorithm which has been developed by expertise in the fields of resuscitation, First Aid and opioid use disorder. - The study group consists of researchers and clinicians with a broad range of expertise concerning opioid overdose management, substance use disorders, First Aid education, emergency medical services, emergency medical dispatch centre operations and community first responder systems, adding several in-depth perspectives to this community first responder model. - A limitation may be that overdose events unreported to emergency dispatch centres will not reach the trials community first responders.

IntroductionHarms associated with recreational nitrous oxide use have been documented. Studies on the prevalence of past-year inhalant use disorder among individuals who have ever used nitrous oxide are lacking. This descriptive study, conducted in the United States from 2021 to 2023, examined the prevalence of ever using nitrous oxide, determined the proportion of people meeting the past-year criteria for an inhalant use disorder, and reported the yearly number of nitrous oxide poisonings. MethodsThis study used a descriptive epidemiological approach to identify and characterize the lifetime use of nitrous oxide and the total number of nitrous oxide poisonings as reported in the United States from 2021 to 2023. ResultsFrom 2021 to 2023, one in twenty people in the U.S. reported ever using nitrous oxide recreationally. The prevalence of inhalant use disorder in the past year among those who ever used nitrous oxide was 1.1%. However, this diagnosis could be due to the use of other inhalants such as poppers. Among individuals who only used nitrous oxide in their lifetime to the exclusion of all other inhalants, and who reported using inhalants in the past year, approximately 10% met the criteria for inhalant use disorder due to their nitrous oxide use. During this period, there were 937 total poisoning cases involving nitrous oxide, with 712 cases involving nitrous oxide as the only reported substance. ConclusionsMore population-level studies are needed to examine the national harms of problematic nitrous oxide use.

IntroductionMaternal mental health conditions, comprising maternal suicide and drug overdose, are currently the leading cause of maternal mortality in the United States. However, the relationship between suicidality and drug use behavior in the perinatal period is not well understood. We examined the association between suicidality and drug use behavior among perinatal individuals. Given the racial disparities in both drug use and suicide rates in the U.S., we also examined any differences in suicidality and drug use behavior by race. MethodsParticipants were recruited from a High-Risk Obstetric & Gynecological Clinic in the Midwestern U.S that specializes in providing obstetric care to perinatal individuals who have histories or current use of opioids and other illicit drugs. Participants (N = 66) were a sub-sample of a larger cohort enrolled in an mHealth intervention to support recovery from opioid and stimulant use disorders. We performed chi-square tests and t-tests to examine any significant associations between lifetime suicidality and drug use behavior during the perinatal period. ResultsThe final analytic sample included participants who had responded to the suicidality survey questions (n=43). Nearly 40% (n=16) of our sample endorsed a lifetime history of suicidal thoughts and behaviors (SITB). Of those, 87% (n=15) reported a previous suicide attempt. SITB was significantly associated with cravings for opioids during the perinatal period (p = .01) as well as comorbidities with perinatal anxiety symptoms? ( p < .05), depression symptoms? (p < .05), and bipolar disorder (p < .05). A higher proportion of recent cannabis use was found among mothers with SITB, compared to those without SITB (p=0.04). Mothers with SITB also had a strong positive correlation between preconception and postnatal nicotine use compared to mothers without SITB (p < .01). Finally, while white mothers endorsed more lifetime overdoses (p= 0.01), Black mothers endorsed higher cravings for opioids during pregnancy (p = 0.03). ConclusionsA history of SITB is a distinct risk factor for both illicit and recreational drug use behavior in the perinatal period, and frequently co-occurs with other perinatal mental health conditions. Further research is needed to better understand the directionality of this relationship and the complex interplay between high risk drug use behavior and suicidality.

Ozempic, along with exercise and diet, is effective in helping individuals lose weight. Prior studies have reported misuse of Ozempic. This descriptive study used a nationally representative sample of persons in the U.S. from the National Survey on Drug Use and Health to identify self-reported use of an Ozempic injection for which the person was not prescribed. In 2024, 28,691 individuals ages 12 and older self-reported ever injecting Ozempic that was not prescribed to them. The entire sample who self-reported misusing Ozempic consisted of women aged at least 18 years (100%). Among this sample, more than 90% reported that their most recent misuse of Ozempic occurred in the past 12 months. Most of the sample was between the ages of 26 and 34 (64%), had a body mass index consistent with obesity (89%), was employed full-time (81%), was a college graduate or higher (91%), and had private health insurance coverage (81%). The entire sample reported consuming alcohol in the past 12 months (100%), and slightly more than half met the criteria for an alcohol use disorder diagnosis (53%). This is the first known study to characterize a nationally representative sample of persons who self-reported misusing Ozempic injections. Future studies are needed to examine the motivations for Ozempic misuse and to determine whether some individuals experience barriers to accessing it.

