Polysubstance Use Among Veterans in Intensive PTSD Programs: Association With Symptoms and Outcomes Following Treatment

Age, sex, and race-varying rates of alcohol use, cannabis use, and alcohol and cannabis co-use in veterans vs. non-veterans

BACKGROUND

Military veterans are a high-risk group for health risk behaviors, including alcohol and cannabis use. However, research on veteran vs. non-veteran rates of alcohol/cannabis use are inconsistent across studies. Further, no research has investigated veteran vs. non-veteran rates of alcohol and cannabis co-use, and few studies have tested whether demographic variables, particularly race/ethnicity, moderate group differences. Therefore, the current study tested whether 1) veteran vs. non-veterans differed in rates of alcohol use, cannabis use, and alcohol and cannabis co-use, and 2) whether demographic covariates (age, sex, race/ethnicity) moderated associations.

METHODS

Data on adults (N = 706,897; 53.4% female) were derived from the 2002-2019 National Study on Drug Use and Health. Participant demographics, alcohol use frequency, drinking quantity, and cannabis use frequency were self-reported.

RESULTS

Non-veterans reported higher drinking quantity, cannabis frequency, and co-use. However, being a veteran was a risk factor for heavier drinking for women, ethnic/racial minoritized participants, and adults under the age of 50. Additionally, veteran status was a risk factor for cannabis use frequency in racial/ethnic minoritized participants and women. Similarly, being a veteran was a risk factor for alcohol and cannabis co-use for racial/ethnic minoritized participants, and the buffering effect of being a Veteran on co-use was reduced for older participants and women.

CONCLUSIONS

Results suggest that, at the population level, non-veterans may be heavier alcohol/cannabis users. However, moderating analyses suggested that being a veteran is a risk factor for women, racial/ethnic minoritized individuals, and younger individuals. Findings are discussed in terms of public health implications.

Combined use of alcohol and cannabis: Introduction to the special issue

OBJECTIVE

Combined use of alcohol and cannabis has increased in recent years among certain age groups, and it is well established that individuals who use both alcohol and cannabis (especially if they use both at the same time) are at increased risk for substance-related harms relative to individuals who use only one substance. Far less attention has been placed on the patterns, predictors, and psychological processes associated with alcohol and cannabis co-use, which may inform prevention and intervention programming. Accordingly, this special issue was assembled to advance our understanding of the characteristics and consequences of combined use of alcohol and cannabis.

METHOD

In this introductory article, the Guest Editors present the background for this work and provide an overview of the 14 articles that comprise this special issue.

RESULTS

Studies contained in this special issue capitalize on a variety of methodologies, with a particular focus on investigating typologies of alcohol and cannabis co-use, clarifying motivational and social contexts of co-use, and tracking co-use in daily life via daily diary and ecological momentary assessment designs. Experimental and neuroimaging examinations of co-use are also included. Collectively, the studies generally provide evidence that combined use of alcohol and cannabis is associated with unique characteristics, predictors, consequences, and psychological processes relative to single-substance use.

CONCLUSIONS

The studies in this special issue provide new insight into combined use of alcohol and cannabis. They also highlight a number of promising avenues for future inquiry as the literature on alcohol and cannabis co-use continues to grow. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Drinking less on cannabis use days: The moderating role of UPPS-P impulsive personality traits

Objective: Several studies suggest that alcohol and cannabis co-users are heavier drinkers and experience more alcohol-related consequences. However, day-level associations between co-use and drinking levels are mixed. One reason may be that individual characteristics moderate the daily impact of using alcohol alone or in conjunction with cannabis. The theory would suggest that highly impulsive individuals may drink more on co-use days, yet this assertion remains untested. Therefore, the current study tested whether impulsivity moderated the effect of co-use on same-day drinking quantity within veterans, a high-risk sample for substance use and impulsivity. Method: In a longitudinal observational study, co-using veterans (N = 139) completed three semi-annual assessments reporting on their daily drinking quantity and cannabis use via Timeline Followback (Observations = 19,245) and impulsivity via the UPPS-P. Mixed effect modeling was used to test hypotheses that co-use (compared to alcohol-only) days would be associated with heavier drinking for those high (but not low) in positive and negative urgency. Results: Significant interactions were found for positive urgency (PU) and lack of perseverance (LP), such that individuals at mean and low levels of PU and LP drank less on co-use (compared to alcohol-only) days. There were no significant interactions for other UPPS-P impulsivity facets. Conclusion: Findings are consistent with a substitution/compensatory effect for individuals at mean and low levels of both UPPS-P facets, and may be a byproduct of frequent cannabis use in veterans. In contrast, findings suggest that co-use and alcohol-only days may be characterized by similarly high levels of drinking for highly impulsive individuals. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Psychiatric Multimorbidity in a Specialized Program for Severely Mentally Ill Veterans

