Use of Veterans Health Administration Mental Health and Substance Use Disorder Treatment After Exiting Prison: The Health Care for Reentry Veterans Program

Health Conditions and Treatment Utilization Among Older Male Veterans Incarcerated in Prisons

BACKGROUND

More than 50,000 older male veterans incarcerated in prisons are expected to return to their communities and utilize the Veterans Health Administration (VHA) and community healthcare systems. To support the continuity of healthcare and overall successful community reentry of older incarcerated veterans, an understanding of their health profiles and treatment utilization while in correctional care is needed.

OBJECTIVE

To assess the health status of older male veterans incarcerated in state prisons and explore demographic, military, and VHA-related factors associated with medical conditions, disabilities, behavioral conditions, and medical and behavioral treatment utilization.

DESIGN/PARTICIPANTS

Cross-sectional observational study of 880 male veterans aged 50 + incarcerated in state prisons using data from the 2016 Bureau of Justice Statistics Survey of Prison Inmates.

MAIN MEASURES

Veteran status, self-report health status, and treatment utilization since prison admission. Prevalence rates for conditions and treatment utilization were calculated. Logistic regression models were used to examine the association of characteristics with conditions and treatment utilization.

KEY RESULTS

Among the 880 older male veterans in state prisons, the majority reported having a current medical condition (79.3%) or disability (61.6%), almost half had history of a mental health condition (44.5%), and more than a quarter (29%) had a substance use disorder. Compared to White veterans, Black veterans were less likely to report a disability or mental health condition. Few demographic, military, and VA-related characteristics were associated with medical or behavioral conditions or treatment utilization.

CONCLUSION

Our results suggest that the VHA and community healthcare systems need to be prepared to address medical and disability conditions among the majority of older male veterans who will be leaving prison and returning to their communities. Integrated medical and behavioral healthcare delivery models may be especially important for these veterans as many did not receive behavioral health treatment while in prison.

Comorbidities, healthcare use, and contact with healthcare transition services in older veterans after incarceration

BACKGROUND

The Health Care for Reentry Veterans (HCRV) program was established to support community reintegration for veterans after incarceration. Yet, it is unclear how those with and without HCRV contact differ. We sought to evaluate differences in medical and psychiatric conditions and healthcare utilization among mid-to late-life reentry veterans who did and did not receive HCRV outreach.

METHODS

Study participants were veterans aged ≥50 years who qualified for Medicare fee-for-service, had experienced incarceration for ≥1 year, and were released from incarceration between October 1, 2006, and September 30, 2018 (N = 9733). Using VA and Medicare claims data, we compared prevalence of medical and psychiatric diagnoses, and use of emergency, inpatient, and outpatient medical and mental health services up to 12 months after release between those with and without HCRV contact.

RESULTS

Veterans with HCRV contact (35.5%) had significantly higher rates of psychiatric conditions and medical conditions related to substance use (e.g., liver disease) compared to veterans without HCRV contact. Average time between release and first healthcare service use was significantly lower for HCRV veterans (36.5 ± SD 59.5 days) versus non-HCRV veterans (58.9 ± SD 77.5 days) and HCRV veterans were more likely to utilize the emergency department, inpatient and outpatient mental health services, and inpatient medical services.

CONCLUSION

HCRV reaches older reentry veterans with a large burden of mental health and substance use disorders. However, levels of multimorbidity were high among all older reentry veterans, pointing to a need to develop specialized geriatric models of care for this reentry population.

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.

Prison Adjustment Among Military Veterans: The Impact of Traumatic Events, Service History, and PTSD

Military veterans have been shown to differ demographically from non-veterans in the criminal justice system. However, relatively little is known about their psychological adjustment, institutional misbehavior, and the efficacy of programing received while incarcerated. Using data taken from a national sample of prison inmates, this study investigates how traumatic events experienced during military service can impact the intensity of negative affect among veterans. Additionally, we examine whether prison misconduct is influenced by military service history and the receipt of substance abuse treatment. Controlling for a host of relevant variables, our results indicate that traumatic events show a significant effect on psychological adjustment only indirectly through veterans who developed post-traumatic stress disorder and that misconduct is lower among those who received an honorable discharge. Overall, these findings suggest that the ability of veterans to resist adverse outcomes may depend on a variety of factors both within and outside the prison environment.

Dialectical behavior therapy for justice-involved veterans: Changes in treatment targets in a small, pre-post design clinical trial

[Correction Notice: An Erratum for this article was reported online in Psychological Services on Jul 13 2023 (see record 2023-89801-001). In the article, the title was incorrect and should have been "Dialectical Behavior Therapy for Justice-Involved Veterans: Changes in Treatment Targets in a Small, Pre-Post Design Clinical Trial." This error did not impact the results or conclusions. All versions of this article have been corrected.] Dialectical Behavior Therapy for Justice-Involved Veterans (DBT-J; Edwards, Dichiara, Epshteyn, et al., 2022) was recently developed as an integrative psychotherapy + case management intervention to address the range of complex criminogenic, mental health, substance use, and case management needs commonly faced by justice-involved veterans. Research to date suggests delivery of DBT-J to be both acceptable and feasible (Edwards, Dichiara, Epshteyn, et al., 2022). However, data on therapeutic change experienced by DBT-J participants has been limited. The present study represents an initial investigation into longitudinal changes in criminogenic risk, psychological distress, substance use, case management needs, and quality of life experienced by 20 justice-involved veterans across their course of DBT-J participation. Results reflected notable improvements across treatment targets from pre- to posttreatment; these gains were largely maintained at 1-month follow-up. Such findings attest to the potential utility of DBT-J and to the need for continued research into the efficacy of this intervention. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Development and evaluation of an online vocational program for veterans with legal convictions and psychiatric illness

PURPOSE

We describe the development and pilot evaluation of an online vocational rehabilitation program, the About Face Online System (AFOS), for veterans with a history of felony convictions and either mental illness and/or substance use disorders.

