Increased Polysedative Use in Veterans with Posttraumatic Stress Disorder

Feasibility of a Virtual Adaptation of a Yoga Intervention for Veterans with Chronic Pain and Posttraumatic Stress Disorder

Purpose/Objective: This study assessed the feasibility and acceptability of a yoga intervention for veterans with comorbid posttraumatic stress disorder (PTSD) and chronic pain (CP) that was adapted for virtual implementation. Research Method/Design: This pilot feasibility study at a large, mid-Atlantic Veteran's Affairs (VA) Medical Center with veterans with both PTSD and CP examined the adaptation of an eight-session virtual yoga group intervention. Participants (n = 18, 11 completers) were primarily male (82.4%), African American (76.5%), with no prior yoga experience (70.6%). A measure of client satisfaction was administered at completion and attendance rates were examined. Self-reported symptom measures were also assessed. Results: There were no instances of injuries or other adverse effects related to the study. This study yielded a 39% attrition rate, consistent with in-person yoga interventions. Mean number of sessions attended was 5.53 (SD = 1.73). Participants rated overall satisfaction as high (M = 28.09; SD = 3.96; potential range 8-32). Conclusions/Implications: This study provides initial data on the acceptability of a virtual yoga intervention for veterans with comorbid PTSD and CP, with attrition and satisfaction rates in line with prior in-person iterations. Implications of virtual adaption and considerations for future efforts will be discussed. This study was not preregistered but has been registered subsequently on ClinicalTrials.gov [CTR #: NCT06123065].

Implementation strategies to improve posttraumatic stress disorder care in rural veterans

PURPOSE

Prior research has noted treatment inequalities in the care of rural veterans with posttraumatic stress disorder (PTSD). This project sought to increase the delivery, or reach, of recommended PTSD treatments in 2 rural health care systems of the Department of Veterans Affairs (VA) using implementation facilitation.

METHODS

The quality improvement project involved 6 months of facilitation to 2 low-reach PTSD clinics within 2 VA health care systems. The clinics were matched to a control clinic at another regional system similar in reach, rurality, and patient volume. We compared the delivery of evidence-based psychotherapies (EBPs) for PTSD at 3 timepoints: baseline, 6 months, and 1 year using difference-in-difference effect estimation. Facilitators and barriers of EBP reach were identified through interviews with clinic staff and informed specific implementation plans. We also measured reductions in benzodiazepine prescriptions and polypharmacy to determine the impact of an academic detailing intervention aimed at improving PTSD prescribing practices at the 2 sites.

FINDINGS

EBP reach at 6 months more than doubled in the 2 PTSD clinics that received facilitation, while our control clinic experienced a decrease in EBP reach (DID = 24.6; SE = 6.71%). Both intervention clinics identified similar administrative barriers to the delivery of EBPs, offering useful information for improvement at other rural clinics. The use of academic detailing as part of our facilitation intervention further appears to have positively impacted care.

CONCLUSIONS

In this preliminary work, facilitation is a promising strategy for increasing the delivery of PTSD EBPs to veterans seen in under-resourced rural VA clinics.

The Impact of Comorbid Chronic Pain on Pharmacotherapy for Veterans with Post-Traumatic Stress Disorder

OBJECTIVE

Chronic pain can worsen PTSD symptomatology and may increase the risk of the prescription of multiple central nervous system (CNS)-active medications. The objective is to determine the impact of chronic pain on the number of CNS medications, including psychiatric medications, as well as the amount of medication changes.

METHODS

Veterans Affairs (VA) administrative data were used to identify VA-served Veterans with PTSD (N = 637,428) who had chronic pain (50.3%) and did not have chronic pain (49.7%) in 2020. The outcomes included the number of changes in psychiatric medications and the number of currently prescribed CNS-active mediations during a one-year observation period.

RESULTS

The number of changes in psychiatric medications was significantly higher for those with chronic pain (mean (M) = 1.8) versus those without chronic pain (M = 1.6) (Z = 38.4, p < 0.001). The mean number of concurrent CNS-active medications were significantly higher for those with chronic pain (M = 2.7) versus those without chronic pain (M = 2.0) (Z = 179.7, p < 0.001). These differences persisted after adjustment for confounding factors using negative binomial regression.

