U.S. Military Veteran Versus Nonveteran Use of Licit and Illicit Substances

Examining associations between disordered eating and harmful substance use in a nationally representative sample of US veterans

OBJECTIVE

The association between eating disorders (EDs) and harmful substance use (substance use that causes psychosocial impairment) is well recognized in the literature, and military veterans may be at heightened risk for both issues due to deployment-related stressors. However, little is known about which ED-related symptoms are associated with harmful substance use in veterans, and whether gender plays a differential role in this relationship. Our aims were to: (1) examine gender differences in ED-related symptoms; and (2) examine whether ED-related symptoms differentially predict harmful substance use in US veteran men and women who had recently separated from service.

METHOD

This study was based on a nationally representative four-wave longitudinal sample of post-9/11 veterans (N = 835; 61.2% female). Longitudinal mixed modeling was used to test whether specific ED-related behaviors at baseline predicted harmful substance use at follow-ups.

RESULTS

We replicated gendered patterns of ED-related symptoms observed in civilian populations, wherein men had higher weight-and-body-related concerns (including excessive exercise and muscle building) and negative attitude toward obesity, and women had higher bulimic and restricting symptoms. For women, alcohol, drug, and marijuana problems were predicted by higher bulimic symptoms, whereas for men, these problems were predicted by higher restricting symptoms.

CONCLUSION

Gender played a differential role in the relationship between EDs and harmful substance use. Bulimic symptoms were the most robust predictor for harmful substance use among veteran women, whereas restricting was the most robust predictor for harmful substance use among veteran men.

PUBLIC SIGNIFICANCE

The current study found that veteran women had higher bulimic symptoms (characterized by binge eating and purging) and restricting than veteran men. In women, bulimic symptoms predicted future harmful use of alcohol, marijuana, and other drugs. In contrast, veteran men had higher weight-and-body-related concerns (characterized by excessive exercise and muscle building) than veteran women. In men, restricting symptoms predicted future harmful use of alcohol, marijuana, and other drugs.

Cigarette Smoking Motives and Stages of Change in Smoking Cessation Among Veterans: Differences by Gender and Sexual Orientation

PURPOSE

To examine differences across gender and sexual orientation in cigarette smoking motives and stages of change in smoking cessation among Veterans.

DESIGN

Secondary data analysis of cross-sectional baseline surveys from a prospective cohort study.

SETTING

United States, self-administered online survey.

PARTICIPANTS

Cisgender Veterans who reported past-year smoking (N = 146); 66.4% identified as lesbian, gay, or bisexual and 52.1% were men.

MEASURES

Smoking motives (i.e., social, self-confidence, boredom relief, and affect regulation), with higher scores indicating stronger motivation to smoke. Stages of change categories included precontemplation, contemplation/preparation, and action/maintenance.

ANALYSIS

Analyses were stratified by gender and sexual orientation. Age-adjusted linear regression models estimated differences in smoking motives scores and multinomial logistic regression models estimated differences in stages of change categories relative to the precontemplation stage (reference category).

RESULTS

In this Veteran sample, gay men reported higher social smoking motives vs heterosexual men (β = 1.50 (95% CI: .04, 2.97), P-value = .045) and higher boredom relief smoking motives vs bisexual men (β = 1.53 (95% CI: .06, 2.29), P-value = .041) in age-adjusted models. Lesbian women were more likely to be in the action/maintenance stage relative to the precontemplation stage when compared to both heterosexual women (aRRR = 4.88 (95% CI: 1.00, 23.79) P-value = .050) and bisexual women (aRRR = 16.46 (95% CI: 2.12, 127.57), P-value = .007) after adjusting for age.

CONCLUSION

Smoking cessation interventions may benefit from enhancing peer support for gay men. Given bisexual and heterosexual women were in less advance stages of change, there may be a greater need for motivational interventions to encourage quitting and additional support to assist with cessation efforts. Overall, findings highlight the diversity of cigarette use within LGB communities.

Child Maltreatment History, Deployment-Related Traumatic Events, and Past 12-Month Cannabis Use Among Veterans in Canada

OBJECTIVE

Cannabis use among veterans in Canada is an understudied public health priority. The current study examined cannabis use prevalence and the relationships between child maltreatment histories and deployment-related traumatic events (DRTEs) with past 12-month cannabis use including sex differences among Canadian veterans.

