Changing Trends in Opioid Overdose Deaths and Prescription Opioid Receipt Among Veterans

Imagine the Possibilities Pain Coalition and Opioid Marketing to Veterans: Lessons for Military and Veterans Healthcare

Background/Objectives: The opioid crisis has disproportionately impacted U.S. military veterans, who face heightened risks of opioid use disorder and overdose due to chronic pain and mental health conditions. The pharmaceutical industry's role in misrepresenting opioid risks-leading to over USD 50 billion in legal settlements-has included targeted marketing to vulnerable populations. This study examines Janssen Pharmaceuticals' "Imagine the Possibilities Pain Coalition" (IPPC), which aimed to increase opioid use among veterans with chronic non-cancer pain. Insights from this public health industry document analysis offer guidance for military medicine and healthcare policymaking. Methods: Using the Opioid Industry Document Archive (OIDA), housed at Johns Hopkins University and the University of California, San Francisco, researchers conducted retrospective content analysis. Documents referencing veterans were identified through keyword searches on Johns Hopkins' SciServer portal and reviewed using CoCounsel, an AI-based legal document platform using a human-in-the-loop approach. Relevant documents were examined by the authors to extract material aligned with the research focus. Results: The IPPC employed strategies to influence opioid prescribing for veterans. These included educational materials that minimized addiction risks and exaggerated long-term benefits and empathy-driven narratives prioritizing immediate pain relief over potential harms. Ghostwriting ensured favorable perspectives on opioids in scientific literature, aligning with broader industry strategies to promote opioids for chronic pain. Conclusions: The targeted marketing of opioids to veterans has exacerbated the opioid crisis, as documented in government reports and litigation. Rigorous oversight of industry-funded coalitions and evidence-based practices are critical to insulating military healthcare from corporate influence and addressing the opioid crisis among veterans.

Access to Firearms and Opioids Among Veterans at Risk for Suicide

Importance

Firearm injury and poisoning, often by drug or medication overdose, account for most suicides among the general population and US veterans. In the Veterans Health Administration, the largest integrated health care system in the US, firearm and opioid access is assessed among patients at risk for suicide who complete suicide safety plans.

Objective

To describe self-reported, clinician-documented access to firearms and opioids, firearm storage practices, distribution of firearm cable locks and naloxone, and counseling on firearm storage and overdose among veterans at elevated risk for suicide who completed suicide safety plans.

Design, Setting, and Participants

This cross-sectional study used electronic health record data from the Veterans Health Administration from December 2021 to February 2023. Participants were veterans identified as having elevated suicide risk through routine screening with the Columbia Suicide Severity Rating Scale Screener who completed a safety plan within 30 days. Data were analyzed from March 2023 to March 2024.

Exposure

Completion of a safety plan, a brief, evidence-based intervention to help prevent or de-escalate suicidal crises.

Main Outcomes and Measures

Firearm and opioid access, as well as firearm storage information, were assessed via the lethal means component of the standardized safety plan note template.

Results

Among 38 454 veterans identified (32 310 [84.0%] male; 15 206 participants [39.5%] aged ≥55 years; 26 960 participants [70.1%] living in urban areas), 9969 (25.9%) were Black and 23 714 (61.7%) were White and 3426 (8.9%) were Hispanic/Latine and 28 892 (75.1%) were not Hispanic/Latine. A total of 10 855 (28.2%) reported access to firearms. Approximately one-third of veterans reported storing at least 1 firearm in each of the following ways: unlocked and loaded (insecure), outside of the home or locked and unloaded (secure), or locked and loaded. Younger and middle-aged veterans, White veterans, veterans who were not Hispanic/Latine, male veterans, and rural veterans were more likely to report firearm access. A total of 2021 veterans (5.3%) reported access to opioids; older veterans, White veterans, veterans who were not Hispanic/Latine, and rural veterans were more likely to report opioid access. Clinicians reported discussing firearm storage with 10 655 veterans (98.2%) and overdose with 1589 veterans (78.6%). Only 1837 veterans (16.9%) offered firearm cable locks and 536 veterans (26.5%) of veterans offered naloxone were documented as accepting them.

Conclusions and Relevance

In this cross-sectional study of electronic health record data, the prevalence of reported access to firearms was lower than expected, suggesting underreporting or underdocumentation, or a lower true prevalence among this at-risk population. Completion of a note template may have encouraged routine discussion of firearm storage and overdose risk, but acceptance of gunlocks and naloxone was low. These findings suggest that White veterans, veterans who were not Hispanic/Latine, and rural veterans may be at particular risk of harm by firearms and opioids.

Pain Care at Home to Amplify Function: Protocol Article

Guidelines recommend strategies to optimize opioid medication safety, including frequent reassessment of the benefits and harms of long-term opioid therapy. Prescribers, who are predominantly primary care providers (PCPs), may lack the training or resources to implement these guideline-concordant practices. Two interventions have been designed to assist PCPs and tested within the Veterans Health Administration (VHA). Telemedicine Collaborative Management (TCM) provides primarily medication management support via care manager-prescriber teams. Cooperative Pain Education and Self-Management (COPES) promotes self-management strategies for chronic pain via cognitive behavior therapy techniques. Each intervention has been shown to improve prescribing and/or patient outcomes. The added value of combining these interventions is untested. With funding and central coordination by the Integrative Management of Chronic Pain and Opioid Use Disorder for Whole Recovery (IMPOWR) Network of the National Institutes of Health Helping to End Addiction Long-term (HEAL) Initiative, we will conduct a multisite patient-level randomized hybrid II effectiveness-implementation trial within VHA to compare TCM to TCM + COPES on the primary composite outcome of pain interference and opioid safety, secondary outcomes of alcohol use, anxiety, depression, and sleep, and other consensus IMPOWR Network measures. Implementation facilitation strategies informed by interviews with healthcare providers will target site-specific needs. The impact of these strategies on TCM implementation will be assessed via established formative and summative evaluation techniques. Economic analyses will evaluate intervention cost-effectiveness.

Trends in Opioid Use Disorder in the Veterans Health Administration, 2005-2022

Importance

Given the personal and social burdens of opioid use disorder (OUD), understanding time trends in OUD prevalence in large patient populations is key to planning prevention and treatment services.

Objective

To examine trends in the prevalence of OUD from 2005 to 2022 overall and by age, sex, and race and ethnicity.

Design, Setting, and Participants

This serial cross-sectional study included national Veterans Health Administration (VHA) electronic medical record data from the VHA Corporate Data Warehouse. Adult patients (age ≥18 years) with a current OUD diagnosis (using International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10-CM] codes) who received outpatient care at VHA facilities from January 1, 2005, to December 31, 2022, were eligible for inclusion in the analysis.

Main Outcomes and Measures

The main outcome was OUD diagnoses. To test for changes in prevalence of OUD over time, multivariable logistic regression models were run that included categorical study year and were adjusted for sex, race and ethnicity, and categorical age.

Results

The final sample size ranged from 4 332 165 to 5 962 564 per year; most were men (89.3%-95.0%). Overall, the annual percentage of VHA patients diagnosed with OUD almost doubled from 2005 to 2017 (0.60% [95% CI, 0.60%-0.61%] to 1.16% [95% CI, 1.15%-1.17%]; adjusted difference, 0.55 [95% CI, 0.54-0.57] percentage points) and declined thereafter (2022: 0.97% [95% CI, 0.97%-0.98%]; adjusted difference from 2017 to 2022, -0.18 [95% CI, -0.19 to -0.17] percentage points). This trend was similar among men (0.64% [95% CI, 0.63%-0.64%] in 2005 vs 1.22% [95% CI, 1.21%-1.23%] in 2017 vs 1.03% [95% CI, 1.02%-1.04%] in 2022), women (0.34% [95% CI, 0.32%-0.36%] in 2005 vs 0.68% [95% CI, 0.66%-0.69%] in 2017 vs 0.53% [95% CI, 0.52%-0.55%] in 2022), those younger than 35 years (0.62% [95% CI, 0.59%-0.66%] in 2005 vs 2.22% [95% CI, 2.18%-2.26%] in 2017 vs 1.00% [95% CI, 0.97%-1.03%] in 2022), those aged 35 to 64 years (1.21% [95% CI, 1.19%-1.22%] in 2005 vs 1.80% [95% CI, 1.78%-1.82%] in 2017 vs 1.41% [95% CI, 1.39%-1.42%] in 2022), and non-Hispanic White patients (0.44% [95% CI, 0.43%-0.45%] in 2005 vs 1.28% [95% CI, 1.27%-1.29%] in 2017 vs 1.13% [95% CI, 1.11%-1.14%] in 2022). Among VHA patients aged 65 years or older, OUD diagnoses increased from 2005 to 2022 (0.06% [95% CI, 0.06%-0.06%] to 0.61% [95% CI, 0.60%-0.62%]), whereas among Hispanic or Latino and non-Hispanic Black patients, OUD diagnoses decreased from 2005 (0.93% [95% CI, 0.88%-0.97%] and 1.26% [95% CI, 1.23%-1.28%], respectively) to 2022 (0.61% [95% CI, 0.59%-0.63%] and 0.82% [95% CI, 0.80%-0.83%], respectively).

Conclusions and Relevance

This serial cross-sectional study of national VHA electronic health record data found that the prevalence of OUD diagnoses increased from 2005 to 2017, peaked in 2017, and declined thereafter, a trend primarily attributable to changes among non-Hispanic White patients and those younger than 65 years. Continued public health efforts aimed at recognizing, treating, and preventing OUD are warranted.

Assessment of harm reduction receipt and infectious diseases outcomes in United States Veterans with opioid use disorder and history of injection drug use

BACKGROUND

Injection drug use (IDU) may lead to negative health outcomes and increased healthcare utilization. In US Veterans (USV) with opioid use disorder (OUD), there is sparse information about healthcare utilization, harm reduction prescription, and outcomes associated with IDU, including severe injection-related infections (SIRI). We assessed psychosocial factors, clinical outcomes, and harm reduction receipt in a cohort of USV with OUD, specifically focusing on persons who inject drugs (PWID).

METHODS

A retrospective cohort study was performed of USV aged ≥ 18 years with a diagnosis of OUD who presented to the Northport Veterans Affairs Medical Center (Long Island, NY) between 2012 and 2022. Demographics, psychosocial factors, history of human immunodeficiency virus (HIV), hepatitis C virus (HCV) infection, and healthcare utilization were compared by IDU status. Prescription of medications for opioid use disorder, naloxone and pre-exposure prophylaxis (PrEP) for HIV were also compared by IDU status. SIRI episodes and associated sequelae were characterized in USV with IDU.

