Bidirectional Associations Between Pain and Perceived Stress Among Veterans: Depressive Disorder as a Predisposing Factor.

OBJECTIVE: Military veterans who were injured in combat very often report pain along with co-occurring perceived stress and preexisting depressive disorder. The systems model of pain is a theoretical model suggesting that pain and perceived stress are bidirectionally associated at the within-person level, and associations are heightened among those with depressive disorder. However, the systems model of pain has not been adequately tested. Testing the systems model of pain could illuminate salient treatment targets for combat-injured veterans with pain and co-occurring psychological problems. METHODS: The present study empirically tests the systems model of pain among a sample of combat-injured veterans ( N = 902) surveyed five times during an 18-month period. We used a multigroup, autoregressive latent trajectory with structured residual statistical model to test the within-person associations between pain and perceived stress and determine whether associations differ between veterans with and without a positive screen for depressive disorder. RESULTS: In line with the systems model of pain, pain and perceived stress were bidirectionally associated only among combat-injured veterans with depressive disorder. Among such veterans, perceived stress was positively associated with subsequent pain ( b = 0.12; 95% confidence interval = 0.06-0.17), and pain was positively associated with subsequent perceived stress ( b = 0.44; 95% CI = 0.11-0.77). CONCLUSIONS: Our work highlights the interplay between pain and its psychological correlates among a particularly at-risk population. Clinicians addressing pain and perceived stress among combat-injured veterans should be prepared to identify and address depressive disorder.

Physical pain among urban Native American emerging adults: Socio-cultural risk and protective factors.

OBJECTIVE: American Indian/Alaska Native (AI/AN) people have high rates of physical pain. Pain is understudied in urban-dwelling, AI/AN emerging adults, a group with unique socio-cultural risk and protective factors. We explore associations between socioeconomic disadvantage, additional socio-cultural factors, and pain among urban AI/AN emerging adults. METHODS: AI/AN participants aged 18-25 (N = 417) were recruited via social media. Regression models tested associations between socioeconomic disadvantage (income and ability to afford healthcare) and pain as well as additional socio-cultural factors (discrimination, historical loss, cultural pride and belonging, visiting tribal lands) and pain. Multi-group regression models tested whether associations between socio-cultural factors and pain differed between participants who were socioeconomically disadvantaged and those who were less disadvantaged. RESULTS: In the full sample, lower income (b = 1.00 - 1.48, p < .05), inability to afford healthcare (b = 1.00, p = .011), discrimination (b = 0.12, p = .001), and historical loss (b = 0.24, p = .006) were positively associated with pain, whereas visiting tribal lands was negatively associated with pain (b = -0.86 - -0.42, p < .05). In the multi-group model, visiting tribal lands 31+ days was negatively associated with pain only among the less socioeconomically disadvantaged group (b = -1.48, p < .001). CONCLUSIONS: Socioeconomic disadvantage may, in part, drive pain disparities among AI/AN emerging adults and act as a barrier to benefitting from visiting tribal lands. Results support a biopsychosocial approach to targeting pain in this population, including addressing socioeconomic challenges and developing culturally informed, strengths-based interventions.

Longitudinal associations between insomnia, cannabis use and stress among US veterans.

Insomnia is highly prevalent among military veterans, with rates nearly double that of civilian populations. Insomnia typically co-occurs with other psychological problems, including substance use (e.g. cannabis) and perceived stress. Much of the research focused on insomnia, stress and cannabis use explores cannabis as a sleep aid and a mechanism for stress relief. However, recent theoretical and empirical evidence suggests a dynamic interplay between insomnia, cannabis use and perceived stress, yet few longitudinal studies exist. Using a sample of 1105 post-9/11 veterans assessed over four time points across 12 months, we used latent difference score modelling to examine proportional change between insomnia, perceived stress and cannabis use. Results revealed a complex interplay between all three constructs. In particular, we show that higher prior levels of insomnia are associated with greater increases in perceived stress, and greater prior levels of stress are associated with greater increases in cannabis use. Perhaps more importantly, our results also point to cannabis use as a catalyst for greater increases in both stress and insomnia severity. Our results suggest there may be both benefits and costs of cannabis use among veterans. Specifically, for veterans who experience chronic sleep problems, perceived stress may become overwhelming, and the benefit of stress reduction from increased cannabis use may come at the cost of increasing insomnia symptomology.

