Although synthetic cannabinoids have been associated with sudden death in the USA and abroad, the exact physiological mechanisms for causation, or initiators to contributing factors, remain unclear. In Case 1, a possible anaphylactic etiology was ruled out by the forensic pathologist. Sudden onset cardiac dysrhythmias or seizure suggest plausible mechanisms. In contrast, Case 2 presented as a protracted, rapidly deteriorating clinical event over 24 h culminating in acute hepatic failure. Another possible biochemical etiology to these unfolding sequelae mayreside in a yet undetermined or unidentified metabolic intermediate of 5F-PB-22. It is noteworthy that a distinct feature of the quinolinyl carboxylate synthetic cannabinoids is an ester linkage. The earlier waves of compounds, such as JWH-018, AM-2201 and XLR-11, contained a ketone linkage between the indole moiety and the naphthoyl or tetramethylcyclopropyl groups. The ester bond may be susceptible to in vivo hydrolysis reactions catalyzed by carboxylesterase enzymes. This mechanism could cause the accumulation of a metabolite that is perhaps analogous to the toxic mechanism peculiar to paracetamol and the accumulation of a quinone metabolite and its reactions with hepatocellular proteins and nucleic acids. Because of the ease of degradation by in vivo hydrolysis reactions, it may be prudent to investigate the possible accumulation of probable metabolites in the blood. Clearly, further investigation is required with respect to the pharmacokinetics of 5F-PB-22 and other synthetic cannabinoids, their role in human toxidromes and their relevance to detection in postmortem casework. Important point sources for this information will continue to include the US National Network of Poison Information Centers,cannabis grow tray reporting emergency departments and urgent care centers and medical examiner/coroner systems with their attendant toxicology laboratories.
Alcohol use and binge drinking in youth aged 12 to 21 are frequent causes of accidents and injuries, preventable death, disease and psychosocial problems. Though past-month binge drinking1 and alcohol use among adolescents and young adults in the United States have declined over the past decade, rates remain high: 23 % report current alcohol use and 14 % binge drinking. Over the past several decades, there have been extensive efforts to address alcohol use among young people. Some interventions have focused on environmental factors while others have been individual or group level interventions aimed at improving knowledge and attitudes, and reducing alcohol use. These have been primarily face-to-face interventions delivered in structured school or community-based settings. The application of theory is widely recognized as a crucial component of behavior change interventions. Theories help explain the pathways that lead to or predict behavior and in doing so, provide guidance on how to influence or change behavior. Interventions, that clearly articulate their use of theories, can contribute to a greater understanding of not just what interventions work, but why they work. While the interventions targeting alcohol use among youth have resulted in mixed findings, this vast body of work has contributed to the evidence base for what constitutes effective interventions. Interventions that are grounded in established theories of behavior change, and include approaches that address social norms, build self-efficacy and enhance skills to resist pressure to use alcohol, have been found to be more effective than those lacking a theoretical framework. As the field of preventing/reducing alcohol use among adolescents and young adults is evolving, there has been growing attention to the development and use of computer-based modes of intervention delivery. Computer-based interventions have a number of advantages over traditional face-to-face interventions. They are more likely to be implemented with fidelity because they do not rely on the skills, motivation, or time of the facilitator; and they provide a standardized approach to delivering the intervention content. In addition, recent technology innovations enable CBIs to be interactive, provide individually tailored messages and simulate experiences where adolescents can learn and practice skills in convenient and private settings.
Additionally, computers have become widely accessible and are especially popular among adolescents and young adults. CBIs provide a promising approach to addressing alcohol use among adolescents and young adults. Over the last decade, there have been five literature reviews that have examined the nascent field of digital interventions for alcohol use prevention targeting adolescents and young adults. Overall, many of the CBIs have been shown to improve knowledge, attitudes, and reduce alcohol use in the short-term. Three of the five literature reviews examined interventions for college students. One review found that CBIs were more effective than no treatment and assessment-only controls, and approximately equivalent to various non-computerized interventions. Another review found that CBIs, when compared to non-CBIs, were more likely to reduce alcohol use. The third review found that CBIs reduced short term alcohol use compared to assessment-only controls, but not compared to face-to-face interventions. In addition to the reviews focused on alcohol use among young adults, there were two reviews of CBIs targeting younger adolescents. One demonstrated that CBIs delivered in middle or secondary schools effectively reduced alcohol, cannabis and/or tobacco use. The other review was a metanalysis focused on computer games to prevent alcohol and drug use among adolescents and concluded that the games improved knowledge, but it did not find sufficient evidence that these games changed substance use attitudes or behaviors. While these reviews suggest that CBIs have the potential to be efficacious, the mechanisms that contribute to improvements in attitudes and behaviors are not well understood. Use of a theoretical framework helps to explain the mechanisms of change by informing the causal pathways between specific intervention components and behavioral outcomes. Understanding these mechanisms improves our understanding of how and why a particular intervention works. There has been little attention as to how theoretical frameworks have informed the development of CBIs focused on alcohol use among adolescents and young adults.