BackgroundLong-acting injectable buprenorphine (LAIB) has been positioned as a potentially transformative option for opioid use disorder (OUD), in part because patient experiences reported in qualitative studies emphasize reduced daily burden, increased "freedom," reduced stigma, and fewer pressures related to diversion--while also noting barriers such as insufficient information, early adverse experiences, and concerns about coercion. MethodsWe conducted a cross-sectional online survey of adults recruited from the Behavioral Health Research Panel (BHRP). Eligibility included age [&ge;]18, English literacy, and OUD diagnosis or problematic opioid use within the past 5 years. Survey content assessed buprenorphine experience, knowledge and attitudes toward LAIB, attribute preferences, and open-text feedback. Descriptive statistics were generated; analyses were stratified by buprenorphine experience (experienced vs naive). ResultsAmong 105 participants, 82.9% reported prior buprenorphine use, and 17.1% were buprenorphine-naive. Overall, 53.3% preferred a long-acting injection regimen (weekly/monthly/3-monthly) versus 46.7% preferring a daily oral tablet/film. Convenience and adherence-related themes (e.g., not missing doses, fewer visits) drove LAIB preference, while oral-route preference and concerns about side effects and safety were prominent among those favoring oral formulations. ConclusionsIn this national convenience sample, preferences were nearly evenly split between daily oral and long-acting injectable buprenorphine regimens, with a slight overall preference for LAIB. Findings align with the qualitative literature, emphasizing the practical and psychosocial benefits of LAIB, alongside persistent needs for improved education, shared decision-making, and attention to tolerability, safety perceptions, and cost/coverage barriers.

BackgroundCannabis use is highly prevalent among people who use unregulated drugs. While daily cannabis use has been hypothesized to provide protective effects through substitution or tolerance mechanisms, the relationship between cannabis use frequency and overdose risk remains poorly understood, particularly for infrequent users. MethodsWe conducted a secondary analysis of cross-sectional interview data from people who use unregulated drugs in Vancouver, British Columbia, collected during the fentanyl crisis (November 2019-July 2021; n=657). Binary logistic regression examined associations between self-reported cannabis use frequency (five categories: less than monthly, 1-3 times per month, weekly, more than weekly and daily) and non-fatal overdose in the preceding six months. Daily use served as the reference category. Models adjusted for age, gender, ethnicity, homelessness, mental health, HIV status, incarceration and daily use of alcohol, opioids, fentanyl, cocaine and stimulants. ResultsAmong 657 participants, 95 (14.5%) reported non-fatal overdose in the past six months. In adjusted models with daily cannabis use as the reference, infrequent cannabis use was associated with significantly increased odds of overdose: use 1-3 times per month (aOR=3.17, 95% CI: 1.50-6.69, p=.002) and more than weekly use (aOR=3.13, 95% CI: 1.70-5.76, p<.001) showed approximately three-fold increased odds compared to daily use. Less frequent use showed non-significant trends in the same direction (less than monthly: aOR=1.73, 95% CI: 0.89-3.37, p=.109; weekly: aOR=1.44, 95% CI: 0.59-3.51, p=.421). Sensitivity analysis restricted to participants with daily stimulant or fentanyl use (n=148) revealed even stronger associations. ConclusionsInfrequent cannabis use was associated with substantially increased overdose risk compared to daily use. This frequency-dependent relationship, with infrequent users at highest risk, likely reflects tolerance differences: infrequent users lack tolerance to synergistic cannabis-opioid effects. These findings were completely obscured in preliminary analyses that dichotomized cannabis use as daily versus less-than-daily, demonstrating how analytical choices can mask critical public health insights. Current harm reduction approaches, including cannabis distribution programs, should incorporate frequency-dependent risk communication and develop strategies to protect infrequent users who may be at heightened overdose risk.