CONCLUSIONS

Veterans with comorbid chronic pain and PTSD are at increased risk for a higher number of medication changes and for receiving CNS-active polytherapy.

Anhedonia modulates benzodiazepine and opioid demand among persons in treatment for opioid use disorder

Background

Benzodiazepine (BZD) misuse is a significant public health problem, particularly in conjunction with opioid use, due to increased risks of overdose and death. One putative mechanism underlying BZD misuse is affective dysregulation, via exaggerated negative affect (e.g., anxiety, depression, stress-reactivity) and/or impaired positive affect (anhedonia). Similar to other misused substances, BZD consumption is sensitive to price and individual differences. Although purchase tasks and demand curve analysis can shed light on determinants of substance use, few studies have examined BZD demand, nor factors related to demand.

Methods

This ongoing study is examining simulated economic demand for alprazolam (among BZD lifetime misusers based on self-report and DSM-5 diagnosis; n = 23 total; 14 male, 9 female) and each participant's preferred-opioid/route using hypothetical purchase tasks among patients with opioid use disorder (n = 59 total; 38 male, 21 female) who are not clinically stable, i.e., defined as being early in treatment or in treatment longer but with recent substance use. Aims are to determine whether: (1) BZD misusers differ from never-misusers on preferred-opioid economic demand, affective dysregulation (using questionnaire and performance measures), insomnia/behavioral alertness, psychiatric diagnoses or medications, or urinalysis results; and (2) alprazolam demand among BZD misusers is related to affective dysregulation or other measures.

Results

Lifetime BZD misuse is significantly (p < 0.05) related to current major depressive disorder diagnosis, opioid-negative and methadone-negative urinalysis, higher trait anxiety, greater self-reported affective dysregulation, and younger age, but not preferred-opioid demand or insomnia/behavioral alertness. Alprazolam and opioid demand are each significantly positively related to higher anhedonia and, to a lesser extent, depression symptoms but no other measures of negative-affective dysregulation, psychiatric conditions or medications (including opioid agonist therapy or inpatient/outpatient treatment modality), or sleep-related problems.

Conclusion

Anhedonia (positive-affective deficit) robustly predicted increased BZD and opioid demand; these factors could modulate treatment response. Routine assessment and effective treatment of anhedonia in populations with concurrent opioid and sedative use disorder may improve treatment outcomes.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT03696017, identifier NCT03696017.

Central nervous system polytherapy among veterans with posttraumatic stress disorder: changes across a decade

OBJECTIVE

The study objectives were to investigate rates and patterns of polytherapy among veterans with PTSD across time (in 2009 and 2019), describe features of polytherapy prescribing, and identify demographic and clinical factors associated with polytherapy.

METHODS

Veterans Affairs (VA) administrative data were used to build cohorts of all VA-served veterans with PTSD in 2009 (N = 458,620) and 2019 (N = 877,785). Frequency of CNS active drug classes, rates of polytherapy (≥5 concurrent CNS drugs), clinical features associated with polytherapy, number of prescribers, and patterns of co-prescribed medications were examined.

RESULTS

The 12-month period prevalence of CNS polytherapy declined from 12.1% in 2009 to 6.9% in 2019. However, polytherapy rates increased from 3.3% in 2009 to 4.1% in 2019, when opioids and benzodiazepines were excluded. In multivariable regression analysis, CNS polytherapy was more common among women, White people, middle-age veterans (45-64 years), rural residents, veterans receiving care at a medical center, and those with psychiatric comorbidities. CNS polytherapy regimens involved a mean of 2.3 prescribers and the majority (86.6%) included at least one medication commonly prescribed for pain management.

CONCLUSIONS

CNS polytherapy declined among veterans with PTSD from 2009 to 2019 and was wholly attributable to decreases in opioid and benzodiazepine prescribing.

Rural differences in psychiatric medication prescribing in veterans with posttraumatic stress disorder

PURPOSE

Disparities in the treatment of posttraumatic stress disorder (PTSD) for rural veterans have been noted in prior research. The objective was to examine rural differences in prescribing for veterans with PTSD, and changes over time, in the Department of Veterans Affairs (VA) health care system.

