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Abid A, Paracha M, Çepele I, Paracha A, Rueve J, Fidahussain A, Rehman H, Engelhardt M, Alyasiry N, Siddiqui Z, Vasireddy S, Kadariya B, Rao N, Das R, Rodriguez W, Meyer D. Examining the relationship between head trauma and opioid use disorder: A systematic review. J Opioid Manag 2024; 20:63-76. [PMID: 38533717 DOI: 10.5055/jom.0846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
OBJECTIVE To examine recent literature and determine common clinical risk factors between antecedent traumatic brain injury (TBI) and the following development of opioid misuse and provide a framework for clinical identification of at-risk subjects and evaluate potential treatment implications within this association. DESIGN A comprehensive systematic literature search of PubMed was conducted for articles between 2000 and December 2022. Studies were included if the human participant had any head trauma exposure and any chronic opioid use or dependence. After eligibility criteria were applied, 16 studies were assessed for thematic trends. RESULTS Opioid use disorder (OUD) risks are heightened in cohorts with head trauma exposed to opioids while in the hospital, specifically with tramadol and oxycodone. Chronic pain was the most common predictor of long-term OUD, and continuous somatic symptoms associated with the TBI can lead to long-term opioid usage. Individuals who present with coexisting psychiatric conditions pose significantly more risk associated with a higher risk of long-term opioid use. CONCLUSION Findings indicate that therapists and clinicians must consider a risk profile for persons with TBI and follow an integrated care approach to account for mental health, prior substance misuse, presenting somatic symptoms, and current medication regimen during evaluation.
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Affiliation(s)
- Ali Abid
- Saint Louis University, St. Louis, Missouri. ORCID: https://orcid.org/0000-0001-5786-4051
| | | | - Iva Çepele
- Saint Louis University, St. Louis, Missouri
| | - Awais Paracha
- Saint Louis University School of Medicine, St. Louis, Missouri
| | | | | | | | - McKimmon Engelhardt
- Midwestern University Chicago College of Osteopathic Medicine, Chicago, Illinois
| | | | - Zohair Siddiqui
- Saint Louis University School of Medicine, St. Louis, Missouri
| | - Satvik Vasireddy
- Touro University Nevada College of Osteopathic Medicine, Henderson, Nevada
| | - Bishal Kadariya
- Edward Via College of Osteopathic Medicine, Blacksburg, Virginia
| | - Nikith Rao
- Midwestern University Chicago College of Osteopathic Medicine, Chicago, Illinois
| | - Rohan Das
- Saint Louis University School of Medicine, St. Louis, Missouri
| | - Wilson Rodriguez
- Department of Neurology and Psychiatry, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Dixie Meyer
- Department of Family and Community Medicine, Saint Louis University, St. Louis, Missouri
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2
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Wilson LD, Maiga AW, Lombardo S, Nordness MF, Haddad DN, Rakhit S, Smith LF, Rivera EL, Cook MR, Thompson JL, Raman R, Patel MB. Dynamic predictors of in-hospital and 3-year mortality after traumatic brain injury: A retrospective cohort study. Am J Surg 2023; 225:781-786. [PMID: 36372578 PMCID: PMC10750767 DOI: 10.1016/j.amjsurg.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/27/2022] [Accepted: 10/05/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Mortality risks after Traumatic Brain Injury (TBI) are understudied in critical illness. We sought to identify risks of mortality in critically ill patients with TBI using time-varying covariates. METHODS This single-center, six-year (2006-2012), retrospective cohort study measured demographics, injury characteristics, and daily data of acute TBI patients in the Intensive Care Unit (ICU). Time-varying Cox proportional hazards models assessed in-hospital and 3-year mortality. RESULTS Post-TBI ICU patients (n = 2664) experienced 20% in-hospital mortality (n = 529) and 27% (n = 706) 3-year mortality. Glasgow Coma Scale motor subscore (hazard ratio (HR) 0.58, p < 0.001), pupil reactivity (HR 3.17, p < 0.001), minimum glucose (HR 1.44, p < 0.001), mSOFA score (HR 1.81, p < 0.001), coma (HR 2.26, p < 0.001), and benzodiazepines (HR 1.38, p < 0.001) were associated with in-hospital mortality. At three years, public insurance (HR 1.78, p = 0.011) and discharge disposition (HR 4.48, p < 0.001) were associated with death. CONCLUSIONS Time-varying characteristics influenced in-hospital mortality post-TBI. Socioeconomic factors primarily affect three-year mortality.
