The epidemiology of substance use disorders in US Veterans: A systematic review and analysis of assessment methods

Associations Between a Primary Care-Delivered Alcohol-Related Brief Intervention and Subsequent Opioid-Related Outcomes

OBJECTIVE

The co-occurrence of unhealthy alcohol use and opioid misuse is high and associated with increased rates of overdose, emergency health care utilization, and death. The current study examined whether receipt of an alcohol-related brief intervention is associated with reduced risk of negative downstream opioid-related outcomes.

METHODS

This retrospective cohort study included all VISN-6 Veterans Affairs (VA) patients with Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) screening results (N=492,748) from 2014 to 2019. Logistic regression was used to examine the association between documentation of an alcohol-related brief intervention and probability of a new 1) opioid prescription, 2) opioid use disorder (OUD) diagnosis, or 3) opioid-related hospitalization in the following year, controlling for demographic and clinical covariates.

RESULTS

Of the veterans, 13% (N=63,804) had "positive" AUDIT-C screen results. Of those, 72% (N=46,216) had a documented alcohol-related brief intervention. Within 1 year, 8.5% (N=5,430) had a new opioid prescription, 1.1% (N=698) had a new OUD diagnosis, and 0.8% (N=499) had a new opioid-related hospitalization. In adjusted models, veterans with positive AUDIT-C screen results who did not receive an alcohol-related brief intervention had higher odds of new opioid prescriptions (adjusted odds ratio [OR]=1.10, 95% CI=1.03-1.17) and new OUD diagnoses (adjusted OR=1.19, 95% CI=1.02-1.40), while new opioid-related hospitalizations (adjusted OR=1.19, 95% CI=0.99-1.44) were higher although not statistically significant. Removal of medications for OUD (MOUD) did not impact associations. All outcomes were significantly associated with an alcohol-related brief intervention in unadjusted models.

CONCLUSIONS

The VA's standard alcohol-related brief intervention is associated with subsequent lower odds of a new opioid prescription or a new OUD diagnosis. Results suggest a reduction in a cascade of new opioid-related outcomes from prescriptions through hospitalizations.

Medical-surgical patients with untreated hazardous drinking: Randomized controlled trial of the DO-MoST intervention to improve health outcomes over 12-month follow-up

INTRODUCTION

High prevalence and harmful consequences of hazardous drinking among medical-surgical patients underscore the importance of intervening with drinking to improve patients' health. This study evaluated a novel intervention, "Drinking Options - Motivate, Shared Decisions, Telemonitor" (DO-MoST).

METHODS

In a randomized design, 155 medical-surgical patients with untreated hazardous drinking were assigned to enhanced usual care or DO-MoST, and followed 3, 6, and 12 months later. We conducted intent-to-treat and per-protocol analyses.

RESULTS

For the primary outcome, percent days of alcohol abstinence in the past 30 days, intent-to-treat analyses did not find superior effectiveness of DO-MoST. However, per-protocol analyses found abstinence increased between 3 and 12 months among participants assigned to DO-MoST who engaged with the intervention (n=46). Among DO-MoST-assigned participants who did not engage (n=27), abstinence stayed stable during follow-up. Group comparisons showed an advantage on abstinence for Engaged compared to Non-Engaged participants on change over time. Intent-to-treat analyses found that DO-MoST was superior to usual care on the secondary outcome of physical health at 12 months; per-protocol analyses found that Engaged DO-MoST-assignees had better physical health at 12 months than Non-Engaged DO-MoST-assignees. DO-MoST-assignees had lower odds of receiving substance use care during follow-up than usual care-assignees.

DISCUSSION

Patients engaged in DO-MoST showed a greater degree of abstinence and better physical health relative to the non-engaged or usual care group. DO-MoST may be a source of alcohol help in itself rather than only a linkage intervention. Work is needed to increase DO-MoST engagement among medical-surgical patients with untreated hazardous drinking.

Written exposure therapy for veterans with co-occurring substance use disorders and PTSD: Study design of a randomized clinical trial

There are high rates of posttraumatic stress disorder (PTSD) among treatment-seeking veterans with substance use disorders (SUD). While addiction programs traditionally do not address PTSD, there is evidence that trauma treatments for individuals with this comorbidity have improved PTSD and SUD outcomes. Written exposure therapy (WET), a five-session evidence-based psychotherapy (EBP) for PTSD, has high patient satisfaction, and lower dropout compared to other EBPs for PTSD. WET may be ideally suited for clinical settings that may not have the trauma expertise found in PTSD specialty clinics, given it requires less training time, treatment sessions, preparation time, and therapist involvement than existing EBPs, and no homework assignments. This paper describes the design, methodology, and protocol of a randomized clinical trial to evaluate whether treatment as usual (TAU) plus WET (n = 51) is superior to TAU plus a neutral topic writing condition (n = 51) on both PTSD and addiction outcomes for veterans in SUD treatment. The primary hypothesis is that participants assigned to TAU+WET, compared to those in TAU+ neutral topic writing, will report reduced symptoms of PTSD. The secondary hypothesis is that veterans receiving WET will have greater decreases in number of days of substance use compared to TAU+ neutral topic controls at follow-up. Assessments will take place at baseline, post-treatment, 8-week, and 12-week follow-up. Exploratory aims will examine the association between heart rate variability and treatment outcomes. If results prove promising, they will support WET as an effective brief, easy to disseminate, adjunct to current SUD treatment for veterans with comorbid PTSD. Trial registration: ClinicalTrials.gov ID NCT05327504.

Emergency Department Visits at Veteran's Health Administration Hospitals Related to Alcohol Intoxication: A Ten-Year Retrospective

We sought to quantify and describe the volume of emergency department visits related to alcohol intoxication at the Veterans Health Administration (VHA), the largest healthcare system in the United States. This is a retrospective cohort study of patients with VHA emergency department visits for alcohol intoxication from 2010-2019 as identified via ICD-9/10 code and/or serum ethanol concentration >50mg/dL. Encounters were identified and demographic and clinical data were acquired by automated query of the VHA Corporate Data Warehouse. Descriptive statistics and univariate analysis were performed. We identified 95,123 patients with a total of 251,310 emergency department visits. The annual number of visits increased over the study period, reaching 32,333 in 2019. Men aged 40-60 were the most common demographic group in the cohort (48% of all patients), and men made up a high proportion of patients in the database (94%) than the VHA population overall (90%). A disproportionate number of visits (32%) came from the top 4.4% of most frequent visitors. Most of the emergency department visits in the database (68%) were associated with medical or psychiatric admission, or interfacility transfer for admission elsewhere. Patients in the cohort accounted for 1.3% of all VHA emergency department visits during the study period, a proportion which is somewhat smaller than what has been reported at non-VHA facilities, and despite the high prevalence of addiction disorders in the VHA patient population. We submit that this lower-than-expected proportion of alcohol-related emergency department visits may be due to the access to primary and mental care which is afforded by VHA patient benefits.

Chronic disease multimorbidity and substance use among African American men: veteran-non-veteran differences

OBJECTIVES

The purpose of the study was to explore the extent to which prior military service may moderate the relationship between chronic disease multimorbidity and substance use among African American men in the United States.

DESIGN

Data for this cross-sectional study was downloaded from the 2016 -2019 United States (US) National Survey on Drug Use and Health. We estimated three survey-weighted multivariable logistic regression models, where use of each of the following substances served as the dependent variables: illicit drugs, opioids, and tobacco. Differences in these outcomes were examined along two primary independent variables: veteran status and multimorbidity (and an interaction term for these variables). We also controlled for the following covariates: age, education, income, rurality, criminal behavior, and religiosity.

RESULTS

From the 37,203,237 (weighted N) African American men in the sample, approximately 17% reported prior military service. Veterans with ≥ 2 chronic diseases had higher rates of illicit drug use (aOR = 1.37, 95% CI = 1.01, 1.87; 32% vs. 28%) than non-veterans with ≥ 2 chronic diseases. Non-veterans with one chronic disease had higher rates of tobacco use (aOR = 0.80, 95% CI = 0.69, 0.93; 29% vs. 26%) and opioid misuse (aOR = 0.49, 95% CI = 0.36, 0.67; 29% vs. 18%) than veterans with one chronic disease.

DISCUSSION

Chronic disease multi-morbidity appears to be a context in which African American veterans may be at greater risk for certain undesirable health behaviors than African American non-veterans and at lower risk for others. This may be due to exposure to trauma, difficulty accessing care, socio-environmental factors, and co-occurring mental health conditions. These complex interactions may contribute to higher rates of SUDs among African American veterans compared to African American non-veterans.

Prevalence and Clinical Characteristics of Recreational and At-Risk/Problematic Gambling Among Low-Income U.S. Veterans: Results from the National Veteran Homeless and Other Poverty Experiences (NV-HOPE) Study

This study examined associations between recreational gambling (RG) and at-risk/problem gambling (ARPG), and clinical measures of mental illness and substance use, functionality, homelessness, in a nationally representative sample of U.S. military veterans. Data were analyzed from 781 veterans who participated National Veteran Homeless and Other Poverty Experiences (NV-HOPE) study conducted in 2021. Chi-square tests, analyses of variance (ANOVAs) and logistic regressions analyses were conducted to examine unadjusted and adjusted associations between gambling group status and sociodemographic, psychiatric, substance use, functioning, and homelessness measures. A significant minority of low-income U.S. veterans reported gambling, with 24.9% (95% confidence interval [CI] 95% CI 21.12-28.76%) exhibiting RG and 6.7% (95% CI 3.88-9.42%) screening positive for ARPG. The prevalence of ARPG was higher among younger, non-White veterans. ARPG was associated with greater symptoms of substance use and anxiety; poorer physical functioning; history of any mental illness; lifetime history of homelessness; and having any student or car loans relative to NG. Veterans who had RG were more likely to screen positive for drug use disorders relative to NG. Results of the current study provide an up-to-date estimate of the current prevalence of RG and ARPG among low-income U.S. veterans and underscore the importance of routine screening, monitoring, and development of interventions for problematic gambling severity, as well as interventions for ARPG in this population. These findings may inform targeted intervention strategies for this vulnerable subpopulation.

