Selected Projects

PHIOS FACULTY FUNDED GRANTS AS OF NOVEMBER 2019 (ONLY NIH GRANTS IN WHICH FACULTY ARE PIs or MPIs  and with substance use outcomes are listed).

VENUES AND RISK NETWORKS: CONTEXT OF SUBSTANCE USE AND HIV AMONG HIGH RISK WOMEN (4/1/2019 - 3/31/2021)
Brook West – Principal Investigator

Act: K01 - Project: DA041233 - Admin / Funding IC: NIDA

DESCRIPTION (provided by applicant): The purpose of this Mentored Research Scientist Development Award (K01) is to provide the candidate with the training and expertise needed to transition to research independence in the science of HIV/STI prevention and intervention. The candidate plans to assess how substance use and the epidemiology of HIV/STI are shaped by physical and social contexts, using this information to design high-impact interventions. To achieve these goals, the proposed career development plan has been designed to augment the candidate's current training in sociology and epidemiology and enable her to: 1) build expertise on the evaluation of HIV/STI risk venues for high-risk females who inject drugs (PWID); 2) develop methodological expertise in social network analysis, with a particular focus on two-mode network methods; 3) gain conceptual and methodological skills in the design of structural interventions focused on venues and risk networks; and 4) obtain additional training in the ethical conduct of place-based, network, and intervention research. These training goals will be achieved through a combination of didactic courses, specialized workshops, hands-on research, and mentoring from an interdisciplinary team of experts. Despite a low national HIV prevalence, incidence is rising among vulnerable populations along the US-México border, especially high risk females. In Tijuana, HIV sequencing data indicates that the local epidemic is characterized by multiple new viral introductions, bridging across risk groups, and phylogenetic clustering among women. This suggests that interventions with high risk women could reduce HIV/STI incidence by tapping into their connections to other high risk groups. Using field observations and survey data on venue affiliations, the proposed research will assess underlying HIV/STI transmission dynamics by identifying venues where high risk networks converge (e.g. bars, shooting galleries, street intersections) and examining how the physical features of these venues (e.g. type, location, policies, safety) and affiliation network patterns (i.e. people's connections to these places) drive substance use, HIV/STI risk behaviors and infection. Incorporating detailed venue information into two-mode network analysis involving high risk female PWID will enhance research on local pathogen transmission patterns and inform targeted public health efforts aimed at reducing HIV/STI incidence. Additionally, the data collected as part of this K01 will inform the development of venue/network-level structural intervention strategies for high risk female PWID. This research responds to the FY2016 Trans-NIH Plan from the Office of AIDS Research, which calls for research on how best to target HIV prevention and treatment resources.114 The proposed research will be conducted as an independent adjunct to an existing NIH/NIDA-funded study that assesses criminal justice and HIV among PWID (R37DA019829, PI: Strathdee), capitalizing on its infrastructure and team of experts. The research findings and methodological skills to be gained from this K01 have wide applicability for infectious disease research and high transferability across diverse research settings.

A RANDOMIZED TRIAL OF ABANDONED HOUSING REMEDIATION, SUBSTANCE ABUSE AND VIOLENCE (4/20/2016 - 3/31/2021)
Charlie Branas – Multiple Principal Investigator

Act: R01 - Project: AA024941 - Admin / Funding IC: NIAAA

DESCRIPTION (provided by applicant): A randomized trial of abandoned housing remediation, substance abuse and violence Housing abandonment poses a major health burden that has grown significantly over the past several decades in the US. As a typical US city, Philadelphia has some 40,000 vacant properties, a significant number with abandoned residential buildings or structures. Research, including our own, has shown that vacant and abandoned properties are associated with drug- dependence, firearm violence, stress, sexually transmitted diseases, and premature mortality. Our prior research also shows that urban residents see abandoned buildings every day on their way to work or school and describe these undesirable structures as foremost, hypervisible detractors to community health, reducing community cohesion and creating trash, rodents, crime, fear, stress, and havens for transients, drug use, and sex work. Multiple theories posit that visible, environmental disorders, such as abandoned buildings, lead to community decline by signaling that a community is uncared-for, incivilities are tolerated, and the ability of residents to engage in shared expectations of social control over neighborhood problems is eroded. As a result, residents are prevented from engaging in positive health behaviors while unhealthy behaviors, such as substance abuse and violence, become sheltered and more prevalent. Direct remediation of abandoned housing could thus be a potent intervention to interrupt longstanding substance abuse and violence. The proposed research team has produced several preliminary/pilot studies that demonstrate its capacity to complete the proposed study: (1) a published, citywide quasi-experimental study of the health and safety effects of a novel abandoned building remediation protocol stemming from the 2011 Philadelphia Doors and Windows Ordinance; (2) multiple published pilot randomized controlled trials (RCTs) of the effects of abandoned and vacant property remediation on health and safety; and (3) a large, citywide RCT of vacant lot greening involving over 600,000 ft2 of land and a 5-wave, random sample survey of over 600 Philadelphians. There have been no RCTs that test the health and safety effects of abandoned housing remediation. The broad objective of this proposal addressed this gap in knowledge by conducting a citywide RCT of the effects of abandoned housing remediation on substance abuse outcomes, both alcohol and drug related, and violence outcomes, particularly firearm violence. A total of 320 randomly selected abandoned houses, stratified into four geographic sections of Philadelphia, will be randomly assigned to four trial arms: full abandoned housing remediation (n=80, full treatment), graffiti and trash clean-up only (n=80, graffiti treatment), trash clean-up only (n=80, contact control), and no housing remediation or clean-up (n=80, no treatment). Longitudinal outcomes on and near the abandoned houses will be measured in the 18 months before and after treatment. Mixed, quantitative and qualitative methods, will be used to achieve the proposed specific aims in determining if abandoned housing remediation is a cost-effective approach to substance abuse and firearm violence.

PLACE MATTERS - ADAPTABLE SOLUTIONS TO VIOLENCE AT THE COMMUNITY LEVEL (8/1/2018 - 7/31/2023)
Charlie Branas – Multiple Principal Investigator

Act: R01 - Project: HD095609 - Admin / Funding IC: NICHD

PROJECT SUMMARY / ABSTRACT Project Title: Place matters - Adaptable Solutions to Violence at the Community Level Violence is a leading health burden in the U.S. and globally, and plays a significant role in shaping population health and health disparities, given both immediate and long-term consequences.4 Remediation of abandoned buildings and vacant lots has been shown to be an effective and cost-beneficial solution to violence, especially firearm violence, in U.S. cities.9-11 This place-based blight remediation may be an effective population-based strategy for primary prevention of serious and lethal violence among youth but few studies have tested this approach among youth, specifically.12 Furthermore, it may have an impact on violence in the home or family violence, including child abuse and intimate partner violence (IPV); but no studies have examined this effect, although research on other forms of neighborhood disorder and the nature of family violence suggest that it may have a substantial impact.15 The objective of the proposed project aims to conduct the first community-level randomized controlled trial aimed at blight remediation for youth and family violence prevention. Our long-term goal is to define and address the role of community infrastructure and its potential impact on multiple forms of violence, and to identify potential buffers that may be included in prevention efforts. Our central hypothesis is that blight remediation will provide fewer locations for illegal weapons storage but will also improve residential sense of community and social control, and reduce stress among residents. This proposal is feasible because it leverages our ongoing evaluation of blight reduction efforts by the City of New Orleans and ongoing neighborhood-based violence research by the PIs. To address the current research gaps and achieve our objectives, we propose to conduct a cluster randomized trial with 600 lots and two intervention arms (n=150 lots in each arm)—one without buildings/structures and greened and one greened and with buildings/structures treated—propensity score matched 1:1 to control lots (n=300) across four New Orleans communities experiencing high rates of violence. A qualitative evaluation will also be conducted to examine the personal impact of blight remediation strategies. Confirmation of our hypotheses that reduction of neighborhood blight impacts not only youth violence (including serious and lethal) but also child abuse and IPV will provide critical information for policy and prevention efforts. Furthermore, examination of potential structural buffers or deterrents will aid in scaling up and translation of this highly innovative community-level program as well as providing further evidence for the interaction between multiple neighborhood conditions on violence-related outcomes.