Childhood adversity, combat experiences, and military sexual trauma: a test and extension of the stress sensitization hypothesis.

BACKGROUND: U.S. veterans report high rates of traumatic experiences and mental health symptomology [e.g. posttraumatic stress disorder (PTSD)]. The stress sensitization hypothesis posits experiences of adversity sensitize individuals to stress reactions which can lead to greater psychiatric problems. We extend this hypothesis by exploring how multiple adversities such as early childhood adversity, combat-related trauma, and military sexual trauma related to heterogeneity in stress over time and, subsequently, greater risk for PTSD. METHODS: 1230 veterans were recruited for an observational, longitudinal study. Veterans responded to questionnaires on PTSD, stress, and traumatic experiences five times over an 18-month study period. We used latent transition analysis to understand how heterogeneity in adverse experiences is related to transition into stress trajectory classes. We also explored how transition patterns related to PTSD symptomology. RESULTS: Across all models, we found support for stress sensitization. In general, combat trauma in combinations with other types of adverse experiences, namely early childhood adversity and military sexual trauma, imposed a greater probability of transitioning into higher risk stress profiles. We also showed differential effects of early childhood and military-specific adversity on PTSD symptomology. CONCLUSION: The present study rigorously integrates both military-specific and early life adversity into analysis on stress sensitivity, and is the first to examine how sensitivity might affect trajectories of stress over time. Our study provides a nuanced, and specific, look at who is risk for sensitization to stress based on previous traumatic experiences as well as what transition patterns are associated with greater PTSD symptomology.

Temporal, Sex-Specific, Social Media-Based Alcohol Influences during the Transition to College.

BACKGROUND: The transition to college is an important developmental phase, usually met with increased social desirability, access to alcohol, and new peer groups. Recently, research has utilized social media as a predictor of events during college, but few have assessed how social media can influence alcohol use during the transition to college. Methods: Participants (N = 320) were recruited prior to entering their first year of college. Participants were 18 years old, 60.7% were women, with 46.3% identifying as White, 16.5% Hispanic, 14.9% Asian, 9.5% Black, and 7.6% other. Each participant was assessed three times: prior to matriculation, first semester, and second semester of their freshman year. We assessed the effect of exposure to alcohol content via social media on long-term trajectories of alcohol use. We also assessed self-reported sex as a moderator. Results: Exposure to alcohol content (over and above one's own posting of alcohol content) was associated with greater frequency of drinking during the transition to college. In the multi-group model, exposure to alcohol content was associated with greater drinking prior to matriculation for men. However, for women, exposure to alcohol content was associated with greater alcohol use in the first semester of college. Conclusion: Our results indicate exposure to alcohol-related media content is a strong predictor, over and above one's own positing, of increased drinking, and this effect varies by sex and point in time. Our results lend support for more tailored and time-specific prevention programming for incoming freshmen that should integrate social media normative feedback.

Patient predictors and utilization of health services within a medical home for homeless persons.