METHODS

Prescribing prevalence in veterans with PTSD during 2009 and 2019 was determined using national VA administrative pharmacy data according to the joint VA-Department of Defense clinical practice guideline as medications recommended for use in PTSD and those recommended against use. Multivariable logistic regression was used to contrast patient residence (urban vs rural) and site of PTSD care (medical center, urban clinic, or rural clinic), while adjusting for clinical covariates.

FINDINGS

Recommended medications were prescribed significantly less often to patients of rural clinics, relative to medical centers in 2009 (OR = 0.91; 95% CI: 0.89-0.94) but reached equivalence in 2019 (OR = 1.01; 95% CI: 0.99-1.03). In addition, rural clinics had significantly lower prescribing of recommended against medications (OR = 0.86; 95% CI: 0.84-0.87) in 2019. Prescribing of medications recommended against the use for PTSD was higher among rural residents, relative to urban residents in 2009 (OR = 1.14; 95% CI: 1.12-1.16), which declined toward equivalence by 2019 (OR = 1.06; 95% CI: 1.05-1.07).

CONCLUSIONS

While some clinically meaningful differences in prescribing for rural veterans with PTSD were observed in 2009, these differences shifted toward equivalency within the following decade. In 2019, we failed to observe any systematic prescribing deficiencies for veterans receiving PTSD care at rural clinics.

Impact of Implementing an Academic Detailing Program on Opioid-Benzodiazepine Co-Prescribing Trends at the U.S. Department of Veterans Affairs

OBJECTIVES

To assess the process and outcomes of academic detailing to enhance the Opioid Safety Initiative and the Psychotropic Drug Safety Initiative to reduce co-prescribing of opioid-benzodiazepine combinations in veterans.

METHODS

A retrospective cohort design was conducted to evaluate the impact of implementing an academic detailing program on opioid-benzodiazepine co-prescribing between October 2014 through March 2019 at the U.S. Department of Veterans Affairs (VA). The primary outcome was the monthly prevalence of veterans (number per 1,000 population) who were co-prescribed opioid-benzodiazepine combination. Process measure was evaluated using implementation reach (proportion of providers who received academic detailing). Station-level analysis was performed using a linear fixed effects regression model to evaluate the rate of change in the prevalence of veterans co-prescribed opioid-benzodiazepine.

RESULTS

Altogether 130 VA stations was included for analysis; 119 stations implemented opioid-related or benzodiazepine-related academic detailing, and 11 stations did not. Stations that had implemented academic detailing had a 33% greater monthly reduction on the opioid-benzodiazepine co-prescribing prevalence compared to stations that did not implement academic detailing (P = .036). In the linear fixed effects regression model, stations that were expected to have 100% of providers exposed to academic detailing were statistically associated with a greater decrease in the monthly prevalence of Veterans co-prescribed opioid-benzodiazepine by 4.9 veterans per 1,000 population (P < .001) compared to stations with 0% of providers exposed to academic detailing.

CONCLUSIONS

Stations that implemented academic detailing and had a higher proportion of providers who were exposed to opioid- or benzodiazepine-related academic detailing had a significant decrease in the monthly prevalence of Veterans co-prescribed opioid-benzodiazepine combinations.

Variation in health service use by veterans with an accepted disability of post-traumatic stress disorder who had a service record post 1975: a cluster analysis

Background

The use of health services is likely to vary among veterans with an accepted disability of post-traumatic stress disorder (PTSD), however, the extent of variation is not known. We aimed to determine the extent and type of health services used by veterans with an accepted disability of PTSD.

Methods

The cohort included veterans who served post 1975, were eligible for all Australian Government Department of Veterans’ Affairs funded health services, had PTSD as an accepted disability prior to July 2015 and were alive at the 30 June 2016. Veterans were assigned to groups based on their use of health services using K-means cluster analysis.

Results

The cohort comprised five clusters involving 2286 veterans. The largest cluster (43%) were a younger, general practitioner (GP) managed cluster who saw their GP quarterly and the psychiatrist twice a year. The second GP cluster (30%) had higher levels of physical comorbidity. The psychiatrist managed cluster (14%) had a mean of 12 psychiatrist visits and one PTSD hospitalisation in the year. The remaining two clusters involved GP and allied healthcare, but no psychologist care. High levels of antidepressant use occurred in all clusters, ranging from 44% up to 69%. The psychiatrist managed cluster had 47% on antipsychotics and 58% on anxiolytics.

