Alcohol Medical Intervention Clinic: A Rapid Access Addiction Medicine Model Reduces Emergency Department Visits Objectives: Problematic alcohol use accounts for a large proportion of Emergency Department (ED) visits and revisits. We developed the Alcohol Medical Intervention Clinic (AMIC), a Rapid Access Addiction Medicine (RAAM) service, to reduce alcohol-related ED re-utilization and improve care for individuals with alcohol problems. This article describes the AMIC model and reports on an evaluation of its impact on patients and the ED system. Methods: Individuals presenting to The Ottawa Hospital Emergency Departments (TOH-ED) for an alcohol-related issue were referred to AMIC. Using data collected via medical chart review, and also self-report questionnaires, we assessed ED visits, revisits, and changes in alcohol use and mental health symptoms in patients before and after receiving services in AMIC. The incidence of alcohol-related ED visits and re-visits from 12-month periods before and after the introduction of AMIC were compared using data from TOH Data Warehouse. Connections made to additional services and patient satisfaction was also assessed. Results: For patients served by AMIC, from May 26, 2016 to June 30, 2017 (n = 194), there was an 82% reduction in 30-day visits and re-visits (P < 0.001). An 8.1% reduction in total alcohol-related 30-day TOH-ED revisit rates and a 10% reduction in total alcohol-related TOH-ED visits were found. After receiving AMIC services, clients reported reductions in alcohol use, depression, and anxiety (P < 0.001). Conclusions: AMIC demonstrated positive impacts on patients and the healthcare system. AMIC reduced ED utilization, connected people with community services, and built system capacity to serve people with alcohol problems. Send correspondence to Kimberly Corace, PhD, The Royal Ottawa Mental Health Centre, 1145 Carling Avenue, Ottawa, Ontario K1Z 7K4, Canada. E-mail: kim.corace@theroyal.ca Received 24 December, 2018 Accepted 19 April, 2019 The authors report no conflicts of interest © 2019 American Society of Addiction Medicine

Do Patients Require Emergency Department Interventions After Prehospital Naloxone? Objective: Patients receiving naloxone for suspected opioid overdose in the prehospital setting are typically transported to the emergency department (ED) for further evaluation, regardless of Glasgow Coma Scale (GCS). The objective of our study is to determine whether patients with GCS ≥14 after receiving prehospital naloxone received additional doses of naloxone and medical interventions in the ED compared with those with GCS <14 after prehospital naloxone. Methods: Our retrospective observational study included patients ≥18 years old treated with naloxone and transported by an inner-city hospital-based Emergency Medical Services (EMS) to its affiliated ED from January 2, 2016 to December 31, 2016. Investigators collected demographic data, prehospital interventions, GCS, ED interventions, and dispositions. Institutional Review Board approval was obtained. The main outcome measures were repeat doses of naloxone and ED interventions. Results: In all, 473 patient encounters were reviewed. Most common route of prehospital naloxone administration was intranasal (68%). Nearly two-thirds (n = 473) of patients had GCS ≥14 upon ED arrival. Repeat naloxone was administered to 3.5% (n = 314) of patients with GCS ≥14 versus 14.6% (n = 159) of patients with GCS <14. ED interventions, such as airway maneuvers, laboratory and radiology testing, and cardiac monitoring, were less common among patients who had improved GCS of 14 or higher (n = 314). There were 8 deaths among patients with GCS <14 (n = 159) and no deaths among patients with GCS ≥14 (n = 314). Conclusion: Patients with GCS score ≥14 after administration of prehospital naloxone are less likely to receive additional naloxone doses and medical interventions in the ED compared with those with a GCS score <14 after prehospital naloxone and may present an invaluable opportunity for the ED to initiate an addiction treatment program for patients with nonfatal overdose. Send correspondence to Rick Hong, MD, Cooper University Hospital, Department of Emergency Medicine, One Cooper Plaza, Camden, NJ 08103. E-mail: hong-rick@cooperhealth.edu Received 8 January, 2019 Accepted 10 July, 2019 The authors declare that they have no conflicts of interest. © 2019 American Society of Addiction Medicine

