Substance abuse as a predictor of VA medical care utilization among Vietnam veterans

A Composite Index of Compliance for Chronic In-Center Hemodialysis Patients

We developed a composite compliance index as the sum of the compliance scores for interdialytic weight gain (IDWG), pre-dialysis serum potassium and phosphorus concentrations (each scored from zero to 3, with 3 indicating the poorest compliance), and skipping hemodialysis sessions (scored from zero to 9, with 9 indicating the poorest compliance). We used this composite score to prospectively evaluate compliance in 25 prevalent hemodialysis patients over a period of 1 year. We then followed these patients for another 3.5 years. The patients studied were divided into two groups: group A (poor compliance) consisted of 9 subjects with composite score ≥ 9 (13.2 ± 3.2); group B (better compliance) consisted of 16 subjects with composite score < 9 (4.7 ± 1.8). Age, duration of hemodialysis, and frequency of diabetes mellitus did not differ between the groups. Group A contained higher fractions of subjects with history of alcoholism (66.7% vs 12.5%, p = 0.010), other substance addiction (44.4% vs 0%, p = 0.010), and severe psychosocial problems (88.9% vs 18.8%, p = 0.002). Mean survival from the beginning of observation, estimated by actuarial life-table survival analysis, was 1.19 years in group A and 2.60 years in group B (p = 0.0265). A composite compliance index incorporating domains indicating adherence to diet, medications, and dialysis schedule identified other behavioral problems in poorly compliant patients. Hemodialysis patients characterized by this composite index as poorly compliant had shortened survival.

A critical review of the epidemiology of Agent Orange/TCDD and prostate cancer

To inform risk assessment and regulatory decision-making, the relationship between 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) and prostate cancer requires clarification. This article systematically and critically reviews the epidemiologic evidence on the association between exposure to TCDD or Agent Orange, a TCDD-contaminated herbicide used during the Vietnam War, and prostate cancer risk. Articles evaluated include 11 studies of three cohorts, four case-control or cross-sectional studies, and three case-only studies of military veterans with information on estimated Agent Orange or TCDD exposure; 13 studies of seven cohorts, one case-control study, and eight proportionate morbidity or mortality studies of Vietnam veterans without information on Agent Orange exposure; 11 cohort studies of workers with occupational exposure to TCDD; and two studies of one community cohort with environmental exposure to TCDD. The most informative studies, including those of Vietnam veterans involved in Agent Orange spraying or other handling, herbicide manufacturing or spraying workers with occupational TCDD exposure, and community members exposed to TCDD through an industrial accident, consistently reported no significant increase in prostate cancer incidence or mortality. Only some potentially confounded studies of Vietnam veterans compared with the general population, studies with unreliable estimates of Agent Orange exposure, and analyses of selected subgroups of Vietnam veterans reported positive associations. Overall, epidemiologic research offers no consistent or convincing evidence of a causal relationship between exposure to Agent Orange or TCDD and prostate cancer. More accurate exposure assessment is needed in large epidemiologic studies to rule out a causal association more conclusively.

A qualitative investigation of long-term zopiclone use and sleep quality among Vietnam war veterans with PTSD

BACKGROUND

Self-reported sleep difficulties are common among patients with posttraumatic stress disorder (PTSD), but the routine use of hypnosedatives over extended periods is not generally recommended.

OBJECTIVE

To examine the effects of the extended use of zopiclone among a cohort of patients with combat-related PTSD.

METHODS

We conducted a 6-month follow-up cohort study of zopiclone usage characteristics for 26 combat veterans with PTSD. Psychometric and sleep assessments were also conducted at baseline and 6 months.

