With increased legalization and access, many Veterans are using cannabis for medical purposes, yet little is known about Veterans’ motives for and experiences of using cannabis, how they make decisions about cannabis use, and if and how clinicians are involved in this decision-making. To better understand and highlight Veterans’ experiences using cannabis, including their perspectives, information needs, and interactions with clinicians. Qualitative interview study. Twenty-three mostly rural Veterans with past 30-day medical cannabis use living in Connecticut, Michigan, or Oregon—where cannabis is legal. In-depth, semi-structured interviews via Webex. We used a qualitative inductive thematic approach, developing an initial codebook then refining as new themes and subthemes emerged. Many Veterans viewed cannabis as an important tool to cope with or alleviate symptoms from a variety of health conditions. They primarily relied on the experiences of trusted peers, recommendations from dispensaries, or their own trial-and-error process to gain information about cannabis. Many Veterans perceived few or no harms from cannabis use, and those who did felt that the benefits outweighed the potential risks. Participants described several reasons they were reluctant to engage with VA clinicians about their cannabis use but identified several strategies VA providers could employ to improve engagement including increasing their knowledge of cannabis and engaging patients in unbiased discussions about their use including seeking to understand patients’ motivations for use. Veterans use cannabis for a variety of health conditions. Veterans who use cannabis obtain information about it from sources other than healthcare professionals and may be reluctant to discuss their cannabis use with clinicians despite its relevance to their care. Clinicians can better support their patients who use cannabis by obtaining information and training on the health effects of cannabis and engaging with patients about their use non-judgmentally.

Importance Cannabis use is common among those with mental health conditions, and many people report using cannabis to manage mental health symptoms. It is important for clinicians to understand the lack of clear benefits of cannabis for mental health conditions and the potential for substantial adverse effects. Observations Overall, the potential benefits of cannabis for mental health conditions remain poorly studied. There is low-certainty evidence that Δ-9-tetrahydrocannabinol (THC)–predominant cannabis may not improve symptoms of posttraumatic stress disorder, and there is largely insufficient evidence to characterize the effects of long-term THC-predominant cannabis use on anxiety, depression, and attention-deficit/hyperactivity disorder. There is emerging low-certainty evidence that the cannabis constituent cannabidiol alone may reduce anxiety in patients with anxiety disorders. THC-predominant cannabis use holds substantial risk for adverse mental health effects, and counseling patients about these risks is crucial to promote safety. These risks include worsening mania symptoms and function in those with bipolar disorder and an increase in psychotic symptoms in those with psychotic spectrum disorders. Among people with past-year cannabis use, about 3 in 10 have cannabis use disorder (CUD), and about one-half those with CUD have moderate or severe disease with negative social, employment, or other adverse outcomes. Regular use of high THC-content products by adolescents and young adults is associated with several concerning risks, including an increased risk of psychosis (estimates range from about 2-fold to 11-fold increased risk), a higher risk of CUD, and self-harm in those with mood disorders. Cannabis use should be avoided in individuals at elevated risk of harms, including adolescents and young adults, those with bipolar or psychotic disorders, pregnant individuals, and those at risk for substance use disorders. Conclusions and Relevance The current evidence base is not sufficient to support the use of cannabis for the treatment of mental health conditions and demonstrates substantial risks of adverse effects. Clinicians should engage patients with mental health conditions in discussions about cannabis use because use is common, has an influence on mental health symptoms, and is likely an important modifiable risk factor for mental health conditions in some populations.

PURPOSE:To create an evidence-based guideline for the evaluation and management of acute low back pain. METHODS:A multidisciplinary guideline development group formulated recommendations based on systematic review (PROSPERO Registration 537276) of evidence and using a protocol based on the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) working group methodology. INTENDED USERS AND SETTINGS:Clinicians providing care to individuals presenting with acute low back pain (<6 weeks duration) with or without radiculopathy in outpatient settings.

