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Koh KA, Szymkowiak D, Tsai J. Benzodiazepine Prescriptions for Homeless Veterans Affairs Service Users With Mental Illness. Psychiatr Serv 2024; 75:316-325. [PMID: 37904492 DOI: 10.1176/appi.ps.20220472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2023]
Abstract
OBJECTIVE Despite elevated risk for substance use disorder and overdose death in the homeless population, benzodiazepine prescribing for this population has not been examined. In this study, the authors used data from the U.S. Department of Veterans Affairs (VA) health care system to examine benzodiazepine prescribing and risky and potentially inappropriate benzodiazepine prescribing practices for homeless VA service users. METHODS Using national VA administrative data (2018-2019), the authors conducted logistic regression to compare likelihood of benzodiazepine prescribing and t tests to compare indicators of risky and potentially inappropriate benzodiazepine prescribing patterns for homeless service users with mental illness (N=244,113) and their housed peers (N=2,763,513). RESULTS Unadjusted analyses showed that benzodiazepines were prescribed for 7.5% of homeless VA service users with mental illness, versus 9.4% of their housed peers (p<0.001). Analyses adjusted for sociodemographic and clinical characteristics and health care utilization showed that homeless service users were less likely than their housed peers to receive a benzodiazepine prescription (AOR=0.70, 99% CI=0.68-0.72). However, compared with their housed peers, homeless service users received higher rates of risky and potentially inappropriate benzodiazepine prescriptions, including multiple concurrent benzodiazepine prescriptions (9.4% vs. 7.0%, p<0.001) and concurrent prescriptions for benzodiazepines and opioids (36.9% vs. 31.2%, p<0.001) or sedatives (61.9% vs. 45.9%, p<0.001). CONCLUSIONS Although homeless VA service users with mental illness were less likely than their housed peers to receive a benzodiazepine prescription, benzodiazepine prescriptions for these service users had more characteristics of risky and potentially inappropriate prescribing.
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Affiliation(s)
- Katherine A Koh
- Department of Psychiatry, Massachusetts General Hospital-Harvard Medical School, and Boston Health Care for the Homeless Program, Boston (Koh); National Center on Homelessness Among Veterans, U.S. Department of Veterans Affairs (VA), Tampa, Florida (Szymkowiak, Tsai); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
| | - Dorota Szymkowiak
- Department of Psychiatry, Massachusetts General Hospital-Harvard Medical School, and Boston Health Care for the Homeless Program, Boston (Koh); National Center on Homelessness Among Veterans, U.S. Department of Veterans Affairs (VA), Tampa, Florida (Szymkowiak, Tsai); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
| | - Jack Tsai
- Department of Psychiatry, Massachusetts General Hospital-Harvard Medical School, and Boston Health Care for the Homeless Program, Boston (Koh); National Center on Homelessness Among Veterans, U.S. Department of Veterans Affairs (VA), Tampa, Florida (Szymkowiak, Tsai); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai)
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Colvard M. Concurrent opioid and alcohol withdrawal management. Ment Health Clin 2023; 13:268-275. [PMID: 38058596 PMCID: PMC10696169 DOI: 10.9740/mhc.2023.12.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 08/04/2023] [Indexed: 12/08/2023] Open
Abstract
Concurrent alcohol and opioid withdrawal syndrome is a common and challenging clinical scenario with little published evidence or guidance to inform pharmacotherapy strategies. Concurrent use of benzodiazepines and opioid agonists, which are considered first-line agents for management of each withdrawal syndrome independently, is controversial and often avoided in clinical practice. Strategies to provide effective, simultaneous medication treatment of alcohol and opioid withdrawal while optimizing patient safety are demonstrated through 3 patient cases.
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Hoggatt KJ, Chawla N, Washington DL, Yano EM. Trends in substance use disorder diagnoses among Veterans, 2009-2019. Am J Addict 2023; 32:393-401. [PMID: 36883297 DOI: 10.1111/ajad.13413] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 01/11/2023] [Accepted: 02/13/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Substance use disorder (SUD) represents a substantial health burden to US Veterans. We aimed to quantify recent time trends in Veterans' substance-specific disorders using Veterans Health Administration (VA) data. METHODS We identified Veteran VA patients for fiscal years (FY) 2010-2019 (October 1, 2009-September 9, 2019) and extracted patient demographics and diagnoses from electronic health records (~6 million annually). We defined alcohol, cannabis, cocaine, opioid, sedative, and stimulant use disorders with ICD-9 (FY10-FY15) or ICD-10 (FY16-FY19) codes and variables for polysubstance use disorder, drug use disorder (DUD), and SUD. RESULTS Diagnoses for substance-specific disorders (excluding cocaine), polysubstance use disorder, DUD, and SUD increased 2%-13% annually for FY10-FY15. Alcohol, cannabis, and stimulant use disorders increased 4%-18% annually for FY16-FY19, while cocaine, opioid, and sedative use disorders changed by ≤1%. Stimulant and cannabis use disorder diagnoses increased most rapidly, and older Veterans had the largest increases across substances. DISCUSSION AND CONCLUSIONS Rapid increases in cannabis and stimulant use disorder present a treatment challenge and key subgroups (e.g., older adults) may require tailored screening and treatment options. Diagnoses for SUD are increasing among Veterans overall, but there is important heterogeneity by substance and subgroup. Efforts to ensure access to evidence-based treatment for SUD may require greater focus on cannabis and stimulants, particularly for older adults. SCIENTIFIC SIGNIFICANCE These findings represent the first assessment of time trends in substance-specific disorders among Veterans, overall and by age and sex. Notable findings include large increases in diagnoses for cannabis and stimulant use disorder and among older adults.