BackgroundA growing population of working-aged men are not in employment, education, or training (NEET). The COVID-19 pandemic increased rates of substance use disorders (SUDs) and affected treatment seeking in the general population, but the COVID era substance use patterns among NEET men are unknown. MethodsWe estimated the prevalence and correlates of NEET status among working-aged (18-64) men using data from the 2022 National Survey on Drug Use and Health, a nationally representative survey of non-institutionalized individuals in the United States. We developed logistic regression models to examine associations between NEET status and substance use behaviors and treatment engagement, adjusted for sociodemographic factors. ResultsAn estimated 11.1% of working-aged men were NEET in 2022 representing 10.6 million individuals. NEET men were significantly more likely to be older, have lower income, be unmarried, and have lower educational attainment and be Non-Hispanic Black compared to non-NEET men. After adjusting for sociodemographic factors, NEET status was significantly associated with higher odds of prescription tranquilizer/sedative use disorder (aOR = 3.54, 1.97-6.37), methamphetamine use disorder (aOR = 3.10, 95% CI: 1.82-5.28), and prescription pain reliever use disorder (aOR = 2.88, 1.82-4.53), while being inversely associated with alcohol use disorder (aOR = 0.68, 0.54-0.85). ConclusionMore than 1 in 10 working-aged men were NEET in 2022. Adjusted models showed higher odds of past-year SUDs but lower rates of alcohol use disorder. Targeted interventions should include age-appropriate, culturally tailored, and substance-specific treatment programs to improve public health.

BackgroundLong-acting injectable buprenorphine (LAI-BUP) is safe and effective, however is dramatically underutilized in comparison to oral formulations. Little is known regarding how buprenorphine prescribers view LAI-BUP, and which medication attributes they prioritize when selecting treatment for opioid use disorder (OUD). MethodsA secondary analysis of a national, cross-sectional online survey of U.S. physicians who prescribe buprenorphine for OUD was conducted. Respondents reported OUD caseload, LAI-BUP use, and the importance of medication attributes relevant to treatment selection (e.g., efficacy, safety, ease of administration, ease of prescribing, and administrative requirements). Providers were categorized as no LAI-BUP use or, among LAI-BUP prescribers, Low vs High use based on a median split. Group comparisons used chi-square (or Fishers exact) tests for categorical variables and Jonckheere-Terpstra tests for ordinal responses. ResultsAmong 125 respondents, 39 (31.2%) reported no patients receiving LAI-BUP. The remaining 86 (68.8%) were LAI-BUP prescribers, split evenly into Low and High (ns=43; 34.4%) groups using a median cut of 23.2%. LAI-BUP use did not differ meaningfully by specialty, region, or practice setting. Greater LAI-BUP use was reported by providers with larger OUD panels. Ratings of key medication attributes were uniformly high. ConclusionsLAI-BUP remains underused, with uptake highest among clinicians managing larger OUD caseloads. Measured attitudes toward medication attributes did not explain these differences. Future work should assess clinic workflow, staffing, reimbursement, and REMS burden, testing targeted implementation strategies using mixed-methods trials. Identifying what shifts clinicians from no use to low and high use may guide scalable implementation interventions.

IntroductionRecreational and medical cannabis use (CU) information is often available within the electronic health record (EHR) in a format that is impractical for health care provider use. Transformation of free-text EHR documentation in notes to discrete elements is possible using natural language processing (NLP) and has the potential to characterize CU efficiently. The objective of this study was to develop an NLP algorithm to identify documentation of CU within EHR unstructured clinical notes. MethodsWe identified EHR notes with cannabis-related terminologies through a keyword search among all Geisinger patients with at least one encounter between 1/1/2013 and 6/30/2022. We trained four NLP models to classify notes into six categories based on time, context, and reliability of CU documentation identified through manual annotation. We compared the demographic characteristics of patients with positive classification for CU using the best-performing model to those of the overall population. ResultsOf the over 1.7 million eligible patients, 150,726 (8.6%) were flagged as cannabis users. The Bio-ClinicalBERT, a transformer-based NLP model, achieved close to human performance in classifying CU (weighted Precision=91.4, Recall=93.3, F-score=92.4). Cannabis users had higher BMI and were at least nine-fold more likely to use tobacco, alcohol, and illicit substances. ConclusionOur study evaluated the prevalence of CU documentation across the entire corpus of EHR notes data without population segmentation. The NLP methodologies used achieved performance close to that of human annotation and laid the foundation for identifying and classifying CU within unstructured data sources, with future applications in research and patient care. Plain Language SummaryMarijuana, also known as cannabis, may impact the health of patients, yet it is not routinely captured in medical records, and when documented, it is often found in unstructured formats (e.g., progress notes) rather than in discrete fields. Incomplete and unstructured capture limits many functional capabilities within the EHR that enhance patient care (e.g., drug interactions, notifications) and limit researchers from identifying patients routinely exposed to marijuana use. The transformation of free-text documentation of cannabis use (CU) into discrete elements can be performed using natural language processing (NLP). The objective of this study was to develop an NLP model to identify CU in unstructured clinical notes in the EHR. We examined the EHRs of Geisinger patients in Pennsylvania over a 10-year period. Among 1.7 million patients, 9% were identified as CU. One of the NLP models tested, Bio-ClinicalBERT, achieved the highest performance. Cannabis users had a higher BMI and were ten-fold more likely to be tobacco users, ten-fold more likely to use alcohol, and nine-fold more likely to use illicit substances. NLP can be used to better understand the risks and benefits of CU at a population level and may improve patient identification to assist clinical decision-making. Future CU epidemiological research should continue to explore other avenues to automate and improve CU documentation by leveraging rapidly evolving technologies, such as artificial intelligence-driven tools.

