Taisia Huckle, Kristen Mummert, Antonia C. Lyons, Tim McCreanor ¡ 6 authors
INTRODUCTION: The study aims are to: (i) explore methods for identifying alcohol company marketing in metaverses; (ii) identify current types of alcohol marketing in metaverses; and (iii) identify dominant portrayals and meanings of alcohol marketing in these settings. METHODS: Our design was exploratory, employing various approaches to identify alcohol company marketing across multiple metaverses. In stage one, we systematically navigated through metaverses as an avatar, documenting and coding all instances of alcohol company marketing. In stage two, the research team collaboratively explored and discussed excerpts of this marketing. The team thematically analysed the transcribed discussion, identifying key meanings and interpretations of immersive and interactive alcohol marketing. RESULTS: Stage one: alcohol company marketing was identified in two metaverses, Decentraland and Sandbox. Within those metaverses were five alcohol company marketing experiences: Heineken Silver, Jose Cuervo Tequila, Wisher Vodka, San Matias Tequila, and Mason Martell Cognac. Marketing strategies included immersive commerce, virtual drinking, immersive branding, immersive engagement, gaming, non-fungible tokens (digital assets), education, non-player characters promoting brands and virtual event-based marketing. Stage two: themes identified were: (i) immersive branding, representing continued exposure to brands that were both foregrounded and on the edge of users' awareness; (ii) immersive engagement, including alcohol-related gaming, quests, and alcohol production; (iii) avatars simulating drinking behaviour (virtual drinking); and (iv) immersive commerce representing how metaverse alcohol marketing may drive alcohol transactions. DISCUSSION AND CONCLUSION: Alcohol companies are using novel immersive marketing techniques in metaverses. The impact on the experiences and drinking behaviours of users are unknown and require investigation.
Abstract Background The intersection of cryptocurrency, especially Bitcoin, with public health issues, particularly synthetic opioid-related deaths, presents an emerging field of study. This research explores the statistical relationship between Bitcoin market fluctuations and synthetic opioid mortalities, against the backdrop of Drug Enforcement Administration (DEA) enforcement actions. Methods Utilizing data from 2009 to 2022, this study employs Pearson correlation and linear regression models to investigate the relationship between annual Bitcoin price fluctuations and synthetic opioid-related death rates, alongside DEA domestic arrest trends. Results A pronounced positive correlation (r = 0.92) was found between Bitcoin price changes and synthetic opioid mortality rates, with the Bitcoin price accounting for approximately 84.78% of the variance in opioid-related deaths (R² = 0.8478). The analysis also notes a disparity between increasing synthetic opioid fatalities and decreasing DEA domestic arrests. Conclusions The findings reveal significant correlations between Bitcoin price fluctuations and synthetic opioid-related fatalities, highlighting potential gaps in current drug enforcement strategies. This study underscores the need for an interdisciplinary approach to address the complexities introduced by cryptocurrency in the opioid crisis and suggests the necessity of integrating financial and public health strategies to combat emerging drug abuse trends.
Harmful product producers, such as alcohol companies, are exploring and already active in the metaverse [1]. Much in the same way as alcohol companies have used digital media platforms to embed alcohol into young people's lives [2-7] and shape behaviour through an all-encompassing marketing environment [8], alcohol company activities in the metaverse that similarly foster excessive consumption and addictive behaviour [9] may pose new and greater risks for young people and other vulnerable groups, accelerating the need for a regulatory response to alcohol marketing. The simplest way to describe the metaverse is as an immersive next-generation version of the internet using virtual or augmented reality technology [10]. The metaverse is a digital immersive reality that combines aspects of social media, online gaming, augmented reality (a digital overlay projected on the real world) [10], virtual reality (accessed using a headset to see and operate within a digital world) and cryptocurrencies [11, 12]. It is a fast-evolving collection of interactions, technologies and business models that will look very different from today's internet [13]. While the metaverse is still young, in the future there may be numerous sophisticated metaverses, providing the infrastructure, especially bandwidth, can be developed to support them [12]. The metaverse will be an observable digital universe made up of millions of digital galaxies (metaverses/platforms) [14]. Each metaverse will likely be designed based on the needs it serves, for example, Meta (previously Facebook) anticipates friends socialising [15] while others envision a place parallel to the physical world where you spend your digital life [16]. The metaverse will offer innovative and expansive economic opportunities for corporations and users alike. The ultimate vision for the metaverse is a world that has its own fully functioning economy, jobs and shopping centres [17] or, in other words, platforms for human leisure, labour and existence in general [10]. Metaverses in which alcohol companies are active will be relevant for public health. Alcohol corporations are developing innovative ways of embedding alcohol into consumers' lives in the metaverse [18]. They were early movers in previous digital technologies and similarly are engaging with the metaverse in its development. Not only will alcohol advertising be more immersive compared to social media platforms and therefore more impactful, but also young people and other vulnerable groups such as those on a path to becoming heavy drinkers will likely be targeted for advertising, much as they are now in social media digital spaces but with expanded access to and analysis of their individual data. These can include the use of biometrics such as heart rate, tracking eye movement and pupil dilation, which are required to produce the immersive experience of virtual reality but can also be used to identify a user's interests and buying preferences [19]. The metaverse can facilitate the integration of virtual and real-life consumption experiences. Like social media, the metaverse may utilise targeted advertising and consumer participation, integrating them with purchasing [20-22] and delivery in real-time to consumers. One company has already linked their virtual drinks to their real-world products where buyers are sent a six-bottle case of actual vodka [23]. These processes will likely be enhanced in the metaverse as e-commerce will evolve into i-commerce (immersive commerce) [13]. Users (as avatars) will be able to enter a virtual alcohol shop or wine retailer and interact with the store avatar. Each bottle will tell you about itselfâbefore you make a physical decision to purchase [13], after which a rapid delivery service may deliver alcohol to your location. Rapid online alcohol delivery is already expanding