METHOD

Phase One was the development and acceptability testing of the online system. Phase Two was a small, randomized trial comparing the likelihood of obtaining employment among people using the AFOS, compared to people receiving a self-directed hardcopy manual, after 6 months.

RESULTS

In Phase One, 17 veterans provided feedback as the system was being developed. The final system allows veterans to receive education on vocational reintegration skills, watch short videos describing the techniques, and communicate with a vocational staff member via chat features. Veterans found the AFOS to be as acceptable as a hardcopy manual that covered similar material. In Phase Two, 38 veterans with a history of felony convictions and either mental illness or substance use disorder were randomized to receive the AFOS or a hardcopy manual. After 6 months, people randomized to the AFOS were more likely to obtain employment than people randomized to the hardcopy manual.

CONCLUSION

An online vocational program may help veterans who cannot attend traditional in-person vocational services to successfully obtain employment.

High Risk of Substance Use Disorder-Related Outcomes in Veterans Released from Correctional Facilities in Mid to Late Life

BACKGROUND

Veterans Affairs (VA) is likely to encounter a growing number of veterans returning to the community in mid to late life following incarceration (i.e., experiencing reentry). Yet, rates of negative health outcomes due to substance use disorders (SUDs) in this population are unknown.

OBJECTIVE

To determine risk of and risk factors for SUD-related emergency department visits and inpatient hospitalizations (ED/IPH) and overdose death among older reentry veterans compared with never-incarcerated veterans.

DESIGN

Retrospective cohort study using national VA and Medicare healthcare systems data.

PARTICIPANTS

Veterans age  ≥50, incarcerated for  ≤5 consecutive years, and released between October 1, 2010, and September 30, 2017 (N = 18,803), were propensity score-matched 1:5 with never-incarcerated veterans (N = 94,015) on demographic characteristics, reason for Medicare eligibility, and SUD history.

MAIN MEASURES

SUD-related ED/IPH (overall and substance-specific) were obtained from in-/outpatient VA health services and CMS data within the year following release date/index date (through September 30, 2018). Overdose death within 1 year was identified using the National Mortality Data Repository. Fine-Gray proportional hazards regression compared risk of SUD-related ED/IPH and overdose death between the two groups.

RESULTS

The number of SUD-related ED/IPHs and overdose deaths was 2470 (13.1%) and 72 (0.38%) in the reentry sample versus 4402 (4.7%) and 198 (0.21%) in the never-incarcerated sample, respectively. Mid-to-late-life reentry was associated with higher risk of any SUD-related ED/IPH (13,136.2 vs. 2252.8 per 100,000/year; adjusted hazard ratio [AHR] = 2.19; 95% confidence interval [CI] = 2.08, 2.30) and overdose death (382.9 vs. 210.6 per 100,000/year; AHR = 2.24, 95% CI = 1.63, 3.08).

CONCLUSIONS

Older reentry veterans have more than double the risk of experiencing SUD-related ED/IPH (overall and substance-specific) and overdose death, even after accounting for SUD history and other likely confounders. These findings highlight the vulnerability of this population. Improved knowledge regarding SUD-related negative health outcomes may help to tailor VA reentry programming.

Substance use and criminogenic thinking: Longitudinal latent class analysis of veterans with criminal histories

INTRODUCTION

The objective of this study was to inform clinical practice by identifying distinct subgroups of US veterans with criminal histories in residential mental health treatment. The study characterized veteran patients on their alcohol and drug use and criminogenic thinking. We also examined predictors and outcomes of subgroup membership.

METHODS

Participants were 341 veterans with a criminal history in residential mental health care. A parallel latent growth trajectory model characterized participants' alcohol and drug use and criminogenic thinking at treatment entry and at 6- and 12-month follow-ups.

RESULTS

The study identified four distinct classes: 53 % Normative Improvement, 27 % High Criminogenic Thinking, 11 % High Recurrence (of substance use), and 9 % High Drug Use. Compared to the Normative Improvement class, prior to treatment entry, patients in the High Recurrence class were less likely to be on parole or probation, and patients in the High Criminogenic Thinking class were more likely to be chronically homeless. Compared to the Normative Improvement class, at follow-ups, patients in the High Drug Use and High Criminogenic Thinking classes were more likely to recidivate, and patients in the High Drug Use class were more likely to report unstable housing. Depression scores were higher (nearly double) in the High Drug Use, High Recurrence, and High Criminogenic Thinking classes at follow-ups compared to the Normative Improvement class.

CONCLUSIONS

That the Normative Improvement class entered mental health residential treatment with relatively low alcohol and drug use and criminogenic thinking, and sustained these low levels, suggests that treatment does not need to be broadened or intensified to improve these domains for these patients with criminal histories. In contrast, findings for the High Drug Use, High Recurrence, and High Criminogenic Thinking classes, which composed 47 % of the sample, suggest that more integrated and sustained treatment may be needed to reduce recidivism, depression, and homelessness among these patients.