Prevalence and Clinical Characteristics of Recreational and At-Risk/Problematic Gambling in a National Sample of U.S. Military Veterans

Gambling among U.S. military veterans is common, with more extensive involvement linked to gambling disorder and associated problems. This study examined associations between recreational gambling (RG) and at-risk/problem gambling (ARPG), and clinical measures (psychiatric disorders, substance use), behaviors (suicidality, homelessness, arrests) and functioning in a nationally representative sample of U.S. military veterans. Data were analyzed from 4069 veterans who participated in the National Health and Resilience in Veterans Study. Chi-square tests, analyses of variance (ANOVAs) and logistic regressions were conducted to examine unadjusted and adjusted associations between gambling group status and lifetime and current psychiatric diagnoses and behavioral and functioning measures. A significant minority of U.S. veterans reported gambling, with 27.3% (95% confidence interval [CI] 25.5-29.1%) exhibiting RG and 4.9% (95% CI 4.0-5.9%) screening positive for ARPG. The prevalence of ARPG was higher among younger, non-White, male veterans, while RG was more prevalent among retired veterans and those with higher household incomes relative to non-gambling (NG) individuals. ARPG was associated with greater trauma burden, lifetime and current psychiatric diagnoses, mental health treatment, alcohol and drug use disorders, suicidal ideation, homelessness, arrests, and poorer functioning relative to NG and RG, with stronger magnitude differences relative to NG. RG was associated with substance use disorders and arrest histories relative to NG. Results of the current study provide an up-to-date estimate of the current prevalence of RG and ARPG among U.S. veterans and underscore the importance of routine screening and monitoring of gambling problems, as well as interventions for ARPG in this population.

Exploring Racial/Ethnic Disparities in Substance Dependence and Serious Psychological Distress among US Veterans

OBJECTIVES

There are substantial racial/ethnic disparities in substance use and mental health among civilian populations, but few studies have examined these disparities in veterans using a nationally representative sample. Thus, we examined differences in substance dependence and serious psychological distress (SPD) by race/ethnicity among a national sample of US veterans.

METHODS

We pooled cross-sectional data from the 2015-2019 waves of the National Survey on Drug Use and Health (N = 7,653 veterans aged 18-64 years). Regression models were utilized to examine racial/ethnic differences in DSM-IV substance dependence and SPD with a Benjamini-Hochberg correction applied.

RESULTS

Compared to non-Hispanic White veterans: American Indian/Alaska Native veterans had significantly higher odds of past-year alcohol dependence (AOR = 2.55, 95% CI: 1.28, 5.08); Asian American veterans had significantly lower odds of past-year alcohol dependence (AOR = 0.12, 95% CI: 0.02, 0.62); non-Hispanic Black (AOR = 0.60, 95% CI: 0.48, 0.77), Hispanic (AOR = 0.47, 95% CI: 0.34, 0.65), and veterans of more than one race (AOR = 0.55, 95% CI: 0.36, 0.83) had significantly lower odds of past-month nicotine dependence; Asian American veterans had significantly lower odds of past-year illicit drug dependence (AOR = 0.05, 95% CI: 0.01, 0.35); and non-Hispanic Black veterans had significantly lower odds of past-year SPD (AOR = 0.69, 95% CI: 0.55, 0.85) after correction for multiple comparisons.

CONCLUSION

Overall, racial/ethnic disparities in substance dependence and SPD among veterans are not as stark as in civilian populations, but some disparities remain.

Network analysis of reasons for and against changing alcohol use among veterans engaged in a web-based intervention for hazardous drinking and PTSD symptoms

Better understanding of reasons for and against change may be an effective strategy for supporting drinking reduction or abstinence among Iraq and Afghanistan veterans. The current study explored connections between reasons for and against changing hazardous alcohol use, as well as the relative importance of a given reason. Data from 366 veterans (86% male, 77% White) between the ages of 21 and 56 (M = 31.8, SD = 7.3) were obtained from a nationwide web-based alcohol and posttraumatic stress disorder randomized clinical trial. Participant-generated reasons for and against change were used to estimate two separate network models. The network of motives for changing alcohol use was generally well connected with predominately positive associations. Veterans reporting motivation to change alcohol use to improve functioning, enhance self-worth, and decrease alcohol-related consequences tended to have higher than average motivation to reduce or abstain from alcohol use. Alternatively, the network structure of motives against changing alcohol use demonstrated a nearly equal number of positive and negative associations. Whereas reasons to cope and sleep may imply higher than average motivation to continue drinking the same, veterans reporting reasons to reduce anxiety and have fun tended to have lower than average motivation to continue drinking. The current study may inform content modifications to self-help tools to more quickly and effectively target users' motivations from the beginning. Capitalizing on intervention users' motivations early may promote sustained engagement or improve therapeutic impact among those who only use the intervention for a short period of time.

Approach avoidance training versus Sham in veterans with alcohol use disorder: protocol for a randomized controlled trial

BACKGROUND

Alcohol use disorder (AUD) is highly prevalent and commonly co-occurs with other psychiatric disorders among Veterans. Provisional evidence supports the use of Approach Avoidance Training (AAT) - a form of computer-delivered cognitive bias modification designed to target implicit approach bias for alcohol-related cues - as an adjunctive program to treat AUD. However, the extent to which AAT is effective for improving AUD recovery outcomes in outpatient Veteran samples and those with psychiatric comorbidities has been understudied to date. Here we describe a double-blind randomized controlled trial of AAT versus a comparison condition (Sham) being conducted in Veterans with comorbid psychiatric conditions completing outpatient standard care.

METHODS

One hundred thirty-six Veterans currently receiving outpatient treatment for AUD will be recruited for this randomized controlled trial with parallel group assignment. Participants will be randomized to either 6 weeks of AAT (n = 68) or Sham (n = 68) training in conjunction with usual care. Assessments will occur at baseline and 6 weeks, 3 months, and 6 months post-baseline. Primary outcome variables will include functional consequences of drinking. Secondary outcome variables will include alcohol consumption, and behavioral indicators of alcohol approach bias. A subset of participants (n = 51) will also complete functional magnetic resonance imaging (fMRI) to assess neural response during an alcohol approach bias assessment.

DISCUSSION

This study is the first randomized controlled trial of AAT administered as an adjunctive treatment to standard care in Veterans with AUD and comorbid psychiatric disorders. Additionally, behavioral and neuroimaging data will be used to determine the extent to which AAT targets approach bias for alcohol cues. If effective, AAT may be a promising low-cost adjunctive treatment option for individuals with AUD.

REGISTRY NAME

AAT for Alcohol Use Disorder in Veterans.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05372029; Date of Registration: 5/9/2022.

Chronic Pain, Cannabis Legalization and Cannabis Use Disorder in Veterans Health Administration Patients, 2005 to 2019

Background

The risk for cannabis use disorder (CUD) is elevated among U.S. adults with chronic pain, and CUD rates are disproportionately increasing in this group. Little is known about the role of medical cannabis laws (MCL) and recreational cannabis laws (RCL) in these increases. Among U.S. Veterans Health Administration (VHA) patients, we examined whether MCL and RCL effects on CUD prevalence differed between patients with and without chronic pain.

Methods

Patients with ≥1 primary care, emergency, or mental health visit to the VHA and no hospice/palliative care within a given calendar year, 2005-2019 (yearly n=3,234,382 to 4,579,994) were analyzed using VHA electronic health record (EHR) data. To estimate the role of MCL and RCL enactment in the increases in prevalence of diagnosed CUD and whether this differed between patients with and without chronic pain, staggered-adoption difference-in-difference analyses were used, fitting a linear binomial regression model with fixed effects for state, categorical year, time-varying cannabis law status, state-level sociodemographic covariates, a chronic pain indicator, and patient covariates (age group [18-34, 35-64; 65-75], sex, and race and ethnicity). Pain was categorized using an American Pain Society taxonomy of painful medical conditions.

Outcomes

In patients with chronic pain, enacting MCL led to a 0·14% (95% CI=0·12%-0·15%) absolute increase in CUD prevalence, with 8·4% of the total increase in CUD prevalence in MCL-enacting states attributable to MCL. Enacting RCL led to a 0·19% (95%CI: 0·16%, 0·22%) absolute increase in CUD prevalence, with 11·5% of the total increase in CUD prevalence in RCL-enacting states attributable to RCL. In patients without chronic pain, enacting MCL and RCL led to smaller absolute increases in CUD prevalence (MCL: 0·037% [95%CI: 0·03, 0·05]; RCL: 0·042% [95%CI: 0·02, 0·06]), with 5·7% and 6·0% of the increases in CUD prevalence attributable to MCL and RCL. Overall, MCL and RCL effects were significantly greater in patients with than without chronic pain. By age, MCL and RCL effects were negligible in patients age 18-34 with and without pain. In patients age 35-64 with and without pain, MCL and RCL effects were significant (p<0.001) but small. In patients age 65-75 with pain, absolute increases were 0·10% in MCL-only states and 0·22% in MCL/RCL states, with 9·3% of the increase in CUD prevalence in MCL-only states attributable to MCL, and 19.4% of the increase in RCL states attributable to RCL. In patients age 35-64 and 65-75, MCL and RCL effects were significantly greater in patients with pain.

Interpretation

In patients age 35-75, the role of MCL and RCL in the increasing prevalence of CUD was greater in patients with chronic pain than in those without chronic pain, with particularly pronounced effects in patients with chronic pain age 65-75. Although the VHA offers extensive behavioral and non-opioid pharmaceutical treatments for pain, cannabis may seem a more appealing option given media enthusiasm about cannabis, cannabis commercialization activities, and widespread public beliefs about cannabis efficacy. Cannabis does not have the risk/mortality profile of opioids, but CUD is a clinical condition with considerable impairment and comorbidity. Because cannabis legalization in the U.S. is likely to further increase, increasing CUD prevalence among patients with chronic pain following state legalization is a public health concern. The risk of chronic pain increases as individuals age, and the average age of VHA patients and the U.S. general population is increasing. Therefore, clinical monitoring of cannabis use and discussion of the risk of CUD among patients with chronic pain is warranted, especially among older patients.

