Richard A. Grucza

Introduction: Oregon is the first US state to permit supervised psilocybin services through a nonmedical, wellness-based model. We examined what prospective clients with psychiatric histories encounter when contacting service centers, including how staff communicate about safety, eligibility, and cost. Methods: We conducted a mystery shopper study of 26 licensed service centers in Oregon (7/2025-9/2025), 4 of which closed before calls began, leaving 22 in the sample. We reviewed websites and conducted 2 waves of scripted phone calls portraying adults with depression. Website and call data were combined at the center level, counting an item as disclosed if it appeared online or during a call. Themes from call field notes were contextualized through structured debriefing interviews with service center staff. Results: Callers reached 15/22 centers, none of which permitted unsupervised consumption or immediate dosing without psychiatric assessment. Staff asked detailed questions about psychiatric comorbidities, addressing information gaps from websites, and none recommended discontinuing antidepressants. The median cost was $1900. Debriefing interviews described financial strain for service centers, with viability constrained by licensing fees and potential misalignment with cannabis-derived business models. Conclusion: Oregon's regulated model appears clinically cautious, while facing high costs for clients, facilitators, and service centers that limit scalability.

Despite well‐documented harms of prenatal alcohol exposure, evidence‐based treatment guidelines for alcohol use disorder (AUD) during pregnancy remain limited. We systematically reviewed international clinical practice guidelines to examine how they address the full cascade of AUD care during pregnancy, including diagnosis, engagement, treatment initiation, and retention. We searched over 40 clinical practice guideline databases (including PubMed and Guidelines International Network) and gray literature sources globally, identifying 1045 records. Using the Population, Interventions, Comparators, Attributes, Recommendation Characteristics (PICAR) framework, we evaluated guidelines from medical organizations in English‐speaking nations addressing alcohol use and AUD management in pregnancy. Our final analysis included 18 guidelines from the United States, Canada, the United Kingdom, Australia/New Zealand, and the World Health Organization published from 2014 to the present. Two reviewers independently assessed each guideline using the Appraisal of Guidelines Research and Evaluation‐Recommendations Excellence (AGREE‐REX) framework to evaluate quality and risk of bias. We used narrative synthesis to summarize findings across key concepts and care cascade stages. Nearly all guidelines (94%) described risks of alcohol exposure and recommended counseling on cessation (89%), yet few extended beyond these early cascade stages. Only 44% mentioned medications for AUD (MAUD), and merely 17% discussed specific psychosocial treatments. Among guidelines addressing MAUD, only one cautiously supported use, while three explicitly recommended against it. Most guidelines (61%) ended treatment recommendations at referral to specialty care, with half limiting guidance to acute alcohol withdrawal management. Taken together, our findings reveal a stark misalignment between screening emphasis and treatment guidance. While guidelines consistently recommend universal screening and brief intervention, they provide minimal actionable frameworks for managing AUD throughout pregnancy. This gap leaves clinicians without evidence‐based pathways for comprehensive AUD treatment during the prenatal period, highlighting an urgent need to strengthen both the evidence base and clinical guidance for AUD management in pregnancy.

Background: Although men have historically exhibited the higher levels of alcohol use and alcohol‐related harm, sex differences in alcohol consumption have narrowed in recent decades. Whether similar convergence has occurred in the proportion of substance‐related acute care encounters involving alcohol remains unclear. Methods: We conducted a retrospective longitudinal cohort study using national administrative claims from the Merative MarketScan Commercial and Multi‐State Medicaid databases (January 2016 to December 2023). Individuals aged 16–64 years with at least one emergency department (ED) or inpatient encounter involving a non‐nicotine substance‐related diagnosis (ICD‐10‐CM F10‐F19, excluding F17) were included. Alcohol involvement was defined using multiple classifications: any alcohol‐related diagnosis, alcohol‐only encounters, inpatient admissions with alcohol as the primary diagnosis, and acute alcohol‐related morbidity identified using CDC external cause codes. We estimated monthly sex‐specific trends in the proportion of substance‐related encounters involving alcohol using generalized estimating equation models with quadratic time terms. Results: The cohort comprised 1,355,161 individuals (54.7% male, 45.3% female) with 5,190,680 substance‐related ED and inpatient encounters. Among individuals with substance‐related encounters, alcohol involvement was more common among males than females (61.5% vs. 43.2%). Across all alcohol‐related outcomes, models demonstrated accelerating convergence in the sex gap over time (all p < 0.001). From 2016 to 2023, the male–female gap in the proportion of substance‐related encounters involving alcohol narrowed by 6.0 percentage points (95% CI, 4.9–7.1), 4.7 points (95% CI, 3.6–5.8) for alcohol‐only encounters, and 4.9 points (95% CI, 4.0–5.8) for inpatient admissions with alcohol as the primary diagnosis. Trends in total substance‐related encounter volume did not differ by sex. Conclusions: From 2016 to 2023, alcohol accounted for an increasing proportional share of substance‐related acute care encounters among women relative to men, independent of changes in overall substance‐related healthcare utilization volume.

