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  • JGIM Supplement Features VA Research on Improving Opioid Safety among Veterans with Chronic Pain and Addiction
    In the fall of 2019, HSR&D convened a state-of-the-art (SOTA) conference – “Effective Management of Pain and Addiction: Strategies to Improve Opioid Safety” – to develop research priorities for advancing the science and clinical practice of opioid safety, including both the use of opioid analgesics and managing opioid use disorder (OUD). A group of researchers and VA clinical stakeholders defined three areas of focus for the SOTA: 1) managing OUD, 2) long-term opioid therapy for pain including consideration for opioid tapering, and 3) treatment of co-occurring pain and substance use disorders. SOTA participants included VA and non-VA health services researchers, clinicians, and policymakers. Funded by HSR&D, this JGIM Supplement presents recommendations from the SOTA, as well as original research papers on opioid safety across the VA healthcare system.
    Date: December 1, 2020
  • Racial and Ethnic Differences in Primary Care Experiences for Veterans with Mental Health and Substance Use Disorders
    This study examined racial and ethnic differences in positive and negative experiences in VA Patient-Centered Medical Home (PCMH) settings among Veterans with mental health or substance use disorders (MHSUDs) who completed VA’s 2013 PCMH Survey of Healthcare Experiences of Patients. Findings showed that positive experiences were reported least often for access. Negative experiences were reported most often for self-management support and comprehensiveness, defined as provider attention to MHSUD concerns. One or more racial/ethnic minority groups reported more negative and/or fewer positive experiences than Whites in the following 4 domains: access, communication, office staff helpfulness/courtesy, and comprehensiveness. Solutions are needed to improve access to care for all Veterans with MHSUDs, with additional attention on improving access for Black, Hispanic, and AI/AN Veterans.
    Date: June 20, 2016
  • Military Sexual Trauma is Independent Risk Factor for Homelessness among Veterans, Particularly Male Veterans
    This study examined the relationship between military sexual trauma (MST) and post-deployment homelessness among a large cohort of OEF/OIF Veterans, including whether the relationship varied by sex, and whether MST was a predictor of homelessness independent of other risk factors (i.e., mental health and/or substance use disorders). Findings showed that a positive MST screen was independently related to post-deployment homelessness. In unadjusted models, Veterans with a positive screen had odds for homelessness that were approximately double those who screened negative. Moreover, findings in the 30-day and 1-year follow-up cohorts suggested a greater risk for homelessness among men with a history of MST than among women. After adjusting for mental health and substance use diagnoses, MST screening status remained a significant predictor of homelessness, with Veterans who had a positive MST screen having approximately 1.5 times greater odds for homelessness than those who screened negative. Findings of greater risk among men also remained. Among Veterans with a positive MST screen, the incidence of homelessness was 2% within 30 days, 4% within one year, and 10% within five years. The stronger risk conferred by MST for homelessness among men suggests that men with a positive MST screen are a particularly vulnerable group.
    Date: June 1, 2016
  • Veterans Exiting Prison Have Extensive Treatment Needs, Particularly for Mental Health and Substance Use Issues
    This study determined incarcerated Veterans’ contact with VA healthcare in the year after a Health Care for Reentry Veterans (HCRV) visit (prior to release from prison), the prevalence of mental health and substance use disorder (SUD) diagnoses, and rates of mental health or SUD treatment entry and engagement in the first month after diagnosis. Findings showed that of the Veterans with an HCRV outreach visit, 56% had contact with VA healthcare within one year, including primary care, mental health or SUD treatment, or other VA services. Among Veterans with an HCRV outreach visit who had contact with VA healthcare, 69% were diagnosed with at least one mental health or substance use disorder, and 35% were diagnosed with co-occurring mental health and substance use disorders. The three most common disorders were depressive disorders, alcohol use disorder, and PTSD. Of Veterans diagnosed with a mental health disorder, 77% entered mental health treatment in the first month after diagnosis and 28% engaged in treatment. At one year after diagnosis, 93% of Veterans had entered and 52% had engaged in mental health treatment. Of those Veterans diagnosed with a SUD, 37% entered and 24% engaged in SUD treatment in the first month, while 57% had entered and 39% engaged in treatment at one year following diagnosis.