Correlates of Incarceration History Among Military Veterans

Veterans with histories of incarceration are at greater risk for poor physical and mental health outcomes, yet prior research in this population has focused on specific subsets of veterans or a narrow range of predictors. We utilized the Bronfenbrenner Socioecological Model as the framework to evaluate correlates of incarceration history in a large sample of Iraq and Afghanistan-era veterans at four levels: demographic, historical, clinical, and contextual. Participants were 2,904 veterans (76.9% male; 49.5% White and 46.5% Black; mean age 38.08, SD = 10.33), 700 of whom reported a history of incarceration. Four logistic regression models predicting history of incarceration were tested, adding demographic, historical, clinical, and contextual variables hierarchically. In the final model, younger age (OR=0.99, 95% CI=0.98-1.00), male gender (OR of being female =0.28, 95% CI=0.21-0.38), belonging to a historically marginalized group (OR of being White =0.69, 95% CI=0.56-0.84), family history of incarceration (OR=1.47, 95% CI=1.10-1.94), adult interpersonal trauma (OR=1.39, 95% CI=1.28-1.51), problematic alcohol use (OR=1.03, 95% CI=1.02-1.05), drug abuse (OR=1.15, 95% CI=1.11-1.19), and unemployment (OR for being employed=0.76, 95% CI=0.62-0.92) were significantly associated with a history of incarceration. Implications of these findings for developing interventions and supporting systems to effectively target this high-risk population of veterans are discussed.

Enhancing community integration after incarceration: findings from a prospective study of an intensive peer support intervention for veterans with an historical comparison group

BACKGROUND

The transition to the community after incarceration presents challenges for returning citizens, including the immediate need to secure housing, employment, and income. Additionally, health care is essential for this population due to high rates of chronic physical health and mental health problems and substance use disorders. There is growing recognition of the need for interventions that support returning citizens as they navigate community reintegration while simultaneously tending to physical and behavioral health needs. We developed and pilot tested a peer support intervention designed to provide social, emotional, and logistic support and promote linkage and engagement in healthcare for returning citizens. We tested the intervention with US military veterans in Massachusetts who were being released from prison and jail. Outcomes related to linkage to and engagement in healthcare were evaluated using an historical comparison group. Engagement in peer support, housing status, and reincarceration rates were monitored for the intervention group.

RESULTS

There were 43 veterans in the intervention group, and 36 in the historical comparison group. For linkage to primary care within 90 days of release, there were no statistically significant differences between the intervention and comparison groups (58% versus 67%). Intervention participants were significantly more likely to receive substance use treatment than the comparison group (86% versus 19%, p < .0001) and the mean monthly substance use visits was greater in the intervention group (0.96 versus 0.34, p < .007). Engagement in mental health services was greater for the intervention group than the comparison group (93% versus 64%, p < .003). There were no significant differences between groups for emergency department use and hospitalization. At the end of the study period, the majority of intervention participants who had been released for over a year were living in permanent housing (84%). Recidivism among the was low, with 7% re-arrested during the study period.

CONCLUSIONS

Augmenting reentry support through intensive peer support appears to have substantial benefits for veterans in terms of engaging them in health care and contributing to their longer-term stability, including housing and recidivism. Flexible reentry support such as this intervention may be well suited to meet the widely varying needs of returning citizens.

Prevalence of Mental Health and Addiction Service use Prior to and During Incarceration in Provincial Jails in Ontario, Canada: A Retrospective Cohort Study

OBJECTIVE

Individuals with mental illness and addiction are overrepresented in prisons. Few studies have assessed mental health and addiction (MHA)-related service use among individuals experiencing incarceration using health administrative data and most focus on service use after prison release. The objective of this study was to determine the prevalence of MHA-related service use in the 5 years prior to and during incarceration.

METHODS

We used linked correctional and administrative health data for people released from Ontario provincial jails in 2010. MHA-related service use in the 5 years prior to the index incarceration was categorized hierarchically into four mutually exclusive categories based on the type of service use: psychiatric hospitalization, MHA-related emergency department (ED) visit, MHA-related outpatient visit (from psychiatrist or primary care physician), and no MHA-related service use. Demographic, diagnostic, and incarceration characteristics were compared across the four service use categories. MHA-related service use during the index incarceration was assessed by category and length of incarceration.

RESULTS

A total of 48,917 individuals were included. Prior to incarceration, 6,116 (12.5%) had a psychiatric hospitalization, 8,837 (18.1%) had an MHA-related ED visit, and 15,866 (32.4%) had an MHA-related outpatient visit. Of the individuals with any MHA-related service prior to incarceration, 60.4% did not receive outpatient care from a psychiatrist prior to incarceration and 65.6% did not receive MHA-related care during incarceration.

CONCLUSION

Despite a high prevalence of mental illness and addiction among people experiencing incarceration, access to and use of MHA-related care prior to and during incarceration is poor. Increasing the accessibility and use of MHA-related services throughout the criminal justice pathway is warranted.

