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Spotlight on Substance Use Disorders

April 2023

Introduction

Substance use disorders (SUDs) are treatable, chronic diseases that can affect anyone. Characterized by problematic and continued use of substances such as alcohol, cigarettes, illicit drugs, or prescription painkillers despite substantial adverse consequences, SUDs continue to be a major health problem in the U.S., with about 40 million Americans aged 12 or older having an SUD in the past year, according to the 2020 National Survey on Drug Use and Health [1]. SUDs are especially common among Veterans—a population greatly affected by factors related to substance use, such as pain, suicide risk, trauma, and homelessness—with lifetime prevalence of an SUD estimated at 53% among Veterans. [2]

Although SUDs range from mild to severe, they can damage many aspects of a person’s life, including health and life at home, school, and work. Many treatment options exist, however, including therapies that improve mental health disorders such as depression or anxiety that might co-occur with an SUD.

VA offers help to Veterans who struggle with substance use through a variety of programs, and supports research that examines SUD prevention, screening, and treatment. HSR&D’s Center for Mental Healthcare and Outcomes Research, for example, focuses on improving healthcare for Veterans with mental health disorders and/or SUDs, with an emphasis on those at high risk for suicide and Veterans who live in rural areas. Some of QUERI’s research teams examine pain care and opioid safety, and work to develop implementation and quality improvement strategies to expand Veterans’ access to treatments. Based on HSR&D and QUERI research, the Pain Management, Opioid Safety, and Prescription Drug Monitoring Program will fund a clinical version of COPES—a technology-based cognitive-behavioral therapy program for Veterans with chronic pain.

Following are some recent studies funded by HSR&D related to SUDs.

Improving Outcomes for Emergency Department Patients with Alcohol Problems

“Peer support in the form of support groups like Alcoholics Anonymous has a long tradition of helping people with alcohol use problems. This study tests whether individualized peer support can be integrated within routine VA clinical care to reach patients with at-risk drinking seen in Emergency Departments who might otherwise fall through the cracks.”

Paul Pfeiffer, MD

young man in hospital

©iStock/sturti

Hazardous use of alcohol is directly related to high rates of illness in Veterans and poses a significant threat to Veterans’ post-deployment health. Many Veterans seen in VA Emergency Departments (EDs) report problematic drinking, but due to limited provider time to screen for alcohol use and deliver alcohol-related services, few individuals receive the needed assistance to reduce or stop drinking and/or link to needed services following their ED visit. VA’s nationwide network of trained peer support specialists could serve a vital role in delivering alcohol brief interventions in the ED and provide continued support and links to services for Veterans with hazardous alcohol use.

About This Study

In this study, researchers are comparing a brief Alcohol Peer Mentorship (APM) intervention that starts in the ED and includes six booster sessions, with clinician-delivered brief advice. Investigators recruited Veterans who received care in the VA Ann Arbor ED and who indicated hazardous drinking behavior. Investigators assessed Veterans’ alcohol use, healthcare use, and other mental health and wellness factors occurring at baseline, three, six, and 12 months following enrollment.

Researchers aim to:

  • Determine the efficacy of APM, a peer-delivered alcohol intervention and mentorship, compared to clinical brief advice to help reduce hazardous drinking.
  • Determine the impact of APM on linkage to primary care and specialty alcohol treatment services, if needed.

Findings are not yet available.

Expected Implications

This trial evaluated the feasibility and effectiveness of an APM, which is a low-cost and easy-to-deliver intervention designed to address the urgent need to reduce alcohol problems among Veterans and to encourage the use of VA resources. VA EDs often serve as a first stop for Veterans who are experiencing acute problems related to hazardous alcohol use and mental health problems, but providing brief interventions for problematic alcohol use in this fast-paced environment can be difficult due to competing staff time demands. Expanding the role of peer mentors to provide brief alcohol advice in the ED, combined with post-ED support, has the potential to fill this gap in ED care and improve outcomes for a vulnerable population in VA and beyond.

Principal Investigators

Paul Pfeiffer, MD

Paul Pfeiffer, MD

Frederic Blow, PhD, (emeritus) and Paul Pfeiffer, MD, are investigators with HSR&D’s Center for Clinical Management Research in Ann Arbor, Michigan.


Virtual Pain Care for High-Risk Veterans on Opioids

“This virtual model of care could improve access and efficiency of treatment to reduce long-term opioid use or help smooth a path to a safer alternative such as buprenorphine.”

—Brent Moore, PhD

Man having videocall videoconference at home with black female doctor therapist using tablet computer. Online virtual telemedicine health care concept.

©iStock/insta_photos

The COVID-19 pandemic has exacerbated the challenges faced by Veterans who are at risk for opioid overdose, including Veterans prescribed moderate- to high-dose long-term opioid therapy (LTOT). Interruptions of pharmacologic and non-pharmacologic therapies (such as exercise) can lead to worsened symptoms, treatment disengagement, and even death, especially if indicated switches to buprenorphine (BUP) are delayed. VA is working to deploy and evaluate virtual models of care for Veterans on high-risk LTOT that provide more accessible, uninterrupted, high-quality care.

