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Objective: In 2017, the Veterans Health Administration (VHA) implemented a national suicide prevention program, called Recovery Engagement and Coordination for Health–Veterans Enhanced Treatment (REACH VET), that uses a predictive algorithm to identify, attempt to reach, assess, and care for patients at the highest risk for suicide. The authors aimed to evaluate whether facilitation enhanced implementation of REACH VET at VHA facilities not meeting target completion rates. Methods: In this hybrid effectiveness-implementation type 2 program evaluation, a quasi-experimental pre-post design was used to assess changes in implementation outcome measures evaluated 6 months before and 6 months after onset of facilitation of REACH VET implementation at 23 VHA facilities. Measures included percentages of patients with documented coordinator and provider acknowledgment of receipt, care evaluation, and outreach attempt. Generalized estimating equations were used to compare differences in REACH VET outcome measures before and after facilitation. Qualitative interviews were conducted with personnel and were explored via template analysis. Results: Time had a significant effect in all outcomes models (p<0.001). An effect of facilitation was significant only for the outcome of attempted outreach. Patients identified by REACH VET had significantly higher odds of having a documented outreach attempt after facilitation of REACH VET implementation, compared with before facilitation. Site personnel felt supported and reported that the external facilitators were helpful and responsive. Conclusions: Facilitation of REACH VET implementation was associated with an improvement in outreach attempts to veterans identified as being at increased risk for suicide. Outreach is critical for engaging veterans in care. [ABSTRACT FROM AUTHOR]

Background: To discover pharmacotherapy prescription patterns and their statistical associations with outcomes through a clinical pathway inference framework applied to real-world data. Methods: We apply machine learning steps in our framework using a 2006 to 2020 cohort of veterans with major depressive disorder (MDD). Outpatient antidepressant pharmacy fills, dispensed inpatient antidepressant medications, emergency department visits, self-harm, and all-cause mortality data were extracted from the Department of Veterans Affairs Corporate Data Warehouse. Results: Our MDD cohort consisted of 252,179 individuals. During the study period there were 98,417 emergency department visits, 1,016 cases of self-harm, and 1,507 deaths from all causes. The top ten prescription patterns accounted for 69.3% of the data for individuals starting antidepressants at the fluoxetine equivalent of 20-39 mg. Additionally, we found associations between outcomes and dosage change. Conclusions: For 252,179 Veterans who served in Iraq and Afghanistan with subsequent MDD noted in their electronic medical records, we documented and described the major pharmacotherapy prescription patterns implemented by Veterans Health Administration providers. Ten patterns accounted for almost 70% of the data. Associations between antidepressant usage and outcomes in observational data may be confounded. The low numbers of adverse events, especially those associated with all-cause mortality, make our calculations imprecise. Furthermore, our outcomes are also indications for both disease and treatment. Despite these limitations, we demonstrate the usefulness of our framework in providing operational insight into clinical practice, and our results underscore the need for increased monitoring during critical points of treatment. [ABSTRACT FROM AUTHOR]

Objectives Clinical text processing offers a promising avenue for improving multiple aspects of healthcare, though operational deployment remains a substantial challenge. This case report details the implementation of a national clinical text processing infrastructure within the Department of Veterans Affairs (VA). Methods Two foundational use cases, cancer case management and suicide and overdose prevention, illustrate how text processing can be practically implemented at scale for diverse clinical applications using shared services. Results Insights from these use cases underline both commonalities and differences, providing a replicable model for future text processing applications. Conclusions This project enables more efficient initiation, testing, and future deployment of text processing models, streamlining the integration of these use cases into healthcare operations. This project implementation is in a large integrated health delivery system in the United States, but we expect the lessons learned to be relevant to any health system, including smaller local and regional health systems in the United States. [ABSTRACT FROM AUTHOR]

Aims: To compare healthcare costs and use between United States (US) Veterans Health Administration (VHA) patients with opioid use disorder (OUD) who experienced an opioid overdose (OD cohort) and patients with OUD who did not experience an opioid overdose (non-OD cohort). Design: This is a retrospective cohort study of administrative and clinical data. Setting: The largest integrated national health-care system is the US Veterans Health Administration's healthcare systems. Participants: We included VHA patients diagnosed with OUD from October 1, 2017 through September 30, 2018. We identified the index date of overdose for patients who had an overdose. Our control group, which included patients with OUD who did not have an overdose, was randomly assigned an index date. A total of 66 513 patients with OUD were included for analysis (OD cohort: n = 1413; non-OD cohort: n = 65 100). Measurements: Monthly adjusted healthcare-related costs and use in the year before and after the index date. We used generalized estimating equation models to compare patients with an opioid overdose and controls in a difference-in-differences framework. Findings: Compared with the non-OD cohort, an opioid overdose was associated with an increase of $16 890 [95% confidence interval (CI) = $15 611--18 169; P < 0.001] in healthcare costs for an estimated $23.9 million in direct costs to VHA (95% CI = $22.1 million, $25.7 million) within the 30 days following overdose after adjusting for baseline characteristics. Inpatient costs ($13 515; 95% CI = $12 378-14 652; P < 0.001) reflected most of this increase. Inpatient days (+6.15 days; 95% CI, = 5.33-6.97; P < 0.001), inpatient admissions (+1.01 admissions; 95% CI = 0.93-1.10; P < 0.001) and outpatient visits (+1.59 visits; 95% CI = 1.34-1.84; P < 0.001) also increased in the month after opioid overdose. Within the overdose cohort, healthcare costs and use remained higher in the year after overdose compared with pre-overdose trends. Conclusions: The US Veterans Health Administration patients with opioid use disorder (OUD) who have experienced an opioid overdose have increased healthcare costs and use that remain significantly higher in the month and continuing through the year after overdose than OUD patients who have not experienced an overdose. [ABSTRACT FROM AUTHOR]

Background: An adequate supply of mental health (MH) professionals is necessary to provide timely access to MH services. Veterans Health Administration (VHA) continues to prioritize the expansion of the MH workforce to meet increasing demand for services. Objective: Validated staffing models are essential to ensure timely access to care, to plan for future demand, to ensure delivery of high-quality care, and to balance the demands of fiscal responsibility and strategic priorities. Design: Longitudinal retrospective cohort of VHA outpatient psychiatry, fiscal years 2016–2021. Participants: Outpatient VHA psychiatrists. Main Measures: Quarterly outpatient staff-to-patient ratios (SPRs), defined as the number of full-time equivalent clinically assigned providers per 1000 veterans receiving outpatient MH care, were calculated. Longitudinal recursive partitioning models were created to identify optimal cut-offs for the outpatient psychiatry SPR associated with success on VHA's measures of quality, access, and satisfaction. Key Results: Among outpatient psychiatry staff, the root node identified an outpatient SPR of 1.09 for overall performance (p < 0.001). For metrics associated with Population Coverage, a root node identified an SPR of 1.36 (p < 0.001). Metrics associated with continuity of care and satisfaction were associated with a root node of 1.10 and 1.07 (p < 0.001), respectively. In all analyses, the lowest SPRs were associated with the lowest group performance on VHA MH metrics of interest. Conclusions: Establishing validated staffing models associated with high-quality MH care is critical given the national psychiatry shortage and increasing demand for services. Analyses support VHA's current recommended minimum outpatient psychiatry-specific SPR of 1.22 as a reasonable target to provide high-quality care, access, and satisfaction. [ABSTRACT FROM AUTHOR]

The authors discuss the need to assess the inability to reduce or discontinue opioids when benefits do not outweigh harms in patients on long-term opioid therapy for pain (LTOT). Topics include two forms of substance use disorders (SUD) contained in previous editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), how clinicians and patients can determine the harms and benefits LTOT for chronic pain, and the use of the term "substance use disorder" according to the DSM-5.