Dialectical behavior therapy for justice-involved veterans (DBT-J): Feasibility and acceptability

Justice-involved veterans are a high-risk, high-need subgroup serviced by behavioral health services within the Veterans Health Administration (VHA) system. Justice-involved veterans often have complex mental health and substance use difficulties, a myriad of case management needs, and a range of criminogenic needs that are difficult to treat with traditional outpatient VHA services. The present study represents an initial evaluation of dialectical behavior therapy for justice-involved veterans (DBT-J), a novel psychotherapy program providing 16 weeks of skills-based group therapy and individualized case management services to veterans with current or recent involvement with the criminal justice system. A total of 13 veterans were successfully enrolled into this initial acceptability and feasibility trial. Results broadly suggested DBT-J to be characterized by high ease of implementation, successful recruitment efforts, strong participant attendance and retention, high treatment fidelity, and high acceptability by veteran participants, DBT-J providers, and adjunctive care providers alike. Although continued research using comparison conditions is necessary, veterans who completed participation in DBT-J tended to show reductions in criminogenic risk across the course of treatment. Cumulatively, these findings suggest DBT-J holds potential as a VHA-based intervention to address the various needs of justice-involved veterans. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Expanding the Scope of Forensic and Other Services for Justice-Involved Veterans

Military veterans are a unique population within the criminal justice system. Numerous criminal justice reforms for this population exist, but there is a dearth of research summarizing and critiquing past and ongoing efforts directed at veterans. This article examines the partnerships developed by the Department of Veterans Affairs with criminal justice agencies to address the needs of justice-involved veterans. Despite these efforts, there is more to be done to support veterans. We provide recommendations for agencies, including enhanced identification of veterans in criminal justice settings, delivery of services to a wider range of veterans, enhancement of partnered relationships with law enforcement, recalibration of the role of Veterans Treatment Courts in the continuum of justice system offerings, expansion of trauma-informed care throughout the criminal justice and partnered health care systems, and sustainment of reform efforts and innovations through advisory bodies. Rigorous research to evaluate reform efforts are needed across all areas. The Veterans Affairs' continuing role as partner to criminal justice agencies and in reform efforts is critical, and improving linkage to and use of health care will result in enhanced health and other outcomes for veterans involved in the criminal justice system.

Legal System Involvement and Opioid-Related Overdose Mortality in U.S. Department of Veterans Affairs Patients

INTRODUCTION

Opioid-related overdose risks are elevated after incarceration. The rates of opioid-related overdose mortality have risen in recent years, including among Veterans Health Administration patients. To inform Veteran overdose prevention, this study evaluates whether opioid-related overdose risks differ for Veterans Health Administration patients with versus those without indicators of legal system involvement.

METHODS

This retrospective national cohort study, conducted in 2019-2021, used Veterans Health Administration electronic health records and death certificate data from the Department of Veterans Affairs/Department of Defense Mortality Data Repository to examine opioid-related overdose mortality from January 1, 2013 through December 31, 2017. The cohort included 5,390,902 Veterans with Veterans Health Administration inpatient or outpatient encounters in 2012 who were alive as of January 1, 2013, of whom 32,284 (0.60%) patients had legal system involvement in 2012, indicated by Veterans Justice Programs outpatient encounters. Cox proportional hazards regression models assessed the associations between legal involvement and risk of opioid-related overdose mortality.

RESULTS

There were 4,670 opioid-related overdose deaths, including 295 (6.31%) among legal-involved Veterans. Veterans with legal involvement had a higher opioid-related overdose mortality rate per 100,000 person-years (191.22, 95% CI=169.40, 213.04 vs 17.76, 95% CI=17.23, 18.29, p<0.001) and an elevated risk of opioid-related overdose mortality (adjusted hazard ratio=1.38, 95% CI=1.22, 1.57, p<0.001) compared with those without.

CONCLUSIONS

Among Veterans receiving Veterans Health Administration care in 2012, documented legal system involvement was associated with an increased risk of opioid-related overdose mortality. Targeting overdose education and naloxone distribution programs and integrating opioid overdose prevention efforts into mental health care may reduce opioid overdose deaths among Veterans with legal involvement.

Utilization of substance use treatment among criminal justice-involved individuals in the United States

Over six million individuals are involved with the criminal justice system in the United States, of which a large proportion report extensive substance use. We examined the extent to which criminal justice-involvement affects substance use treatment utilization among participants from one of the largest annual surveys on substance use in the U.S., the National Survey on Drug Use and Health (NSDUH). Multivariable logistic regression analyses indicated that criminal justice involvement was significantly associated with receiving substance use treatment in the past year (AOR 8.00, 95% CI: 6.23-10.27, p < 0.001). However, those with criminal justice histories continue to face barriers to treatment. Among individuals ages 12 and older who reported past year criminal justice involvement and met criteria for a substance use disorder, 18.9% reported receiving past year substance use treatment. After controlling for key demographic and drug use characteristics in a multivariable logistic regression model, Black criminal justice involved Americans were somewhat less likely to report receiving substance use treatment in the past year compared to White criminal justice involved Americans, although the association was not significant (AOR 0.87, 95% CI 0.58-1.29, p = 0.481). Treatment programs targeted to increase minority engagement and address persistent barriers to substance use treatment may be valuable for curbing substance use and recidivism among criminal justice-involved individuals.

Strategies to improve implementation of medications for opioid use disorder reported by veterans involved in the legal system: A qualitative study

BACKGROUND

Veterans involved in the legal system have a high risk of overdose mortality but limited utilization of medications for opioid use disorder (MOUD). To increase the use of MOUD in Veterans Health Administration (VHA) facilities and reduce overdose mortality, the VHA should incorporate strategies identified by legal-involved veterans to improve quality of care and ensure that their patients' experiences are integrated into care delivery. This study aims to determine strategies to increase use of MOUD from the perspective of legal-involved veterans with a history of opioid use or opioid use disorder (OUD).

