Telepharmacy Model of Care.

PURPOSE: This study assessed the feasibility of the Telepharmacy Model of Care, a medication review and deprescribing model for use in older adults, with innovations in cognitive and functional evaluation, in telemedicine delivery, and in the use of a pharmacy technician. METHODS: This retrospective medical record review/abstraction analyzed (from March 1, 2022, to December 31, 2022) data from US veteran participants in a pilot implementation (April 13, 2021, to May 20, 2022) of the Telepharmacy Model of Care at the Veterans Affairs Ann Arbor Healthcare System (Ann Arbor, Michigan). The project team assessed and made recommendations about multiple factors in medication management: medication list accuracy; safety of medications and their combinations; older adults' cognition, health literacy, and physical abilities and impairments in self-managing medications; and caregivers' ability to compensate for those impairments. FINDINGS: The pilot included 60 US veterans (mean age, 75 years [range, 59-93 years]; 97% were men). Overall, participants were successful in using telemedicine (98%). Encounters required 30 to 45 minutes for the visit and 20 minutes for follow-up and documentation (P = 0.14 pharmacist vs pharmacy technician). The median number of medications per patient was 18. A total of 57% of patients had four or more medication-related discrepancies; fewer patients experienced medication-adherence problems, drug-drug interactions, problematic medication combinations, and untreated/undertreated conditions. Using the Safe Medication Algorithm for Older Adults tool, 35% were identified as taking a Red Flag medication (contraindicated in older adults), and 74%, a High Risk medication (eg, an anticoagulant). A total of 37% had cognitive and health literacy impairments, and 45%, physical impairments, interfering with the ability to self-manage medications. Recommendations on deprescribing were made in 98% of patients. IMPLICATION: The telemedicine-based and pharmacist/pharmacy technician-delivered model was a feasible method for addressing comprehensive medication review and deprescribing in these cognitively and functionally impaired US veterans.

A virtual breakthrough series collaborative to support deprescribing interventions across Veterans Affairs healthcare settings.

BACKGROUND: Virtual collaborative models are a practical way to implement a supportive environment for multi-team learning. In this project, we aimed to describe the processes and outcomes of a virtual deprescribing collaborative that facilitated implementation of deprescribing interventions around the country. METHODS: Two successive cohorts comprised of multidisciplinary teams from geographically diverse veterans affairs (VA) sites were selected via an application process to participate in a virtual deprescribing collaborative. Each site developed its own deprescribing protocol and took part in regular meetings, mentoring groups, monthly data reporting, and other learning activities over an approximate 9 month period, per cohort. Standard measures were number of veterans served and medications deprescribed. Descriptive and qualitative analyses were utilized. RESULTS: Twenty-one total VA sites were selected to participate in the deprescribing collaborative in two cohorts (Cohort 1, n = 12 sites; Cohort 2, n = 9 sites). The majority of sites' practice areas directly served the older adult population, and the majority of site leads were pharmacists. The most utilized tool used by the collaborative sites was the VA VIONE decision support tool (n = 14) and the most common strategy was individualized medication review. Combining outcomes from both Cohorts 1 and 2, a total of n = 4770 veterans were served, with 8332 medications deprescribed. Eighty-two percent of Cohort 1 sites surveyed reported their deprescribing program was still being utilized after 1 year follow up. CONCLUSIONS: This virtual deprescribing collaborative aided in the successful implementation of both established and novel deprescribing practices across a variety of VA practice sites that care for older adults. The shared learning experience enhanced problem solving and allowed for interdisciplinary teamwork. Overall the collaborative was successful in improving polypharmacy for several thousand older adults.

Neuroscience: The New English Major?

Once strictly the domain of medical and graduate education, neuroscience has made its way into the undergraduate curriculum with over 230 colleges and universities now offering a bachelor's degree in neuroscience. The disciplinary focus on the brain teaches students to apply science to the understanding of human behavior, human interactions, sensation, emotions, and decision making. In this article, we encourage new and existing undergraduate neuroscience programs to envision neuroscience as a broad discipline with the potential to develop competencies suitable for a variety of careers that reach well beyond research and medicine. This article describes our philosophy and illustrates a broad-based undergraduate degree in neuroscience implemented at a major state university, Virginia Tech. We highlight the fact that the research-centered Experimental Neuroscience major is least popular of our four distinct majors, which underscores our philosophy that undergraduate neuroscience can cater to a different audience than traditionally thought.

Team VA Video Connect (VVC) to optimize mobility and physical activity in post-hospital discharge older veterans: baseline assessment.