    Date: December 21, 2015
  • Individual and Facility-Level Factors Associated with Higher Risk of Suicide Attempt among Veterans Receiving Opioid Therapy
    This study examined the associations between the receipt of guideline-recommended care for opioid therapy and risk of suicide-related events, assessing associations between individual-level and facility-level delivery of recommended care, and individual-level suicide-related events. Findings showed that within 180 days following opioid prescription, 1.6% of the study population on chronic short-acting opioids and 2.1% of the study population on long-acting opioids experienced suicide-related events. At the individual level, Veterans who received opioid therapy and had medical frailty, drug, alcohol, or mood disorder, and/or traumatic brain injury had a higher risk of suicide-related events. Patients on opioid therapy within VA facilities that ordered more drug screens were associated with a decreased risk of suicide-related events. Patients on long-acting opioid therapy within facilities that provided more follow-up after new prescriptions also were associated with decreased risk of suicide-related events. Patients on long-acting opioid therapy within facilities having higher sedative co-prescription rates had an increased risk of suicide -related events. Among the sub-population of patients with a substance use disorder and a short-acting opioid prescription, the facility rate use of specialty substance use disorder treatment was associated with lower risk of suicide-related events. Encouraging facilities to make more consistent use of drug screening, providing follow-up within four weeks for patients initiating new opioid prescriptions, avoiding sedative co-prescription in combination with long-acting opioids, and engaging patients with substance use disorders in specialty substance use treatment, may help prevent suicide-related events.
    Date: July 1, 2015
  • NEJM Perspective Discusses Withholding of CMS Data Related to Substance Use Disorder and Its Impact on Research
    In November 2013, the Centers for Medicare and Medicaid Services (CMS) began to withhold from research data sets any Medicare or Medicaid claim with a substance use disorder (SUD) diagnosis or related procedure code. This move — the result of privacy-protection regulations overseen by the Substance Abuse and Mental Health Services Administration — affects about 4.5% of inpatient Medicare claims [recent research suggests this figure is closer to 7%] and about 8% of inpatient Medicaid claims from key research files, impeding a wide range of research evaluating policies and practices intended to improve care for patients with substance use disorders. As a consequence, VA researchers cannot see the full utilization of Veterans who also use Medicare- or Medicaid-financed healthcare. This Perspective summarizes the problem, quantifies it, describes how it arose, and argues that research access to such data should be restored.
    Date: April 15, 2015
  • Affordable Care Act May Impact Continuity of Care for Homeless VA Healthcare Users
    This study compared Veterans who are likely eligible for the Medicaid expansion (LEME) and those who are not LEME, stratified by homeless status. Findings showed that among all VA healthcare users under the age of 65, homeless Veterans were two times more likely to be LEME than non-homeless Veterans (64% vs. 30%). Regardless of housing status, Veterans who were LEME were physically healthier than those not LEME. However, Veterans who were LEME were more likely to have substance use disorders and PTSD. Among homeless VA healthcare users, those who were LEME were less than half as likely to be married, to be an OEF/OIF/OND Veteran, and had less than one-third the income of Veterans who were not LEME. Among non-homeless VA healthcare users, those who were LEME were younger and more likely to be OEF/OIF/OND Veterans. Cross-sytem use of VA and Medicaid-funded services may be advantageous for Veterans with extensive medical and psychiatric needs, but also risks fragmented care. Information and education for VA clinicians and patients about possible implications of the Affordable Care Act may be important.
    Date: September 1, 2014
  • Factors Related to Use of Psychotherapy among Veterans
    This study sought to examine predisposing, enabling, and need factors related to low, moderate, high, and very high levels of psychotherapy use among Veterans newly diagnosed with PTSD, depression, and anxiety. Findings showed that need factors appeared to be most strongly linked to psychotherapy utilization. Very high psychotherapy users had higher rates of PTSD and substance use disorders (SUD), more comorbid psychiatric diagnoses, and more inpatient psychiatric stays. In the year after initiating psychotherapy, half of the sample received only 1-3 psychotherapy sessions (low-users); 42% received 4-18 sessions (moderate-users); 5% received 19-51 sessions (high-users), and 2% received more than 52 sessions (very high-users). Low-users predominantly received individual psychotherapy; very high-users received relatively more group psychotherapy. Younger (<35) and older (65+) Veterans were proportionately more likely to be low-users. Low-users also had lower psychiatric comorbidity, fewer inpatient days, and were less likely to be diagnosed with PTSD and SUD. Results suggest many Veterans may not receive a clinically optimal dose of psychotherapy, highlighting the need to enhance retention in therapy for low utilizers and examine whether very high utilizers are benefitting from extensive courses of treatment.