BACKGROUND: The Veterans Health Administration (VHA) established a patient-centered medical home model of care for veterans experiencing homelessness called a Homeless Patient Aligned Care Team (HPACT) to improve engagement with primary care and reduce utilization of hospital-based services. To evaluate the impact of the HPACT model, this study compares the number and type of health care visits in the 12 months before and after enrollment in HPACT at one VHA facility, and explores patient characteristics associated with increases and decreases in visits. METHODS: Chart reviews of VHA medical records were conducted for all patients enrolled in an HPACT in Pittsburgh, Pennsylvania, between May 2012 and December 2013 (N = 179). Multivariable mixed-effect logistic regressions estimated differences in having any visit in the 0-6 months and 7-12 months before and after HPACT enrollment, and multinomial logistic regressions predicted increases or decreases versus no change in number of visits over 12 months. RESULTS: Compared with 0-6 months prior to HPACT, patients were more likely to visit primary care in the 0-6 months (adjusted odds ratio [aOR] = 4.91, 95% confidence interval [CI] = 2.94-8.20) and 7-12 months (aOR = 2.30, 95% CI = 1.42-3.72) following HPACT. Patients were less likely to visit the emergency department (ED) or to be hospitalized in the 0-6 months (aOR = 0.57, 95% CI = 0.34-0.94; and aOR = 0.55, 95% CI = 0.25-0.76) and 7-12 months (aOR = 0.43, 95% CI = 0.33-0.91; and aOR = 0.45, 95% CI = 0.26-0.80) following HPACT. Patients were less likely to visit mental health (aOR = 0.35, 95% CI = 0.20-0.60) and addiction specialists (aOR = 0.39, 95% CI = 0.18-0.84) in the 7-12 months following HPACT. Overall, 59% of patients had increases in primary care visits following HPACT. Female patients and those with self-housing were less likely to have increases versus no change in primary care visits (adjusted relative risk ratio [aRRR] = 0.15, 95% CI = 0.03-0.74; and aRRR = 0.35, 95% CI = 0.14-0.90). CONCLUSIONS: An integrated HPACT model was successful in engaging homeless veterans in primary care for 1 year, potentially contributing to reductions in ED use. More tailored approaches may be needed for vulnerable populations experiencing homelessness, including homeless women.

Homeless veterans' experiences with substance use, recovery, and treatment through photo elicitation.

BACKGROUND: Homeless veterans often have addictions and comorbidities that complicate utilization of longitudinal health care services, such as primary care. An understanding of experiences of veterans enrolled in a Homeless Patient Aligned Care Team (H-PACT) may improve addiction treatment engagement in these settings. The authors aimed to describe H-PACT veterans' experiences with substance use (SU), substance use recovery (SUR), and substance use treatment (SUT). METHODS: Homeless veterans were recruited from a veteran primary care medical home clinic between September 2014 and March 2015. Twenty veterans were given digital cameras and prompts for taking photographs about their health and health care and participated in 2 photo elicitation interviews. For this secondary analysis, transcripts from the audio-recorded interviews were analyzed by 2 coders using qualitative content analysis. RESULTS: The majority of participants (75%, n = 15) discussed SU, SUR, and/or SUT in regards to their health and health care utilization. SU themes centered on disclosure of addiction or dependency; substances used; repercussions of SU; SU as a coping mechanism; and association of SU with military service. SUR themes included disclosure of length of sobriety; perceived facilitators of SUR in health, beliefs, social, environmental, financial, and creative pursuit domains; and perceived barriers to SUR in beliefs, social, and environmental domains. SUT themes focused on perceived facilitators of SUT in access to Department of Veterans Affairs (VA) and non-VA services and social domains and perceived barriers to SUT in the social domain. CONCLUSIONS: Providers seeking to elicit addiction-related clinical history and facilitate SUR and SUT might look to the current findings for guidance. Provider training in motivational interviewing may be warranted, which allows for an exploration of health-related consequences of SU and supports patients' self-efficacy.

Left, right, and meeting in the middle: Addressing addiction is something we can agree about.

The United States faces an addiction health crisis. Presidential election cycles in the United States are cause for creation of political party platforms. These platforms provide general stances and specific policies on a variety of issues. We undertook a review of the addiction policies of the 2016 Republican and Democratic platforms. Despite differences in focus, we found more similarities than differences between the two. We call upon those in political power to use every evidence-based policy at their disposal to promote addiction treatment and prevention.

Barriers and Facilitators to Behavioral Healthcare for Women Veterans: a Mixed-Methods Analysis of the Current Landscape.

