Ziming Xuan

Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis

Objective To evaluate the impact of state supported overdose education and nasal naloxone distribution (OEND) programs on rates of opioid related death from overdose and acute care utilization in Massachusetts. Design Interrupted time series analysis of opioid related overdose death and acute care utilization rates from 2002 to 2009 comparing community-year strata with high and low rates of OEND implementation to those with no implementation. Setting 19 Massachusetts communities (geographically distinct cities and towns) with at least five fatal opioid overdoses in each of the years 2004 to 2006. Participants OEND was implemented among opioid users at risk for overdose, social service agency staff, family, and friends of opioid users. Intervention OEND programs equipped people at risk for overdose and bystanders with nasal naloxone rescue kits and trained them how to prevent, recognize, and respond to an overdose by engaging emergency medical services, providing rescue breathing, and delivering naloxone. Main outcome measures Adjusted rate ratios for annual deaths related to opioid overdose and utilization of acute care hospitals. Results Among these communities, OEND programs trained 2912 potential bystanders who reported 327 rescues. Both community-year strata with 1-100 enrollments per 100 000 population (adjusted rate ratio 0.73, 95% confidence interval 0.57 to 0.91) and community-year strata with greater than 100 enrollments per 100 000 population (0.54, 0.39 to 0.76) had significantly reduced adjusted rate ratios compared with communities with no implementation. Differences in rates of acute care hospital utilization were not significant. Conclusions Opioid overdose death rates were reduced in communities where OEND was implemented. This study provides observational evidence that by training potential bystanders to prevent, recognize, and respond to opioid overdoses, OEND is an effective intervention.

Effects of Prenatal Poverty on Infant Health: State Earned Income Tax Credits and Birth Weight

This study estimates the effects of prenatal poverty on birth weight using changes in state Earned Income Tax Credits (EITC) as a natural experiment. We seek to answer two questions about poverty and child wellbeing. First, are there associations between prenatal poverty and lower birth weights even after factoring out unmeasured potential confounders? Because birth weight predicts a range of outcomes across the life course, lower birth weights that result from poverty may have lasting consequences for children’s life chances. Second, how have recent expansions of a work-based welfare program (i.e., the EITC) affected maternal and infant health? In recent decades, U.S. poverty relief has become increasingly tied to earnings and labor markets, but the consequences for children’s wellbeing remain controversial. We find that state EITCs increase birth weights and reduce maternal smoking. However, results related to AFDC/TANF and varying EITC effects across maternal ages raise cautionary messages.

Disproportionate exposure to early-life adversity and sexual orientation disparities in psychiatric morbidity

OBJECTIVES Lesbian, gay, and bisexual (LGB) populations exhibit elevated rates of psychiatric disorders compared to heterosexuals, and these disparities emerge early in the life course. We examined the role of exposure to early-life victimization and adversity-including physical and sexual abuse, homelessness, and intimate partner violence-in explaining sexual orientation disparities in mental health among adolescents and young adults. METHODS Data were drawn from the National Longitudinal Study of Adolescent Health, Wave 3 (2001-2002), a nationally representative survey of adolescents. Participants included gay/lesbian (n=227), bisexual (n=245), and heterosexual (n=13,490) youths, ages 18-27. We examined differences in the prevalence of exposure to child physical or sexual abuse, homelessness or expulsion from ones home by caregivers, and physical and sexual intimate partner violence according to sexual orientation. Next we examined the associations of these exposures with symptoms of psychopathology including suicidal ideation and attempts, depression, binge drinking, illicit drug use, tobacco use, alcohol abuse, and drug abuse. Finally, we determined whether exposure to victimization and adversity explained the association between sexual orientation and psychopathology. RESULTS Gay/lesbian and bisexual respondents had higher levels of psychopathology than heterosexuals across all outcomes. Gay/lesbian respondents had higher odds of exposure to child abuse and housing adversity, and bisexual respondents had higher odds of exposure to child abuse, housing adversity, and intimate partner violence, than heterosexuals. Greater exposure to these adversities explained between 10 and 20% of the relative excess of suicidality, depression, tobacco use, and symptoms of alcohol and drug abuse among LGB youths compared to heterosexuals. Exposure to victimization and adversity experiences in childhood and adolescence significantly mediated the association of both gay/lesbian and bisexual orientation with suicidality, depressive symptoms, tobacco use, and alcohol abuse. CONCLUSIONS Exposure to victimization in early-life family and romantic relationships explains, in part, sexual orientation disparities in a wide range of mental health and substance use outcomes, highlighting novel targets for preventive interventions aimed at reducing these disparities.