RESULTS

A total of 502 USV with OUD were included and 216 (43%) were PWID. Mean age was 52.6 years. PWID were more likely to use multiple stimulants (14.4% PWID vs. 7.3% non-PWID, p < 0.011), be hospitalized with an infection (26.4% PWID vs. 12.2% non-PWID, p < 0.001) and had more frequent inpatient admissions (n = 5.5 PWID vs. n = 3.51 non-PWID, p = 0.003). Among PWID, 134 (62%) had a history of HCV infection, 9 (4.2%) had HIV, and 35 (16.2%) had at least one SIRI episode. PWID had a higher frequency of current (51.9% PWID vs. 38.5% non-PWID, p = 0.003) or previous MOUD use (45.8% PWID vs. 31.1% non-PWID, p < 0.001). Overall PrEP receipt in our cohort (0.46% PWID vs. 1.4% non-PWID, p = 0.4) was low.

CONCLUSIONS

USV with OUD and a history of IDU had a high prevalence of concurrent stimulant use, HCV, SIRI episodes, and were more likely to be hospitalized than USV with OUD and no history of IDU. Harm reduction strategies such as MOUD or PrEP, can help decrease the risk of infectious diseases, yet PrEP was underutilized in our population regardless of IDU status. USV with OUD would benefit from improved integration of OUD treatment, infectious diseases clinical care and harm reduction interventions.

Suicide deaths involving opioid poisoning in the United States, by sex, 1999-2021

Suicide remains a leading cause of death in the United States, and recent data suggest suicide deaths involving opioids are increasing. Given unprecedented increases in drug-poisoning deaths, suicidality, and suicide deaths in recent years, an updated examination of the trends in suicide deaths involving opioids is warranted. In this descriptive epidemiologic analysis, we leverage final and provisional mortality data from the US Centers for Disease Control and Prevention's WONDER database to examine trends in suicide deaths involving opioid poisoning from 1999 to 2021 by biological sex. Results reveal complex changes over time: the number and age-adjusted rate of suicide deaths involving opioid poisoning among male and female residents tended to track together, and both increased through 2010, but then diverged, with the number and rate of suicide deaths involving opioid poisoning among female residents outpacing that of male residents. However, the number and rate of suicide deaths involving opioid poisoning among male residents then began to stabilize, while that of female residents declined, closing the sex-based gap. Across all years of data, the proportion of suicide deaths that involved opioid poisoning was consistently higher among female decedents (5.8%-11.0%) compared with male decedents (1.4%-2.8%). Findings have implications for improved suicide prevention and harm reduction efforts. This article is part of a Special Collection on Mental Health.

Sexually Transmitted Infection (STI) Incidence, STI Screening, and Human Immunodeficiency Virus Preexposure Prophylaxis Uptake in United States Veterans With Opioid Use Disorder in Long Island, New York

Background

Opioid use disorder (OUD) confers increased risk of contracting bloodborne and sexually transmitted infections (STIs). Limited data exist on infectious disease screening and preexposure prophylaxis (PrEP) usage among United States Veterans (USVs) with OUD, including persons who inject drugs (PWID). This study aimed to evaluate the epidemiology of human immunodeficiency virus (HIV), hepatitis C virus (HCV), bacterial STIs, and PrEP uptake in USVs with OUD, including PWID.

Methods

A retrospective chart review of USVs with OUD seeking care at Northport Veterans Affairs Medical Center between 2012 and 2022 was completed. Sociodemographics, HIV, HCV, STI testing rates and diagnosis, and PrEP uptake were compared between USVs, stratified by injection drug use history.

Results

We identified 502 USVs with OUD; 43% had a history of injection drug use. Overall, 2.2% of USVs had HIV and 28.7% had HCV. An STI was diagnosed in 10% of USVs, most frequently syphilis (1.8%). PWID were more likely to be tested for HIV (93.5% PWID vs. 73.1% non-PWID; P < .001), HCV (95.8% PWID vs. 80.8% non-PWID; P < .001), and syphilis (80% PWID vs. 69.2% non-PWID; P = .006). Total gonorrhea and chlamydia testing rates were 31.9% and 33.7%, respectively, without difference between the groups. PrEP was prescribed in 1.2% of USVs.

Conclusions

In USVs with OUD, gonorrhea and chlamydia screening occurred less frequently than syphilis, HCV, and HIV. PWID were more likely to be screened for HIV, HCV, and syphilis. PrEP uptake was low. Both PWID and non-PWID may benefit from increased STI screening and linkage to PrEP.

Qualitative Evaluation Informs the Implementation of a Telehealth Program to Manage Chronic Pain

In response to the opioid epidemic and high rates of chronic pain among the veteran population, the U.S. Department of Veterans Affairs implemented the TelePain-Empower Veterans Program (EVP), a nonpharmacological pain management program for veterans. Delivered virtually, TelePain-EVP incorporates integrated health components (Whole Health, Acceptance and Commitment Therapy, and Mindful Movement) through interdisciplinary personalized coaching. The objective of this quality improvement project was to evaluate the implementation of TelePain-EVP to identify determinants to implementation, benefits and challenges to participation, and recommendations for future direction. We used a qualitative descriptive design to conduct semistructured telephone interviews with TelePain-EVP leaders (n = 3), staff (n = 10), and veterans (n = 22). The interview guides aligned with the Consolidated Framework for Implementation Research (CFIR). Thematic content analysis organized and characterized findings. Several CFIR domains emerged as determinants relevant to program implementation, including innovation (eg, design); individuals (eg, deliverers, recipients); inner (eg, communications) and outer settings (eg, local conditions); and implementation process (eg, reflecting and evaluating). Identified determinants included facilitators (eg, virtual delivery) and barriers (eg, staff shortages). Participants reported improvements in pain management coping skills, interpersonal relationships, and sense of community, but no self-reported reductions in pain or medication use. Program improvement recommendations included using centralized staff to address vacancies, collecting electronic data, offering structured training, and providing course materials to veteran participants. Qualitative data can inform the sustained implementation of TelePain-EVP and other similar telehealth pain management programs. These descriptive data should be triangulated with quantitative data to objectively assess participant TelePain-EVP outcomes and associated participant characteristics. PERSPECTIVE: A qualitative evaluation of a telehealth program to manage chronic pain, guided by the CFIR framework, identified determinants of program implementation. Additionally, participants reported improvements in pain management coping skills, interpersonal relationships, and sense of community, but no self-reported reductions in pain or medication use.

The effect of combat deployments on veteran opioid abuse

Grim national statistics about the U.S. opioid crisis are increasingly well known to the American public. Far less well known is that U.S. servicemembers are at ground zero of the epidemic, with veterans facing an overdose death rate of up to twice that of civilians. Exploiting a quasi-experiment in overseas deployment assignment, this study estimates the causal impact of combat exposure among the deployed in the Global War on Terrorism on opioid abuse. We find that exposure to war theater substantially increased the risk of prescription painkiller abuse and illicit heroin use among active duty servicemen. The magnitudes of our estimates imply lower-bound combat exposure-induced healthcare costs of $1.04 billion per year for prescription painkiller abuse and $470 million per year for heroin use.

Oral opioid prescribing to active duty US military personnel: a cross-sectional population

INTRODUCTION

While civilian opioid prescriptions have seen a dramatic decline in recent years, there are few studies investigating trends in opioid prescription in the active duty military population. We evaluated oral opioid prescribing patterns to active duty military personnel in the Military Health System (MHS) from 2017 to 2020 to determine the incidence of opioid prescriptions as well as demographic and military-specific risk factors for receiving an oral opioid prescription.

METHODS

The MHS Data Repository was queried from 2017 to 2020 to identify all outpatient oral opioid prescriptions to active duty military personnel in August of each year as well as demographic information on the study population. Data were evaluated in a logistic regression model, and ORs of receiving an oral opioid prescription were calculated for each factor.

RESULTS

The proportion of active duty military personnel receiving an oral opioid prescription declined from 2.71% to 1.26% (53% relative reduction) over the study period. Within the logistic regression model, female military personnel were significantly more likely to receive opioid prescriptions compared with men, and there was a stepwise increase in likelihood of an opioid prescription with increasing age. Army and Marine personnel, personnel without a history of military deployment and those stationed within the continental USA were significantly more likely to receive an opioid prescription.

DISCUSSION

The substantial decrease in oral opioid prescriptions to active duty military personnel mirrors data published in the civilian community. The identified risk factors for receiving an opioid prescription may be potential targets for future interventions to further decrease prescribing.

Identifying Barriers and Facilitators to Veterans Affairs Whole Health Integration Using the Updated Consolidated Framework for Implementation Research

BACKGROUND

Veterans Affairs (VA) implemented the Veteran-centered Whole Health System initiative across VA sites with approaches to implementation varying by site.

PURPOSE

Using the Consolidated Framework for Implementation Research (CFIR), we aimed to synthesize systemic barriers and facilitators to Veteran use with the initiative. Relevance to healthcare quality, systematic comparison of implementation procedures across a national healthcare system provides a comprehensive portrait of strengths and opportunities for improvement.

METHODS

Advanced fellows from 11 VA Quality Scholars sites performed the initial data collection, and the final report includes CFIR-organized results from six sites.

RESULTS

Key innovation findings included cost, complexity, offerings, and accessibility. Inner setting barriers and facilitators included relational connections and communication, compatibility, structure and resources, learning centeredness, and information and knowledge access. Finally, results regarding individuals included innovation deliverers, implementation leaders and team, and individual capability, opportunity, and motivation to implement and deliver whole health care.

DISCUSSION AND IMPLICATIONS

Examination of barriers and facilitators suggest that Whole Health coaches are key components of implementation and help to facilitate communication, relationship building, and knowledge access for Veterans and VA employees. Continuous evaluation and improvement of implementation procedures at each site is also recommended.

Effectiveness of residential treatment services for veterans with substance use disorders: A propensity score matching evaluation

BACKGROUND

Prior reviews of substance use disorder (SUD) treatment have found mixed support for residential level of care but are limited by methodology problems and the ethical concerns of randomizing patients with severe SUD to lower levels of care.

METHODS

The present study is the first to use a large archival SUD residential sample with a matched comparison group and one-year follow-up period to examine the benefits of residential treatment provided to adults clinically assessed as warranting SUD residential care. We used propensity score matching in our sample (N = 6177) of veterans with a SUD who were screened and accepted for Veterans Affairs (VA) SUD residential treatment between January 1st, 2019 and June 30th, 2019.