BACKGROUND: Telehealth is increasingly used for rehabilitation and exercise but few studies include older adult participants with comorbidities and impairment, particularly cognitive. Using Veterans Administration Video Connect (VVC), the aim of the present study is to present the screening, recruitment, baseline assessment, and initial telehealth utilization of post-hospital discharge Veterans in a VVC home-telehealth based program to enhance mobility and physical activity. METHODS: Older adult Veterans (n = 45, mean age 73), recently discharged from the hospital with physical therapy goals, were VVC-assessed in self-report and performance-based measures, using test adaptations as necessary, by a clinical pharmacy specialist and social worker team. RESULTS: Basic and instrumental ADL disabilities were common as were low mobility (Short Portable Performance Battery) and physical activity levels (measured by actigraphy). Half had Montreal Cognitive Assessment (MoCA) scores in the mild cognitive impairment range (< 24). Over 2/3 of the participants used VA-supplied tablets. While half of the Veterans were fully successful in VVC, 1/3 of these and an additional group with at least one failed connection requested in-person visits for assistance. One-quarter had no VVC success and sought help for tablet troubleshooting, and half of these eventually "gave up" trying to connect; difficulty with using the computer and physical impairment (particularly dexterity) were described prominently in this group. On the other hand, Veterans with at least mild cognitive impairment (based on MoCA scores) were present in all connectivity groups and most of these used caregiver support to facilitate VVC. CONCLUSIONS: Disabled older post-hospital discharged Veterans with physical therapy goals can be VVC-assessed and enrolled into a mobility/physical activity intervention. A substantial proportion required technical support, including in-person support for many. Yet, VVC seems feasible in those with mild cognitive impairment, assuming the presence of an able caregiver. Modifications of assessment tools were needed for the VVC interface, and while appearing feasible, will require further study. TRIAL REGISTRATION: ClinicalTrials.gov NCT04045054 05/08/2019.

Cognitive status as a robust predictor of repeat falls in older Veterans in post-acute care.

BACKGROUND: While repeat falls are common in post-acute care (PAC), risk factors have not been fully elucidated. AIMS: The objective of thids study is to evaluate the contribution of cognitive function to repeat falls in older PAC Veterans. METHODS: Data were collected from medical records for 91 single and 30 repeat fallers over 5 consecutive years (2011-2016). RESULTS: After controlling for demographic and medical factors, lower Mini-Mental State Exam (MMSE) score was associated with increased odds of repeat falls. MMSE scores below 20 (with age held constant at the mean) were associated with a greater than 50% chance of a repeat fall (compared to 24.7% base rate). Admission for a neurologic reason further increased risk. DISCUSSION: PAC Veterans who experience a fall have an increased risk of repeat falls with concomitant cognitive dysfunction and/or admission for neurologic reasons. CONCLUSIONS: Results support tailoring multi-component interventions for those with cognitive dysfunction utilizing standardized mental status screening upon admission.

Calcium Hypothesis of Gulf War Illness: Role of Calcium Ions in Neurological Morbidities in a DFP-Based Rat Model for Gulf War Illness.

Gulf War Illness (GWI) refers to a multi-system disorder that afflicts approximately 30% of First Gulf War (GW) veterans. Amongst the symptoms exhibited, mood and memory impairment are commonly reported by GW veterans. Exposure to organophosphate (OP) compounds which target the cholinergic system is considered a leading cause for GWI symptoms. It is hypothesized that chronic OP-based war-time stimulation of cholinergic signaling led to recruitment of excitatory glutamatergic signaling and other downstream signaling cascades leading to neuronal injury, neuroinflammation, generation of reactive oxygen species, oxidative stress, and mitochondrial damage within the central nervous system. These findings have been observed in both experimental models and GWI veterans. In this context the role of calcium (Ca2+) signaling in GWI has come to the forefront. Here we present our Ca2+ hypothesis of GWI that suggests sustained neuronal Ca2+ elevations serve as a molecular trigger for pathological synaptic plasticity that has allowed for the persistence of GWI symptoms. Subsequently we discuss that therapeutic targeting of Ca2+ homeostatic mechanisms provides novel targets for effective treatment of GWI-related neurological signs in our rodent model.

Distress and Factors Associated with Suicidal Ideation in Veterans Living with Cancer.

BACKGROUNDS AND OBJECTIVES: Eliminating veteran suicide is a top priority for the US Department of Veterans Affairs (VA). Veterans with cancer may be at particular risk for suicidal ideation (SI). The current study aimed to understand factors associated with distress in veterans with cancer who were referred for psychology services, and identify problems associated with SI. METHODS: Health records of veterans with cancer (N = 174) were reviewed to abstract data, including results of National Comprehensive Cancer Network (NCCN) Distress Thermometer and Problems List and clinical suicide risk assessments. RESULTS: Veterans with severe distress were significantly more likely to endorse SI and have a history of suicide attempt(s) when compared with veterans with mild or moderate distress (χ2 = 18.36, P < .001). Of the problems endorsed on the NCCN Problems List, family problems were most strongly linked to SI (χ2 = 5.54, degrees of freedom [df] = 1, P = .02). Specifically, veterans who endorsed problems with their partner were 5 times more likely to experience SI when compared with veterans who did not endorse this problem (Wald = 15.142; df = 1, P < .001). CONCLUSIONS: This study is among the first to find partner problems as a suicide risk factor for veterans with cancer; and, underscore the importance of assessing for partner problems and suicidal ideation among veterans with cancer. This study supports the VA mission to end veteran suicide and addresses a gap in current literature by investigating the understudied population of veterans living with cancer and risk factors for SI.

