Analysis of nonfatal suicide attempts and demographic characteristics of US military veterans with opioid use disorder: A descriptive VA medical center study.

BACKGROUND AND OBJECTIVES: Suicide and opioid use disorder (OUD) frequently co-occur, and veterans are at a high risk for both conditions. This study aims to determine the characteristics of a cohort of veterans with co-occurring OUD and suicide attempts. METHOD: Three hundred fifty-three (n = 353) veterans registered at a VA medical center with OUD and at least one suicide attempt between January 2010 and December 2021 were analyzed. RESULTS: 9.4% of OUD veterans had lifetime suicide attempts, with 7.1% attempting postdiagnosis. High rates of unemployment (88.1%) and housing instability (73.1%) were observed, along with a 98% prevalence of comorbid psychiatric conditions. DISCUSSION AND CONCLUSIONS: Gaining a deeper understanding of this patient population can help improve strategies for preventing suicide and treating OUD more effectively. SCIENTIFIC SIGNIFIANCE: This study is unique in the current literature for investigating and comparing nonfatal lifetime suicide attempt rates in veterans before and after an OUD diagnosis.

A detox dilemma beyond benzodiazepines; clonidine's quandary in alcohol withdrawal management.

BACKGROUND AND OBJECTIVES: Benzodiazepines are the primary method of treatment of alcohol withdrawal, though the American Society of Addiction Medicine guidelines also include alternative agents for consideration. Observations in a Department of Veterans Affairs (VA) psychiatric emergency room noted consistent benzodiazepine use with an overall lack of use of alternative agents, even with low Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scores and in the absence of other concerning symptoms. Due to concerns of potential more-than-necessary benzodiazepine use, we analyzed adjunctive clonidine use for elevated blood pressure/pulse in alcohol withdrawal among this Veteran population. METHODS: This is a single-site VA retrospective chart review of the psychiatric emergency room from July 1, 2022, to June 30, 2023, focused on patients with alcohol withdrawal managed on a CIWA protocol. Excluding concurrent opioid withdrawal and clonidine as home medication, 167 patient charts were analyzed for this study. RESULTS: Among 167 patients, 99 (59.3%) had comorbid hypertension. A total of 614 medication doses were given for elevated CIWA (373, 60.8%) and elevated blood pressure/pulse (241, 39.2%). Of the 241 doses for elevated blood pressure/pulse, only 2.5% were clonidine. Among all benzodiazepine doses, 75.3% were given to patients with comorbid hypertension. Clonidine was administered to 3.0% of patients, making up 2.5% of total dosing. DISCUSSION AND CONCLUSIONS: Alcohol withdrawal management lacks optimization. Integrating adjunctive medications could reduce potential benzodiazepine overuse effectively addressing elevated blood pressure/pulse. SCIENTIFIC SIGNIFICANCE: This study sheds light on the potential underutilization of clonidine and its potential role in improving alcohol withdrawal syndrome management. By addressing elevated blood pressure/pulse and curbing potential overuse of benzodiazepines, it may contribute to further optimizing patient care.

Reducing Nighttime Interruptions and Improving Sleep for Hospitalized Patients by Restructuring Nighttime Clinical Workflow.

BACKGROUND: Nighttime sleep disruptions negatively impact the experience of hospitalized patients. OBJECTIVE: To determine the impact of adopting a sleep-promoting nighttime clinical workflow for hospitalized patients on nocturnal disruptions and sleep. DESIGN: Survey-based pre- and post-intervention cross-sectional study using convenience samples. PARTICIPANTS: Hospitalized veterans on a 23-bed general medical ward at a tertiary Veterans Administration Hospital. INTERVENTIONS: Baseline sleep surveys (N=149) identified two major sources of interruptions: blood pressure checks at 4 am for telemetry patients and subcutaneous (SQ) heparin injections between 4:30 and 6 am for venous thromboembolism prophylaxis. Clinical workflow was restructured to eliminate these disruptions: moving 4 am blood pressure checks to 6 am and providing daily SQ enoxaparin at 9 am as an alternative to Q 8-h SQ heparin, which had prompted an injection between 4:30 and 6 am. The impact of these changes was assessed in a second round of surveys (N=99). MAIN MEASURES: Frequency and sources for nighttime sleep disruptions; percentage of patients reporting longer time to fall asleep, more interruptions, and worse sleep quality (vs. home) before and after restructuring nighttime clinical workflow. KEY RESULTS: After restructuring nighttime clinical workflow, medication administration as a source of nighttime disruption decreased from 40% (59/149) to 4% (4/99) (p<0.001). Blood pressure checks as a source of disruption decreased from 56% (84/149) to 42% (42/99) (p=0.033). Fewer patients reported taking longer to fall asleep in the hospital vs. home (39% pre-intervention vs. 25% post-intervention, p=0.021). Similarly, fewer patients experienced waking up more frequently in the hospital vs. home (46% pre-intervention vs. 32% post-intervention, p=0.036). Fewer patients reported sleeping worse in the hospital (44% pre-intervention vs. 39% post-intervention), though this trend was not statistically significant (p=0.54). CONCLUSIONS: Nighttime disruptions in hospitalized patients frequently interfere with sleep. Restructuring of the clinical workflow significantly reduced disruptions and improved sleep.