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Affiliation(s)
- Laura D Wilson
- Oxley College of Health Sciences, Communication Sciences and Disorders, The University of Tulsa, 800 S Tucker Dr, Tulsa, OK, 74104, USA
| | - Amelia W Maiga
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA
| | - Sarah Lombardo
- Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA; Section of Acute Care Surgery, Division of General Surgery, Department of Surgery, University of Utah Health, 30 N 1900 E, Salt Lake City, UT, 84132, USA
| | - Mina F Nordness
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA
| | - Diane N Haddad
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA; The Trauma Center at Penn, 51 North 39th ST, MOB Suite 120, Philadelphia, PA, 19104, USA
| | - Shayan Rakhit
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA
| | - Laney F Smith
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Georgetown Lombardi Comprehensive Cancer Center, 3800 Reservoir Rd, NW., Washington, D.C., 20057, USA
| | - Erika L Rivera
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA
| | - Madison R Cook
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA; Meharry Medical College, 1005 Dr DB Todd Jr Blvd, Nashville, TN, 37208, USA; Department of Surgery, Temple University Hospital, 3401 N. Broad Street, Parkinson Pavilion, Suite 400, Philadelphia, PA, 19140, USA
| | - Jennifer L Thompson
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Department of Biostatistics, Vanderbilt University Medical Center, Room 11133B, 2525 West End Avenue Nashville, TN, 37203, USA; Devoted Health, 221 Crescent St #202, Waltham, MA, 02453, USA
| | - Rameela Raman
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Department of Biostatistics, Vanderbilt University Medical Center, Room 11133B, 2525 West End Avenue Nashville, TN, 37203, USA
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, & Survivorship Center, Vanderbilt Center for Health Services Research, Vanderbilt Institute for Medicine and Public Health, Vanderbilt University Medical Center, Suite 450, 4th Floor, 2525 West End Avenue Nashville, TN, 37203, USA; Division of Acute Care Surgery, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, 1211 21st Avenue South, Suite 404, Nashville, TN, 37212, USA; Vanderbilt University Medical Center, Geriatric Research Education and Clinical Center, Surgical Services, Tennessee Valley Healthcare System, USA.
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Kumar H, Katyal J, Joshi D, Gupta YK. Effect of morphine administration after status epilepticus on epileptogenesis in rats. Epilepsy Behav 2022; 135:108905. [PMID: 36116361 DOI: 10.1016/j.yebeh.2022.108905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/26/2022] [Accepted: 08/26/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Morphine is widely used in patients and has been reported to alter seizure threshold, but its role in the development of epilepsy is unknown. In this study, role of morphine administration in the development of epilepsy using the status epilepticus (SE) model was determined in rats. METHODS Rats experiencing SE with lithium-pilocarpine (LiP) were randomized into four groups- saline, morphine low dose (5 mg/kg, s.c.), morphine high dose (5-20 mg/kg, s.c.), and naloxone (1 mg/kg, s.c.). Treatments were started 90 min after termination of SE and repeated twice daily for next three days. Rats were video monitored daily for 21 days to determine onset and frequency of spontaneous convulsive seizures (SS). RESULTS Morphine in low doses increased frequency of SS (1.51 ± 0.15 vs LiP 0.60 ± 0.12 seizures/rat/day, p-value = 0.0026) and seizures occurred during handling (SDH) (0.08 ± 0.02 vs LiP control 0.01 ± 0.01) (p-value = 0.0018). In high doses, no significant change in SS and SDH was found as compared to LiP. No effect of morphine on the onset of SS and percentage of rats experienced SS was found. No effect of naloxone per se was found on SS. CONCLUSION Morphine administration after SE does not affect epileptogenesis as no change in the onset of SS and percentage of rats experiencing SS was found. However, it might alter the susceptibility and frequency of SS. As no other study is available with a similar finding, it needs further evaluation.
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Affiliation(s)
- Hemant Kumar
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), New Delhi, India.