OPTIMIZING CONFIGURATIONS OF ROADSIDE SOBRIETY TESTING CHECKPOINTS TO REDUCE ALCOHOL-INVOLVED CRASHES (9/1/2018- 8/31/2020)
Chris Morrison – Principal Investigator

Act: R21 - Project: AA025749- Admin / Funding IC: NIAAA

PROJECT SUMMARY Roadside sobriety testing is an intervention in which police stationed at temporary checkpoints stop motorists in order to conduct a brief sobriety test. Scientific studies provide substantial evidence that the approach reduces rates of alcohol-involved crashes, and general deterrence theory provides a clear mechanism by which the presence of checkpoints will reduce crash rates over the extent of a city. However, despite this strong empirical and theoretical support, and the potential for roadside sobriety testing to greatly reduce rates of alcohol-involved crashes, the approach is underutilized in the United States and important aspects are poorly understood. Critically, police departments have no empirical guidance regarding the optimal spatial configurations (the physical location of checkpoints within cities), temporal configurations (the days and times at which checkpoints are conducted), and site configurations (the number of sobriety tests and duration of the checkpoints) that will maximize reductions in alcohol-involved crashes and minimize law enforcement costs. The specific aims of this study are to (i) assess the immediate effect and rate of sustained impact over time of individual roadside sobriety testing checkpoints on alcohol-involved crashes within cities, (ii) assess the effect of individual roadside sobriety testing checkpoints on alcohol-involved crashes at multiple spatial scales, and (iii) identify optimal configurations of roadside sobriety testing checkpoints, p, to minimize travel time, t, to alcohol-involved crashes within cities. To achieve these aims we will access detailed checkpoint and crash data from the Australian state of Queensland, a jurisdiction where roadside sobriety testing is widely used and where checkpoint data are available at a spatial and temporal resolution and over a geographic extent that is not possible in the US. Because all roadside sobriety testing programs affect alcohol-involved crashes through the same theoretical mechanism, results will be generalizable to the United States. Selecting all 15 Queensland cities with populations between 10,000 and 500,000, we will calculate counts of checkpoints and crashes at two spatial scales (within cities, and within small Census units nested within the cities). We will use censored regression analyses to assess temporal relationships within cities, and Bayesian conditional autoregressive analyses to assess spatial relationships within Census units and across the extent of cities. We will then use a location-allocation heuristic to identify optimal configurations of checkpoints within cities, and will enumerate the predicted trade-off between benefits (crashes averted) and costs (checkpoints). Based on the results of these analyses, we will produce recommendations to US police departments regarding the optimal spatial, temporal, and site configurations of roadside sobriety checkpoints that minimize burdens on scarce police resources, maximize the effectiveness of existing programs, encourage wider use of roadside sobriety testing, and ultimately reduce rates of alcohol-involved crashes.

INFLUENCES OF IN-PERSON SOCIAL NETWORKS, DIGITAL SOCIAL NETWORKS AND NEIGHBORHOODS ON ADOLESCENT ALCOHOL CONSUMPTION (9/1/2018- 8/31/2023)
Chris Morrison – Principal Investigator

Act: K01 - Project: AA026327- Admin / Funding IC: NIAAA

PROJECT SUMMARY This Mentored Research Scientist Development Award (K01) will provide support for Dr. Christopher Morrison to develop the skills necessary to become an independent investigator examining environmental prevention strategies to reduce adolescent alcohol consumption and alcohol-related harms. Alcohol consumption by adolescents under 21 is an important public health problem because alcohol contributes to over 4,300 adolescent deaths every year and to increased risks for alcohol use disorders and other problems in later life. An integrated program of coursework, mentorship and research will allow Dr. Morrison to accomplish three training objectives: developing comprehensive expertise 1) in theory, data collection, and statistical analysis for social networks; 2) in research methods and statistical analysis for longitudinal and geographically referenced survey data, and 3) conducting research to assess exposure to social media as a determinant of alcohol consumption among adolescents. The research program comprises two complementary studies. The first is an innovative use of data from Waves I to IV of the National Longitudinal Study of Adolescent to Adult Health (Add Health), an ongoing longitudinal study of a school-based sample who were adolescents in 1994/95. Participants' alcohol consumption will be related to their friends' alcohol consumption, the characteristics and structures of their social networks, and characteristics of the neighborhoods in which they live (e.g. social disorganization, alcohol outlet density). The second study uses data from Healthy Communities for Teens (HCT), an ongoing study of 261 adolescents aged 14-16 years (R01-HD078415; PI: Byrnes, H) of neighborhood exposures and alcohol consumption. A follow-up data collection will assess participants' engagement with digital social media, their exposure to alcohol through digital social media, and the structure of their digital social networks. Study One, using Add Health data, will address two Specific Aims: 1) to build a multiscale and dynamic model of adolescents' alcohol consumption based on their location within a social network, the structure of the network, and other members' attitudes and behaviors towards alcohol, and 2) to assess interrelationships between social networks, neighborhood conditions, and alcohol consumption during adolescence, and the effects on alcohol consumption into young adulthood. Study Two, using HCT data, will address Aim 3) to test the differential effects of exposure to alcohol through in-person social networks and digital social networks on adolescent alcohol consumption. The short-term objective of the research is to identify the people through whom, the places where, and the in-person vs. digital platforms through which social networks most substantially influence adolescents' alcohol consumption. The overall career development program will provide critical support for Dr. Morrison to progress to independent scientist, conducting innovative studies of adolescents' alcohol consumption and their social and physical environments, and identifying areas for effective preventive intervention.

HEALTHCALL: ENHANCING BRIEF INTERVENTION FOR HIV PRIMARY CARE ALCOHOL DEPENDENCE (9/25/2014 - 7/31/2020)
Deborah Hasin – Principal Investigator

Act: R01 - Project: AA023163 - Admin / Funding IC: NIAAA

DESCRIPTION (provided by applicant): Among those with HIV, heavy drinking predicts poor antiretroviral therapy (ART) adherence, and substantially increases mortality and morbidity through harmful effects on the liver. Thus, effective and scalable drinking interventions are urgently needed to improve the health and survival of heavy-drinking HIV patients. Brief drinking interventions in non-dependent general primary care patients are effective, but alcohol dependent patients need more extensive intervention. Tested drinking-reduction interventions for HIV populations require considerable personnel time. To extend brief intervention in the HIV clinic with little extra demand on staff time, we harnessed communication technology to develop HealthCall, an innovative enhancement of brief drinking- reduction intervention for urban HIV patients. HealthCall uses technology to engage patients in brief daily self- monitoring of drinking, ART adherence, and other health behaviors over 60 days. The self-monitoring data are then summarized for patients, providing personalized feedback for brief review and discussion at 30 and 60 days. Patient satisfaction with HealthCall is high. Importantly, in urban alcohol dependent HIV primary care patients, we showed that HealthCall is effective at reducing heavy drinking when paired with brief Motivational Interviewing (MI; MI+HealthCall). Since then, formative work also indicated ways to increase HealthCall focus on antiretroviral therapy (ART) adherence. MI is theory-driven, evidence-based, and effective, but requires careful training, supervision and skill for successful outcome. Pairing HealthCall with a more scalable brief intervention would offer wider public health benefits. NIAAA recommends the Clinician's Guide (CG) as a brief, evidence-based approach to alcohol intervention for health care personnel who do not have counseling backgrounds. Compared to MI, CG requires less training and specific skills, thus potentially lowering costs and improving scalability when paired with HealthCall. CG also can readily incorporate attention to ART adherence. We propose a randomized trial to compare MI+HealthCall, CG+HealthCall and CG-only in 300 English- or Spanish-speaking alcohol dependent HIV patients at three diverse urban HIV clinics. The primary outcome is drinking reduction. Important secondary outcomes are ART adherence, viral load, and retention in HIV care, smoking, and the relative cost of each intervention. We will also explore if treatment effects on drinking are moderated by site or patient characteristics, and mediated by theoretically based mechanisms (commitment to change; self-efficacy). Durability of effects will be assessed through 12-month follow-up. Our scientific team has expertise in alcohol, ART adherence, technology-based brief interventions, and cost analysis, and is thus well positioned for a successful study. Responding to PA-13-121, this study will provide information on the efficacy of HealthCall to reduce drinking in HIV alcohol dependent patients when paired with two brief, evidence-based interventions that differ in their potential for scalability, addressing the need for innovative yet evidence-based brief interventions to improve the health and survival of alcohol dependent HIV patients.