Sleep-wake disorders in veterans with opioid use disorder: Prevalence and comorbidities.

OBJECTIVE: To determine the prevalence of sleep-wake disorders among veterans with opioid use disorder (OUD) and the demographic characteristics, medical comorbidities, and outpatient medications in this group. METHODS: US veterans seeking care in the VA Connecticut Healthcare System between January 1, 2000, and December 31, 2021 with a diagnosis of OUD (N = 5937) were analyzed retrospectively for sleep-wake disorders (N = 1447). That group was analyzed for demographic characteristics, comorbidities, and medications. RESULTS: Of those with OUD, 24.4% had a diagnosis of any sleep-wake disorder. The most common was obstructive sleep apnea (73.7%). Major depressive disorder (68.6%) and hypertension (67.1%) were the most common comorbid conditions. Commonly prescribed medications included antidepressants (91%) and benzodiazepines (62%). CONCLUSIONS: Veterans with OUD frequently suffer from sleep-wake disorders. Comorbid medical and psychiatric conditions and the detrimental effects of specific medication classes should be considered in this patient population to create more effective prevention and treatment strategies.

Clinical and virologic factors associated with outcomes of COVID-19 before and after vaccination among Veterans: Retrospective analysis from six New England states.

We aimed to characterize clinical and demographic factors affecting clinical outcomes of COVID-19 and describe viral epidemiology among unvaccinated Veterans in New England. Veterans infected with COVID-19 in Veterans Administration healthcare systems in six New England states from April 8, 2020, to September 2, 2021, were correlated with outcomes of 30-day mortality, nonpsychiatric hospitalization, and intensive care unit admission (ICU-care). We sequenced 827 viral genomes. Of 3950 Veterans with COVID-19 before full vaccination, 81% were White, 8% were women, and the mean age was 60 years. Overall, 19% of Veterans required hospitalization, 2.8% required ICU care, and 4.9% died. In this largely male and older cohort, poor outcomes correlated with increasing age. Most New England Veterans (>97%) were infected with B.1 sublineages with the D614G mutation in 2020 and early 2021. B.1.617.2 lineage (68%) predominated after July 2021.

COVID-19 Outcomes and Genomic Characterization of SARS-CoV-2 Isolated From Veterans in New England States: Retrospective Analysis.

BACKGROUND: Clinical and virologic characteristics of COVID-19 infections in veterans in New England have not been described. The average US veteran is a male older than the general US population. SARS-CoV-2 infection is known to cause poorer outcomes among men and older adults, making the veteran population an especially vulnerable group for COVID-19. OBJECTIVE: This study aims to evaluate clinical and virologic factors impacting COVID-19 outcomes. METHODS: This retrospective chart review included 476 veterans in six New England states with confirmed SARS-CoV-2 infection between April and September 2020. Whole genome sequencing was performed on SARS-CoV-2 RNA isolated from these veterans, and the correlation of genomic data to clinical outcomes was evaluated. Clinical and demographic variables were collected by manual chart review and were correlated to the end points of peak disease severity (based on oxygenation requirements), hospitalization, and mortality using multivariate regression analyses. RESULTS: Of 476 veterans, 274 had complete and accessible charts. Of the 274 veterans, 92.7% (n=254) were men and 83.2% (n=228) were White, and the mean age was 63 years. In the multivariate regression, significant predictors of hospitalization (C statistic 0.75) were age (odds ratio [OR] 1.05, 95% CI 1.03-1.08) and non-White race (OR 2.39, 95% CI 1.13-5.01). Peak severity (C statistic 0.70) also varied by age (OR 1.07, 95% CI 1.03-1.11) and O2 requirement on admission (OR 45.7, 95% CI 18.79-111). Mortality (C statistic 0.87) was predicted by age (OR 1.06, 95% CI 1.01-1.11), dementia (OR 3.44, 95% CI 1.07-11.1), and O2 requirement on admission (OR 6.74, 95% CI 1.74-26.1). Most (291/299, 97.3%) of our samples were dominated by the spike protein D614G substitution and were from SARS-CoV-2 B.1 lineage or one of 37 different B.1 sublineages, with none representing more than 8.7% (26/299) of the cases. CONCLUSIONS: In a cohort of veterans from the six New England states with a mean age of 63 years and a high comorbidity burden, age was the largest predictor of hospitalization, peak disease severity, and mortality. Non-White veterans were more likely to be hospitalized, and patients who required oxygen on admission were more likely to have severe disease and higher rates of mortality. Multiple SARS-CoV-2 lineages were distributed in patients in New England early in the COVID-19 era, mostly related to viruses from New York State with D614G mutation.