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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]

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. 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 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]

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]

ABSTRACT Aims To determine whether substituting Seeking Safety (SS), a manualized therapy for comorbid substance use disorders (SUD) and post-traumatic stress disorder (PTSD) for part of treatment-as-usual (TAU) improves substance use outcomes. Design Randomized controlled effectiveness trial. Settings Out-patient Veterans Administration Health Care System SUD clinic. Participants Ninety-eight male military Veterans with a SUD and co-occurring PTSD symptomatology. Measurements Drug and alcohol use and PTSD severity, measured on the first day of treatment, and 3 (i.e. the planned end of SS sessions) and 6 months following the baseline assessment. Treatment attendance and patient satisfaction were measured following treatment (3-month follow-up). Active coping was measured at treatment intake and following treatment. Findings SS compared to TAU was associated with better drug use outcomes ( P < 0.05), but alcohol use and PTSD severity decreased equally under both treatments ( P's < 0.01). SS versus TAU was associated with increased treatment attendance, client satisfaction and active coping (all P's < 0.01). However, neither these factors nor decreases in PTSD severity mediated the effect of treatment on drug use. Conclusions The manualized treatment approach for substance use disorder, Seeking Safety, is well received and associated with better drug use outcomes than 'treatment as usual' in male veterans with post-traumatic stress disorder. However, the mechanism of its effect is unclear. [ABSTRACT FROM AUTHOR]