Research in Context

Evidence before this study: Only three studies have examined the role of state medical cannabis laws (MCL) and/or recreational cannabis laws (RCL) in the increasing prevalence of cannabis use disorder (CUD) in U.S. adults, finding significant MCL and RCL effects but with modest effect sizes. Effects of MCL and RCL may vary across important subgroups of the population, including individuals with chronic pain. PubMed was searched by DH for publications on U.S. time trends in cannabis legalization, cannabis use disorders (CUD) and pain from database inception until March 15, 2023, without language restrictions. The following search terms were used: (medical cannabis laws) AND (pain) AND (cannabis use disorder); (recreational cannabis laws) AND (pain) AND (cannabis use disorder); (cannabis laws) AND (pain) AND (cannabis use disorder). Only one study was found that had CUD as an outcome, and this study used cross-sectional data from a single year, which cannot be used to determine trends over time. Therefore, evidence has been lacking on whether the role of state medical and recreational cannabis legalization in the increasing US adult prevalence of CUD differed by chronic pain status.Added value of this study: To our knowledge, this is the first study to examine whether the effects of state MCL and RCL on the nationally increasing U.S. rates of adult cannabis use disorder differ by whether individuals experience chronic pain or not. Using electronic medical record data from patients in the Veterans Health Administration (VHA) that included extensive information on medical conditions associated with chronic pain, the study showed that the effects of MCL and RCL on the prevalence of CUD were stronger among individuals with chronic pain age 35-64 and 65-75, an effect that was particularly pronounced in older patients ages 65-75.Implications of all the available evidence: MCL and RCL are likely to influence the prevalence of CUD through commercialization that increases availability and portrays cannabis use as 'normal' and safe, thereby decreasing perception of cannabis risk. In patients with pain, the overall U.S. decline in prescribed opioids may also have contributed to MCL and RCL effects, leading to substitution of cannabis use that expanded the pool of individuals vulnerable to CUD. The VHA offers extensive non-opioid pain programs. However, positive media reports on cannabis, positive online "information" that can sometimes be misleading, and increasing popular beliefs that cannabis is a useful prevention and treatment agent may make cannabis seem preferable to the evidence-based treatments that the VHA offers, and also as an easily accessible option among those not connected to a healthcare system, who may face more barriers than VHA patients in accessing non-opioid pain management. When developing cannabis legislation, unintended consequences should be considered, including increased risk of CUD in large vulnerable subgroups of the population.

Trends in substance use disorder diagnoses among Veterans, 2009-2019

BACKGROUND AND OBJECTIVES

Substance use disorder (SUD) represents a substantial health burden to US Veterans. We aimed to quantify recent time trends in Veterans' substance-specific disorders using Veterans Health Administration (VA) data.

METHODS

We identified Veteran VA patients for fiscal years (FY) 2010-2019 (October 1, 2009-September 9, 2019) and extracted patient demographics and diagnoses from electronic health records (~6 million annually). We defined alcohol, cannabis, cocaine, opioid, sedative, and stimulant use disorders with ICD-9 (FY10-FY15) or ICD-10 (FY16-FY19) codes and variables for polysubstance use disorder, drug use disorder (DUD), and SUD.

RESULTS

Diagnoses for substance-specific disorders (excluding cocaine), polysubstance use disorder, DUD, and SUD increased 2%-13% annually for FY10-FY15. Alcohol, cannabis, and stimulant use disorders increased 4%-18% annually for FY16-FY19, while cocaine, opioid, and sedative use disorders changed by ≤1%. Stimulant and cannabis use disorder diagnoses increased most rapidly, and older Veterans had the largest increases across substances.

DISCUSSION AND CONCLUSIONS

Rapid increases in cannabis and stimulant use disorder present a treatment challenge and key subgroups (e.g., older adults) may require tailored screening and treatment options. Diagnoses for SUD are increasing among Veterans overall, but there is important heterogeneity by substance and subgroup. Efforts to ensure access to evidence-based treatment for SUD may require greater focus on cannabis and stimulants, particularly for older adults.

SCIENTIFIC SIGNIFICANCE

These findings represent the first assessment of time trends in substance-specific disorders among Veterans, overall and by age and sex. Notable findings include large increases in diagnoses for cannabis and stimulant use disorder and among older adults.

Working Toward a Gold Standard: The Severity of Ethanol Withdrawal Scale (SEWS) Versus the Clinical Institute Withdrawal Assessment Alcohol Scale (CIWA-Ar)

AIM

Proving the Severity of Ethanol Withdrawal Scale (SEWS) significantly reduces Alcohol Withdrawal Syndrome (AWS) treatment Time on Medication Protocol (TOMP).

METHOD

Head-to-head Quality Assurance outcome compared separate cohorts of SEWS or Clinical Institute Withdrawal Assessment Alcohol Scale, Revised (CIWA-Ar) data using Student's t and Wilcoxon tests.

RESULTS

SEWS-driven treatment (n = 244) reduced TOMP to 2.2 days versus 3.4 days for CIWA-Ar (n = 137); P < 0.0001.

CONCLUSION

The SEWS is the superior measure of AWS symptoms.

The integration of harm reduction services in the Veterans Health Administration (VHA): a qualitative analysis of barriers and facilitators

BACKGROUND

Substance use is common among U.S. military veterans and veterans are at high risk for negative consequences associated with substance use, such as injection-related infections and overdose. Although harm reduction services (HRS) are highly evidence-based, implementation in traditional healthcare settings has been limited. This formative, qualitative study sought to identify barriers and facilitators to the integration of HRS and identify appropriate implementation strategies to support the optimized integration of a comprehensive bundle of HRS in the Veterans Health Administration (VHA).

METHODS

Semi-structured interviews explored how harm reduction is currently understood by VHA providers and elicited input on perceived facilitators and barriers to implementation. Data were analyzed using a directed content analysis and the Practical, Robust Implementation and Sustainability Model (PRISM) implementation framework was used to organize findings. Results were then mapped to relevant implementation strategies using the Consolidated Framework for Implementation Research - Expert Recommendations for Implementing Change (CFIR - ERIC) tool.

RESULTS

15 interviews with VHA providers were conducted across 5 sites. Respondents reported that current HRS are fragmented and dependent on the knowledge, time, and comfort level of individual providers. Stigma around substance use at the patient, provider, and institutional levels was noted to be a key barrier to HRS adoption. Based on identified barriers and facilitators, strategies that may be effective for increasing adoption of HRS include engagement of champions, communication and educational strategies, and adaptation of existing infrastructure.

CONCLUSIONS

Many of the barriers identified in this formative study may be addressed using evidence-based implementation strategies. Additional research is needed to identify implementation strategies that are effective for addressing stigma, which is perceived to be a persistent challenge to the provision of integrated harm reduction services.

State Cannabis Legalization and Cannabis Use Disorder in the US Veterans Health Administration, 2005 to 2019

Importance

Cannabis use disorder (CUD) is increasing among US adults. Few national studies have addressed the role of medical cannabis laws (MCLs) and recreational cannabis laws (RCLs) in these increases, particularly in patient populations with high rates of CUD risk factors.

Objective

To quantify the role of MCL and RCL enactment in the increases in diagnosed CUD prevalence among Veterans Health Administration (VHA) patients from 2005 to 2019.

Design, Setting, and Participants

Staggered-adoption difference-in-difference analyses were used to estimate the role of MCL and RCL in the increases in prevalence of CUD diagnoses, fitting a linear binomial regression model with fixed effects for state, categorical year, time-varying cannabis law status, state-level sociodemographic covariates, and patient age group, sex, and race and ethnicity. Patients aged 18 to 75 years with 1 or more VHA primary care, emergency department, or mental health visit and no hospice/palliative care within a given calendar year were included. Time-varying yearly state control covariates were state/year rates from American Community Survey data: percentage male, Black, Hispanic, White, 18 years or older, unemployed, income below poverty threshold, and yearly median household income. Analysis took place between February to December 2022.

Main Outcomes and Measures

As preplanned, International Classification of Diseases, Clinical Modification, ninth and tenth revisions, CUD diagnoses from electronic health records were analyzed.

Results

The number of individuals analyzed ranged from 3 234 382 in 2005 to 4 579 994 in 2019. Patients were largely male (94.1% in 2005 and 89.0% in 2019) and White (75.0% in 2005 and 66.6% in 2019), with a mean (SD) age of 57.0 [14.4] years. From 2005 to 2019, adjusted CUD prevalences increased from 1.38% to 2.25% in states with no cannabis laws (no CLs), 1.38% to 2.54% in MCL-only enacting states, and 1.39% to 2.56% in RCL-enacting states. Difference-in-difference results indicated that MCL-only enactment was associated with a 0.05% (0.05-0.06) absolute increase in CUD prevalence, ie, that 4.7% of the total increase in CUD prevalence in MCL-only enacting states could be attributed to MCLs, while RCL enactment was associated with a 1.12% (95% CI, 0.10-0.13) absolute increase in CUD prevalence, ie, that 9.8% of the total increase in CUD prevalence in RCL-enacting states could be attributed to RCLs. The role of RCL in the increases in CUD prevalence was greatest in patients aged 65 to 75 years, with an absolute increase of 0.15% (95% CI, 0.13-0.17) in CUD prevalence associated with RCLs, ie, 18.6% of the total increase in CUD prevalence in that age group.

Conclusions and Relevance

In this study of VHA patients, MCL and RCL enactment played a significant role in the overall increases in CUD prevalence, particularly in older patients. However, consistent with general population studies, effect sizes were relatively small, suggesting that cumulatively, laws affected cannabis attitudes diffusely across the country or that other factors played a larger role in the overall increases in adult CUD. Results underscore the need to screen for cannabis use and CUD and to treat CUD when it is present.