    Date: May 19, 2014
  • Strong Association between Substance Abuse and Homelessness among Veterans
    This study examined the prevalence of alcohol and drug use disorders among homeless Veterans entering the HUD-VASH program, and its association with both housing and clinical outcomes. Findings showed that there was a strong association between substance abuse and homelessness, particularly in Veterans with comorbid alcohol and drug use disorders. The majority (60%) of homeless Veterans admitted to the HUD-VASH program had a substance use disorder (SUD), and the majority (54%) of those had both an alcohol and drug use disorder. In the first 6 months after entering the HUD-VASH program, significant improvements were observed in both housing and clinical outcomes, with no significant differences between Veterans with and without substance use disorders on housing outcomes. However, Veterans with any substance use disorder showed improvement at a slower rate than those with no SUD. These findings suggest that despite strong associations between SUD and homelessness, the HUD-VASH program is able to successfully house homeless Veterans with SUD, although additional services may be needed to address their substance abuse after they become housed. Before entering supported housing, homeless Veterans with comborbid alcohol and drug use disorders had more extensive histories of being homeless than Veterans with only alcohol or only drug use disorders, while those with no SUD had the least extensive homeless histories. Compared to other homeless Veterans, those with both alcohol and drug use disorders were most likely to have comorbid psychotic or mood disorders. Homeless Veterans with both alcohol and drug use disorders or only a drug use disorder were more likely to also have PTSD.
    Date: February 1, 2014
  • Anxiety Disorders and Depression Associated with Risk of Future Heart Failure among Veterans
    This study sought to determine if the risk of heart failure (HF) was greater in Veterans with: 1) a diagnosis of one or more anxiety disorders but who were free of major depressive disorder (MDD); 2) MDD but free of anxiety disorders; or 3) comorbid anxiety and depressive disorders. Findings showed that in the model that corrected for age only, Veterans with anxiety disorders, MDD, or both were each about 20% more likely to develop HF compared to Veterans without these conditions. This effect remained significant after adjusting for other HF risk factors (e.g., sociodemographics, nicotine use, substance use disorders), and was even greater after adjusting for psychotropic medications. Compared to Veterans without HF, patients with HF were significantly older and more frequently male, non-white, unmarried, holders of supplemental insurance, and were significantly more likely to have diagnoses of hypertension, diabetes, and obesity. Veterans with both anxiety and MDD were more likely to have a diagnosis of substance abuse or dependence and history of nicotine use – and to receive a prescription for psychotropic medication.
    Date: February 1, 2014
  • Suicidal Ideation is Common among OEF/OIF Veterans who Receive VA Healthcare
    This study sought to determine the prevalence and correlates of suicidal ideation among OEF/OIF Veterans who screened positive for depression following implementation of required brief assessments. Findings showed that suicidal ideation is common among OEF/OIF Veterans who receive VA healthcare: one in three Veterans who screened positive for depression acknowledged possible suicidal ideation. High PHQ-2 scores (> 5) nearly doubled the odds of suicidal ideation, even when controlling for diagnoses of depression. Depression and bipolar or schizophrenia diagnoses significantly increased the odds of suicidal ideation. In addition, having a single diagnosed psychiatric disorder did not significantly increase the odds of suicidal ideation, but two disorders were associated with a 60% increase, and three or more disorders more than doubled the odds. In contrast to previous reports, this study found no increase in suicidal ideation for Veterans with PTSD, substance use disorders, anxiety disorders, or traumatic brain injury. However, the authors note that a recently published evidence-based synthesis concluded that despite mixed results, PTSD should be considered a risk factor for suicide attempts and completion among Veterans.