RESULTS

We found evidence that VA SUD residential treatment saves veteran lives with an average 66% all-cause mortality risk reduction during the study period (b = -1.09, exp(b) = 0.34, p <0.001). Medium-to-large residential pre- to post-treatment self-reported mental health and SUD symptom improvements (|SMDrobust| = 0.54-0.93) were sustained by one-year post-screening. These residential treatment improvements were significantly larger than estimated counterfactual outcomes across self-reported SUD and stress disorder symptoms at one-year post-screening (ps <0.001). We found mixed behavioral, service utilization, and other self-reported mental health outcomes.

CONCLUSIONS

We conclude that VA SUD residential treatment is an effective level of care for veterans warranting residential care particularly for SUD symptom improvements and reductions in mortality risk.

Self-reported Impacts of the COVID-19 Pandemic and Economic Inflation on the Well-being of Low-income U.S. Veterans

The health and well-being of low-income populations may be disproportionately impacted by major public health and economic events. This study examined written self-reported impacts of the Coronavirus Disease-2019 (COVID-19) pandemic and the economic inflationary period on health from a national sample of 854 low-income U.S. veterans. Responses were analyzed using rapid assessment procedures. In response to the COVID-19 pandemic, 59% of participants reported the pandemic had "no effect" on their health, 7% reported increased social isolation, and small proportions of participants reported negative effects on physical and mental health. In response to economic inflation, 43% of participants reported inflation had "no effect" on their health, 11% reported concerns about personal finances, and only small proportions reported other negative psychosocial impacts. Collectively, these findings suggest many low-income veterans are resilient during major events. Further research is needed on long-term health effects of inflation on this population.

Healthcare costs and use before and after opioid overdose in Veterans Health Administration patients with opioid use disorder

AIMS

To compare healthcare costs and use between United States (US) Veterans Health Administration (VHA) patients with opioid use disorder (OUD) who experienced an opioid overdose (OD cohort) and patients with OUD who did not experience an opioid overdose (non-OD cohort).

DESIGN

This is a retrospective cohort study of administrative and clinical data.

SETTING

The largest integrated national health-care system is the US Veterans Health Administration's healthcare systems.

PARTICIPANTS

We included VHA patients diagnosed with OUD from October 1, 2017 through September 30, 2018. We identified the index date of overdose for patients who had an overdose. Our control group, which included patients with OUD who did not have an overdose, was randomly assigned an index date. A total of 66 513 patients with OUD were included for analysis (OD cohort: n = 1413; non-OD cohort: n = 65 100).

MEASUREMENTS

Monthly adjusted healthcare-related costs and use in the year before and after the index date. We used generalized estimating equation models to compare patients with an opioid overdose and controls in a difference-in-differences framework.

FINDINGS

Compared with the non-OD cohort, an opioid overdose was associated with an increase of $16 890 [95% confidence interval (CI) = $15 611-18 169; P < 0.001] in healthcare costs for an estimated $23.9 million in direct costs to VHA (95% CI = $22.1 million, $25.7 million) within the 30 days following overdose after adjusting for baseline characteristics. Inpatient costs ($13 515; 95% CI = $12 378-14 652; P < 0.001) reflected most of this increase. Inpatient days (+6.15 days; 95% CI, = 5.33-6.97; P < 0.001), inpatient admissions (+1.01 admissions; 95% CI = 0.93-1.10; P < 0.001) and outpatient visits (+1.59 visits; 95% CI = 1.34-1.84; P < 0.001) also increased in the month after opioid overdose. Within the overdose cohort, healthcare costs and use remained higher in the year after overdose compared with pre-overdose trends.

CONCLUSIONS

The US Veterans Health Administration patients with opioid use disorder (OUD) who have experienced an opioid overdose have increased healthcare costs and use that remain significantly higher in the month and continuing through the year after overdose than OUD patients who have not experienced an overdose.

Impact of Mandated Case Review Policy on Opioid Discontinuation and Mortality Among High-Risk Long-Term Opioid Therapy Patients: The STORM Stepped-Wedge Cluster Randomized Controlled Trial

BACKGROUND

Although long-term opioid therapy (LTOT) has its own risks, opioid discontinuation could pose harm for high-risk Veterans Health Administration (VHA) patients receiving LTOT. There is limited information on the impact of a mandate requiring providers to perform case reviews on high-risk patients with an active opioid prescription (ie, mandated case review policy) on opioid discontinuation and mortality.

METHODS

Our study is a secondary data analysis of a 23-month stepped-wedge cluster randomized controlled trial between April 2018 and March 2020. The study included 10 685 LTOT patients with a predicted risk of a serious adverse event between the top 1% to 5% nationally who entered the risk range between 4/18/2018 and 11/9/2019. We examined whether the mandated case review policy had an impact on opioid discontinuation and mortality for the patients.

RESULTS

Among 10 685 LTOT patients (88.2% male; mean [SD] age, 61.1 [11.7] years), 29.1% experienced discontinuation and the mortality rate was 9.5%. Patients under mandated case review had a decreased risk of opioid discontinuation (average marginal effect [AME], -11.16 [95% CI, -15.30 to -7.01] percentage points) and all-cause mortality (AME, -3.31 [95% CI, -5.63 to -1.00] percentage points), relative to patients who were not under the mandate.

CONCLUSIONS

The VHA mandated case review policy was associated with lower probability of discontinuation and all-cause mortality for high-risk patients receiving LTOT. Interventions that maintain care engagement while optimizing pain management for high-risk patients may be beneficial for minimizing mortality and other risks associated with discontinuation.

Video-telecare collaborative pain management during COVID-19: a single-arm feasibility study

BACKGROUND

Chronic pain is among the most common conditions presenting to primary care and guideline-based care faces several challenges. A novel pain management program, Video-Telecare Collaborative Pain Management (VCPM), was established to support primary care providers and meet new challenges to care presented by the COVID-19 pandemic.

METHODS

The present single-arm feasibility study aimed to evaluate the feasibility and acceptability of VCPM and its components among U.S. veterans on long-term opioid therapy for chronic pain at ≥ 50 mg morphine equivalent daily dose (MEDD). VCPM consists of evidence-based interventions, including opioid reassessment and tapering, rotation to buprenorphine and monitoring, and encouraging behavioral pain and opioid-use disorder self-management.

RESULTS

Of the 133 patients outreached for VPCM, 44 completed an initial intake (33%) and 19 attended multiple VCPM appointments (14%). Patients were generally satisfied with VCPM, virtual modalities, and provider interactions. Nearly all patients who attended multiple appointments maintained a buprenorphine switch or tapered opioids (16/19; 84%), and buprenorphine switches were generally reported as acceptable by patients. Patients completing an initial intake with VCPM had reduced morphine equivalent daily dose after three months (means = 109 mg MEDD vs 78 mg), with greater reductions among those who attended multiple appointments compared to intake only (ΔMEDD = -58.1 vs. -8.40). Finally, 29 referrals were placed for evidence-based non-pharmacologic interventions.

CONCLUSION

Pre-defined feasibility and acceptability targets for VCPM and its components were broadly met, and preliminary data are encouraging. Novel strategies to improve enrollment and engagement and future directions are discussed.

Empower Veterans Program (EVP): a chronic pain management program demonstrates positive outcomes among veterans

BACKGROUND

Chronic pain is a highly prevalent health condition among veterans. Traditional pharmacological interventions present unique challenges for chronic pain management including prescription opioid addiction and overdose. In alignment with the 2016 Comprehensive Addiction and Recovery Act and VA's Stepped Care Model to meet veterans' pain management needs, the Offices of Rural Health and Pain Management, Opioid Safety, and Prescription Drug Monitoring Program (PMOP) funded an enterprise-wide initiative to implement a Step 3 integrated tele-pain program: Empower Veterans Program (EVP). EVP provides veterans with chronic pain self-care skills using a whole health driven approach to pain management.

OBJECTIVES

The Comprehensive Addiction and Recovery Act prompted the strategic approach to offer non-pharmacological options to meet veterans' pain management needs. EVP, a 10-week interdisciplinary group medical appointment, leverages Acceptance and Commitment Therapy, Mindful Movement, and Whole Health to provide veterans with chronic pain self-care skills. This evaluation was conducted to describe participant characteristics, graduation, and satisfaction rates; and assess pre-post patient-reported outcomes (PRO) associated with EVP participation.

METHODS

A sample of 639 veterans enrolled in EVP between May, 2015 and December, 2017 provided data to conduct descriptive analyses to assess participant demographics, graduation, and satisfaction rates. PRO data were analyzed using a within-participants pre-post design, and linear mixed-effects models were used to examine pre-post changes in PRO.

RESULTS

Of 639 participants, 444 (69.48%) graduated EVP. Participant median program satisfaction rating was 8.41 (Interquartile Range: 8.20-9.20). Results indicate pre-post EVP improvements (Bonferroni-adjusted p < .003) in the three primary pain outcomes (intensity, interference, catastrophizing), and 12 of 17 secondary outcomes, including physical, psychological, health-related quality of life (HRQoL), acceptance, and mindfulness measures.

DISCUSSION

Data suggest that EVP has significant positive outcomes in pain, psychological, physical, HRQoL, acceptance, and mindfulness measures for veterans with chronic pain through non-pharmacological means. Future evaluations of intervention dosing effect and long-term effectiveness of the program is needed.

Evaluation of a non-pharmacological interdisciplinary pain rehabilitation and functional restoration program for chronic pain in veterans

OBJECTIVE

To conduct a quality improvement evaluation of the Empower Veterans Program (EVP), an interdisciplinary pain rehabilitation/functional restoration program option for functional restoration for high-impact chronic pain, offered in a large metro-area Veterans Health Administration (VHA) system.

DATA SOURCES

VHA Corporate Data Warehouse electronic medical record data for patients treated by EVP between 2015 and 2019.

EVALUATION DESIGN

This retrospective design first compared EVP patients considered engaged or not engaged in completing treatment in terms of demographic characteristics and post-treatment changes in clinical measures related to opioid use and mental health. We then compared mortality risk between matched groups of treated and untreated patients with chronic pain and concurrent opioid prescriptions using propensity score matching and Cox proportional hazards methods. "Treated" in the matched groups was defined as any level of EVP participation (i.e., both engaged and not engaged).