Background: Risk of overdose, suicide, and other adverse outcomes are elevated among sub-populations prescribed opioid analgesics. To address this, the Veterans Health Administration (VHA) developed the Stratification Tool for Opioid Risk Mitigation (STORM)—a provider-facing dashboard that utilizes predictive analytics to stratify patients prescribed opioids based on risk for overdose/suicide. Objective: To evaluate the impact of the case review mandate on serious adverse events (SAEs) and all-cause mortality among high-risk Veterans. Design: A 23-month stepped-wedge cluster randomized controlled trial in all 140 VHA medical centers between 2018 and 2020. Participants: A total of 44,042 patients actively prescribed opioid analgesics with high STORM risk scores (i.e., percentiles 1% to 5%) for an overdose or suicide-related event. Intervention: A mandate requiring providers to perform case reviews on opioid analgesic-prescribed patients at high risk of overdose/suicide. Main Measures: Nine serious adverse events (SAEs), case review completion, number of risk mitigation strategies, and all-cause mortality. Key Results: Mandated review inclusion was associated with a significant decrease in all-cause mortality within 4 months of inclusion (OR: 0.78; 95% CI: 0.65–0.94). There was no detectable effect on SAEs. Stepped-wedge analyses found that mandated review patients were five times more likely to receive a case review than non-mandated patients with similar risk (OR: 5.1; 95% CI: 3.64–7.23) and received more risk mitigation strategies than non-mandated patients (0.498; CI: 0.39–0.61). Conclusions: Among VHA patients prescribed opioid analgesics, identifying high risk patients and mandating they receive an interdisciplinary case review was associated with a decrease in all-cause mortality. Results suggest that providers can leverage predictive analytic-targeted population health approaches and interdisciplinary collaboration to improve patient outcomes. Trial Registration: ISRCTN16012111 [ABSTRACT FROM AUTHOR]

Key Points: Question: Is there a genetic basis for suicidal thoughts and behaviors (SITB)? Findings: This genome-wide association study of SITB including 633 778 US military veterans identified 7 genome-wide significant cross-ancestry risk loci through meta-analysis, and top loci were independently replicated in a large international cohort. Meaning: This study identified multiple novel cross-ancestry candidate risk genes for SITB; however, more work is needed to replicate these findings and determine whether these genes might impact clinical care. This genome-wide association study including 633 778 US military veterans evaluates potential genetic risk loci for suicidal thoughts and behaviors among US military veterans. Importance: Suicide is a leading cause of death; however, the molecular genetic basis of suicidal thoughts and behaviors (SITB) remains unknown. Objective: To identify novel, replicable genomic risk loci for SITB. Design, Setting, and Participants: This genome-wide association study included 633 778 US military veterans with and without SITB, as identified through electronic health records. GWAS was performed separately by ancestry, controlling for sex, age, and genetic substructure. Cross-ancestry risk loci were identified through meta-analysis. Study enrollment began in 2011 and is ongoing. Data were analyzed from November 2021 to August 2022. Main Outcome and Measures: SITB. Results: A total of 633 778 US military veterans were included in the analysis (57 152 [9%] female; 121 118 [19.1%] African ancestry, 8285 [1.3%] Asian ancestry, 452 767 [71.4%] European ancestry, and 51 608 [8.1%] Hispanic ancestry), including 121 211 individuals with SITB (19.1%). Meta-analysis identified more than 200 GWS (P < 5 × 10−8) cross-ancestry risk single-nucleotide variants for SITB concentrated in 7 regions on chromosomes 2, 6, 9, 11, 14, 16, and 18. Top single-nucleotide variants were largely intronic in nature; 5 were independently replicated in ISGC, including rs6557168 in ESR1, rs12808482 in DRD2, rs77641763 in EXD3, rs10671545 in DCC, and rs36006172 in TRAF3. Associations for FBXL19 and AC018880.2 were not replicated. Gene-based analyses implicated 24 additional GWS cross-ancestry risk genes, including FURIN, TSNARE1, and the NCAM1-TTC12-ANKK1-DRD2 gene cluster. Cross-ancestry enrichment analyses revealed significant enrichment for expression in brain and pituitary tissue, synapse and ubiquitination processes, amphetamine addiction, parathyroid hormone synthesis, axon guidance, and dopaminergic pathways. Seven other unique European ancestry–specific GWS loci were identified, 2 of which (POM121L2 and METTL15/LINC02758) were replicated. Two additional GWS ancestry-specific loci were identified within the African ancestry (PET112/GATB) and Hispanic ancestry (intergenic locus on chromosome 4) subsets, both of which were replicated. No GWS loci were identified within the Asian ancestry subset; however, significant enrichment was observed for axon guidance, cyclic adenosine monophosphate signaling, focal adhesion, glutamatergic synapse, and oxytocin signaling pathways across all ancestries. Within the European ancestry subset, genetic correlations (r > 0.75) were observed between the SITB phenotype and a suicide attempt-only phenotype, depression, and posttraumatic stress disorder. Additionally, polygenic risk score analyses revealed that the Million Veteran Program polygenic risk score had nominally significant main effects in 2 independent samples of veterans of European and African ancestry. Conclusions and Relevance: The findings of this analysis may advance understanding of the molecular genetic basis of SITB and provide evidence for ESR1, DRD2, TRAF3, and DCC as cross-ancestry candidate risk genes. More work is needed to replicate these findings and to determine if and how these genes might impact clinical care. [ABSTRACT FROM AUTHOR]

The U.S. Veterans Health Administration developed a suicide prediction statistical model and implemented a novel clinical program, Recovery Engagement and Coordination for Health–Veterans Enhanced Treatment (REACH VET). This high-value suicide prevention program aims to efficiently identify patients at risk and connect them with care. Starting in April 2017, national REACH VET metric data were collected from electronic health records to evaluate required task completion. By October 2020, 98% of veterans identified (N=6,579) were contacted by providers and had their care evaluated. In the nation's largest health care system, it was feasible to implement a clinical program based on a suicide prediction model. [ABSTRACT FROM AUTHOR]

Background: The Veterans Health Administration (VHA) developed a dashboard Stratification Tool for Opioid Risk Mitigation (STROM) to guide clinical practice interventions. VHA released a policy mandating that high-risk patients of an adverse event based on the STORM dashboard are to be reviewed by an interdisciplinary team of clinicians. Aim: Randomized program evaluation to evaluate if patients in the oversight arm had a lower risk of opioid-related serious adverse events (SAEs) or death compared to those in the non-oversight arm. Setting and Participants: One-hundred and forty VHA facilities (aka medical centers) were randomly assigned to two groups: oversight and non-oversight arms. VHA patients who were prescribed opioids between April 18, 2018, and November 8, 2019, were included in the cohort. Program Description: We hypothesized that patients cared for by VHA facilities that received the policy with the oversight accountability language would achieve lower opioid-related SAEs or death. Program Evaluation: We did not observe a relationship between the oversight arm and opioid-related SAEs or death. Patients in the non-oversight arm had a significantly higher chance of receiving a case review compared to those in the oversight arm. Discussion: Even though our findings were unexpected, the STORM policy overall was likely successful in focusing the provider's attention on very high-risk patients. [ABSTRACT FROM AUTHOR]

