What Do We Know About the Association Between Firearm Legislation and Firearm-Related Injuries?

Firearms account for a substantial proportion of external causes of death, injury, and disability across the world. Legislation to regulate firearms has often been passed with the intent of reducing problems related to their use. However, lack of clarity around which interventions are effective remains a major challenge for policy development. Aiming to meet this challenge, we systematically reviewed studies exploring the associations between firearm- related laws and firearm homicides, suicides, and unintentional injuries/deaths. We restricted our search to studies published from 1950 to 2014. Evidence from 130 studies in 10 countries suggests that in certain nations the simultaneous implementation of laws targeting multiple firearms restrictions is associated with reductions in firearm deaths. Laws restricting the purchase of (e.g., background checks) and access to (e.g., safer storage) firearms are also associated with lower rates of intimate partner homicides and firearm unintentional deaths in children, respectively. Limitations of studies include challenges inherent to their ecological design, their execution, and the lack of robustness of findings to model specifications. High quality research on the association between the implementation or repeal of firearm legislation (rather than the evaluation of existing laws) and firearm injuries would lead to a better understanding of what interventions are likely to work given local contexts. This information is key to move this field forward and for the development of effective policies that may counteract the burden that firearm injuries pose on populations

What Do We Know About the Association Between Firearm Legislation and Firearm-Related Injuries?

Firearms account for a substantial proportion of external causes of death, injury, and disability across the world. Legislation to regulate firearms has often been passed with the intent of reducing problems related to their use. However, lack of clarity around which interventions are effective remains a major challenge for policy development. Aiming to meet this challenge, we systematically reviewed studies exploring the associations between firearm-related laws and firearm homicides, suicides, and unintentional injuries/deaths. We restricted our search to studies published from 1950 to 2014. Evidence from 130 studies in 10 countries suggests that in certain nations the simultaneous implementation of laws targeting multiple firearms restrictions is associated with reductions in firearm deaths. Laws restricting the purchase of (e.g., background checks) and access to (e.g., safer storage) firearms are also associated with lower rates of intimate partner homicides and firearm unintentional deaths in children, respectively. Limitations of studies include challenges inherent to their ecological design, their execution, and the lack of robustness of findings to model specifications. High quality research on the association between the implementation or repeal of firearm legislation (rather than the evaluation of existing laws) and firearm injuries would lead to a better understanding of what interventions are likely to work given local contexts. This information is key to move this field forward and for the development of effective policies that may counteract the burden that firearm injuries pose on populations

Worldwide Prevalence and Trends in Unintentional Drug Overdose: A Systematic Review of the Literature