| | - Jatinder Katyal
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Dinesh Joshi
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Yogendra Kumar Gupta
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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Best KM, Mojena MM, Barr GA, Schmidt HD, Cohen AS. Endogenous Opioid Dynorphin Is a Potential Link between Traumatic Brain Injury, Chronic Pain, and Substance Use Disorder. J Neurotrauma 2022; 39:1-19. [PMID: 34751584 PMCID: PMC8978570 DOI: 10.1089/neu.2021.0063] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Traumatic brain injury (TBI) is a serious public health problem associated with numerous physical and neuropsychiatric comorbidities. Chronic pain is prevalent and interferes with post-injury functioning and quality of life, whereas substance use disorder (SUD) is the third most common neuropsychiatric diagnosis after TBI. Neither of these conditions has a clear mechanistic explanation based on the known pathophysiology of TBI. Dynorphin is an endogenous opioid neuropeptide that is significantly dysregulated after TBI. Both dynorphin and its primary receptor, the ĸ-opioid receptor (KOR), are implicated in the neuropathology of chronic pain and SUD. Here, we review the known roles of dynorphin and KORs in chronic pain and SUDs. We synthesize this information with our current understanding of TBI and highlight potential mechanistic parallels between and across conditions that suggest a role for dynorphin in long-term sequelae after TBI. In pain studies, dynorphin/KOR activation has either antinociceptive or pro-nociceptive effects, and there are similarities between the signaling pathways influenced by dynorphin and those underlying development of chronic pain. Moreover, the dynorphin/KOR system is considered a key regulator of the negative affective state that characterizes drug withdrawal and protracted abstinence in SUD, and molecular and neurochemical changes observed during the development of SUD are mirrored by the pathophysiology of TBI. We conclude by proposing hypotheses and directions for future research aimed at elucidating the potential role of dynorphin/KOR in chronic pain and/or SUD after TBI.
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Affiliation(s)
- Kaitlin M. Best
- Department of Nursing and Clinical Care Services, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marissa M. Mojena
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Gordon A. Barr
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Psychology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Heath D. Schmidt
- Department of Biobehavioral Health Sciences, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Akiva S. Cohen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Address correspondence to: Akiva S. Cohen, PhD, Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3615 Civic Center Boulevard, Room 816-I, Philadelphia, PA 19104, USA
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Association of Lifetime History of Traumatic Brain Injury With Prescription Opioid Use and Misuse Among Adults. J Head Trauma Rehabil 2021; 36:328-337. [PMID: 34489383 DOI: 10.1097/htr.0000000000000729] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate associations of lifetime history of traumatic brain injury (TBI) with prescription opioid use and misuse among noninstitutionalized adults. PARTICIPANTS Ohio Behavioral Risk Factor Surveillance System (BRFSS) participants in the 2018 cohort who completed the prescription opioid and lifetime history of TBI modules (n = 3448). DESIGN Secondary analyses of a statewide population-based cross-sectional survey. MAIN MEASURES Self-report of a lifetime history of TBI using an adaptation of the Ohio State University TBI-Identification Method. Self-report of past year: (1) prescription pain medication use (ie, prescription opioid use); and (2) prescription opioid misuse, defined as using opioids more frequently or in higher doses than prescribed and/or using a prescription opioid not prescribed to the respondent. RESULTS In total, 22.8% of adults in the sample screened positive for a lifetime history of TBI. A quarter (25.5%) reported past year prescription opioid use, and 3.1% met criteria for prescription opioid misuse. A lifetime history of TBI was associated with increased odds of both past year prescription opioid use (adjusted odds ratio [AOR] = 1.52; 95% CI, 1.27-1.83; P < .01) and prescription opioid misuse (AOR = 1.65; 95% CI, 1.08-2.52; P < .05), controlling for sex, age, race/ethnicity, and marital status. CONCLUSION Results from this study support the "perfect storm" hypothesis-that persons with a history of TBI are at an increased risk for exposure to prescription opioids and advancing to prescription opioid misuse compared with those without a history of TBI. Routine screening for a lifetime history of TBI may help target efforts to prevent opioid misuse among adults.
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Risk Factors Associated With the Prescription of Opioids Among Service Members Following a First Mild Traumatic Brain Injury. J Head Trauma Rehabil 2021; 36:345-353. [PMID: 34489385 DOI: 10.1097/htr.0000000000000711] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate factors impacting opioid receipt among active-duty service members (SMs) following a first mild traumatic brain injury (mTBI). SETTING Active-duty SMs receiving care within the Military Health System. PARTICIPANTS In total, 14 757 SMs who have sustained an initial mTBI, as documented within electronic health records (EHRs), between 2016 and 2017. DESIGN A retrospective analysis of EHR metadata. MAIN MEASURES Multivariable logistic regression assessed factors impacting opioid receipt and initiation. Factors include demographics, military characteristics, and preexisting clinical conditions, including prior opioid prescription. RESULTS Of the sample population, 33.4% (n = 4927) were prescribed opioids after their initial mTBI, of which, 60.6% (n = 2985) received opioids for the first time following injury. Significant risk factors associated with the increased probability of opioid receipt included age, gender, and preexisting behavioral health and musculoskeletal conditions. Military characteristics also exhibited changes in the probability of opioid receipt, both among initiation and new prescription. No changes were observed among race, nor among those with preexisting headaches or migraines. CONCLUSION Despite concerns about the negative impact on recovery, the prescribing of opioids is common in this population of active-duty SMs first diagnosed with an mTBI. As several demographic and preexisting health conditions are factors in the receipt of opioids post-mTBI, the entire medical history of these patients should be considered prior to prescription. Understanding these factors may further inform policy for opioid use in the Military Health System.