About This Study

The objectives of this project were to:

  • Evaluate the feasibility and acceptability of Video-Telecare Collaborative Pain Management (VCPM) among 60 Veterans on high-risk LTOT.
  • Develop decision aids for ascertaining patient preference for communication and care delivery.
  • Examine feasibility of virtual outcome assessment as part of clinical care.

Researchers recruited 44 patients at two VA sites, one in Colorado and one in Connecticut. Eligible Veterans were currently receiving LTOT for chronic pain at 50 mg morphine equivalent daily dose. If a BUP switch was offered and accepted, the physician completed brief evaluations and discussed VCPM, a multi-component intervention that consists of established care processes and materials and uses audio-video visits (with telephone as a back-up). Veterans completed scheduled follow-up phone visits on days four, seven, and 14 and at one, two, and three months. The patient's preferred mode for information receipt (web, email, regular mail) and communication (video vs. telephone) guided decisions, and researchers refined methods to align with these preferences.

Findings

  • Among 104 initial contact calls, 49 (47%) Veterans declined the intervention. Of those who attended an initial virtual visit, 20 (45%) chose to continue their care with their PCP, rather than the VCPM team.
  • Of the 19 patients who chose to engage in longitudinal care with the VCPM team, 17 (89%) had improved outcomes as indicated by reduced opioid medication and improved pain functioning.
  • Most patients engaged in VCPM reported that they would recommend it to a friend who has a pain problem. A follow-up survey on satisfaction and the ease of use of virtual care indicated strong satisfaction with the virtual care component of VCPM.

Implications

Veterans who engage in VCPM are likely to reduce risks associated with long-term opioid therapy and improve functioning, but the large number of patients who declined the intervention and did not engage in care with the VCPM team indicates that recruitment/engagement feasibility for VCPM as implemented is low. Reluctance to engage in changes to LTOT is common among Veterans, but video testimonials from successful VCPM patients are now available for future implementation and evaluation of VCPM. With improved engagement, VCPM could be quickly scaled regionally and nationally.

Principal Investigators

 Brent Moore, PhD (left) and William Becker, MD (right)

Brent Moore, PhD (left) and William Becker, MD (right)

Brent Moore, PhD, and William Becker, MD, are investigators with HSR&D’s Pain Research, Informatics, Multi-morbidities, and Education Center in West Haven, CT.


Joseph Frank, MD, MPHJoseph Frank, MD, MPH, is an investigator with the Seattle/Denver Center of Innovation for Veteran Centered and Value Driven Care.



Recent related research by these investigators

Edmond S, Wesolowicz D, Moore B, et al. Opioid tapering support using a web-based app: Development and protocol for a pilot randomized controlled trial. Contemporary Clinical Trials. August 2022;1190:106857.

video icon Click here to watch brief VA-produced videos that present information on buprenorphine, virtual care, and long-term opioids.

Pain-Related Anxiety Intervention for Smokers with Chronic Pain

“Given the high burden of chronic pain and mental health comorbidities in Veterans who smoke cigarettes, it's important that we have a smoking cessation intervention that addresses not just smoking but also the pain and depressed mood associated with smoking.”—Lori Bastian, MD, MPH

Man smoking cigarette

©iStock/Nopphon Pattanasri

Smoking is widespread among Veterans—approximately 20% of Veterans smoke—and has a staggering impact on Veterans’ health. Pain is also frequently reported by Veterans, and research suggests smoking is associated with pain intensity. Although smoking cessation among patients with chronic medical illnesses substantially decreases morbidity and mortality, many patients (>50%) with chronic pain continue to smoke. Standard smoking cessation intervention augmented with a cognitive behavioral intervention (CBI) aims to teach Veterans who smoke coping strategies for emotional distress and cues that interfere with efforts to quit, while removing barriers that limit access to and participation in effective interventions.

About This Study

This study compared the effectiveness of a telephone-based smoking cessation intervention that included CBI for pain (SMK-CBI) to a contact-equivalent, standard telephone-based smoking cessation intervention (SMK-STD). Researchers randomized 371 smokers with moderate to severe pain to receive either SMK-STD or SMK-CBI. Participants were mostly unemployed (70%) males (88%) with a median age of 60 years old who smoked a median of 15 cigarettes per day for a median of 40 years. More than half (59%) had mental health symptoms that passed the clinical threshold for major depression, and 11% experienced suicidal ideation. Additionally, nearly one-third (32%) screened positive for potential alcohol problems. These baseline characteristics reflected a socioeconomically vulnerable population with a high burden of mental health comorbidities and multiple barriers to smoking cessation.

Each participant was offered five telephone-based counseling sessions within 12–14 weeks and combined nicotine replacement therapy. In addition, Veterans were surveyed upon enrollment and six and 12 months post-intervention for pain intensity, pain interference, self-efficacy to quit, demographics, smoking history, depression, smoking status, nicotine withdrawal symptoms, use of intervention materials, and intervention acceptability. Researchers aimed to:

  • Evaluate the impact of SMK-CBI on cigarette abstinence rates among Veteran smokers with chronic pain at six and 12 months compared to SMK-STD.
  • Evaluate the impact of SMK-CBI on pain intensity and pain interference among Veterans compared to SMK-STD.
  • Assess whether baseline depression affected the impact of SMK-CBI on smoking cessation in Veterans with pain compared to SMK-STD.