Background. Drug overdose is an important, yet an inadequately understood, public health problem. Global attention to unintentional drug overdose has been limited by comparison with the scope of the problem. There has been a substantial increase in drug overdose incidence and prevalence in several countries worldwide over the past decade, contributing to both increased costs and mortality. Objectives. The aim of this study was to systematically synthesize the peer-reviewed literature to document the global epidemiological profile of unintentional drug overdoses and the prevalence, time trends, mortality rates, and correlates of drug overdoses. We searched different combinations of Medical Subject Headings (MeSH) terms in PubMed for articles published from 1980 until July 2013, and we organized these results in tabular spreadsheets and compared them. We restricted the search to English-language articles that deal with unintentional overdose, focusing on 1 or more of the following key constructs: prevalence, time trends, mortality rates, and correlates. The term “overdose” as a MeSH major topic yielded 1076 publications. In addition, we searched the following combinations of nonmajor MeSH terms: “street drugs” and “overdose” yielded 180, “death” and “overdose” yielded 114, and “poisoning” and “drug users” yielded 17. There was some overlap among the searches. Based on the search and inclusion and exclusion criteria, we selected a total of 169 relevant articles for this article based on a close review of abstracts. Results. We found wide variability in lifetime prevalence of experiencing a nonfatal overdose or witnessing an overdose, and in mortality rates attributable to overdose. Lifetime prevalence of witnessed overdose among drug users (n = 17 samples) ranged from 50% to 96%, with a mean of 73.3%, a median of 70%, and a standard deviation of 14.1%. Lifetime prevalence of drug users personally experiencing a nonfatal overdose (n = 27 samples), ranged from 16.6% to 68.0% with a mean of 45.4%, a median of 47%, and a standard deviation of 14.4%. Population-based crude overdose mortality rates (n = 28 samples) ranged from 0.04 to 46.6 per 100 000 person-years. This range is likely attributable to the diversity in regions, time periods, and samples. Most studies on longitudinal trends of overdose death rates or overdose-related hospitalization rates showed increases in overdose death rates and in overdose-related hospitalization rates across time, which have led to peaks in these rates at the present time. An overall trend of increasing deaths from prescription opioid use and decreasing deaths from illicit drug use in the past several years has been noted across most of the literature. With the increase in prescription opioid overdose deaths, drug overdose is not just an urban problem: rural areas have seen an important increase in overdose deaths. Lastly, cocaine, prescription opioids, and heroin are the drugs most commonly associated with unintentional drug overdoses worldwide and the demographic and psychiatric correlates associated with unintentional drug overdoses are similar globally. Conclusions. There is a need to invest in research to understand the distinct determinants of prescription drug overdose worldwide. Several other countries need to collect in a systematic and continuous fashion such data on sales of prescription opioids and other prescription drugs, nonmedical use of prescription drugs, and hospitalization secondary to overdoses on prescription drugs. The sparse evidence on the environmental determinants of overdose suggests a need for research that will inform the types of environmental interventions we can use to prevent drug overdose. Methodological issues for future studies include enhancing data collection methods on unintentional fatal and nonfatal overdoses, and collecting more detailed information on drug use history, source of drug use (for prescription drugs), and demographic and psychiatric history characteristics of the individual who overdosed

Nonmedical Prescription Opioid Use in Childhood and Early Adolescence Predicts Transitions to Heroin Use in Young Adulthood: A National Study

Objectives: To examine the relationship between nonmedical use of prescription opioids and heroin initiation from childhood to young adulthood, and to test whether certain ages, racial/ethnic, and income groups were at higher risk for this transition. Study design: Among a nationally representative sample of US adolescents assessed in the 2004-2011 National Surveys on Drug Use and Health cross-sectional surveys (n = 223 534 respondents aged 12-21 years), discrete-time hazard models were used to estimate the age-specific hazards of heroin initiation associated with prior history of nonmedical use of prescription opioids. Interactions were estimated between prior history of nonmedical use of prescription opioids and age of nonmedical use of prescription opioid initiation, race/ethnicity, and income. Results: A prior history of nonmedical use of prescription opioids was strongly associated with heroin initiation (hazard ratio 13.12, 95% CI 10.73, 16.04). Those initiating nonmedical use of prescription opioids at ages 10-12 years had the highest risk of transitioning to heroin use; the association did not vary by race/ethnicity or income group. Conclusions: Prior use of nonmedical use of prescription opioids is a strong predictor of heroin use onset in adolescence and young adulthood, regardless of the user's race/ethnicity or income group. Primary prevention of nonmedical use of prescription opioids in late childhood may prevent the onset of more severe types of drug use such as heroin at later ages. Moreover, because the peak period of heroin initiation occurs at ages 17-18 years, secondary efforts to prevent heroin use may be most effective if they focus on young adolescents who already initiated nonmedical use of prescription opioids

Racial/ethnic differences in trends in heroin use and heroin-related risk behaviors among nonmedical prescription opioid users