METHODS

Between February 2018 and March 2019, we conducted semistructured interviews with 18 veterans with a history of opioid use or OUD and legal involvement (15 men and 3 women; mean age 41, standard deviation 13, range 28-61). Veterans were from 9 geographically dispersed United States VHA facilities. The study analyzed verbatim transcripts using the framework method. The primary focus was themes that represented legal-involved veteran-identified strategies to improve the use of MOUD.

RESULTS

The 18 veterans interviewed had legal involvement directly related to their opioid use and most (n = 15; 83%) had previously used MOUD. Veteran-identified strategies to improve access to and use of MOUD included: (1) VHA should provide transportation or telehealth services; (2) legal agencies should increase access to MOUD during incarceration; (3) the VHA should reduce physician turnover; (4) the VHA should improve physician education to deliver compassionate, patient-centered treatment; (5) the VHA should improve veteran education about MOUD; and (6) the VHA should provide social support opportunities to veterans.

CONCLUSIONS

Legal-involved veterans provided strategies that can inform and expand MOUD to better meet their needs and the treatment needs of all patients with OUD. The VHA should consider incorporating these strategies into care, and should evaluate their impact on patients' experience, initiation of and retention on medications, and overdose rates.

Substance Use Rates of Veterans with Depression Leaving Incarceration: A Matched Sample Comparison with General Veterans

Formerly incarcerated military veterans—comprising approximately 8% of the prison population—experience significant barriers to reentry including homelessness, mental illness, and mortality. One of the most consequential barriers is relapsing into substance use. Most justice-involved veterans (JIV) possess histories of substance abuse before imprisonment, and this rate continues upon release. Mental illness—depression in particular—is often comorbid with substance abuse. With high rates of depression and substance use in a JIV population, it is important to determine to what extent release from prison contributes to predicting substance use and negative clinical outcomes. This study compares rates of substance use and negative outcomes between two matched samples of JIV and general veterans, both with depression and a substance use disorder. It is hypothesized that JIV will have a higher rate of substance use and that use will be associated with higher negative outcomes in the JIV condition. Rates of use of veterans released from prison and general veterans were collected during six-year follow-up periods. Use was defined as the use of an illicit substance or alcohol, if an alcohol use disorder was present, and determined by urine drug tests or self-report recorded in medical notes. Results indicate that JIV used substances at a higher rate compared to those not recently incarcerated, and that such use is predictive of several other negative outcomes including homelessness, use of inpatient substance treatment, and reincarceration. Structured drug treatment programs and other interventions should cater to veterans recently released from prison to offer help in these areas.

Social determinants of mental health care systems: intensive community based Care in the Veterans Health Administration

BACKGROUND

Since deinstitutionalization in the 1950s-1970s, public mental health care has changed its focus from asylums to general hospitals, outpatient clinics and specialized community-based programs addressing both clinical and social determinants of mental health. Analysis of the place of community-based programs within a comprehensive health system such as the Veterans Health Administration (VHA) may illuminate the role of social forces in shaping contemporary public mental health systems.

METHODS

National VHA administrative data were used to compare veterans who exclusively received outpatient clinic care to those receiving four types of specialized community-based services, addressing: 1) functional disabilities from severe mental illness (SMI), 2) justice system involvement, 3) homelessness, and 4) vocational rehabilitation. Bivariate comparisons and multinomial logistic regression analyses compared groups on demographics, diagnoses, service use, and psychiatric prescription fills.

RESULTS

An hierarchical classification of 1,386,487 Veterans who received specialty mental health services from VHA in Fiscal Year 2012, showed 1,134,977 (81.8%) were seen exclusively in outpatient clinics; 27,931 (2.0%) received intensive SMI-related services; 42,985 (3.1%) criminal justice services; 160,273 (11.6%) specialized homelessness services; and 20,921 (1.5%) vocational services. Compared to those seen only in clinics, veterans in the four community treatment groups were more likely to be black, diagnosed with HIV and hepatitis, had more numerous substance use diagnoses and made far more extensive use of mental health outpatient and inpatient care.

CONCLUSIONS

Almost one-fifth of VHA mental health patients receive community-based services prominently addressing major social determinants of health and multimorbid substance use disorders.

Veterans Justice Programs: Assessing Population Risks for Suicide Deaths and Attempts

OBJECTIVES

Understanding suicide risks among Veteran subpopulations is a national priority. This study assessed risks of suicide, suicide attempts, and other-cause mortality among recipients of Veterans Health Administration (VHA) Veterans Justice Program services as compared to other Veteran VHA users.

METHODS

Per VHA records, the cohort included 5,401,192 Veterans alive as of January 1, 2013 and with VHA utilization in 2012. Receipt of Veterans Justice Outreach (VJO) or Health Care for Reentry Veterans (HCRV) services in 2012 was assessed using encounter codes. Multivariable proportional hazards regression assessed risks of suicide (per National Death Index search results from the VA/DoD Mortality Data Repository) and attempts (per diagnoses and site reports) in 2013-2016, adjusting for demographic and clinical indicators.

RESULTS

Compared to other patients, Veterans with VJO encounters had greater risk of suicide (unadjusted HR = 2.80, 95% confidence interval [CI] = 2.30-3.40; adjusted HR = 1.25, 95% CI = 1.02-1.53) and attempts (unadjusted HR = 8.88, 95% CI = 8.45-9.35; adjusted HR = 1.06, 95% CI = 1.00-1.11). Veterans with HCRV encounters had elevated risk of suicide attempts (unadjusted HR = 4.56, 95% CI = 4.00-5.20; adjusted HR = 1.42, 95% CI = 1.24-1.62). Risks were also elevated for other external causes of mortality.