Conclusion

Our study highlights the heterogeneity in health service use. These results identify the significant health utilisation required for up to one-sixth of veterans with PTSD and the significant role of primary care physicians in supporting veterans with PTSD.

Development and Application of a Measurement Framework to Evaluate Safe, Effective and Efficient Medication Use Among Older Adults

BACKGROUND

A majority of older adults in the United States (US) use prescription medications. Comprehensive population-level approaches to examine medication safety, effectiveness, and costs among older adults are needed.

OBJECTIVES

The objectives of this study were to develop a framework of quality measures spanning the domains of safety, effectiveness, and efficiency of prescription medication use among older adults, and to apply those measures using pharmacy claims data.

METHODS

We performed a retrospective study among adults age 65 years and older of a US East Coast state who filled at least one prescription from a particular pharmacy chain during 2016 (N = 99,056). Firstly, we performed an environmental scan to identify quality measures and potentially relevant measures addressing prescription medication use. These measures were reviewed and rated by local geriatric pharmacotherapy experts. After evaluating feasibility, evidence, and relevance, a total of 19 measures representing the domains of safety (n = 7), effectiveness (n = 7), and efficiency (n = 5) were identified. These measures were then applied to an older adult population using prescription data for the year 2016 provided by a national pharmacy chain. All measures were configured such that a score of 100% corresponded to optimal performance.

RESULTS

For the domain of safety, 12.8% of patients received a benzodiazepine chronically, 23.6% received central nervous system depressants, 16.7% received fluoroquinolones as first-line antibiotic therapy, and 21.9% of those who were prescribed opioids received them in excessive quantities. For the domain of effectiveness, one-fourth of the diabetes patients did not receive statins and angiotensin-acting medications, while 18.0% were not adherent to oral anticoagulant medications and 54% were not adherent to respiratory inhalers. For the domain of efficiency, 12.0% of the patients received prescriptions from five or more unique prescribers. Overall, 85.7%, 76.1%, and 87.9% of the older adults showed safe, effective, and efficient prescription medication use, respectively.

CONCLUSION

A novel approach to comprehensively examine the quality of medication use among older adults using prescription claims data is provided in our study. A considerable proportion of the older adults in our study received safe, effective, and efficient prescription medications. However, within each domain, several opportunities for improving the alignment of prescription medication use with current recommendations were identified.

Acquired Stuttering in Veterans of the Wars in Iraq and Afghanistan: The Role of Traumatic Brain Injury, Post-Traumatic Stress Disorder, and Medications

Introduction

Determine the association between acquired stuttering (AS), traumatic brain injury (TBI), and post-traumatic stress disorder (PTSD) in a cohort of 309,675 U.S. Iraq and Afghanistan veterans. The secondary aim was to determine the association between AS and medication patterns for veterans in the sample.

Materials and Methods

Retrospective study using data from the Veterans Health Administration National Repository for veterans deployed in support of combat operations in Iraq and Afghanistan and who received Veterans Health Administration care in 2010 and 2011. We identified stuttering using ICD-9 codes to establish the association between AS, TBI, and PTSD, controlling for demographic characteristics and other comorbidities. Multivariable logistic regression was used to determine the association between comorbid conditions and potentially problematic medications associated with stuttering.

Results

Two hundred thirty-five veterans (0.08%) were diagnosed with AS in the cohort. There was the greater likelihood of an AS diagnosis for veterans with concomitant TBI and PTSD when compared with veterans without these diagnoses. Over 66% of those with stuttering were prescribed at least one medication that affected speech fluency (antidepressants, anxiolytics, and antiepileptic drugs) compared with 35% of those without AS.

Conclusion

Veterans with a comorbid diagnosis of TBI and PTSD were more likely to be diagnosed with AS AOR: 9.77 (95% CI = 6.93-13.78, p < 0.05) and more likely to have been prescribed medications known to affect speech production OR: 3.68 (95% CI = 2.81-4.82, p < 0.05). Clinicians treating veterans with these complex comorbid conditions should consider the impact of medications on speech fluency.

Trauma and Aging

PURPOSE OF REVIEW

The aim of this paper is to present a succinct summary of the major scientific findings on trauma, posttraumatic stress disorder (PTSD), and aging over the past few years.