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Ashraf AJ, Gilbert TA, Holmer HK, Cook LJ, Carlson KF. Receipt of Concurrent VA and Non-VA Opioid and Sedative-Hypnotic Prescriptions Among Post-9/11 Veterans With Traumatic Brain Injury. J Head Trauma Rehabil 2021; 36:364-373. [PMID: 34489387 DOI: 10.1097/htr.0000000000000728] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Receipt of concurrent psychotropic prescription medications from both US Department of Veterans Affairs (VA) and non-VA healthcare providers may increase risk of adverse opioid-related outcomes among veterans with traumatic brain injury (TBI). Little is known about patterns of dual-system opioid or sedative-hypnotic prescription receipt in this population. We estimated the prevalence and patterns of, and risk factors for, VA/non-VA prescription overlap among post-9/11 veterans with TBI receiving opioids from VA providers in Oregon. SETTING Oregon VA and non-VA outpatient care. PARTICIPANTS Post-9/11 veterans in Oregon with TBI who received an opioid prescription from VA providers between the years of 2014 and 2019. DESIGN Historical cohort study. MAIN MEASURES Prescription overlap of VA opioids and non-VA opioids or sedative-hypnotics; proportions of veterans who received VA or non-VA opioid, benzodiazepine, and nonbenzodiazepine sedative-hypnotic prescriptions were also examined by year and by veteran characteristics. RESULTS Among 1036 veterans with TBI receiving opioids from the VA, 210 (20.3%) received an overlapping opioid prescription from a non-VA provider; 5.3% received overlapping benzodiazepines; and none received overlapping nonbenzodiazepine sedative-hypnotics. Proportions of veterans with prescription overlap tended to decrease over time. Veterans with other than urban versus urban addresses (OR = 1.4; 95% CI, 1.0-1.8), high versus medium average annual VA visits (OR = 1.7; 95% CI, 1.1-2.6), and VA service connection of 50% or more versus none/0% to 40% (OR = 4.3; 95% CI, 1.3-14.0) were more likely to have concurrent VA/non-VA prescriptions in bivariable analyses; other than urban remained associated with overlap in multivariable models. Similarly, veterans with comorbid posttraumatic stress disorder diagnoses were more likely to have concurrent VA/non-VA prescriptions in both bivariable and multivariable (OR = 2.1; 95% CI, 1.0-4.1) models. CONCLUSION Among post-9/11 veterans with TBI receiving VA opioids, a considerable proportion had overlapping non-VA prescription medications. Providers and healthcare systems should consider all sources of psychotropic prescriptions, and risk factors for overlapping medications, to help mitigate potentially unsafe medication use among veterans with TBI.
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Affiliation(s)
- Alexandria J Ashraf
- VA HSR&D Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, Oregon (Mss Ashraf and Gilbert and Drs Holmer and Carlson); Oregon Health & Science University, Portland State University School of Public Health, Portland (Ms Ashraf and Dr Carlson); and Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City (Dr Cook)
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Starosta AJ, Adams RS, Marwitz JH, Kreutzer J, Monden KR, Dams O'Connor K, Hoffman J. Scoping Review of Opioid Use After Traumatic Brain Injury. J Head Trauma Rehabil 2021; 36:310-327. [PMID: 34489382 PMCID: PMC8428300 DOI: 10.1097/htr.0000000000000721] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To summarize the current literature to identify what research has been conducted, examine the approaches used, and determine what is presently known about prescription and nonprescription opioid receipts and use among individuals with traumatic brain injury (TBI). DATA SOURCES The search strategy included the following: opioid; opiate; analgesics, opioid; opiate alkaloids; or opioid-related disorders; AND brain injury; brain injuries; brain injuries, traumatic; head injury; head injuries; head injuries, closed; head injuries, penetrating; brain concussion; diffuse axonal injury; diffuse axonal injuries; brain trauma/s; head trauma/s; concussion; craniocerebral trauma/s; or TBI. Filters included English and Adults (19+ years). Study Selection: Inclusion: English language, adults with stable TBI, and prescription opioid receipt or use after TBI. Exclusion: Animal models, populations with other acquired brain injury, acute TBI management, and non-peer-reviewed articles, theses, or conference abstracts. Multiple reviewers screened abstracts and full-text articles for eligibility. In total, 771 abstracts were screened, 183 full texts were reviewed, and 21 met eligibility criteria. Data Extraction: Relevant content was independently extracted by multiple observers, including authors, design, sample identification and data source/s, TBI severity, TBI assessment, opioid assessment, study population (demographics, N), military affiliation, comparison groups, date of data collection, and summary of findings. RESULTS Studies were published between 1987 and 2019; most data were collected prior to 2015. The majority utilized administrative and electronic medical record data from the Department of Veterans Affairs and retrospective cohort designs, and most focused on prescription opioids. There were no studies evaluating interventions to reduce use of opioids in TBI populations. Preliminary findings suggest that prescription opioid receipt is strongly related to psychological symptoms, including comorbid depression, anxiety, and posttraumatic stress disorder. CONCLUSIONS Despite increased awareness of opioid receipt and use following TBI, there is limited investigation on the examination of this issue. Future studies should include more varied patient populations as well as evaluate interventions to reduce opioid use following TBI.