DATA COLLECTION/EXTRACTION METHODS

We first identified 1053 EVP patients with 1 year of pre-and post-treatment follow-time and determined their engagement level. From those with chronic pain and prescription opioids, we matched 237 EVP patients to 375 untreated patients.

PRINCIPAL FINDINGS

Engaged patients (57.4% of treated patients), were somewhat older than the non-engaged (mean age 57.1 vs. 53.7, Cohen's D = 0.30), and achieved lower mean PHQ9 depression scores in the post-treatment year (9.2 vs. 10.6, Cohen's D = 0.20). Participation in EVP was associated with a 65% lower mortality risk among Veterans with chronic pain and opioid use when compared to the untreated patients: (HR: 0.35, 95% CI: 0.17, 0.75).

CONCLUSIONS

EVP was associated with a large reduction in mortality risk for Veterans with both chronic pain and opioid use. This result could inform the decision process in a VA station or region when considering providing or expanding access to an interdisciplinary rehabilitation/functional restoration program for chronic pain.

Prescription Opioid Misuse and Suicidal Behaviors Among US Veterans: A Cross-Sectional Study from the 2015-2019 National Survey on Drug Use and Health

Suicide continues to be a serious public health issue for the US veteran population as its prevalence has skyrocketed over the last 15 years. This cross-sectional study estimates the prevalence of suicidal behaviors and prescription opioid misuse among veterans and identifies associations between suicidal behaviors and misuse of prescription opioids using data from the National Survey on Drug Use and Health. The findings show that approximately 3.7% of all veterans in this sample experienced suicidal behaviors, while nearly 3.0% reported misusing prescription opioids. Veterans who misused prescription opioids had a much higher prevalence of suicidal behaviors (16.3%) than veterans who used prescription opioids without misuse (4.8%) and those who did not use prescription opioids at all (2.5%). Opioid misuse is strongly associated with suicidal behaviors among veterans. Immediate substance use and mental health screenings, upon first contact with a healthcare system, are imperative in preventing and reducing suicide rates within this vulnerable population.

An Online Acceptance and Mindfulness Intervention for Chronic Pain in Veterans: Development and Protocol for a Pilot Feasibility Randomized Controlled Trial

BACKGROUND

In the veteran community, chronic pain is particularly prevalent and often debilitating. Until recently, veterans with chronic pain were offered primarily pharmacological intervention options, which rarely suffice and can also have negative health consequences. To better address chronic pain in veterans, the Veterans Health Administration has invested in novel, nonpharmacological behavior interventions that target both pain management and chronic pain-related functional issues. One approach, acceptance and commitment therapy (ACT) for chronic pain, is supported by decades of efficacy evidence for improving pain outcomes; however, ACT can be difficult to obtain owing to issues such as a lack of trained therapists or veterans having difficulty committing to the time and resources needed for the full clinician-led ACT protocol. Given the strong ACT evidence base combined with access limitations, we set out to develop and evaluate Veteran ACT for Chronic Pain (VACT-CP), an online program guided by an embodied conversational agent to improve pain management and functioning.

OBJECTIVE

The aims of this study are to develop, iteratively refine, and then conduct a pilot feasibility randomized controlled trial (RCT) of a VACT-CP group (n=20) versus a waitlist and treatment-as-usual control group (n=20).

METHODS

This research project includes 3 phases. In phase 1, our research team consulted with pain and virtual care experts, developed the preliminary VACT-CP online program, and conducted interviews with providers to obtain their feedback on the intervention. In phase 2, we incorporated feedback from phase 1 into the VACT-CP program and completed initial usability testing with veterans with chronic pain. In phase 3, we are conducting a small pilot feasibility RCT, with the primary outcome being assessment of usability of the VACT-CP system.

RESULTS

This study is currently in phase 3; recruitment for the RCT began in April 2022 and is expected to continue through April 2023. Data collection is expected to be completed by October 2023, with full data analysis completed by late 2023.

CONCLUSIONS

The findings from this research project will provide information on the usability of the VACT-CP intervention, as well as secondary outcomes related to treatment satisfaction, pain outcomes (pain-related daily functioning and pain severity), ACT processes (pain acceptance, behavioral avoidance, and valued living), and mental and physical functioning.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03655132; https://clinicaltrials.gov/ct2/show/NCT03655132.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45887.

Concordance between controlled substance receipt and post-mortem toxicology in opioid-detected overdose deaths: A statewide analysis

BACKGROUND

Opioid overdoses are a leading cause of preventable death in the United States. There is limited research linking decedents' receipt of controlled substances and presence of controlled substances on post-mortem toxicology (PMT).

METHODS

We linked data on opioid-detected deaths in Connecticut between May 3, 2016, and December 31, 2017 from the Office of the Chief Medical Examiner, Department of Consumer Protection, and Department of Mental Health and Addiction Services. Exposure was defined as receipt of an opioid or benzodiazepine prescription within 90 days prior to death. Our primary outcome was concordance between medication received and metabolites in PMT.

RESULTS

Our analysis included 1412 opioid-detected overdose deaths. 47 % received an opioid or benzodiazepine 90 days prior to death; 36 % received an opioid and 27 % received a benzodiazepine. Concordance between receipt of an opioid or benzodiazepine and its presence in PMT was observed in 30 % of opioid-detected deaths. Concordance with an opioid was present in 17 % of opioid-detected deaths and concordance with a benzodiazepine was present in 21 % of opioid-detected deaths. Receipt of an opioid or benzodiazepine and concordance with PMT were less common in fentanyl or heroin-detected deaths and more common in pharmaceutical opioid-detected deaths.

DISCUSSION

Our results suggest medically supplied opioids and benzodiazepines potentially contributed to a substantial number, though minority, of opioid-detected deaths during the study period. Efforts to reduce opioid and benzodiazepine prescribing may reduce risk of opioid-detected deaths in this group, but other approaches will be needed to address most opioid-detected deaths that involved non-pharmaceutical opioids.

Opioid use and opioid use disorder in mono and dual-system users of veteran affairs medical centers

Introduction

Efforts to achieve opioid guideline concordant care may be undermined when patients access multiple opioid prescription sources. Limited data are available on the impact of dual-system sources of care on receipt of opioid medications.

Objective

We examined whether dual-system use was associated with increased rates of new opioid prescriptions, continued opioid prescriptions and diagnoses of opioid use disorder (OUD). We hypothesized that dual-system use would be associated with increased odds for each outcome.

Methods

This retrospective cohort study was conducted using Veterans Administration (VA) data from two facilities from 2015 to 2019, and included active patients, defined as Veterans who had at least one encounter in a calendar year (2015-2019). Dual-system use was defined as receipt of VA care as well as VA payment for community care (non-VA) services. Mono users were defined as those who only received VA services. There were 77,225 dual-system users, and 442,824 mono users. Outcomes were three binary measures: new opioid prescription, continued opioid prescription (i.e., received an additional opioid prescription), and OUD diagnosis (during the calendar year). We conducted a multivariate logistic regression accounting for the repeated observations on patient and intra-class correlations within patients.

Results

Dual-system users were significantly younger than mono users, more likely to be women, and less likely to report white race. In adjusted models, dual-system users were significantly more likely to receive a new opioid prescription during the observation period [Odds ratio (OR) = 1.85, 95% confidence interval (CI) 1.76-1.93], continue prescriptions (OR = 1.24, CI 1.22-1.27), and to receive an OUD diagnosis (OR = 1.20, CI 1.14-1.27).

Discussion

The prevalence of opioid prescriptions has been declining in the US healthcare systems including VA, yet the prevalence of OUD has not been declining at the same rate. One potential problem is that detailed notes from non-VA visits are not immediately available to VA clinicians, and information about VA care is not readily available to non-VA sources. One implication of our findings is that better health system coordination is needed. Even though care was paid for by the VA and presumably closely monitored, dual-system users were more likely to have new and continued opioid prescriptions.

Effect of a Veterans Health Administration mandate to case review patients with opioid prescriptions on mortality among patients with opioid use disorder: a secondary analysis of the STORM randomized control trial

AIMS

The Veterans Health Administration (VHA) implemented the Stratification Tool for Opioid Risk Mitigation (STORM) to reduce the risk of serious adverse events (SAE) among patients with opioid analgesic prescriptions. VHA facilities were mandated to case review patients identified as high risk by STORM. The aim of this study was to measure the effect of this mandate on all-cause mortality and SAEs among VHA patients newly diagnosed with opioid use disorder (OUD).

DESIGN

Secondary analysis of a stepped-wedged cluster randomized controlled trial conducted at all 140 VHA facilities, with facility as the unit of randomization, from 2018 to 2020.

SETTING AND PARTICIPANTS

United States VHA facilities were randomized to case review the top 1 or 5% of high-risk patients prescribed opioid analgesics identified by STORM. A total of 28 251 patients were diagnosed with OUD during the trial and were considered control or treatment depending on the status of the facility where they received their OUD diagnosis. Post-hoc analyses among patients who had at least one opioid analgesic prescription in the 90 days prior to diagnosis were conducted and were then stratified by receipt of a prescription in the 90 days following diagnosis to assess the sensitivity of results to opioid discontinuation.

MEASUREMENTS

All-cause mortality and opioid-related, drug-related, suicide-related and other SAEs within 90 days of OUD diagnosis.

FINDINGS

Mandated case review increased the odds of 90-day mortality [odds ratio (OR) = 1.74, 95% confidence interval (CI) = 1.06, 2.87], but did not significantly change the odds of SAEs. Among patients who received an opioid prescription prior to but not after OUD diagnosis, the odds of all-cause mortality within 90 days was 5.87 (95% CI = 1.85, 18.58) relative to control patients.

CONCLUSIONS

Veterans Health Administration patients newly diagnosed with opioid use disorder experienced increased all-cause mortality following expansion of a case review mandate for high-risk patients prescribed opioids.

Medication Use Evaluation of High-Dose Long-Term Opioid De-prescribing in Multiple Veterans Affairs Medical Centers

BACKGROUND

The Opioid Safety Initiative (OSI) was implemented in 2013 to enhance the safe and appropriate use of opioids in the Veterans Health Administration (VA). Opioid use decreased nationally in subsequent years, but characterization of opioid de-prescribing practices has not been well established.

OBJECTIVES

To describe changes in patient characteristics and patterns of de-prescribing since OSI implementation for opioid users at > 90 morphine equivalent daily dose for at least 90 days for those that discontinued opioids within the VA.