Methamphetamine-associated heart failure: a systematic review of observational studies

OBJECTIVE

To conduct a systematic review of observational studies on methamphetamine-associated heart failure (MethHF) .

METHODS

Six databases were searched for original publications on the topic. Title/abstract and included full-text publications were reviewed in duplicate. Data extraction and critical appraisal for risk of bias were performed in duplicate.

RESULTS

Twenty-one studies are included in the final analysis. Results could not be combined because of heterogeneity in study design, population, comparator, and outcome assessment. Overall risk of bias is moderate due to the presence of confounders, selection bias and poor matching; overall certainty in the evidence is very low. MethHF is increasing in prevalence, affects diverse racial/ethnic/sociodemographic groups with a male predominance; up to 44% have preserved left-ventricular ejection fraction. MethHF is associated with significant morbidity including worse heart failure symptoms compared with non-methamphetamine related heart failure. Female sex, methamphetamine abstinence and guideline-directed heart failure therapy are associated with improved outcomes. Chamber dimensions on echocardiography and fibrosis on biopsy predict the extent of recovery after abstinence.

CONCLUSIONS

The increasing prevalence of MethHF with associated morbidity underscores the urgent need for well designed prospective studies of people who use methamphetamine to accurately assess the epidemiology, clinical features, disease trajectory and outcomes of MethHF. Methamphetamine abstinence is an integral part of MethHF treatment; increased availability of effective non-pharmacological interventions for treatment of methamphetamine addiction is an essential first step. Availability of effective pharmacological treatment for methamphetamine addiction will further support MethHF treatment. Using harm reduction principles in an integrated addiction/HF treatment programme will bolster efforts to stem the increasing tide of MethHF.

Journey to wellness: A socioecological analysis of veterans in recovery from substance use disorders

Substance use disorders are increasingly prevalent among veterans in the United States. Veterans in recovery face unique challenges, such as high rates of psychiatric comorbidities, difficulties adjusting to civilian life, and inadequate housing and mental health services. While prior research has explored veterans' experiences in recovery, studies have not implemented a multilevel perspective in their analyses. The current qualitative study examined how individual veteran experiences intersect with interpersonal and systemic factors. Semistructured focus groups were conducted with veterans who were former or current residents of recovery homes (N = 20). Thematic analysis was utilized to explore veterans' personal experiences through the CHIME-D framework (connectedness, hope & optimism, identity, meaning in life, empowerment, and difficulties). The data were further analyzed within a socioecological model (intrapersonal, interpersonal, and community). Each component of the CHIME-D framework was salient across all focus groups, with connectedness, empowerment, and difficulties being the most prominent themes that occurred across all socioecological levels. Results suggest that recovery initiatives can effectively assist veterans by promoting empowerment, facilitating social connections, and addressing cooccurring difficulties across multiple socioecological contexts. Additionally, treatment programs should encourage veterans to take on meaningful roles in their communities. Future research should continue to explore veterans' recovery experiences using a socioecological model.

Medicaid Expansion and Veterans' Reliance on the VA for Depression Care

Background

In 2001, before the Affordable Care Act (ACA), some states expanded Medicaid coverage to include an array of mental health services, changing veterans' reliance on US Department of Veterans Affairs (VA) services.

Methods

Using Medicaid and VA administrative data from 1999 to 2006, we used a difference-in-difference design to calculate shifts in veterans' reliance on the VA for depression care in New York and Arizona after the 2 states expanded Medicaid coverage to adults in 2001. Demographically matched, neighbor states Pennsylvania and New Mexico/Nevada were used as paired comparisons, respectively. Fractional logit was used to capture the distribution of inpatient and outpatient depression care utilization between the VA and Medicaid, while ordered logit and negative binomial regressions were applied to model Medicaid-VA dual users and per capita utilization of total depression care services, respectively.

Results

Medicaid expansion was associated with a 9.50 percentage point (pp) decrease (95% CI, -14.61 to -4.38) in reliance on the VA for inpatient depression care among service-connected veterans and a 13.37 pp decrease (95% CI, -21.12 to -5.61) among income-eligible veterans. For outpatient depression care, VA reliance decreased by 2.19 pp (95% CI, -3.46 to -0.93) among income-eligible veterans. Changes among service-connected veterans were nonsignificant (-0.60 pp; 95% CI, -1.40 to 0.21).

Conclusions

After Medicaid expansion, veterans shifted depression care away from the VA, with effects varying by health care setting, income- vs service-related eligibility, and state of residence. Issues of overall cost, care coordination, and clinical outcomes deserve further study in the ACA era of Medicaid expansions.

What's sleep got to do with it? Longitudinal associations between insomnia, PTSD, and alcohol use among U.S. Veterans

U.S. veterans are at risk for insomnia, which often co-occurs with symptoms of posttraumatic stress disorder (PTSD) and alcohol use. Much of the research on veterans and these three constructs is cross-sectional and focused on unidirectional pathways. Recent theoretical and empirical evidence suggests a dynamic interplay between insomnia, PTSD, and alcohol use, yet few longitudinal studies exist. A clearer understanding of these pathways is needed to help inform integrated treatments. Using a sample of 1,230 post-9/11 veterans assessed over four time points across 12 months, we used a latent difference score modeling approach to examine proportional and dynamic change between insomnia, PTSD, and alcohol. Results revealed a complex interplay between all three constructs. Higher prior levels of both PTSD and alcohol use were associated with greater subsequent changes in insomnia symptoms (i.e., worse sleep). Moreover, although veterans drank less frequently as their insomnia symptoms worsened over time, greater changes in insomnia symptoms (i.e., worse symptoms) was a mechanism linking PTSD and more frequent drinking. As the research on interventions addressing insomnia, PTSD, and alcohol is limited, there are opportunities for researchers and clinicians to develop programs that effectively target all three in integrated treatments.

Predictors of 30-Day Pulmonary Complications after Video-Assisted Thoracoscopic Surgery Lobectomy

BACKGROUND

 Pulmonary complications are the most common adverse event after lung resection, yet few large-scale studies have examined pertinent risk factors after video-assisted thoracoscopic surgery (VATS) lobectomy. Veterans, older and less healthy compared with nonveterans, represent a cohort that requires further investigation. Our objective is to determine predictors of pulmonary complications after VATS lobectomy in veterans.

METHODS

 A retrospective review was conducted on patients who underwent VATS lobectomy from 2008 to 2018 using the Veterans Affairs Surgical Quality Improvement Program database. Patients were divided into two cohorts based on development of a pulmonary complication within 30 days. Patient characteristics were compared via multivariable analysis to determine clinical predictors associated with pulmonary complication and reported as adjusted odds ratios (aORs) with 95% confidence intervals. Patients with preoperative pneumonia, ventilator dependence, and emergent cases were excluded.

RESULTS

 In 4,216 VATS lobectomy cases, 480 (11.3%) cases had ≥1 pulmonary complication. Preoperative factors independently associated with pulmonary complication included chronic obstructive pulmonary disease (COPD) (aOR = 1.37 [1.12-1.69]; p = 0.003), hyponatremia (aOR = 1.50 [1.06-2.11]; p = 0.021), and dyspnea (aOR = 1.33 [1.06-1.66]; p = 0.013). Unhealthy alcohol consumption was associated with pulmonary complication via univariable analysis (17.1 vs. 13.0%; p = 0.016). Cases with pulmonary complication were associated with increased mortality (12.1 vs. 0.8%; p < 0.001) and longer length of stay (12.0 vs. 6.8 days; p < 0.001).

CONCLUSION

 This analysis revealed several preoperative factors associated with development of pulmonary complications. It is imperative to optimize pulmonary-specific comorbidities such as COPD or dyspnea prior to VATS lobectomy. However, unhealthy alcohol consumption and hyponatremia were linked with development of pulmonary complication in our analysis and should be addressed prior to VATS lobectomy. Future studies should explore long-term consequences of pulmonary complications.

Does cannabis testing in the military drive synthetic cannabinoid use? Self-reported use motivations among justice-involved veterans

BACKGROUND

Though synthetic cannabinoid receptor agonists (SCRAs) were controlled after being introduced as a 'legal high,' SCRAs likely remain appealing to individuals subject to routine drug screens as not all testing programs consistently include SCRAs. Military populations have been linked to SCRAs due to the unconfirmed supposition that testing protocols led many to substitute SCRAs for cannabis. This study aimed to explore SCRA use prevalence, correlates, and use motivations among veterans, with a particular focus on whether United States military personnel substituted SCRAs for cannabis to subvert testing protocols.

METHODS

All veterans appearing in one of eight civilian criminal courts in three U.S. states were invited to answer questionnaire items related to military service, court functionality, and substance use. Of the 579 veterans eligible, 54.9% chose to participate, yielding a cross-sectional sample of 318 veterans charged with a criminal offense by civilian authorities.

RESULTS

Sixty-five (21.3%) justice-involved veterans reported lifetime SCRA use. Use while within the military was reported by 15.0% of veterans enlisting after 2008. Only eight (12.3%) reported SCRAs were used as a substitute for cannabis. Boredom (36.9%), experimentation (27.7%), and social aspects of SCRA use (32.3%) were more commonly reported motives. Logistic regression models indicated that use of cannabis (aPR=2.06, p<.05), hallucinogens (aPR=2.50, p<.01), and SCRAs (aPR=2.49, p<.05) while in the military were risk factors for SCRA use after leaving the military, whereas older age at time of military exist was a protective factor (aPR=.87, p<.01) CONCLUSIONS: Drug testing programs within the military do not appear to have the unintended consequence of routing individuals to more risky drugs; however, SCRAs appear to have been an underappreciated problem within the military. Further, use extends beyond the military with many only initiating use after discharge, suggesting SCRA use may jeopardize the health of veterans post-service.