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Affiliation(s)
- Amy J Starosta
- Division of Rehabilitation Psychology, Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle (Drs Starosta and Hoffman); Institute for Behavioral Health at the Heller School for Social Policy & Management, Brandeis University, Waltham, Massachusetts (Dr Adams); Rocky Mountain Mental Illness Research Education and Clinical Center, Veterans Health Administration, Aurora, Colorado (Dr Adams); Division of Rehabilitation Psychology and Neuropsychology (Dr Kreutzer), Department of Physical Medicine and Rehabilitation (Ms Marwitz), Department of Rehabilitation Medicine, University of Minnesota, Minneapolis (Dr Monden); Brain Injury Research Center of Mount Sinai, Departments of Rehabilitation Medicine and Neurology, Icahn School of Medicine at Mount Sinai, New York City, New York (Dr Dams O'Connor)
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Molero Y, Sharp DJ, D'Onofrio BM, Larsson H, Fazel S. Psychotropic and pain medication use in individuals with traumatic brain injury-a Swedish total population cohort study of 240 000 persons. J Neurol Neurosurg Psychiatry 2021; 92:519-527. [PMID: 33563808 PMCID: PMC8053342 DOI: 10.1136/jnnp-2020-324353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/05/2020] [Accepted: 11/24/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To examine psychotropic and pain medication use in a population-based cohort of individuals with traumatic brain injury (TBI), and compare them with controls from similar backgrounds. METHODS We assessed Swedish nationwide registers to include all individuals diagnosed with incident TBI between 2006 and 2012 in hospitals or specialist outpatient care. Full siblings never diagnosed with TBI acted as controls. We examined dispensed prescriptions for psychotropic and pain medications for the 12 months before and after the TBI. RESULTS We identified 239 425 individuals with incident TBI, and 199 658 unaffected sibling controls. In the TBI cohort, 36.6% had collected at least one prescription for a psychotropic or pain medication in the 12 months before the TBI. In the 12 months after, medication use increased to 45.0%, an absolute rate increase of 8.4% (p<0.001). The largest post-TBI increases were found for opioids (from 16.3% to 21.6%, p<0.001), and non-opioid pain medications (from 20.3% to 26.6%, p<0.001). The majority of prescriptions were short-term; 20.6% of those prescribed opioids and 37.3% of those with benzodiazepines collected prescriptions for more than 6 months. Increased odds of any psychotropic or pain medication were associated with individuals before (OR: 1.62, 95% CI: 1.59 to 1.65), and after the TBI (OR: 2.30, 95% CI: 2.26 to 2.34) as compared with sibling controls, and ORs were consistently increased for all medication classes. CONCLUSION High rates of psychotropic and pain medications after a TBI suggest that medical follow-up should be routine and review medication use.