DRINKING LEVELS (BINGE, VOLUME) AND ALCOHOL CONSEQUENCES: USING NATIONAL DATA TO IDENTIFY CLINICAL TRIAL ENDPOINTS  (3/10/2016 - 2/28/2021)
Deborah Hasin – Principal Investigator

Act: R01 - Project: AA025309 - Admin / Funding IC: NIAAA

Project Summary Randomized controlled trials, the gold standard in evaluating treatments for alcohol use disorders (AUDs), use drinking-reduction endpoints as the main outcomes. However, considerable uncertainty exists about how best to define drinking-reduction outcomes. Although clinicians and the Food and Drug Administration (FDA) long considered total abstinence as the best indicator of treatment efficacy, this is now seen as an overly restrictive outcome. The FDA presently focuses on the proportion of subjects with no Heavy-Drinking Days (HDD ≥5 drinks, or ≥5 for men, ≥4 for women) during a defined treatment period to define treatment efficacy. Another measure, Average Daily Volume (ADV; mean ETOH gm/day) developed by the World Health Organization (WHO) to define drinking levels for research purposes, has been adopted by the European Medicines Agency (EMA, the EU equivalent of the FDA), to define treatment success. However, because the evidence base for both HOD and ADV as clinical trial outcomes has many serious limitations, drinking outcome measures are considered a key methodological barrier to progress in developing more effective alcohol treatments. Empirical support for a drinking outcome's utility consists of its relationship to clinically relevant consequences, including interpersonal and occupational functioning, medical status, and alcohol use disorders. To examine empirical support for varying definitions of HOD, ADV and other drinking outcomes, the large, representative NESARC surveys (National Epidemiologic Survey on Alcohol and Related Conditions) offer important advantages, including richness and consistency of drinking and consequence measures. For this study, we will utilize data from NESARC Wave 1 (2001-2002; N=43,093) and Wave 2 (3-year follow-ups of Wave 1 participants, N=34,653) and NESARC-111 (2012-2013; N=36,318 new participants). We will use regression splines to determine the most informative functional relationships between HOD, ADV and consequences and identify key change-points in these relationships, to address the following key questions: (1) What levels of HOD and ADV are associated with higher risk of consequences? (2) What level of change in HOD and ADV over 3 years predicts change in consequences over the same period? (3) Are these associations modified by alcohol diagnoses and other alcohol characteristics (potential clinical trial eligibility, treatment history, early heavy drinking)? (4) Do these relationships differ between young and other adults (18-25 vs. 26+), by gender, race/ethnicity, or psychiatric comorbidity? We will also explore the following: Do alternative definitions of HOD and ADV influence findings? Does HOD or ADV offer advantages as outcomes? How do consequences relate to other common clinical trial outcomes: % days abstinent; mean drinks per drinking day? Study findings will help to define the relationship of different potential drinking outcome measures to consequences. The study is positioned to have a substantial impact on alcoholism treatment research by improving the ability to identify effective treatments for alcohol use disorders by defining the most clinically meaningful outcome measures.

DSM-IV DEPENDENCE AND DSM-5 SUD: RELIABILITY AND VALIDITY IN PATIENT SAMPLES (9/30/2004 - 6/30/2020)
Deborah Hasin – Principal Investigator

Act: R01 - Project: DA018652 - Admin / Funding IC: NIDA

DESCRIPTION (provided by applicant): Reliable and valid psychiatric diagnoses are central to clinical practice and research, and these are defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM), a common language for clinicians and researchers. In DSM-IV, substance dependence was a reliable and valid diagnosis. However, problems were identified with DSM-IV abuse, and with the DSM-IV distinction between abuse and dependence. In DSM-5, just published in May, 2013, the abuse-dependence distinction was replaced by a single Substance Use Disorder (SUD). The new DSM-5 SUD is defined by 11 criteria: all DSM-IV dependence criteria, three abuse criteria, and craving, with a threshold of e2 criteria, and severity indicated by a criteria count. While many problems were solved by the DSM-5 SUD changes, they proved surprisingly controversial, with data lacking from current populations, especially treated ones, to answer some of the questions. During the initial funding for R01DA018652, we analyzed existing data (largely epidemiologic) on the relationship of abuse and dependence. This study was productive and successful, contributing some of evidence regarding the DSM-5 SUD changes. However, to address controversies and questions about DSM-5 SUD, more knowledge is needed about its reliability and validity, particularly among patients currently in treatment. We propose a renewal to investigate the strengths and potential weaknesses of the new DSM-5 SUD in clinical samples, and to identify ways to improve it in DSM-5.1, 5.2 etc. (anticipated at briefer intervals than the time between DSM- IV and DSM-5). We will address these issues by collecting new data from 600 substance-using patients in four New York City community treatment settings, all with successful prior research collaborations. The sample will be diverse in patient characteristics and in substances used. We will focus on alcohol, cannabis, cocaine, nicotine and opioids. Trained clinician interviewers will give diagnostic interviews covering DSM-IV and DSM-5 SUD criteria at baseline, retest (1-21 days later), 3 months and 6 months. Validation will utilize antecedent variables (e.g., family history); concurrent variables (e.g., substance use level, functioning, comorbidity); and prediction/prognosis (e.g., remission and relapse in symptoms and use, functioning). Technology-assisted data collection will include Computer-Assisted Personal Interviews (CAPI); Audio Computer-Assisted Self- administered measures for private assessment of validation variables (A-CASI); and, for prospective validation, brief daily self-reports of substance use, craving, and functioning via interactive voice response (IVR). We will also investigate thresholds; whether patient characteristics affect reliability or validity; and importantly, whethe a valid subset of the 11 DSM-5 SUD criteria can be identified to provide a shorter, easier-to-use list. The team is highly experienced with the issues and methods. Our pilot work demonstrates project feasibility. This revised proposal for a renewal of R01DA018652 responds to PA-11-230 (drug phenotypes for prevention, services and etiologic research), of which conditions defined by DSM-5 form a large, important subset.

SUBSTANCE ABUSE EPIDEMIOLOGY TRAINING PROGRAM (SAETP) AT COLUMBIA UNIVERSITY (7/1/2012 - 6/30/2022)
Deborah Hasin – Principal Investigator

Act: T32 - Project: DA031099 - Admin / Funding IC: NIDA

Substance use and substance use disorders (SUD), with their associated disability, comorbidity and mortality, constitute major public health problems. Combatting these problems requires cutting-edge public health research conducted by scientists of the highest caliber. The Substance Abuse Epidemiology Training Program (SAETP) at Columbia University Medical Center (CUMC) was established in 2012 to train talented young scientists to become the next generation of leaders in substance abuse epidemiology. Thus far, SAETP has been very successful, competitively attracting fellows who are productive and successful during and after their training. Completed SAETP and SAETP-affiliated fellows have attained prestigious research positions in academic medical center settings. We now propose a 5-year renewal cycle for SAETP. CUMC offers a rich array of research and training resources for SAETP, based in the Department of Epidemiology, Mailman School of Public Health, in collaboration with the Department of Psychiatry. SAETP has a cells-to-society perspective on substance abuse epidemiology, offering training at multiple levels of causation ranging from molecular to large-scale social forces. With its specialized training for substance abuse epidemiology careers, SAETP is unique at CUMC. Dr. Deborah Hasin, SAETP director, is an internationally recognized substance abuse epidemiologist with extensive successful mentoring experience. She will continue to direct SAETP in its next cycle. The disciplines of the 23 other internationally recognized SAETP faculty members include epidemiology, psychology, medicine, sociology, biostatistics, neuroscience and genetics, making for an interdisciplinary program. SAETP faculty have outstanding records in publishing, funding, and mentoring productive and successful trainees. At any given time in the renewal, SAETP will be training 4 pre-doctoral fellows (for training periods of 3-5 years each), and 4 post-doctoral fellows (for training periods of 2-3 years each). Fellows will be selected based on interest in and commitment to substance abuse epidemiology, experience, and prior accomplishments. Recruitment efforts to enroll under-represented minority trainees have been successful, with 25% of SAETP fellows from such groups to date; we will continue these recruitment efforts. SAETP will provide broad, intensive training in substance abuse epidemiology and related areas; depth in one or more areas of specialization; methodological and conceptual skills, including formulation of key research questions and testable hypotheses, and how to design and conduct high-quality substance abuse epidemiology studies. Fellows will receive mentoring and co-mentoring, and participate in many training components, e.g., a weekly substance abuse epidemiology faculty-fellow seminar; academic courses; field placements. Training will enable fellows to publish papers, hone their presentation skills in seminars and conferences, learn to write grant proposals; become knowledgeable about the responsible conduct of research, and enhance collaboration and leadership skills.