Objective: Quality measures that are used to evaluate health care services have a central role in monitoring and incentivizing quality improvement and the provision of evidence-based treatment. This systematic scan aimed to catalog quality-of-care measures for mental and substance use disorders and assess gaps and redundancies to inform efforts to develop and retire measures.Methods: Quality measure inventories were analyzed from six organizations that evaluate health care quality in the United States. Measures were included if they were defined via symptoms or diagnoses of mental and substance use disorders or specialty treatments or treatment settings for adults.Results: Of 4,420 measures analyzed, 635 (14%) met inclusion criteria, and 376 unique quality-of-care measure constructs were cataloged and characterized. Symptoms or diagnoses of disorders were most commonly used to define measures (46%, N=172). Few measures were available for certain disorders (e.g., anxiety disorders), evidence-based treatments (e.g., psychotherapy), and quality domains (e.g., equity). Only one in four measures was endorsed by the National Quality Forum, which independently and critically evaluates quality measures. Among measures that were actively in use for national quality improvement initiatives (N=319), process measures (57%) were most common, followed by outcome measures (30%), the latter of which focused most often on experience of care.Conclusions: A vast landscape of mental and substance use disorder quality-of-care measures currently exists, and continued efforts to harmonize duplicative measures and to develop measures for underrepresented evidence-based treatments and quality domains are warranted. The authors recommend reinvesting in a national, centralized system for measure curation, with a stakeholder-centered process for independent measure review and endorsement. [ABSTRACT FROM AUTHOR]

Patient care contracts, such as an opioid pain care agreement, may use coercive language that patients perceive as intimidating or threatening, leading to distrust between patients and providers and decreased likelihood of seeking needed care.19-23 Their potential for stigmatizing patients may result in undertreatment of pain, physician refusal to prescribe opioids, and patient refusal to agree to perceived unfair and one-sided terms. Opioid tier was defined as the type of LTOT initiated - long acting, if any opioid prescriptions during a patient's LTOT episode were for a long-acting opioid, otherwise, chronic short acting. This distinction was made because the SIC process and its impact on care engagement may vary between patients who initiated a long-acting opioid or who were initially started on a short-acting opioid and switched to a long-acting opioid, and patients who continued to stay on a short-acting opioid after LTOT was initiated. Keywords: chronic pain; opioid therapy; informed consent; care engagement EN chronic pain opioid therapy informed consent care engagement 1553 1562 10 06/09/22 20220501 NES 220501 Introduction The increased morbidity and mortality risks associated with long-term opioid therapy (LTOT) are well established in the clinical and scientific literature.[1],[2] A recent systematic review found in the Cochrane library estimates that 78% of patients using opioids for chronic pain management experience adverse events, such as nausea, constipation, and dizziness, and 7.5% experience serious adverse events such as addiction, suicide, overdose, and death.[2] Between 1999 and 2015, more than 183,000 people died from overdoses related to prescription opioids. [Extracted from the article]

Objective: This interrupted time-series analysis examined whether activating a quality measure, supported by education and a population management tool, was associated with higher postdischarge engagement (PDE) in outpatient care after inpatient and residential stays for mental or substance use disorder care.Methods: Discharges from October 2016 to May 2019 were identified from national Veterans Health Administration (VHA) records representing all 140 VHA health care systems. Engagement was defined as multiple mental or substance use disorder outpatient visits in the 30 days postdischarge. The number of such visits required to meet the engagement definition depended on a patient's suicide risk and acuity level of inpatient or residential treatment. Health care system-level performance was calculated as the percentage of qualifying discharges with 30-day PDE. A segmented mixed-effects linear regression model tested whether monthly health care system performance changed significantly after activation of the PDE measure (activation rollout period, October-December 2017).Results: A total of 322,344 discharges qualified for the measure. In the regression model, average health care system performance was 65.6% at the beginning of the preactivation period (October 2016) and did not change significantly in the following 12 months. Average health care system performance increased by 5.7% (SE=0.8%, p<0.001) after PDE measure activation and did not change significantly thereafter-a difference representing 11,464 more patients engaging in care than would have without activation of the measure.Conclusions: Results support use of this measure, along with education, technical assistance, and population management tools, to improve engagement after discharge from residential and inpatient mental and substance use disorder treatment. [ABSTRACT FROM AUTHOR]

Background and aims: While long‐term medication‐assisted treatment (MAT) using methadone or buprenorphine is associated with significantly lower all‐cause mortality for individuals with opioid use disorder (OUD), periods of initiating or discontinuing treatment are associated with higher mortality risks relative to stable treatment. This study aimed to identify the OUD treatment durations necessary for the elevated mortality risks during treatment transitions to be balanced by reductions in mortality while receiving treatment. Design Simulation model based on a compartmental model of OUD diagnosis, MAT receipt and all‐cause mortality among Veterans with OUD in the United States Veterans Health Administration (VA) in 2017–2018. We simulated methadone and buprenorphine treatments of varying durations using parameters obtained through calibration and published meta‐analyses of studies from North America, Europe and Australia. Setting: United States. Participants: Simulated cohorts of 10 000 individuals with OUD. Measurements All‐cause mortality over 12 months. Findings Receiving methadone for 4 months or longer or buprenorphine for 2 months or longer resulted in 54 [95% confidence interval (CI) = 5–90] and 65 (95% CI = 21–89) fewer deaths relative to not receiving MAT for the same duration, using VA‐specific mortality rates. We estimated shorter treatment durations necessary to achieve net mortality benefits of 2 months or longer for methadone and 1 month or longer for buprenorphine, using non‐VA population literature estimates. Sensitivity analyses demonstrated that necessary treatment durations increased more with smaller mortality reductions on treatment than with larger relative risks during treatment transitions. Conclusions: Short periods (< 6 months) of treatment with either methadone or buprenorphine are likely to yield net mortality benefits for people with opioid use disorder relative to receiving no medications, despite periods of elevated all‐cause mortality risk during transitions into and out of treatment. Retaining people with opioid use disorder in treatment longer can increase these benefits. [ABSTRACT FROM AUTHOR]

