Characteristics of women seeking intensive outpatient substance use treatment in the VA

Treatment of hepatitis C virus infection in people with opioid use disorder: a real-world study of elbasvir/grazoprevir in a US Department of Veterans Affairs population

Background: Hepatitis C virus (HCV) infections in the United States have increased in recent years, with the most rapid rise among people who inject drugs (PWIDs). Historically, there have been concerns regarding treatment adherence among PWIDs with HCV infection, leading to undertreatment of this population and increased HCV transmission. Elbasvir (EBR)/grazoprevir (GZR) has demonstrated high rates of virologic cure (sustained virologic response [SVR]) in clinical trials enrolling PWIDs with HCV infection. Objective: To evaluate the real-world effectiveness of EBR/GZR in HCV genotype (GT) 1-infected patients with a diagnosis of opioid use disorder. Methods: A retrospective analysis of electronic medical records from the US Department of Veterans Affairs Corporate Data Warehouse. Adults with chronic HCV GT1 infection, ≥1 prescription for EBR/GZR, and ≥1 clinic visit were included. All patients had ≥1 ICD-9/10 code of opioid use disorder. SVR was the primary outcome. Results: 419 patients were included; 97.1% had a history of any illicit drug use and 40.8% were receiving medication for opioid use disorder (MOUD). SVR was achieved by 96.9% (406/419) of all patients, 97.0% (350/361) of those receiving EBR/GZR for 12 weeks, and 95.3% (163/171) of those receiving MOUD. SVR in patients receiving psychiatric medications ranged from 96.1% (221/230) in those taking antidepressant medications to 98.5% (128/130) in those taking mood stabilizers. Conclusion: In this real-world setting, high rates of virologic cure were achieved in patients with HCV GT1 infection on MOUD receiving EBR/GZR for 12 weeks, including patients with multiple comorbidities and high rate of psychiatric medication use.

Longitudinal assessment of PTSD and illicit drug use among male and female OEF-OIF veterans

OBJECTIVES

Posttraumatic stress disorder (PTSD) and substance use share both directional ("self-medication") and mutually-reinforcing associations over time. Research on gender differences regarding the co-occurrence of PTSD and substance use over time remains limited and largely focused on alcohol use; less is known regarding the co-occurrence of PTSD and illicit drug use, especially among veteran men vs. women. As the proportion of women in the military expands, we believe a greater focus on gender differences is warranted.

METHOD

We conducted a cross-lagged panel analysis of PTSD symptoms and drug use problems using two waves of data from a large, nationwide longitudinal registry of post-9/11 veterans. Participants included 608 men and 635 women (N = 1243; M_age = 42.3; 75.2% White) who completed self-report PTSD and drug use problem questionnaires at T1 and again at T2 15-37 months later.

RESULTS

Veteran men reported more severe drug use and related problems overall, yet the cross-sectional correlation between PTSD and drug use problems was strongest among drug using veteran women. In our cross-lagged models, we found that PTSD symptoms predicted future drug use problems among veteran men, whereas drug use problems predicted future PTSD symptom severity among women.

CONCLUSIONS

These results support the self-medication pathway among veteran men but not women, for whom drug use problems might prolong or exacerbate PTSD symptom severity over time. These results are consistent with some emerging evidence but also provide novel insight into functional associations governing the longitudinal course of PTSD and drug use problems for men vs. women.

Psychosocial Factors that Shape Substance Abuse and Related Mental Health of Women Military Veterans who Use Community-Based Services

BACKGROUND

Women Veterans who use the Veterans Health Administration (VA) have high rates of substance abuse and poorer health than non-Veteran women. Less is known about the psychosocial needs of women Veterans who seek care in non-VA settings.

OBJECTIVES

We provide a grounded description of factors that impact substance abuse, mental health, and related quality of life of women Veterans who use non-VA community-based health and social services.

METHODS

Utilizing a mixed methods design, we conducted semi-structured in-person interviews with 22 women Veterans in Los Angeles in 2013-2015.

RESULTS

The current health of these women Veterans was shaped by substance abuse and several other factors, including: histories of trauma (in childhood, during military service) and discrimination, and associated mental health conditions; post-military socio-economic stressors; shifting social roles and adverse social support; and lost personal identity after military service. Psychosocial factors collectively underscore areas in which delivery of health and social services to women Veterans being treated in non-VA settings could be improved: (1) diffuse, implement, and sustain evidence-based gender-sensitive substance abuse treatment; (2) address traumas contributing to poor health; (3) recognize stress proliferation processes erode women's capacity to access healthcare or cope with stressors in healthy ways; (4) champion women Veterans who embody resilience and thereby can help others to form empowered personal identities of health and wellness.