IMPACT OF MEDICAL AND RECREATIONAL MARIJUANA LAWS ON CANNABIS, OPIOIDS AND PSYCHIATRIC MEDICATIONS: NATIONAL STUDY OF VA PATIENTS, 2000 - 2024 (7/1/2019 - 4/30/2024)
Deborah Hasin – Principal Investigator

Act: R01 – Project: DA048860 - Admin / Funding IC: NIDA

Thirty states now have medical marijuana laws (MML), 9 have recreational marijuana laws (RML), and many more states are considering such laws. The health effects of cannabis laws are controversial; understanding them is a major public health and NIDA priority (PA-17-135). Thus far, only 3 studies of adults (2 of them ours; Hasin et al., 2017, Martins et al., 2016) used multi-level modeling to examine MML effects on cannabis outcomes with individual data. These studies suggested post-MML increases in cannabis use and Cannabis Use Disorder (CUD). However, they left many questions unanswered, including whether MML have stronger effects in those with key vulnerability factors (chronic pain, psychiatric disorders). In addition, soaring rates of opioid prescriptions and overdoses have led to calls for MML as part of the solution to the US opioid crisis, but most MML-opioid studies are ecological (a weak design to study individual behavior), and results from individual-level studies leave the evidence unclear. Ecological studies also suggest that through cannabis substitution, MML reduce medication prescriptions for common psychiatric disorders (e.g., PTSD, depression), but no individual-level studies of this have been conducted. Importantly, RML effects are almost entirely unknown, a major gap in knowledge. In Veterans Administration (VA) patients, CUD prevalence has doubled since 2002, and in those age ≥35, is 2-6 times higher than in the general population. VA patients also have high rates of opioid prescriptions, overdoses, and of chronic pain and psychiatric disorders that may increase their vulnerability to adverse MML and RML effects. They thus are a large, vulnerable population in whom MML and RML effects are unknown. We will investigate MML and RML effects utilizing a major resource, the individual data from the VA Electronic Medical Record, available since 2000 from the ~5,000,000 patients served each year by the VA healthcare system. We will create yearly EMR datasets, and merge this with National Death Index data, Medicare data (for those age ≥65) and state-year MML and RML variables that we will create. Using multi-level models and difference-in-difference tests, we will examine MML and RML effects on three main outcomes: cannabis (use, CUD), opioids (prescriptions, fatal and non-fatal overdoses, opioid use disorders), and psychotropic medication prescriptions (antidepressants, anxiolytics, sedatives/hypnotics). Importantly, we will determine if pain, psychiatric disorders or demographics (sex, age, race/ethnicity) modify MML/RML effects. We will also examine specific MML/RML provisions, time lags, and breakpoints in trends reflecting federal policy changes. Analyses will incorporate individual- and state-level confounders, e.g., state norms, economic factors. We will also explore alcohol and tobacco outcomes. The research team includes substance epidemiology/policy experts and VA addiction and internal medicine experts. Findings will be disseminated to clinicians and policy-makers. Determining MML/RML effects in VA patients will make a major contribution to the limited adult literature on MML/RML, contributing to knowledge that will inform policy and the care of individuals with vulnerability factors.

MECHANISMS LINKING NEIGHBORHOOD POVERTY TO PROBLEMATIC ADOLESCENT DRUG USE (03/15/2018 - 12/31/2021)
Kara Rudolph – Principal Investigator

Act: R00 – Project: DA042127 - Admin / Funding IC: NIDA

PROJECT SUMMARY/ABSTRACT Where a child grows up can influence his or her risk of problematic drug use. Surprisingly, policies and programs designed to improve neighborhood conditions have yielded conflicting results in which some children benefit but others are harmed. Understanding the mechanisms by which neighborhoods act to affect problem- atic drug use and how these mechanisms differ across subgroups and cities—that is, understanding where and for whom mechanisms apply—is essential to optimize the effectiveness of future neighborhood interventions. Mechanisms involving mediation by aspects of the school environment have been unexamined, but could prove promising for understanding differential effects of neighborhood on problematic drug use. The objective of this K99/R00 is to identify school-based mechanisms that mediate the relationship between neighborhood poverty and problematic drug use and to develop statistical methods to understand how mediation effects differ across subgroup and place. This objective contributes to the long-term goal of improving the effectiveness of interven- tions to prevent drug abuse and dependence by tailoring interventions to address the most relevant mechanisms of action for each target population based on place and individual-level characteristics. The K99 phase fills the following training gaps that are critical to achieving the research objective and long-term goal: 1) methodologic training in causal mediation analysis; 2) subject-matter training in drug abuse and dependence prevention in ur- ban populations; and 3) involvement in real-world school-based interventions to develop methods with practical utility. Aim 1 of the proposed research identifies the school environment mechanisms that mediate the relationship between neighborhood poverty and adolescent problematic drug use and modifiers of those mechanisms. Aim 2 extends a statistical method recently developed by the proposed research team for generalizing intervention ef- fects from one city to another to generalizing mediation effects. Finally, Aim 3 uses the method developed in Aim 2 to identify how the school environment mechanisms mediating neighborhood poverty and problematic drug use differ across major U.S. cities. The proposed research is expected to identify school-based mechanisms underly- ing differential effects of neighborhood poverty on adolescent problematic drug use by subgroup and place using the only study of randomized neighborhood residence. In addition, it is expected to contribute a novel statistical method that incorporates cutting-edge machine learning techniques to identify which mediation mechanisms can generalize across place, advancing translational research. Successful interventions are assumed to work in differ- ent settings, but that is not the case in practice. The proposed research will allow us to predict intervention effects while accounting for differences in population composition and modifiers of the mediation mechanism. This will make a significant contribution to improving health by informing the design and targeting of future neighborhood interventions to adolescents and places that may be most impacted in terms of problematic drug use prevention.

AGE, PERIOD, AND COHORT EFFECTS ON GENDER DIFFERENCES IN ALCOHOL USE AND ALCOHOL USE DISORDERS IN 47 NATIONAL, LONGITUDINALLY-FOLLOWED COHORTS (8/1/2018 - 4/30/2023)
Kerry Keyes – Multiple Principal Investigator

Act: R01 - Project: AA026861 - Admin / Funding IC: NIAAA

Age, period, and cohort effects on gender differences in alcohol use and alcohol use disorders in 47 national, longitudinally-followed cohorts Project abstract: Available evidence suggests that, across the lifecourse, gender patterns in alcohol use and alcohol use disorders are converging; however, (a) whether this convergence depends on developmental stage, (b) whether it is due to more rapid increases among women compared with men or, conversely, more rapid decreases among men compared with women, and (c) why it is happening all remain inadequately understood - representing a critical knowledge gap. Indeed, intervention and prevention efforts require information about whether convergence is limited to certain age groups, and most critically, why they occur. Further, potential increases in drinking among women portend a potential public health crisis, requiring accurate forecasting of future burden. Without such information, intervention and prevention efforts can be misplaced, focusing on the wrong age groups, or the wrong mediating factors. Only data with sufficient variation both historically and developmentally can answer foundational questions about diminishing gender differences in alcohol-related outcomes. Drawing from a lifecourse perspective, the present project will leverage 47 longitudinal cohorts collected through the Monitoring the Future (MTF) project, from 1976 through 2022, and apply rigorous age-period-cohort growth curve modeling to illuminate: when in historical time and during what developmental periods from ages 18 to 45 gender patterns have been converging; how gender patterns are converging (i.e. because women are increasing, men are decreasing, or both), and why gender patterns are converging. To determine why we will examine an unprecedented array of potential mediating factors including sociological trends in role transitions (marriage, parenthood, education, residential independence, and employment), gender and societal attitudes, and psychological factors (drinking attitudes and reasons, future intentions for partnership and parenthood, parenting and marriage satisfaction). We will employ rigorous age-period-cohort growth models to accomplish three aims: (1) Test when in historical time and at what developmental age gender patterns in alcohol consumption, binge drinking, and alcohol use disorder symptoms are converging or have converged; (2) Forecast future public health burden of alcohol consumption, binge drinking, and alcohol use disorder symptoms and (3) Analyze sociological, psychological, and attitudinal factors as potential mediators of gender convergences across historical time and developmental age. Mediation will be estimated with novel methods developed for epidemiological applications that overcome problematic assumptions of previous approaches. MTF data have been a key source of information on substance use for more than four decades; studies have not to date been used to examine age- period-cohort trends in gender differences in alcohol consumption. When, how, and why gender differences in alcohol consumption vary across both the lifecourse and generations represents an important gap in the literature; our proposed use of MTF data stands to be a seminal contribution.