Co-occurring Substance Use Disorders in Youth With Chronic Medical Conditions: The Need for Integration of Addiction Treatment into Mainstream Medical Facilities Approximately 5% of adolescents in the US meet criteria for a substance use disorder (SUD), and many of them benefit from residential treatment programs at points in the course of the disorder to achieve early sobriety and stabilization. Youth with chronic medical conditions use alcohol, marijuana, and other substances at levels similar to peers, but are at greater risk of progression to heavy or problem use of alcohol, marijuana, and tobacco by young adulthood and often encounter unique treatment barriers that limit access to an appropriate level of care. We describe 2 such adolescents; a 15-year-old boy with type 1 diabetes who experienced interruptions in substance use treatment because of concerns regarding routine glycemic management and a 17-year-old boy with inflammatory bowel disease, who experienced treatment delays in the context of increasing alcohol and marijuana use because of digestive symptoms. For both of these adolescents, lack of access to professionals who could manage chronic medical conditions prevented delivery of substance use treatment and resulted in an increase in substance use behaviors. These cases illustrate the need for integrated substance use care within medical specialty settings. We propose opportunities for improvement, such as providing cross-training for medical and addiction treatment teams and integration of substance use treatment within traditional medical facilities. Send correspondence to Nicholas Chadi, MD, MPH, Adolescent Substance Use and Addiction Program, Division of Developmental Medicine, Department of Pediatrics, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115. E-mail: nicholas.chadi@childrens.harvard.edu Received 2 February, 2019 Accepted 26 May, 2019 The authors have indicated they have no potential conflicts of interest to disclose. © 2019 American Society of Addiction Medicine

Perceived Behavioral Control and Barriers to Cleaning Skin Before Injecting Drugs Objectives: Skin and soft-tissue infections (SSTI) among people who inject drugs (PWID) are common and represent a significant public health burden. In the current study, we examined the relationship between perceived behavioral control and perceived barriers to cleaning skin before injecting drugs. Methods: Participants (n = 248; 37.9 [±10.7] years of age, 58.5% male, 59.3% white, 16.1% Hispanic) were patients seeking medical care at a large urban hospital in the northeastern United States. We used ordinary least squares regression to estimate the associations between perceived barriers to skin cleaning with background characteristics and perceived behavioral control. Results: Controlling for background and other study variables, greater number of past-year skin abscesses was associated with greater level of perceived barriers to skin cleaning (P < 0.001), whereas higher level of education and higher perceived behavioral control were associated with lower levels of perceived barriers to skin cleaning (P < 0.001). Conclusions: Interventions aiming to reduce the likelihood for SSTI among people who inject drugs may benefit from strengthening individual's behavioral control and providing skin cleaning skills training. Send correspondence to Shannon R. Kenney, PhD, MPH, Department of Psychiatry and Human Behavior at Brown University, Butler Hospital, 345 Blackstone Blvd., Providence, RI 02906. E-mail: Shannon_Kenney@brown.edu. Received 2 March, 2019 Accepted 15 July, 2019 Funding: This study was funded by the National Institutes of Health (R01DA034957). The authors have no conflicts of interest to disclose. © 2019 American Society of Addiction Medicine

Sedative/Tranquilizer Misuse is Associated with Alcohol and Illicit Drug Problems, Mental Health Issues, and Impulsivity and Compulsivity in University Students Background: This study examined the prevalence of sedative/tranquilizer misuse among university students and its associations with psychosocial correlates. Methods: Nine thousand four hundred forty-nine students received a 156-item anonymous online survey, which assessed the use of prescription sedative/tranquilizer (ever or past year), alcohol and drug use, mental health issues, and impulsive and compulsive traits. Sedative/tranquilizer misuse was defined as intake of these prescription drugs by individuals who had not been prescribed them. Results: Three thousand five hundred twenty-five university students (57.7% women) responded to the survey. The prevalence of past 12-month prescription sedative/tranquilizer misuse was 2.1%, with 2.8% reporting having used more than 12 months ago. Prescription sedative/tranquilizer misuse was associated with the use of multiple other drugs (eg, alcohol, opiates each P < 0.001). Those who misuse sedative/tranquilizers were significantly more likely to have mental health histories (P < 0.001), engage in riskier sexual behavior (ie, earlier sexual acts [P < 0.001] and less frequent use of barrier contraception [P = 0.001]), report low self-esteem (P = 0.001), and endorse traits of impulsivity (P < 0.001) and compulsivity (P < 0.001). Effect sizes were small to medium. Conclusions: Misuse of prescription sedative/tranquilizers was reported by 2% to 3% of university students and was associated with a variety of mental health and drug use problems. Clinicians should be aware that certain mental health conditions are more likely in those who misuse sedatives. This study indicates the need for longitudinal research into the effects of chronic sedative use on brain function and mental health, especially in young people. Such research should address the extent to which impulsive traits predispose to various substance use problems, versus the direct effects of sedatives (and other substances) on mental health Send correspondence to Professor. Jon E. Grant, JD, MD, MPH, Department of Psychiatry & Behavioral Neuroscience, University of Chicago, Pritzker School of Medicine, 5841 S. Maryland Avenue, MC 3077, Chicago, IL 60637. E-mail: jongrant@uchicago.edu Received 9 May, 2019 Accepted 28 June, 2019 The authors report no conflicts of interest. This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0 © 2019 American Society of Addiction Medicine