Gender norms and economic empowerment intervention to reduce intimate partner violence against women in rural Côte d’Ivoire: a randomized controlled pilot study

BackgroundGender-based violence against women, including intimate partner violence (IPV), is a pervasive health and human rights concern. However, relatively little intervention research has been conducted on how to reduce IPV in settings impacted by conflict. The current study reports on the evaluation of the incremental impact of adding “gender dialogue groups” to an economic empowerment group savings program on levels of IPV. This study took place in north and northwestern rural Côte d’Ivoire.MethodsBetween 2010 and 2012, we conducted a two-armed, non-blinded randomized-controlled trial (RCT) comparing group savings only (control) to “gender dialogue groups” added to group savings (treatment). The gender dialogue group consisted of eight sessions that targeted women and their male partner. Eligible Ivorian women (18+ years, no prior experience with group savings) were invited to participate. 934 out of 981 (95.2%) partnered women completed baseline and endline data collection. The primary trial outcome measure was an overall measure of past-year physical and/or sexual IPV. Past year physical IPV, sexual IPV, and economic abuse were also separately assessed, as were attitudes towards justification of wife beating and a woman’s ability to refuse sex with her husband.ResultsIntent to treat analyses revealed that compared to groups savings alone, the addition of gender dialogue groups resulted in a slightly lower odds of reporting past year physical and/or sexual IPV (OR: 0.92; 95% CI: 0.58, 1.47; not statistically significant). Reductions in reporting of physical IPV and sexual IPV were also observed (not statistically significant). Women in the treatment group were significantly less likely to report economic abuse than control group counterparts (OR = 0.39; 95% CI: 0.25, 0.60, p < .0001). Acceptance of wife beating was significantly reduced among the treatment group (β = -0.97; 95% CI: -1.67, -0.28, p = 0.006), while attitudes towards refusal of sex did not significantly change Per protocol analysis suggests that compared to control women, treatment women attending more than 75% of intervention sessions with their male partner were less likely to report physical IPV (a OR: 0.45; 95% CI: 0.21, 0.94; p = .04) and report fewer justifications for wife beating (adjusted β = -1.14; 95% CI: -2.01, -0.28, p = 0.01) ; and both low and high adherent women reported significantly decreased economic abuse (a OR: 0.31; 95% CI: 0.18, 0.52, p < 0.0001; a OR: 0.47; 95% CI: 0.27, 0.81, p = 01, respectively). No significant reductions were observed for physical and/or sexual IPV, or sexual IPV alone.ConclusionsResults from this pilot RCT suggest the importance of addressing household gender inequities alongside economic programming, because this type of combined intervention has potential to reduce levels of IPV. Additional large-scale intervention research is needed to replicate these findings.Trial registrationRegistration Number: NCT01629472.

Opioid overdose prevention with intranasal naloxone among people who take methadone

Overdose education and naloxone distribution (OEND) is an intervention that addresses overdose, but has not been studied among people who take methadone, a drug involved in increasing numbers of overdoses. This study describes the implementation of OEND among people taking methadone in the previous 30 days in various settings in Massachusetts. From 2008 to 2010, 1553 participants received OEND who had taken methadone in the past 30 days. Settings included inpatient detoxification (47%), HIV prevention programs (25%), methadone maintenance treatment programs (MMTP) (17%), and other settings (11%). Previous overdose, recent inpatient detoxification and incarceration, and polysubstance use were overdose risks factors common among all groups. Participants reported 92 overdose rescues. OEND programs are public health interventions that address overdose risk among people who take methadone and their social networks. OEND programs can be implemented in MMTPs, detoxification programs, and HIV prevention programs.

Efficacy and the strength of evidence of U.S. alcohol control policies

BACKGROUND Public policy can limit alcohol consumption and its associated harm, but no direct comparison of the relative efficacy of alcohol control policies exists for the U.S. PURPOSE To identify alcohol control policies and develop quantitative ratings of their efficacy and strength of evidence. METHODS In 2010, a Delphi panel of ten U.S. alcohol policy experts identified and rated the efficacy of alcohol control policies for reducing binge drinking and alcohol-impaired driving among both the general population and youth, and the strength of evidence informing the efficacy of each policy. The policies were nominated on the basis of scientific evidence and potential for public health impact. Analysis was conducted in 2010-2012. RESULTS Panelists identified and rated 47 policies. Policies limiting price received the highest ratings, with alcohol taxes receiving the highest ratings for all four outcomes. Highly rated policies for reducing binge drinking and alcohol-impaired driving in the general population also were rated highly among youth, although several policies were rated more highly for youth compared with the general population. Policy efficacy ratings for the general population and youth were positively correlated for reducing both binge drinking (r=0.50) and alcohol-impaired driving (r=0.45). The correlation between efficacy ratings for reducing binge drinking and alcohol-impaired driving was strong for the general population (r=0.88) and for youth (r=0.85). Efficacy ratings were positively correlated with strength-of-evidence ratings. CONCLUSIONS Comparative policy ratings can help characterize the alcohol policy environment, inform policy discussions, and identify future research needs.