AS ADOLESCENT SUBSTANCE USE DECLINES, INTERNALIZING SYMPTOMS INCREASE: IDENTIFYING HIGH-RISK SUBSTANCE USING GROUPS AND THE ROLE OF SOCIAL MEDIA, PARENTAL SUPERVISION, AND UNSUPERVISED TIME (6/15/2019 - 3/31/2024)
Kerry Keyes – Principal Investigator

Act: R01 - Project: DA048853 - Admin / Funding IC: NIDA

ABSTRACT Multiple data sources indicate that adolescent psychopathology, particularly internalizing symptoms, is at historically unprecedented highs in the United States. These include cognitive (low self-esteem, self- derogation), affective (depressive affect), and social (loneliness) dimensions of adolescent internalizing symptoms, which have been rapidly increasing since ~ 2009. Coinciding with these trends has been declines in adolescent alcohol and other drug (AOD) use (except marijuana), contrary to what would be expected given the historically strong relationship between AOD use and internalizing symptoms. Declines are also apparent in high intensity alcohol use (e.g. 10+ drinks per drinking occasion), high-frequency AOD use (although not marijuana), and simultaneous use of AOD (including marijuana). The strength of the relationship between internalizing symptoms and AOD use among adolescents is also decreasing; for the first time approaching null in 2016, which has serious implications for risk factor assessment, prevention and intervention. Divergences may vary across demographic subgroups, however. Little work has estimated why these diverging trends are occurring; the most prominent hypothesis is smartphones and social media. These technologies are hypothesized to underlie less face-to-face time among adolescents, increase real-time parental monitoring, and negative feelings such as envy and low self-worth. Such a shift may underlie decreases in AOD use (less unsupervised time with other adolescents, more parental monitoring) and increases in internalizing symptoms (negative feelings and self-worth). However, existing literature is not based on nationally-representative data, and the relationship with AOD use has not been investigated. The present study will utilize the Monitoring the Future (MTF) cross-sectional surveys of ~45,000 adolescents per year. MTF includes a breadth measures related to internalizing symptoms, substance use, adolescent interaction, as well as a diverse array of potential confounders. We will address three aims: (1) Examine time trends in the relationship between internalizing symptoms (low self-esteem, self-derogation, depressive affect, loneliness) with any, high-intensity, high frequency AOD use, testing the magnitude of the relationship across time and by race, sex, and SES; (2) Examine time trends in the relationship between internalizing symptoms and simultaneous use of AOD (e.g., alcohol and marijuana use, alcohol and opioid use, others), testing the magnitude of the relationship across time and by subgroups; (3) Test the extent to which social media use, parental supervision, and unsupervised time with friends are associated with internalizing symptoms, AOD use, simultaneous use of AOD, and whether the magnitude of these associations explains changes in trends over time. Methods to address these aims will include time-varying effect modeling as well as parallel process growth models. This study will provide evidence for public health action by delineating the relationship between AOD and internalizing symptoms over time, and by examining the role of new technology and the changing landscape of adolescent interaction.

HEALTH AND PSYCHOSOCIAL NEED: THE ASENZE STUDY OF RISK AND PROTECTION IN ADOLESCENCE (9/15/2018 - 2/28/2022)
Leslie Davidson – Multiple Principal Investigator

Act: R01 - Project: TW011228 - Admin / Funding IC: FIC

South Africa (SA) has the largest HIV epidemic globally, and is simultaneously affected by poverty, inequality, violence and other legacies of Apartheid. Children growing up in disadvantaged communities affected by HIV are at high risk for cognitive, behavioral, health and educational problems that, in turn, increase their risk of acquiring or transmitting HIV. This study has the long-term goal of halting the devastation of the HIV epidemic by intervening to promote better cognitive, behavioral, and psychosocial functioning of adolescents in SA. We will use a socio-ecological model with a life course perspective to prospectively investigate factors linked to drug use, binge drinking and unprotected sex including adolescent attributes such as executive function, and past and current family and contextual factors. The population-based Asenze cohort of 4-6 year old children and their primary caregiver, funded through R01 DA023697, will form the study sample. They reside in five disadvantaged areas in KwaZulu-Natal. The children, born between 2004 and 2006, were previously assessed at two time points on cognitive, bio- medical, and psychosocial functioning and their caregivers were interviewed about caregiver HIV, mental health, substance use, stress, support, household assets and household substance use. Over 25% of caregivers were HIV+; 9% reported binge drinking, 31% screened positive for a psychiatric disorder, over 30% had experienced partner violence and 17% reported that someone in the household had a drinking problem. Only 9% of households contained an adult who had completed secondary school. The Asenze cohort, reaching adolescence between 2017-2019, provides a unique opportunity to investigate the early-life origins of adolescent risk behavior in a disadvantaged population while building a strong foundation for later investigations into adulthood. We will investigate the pathways through which adolescent executive function and impulsivity, interact with both early and current social context (including their family adversity, disorganization and support as well as the behavior of their friends) affect the initiation of risky behaviors (drug use, binge drinking and unprotected sex). We will link the childhood cohort assessments of development and early adversity to those to be collected in both early and mid adolescence, including cognitive development, executive function and the initiation of risky behaviors. The findings will be crucial for informing critical prevention programs to halt the spread of HIV and promote healthy adolescent functioning. We will build research capacity through mentoring and training emerging South African scientists, masters, doctoral and post-doctoral students to build research expertise focused on investigating the impact of adolescent neurocognitive development on the initiation of risky behaviors, which result in negative education and sexual health outcomes, including HIV infection. We will also develop a SA research network of investigators working with cohort studies to promote their use in neuroscience and mental health outcomes.  

TRAINING PROGRAM ON HIV AND SUBSTANCE USE IN THE CRIMINAL JUSTICE SYSTEMACCESS (07/01/2014 - 06/30/2024)
Lisa Metsch  – Multiple Principal Investigator

Act: T32 - Project: DA037801 - Admin / Funding IC: NIDA

PROJECT SUMMARY This T32 training program was established in 2014 to train the next generation of pre- and post- doctoral scholars in the prevention, treatment, and care of HIV and substance use among individuals in the criminal justice (CJ) system. The training program is a partnership between the Columbia University School of Social Work (SSW) and the Mailman School of Public Health (MSPH), with strong support from longstanding partnerships with a number of research centers, schools, and departments at Columbia University Medical Center. We propose to renew the program by continuing its unique position as the only NIDA-funded T32 program jointly run out of a school of social work and school of public health as well as the successful administration and activities; the renewal also proposes to focus on two key significant themes for the nation and the field: (1) the opioid epidemic; and (2) implementation science. The training program provides: (1) interdisciplinary research instruction and training for pre-doctoral students and post- doctoral fellows on the intersecting issues of substance use (particularly opioid use disorders and overdose), HIV, and implementation research with the CJ system and CJ-involved populations; and (2) hands-on, mentored experience conducting independent research in the study implementation of evidence-based HIV and/or substance use prevention, treatment, and care for criminal justice-involved populations. This program is designed to strengthen the pool of researchers by increasing the diversity of academic backgrounds—e.g., social work, public health, medicine, sociology, political science, anthropology—and those from underrepresented populations—e.g., underrepresented minorities (URM), people with disabilities, individuals from disadvantaged backgrounds. Participating faculty are leaders in HIV, substance/opioid use, implementation science, and criminal justice fields, with strong track records of support from NIH. They are also well-qualified to provide training, as evidenced by their strong records of mentorship of pre- and post-doctoral early career scholars. The program supports 4 pre-doctoral students and 4 post-doctoral trainees per year at capacity (a total of 6-8 pre-doctoral trainees and 8-10 post- doctoral trainees in the renewal period). Thus, the program will add a substantial number of highly qualified new scholars to the field focusing on HIV, substance use, opioid use disorders and overdose, and implementation science among criminal justice-involved populations. Dr. Nabila El-Bassel and Dr. Lisa Metsch will continue to serve successfully as PIs/Co-Directors for the proposed training program, which provides an opportunity for two noted and distinguished scientists to collaborate and lead this initiative. They each contribute over 25 years of experience in the fields of HIV, substance/opioid use disorder treatment and overdose prevention, implementation science, and criminal justice.

ENHANCED ACCESS TO HIV CARE FOR DRUG USERS IN SAN JUAN, PUERTO RICO (02/01/2013 - 01/31/2020)
Lisa Metsch  – Multiple Principal Investigator

Act: R01 - Project: DA035280 - Admin / Funding IC: NIDA

DESCRIPTION (provided by applicant): Recent scientific advances demonstrate that for people living with HIV, antiretroviral therapy (ART) is the most effective strategy to improve immune function, reduce morbidity, improve quality of life, prolong survival, and prevent HIV transmission. Translating this knowledge into practice, however, requires prompt diagnosis and linkage to care, entry into care with timely ART initiation, and engagement in care, support for ART adherence, and retention to promote durable virologic suppression. Addressing failures in the implementation of this cascade of care, often referred to as the "Seek, Test, Treat, and Retain (STTR)" paradigm, is vital to achieving the goals of the National HIV/AIDS strategy in the United States. To date, much of the research and discussion surrounding this strategy has focused on expanding HIV testing to improve the early identification of new cases. There has been less attention focused on linkage to, engagement in, and retention in care. Specifically, little attention has focused on identifying HIV-infected individuals who, despite being aware of their diagnosis, have never been in HIV care, are intermittent users of care, or have dropped out of care. A particularly difficult subpopulation to link to and retain in HIV care are HIV-infected drug users. In Puerto Rico, drug use, especially injection drug use, continues to fuel a fast-growing HIV epidemic. Within this context, the overall goal of our proposed project is to implement and evaluate a community-level, structured approach to enhance HIV care access and retention for drug users in San Juan, Puerto Rico. The proposed intervention will be to: 1) identify drug users living with HIV who either do not know their HIV status and/or are not engaged in HIV care; 2) provide direct HIV care services through a mobile health van; and 3) support identified HIV-infected drug users with patient navigators to enhance their ability to engage in HIV care, to initiate antiretroviral therapy, and maintain adherence to their treatment regimens. We are proposing to evaluate our structural enhanced care approach through a randomized roll-out design, a refinement of the stepped-wedge design. The community-level success of the intervention will be assessed by evaluating virologic suppression (primary biological outcome), increased attendance to HIV care visits, uptake of antiretroviral therapy, adherence to HIV treatment regimens, and decreased substance use (as secondary behavioral outcomes) in an independent cohort of HIV-positive individuals drawn from each of the neighborhoods included in the intervention. We will also evaluate the implementation process and cost of the enhanced care approach including implications for cost-effectiveness, feasibility of expansion, and sustainability.