Background: Healthcare systems monitor and improve mental health treatment quality, access, continuity and satisfaction through use of population-based and efficiency-based staffing models, the former focused on staffing ratios and the latter, staff productivity. Preliminary evidence suggests that both high staffing ratios and moderate-to-high staff productivity are important for ensuring a full continuum of mental health services to indicated populations. Methods & findings: With an information-theoretic approach, we conducted a longitudinal investigation of mental health staffing, productivity and treatment at the largest integrated healthcare system in American, the Veterans Health Administration (VHA). VHA facilities (N = 140) served as the unit of measure, with mental health treatment quality, access, continuity and satisfaction predicted by facility staffing and productivity in longitudinal mixed models. An information-theoretic approach: (a) entails the development of a comprehensive set of plausible models that are fit, ranked and weighted to quantitatively assess the relative support for each, and (b) accounts for model uncertainty while identifying best-fit model(s) that include important and exclude unimportant explanatory variables. In best-fit models, higher staffing was the strongest and most consistent predictor of better treatment quality, access, continuity and satisfaction. Higher staff productivity was often, but not always associated with better treatment quality, access, continuity and satisfaction. Results were further nuanced by differential prediction of treatment by between- and within-facility predictor effects and variable interactions. Conclusions: A population-based mental health staffing ratio and an efficiency-based productivity value are important longitudinal predictors of mental health treatment quality, access, continuity and satisfaction. Our longitudinal design and use of mixed regression models and an information-theoretic approach addresses multiple limitations of prior studies and strengthen our results. Results are discussed in terms of the provision of mental health treatment by healthcare systems, and analytical modeling of treatment quality, access, continuity and satisfaction. [ABSTRACT FROM AUTHOR]

Importance: Opioid use disorder (OUD) is a significant cause of morbidity and mortality in the US, yet many individuals with OUD do not receive treatment.Objective: To assess the cost-effectiveness of OUD treatments and association of these treatments with outcomes in the US.Design and Setting: This model-based cost-effectiveness analysis included a US population with OUD.Interventions: Medication-assisted treatment (MAT) with buprenorphine, methadone, or injectable extended-release naltrexone; psychotherapy (beyond standard counseling); overdose education and naloxone distribution (OEND); and contingency management (CM).Main Outcomes and Measures: Fatal and nonfatal overdoses and deaths throughout 5 years, discounted lifetime quality-adjusted life-years (QALYs), and costs.Results: In the base case, in the absence of treatment, 42 717 overdoses (4132 fatal, 38 585 nonfatal) and 12 660 deaths were estimated to occur in a cohort of 100 000 patients over 5 years, and 11.58 discounted lifetime QALYs were estimated to be experienced per person. An estimated reduction in overdoses was associated with MAT with methadone (10.7%), MAT with buprenorphine or naltrexone (22.0%), and when combined with CM and psychotherapy (range, 21.0%-31.4%). Estimated deceased deaths were associated with MAT with methadone (6%), MAT with buprenorphine or naltrexone (13.9%), and when combined with CM, OEND, and psychotherapy (16.9%). MAT yielded discounted gains of 1.02 to 1.07 QALYs per person. Including only health care sector costs, methadone cost $16 000/QALY gained compared with no treatment, followed by methadone with OEND ($22 000/QALY gained), then by buprenorphine with OEND and CM ($42 000/QALY gained), and then by buprenorphine with OEND, CM, and psychotherapy ($250 000/QALY gained). MAT with naltrexone was dominated by other treatment alternatives. When criminal justice costs were included, all forms of MAT (with buprenorphine, methadone, and naltrexone) were associated with cost savings compared with no treatment, yielding savings of $25 000 to $105 000 in lifetime costs per person. The largest cost savings were associated with methadone plus CM. Results were qualitatively unchanged over a wide range of sensitivity analyses. An analysis using demographic and cost data for Veterans Health Administration patients yielded similar findings.Conclusions and Relevance: In this cost-effectiveness analysis, expanded access to MAT, combined with OEND and CM, was associated with cost-saving reductions in morbidity and mortality from OUD. Lack of widespread MAT availability limits access to a cost-saving medical intervention that reduces morbidity and mortality from OUD. Opioid overdoses in the US likely reached a record high in 2020 because of COVID-19 increasing substance use, exacerbating stress and social isolation, and interfering with opioid treatment. It is essential to understand the cost-effectiveness of alternative forms of MAT to treat OUD. [ABSTRACT FROM AUTHOR]

Background: Preoperative patient-specific risk factors may elucidate the mechanisms leading to the persistence of pain and opioid use after surgery. This study aimed to determine whether similar or discordant preoperative factors were associated with the duration of postoperative pain and opioid use. Methods: In this post hoc analysis of a randomized, double-blind, placebo-controlled trial of perioperative gabapentin vs active placebo, 410 patients aged 18– 75 years, undergoing diverse operations underwent preoperative assessments of pain, opioid use, substance use, and psychosocial variables. After surgery, a modified Brief Pain Inventory was administered over the phone daily up to 3 months, weekly up to 6 months, and monthly up to 2 years after surgery. Pain and opioid cessation were defined as the first of 5 consecutive days of 0 out of 10 pain or no opioid use, respectively. Results: Overall, 36.1%, 19.8%, and 9.5% of patients continued to report pain, and 9.5%, 2.4%, and 1.7% reported continued opioid use at 3, 6, and 12 months after surgery. Preoperative pain at the future surgical site (every 1-point increase in the Numeric Pain Rating Scale; HR 0.93; 95% CI 0.87– 1.00; P=0.034), trait anxiety (every 10-point increase in the Trait Anxiety Inventory; HR 0.79; 95% CI 0.68– 0.92; P=0.002), and a history of delayed recovery after injury (HR 0.62; 95% CI 0.40– 0.96; P=0.034) were associated with delayed pain cessation. Preoperative opioid use (HR 0.60; 95% CI 0.39– 0.92; P=0.020), elevated depressive symptoms (every 5-point increase in the Beck Depression Inventory-II score; HR 0.88; 95% CI 0.80– 0.98; P=0.017), and preoperative pain outside of the surgical site (HR 0.94; 95% CI 0.89– 1.00; P=0.046) were associated with delayed opioid cessation, while perioperative gabapentin promoted opioid cessation (HR 1.37; 95% CI 1.06– 1.77; P=0.016). Conclusion: Separate risk factors for prolonged post-surgical pain and opioid use indicate that preoperative risk stratification for each outcome may identify patients needing personalized care to augment universal protocols for perioperative pain management and conservative opioid prescribing to improve long-term outcomes. [ABSTRACT FROM AUTHOR]

Background: In 2018, the Department of Veterans Affairs (VA) issued Notice 2018-08 requiring facilities to complete "case reviews" for Veterans identified in the Stratification Tool for Opioid Risk Mitigation (STORM) dashboard as high risk for adverse outcomes among patients prescribed opioids. Half of the facilities were randomly assigned to a Notice version including additional oversight. We evaluated implementation strategies used, whether strategies differed by randomization arm, and which strategies were associated with case review completion rates.Methods: Facility points of contact completed a survey assessing their facility's use of 68 implementation strategies based on the Expert Recommendations for Implementing Change taxonomy. We collected respondent demographic information, facility-level characteristics, and case review completion rates (percentage of high-risk patients who received a case review). We used Kruskal-Wallis tests and negative binomial regression to assess strategy use and factors associated with case reviews.Results: Contacts at 89 of 140 facilities completed the survey (64%) and reported using a median of 23 (IQR 16-31) strategies. The median case review completion rate was 71% (IQR 48-95%). Neither the number or types of strategies nor completion rates differed by randomization arm. The most common strategies were using the STORM dashboard (97%), working with local opinion leaders (80%), and recruiting local partners (80%). Characteristics associated with case review completion rates included respondents being ≤ 35 years old (incidence rate ratio, IRR 1.35, 95% CI 1.09-1.67) and having < 5 years in their primary role (IRR 1.23; 95% CI 1.01-1.51), and facilities having more prior academic detailing around pain and opioid safety (IRR 1.40, 95% CI 1.12-1.75). Controlling for these characteristics, implementation strategies associated with higher completion rates included (1) monitoring and adjusting practices (adjusted IRR (AIRR) 1.40, 95% CI 1.11-1.77), (2) identifying adaptations while maintaining core components (AIRR 1.28, 95% CI 1.03-1.60), (3) conducting initial training (AIRR 1.16, 95% CI 1.02-1.50), and (4) regularly sharing lessons learned (AIRR 1.32, 95% CI 1.09-1.59).Conclusions: In this national evaluation of strategies used to implement case reviews of patients at high risk of opioid-related adverse events, point of contact age and tenure in the current role, prior pain-related academic detailing at the facility, and four specific implementation strategies were associated with case review completion rates, while randomization to additional centralized oversight was not.Trial Registration: This project is registered at the ISRCTN Registry with number ISRCTN16012111. The trial was first registered on May 3, 2017. [ABSTRACT FROM AUTHOR]