It has been suggested that psychiatric multimorbidity may better characterize severely impaired psychiatric patients than individual severe mental illness (SMI) diagnoses, and that these patients may be better served by centers offering integrated co-located, psychiatric and social services than in conventional clinics providing one-to-one care. We tested the hypothesis that multimorbidity is a critical characteristic of Veterans treated at a co-located multi-service Veteran's Health Administration (VHA) program originally established to treat Veterans living with SMI. Administrative data from the VA Connecticut Health Care System from fiscal year 2012 were used to compare veterans using diverse mental health and social services at the Errera Community Care Center (ECCC), an integrated "one-stop shop" for SMI veterans, and those seen exclusively at standard outpatient mental health clinics. Bivariate and multiple logistic regression analyses were used to compare groups on demographic characteristics, psychiatric and medical diagnoses, service utilization, and psychotropic medication fills. Results: Of the 11,092 veterans included in the study, 2281 (20.6%) had been treated at the ECCC and 8811 (79.4%) had not. Multivariable analysis highlighted the association of treatment in the ECCC and younger age, lower income, homelessness, and especially multimorbidity including both multiple substance use and multiple psychiatric diagnoses. Programs originally designed to address the diverse needs of patients living with SMI and homelessness may be usefully characterized as treating patients with psychiatric multimorbidity, a term of greater clinical relevance. Effectiveness research is needed to evaluate the one-stop shop approach to their treatment.

Examining Sex and Racial/Ethnic Differences in Co-use of Alcohol, Cannabis, and Cigarettes in a Community Sample of Adolescents

INTRODUCTION

Although adolescents often co-use alcohol, cigarettes, and cannabis, little is known about sex and racial/ethnic differences in the co-use of these substances. Therefore, this investigation examined sex and racial/ethnic differences in alcohol, cigarette, and cannabis co-use in a large and ethnically diverse group. Methods: Participants were drawn from a large, multi-site study of adolescents from three regions in the United States (N = 4,129; Mage=16.10 years, SD = 0.59; 51% female, 49% male; 37% Black, 37% Hispanic, 25% White). Participants were categorized into eight mutually exclusive groups based on their self-reported use of alcohol, cannabis, and cigarettes in the last 30 days. Results: Unadjusted multinomial logistic regression revealed that males were more likely than females to use cannabis-only and to co-use all three substances. Additionally, Black and Hispanic adolescents were more likely to use cannabis-only, while White adolescents were more likely than Black and Hispanic adolescents to co-use alcohol and cigarettes. After adjusting for other sociodemographic variables (age, household income, parental education, and parent marital status), males were more likely to use cannabis-only than females; White youth were more likely than Hispanic youth to use cigarettes only and co-use cigarettes and alcohol. White youth were more likely than Black youth to co-use alcohol and cigarettes and co-use all three substances. Discussion: These results indicate sex and racial/ethnic differences in substance co-use that were not explained by socioeconomic factors. Results of this work suggest potential strategies for targeted prevention efforts and underscore the importance of continued efforts to better understand patterns of alcohol and substance co-use.

Impact of cannabis on non-medical opioid use and symptoms of posttraumatic stress disorder: a nationwide longitudinal VA study

BACKGROUND

Multiple states have authorized cannabis as an opioid substitution agent and as a treatment for posttraumatic stress disorder (PTSD).

OBJECTIVES

This study sought to investigate the relationship between cannabis use, non-medical opioid use, and PTSD symptoms among U.S. veterans.