Tobacco use disorder (TUD) remains a leading cause of preventable mortality, and existing pharmacotherapies yield 12-month abstinence rates below 30%. As cannabis legalization expands, approximately 18-22% of people who use tobacco report concurrent cannabis use, yet the impact of co-use on cessation outcomes and the therapeutic potential of endocannabinoid system (ECS) modulation remain unclear. We conducted a translational systematic review and meta-analysis following PRISMA 2020 guidelines, searching Ovid MEDLINE, Embase, APA PsycInfo, and Web of Science through January 2026 (PROSPERO: CRD420250652724). Three study categories were eligible: observational studies of cannabis co-use and cessation outcomes; preclinical studies of cannabinoid modulators on nicotine-related behaviors; and human experimental studies of ECS-targeted interventions. Of 4,869 records screened, 52 studies met inclusion criteria. Meta-analysis of 18 observational studies (N=229,630) revealed that cannabis use was associated with 35% lower odds of achieving tobacco smoking cessation (OR=0.65; 95% CI: 0.55-0.78; p<0.0001; I{superscript 2}=88.1%). Preclinical evidence (15 studies) demonstrated that CB1 receptor antagonists robustly reduced nicotine self-administration and reinstatement, while cannabidiol (CBD) attenuated both nicotine intake and withdrawal without affecting food reinforcement. Clinical translation of CB1 receptor inverse agonists failed due to psychiatric adverse effects, but CBD showed promise by reducing cigarette consumption by 40%, reversing attentional bias to smoking cues, and alleviating withdrawal severity. These findings distinguish naturalistic cannabis exposure from potentially beneficial targeted ECS modulation, and support CBD as a promising candidate for adequately powered tobacco cessation trials.

PurposeThe COVID-19 pandemic coincided with worsening U.S. drug overdose mortality and widening racial and ethnic disparities. We estimated race/ethnicity-specific excess overdose deaths at the state level during 2020-2023 and examined how these burdens scale with population size. MethodsWe analyzed annual overdose deaths from 2014-2023 for five racial/ethnic groups in 47 states and the District of Columbia. Pre-pandemic trends (2014-2019) were fit using a generalized growth model, and deaths exceeding projections in 2020-2023 were classified as excess deaths. Scaling was evaluated by regressing excess and total deaths on 2020 state population in log-log models and relating excess-death rates to social and behavioral indicators. ResultsWhite populations experienced the largest absolute excess, peaking in 2021. Black populations showed minimal excess in 2020 but rose sharply in 2021-2022, nearly matching White deaths by 2023; Hispanic excesses were intermediate. Scaling analyses showed sublinear growth of Black deaths with population, while White and Hispanic deaths scaled approximately proportionally. Within-state rank tests indicated higher excess-death rates for Black than for White or Hispanic populations. ConclusionsExcess-mortality and scaling analyses reveal heterogeneous and inequitable overdose burdens across racial and ethnic groups during the pandemic and can inform equity-focused surveillance and prevention efforts.