Pregnancy, Substance Use, and Research: How do We Protect Women while Increasing their Participation in Research? No abstract available

Drug Legalization and Decriminalization Beliefs Among Substance-using and Nonusing Individuals Objectives: There has been advocacy for legalization of abusable substances, but systematic data on societal beliefs regarding such legalization are limited. People who use substances may have unique beliefs about legalization, and this study assessed whether they would be in favor of drug legalization/decriminalization. It was hypothesized that those who use particular drugs (especially marijuana) would support its legalization/decriminalization, but that this would not be the case across all classes (especially opioids and stimulants). Methods: A nationwide sample of 506 adults were surveyed online to assess demographic characteristics, substance misuse, and beliefs regarding drug legalization/decriminalization. Legalization/decriminalization beliefs for specific drugs were assessed on an 11-point scale (0, strongly disagree; 10, strongly agree). Results: For persons with opioid misuse (15.4%), when asked about their agreement with: “heroin should be legalized,” the mean score was 4.6 (SEE = 0.4; neutral). For persons with stimulant misuse (12.1%), when asked about their agreement with: “cocaine should be legalized,” the score was 4.2 (0.5). However, for persons with marijuana misuse (34.0%), when asked about their agreement with: “medical marijuana should be legalized” the score was 8.2 (0.3; indicating agreement), and for “recreational marijuana” the score was also 8.2 (0.3). Conclusions: These results suggest that persons who used marijuana strongly support the legalization of both recreational and medical marijuana, whereas persons who primarily have opioid or stimulant misuse have less strongly held beliefs about legalization of substances within those respective categories. By including those who misuse drugs, these data assist in framing discussions of drug legalization and have the potential to inform drug policy considerations. Send correspondence to Alexis S. Hammond, MD, PhD, Behavioral Pharmacology Research Unit (BPRU), Department of Psychiatry and Behavioral Sciences, the Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224. E-mail: Ahammon9@jhmi.edu. Received 30 August, 2018 Accepted 13 March, 2019 This work was supported by internal funding from the Johns Hopkins University School of Medicine. The authors report no conflicts of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.journaladdictionmedicine.com). © 2019 American Society of Addiction Medicine

Sociodemographic Characteristics and the Stigmatization of Prescription Opioid Addiction Objectives: The aim of this study was to investigate the relationship between participants’ sociodemographic characteristics and the degree to which they stigmatize people with an opioid addiction. Methods: A randomized, between-subjects case vignette study (n = 2605) was conducted with a nationwide online survey. We investigated how the stigmatization toward a hypothetical individual who misused prescription opioids differed across participants’ sociodemographic factors (ie, age, gender, education, race, and income). Results: Our results showed that study participants who were male, white, low-income, college graduates, and younger rated the hypothetical individual with an opioid addiction with lower stigma. In addition, we showed that participant gender moderated the relationship between information given about initiation of opioid use (received prescription opioids from a doctor vs took prescription opioids from a friend) and opioid stigma perceptions. Conclusions: Our results support previous findings that stigmatizing attitudes towards drug use vary across participant sociodemographic characteristics. The findings from our study provide a better understanding of how stigmatizing attitudes towards prescription opioid use differ across sociodemographic characteristics and can serve to improve negative perceptions of those with an opioid addiction. Send correspondence to Kimberly Goodyear, PhD, Department of Behavioral and Social Sciences, Brown University, Providence, RI. E-mail: kimberly_goodyear@brown.edu Received 10 January, 2019 Accepted 26 May, 2019 Funding: This study was funded by Connecticut College, faculty support account 152-10000-202380 (PI: Dr. Chavanne). Dr Goodyear is supported by the 5T32AA007459 training grant at NIAAA. Conflict of interest: The authors report no biomedical financial interests or potential conflicts of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.journaladdictionmedicine.com). © 2019 American Society of Addiction Medicine