    Date: July 1, 2013
  • Opioid Prescribing for Veterans with Chronic Non-Cancer Pain
    This study sought to describe patterns of prescription opioid initiation, identify correlates of opioid initiation, and examine correlates of receipt of chronic opioid therapy (COT) among Veterans with persistent non-cancer pain. Findings showed that the initiation of opioid drug therapy is common among Veterans with persistent pain, but most Veterans are not prescribed opioids long-term. During the study year, 35% of Veterans in the sample received an opioid prescription: 30% were prescribed opioids on a short-term basis (<90 days), and 5% received chronic opioid therapy (>90 days). Clinical factors associated with initiating COT include increased pain intensity, nicotine dependence, substance use disorders, and major depression diagnoses. Nearly one-quarter of Veterans prescribed COT also received prescriptions for benzodiazepine medications, which is a concern given that overdose deaths have been linked to the use of multiple sedating medications. Two-thirds of opioid prescriptions resulting in COT were initiated by primary care clinicians. The authors suggest that this supports the development of guidelines geared toward primary care practice. It also supports the provision of interventions and structures in primary care that facilitate proactive planning around opioid use and its monitoring.
    Date: February 1, 2013
  • Substance Use Disorders Significantly Increase the Risk of All-Cause Mortality among Veterans with PTSD
    This study sought to estimate the predictive association between substance use disorders (SUDs) and the risk of mortality among a cohort of Veterans with PTSD. Findings showed that having a substance use disorder significantly increased the risk of all-cause mortality among Veterans with PTSD. The association between SUDs and non-injury-related mortality was most pronounced in the youngest age group (<45 years), which included OEF/OIF Veterans, compared with the 45-64 or >65 group. Regardless of age group, SUD was a strong predictor of injury-related mortality. It was a significantly stronger predictor of injury-related vs. non-injury related death among Veterans in the 45-64 years and >65 years age groups. However, it is important to note that injury-related mortality accounted for a relatively small proportion of all deaths (~10%) among Veterans with PTSD.
    Date: September 10, 2012
  • Cannabis Use Disorder Diagnoses in the VA Healthcare System Double Over the Past Seven Years
    The prevalence of cannabis use disorder (CUD) diagnoses overall within VA has increased nearly 60% (from 0.66% to 1.05%) over the past 7 years, with the prevalence of CUD diagnoses among those without other illicit substance use disorders (SUD) having risen 115% (from 0.27% to 0.58%) during the same time period. Rates of other substance use disorder diagnoses within VA (i.e., alcohol-only and other-drug disorder) increased to a much smaller degree. Although rates of CUD diagnosis within VA have increased dramatically, they remain significantly lower than rates of CUD observed in the U.S. population. States with laws allowing for the legal use of cannabis for medicinal purposes had significantly higher rates of CUD diagnoses within VA in 2002, 2008, and 2009. Rates of psychiatric diagnoses, and PTSD specifically, were higher among patients with a CUD diagnosis but no other illicit SUD, as compared to other SUD groups. Rates of specialty SUD treatment utilization among those with a CUD diagnosis but no other illicit SUD have decreased within VA.
    Date: May 7, 2012
  • Killing Experiences Independently Associated with Suicidal Ideation among Vietnam Veterans
    Vietnam Veterans in this study with war-related killing experiences were twice as likely to report suicidal ideation as those who did not kill, even after accounting for PTSD, depression, substance use disorder diagnoses, and combat exposure. This is the first study demonstrating that killing experiences are independently associated with suicidal ideation, after taking mental health diagnoses into account. In regression analyses that included demographic variables, PTSD, depression, substance use disorders, combat experiences, and killing experiences, PTSD was the only variable significantly associated with suicide attempts. Nearly 14% of Veterans in this study met diagnostic criteria for current PTSD.
    Date: April 13, 2012
  • Importance of Pre-Operative Alcohol Screening
    Among the Veterans in this study, 16% of men and 5% of women screened positive for alcohol misuse at levels associated with increased post-operative complications in the year before surgery. A majority of male and female surgical patients with alcohol misuse were relatively healthy and did not have diagnoses or chronic conditions commonly associated with alcohol misuse that might alert providers to their alcohol misuse. This finding highlights the value of routine pre-operative alcohol screening to proactively identify Veterans who misuse alcohol and to potentially implement interventions before surgery. Screening positive for alcohol misuse (AUDIT-C >5) was more common among men who were: younger than 60 years old, divorced or separated, current smokers, or ASA class 1-2 (pre-operative assessment by anesthesiologist as healthy patient or patient with mild systemic disease), and among men with cirrhosis, hepatitis, or substance use disorders.