RECENT FINDINGS

There have been several reports from longitudinal investigations using representative samples of veterans regarding traumatic exposure and subsequent effects on health and functioning. There has also been further documentation of the significant association between PTSD and dementia as well as accelerated aging in late life. Several studies indicate that older adults with PTSD are at risk of not receiving timely and appropriate mental health treatment, indicating that targeted outreach could be helpful in increasing service use and improving care. The current knowledge base would benefit from more research on traumatized older adults from non-industrialized countries, as well as those in North America from diverse backgrounds, including ethnic and racial minorities, women, and those with cognitive impairments. Studies limited to adults aged 65 and over as well as those addressing disparities in the availability of mental health-related services within this population are warranted.

Prescription Opioid Quality Measures Applied Among Pennsylvania Medicaid Enrollees

BACKGROUND

The Pharmacy Quality Alliance (PQA) recently developed 3 quality measures for prescribing opioids: high dosages, multiple providers and pharmacies, and concurrent use of opioids and benzodiazepines.

OBJECTIVE

To examine the prevalence of the PQA measures and identify the patient demographic and health characteristics associated with the measures.

METHODS

We conducted a cross-sectional analysis using Pennsylvania Medicaid data (2013-2015). We limited our analyses to noncancer patients who were aged 18-64 years and not dual-eligible for Medicare/Medicaid. Per PQA specifications, patients were required to possess ≥ 2 opioid prescriptions for ≥ 15 days annual supply each year. Outcome measures included (a) high dosages, defined as > 120 morphine milligram equivalents for ≥ 90 consecutive days; (b) multiple providers/pharmacies, defined as receiving opioid prescriptions from ≥ 4 providers and ≥ 4 pharmacies; and (c) concurrent use of opioids and benzodiazepines, defined as ≥ 30 cumulative days of overlapping opioids and benzodiazepines among individuals having ≥ 2 opioid and ≥ 2 benzodiazepine fills. Patient characteristics assessed included demographics; other medication use; and physical, mental, and behavioral health comorbidities. We present descriptive and multivariable statistical analyses of the data to describe trends in quality measure prevalence and associations with enrollee health characteristics.

RESULTS

Numbers of enrollees meeting inclusion criteria ranged from 73,082 in 2013 to 85,710 in 2015. From 2013 to 2015, high dosage prevalence increased from 5.1% to 5.5%; the use of multiple providers/pharmacies decreased from 7.1% to 5.0%; and concurrent use of opioids and benzodiazepines decreased from 29.1% to 28.4% (all P < 0.05). A substantial portion of patients with > 1 PQA measure from 2013 to 2015 was eligible for Medicaid because of disability (41.8%-81.9%). Enrollees with opioid use disorder were more likely to have high dosages (adjusted odds ratio [AOR] = 2.01, 95% CI = 1.83-2.21). Enrollees with anxiety and mood disorders were more likely to have multiple providers/pharmacies (anxiety: AOR = 1.54, 95% CI = 1.43-1.65; mood: AOR = 1.15, 95% CI = 1.06-1.25) and concurrent use of opioids and benzodiazepines (anxiety: AOR = 3.50, 95% CI = 3.38-3.63; mood: AOR = 1.42, 95% CI = 1.36-1.48).

CONCLUSIONS

Given high levels of eligibility based on disability and the prevalence of mood, anxiety, and opioid use disorders among those identified by the quality measures, providers may require additional support to care for this patient population.

DISCLOSURES

This project was supported by a grant from the Centers for Disease Control and Prevention and was also supported by an intergovernmental agreement between the Pennsylvania Department of Human Services and the University of Pittsburgh. Lo-Ciganic was supported by the University of Arizona Health Sciences Career Development Award. The other authors have nothing to disclose. The conclusions, findings, and opinions expressed by authors contributing to this article do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the Commonwealth of Pennsylvania. A portion of these results was presented at the Association for Medical Education and Research in Substance Abuse 41st National Conference; November 2-4, 2017; Washington, DC.

An Evidence Map of the Women Veterans' Health Research Literature (2008-2015)

BACKGROUND

Women comprise a growing proportion of Veterans seeking care at Veterans Affairs (VA) healthcare facilities. VA initiatives have accelerated changes in services for female Veterans, yet the corresponding literature has not been systematically reviewed since 2008. In 2015, VA Women's Health Services and the VA Women's Health Research Network requested an updated literature review to facilitate policy and research planning.