DESCRIPTION:The American College of Physicians (ACP) developed these rapid practice points addressing the efficacy, comparative effectiveness, and harms of respiratory syncytial virus (RSV) vaccines in adults aged 18 years or older who are not pregnant or immunocompromised. METHODS:The ACP Population Health and Medical Science Committee developed the rapid practice points based on a rapid review by the ACP Center for Evidence Reviews at Cochrane Austria. The practice points apply to adults aged 60 years or older who are not immunocompromised. PRACTICE POINT 1:Adults aged 75 years or older should receive a protein subunit RSV vaccine. PRACTICE POINT 2:Adults aged 60 to 74 years who are at increased risk for severe RSV may consider receiving a protein subunit RSV vaccine.

BackgroundTwo-thirds of adults in the United States (U.S.) find recreational and medical cannabis use acceptable. Evidence shows that cannabis use is an effective treatment for pain, and as a harm reducing therapeutic for Substance Use Disorder (SUD). In contrast to most SUD treatment models, some models allow illegal substance use as a harm reduction strategy, which is the case for the SUD treatment program examined in this study. Little is known about veterans with SUD and their perspectives on cannabis use to treat pain. This study characterizes veteran perspectives on cannabis use to manage chronic pain, and pain-related anxiety and poor sleep, during treatment for non-cannabis SUD.MethodsThirty-three U.S. military veterans with a diagnosis of chronic pain, who were receiving care from a Veterans Affairs (VA) SUD treatment program were eligible to participate. Patients with polysubstance use could continue to use substances, as long as they committed to a goal of abstaining from the substance that was the primary focus of their SUD treatment. Most patients had a primary diagnosis of alcohol use disorder (70%), followed by opioid use disorder (18%), and stimulant use disorder (12%). Patients with a primary cannabis SUD were excluded. Patients completed a semi-structured interview. Content analysis identified key narrative themes.ResultsApproximately one-third of patients reported cannabis use during SUD treatment. Motivations for cannabis use were to alleviate pain, pain-related anxiety and poor sleep quality, and viewing cannabis as a harm reducing therapeutic. Approximately half of patients abstained from cannabis due to negative physical and mental effects experienced in the past, fear of returning to use their primary SUD substance, and to avoid the violation of policies or laws prohibiting cannabis use. Some patients who did not use cannabis showed interest in future cannabis use for pain based on recent cannabis science, laymen's knowledge and curiosity.ConclusionsPatients with non-cannabis SUD may choose to use cannabis to alleviate chronic pain, pain-related anxiety and poor sleep quality, and as a harm reducing therapeutic during SUD treatment. VA and other federally employed clinicians, particularly in states where cannabis is legal, should prepare to educate patients on the medical evidence, gaps, policies and laws related to cannabis to help patients make more informed healthcare decisions related to cannabis use.

Importance:Cannabis use is common among those with mental health conditions, and many people report using cannabis to manage mental health symptoms. It is important for clinicians to understand the lack of clear benefits of cannabis for mental health conditions and the potential for substantial adverse effects. Observations:Overall, the potential benefits of cannabis for mental health conditions remain poorly studied. There is low-certainty evidence that Δ-9-tetrahydrocannabinol (THC)-predominant cannabis may not improve symptoms of posttraumatic stress disorder, and there is largely insufficient evidence to characterize the effects of long-term THC-predominant cannabis use on anxiety, depression, and attention-deficit/hyperactivity disorder. There is emerging low-certainty evidence that the cannabis constituent cannabidiol alone may reduce anxiety in patients with anxiety disorders. THC-predominant cannabis use holds substantial risk for adverse mental health effects, and counseling patients about these risks is crucial to promote safety. These risks include worsening mania symptoms and function in those with bipolar disorder and an increase in psychotic symptoms in those with psychotic spectrum disorders. Among people with past-year cannabis use, about 3 in 10 have cannabis use disorder (CUD), and about one-half those with CUD have moderate or severe disease with negative social, employment, or other adverse outcomes. Regular use of high THC-content products by adolescents and young adults is associated with several concerning risks, including an increased risk of psychosis (estimates range from about 2-fold to 11-fold increased risk), a higher risk of CUD, and self-harm in those with mood disorders. Cannabis use should be avoided in individuals at elevated risk of harms, including adolescents and young adults, those with bipolar or psychotic disorders, pregnant individuals, and those at risk for substance use disorders. Conclusions and Relevance:The current evidence base is not sufficient to support the use of cannabis for the treatment of mental health conditions and demonstrates substantial risks of adverse effects. Clinicians should engage patients with mental health conditions in discussions about cannabis use because use is common, has an influence on mental health symptoms, and is likely an important modifiable risk factor for mental health conditions in some populations.