Background: This study examines changing patterns of past-year heroin use and heroin-related risk behaviors among individuals with nonmedical use of prescription opioids (NMUPO) by racial/ethnic groups in the United States. Methods: We used data from the National Survey on Drug Use and Health (NSDUH) from 2002 to 2005 and 2008 to 2011, resulting in a total sample of N = 448,597. Results: Past-year heroin use increased among individuals with NMUPO and increases varied by frequency of past year NMUPO and race/ethnicity. Those with NMUPO in the 2008–2011 period had almost twice the odds of heroin use as those with NMUPO in the 2002–2005 period (OR = 1.89, 95%CI: 1.50, 2.39), with higher increases in non-Hispanic (NH) Whites and Hispanics. In 2008–2011, the risk of past year heroin use, ever injecting heroin, past-year heroin abuse or dependence, and the perception of availability of heroin increased as the frequency of NMUPO increased across respondents of all race/ethnicities. Conclusion: Individuals with NMUPO, particularly non-Hispanic Whites, are at high risk of heroin use and heroin-related risk behaviors. These results suggest that frequent nonmedical users of prescription opioids, regardless of race/ethnicity, should be the focus of novel public health efforts to prevent and mitigate the harms of heroin use

Exploring the latent trait of opioid use disorder criteria among frequent nonmedical prescription opioid users

Background: There is a need to explore the dimensional and categorical phenotypes of criteria of opioid use disorder among frequent nonmedical users of prescription opioids (NMUPO) users. Methods: We used pooled data of 2011–2012 National Survey on Drug Use and Health to examine reliability and phenotypic variability in the diagnosis of OUD secondary to NMUPO in a nationally-representative sample of 18+ years-old frequent past-year NMUPO users (120+ days, n = 806). Through exploratory factor analysis (EFA) and latent class analysis (LCA), we examined 10 past-year OUD criteria. We examined associations between the latent classes and sociodemographic/psychiatric/NMUPO correlates. Results: OUD criteria were unidimensional, and a three-class model was the overall best fitting solution for characterizing individuals into phenotypes along this unidimensional continuum: a “non-symptomatic class” (40.7%), “Tolerance-Time spent class” (29.0%) with high probability of endorsing Tolerance/Time Spent criteria, and a “High-moderate symptomatic class” (30.1%). The last class was significantly associated with being male, having insurance and obtaining prescription opioids (PO) nonmedically via “doctor shopping” as compared to the non-symptomatic class. “Tolerance-Time spent class” was significantly associated with being younger (18–25 years) and obtaining PO nonmedically from family/friends as compared to the non-symptomatic class. Conclusion: This study revealed the different characteristics and routes of access to PO of different classes of frequent NMUPO users. It is possible that these groups may respond to different interventions, however such conclusions would require a clinical study

Prevalence of marijuana use does not differentially increase among youth after states pass medical marijuana laws: Commentary on Stolzenberg et al. (2015) and reanalysis of US National Survey on Drug Use in Households data 2002–2011

There is considerable interest in the effects of medical marijuana laws (MML) on marijuana use in the USA, particularly among youth. The article by Stolzenberg et al. (2015) “The effect of medical cannabis laws on juvenile cannabis use” concludes that “implementation of medical cannabis laws increase juvenile cannabis use”. This result is opposite to the findings of other studies that analysed the same US National Survey on Drug Use in Households data as well as opposite to studies analysing other national data which show no increase or even a decrease in youth marijuana use after the passage of MML. We provide a replication of the Stolzenberg et al. results and demonstrate how the comparison they are making is actually driven by differences between states with and without MML rather than being driven by pre and post-MML changes within states. We show that Stolzenberg et al. do not properly control for the fact that states that pass MML during 2002–2011 tend to already have higher past-month marijuana use before passing the MML in the first place. We further show that when within-state changes are properly considered and pre-MML prevalence is properly controlled, there is no evidence of a differential increase in past-month marijuana use in youth that can be attributed to state MML

Mapping Concentrations of Posttraumatic Stress and Depression Trajectories Following Hurricane Ike