in many countries and is of concern as it is under-regulated [24]. Consumers will be able to go to virtual bars and buy virtual drinks [25]. Miller Lite is opening its first virtual bar and Heineken has opened a virtual brewery in Decentraland [26, 27]. Young consumers are already interacting in virtual bars in the metaverse [23]. The metaverse can allow for enhanced engagement with alcohol marketing. Engagement with merchandise will be facilitated by branded items being created in collaboration with upcoming Non Fungible Tokens artists (Non Fungible Tokens are blockchain-based tokens that each represent a unique asset like a piece of art, digital content, media or land title) [11], as well as new ways to encourage engagement via consumer-driven and viral advertising [28]. Brands do not necessarily expect the end result to be an immediate purchase; the bigger win is the chance to build a brand pathway, develop a relationship and engage in deeper dialogue with audiences that turns users into followers, customers and, hopefully 1 day, brand evangelists [29]. The metaverse could boost the impact of techniques already used by marketers. Influencers on social media have the power to affect purchase decisions of others because of their authority and popularity [30]. The metaverse will allow influencers to interact in 3D, to hold alcohol-branded events, concerts or virtual parties. Celebrities, famous musicians and users could be invited and attend. The power of influencers, paid for by alcohol companies, is likely to be magnified in an immersive environment and the metaverse will provide new ways to âinfluenceâ. Manipulation exploiting psychology and our reward system could be used in the metaverse [31] given these tactics are already employed on social media [9, 32]. One example is dark advertising exploiting cognitive bias [33] or dark patterns to create a cycle that provides unpredictability, which gives consumers dopamine hits [34]. In social media these are likes and shares, or the excitement of seeing what's new in the feed. In the metaverse, there will be unpredictability in 3D [34]. Unpredictability can include attending an alcohol branded concert or alcohol sponsored party to meet celebrities. Consumers can be a part of any exciting event they choose, which can then elevate dopamine levels [34]. The âaddiction by designâ techniques already harnessed on social media by global industries producing harmful products [9] will likely become more innovative and exacerbated in the metaverse. Behavioural scientists have raised the need to scrutinise the development of the metaverse given the enhancement of the negative aspects of social media [34] and because commercial interests have also recognised the potential impact of these concerns and responded accordingly. The social media platforms most involved in the development of the metaverse, including Facebook, now renamed Meta, have recognised the potential concerns of regulators in relation to issues such as data privacy. Facebook has established a research fund to collaborate with âpolicymakers, experts and industry partners to build the âmetaverseâ in a responsible mannerâ. This includes engaging with academic institutions on issues such as biometrics and human computer interaction and privacy models in the context of wearables such as virtual reality headsets [35]. While the metaverse is still in its early stages of development, public health needs to understand the metaverse. How will producers of harmful products target, engage and capture the attention of young people in the metaverse? What will the health impacts be? Or will young people drink less because they spend their time in the metaverse engaged in other activities, such as investing in Non Fungible Tokens or property, or socialising? Public health also needs to learn lessons from the failures to regulate alcohol on Facebook, Instagram, Twitter and social media generally. Many metaverses are being developed by private companies in the current unregulated environment, which means the problems we have regulating technology companies now could be reproduced and amplified in the metaverse [36]. Relying on self-regulation by corporations has been shown to be ineffective [37]. Prohibiting alcohol marketers from using user-generated content and distributing content that is intended to be shared by consumers, such as in Finland, does not affect marketers' ability to increase consumer engagementâthe most important aspect of marketing in terms of effectiveness [38]. While some countries have bans on alcohol marketing online including social media, no good evaluations have been completed [39]. Other metaverses are user owned, where users may have the rights to sell direct ads [40] and it is not known how these could be regulated. Policy makers need to understand the metaverse and the potential challenges it poses to public health. Early research documenting developments is needed to avoid the same failure to act in time, as happened with social media [36]. While early engagement with the creators and owners of metaverses may lead to enhanced user safety, it is more likely government regulation will be needed, including a global treaty. What is certain is that we cannot let the metaverse develop unscrutinised, nor without effective strategies to protect the health and well-being of young people. Taisia Huckle: Conceptualisation; writing â original draft. Sally Casswell: Conceptualisation; writing â review and editing. Open access publishing facilitated by Massey University, as part of the Wiley - Massey University agreement via the Council of Australian University Librarians. None.
BACKGROUND: In 2013, around 40 % of the schools in Sweden had structured programs to prevent tobacco and alcohol debut in compulsory school. There has unfortunately been a lack of scientific evidence to support most of the prevention methods focusing on primary prevention in schools in Sweden. The aim and purpose of the present study is to evaluate the effectiveness of the Non-Governmental Organization SMART contract-signing strategy in reducing the growth of youth substance use and other problem behaviors amongst Swedish adolescents. METHODS: Students from five schools in a medium-sized Swedish municipality were surveyed in three waves from 7(th) to 9(th) grade of compulsory school. We used General Linear Model (GLM) repeated-measures ANOVA to test if the outcome measures smoking, use of snus and alcohol, drunkenness, delinquency, and bullying significantly changed different amounts over time in groups that had participated in the SMART program for long time, a short time, sporadically- or not at all. Groups were compared on demographic background variables, and outcome measures were assessed on all measurement occasions by a one-way ANOVA. The magnitude of group differences at the end of the study was estimated according to Cohen's d. RESULTS: Number of years with a contract has an effect on the levels of self-reported youth problems in 9(th) grade. We found small to medium-sized differences in measured outcomes between students who participated in the program for the longest period of time, 5 years, and who participated for the shortest time, 0-2 years. CONCLUSION: Findings suggests that the SMART program has preventive effects on adolescent substance use.
