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Substance use disorders (SUDs) occur when the recurrent use of alcohol and/or drugs (including prescription medications) cause clinically significant impairment—such as health problems, disability, and failure to meet major responsibilities at work, school, or home. According to the Substance Abuse and Mental Health Services Administration’s most recently available National Survey on Drug Use,1 about 21.5 million Americans ages 12 and older (8.1%) were classified with a substance use disorder in the past year. Of those, 2.6 million had problems with both alcohol and drugs, 4.5 million had problems with drugs but not alcohol, and 14.4 million had problems with alcohol only.
Substance use disorders impact Veterans in unique ways, and often co-occur with mental health concerns. Veterans may inappropriately use alcohol or prescription medications in order to cope with post-traumatic stress disorder (PTSD) or chronic pain, and that can have a substantial negative impact on everything from family relationships to work performance and housing stability. It’s estimated that the number of Veterans with SUDs (other than nicotine dependence) increased from 270,991 (6% of VHA patients) in 2002 to 461,927 (8% of VHA patients) in 2010. Moreover, it is estimated that Veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) have a 27% higher rate of SUD diagnoses than Veterans of other conflicts who receive VA healthcare services.2
Research that addresses all aspects of substance use disorders is critical to improving the care delivery and quality of life for our nation’s Veterans. Investigators with VA’s Health Services Research & Development Service (HSR&D) conduct a variety of studies that focus on the differing impacts of SUDs. The following are just a few of those recently concluded and ongoing investigations.
Opioid therapy for patients with chronic pain is common, and recent data suggest that prescription rates may be declining— by mid-2016 the number of Veterans dispensed an opioid each quarter had decreased by 172,000, or about 25%.3 While several factors, including lack of information about the long-term efficacy, heightened awareness about adverse events, closer monitoring of patients for opioid-related aberrant behaviors, and greater restrictions around opioid prescribing, may impact discontinuation rates, more data are needed.
Substantial evidence indicates that patients with active or historical substance use disorder (SUD) are at increased risk for engaging in opioid-related hazardous behaviors, yet these patients are more likely to be prescribed long-term opioid therapy (LTOT). Further, in the last several years, both the American Pain Society (APS), the CDC, and the VA and Department of Defense (VA/DoD) all issued clinical practice guidelines that support discontinuation of opioid therapy for patients at high-risk for opioid-related adverse events. In this retrospective cohort study, HSR&D investigators compared reasons for accelerated opioid discontinuation rates for patients receiving care in the VA healthcare system with the year immediately following issuance of the APS and VA/DoD guidelines.
Investigators used VA administrative data to identify a cohort of 600 Veterans with (n=300) and without (n=300) SUD, and reviewed their medical records to determine the reasons for LTOT discontinuation during 2012. (For this study, LTOT was defined as having been prescribed opioid therapy for the entirety of 2011, allowing prescription opioid refill gaps of no more than 30 days between the completion of an opioid prescription and a refill.) Investigators also assessed patient demographics, rural vs. urban residence, service-connected disability status, and comorbidities.
Findings: Study results indicated that 85% of Veterans discontinued opioid use because their clinician stopped prescribing, rather than their deciding to stop. For patients whose clinicians initiated discontinuation, 75% were due to opioid-related aberrant behaviors (i.e., suspected substance abuse at 51% and aberrant urine drug test at 44%). Veterans with SUD diagnoses were more likely to discontinue LTOT due to aberrant behaviors, particularly abuse of alcohol or other substances, compared to Veterans without SUD (81% vs. 68%).
High proportions of patients received diagnoses for mental health disorders in the year prior to discontinuation of LTOT, including PTSD (31%), anxiety disorders other than PTSD (25%), and depressive disorders (25%).
Implications: Increasing rates of opioid discontinuation are likely to occur due to policies and programs that encourage close monitoring of Veterans on LTOT for opioid misuse behaviors. Integrating non-opioid pain therapies and SUD treatment into multiple settings such as primary care and specialty SUD care is one possible approach to enhance their care.