CONCLUSION

Findings can inform interventions and services that ameliorate vulnerability to substance abuse and other health risks among women Veterans.

Predicting utilization of healthcare services in the veterans health administration by returning women veterans: The role of trauma exposure and symptoms of posttraumatic stress

Combat exposure and military sexual trauma (MST) are prevalent among returning women veterans and are associated with increased alcohol use and psychological distress. However, it remains unclear the extent to which combat exposure and MST are associated with utilization of health care in the Veterans Health Administration (VHA). The current study explored the relationships among alcohol use and distress in women who deployed in support of Operations Enduring Freedom, Iraqi Freedom, and New Dawn. It was hypothesized that increased posttraumatic stress disorder (PTSD) and depression symptomatology and trauma exposure would be related to greater VHA utilization, whereas alcohol misuse would predict lower VHA use. Participants (N = 133) completed an Internet-based survey of deployment experiences, substance use, mental health, and utilization of VHA services. In this sample, 33% endorsed MST exposure, 64% endorsed combat exposure, and 78% indicated exposure to the aftermath of battle. Multiple regression models found combat exposure-but not MST or aftermath-to be significantly associated with alcohol use and symptoms of PTSD and depression. Only 37% of participants reported use of VHA services, and logistic regression models indicated that PTSD symptomatology was the only unique predictor of VHA use. Findings suggest potential barriers for women who endured sexually based trauma in a military setting in seeking treatment at the VHA.

The Prevalence of Posttraumatic Stress Disorder Symptoms among Addiction Treatment Patients with Cocaine Use Disorders

Co-occurring cocaine use and posttraumatic stress disorders are prevalent and associated with negative treatment, health and societal consequences. This study examined the relationships among PTSD symptoms, gender, and cocaine use problems. Within a cross-sectional design, we gathered archival point prevalence data on new admissions (n = 573) to three addiction treatment agencies. Demographic, substance use, and PTSD symptom information were collected across the three agencies. Logistic regression analyses revealed that patients with cocaine use disorders had a two-fold increased odds for a probable PTSD diagnosis, compared to patients without a cocaine use disorder (OR = 2.19, 95% CI = 1.49-3.22, p < 0.001). Among females with cocaine use disorder, multinomial regression yielded a significant increase in the risk of moderate (RRR = 2.12, 95% CI = 1.10-4.10, p < 0.05) and severe (RRR = 2.87, 95% CI = 1.33-6.21, p < 0.01) PTSD symptoms. Males with cocaine use disorders had a two-fold increase in the risk of moderate PTSD symptoms (RRR = 2.13, 95% CI = 1.23-3.68, p < 0.01), but had no increased risk of developing severe PTSD symptoms (RRR = 1.93, 95% CI = 0.85-4.39, p = 0.117). Cocaine use appears to impact the risk of PTSD symptoms, especially in females. Future research should explore the generalizability of these findings to more racially and ethnically diverse samples, as well as among persons with this comorbidity who are not engaged in treatment services.

Cessation of injecting drug use: The effects of health service utilisation, drug use and demographic factors

BACKGROUND

Injecting drug use is associated with a range of harms, however cessation of injecting is rare. There is a lack of evidence on factors associated with cessation, notably those related to health services other than drug treatment. We examined the incidence and identified longitudinal correlates of first episode of cessation in a cohort of people who inject drugs (PWID).

METHODS

Using discrete-time survival analysis, we examined correlates of the first episode of cessation (no self-reported injecting drug use in the past 12 months), including the use of health services, socio-demographics and drug-related behaviour in a cohort of PWID recruited between 2008 and 2010.

RESULTS

The cohort of 467 participants contributed 1527 person-years from recruitment to 2014. Under a fifth (17.8%) of people reported cessation of 12 months or more, yielding a cessation rate of 5.4 events per 100 person-years. Younger age (25-29 compared to 30 and above) (adjusted hazard ratio (AHR) 1.79, 95% confidence interval (CI) 1.07-3.00) and male gender (AHR 1.67, 95% CI 2.01-2.76) were positively associated with cessation, while past year use of benzodiazepines (AHR 0.45, 95% CI 0.28-0.72), arrest in the past year (AHR 0.50, 95% CI 0.30-0.83) and low SF-8 physical dimension score (AHR 0.42, 95% CI 0.20-1.88) were negatively associated with cessation. Outpatient service use had the largest effect on cessation (AHR 2.28, 95% CI 0.94-5.48, p=0.067).

CONCLUSIONS

Low rates of cessation emphasise the need for sustained and comprehensive harm reduction services. The relationship between outpatient services and cessation suggests that further research into the use in health services among PWID is warranted.