Women veterans have historically faced barriers to behavioral health treatment, particularly through the VA. In conjunction, there have been changes in behavioral healthcare delivery resulting from efforts to improve care for women veterans and the COVID-19 pandemic (e.g., widespread telehealth implementation). The current study draws on a quantitative and qualitative study centering current perspectives of women veterans in their choices to seek or not seek behavioral healthcare in VA and non-VA settings through interviewing 18 women recruited from a larger survey study on veteran behavioral health (n = 83 women, n = 882 men) on their experiences with behavioral health care access and satisfaction, including barriers and facilitators to seeking care. Quantitative findings are descriptively reported from the larger study, which outlined screening for behavioral health problems, behavioral health utilization, treatment modality preferences, and barriers/facilitators to care. While women in the survey sample screened for various behavioral health disorders, rates of treatment seeking remained relatively low. Women reported positive and negative experiences with telehealth and endorsed many barriers to treatment seeking in interviews not captured by survey findings, including lack of women-specific care (e.g., care for military sexual trauma, women-only groups), reports of stranger harassment at the VA, and lack of female providers. Women veterans continue to face barriers to behavioral healthcare; however, ongoing efforts to improve care access and quality, including the implementation of telehealth, show promise in reducing these obstacles. Continued efforts are needed to ensure diverse treatment modalities continue to reach women veterans as this population grows.

Exploring predictors of substance use disorder treatment engagement with machine learning: The impact of social determinants of health in the therapeutic landscape.

BACKGROUND: Improved knowledge of factors that influence treatment engagement could help treatment providers and systems better engage patients. The present study used machine learning to explore associations between individual- and neighborhood-level factors, and SUD treatment engagement. METHODS: This was a secondary analysis of the Global Appraisal of Individual Needs (GAIN) dataset and United States Census Bureau data utilizing random forest machine learning and generalized linear mixed modelling. Our sample (N = 15,873) included all people entering SUD treatment at GAIN sites from 2006 to 2012. Predictors included an array of demographic, psychosocial, treatment-specific, and clinical measures, as well as environment-level measures for the neighborhood in which patients received treatment. RESULTS: Greater odds of treatment engagement were predicted by adolescent age and psychiatric comorbidity, and at the neighborhood-level, by low unemployment and high population density. Lower odds of treatment engagement were predicted by Black/African American race, and at the neighborhood-level by high rate of public assistance and high income inequality. Regardless of the degree of treatment engagement, individuals receiving treatment in areas with high unemployment, alcohol sale outlet concentration, and poverty had greater substance use and related problems at baseline. Although these differences reduced with treatment and over time, disparities remained. CONCLUSIONS: Neighborhood-level factors appear to play an important role in SUD treatment engagement. Regardless of whether individuals engage with treatment, greater loading on social determinants of health such as unemployment, alcohol sale outlet density, and poverty in the therapeutic landscape are associated with worse SUD treatment outcomes.

American Veterans in the Era of COVID-19: Reactions to the Pandemic, Posttraumatic Stress Disorder, and Substance Use Behaviors.

The COVID-19 pandemic may have a compounding effect on the substance use of American veterans with posttraumatic stress disorder (PTSD). This study investigated the relationship between PTSD and current reactions to COVID-19 on alcohol and cannabis use among veterans who completed a survey 1 month prior to the pandemic in the USA and a 6-month follow-up survey. We hypothesized that veterans with PTSD would experience more negative reactions to COVID-19 and increased alcohol and cannabis use behaviors over those without PTSD. Veterans with PTSD prior to the pandemic, relative to those without, endorsed poorer reactions, greater frequency of alcohol use, and greater cannabis initiation and use during the pandemic. Veterans with PTSD may use substances to manage COVID-related stress. Clinicians may see an increase in substance use among this group during and after the pandemic and may need to implement specific behavioral interventions to mitigate the negative effects of COVID-19.

Pain Trajectories among U.S. Veterans During COVID-19.

Physical pain is highly prevalent among military veterans. As stress can impact pain, COVID-19-related stressors may have heightened pain among veterans. A prospective analysis of pain could advance understanding of how veterans fared during COVID-19 and lend knowledge of risk factors important beyond the pandemic. The present study employs growth mixture modeling with a sample of U.S. veterans high in pain (N = 1,230) followed from just before COVID-19 (February 2020) to 12 months later (February 2021; 81.7% retention). We explored heterogeneous pain trajectories as well as baseline and COVID-19-related predictors of pain. Results revealed 4 pain trajectory classes: 1) Chronic Pain (17.3% of the sample); 2) Decreasing Pain (57.2% of the sample); 3) Stable Mild Pain (19.8% of the sample); and 4) Increasing Pain (5.7% of the sample). Those with childhood trauma exposure were especially likely to report chronic pain. Female and racial/ethnic minority veterans were also relatively likely to fare poorly in pain. Loneliness was associated with subsequent pain among several classes. Most veterans in our sample fared better than expected in terms of pain. However, as those with childhood trauma and certain disadvantaged groups were less likely to fare well, we add to the important literature on disparities in pain. Clinicians should identify whether loneliness and other factors impacted pain during COVID-19 among their patients to inform ongoing, person-centered pain management approaches. PERSPECTIVE: This article presents pain trajectories and correlates of pain among a high-pain sample of U.S. veterans surveyed prior to and during COVID-19. Pain clinicians should screen for childhood trauma and remain vigilant in addressing health disparities.

