Do veterans with risky substance use (RSU) use distinct pain treatment modalities?

BACKGROUND AND OBJECTIVES: Risky substance use (RSU) is common among people with chronic pain and is associated with worse pain treatment outcomes. Nonopioid treatment is recommended, but it is unknown whether people with RSU use different or fewer pain treatment modalities. This study describes use of different pain treatments by veterans with and without RSU and those receiving versus not receiving opioid medication. METHODS: Veterans (N = 924) who filed service-connected disability claims related to musculoskeletal conditions and rated their pain four or higher on the Numeric Rating Scale, reported on 25 different pain services in the preceding 90 days. Recent RSU was identified via Alcohol, Smoking, and Substance Involvement Test (ASSIST) cutoffs and/or nail sample toxicology. RESULTS: Overall, RSU was not associated with number of provider-delivered or self-delivered pain modalities. Over-the-counter medications (71%), self-structured exercise (69%), and nonopioid prescription medications (38%) were the most used modalities. Veterans receiving prescribed opioids (8.4%) were more likely to see primary care, receive injections, and attend exercise and/or meditation classes, compared to those without opioid prescriptions. DISCUSSION AND CONCLUSIONS: Opioid and nonopioid pain treatment utilization did not differ based on RSU, and those prescribed opioids were more likely to engage in other nonopioid pain treatments. Regardless of RSU, veterans appear willing to try provider-delivered (58%) and self-delivered (79%) pain treatment. SCIENTIFIC SIGNIFICANCE: In this first-ever evaluation of 25 different pain treatment modalities among veterans with and without RSU, people with RSU did not use less treatment modalities.

Sensitivity, specificity, and discordance with self-report of nail sample testing for alcohol and cannabis.

BACKGROUND: Nails accumulate the alcohol metabolite, ethyl glucuronide (ETG), and the cannabis metabolite, carboxy- delta-9-THC over 3-6 months. Few studies have examined nail toxicology testing's sensitivity and specificity and the agreement between nail testing and self-reported alcohol and marijuana use. METHODS: In an ongoing clinical trial, 1101 veterans completed initial telephone questionnaires and were then asked to mail nail clippings for substance use analysis. We examined sensitivity and specificity of ETG and carboxy- delta-9-THC in nails compared to self-report of alcohol use patterns (the AUDIT-C) and substance-related harms (alcohol and THC subscales of the ASSIST). We then examined factors associated with discordance between nails and self-report. RESULTS: Almost two-thirds (707/1101) of respondents mailed in nail clippings. Those with returned nails were disproportionately married, white race, older, and less depressed. At a threshold of 8pg/mg, sensitivity was only.50 to detect risky alcohol use and.49 to detect alcohol-related issues. Sensitivity for marijuana issues was only.61. Specificity was greater than.77 for all measures. Factors associated with positive nails/negative self-report (i.e. false positives) for risky alcohol use on the Audit-C included more pain and being unmarried; false positive nails for alcohol-related issues on the ASSIST were associated with being unmarried and non-Hispanic ethnicity. False positive nails for THC-related issues on the ASSIST were associated with being African American, Hispanic, and having had legal issues. CONCLUSIONS: At standard cut-offs, nail measures had low sensitivity and higher specificity. The groups who disproportionately submit positive nails/negative self-report could have substance use patterns not adequately captured by self-report, inaccurate self-report due to social pressures, or distinct drug metabolism.

Provider-patient relationships and trauma among pregnant patients with opioid-use disorder.

BACKGROUND AND OBJECTIVES: The provider-patient relationship is integral to medical practice and health outcomes, particularly among vulnerable patient populations. This study compared the provider-patient relationship among pregnant patients with opioid-use disorder (OUD), who did or did not have a history of moderate to severe trauma. METHODS: This was an exploratory data analysis of 119 patients enrolled in the Support Models for Addiction Related Treatment trial. Probable posttraumatic stress disorder (PTSD) was determined by a score ≥ 31 on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. The provider-patient relationship was assessed at 26 ± 4 weeks of pregnancy using the Kim Alliance Scale (KAS). Multivariable regression was used to examine the association of KAS with probable PTSD among pregnant people with OUD. RESULTS: The mean KAS score for pregnant participants without probable PTSD (N = 88) was 61.4 (SD ± 2.8) and for pregnant participants with probable PTSD (N = 31) was 59.6 (SD ± 3.7). Results demonstrated significant differences in KAS scores between those with and without probable PTSD after adjusting for demographic variables. Adjusted mean total KAS scores and scores on Empowerment and Communication subscales were significantly lower among those with probable PTSD compared to those without (p = .04 and 0.02, respectively) but did not differ significantly on Collaboration and Integration subscales. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Analyses show an association between probable PTSD and provider-patient relationship among pregnant patients with OUD, with those with probable PTSD having a worse alliance with obstetric providers. This novel finding helps characterize the provider-patient relationship among a uniquely vulnerable population and can inform efforts to integrate trauma-informed practices into prenatal care.