RESULTS

The mean baseline score obtained on the tranquilizer dependence questionnaire was 20.4 +/- 13.4, below the cutoff score proposed as indicative of a high likelihood of dependence (23 points). Eight (30.7%) subjects exceeded the proposed cutoff score for dependence at baseline. Most (n = 24) subjects reported poor sleep quality at baseline. Actigraphy revealed that the mean sleep efficiency score was 71.2 +/- 13.7% at baseline. A cohort of 13 men was available for inclusion in the follow-up phase of the study. The tranquilizer dependence questionnaire score at follow-up was broadly similar to the baseline score after a further 6 months of zopiclone use (18.9 at baseline compared with 19.9 +/- 2.6 at follow-up). Individual analysis revealed that the tranquilizer dependence scale score increased for 5 subjects and decreased for 8 subjects at follow-up. Four (30.7%) subjects in the follow-up cohort exceeded the proposed cutoff score for dependence at baseline and 6 (46.1%) subjects exceeded it at follow-up. Actigraphy data were consistent across measurements for individual subjects at baseline and follow-up, with similar mean sleep efficiency scores at baseline and after 6 months of treatment with zopiclone (69.6 +/- 12.7% at baseline; 71.33 +/- 19.0% at follow-up). The proportion of relatively poor sleepers (5/13 at baseline and 4/13 at follow-up) remained essentially unchanged.

CONCLUSIONS

Overall, the results of this study suggest that, although the subjects in the follow-up phase of the research continued to use zopiclone on a regular basis for an extended period, the efficacy of this intervention for addressing PTSD-related sleep disturbance was low. Extended treatment with zopiclone may not necessarily be associated with increased risk for dependence. Further robust research to examine the consequences of long-term zopiclone therapy for PTSD-related sleep disturbance is warranted.

Post-traumatic stress disorder, drug dependence, and suicidality among male Vietnam veterans with a history of heavy drug use

This study examines the roles of post-traumatic stress disorder (PTSD) and drug dependence in non-fatal suicidality, i.e., suicidal ideation and suicide attempt, among Vietnam veterans in their adult years. The sample includes male veterans deployed to Vietnam, including an oversample of those who tested positive for opiates at their return (n = 642). PTSD, substance abuse, suicidality, and other psychopathology are analyzed using three waves of survey and military data covering the time period from early adolescence to middle adulthood. Measures include the onset and recency of each of the lifetime DSM-IV PTSD symptom criteria, and yearly symptom measures of DSM-IV dependence for alcohol and eight classes of psychoactive substances. Survival and hazard models are applied to assess the effects of drug dependence, PTSD, and other psychopathology on the duration of suicidality. Longitudinal models estimate the casual relationships among PTSD, drug dependence, and suicidality over a 25-year period. Results show evidence of strong continuity of PTSD, drug dependence, and suicidality over time. The causal role of drug dependence on PTSD and suicidality is limited to young adulthood. Evidence is stronger for self-medication in later adulthood. The results indicate that a life course perspective is needed for the combined treatment of PTSD and drug dependence for severely traumatized populations.

Discriminators of suicide thoughts and attempts among homeless veterans who abuse substances

Six hundred homeless military veterans who abused substances were examined to determine what factors discriminate between nonsuicidal veterans, those who had suicidal thoughts, and persons who had attempted suicide. Several factors were considered based on attachment theory, including caregiver attachment, sexual abuse, physical abuse, resilience, self-efficacy, and self-esteem. Suicide attempters were discriminated from others by psychiatric comorbidity, early abuse, severity of substance abuse, and longevity of drug use. In contrast, the discriminators between nonsuicidal homeless substance abusers and others were elements of attachment and commitments such as marriage, employment, and religiosity. Some implications of the findings for intervention are discussed.

Alcohol use, alcohol disorders, and the use of health services: results from a population survey

Data from a population survey were used to explore relationships among drinking levels/patterns, alcohol dependence or abuse, and the use of emergency services, hospital admissions, and frequent visits to general practitioners in the past year. For both males and females, self-reported hospital admissions were less common among daily moderate drinkers than among lifetime abstainers. Among males, drinkers with no history of alcohol dependence or abuse were less likely to report being in hospital in the last year than lifetime abstainers. For females, some groups defined by drinking patterns/levels and current drinkers without symptoms of alcohol abuse or dependence were more likely to report using emergency services than lifetime abstainers.

Remission from drug abuse over a 25-year period: patterns of remission and treatment use

OBJECTIVES

Using an epidemiologically obtained sample, we examined patterns of illicit drug use, abuse, and remission over a 25-year period and recent treatment use.