Associations between trauma-related guilt, symptoms of posttraumatic stress disorder, and problematic alcohol use.

Trauma-related guilt, or a belief that one should have felt, thought, or acted differently during a traumatic event in which someone's life or physical integrity was threatened, has been consistently associated with mental health disorders such as posttraumatic stress disorder (PTSD). Theories of trauma-related guilt suggest that some avoidant coping behaviors, such as problematic alcohol use, are crucial pathways connecting trauma-related guilt to PTSD but have not been thoroughly investigated. The present study uses data from a longitudinal cohort of veterans to examine two models: the first assessed problematic alcohol use as a mechanism linking trauma-related guilt and PTSD. The second explored PTSD as a mechanism linking trauma-related guilt to problematic alcohol use. Results indicated that problematic alcohol use was a significant mechanism linking global guilt and guilt cognitions with PTSD. Further, results indicated that PTSD was a significant mechanism linking global guilt and distress with problematic alcohol use. Results of our study indicate that alcohol use is a key construct that has been overlooked in the trauma-related guilt literature, despite the high prevalence of co-occurring PTSD and alcohol use (and alcohol use disorder). Targeting trauma-related guilt during integrated treatments for PTSD and alcohol use disorder may be particularly important for veterans.

Associations between childhood maltreatment and physiological dysregulation in adulthood: Methodological decisions and implications.

BACKGROUND: Childhood maltreatment is linked with health problems in adulthood. Theoretical models suggest that maltreatment leads to dysregulation in several bodily systems, and this has been corroborated using measures of physiological function (i.e., biomarkers). Methodological decisions involving the measurement of maltreatment and dimension reduction with respect to biomarkers (i.e., combining information across multiple measures) may influence research findings. OBJECTIVE: The present study compares associations between childhood maltreatment and adult physiological dysregulation using multiple dimension reduction approaches and measures of maltreatment. PARTICIPANTS AND SETTING: Participants were recruited, as children, to a prospective study of the correlates and consequences of childhood maltreatment. 253 participants were retained and provided biomarker data at midlife. Physiological dysregulation was operationalized with a conventional allostatic load approach and a novel statistical distance approach. METHODS: Regression models were employed with allostatic load or statistical distance as the outcome and prospectively or retrospectively measured child maltreatment as the primary predictor. RESULTS: When using allostatic load as the outcome, prospectively measured childhood maltreatment was positively associated with physiological dysregulation (b = 0.70, SE = 0.31, p = 0.02). When using statistical distance as the outcome, retrospectively measured childhood maltreatment was positively associated with physiological dysregulation (b = 0.69, SE = 0.19 p < 0.001). CONCLUSIONS: We report a positive association between childhood maltreatment and physiological dysregulation at midlife. However, the significance and magnitude of effects varied with different maltreatment and physiological dysregulation measures. Further review of the methods used to study adult health conditions and their relation to childhood maltreatment is needed.

Development of a mobile mindfulness smartphone app for post-traumatic stress disorder and alcohol use problems for veterans: Beta test results and study protocol for a pilot randomized controlled trial.