DESIGN

Retrospective observational pre-post intervention medication use evaluation using VA data and electronic health records to identify differences in opioid de-prescribing between fiscal year 2013 (FY13; early OSI) and FY17 (late OSI). Reviewers' insights for local opioid management and de-prescribing practices collected through web-based post-data collection survey.

PARTICIPANTS

Veterans prescribed high-dose long-term opioid therapy in FY13 and FY17 who subsequently discontinued opioids at 27 VA medical centers.

MAIN MEASURES

Chart review data from local facility reviewers identified socioeconomic characteristics, opioid de-prescribing rationale (e.g., risk-benefit, diversion) and practices (e.g., rate of opioid discontinuation, taper monitoring activities, withdrawal monitoring), and outcomes following discontinuation.

KEY RESULTS

Among 315 patients in FY13 and 322 patients in FY17 with opioid discontinuation, discontinuation rationale focused on diversion in FY13 and risk-benefit in FY17. Clinical pharmacists and pain management specialists had increased involvement in FY17 opioid discontinuations (36% versus 16%). Of all discontinuations, 56% of patients were tapered in FY13 versus 70% of patients in FY17. Tapering plans were longer in FY17 than in FY13 (163 days versus 65 days). Transitions to non-opioid pain therapy following opioid discontinuation were higher in FY17 compared to FY13 (70% versus 60%).

CONCLUSIONS

Veterans discontinued from high-dose long-term opioids in FY17 were more optimally managed compared to those in FY13. Findings suggest improvements in opioid de-prescribing following OSI implementation, but interpretation is limited by study design.

U.S. Military veterans and the opioid overdose crisis: a review of risk factors and prevention efforts

U.S. military veterans have been heavily impacted by the opioid overdose crisis, with drug overdose mortality rates increasing by 53% from 2010-2019. Risk for overdose among veterans is complex and influenced by ongoing interaction among physiological/biological, psychological, and socio-structural factors. A thorough understanding of opioid-related overdose among veterans, one that goes beyond simple pharmacological determinism, must examine the interplay of pain, pain treatment, and stress, as well as psychological and social experiences-before, during, and after military service. Comprehensive efforts to tackle the overdose crisis among veterans require interventions that address each of these dimensions. Promising interventions include widespread naloxone distribution and increased provision of low-threshold wrap-around services, including medications for opioid use disorder (MOUD) and holistic/complementary approaches. Interventions that are delivered by peers - individuals who share key experiential or sociodemographic characteristics with the population being served - may be ideally suited to address many of the barriers to opioid-related risk mitigation common among veterans. Community care models could be beneficial for the large proportion of veterans who are not connected to the Veterans Health Administration and for veterans who, for various reasons including mental health problems and the avoidance of stigma, are socially isolated or reluctant to use traditional substance use services. Interventions need to be tailored in such a way that they reach those more socially isolated veterans who may not have access to naloxone or the social support to help them in overdose situations. It is important to incorporate the perspectives and voices of veterans with lived experience of substance use into the design and implementation of new overdose prevention resources and strategies to meet the needs of this population. Key messagesU.S. military veterans have been heavily impacted by the opioid overdose crisis, with drug overdose mortality rates increasing by 53% from 2010-2019.The risks for overdose that veterans face need to be understood as resulting from an ongoing interaction among biological/physiological, psychological, and social/structural factors.Addressing drug overdose in the veteran population requires accessible and non-judgemental, low threshold, wraparound, and holistic solutions that recognise the complex aetiology of overdose risk for veterans.

Non-pharmacological Treatment for Chronic Pain in US Veterans Treated Within the Veterans Health Administration: Implications for Expansion in US Healthcare Systems

BACKGROUND

Consensus guidelines recommend multimodal chronic pain treatment with increased use of non-pharmacological treatment modalities (NPM), including as first-line therapies. However, with many barriers to NPM uptake in US healthcare systems, NPM use may vary across medical care settings. Military veterans are disproportionately affected by chronic pain. Many veterans receive treatment through the Veterans Health Administration (VHA), an integrated healthcare system in which specific policies promote NPM use.

OBJECTIVE

To examine whether veterans with chronic pain who utilize VHA healthcare were more likely to use NPM than veterans who do not utilize VHA healthcare.

DESIGN

Cross-sectional nationally representative study.

PARTICIPANTS

US military veterans (N = 2,836).

MAIN MEASURES

In the 2019 National Health Interview Survey, veterans were assessed for VHA treatment, chronic pain (i.e., past 3-month daily or almost daily pain), symptoms of depression and anxiety, substance use, and NPM (i.e., physical therapy, chiropractic/spinal manipulation, massage, psychotherapy, educational class/workshop, peer support groups, or yoga/tai chi).

KEY RESULTS

Chronic pain (45.2% vs. 26.8%) and NPM use (49.8% vs. 39.4%) were more prevalent among VHA patients than non-VHA veterans. After adjusting for sociodemographic characteristics, psychiatric symptoms, physical health indicators, and use of cigarettes or prescription opioids, VHA patients were more likely than non-VHA veterans to use any NPM (adjusted odds ratio [aOR] = 1.52, 95% CI: 1.07-2.16) and multimodal NPM (aOR = 1.80, 95% CI: 1.12-2.87) than no NPM. Among veterans with chronic pain, VHA patients were more likely to use chiropractic care (aOR = 1.90, 95% CI = 1.12-3.22), educational class/workshop (aOR = 3.02, 95% CI = 1.35-6.73), or psychotherapy (aOR = 4.28, 95% CI = 1.69-10.87).

CONCLUSIONS

Among veterans with chronic pain, past-year VHA use was associated with greater likelihood of receiving NPM. These findings may suggest that the VHA is an important resource and possible facilitator of NPM. VHA policies may offer guidance for expanding use of NPM in other integrated US healthcare systems.

Comparing Outpatient Opioids, High-Risk Prescribing, and Opioid Poisoning Between Transgender and Cisgender Veterans: A Cross-sectional Analysis

INTRODUCTION

Transgender veterans have a high prevalence of substance use disorder and physical and mental-health comorbidities, which are associated with prescription opioid use and overdose risk. This study compares receipt of outpatient opioids, high-risk opioid prescribing, and opioid poisoning between transgender and cisgender (i.e., nontransgender) veterans.

METHODS

A secondary analysis of Veterans Health Administration health record data from January 1, 2018 to December 31, 2018 was conducted in 2021. Transgender veterans (n=9,686) were randomly matched to 3 cisgender veterans (n=29,058) on the basis of age and county. Using the same matching criteria, a second cohort was created of all transgender veterans and a matched sample of cisgender veterans who were prescribed an outpatient opioid (n=7,576). Stratified Cox proportional hazard regression measured the RR of each prescription outcome and opioid poisoning.

RESULTS

Transgender veterans had a 20% higher risk of being prescribed any outpatient opioid than cisgender veterans (adjusted RR=1.20, 95% CI=1.13, 1.27). Transgender and cisgender veterans who were prescribed an opioid did not have different risks of high-risk prescribing: overlapping opioid prescriptions (adjusted RR=0.93, 95% CI=0.85, 1.02), daily dose >120 morphine milligram equivalents (adjusted RR=0.86, 95% CI=0.66, 1.10), or overlapping opioid and benzodiazepine prescriptions (adjusted RR=1.05, 95% CI=0.96, 1.14). Overall, transgender veterans had more than twice the risk of opioid poisoning than cisgender veterans (RR=2.76, 95% CI=1.57, 4.86). The risk of opioid poisoning did not differ between transgender and cisgender veterans who were prescribed an opioid (RR=1.09, 95% CI=0.56, 2.11).

CONCLUSIONS

Transgender veterans had a greater risk of being prescribed an outpatient opioid than cisgender veterans but did not have different risks of high-risk opioid prescribing.

Marketing Opioids to Veterans and Older Adults: A Content Analysis of Internal Industry Documents Released from State of Oklahoma v. Purdue Pharma LP, et al

CONTEXT

From 1999 to 2018 the opioid epidemic claimed more than 500,000 lives in the United States. Military veterans and older adults were particularly affected; veterans' deaths attributed to opioid use increased by 65% from 2010 to 2016, while opioid prescriptions for older adults increased ninefold between 1995 and 2010.

METHODS

We reviewed internal pharmaceutical industry documents released in legal discovery to determine how companies targeted these groups to increase prescribing and sales. This review included an analysis of corporate goals and plans identified through internal emails, sales pitches, and presentations.

FINDINGS

These policy and advertising campaigns focused on (a) lobbying policy makers, (b) undertaking unbranded campaigns promoting opioid use, and (c) promoting opioid use in research and the popular media. Opioid manufacturers claimed that opioids could resolve preexisting concerns identified among military veterans and older adults and that the use of opioids would improve quality of life. These campaigns were positioned as public health initiatives and efforts to increase disease awareness.

CONCLUSIONS

The findings suggest a need for regulatory reform and transparency related to lobbying, advocacy group relationships with industry, and pharmaceutical advertising.

Training in Safe Opioid Prescribing and Treatment of Opioid Use Disorder in Internal Medicine Residencies: a National Survey of Program Directors

BACKGROUND

Training future clinicians in safe opioid prescribing (SOP) and treatment of opioid use disorder (OUD) is critical to address the opioid epidemic. The Accreditation Council on Graduate Medical Education requires all programs to provide instruction and experience in pain management and will mandate addiction medicine clinical experiences for internal medicine trainees.

OBJECTIVE

Assess residents' training in SOP and treatment of OUD and identify training barriers.

DESIGN

Cross-sectional nationally representative survey was emailed in 2019.

PARTICIPANTS

Four hundred twenty-two Association of Program Directors in Internal Medicine members in US internal medicine residency programs.

MAIN MEASURES

Program opportunities and challenges to developing or implementing training in SOP, treatment of OUD, and buprenorphine waiver training, and perceived curricular effectiveness.

KEY RESULTS

The response rate was 69.4% (293/422). Most programs required didactics in SOP (94.2%) and treatment of OUD (71.7%). Few programs required clinical experiences including addiction medicine clinics (28/240, 11.7%), inpatient consult services (11/240, 4.6%), or offsite treatment rotations (8/240, 3.3%). Lack of trained faculty limited developing or implementing curricula (61.5%). Few respondents reported that their program was "very effective" in teaching SOP (80/285, 28.1%) or treatment of OUD (43/282, 15.3%). Some programs offered buprenorphine waiver training to residents (83/286, 29.0%) and faculty (94/286, 32.9%) with few mandating training (11.7% (28/240) and 5.4% (13/240) respectively). Only 60 of 19,466 (0.3%) residents completed buprenorphine waiver training. Primary care programs/tracks were more likely to offer waiver training to residents (odds ratio [OR], 3.07; 95% CI, 1.68-5.60; P < 0.001) and faculty (OR, 1.08; 95% CI, 1.01-3.22; P = 0.05).