METHOD

Data were drawn from the 2018 Canadian Armed Forces Members and Veterans Mental Health Follow-up Survey (response rate 68.7%; veterans only n = 1,992). Five child maltreatment types and 9 types of DRTEs were assessed in relation to the past 12-month cannabis use.

RESULTS

The prevalence of lifetime and past 12-month cannabis use was 49.4% and 16.7%, respectively. Females were less likely than males to report lifetime cannabis use (41.9% vs. 50.4%; odds ratio [OR] 0.71; 95% CI, - 0.59 to 0.86). No sex differences were noted for past 12-month cannabis use (14.1% vs. 17.0%; OR 0.80; 95% CI, 0.60 to 1.07). Physical abuse, sexual abuse, neglect, any child maltreatment, most individual DRTEs, and any DRTE were associated with increased odds of past 12-month cannabis use after adjusting for sociodemographic and military variables. Some models were attenuated and/or nonsignificant after further adjustments for mental disorders and chronic pain conditions. Sex did not statistically significantly moderate these relationships. Cumulative effects of having experienced both child maltreatment and DRTEs compared to DRTEs alone increased the odds of past 12-month cannabis use. Statistically significant interaction effects between child maltreatment history and DRTE on cannabis use were not found.

CONCLUSIONS

Child maltreatment histories and DRTEs increased the likelihood of past 12-month cannabis use among Canadian veterans. A history of child maltreatment, compared to DRTEs, indicated a more robust relationship. Understanding the links between child maltreatment, DRTEs, and cannabis use along with mental disorders and chronic pain conditions is important for developing interventions and improving health outcomes among veterans.

Demographic differences in the cascade of care for unhealthy alcohol use: A cross-sectional analysis of data from the 2015-2019 National Survey on Drug Use and Health

BACKGROUND

The screening, brief intervention, and referral to treatment (SBIRT) model is recommended by the U.S. Preventive Services Task Force to improve recognition of and intervention for unhealthy alcohol use. How SBIRT implementation differs by demographic characteristics is poorly understood.

METHODS

We analyzed data from the 2015-2019 National Survey on Drug Use and Health from respondents ≥18 years old who used an outpatient clinic and had at least one alcoholic drink within the past year. Respondents were grouped into one of three mutually exclusive groups: "no binge drinking or alcohol use disorder (AUD)," "binge drinking without AUD," or "AUD." Outcome variables were likelihood of screening, brief intervention (BI), referral to treatment (RT), and AUD treatment. The demographic predictors on which outcomes were regressed included gender, age, race and ethnicity, sexual orientation, insurance status, and history of military involvement. Consistent with SBIRT guidelines, the entire sample was included in the screening model; screened persons with either binge drinking without AUD or with AUD were included in the BI model; screened persons with AUD were included in the RT model, and persons referred to treatment with AUD were included in the AUD treatment model.

RESULTS

Analyses included 120,804 respondents. Women were more likely than men to be screened, but less likely to receive BI or RT. When referred to treatment, women were more likely than men to receive it. Persons aged ≥50 were least likely to be screened about alcohol, but most likely to receive BI, while persons aged 18-25 were least likely to receive BI or AUD treatment. Racial and ethnic minorities were less likely than White persons to be screened; Asians were less likely to receive RT, and Black persons were less likely to receive treatment than White persons. Persons identifying as gay, lesbian, or bisexual were equally as likely or more likely to receive SBIRT or AUD treatment as those identifying as heterosexual. Persons without insurance were less likely to be screened than those with insurance. Persons with a history of military involvement were more likely to be screened and receive BI and RT than persons who had not served in the military.

CONCLUSIONS

Demographic disparities in SBIRT implementation exist. Addressing the sources of these disparities and minimizing attrition from care could improve outcomes for persons with unhealthy alcohol use.

Substance Use in U.S. Vietnam War Era Veterans and Nonveterans: Results from the Vietnam Era Health Retrospective Observational Study