The role of PTSD symptom clusters and criterion in predicting future high-risk drug and alcohol use among returning veteran men and women

The prevalence of co-occurring posttraumatic stress disorder (PTSD) and substance use disorder (SUD) remains exceptionally high among returning veterans, with numerous studies linking PTSD, but not specific PTSD symptoms, to future SUD risk. Further explication of PTSD symptom effects on future SUD risk will likely promote intervention development and refinement while offsetting SUD risk. Accordingly, In this study we explored the prospective associations between PTSD symptom clusters, symptoms, and future SUD risk and use of specific drug classes. Returning veterans (N = 1,295; M_age = 42.3, SD = 9.89; 51% female; 66.8% White) completed structured diagnostic interviews to assess PTSD symptoms and self-report measures of substance use 14-36 months later (M = 24.59, SD = 2.97). Hyperarousal and reckless/self-destructive symptoms specifically predicted future high-risk drug use and binge drinking behavior, and avoidance of internal stimuli (i.e., of trauma memories, thoughts, and feelings) differentiated individuals classified as high-risk for alcohol use based on their AUDIT total score. Further, negative alterations in cognition and mood predicted future opioid (i.e., nightmares) and stimulant use (i.e., flashbacks), whereas concentration difficulties were inversely associated with future binge drinking. This longitudinal study identified prospective and enduring associations between specific PTSD symptom clusters, symptoms, and future high-risk substance use patterns among returning veterans. Accordingly, careful assessment of specific PTSD criteria and differential motivations for substance use is warranted, along with tailored interventions to offset risk for opioid, stimulant, and alcohol use among returning veterans. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Longitudinal course of mental health symptoms among veterans with and without cannabis use disorder

OBJECTIVE

Cannabis use disorder (CUD) is the most common non-alcohol related substance use disorder (SUD) in the United States and is especially prevalent among returning veterans. The long-term mental health correlates of CUD remain unknown, which is significant given the rise in legalization and also recreational and medicinal cannabis use nationally.

METHOD

Using a gender-balanced, national sample of 1,649 veterans (n = 115 with CUD; 75.2% White; M age = 37.49, SD = 9.88), we used latent growth curve modeling to examine posttraumatic stress disorder (PTSD) symptom severity, depressive symptoms, generalized anxiety, alcohol use, and psychosocial functioning between veterans with versus without a prior diagnosis of CUD over five time points, spanning an average of 7 years.

RESULTS

Returning veterans with CUD compared to those without reported higher alcohol use, depression, anxiety, PTSD symptom severity, and worse psychosocial functioning at baseline. We observed nonlinear change across each outcome. We also found that CUD moderated change in alcohol use (quadratic: b = -.129, p < .001) and PTSD symptoms (quadratic: b = -.280, p = .019), such that individuals with CUD evidenced decelerated change and worse outcomes relative to veterans without a previously documented CUD diagnosis. Trajectories of depression, anxiety, and psychosocial functioning were similar across individuals with versus without CUD.

CONCLUSIONS

In the first long-term and longitudinal evaluation of mental health and alcohol use course among returning veterans, CUD was associated with worse and more persistent alcohol use and PTSD symptom severity over time. These data have implications for clinical assessment, case conceptualization, and treatment of veterans and may inform efforts to offset risk for hazardous drinking and PTSD following a diagnosis of CUD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Effects of Substance Use Disorder on In-Hospital Outcomes of Young Patients Presenting With a Cardiovascular Event: A Nationwide Analysis

Background

Substance use is widely prevalent among young adults and is associated with increased cardiovascular morbidity and mortality such as sudden cardiac arrest, acute coronary syndrome, arrhythmias, and cardiomyopathy. However, they are limited studies analyzing the impact of substance use disorder on in-hospital outcomes among young patients with cardiovascular events.

Methods

All patients aged 18-39 years admitted primarily for major cardiovascular events including acute myocardial infarction (AMI), arrhythmia, cardiac arrest, acute ischemic stroke, and venous thromboembolic events in 2019 were identified in the National Inpatient Sample database. They were then categorized into those with and without concomitant substance use disorder (SUD). The primary outcome was in-hospital mortality. Unadjusted and adjusted analysis was performed on appropriate variables of interest.

Results

Of 57,985 hospitalizations with cardiac events, 12,115 (20%) of young adults had concomitant SUD. SUD was significantly associated with cardiac arrest (OR 3.3; CI 2.4-4.4), atrial fibrillation (OR 1.5; CI 1.3-1.7), AMI (OR 1.3; CI 1.2-1.6), heart failure (OR 2.6; CI 2.4-3.0) (all p<0.05) despite a lower prevalence of traditional cardiovascular risk factors than non-users. Logistic regression showed acute kidney injury (aOR 1.5; CI 1.3-1.8; p<0.001) and inpatient mortality (aOR 1.6; CI 1.2-2.2; p<0.001) were also significantly higher in young patients presenting with cardiac events and concomitant SUD. There was no difference in the length of stay or incidence of gastrointestinal bleed between the two groups.

Conclusion

In young patients presenting with a cardiovascular event, concurrent substance use disorder was associated with increased in-hospital mortality despite significantly lower comorbidities.

Psychedelic treatment for co-occurring alcohol misuse and post-traumatic stress symptoms among United States Special Operations Forces Veterans

Background & aims

Special Operations Forces Veterans (SOFV) have unique treatment needs stemming from multiple repeated forms of combat exposure resulting in a complex sequela of problems including alcohol misuse and post-traumatic stress symptoms. Current approved pharmacologic treatments for alcohol misuse and PTSD are lacking in adherence and efficacy, warranting novel treatment development. The current study examined the correlations between psychedelic treatment and changes in alcohol misuse among trauma exposed United States SOFV.

Method

An anonymous internet-based survey was conducted among SOFV who completed a specific psychedelic clinical program in Mexico. Retrospective questions probed alcohol use and post-traumatic stress symptoms during the 30-days before and 30-days after the psychedelic treatment. A total of 65 SOFV completed treatment and were eligible for contact. Of these, 51 (78%) completed the survey, and 27 (42%) reported alcohol misuse (≥4 on the AUDIT-C) in the 30 days prior to treatment and were included in analyses (Mean Age = 40; male = 96%; Caucasian/White = 96%).

Results

There were significant and very large reductions in retrospective reports of alcohol use (P < 0.001; d = –2.4) and post-traumatic stress symptoms (P < 0.001; d = –2.8) and a significant and large increase in psychological flexibility (P < 0.001; d = –1.8), from before-to-after the psychedelic treatment. In the 30 days after treatment, 85% reduced their alcohol consumption to non-risky levels (33% abstinent; 52% non-risky drinking). Increases in psychological flexibility were strongly associated with reductions in alcohol use and post-traumatic stress symptoms (rs range 0.38–0.90; ps < 0.05).

Conclusion

Rigorous longitudinal studies should be conducted to determine whether psychedelic-assisted therapy holds promise as an intervention in this population.

Computerized Relational Agent to Deliver Alcohol Brief Intervention and Referral to Treatment in Primary Care: a Randomized Clinical Trial

BACKGROUND

Alcohol screening and brief intervention have demonstrated efficacy but limited effectiveness and implementation in real-world primary care settings.

OBJECTIVE

To evaluate the effectiveness of a computerized Relational Agent programmed to provide alcohol screening, brief intervention, and referral to treatment. We hypothesized that participants in the experimental condition would report greater reductions in their drinking and higher rates of brief intervention and referrals to specialty care compared to those in treatment as usual (TAU).

DESIGN

This was a Hybrid I implementation design and stratified RCT. Participants were randomized to TAU or Relational Agent + TAU and assessed at baseline and 3-month follow-up.

PARTICIPANTS

A total of 178 veteran participants were recruited by referral from primary care staff after a positive alcohol screen, or via letter sent do patients screening positive during recent visit.

INTERVENTION(S)

TAU involved yearly reminders to screen alcohol use and provide brief intervention and treatment referrals, as needed. The Relational Agent added an automated brief intervention, a 1-month follow-up Relational Agent visit, and referral to treatment if needed.

MAIN MEASURES

We measured average drinks per day, drinking days per week, number of brief interventions, and number of referrals over 3 months.

KEY RESULTS

Participants decreased their drinking in both study conditions, with no significant between-group differences on primary alcohol measures. However, Relational Agent + TAU participants evidenced greater improvements regarding negative alcohol-related consequences over 3 months, and were significantly more likely to receive a brief intervention and referral to specialty care.

CONCLUSIONS

The Relational Agent successfully provided brief intervention and referred many more patients to specialty care and was able to intervene with patients with less severe drinking without increasing primary care burden.

TRIAL REGISTRATION

clinicaltrials.gov , NCT02030288, https://clinicaltrials.gov/ct2/home.

Historical Trends in Veteran Community Substance Use Treatment: 2000-2019

Background: Substance use is a significant health crisis for the Veteran population. Prior research has thoroughly examined Veteran substance use within Veterans Health Administration (VHA) settings. However, such data tends to be outdated, and there is minimal research on substance use services delivered outside of VHA systems. This study examines historical patterns of Veteran substance use using a large sample of community-based substance-use treatment admissions. Methods: Data were drawn from the Substance Abuse and Mental Health Data Archive Treatment Episode Data Set-Admissions. Of the 39,425,886 total admissions between 2000 and 2019, 1,361,339 were of Veterans. Analyses compared Veteran versus non-Veteran admissions on demographics and historical trends in nature of substance-use admissions. Results: Relative to non-Veterans, Veteran admissions were more likely to be prompted by alcohol use. Over time, heterogeneity in substances prompting admissions has increased dramatically for both Veterans and non-Veterans, with particularly notable increases in opiate and stimulant use. Conclusion: Results suggest Veterans admitted to community substance-use treatment are unique relative to their non-Veteran peers. Development and implementation of treatments to target a range of substances while also considering the environmental challenges (e.g., homelessness) commonly faced by this population appear essential to best servicing community-based Veterans.