Findings

  • Overall, participants who received SMK-CBI reported higher seven-day (17% vs. 14% at six months and 18% vs. 12% at 12 months) and 30-day (12% vs. 6% at six months and 13% vs. 10% at 12 months) abstinence compared to those who received SMK-STD.
  • At six months, SMK-CBI patients reported greater improvement of pain interference (34% vs. 19%) compared to those who received SMK-STD. Smoking cessation rates and pain interference diminished at 12 months.
  • Those without depression had higher 30-day abstinence and a 30% reduction in pain interference at six months in the SMK-CBI vs. SMK-STD groups (17% vs. 6% and 44% vs. 23%, respectively); among those with depression, no differences between the two interventions were observed.

Implications

Given the high burden of depression in this population, future interventions for Veterans who smoke and have chronic pain should consider targeting co-occurring depression to optimize treatment and sustain improvements in smoking cessation rates and pain.

Principal Investigators

Lori Bastian, MD, MPHLori Bastian, MD, MPH, is director of HSR&D’s Pain Research, Informatics, Multi-morbidities, and Education Center (PRIME) in West Haven, CT.


William Becker, MD William Becker, MD, is a principal investigator at PRIME and co-leads HSR&D’s Pain and Opioid CORE.


Recent related research by these investigators

Lee M, Bastian L, Becker W, et al. Perceived pain and smoking interrelations among Veterans with chronic pain enrolled in a smoking cessation trial. Pain Medicine. November 2022;23(11):1820–1827.

Bastian L, Driscoll M, Becker W, et al. Pain and smoking study (PASS): A comparative effectiveness trial of smoking cessation counseling for Veterans with chronic pain. Contemporary Clinical Trials Communications. September 1, 2021;23:100839.

Complementary/Integrative Health Interventions for Opioid Use

Close-up view of a man lying face down and being treated by the acupuncturist. He's applying the needle on man's back area.

©iStock/LukaTDB

Opioid misuse, abuse, addiction, and overdose are a leading cause of death in the U.S. Complementary and integrative health (CIH) interventions—such as meditation, yoga, and acupuncture, which are not typically part of mainstream American medicine—might help prevent or reduce opioid-related harms, but evidence regarding the effectiveness of these interventions for reducing opioid use is limited, and the impact of CIH on opioid use, co-prescriptions, pain, and related outcomes in VA is poorly understood.

About This Study

PTSD accompanied by pain is a common mental health diagnosis in VA. Veterans with PTSD and pain face increased risk of opioid-related harms, and there is potential mutual reinforcement between PTSD and pain symptoms. CIH as therapy for PTSD and chronic pain might substantially decrease rates of opioid initiation and harms and have broad clinical implications for improving chronic pain and mental health services in VA primary care, but strategies to identify CIH use and its effects are needed. In this study, researchers examined CIH use and non-use among Veterans with musculoskeletal disorders (MSD) and compared opioid and pain outcomes by PTSD status. Researchers aimed to:

  • Assess the impact of CIH on opioid initiation among Veterans with MSD.
  • Estimate whether the effect of CIH varies by Veterans’ demographic and clinical characteristics, with particular attention to Veterans’ PTSD status.
  • Examine potential harms of CIH use.

Researchers identified 7,621 Veteran CIH users among an MSD cohort in FY11–FY13 (n=309,277), of which 21% had a PTSD diagnosis. Opioid and other medication use was identified from pharmacy data, and researchers examined acupuncture, massage, meditation/mindfulness, and yoga as they were currently or likely to be integrated into routine VA care.

Findings are not yet available.

Implications

MSD and PTSD are two of the most prevalent disorders among Veterans in VA care, and their comorbidity is high. VA and DoD guidelines suggest a role for select CIH for pain and PTSD, and the CDC promotes non-pharmacologic treatments for chronic pain, making it likely that the demand for CIH will increase. Findings of this study provide an opportunity to anticipate future needs for CIH and to examine patterns of benefit and harms.

Principal Investigators

Joseph Goulet, PhD, MS, is an investigator at HSR&D’s Pain Research, Informatics, Multi-morbidities, and Education Center in West Haven, CT.

Qing Zeng, PhD, is an HSR&D investigator at the Washington, DC VA Medical Center.

Recent related research by these investigators

Buta E, Gordon K, Goulet J, et al. Joint longitudinal trajectories of pain intensity and opioid prescription in Veterans with back pain. Pharmacoepidemiology & Drug Safety. December 2022;31(12):1262–1271.

Han L, Goulet J, Zeng Q, et al. Complementary and integrative health approaches and opioid prescriptions among older Veterans with chronic pain. Innovation in Aging. December 17, 2021;5(S1):933.

Dr. Goulet discussed this study in an HSR&D Cyberseminar on March 16, 2023.




[1] Substance Use Disorders (SUDs) | Disease or Condition of the Week | CDC

[2] Substance Use - Whole Health Library (va.gov)


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