METHODS

The Minneapolis VA Evidence-based Synthesis Program performed a systematic search of research related to female Veterans' health published from 2008 through 2015. We extracted study characteristics including healthcare topic, design, sample size and proportion female, research setting, and funding source. We created an evidence map by organizing and presenting results within and across healthcare topics, and describing patterns, strengths, and gaps.

RESULTS

We identified 2276 abstracts and assessed each for relevance. We excluded 1092 abstracts and reviewed 1184 full-text articles; 750 were excluded. Of 440 included articles, 208 (47%) were related to mental health, particularly post-traumatic stress disorder (71 articles), military sexual trauma (37 articles), and substance abuse (20 articles). The number of articles addressing VA priority topic areas increased over time, including reproductive health, healthcare organization and delivery, access and utilization, and post-deployment health. Three or fewer articles addressed each of the common chronic diseases: diabetes, hypertension, depression, or anxiety. Nearly 400 articles (90%) used an observational design. Eight articles (2%) described randomized trials.

CONCLUSIONS

Our evidence map summarizes patterns, progress, and growth in the female Veterans' health and healthcare literature. Observational studies in mental health make up the majority of research. A focus on primary care delivery over clinical topics in primary care and a lack of sex-specific results for studies that include men and women have contributed to research gaps in addressing common chronic diseases. Interventional research using randomized trials is needed.

Psychotropic Medication Prescribing in Iraq/Afghanistan Veterans and Vietnam Era Veterans With Posttraumatic Stress Disorder

A new generation of veterans from Iraq/Afghanistan wars is seeking psychotropic pharmacotherapy for posttraumatic stress disorder (PTSD) from the Veterans Health Administration, but little is known about differences in prescribing practices between this group and Vietnam era veterans with the same diagnosis. The Veterans Health Administration administrative data for fiscal year 2012 were used to compare prescribing for 155,631 Iraq/Afghanistan veterans and for 327,634 Vietnam era veterans diagnosed with PTSD. The proportion of veterans who were prescribed psychotropic medications (altogether and within five of seven medication classes) were not substantially different between veteran groups. Iraq/Afghanistan veterans were more frequently prescribed prazosin (p < 0.0001, relative risk = 1.51). However, the number of prescriptions for anxiolytics/sedatives/hypnotics as well as prazosin and opiates filled by this younger group was lower by a small magnitude (Cohen's d < 0.2). Iraq/Afghanistan veterans have good access to psychopharmacological treatment for PTSD but fill somewhat fewer prescriptions than Vietnam era veterans.

Prescription Opioid Misuse Among Rural Community Pharmacy Patients: Pilot Study for Screening and Implications for Future Practice and Research

BACKGROUND

Opioid misuse imposes a disproportionately heavy burden on individuals living in rural areas. Community pharmacy has the potential to expand and coordinate with health professionals to identify and intervene with those who misuse opioids.

OBJECTIVE

Rural and urban community pharmacy patients were recruited in this pilot project to describe and compare patterns of opioid misuse.

METHODS

We administered a health screening survey in 4 community pharmacies among patients filling opioid medications. Univariate statistics were used to assess differences in health characteristics and opioid medication misuse behaviors between rural and urban respondents. Multivariable statistics were used to identify risk factors associated with rural and urban opioid misuse.

RESULTS

A total of 333 participants completed the survey. Participants in rural settings had poorer overall health, higher pain levels, lower education, and a higher rate of unemployment compared to patients in urban pharmacies. Rural respondents with illicit drug use (adjustable odds ratio [aOR]: 14.34, 95% confidence interval [CI] = 2.16-95.38), posttraumatic stress disorder (aOR: 5.44, 95% CI = 1.52-19.50), and ≤high school education (aOR: 6.68, 95% CI = 1.06-42.21) had increased risk for opioid misuse.

CONCLUSIONS

Community pharmacy represents a promising resource for potential identification of opioid misuse, particularly in rural communities. Continued research must extend these findings and work to establish collaborative services in rural settings.