METHODS

The surviving members of the cohort (n = 841), previously surveyed in 1972 and 1974, comprised 3 subsamples of Vietnam War enlisted men and civilian controls. Retrospectively obtained year-to-year measures from the 1996-1997 survey included use and remission of sedatives, stimulants, marijuana, cocaine, and opiates, as well as substance abuse and psychiatric treatment use.

RESULTS

Relatively stable patterns of frequent use in adulthood were found, with the mean duration from initiation to the last remission ranging from 9 to 14 years. A majority attempted to quit; however, most did not use traditional drug treatment in their last attempts. Fewer than 9% of the then-current drug users were treated in inpatient or outpatient settings at the time of data collection.

CONCLUSIONS

Most drug abusers who had started using drugs by their early 20s appeared to gradually achieve remission. Spontaneous remission was the rule rather than the exception. Nonetheless, considerable unmet needs existed for those who had continued use into middle age.

Inpatient rehabilitation after stroke: a comparison of lengths of stay and outcomes in the Veterans Affairs and non-Veterans Affairs health care system

BACKGROUND

Patients have longer lengths of hospital stay (LOS) in VA medical centers than in the general health care system.

OBJECTIVE

The objective of this study was to determine whether resource use and outcome differences between VA and non-VA inpatient rehabilitation facilities remain after controlling for patient and medical care delivery differences.

DESIGN

This analysis involved 60 VA inpatient rehabilitation units and 467 non-VA rehabilitation hospitals and units. Multivariate adjusted resource use and patient outcome differences were compared across setting within patients grouped by severity of disability at admission through assignment to the Function Related Group (FRG) patient classification system.

SUBJECTS

The study included 55,438 stroke patients.

MEASURES

Study measures were LOS, functional status at discharge, and community discharge.

RESULTS

The VA serves a higher proportion of patients who are single, separated, or divorced; are unemployed or retired as a result of disability, and are not white (P < 0.0001). These traits tended to be associated with longer LOS, lower functional outcomes, and reduced rates of community discharge. After adjusting for these and other differences, depending on FRG, average LOS remained from 30% to 200% longer in the VA centers (P < 0.05); average functional outcomes were significantly higher in 8 and lower in 2 FRGs (P < 0.05); and community discharge rates were lower in 12 FRGs (P < 0.05).

CONCLUSIONS

While certain variables accounted for some of the observed differences in resource use and outcomes, differences remained after adjustment. Fewer incentives for cost containment and less support in patients' home environments may be among the most important unmeasured determinants of VA differences.

Characteristics of tranquilizer use among Australian Vietnam War veterans

OBJECTIVE

To examine characteristics of tranquilizer use in a cohort of Australian Vietnam War veterans.

DESIGN

Prospective analysis of medication use and assessment of social and clinical variables, including tranquilizer dependence.

PATIENTS

Fifty-one Australian Vietnam War veterans were recruited from the department of psychiatry of an Australian teaching hospital. All subjects were men, with a mean +/- SD age of 52.2 +/- 3.3 years.

MAIN OUTCOME MEASURES

A structured interview was used to obtain details of medical and psychiatric history, medication use, substance use, forensic history, and health service utilization data. Anxiety was assessed using the Hamilton Anxiety Rating Scale (Ham-A). A validated tranquilizer dependence rating scale was administered for each patient.

RESULTS

Commonly used tranquilizers included diazepam (n = 19 patients) and zopiclone (26). Most patients (44) reported the use of one or more drugs for the purpose of nighttime sedation, while exclusive daytime use of tranquilizers for anxiolytic effect was uncommon. The median time spent in the hospital during the preceding year was 21.0 +/- 56.8 days. Symptoms of anxiety were prevalent, with a mean Ham-A score of 35.5 +/- 7.8. Screening criteria suggestive of tranquilizer dependence were met in 34 subjects. Health service utilization was correlated with tranquilizer intake and overall medication use. Tranquilizer dependence was independently associated with cigarette smoking (p = 0.039; odds ratio = 5.13, 95% CI 1.08 to 24.33).

CONCLUSIONS

This study provides insight into the nature of tranquilizer use in an Australian population of Vietnam War veterans. The extensive use of these drugs suggests that further research and possibly intervention in this area is needed.