Objective To determine an association between opioid use upon hospital discharge (ongoing and newly started) in surgical patients and risks of opioid overdose and delirium for the first year. Design Retrospective, cohort study. Setting Population-level study of Veterans Health Administration patients. Subjects All Veterans Health Administration patients (N = 64,391) who underwent surgery in 2011, discharged after one or more days, and without a diagnosis of opioid overdose or delirium from 90 days before admission through 30 days postdischarge (to account for additional opioid dosing in the context of chronic use). Methods Patients' opioid use was categorized as 1) no opioids, 2) tramadol only, 3) short-acting only, 4) long-acting only, 5) short- and long-acting. We calculated unadjusted incidence rates and the incidence rate ratio (IRR) for opioid overdose and drug delirium for two time intervals: postdischarge days 0–30 and days 31–365. We then modeled outcomes of opioid overdose and delirium for postdischarge days 31–365 using a multivariable extended Cox regression model. Sensitivity analysis examined risk factors for overdose for postdischarge days 0–30. Results Incidence of overdose was 11-fold greater from postdischarge days 0–30 than days 31–365: 26.3 events/person-year (N = 68) vs 2.4 events/person-year (N = 476; IRR = 10.80, 95% confidence interval [CI] = 8.37–13.92). Higher-intensity opioid use was associated with increasing risk of overdose for the year after surgery, with the highest risk for the short- and long-acting group (hazard ratio = 4.84, 95% CI = 3.28–7.14). Delirium (IRR = 10.66, 95% CI = 7.96–14.29) was also associated with higher opioid intensity. Conclusions Surgical patients should be treated with the lowest effective intensity of opioids and be monitored to prevent opioid-related adverse events. [ABSTRACT FROM AUTHOR]

Objective: Mental health treatment access and quality are influenced by the interplay of structural, organizational, and performance factors-including the number of mental health staff providing direct clinical care relative to patients treated (i.e., staffing ratio), mental health staff productivity, and wait times for scheduled mental health appointments. With no industry standards to follow, the Veterans Health Administration (VHA) developed an outpatient mental health staffing model and a recommended minimum total staffing ratio.Methods: At the level of VHA health care facility (N=140), we conducted cross-sectional regression analyses to examine the relative importance of outpatient mental health staffing and productivity and mental health patient wait times in predicting measures of mental health treatment access and quality.Results: Outpatient mental health staffing ratios (especially total and therapist staffing ratios) had substantial, positive relationships with overall mental health treatment access and quality, broadly and in specific domains. Staffing ratios generally had stronger relationships with treatment access and quality than did staff productivity and patient wait times.Conclusions: Mental health staffing ratios should be a primary consideration when trying to improve mental health treatment access and quality at the facility level. Having more mental health staff of all types is associated with better overall access to and quality of mental health services, and multiple staff types are needed to provide high-quality mental health care. Knowledge gained may guide efforts to address challenges in improving access to and quality of mental health services within and outside of VHA. [ABSTRACT FROM AUTHOR]

This study provides an example of how healthcare system-wide progress in implementation of opioid-therapy guideline recommendations can be longitudinally assessed and then related to subsequent opioid-prescribed patient health and safety outcomes. Using longitudinal linear mixed effects analyses, we determined that in the Department of Veterans Affairs (VA) healthcare system ( n = 141 facilities), over the 4-year interval from 2010 to 2013, a key opioid therapy guideline recommendation, urine drug screening (UDS), increased from 29 to 42 %, with an average within-facility increase rate of 4.5 % per year. Higher levels of UDS implementation from 2010 to 2013 were associated with lower risk of suicide and drug overdose events among VA opioid-prescribed patients in 2013, even after adjusting for patients' 2012 demographic characteristics and medical and mental health comorbidities. Findings suggest that VA clinicians and healthcare policymakers have been responsive to the 2010 VA/Department of Defense (DOD) UDS treatment guideline recommendation, resulting in improved patient safety for VA opioid-prescribed patients. [ABSTRACT FROM AUTHOR]

Implementation planning typically incorporates stakeholder input. Quality improvement efforts provide data-based feedback regarding progress. Participatory system dynamics modeling (PSD) triangulates stakeholder expertise, data and simulation of implementation plans prior to attempting change. Frontline staff in one VA outpatient mental health system used PSD to examine policy and procedural 'mechanisms' they believe underlie local capacity to implement evidence-based psychotherapies (EBPs) for PTSD and depression. We piloted the PSD process, simulating implementation plans to improve EBP reach. Findings indicate PSD is a feasible, useful strategy for building stakeholder consensus, and may save time and effort as compared to trial-and-error EBP implementation planning. [ABSTRACT FROM AUTHOR]

Objective. This study aims to determine 1) the epidemiology of perioperative opioid use; and 2) the association between patterns of preoperative opioid use and time-to-cessation of postoperative opioids. Design. Retrospective, cohort study. Setting. National, population-level study of Veterans Healthcare Administration (VHA) electronic clinical data. Subjects. All VHA patients (n564,391) who underwent surgery in 2011, discharged after stays of ≥1 day, and receiving ≥1 opioid prescription within 90 days of discharge. Methods. Patients' preoperative opioid use were categorized as 1) no opioids, 2) tramadol only, 3) shortacting (SA) acute/intermittent (≤ 90 days fill), 4) SA chronic (> 90 days fill), or 5) any long-acting (LA). After defining cessation as 90 consecutive, opioidfree days, the authors calculated time-to-opioid-cessation (in days), from day 1 to day 365, after hospital discharge. The authors developed extended Cox regression models with a priori identified predictors. Sensitivity analyses used alternative cessation definitions (30 or 180 consecutive days). Results. Almost 60% of the patients received preoperative opioids: tramadol (7.5%), SA acute/intermittent (24.1%), SA chronic (17.5%), and LA (5.2%). For patients opioid-free preoperatively, median time-to-cessation of opioids postoperatively was 15 days. The SA acute/intermittent cohort (HR51.96; 95% CI51.92-2.00) had greater risk for prolonged time-to-cessation than those opioid-free (reference), but lower risk than those taking tramadol only, SA chronic (HR5 9.09; 95% CI5 8.33-9.09), or LA opioids (HR59.09; 95% CI58.33-10.00). Diagnoses of chronic pain, substance-use, or affective disorders were weaker positive predictors. Sensitivity analyses maintained findings. Conclusion. Greater preoperative levels of opioid use were associated with progressively longer time to- cessation postoperatively. [ABSTRACT FROM AUTHOR]