Lovejoy T, Morasco B, Demidenko M, et al. Reasons for Discontinuation of Long-Term Opioid Therapy in Patients with and without Substance Use Disorders. Pain. March 2017; 158(3):526-34.
Mental health symptoms are highly prevalent among Veterans returning from the current conflicts. Several recent small sample studies have indicated high rates of mental health issues and suicidal ideation among Veterans attending college, as well as reported links between non-Veteran student mental health, poor college performance, and failure to graduate.
In this recently concluded study, investigators assessed the prevalence of mental health symptoms, hazardous alcohol use, and levels of wellbeing among a representative sample of Veterans attending college and comparison college students. Additional goals included assessing a constellation of factors around mental health treatment use and preferences; looking at relationships between mental health, treatment use, and academic performance; and understanding Veteran and comparison student work status and functioning when work is concurrent with studies and during college "stop outs."
Investigators used survey data from a representative sample of Veteran students (n=60) and comparison non-Veteran students (n=5,451), which was supplemented by surveys of college administrators, academic administrative data, and VA healthcare data for Veteran students who provided additional consent. Baseline, one-, and two-year follow-up surveys assessed well-being, mental health symptoms, alcohol use, social and academic integration, and treatment use. Final study data are still being compiled.
Implications. VA remains the major resource for care for Veteran students, and this study has wide implications. Obtaining data regarding the impact of mental health symptoms and hazardous alcohol use among this population will help VA make informed decisions regarding optimal resource allocation for outreach efforts, the types of interventions that might be needed and desired by this target population, and the attributes of colleges where such interventions might be most needed and have the broadest impact.
Smoking is the most preventable cause of morbidity and mortality among U.S. Veterans, and rural Veterans, in particular, have an elevated risk for smoking and smoking-related illness. However, rural-dwelling Veterans underutilize smoking-cessation treatment. While VA has implemented strategies to expand smoking-cessation treatment beyond the clinic to include telemedicine, cognitive-behavioral telephone counseling, and internet-based interventions, it has been suggested that there is a need for more innovative and intensive approaches to smoking cessation in order to improve quit rates among rural-dwelling Veterans.
Investigators conducted a randomized controlled trial that evaluated the effectiveness of an intervention that combined evidenced-based treatment for smoking-cessation with smart-phone based, portable contingency management on smoking rates. Smokers were identified using VA electronic medical records. Participants (N=310) were randomized to a control group consisting of usual care (telephone counseling and telemedicine), or to the intervention group that used Abstinence Reinforcement Therapy (ART), which combines evidenced-based cognitive behavioral telephone counseling (TC), a telemedicine clinic for access to nicotine replacement (NRT), and mobile contingency management. Participating patients were surveyed at 3 months, 6 months, and 12 months post-randomization. In this recently concluded study, the primary outcome measure was self-reported and biochemically validated prolonged abstinence from smoking at 6-month follow-up. Further results from this trial are still being complied.
Implications: It is expected that results from this trial will offer support for a mobile-health based intervention that increases rural-dwelling Veterans’ engagement in smoking-cessation efforts.
Wilson SM, Hair LP, Hertzberg JS, et al. Abstinence Reinforcement Therapy (ART) for rural veterans: Methodology for an mHealth smoking cessation intervention. Contemporary Clinical Trials. Sep 1 2016; (50):157-65.
VA has demonstrated national leadership in the area of screening for alcohol misuse through the implementation of electronic clinical reminders and establishing performance measures for both screening and brief intervention. Nationally, about 93% of Veterans are screened for alcohol misuse each year. However, more information is needed about the percentage, quality, and effectiveness of brief interventions for alcohol misuse. Tailored, computer-based interventions using Relational Agents (RA) may help close existing performance gaps. Relational Agents are on-screen characters that speak directly to patients, establishing a "relationship" with them. When adapted to use Motivational Interviewing and behavior change principles, RAs guide patients to consider change. They also may provide patients with a potentially more comfortable vehicle for "discussing" a stigmatized topic such as risky alcohol use.