A  CLUSTER RCT TO INCREASE HIV TESTING IN SUBSTANCE USE TREATMENT PROGRAMS (09/01/2016 - 07/31/2021)
Lisa Metsch  – Multiple Principal Investigator

Act: R01 - Project: DA043130 - Admin / Funding IC: NIDA

Project Summary/Abstract Approximately one in eight people living with HIV in the US are unaware of their infection and the majority of adults in the US have never been HIV tested. The CDC and WHO have called for expanding HIV testing in settings where high-risk persons receive health services, including opioid treatment programs (OTPs). Persons who use opioids and other substances have high HIV risk compared with the general population; yet fewer than half of US substance use disorder (SUD) treatment programs offer on-site HIV testing and the proportion of OTPs that do has declined in the past decade. There is widespread recognition of the need for increased HIV testing and the effectiveness and economic value of on-site HIV testing in SUD treatment programs has been demonstrated. Recent recommendations from the US Preventive Services Task Force (USPSTF) that adolescents and adults should be screened for HIV in health care settings provide new opportunities for expanding access to HIV testing in OTPs. To optimize this opportunity, OTPs must address and overcome organizational-level barriers to testing, including staffing, training, concerns about delivering HIV test results and linkage to care, and the need to set up systems to support reimbursement for HIV testing services. Additionally, Hepatitis C (HCV) testing is perceived as an even greater need by some SUD programs. HCV prevalence, high among opioid users, is higher than HIV prevalence and more individuals with chronic HCV infection are unaware of their infection. Thus, we will examine whether the offer of HCV testing with HIV testing would be a motivator for adoption and implementation of HIV testing. Within this context, a 3- arm cluster-RCT of 51 OTPs will be used to test 2 active evidence-based “practice coaching” (PC) interventions to improve the provision and sustained implementation of 1) HIV testing and linkage to care and 2) joint HIV/HCV testing and linkage to care among OTP patients. In PC, change agents and key OTP staff are provided training and support to facilitate the implementation of innovation and sustain resulting improvements. Specific aims are: Aim 1: To evaluate the effectiveness of the PC interventions on improving patient uptake of HIV testing in OTPs including the incremental impact of the HIV/HCV intervention on HIV testing. Aim 2: To examine, using mixed-methods, the impact of the PC interventions on the initiation and sustained provision of HIV testing and timely linkage to care. Aim 3: To evaluate the health outcomes, health care utilization, and cost-effectiveness of the PC interventions compared incrementally to one another and to the control condition. This will be the first study to test organizational approaches to increase HIV and HIV/HCV testing and linkage to care among patients in OTPs. This proposal is aligned with the new NIH-wide priorities for HIV/AIDS research. The first priority is to reduce HIV/AIDS incidence and one of the main points is to develop, test, and implement strategies to improve HIV testing and entry into prevention services.

HEALTH CARE POLICY AND SUBSTANCE ABUSE TREATMENT ACCESS (2/15/2017 - 11/30/2021)
Mark Olfson – Multiple Principal Investigator

Act: R01 - Project: DA039137 - Admin / Funding IC: NIDA

DESCRIPTION (provided by applicant): Excessive alcohol consumption and illicit drug use are leading causes of death in the United States. Because a great majority of individuals with substance use disorders (SUDs) receive no treatment for their addictions, increasing SUD treatment access is one of the great public health challenges facing the US health care system. A project is proposed to evaluate the effects of the Patient Protection and Affordable Care Act (ACA) on rates of Medicaid and private health insurance enrollment as well as SUD treatment among adults with SUDs. The results will help state and federal health care policy makers gauge the early effects of the ACA on SUD treatment patterns and focus policies and programs on groups who have persistently low levels of health insurance and high levels of unmet need for SUD treatment. The specific aims of the project are to: 1) assess change in Medicaid and private insurance enrollment following ACA implementation among adults with SUDs; 2) determine whether among adults with SUDs, the ACA Medicaid expansion and private insurance subsidy provisions are associated with increases in SUD treatment and whether such increases are mediated by Medicaid and private insurance enrollment; and 3) explore associations between ACA implementation and likelihood of receiving specific SUD treatment services, sustained treatment, and treatment for alcohol and drug use disorders. We will address these aims by merging data from 1) the National Survey on Drug Use and Health (2010-2017), an annual face-to-face survey of approximately 70,000 state and national representative respondents that includes in depth information on the prevalence and treatment of SUDs; 2) the National Survey of Substance Abuse Treatment Services that includes detailed information on substance abuse treatment service capacity at the county level; 3) federal block grant funding levels to the states for substance abuse treatment and prevention services; 4) county resource characteristics from the Area Resource File; and 5) state-level participation in the ACA Medicaid expansion. A well-established conceptual model will guide selection of need, predisposing, and enabling control variables at the individual, county, and state levels. The analytic plan will model ACA implementation in a manner that is sensitive to ACA implementation period and target population of the ACA provisions by separately considering their effects on poor/near poor adults and middle income adults with SUDs. This project will generate a national assessment of the early effects of ACA on health insurance enrollment and treatment of adults with SUDs. In addition to the effects of the ACA on overall SUD treatment, the project will yield vital new information on how the legislation has influenced use of specialty inpatient and outpatient services, general outpatient services, and acute services for SUDs and its effects on populations of special interest including low income persons, young adults, females, and ethnic/racial minorities.

IMPROVING THE EMERGENCY DEPARTMENT MANAGEMENT OF DELIBERATE SELF-HARM (5/1/2016 - 3/31/2021)
Mark Olfson – Multiple Principal Investigator

Act: R01 - Project: MH107452 - Admin / Funding IC: NIMH

DESCRIPTION (provided by applicant): Preventing suicide is one of the great public health challenges facing the US health care system. People who seek emergency care in general hospitals for deliberate self-harm are at exceptionally high short-term risk of repeated self-harm and suicide. Yet only about one-half of these patients receive emergency mental health evaluations. Among self-harm patients who are discharged to the community, only one-half receive follow-up outpatient mental health care in the following month. The proposed study will inform efforts to address deficiencies in the emergency management of deliberate self-harm by testing whether access to each of the following five emergency services influences inpatient admission, timely outpatient mental health care, short- term risk of repeated self-harm and suicide: 1) suicide risk assessment and triage procedures, 2) routine use of safety plans, 3) an on-site discharge planner, 4) an on-site or on-call mental health specialist, and 5) availability o crisis mental health services. The specific aims of the study are 1) to identify patient, hospital and service environment characteristics that influence access to these five emergency mental health services; 2) to determine whether access to each of these emergency mental health services influences inpatient admission, increases the likelihood of timely outpatient mental health follow-up care and reduces the short-term risk of deliberate self-harm and suicide, and 3) to understand qualitatively how these emergency mental health services operate in community practice. We will address these aims by extracting a sample of over ten thousand privately and Medicaid insured deliberate self-harm patients from approximately 500 emergency departments. At each of the treating hospitals, we will survey emergency medical directors to determine the presence or absence of the five emergency department services. Additional information about the emergency departments will be available from the Statewide Emergency Department Databases, hospital information will be available from the American Hospital Association Annual Survey, and regional mental health service information will be available from the Substance Abuse and Mental Health Services Administration surveys. Repeated deliberate self-harm will be assessed with administrative claims records and suicide will be determined by matching individual patients to the National Death Index. We will then use this patient, emergency department, hospital, and service environment information in propensity score adjusted models of the effects of the key emergency services on inpatient admission, follow-up outpatient mental health care, early repeated deliberate self-harm, and suicide. These issues will be examined in greater detail through qualitative interviews with key front line staff at selected emergency departments to probe how these services operate and what impedes their implementation in community practice. This new information will guide improvements in the emergency management of deliberate self-harm.