Polypharmacy and risk of non-fatal overdose for patients with HIV infection and substance dependence

INTRODUCTION

People living with HIV (PLWH) are at risk of both polypharmacy and unintentional overdose yet there are few data on whether polypharmacy increases risk of overdose. The study objective was to determine if the number and type of medication (e.g., sedating) were associated with non-fatal overdose (OD) among PLWH with past-year substance dependence or a lifetime history of injection drug use.

MATERIALS AND METHODS

This was a longitudinal study of adults recruited from two urban, safety-net HIV clinics. Outcomes were i) lifetime and ii) past-year non-fatal OD assessed at baseline and a 12-month follow-up. We used logistic regression to examine the association between each outcome and the number of medications (identified from the electronic medical record) in the following categories: i) overall medications, ii) non-antiretroviral (non-ARV), iii) sedating, iv) non-sedating, as well as any vs no opioid medication and any vs no non-opioid sedating medication. Covariates included demographics, medical comorbidities, depressive and anxiety symptoms, and substance use.

RESULTS

Among 250 participants, 80% were prescribed a sedating medication, 50% were prescribed an opioid; 51% exceeded risky drinking limits. In the past month, 23% reported illicit opioid use and 9% illicit opioid sedative use; 37% reported lifetime non-fatal OD and 7% past-year non-fatal OD. The median number (interquartile range) of total medications was 10 (7, 14) and 2 (1, 3) sedating. The odds of lifetime non-fatal OD were significantly higher with each additional sedating medication (OR 1.26, 95% CI 1.08, 1.46) and any opioid medication (OR 2.31; 95% CI 1.37, 3.90), but not with each overall, non-ARV, or non-sedating medication. The odds of past year non-fatal OD were greater with each additional sedating medication (OR 1.18; 95% CI 1.00, 1.39, p=0.049), each additional non-ARV medication (OR 1.07; 95% CI 1.00, 1.15, p=0.048), and non-significantly for any opioid medication (OR 2.23; 95% CI 0.93, 5.35).

CONCLUSIONS

In this sample of PLWH with substance dependence and/or injection drug use, number of sedating medications and any opioid were associated with non-fatal overdose; sedating medications were prescribed to the majority of patients. Polypharmacy among PLWH and substance dependence warrants further research to determine whether reducing sedating medications, including opioids, lowers overdose risk.

Symptom Presentation and Prescription of Sleep Medications for Veterans With Posttraumatic Stress Disorder

This study tested whether sleep medications prescribed to veterans diagnosed with posttraumatic stress disorder (PTSD) are being targeted to patients who report more severe insomnia or nightmares. Secondary analysis of survey and pharmacy data was conducted in samples of veterans from two periods: from 2006 to 2008 and from 2009 to 2013. Logistic regression tested associations between self-reported insomnia and nightmare severity, and being prescribed trazodone, prazosin, zolpidem, and benzodiazepines, controlling for PTSD severity and other covariates. In both samples, insomnia severity independently predicted trazodone receipt, and nightmare severity independently predicted prazosin receipt. In the later study, insomnia severity predicted receipt of zolpidem. Veterans in the later sample were more likely to receive trazodone, prazosin, and non-benzodiazepine hypnotics, and less likely to receive benzodiazepines than those in the earlier sample. Further research is needed to evaluate and optimize pharmacological and psychosocial treatments for sleep problems among veterans with PTSD.

Prevalence of Central Nervous System Polypharmacy and Associations with Overdose and Suicide-Related Behaviors in Iraq and Afghanistan War Veterans in VA Care 2010-2011

BACKGROUND

The increase in the quantities of central nervous system (CNS)-acting medications prescribed has coincided with increases in overdose mortality, suicide-related behaviors, and unintentional deaths in military personnel deployed in support of the wars in Iraq and Afghanistan. Data on the extent and impact of prescribing multiple CNS drugs among Iraq and Afghanistan Veterans (IAVs) are sparse.

OBJECTIVES

We sought to identify the characteristics of IAVs with CNS polypharmacy and examine the association of CNS polypharmacy with drug overdose and suicide-related behaviors controlling for known risk factors.

METHODS

This cross-sectional cohort study examined national data of Iraq and Afghanistan Veterans (N = 311,400) who used the Veterans Health Administration (VHA) during the fiscal year 2011. CNS polypharmacy was defined as five or more CNS-acting medications; drug/alcohol overdose and suicide-related behaviors were identified using ICD-9-CM codes. Demographic and clinical characteristics associated with CNS polypharmacy were identified using a multivariable logistic regression model.