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Affiliation(s)
- Yasmina Molero
- Clinical Neuroscience, Center for Psychiatry Research, Karolinska Institute, Stockholm, Sweden.,Psychiatry, University of Oxford, Oxford, UK.,Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | | | - Brian Matthew D'Onofrio
- Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden.,Psychological and Brain Sciences, Indiana University Bloomington, Bloomington, Indiana, USA
| | - Henrik Larsson
- Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden.,School of Medical Sciences, Örebro Universitet, Orebro, Sweden
| | - Seena Fazel
- Psychiatry, University of Oxford, Oxford, UK
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de Oliveira Costa J, Bruno C, Baranwal N, Gisev N, Dobbins TA, Degenhardt L, Pearson SA. Variations in Long-term Opioid Therapy Definitions: A Systematic Review of Observational Studies Using Routinely Collected Data (2000-2019). Br J Clin Pharmacol 2021; 87:3706-3720. [PMID: 33629352 DOI: 10.1111/bcp.14798] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/21/2020] [Accepted: 02/17/2021] [Indexed: 12/27/2022] Open
Abstract
Routinely collected data have been increasingly used to assess long-term opioid therapy (LTOT) patterns, with very little guidance on how to measure LTOT from these data sources. We conducted a systematic review of studies published between January 2000 and July 2019 to catalogue LTOT definitions, the rationale for definitions and LTOT rates in observational research using routinely collected data in nonsurgical settings. We screened 4056 abstracts, 210 full-text manuscripts and included 128 studies, mostly from the United States (81%) and published between 2015 and 2019 (69%). We identified 78 definitions of LTOT, commonly operationalised as 90 days of use within a year (23%). Studies often used multiple criteria to derive definitions (60%), mostly based on measures of duration, such as supply days/days of use (66%), episode length (21%) or prescription fills within specified time periods (12%). Definitions were based on previous publications (63%), clinical judgment (16%) or empirical data (3%); 10% of studies applied more than one definition. LTOT definition was not provided with enough details for replication in 14 studies and 38 studies did not specify the opioids evaluated. Rates of LTOT within study populations ranged from 0.2% to 57% according to study design and definition used. We observed a substantial rise in the last 5 years in studies evaluating LTOT with large variability in the definitions used and poor reporting of the rationale and implementation of definitions. This variation impacts on research reproducibility, comparability of findings and the development of strategies aiming to curb therapy that is not guideline-recommended.
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Affiliation(s)
| | - Claudia Bruno
- Centre for Big Data Research in Health, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Navya Baranwal
- Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Timothy A Dobbins
- National Drug and Alcohol Research Centre, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia.,Menzies Centre for Health Policy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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11
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Traumatic brain injury and the misuse of alcohol, opioids, and cannabis. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2020; 157:195-243. [PMID: 33648670 DOI: 10.1016/bs.irn.2020.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Traumatic brain injury (TBI), most often classified as concussion, is caused by biomechanical forces to the brain resulting in short- or long-term impairment in brain function. TBI resulting from military combat, sports, violence, falls, and vehicular accidents is a major cause of long-term physical, cognitive, and psychiatric dysfunction. Psychiatric disorders associated with TBI include depression, anxiety, and substance use disorder, all having significant implications for post-TBI recovery and rehabilitation. This chapter reviews the current preclinical and clinical literature describing the bidirectional relationship between TBI and misuse of three commonly abused drugs: alcohol, opioids, and cannabis. We highlight the influence of each of these drugs on the incidence of TBI, as well as trends in their use after TBI. Furthermore, we discuss factors that may underlie post-injury substance use. Understanding the complex relationship between TBI and substance misuse will enhance the clinical treatment of individuals suffering from these two highly comorbid conditions.
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12
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Dunn LK, Taylor DG, Smith SJ, Skojec AJ, Wang TR, Chung J, Hanak MF, Lacomis CD, Palmer JD, Ruminski C, Fang S, Tsang S, Spangler SN, Durieux ME, Naik BI. Persistent post-discharge opioid prescribing after traumatic brain injury requiring intensive care unit admission: A cross-sectional study with longitudinal outcome. PLoS One 2019; 14:e0225787. [PMID: 31774864 PMCID: PMC6880998 DOI: 10.1371/journal.pone.0225787] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 11/12/2019] [Indexed: 12/16/2022] Open
Abstract
Traumatic brain injury (TBI) is associated with increased risk for psychological and substance use disorders. The study aim is to determine incidence and risk factors for persistent opioid prescription after hospitalization for TBI. Electronic medical records of patients age ≥ 18 admitted to a neuroscience intensive care unit between January 2013 and February 2017 for an intracranial injury were retrospectively reviewed. Primary outcome was opioid use through 12 months post-hospital discharge. A total of 298 patients with complete data were included in the analysis. The prevalence of opioid use among preadmission opioid users was 48 (87%), 36 (69%) and 22 (56%) at 1, 6 and 12-months post-discharge, respectively. In the opioid naïve group, 69 (41%), 24 (23%) and 17 (19%) were prescribed opioids at 1, 6 and 12 months, respectively. Preadmission opioid use (OR 324.8, 95% CI 23.1-16907.5, p = 0.0004) and higher opioid requirements during hospitalization (OR 4.5, 95% CI 1.8-16.3, p = 0.006) were independently associated with an increased risk of being prescribed opioids 12 months post-discharge. These factors may be used to identify and target at-risk patients for intervention.