Recovery From Opioid Problems in the US Population: Prevalence, Pathways, and Psychological Well-Being Objectives: Research has enhanced our understanding of opioid misuse prevalence and consequences, but few studies have examined recovery from opioid problems. Estimating national recovery prevalence and characterizing individuals who have resolved opioid problems can inform policy and clinical approaches to address opioid misuse. Methods: We conducted a cross-sectional investigation of a nationally-representative sample of US adults who reported opioid problem resolution (OPI). For reference, OPI was compared with an alcohol problem resolution group (ALC). Analyses estimated OPI/ALC prevalence, differences in treatment/recovery service use, and psychological well-being, within 2 recovery windows: <1 year (early recovery) and 1 to 5 years (mid-recovery) since OPI/ALC problem resolution. Results: Of those who reported alcohol or drug use problem resolution, weighted problem resolution prevalence was 5.3% for opioids (early recovery 1.2%, mid-recovery 2.2%) and 51.2% for alcohol (early recovery 7.0%, mid-recovery 11.5%). In mid-recovery, lifetime use of formal treatment, pharmacotherapy, recovery support services, mutual help, and current pharmacotherapy were more prevalent in OPI than ALC. Service utilization did not differ between early-recovery OPI and ALC. Common services used by OPI included inpatient treatment (37.8%) and state/local recovery organizations (24.4%) in mid-recovery; outpatient treatment (25.7%) and recovery community centers (27.2%) in early recovery; Narcotics Anonymous (40.2%–57.8%) and buprenorphine-naloxone (15.3%–26.7%) in both recovery cohorts. Regarding well-being, OPI reported higher self-esteem than ALC in early recovery, and lower self-esteem than ALC in mid-recovery. Conclusions: An estimated 1.2 million American adults report resolving an opioid problem. Given the service use outcomes and longer-term problem resolution of mid-recovery OPI, early-recovery OPI may require encouragement to utilize additional or more intensive services to achieve longer-term recovery. OPI beyond recovery-year 1 may need enhanced support to address deficient self-esteem and promote well-being. Send correspondence to Lauren A. Hoffman, PhD, Recovery Research Institute, 151 Merrimac Street, 6th Floor, Boston, MA 02114. E-mail: lhoffman1@mgh.harvard.edu Received 23 February, 2019 Accepted 11 July, 2019 Funding: This research was supported by the Recovery Research Institute at the Massachusetts General Hospital, Harvard Medical School. Financial disclosures: Dr Hoffman was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number F32 DA047741. Dr. Vilsaint and Dr Kelly were supported by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health under Award Numbers F32AA025823 and K24AA022136, respectively. The authors declare no financial or other conflict of interests that could affect the integrity or veracity of this work. © 2019 American Society of Addiction Medicine

Patient and Physician Perspectives on Treating Tobacco Dependence in Hospitalized Smokers With Substance Use Disorders: A Mixed Methods Study Objective: Individuals with substance use disorders have a high prevalence of smoking cigarettes. Hospitalization represents an opportunity to deliver concurrent treatment for tobacco and other substances. Using a sequential explanatory mixed methods design, we characterized practices and perspectives of patients and physicians about smoking cessation counseling during inpatient addiction medicine consultations. Methods: We abstracted data from 694 consecutive inpatient addiction consult notes to quantify how often physicians addressed tobacco dependence using the guideline-recommended 5As framework. We conducted semi-structured interviews with 9 addiction medicine physicians and 20 hospitalized smokers with substance use disorders. We analyzed transcripts to explore physicians’ and patients’ perspectives on smoking cessation conversations during inpatient addiction consultations, physician-perceived barriers and facilitators to engaging inpatients in tobacco treatment, and strategies to improve tobacco treatment in this context. Results: 75.5% (522/694) of hospitalized substance use disorder patients were current smokers. Among smokers, 20.9% (109/522) were offered nicotine replacement while hospitalized, but only 5.4% (28/522) received the full guideline-recommended 5As. Patients and physicians reported minimal discussion about tobacco addiction during hospitalization. Physicians cited tobacco not being an immediate health threat and the perception that quitting tobacco is not a priority to patients as barriers, often limiting thorough counseling to patients with smoking-related admissions. Physicians and patients offered strategies to integrate treatment of tobacco dependence and other substances. Conclusions: Inpatient addiction consultations represent a missed opportunity to counsel patients with substance use disorders to quit smoking. System-level changes are needed to coordinate treatment of tobacco and other drug dependence in hospitalized smokers. Send correspondence to Hasmeena Kathuria, MD, Pulmonary Center, 72 E. Concord St R304, Boston, MA 02118. E-mail: hasmeena@bu.edu. Received 10 July, 2018 Accepted 14 November, 2018 Primary Source of Funding: This work was supported by the Boston University Evans Center for Implementation and Improvement Sciences (CIIS) and supported in part by resources from the Edith Nourse Rogers Memorial VA Hospital. Conflicts of interest: Dr. Kathuria has consulted for Remedy Partners on relevance of codes for pulmonary services. The authors have no other conflicts of interests to disclose. Disclaimer: The views expressed in this article do not necessarily represent the views of the Department of Veterans Affairs or the United States Government. The funding organizations had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; or the preparation, review, or approval of the manuscript. © 2019 American Society of Addiction Medicine