Description: The American College of Physicians' Population Health and Medical Science Committee (PHMSC) developed this best practice advice to inform clinicians about what is currently known about the benefits and harms of cannabis or cannabinoids in the management of chronic noncancer pain and to provide advice for clinicians counseling patients seeking this therapy. Methods: The PHMSC considers areas where evidence is uncertain or emerging or practice does not follow the evidence to provide clinical advice based on a review and assessment of scientific work, including systematic reviews and individual studies. Sources of evidence included a living systematic review on cannabis and cannabinoid treatments for chronic noncancer pain and a series of living systematic reviews and primary studies. Best Practice Advice 1a: Clinicians should counsel patients about the benefits and harms of cannabis or cannabinoids when patients are considering whether to start or continue to use cannabis or cannabinoids to manage their chronic noncancer pain. Best Practice Advice 1b: Clinicians should counsel the following subgroups of patients that the harms of cannabis or cannabinoid use for chronic noncancer pain are likely to outweigh the benefits: young adult and adolescent patients, patients with current or past substance use disorder, patients with serious mental illness, and frail patients and those at risk for falling. Best Practice Advice 2: Clinicians should advise against starting or continuing to use cannabis or cannabinoids to manage chronic noncancer pain in patients who are pregnant or breastfeeding or actively trying to conceive. Best Practice Advice 3: Clinicians should advise patients against the use of inhaled cannabis to manage chronic noncancer pain.

Prenatal cannabis use continues to increase, and cannabis remains the most commonly used illegal substance in pregnancy. Accumulating evidence suggests potential adverse effects on fetal and neonatal outcomes following cannabis use in pregnancy. To update a living systematic review and meta-analysis to provide a timely understanding regarding cannabis use in pregnancy and fetal and neonatal outcomes. The previous review was updated by searching bibliographic databases MEDLINE, CINAHL, PsycInfo, Global Health, and Evidence-Based Medicine Reviews Cochrane Database of Systematic Reviews from November 1, 2021, through April 4, 2024. Cohort or case-control studies comparing pregnancies with and without prenatal cannabis use on prespecified fetal or neonatal outcomes with adjustment for confounders, such as co-use of tobacco products, were included. Two independent reviewers screened studies, with disagreements resolved through discussion. Included studies were extracted by 1 reviewer and confirmed by a second. Risk of bias was assessed with the Newcastle-Ottawa Scale. Random-effects meta-analyses of unadjusted and adjusted odds ratios (ORs) were performed for all primary outcomes. Results were synthesized using the Grading of Recommendations Assessment, Development, and Evaluation approach. Primary outcomes were preterm birth (PTB; <37 weeks of gestation), small for gestational age (SGA), low birth weight (LBW; <2500 g), and perinatal mortality. For this update, 8 new studies with 1 709 998 participants were added, for a total of 51 studies synthesized (N = 21 146 938). From meta-analyses of adjusted effect sizes, moderate-certainty evidence indicated that cannabis use in pregnancy was associated with increased odds of LBW (20 studies; OR, 1.75; 95% CI, 1.41-2.18), PTB (20 studies; OR, 1.52; 95% CI, 1.26-1.83), and SGA (12 studies; OR, 1.57; 95% CI, 1.36-1.81), and low-certainty evidence indicated that it was associated with greater odds of perinatal mortality (6 studies; OR, 1.29; 95% CI, 1.07-1.55). Previously, the evidence was rated as very low or low certainty. Cannabis use in pregnancy was associated with greater odds of PTB, SGA, and LBW even after adjusting for co-use of tobacco products, and confidence in these findings increased from low in the prior review to moderate in the current meta-analysis. The findings of this study may help inform patient counseling and future public health policies.