Understanding motives for and against hazardous drinking and change among returning veterans

The prevalence of hazardous drinking is elevated among returning veterans of Iraq and Afghanistan wars, particularly among returning veterans and those with co-occurring posttraumatic stress disorder (PTSD) symptoms. Understanding the reasons for drinking as well as motivations for change can tremendously improve intervention efforts. Unfortunately, little is currently known regarding the motivations that might facilitate or hinder change among returning veterans. In the current study, we examined returning veterans' reasons to change or not change drinking through analysis of responses to an open-ended decisional balance exercise. We included 366 returning veterans selected from a larger sample of returning veterans enrolled in a web-based randomized-controlled trial of an online intervention for alcohol use and PTSD. We used qualitative content analysis to systematically classify responses into categories through identification of common themes. Top reasons to change/reduce drinking included reducing negative physical effects, improve finances, and expected social/interpersonal benefits of reduction or abstaining. Top reasons to continue drinking/not change included facilitation of social interaction, promote sleep, and reduce tension. The current study adds to our phenomenological understanding of motivations for and against changing drinking among returning veterans. Whereas many motives were consistent with those of nonveteran samples, others appear to distinguish, and are uniquely salient among, returning veterans (e.g., to manage sleep and PTSD symptoms). These results provide insight into key assessment and intervention points regarding hazardous drinking among returning veterans. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Binge drinking following residential treatment for posttraumatic stress disorder among veterans with and without alcohol use disorder

Posttraumatic stress disorder (PTSD) is complicated by high rates of problematic drinking and comorbid alcohol use disorder (AUD). This study examined veterans seeking residential PTSD treatment, comparing those with and without AUD, to determine whether trauma type and/or PTSD symptom changes during treatment were associated with binge drinking at 4-month follow-up. Analyses compared characteristics of veterans (N = 758) in residential treatment, as well as associations of demographic, trauma, and alcohol-related variables, with binge drinking episodes at follow-up. Results showed no differences in PTSD symptom improvements based on AUD diagnosis. Among AUD-diagnosed veterans, 21.3% endorsed binge drinking 4 or more (14.3% endorsed 9 or more) days, while 10.8% of veterans without AUD endorsed binge drinking 4 or more (5.2% endorsed 9 or more) days at follow-up. Among AUD-diagnosed veterans, while PTSD symptom improvements were not associated with binge drinking outcomes, drinking days at admission and military sexual trauma (MST) predicted a greater likelihood of binge drinking. Among veterans without AUD, drinking days at admission, PTSD symptom increases, being unmarried, 'other' race, and less education, were associated with a higher likelihood of binge drinking, while MST and combat exposure predicted a lower likelihood of binge drinking. In conclusion, drinking days at admission is a predictor of binge drinking following treatment; thus, alcohol use should be assessed at intake and addressed among those who endorse drinking to reduce the likelihood of alcohol resumption following residential treatment. Furthermore, among AUD-diagnosed veterans, despite PTSD symptom decreases during treatment, MST predicted a greater likelihood of 9 or more binge drinking days at follow-up.

Prevalence of substance use and substance-related disorders among US Veterans Health Administration patients

BACKGROUND

Substance use and related disorders are common among US Veterans, but the population burden of has never been directly assessed among Veterans Health Administration (VA) patients. We surveyed VA patients to measure substance use and related disorders in the largest US integrated healthcare system.

METHODS

We surveyed N = 6000 outpatients from 30 geographically-representative VA healthcare systems. We assessed substance use (lifetime, past 12-month, daily in past 3 months) and past 12-month disorders following DSM-5 criteria and estimated the association with Veteran characteristics (age, gender, race/ethnicity, socioeconomic status, VA utilization).

RESULTS

Alcohol was the most commonly-reported substance (24% used past 12 months, 11% daily in past 3 months, 10% met criteria for alcohol use disorder), followed by cannabis (42% lifetime use, 12% use in past 12 months, 5% daily use in past 3 months, 3% met criteria for cannabis use disorder). Overall, 5% met criteria for non-alcohol drug use disorder (13% for substance use disorder (SUD)). SUD prevalence was highest for young Veterans and those who were unemployed or otherwise not employed for wages. Past 12-month cannabis use was common, even among older adults (65-74 years: 10%; 75 and older: 2%).

CONCLUSIONS

Prevalence data are important inputs into decisions around population health monitoring, treatment capacity, and quality measurement strategies. Substance use and SUD are more prevalent than previously reported, and VA may need to screen for non-alcohol drugs to identify patients who need care. More tailored assessment may be needed for cannabis use, high-prevalence subgroups, and older adults.

"It's like a Brotherhood": Thematic analysis of veterans' identity processes in substance abuse recovery homes

This exploratory study aimed to understand how veterans' social identity influenced their experiences living in Oxford Houses (OH)-the largest network of substance use recovery homes in the United States. We conducted three focus groups, with 20 veterans who were current or former OH residents. Thematic analysis revealed several ways in which participants' veteran identity influenced their experiences living in OH, including: (1) thriving through OH organizational similarities with the military, (2) relationships with other OH residents, and (3) and growth and reintegration. The themes were interpreted using the Social Identity Theory and the Social Identity Model of Identity Change perspectives. Social identity processes were found to play an influential role in veterans' experiences in their recovery homes and reintegration into civilian life. Findings highlight the importance of veterans developing a community within a culturally congruent setting to facilitate their recovery from substance use disorders and adjustment to life post-military service.

Parental Reflectiveness, Posttraumatic Symptoms and Alcohol Use Disorder among Israeli Combat-Veteran Fathers

Combat veterans are highly prone to develop Alcohol Use Disorder (AUD) following their release from duty, presumably due to high prevalence of prolonged aversive emotional symptoms such as Posttraumatic Stress Symptoms (PTSS). Parental Reflective Functions (PRF) and Parental Sense of Competence (PSOC) have been identified as key protective factors in predicting maternal functioning and well-being, yet little is known of its role among fathers, let alone combat veteran fathers. In this study we explored whether PRF and PSOC moderated the association between PTSS and AUD among 189 Israel Defense Forces (IDF) male combat veterans. Participants filled out validated measures assessing PTSS, PRF, PSOC and AUD. Results indicated that PTSS, as well as PRF's "interest and curiosity regarding the child's mental states" subscale, were positively correlated to AUD. In addition, PRF's "certainty about child mental states" subscale moderated the association between PTSS and AUD, so that PTSS and AUD were significantly correlated for participants who reported average or high levels of certainty about their child's mental states. This finding may imply that intrusive mentalizing ("hypermentalizing") by veteran fathers may facilitate the association between PTSS and AUD, presumably by constituting a maladaptive mechanism for coping with the stressful uncertainty embedded in the parent-child relationship.

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.

Electrophysiological predictors and indicators of contingency management treatment response: Rationale and design for the ways of rewarding abstinence project (WRAP)

Background

Electrophysiological measures can predict and reflect substance use treatment response. Veterans are disproportionately affected by disorders of addiction; cocaine use disorder (CUD) being particularly problematic due to high relapse rates and the absence of approved pharmacotherapies. Prize-based Contingency Management (PBCM) is an evidence-based behavioral intervention for CUD, involving incentives for cocaine abstinence but treatment response is variable. Measurement-based adaptation of PBCM has promise to improve effectiveness but remains to be usefully developed.

Methods

This trial aims to determine if individuals with distinct neurocognitive profiles differentially benefit from one of two existing versions of PBCM. CUD patients will be randomized into treatment-as-usual or 12-weeks of PBCM using either monetary or tangible prize incentives. Prior to randomization, EEG will be used to assess response to monetary versus tangible reward; EEG and cognitive-behavioral measures of working memory, cognitive control, and episodic future thinking will also be acquired. Substance use and treatment engagement will be monitored throughout the treatment interval and assessments will be repeated at post-treatment.

Discussion

Results of this trial may elucidate individual differences contributing to PBCM treatment response and reveal predictors of differential benefits from existing treatment variants. The design also affords the opportunity to evaluate treatment-related changes in neurocognitive functioning over the course of PBCM. Our model posits that PBCM scaffolds future-oriented goal representation and self-control to support abstinence. Individuals with poorer functioning may be less responsive to abstract monetary reward and will therefore achieve better outcomes with respect to abstinence and treatment engagement when tangible incentives are utilized.

Veterans' Reported Comfort in Disclosing Sexual Orientation and Gender Identity

BACKGROUND

The Veterans Health Administration (VHA) does not routinely collect and document sexual orientation and gender identity (SOGI) data despite research on health disparities among sexual and gender minority (SGM) veterans. Due to the legacy of previous Department of Defense policies that prohibited disclosure of sexual or gender minority identities among active-duty personnel, minority veterans may be reluctant to respond to SOGI questions on confidential VHA surveys and in discussions with their VHA providers. Veterans may generally find SOGI questions uncomfortable and may not appreciate their relevance to health care.

OBJECTIVE

The purpose of this research was to examine veterans' comfort in reporting identity characteristics on confidential VHA surveys and in discussion with their VHA providers and whether comfort differed by sociodemographic characteristics.

RESEARCH DESIGN

The project involves the secondary analysis of quantitative data from a quality improvement survey project.

SUBJECTS

A total of 806 veterans were surveyed.

RESULTS

Overall, 7.15% endorsed sexual or gender minority identity which is a higher rate than the 4.5% noted in the general US population. Cisgender and heterosexual veterans were more comfortable reporting identity characteristics both on VHA confidential surveys and in discussion with VHA providers compared with SGM veterans.

CONCLUSIONS

These data suggest that the majority of veterans feel comfortable reporting their identities both on surveys and in the context of health care. Understanding these perceptions can assist VHA programs in implementing SOGI data collection and disclosure in clinical care, creating a welcoming environment of care for SGM veterans that does not make veterans from other backgrounds feel uncomfortable.

Mental health and addiction service use among United States veterans with liver disease nationally in the Veterans Health Administration

Purpose

While many studies have shown that liver diseases (LD) can be caused or exacerbated by substance use disorders (SUD), few have examined the proportion of adults with LD and SUD who receive mental health and addiction treatment or correlates of such use.