ASSESSING THE IMPACT OF STATE-LEVEL POLICIES ON DRUG USE AND HIV RISK FOR YMSM (06/15/2016 - 5/31/2021)
Morgan Philbin– Principal Investigator

Act: K01 - Project: DA039804 - Admin / Funding IC: NIDA

DESCRIPTION (provided by applicant): The purpose of this Mentored Research Scientist Development Award (K01) is to help me become an independent researcher focused on identifying modifiable structural factors that can explain and address disparities in substance use and sexual risk behaviors, and thus rates of HIV acquisition, among young men who have sex with men (YMSM) in the U.S. The training from this K01 will allow me to 1) apply my qualitative skills to policy case study analysis; 2) learn and apply key quantitative methods (i.e. structural equation modeling and longitudinal data analysis) to analyze population-based data and the impact of structural interventions; 3) understand the multi-level factors that influence substance use and sexual risk for YMSM; and 4) gain skills in public health ethics relevant to substance use, HIV and YMSM. My career development plan includes specific seminars, workshops, coursework, conferences, hands-on practica and tailored mentoring with a mentorship team comprised of experts in structural HIV prevention, HIV risk for YMSM, substance use- and sexual health- focused policies, quantitative methods and public health policy analysis. The focus on YMSM is particularly important as they are at nearly twice the risk of substance use compared to their heterosexual peers. In 2013 YMSM constituted 92% of new HIV infections among young men; indeed, YMSM are the group for whom HIV incidence is increasing most rapidly. The majority of YMSM-focused HIV interventions have targeted individual- level factors; little is known about how structural factors influence HIV risk for YMSM To achieve the combination HIV prevention approach outlined in the US National HIV/AIDS Strategy, and a goal of NIDA, it is important to identify modifiable structural-level factors (e.g. state-level policies) that can be intervened upon to address HIV risk for YMSM on a population level. However, no published studies have examined how the state-level policy climate-i.e., the aggregate impact of public health policies-affects HIV risk for YMSM. To fill this gap, the proposed research will first examine whether the state-level policy climate explains differences in substance use and sexual risk for YMSM across the US. It will then use longitudinal data analysis and policy case study analysis to assess how a state's political context influences the adoption of two specific policies relevant to HIV risk for YMSM-prescription drug monitoring database programs and parental notification of minors' HIV testing. This research will provide critical formative data that will be used to develop a NIDA R01 proposal that will examine the etiologic pathways through which state-level policies affect HIV risk behaviors for YMSM. The new skills acquired through this K01 will help me achieve my career goal to become an independent investigator who conducts innovative, high impact research examining how and why state-level factors affect substance use and sexual risk behaviors for YMSM with a goal of informing structural-level HIV interventions. This training will position me as one of the few mult-methods researchers working in the policy domain of HIV prevention and enable me to uniquely contribute to the Department of Sociomedical Sciences at Columbia University.

MULTI-LEVEL ASSOCIATIONS BETWEEN MEDICAL MARIJUANA LAWS AND SUBSTANCE USE DISORDER TREATMENT (8/1/2018 - 7/31/2023)
Pia Mauro – Principal Investigator

Act: K01 - Project: DA045224 - Admin / Funding IC: NIDA

TITLE: Multi-level associations between medical marijuana laws and substance use disorder treatment Medical marijuana laws (MMLs) have been increasingly adopted throughout the United States; more than half of people live in states that permit medical use of marijuana. While MMLs have been associated with treatment admissions for substance use disorders (SUDs), the relationship between MML and SUD treatment is complex and dynamic and can vary based on specific MML provisions. Marijuana dispensaries, for example, have been associated with increases in marijuana treatment and decreases in opioid treatment admissions. However, there are critical gaps in the literature regarding the mechanisms through which MMLs can affect SUD treatment use and related outcomes. The proposed research takes a multidisciplinary approach to understand and isolate the effects of MML on SUD treatment across gender and racial/ethnic groups, accounting for individual- (e.g., perceptions), community- (e.g., criminal justice), and state-level (e.g., Medicaid expansion) factors. Estimating the effect of structural factors such as MMLs on SUD treatment use could have significant public health impact, as SUDs are associated with a variety of negative health consequences, and the majority of people who meet SUD criteria do not receive SUD treatment. MML effects on individual SUD treatment need and perceptions will be estimated using data from the restricted use National Survey on Drug Use and Health from 2004 onwards. MML effects on criminal justice referrals to SUD treatment will be estimated using the 1992-2014 Treatment Episodes Data Set. The effects of MMLs on health outcomes and service costs between 2004 and 2014 will be assessed in a cohort of adults with Medicare/Medicaid. Interactions between gender and race/ethnicity will be tested in order to determine whether MMLs are contributing to changes in health care disparities. The research in this K01 proposal supports the National Institute on Drug Abuse objective to “assess the impact of federal, state-, and systems-level policies related to drug use and substance use disorders on public health and well-being.” Three specific training areas will be incorporated to carry out the research aims, including: (a) structural contributors to health care disparities in SUD treatment; (b) dynamics between criminal justice, health policy, and treatment systems; and (c) health financing and health economics analysis. The ambitious training and research aims are feasible in the 5-year K01 award with the support of the interdisciplinary mentorship team at Columbia University (Drs. Martins, Metsch, Hasin, and Muennig) and collaborators (Dr. Fagan, Crystal and Alexandre), culminating in the development of an R01. The career development plan will support the applicant’s goals and trajectory towards research independence.

ROLE OF DEPRESSION AND ANXIETY IN THE TOBACCO EPIDEMIC (7/3/2017 - 6/30/2020)
Renee Goodwin – Principal Investigator

Act: R01 - Project: DA020892 - Admin / Funding IC: NIDA

DESCRIPTION (provided by applicant): The majority of smokers in the U.S. would like to quit. Despite declines in cigarette use during the past several decades, smoking remains common (21%) among U.S. adults and is the leading preventable cause of death. Tobacco control efforts have greatly reduced smoking prevalence (from 43% in 1964). However, extensive evidence shows that the decline in smoking prevalence has stagnated for the past 10 years. The reasons for this stagnation are unknown. While tobacco control efforts have been very successful, ultimately, these strategies may not reach all smokers. Therefore, the proposed study will examine whether the prevalence of specific factors that impede successful quitting have become more common among smokers over the past two decades. We will also examine potential pathways through which these factors may lead to persistent smoking. The results of this study will lead to a better understanding of the barriers to cessation among remaining smokers, informing the debate over how to lower the prevalence of smoking in the US.

ADOLESCENT SUBSTANCE USE AS DETERMINANT AND CONSEQUENCE OF THE SCHOOL-TO-PRISON PIPELINE: DISENTANGLING INDIVIDUAL RISK, SOCIAL DETERMINANTS, AND GROUP DISPARITIES (2/1/2019 - 1/31/2024)
Seth Prins – Principal Investigator

Act: K01 - Project: DA045955 - Admin / Funding IC: NIDA

PROJECT SUMMARY/ABSTRACT The purpose of this Mentored Research Scientist Development Award (K01) is to help me become an independent investigator who conducts interdisciplinary, policy-relevant research on the individual, school, and community factors that put adolescents at risk for substance use and justice system contact. Specifically, I propose to investigate an issue previously unexplored: the role of substance use as a determinant and consequence of the “school-to-prison pipeline”—a set of policies and practices that make it more likely for some adolescents to become entrenched in the criminal justice system than to receive a quality education. The training from this K01 will allow me to (1) learn and apply more specialized, advance quantitative methods in complex nested data and causal inference for mediation and interaction; (2) gain expertise in racial and LGBTQ health disparities and (3) adolescent health and juvenile justice; and (4) gain skills in grant-writing, professional development, sampling methods, and data collection/acquisition necessary for submitting my first R01 proposal. My career development plan includes specific seminars, workshops, coursework, conferences, and tailored mentoring from a multidisciplinary team comprising experts in social/behavioral sciences, advanced quantitative methods, adolescent trajectories of substance use and mental illness, racial and LGBTQ disparities in health and school discipline, school policy and adolescent health, adolescent exposure to the criminal justice system, and criminological theory and juvenile justice. The proposed research is particularly important because school- based arrests have skyrocketed 300-500% since the 1990s, and out-of-school suspensions (which double the risk of arrest) have more than doubled over the past 40 years. However, there is a substantial gap in knowledge about the public health consequences of these trends, given that (1) adolescents with substance use problems have increased risk of exposure to the justice system, and exposure to the justice system increases subsequent risk of substance use problems; (2) substance use is a prototypical “zero tolerance” infraction implicated in school discipline/arrest; and (3) there are known racial and sexual orientation disparities in school discipline and substance use. To fill this gap, the proposed research will (1) investigate prospective associations among substance use, teacher/school factors, school discipline, community factors, and school-based arrests with unprecedented multi-level, multi-source data on students, teachers, schools, and communities; (2) determine whether modifiable individual, teacher, school, and community factors explain racial and LGBTQ disparities in substance-use-related school discipline/arrests; and (3) test whether there is a reciprocal relationship between substance use, school discipline, and school-based arrests. This project will inform a NIDA R01 proposal that will expand and further develop K01 research findings. The new skills I acquire through this K01 will position me to become an independent researcher who integrates substance use, public health, and criminal justice research, and one of the few investigators studying the substance-use-related school-to-prison pipeline.