    Date: April 11, 2012
  • Racial and Ethnic Differences in Blood Pressure Control among Veterans with Type 2 Diabetes
    This study examined racial/ethnic differences in blood pressure control among Veterans with type 2 diabetes and uncontrolled BP at baseline. Findings showed that the adjusted proportion of Veterans with uncontrolled BP (>=140/90 mmHg) decreased in all groups over the study period. However, ethnic minority Veterans had significantly increased odds of poor BP control over a mean follow-up of 5 years compared to non-Hispanic White Veterans, independent of socio-demographic factors and comorbidity patterns. Compared to non-Hispanic Whites (45%), 54% of non-Hispanic Black Veterans, 48% of Hispanic Veterans, and 49% of Veterans with unknown race had poor blood pressure control. In using a more stringent BP cutoff (>=130/80 mmHg) to define poor BP control, 74% of non-Hispanic White Veterans had poor blood pressure control over the 5 years compared to 82% of non-Hispanic Black Veterans, 75% of Hispanic Veterans, and 79% of Veterans with unknown race/ethnicity. The presence of a hypertension diagnosis at the time of study entry appears to be associated with higher odds of achieving BP control over time. Among other comorbidities, cancer, coronary heart disease, congestive heart failure, and substance use disorders were all associated with increased odds of good BP control over time.
    Date: June 14, 2011
  • Journal Section Focuses on Implementing Evidence-Based Interventions for Substance Use Disorders
    This article introduces a special section of Psychology of Addictive Behaviors, which provides an overview of conceptual frameworks for and research on the implementation of evidence-based practices and treatments for substance use disorders (SUDs). The types of treatments that are examined range from brief interventions to psychological treatments and continuing care to pharmacological treatment. The settings in which treatments are implemented range from primary care to specialty SUD care settings.
    Date: June 1, 2011
  • Women Veterans with History of Sexual Abuse at Higher Risk for Substance Use Disorder
    This study examined the associations between rape history and substance use disorders among women Veterans (age <51 years) who received care at two Midwestern VAMCs. Findings showed that lifetime substance abuse disorder was higher for women Veterans with a history of rape. Two-thirds (62%) of study participants reported lifetime sexual assault, including 11% reporting attempted rape and 51% reporting at least one completed rape. Women with women as sex partners had significantly higher rates of rape and lifetime substance use disorder (73% of women with women as sex partners reported lifetime rape vs. 48% of exclusively heterosexual women). Women with lifetime rape were more likely to report abstinence from drinking (50%) than women with no rape (41%). Women reported the highest rates of rape during childhood and military service (51% and 25%, respectively), and those reporting rape in any period of their lives were significantly more likely to report rape in other periods. For example, women Veterans reporting in-military rape were significantly more likely to report post-military rape (18% vs. 9%).
    Date: June 1, 2011
  • Veterans Receiving Higher-Dose Opioid Prescriptions for Pain at Increased Risk of Death from Overdose
    This study examined the association of maximum prescribed daily opioid dose and dosing schedule (“as needed,” regularly scheduled, or both) with risk of opioid overdose death among Veterans with cancer, chronic pain, acute pain, and substance use disorders. Findings showed that among Veterans receiving opioid prescriptions for pain, higher opioid doses were associated with increased risk of death from opioid overdose. The frequency of fatal overdose among Veterans treated with opioids was rare – estimated to be 0.04% - and was directly related to the maximum prescribed daily dose of opioid medication. There was no significant increased risk of opioid overdose among Veterans who were treated with both “as-needed” and regularly scheduled opioids – a strategy for treating pain exacerbations – after adjusting for maximum daily dose and patient characteristics. Veterans who died from opioid overdose were significantly more likely to have chronic or acute pain, substance use disorders, and other psychiatric disorders, but they were less likely to have cancer. This study highlights the importance of implementing strategies for reducing opioid overdose among patients being treated for pain, for example, ascertaining history of substance abuse, using treatment contracts, and scheduling frequent follow-up visits and toxicological screens for patients at special risk.