Background and AimsAlcohol use disorder (AUD) remains a major public health concern, with persistent disparities in access to evidence-based treatment. This study aimed to examine associations between perceived discrimination in healthcare settings (PDHS), patient-clinician communication (PCC), and receipt of treatment for AUD, and compared these with sociodemographic and insurance-related factors. DesignCross-sectional analysis using structural equation modeling (SEM), logistic and multinomial logistic regression, and machine learning approaches including SHapley Additive exPlanations (SHAP). SettingUnited States, using data from the National Institutes of Health All of Us Research Program. ParticipantsA total of 5,287 adults with AUD (mean age 61 years; 57% men), including 71.6% non-Hispanic White, 12.2% Black, and 8.6% Hispanic participants. Insurance coverage included 52% government (Medicaid/Medicare), 37% private, and 21% military with 19% reporting more than one type. MeasurementsPrimary outcomes were receipt of Food and Drug Administration-approved pharmacotherapy and/or psychotherapy for AUD, examined as binary and multinomial outcomes. The primary exposure was PDHS, measured using a 7-item scale (range 7-35), with higher scores indicating more frequent discrimination. PCC, assessed using a 2-item scale (range 2-8) with higher scores indicating poorer communication, was examined as a potential mediator. Models were adjusted for age group, sex at birth, race/ethnicity, insurance type (government, private, military), household income, and Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) scores (range 0-12). FindingsPDHS was associated with poorer PCC ({beta} = 0.209, p < 0.001), although communication was not independently associated with treatment receipt. The indirect pathway from discrimination to treatment via communication was not supported. Military insurance was the strongest predictor of treatment receipt, with 6-7 times higher odds compared with other insurance types. Higher AUDIT-C scores and greater PDHS were also associated with increased likelihood of treatment. In analyses restricted to civilian participants, PDHS showed a stronger association with treatment receipt, while PCC demonstrated more modest effects. Machine learning models identified PDHS, AUDIT-C, and PCC as strong contributors, with the impact of poor communication most pronounced among individuals with lower income. ConclusionsAccess to treatment for alcohol use disorder is most strongly associated with insurance coverage, particularly military insurance. PDHS and PCC also contribute to treatment engagement, with differential effects across socioeconomic groups. These findings highlight the importance of addressing structural and interpersonal barriers to improve equitable access to evidence-based AUD treatment.

BackgroundPsychotherapy is proven efficacious for the treatment of alcohol use disorder (AUD). However, the patient-perceived importance of its effect is not fully appreciated in the evidence base. The smallest worthwhile difference (SWD) represents the smallest beneficial effect of an intervention that patients deem worthwhile in exchange for the harms, expenses, and inconveniences associated with the intervention, and facilitates the interpretation of patient perceived worthiness of an intervention. MethodsThe proposed study will estimate the SWD of NIAAA recommended psychotherapies for AUD treatment with English-speaking American respondents aged 18 and older. Primary participants will be recruited using the Prolific research crowdsourcing site. The SWD will be estimated using the Benefit-Harm Trade-off Method, presenting survey respondents with variable, hypothetical magnitudes of psychotherapy outcomes to find the smallest acceptable effect over a natural remission alternative. The overall average SWD, and subgroup distributions by participant AUD treatment experiences and AUD symptomology will be described. Secondary findings will estimate the smallest recommendable risk difference for AUD psychotherapy from providers and criminal justice professionals. Expected ResultsWe expect to find an estimate of the SWD for AUD psychotherapy. Further, we expect that the SWD will vary between clinical subgroups based on AUD symptomology and treatment experiences. We expect differences in SWDs between the general population and those of providers and criminal justice professionals. Findings from this project will inform the treatment decision process about psychotherapy during the clinical consultation for people with AUD.