METHODS

From 1992-2011, veterans admitted to specialized intensive PTSD treatment participated in a national evaluation with assessments at intake and four months after discharge. Participants with non-medical opioid use ≥ 7 days during the 30 days preceding admission were divided into two groups: those with cannabis use ≥ 7 days, and those without cannabis use. These two groups were compared on measures of substance use and PTSD symptoms at baseline and 4-months outpatient follow-up. We hypothesized that, at both assessments, the group with baseline cannabis use would show less non-medical opioid use and less severe PTSD symptoms.

RESULTS

Of 1,413 veterans with current non-medical opioid use, 438 (30.3%) also used cannabis, and 985 (69.7%) did not. At baseline, veterans with concurrent non-medical opioid and cannabis use had slightly fewer days of non-medical opioid use (p < .005; d = -0.16), greater use of other substances (p < .0001) and more PTSD symptoms (p = .003; d = 0.16), compared to veterans who used non-medical opioids but not cannabis. At follow-up, substance use or PTSD symptoms did not significantly differ.

CONCLUSION

Cannabis use was not associated with a substantial reduction of non-medical opioid use, or either improvement or worsening of PTSD symptoms in this population. Hence, these data do not encourage cannabis use to treat either non-medical opioid use or PTSD.

Gender Difference in Substance Use and Psychiatric Outcomes Among Dually Diagnosed Veterans Treated in Specialized Intensive PTSD Programs

OBJECTIVES

Posttraumatic stress disorder (PTSD) is a problem of growing importance among female veterans, which is especially challenging when accompanied by comorbid substance use disorder (SUD). Since women are still a small minority of Veterans Health Administration (VHA) patients, there is concern that outcomes among dually diagnosed women may be worse than among men.

METHOD

National program evaluation data were collected at admission and 4 months after discharge from 7,074 dually diagnosed veterans including 203 women (2.9%) treated at 57 specialized intensive VHA PTSD treatment programs between 1993 and 2011. Multiple regression was used to compare clinical change in women and men adjusting for baseline differences.

RESULTS

Women showed no significant differences from men in measures of substance use or total PTSD symptoms at admission although they were more likely to have experienced sexual trauma and less likely to report combat exposure. With adjustment for these differences, there were no significant gender differences in length of stay, satisfaction with treatment, or measures of change in substance use or total PTSD symptoms 4 months after discharge. Reductions in an index of days of substance use was associated with reduction in total PTSD symptoms among both women (R = 0.33; p = .01) and men (R = 0.44, p < .0001) with no significant gender difference.

CONCLUSION

No significant gender differences were observed in substance use or PTSD outcomes, despite the extreme minority status of women in VHA programs. Highly vulnerable women can benefit as much as men, even when treatment is not formally tailored to address gender-specific needs.

Early Discontinuation of Buprenorphine Therapy for Opioid Use Disorder Among Privately Insured Adults

OBJECTIVE

This study examined the temporal relationship between early discontinuation of buprenorphine treatment and health care expenditures before and after treatment initiation.

METHODS

MarketScan commercial claims for patients who initiated buprenorphine for opioid use disorder in 2013 and had continuous insurance for the subsequent 12 months (N=6,444) were used to examine the relationship between treatment retention and health care expenditures before and after buprenorphine initiation. Analysis of covariance and generalized linear models (with gamma distribution/log link) were used to compare expenditures across four buprenorphine-retention groups (0-3, 3-6, 6-12, and 12 or more months).

RESULTS

Average total health care expenditures in the 3 months prior to buprenorphine initiation ranged from a high of $7,588 among those with the shortest retention to $4,929 among those with the longest retention (p<0.001). In the 12 months after buprenorphine initiation, total health care expenditures averaged $26,332 per year, with $2,916 (11.1%) in out-of-pocket expenditures. Average annual expenditures for medication were highest among patients with the longest buprenorphine retention, and total health care expenditures were highest among those with the shortest retention. Expenditures for health care services other than medication were highest among those with early discontinuation both before the initiation of buprenorphine and during the initial period after initiation but not in subsequent quarters.

CONCLUSIONS

Poorer treatment retention among privately insured adults was associated with greater clinical and financial burdens that preceded and continued during the period shortly following treatment initiation, suggesting that cost burdens may contribute to poor retention among privately insured adults.