Importance Prenatal cannabis use continues to increase, and cannabis remains the most commonly used illegal substance in pregnancy. Accumulating evidence suggests potential adverse effects on fetal and neonatal outcomes following cannabis use in pregnancy. Objective To update a living systematic review and meta-analysis to provide a timely understanding regarding cannabis use in pregnancy and fetal and neonatal outcomes. Data Sources The previous review was updated by searching bibliographic databases MEDLINE, CINAHL, PsycInfo, Global Health, and Evidence-Based Medicine Reviews Cochrane Database of Systematic Reviews from November 1, 2021, through April 4, 2024. Study Selection Cohort or case-control studies comparing pregnancies with and without prenatal cannabis use on prespecified fetal or neonatal outcomes with adjustment for confounders, such as co-use of tobacco products, were included. Two independent reviewers screened studies, with disagreements resolved through discussion. Data Extraction and Synthesis Included studies were extracted by 1 reviewer and confirmed by a second. Risk of bias was assessed with the Newcastle-Ottawa Scale. Random-effects meta-analyses of unadjusted and adjusted odds ratios (ORs) were performed for all primary outcomes. Results were synthesized using the Grading of Recommendations Assessment, Development, and Evaluation approach. Main Outcomes and Measures Primary outcomes were preterm birth (PTB; <37 weeks of gestation), small for gestational age (SGA), low birth weight (LBW; <2500 g), and perinatal mortality. Results For this update, 8 new studies with 1 709 998 participants were added, for a total of 51 studies synthesized (N = 21 146 938). From meta-analyses of adjusted effect sizes, moderate-certainty evidence indicated that cannabis use in pregnancy was associated with increased odds of LBW (20 studies; OR, 1.75; 95% CI, 1.41-2.18), PTB (20 studies; OR, 1.52; 95% CI, 1.26-1.83), and SGA (12 studies; OR, 1.57; 95% CI, 1.36-1.81), and low-certainty evidence indicated that it was associated with greater odds of perinatal mortality (6 studies; OR, 1.29; 95% CI, 1.07-1.55). Previously, the evidence was rated as very low or low certainty. Conclusions and Relevance Cannabis use in pregnancy was associated with greater odds of PTB, SGA, and LBW even after adjusting for co-use of tobacco products, and confidence in these findings increased from low in the prior review to moderate in the current meta-analysis. The findings of this study may help inform patient counseling and future public health policies.

Despite the advantages of integrated care for co-occurring chronic pain and posttraumatic stress disorder (CP + PTSD), barriers impede its implementation. In this qualitative study, we examined facilitators and barriers of integrated care for CP + PTSD at a single Veterans Affairs medical center. We used purposive sampling and snowball recruitment to identify key stakeholders. We conducted semistructured interviews (N = 38) via video teleconferencing between January and May of 2022. We analyzed interview data employing both thematic and matrixed analysis methodologies. We interviewed VA staff (providers [n = 11], clinic managers [n = 5], and administrators [n = 2]) and patients with CP + PTSD (n = 19). There were three main findings: (a) current models disconnect care for CP + PTSD and fail in fully addressing the intricacies of this comorbidity, (b) the interconnection of CP + PTSD symptoms supports the need to overcome barriers to integrated treatment, and (c) facility- and system-level barriers to implementation of integrated care include staffing and having an evidence-based protocol. Staff and patient stakeholders recognized growing momentum supporting the development of integrated, nonpharmacological treatments for CP + PTSD. However, interventions to address barriers are needed to increase wider adoption and implementation. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

Description: The American College of Physicians (ACP) developed these rapid practice points addressing the comparative effectiveness and harms of trivalent (3 different influenza viruses or viral proteins) and quadrivalent (4 different influenza viruses or viral proteins) influenza vaccines in adults aged 18 years or older who are not pregnant or immunocompromised. These practice points do not address adults aged 18 years or older who are pregnant or immunocompromised. Methods: The ACP Population Health and Medical Science Committee (PHMSC) developed the rapid practice points on the basis of a rapid review by the ACP Center for Evidence Reviews at Cochrane Austria. The rapid review was a focused update of the 2024 comprehensive, high-quality systematic review and meta-analysis conducted by the European Centre for Disease Prevention and Control. The ACP PHMSC focused on the comparative effectiveness of influenza vaccines compared with each other because of the established efficacy and safety of the standard influenza vaccines. Practice Point 1: Adults aged 18 to 64 years who are not pregnant or immunocompromised should receive either a standard-dose trivalent or a standard-dose quadrivalent (cell-based, egg-based, MF59-adjuvanted, or recombinant) influenza vaccine for the 2025-2026 influenza season. Practice Point 2: Adults aged 65 years or older who are not immunocompromised should receive either a high-dose trivalent or a high-dose quadrivalent egg-based influenza vaccine for the 2025-2026 influenza season.

