Background and Aims
Limited information is available regarding links between specific substance use disorders (SUDs) and suicide mortality; however, the preliminary evidence that is available ...suggests that suicide risk associated with SUDs may differ for men and women. This study aimed to estimate associations between SUDs and suicide for men and women receiving Veterans Health Administration (VHA) care.
Design
A cohort study using national administrative health records.
Setting
National VHA system, USA.
Participants
All VHA users in fiscal year (FY) 2005 who were alive at the beginning of FY 2006 (n = 4 863 086).
Measurements
The primary outcome of suicide mortality was assessed via FY 2006–2011 National Death Index (NDI) records. Current SUD diagnoses were the primary predictors of interest, and were assessed via FY 2004–2005 VHA National Patient Care Database (NPCD) records.
Findings
In unadjusted analyses, a diagnosis of any current SUD and the specific current diagnoses of alcohol, cocaine, cannabis, opioid, amphetamine and sedative use disorders were all associated significantly with increased risk of suicide for both males and females hazard ratios (HRs) ranging from 1.35 for cocaine use disorder to 4.74 for sedative use disorder for men, and 3.89 for cannabis use disorder to 11.36 for sedative use disorder for women. Further, the HR estimates for the relations between any SUD, alcohol, cocaine and opioid use disorders and suicide were significantly stronger for women than men (P < 0.05). After adjustment for other factors, most notably comorbid psychiatric diagnoses, associations linking SUDs with suicide were attenuated markedly and the greater suicide risk among females was observed for only any SUD and opioid use disorder (P < 0.05).
Conclusions
Current substance use disorders (SUDs) signal increased suicide risk, especially among women, and may be important markers to consider including in suicide risk assessment strategies. None the less, other co‐occurring psychiatric disorders may partially explain associations between SUDs and suicide, as well as the observed excess suicide risk associated with SUDs among women.
Many primary care clinics are resistant to accept new patients taking prescription opioids for chronic pain. It is unclear how much of this practice is specific to individuals who may be perceived to ...have aberrant opioid use. This study sought to determine whether clinics are more or less willing to accept and prescribe opioids to patients depending on whether their history is more or less suggestive of aberrant opioid use by conducting an audit survey of primary care clinics in 9 states from May to July 2019. Simulated patients taking opioids for chronic pain called each clinic twice, giving one of 2 scenarios for needing a new provider: their previous physician had either (1) retired or (2) stopped prescribing opioids for unspecified reasons. Clinic willingness to continue prescribing opioids and accept the patient for general primary care were assessed. Of 452 clinics responding to both scenarios (904 calls), 193 (43%) said their providers would not prescribe opioids in either scenario, 146 (32%) said their providers might prescribe in both, and 113 (25%) responded differently to each scenario. Clinics responding differently had greater odds (odds ratio = 1.83 confidence interval 1.23-2.76) of willingness to prescribe when the previous doctor retired than when the doctor had stopped prescribing. These findings suggest that primary care access is limited for patients taking opioids for chronic pain, and differentially further reduced for patients whose histories are suggestive of aberrant use. This denial of care could lead to unintended harms such as worsened pain or conversion to illicit substances.
•DUIA was the most common behavior, with a peak of 8.7% in the US population in 2017.•From 2016 to 2020, there was a decline in DUIA among those with past year use.•At the US population level, ...cannabis use and DUIC increased from 2016 to 2019.•However, there was a declining trend in DUIC among those who used in the past year.•Driving under the influence of other drugs remained stable.
Driving under the influence (DUI) of substances increases motor vehicle crash risk. Understanding current national trends of driving under the influence of alcohol (DUIA), cannabis (DUIC), and drugs other than cannabis (DUID) can inform public health efforts. Herein, we provide updated trends among United States (US) adults regarding DUIA, DUIC, DUID, and DUI of any substance.
We used nationally-representative National Survey on Drug Use and Health (2016-2020) data to derive prevalence estimates of past-year DUIC, DUIA, DUID, and DUI of any substance among non-institutionalized US adults and among those reporting respective past-year substance use. Prevalence estimates and adjusted logistic regressions characterized temporal trends of these behaviors among US adults, among those with respective past-year substance use, and among stratified demographic subpopulations.
Over 1 in 10 US adults reported DUI of any substance annually from 2016 to 2020.DUIA was most prevalent among all US adults (8.7% in 2017); however, this behavior is decreasing (AOR:0.96; 95%CI:0.94,0.98). No change in DUIC among the US adult population was found, but a decrease was found among those with past-year cannabis use (AOR:0.95; 95%CI:0.93,0.98), which coincided with a 29.1% increase in past-year cannabis use. There were no significant changes in overall DUID; however, females, those ages 26-34 and 65 or older with past-year use displayed increasing trends. DUI of any substance decreased among the US adult population.
DUI remains a salient public health concern in the US and results indicate population subgroups who may benefit from impaired driving prevention interventions.
Characterization of population subgroups based on where they acquire cannabis is unexplored. We examine relationships between sociodemographic characteristics, cannabis use modality, risky cannabis ...use, and source of cannabis.