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Affiliation(s)
- Katherine J Hoggatt
- San Francisco VA Health Care System, Research Division, San Francisco, California, USA
- Department of Medicine, University of California, San Francisco, California, USA
| | - Neetu Chawla
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Research Division, Los Angeles, California, USA
| | - Donna L Washington
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Research Division, Los Angeles, California, USA
- Division of General Internal Medicine and Health Services Research, Department of Medicine, UCLA Geffen School of Medicine, Los Angeles, California, USA
| | - Elizabeth M Yano
- VA Health Services Research & Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Research Division, Los Angeles, California, USA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
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Bounthavong M, Shayegani R, Manning JM, Marin J, Spoutz P, Harvey MA, Hoffman JD, Himstreet JE, Kay CL, Freeman BA, Grana A, LD Christopher M. Comparison of virtual to in-person academic detailing on naloxone prescribing rates at three U.S. Veterans Health Administration regional networks. Int J Med Inform 2022; 161:104712. [DOI: 10.1016/j.ijmedinf.2022.104712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 01/08/2022] [Accepted: 01/28/2022] [Indexed: 12/29/2022]
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Himstreet JE, Shayegani R, Spoutz P, Hoffman JD, Midboe AM, Hillman A, Marin J, Chen A, Smith JP, Manning J, Grana A, Gray C, Erhardt T, Garcia C, Freeman B, Christopher MLD, Bounthavong M. Implementation of a pharmacy-led virtual academic detailing program at the US Veterans Health Administration. Am J Health Syst Pharm 2022; 79:909-917. [PMID: 35084487 DOI: 10.1093/ajhp/zxac024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE To provide a summary of the implementation of a virtual academic detailing pilot program at the US Department of Veterans Affairs (VA). SUMMARY In September 2018, VA Pharmacy Benefits Management implemented a virtual academic detailing ("e-Detailing") pilot program across three regional networks. Academic detailing involves multifaceted collaborative outreach delivered by trained healthcare clinicians to other clinicians using targeted educational interventions that improve clinical decision-making. Across VA, academic detailing programs are primarily staffed by specially trained clinical pharmacist specialists. Implementation began with an in-person meeting to train academic detailers on using the virtual academic detailing platform (VA Video Connect) and virtual soft skills, which was followed by regular facilitation meetings to address issues and share experiences. During e-Detailing program implementation, the coronavirus disease 2019 (COVID-19) emerged, prompting the US Department of Health and Human Services to declare a public health emergency. VA followed with restrictions on nonessential travel for all employees, thus hampering in-person academic detailing activities. Fortunately, e-Detailing provided an alternative channel for academic detailers across VA to continue delivering critical outreach to providers during the pandemic. Qualitative assessment of academic detailers' and providers' perceptions on e-Detailing highlighted the need for local leadership support for e-Detailing and telehealth, the efficiency of virtual compared to in-person visits, and potential time savings resulting from avoidance of long commutes. CONCLUSION The timing of e-Detailing implementation during the COVID-19 pandemic illustrates the need and potential for a virtual platform to deliver timely provider outreach.
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Affiliation(s)
| | - Ramona Shayegani
- VISN Program Manager, Academic Detailing Service, VA Sierra Pacific Network (VISN 21), Pleasant Hill, CA, USA
| | - Patrick Spoutz
- VA Northwest Network (VISN 20), Pharmacy Benefits Management, Vancouver, WA, USA
| | - Jonathan D Hoffman
- VA Rocky Mountain Network (VISN 19), Pharmacy Benefits Management, Glendale, CO, USA
| | - Amanda M Midboe
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, and Stanford University School of Medicine, Palo Alto, CA, USA
| | - Ashley Hillman
- VA Northwest Network (VISN 20), Pharmacy Benefits Management, Vancouver, WA, USA
| | - Jennifer Marin
- VA Sierra Pacific Network (VISN 21), Pharmacy Benefits Management, Pleasant Hill, CA, USA
| | - Andrea Chen
- Academic Detailing Service; VA Heartland Network (VISN 15), Kansas City, MO, USA
| | - Jason P Smith
- VA Rocky Mountain Network (VISN 19), Pharmacy Benefits Management, Glendale, CO, USA
| | - Jane Manning
- VA Northwest Network (VISN 20), Pharmacy Benefits Management, Vancouver, WA, USA
| | - Andrea Grana
- Academic Detailing Service, VA Pharmacy Benefits Management, West Palm Beach, FL, USA
| | - Caroline Gray
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Taryn Erhardt
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Carla Garcia
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Blake Freeman
- Academic Detailing Service, VA Pharmacy Benefits Management, New York, NY, USA
| | | | - Mark Bounthavong
- Academic Detailing Service, VA Pharmacy Benefits Management, San Diego, CA, and Division of Clinical Pharmacy, UCSD Skaggs School of Pharmacy & Pharmaceutical Sciences, La Jolla, CA, USA
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