EXAMINING THE SYNERGISTIC EFFECTS OF CANNABIS AND PRESCRIPTION OPIOID POLICIES ON CHRONIC PAIN, OPIOID PRESCRIBING, AND OPIOID OVERDOSE (1/1/2019 - 11/30/2023)
Silvia Martins – Multiple Principal Investigator

Act: R01 - Project: DA045872 - Admin / Funding IC: NIDA

Abstract The rapid rise in opioid overdose deaths in the past 17 years has coincided with a tripling of prescription opioid (PO) prescriptions dispensed, largely to treat chronic pain. Increased co-prescription of benzodiazepines (BZDs) and opioids also substantially increased the risk of overdose. Cannabis has been proposed as an alternative treatment for chronic pain that could ameliorate opioid withdrawal symptoms and assist in recovery from opioid and BZD dependence. Two major policy shifts are likely to change prescribing practices and abuse of POs and BZDs. First, in the past decade, most states have enacted policies that regulate PO prescribing and dispensing. Second, since 1996, 29 states have legalized use of cannabis for medical purposes, and 9 states have legalized cannabis for recreational use. Policies that regulate access to POs may decrease the number of opioid prescriptions for chronic pain and co-occurring PO/BZD prescribing, while laws that allow greater access to cannabis may offer a substitute for POs, heroin, and BZDs. The combination of stricter PO policies and less restrictive cannabis laws may reduce opioid-related harm to a greater extent than either measure alone. As states make unprecedented changes to PO policies and cannabis laws, we need to examine the independent and synergistic contributions that both types of measures have on opioid prescribing practices and opioid overdoses, with and without BZDs. We propose to pursue this aim in two populations: (1) in the U.S. population, using repeated cross-sectional data of individuals nested in states from the National Survey on Drug Use and Health; and (2) among Medicaid patients with chronic pain (who have 10 times greater risk of opioid use disorder relative to privately insured patients), using a 45-state Medicaid Analytic Extract longitudinal cohort. Our specific aims are: (1) to examine, in NSDUH, whether nonmedical use of POs, BZDs and heroin, and opioid and BZD use disorders decrease (and cannabis use/disorder increases) following enactment of more restrictive PO policies and less restrictive cannabis laws in 2004-2019, compared to trends in states that did not enact these measures; and (2) to test whether Medicaid patients are less likely to have claims for opioid prescribing (alone and overlapping with BZDs), clinic visits for chronic pain, and opioid overdoses (with and without co-occurring BZD overdose) following enactment of more restrictive PO policies and less restrictive cannabis laws in 2001-2019, compared to patients in states that did not enact these measures. For Aim 2, we will sample 10,000 Medicaid patients with chronic pain per year, follow each cohort for 4 years (n=190,000), and combine the cohorts to construct an accelerated longitudinal cohort. States will be classified by how restrictive or lenient their PO policies are (e.g., prescription drug monitoring programs, pain clinic regulations), and whether they legalized cannabis for medical and/or recreational use. At a time when opioid overdose deaths are increasing at an unprecedented rate, this study will provide critical, policy-relevant findings about the types of policies that are most likely to end the opioid epidemic.

STATE MEDICAL MARIJUANA LAWS AND NSDUH MARIJUANA USE AND CONSEQUENCES SINCE 2004 (9/15/2014 - 8/31/2020)
Silvia Martins – Principal Investigator

Act: R01 - Project: DA037866 - Admin / Funding IC: NIDA

Since 1996, 20 states and DC passed laws legalizing medical use of marijuana (40% of all states), and other states are considering such laws. Whether these fast-changing laws lead to increases in marijuana use (MU) is now largely a matter of opinion and debate. Responding to NIDA PA 11-230, we propose to investigate the relationship between MML and MU, MU disorders and consequences of MU in both adolescents and adults, using an outstanding resource, the restricted access data files from the National Survey on Drug Use and Health (NSDUH), 2004 and onwards, that we are authorized to access through SAMHSA's new NSDUH Restricted Use Files Data Portal. These data files include important variables not included in the public use files, including state of residence, exact respondent age, and detailed race/ethnicity information. We will also incorporate state-level data external to NSDUH (e.g., Census demographic data, state arrest rates, emergency department visits, MML variation) as potential confounders and outcomes in our models comparing states with and without MML. The proposed study is a comprehensive, timely, and innovative investigation of these issues, designed to provide much-needed, important information to health scientists, policy-makers and the public. Primary aims are to: 1a) Examine individual-level MU and MU disorder from 2004 to 2014 as a function of state-level MML; 1b) Using data from the US states that approved MML after 2004, examine the effects of different time lags (e.g., 1-, 2-years) before and after passage of the laws on individual-level MU and MU disorder. 2) Explore whether state-level variations in MML or specific aspects of MML (e.g., variations of amounts allowed per patient, registration rules, permitted medical conditions) are associated with the prevalence of MU, how individuals acquire marijuana, and how much they pay for it. 3) Investigate whether passage of state MML is followed by change in individual risk for (a) other substances (alcohol, nonmedical prescription opioid, cocaine, heroin use), relative to trends in the US states without MML (increase, per the gateway hypothesis; or decrease, per the substitution hypothesis); (b) consequences related to marijuana use (i.e., arrests, incarceration, legal problems), relative to any change in the risk for these consequences in states without MML. 4) Investigate whether racial/ethnic (non-Hispanic White, non-Hispanic Black, Asian, and Hispanic) and age (i.e., adolescents, young adults, and older adults) differences in past-year and past-month prevalence of MU and MU disorders and potential consequences of MU change as a function of the passage of state-level MML. Our research team includes experts in substance abuse epidemiology and biostatistics as well as an expert with extensive expertise in marijuana laws and marijuana markets. Our analyses will employ multilevel regression modeling. This study will address questions of major public health significance, adding important knowledge about fast-changing marijuana laws and their effects on MU among adults and adolescents, contributing to general knowledge about the relationship of legislation to substance use.

PREDICTORS OF HIGH-RISK BEHAVIOR AMONG YOUTH (3/1/2009 - 1/31/2020)
Silvia Martins – Principal Investigator

Act: R01 - Project: HD060072 - Admin / Funding IC: NICHHD

DESCRIPTION (provided by applicant): While for most people gambling is just an enjoyable experience without major consequences, for approximately 5% of adults, gambling can result in significant problems such as family, interpersonal and financial problems. Existing evidence, including work supported by this application's parent grant (R01HD060072, PI: Martins), demonstrates that PG is multifactorial and that it is influenced by a broad range of variables. However, PG research has been seriously constrained by the absence of longitudinal data and of a theory-driven and empirically-supported etiological model that integrates an array of risk and associated factors. This study integrates a developmental model of PG, Blaszczynski and Nower's Pathways model (so far only examined cross-sectionally) with a context -and intervention-informed developmental model of other risk behaviors (Ecodevelopmental theory). We propose to collect new information about gambling behaviors and PG in two time-points on a high-risk population of 1,100 youth/young adults from two population-based samples of Puerto Rican (ages 17-25) from two sites: the South Bronx (SBx), NYC and San Juan, Puerto Rico (PR) by taking advantage of an ongoing study, the Boricua Youth Study (BYS-R01DA033172, PI: Duarte and R01MH09837, PIs: Alegria, Canino & Duarte), which has been following Puerto Rican individuals prospectively since 2001. The specific aims of this study are to 1) Estimate: (1a) the prevalence (past year and past three- month) of any gambling, frequent gambling, and severity of PG during late adolescence/early adulthood; (1b) changes in the patterns of gambling and severity of PG over a two-year period when gambling behaviors are known to be undergoing the most changes; (1c) the characteristics of individuals who gamble (age, gender, age of onset of gambling and PG, and family history of PG), determining if PG estimates and characteristics differ between PR and SBx. 2) Examine developmental PG pathways from childhood to young adulthood, specifically (a) the relationship of externalizing, internalizing disorders and related risk factors with PG prevalence and change in late adolescence/young adulthood; (b) the influence of contextual factors (e.g. social support, neighborhood disadvantage) on PG pathways. 3) Understand how PG is related to other risk behaviors also being shaped during late adolescence/young adulthood, by determining different risk behavior clusters involving PG, HIV/STD risk behaviors, school drop-out, and antisocial behaviors. This innovative approach, using state of the art latent variable modeling, focuses on policy-modifiable risk factors within broader risk/resource contexts. By focusing on Puerto Ricans living in two settings we can also examine the important role of environment in PG in an ethnically homogeneous group. The proposed study, by building on existing and ongoing efforts, is a highly cost-effective way of generating unprecedented information about gambling behaviors among Puerto Ricans as well as examining the Pathways model longitudinally.