BACKGROUND: Post-traumatic stress disorder (PTSD) and alcohol use disorder (AUD) are highly prevalent, and co-occurring among post-9/11 veterans. Mobile health (mHealth) applications, specifically those focused on mindfulness-based techniques, may be an effective avenue to intervene with veterans who cannot or will not seek care at traditional in-person settings. Thus, to address areas of improvement in mHealth for veterans, we developed Mind Guide and prepared it for testing in a pilot randomized controlled trial (RCT) with veterans. METHODS: We have completed phase 1 (treatment development) and Phase 2 (beta test) of our mobile mHealth app, Mind Guide. In this paper we describe the methods for Phase 1 as well as results for our beta test (n = 16; inclusion criteria included screen for PTSD, AUD, a post-9/11 veteran, and not currently receiving treatment) for Mind Guide as well as outline procedures for our pilot RCT of Mind Guide (Phase 3). The PTSD Checklist, self-reported alcohol use, the Perceived Stress Scale, Penn Alcohol Craving Scale, and the Emotion Regulation Questionnaire were used. RESULTS: Results of our beta test of Mind Guide show promising past 30 day effects on PTSD (d = -1.12), frequency of alcohol use (d = -0.54), and alcohol problems (d = -0.44), and related mechanisms of craving (d = -0.53), perceived stress (d = -0.88), and emotion regulation (d = -1.22). CONCLUSION: Our initial beta-test of Mind Guide shows promise for reducing PTSD and alcohol related problems among veterans. Recruitment is ongoing for our pilot RCT in which 200 veterans will be recruited and followed up for 3 months. CLINICALTRIALS: gov Identifier: NCT04769986.

Toward a dual process model of moral injury and traumatic illness.

Moral injury has emerged as a topic of significant research and clinical interest over the last decade. However, much work remains to be done to comprehensively define the moral injury construct, with implications for understanding the etiology and maintenance of moral injury, its symptoms, associations with and distinctions from traumatic illness, and treatment approaches. We provide a brief overview of the existing moral injury literature and introduce a novel dual process model (DPM) of moral injury and traumatic illness. The DPM posits an event exposure which may satisfy DSM-5 posttraumatic stress disorder (PTSD) criterion A, potential morally injurious event (PMIE) criteria, or both, followed by individual role appraisal as a perpetrator through action or inaction, a witness, a victim, or a combination of the these. Role appraisal influences symptoms and processes across biological, psychological, behavioral, social, spiritual/religious, as well as values, character, and identity domains to support a label of traumatic illness, moral injury, or both. The DPM provides a flexible analytical framework for evaluating symptoms associated with moral injury and traumatic stress and has important implications for treatment. The most thoroughly reviewed evidence-based interventions for traumatic stress hinge on exposure and habituation mechanisms to manage dysregulation of fear and memory systems, but these mechanisms often do not address core domains of moral injury identified in the DPM, including spiritual, religious, values, character, and identity domains as these exist largely outside of the putative fear network. We provide brief vignettes to illustrate the practical application of the DPM and argue that adjunct and stand-alone approaches which address values and character domains, leveraging principles of Stoicism, non-judgment of experience, acceptance, and values-oriented action, are more likely than traditional trauma treatment approaches to positively affect moral injury symptoms.

Moral injury events and behavioral health outcomes among American veterans.

Among American veterans, the behavioral health impact of potentially morally injurious experiences (PMIEs) has recently garnered attention. There is heterogeneity in the types of experiences that are classified as PMIEs, and different PMIEs may be differentially associated with various outcomes. We aimed to explore heterogeneity in PMIEs among veterans, and whether PMIE classes are differentially associated with several behavioral health outcomes (i.e., symptoms of posttraumatic stress disorder, depression, anxiety, and anger). Data were from a survey study of veteran health attitudes and behavior (N=1004). We employed a Latent Class Analysis approach to identify sub-groups of participants with similar PMIE response patterns on the Moral Injury Events Scale and to determine the relationship between class membership and behavioral health outcomes. A 4-class solution best fit our data, with classes including (1) high all, (2) witnessed transgressions, (3) troubled by failure to act, and (4) moderate all. There was a link between class membership and behavioral health, with the high all class and moderate all classes consistently reporting especially poor outcomes. Our results are in line with cumulative stress models suggesting exposure to multiple forms of adversity may place individuals at particular risk of poor health and functioning. Clinicians working with veterans should screen for exposure to the full range of PMIE types and be prepared to address the multitude of behavioral health impacts.

Changes in perceived stress during the COVID-19 pandemic among American veterans.