In this ongoing study, investigators are first developing a tailored RA for the Veteran population, and will then use that RA to conduct a randomized controlled trial (RCT), consisting of usual care versus usual care in concert with RA screening for unhealthy alcohol use. In addition, investigators will conduct an in-depth examination of Veterans' experience with the RA intervention. Working with VA primary care physicians, investigators will identify Veterans who screen positive for unhealthy alcohol use, and recruit them for study participation. Veteran participants will then be randomly assigned to either usual care, or the intervention (RA plus usual care). Additional follow-up will be conducted by telephone at three months.
Findings to date focused on the initial phase of the study—acceptance of various RAs. The four women and 16 men initially recruited were shown 10 different possible RAs. In general, all Veterans preferred a female character wearing business-like clothes in an office setting, as opposed to male characters wearing casual clothes or lab coats, in home-based or other settings. Veterans preferred characters that showed more empathy using voice and facial expressions. Findings from the RCT component are still being compiled.
Implications: Investigators expect that study results will have wide implication both within and outside VA. RAs may expand access to care for patients by reducing the resource burden on primary care physicians, result in improved overall care experiences by offering patients a more comfortable environment in which to address challenging subjects such as alcohol misuse, and increase alcohol misuse intervention rates.
Every year, approximately 30,000 Veterans receive inpatient detoxification for substance use disorders. Veterans undergoing inpatient detoxification who enter SUD treatment and peer-based mutual-help groups (e.g., Alcoholics Anonymous) have better outcomes (less substance use and homelessness, and fewer re-hospitalizations and Emergency Department visits) than those who do not. However, because of their unique characteristics (i.e., comorbidities, lack of resources, self- and provider-perceptions as unsuitable for treatment), most Veterans discharged from inpatient detoxification do not enter SUD treatment. For many Veterans, a pattern of repeated inpatient detoxification, with each episode incurring higher risk of overdose, occurs. Therefore, VA’s Mental Health Operations’ Uniform Services Handbook places major emphasis on increasing the rate of SUD treatment initiation and engagement following detoxification in order to improve Veterans’ overall health outcomes.
In this ongoing study, investigators sought to implement and evaluate Enhanced Telephone Monitoring (ETM) to facilitate the transition from inpatient detoxification to SUD specialty treatment (residential, outpatient, pharmacotherapy). Telehealth interventions, a promising way to improve treatment access and outcomes by addiction patients, have not been utilized with the challenging population of detoxification inpatients before. In a randomized trial at two VA care sites (VA Palo Alto and Boston), Veterans were randomly assigned to usual care (n=150), or to the Enhanced Telephone Monitoring (n=148) intervention. Preliminary findings at the three-month follow-up (90% follow-up rate) indicated that patients in the intervention had better outcomes related to substance use. In addition, detoxification and addiction treatment provider interviews showed that they viewed the intervention as compatible with ongoing clinical practices.
Implications: VA Mental Health Operations (VA MHO) is committed to providing Veterans’ with needed detoxification services and substance use disorder treatment. This project is helping to accomplish that goal by using telehealth interventions to assist in implementing the Uniform Services Handbook guidelines by increasing Veterans' access to, engagement in, and benefit from addiction treatment services—particularly among Veterans who are using VA medical services and need substance use disorder services but are not receiving them.
1 Substance Abuse and Mental Health Services Administration’s 2014 National Survey on Drug Use
2 VA Health Services Research & Development Service Collaborative Research to Enhance and Advance Transformation & Excellence: Promoting Access and Value in Substance Use Disorder Treatment. https://www.hsrd.research.va.gov/centers/create/sud.cfm/centers/create/sud.cfm
3 Gellad W, Good C, and Shulkin D. Addressing the opioid epidemic in the United States: Lessons from the Department of Veterans Affairs. JAMA Internal Medicine. May 1, 2017;177(5):611-612.