    Date: April 6, 2011
  • Measuring the Quality of Mental Healthcare: Barriers and Strategies
    This article discusses the barriers to mental health quality measurement – and identifies strategies to enhance the development and use of quality measures in order to improve outcomes for people with mental health disorders. The authors suggest that key reasons for the lag in mental health performance measurement include: lack of sufficient evidence regarding appropriate mental health care, poorly defined quality measures, limited descriptions of mental health services from existing clinical data, and lack of linked electronic health information. The refinement of quality measures and, ultimately, enhanced outcomes in mental health will require investment in information technology, additional studies to support the evidence base, and the development of a culture of measurement-based care. Sustaining efforts to improve mental health performance measurement will require rethinking how quality measurement is used to promote the uptake of evidence-based mental healthcare across systems of care. In addition, measurement systems should cut across mental health disorders, physical disorders, and substance use disorders, which often co-occur.
    Date: September 1, 2010
  • Minor Depression Highly Prevalent among Women Veterans with Complex Chronic Illness
    This study compared the rates of major and minor depression among women Veterans with chronic conditions (diabetes, heart disease, or hypertension) who received VA care in FY02. Of 13,430 women Veterans with depression, 60% were diagnosed with minor depression and 40% with major depressive disorders. Compared to major depression, minor depression was significantly more likely among women Veterans who were older, and those without any other psychiatric condition or substance use disorders. Results also show that compared to the hypertension only group, women Veterans with diabetes only or diabetes plus hypertension had higher rates of major depression. Moreover, all types of psychiatric conditions and substance use were associated with higher rates of major depression, and 22% of the study population had a substance use disorder. The authors suggest that the generally high rates of depressive disorders among women Veterans with chronic physical illnesses indicate the need for a continuum of care that encompasses both physical and mental illness domains.
    Date: August 1, 2010
  • Homelessness Affects Substance Use Treatment Outcomes and Costs among Veterans
    This analysis evaluated homelessness among Veterans who had entered VA outpatient substance use disorder treatment, and also explored associations between housing status, treatment outcomes, and use of VA services over one year. Findings suggest that the problem of homelessness among Veterans with substance use disorders remains large, with 65% of 622 Veterans in this study spending at least one night homeless at some point during the study period. Veterans experiencing homelessness during the six months prior to treatment admission had more severe alcohol, medical, employment, legal, and psychiatric problems than Veterans with housing. Abstinence rates did not differ between the homeless and housed groups, and about 65% of participants in each group remained engaged in treatment for 90 days. In addition, results showed that homeless Veterans used more services and had higher total costs than housed Veterans, e.g., homeless Veterans had more inpatient admissions and were more likely to use the emergency room.
    Date: July 1, 2010
  • Most VA Patients with Substance Use Disorders Who Die from Suicide Use Violent Means
    Most VA patients with substance use disorders (SUDs) who died from suicide used violent means (70%, n=600), and the majority were carried out with firearms. No specific SUD was associated with increased risks of violent suicide, but several SUD diagnoses (e.g., cocaine use and opiate use) were associated with a higher risk of non-violent suicide. Alcohol use was associated with a lower likelihood of non-violent suicide. While many psychiatric disorders (e.g., major depression, PTSD, schizophrenia) were associated with increased risk of both violent and non-violent suicide, the strength of the association between the disorder and type of suicide was greater for non-violent than violent suicide. The authors suggest that by linking data on risk factors to information about the specific methods used, future interventions designed to decrease access to lethal means could be tailored to focus on those at greatest risk of dying by specific means.
    Date: July 1, 2010
  • Military Sexual Trauma: Important Mental Health Issue for OEF/OIF Veterans
    Of the 125,729 OEF/OIF Veterans who received VA primary care or mental health services between 10/01 and 9/07, 15% of women and 0.7% of men reported military sexual trauma (MST) based on results of universal screening that asks about sexual assault or harassment. Women and men who reported a history of MST were significantly more likely than those who did not to be diagnosed with mental health conditions, including PTSD, other anxiety disorders, depression, and substance use disorders. This finding remained consistent after adjusting for demographics, healthcare use, and military service characteristics. The relationship of MST to PTSD was stronger among women compared to men, suggesting that MST may be a particularly relevant issue for women Veterans seeking care for PTSD. There were high rates of post-deployment mental health conditions among all OEF/OIF patients.
    Date: June 17, 2010
  • Prior Violence Associated with Greater Risk of Suicidal Thoughts and Attempts in Patients Seeking SUD Treatment
    Even after accounting for other known risk factors, such as symptoms of depression or childhood victimization, a history of violent behavior was consistently associated with a higher likelihood of lifetime suicidal thoughts and behaviors. Suicidal thoughts and attempts are common in those with substance use disorders (SUD): more than 43% of the participants in this study reported either prior suicide attempts or suicidal ideation at some point in their lives. A history of either suicidal ideation or suicide attempt(s) was more common among substance users who were female and those with a history of depression or childhood abuse.