BackgroundSubstance use disorders (SUD) are associated with a high global burden of disease, with 5.4% of all disability-adjusted life years lost due to alcohol and illicit drugs. Highly prevalent multimorbidity includes polysubstance use, mental health conditions, and other non-communicable and infectious diseases. Where traditional treatments are insufficient alone, music therapy (MT) is highly engaging and improves motivation and reduces craving; however, its long-term effects are unknown. The present study aims to examine long-term effects of active music groups (AMG) and music listening groups (MLG) versus treatment as usual (TAU) on addiction severity, recovery, and other outcomes in people with SUD Immediate and short-term effects, as well as mechanisms of these interventions, will also be examined. MethodsIn individuals with SUD across a wide range of age, gender, socioeconomic, and cultural backgrounds, a parallel 3-arm assessor-blinded pragmatic multinational randomised controlled trial (RCT) with embedded exploratory trials and mechanistic studies will determine long-term effects of AMG and MLG versus TAU on addiction severity (primary endpoint: 1 year), recovery, and other outcomes. Embedded trials will examine immediate effects of AMG or MLG combined with individual components of TAU combined to determine the best combinations of interventions. Experimental studies will examine mechanisms using cognitive testing and brain imaging. With 600 participants in 7 countries randomised, the trial will have 80% power on the primary outcome. Patient representatives, health technology assessment (HTA) bodies, and interventionists have been involved from conception and will ensure feasibility and applicability of the intervention across Europe. DiscussionThis document describes the FALCO RCT, the main part of the FALCO project, which aims to reduce disease burden through innovative, effective, and affordable treatment, and will strengthen research and innovation expertise. Recommendations from FALCO will inform intervention delivery across Europe and beyond, leading to increased safety, effectiveness, and cost-effectiveness, and improved quality of life for individuals with SUD. Stakeholders will be involved in communicating findings across all European countries and regions and ensuring that findings are effectively implemented. Trial registrationClinicalTrials.gov, NCT07028983, registered 11th of June 2025. https://clinicaltrials.gov/study/NCT07028983

BackgroundNon-medical use of prescription psychotropic medications (NMUPM) among adolescents and young adults in low- and middle-income countries (LMICs) is an emerging public health concern. Such practices are associated with psychiatric comorbidities, increased risk behaviors, and long-term dependence. Limited access to mental health services, weak regulatory enforcement, and the widespread availability of prescription drugs contribute to NMUPM. Despite anecdotal reports, comprehensive epidemiological synthesis across LMICs is scarce. ObjectiveTo systematically review the prevalence, patterns, psychiatric correlates, and health-system drivers of NMUPM among young people (aged 10-35 years) in LMICs and provide a pooled estimate of prevalence through meta-analysis. MethodsWe conducted a systematic review following the PRISMA 2020 guidelines. PubMed/MEDLINE, Scopus, Web of Science, Embase, PsycInfo, LILACS, AJOL, WHO GIM, Google Scholar, and regional LMIC repositories were searched for studies published between 2000 and 2026 reporting NMUPM among adolescents and young people. Inclusion criteria comprised cross-sectional surveys, community or school-based studies, and national or regional surveillance reports. Data were extracted on sample size, prevalence, commonly misused drugs, sources of medication, and motivations. A random-effects generalized linear mixed model (GLMM) with logit transformation was used to estimate pooled prevalence, and heterogeneity was assessed using I{superscript 2} statistics. Risk of bias was evaluated using the Joanna Briggs Institute (JBI) checklist. ResultsA total of 13 studies were included in the systematic review, with 10 studies (N = 6,728 participants) suitable for quantitative meta-analysis. The pooled prevalence of NMUPM among young people in LMICs was 18.4% (95% CI: 12.1-26.2%), with substantial heterogeneity (I{superscript 2} > 90%). Benzodiazepines and tramadol were the most commonly misused drugs. Primary drivers included prior experience with medications, ease of access through pharmacies or peers, and limited awareness of potential harms. NMUPM was associated with psychiatric symptoms, risky behaviors, and early progression to substance use disorders. ConclusionNon-medical use of psychotropic medications is prevalent among adolescents and young adults in LMICs, posing significant psychiatric and public health challenges. Interventions are urgently needed to strengthen regulatory enforcement, improve public awareness, enhance mental health service accessibility, and promote safe medication practices. Future research should focus on longitudinal studies to clarify causal pathways and test behavioral interventions to reduce NMUPM.