Only two of the five aforementioned literature reviews covering CBIs for alcohol use in youth examined the underlying theoretical basis of the CBIs. In both of these reviews, the names of the theory and/or specific theoretical constructs were mentioned; however, there was little examination of how the theories were applied to the CBIs. In addition to the reviews focused specifically on adolescent and young adult substance use,vertical grow systems for sale there was an additional systematic review that examined the relationship between the use of theory and the effect sizes of internet-based interventions. This study found that extensive use of theory was associated with greater increases in the effect size of behavioral outcomes. They also found that interventions that utilized multiple techniques to change behavior change tended to have larger effect sizes compared to those using fewer techniques. This review builds on prior work demonstrating that health interventions grounded in established theory are more effective than those with no theoretical basis. However, this review did not exclusively focus on alcohol use or adolescents specifically. It is therefore important to build upon this knowledge base and focus on the application of theory in CBIs to address adolescent/young adult alcohol use. The primary goal of this study is to conduct a review of how theory is integrated into CBIs that target alcohol use among adolescents and young adults. Specifically, this study examines which CBIs are guided by a theoretical framework, the extent to which theory is applied in the CBIs and what if any measures associated with the theoretical framework are included in the CBI’s evaluation. A secondary goal is to provide an update of CBIs addressing alcohol use among youth in order to expand our understanding of their effectiveness.To be included in this review, the main component of the intervention was required to be delivered via computer, tablet or smartphone. Interventions could include a video game, computer program, or online module. In addition, the intervention needed to target alcohol use among adolescents and young adults between the ages of 12 to 21 years. While adolescence covers a wide range, we chose this age range because there is general consensus that it has begun by age 12, and we included youth up to age 21 since that is the legal drinking age in the U.S. Studies whose participants’ had a mean age between 12 and 21 years were included even when individual study’s participants’ ages extended outside this age range. Interventions intended to treat a substance use disorder were excluded. Non-English language articles, research protocols, and intervention studies that did not report outcomes were also excluded from analyses.Once eligible studies were identified, the characteristics of the intervention, the context of the intervention, the population targeted, intervention dosage, study author, year and outcomes were entered into a spreadsheet for analyses. Duplicate articles were deleted and journal articles which discussed the same intervention were grouped together. When there was more than one unique article for any given CBI, the CBI was counted only once. In some cases, a given CBI existed in several editions, was modified, or was applied to a different study population. These variations of the CBI were grouped together.
Painter et al.’s classification system was used to categorize the use of theory in each of the CBIs. Consistent with this system, first a CBI was examined to see if an established, broad theory was mentioned in any of the corresponding articles for a given CBI. If so, the CBI was classified as “mentioned”. Second, articles were reviewed to see if they provided any information about how the CBI used theory to inform the intervention. If any of the articles associated with a given CBI provided any information about the use of theory, the CBI was classified as “applied. For our third category, we used “measured” to classify CBIs if any associated article included at least one specific measure of a construct within the theoretical framework. This third category is a slight departure from Painter’s typology which classifies interventions as “tested” if over half of the constructs in the theory are measured in the evaluation of the intervention. We opted for “measured” because testing theories is a complex process and not a common practice of CBIs. We did not use Painter’s 4th category, “building or creating theory” because this was not applicable for any of these interventions. For all articles reporting on effects of the intervention on alcohol use, attitudes, or knowledge on an included CBI, the effectiveness of the CBI on these outcomes was also examined. Two senior health research scientists , with advanced training in theories of behavior change, oversaw the classifications system and addressed questions about the application of a theory/theoretical constructs. The review was conducted by a trained research associate with a master’s degree in public health. A spread sheet was created that included each classification, a description of how the theory was applied, and a list of relevant constructs that were measured.The search strategy yielded a total of 600 unique articles published between 1999 and 2014, including 15 articles identified through hand searches and reviews of previous literature reviews. Of these, 500 were excluded because they did not meet the study inclusion criteria. The final sample consisted of 100 articles of 42 unique CBIs. There were more articles than interventions because multiple articles were published on any one CBI intervention. See Fig. 1 for a more full explanation of the articles excluded and yielded during the search process. The list of the 42 interventions and corresponding articles associated with the intervention are provided in Tables 1 and 2. Of the interventions reviewed for this study, 50 % were not included in previous review articles. Of the 42 CBIs in this study, 33 were delivered in school settings and the remaining CBIs were administered in home or in clinic settings.Table 1 provides a list of the CBIs and how theory was used according to the classifications of “mentioned”, “applied” or “measured”. In addition, if the theory was applied to the intervention, a brief description of its application is provided. Similarly if it was classified as “measured” the measure of the theoretical construct was also listed. The CBIs in Table 1 all indicated use of a broad theoretical framework. Broad theories specify the relationship between a number of constructs and associated variables that explain or predict behaviors. Broad theories of behavior change take into account a number of complex contextual factors and inter-related sets of constructs that influence behaviors. CBIs that did not mention use of a broad theoretical framework are listed in Table 2.