American veterans are a population that suffer from both context specific stressors as well as many population-specific major-life events. The present exploratory study utilises a longitudinal cohort of 1230 U.S. veterans surveyed from February 2020 through February 2021. We sought to understand heterogeneity in perceived stress, using growth mixture modelling, over this time period, how COVID-specific factors such as negative reactions to the pandemic, loneliness, and employment disruptions influence perceived stress trajectories, and how veterans vary across distal outcomes including posttraumatic stress disorder (PTSD), pain, depression, sleep problems, physical health, and alcohol use disorder. Results revealed a 4-class solution: Stable High, Stable Low, Steady Increasing, and Steady Decreasing classes. In terms of COVID specific factors, negative reactions to COVID were consistently associated with perceived stress for those in the Stable High and Steady Increasing classes whereas loneliness was associated with stress trajectories for all emergent classes. Finally, in terms of our distal outcomes, results showed a relatively robust pattern with veterans in the Stable High or Steady Increasing classes reporting worse scores across all outcomes including PTSD, pain, sleep problems, physical health, depression, and alcohol use disorder. Understanding the interplay between existing vulnerabilities, ongoing stressors, and behavioural health outcomes among veterans is crucial for prevention and intervention efforts.

Identifying individual and environmental predictors of opioid and psychostimulant use among adolescents and young adults following outpatient treatment.

BACKGROUND: The United States (US) continues to grapple with a drug overdose crisis. While opioids remain the main driver of overdose deaths, deaths involving psychostimulants such as methamphetamine are increasing with and without opioid involvement. Recent treatment admission data reflect overdose fatality trends suggesting greater psychostimulant use, both alone and in combination with opioids. Adolescents and young adults are particularly vulnerable with generational trends showing that these populations have particularly high relapse rates following treatment. METHODS: We assessed demographic, psychosocial, psychological comorbidity, and environmental factors (percent below the poverty line, percent unemployed, neighborhood homicide rate, population density) that confer risk for opioid and/or psychostimulant use following substance use disorder treatment using two complementary machine learning approaches-random forest and least absolute shrinkage and selection operator (LASSO) modelling-with latency to opioid and/or psychostimulant as the outcome variable. RESULTS: Individual level predictors varied by substance use disorder severity, with age, tobacco use, criminal justice involvement, race/ethnicity, and mental health diagnoses emerging at top predictors. Environmental variabels including US region, neighborhood poverty, population, and homicide rate around patients' treatment facility emerged as either protective or risk factors for latency to opioid and/or psychostimulant use. CONCLUSIONS: Environmental variables emerged as one of the top predictors of latency to use across all levels of substance use disorder severity. Results highlight the need for tailored treatments based on severity, and implicate environmental variables as important factors influencing treatment outcomes.

Applying polyvictimization theory to veterans: Associations with substance use and mental health.

OBJECTIVE: Prior work has linked exposure to multiple types of trauma (i.e., polyictimization) to increased risk of negative behavioral health outcomes compared with exposure to any single event. However, few studies have attempted to understand how polyvictimization theory relates specifically to veterans' experiences and behavioral health outcomes. The present study assessed heterogeneity in reports of childhood trauma, combat trauma, and military sexual trauma. METHOD: We recruited 1,230 veterans outside of traditional Veterans Health Administration settings to participate in a study assessing behavioral health. On average, participants were 34.5 years old with the majority identifying as White (79.3%) and male (88.7%). We used latent class analysis to extract classes of traumatic experience exposure including childhood trauma, combat trauma, and military sexual trauma. RESULTS: Five classes emerged: (a) high all; (b) moderate combat trauma, high military sexual trauma; (c) high combat trauma, moderate military sexual harassment; (d) moderate childhood trauma and combat trauma; and (e) combat trauma only. Overall, veterans in profiles that endorsed multiple trauma types (i.e., polyvictimization) evidenced greater symptoms of depression, posttraumatic stress disorder, and hazardous alcohol or cannabis use. Further, women were overly represented in profiles that included multiple victimization typologies, especially when profiles included elevated endorsement of military sexual trauma. CONCLUSION: A polyvictimization framework was partially supported, with differential effects on behavioral health outcomes noted across trauma experiences. (PsycInfo Database Record (c) 2022 APA, all rights reserved).