ABSTRACT:The American Society of Addiction Medicine (ASAM) has published clinical practice guidelines (CPGs) since 2015. As ASAM's CPG work continues to develop, it maintains an organizational priority to establish rigorous standards for the trustworthy production of these important documents. In keeping with ASAM's mission to define and promote evidence-based best practices in addiction prevention, treatment, and recovery, ASAM has rigorously updated its CPG methodology to be in line with evolving international standards. The CPG Methodology and Oversight Subcommittee was formed to establish and publish a methodology for the development of ASAM CPGs and to develop an ASAM CPG strategic plan. This article provides a focused overview of the ASAM CPG methodology.

BACKGROUND:The prevalence of osteoporosis is increasing in the United States.PURPOSE:To evaluate low bone mass and osteoporosis treatments to prevent fractures.DATA SOURCES:Ovid MEDLINE ALL, Ovid Evidence Based Medicine Reviews: Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov from 2014 through February 2022.STUDY SELECTION:Adults receiving eligible interventions for low bone mass or osteoporosis. Randomized controlled trials (RCTs) for fracture outcomes, and RCTs and large observational studies (n ≥1000) for harms.DATA EXTRACTION:Abstracted by 1 reviewer and verified by a second. Independent, dual assessments of risk of bias and certainty of evidence (CoE).DATA SYNTHESIS:We included 34 RCTs (in 100 publications) and 36 observational studies. Bisphosphonates and denosumab reduced hip, clinical and radiographic vertebral, and other clinical fractures in postmenopausal females with osteoporosis (moderate to high CoE). Bisphosphonates for 36 months or more may increase the risk for atypical femoral fractures (AFFs) and osteonecrosis of the jaw (ONJ), but the absolute risks were low. Abaloparatide and teriparatide reduced clinical and radiographic vertebral fractures but increased the risk for withdrawals due to adverse events (WAEs; moderate to high CoE). Raloxifene and bazedoxifene for 36 months or more reduced radiographic vertebral but not clinical fractures (low to moderate CoE). Abaloparatide, teriparatide, and sequential romosozumab, then alendronate, may be more effective than bisphosphonates in reducing clinical fractures for 17 to 24 months in older postmenopausal females at very high fracture risk (low to moderate CoE). Bisphosphonates may reduce clinical fractures in older females with low bone mass (low CoE) and radiographic vertebral fractures in males with osteoporosis (low to moderate CoE).LIMITATION:Few studies examined participants with low bone mass, males, or Black-identifying persons, sequential therapy, or treatment beyond 3 years.CONCLUSION:Bisphosphonates, denosumab, abaloparatide, teriparatide, and romosozumab, followed by alendronate, reduce clinical fractures in postmenopausal females with osteoporosis. Abaloparatide and teriparatide increased WAEs; longer duration bisphosphonate use may increase AFF and ONJ risk though these events were rare.PRIMARY FUNDING SOURCE:American College of Physicians. (PROSPERO: CRD42021236220).