Jennan A. Phillips, Michael Holland, Debra D. Baldwin, Linda Gifford Meuleveld ¡ 8 authors
Marijuana (cannabis) is the most frequently used illicit drug of abuse in the United States and worldwide. Moreover, it is second only to alcohol as the most prevalent psychoactive substance seen in cases of driving under the influence of drugs.1,2 It is also by a wide margin, the drug most often detected in workplace drug-testing programs. The primary psychoactive substance in marijuana is delta-9-tetrahydrocannabinol, known simply as THC. Present in steadily increasing concentrations in street-purchased, smokeable plant material, the THC content in marijuana averaged 3% in the 1980s, but by 2012 it had increased to 12%.3 The US government classifies marijuana as a Schedule I drug (defined as those drugs with no currently accepted medical use and a high potential for abuse,4 and the use/possession of which is subject to prosecution). Workers covered by federal drug-testing programs are uniformly prohibited from using marijuana at any time. In addition, federal law allows employers in every state to prohibit employees from working while under the influence of marijuana and are permitted to discipline employees who violate this prohibition. Nevertheless, with public attitudes toward marijuana use changing, prohibitions for its consumption outside of federal law now vary from state to state. Although the possession and use of marijuana continue to be prohibited by federal law, numerous states and the District of Columbia currently have enacted laws regarding marijuana use that conflict with federal law and policy,5 with legislation pending in other states.6â8 This changing legal environment and the evolving scientific evidence of its effectiveness for treatment of select health conditions require an assessment of the safety of marijuana use by the American workforce. Although studies have suggested that marijuana may be used with reasonable safety in some controlled environments, there are potential workplace consequences involved in its use that warrant scrutiny and concern. The potential consequences of marijuana use in the workplace include the risk and associated cost of adverse events and the loss of productivity. These safety concerns and the changing legal scene have led the American College of Occupational and Environmental Medicine (ACOEM) and the American Association of Occupational Health Nurses (AAOHN) to develop this guidance document to assist occupational health professionals and employers in identifying and addressing impairment issues related to the use of marijuana and prevention of injuries related to impairment. This guidance summarizes current evidence regarding marijuana consumption, discusses possible side effects including temporary impairment as it relates to the workplace, reviews existing federal and state laws and legal implications for health care professionals and employers, and suggests various strategies available to employers for monitoring workers for marijuana use. It is outside the scope of this article to address any potential medical benefit of marijuana. Studies conducted to evaluate the effects of marijuana drug use by workers have demonstrated variable risk. This variability relates to study design, demographics, work type, and potential confounders (eg, general risk-taking behavior among illicit drug users). This discussion on the effects of marijuana is based on a literature search of the currently available evidence (see the Appendix). Articles were graded using the following criteria: inadequate for evidence due to low-quality research; adequate for evidence (+); or high quality (++). High-quality studies, meta-analyses, or multiple adequate studies with the same conclusion qualified as good evidence for the guidance purposes of this document. Statements referring to evidence without a qualifier reflect the results of an adequate study. Other articles are also cited when appropriate to clarify issues that may not have been addressed by studies qualifying as evidence. LEGAL IMPLICATIONS OF MARIJUANA LEGISLATION In late 2009, the US Department of Justice initiated a change in marijuana enforcement policy by issuing a memorandum encouraging federal prosecutors not to prosecute individuals who distribute marijuana for medical purposes in accordance with state law.9 Nevertheless, after voters in Colorado and Washington approved the recreational use of marijuana, the Department of Justice issued another memorandum in August 2013 that reiterated its right to contest the legality of state marijuana laws, stating that the Department âexpects states like Colorado and Washington to create strong, state-based enforcement efforts... and will defer the right to challenge their legalization laws at this time.â10 This discordance about use, regulation, and legislation places employers in the challenging position of maintaining compliance with divergent and evolving legislation, while continuing to provide a safe workplace. Americans with Disabilities Act The Occupational Health and Safety Act of 1970 contains a general duty clause that requires employers under its jurisdiction to, among other things, maintain conditions or adopt practices reasonably necessary and appropriate to protect workers on the job.11 This duty may necessitate exclusion of those who are impaired or potentially impaired because of marijuana use. As long as marijuana is illegal under federal law, employers who fire or refuse to hire employees for using marijuana are not in violation of the Americans with Disabilities Act (ADA) or any other federal antidiscrimination statute, although there are restrictions on drug testing.12 Nevertheless, some states limit employer action against workers who use marijuana according to state standards. If drug testing is done, the decision to test must be job-related and necessary for business, and conducted when there is evidence of a safety or job performance problem. Currently, the ADA does not require employers to permit marijuana use as a reasonable accommodation for an individual with a disability, even if that person is a registered medical marijuana patient. In some states, court rulings involving the use of marijuana for medical purposes have held that employers are under no obligation to accommodate medical marijuana users, regardless of whether or not its use is permitted by state law.13 The basis of the rulings has been that a person âcurrently engaging in the illegal use of drugsâ is not a âqualified individual with a disability,â and marijuana is still an illegal drug for the purposes of federal law. Nevertheless, the ultimate effects of specific state laws on this issue are yet unknown.14 Drug and Alcohol Testing Regulations The majority of private employers across the United States are not necessarily required to drug test, and many state and local governments have statutes that limit or prohibit workplace testing unless required by state or federal regulations due to the nature of the job. Guidance issued by the US Department of Transportation (DOT) for its Drug and Alcohol Testing Regulations state that marijuana use remains unacceptable for any safety-sensitive employee subject to drug testing under DOT regulations.9 This safety-sensitive category includes pilots, bus and truck drivers, locomotive engineers, subway operators, aircraft maintenance personnel, transit fire-armed security personnel, and ship captains, among others.9 Federal agencies conducting drug testing must follow standardized procedures established by the Substance Abuse and Mental Health Services Administration (SAMHSA).15 Private nonunion employers who require drug testing