CONCLUSIONS

Findings document increased risk of suicidal behavior among Veterans Justice Program recipients. These results have informed VHA suicide prevention activities.

Measuring Exposure to Incarceration Using the Electronic Health Record

BACKGROUND

Electronic health records (EHRs) are a rich source of health information; however social determinants of health, including incarceration, and how they impact health and health care disparities can be hard to extract.

OBJECTIVE

The main objective of this study was to compare sensitivity and specificity of patient self-report with various methods of identifying incarceration exposure using the EHR.

RESEARCH DESIGN

Validation study using multiple data sources and types.

SUBJECTS

Participants of the Veterans Aging Cohort Study (VACS), a national observational cohort based on data from the Veterans Health Administration (VHA) EHR that includes all human immunodeficiency virus-infected patients in care (47,805) and uninfected patients (99,060) matched on region, age, race/ethnicity, and sex.

MEASURES AND DATA SOURCES

Self-reported incarceration history compared with: (1) linked VHA EHR data to administrative data from a state Department of Correction (DOC), (2) linked VHA EHR data to administrative data on incarceration from Centers for Medicare and Medicaid Services (CMS), (3) VHA EHR-specific identifier codes indicative of receipt of VHA incarceration reentry services, and (4) natural language processing (NLP) in unstructured text in VHA EHR.

RESULTS

Linking the EHR to DOC data: sensitivity 2.5%, specificity 100%; linking the EHR to CMS data: sensitivity 7.9%, specificity 99.3%; VHA EHR-specific identifier for receipt of reentry services: sensitivity 7.3%, specificity 98.9%; and NLP, sensitivity 63.5%, specificity 95.9%.

CONCLUSIONS

NLP tools hold promise as a feasible and valid method to identify individuals with exposure to incarceration in EHR. Future work should expand this approach using a larger body of documents and refinement of the methods, which may further improve operating characteristics of this method.

Coordinating across correctional, community, and VA systems: applying the Collaborative Chronic Care Model to post-incarceration healthcare and reentry support for veterans with mental health and substance use disorders

BACKGROUND

Between 12,000 and 16,000 veterans leave incarceration annually. As is known to be the case for justice-involved populations in general, mental health disorders (MHDs) and substance use disorders (SUDs) are highly prevalent among incarcerated veterans, and individuals with MHDs and SUDs reentering the community are at increased risk of deteriorating health and recidivism. We sought to identify opportunities to better coordinate care/services across correctional, community, and VA systems for reentry veterans with MHDs and SUDs.

METHODS

We interviewed 16 veterans post-incarceration and 22 stakeholders from reentry-involved federal/state/community organizations. We performed a grounded thematic analysis, and recognizing consistencies between the emergent themes and the evidence-based Collaborative Chronic Care Model (CCM), we mapped findings to the CCM's elements - work role redesign (WRR), patient self-management support (PSS), provider decision support (PDS), clinical information systems (CIS), linkages to community resources (LCR), and organizational/leadership support (OLS).

RESULTS

Emergent themes included (i) WRR - coordination challenges among organizations involved in veterans' reentry; (ii) PSS - veterans' fear of reentering society; (iii) PDS - uneven knowledge by reentry support providers regarding available services when deciding which services to connect a reentry veteran to and whether he/she is ready and/or willing to receive services; (iv) CIS - lapses in MHD/SUD medications between release and a first scheduled health care appointment, as well as challenges in transfer of medical records; (v) LCR - inconsistent awareness of existing services and resources available across a disparate reentry system; and (vi) OLS - reentry plans designed to address only immediate transitional needs upon release, which do not always prioritize MHD/SUD needs.

CONCLUSIONS

Applying the CCM to coordinating cross-system health care and reentry support may contribute to reductions in mental health crises and overdoses in the precarious first weeks of the reentry period.

Veterans in Prison for Sexual Offenses: Characteristics and Reentry Service Needs

Among prison-incarcerated men in the United States, more veterans (35%) have a sexual offense conviction than nonveterans (23%). Limited research has investigated factors explaining the link between military service and sexual offending. Nationally representative data from prison-incarcerated men (n = 14,080) were used to examine the association between veteran status and sexual offenses, adjusting for demographic, childhood, and clinical characteristics. Veterans had 1.35 higher odds (95% confidence interval = [1.12, 1.62], p < .01) of a sexual offense than nonveterans. Among veterans, those who were homeless or taking mental health medications at arrest had lower odds and veterans with a sexual trauma history had higher odds of a sexual offense compared with other offense types. Offering mental health services in correctional and health care settings to address trauma experiences and providing long-term housing options can help veterans with sexual offenses as they transition from prison to their communities.

A scoping review of military veterans involved in the criminal justice system and their health and healthcare

BACKGROUND

In the criminal justice system, special populations, such as older adults or patients with infectious diseases, have been identified as particularly vulnerable to poor health outcomes. Military veterans involved in the criminal justice system are also a vulnerable population warranting attention because of their unique healthcare needs. This review aims to provide an overview of existing literature on justice-involved veterans' health and healthcare to identify research gaps and inform policy and practice.

METHODS

A systematic search was conducted to identify research articles related to justice-involved veterans' health and healthcare that were published prior to December 2017. Study characteristics including healthcare category, study design, sample size, and funding source were extracted and summarized with the aim of providing an overview of extant literature.