ImportanceIntensive primary care interventions have been promoted to reduce hospitalization rates and improve health outcomes for medically complex patients, but evidence of their efficacy is limited.ObjectiveTo assess the efficacy of a multidisciplinary ambulatory intensive care unit (A-ICU) intervention on health care utilization and patient-reported outcomes.Design, Setting, and ParticipantsThe Streamlined Unified Meaningfully Managed Interdisciplinary Team (SUMMIT) randomized clinical trial used a wait-list control design and was conducted at a health care clinic for patients experiencing homelessness in Portland, Oregon. The first patient was enrolled in August 2016, and the last patient was enrolled in November 2019. Included patients had 1 or more hospitalizations in the prior 6 months and 2 or more chronic medical conditions, substance use disorder, or mental illness. Data analysis was performed between March and May 2021.InterventionThe A-ICU included a team manager, a pharmacist, a nurse, care coordinators, social workers, and physicians. Activities included comprehensive 90-minute intake, transitional care coordination, and flexible appointments, with reduced panel size. Enhanced usual care (EUC), consisting of team-based primary care with access to community health workers and mental health, addiction treatment, and pharmacy services, served as the comparator. Participants who received EUC joined the A-ICU intervention after 6 months.Main Outcomes and MeasuresThe main outcome was the difference in rates of hospitalization (primary outcome), emergency department (ED) visits, and primary care physician (PCP) visits per person over 6 months (vs the prior 6 months). Patient-reported outcomes included changes in patient activation, experience, health-related quality of life, and self-rated health at 6 months (vs baseline). We performed an intention-to-treat analysis using a linear mixed-effects model with a random intercept for each patient to examine the association between study group and outcomes.ResultsThis study randomized 159 participants (mean [SD] age, 54.9 [9.8] years) to the A-ICU SUMMIT intervention (n = 80) or to EUC (n = 79). The majority of participants were men (102 [65.8%]) and most were White (121 [76.1%]). A total of 64 participants (41.0%) reported having unstable housing at baseline. Six-month hospitalizations decreased in both the A-ICU and EUC groups, with no difference between them (mean [SE], −0.6 [0.5] vs −0.9 [0.5]; difference, 0.3 [95% CI, −1.0 to 1.5]). Emergency department use did not differ between groups (mean [SE], −2.0 [1.0] vs 0.9 [1.0] visits per person; difference, −1.1 [95% CI, −3.7 to 1.6]). Primary care physician visits increased in the A-ICU group (mean [SE], 4.2 [1.6] vs −2.0 [1.6] per person; difference, 6.1 [95% CI, 1.8 to 10.4]). Patients in the A-ICU group reported improved social functioning (mean [SE], 4.7 [2.0] vs −1.1 [2.0]; difference, 5.8 [95% CI, 0.3 to 11.2]) and self-rated health (mean [SE], 0.7 [0.3] vs −0.2 [0.3]; difference, 1.0 [95% CI, 0.1 to 1.8]) compared with patients in the EUC group. No differences in patient activation or experience were observed.Conclusions and RelevanceThe A-ICU intervention did not change hospital or ED utilization at 6 months but increased PCP visits and improved patient well-being. Longer-term studies are needed to evaluate whether these observed improvements lead to eventual changes in acute care utilization.Trial RegistrationClinicalTrials.gov Identifier: NCT03224858

BACKGROUND:Therapeutic use of cannabis is common in the United States (up to 18.7% of Americans aged ≥12), and dispensaries in the US are proliferating rapidly. However, the efficacy profile of medical cannabis is unclear, and customers often rely on dispensary staff for purchasing decisions. The objective was to describe cannabis dispensary staff perceptions of medical cannabis benefits and risks, as well as its safety in high-risk populations.METHODS:Online Survey study conducted using Qualtrics from February 13, 2020 to October 2, 2020 with a national sample of dispensary staff who reportedinteracting with customers in a cannabis dispensary selling tetrahydrocannabinol-containing products. Participants were queried about benefits ("helpfulness") and risks ("worry") about cannabis for a variety of medical conditions, and safety in older adults and pregnant women on a five-point Likert scale. These results were then collapsed into three categories including "neutral" (3/5). "I don't know" (uncertainty) was a response option for helpfulness and safety.RESULTS:Participants (n = 434) were from 29 states and included patient-facing dispensary staff (40%); managers (32%); pharmacists (13%); and physicians, nurse practitioners, or physician assistants (5%). Over 80% of participants perceived cannabis as helpful for post-traumatic stress disorder (88.7%), epilepsy (85.3%) and cancer (83.4%). Generally, participants were not concerned about potential cannabis risks, including increased use of illicit drugs (76.3%), decreases in intelligence (74.4%), disrupted sleep (71.7%), and new/worsening health problems from medical cannabis use (70.7%). Cannabis was considered safe in older adults by 81.3% of participants, though there was much less consensus on safety in pregnancy.CONCLUSIONS:Cannabis dispensary staff generally view medical cannabis as beneficial and low-risk. However, improvements in dispensary staff training, an increased role for certifying clinicians, and interventions to reduce dispensary staff concerns (e.g., cost, judgment) may improve evidence-based staff recommendations to patients seeking medical cannabis.