for applicants employees are not required to follow but to the legality of In the of testing programs must be even when federal regulations require Act The Act enacted in to safety and requires federal to that will provide as a of a federal of or a federal of any and for federal are required to good to with workplace The does not require drug but it does require that employers and distribute a policy that will be against employees who violate the and provide in the workplace about the of drug use and available and employee are not required to fire employees on the basis of the results of a drug The Act requires employees to by the of the policy and the employer if are of a drug violation in the The or must be after that a covered employee has been of a drug violation in the who work for federal may be subject to including if marijuana use is regardless of whether its use is permitted by state Federal and Transportation of Marijuana marijuana are also subject to federal and local of marijuana if state with the even if are states that medical marijuana. As the US Transportation Safety Administration federal on marijuana on an is illegal and to federal drug Federal agencies in some also many states and the District of Columbia enacted medical marijuana laws or its use, an legal right to fire or refuse to hire an for an drug test due to medical marijuana use on whether the state of has a medical marijuana law that includes employee states that have medical marijuana not provide for employee although there are as and an and against action at work for registered when a marijuana on or to work and have an employer from against a registered qualifying employee who has a drug test for marijuana or if the employee or impaired by marijuana at the work or if to an employee who a drug test violate a or benefit under federal States that to have laws recreational marijuana not provide for employee Colorado allows employers to prohibit the use of marijuana at Nevertheless, another state law, the statute, employers in this state from employees for engaging in while and legal have with to employees who have been for testing for marijuana, and as of this issue is under by the Colorado state and federal laws legal and in the workplace will Although state laws laws marijuana require employers to permit drug use in the workplace to employees who to work this employers may to that employees to work in an state and not or while and state laws in to permitted use in the workplace, and drug testing be employer with legal to that with any state or local laws and their testing programs to legal of the legal the medical implications of marijuana use for the must be In to the risk of due to employers must also the that in and may as available to In that of workers were in some of illicit drug use the the legalization of marijuana in states, this that of to work after marijuana majority the drug Although this may not reflect the behavior of the US working as a the the for workplace addressing workers who use and marijuana is THC because of across the THC after due to of the substance to the and as as The and associated impairment as of the of when are and THC is the of the THC is by the the psychoactive which in the after the THC and The or and for or even in This is the in workplace drug-testing programs. vary with the and the of marijuana, impairment after and in about and to after studies that impairment in test studies on the of impairment after use were conducted when marijuana had a THC the of study results to is as the of may be studies have demonstrated impairment to to on specific performance but studies are and the studies this used In addition, no of performance impairment associated with every and accepted in the workplace the the use of As impairment studies were also conducted when had a is available It is that impairment may be and with marijuana. The majority of studies of impairment related to driving and to a state to after marijuana among recreational behavior from use and is good evidence that marijuana impairment from THC users, but the to which impairment is in safety-sensitive is This be to the who has at a alcohol a yet is still or are the to and effects are with concentrations and of among marijuana to the nature of or to is also by not for a because the of the and from the the has been The after after is some evidence that with impairment to a of performance study of demonstrated impairment of driving to after of This impairment not with In addition, although a state may have regulations regarding the of THC to be used in it is not this is may have the in The from marijuana use with THC of and of with the effects are of and increased and a of and effects include of impaired and in and and These effects are by of a in and increased and study that and to were the most related to marijuana of are used by drug law enforcement who of Marijuana Although studies that impairment in the workplace due to marijuana are now to numerous studies using driving and impairment of the necessary for safe of a by use have been of the regarding impairment and risk in the workplace due to alcohol has been from studies of driving impairment and same of studies be used to impairment in the workplace from studies have been to the of driving impairment in to the of THC in or studies of risk associated with use to impairment in because some of studies used the of the as evidence of drug use. In addition, many potentially had for THC after and even from the of the and of THC from the studies and of studies, including driving and that and related to driving performance were impaired in a with increasing THC is good evidence from a and the following and driving studies that marijuana of and and to on from studies of risk have that when marijuana in were to be at and there a with THC concentrations to be for the Studies have that while using individuals impaired performance in driving and In the driving studies, the were in to and maintain and and on for a study of from in an increased for a from for THC to for THC or studies have that with a test were to to be involved in a without In a study of effects of marijuana, that any of the psychoactive associated with the impairment of the to with a of THC and concentrations study that under THC a of to established and of THC to were of study that impaired on THC drivers, and those with of THC were at increased risk of In there is good evidence from a of studies and a that of an of to for and to for marijuana impairment to a of on a of of THC be used as with other medical of impairment from marijuana. The also be and it may provide regarding impairment. Nevertheless, as the of THC and to use as a for impairment is not known at this the the for to impairment and to this impairment to may to use the of THC and to impairment because is to THC. are to impairment by some performance and effects at most of a for allows some for of the in effects to a of or using the seen in the impairment studies the current of alcohol impairment for safety-sensitive workers under federal testing laws this may be used to an of the of this THC and may not impairment in an individual This be only when a medical for impairment has been in with of the which led to the for the basis of the the is a of THC of to impairment. The that there are states using for driving under the influence of drugs (eg, Colorado and Washington use in to in of THC and as a for driving under the influence when by behavior states address marijuana and of have for any of It is the of the that a of be used to a safe workplace Marijuana a is of impaired by marijuana use, and of impairment must be in and of that for testing be