    Date: February 1, 2010
  • Mental Illness and Substance Use Disorders Highly Prevalent Among Veterans with Spinal Cord Injury
    Using VA and Medicare data, this study sought to estimate the prevalence of mental illness and substance use disorders (SUDs) among 8,338 Veterans with spinal cord injury (SCI) who used outpatient or hospital care in VA or Medicare facilities between FY00 and FY01. Findings show that mental illness and SUDs are highly prevalent among Veterans with SCI. Overall, 47% of the Veterans in this study had either a mental illness or SUD. The most common mental illness was depression (27%), followed by anxiety (10%) and PTSD (6%). Tobacco use also was prevalent (19%), followed by alcohol (9%) and illicit drugs (8%). Moreover, mood and anxiety disorders were highly prevalent among those with chronic physical conditions such as diabetes, hypertension, and COPD. Results also showed that women Veterans had higher rates of mental illness and lower rates of SUD, and were significantly more likely to have mental illness only. In addition, as the duration of SCI increased, the likelihood of mental illness or SUD alone or in combination decreased.
    Date: November 1, 2009
  • Low Rates of HIV Screening among Veterans with Substance Use Disorders
    This study sought to determine the rate of HIV screening among Veterans with substance use disorders. Findings show that among the 371,749 Veterans with substance use disorders in this study, only 20% had evidence of ever having been screened for HIV. HIV screening was lowest among Veterans with alcohol use disorders alone (11%), and highest among Veterans treated in substance use programs (28%) or receiving inpatient care (28%). Authors suggest that these findings support the need for more widespread interventions to expand routine voluntary HIV screening nationally – within and outside VA.
    Date: October 1, 2009
  • Study Questions Validity of HEDIS Quality Measures for Substance Use Disorder Specialty Care
    Healthplan Employer Data and Information Set (HEDIS) is the most widely used set of quality measures, thus many healthcare systems now track HEDIS measures of Initiation and Engagement in Alcohol and Other Drug Dependence Treatment. Using VA data, this study identified 320,238 Veterans who received at least one of the HEDIS-specified substance use disorder (SUD) diagnoses during FY06. Investigators then developed a model to determine their progression through Initiation and Engagement, with a focus on clinical setting and care specialty. Findings show that Veterans who have contact with SUD specialty treatment have higher rates of advancing from diagnosis to Initiation – and from Initiation to Engagement – compared to Veterans who are diagnosed with substance use disorders in psychiatric or other medical locations. For example, outpatients who were diagnosed in SUD specialty treatment settings were much more likely to “initiate” than those who were diagnosed in psychiatric and other specialty settings. Results also showed that 85% of the Veterans who received an SUD diagnosis in FY06 did so first in an outpatient setting, and that more than 40% of “engagement” occurred outside of SUD specialty care. Therefore, the usual combining of inpatient and outpatient performance on these measures into overall facility scores may affect measurement and interpretation. The authors suggest that these particular quality measures be considered measures of facility performance rather than measures of the quality of SUD specialty care.
    Date: August 1, 2009
  • Continuity of Care Performance Measure Not Associated with Improved Outcomes for Veterans with Substance Use Disorders
    The Continuity of Care (CoC) performance measure specifies that patients should receive at least two substance use disorder (SUD) outpatient visits in each of the three consecutive 30-day periods after they qualify as new SUD patients. Findings from this study show that meeting the CoC performance measure was not associated with patient-level improvements in the Addiction Severity Index (ASI) alcohol or drug composites, days of alcohol intoxication, or days of substance-related problems. Higher facility-level rates of CoC were negatively associated with improvements in ASI alcohol and drug composites – and were not associated with follow-up abstinence rates.
    Date: April 1, 2009
  • Treatments for Co-Occurring Schizophrenia and Substance Use Disorders
    While studies to date suggest better outcomes with second-generation antipsychotics (SGAs), for example, olanzapine and risperidone, the available evidence does not clearly demonstrate an advantage for any particular SGA; thus investigators recommend that clinicians select the medication that balances efficacy and side effects for each individual patient.
    Date: October 1, 2008

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