CONCLUSIONS

In this nationally representative survey, few internal medicine residency programs provided clinical training in SOP and treatment of OUD, and training was not viewed as very effective. Lack of effective training may have adverse implications for patients, clinicians, and society.

Transition from Military Service: Mental Health and Well-being Among Service Members and Veterans with Service-connected Disabilities

Transitioning from military service is stressful for veterans with service-connected disabilities seeking civilian employment. This descriptive study examined self-assessed mental health, well-being, and substance use of men and women shortly before or after transition from US military service, compared to norms from community and military samples. As part of a prospective study evaluating an innovative employment program, researchers interviewed 229 current and former service members with service-connected disabilities transitioning from U.S. military service. Compared to published norms, respondents reported significantly poorer outcomes on 5 of 6 standardized measures, indicating less life satisfaction, poorer mental health, more symptoms of depression and posttraumatic stress disorder, and greater financial distress. In the previous year, 42% were prescribed opioid medications, over twice the annual opioid prescription rate of 19% in the general US population. Systematic strategies are needed to ensure access for transitioning veterans with serious behavioral health issues to appropriate evidence-based practices.

Opioid and Alcohol Misuse in Veterans with Chronic Pain: A Risk Screening Study

In United States military veterans, chronic pain represents a risk factor for opioid and alcohol misuse, yet few studies have examined interactions among chronic pain, opioid prescription, and opioid and alcohol misuse. Previous work found substantial risk of co-morbid alcohol and opioid misuse in a community sample of opioid-prescribed individuals with chronic pain, a finding expanded upon here. Specifically, 211 veterans assessed within a chronic pain treatment service for opioid-prescribed individuals completed self-report measures of opioid misuse, alcohol misuse, pain intensity, depression, pain catastrophizing, and post-traumatic stress symptoms (PTS). Based on the substance misuse measures, 32% (n = 68) were misusing neither opioids nor alcohol, 23% (n = 48) were misusing both opioids and alcohol, 40% (n = 84) were misusing opioids alone, and 5% (n = 11) were misusing alcohol alone. Group comparisons indicated that individuals not misusing either substance were less distressed in comparison to those who were misusing opioids alone or both substances. The latter groups differed in PTS. Overall, misuse frequencies mirrored previous work, with approximately 1 of 3 misusing opioids and approximately 1 of 5 misusing both substances. There is a need for increased focus on both polysubstance misuse and the development of integrated treatment.

Veteran drug overdose mortality, 2010-2019

BACKGROUND

Prior work documents that Veteran drug overdose mortality increased from 2010 to 2016. The present study assessed trends from 2010 to 2019, by drug type and recent receipt of Veterans Health Administration (VHA) services, and compared rates for Veteran and non-Veteran US adults.

METHODS

This retrospective cross-sectional study used data from Veterans Affairs (VA) medical records, the VA/Department of Defense Mortality Data Repository, and CDC WONDER. Trends were compared using Joinpoint regression.

RESULTS

From 2010-2019, age-adjusted overdose mortality rates increased 53.2% among Veterans and 79.0% among non-Veterans. Age-adjusted rates of overdose mortality among Veterans rose from 19.8/100,000 in 2010 to 32.6/100,000 in 2017, before falling to 30.3/100,000 in 2019. Despite the decrease from 2017 to 2019 in overall overdose mortality, rates of overdose deaths involving synthetic opioids other than methadone and involving psychostimulants continued to increase through 2019. In 2019, overdose mortality was lower for male Veterans than male non-Veterans (standardized rate ratio (SRR) = 0.81, 95% confidence interval (CI): 0.77-0.84). Among male Veterans, rates were higher in all years for those with recent VHA use than those without (2019: SRR=1.69, 95% CI: 1.56-1.83). From 2010-2019, overdose mortality rates increased faster among female Veterans without VHA use than those with VHA use.

CONCLUSIONS

From 2015 onward, Veteran men experienced lower age-adjusted overdose rates than non-Veteran men. In all years, overdose rates were higher among male Veterans with recent VHA use than those without recent use. While overall rates of Veteran overdose deaths declined from 2017 to 2019, rates involving psychostimulants and synthetic opioids continued to rise.

Associations Among Military Sexual Trauma, Opioid Use Disorder, and Gender

INTRODUCTION

Opioid use disorder and high-risk opioid prescription increase the risks for overdose and death. In Veterans, military sexual trauma is associated with increased risk for assorted health conditions. This study evaluates the association of military sexual trauma with opioid use disorder and high-risk opioid prescription and potential moderation by gender.

METHODS

In a national sample of Veterans Health Administration outpatients receiving care from October 1, 2009 to August 1, 2017, logistic regression models were fit to evaluate the associations between military sexual trauma and opioid use disorder and high-risk opioid prescription, adjusting for demographic and clinical covariates. A second set of models included a gender X military sexual trauma interaction. Analyses were conducted in 2020-2021.

RESULTS

Patients with history of military sexual trauma (n=327,193) had 50% higher odds of opioid use disorder diagnosis (AOR=1.50, 95% CI=1.45, 1.54, p<0.001) and 5% higher odds of high-risk opioid prescription (AOR=1.05, 95% CI=1.04, 1.07, p<0.001) than those without history of military sexual trauma (n=7,738,665). The effect of military sexual trauma on opioid use disorder was stronger in men than in women . The predicted probability of opioid use disorder among men with history of military sexual trauma (1.5%) was nearly double that of women with history of military sexual trauma (0.8%).

CONCLUSIONS

Military sexual trauma was a significant risk factor for opioid use disorder and high-risk opioid prescription, with the former association particularly strong in men. Clinical care for Veterans with military sexual trauma should consider elevated risk of opioid use disorder and high-risk opioid prescription.

Suicide Mortality Among Veterans Health Administration Care Recipients With Suicide Risk Record Flags

OBJECTIVE

In 2008, the Veterans Health Administration (VHA) established a suicide high-risk flag (HRF) for patient records. To inform ongoing suicide prevention activities as part of operations and quality improvement work in the U.S. Department of Veterans Affairs, the authors evaluated suicide risk following HRF activations and inactivations.

METHODS

For annual cohorts of VHA users, HRF receipt and demographic and clinical care contexts in the 30 days before HRF activations were examined for 2014-2016 (N=7,450,831). Veterans were included if they had VHA inpatient or outpatient encounters during the index or previous year. Suicide rates in the 12 months after HRF activations and inactivations were assessed. Using multivariable Cox proportional hazards regression, the authors compared suicide risk following HRF activation and inactivation with veterans without HRFs, adjusted for age, gender, and race-ethnicity.

RESULTS

HRF activation (N=47,015) was commonly preceded within 30 days by a documented suicide attempt (39.5%) or inpatient mental health admission (40.1%). Suicide risk was elevated in the 12 months after flag activation (crude suicide rate=682 per 100,000 person-years, adjusted hazard ratio [HR]=21.00, 95% confidence interval [CI]=18.55-23.72) compared with risk among VHA users without HRF activity. Risk after HRF inactivation (N=41,251) was also elevated (crude suicide rate=408 per 100,000 person-years, adjusted HR=12.43, 95% CI=10.57-14.63) compared with risk among VHA users without HRF activity.

CONCLUSIONS

Suicide risk after HRF activation was substantially elevated and also high after HRF inactivation. Findings suggest the importance of comprehensive suicide risk mitigation and support recent VHA process enhancements to formalize inactivation criteria and support veterans after HRF inactivation.

Rationale, design and methods of VA-BRAVE: a randomized comparative effectiveness trial of two formulations of buprenorphine for treatment of opioid use disorder in veterans

Background

To address the US opioid epidemic, there is an urgent clinical need to provide persons with opioid use disorder (OUD) with effective medication treatments for OUD (MOUD). Formulations of sublingual buprenorphine/naloxone (SL-BUP/NLX) are considered the standard of care for OUD including within the Veterans Healthcare Administration (VHA). However, poor retention on MOUD undermines its effectiveness. Long-acting injectable monthly buprenorphine (INJ-BUP) (e.g., Sublocade®) has the potential to improve retention and therefore reduce opioid use and overdose. Designing and conducting studies for OUD pose unique challenges. The strategies and solutions to some of these considerations in designing Cooperative Studies Program (CSP) 2014, Buprenorphine for Treating Opioid Use Disorder in Veterans (VA-BRAVE), a randomized, 20-site, clinical effectiveness trial comparing INJ-BUP to SL-BUP/NLX conducted within the VHA may provide valuable guidance for others confronted with similar investigation challenges.

Methods

This 52-week, parallel group, open-label, randomized controlled trial (RCT) evaluates the comparative effectiveness of two current FDA-approved formulations of buprenorphine: (1) daily SL-BUP/NLX vs. (2) monthly (28-day) INJ-BUP for Veterans with moderate to severe OUD (n = 952). The primary outcomes are (1) retention in MOUD and (2) opioid abstinence. Secondary outcomes include measures of other drug use, psychiatric symptoms, medical outcomes including prevalence rates of HIV, hepatitis B and C as well as social outcomes (housing instability, criminal justice involvement), service utilization and cost-effectiveness. Special considerations in conducting a comparative effectiveness trial with this population and during COVID-19 pandemic were also included.

Discussion

The evaluation of the extended-release formulation of buprenorphine compared to the standard sublingual formulation in real-world VHA settings is of paramount importance in addressing the opioid epidemic. The extent to which this new treatment facilitates retention, decreases opioid use, and prevents severe sequelae of OUD has not been studied in any long-term trial to date. Positive findings in this trial could lead to widespread adoption of MOUD, and, if proven superior INJ-BUP, by clinicians throughout the VHA and beyond. This treatment has the potential to reduce opioid use among Veterans, improve medical, psychological, and social outcomes, and save lives at justifiable cost.

Trial registration Registered at Clinicaltrials.gov NCT04375033

Workforce Development to Improve Access to Pain Care for Veterans: A Qualitative Analysis of VA-ECHO Participant Experiences

Background/Objective

The prevalence of chronic pain and its links to the opioid epidemic have given way to widespread aims to improve pain management care and reduce opioid use, especially in rural areas. Pain Management Specialty Care Access Network-Extension for Community Health Outcomes (VA-ECHO) promotes increased pain care access to rural Veterans through knowledge sharing from specialists to primary care providers (PCPs). We explored PCP participants’ experiences in VA-ECHO and pain management care.