This is the same policy as that used for in drug-testing programs. impairment is employees are for alcohol and drug drug testing for marijuana by testing the which be for after use, and has no with impairment. This testing is for programs and in marijuana use is illegal or prohibited by the Nevertheless, a drug test use is not evidence of impairment. Although this use is still prohibited under this not be reasonable or in employer drug testing programs in states with recreational use. to prohibit the use of marijuana in states it is legal with regarding this of THC in the of recreational after legal use of marijuana be to in the of a of results impairment or violation of a law in states marijuana is this in states marijuana use, workplace drug testing of impaired employees be Although alcohol be used to alcohol psychoactive THC be detected in the same and currently requires a It is suggested that the employee of impaired be as the suggests that employers include an of the impaired employee at an occupational in The include a to the or of a alcohol test, and a drug for marijuana, a test for the and evaluate potential impairment from use. The employee be on results established If THC THC for employers who to evaluate psychoactive are a of the employee is impaired by use. THC be in of impairment by a demonstrated on a medical also be Testing of that may in the as a to whether testing is MARIJUANA LEGAL who to be impaired in the workplace be according to employer of THC not with impairment. include an of impairment. The of on impairment includes for the of of and other who to or are required to use of medical recreational marijuana with state law must risk of impairment from marijuana use, for those employees in safety-sensitive The following be medical and other occupational health professionals be with legal in about policy or individual use of marijuana. regarding testing for and possible impairment be and to are for and employees the implications of the results for their based on the policy and for marijuana and other drug use. statutes provide when a is under the influence of alcohol or illegal of use impairment may be necessary in The occupational health for a medical of for duty and on the for which use of medical marijuana be It is for medical to of state for medical the of use to working used (eg, plant material, the for any the job and of use. The occupational health work with to risk based on the safety-sensitive nature of the job. of workplace safety in the of the medical for which marijuana has been may also be who are in federal workplace drug testing programs are prohibited from on state law as a for marijuana or other Schedule I substance Nevertheless, employers be that the and Drug Administration is a Schedule is not a prohibited substance although it may a safety in some Other may be in the are available in other OF Occupational Safety and Health Administration employers have a federal to address impaired workers who to work The for employers is to with a policy regarding use and substance policy includes for and workplace drug assessment workplace drug assessment be based on a the and the employer regarding established by the is a who is by an approved by the US Department of Health and The of the with the and of results test those a test is for the the to about the the used marijuana or a If the use or states that it in the the will about as If that drug has been the this the for of the the the test as for THC whether or not the In the of a test for marijuana in an individual who is a registered medical marijuana the this as a test to the is to the employer to the if under policy and state law. If the test is in the environment (eg, DOT the individual must be from safety-sensitive as driving a In the of an the individual must not be on safety-sensitive in the testing employers in most states may to the registered medical marijuana with a test to that of a recreational legal or The employer and the be in their regulations to for the registered medical marijuana patient. In states this has been the have for the most in of the right to maintain a workplace and medical marijuana with a marijuana test, whether or not use or Although no federal laws prohibit states have laws that limit drug testing for workers in Drug testing is also prohibited in some unless there is reasonable the is impaired and to job workplace that on the of specific individual influence or impairment a specific drug test in may provide a private employer with The of a workplace is a impairment policy that be and by the in with the health and and occupational health also programs to employee including those related to substance without an are also required to follow federal regarding substance The and and DOT regulations drug and alcohol impairment in the workplace at the federal The have a to that and programs are with regulations from Drug and alcohol or impairment programs are not required for every Nevertheless, some state and federal regulations require programs in specific that employee drug testing and in some health care and also require workplace drug regulations drug-testing In the private state laws drug testing for employees or after hire may from nonunion federal regulations require their use, workplace on drug testing must be in and even if of the policy must be laws for medical and recreational marijuana use employers legal when the workplace policy specific to medical marijuana use by employees the work and the job. Although every policy must be to regulations to the specific workplace, employers use the following content as a for workplace for medical marijuana and other of the employees covered by the when the policy prohibited whether employees are required to their of medical marijuana or whether the policy and of the search and of job for work for drug testing with from the consequences for policy whether are after an related to substance to protect employee for policy to policy to occupational health when and and their and is available to substance use or with legal when regarding employee use of medical marijuana. employees in safety-sensitive have been held to regarding use. a reasonable basis for employers to or medical marijuana use by states have the right to employees who were using medical marijuana in accordance with state even if were not using it at the workplace. Nevertheless, currently of simply for the medical use of marijuana. The of legal cases will be in and is is whether the ADA may have implications for medical treatment with marijuana. use of marijuana another issue as some states have laws that protect employees from when in legal outside the workplace the for a policy and medical assessment of employees who to be impaired at the workplace be are often in a position to accommodate state laws that the use of marijuana for medical purposes while federal or based on federal law. workplace safety as as compliance with state and federal legislation, employers state laws on against marijuana and that enacted are with the antidiscrimination Although it that in most states that medical marijuana use, employers continue or the use of marijuana, this may change on the basis of court The that marijuana use be for employees in safety-sensitive whether or not covered by federal drug-testing employers marijuana use at in compliance with state laws, may to simply prohibit their employees from working while using or impaired by marijuana. In some states, employers may to prohibit marijuana use by of their whether on or Nevertheless, in a policy to on when marijuana use is and to evaluate for impairment must be and to policy and is to compliance with and law. and drug-testing