RESULTS

We found that 25,546 (8.4 %) of Iraq and Afghanistan Veterans had CNS polypharmacy. Those with only post-traumatic stress disorder (PTSD) (adjusted odds ratio (AOR) 6.50, 99 % confidence interval (CI) 5.96-7.10), only depression (AOR 6.42, 99 % CI 5.86-7.04), co-morbid PTSD and depression (AOR 12.98, 99 % CI 11.97-14.07), and co-morbid traumatic brain injury (TBI), PTSD, and depression (AOR 15.30, 99 % CI 14.00-16.73) had the highest odds of CNS polypharmacy. After controlling for these co-morbid conditions, CNS polypharmacy was significantly associated with drug/alcohol overdose and suicide-related behavior.

CONCLUSION

CNS polypharmacy was most strongly associated with PTSD, depression, and TBI, and independently associated with overdose and suicide-related behavior after controlling for known risk factors. These findings suggest that CNS polypharmacy may be used as an indicator of risk for adverse outcomes. Further research should evaluate whether CNS polypharmacy may be used as a trigger for evaluation of the current care provided to these individuals.

Trends in prevalent and incident opioid receipt: an observational study in Veterans Health Administration 2004-2012

BACKGROUND

Improved understanding of temporal and regional trends may support safe and effective prescribing of opioids.

OBJECTIVE

We describe national, regional, and facility-level trends and variations in opioid receipt between fiscal years (FY) 2004 and 2012.

DESIGN

Observational cohort study using Veterans Health Administration (VHA) administrative databases.

PARTICIPANTS

All patients receiving primary care within 137 VHA healthcare systems during a given study year and receiving medications from VHA one year before and during a given study year.

MAIN MEASURES

Prevalent and incident opioid receipt during each year of the study period.

KEY RESULTS

The overall prevalence of opioid receipt increased from 18.9% of all veteran outpatients in FY2004 to 33.4% in FY2012, a 76.7% relative increase. In FY2012, women had higher rates of prevalent opioid receipt than men (42.4% vs. 32.9%), and the youngest veterans (18-34 years) had higher prevalent opioid receipt compared to the oldest veterans (≥ 80 years) (47.6% vs. 17.9%). All regions in the United States saw increased rates of prevalent opioid receipt during this time period. Prevalence rates varied widely by facility: in FY2012, the lowest-prescribing facility had a rate of 13.5%, and the highest of 50.8%. Annual incident opioid receipt increased from 8.8% in FY2004 to 10.2% in FY2011, with a decline to 9.8% in FY2012. Incident prescribing increased at some facilities and decreased at others. Facilities with high prevalent prescribing tended to have flat or decreasing incident prescribing rates during the study time frame.

CONCLUSIONS

Rates of opioid receipt increased throughout the study time frame, with wide variation in prevalent and incident rates across geographical region, sex, and age groups. Prevalence and incidence rates reflect distinct prescribing practices. Areas with the highest prevalence tended to have lower increases in incident opioid receipt over the study period. This likely reflects facility-level variations in prescribing practices as well as baseline rates of prevalent use. Future work assessing opioid prescribing should employ methodologies to account for and interpret both prevalent and incident opioid receipt.

Vintage treatments for PTSD: a reconsideration of tricyclic drugs

Serotonin (SSRI) and serotonin-norepinephrine (SNRI) reuptake inhibitors (SSRI) are the first-line recommended drug treatments for post-traumatic stress disorder (PTSD); but despite their benefits, much residual pathology remains and no new drugs have yet emerged with a clearly demonstrated benefit for treating the disorder. A case is made that tricyclic drugs deserve a closer look, based on their ability to affect several of the main neurotransmitters that are relevant to PTSD. Their promising efficacy, which was shown 30 years ago, had not been followed up, until a recent trial of desipramine found advantages over a SSRI in PTSD with comorbid alcohol dependence. Opportunities exist for studying newer and purportedly safer tricyclic formulations, as well as further the work with older, established compounds. A reappraisal of their risk:benefit ratio seems in order, when treating PTSD.