Analyzing a representative sample (unweighted
= 8,089) of U.S. adults living in medical cannabis-permitting states with past-year cannabis use from the 2021 National Survey on Drug Use and Health, we determined source of last cannabis used. Outcome groups were
, or
. Incorporating the complex survey design, descriptive statistics and adjusted multinomial logistic regressions evaluated associations between sociodemographic, individual cannabis use characteristics, and source of cannabis. Secondary analyses described cannabis purchasing characteristics among the subsample who last purchased cannabis.
Purchasing from a dispensary was the most common source of cannabis (42.5%). Significant relationships between sociodemographic characteristics, cannabis use modality, risky cannabis use, and source of cannabis were found. Recent cannabis initiates and those with cannabis vaporizer use had an increased likelihood of purchasing cannabis from a dispensary. Purchasing from a nondispensary source was most likely among those with daily cannabis use, past-month blunt use, past-year driving under the influence, cannabis use disorder, and cannabis and alcohol co-use. Among those purchasing cannabis, joints and other forms of cannabis were more likely to be purchased from a dispensary than purchased from other sources.
We identified key sociodemographic and cannabis use characteristics that may influence where individuals obtain cannabis, which are important for cannabis behavior surveillance and cannabis use prevention and intervention strategies to consider.
BACKGROUNDAlthough most veterans with posttraumatic stress disorder (PTSD) benefit from evidence-based treatments, questions persist concerning the profiles of those at risk for poor outcomes. To ...help address these gaps, this study analyzed a large clinical cohort of veterans receiving prolonged exposure (PE) or cognitive processing therapy (CPT). METHODSCluster analysis using Ward's method with Euclidian distances identified clinically meaningful subgroups of veterans in a national cohort (n = 20,848) using variables maintained in the electronic medical record. The clusters were then compared via one-way analysis of variance and Tukey's HSD on indicators of treatment progress including PTSD symptom change, clinical recovery, clinically significant change, remission, and treatment completion. RESULTSEffect size differences on clinical outcome measures for PE and CPT were negligible. Less than half of veterans achieved at least a 15-point reduction in PCL-5 score and half completed treatment. We identified 10 distinct clusters. Higher rates of PTSD service-connected disability were linked to poorer outcomes across multiple clusters, especially when combined with Post-Vietnam service era. Non-White race was also linked with poorer clinical outcomes. Factors associated with better outcomes included a greater proportion of female veterans, especially when combined with recent service era, and longer PTSD diagnosis duration. CONCLUSIONSThis study suggests the need to improve PTSD treatment outcomes for non-White and male veterans, examine treatment response in Post-Vietnam era veterans, and consider ways in which the service connection process could hinder treatment response. The results from this study also indicate the benefits of integrating elements of clinical complexity into an analytic approach.
The U.S. Department of Veterans Affairs (VA) has placed increased emphasis on the availability and use of evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD). However, many ...individuals do not complete a full course of EBP. The current study aimed to quantify the percentage of veterans receiving adequate EBP in VA hospitals and identify factors related to treatment completion.
A national sample of 16,559 VA patients who began cognitive processing therapy (CPT) or prolonged exposure (PE) during fiscal year 2015 was obtained via administrative data. Generalized estimating equations were used to evaluate individual-level predictors of treatment adequacy, defined as eight sessions within 14 weeks. Generalized linear models were used to examine facility-level factors.
A total of 5,142 (31.1%) veterans completed eight or more sessions of psychotherapy. Older age was associated with greater odds of completing eight or more sessions (odds ratio OR=1.02, 95% confidence interval CI=1.01, 1.02, p<0.001), and comorbid bipolar or psychotic disorders were associated with reduced odds of completion (OR=0.89, 95% CI=0.80, 0.99, p=0.03). The percentage of patients who completed eight or more sessions was higher at facilities with higher percentages of EBP use among all patients with PTSD (β=6.55, SE=1.97, p=0.001) and greater numbers of EBP-certified providers (β=0.004, SE=0.002, p=0.038) and lower at facilities with a higher percentage of patients receiving a PTSD Checklist (β=-1.16, SE=0.46, p=0.011).
A minority of VA patients with PTSD complete an adequate dose of EBPs for PTSD. Individual and facility-level factors related to treatment adequacy may point to opportunities for intervention.
To better understand processes of mental health crisis line utilization by examining associations between reasons for contacting a crisis line with the initiation of emergency dispatches (i.e., ...activation of 911 or local emergency services) in a national sample.
Contacts (i.e., calls, texts, email, and chats) to the Veterans Crisis Line (VCL) across 2017–2020 were used to examine associations among stated reasons for the contact and the use of an emergency dispatch. Hierarchical logistic regression models were used to determine the odds of an emergency dispatch by reason for the contact.