How Do Gamblers End Gambling: Longitudinal Analysis of Internet Gambling Behaviors Prior to Account Closure Due to Gambling Related Problems

Objective: To examine behavioral patterns of actual Internet gamblers who experienced gambling-related problems and voluntarily closed their accounts. Design: A nested case–control design was used to compare gamblers who closed their accounts because of gambling problems to those who maintained open accounts. Setting: Actual play patterns of in vivo Internet gamblers who subscribed to an Internet gambling site. Participants: 226 gamblers who closed accounts due to gambling problems were selected from a cohort of 47,603 Internet gamblers who subscribed to an Internet gambling site during February 2005; 226 matched-case controls were selected from the group of gamblers who did not close their accounts. Daily aggregates of behavioral data were collected during an 18-month study period. Main outcome measures: Main outcomes of interest were daily aggregates of stake, odds, and net loss, which were standardized by the daily aggregate number of bets. We also examined the number of bets to measure trajectory of gambling frequency. Results: Account closers due to gambling problems experienced increasing monetary loss as the time to closure approached; they also increased their stake per bet. Yet they did not chase longer odds; their choices of wagers were more probabilistically conservative (i.e., short odds) compared with the controls. The changes of monetary involvement and risk preference occurred concurrently during the last few days prior to voluntary closing. Conclusions: Our finding of an involvement-seeking yet risk-averse tendency among self-identified problem gamblers challenges the notion that problem gamblers seek “long odds” during “chasing.”

Past 15-year trends in adolescent marijuana use: Differences by race/ethnicity and sex

BACKGROUND The potential for increases in adolescent marijuana use is an important concern given recent changes in marijuana policy. The purpose of this study was to estimate trends in marijuana use from 1999 to 2013 among a national sample of US high school students. We examine changes over time by race/ethnicity and sex. METHODS Data are from the National Youth Risk Behavior Survey (YRBS), which involves biennial, school-based surveys that generate nationally representative data about 9th-12th grade students in the United States. Students self-reported sex, race/ethnicity, and marijuana use (i.e., lifetime use, past 30-day use, any use before age 13). We generated national estimates of the prevalence of marijuana use for the time period, and also tested for linear and quadratic trends (n=115,379). RESULTS The prevalence of lifetime marijuana use decreased modestly from 1999 to 2009 (44% to 37%), and has increased slightly since 2009 (41%). Other marijuana use variables (e.g., past 30-day use) followed a similar pattern over time. The prevalence of past 30-day use from 1999 to 2013 for all groups and both sexes was 22.5%, and it was lowest among Asians and highest among American Indian/Alaska Natives. Although boys have historically had a higher prevalence of marijuana use, results indicate that male-female differences in marijuana use decreased over time. CONCLUSION Despite considerable changes in state marijuana policies over the past 15 years, marijuana use among high school students has largely declined. Continued surveillance is needed to assess the impact of policy changes on adolescent marijuana use.

A new scale of the U.S. Alcohol policy environment and its relationship to binge drinking

BACKGROUND Of outcomes related to excessive drinking, binge drinking accounts for approximately half of alcohol-attributable deaths, two thirds of years of potential life lost, and three fourths of economic costs. The extent to which the alcohol policy environment accounts for differences in binge drinking in U.S. states is unknown. PURPOSE The goal of the study was to describe the development of an Alcohol Policy Scale (APS) designed to measure the aggregate state-level alcohol policy environment in the U.S. and assess the relationship of APS scores to state-level adult binge drinking prevalence in U.S. states. METHODS Policy efficacy and implementation ratings were developed with assistance from a panel of policy experts. Data on 29 policies in 50 states and Washington DC from 2000-2010 were collected from multiple sources and analyzed between January 2012 and January 2013. Five methods of aggregating policy data to calculate APS scores were explored; all but one was weighted for relative policy efficacy and/or implementation. Adult (aged ≥18 years) binge drinking prevalence data from 2001-2010 was obtained from the Behavioral Risk Factor Surveillance System surveys. APS scores from a particular state-year were used to predict binge drinking prevalence during the following year. RESULTS All methods of calculating APS scores were significantly correlated (r >0.50), and all APS scores were significantly inversely associated with adult binge drinking prevalence. Introducing efficacy and implementation ratings optimized goodness of fit in statistical models (e.g., unadjusted beta=-3.90, p<0.0001, R(2)=0.31). CONCLUSIONS The composite measure(s) of the alcohol policy environment have internal and construct validity. Higher APS scores (representing stronger policy environments) were associated with less adult binge drinking and accounted for a substantial proportion of the state-level variation in binge drinking among U.S. states.

An empirical evaluation of the US Beer Institute's self-regulation code governing the content of beer advertising.

OBJECTIVES We evaluated advertising code violations using the US Beer Institute guidelines for responsible advertising. METHODS We applied the Delphi rating technique to all beer ads (n = 289) broadcast in national markets between 1999 and 2008 during the National Collegiate Athletic Association basketball tournament games. Fifteen public health professionals completed ratings using quantitative scales measuring the content of alcohol advertisements (e.g., perceived actor age, portrayal of excessive drinking) according to 1997 and 2006 versions of the Beer Institute Code. RESULTS Depending on the code version, exclusion criteria, and scoring method, expert raters found that between 35% and 74% of the ads had code violations. There were significant differences among producers in the frequency with which ads with violations were broadcast, but not in the proportions of unique ads with violations. Guidelines most likely to be violated included the association of beer drinking with social success and the use of content appealing to persons younger than 21 years. CONCLUSIONS The alcohol industrys current self-regulatory framework is ineffective at preventing content violations but could be improved by the use of new rating procedures designed to better detect content code violations.