Design/methodology/approach

Using national Fiscal Year (FY) 2012 data from the United States Veterans Health Administration (VHA), the authors studied all 43,246 veterans diagnosed with both LD and SUD in FY 2012 and compared those who received mental health treatment (n = 30,456; 70.4%) to those who did not (n = 12,790; 29.6%).

Findings

Veterans who received mental health treatment were less like to be older than 75 years of age, more likely to have served during recent Middle East conflicts (Operation Iraqi Freedom or Operation Enduring Freedom), more likely to have been recently homeless and to have drug dependence as contrasted with alcohol dependence when compared with those who did not receive mental health treatment. Although the majority, 70.4%, received mental health treatment, only 30.6% of the total received specialized addiction treatment, and these veterans were more likely to experience homelessness and have drug dependence diagnoses.

Originality/value

This is the first study as per the authors’ best knowledge that broadly examines mental health and addiction treatment received by veterans with LD and SUD. High rates of mental health treatment in this population likely reflect the integrated nature of the VHA and its emphasis on providing comprehensive services to homeless veterans. Further research is needed to identify barriers to specialized addiction treatment in this population.

Positive emotional intensity and substance use: the underlying role of positive emotional avoidance in a community sample of military veterans

Background: Military veterans are at greater risk for substance misuse. Positive emotional intensity is one well-established antecedent of substance misuse in this population. Positive emotional avoidance, or attempts to alter the form, frequency, or context of positive emotions, may help to explain this association. While clinical practice typically aims to increase positive emotions, such approaches may have iatrogenic effects, as high-intensity positive emotions may be experienced as distressing and prompt avoidance for some populations. This suggests a need to better understand responses to positive emotions to inform clinical practice.Objectives: The goal of the current study was to advance theory, research, and clinical practice by exploring the role of positive emotional avoidance in the associations between positive emotional intensity and both alcohol and drug misuse. We hypothesized that positive emotional intensity would indirectly influence alcohol and drug misuse through positive emotional avoidance.Methods: Participants were a community sample of United States military veterans recruited through Amazon's Mechanical Turk (n = 535, Mage = 37.45, 71.8% male, 69.5% White).Results: Correlations among positive emotional intensity, positive emotional avoidance, and alcohol and drug misuse were significant and positive (rs range from.13 to.41). Further, positive emotional avoidance was found to account for the relations of positive emotional intensity to alcohol (indirect effect: b =.04, 95%CI [.01,.08]) and drug misuse (indirect effect: b =.01, 95%CI [.01,.02]).Conclusions: Results provide preliminary support for the potential clinical utility of targeting avoidance responses to positive emotions in interventions targeting alcohol and drug misuse among military veterans.

Emotion regulation and experiential avoidance moderate the association between posttraumatic symptoms and alcohol use disorder among Israeli combat veterans

INTRODUCTION

the association between Posttraumatic Stress symptoms (PTSS) and Alcohol Use Disorder (AUD) among combat veterans is well established. However, little is known concerning the intertwining effect of distress oriented coping mechanisms on this association. In this study, we sought to explore the moderating role of experiential avoidance (EA), cognitive reappraisal (CR) and expressive suppression (ES) on the association between PTSS and AUD among Israeli combat veterans.

METHOD

Participants were 189 Israel Defense Forces (IDF) male combat veterans (mean age = 30.03) who completed a set of validated self-report questionnaires assessing PTSS, AUD, EA, CR and ES. Moderation analyses were conducted using a four-step hierarchical regression analysis and an ordinary least squares regression analysis.

RESULTS

Analyses indicated that individuals with average or high levels of EA or ES exhibited significant positive association between PTSS and AUD, yet those with low levels of EA or ES exhibited no significant association between PTSS and AUD (b = 0.14,Confidence Interval (CI)[0.06, 0.22, SE = 0.04, t = 3.65, p = .000, 95%] for EA and b = 0.17, CI[0.07, 0.25, SE = 0.04, t = 3.69, p = .000, 95%] for ES). In addition, CR moderated the association between PTSS and AUD (b = 0.18, CI[0.07, 0.29, SE = 0.06, t = 3.24, p = .001, 95%]), so that the association between PTSS and AUD is positive and stronger for higher levels of CR.

CONCLUSIONS

Our findings imply that EA, ES and CR and emotion regulation may be major facilitators of the association between PTSS and AUD among combat veterans. These findings are discussed in the Israeli context as well as in light of a general psychological perspective.

Differential alcohol treatment response by gender following use of VetChange

OBJECTIVE

Proportionally more women use online alcohol interventions but also report less robust treatment outcomes compared to men. Less is known about outcome disparities among veteran women, who are a growing demographic nationally. The current study examined gender differences among returning veteran men and women who used VetChange, a web-based intervention for hazardous drinking and posttraumatic stress symptoms (PTSS).

METHOD

Using data from a nationwide implementation study of returning combat veterans (n = 222), we performed hierarchical linear modeling to examine gender differences in alcohol and PTSS outcomes over six months following VetChange registration. Additional analyses examined gender differences in proportional changes in hazardous drinking and at each assessment point.

RESULTS

Returning veterans reported significant decreases in alcohol use and PTSS over time, yet men evidenced significantly greater reduction in average weekly drinks and drinks per drinking day compared to women. Follow up analyses indicated that women were significantly less likely than men to achieve low-risk drinking by one month post-registration. Proportional change in alcohol use yielded marginal and non-significant trends that were, nonetheless, consistent with the overall pattern of gender differences.

CONCLUSION

These results contribute to emerging literature suggesting that women use online alcohol use interventions at proportionately higher rates than do men, but do not reduce their drinking as much as men. There are a number of potential content changes that could improve outcomes for returning veteran women using online interventions, and data-driven adaptations based on stakeholder input are recommended.

Equine-Assisted Activities and Therapies for Veterans With Posttraumatic Stress Disorder: Current State, Challenges and Future Directions

Posttraumatic stress disorder is common among military Veterans. While effective treatments exist, many Veterans either do not engage in treatment or fail to achieve full remission. Thus, there is a need to develop adjunctive complementary interventions to enhance treatment engagement and/or response. Equine-assisted activities and therapies (EAAT) are one category of animal assisted interventions that might serve this function. The aim of this article is to review the current state and challenges regarding the use of EAAT for Veterans with PTSD and provide a roadmap to move the field forward. EAAT hold promise as adjunctive complementary interventions for symptom reduction among Veterans with PTSD. Additionally, there is evidence that these approaches may enhance wellbeing in this population. At this time, many gaps in the literature exist and rigorous randomized controlled trials are needed before definitive conclusions can be drawn. The authors of this work provide recommendations as a roadmap to move the field forward. These include standardizing the EAAT nomenclature, focusing mechanism of action studies on the human-horse bond using biological metrics and using a standardized intervention model across studies.

Using administrative health data to estimate prevalence and mortality rates of alcohol and other substance-related disorders for surveillance purposes

INTRODUCTION

Administrative health databases (AHD) are critical to guide health service management and can inform the whole spectrum of substance-related disorders (SRD). This study estimates prevalence and mortality rates of SRD in administrative health databases.

METHODS

The Quebec Integrated Chronic Disease Surveillance System consists of linked AHD. Analyses were performed on data of all Quebec residents aged 12 and over and eligible for health-care coverage using the International Classification of Diseases (ninth or tenth revision) for case identification. Mortality rate ratios stratified by causes of death were obtained to calculate an excess of mortality.

RESULTS

Since 2001-2002, the annual age-adjusted prevalence rate of diagnosed overall SRD remained stable (8.6 per 1000 in 2017-2018). In any given year, the annual prevalence rate was significantly higher in males; adolescents had the lowest rate, while adults 65 years and older the highest. The annual 2017-2018 rate was 2.1 per 1000 for alcohol-induced disorder, 1.9 for other drug-induced disorder, 0.7 for alcohol intoxication and 0.6 for other drug intoxications. Cumulative rate of any diagnosis related to alcohol was 32 per 1000 females and 53 per 1000 males (2001-2018), and 33 per 1000 females and 49 per 1000 males for any diagnosis related to other drugs. There was an excess of all-cause mortality among individuals with SRD compared to the general population.

DISCUSSION AND CONCLUSIONS

AHD can complement epidemiological surveys in monitoring SRD jurisdiction-wide. Surveillance of services utilisation and interventions, coupled with health outcomes like mortality, could be useful in guiding health services planning.

Depressive symptomatology and alcohol misuse among treatment-seeking military veterans: Indirect associations via ruminative thinking

BACKGROUND

Veterans are particularly vulnerable to experiencing concurrent issues related to depression and alcohol misuse. Despite this well-established susceptibility, research explicating targetable mechanisms that can account for this comorbidity remains limited. The present study sought to examine the explanatory role of ruminative thought processing within the depression and alcohol misuse relationship.

METHOD

The sample included 230 veterans presenting to a general mental health clinic at a large Veterans Affairs (VA) hospital (83% male, 58% African American, M_age = 50.61, SD_age = 13.79). As part of their intake evaluation, veterans completed a brief battery of self-report questionnaires to assist with diagnostic clarification and treatment planning.

RESULTS

A significant total effect was observed between depression and alcohol misuse. An indirect effect between depression and alcohol misuse via rumination was also found. Notably, when examining two subtypes of rumination, an indirect effect between depression and alcohol misuse via reflective pondering but not brooding was evinced.

CONCLUSIONS

Findings suggest that ruminative thought processing may be an explanatory risk factor within the depression and alcohol misuse relationship. By testing the simultaneous indirect effects of brooding rumination and reflective pondering, the present study also offers novel insights concerning the circumstances under which reflection may become a maladaptive process.