Background: Buprenorphine is the most commonly used medication for treating opioid use disorder (OUD). It may also be beneficial for individuals with chronic pain who are physically dependent on opioids but do not meet the criteria for OUD. Therefore, the buprenorphine patient population may be heterogeneous in terms of OUD and comorbidities. Objectives: To characterize the heterogeneity of patient profiles among those initiating buprenorphine treatment in a large multi-state healthcare system, focusing on comorbid pain, psychiatric, and substance use disorder diagnoses, and other patient characteristics associated with profiles. Design: Retrospective cohort study using electronic health record data. Partcipipants: Patients with at least 12 months of data before a new buprenorphine prescription (OUD formulation) and at least 6 months of follow-up. Main Measures: Presence vs absence of opioid use disorder diagnoses and latent class profiles of comorbid diagnoses and clinical characteristics. Post-index outcomes, including the number of buprenorphine orders and incidence of drug-related poisoning, were assessed for each class. Key Results: In a cohort of 5726 individuals (mean age 38.6 years, 56.2% female, 84.0% white), four latent classes were identified: (1) high multimorbidity burden; (2) moderate multimorbidity burden; (3) high rates of comorbid pain diagnoses but lower rates of psychiatric and substance use disorder diagnoses, with most patients lacking opioid use disorder diagnoses; (4) lower rates of pain diagnoses but high rates of comorbid psychiatric and substance use disorder diagnoses. Post-index measures aligned well with comorbidity profiles. Conclusion: Patients receiving buprenorphine in general healthcare settings likely form a heterogeneous group. This includes a subgroup with low rates of opioid use disorder diagnoses (class 2, pain comorbidity), who may resemble chronic pain patients more than conventional OUD patients.

Background: Deaths from alcohol‐related liver disease and associated conditions (ALD+), a major driver of alcohol‐attributable mortality in the United States, are rising more rapidly than per capita alcohol consumption. These trends may stem from a broader “deaths of despair” epidemic disproportionately affecting those without a college degree. However, how ALD+ mortality trends vary by educational attainment remains underexplored. To address this, we analyzed ALD+ mortality from 2001 to 2020, focusing on disparities across educational and demographic subgroups. Methods: We analyzed US mortality trends for adults 25 and older using a repeated cross‐sectional dataset combining death records for ALD+ with population data from the American Community Survey. We examined differences in mortality trends by age, sex, race/ethnicity, and educational attainment (college degree or not). Trends were modeled using logistic regression with age as a covariate and quadratic time terms. Outcomes included proportional change in mortality (odds ratios for 2020 vs. 2001), modeled age‐adjusted death rates for 2001 and 2020, and absolute change in death rate (Δ). Results: Between 2001 and 2020, the ALD+ death rate increased by 63% (OR = 1.63; 95% CI: 1.55, 1.72), from 8.8 to 16.6 deaths per 100,000. Increases were greater among individuals without a college degree compared to those with a college degree (Δ = 12.7 vs. 2.4 per 100,000). Disparities by education widened across nearly all demographic groups. Conclusion: Disparities in ALD+ mortality by educational attainment widened substantially between 2001 and 2020. Findings are partially consistent with the “deaths of despair” framework that initially focused on mortality among middle‐aged non‐Hispanic Whites but also reveal widening disparities in other demographic groups. Increased alcohol consumption alone is unlikely to fully explain these trends. Identification of social, behavioral, and medical factors contributing to increasing ALD+ deaths will shed light on opportunities for intervention focused on factors beyond alcohol consumption.

Objectives: To estimate the association between suicide deaths and both occupational skill level and educational attainment in the United States. Methods: Suicide deaths, employment, education, and demographic data from the 2021 National Center for Health Statistics Multiple Cause of Death Files, for ages 18-64 with a lifetime history of employment, were combined with comparable participants from the 2020-2022 Current Population Survey. Outcomes of interest were associations between suicide death and occupational skill level, assessed as a 5-level variable, and educational attainment. Logistic regression models were used to estimate these associations before and after adjusting for educational attainment, age, and sex, in each racial/ethnic subpopulation. Results: We found a significant gradient in suicide death across occupational skill levels, with lower-skill occupations associated with higher suicide rates than higher-skill occupations. This gradient was more pronounced among non-Hispanic White (NHW) people and non-Hispanic Black (NHB) people than Hispanic people. However, upon controlling for educational attainment, this association was attenuated, indicating that the initial link was likely confounded by education. Conclusions: The results suggest that educational attainment is a more robust predictor of suicide risk than occupational skill level. Targeted interventions addressing educational and ethnic disparities within higher-risk occupational groups can mitigate suicide risk.