Methods

This qualitative study is based on a descriptive secondary analysis of semi-structured interviews (n = 10) and 3 focus groups with PCPs participating in VA-ECHO from 2017–2019. A rapid matrix analysis approach was used to analyze participants’ responses.

Results

VA-ECHO was an effective workforce development strategy for meeting PCPs’ training needs by providing pain management knowledge and skills training (eg alternative care approaches and communicating treatment options). Having protected time to participate in VA-ECHO was a challenge for many PCPs, mitigated by leadership and administrative support. Participants who volunteer to participate had more positive experiences than those required to attend.

Conclusions

VA-ECHO could be used for meeting the workforce development needs of PCPs. Respondents were satisfied with the program citing improvement in their practice and increased confidence in providing pain management care to Veterans despite some challenges to participation. These findings offer insight into using VA-ECHO to meet the VHA’s workforce development to improve Veterans’ access to pain management care. The ECHO model presents opportunities for workforce development in large complex healthcare systems and garnering ongoing support for this training model is necessary for promoting workforce development for PCPs.

Controlled Substance Prescription History among Individuals Who Died of an Accidental Opioid-Involved Drug Overdose in Rhode Island

Background: Accidental opioid-involved overdose deaths are increasing nationally in the wake of the COVID-19 pandemic, but it is unclear if this reflects a change in populations most at risk. Objective: To determine whether the demographic characteristics and controlled substance prescription history of accidental opioid-involved drug overdose decedents in 2020 differed from prior years. Methods: We identified accidental opioid-involved overdose decedents using Rhode Island (RI) State Medical Examiner's Office data. Decedents were linked to the RI Prescription Drug Monitoring Program database. We compared demographic characteristics and prescription history by year of death. Results: From 2018 to 2020, 763 RI residents died from accidental opioid-involved overdose in RI. From 2018 to 2019, deaths decreased by 7%, but then increased by 31% from 2019 to 2020. Demographic characteristics were similar by year of death (all p > 0.05). The percentage of decedents with a prior opioid prescription and a prior benzodiazepine prescription declined from 2018 to 2020 (p < 0.01 and p = 0.03). Conclusions: We found that opioid-involved overdose deaths in RI are increasing overall, but without significant changes in demographics. While prior exposure to some controlled substances did decline over time, it is not clear if these changes reflect more responsible prescribing practices, or a more concerning pattern such as patient abandonment or decreased healthcare access. More studies are needed to better describe the current trend of increasing opioid-involved deaths while also pursuing current evidence-based interventions.

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.

Alcohol-involved overdose deaths in US veterans

BACKGROUND

Alcohol-involved overdose deaths are increasing and often occur with other substances but have been minimally studied compared to other causes of overdose.

METHODS

We used national Veterans Health Administration (VHA) records linked to National Death Index data from 2012 to 2018 to examine trends in alcohol-related overdose mortality. Patient characteristics and treatment receipt were compared across categories of alcohol overdose deaths (alcohol-only, alcohol+opioids which may include additional substances, and alcohol+other substances without opioids).

RESULTS

From 2012-2018, 2421 Veterans died from an alcohol-involved overdose (alcohol-only: 868, alcohol+opioids: 1269, alcohol+other substances: 284). The alcohol-involved overdose rate increased 57% during this period. Compared to those who died of an alcohol-only overdose, Veterans who died from alcohol+opioids and alcohol+other substances were more likely Black or Hispanic, and to have an opioid use disorder, but less likely to live in rural areas or to be diagnosed with alcohol use disorder (AUD). Only 32.5% of those who died from alcohol-involved overdose received treatment in a substance use disorder clinic in the year preceding death, compared to 65.1% seen in mental health and 85.7% in primary care. Only 9.5% of Veterans who died from alcohol overdose received medication treatment for AUD and 24.8% received psychotherapy for AUD in the year preceding death.

CONCLUSIONS

Alcohol overdose is increasing primarily related to overdoses involving opioids and other substances. Most patients did not receive any effective medication or psychotherapy treatments for AUD, suggesting further need to identify those at risk and to target treatment for this vulnerable group in healthcare settings.

Association of Preoperative Opioid Use With Complication Rates and Resource Use in Patients Undergoing Hip Arthroscopy for Femoroacetabular Impingement

Background

Preoperative opioid use has been shown to be a negative predictor of patient outcomes, complication rates, and resource utilization in a variety of different orthopaedic procedures. To date, there are no studies investigating its effect on outcomes after hip arthroscopy in the setting of femoroacetabular impingement (FAI).

Purpose

To determine the association of preoperative opioid use with postoperative outcomes after hip arthroscopy in patients with FAI.

Study Design

Cohort study; Level of evidence, 3.

Methods

The Truven Health MarketScan Commercial Claims and Encounters Database was queried for all patients who underwent hip arthroscopy for FAI between 2011 and 2018. Opioid prescriptions filled in the 6 months preceding surgery were queried, and the average daily oral morphine equivalents (OMEs) in this period were computed for each patient. Patients were divided into 4 cohorts: opioid naïve, <1 OME per day, 1 to 5 OMEs per day, and >5 OMEs per day. Postoperative 90-day complications, health care utilization, perioperative costs, postoperative opioid use, and 1- and 3-year revision rates were then compared among cohorts.

Results

A total of 22,124 patients were ultimately included in this study; 31.2% of these patients were prescribed opioids preoperatively. Overall, the percentage of preoperative opioid-naïve patients increased from 64.5% in 2011 to 78.9% in 2018. Patients who received preoperative opioids had a higher rate of complications, increased resource utilization, and increased revision rates. Specifically, on multivariate analysis, patients taking >5 OMEs per day (compared with patients who were preoperatively opioid naïve) had increased odds of a postoperative emergency department visit (Odds Ratio, 2.23; 95% confidence interval [CI], 1.94-2.56; P < .001), 90-day readmission (OR, 2.25; 95% CI, 1.77-2.87; P < .001), increased acute postoperative opioid use (OR, 25.56; 95% CI, 22.98-28.43; P < .001), prolonged opioid use (OR, 10.45; 95% CI, 8.92-12.25; P < .001), and 3-year revision surgery (OR, 2.14; 95% CI, 1.36-3.36; P < .001). Perioperative adjusted costs were increased for all preoperative opioid users and were highest for the >5 OMEs per day cohort ($6255; 95% CI, $5143-$7368).

Conclusion

A large number of patients with FAI are prescribed opioids before undergoing hip arthroscopy, and use of these pain medications is associated with increased health care utilization, increased costs, prolonged opioid use, and early revision surgery.

Advanced models for improved prediction of opioid-related overdose and suicide events among Veterans using administrative healthcare data

Veterans suffer disproportionate health impacts from the opioid epidemic, including overdose, suicide, and death. Prediction models based on electronic medical record data can be powerful tools for identifying patients at greatest risk of such outcomes. The Veterans Health Administration implemented the Stratification Tool for Opioid Risk Mitigation (STORM) in 2018. In this study we propose changes to the original STORM model and propose alternative models that improve risk prediction performance. The best of these proposed models uses a multivariate generalized linear mixed modeling (mGLMM) approach to produce separate predictions for overdose and suicide-related events (SRE) rather than a single prediction for combined outcomes. Further improvements include incorporation of additional data sources and new predictor variables in a longitudinal setting. Compared to a modified version of the STORM model with the same outcome, predictor and interaction terms, our proposed model has a significantly better prediction performance in terms of AUC (84% vs. 77%) and sensitivity (71% vs. 66%). The mGLMM performed particularly well in identifying patients at risk for SREs, where 72% of actual events were accurately predicted among patients with the 100,000 highest risk scores compared with 49.7% for the modified STORM model. The mGLMM’s strong performance in identifying true cases (sensitivity) among this highest risk group was the most important improvement given the model’s primary purpose for accurately identifying patients at most risk for adverse outcomes such that they are prioritized to receive risk mitigation interventions. Some predictors in the proposed model have markedly different associations with overdose and suicide risks, which will allow clinicians to better target interventions to the most relevant risks.

Evaluation of Chronic, Noncancer Pain Management Initiative in a Multidisciplinary Pain Clinic

BACKGROUND

Chronic pain management is a major challenge for primary care providers (PCPs). PCPs manage many patients with chronic pain and other comorbidities including mental health problems like post-traumatic stress disorder (PTSD) and depression. Chronic pain and opioid problems are a national crisis, particularly among veterans (U.S. Department of Veterans Affairs, 2019). There are many veterans with chronic non-cancer pain who are being treated with opioids. Chronic opioid use has contributed to an epidemic of opioid-related adverse events (VA, 2017). Opioids not only result in poor pain control, but have associated risks such as misuse, overdose, and diversion which may be fatal (Frieden & Houry, 2016).

AIMS

The aim of this project was to evaluate chronic non-cancer pain management of veterans using an advanced practice registered nurse (APRN)-led multidisciplinary team approach to incorporate non-opioid and non-pharmacologic modalities to affect self-reported pain and use of prescribed opioids.

METHODS

A retrospective quality improvement (QI) project was conducted in the multidisciplinary pain (MDP) clinic. The APRN used a biopsychosocial approach for chronic pain management guided by the Plan, Do, Study, Act (PDSA) cycle framework. Thirty-four patients who were utilizing opioids for pain management were included using convenience sampling from the MDP clinic. The APRN educated and treated patients with non-opioid medications and non-pharmacolog therapies. A 10-point pain scale and morphine equivalent daily dose (MEDD) were utilized pre- and post-intervention to evaluate the MDP clinic.

RESULTS

Participants were predominantly male (91.8%), with a mean age of 63.18 ± 15.39 years, and 36.4% of whom were retired. Only 20.6% of the participants reported the use of opioids for <12 months. Low back pain (93%) was the most common pain location. The mean baseline MEDD was 41.04 and the post tapered MEDD was 23.05; this revealed a significant decline in MEDD (p < .0001). A decline was also found between pre- and post-pain scores (ranges 0-8). There was a significant reported decline in pain scores with a baseline of 6.11 to post tapering pain of 3.1 (t = 4.99, df = 28, p < .0001). Participants preferred non-opioid medications 94% and non-pharmacologic therapy 86%, like physical therapy, yoga, and acupuncture. Fifty-one percent of patients were referred for injections and 46% were referred to primary care behavior health, which includes pain school, sleep hygiene classes, and cognitive behavior therapy.