Impulsivity and Medical Care Utilization in Veterans Treated for Substance Use Disorder

Impulsivity has been defined by acting rashly during positive mood states (positive urgency; PU) or negative mood states (negative urgency; NU) and by excessive de-valuation of deferred rewards. These behaviors reflect a "live in the now" mentality that is not only characteristic of many individuals with severe substance use disorder (SUD) but also impedes medical treatment compliance and could result in repeated hospitalizations or other poor health outcomes. Purpose/objectives: We sought preliminary evidence that impulsivity may relate to adverse health outcomes in the veteran population. Impulsivity measured in 90 veterans receiving inpatient or outpatient SUD care at a Veterans Affairs Medical Center was related to histories of inpatient/residential care costs, based on VA Health Economics Resource Center data. Results: We found that positive urgency, lack of persistence and lack of premeditation, but not sensation-seeking or preference for immediate or risky rewards, were significantly higher in veterans with a history of one or more admissions for VA-based inpatient or residential health care that either included (n = 30) or did not include (n = 29) an admission for SUD care. Among veterans with a history of inpatient/residential care for SUD, NU and PU, but not decision-making behavior, correlated with SUD care-related costs. Conclusions/Importance: In veterans receiving SUD care, questionnaire-assessed trait impulsivity (but not decision-making) related to greater care utilization within the VA system. This suggests that veterans with high impulsivity are at greater risk for adverse health outcomes, such that expansion of cognitive interventions to reduce impulsivity may improve their health.

Concurrent use of opioids and benzodiazepines/Z-drugs in Alberta, Canada and the risk of hospitalisation and death: a case cross-over study

OBJECTIVES

Coprescribing of benzodiazepines/Z-drugs (BZDs) and opioids is a drug-use pattern of considerable concern due to risk of adverse events. The objective of this study is to estimate the effect of concurrent use of BZDs on the risk of hospitalisations/emergency department (ED) visits and deaths among opioid users.

DESIGN, SETTING AND PARTICIPANTS

We conducted a population-based case cross-over study during 2016-2018 involving Albertans 18 years of age and over who received opioids. From this group, we identified 1 056 773 people who were hospitalised or visited the ED, and 31 998 who died.

INTERVENTION

Concurrent use of opioids and BZDs.

OUTCOMES

We estimated the risk of incident all-cause hospitalisation/ED visits and all-cause mortality associated with concurrent BZD use by applying a matched-pair analyses comparing concurrent use to opioid only use.

RESULTS

Concurrent BZD use occurred in 17% of opioid users (179 805/1 056 773). Overall, concurrent use was associated with higher risk of hospitalisation/ED visit (OR 1.13, p<0.001) and all cause death (OR 1.90; p<0.001). The estimated risk of hospitalisation/ED visit was highest in those >65 (OR 1.5; p<0.001), using multiple health providers (OR 1.67; p<0.001) and >365 days of opioid use (OR 1.76; p<0.001). Events due to opioid toxicity were also associated with concurrent use (OR 1.8; p<0.001). Opioid dose-response effects among concurrent patients who died were also noted (OR 3.13; p<0.001).

INTERPRETATION

Concurrent use of opioids and BZDs further contributes to the risk of hospitalisation/ED visits and mortality in Alberta, Canada over opioid use alone, with higher opioid doses, older age and increased number of unique health providers carrying higher risks. Regulatory bodies and health providers should reinforce safe drug-use practices and be vigilant about coprescribing.

Prescription opioid misuse and its correlates among veterans and military in the United States: A systematic literature review

BACKGROUND

Prescription opioid misuse (POM) has become a critical public health issue in the United States (US), with veteran and military population being especially vulnerable to POM. However, limited behavioral interventions have been developed for veterans and military to reduce POM risk due to the lack of an adequate understanding of POM andrelated factors among veterans and military. The current study aims to review and synthesize empirical findings regarding POM and its correlates among US veterans and military.

METHODS

We conducted a systematic review of 17 empirical studies (16 quantitative studies and one qualitative study) from 1980 to 2019 that reported POM statistics (e.g., prevalence) and examined correlates of POM in veterans and military.

RESULTS

The prevalence of POM in veterans and military ranged from 6.9%-77.9% varying by study samples, individual POM behaviors, and recalled time periods. Several factors were identified to be associated with POM in veterans and military. These factors included socio-demographic factors (age, race/ethnicity, education, relationship status, and military status), pain-related factors (pain symptoms, severity, interference, and cognitions), other physical factors (e.g., common illness), opioid-medication-related factors (receipt of opioid medications and quantity of opioid medications), behavioral factors (substance use disorder, alcohol use, cigarette use, and other prescription drug use), and psychological factors (psychiatric symptoms and cognitive factors).

CONCLUSIONS

POM was prevalent in veterans and military and could be potentially influenced by multiple psycho-behavioral factors. Future research guided by a theoretical framework is warranted to examine psycho-behavioral influences on POM and their mechanisms and to inform effective psychosocial POM interventions in veterans and military.

Alcohol misuse and separation from military service: A dyadic perspective

OBJECTIVE

Alcohol misuse is a prevalent problem among military service members and their spouses. Service member alcohol misuse may contribute to poor job performance, legal infractions, and failure to meet physical standards. Spousal alcohol misuse may indicate problems with military life. However, limited information is available about how alcohol misuse in military families affects occupational outcomes, specifically military attrition.

METHOD

The current study examined 7,965 opposite sex married couples from the Millennium Cohort Family Study with one military and one civilian/veteran partner. Both partners reported on three measures of alcohol misuse (binge drinking, alcohol problems, and heavy weekly drinking). The associations between each partner's measures of alcohol misuse and subsequent military separation were evaluated using logistic regression. Sex, concordance of alcohol misuse, mental health, and service branch were explored as moderators.

RESULTS

In fully adjusted models, service member alcohol problems were directly related to military separation. Additionally, service member heavy weekly drinking was strongly associated with military separation among female service members but not male service members. Service member and spouse binge drinking interacted such that when only one partner reported binge drinking military separation was less likely, but both partners' binge drinking conveyed a marginally increased risk of military separation.

CONCLUSIONS

Prevalence of alcohol misuse was high among military families. Service member alcohol misuse was more strongly related to military separation than spouse alcohol misuse. Additionally, heavy weekly drinking among female service members may be an indicator of a significant issue that merits interventions aimed at retaining these service members.

Social Network Cohesion among Veterans Living in Recovery Homes

Recovery homes for individuals with substance use disorders (SUD) called Oxford House (OH) have been shown to improve the prospects of a successful recovery across different sub-populations, and these homes may be particularly beneficial for veterans in recovery. An estimated 18% of OH residents are veterans; however, not much is known about their experiences living in these homes. Participants included 85 veterans and non-veterans living in 13 OHs located in different regions of the United States. Using social network analysis and multi-level modeling, we investigated whether the social networks of veterans residing with other veterans were more cohesive compared to veterans living with only non-veterans. Results indicated that veterans residing with other veterans had stronger relationships with other OH residents compared to veterans that reside with all non-veterans. The implications for theory and practice are discussed. Further research is needed to determine if greater social network cohesion leads to better recovery outcomes for veterans.

Parallel process modeling of posttraumatic stress disorder symptoms and alcohol use severity in returning veterans

Posttraumatic stress disorder (PTSD) is associated with higher levels of alcohol use among returning veterans. Persistent PTSD symptoms can predict alcohol use over the span of hours, days, weeks, and months; however, knowledge of the strength of these associations beyond 1 year remains limited. In this study, we examined the 6-year course of co-occurring PTSD and alcohol use to explicate the directional and possible enduring effects of PTSD on alcohol use severity over time. Our study included 1,649 returning veterans (M age = 37.49; SD = 9.88) who completed 4 waves of data collection between 2010 and 2016. We used parallel process modeling to evaluate temporal associations between PTSD symptoms and alcohol use severity across 4 (T1-T4) waves of data collection. PTSD and alcohol use both decreased significantly between T1 and T4 and in tandem with one another. That is, decreases in one were associated with decreases in the other. Further, individuals with higher levels of PTSD symptom severity at T1 reported accelerated rates of change regarding PTSD symptoms and alcohol use over time. Conversely, baseline alcohol use severity did not predict the rate of change in PTSD symptom severity. Our findings provide evidence of a prospective association between PTSD symptoms and alcohol use and highlight the potential for reciprocal associations between them over the span of years. Importantly, our demonstration of the natural course of co-occurring PTSD symptoms and alcohol use suggests further trauma-focused and combined intervention strategies are needed to disrupt this enduring and reciprocal pattern among returning veterans. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Changes in alcohol use, PTSD hyperarousal symptoms, and intervention dropout following veterans' use of VetChange

OBJECTIVE

Veterans of Iraq and Afghanistan conflicts report high rates of drinking, PTSD, and low rates of treatment engagement. Web interventions may help address unmet treatment need; unfortunately, little is known regarding outcomes or adherence to these interventions. In this study, we examined VetChange treatment outcomes and downstream effects of alcohol reduction on PTSD symptoms and intervention dropout rates over six months.

METHOD

Participants included 222 veterans (77.5% men, 78.3% White) between 22 and 57 (mean age = 36.02, SD = 7.19). All VetChange users completed a brief alcohol assessment and received personal feedback, then received full access to intervention content including psychoeducation; motivational and cognitive-behavioral modules for relapse prevention, goal-setting, social support, stress, anger, and sleep management; and mood and drink tracking. Veterans completed self-report measures of alcohol use and PTSD symptoms at baseline, one, three, and six months.

RESULTS

Alcohol use dropped by 43% over six months, p < .001, with the largest decrease occurring within the first month. Greater alcohol reduction in the first month predicted higher subsequent PTSD hyperarousal severity. Over half (52.3%) dropped out by month one, followed by 12.2% and 37.6% by months three and six. Hyperarousal symptoms, hypervigilance specifically, but not alcohol use predicted subsequent intervention dropout.

CONCLUSION

These results highlight the importance of attending to the association between alcohol use and PTSD symptom change in web-based interventions for veterans. The fact that hyperarousal symptoms were associated with elevated risk for intervention dropout signifies the need for online intervention refinement aimed at tailoring content to time-varying symptom presentations.