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Affiliation(s)
- Lauren K. Dunn
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
- * E-mail:
| | - Davis G. Taylor
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Samantha J Smith
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Alexander J. Skojec
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Tony R. Wang
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Joyce Chung
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Mark F. Hanak
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Christopher D. Lacomis
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Justin D. Palmer
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Caroline Ruminski
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Shenghao Fang
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Siny Tsang
- Nutrition and Exercise Physiology, Washington State University, Spokane, Washington, United States of America
| | - Sarah N. Spangler
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Marcel E. Durieux
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Bhiken I. Naik
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, United States of America
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, United States of America
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13
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Cogan AM, McCaughey VK, Scholten J. Gender Differences in Outcomes after Traumatic Brain Injury among Service Members and Veterans. PM R 2019; 12:301-314. [PMID: 31400285 DOI: 10.1002/pmrj.12237] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 07/27/2019] [Indexed: 11/08/2022]
Abstract
This scoping study describes the range of outcomes in traumatic brain injury (TBI) studies of military service members and veterans addressing gender differences. A secondary purpose is to identify differences in outcomes between male and female participants in such studies. We searched PubMed, CiNAHL, and PsycInfo databases for relevant articles. Two reviewers independently screened results. Of 822 unique titles and abstracts screened for eligibility, 55 full articles were reviewed, with 29 studies meeting full inclusion criteria. Twenty of the 29 included studies used retrospective designs and all but two used data collected from Veterans Affairs or Department of Defense health care settings. TBI was diagnosed by self-report, screening, and evaluation procedures, and medical record documentation. Ten different outcome categories were identified among the included studies. In general, female service members and veterans have not been well represented in TBI outcomes research. Evidence suggests that female veterans with mild TBI (mTBI) report more neurobehavioral symptoms and use more outpatient services than male veterans. Studies also indicate that female veterans with TBI are more frequently diagnosed with depression. Additional research is essential to support precision treatment recommendations for female veterans with TBI, as women represent a growing proportion of the patients served by the Veterans Health Administration. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- Alison M Cogan
- Department of Physical Medicine and Rehabilitation, Washington DC VA Medical Center, Washington, DC
| | - Virginia K McCaughey
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, Boston, MA
| | - Joel Scholten
- Physical Medicine and Rehabilitation Program Office, Veterans Health Administration, Washington, DC
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14
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Adams RS, Corrigan JD, Dams-O'Connor K. Opioid Use among Individuals with Traumatic Brain Injury: A Perfect Storm? J Neurotrauma 2019; 37:211-216. [PMID: 31333067 DOI: 10.1089/neu.2019.6451] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Rachel Sayko Adams
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts.,VHA Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado
| | - John D Corrigan
- Department of Physical Medicine and Rehabilitation, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kristen Dams-O'Connor
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
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15
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Mesley MS, Edelman K, Sharpless J, Borrasso A, Billigen JB, Puffer R, Williams D, Benso S, Puccio AM, Schneider W, Soose R, Beers S, Kontos A, Collins M, Okonkwo DO. Impact of Multi-Disciplinary Care and Clinical Coach Coordinators on Participant Satisfaction and Retention in TBI Clinical Trials: A TEAM-TBI Study. Mil Med 2019; 184:155-159. [PMID: 30901471 DOI: 10.1093/milmed/usy386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/13/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Targeted Evaluation Action and Monitoring of Traumatic Brain Injury (TEAM-TBI) is a monitored, multiple interventional research identifying clinical profiles and assigns individualized, evidence-based treatment program. The objective of the current study was to assess overall participant satisfaction of the multi-disciplinary care team and approach. METHODS Between 2014 and 2017, 90 participants completed the 4-day TEAM-TBI clinical intake evaluation resulting in individualized treatment recommendations followed by a six-month intervention phase follow-up. Inclusion criteria were: age 18-60, history of chronic TBI (>6 months post-injury) with refractory clinical sequelae at screening (Post-Concussion Symptom Scale [PCSS] score >30). RESULTS A total of 85/90 (94%) participants completed the survey at baseline focusing on intake evaluation and approach; 90% of eligible participants also completed the follow-up time-point. Hundred percent of participants had a mean score of >4 across all questions at the initial time point." CONCLUSIONS The multi-disciplinary care approach and individualized treatment plans of the TEAM-TBI study yielded high participant retention and satisfaction scores. The Clinical Coach component of the trial was one of the highest rated aspects of the program and was associated with participant motivation and high retention rates.