Background and Aims Chronic pain is difficult to treat in individuals with substance use disorders and, when not resolved, can have a negative impact on substance use disorder treatment outcomes. This study tested the efficacy of a psychosocial pain management intervention, ImPAT (improving pain during addiction treatment), that combines pain management with content related to managing pain without substance use. Design Single-site, parallel-groups randomized controlled trial comparing ImPAT to a supportive psychoeducational control (SPC) condition; follow-up assessments occurred at 3, 6 and 12 months. Setting The Ann Arbor VA Substance Use Disorder treatment program, USA. Participants Veterans Health Administration patients { n = 129; mean [standard deviation (SD)], age = 51.7 (9.5); 115 of 129 (89%) male; ImPAT ( n = 65); SPC ( n = 64)}. Intervention ImPAT combines principles of cognitive-behavioral therapy and acceptance-based approaches to pain management with content related to avoiding the use of substances as a coping mechanism for pain. The SPC used a psychoeducational attention control treatment for alcoholism modified to cover other substances in addition to alcohol. Measurements Primary: Pain intensity over 12 months; secondary: pain-related functioning, frequency of alcohol and drug use over 12 months. Findings Primary: randomization to the ImPAT intervention versus SPC predicted significantly lower pain intensity {β [standard error (SE)] = −0.71 (0.29); 95% confidence interval (CI) = −1.29, −0.12}; secondary: relative to the SPC condition, those who received ImPAT also reported improved pain-related functioning [β (SE) = 0.27 (0.11); 95% CI = 0.05, 0.49] and lower frequency of alcohol consumption [β (SE) = −0.77; 95% CI = −1.34, −0.20]. No differences were found between conditions on frequency of drug use over follow-up. Conclusions For adults with pain who are enrolled in addictions treatment, receipt of a psychological pain management intervention (improving pain during addiction treatment) reduced pain and alcohol use and improves pain-related functioning over 12 months relative to a matched-attention control condition. [ABSTRACT FROM AUTHOR]

Objective. Preoperative determinants of pain duration following surgery are poorly understood. We identified preoperative predictors of prolonged pain after surgery in a mixed surgical cohort. Methods. We conducted a prospective longitudinal study of patients undergoing mastectomy, lumpectomy, thoracotomy, total knee replacement, or total hip replacement. We measured preoperative psychological distress and substance use, and then measured pain and opioid use after surgery until patients reported the cessation of both opioid consumption and pain. The primary endpoint was time to opioid cessation, and those results have been previously reported. Here, we report preoperative determinants of time to pain resolution following surgery in Cox proportional hazards regression. Results. Between January 2007 and April 2009, we enrolled 107 of 134 consecutively approached patients undergoing the aforementioned surgical procedures. In the final multivariate model, preoperative self-perceived risk of addiction predicted more prolonged pain. Unexpectedly, anxiety sensitivity predicted more rapid pain resolution after surgery. Each one-point increase (on a four point scale) of self-perceived risk of addiction was associated with a 38% (95% CI 3-61) reduction in the rate of pain resolution (P=0.04). Furthermore, higher anxiety sensitivity was associated with an 89% (95% CI 23- 190) increased rate of pain resolution (P=0.004). Conclusions. Greater preoperative self-perceived risk of addiction, and lower anxiety sensitivity predicted a slower rate of pain resolution following surgery. Each of these factors was a better predictor of pain duration than preoperative depressive symptoms, post-traumatic stress disorder symptoms, past substance use, fear of pain, gender, age, preoperative pain, or preoperative opioid use. [ABSTRACT FROM AUTHOR]

Background: In fiscal year (FY) 2008, 133,658 patients were provided services within substance use disorders treatment programs (SUDTPs) in the U.S. Department of Veterans Affairs (VA) health care system. To improve the effectiveness and cost-effectiveness of SUDTPs, we analyze the impacts of staffing mix on the benefits and costs of specialty SUD services. This study demonstrates how cost-effective staffing mixes for each type of VA SUDTPs can be defined empirically.Methods: We used a stepwise method to derive prediction functions for benefits and costs based on patients' treatment outcomes at VA SUDTPs nationally from 2001 to 2003, and used them to formulate optimization problems to determine recommended staffing mixes that maximize net benefits per patient for four types of SUDTPs by using the solver function with the Generalized Reduced Gradient algorithm in Microsoft Excel 2010 while conforming to limits of current practice. We conducted sensitivity analyses by varying the baseline severity of addiction problems between lower (2.5 %) and higher (97.5 %) values derived from bootstrapping.Results and Conclusions: Compared to the actual staffing mixes in FY01-FY03, the recommended staffing mixes would lower treatment costs while improving patients' outcomes, and improved net benefits are estimated from $1472 to $17,743 per patient. [ABSTRACT FROM AUTHOR]

Background: In order to monitor and ultimately improve the quality of addiction treatment, professional societies, health care systems, and addiction treatment programs must establish clinical practice standards and then operationalize these standards into reliable, valid, and feasible quality measures. Before being implemented, quality measures should undergo tests of validity, including predictive validity. Predictive validity refers to the association between process-of-care quality measures and subsequent patient outcomes. This study evaluated the predictive validity of two process quality measures of residential substance use disorder (SUD) treatment. Methods: Washington Circle (WC) Continuity of Care quality measure is the proportion of patients having an outpatient SUD treatment encounter within 14 days after discharge from residential SUD treatment. The Early Discharge measure is the proportion of patients admitted to residential SUD treatment who discharged within 1 week of admission. The predictive validity of these process measures was evaluated in US Veterans Health Administration patients for whom utilization-based outcome and 2-year mortality data were available. Propensity score-weighted, mixed effects regression adjusted for pre-index imbalances between patients who did and did not meet the measures' criteria and clustering of patients within facilities. Results: For the WC Continuity of Care measure, 76 % of 10,064 patients had a follow-up visit within 14 days of discharge. In propensity score-weighted models, patients who had a follow-up visit had a lower 2-year mortality rate [odds ratio (OR) = 0.77, p = 0.008], but no difference in subsequent detoxification episodes relative to patients without a follow-up visit. For the Early Discharge measure, 9.6 % of 10,176 discharged early and had significantly higher 2-year mortality (OR = 1.49, p < 0.001) and more subsequent detoxification episodes. Conclusions: These two measures of residential SUD treatment quality have strong associations with 2-year mortality and the Early Discharge measure is also associated with more subsequent detoxification episodes. These results provide initial support for the predictive validity of residential SUD treatment quality measures and represent the first time that any SUD quality measure has been shown to predict subsequent mortality. [ABSTRACT FROM AUTHOR]