Alcohol use, military sexual trauma, expectancies, and coping skills in women veterans presenting to primary care

BACKGROUND

Little is known regarding alcohol use and its correlates in women veterans. An understanding of these variables is of utility to providers in primary care at Veterans Affairs (VA) hospitals, who are among the first to identify and intervene for problem drinking.

OBJECTIVE

The objective of this study was to describe and explore the associations between posttraumatic stress disorder symptoms, experience of military sexual trauma (MST), expectancies for alcohol use, and coping skills in predicting drinking behavior.

DESIGN

Each month all women veterans attending appointments in primary care were mailed a letter alerting them to the study. Women then received a call asking them to participate, and many were directly recruited at their primary care appointment. Participants then completed a survey of current alcohol use and related variables in a private room.

PARTICIPANTS

Participants were 93 women veterans seeking care at VA.

MAIN MEASURES

Measures included the Alcohol Use Disorders Identification Test, a modified version of the VA MST screen, the Davidson Trauma Scale; the Coping Inventory for Stressful Situations, and the Brief Comprehensive Effects of Alcohol Questionnaire.

KEY RESULTS

Positive expectancies and evaluations emerged as significant correlates of AUDIT scores, while PTSD symptoms were not related to AUDIT scores. A hierarchical regression revealed a significant positive interaction between avoidance coping and positive evaluations. Depression, positive evaluations and avoidance coping were significant independent predictors of AUDIT scores in the final model, but MST was not.

CONCLUSIONS

Findings highlight the importance of considering of the function of alcohol use when delivering clinical interventions and the need for further research on the association between MST and drinking in women veterans.

Substance use among women veterans: epidemiology to evidence-based treatment

An increasing percentage of women are U.S. Military Veterans. We review the substance misuse rates and comorbidities and the risk factors for and consequences of substance use among women Veterans. Women Veterans may have higher rates of substance misuse and comorbid psychiatric and medical disorders than male Veterans and women who are not Veterans. Studies support the AUDIT-C as a scaled marker of alcohol-related risk among female Veterans, but validated drug screening instruments are needed. We discuss evidence-based approaches in terms of treating women Veterans' substance misuse in primary and specialty care settings, along with knowledge gaps and potential research priorities to improve care in this special population.

An examination of psychiatric comorbidities as a function of gender and substance type within an inpatient substance use treatment program

BACKGROUND

There are elevated rates of comorbid psychiatric disorders among individuals with substance dependence; however, little research examines these rates within inpatient settings, particularly in relation to gender and type of substance. The current study aimed to fill this gap.

METHOD

465 patients (71.4% male) were recruited from an inpatient substance use treatment facility from 2006 to 2009. These patients were interviewed and diagnosed using the Structure Clinical Interview for DSM-IV and the Diagnostic Interview for Personality Disorders.

RESULTS

60.6% of patients with substance dependence had a current comorbid psychiatric disorder, and more than 30% had at least two psychiatric disorders. The most common current Axis I diagnosis was major depressive disorder (25.8%), followed by PTSD (14%). Comparable rates were found for Antisocial and Borderline Personality Disorders. Females were significantly more likely to meet diagnostic criteria for a psychiatric disorder than were males (73.7% versus 55.4%). When examining comorbidities across different substance dependences, the highest rates of comorbid psychiatric disorders were found among individuals with alcohol dependence (76.8%) and cannabis dependence (76%), although rates were above 60% for cocaine and opioid dependence. Rates of psychiatric diagnoses were significantly lower (27%) among patients who did not meet diagnostic criteria for substance dependence.

CONCLUSIONS

There are particularly elevated rates of psychiatric disorders among individuals with substance dependence in inpatient treatment. These rates differ as a function of substance dependence type and gender, making these factors important to consider when researching and treating this type of population.

Female veterans of the OEF/OIF conflict: concordance of PTSD symptoms and substance misuse

This study examined the post-deployment rates of comorbid PTSD and substance abuse in a cohort of female veterans who served in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). Female OEF/OIF veterans and reservists (N=36) completed a battery of assessments as part of a larger study. Of the 36 participants, 11 (31%) screened positive for posttraumatic stress disorder (PTSD), 17 (47%) screened positive for high-risk drinking and 2 (6%) screened positive for drug abuse. Higher scores on measures of alcohol and drug use predicted positive PTSD status (p < or = 0.01) and alcohol misuse was significant in explaining unique variance of PTSD status (p < or = 0.05). Our findings suggest a trend toward increased problematic drinking among female OEF/OIF veterans and reservists and a relationship between substance misuse and PTSD. Future research should investigate needs for gender-specific PTSD and substance-abuse treatment needs.