Suicidal thoughts/crisis were present in 61.5% of contacts that ended in emergency dispatches and were associated with the largest adjusted odds of a dispatch, (Adjusted Odds Ratio AOR 95% CI = 9.34 9.21, 9.48), followed by homicidal thoughts/crisis (AOR 95% CI = 3.84 3.73, 3.95), and third-party concerns (AOR 95% CI = 2.42 2.37, 2.47). Substance use/ addiction (AOR 95% CI = 2.14 2.10, 2.18), abuse and violence (AOR 95% CI = 1.89 1.82, 1.96), and physical health (AOR 95% CI = 1.87 1.84, 1.91) were also associated with increased odds of a dispatch.
Emergency dispatches are primarily used in response to imminent suicide risk but are also used in other potentially violent or lethal circumstances such as homicides, violence or abuse, and other crises. These findings highlight the role that crisis lines play in emergency service delivery, and the need to better understand how they are utilized under real world circumstances.
•Veterans Crisis Line (VCL) contacts that were most likely to result in an emergency dispatch were those with suicidal thoughts/crisis•Homicidal thoughts/crisis, third party concerns, substance use/addiction, abuse and violence, and physical health were also associated with emergency dispatches•Emergency dispatches are primarily used for suicidal crises, but are also used for other contacts with potential for injury or death
•We investigated predictors of PTSD treatment response in residential settings.•Significant factors included psychological, social, and physical health resources.•Treatment modifications may be ...needed for subgroups at risk of poor response.
Although several treatments for PTSD have demonstrated efficacy, a substantial portion of patients do not experience clinically significant improvement. Predictors of treatment response are poorly understood. The current study was designed to investigate predictors of PTSD symptom change in a large national sample of treatment-seeking Veterans with PTSD.
We analyzed predictors of treatment response among Veterans engaged in residential PTSD treatment from 2012 to 2013 (N = 2715). Multilevel modeling was used to assess the association between individual-level factors and symptom improvement from treatment entry to post-discharge. Guided by the theory of Resources, Life Events and Changes in Psychological States, we hypothesized that individuals with greater psychological, social/contextual, material, and physical health resources would exhibit better treatment response.
In adjusted analyses, accounting for facility, factors that predicted better treatment response included female gender, more psychological and social/contextual protective factors, and more years of education. Factors that predicted worse treatment response included Black race, comorbid personality disorder, greater pain severity, and current application for disability-related compensation.
These findings highlight factors that place individuals at risk of poor treatment response. Treatment modifications may be needed in order to optimize response for subgroups who are less likely to benefit from residential PTSD treatment.
Crisis line responders initiate emergency dispatches by activating 911 or other local emergency services when individuals are determined to be at imminent risk for undesired outcomes. This study ...examined the association of characteristics, psychiatric diagnoses, and somatic symptoms with emergency dispatches in a national sample. Veterans Crisis Line data were used to identify contacts (i.e., calls, texts, chats, emails) that were linked with medical records and had a medical encounter in the year prior to contact. Hierarchical logistic regression clustered by responders was used to identify the association among demographics, psychiatric diagnoses, and somatic disorders, and emergency dispatches. Analyses examined 247,340 contacts from 2017 to 2020, with 27,005 (10.9%) emergency dispatches. Odds of an emergency dispatch increased with each diagnosis (three diagnoses Adjusted Odds Ratio AOR (95% CI) = 1.88 1.81,1.95). Odds were highest among individuals with substance use disorders (SUD) (alcohol AOR (95% CI) = 1.85 1.80,1.91; drugs AOR (95% CI) = 1.63 1.58, 1.68), which may be a result of intoxication or overdose during contact, requiring further research. Having more psychiatric and somatic conditions was associated with greater odds of an emergency dispatch, indicating that comorbidity contributed to the need for acute care.
ABSTRACT
BACKGROUND
There is limited data on the extent to which indicated alcohol interventions are delivered in U.S. ambulatory care settings.
OBJECTIVE
To assess the receipt of alcohol-related ...services, including assessment of use, advice to reduce drinking, and information about alcohol treatment, during ambulatory care visits.
DESIGN
Secondary data analysis of the 2013 National Survey on Drug Use and Health, a cross-sectional, nationally representative survey of civilians in the non-institutionalized U.S. general population (response rate 71.7 %).
PARTICIPANTS
Adult ambulatory care users in the public use data file who did not obtain emergency or inpatient services (
n
= 17,266).
MAIN MEASURES
Measurements included respondents’ alcohol consumption, heavy episodic drinking, alcohol use disorder, healthcare use, and receipt of alcohol-related interventions.
KEY RESULTS
Approximately 71.1 % of ambulatory care users received an alcohol assessment. Among past-month heavy episodic drinkers without an alcohol use disorder who reported receiving an alcohol assessment, 4.4 % were advised to cut back. Among individuals with alcohol abuse and alcohol dependence who reported receiving an alcohol assessment, 2.9 % and 7.0 %, respectively, were offered information about treatment.
CONCLUSIONS
Rates of alcohol screening and assessment were relatively high among adults who attended healthcare visits, but rates of intervention were low, even when individuals were assessed for use. Efforts are needed to expand delivery of interventions when patients are identified as positive for risky drinking, hazardous alcohol use, and alcohol use disorders during ambulatory care visits.
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