We investigated geographic concentration in elevated risk for a range of postdisaster trajectories of chronic posttraumatic stress symptom (PTSS) and depression symptoms in a longitudinal study (N = 561) of a Hurricane Ike affected population in Galveston and Chambers counties, TX. Using an unadjusted spatial scan statistic, we detected clusters of elevated risk of PTSS trajectories, but not depression trajectories, on Galveston Island. We then tested for predictors of membership in each trajectory of PTSS and depression (e.g., demographic variables, trauma exposure, social support), not taking the geographic nature of the data into account. After adjusting for significant predictors in the spatial scan statistic, we noted that spatial clusters of PTSS persisted and additional clusters of depression trajectories emerged. This is the first study to show that longitudinal trajectories of postdisaster mental health problems may vary depending on the geographic location and the individual- and community-level factors present at these locations. Such knowledge is crucial to identifying vulnerable regions and populations within them, to provide guidance for early responders, and to mitigate mental health consequences through early detection of mental health needs in the population. As human-made disasters increase, our approach may be useful also in other regions in comparable settings worldwide

Nonmedical prescription drug use among US young adults by educational attainment

Purpose: Little is known about nonmedical use of prescription drugs among non-college-attending young adults in the United States. Methods: Data were drawn from 36,781 young adults (ages 18–22 years) from the 2008–2010 National Survey on Drug Use and Health public use files. The adjusted main effects for current educational attainment, along with its interaction with gender and race/ethnicity, were considered. Results: Compared to those attending college, non-college-attending young adults with at least and less than a HS degree had a higher prevalence of past-year nonmedical use of prescription opioids [NMUPO 13.1 and 13.2 %, respectively, vs. 11.3 %, adjusted odds ratios (aORs) 1.21 (1.11–1.33) and 1.25 (1.12–1.40)], yet lower prevalence of prescription stimulant use. Among users, regardless of drug type, non-college-attending youth were more likely to have past-year disorder secondary to use [e.g., NMUPO 17.4 and 19.1 %, respectively, vs. 11.7 %, aORs 1.55 (1.22–1.98) and 1.75 (1.35–2.28)]. Educational attainment interacted with gender and race: (1) among nonmedical users of prescription opioids, females who completed high school but were not enrolled in college had a significantly greater risk of opioid disorder (compared to female college students) than the same comparison for men; and (2) the risk for nonmedical use of prescription opioids was negligible across educational attainment groups for Hispanics, which was significantly different than the increased risk shown for non-Hispanic whites. Conclusions: There is a need for young adult prevention and intervention programs to target nonmedical prescription drug use beyond college campuses

Patterns of major depression and nonmedical use of prescription opioids in the United States

Introduction: Recent epidemiologic studies have shown that nonmedical use of prescription opioids (NMUPO) and major depression frequently co-occur. Comorbid forms of drug use and mental illness such as NMUPO and depression pose a greater disease burden than either condition alone. However, sociodemographic and substance use differences between individuals with either NMUPO or depression and those with comorbid conditions have not yet been fully investigated. Methods: Data came from the 2011 and 2012 National Survey on Drug Use and Health (NSDUH). Adolescents and adults were examined independently because of differences in screening for major depressive episodes (MDE). Weighted multinomial logistic regression investigated differences between persons with either past-year NMUPO (4.0%) or MDE (5.5%) and those with comorbid NMUPO and MDE (0.6%), compared to persons with neither condition. Results: Females were more likely than males to report either MDE-alone and comorbid NMUPO and MDE, whereas adult men were marginally more likely to report NMUPO-alone (not significant among adolescents). Polydrug use and alcohol use disorders were more pronounced among those with comorbid NMUPO and MDE than persons with either NMUPO-alone or MDE-alone. Persons with independent and comorbid NMUPO and MDE were more likely to report lower income and unemployment versus employment. Conclusions: This study found that independent and comorbid NMUPO and MDE were disproportionately clustered with burdens of lower socioeconomic position, suggesting that a population-based approach to address NMUPO would target these social determinants of health, whereas a high-risk approach to prevention should be tailored to females experiencing MDE symptoms and polydrug users