RESULTS

The search strategy initially identified 1830 unique abstracts with 1387 abstracts then excluded. Full-text review of 443 articles was conducted with 252 excluded. There were 191 articles included, most related to veterans' mental health (130/191, 68%) or homelessness (24/191, 13%). Most studies used an observational design (173/191, 91%).

CONCLUSIONS

Knowledge gaps identified from the review provide guidance on future areas of research. Studies on different sociodemographic groups, medical conditions, and the management of multiple conditions and psychosocial challenges are needed. Developing and testing interventions, especially randomized trials, to address justice-involved veterans care needs will help to improve their health and healthcare. Finally, an integrated conceptual framework that draws from diverse disciplines, such as criminology, health services, psychology, and implementation science is needed to inform research, policy and practice focused on justice-involved veterans.

Utilization of addiction treatment among U.S. adults with history of incarceration and substance use disorders

Background

The high prevalence of substance use disorders (SUDs) among incarcerated adults in the U.S. is well-known, but there has been less examination of SUD treatment and rates of incarceration among the population of adults with SUDs as the denominator. The current study uses a population-based sample to address three questions: (1) What is the rate of lifetime incarceration among the population of U.S. adults with SUDs?; (2) Among adults with SUDs, what proportion of those with incarceration histories use SUD treatment compared to those without incarceration histories?; and (3) What individual characteristics are associated with utilization of SUD treatment among adults with incarceration histories?

Methods

Data were based on the National Epidemiologic Survey on Alcohol and Related Conditions-III which surveyed a nationally representative sample of U.S. adults through structured interviews. This study focused on the 10,853 respondents who had any lifetime SUD, including 2670 (weighted 22.4%) who reported a lifetime history of incarceration.

Results

In the total weighted sample of respondents with SUDs, 22% had been incarcerated before but only 37% had used any alcohol use disorder treatment and 18% had used drug use disorder treatment. Controlling for confounding variables, respondents with SUDs and incarceration histories had 3.1 times the odds of using alcohol use disorder treatment and 1.6 times the odds of using drug use disorder treatment compared to their counterparts with SUDs and no incarceration histories. Having an opioid use disorder, especially heroin use disorder, and a stimulant use disorder, such as cocaine use disorder, had strong associations with any SUD treatment use.

Conclusions

Many U.S. adults with SUDs have histories of incarceration but only a minority use any SUD treatment. Public health approaches that increase access and incentives to engage in and complete SUD treatment may help resolve problems of both incarceration and SUDs in the population.

Past year and prior incarceration and HIV transmission risk among HIV-positive men who have sex with men in the US

Three quarters of new HIV infections in the US are among men who have sex with men (MSM). In other populations, incarceration is a social determinant of elevations in viral load and HIV-related substance use and sex risk behavior. There has been limited research on incarceration and these HIV transmission risk determinants in HIV-positive MSM. We used the Veterans Aging Cohort Study (VACS) 2011-2012 follow-up survey to measure associations between past year and prior (more than one year ago) incarceration and HIV viral load and substance use and sex risk behavior among HIV-positive MSM (N = 532). Approximately 40% had ever been incarcerated, including 9% in the past year. In analyses adjusting for sociodemographic factors, past year and prior incarceration were strongly associated with detectable viral load (HIV-1 RNA >500 copies/mL) (past year adjusted odds ratio (AOR): 3.50 95% confidence interval (CI): 1.59, 7.71; prior AOR: 2.48 95% CI: 1.44, 4.29) and past 12 month injection drug use (AORs > 6), multiple sex partnerships (AORs > 1.8), and condomless sex in the context of substance use (AORs > 3). Past year incarceration also was strongly associated with alcohol and non-injection drug use (AOR > 2.5). Less than one in five HIV-positive MSM recently released from incarceration took advantage of a jail/prison re-entry health care program available to veterans. We need to reach HIV-positive MSM leaving jails and prisons to improve linkage to care and clinical outcomes and reduce transmission risk upon release.

Receipt of Pharmacotherapy for Alcohol Use Disorder by Male Justice-Involved U.S. Veterans Health Administration Patients

This study examined whether, among Veterans Health Administration (VHA) patients, veterans with recent or current justice involvement have equal receipt of pharmacotherapy for alcohol use disorder compared to veterans with no justice involvement. Using national VHA records, we calculated the overall and facility rates of receipt as the number of patients who received pharmacotherapy for alcohol use disorder divided by the number of patients diagnosed with an alcohol use disorder. Using a mixed-effects logistic regression model, we tested whether justice involvement was associated with pharmacotherapy receipt. Male veterans with jail/court involvement had significantly higher odds of receiving pharmacotherapy for alcohol use disorder compared to other male veterans. Justice-involved veterans had equal or better receipt of pharmacotherapy for alcohol use disorder compared to veterans with no justice involvement. Pharmacotherapy rates are low overall, suggesting that more work can be done to connect veterans to these medications.

Study protocol: a hybrid effectiveness-implementation trial of Moral Reconation Therapy in the US Veterans Health Administration

Background

Moral Reconation Therapy (MRT) is a cognitive-behavioral intervention aimed at reducing risk for criminal recidivism by restructuring antisocial attitudes and cognitions (i.e., “criminogenic thinking”). MRT has empirical support for reducing risk for criminal recidivism among civilian offenders. Recently, a version of MRT was developed for military veterans; however, no randomized controlled trials (RCT) have been conducted with the veteran-specific protocol, and the effectiveness and implementation potential of MRT outside of correctional settings has not been established.