ObjectiveGiven the potential severity and economic burden of falls, we compared the short-term risk of falls following initiation of sustained-release (SR) tapentadol versus controlled-release (CR) oxycodone in real-world clinical practice. DesignActive comparator, new user retrospective cohort study using routinely collected health data from 2014 to 2020. SettingNew South Wales, Australia. ParticipantsPeople aged [&ge;]18 years initiating publicly subsidised tapentadol (SR) or oxycodone (CR). InterventionsInitiation of tapentadol (SR) or oxycodone (CR). Main outcome measuresComposite measure of fall-related emergency department presentations, hospitalisations or deaths. We used propensity score matching to adjust for baseline confounding and approximated relative risks (RR) of falls at 7, 14, and 28 days after initiation using conditional logistic regression models. We calculated absolute risk differences and estimated the number of people that would need to be treated with oxycodone (CR) vs tapentadol (SR) for one additional fall to occur (NNTH). We conducted subgroup analyses restricted to people aged [&ge;]65 and [&ge;]80 years and by recent opioid exposure (within 90 days prior to initiation). ResultsWe identified 103,924 tapentadol (SR) and 419,732 oxycodone (CR) initiators; after matching each cohort comprised 103,758 initiators. Most people (74%) were aged between 45-84 years, and slightly more than half were female. Within 28 days of initiation, 652 (0.6%) oxycodone (CR) initiators and 457 (0.4%) tapentadol initiators suffered a fall. Across all time points, tapentadol (SR) initiation was associated with a lower risk of falls compared with oxycodone (CR) (7 days: RR 0.57 [95% CI 0.48 to 0.69]; 14 days: 0.62 [0.54 to 0.71]; 28 days: 0.70 [0.62 to 0.79]). Absolute differences were small at all time points (approximately 1-2 fewer falls per 1,000 patients treated), corresponding to NNTH for one additional fall ranging from 739 to 529. These patterns persisted regardless of recent opioid exposure. Relative risks were similar in the older age groups while absolute differences were slightly larger ([&ge;]65 years: 2-3 fewer falls/1,000; [&ge;]80 years: 4-8 fewer falls/1,000). The greatest absolute differences were among opioid-naive people aged [&ge;]80 years (6-10 fewer falls/1,000, corresponding to NNTH ranging from 173 to 97). Fall risks were attenuated among people aged [&ge;]80 years with recent opioid exposure. ConclusionsTapentadol (SR) was associated with a lower risk of falls than oxycodone (CR) up to four weeks after initiation, although absolute differences were small. The reduction in risk may be an important consideration in older patients where the consequences of falls are most severe. What is already known on this topicO_LIClinical trials suggest that sustained-release (SR) tapentadol has a lower incidence of adverse central nervous system effects compared to controlled-release (CR) oxycodone C_LIO_LIpioids are associated with increased risks of falls, particularly immediately following initiation C_LI What this study addsO_LIInitiation of tapentadol (SR) was associated with a lower short-term risk of falls resulting in ED presentation, hospitalisation, or death compared to initiation of oxycodone (CR) C_LIO_LIAbsolute risk differences were small but reached 1% among opioid-naive people aged 80 years and older where consequences of falls are most severe C_LI

BackgroundCo-occurring substance use and mental health disorders (COD) represent a growing public health concern, yet healthcare utilization studies with a large sample size remain limited. This study examined healthcare utilization patterns and sociodemographic correlates among COD adults using data from the All of Us Research Program (2018-2023). MethodsElectronic health record data were analyzed for adults aged [&ge;]18 years with confirmed diagnoses of substance use and mental health disorders recorded on at least two occasions. Healthcare services were identified using the standardized Current Procedural Terminology and Healthcare Common Procedure Coding System codes and categorized into counseling and therapy, medication/somatic services, online or telehealth care, and other supportive modalities. Multivariable logistic regression was employed to assess sociodemographic and structural correlates of healthcare utilization. ResultsAmong 19,423 adults with COD, 57.1% received healthcare. Counseling and therapy accounted for the largest share of encounters, while online services surged in 2020 during the COVID-19 pandemic. Healthcare utilization was higher among older adults ([&ge;]65 years: aOR=1.52, 95%CI:1.29-1.78), males (aOR=1.19, 95%CI:1.12-1.26), individuals with disabilities (aOR=1.46, 95%CI:1.36-1.56), and those with employer-sponsored (aOR=1.22, 95%CI:1.10-1.36) or other private insurance (aOR=2.15, 95%CI:1.97-2.34). The level of healthcare utilization was lower among participants with lower income ([&le;]$25,000: aOR=0.75, 95%CI:0.69-0.81) or Medicaid coverage (aOR=0.83, 95%CI:0.77-0.89). ConclusionsDespite high clinical need, healthcare utilization among adults with COD remains suboptimal and is shaped by structural inequities across income and insurance lines. Findings highlight the need to expand integrated healthcare services, strengthen Medicaid coverage, and sustain telehealth infrastructure to promote equitable, long-term engagement in care. Highlights{o} Individuals with co-occurring disorders continue to face low healthcare utilization. {o} Counseling and therapy were the major mode of care, while telehealth peaked during COVID-19. {o} Lower income and Medicaid coverage were tied to lower healthcare utilization. {o} Older adults and people with disabilities were more likely to use healthcare services. {o} Findings highlight the needs to expand integrated, equitable behavioral care.