Background: Though a growing number of US Veterans are being diagnosed with cannabis use disorders, with posttraumatic stress disorder (PTSD) observed as the most frequently co-occurring psychiatric disorder among this population, no research has investigated the impact of PTSD diagnosis on cannabis quit success.Objectives: The present study sought to determine the impact of PTSD on cannabis use following a self-guided quit attempt.Methods: Participants included 104, primarily male, cannabis-dependent US Veterans (Mage = 50.90 years,SDage = 9.90). The study design was prospective and included an assessment immediately prior to the quit attempt, and assessments weekly for the first 4 weeks post-quit, and then monthly through 6 months post-quit.Results: Results indicated that PTSD diagnosis was not associated with time to first lapse or relapse. However, individuals with PTSD used more cannabis at baseline and evidenced a slower initial decline in cannabis use immediately following the quit attempt. All findings were significant after accounting for alcohol and tobacco use across the cessation period, as well as co-occurring mood and anxiety disorder diagnoses.Conclusion: Findings highlight the potential utility of interventions for individuals with cannabis use disorder and co-occurring PTSD, particularly early in a cessation attempt. [ABSTRACT FROM PUBLISHER]

IMPORTANCE: Patients receiving opioid therapy are at elevated risk of attempting suicide. Guidelines recommend practices to mitigate risk, but it is not known whether these are effective. OBJECTIVE: Our aim was to examine associations between the receipt of guideline-recommended care for opioid therapy and risk of suicide attempt. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective analysis of administrative data for all Veteran patients prescribed any short-acting opioids on a chronic basis or any long-acting opioids from the Veterans Health Administration during fiscal year 2010. MAIN OUTCOMES AND MEASURES: Multivariate, mixed-effects logistic regression analyses were conducted to define the associations between the risk of suicide attempt and receipt of guideline-recommended care at the individual level and rates of use of recommended care at the facility level, while accounting for patient risk factors. RESULTS: At the individual level, having a mood disorder was highly associated with suicide attempts (odds ratios [ORs] = 3.5, 3.9; 95 % confidence intervals [CIs] = 3.3-3.9, 3.3-4.6 for chronic short-acting and long-acting groups, respectively). At the facility level, patients on opioid therapy within the facilities ordering more drug screens were associated with decreased risk of suicide attempt (ORs = 0.2, 0.3; CIs = 0.1-0.3, 0.2-0.6 for chronic short-acting and long-acting groups, respectively). In addition, patients on long-acting opioid therapy within the facilities providing more follow-up after new prescriptions were associated with decreased risk of suicide attempt (OR = 0.2, CI = 0.0-0.7), and patients on long-acting opioid therapy within the facilities having higher sedative co-prescription rates were associated with increased risk of suicide attempt (OR = 20.3, CI = 1.1-382.2). CONCLUSIONS AND RELEVANCE: Encouraging facilities to make more consistent use of drug screening, provide follow-up within 4 weeks for patients initiating new opioid prescriptions, and avoid sedative co-prescription in combination with long-acting opioids may help prevent suicide attempts. Some clinicians may selectively employ guideline-recommended practices with at-risk patients. [ABSTRACT FROM AUTHOR]

Background Women experience chronic pain and use pain-related health care at higher rates than men. It is not known whether the pain-related health care female veterans receive is consistent with clinical practice guideline recommendations or whether receipt of this care differs between men and women. Objective The aim of this study was to identify whether sex differences in chronic pain management care exist for patients served by the Veterans Health Administration ( VHA). Design Data on patient demographics, diagnostic criteria, and health care utilization were extracted from VHA administrative databases for fiscal year 2010 ( FY10). Patients Patients in this study included all VHA patients (excluding metastatic cancer patients) who received more than 90 days of a short-acting opioid medication or a long-acting opioid medication prescription in FY10 study. Measures Multilevel logistic regressions were conducted to identify sex differences in receipt of guideline-recommended chronic pain management. Results A total of 480,809 patients met inclusion criteria. Female patients were more likely to receive most measures of guideline-recommended care for chronic pain including mental health assessments, psychotherapy, rehabilitation therapy, and pharmacy reconciliation. However, women were more likely to receive concurrent sedative prescriptions, which is inconsistent with guideline recommendations. Most of the observed sex differences persisted after controlling for key demographic and diagnostic differences. Conclusions Findings suggest that female VHA patients are more likely to receive an array of pain management practices than male patients, including both contraindicated and recommended polypharmacy. Quality improvement efforts to address underutilization of mental health and rehabilitative services for pain by male patients and polypharmacy in female patients should be considered. [ABSTRACT FROM AUTHOR]

Problematic alcohol use has been shown to negatively impact cognitive functions germane to achieving optimal HIV health outcomes. The present study, a secondary data analysis, examined the impact of problematic alcohol use on aspects of everyday memory functioning in a sample of 172 HIV-infected individuals (22 % female; M = 48.37 years, SD = 8.64; 39 % Black/non-Hispanic). Additionally, we tested whether self-reported memory functioning explained the relation between problematic alcohol use and HIV symptom severity. Results indicated that problematic patterns of alcohol use were associated with lower total memory functioning, retrieval (e.g., recall-difficulty) and memory for activity (e.g., what you did yesterday) and greater HIV symptom severity. Memory functioning mediated the relation between problematic alcohol use and HIV symptom severity. However, the direction of this relation was unclear as HIV symptom severity also mediated the relation between problematic alcohol use and memory functioning. Findings highlight the importance of integrated care for HIV and alcohol use disorders and suggest that routine alcohol and cognitive screenings may bolster health outcomes among this vulnerable population. [ABSTRACT FROM AUTHOR]

Objective We previously reported that increased preoperative Beck Depression Inventory II ( BDI- II) scores were associated with a 47% (95% CI 24%-64%) reduction in the rate of opioid cessation following surgery. We aimed to identify the underlying factors of the BDI- II (affective/cognitive vs somatic) associated with a decreased rate of opioid cessation after surgery. Methods We conducted a secondary analysis of the data from a previously reported prospective, longitudinal, observational study of opioid use after five distinct surgical procedures (total hip replacement, total knee replacement, thoracotomy, mastectomy, and lumpectomy) in 107 patients. The primary endpoint was time to opioid cessation. After exploratory factor analysis of the BDI- II, mean summary scores were calculated for each identified factor. These scores were evaluated as predictors of time to opioid cessation using Cox proportional hazards regression. Results The exploratory factor analysis produced three factors (self-loathing symptoms, motivational symptoms, emotional symptoms). All three factors were significant predictors in univariate analysis. Of the three identified factors of the BDI- II, only preoperative self-loathing symptoms (past failure, guilty feelings, self-dislike, self-criticalness, suicidal thoughts, worthlessness) independently predicted a significant decrease in opioid cessation rate after surgery in the multivariate analysis ( HR 0.86, 95% CI 0.75-0.99, P value 0.037). Conclusions Our results identify a set of negative cognitions predicting prolonged time to postoperative opioid cessation. Somatic symptoms captured by the BDI- II were not primarily responsible for the association between preoperative BDI- II scores and postoperative prolonged opioid use. [ABSTRACT FROM AUTHOR]