Background: Substance use (SU) is associated with physical injury and mental health disorders in older persons, but recent research has scarcely examined SU in U.S. Vietnam-era veterans who are mostly in or near their eighth decade of life. Objectives: We compared the prevalence of self-reported lifetime and current SU and modeled current usage patterns in a nationally representative sample of veterans versus a matched nonveteran cohort. Methods: Cross-sectional, self-reported survey data were analyzed from the 2016-2017 Vietnam Era Health Retrospective Observational Study (VE-HEROeS) (n = 18,866 veterans, n = 4,530 nonveterans). We assessed lifetime and current alcohol and drug use disorders; lifetime and current use of cannabis, opioids, stimulants, sedatives, "other drugs" (psychedelics, prescription or over-the-counter drugs not prescribed/used as intended); and current SU patterns (alcohol-use-only, drug-use-only, dual-SU, no SU). Weighted descriptive, bivariable, and multivariable statistics were calculated. Covariates in multinomial modeling included sociodemographic characteristics, lifetime cigarette smoking, depression, potentially traumatic events (PTEs), and current pain (SF-8^TM). Results: Prevalence of lifetime opioid and sedative use (p ≤ .01), drug and alcohol use disorders (p < .001), and current "other drug" use (p < .001) were higher in veterans versus nonveterans. Current use of alcohol and cannabis was high in both cohorts. In veterans, very severe/severe pain, depression, and PTEs were highly associated with drug-use-only (p < .001) and dual-SU (p < .01), but these associations were fewer for nonveterans. Conclusion: This research confirmed existing concerns over substance misuse in older individuals. Vietnam-era veterans may be at particular risk due to service-related experiences and later-life tribulations. Era veterans' unique perceptions toward healthcare assistance for SU may need greater provider focus to maximize self-efficacy and treatment.

Age, sex, and race-varying rates of alcohol use, cannabis use, and alcohol and cannabis co-use in veterans vs. non-veterans

BACKGROUND

Military veterans are a high-risk group for health risk behaviors, including alcohol and cannabis use. However, research on veteran vs. non-veteran rates of alcohol/cannabis use are inconsistent across studies. Further, no research has investigated veteran vs. non-veteran rates of alcohol and cannabis co-use, and few studies have tested whether demographic variables, particularly race/ethnicity, moderate group differences. Therefore, the current study tested whether 1) veteran vs. non-veterans differed in rates of alcohol use, cannabis use, and alcohol and cannabis co-use, and 2) whether demographic covariates (age, sex, race/ethnicity) moderated associations.

METHODS

Data on adults (N = 706,897; 53.4% female) were derived from the 2002-2019 National Study on Drug Use and Health. Participant demographics, alcohol use frequency, drinking quantity, and cannabis use frequency were self-reported.

RESULTS

Non-veterans reported higher drinking quantity, cannabis frequency, and co-use. However, being a veteran was a risk factor for heavier drinking for women, ethnic/racial minoritized participants, and adults under the age of 50. Additionally, veteran status was a risk factor for cannabis use frequency in racial/ethnic minoritized participants and women. Similarly, being a veteran was a risk factor for alcohol and cannabis co-use for racial/ethnic minoritized participants, and the buffering effect of being a Veteran on co-use was reduced for older participants and women.

CONCLUSIONS

Results suggest that, at the population level, non-veterans may be heavier alcohol/cannabis users. However, moderating analyses suggested that being a veteran is a risk factor for women, racial/ethnic minoritized individuals, and younger individuals. Findings are discussed in terms of public health implications.

Serious Mental Illness Diagnosis and COVID-19 Vaccine Uptake in the Veterans Health Administration

OBJECTIVE

This study examined the association between serious mental illness diagnoses and COVID-19 vaccination among Veterans Health Administration (VHA) patients.

METHODS

The sample (N=4,890,693) comprised veterans ages ≥18 years with VHA outpatient visits from March 1, 2018, through February 29, 2020. Veterans with serious mental illness were identified with ICD-10 diagnostic codes from electronic health records of the U.S. Department of Veterans Affairs. Receipt of a VHA COVID-19 vaccine from December 1, 2020, through June 1, 2021, was documented by using procedure codes. Treatment effects estimation with inverse-probability weighting was used to estimate the effects of serious mental illness on COVID-19 vaccine uptake.

RESULTS

Patients with serious mental illness and patients without serious mental illness were equally likely to receive a vaccination (48% and 46%, respectively; average effect of serious mental illness=-0.4%, 95% confidence interval=-0.8% to 0.1%).

CONCLUSIONS

VHA outreach activities have contributed to equitable distribution of the COVID-19 vaccine.

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

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

A real-world evaluation of a smokeless tobacco cessation text message program for veterans: Outcomes and comparison to cigarette smokers

INTRODUCTION

Smokeless tobacco (ST) use and cessation rates have remained unchanged while cigarette smoking has declined, and cessation rates have increased. Text message programs have proved effective for cigarette smokers but have not been evaluated for ST users. The Veterans Health Administration (VHA) created a ST-specific arm of its SmokefreeVET automated text message program to help veteran ST users quit.