regarding impairment and marijuana use outside of work for use by and when referring employees of impairment for an by a qualified occupational health are based on the medical results must also be for and The that employers the following when workplace that address marijuana use in the employees covered by federal drug testing regulations (eg, DOT and other workers under federal marijuana use, on or the is employers may use drug in this in safety-sensitive must not be impaired at work by any whether it be or available may on the job marijuana use for employees in safety-sensitive even when not covered by federal drug testing Nevertheless, legal of the policy in the of state statutes is employers medical marijuana use by with a qualified occupational health is in or states that the use of recreational marijuana must a policy regarding use of marijuana. In many states, the employer may to prohibit employees from simply working while using or under the influence of marijuana or may to prohibit marijuana use on and the job. drug testing or testing at any be reasonable for the employer to and use. a limit of of THC in or as THC the of THC for employers who to evaluate psychoactive the of identifying individuals most to be Nevertheless, employers using the to the of using a to a medical on identifying impairment is is Although it that in most states that the use of medical marijuana, employers may be to continue or the use of marijuana as this may change on the basis of law. the ADA does not in because marijuana is illegal under federal law. is statutes when a is under the influence of alcohol or illegal be as a second test may be of use impairment is required for and a drug test the does not impairment. The of be used for evidence of impairment in is most in of cases because legal may be employers have and procedures for to follow regarding the for identifying potential impairment and the for referring an employee of impairment for an occupational medical include action required by based on the results of the is to compliance with is at hire and at Workers must the substance policy and for The to a workplace and existing policy will influence the a employees their and job and employees also be about to of whether the is medical marijuana, illegal or any In states marijuana use is employers provide regarding the effects of marijuana use, including regarding and effects of This may be from and state The safety of workers and the public must be to workplace and employers must that legalization of marijuana for recreational or medical use does not workplace for safe job The evolving legal on medical and recreational marijuana requires employers to with legal to policy and clarify implications of impaired This changing environment marijuana use requires employers, occupational health and legal to that workplace safety is not The the following for their and
Alcohol is the drug of choice among youth, with 12% of 8th-graders, 22% of 10th-graders, and 29% of 12th-graders reporting heavy episodic drinking. Although prevalence rates are at historic lows, alcohol use continues to be widespread among adolescents, and pediatricians must screen for underage and family alcohol use in health assessment visits.After completing this article, readers should be able to:National surveys make it clear that the use of alcohol among adolescents is both widespread and harmful. By the 12th grade, close to three-quarters of adolescents in high school report ever having an alcoholic drink, and more than one-quarter report having their first drink before age 13 years. Data from Monitoring the Future, an annual survey of youth in the United States, show that 71% of high school seniors reported some experience with alcohol in the past; 41% reported use in the last 30 days and, of great concern, 3% reported daily use. More than one-half (58%) of 10th-graders and more than one-third (36%) of 8th-graders report having consumed alcohol at some point in their lives, and more than one-third of 10th-graders (37%) and one of six 8th-graders (16%) report having been drunk in the past. (1) The good news is that the use of alcohol by teens, as well as the use of many of the illicit drugs, has declined over the past decade. The bad news is that, although these declines are encouraging, alcohol remains the drug of choice among youth.The pattern of alcohol use that is exhibited by many adolescents is one of drinking too much and at too early an age, thereby creating problems for themselves, for people around them, and for society as a whole. Underage drinking is a leading public health problem in this country. Underage drinkers consume, on average, four to five drinks per occasion approximately six times per month. By comparison, older adult drinkers, ages 26 and older, consume, on average, two to three drinks per occasion approximately nine times per month. A particularly worrisome trend is the high prevalence of heavy episodic or binge drinking in adolescents, which is defined often as five or more drinks in a row in a single episode. Monitoring the Future data show that 12% of 8th-graders, 22% of 10th-graders, and 29% of 12th-graders report engaging in heavy episodic drinking.Studies find that drinking alcohol often starts at very young ages. Moreover, studies indicate that the younger children and adolescents are when they begin to drink, the more likely they are to engage in behaviors that can harm themselves and others. Those who start to drink before age 13 years, for example, are nine times more likely to binge drink frequently as high school students than those who begin drinking later. Data from recent surveys show that approximately 10% of 9- to 10-year-olds have already started drinking; nearly one third of youth begin drinking before age 13, and more than one in four 14-year-olds report drinking within the past year. (2)(3)A number of studies show that the early onset of alcohol use, as well as the escalation of drinking in adolescence, are risk factors for the development of alcohol-related problems in adulthood. Initiating alcohol use earlier in adolescence or in childhood is a marker for later problems, including heavier use of alcohol and other drugs. Individuals who report initiation of alcohol use before age 15 years were four times more likely to meet criteria for alcohol dependence and two times more likely to meet criteria for alcohol abuse as those individuals who began drinking after age 21 years. (4)The consequences of underage drinking include a range of physical, academic, and social problems. Perhaps most frightening is the fact that alcohol is the leading contributor to morbidity and mortality in youth. Alcohol use is the leading contributor to death due to injuries, the primary cause of death in individuals younger than 21 years of age. Annually, 5,000 youth die of alcohol-related injuries that involve underage drinking. This includes injuries sustained in motor vehicle crashes (âź1,900), homicides (âź1,600), and suicides (âź300), as well as unintentional injuries not related to motor vehicle crashes. Among studies of adolescent trauma victims, alcohol is reported in 32% to 45% of hospital admissions. The association between alcohol use and violent behavior is well documented. Numerous studies of adolescents report that alcohol use is linked to both violent behavior and to violence-related injuries. (5)(6)Other harmful behaviors and negative consequences frequently related to excessive drinking among adolescents are high-risk sexual behaviors (unplanned and unprotected intercourse); sexual misconduct, including rape; and assaults. Having multiple sexual partners, failing to use condoms, and performing