Methods

Using a Hybrid Type 1 RCT design, this study will test the effectiveness of MRT to reduce risk for criminal recidivism and improve health-related outcomes among justice-involved veterans entering mental health residential treatment at three US Veterans Health Administration (VHA) Medical Centers. Upon admission to the treatment program, justice-involved veterans will complete a baseline assessment, be randomized to usual care (UC) or UC + MRT, and be followed 6 and 12 months post-baseline. A process evaluation will also be conducted to identify barriers and facilitators to implementation of MRT in residential treatment.

Discussion

The primary aim of this study is to evaluate the effectiveness of MRT with justice-involved veterans. If MRT proves effective in this trial, the findings can provide large healthcare systems that serve veterans with an evidence-based intervention for addressing criminogenic thinking among justice-involved adults, as well as guidance on how to facilitate future implementation of MRT in non-correctional settings.

Trial registration

This trial is funded by the VA Health Services Research & Development Program (IIR 14–081) and is registered with ClinicalTrials.gov (ID: NCT02524171).

Justice Involvement and Treatment Use Among Rural Veterans

Veterans in rural areas and veterans involved in the criminal justice system have experienced less access to, and use of, health care. However, there is limited information on the treatment needs and health care access of justice-involved veterans who live in rural areas. This study used national Veterans Health Administration data from fiscal year 2014 to examine the interactive effect of rural/urban residence and justice involvement on mental health and substance use disorder treatment entry among veterans diagnosed with mental health or substance use disorders. Of veterans residing in rural areas, 15,328 (2.5%) were justice-involved and 607,819 (97.5%) veterans had no known justice involvement. Among veterans in urban areas, 54,525 (4.3%) were justice-involved and 1,213,766 (95.7%) had no known justice involvement. Rural residence was associated with lower access to mental health or substance use disorder treatment in the non-justice-involved sample but not the justice-involved sample. Justice-involvement was associated with higher odds of entering mental health or substance use disorder treatment for veterans in rural and in urban areas. Substance use disorder treatment entry could be improved for all veterans, particularly rural veterans who are not justice-involved. Telehealth, outreach services, and integrated treatment may help address challenges to treatment entry experienced by rural veterans and justice-involved veterans.

A two-state comparative implementation of peer-support intervention to link veterans to health-related services after incarceration: a study protocol

BACKGROUND

Approximately 600,000 persons are released from prison annually in the United States. Relatively few receive sufficient re-entry services and are at risk for unemployment, homelessness, poverty, substance abuse relapse and recidivism. Persons leaving prison who have a mental illness and/or a substance use disorder are particularly challenged. This project aims to create a peer mentor program to extend the reach and effectiveness of reentry services provided by the Department of Veterans' Affairs (VA). We will implement a peer support for reentry veterans sequentially in two states. Our outcome measures are 1) fidelity of the intervention, 2) linkage to VA health care and, 3) continued engagement in health care. The aims for this project are as follows: (1) Conduct contextual analysis to identify VA and community reentry resources, and describe how reentry veterans use them. (2) Implement peer-support, in one state, to link reentry veterans to Veterans' Health Administration (VHA) primary care, mental health, and SUD services. (3) Port the peer-support intervention to another, geographically, and contextually different state.

DESIGN

This intervention involves a 2-state sequential implementation study (Massachusetts, followed by Pennsylvania) using a Facilitation Implementation strategy. We will conduct formative and summative analyses, including assessment of fidelity, and a matched comparison group to evaluate the intervention's outcomes of veteran linkage and engagement in VHA health care (using health care utilization measures). The study proceeds in 3 phases.

DISCUSSION

We anticipate that a peer support program will be effective at improving the reentry process for veterans, particularly in linking them to health, mental health, and SUD services and helping them to stay engaged in those services. It will fill a gap by providing veterans with access to a trusted individual, who understands their experience as a veteran and who has experienced justice involvement. The outputs from this project, including training materials, peer guidebooks, and implementation strategies can be adapted by other states and regions that wish to enhance services for veterans (or other populations) leaving incarceration. A larger cluster-randomized implementation-effectiveness study is planned.

TRIAL REGISTRATION

This protocol is registered with clinicaltrials.gov on November 4, 2016 and was assigned the number NCT02964897 .

Barriers to and facilitators of pharmacotherapy for alcohol use disorder in VA residential treatment programs

Among US military veterans, alcohol use disorder (AUD) is prevalent and in severe cases patients need intensive AUD treatment beyond outpatient care. The Department of Veterans Affairs (VA) delivers intensive, highly structured addiction and psychosocial treatment through residential programs. Despite the evidence supporting pharmacotherapy among the effective treatments for AUD, receipt of these medications (e.g., naltrexone, acamprosate) among patients in residential treatment programs varies widely. In order to better understand this variation, the current study examined barriers and facilitators to use of pharmacotherapy for AUD among patients in VA residential treatment programs. Semi-structured qualitative interviews with residential program management and staff were conducted and the Consolidated Framework for Implementation Research was used to guide coding and analysis of interview transcripts. Barriers to use of pharmacotherapy for AUD included cultural norms or philosophy against prescribing, lack of access to willing prescribers, lack of interest from leadership, and perceived lack of patient interest or need. Facilitators included cultural norms of openness or active promotion of pharmacotherapy; education for patients, program staff and prescribers; having prescribers on staff, and care coordination within residential treatment and with other clinic settings in and outside VA. Developing and testing improvement strategies to increase care coordination and consistent support from leadership may also yield increases in the use of pharmacotherapy for AUD among residential patients.