CONCLUSIONS

APRNs are in a key position to assess and treat patients based on current evidence while facilitating opioid titration. This initiative highlights that safe tapering of opioids is possible when utilizing a multidisciplinary approach for chronic pain management. Findings support the use of non-pharmacologic and non-opioid therapy for chronic pain management which can result in reduced patient-reported pain. Further research is warranted to examine both pharmacologic (non-opioid) and non-pharmacologic strategies that promote pain management while tapering opioids.

Effectiveness of a substance use treatment program for veterans with chronic pain and opioid use disorder

OBJECTIVE

Veterans suffer disproportionately from the combined adverse health impacts of chronic pain and hazardous opioid use. This evaluation involved a substance use treatment program that included medication for opioid use disorder (SATP-MOUD) in a large metro-area Veterans Health Administration (VHA). This form of treatment has become increasingly important during the opioid crisis and is among several important Department of Veteran's Affairs (VA) initiatives to improve treatment for opioid use disorder (OUD), for which chronic pain is often a comorbid condition.

METHODS

We compared clinical measures related to substance use and mental health between groups who were considered either engaged or not engaged in completing treatment. The study used propensity score matching methods and Cox proportional hazards models to compare the mortality risk for treated and untreated veterans who had chronic pain with concurrent opioid use.

RESULTS

We identified 1559 SATP-MOUD patients with 1 year of pre- and post-treatment follow-time. From those with chronic pain and concurrent opioid use, we matched 478 SATP-MOUD patients to 647 untreated patients. Engaged patients (at least 4 visits in the first 8 weeks of treatment) had significant improvements in Brief Addiction Monitor (BAM) scores and in PHQ-9 depression screening scores compared to those who started treatment but did not meet the engagement threshold. In Cox proportional hazards analysis, participation in SATP-MOUD was associated with a 38% lower mortality risk among veterans with chronic pain and opioid use when compared to the untreated group: (HR: 0.62, 95% CI: 0.47, 0.82).

CONCLUSIONS

SATP-MOUD, as delivered in actual practice, was associated with significant improvements in depression and addiction severity scores, and was associated with reduced mortality risk for veterans with chronic pain and OUD.

The Newest Battlefield Opioid, Sublingual Sufentanil: A Proposal to Refine Opioid Usage in the U.S. Military

There is an ongoing opioid epidemic in the USA, and the U.S. military is not immune to the health threat. To combat the epidemic, the Department of Defense (DoD) and Department of Veterans' Affairs (DVA) issued new clinical practice guidelines and launched the Opioid Safety Initiative aimed at reducing opioid prescriptions. Furthermore, the DoD continually refined opioid protocols for acute pain on the battlefield, evolving from intramuscular morphine to intravenous morphine administration to oral transmucosal fentanyl citrate lollipops (Actiq) to finally sublingual sufentanil tablets (SSTs, Dsuvia). Interestingly, the newest introduction of SSTs into the military sparked great controversy, as there are concerns over the drug's potential for misuse. However, although the opioid crisis may understandably foster an aversion to new candidate opioids, the therapeutic benefits of effective opioids in acute trauma settings should not be overlooked. SSTs may offer an improved analgesic option to meet the battlefield's unmet needs with its non-invasive, sublingual delivery system and favorable pharmacologic properties that mitigate the risk for side effects, addiction, and adverse outcomes. Accordingly, this commentary aims to (1) review the evolution of opioid use on the battlefield and discuss the medical benefits and limitations of SSTs in acute trauma settings, (2) highlight the importance of chronic pain management post-deployment through evidence-based non-opioid modalities, and (3) explore avenues of future research. Ultimately, we propose that SSTs are an important improvement from existing battlefield opioids and that refining, not abandoning, opioid usage will be key to effectively managing pain in the military.

Opioid use as a predictor of pain outcomes in Iraq and Afghanistan Veterans with chronic pain: Analysis of a randomized controlled trial

OBJECTIVE

Our objectives were to: 1) assess the relationship between self-reported opioid use and baseline demographics, clinical characteristics and pain outcomes; and 2) examine whether baseline opioid use moderated the intervention effect on outcomes at 9 months.

DESIGN

We conducted a secondary analysis of data from the Evaluation of Stepped Care for Chronic Pain (ESCAPE) trial, which found stepped-care to be effective for chronic pain in military veterans.

SETTING

A post-deployment clinic and 5 general medicine clinics at a Veteran Affairs Medical Center.

SUBJECTS

241 veterans with chronic musculoskeletal pain; 220 with complete data at 9 months.

METHODS

Examination of baseline relationships and multivariable linear regression to examine baseline opioid use as a moderator of pain-related outcomes including Roland Morris Disability Questionnaire (RMDQ), Brief Pain Inventory (BPI) Interference scale, and Graded Chronic Pain Scale (GCPS) at 9 months.

RESULTS

Veterans reporting baseline opioid use (n = 80) had significantly worse RMDQ (16.0 ± 4.9 vs. 13.4 ± 4.2, P < 0.0001), GCPS (68.7 ± 12.0 vs. 65.0 ± 14.4, p = 0.049), BPI Interference (6.2 ± 2.2 vs. 5.0 ± 2.1, P < 0.0001), and depression (PHQ-9 12.5 ± 6.2 vs. 10.6 ± 5.7, p = 0.016) compared to veterans not reporting baseline opioid use. Using multivariable modeling we found that baseline opioid use moderated the intervention effect on pain-related disability (RMDQ) at 9 months (interaction Beta = -3.88, p = 0.0064), but not pain intensity or interference.

CONCLUSIONS

In a stepped-care trial for pain, patients reporting baseline opioid use had greater improvement in pain disability at 9 months compared to patients not reporting opioid use.

Long-term prescription opioid use among US military service members injured in combat

INTRODUCTION

During the Global War on Terrorism, many US Military service members sustained injuries with potentially long-lasting functional limitations and chronic pain. We sought to understand the patterns of prescription opioid use among service members injured in combat.

METHODS

We queried the Military Health System Data Repository to identify service members injured in combat between 2007 and 2011. Sociodemographics, injury characteristics, treatment information, and costs of care were abstracted for all eligible patients. We surveyed for prescription opioid utilization subsequent to hospital discharge and through 2018. Negative binomial regression was used to identify factors associated with cumulative prescription opioid use.

RESULTS

We identified 3,981 service members with combat-related injuries presenting during the study period. The median age was 24 years (interquartile range [IQR], 22-29 years), 98.5% were male, and the median follow-up was 3.3 years. During the study period, 98% (n = 3,910) of patients were prescribed opioids at least once and were prescribed opioids for a median of 29 days (IQR, 9-85 days) per patient-year of follow-up. While nearly all patients (96%; n = 3,157) discontinued use within 6 months, 91% (n = 2,882) were prescribed opioids again after initially discontinuing opioids. Following regression analysis, patients with preinjury opioid exposure, more severe injuries, blast injuries, and enlisted rank had higher cumulative opioid use. Patients who discontinued opioids within 6 months had an unadjusted median total health care cost of US $97,800 (IQR, US $42,364-237,135) compared with US $230,524 (IQR, US $134,387-370,102) among those who did not discontinue opioids within 6 months (p < 0.001).

CONCLUSION

Nearly all service members injured in combat were prescribed opioids during treatment, and the vast majority experienced multiple episodes of prescription opioid use. Only 4% of the population met the criteria for sustained prescription opioid use at 6 months following discharge. Early discontinuation may not translate to long-term opioid cessation in this population.

LEVEL OF EVIDENCE

Epidemiology study, level III.

Learning health systems: Driving real-world impact in mental health and substance use disorder research

The Veterans Health Administration (VHA), under the U.S. Department of Veterans Affairs (VA), is one of the largest single providers of health care in the U.S. VA supports an embedded research program that addresses VA clinical priorities in close partnership with operations leaders, which is a hallmark of a Learning Health System (LHS). Using the LHS framework, we describe current VA research initiatives in mental health and substance use disorders that rigorously evaluate national programs and policies designed to reduce the risk of suicide and opioid use disorder (data to knowledge); test implementation strategies to improve the spread of effective programs for Veterans at risk of suicide or opioid use disorder (knowledge to performance); and identify novel research directions in suicide prevention and opioid/pain treatments emanating from implementation and quality improvement research (performance to data). Lessons learned are encapsulated into best practices for building and sustaining an LHS within health systems, including the need for early engagement with clinical leaders; pragmatic research questions that focus on continuous improvement; multi-level, ongoing input from regional and local stakeholders, and business case analyses to inform ongoing investment in sustainable infrastructure to maintain the research-health system partnership. Essential ingredients for supporting VA as an LHS include data and information sharing capacity, protected time for researchers and leaders, and governance structures to enhance health system ownership of research findings. For researchers, incentives to work with health systems operations (e.g., retainer funding) are vital for LHS research to be recognized and valued by academic promotion committees.

Telehealth and rural-urban differences in receipt of pain care in the Veterans Health Administration

OBJECTIVE

Examine changes in specialty pain utilization in the Veterans Health Administration (VHA) after establishing a virtual interdisciplinary pain team (TelePain).

DESIGN

Retrospective cohort study.

SETTING

A single VHA healthcare system, 2015-2019.

SUBJECTS

33,169 patients with chronic pain-related diagnoses.

METHODS

We measured specialty pain utilization (in-person and telehealth) among patients with moderate to severe chronic pain. We used generalized estimating equations to test the association of time (pre- or post-TelePain) and rurality on receipt of specialty pain care.

RESULTS

Among patients with moderate to severe chronic pain, the reach of specialty pain care increased from 11.1% to 16.2% in the pre- to post-TelePain periods (aOR: 1.37, 95% CI: 1.26-1.49). This was true of both urban patients (aOR: 1.62, 95% CI: 1.53-1.71) and rural patients (aOR: 1.16, 95% CI: 0.99-1.36), although the difference for rural patients was not statistically significant. Among rural patients who received specialty pain care, a high percentage of the visits were delivered by telehealth (nearly 12% in the post-TelePain period), much higher than among urban patients (3%).

CONCLUSIONS

We observed increased use of specialty pain services among all patients with chronic pain. Although rural patients did not achieve the same degree of access and utilization overall as urban patients, their use of pain telehealth increased substantially and may have substituted for in-person visits. Targeted implementation efforts may be needed to further increase the reach of services to patients living in areas with limited specialty pain care options.