other high-risk sexual behaviors have been associated with alcohol use in adolescents. Furthermore, alcohol use by the offender, victim, or both has been linked to sexual assault, including date rape.As youth move from adolescence to young adulthood, they encounter dramatic physical, emotional, and lifestyle changes. Developmental transitions, such as puberty and increasing independence, have been associated with alcohol use. Because drinking is so widespread among adolescents, simply being an adolescent may be a key risk factor for initiation of alcohol use, as well as for drinking dangerously.Data from imaging studies show that the brain continues developing well into the twenties, during which time it continues to establish important communication connections and further refines its function. Many believe that this lengthy developmental period may help to explain some of the behaviors characteristic of adolescence, such as the propensity to seek out new and potentially dangerous situations. For some adolescents, thrill-seeking includes experimenting with alcohol use. Developmental changes also may offer a possible physiologic explanation for why teens act so impulsively, often not recognizing that their actionsâsuch as drinkingâhave consequences.How adolescents view alcohol and its effects also influences their drinking behavior, including whether they begin to drink and how much. An adolescent who expects drinking to be a pleasurable experience is more likely to drink than one who does not. Beliefs about alcohol are established very early in life, even before entering elementary school. Before age 9 years, children generally view alcohol negatively and see drinking as bad and associated with adverse effects. By approximately age 13 years, however, their expectancies shift, becoming more positive. Accordingly, adolescents who drink the most also place the greatest emphasis on the positive and arousing effects of alcohol.Differences between the adult brain and the brain of the maturing adolescent may explain why many young drinkers are able to consume much larger amounts of alcohol than adults before experiencing the negative consequences of drinking, such as drowsiness, lack of coordination, and withdrawal or hangover effects. This unusual tolerance may help to explain the high rates of binge drinking among many adolescents and young adults. At the same time, adolescents appear to be particularly sensitive to the positive effects of drinking, such as feeling more at ease in social situations, and young people may drink more than adults because of these positive social experiences.Children who begin to drink at a very early age (before age 12 years) often share similar personality characteristics that may make them more likely to start drinking. Young people who are disruptive, hyperactive, and aggressiveâoften referred to as having conduct problems or being antisocialâas well as those who are depressed, withdrawn, or anxious, may be at greatest risk for alcohol problems. Other behavior problems associated with alcohol use include rebelliousness, difficulty avoiding harm or harmful situations, and a host of other traits seen in young people who act out without regard for rules or the feelings of others (ie, disinhibition).Some of the behavioral and physiologic factors that converge to increase or decrease a personâs risk for alcohol problems, including tolerance to alcoholâs effects, may be linked directly to genetic factors. For example, being a child of an alcoholic or having several alcoholic family members places a person at greater risk for alcohol problems. Children of alcoholics (COAs) are between 4 and 10 times more likely to become alcoholics themselves than are children who have no close relatives with alcoholism. (7) COAs also are more likely to begin drinking at a young age and to progress to drinking problems more quickly.Research shows that COAs may have subtle brain differences that could be markers for developing later alcohol problems. For example, by the use of newer brain-imaging techniques, scientists have found that COAs have a distinctive feature in one brainwave pattern (called a P300 response) that could be a marker for later alcoholism risk. (8) Some studies suggest that these brain differences may be particularly evident in people who also have certain behavioral traits, such as signs of conduct disorder, antisocial personality disorder, sensation-seeking, or poor impulse control. (9)Drinking and alcohol-related problem behavior reflect a complex interplay between inherited and social-environmental factors, the implications of which are only beginning to be explored in adolescents. And although even more is understood about the role and contribution of genetics, this knowledge still does not tell the entire story.Social and environmental factors, such as the influence of parents and peers, also play a role in alcohol use. For example, parents who drink more and who view drinking favorably may have children who drink more. Other influences, such as the impact of the media, have been examined and are felt to play an important role. Today, alcohol is widely available and aggressively promoted through television, radio, billboards, and the Internet.Although the severe health problems associated with harmful alcohol use are not as common in adolescents as they are in adults, studies show that adolescents who drink heavily may put themselves at risk for a range of health problems.Chronic heavy drinking during adolescence and into young adulthood appears to be associated with detrimental effects on brain development, brain functioning, and neuropsychological performance. Recent evidence suggests that heavy drinking during adolescence is associated with poorer neurocognitive functioning during the young adult years and is associated particularly with impairment of attention and visuospatial skills. (10)Brain imaging and studies of event-related potentials have demonstrated subtle but significant abnormalities in brain structure and function. In a recent study, researchers used magnetic resonance imaging to determine the effects of heavy drinking on the changing brain structure of teens and young adults with alcohol use disorders. Hippocampal volumes were smaller in youths with alcohol use disorders than in matched controls and correlated with the onset of alcohol use disorder and with the duration of alcohol use disorder. (11) The earlier an individual developed an alcohol use disorder and the longer the duration of the alcohol use disorder, the smaller was the volume of his or her hippocampus. (12) Other studies have looked at the effect of alcohol on the structure of white matter and have demonstrated that white matter integrity was reduced in the corpus callosum of youths with alcohol use disorders.Research studies indicate that a number of factors seem to influence how and to what extent alcohol affects the brain, including:Elevated liver enzymes, indicating some degree of liver damage, have been found in some adolescents who drink Young drinkers who are or liver enzymes, even with only of both and puberty is a period associated with including in the and in increase of other and factors, which are for alcohol during this period of and development (ie, before or during may the for development of and are the in the in of At the same time, they experience high rates of mortality and morbidity because of their behavior, including the use of many including adolescence is a time of risk and for many young people in some of that alcohol use. 