Objective: To determine whether prenatal cannabis use alone increases the likelihood of fetal and neonatal morbidity and mortality. Study Design: We searched bibliographic databases, such as PubMed, Embase, Scopus, Cochrane reviews, PsycInfo, MEDLINE, Clinicaltrials.gov, and Google Scholar from inception through February 14, 2022. Cohort or case-control studies with prespecified fetal or neonatal outcomes in pregnancies with prenatal cannabis use. Primary outcomes were preterm birth (PTB; <37 weeks of gestation), small-for-gestational-age (SGA), birthweight (grams), and perinatal mortality. Two independent reviewers screened studies. Studies were extracted by one reviewer and confirmed by a second using a predefined template. Risk of bias assessment of studies, using the Newcastle-Ottawa Quality Assessment Scale, and Grading of Recommendations Assessment, Development, and Evaluation for evaluating the certainty of evidence for select outcomes were performed by two independent reviewers with disagreements resolved by a third. Random effects meta-analyses were conducted, using adjusted and unadjusted effect estimates, to compare groups according to prenatal exposure to cannabis use status. Results: Fifty-three studies were included. Except for birthweight, unadjusted and adjusted meta-analyses had similar results. We found very-low- to low-certainty evidence that cannabis use during pregnancy was significantly associated with greater odds of PTB (adjusted odds ratio [aOR], 1.42; 95% confidence interval [CI], 1.19 to 1.69; I2, 93%; p=0.0001), SGA (aOR, 1.76; 95% CI, 1.52 to 2.05; I2, 86%; p<0.0001), and perinatal mortality (aOR, 1.5; 95% CI, 1.39 to 1.62; I2, 0%; p<0.0001), but not significantly different for birthweight (mean difference, -40.69 g; 95% CI, -124.22 to 42.83; I2, 85%; p=0.29). Because of substantial heterogeneity, we also conducted a narrative synthesis and found comparable results to meta-analyses. Conclusion: Prenatal cannabis use was associated with greater odds of PTB, SGA, and perinatal mortality even after accounting for prenatal tobacco use. However, our confidence in these findings is limited. Limitations of most existing studies was the failure to not include timing or quantity of cannabis use. This review can help guide health care providers with counseling, management, and addressing the limited existing safety data. Protocol Registration: PROSPERO CRD42020172343.

Background Legal cannabis is available in more than half of the United States. Health care professionals (HCPs) rarely give recommendations on dosing or safety of cannabis due to limits imposed by policy and lack of knowledge. Customer-facing cannabis dispensary staff, including clinicians (pharmacists, nurses, physician’s assistants), communicate these recommendations in the absence of HCP recommendations. Little is known about how dispensary staff approach individuals with complex medical and psychiatric comorbidities. Using responses from a national survey, we describe how cannabis dispensary staff counsel customers with medical and psychiatric comorbidities on cannabis use and examine whether state-specific cannabis policy is associated with advice given to customers. Methods National, cross-sectional online survey study from February 13, 2020 to October 2, 2020 of dispensary staff at dispensaries that sell delta-9-tetrahydrocannabinol containing products. Measures include responses to survey questions about how they approach customers with medical and psychiatric comorbidities; state medicalization score (scale 0-100; higher score indicates more similarity to regulation of traditional pharmacies); legalized adult-use cannabis (yes/no). We conducted multiple mixed effects multivariable logistic regression analyses to understand relationships between state medicalization and dispensary employees’ perspectives. Results Of 434 eligible respondents, most were budtenders (40%) or managers (32%), and a minority were clinicians (18%). State medicalization score was not associated with responses to most survey questions. It was associated with increased odds of encouraging customers with medical comorbidities to inform their traditional HCP of cannabis use (Odds ratio [OR]=1.2, 95% confidence interval [CI] 1.0-1.4, p =0.03) and reduced odds of recommending cannabis for individuals with cannabis use disorder (CUD) (OR=0.8, 95% CI 0.7-1.0, p =0.04). Working in a state with legalized adult-use cannabis was associated with recommending traditional health care instead of cannabis in those with serious mental illness (OR 2.2, 95% CI 1.1-4.7, p =0.04). Less than half of respondents believed they had encountered CUD (49%), and over a quarter did not believe cannabis is addictive (26%). Conclusions When managing cannabis dosing and safety in customers with medical and psychiatric comorbidity, dispensary staff preferred involving individuals’ traditional HCPs. Dispensary staff were skeptical of cannabis being addictive. While state regulations of dispensaries may impact the products individuals have access to, they were not associated with recommendations that dispensary staff gave to customers. Alternative explanations for dispensary recommendations may include regional or store-level variation not captured in this analysis.