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Affiliation(s)
- Matthew S Mesley
- University of Pittsburgh Medical Center, Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA
| | - Kathryn Edelman
- University of Pittsburgh Medical Center, Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA
| | - Jane Sharpless
- University of Pittsburgh Medical Center, Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA
| | - Allison Borrasso
- University of Pittsburgh Medical Center, Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA
| | - Julia B Billigen
- University of Pittsburgh Medical Center, Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA
| | - Ross Puffer
- University of Pittsburgh Medical Center, Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA
| | - Dana Williams
- University of Pittsburgh Medical Center, Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA
| | - Steven Benso
- University of Pittsburgh Medical Center, Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA
| | - Ava M Puccio
- University of Pittsburgh Medical Center, Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA
| | - Walt Schneider
- University of Pittsburgh Medical Center, Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA
| | - Ryan Soose
- University of Pittsburgh Medical Center, Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA
| | - Sue Beers
- University of Pittsburgh Medical Center, Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA
| | - Anthony Kontos
- University of Pittsburgh Medical Center, Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA
| | - Michael Collins
- University of Pittsburgh Medical Center, Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA
| | - David O Okonkwo
- University of Pittsburgh Medical Center, Presbyterian Hospital, 200 Lothrop Street, Pittsburgh, PA
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16
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Corrigan JD, Adams RS. The intersection of lifetime history of traumatic brain injury and the opioid epidemic. Addict Behav 2019; 90:143-145. [PMID: 30391775 PMCID: PMC6496936 DOI: 10.1016/j.addbeh.2018.10.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 10/15/2018] [Accepted: 10/20/2018] [Indexed: 12/15/2022]
Affiliation(s)
- John D Corrigan
- Department of Physical Medicine & Rehabilitation, Wexner Medical Center, The Ohio State University, 2145 Dodd Hall, 480 Medical Center Drive, Columbus, OH 43210-1234, United States
| | - Rachel Sayko Adams
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, MS 035, Waltham, MA 02453-2728, United States.
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17
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Bertenthal D, Yaffe K, Barnes DE, Byers AL, Gibson CJ, Seal KH. Do postconcussive symptoms from traumatic brain injury in combat veterans predict risk for receiving opioid therapy for chronic pain? Brain Inj 2018; 32:1188-1196. [PMID: 29985653 DOI: 10.1080/02699052.2018.1493535] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Opioid therapy is contraindicated in patients with traumatic brain injury (TBI) with neuropsychological impairment, yet guidelines do not consistently predict practice. We evaluated independent risk for initiation of opioid therapy among combat veterans with chronic pain diagnoses and persistent postconcussive symptoms. METHODS We assembled a retrospective cohort of 53 124 Iraq and Afghanistan veterans in Veterans Affairs (VA) healthcare between October 2007 and March 2015 who received chronic pain diagnoses, completed a Comprehensive TBI Evaluation (CTBIE) and had not received opioid therapy in the prior year. Primary exposure variables were self-reported severe or very severe Emotional, Vestibular, Cognitive and Somatic/Sensory symptoms measured using the Neurobehavioral Symptom Inventory. Outcome measures were initiation of short-term and long-term opioid therapy within the year following CTBIE. RESULTS Self-reported severe and very severe postconcussive symptoms predicted initiation of long-term and short-term opioid use for chronic pain in both unadjusted and adjusted analyses. In adjusted analyses, all four postconcussive symptom domains significantly predicted initiation of long-term opioid therapy, with Emotional symptoms being the strongest predictor [ARR = 1.68 (1.52, 1.86)]. CONCLUSIONS Increased opioid prescribing in veterans with self-reported severe persistent postconcussive symptoms indicates a need to educate prescribers and make non-opioid pain management options available for veterans with TBI and neuropsychological sequelae.
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Affiliation(s)
- Daniel Bertenthal
- a San Francisco Veterans Affairs Health Care System , San Francisco , CA, USA
| | - Kristine Yaffe
- a San Francisco Veterans Affairs Health Care System , San Francisco , CA, USA.,b Department of Psychiatry, University of California , San Francisco , CA, USA.,c Department of Epidemiology and Biostatistics, University of California , San Francisco , CA, USA.,d Department of Neurology, University of California , San Francisco , CA, USA
| | - Deborah E Barnes
- a San Francisco Veterans Affairs Health Care System , San Francisco , CA, USA.,b Department of Psychiatry, University of California , San Francisco , CA, USA.,c Department of Epidemiology and Biostatistics, University of California , San Francisco , CA, USA
| | - Amy L Byers
- a San Francisco Veterans Affairs Health Care System , San Francisco , CA, USA.,b Department of Psychiatry, University of California , San Francisco , CA, USA.,c Department of Epidemiology and Biostatistics, University of California , San Francisco , CA, USA
| | - Carolyn J Gibson
- a San Francisco Veterans Affairs Health Care System , San Francisco , CA, USA.,e Department of Medicine, University of California , San Francisco , CA, USA
| | - Karen H Seal
- a San Francisco Veterans Affairs Health Care System , San Francisco , CA, USA.,b Department of Psychiatry, University of California , San Francisco , CA, USA.,e Department of Medicine, University of California , San Francisco , CA, USA
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