Occasional cannabis use has been associated with increased antiretroviral therapy (ART) adherence and relief of HIV symptoms, while heavy use has been associated with low ART adherence and negative psychological symptoms. The purpose of the present study was to investigate differences between non-cannabis use (NC), non-dependent cannabis use (C), and dependent use (CD) in terms of ART adherence and HIV symptoms/ART side effects. A cross-sectional sample of 180 HIV+ individuals (78.3 % male) completed measures of substance use and psychopathology, medication adherence, and HIV symptoms/ART side effects. Adherence was also measured via pill count, viral load, and CD4 count. Results indicated that the CD group reported lower adherence and greater HIV symptoms/ART side effects than the other two groups, with no differences observed between NC and C groups. There is a clinical need to address dependent cannabis use among those prescribed ART. Further examination is needed to ascertain the functions of cannabis use among individuals with HIV. [ABSTRACT FROM AUTHOR]

Background: Substance use disorders (SUDs) are a substantial problem in the United States (U.S.), affecting far more people than receive treatment. This is true broadly and within the U.S. military veteran population, which is our focus. To increase funding for treatment, the Veterans Health Administration (VA) has implemented several initiatives over the past decade to direct funds toward SUD treatment, supplementing the unrestricted funds VA medical centers receive. We study the 'flypaper effect' or the extent to which these directed funds have actually increased SUD treatment spending. Methods: The study sample included all VA facilities and used observational data spanning years 2002 to 2010. Data were analyzed with a fixed effects, ordinary least squares specification with monetized workload as the dependent variable and funding dedicated to SUD specialty clinics the key dependent variable, controlling for unrestricted funding. Results: We observed different effects of dedicated SUD specialty clinic funding over the period 2002 to 2008 versus 2009 to 2010. In the earlier period, there is no evidence of a significant portion of the dedicated funding sticking to its target. In the later period, a substantial proportion-38% in 2009 and 61% in 2010-of funding dedicated to SUD specialty clinics did translate into increased medical center spending for SUD treatment. In comparison, only five cents of every dollar of unrestricted funding is spent on SUD treatment. Conclusions: Relative to unrestricted funding, dedicated funding for SUD treatment was much more effective in increasing workload, but only in years 2009 and 2010. The differences in those years relative to prior ones may be due to the observed management focus on SUD and SUD-related treatment in the later years. If true, this suggests that in a centrally directed healthcare organization such as the VA, funding dedicated to a service is a necessary, but not sufficient condition for increasing resources expended for that service. [ABSTRACT FROM AUTHOR]

Background: Opioid agonist therapy (OAT) through addiction specialty clinic settings (clinic-based OAT) using methadone or buprenorphine or office-based settings using buprenorphine (office-based OAT) is an evidence-based treatment for opioid dependence. The low number of clinic-based OATs available to veterans ( N =  53) presents a barrier to OAT access; thus, the expansion in office-based OAT has been encouraged. Objectives: To examine trends in office-based OAT utilization over time and whether availability of office-based OAT improved the proportion of veterans with opioid use disorders treated with OAT. Methods: We examined Veterans Health Administration (VHA) administrative data for evidence of buprenorphine prescribing and clinic-based OAT clinic stops from October 2003 through September 2010 [fiscal years (FY) 2004-2010]. Results: The number of patients receiving buprenorphine increased from 300 at 27 facilities in FY2004 to 6147 at 118 facilities in FY2010. During this time, the number of patients diagnosed with an opioid use disorder increased by 45%; however, the proportion of opioid use disorder patients receiving OAT remained relatively stable, ranging from 25% to 27%, Conclusions: Office-based OAT utilization and the number of opioid use disorder veterans treated with OAT are increasing at the same rate over time, suggesting that office-based OAT is being used to meet the growing need for OAT care. Although office-based OAT is increasingly being used within the VHA and may be one way the VHA is keeping up with the demand for OAT, more research is needed to understand how to engage a greater proportion of opioid use disorder patients in treatment. [ABSTRACT FROM AUTHOR]

We examined patient- and facility-level correlates of specialty substance use disorder (SUD) outpatient treatment receipt (at least 1 visit) and engagement (visit count) for female Veterans Health Administration patients in 2008. Overall, 33% of 15,653 females with SUD received specialty SUD outpatient treatment. Treatment receipt and engagement were positively related to being age 31 to 55, having a psychiatric comorbidity, and receiving treatment at facilities providing women's services. Additional facility-level factors related to treatment receipt were treatment at a facility with comorbid psychiatric services and more licensed psychosocial treatment providers per patient. More prescribers per patient was associated with more treatment engagement. [ABSTRACT FROM AUTHOR]

Objective: This study assessed changes since 2007 at Veterans Health Administration (VHA) facilities (N=129) in use of the medications approved by the U.S. Food and Drug Administration for treatment of alcohol use disorders. Methods: VHA data from fiscal years (FYs) 2008 and 2009 were used to identify patients with a diagnosis of an alcohol use disorder who received oral or extended-release naltrexone, disulfiram, or acamprosate as well as the proportion of days covered (PDC) in the 180 days after initiation and the time to first ten-day gap in possession (persistence) for each medication. Multilevel, mixed-effects logistic regression models examined the association between patient and facility characteristics and use of medications. Results: Nationally, 3.4% of VHA patients with an alcohol use disorder received medications in FY 2009 (11,165 of 331,635 patients), up from 3.0% in FY 2007. Use of medications by patients at the facilities ranged from 0% to 12%. In fully adjusted analyses, facilities offering evening and weekend services had higher rates of medication receipt, but other facility characteristics, such as having prescribers on the addiction program's staff or using medication to treat opioid or tobacco dependence, were unrelated to medication receipt. The mean PDC of acamprosate was significantly lower than mean PDCs of the other medications (p<.05), and persistence in use of naltrexone was significantly greater than use of acamprosate and significantly less than use of disulfiram (p<.05). Conclusions: Use of these medications is increasing but remains variable across the VHA system. Interventions are needed to optimize initiation of and persistence in use of these medications. [ABSTRACT FROM AUTHOR]

Objective. The objective of this study was to explore the relationship between patterns of opioid use, pain severity, and pain-related mental health in chronic pain patients prescribed opioids. Design. The study was designed as a one-time patient interview with structured pain and opioid use assessments. Setting. The study was set in a tertiary care medical center in the United States Department of Veterans Affairs. Patients. Study participants were primary care patients with a pain condition for greater than 6 months who received at least one prescription for an opioid in the prior 12 months. Outcome Measures. The Prescription Drug Use Questionnaire was used to assess patterns of opioid use. The Pain Outcomes Questionnaire was used to assess pain-related functioning. Results. Symptomatic use of opioid medication (e.g., taking an opioid in response to increased pain) was more common than scheduled (i.e., taking an opioid at regular times) or strategic use of opioid medication (e.g., taking an opioid specifically to engage in activities). Symptomatic use of opioids was associated with poorer pain-related mental health, after controlling for pain duration and pain-related physical functioning. Use of opioids in a scheduled pattern was associated with better pain-related mental health. Patients rarely reported that they used opioids strategically to facilitate functional activities. Conclusions. The patterns in which patients use their opioid medications are associated with their psychological functioning. This is consistent with theory regarding the potential impact of reinforcing effects of opioid medication on functional outcomes. Interventions to encourage strategic or scheduled opioid use warrant investigation as methods to improve pain outcomes with opioids. [ABSTRACT FROM AUTHOR]