METHODS

A retrospective evaluation was conducted on a real-world sample of veteran ST users (n=1,139) who subscribed to SmokefreeVET between 2017 and 2020. Time in program, abstinence, and nicotine replacement therapy (NRT) use were evaluated and compared to 9,764 cigarette smokers who subscribed to SmokefreeVET.

RESULTS

Younger subscribers were more likely to opt out early; 54% of ST users and 60% of cigarette smokers completed the 6-week program. ST users were more likely to report abstinence than cigarette smokers at all time points: the primary outcome, 30-day abstinence at 6 months, was 3.9% in ST users and 2.6% in cigarette smokers (p=.05) and the secondary outcome, abstinence at 3 months, was 5.3% in ST users and 3.4% in cigarette smokers (p=.03). NRT was used by 17% of ST users and was associated with a trend toward higher abstinence compared to ST users who did not use NRT.

CONCLUSION

A real-world sample of ST users were more likely to report abstinence after using the SmokefreeVET text program than cigarette smokers. Automated text message programs may be effective for increasing cessation among ST users and warrant further investigation.

IMPLICATIONS

Smokeless tobacco (ST) cessation is an important public health priority and of importance for veteran and military populations that have higher rates of ST use. There have been relatively few studies conducted investigating the effectiveness of text message interventions for ST cessation, despite the proven efficacy for cigarette smokers. This study provides evidence from a large, real-world sample that text message programs may be effective for ST users and suggests that further research into this treatment modality for ST users is needed.

Drinking less on cannabis use days: The moderating role of UPPS-P impulsive personality traits

Objective: Several studies suggest that alcohol and cannabis co-users are heavier drinkers and experience more alcohol-related consequences. However, day-level associations between co-use and drinking levels are mixed. One reason may be that individual characteristics moderate the daily impact of using alcohol alone or in conjunction with cannabis. The theory would suggest that highly impulsive individuals may drink more on co-use days, yet this assertion remains untested. Therefore, the current study tested whether impulsivity moderated the effect of co-use on same-day drinking quantity within veterans, a high-risk sample for substance use and impulsivity. Method: In a longitudinal observational study, co-using veterans (N = 139) completed three semi-annual assessments reporting on their daily drinking quantity and cannabis use via Timeline Followback (Observations = 19,245) and impulsivity via the UPPS-P. Mixed effect modeling was used to test hypotheses that co-use (compared to alcohol-only) days would be associated with heavier drinking for those high (but not low) in positive and negative urgency. Results: Significant interactions were found for positive urgency (PU) and lack of perseverance (LP), such that individuals at mean and low levels of PU and LP drank less on co-use (compared to alcohol-only) days. There were no significant interactions for other UPPS-P impulsivity facets. Conclusion: Findings are consistent with a substitution/compensatory effect for individuals at mean and low levels of both UPPS-P facets, and may be a byproduct of frequent cannabis use in veterans. In contrast, findings suggest that co-use and alcohol-only days may be characterized by similarly high levels of drinking for highly impulsive individuals. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Methamphetamine exacerbates pathophysiology of traumatic brain injury at high altitude. Neuroprotective effects of nanodelivery of a potent antioxidant compound H-290/51

Military personnel are often exposed to high altitude (HA, ca. 4500-5000m) for combat operations associated with neurological dysfunctions. HA is a severe stressful situation and people frequently use methamphetamine (METH) or other psychostimulants to cope stress. Since military personnel are prone to different kinds of traumatic brain injury (TBI), in this review we discuss possible effects of METH on concussive head injury (CHI) at HA based on our own observations. METH exposure at HA exacerbates pathophysiology of CHI as compared to normobaric laboratory environment comparable to sea level. Increased blood-brain barrier (BBB) breakdown, edema formation and reductions in the cerebral blood flow (CBF) following CHI were exacerbated by METH intoxication at HA. Damage to cerebral microvasculature and expression of beta catenin was also exacerbated following CHI in METH treated group at HA. TiO2-nanowired delivery of H-290/51 (150mg/kg, i.p.), a potent chain-breaking antioxidant significantly enhanced CBF and reduced BBB breakdown, edema formation, beta catenin expression and brain pathology in METH exposed rats after CHI at HA. These observations are the first to point out that METH exposure in CHI exacerbated brain pathology at HA and this appears to be related with greater production of oxidative stress induced brain pathology, not reported earlier.