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The USA is entering an era of major change in the financing and delivery of health-care services, including a greater emphasis on evidence-based treatment. Mainstream US alcohol treatment is an amalgam of experience- and evidence-based approaches; the National Institute for Health and Clinical Excellence (NICE) alcohol guideline could provide a model for reform in the USA. The NICE guideline 1 on the diagnosis, assessment and management of harmful drinking and alcohol dependence should be required reading for anyone concerned about evidence-based approaches to alcohol treatment. The guideline was developed to âimprove standards of care, diminish unacceptable variations in the provision and quality of care ⌠and ensure that the health service is patient centredâ (p. 13). Under the UK single-payer model, once a NICE guideline is published and disseminated, local health-care groups are expected to develop a plan to implement the guideline. The guideline covers five major domains, offering a comprehensive set of recommendations that carefully distinguishes the needs of persons with harmful drinking/mild alcohol dependence from the needs of those with more severe dependence. Key recommendations focus on the therapeutic relationship; family involvement; use of standardized assessment tools; development of agreed-upon drinking goals; use of care coordination and case management; use of evidence-based treatments, such as motivational interviewing, Twelve-step facilitation, behavioral couple therapy, and pharmacotherapies; mutual help groups; treatment of comorbid psychological problems; and outcomes monitoring. This is an excellent guideline, but could it be applied in the USA? The delivery of alcohol treatment is quite different in the USA than in the UK; these differences might limit the applicability of the guideline. In the USA, alcohol and drug problems are typically treated in the same programs, and the administration of policy and services occurs through a single state authority over both alcohol and other drug issues. There are approximately 13 000 substance abuse treatment programs in the country. Treatment is provided through private programs, funded through health-care insurance, self-payment, or endowments; and public programs, funded through sources including Medicaid (for low income individuals and those with disabilities), Medicare (for older adults) and block grants from the Federal government to each state. Each of the 50 states independently governs the system of care within that state; sometimes authority is assigned at the county level (with 3033 counties or county-equivalents in the USA). The large number of programs and decentralization of authority challenge the application of any uniform standard across the country. The vast majority of US programs view alcohol problems from a disease perspective and incorporate Twelve-step principles into the treatment, but more than half also say they have adopted motivational interviewing, motivational enhancement therapy, and cognitive-behavioral approaches 2. The primary goal of treatment is typically abstinence from all psychoactive drugs. In contrast to the UK, the USA has no systematic approach to incorporating research findings into alcohol treatment, nor are there US-wide mandated standards of care. The US Preventive Task Force (USPSTF) is tasked with making evidence-based recommendations about preventive and treatment health services, leading to guidelines for clinical care that are adopted by Medicaid and Medicare. The only alcohol-related USPSTF guideline is for alcohol screening and counseling in primary care settings 3. Various other groups have developed and promulgated practice guidelines 4; some private insurance companies use such guidelines for the purposes of reimbursement. The structure and delivery of health-care services in the USA is likely to change considerably with the 2008 passage of mental health/substance abuse parity legislation, and full implementation of the 2010 Patient Protection and Affordable Care Act (ACA) (upheld by the US Supreme Court in June 2012). The ACA requires that alcohol and other substance use disorders (SUD) be part of the âessential health benefitâ package and prohibits insurers from denying coverage for pre-existing conditions. The ACA mandates SUD/mental health screening and referral in primary care settings. It is anticipated that expanded health-care coverage will lead to a greater number of individuals with SUDs who have insurance, resulting in a greater demand for SUD services. The guideline represents a different philosophical approach to alcohol problems than that of the current US system and there are significant differences in the systems of care, but many of the assessment and treatment recommendations are highly pertinent to the USA. Philosophically, the mainstream US treatment system takes a medical approach. A formal Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis is required, and individuals are referred to as âpatientsâ or âclientsâ (versus âservice usersâ in the guideline) who receive âtreatmentâ (versus âcareâ). Although programs and providers aligned with the guideline perspective exist in the USA, they do not represent a majority. Views of the family also differ. The guideline recognizes family engagement and support as a central component of treatment; mainstream US programs rarely, or only superficially, include a family component in treatment. The guideline is supposed to lead directly to changes in the delivery of services; currently the USA has no similar system to enforce change. With the full implementation of the ACA, the USA will have to develop better ways to deliver evidence-based treatments and monitor/enforce their use; the UK system could provide a model. The US integration of alcohol and other substance use services within the same programs could make it more difficult to apply the guideline in the USA. However, there are sufficient similarities in the service delivery systems in terms of levels of care and differentiation of service needs based on problem severity that many of the guideline recommendations could be adopted. The guideline recommends the use of standardized measures to assess individuals seeking services. The US system also is moving to a standardized intake assessment model, with many states requiring the use of the Addiction Severity Index 5. The US system would do well to consider the more alcohol-specific measures recommended in the guideline. The selection of drinking goals continues to be more controversial in the USA than elsewhere. The guideline provides a sensible, evidence-based model for working collaboratively with clients to select treatment goals; the USA should more fully embrace that model. Finally, the guideline provides an excellent blueprint for selection of treatments based on presenting concerns and the severity of the drinking problem. The research literature that underpins the recommendations represents work of US, UK and other European scientists, suggesting a knowledge base that is generalizable across cultures. More fully adopting the assessment, goal-setting and treatments recommended by the guideline could improve outcomes and efficiency in the US system. In conclusion, the Guideline Development Group (GDG) has performed an incredible service for those affected by problematic drinking. The US system of care is in a state of change as the ACA and the attendant changes in health-care delivery are enacted across the country. Philosophical perspectives on drinking problems and approaches to treatment are evolving slowly in the USA; the perspective and recommendations of the GDG should form a blueprint for advancing efficacious treatments on both sides of the Atlantic. None.