Background: Despite demonstrated efficacy, medication treatment for opioid use disorder (MOUD) remain inaccessible to many patients, with barriers identified at the individual, clinic and system level. A wide array of implementation strategies have guided efforts to expand access to MOUD, with most centered around externally-facilitated approaches to practice change. While effective, such approaches may be inaccessible to those clinics and systems that lack the resources necessary to partner with an external team, suggesting a need to identify and describe change-processes that are internally developed and promoted. Methods: Guided by the Consolidated Framework for Implementation Research (CFIR), we utilized qualitative interviews and ethnographic observation to investigate the planning, design and implementation of a locally-initiated process to expand access to MOUD within one health care system. All study documents were coded by a primary coder and secondary reviewer using a codebook designed for use with the CFIR. To analyze data, we reviewed text tagged by key codes, compared these textual excerpts both across and within documents, and organized findings into themes. Processes identified were mapped to established implementation science constructs and strategies. Results: Interviews with clinicians and administrators (n =9) and ethnographic observation of planning meetings (n =3) revealed how a self-appointed local team developed, established broad support for, and successfully implemented a Primary Care-based Buprenorphine Clinic and E-Consult Service to expand access to MOUD to patients across the health care system. First, national and local policy changes-including altered clinical practice guidelines, performance pay incentives regarding opioid prescribing, and a directive from VA Central Office increased individual staff and administrators' perception of the need for change and willingness to invest time and resources. Then, a self-appointed interdisciplinary team utilized cross-clinic meetings and information gathering to identify appropriate, and widely supported, models of care delivery and care consultation. Finally, the team increased staff investment in these change efforts by bringing them into the planning process and encouraging collaborative problem solving. Conclusions: This study reveals how a local team developed and built widespread support for new processes of care that were tailored to local needs and well-positioned for sustainability over time.

Living systematic reviews are a relatively new approach to keeping the evidence in systematic reviews current by frequent surveillance and updating. The Agency for Healthcare Research and Quality’s Evidence-based Practice Center Program recently commissioned a systematic review of plant-based treatments for chronic pain management. This white paper describes the team’s experience in implementing the protocol that was developed a priori, and reflects on the challenges faced and lessons learned in the process of developing and maintaining a living systematic review. Challenges related to scoping, conducting searches, selecting studies, abstracting data, assessing risk of bias, conducting meta-analysis, performing narrative synthesis, assessing strength of evidence, and generating conclusions are described, as well as potential approaches to addressing these challenges.

Objective:Previous pandemics may offer evidence on mediating factors that contributed to disparities in infection and poor outcomes, which could inform the effort to mitigate potential unequal outcomes during the current COVID-19 pandemic. This systematic review sought to examine those factors.Methods:We searched MEDLINE, PsycINFO, and Cochrane to May 2020. We included studies examining health disparities in adult U.S. populations during infectious disease epidemics or pandemics. Two investigators screened abstracts and full text. We assessed study quality using the Newcastle/Ottawa Scale or the Critical Appraisal Skills Programme Checklist for Qualitative Studies.Results:Sixteen articles were included, of which 14 focused on health disparities during the 2009 H1N1 influenza pandemic. Studies showed that disparities during the H1N1 pandemic were more related to differential exposure to the virus than to susceptibility or access to care. Overall, pandemic-related disparities emanate primarily from inequalities in social conditions that place racial and ethnic minorities and low socioeconomic status populations at greater risk of exposure and infection, rather than individual-level factors such as health behaviors and comorbidities.Conclusions:Policy- and systems-level interventions should acknowledge and address these social determinants of heightened risk, and future research should evaluate the effects of such interventions to avoid further exacerbation of health inequities during the current and future pandemics.