Assessment of Ketamine and Its Enantiomers in an Organophosphate-Based Rat Model for Features of Gulf War Illness.

Approximately 33% of U.S. soldiers from the first Gulf War suffer from a multi-system disorder known as the Gulf War Illness (GWI). GW veterans suffer from a cluster of symptoms that prominently include fatigue and can include mood-related symptoms. Compared to traditional antidepressants, ketamine (KET) produces a fast-onset and long-lasting antidepressant response, but assessments of KET for GWI-related depression are lacking. The etiology of GWI is multi-factorial and exposure to organophosphates (OP) during deployment is one of the factors underlying GWI development. Here, male Sprague-Dawley rats were repeatedly exposed to an OP DFP and three months later these rats, when assessed on a battery of rodent behavioral assays, displayed signs consistent with aspects of GWI characteristics. When treated with a sub-anesthetic dose of KET (3, 5, or 10 mg/kg, i.p.), DFP-treated rats exhibited a significant improvement in immobility time, open-arm exploration, and sucrose consumption as early as 1 h and much of these effects persisted at 24-h post-KET injection. KET's stereoisomers, R-KET and S-KET, also exhibited such effects in DFP rats, with R-KET being the more potent isomer. Our studies provide a starting point for further assessment of KET for GWI depression.

Suicidal Ideation among Veterans Living with Cancer Referred to Mental Health.

Objectives: Eliminating Veteran suicide is a top priority for the Department of Veterans' Affairs (VA). This study identified factors associated with suicidal ideation (SI) among a rarely studied subgroup of Veterans: those with cancer.Methods: Veterans (age M = 61.83) with cancer (N= 175) referred for psychological evaluation completed measures of pain, sleep, depressive, anxiety, and PTSD symptoms. SI was defined by endorsing on paper-and-pencil questionnaire thoughts of killing oneself in the past 2 weeks or during clinical interview.Results: 25.1% reported SI. Compared to those without SI, Veterans with SI had higher ratings on measures of depression, anxiety, and PTSD symptoms. History of suicide attempt(s) was included in the model due to clinical significance. Logistic regression was performed with these variables as predictors of SI. The omnibus model was significant (p< .001). However, only anhedonia and depressed mood had a statistically significant contribution to the model (ß = 0.540, p= .001).Conclusions: Anhedonia and depressed mood predicted SI among Veterans with cancer above and beyond other risk factors.Clinical Implications: This study's findings highlight the importance of incorporating suicide risk screenings in oncology clinics across VA medical centers.

Mental health utilization among veterans at risk for suicide: Data from a post-deployment clinic.

The current study aim was to examine mental health characteristics in a sample of returning OEF/OIF/OND veterans initially enrolling in Department of Veterans Affairs (VA) health care (N = 1,307), with a particular focus on a subgroup considered at risk for suicide (N = 445). Methods included examination of mental health screening measures and clinical interview data from a VA postdeployment clinic. Half of the sample met criteria for a mental health disorder, whereas 10% reported current suicidal or death ideation (e.g., thoughts of being better off dead or hurting oneself in some way) and 6% reported a history of suicide attempt. Sixty-eight percent of the at-risk subgroup accepted a referral for mental health treatment and a promising majority (78%) of those individuals attended their initial specialty mental health visit. At-risk veterans who accepted mental health referral were more likely to report current suicidal/death ideation; they were also more likely to have a diagnosis of a depressive disorder, anxiety disorder, or posttraumatic stress disorder. Factors associated with mental health appointment attendance included older age, being enrolled in college, and more years of military service. Results highlight the importance of early screening and referral to appropriate mental health follow-up. Implications for clinical practice and increasing engagement in VA mental health services among veterans at risk for suicide are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Targeting Intracellular Calcium Stores Alleviates Neurological Morbidities in a DFP-Based Rat Model of Gulf War Illness.

Gulf War Illness (GWI) is a chronic multi-symptom disorder afflicting the veterans of the First Gulf War, and includes neurological symptoms characterized by depression and memory deficits. Chronic exposure to organophosphates (OPs) is considered a leading cause for GWI, yet its pathobiology is not fully understood. We recently observed chronic elevations in neuronal Ca2+ levels ([Ca2+]i) in an OP-diisopropyl fluorophosphate (DFP)-based rat model for GWI. This study was aimed at identifying mechanisms underlying elevated [Ca2+]i in this DFP model and investigating whether their therapeutic targeting could improve GWI-like neurological morbidities. Male Sprague-Dawley rats (9 weeks) were exposed to DFP (0.5 mg/kg, s.c., 1×-daily for 5 days) and at 3 months postDFP exposure, behavior was assessed and rats were euthanized for protein estimations and ratiometric Fura-2 [Ca2+]i estimations in acutely dissociated hippocampal neurons. In DFP rats, a sustained elevation in intracellular Ca2+ levels occurred, and pharmacological blockade of Ca2+-induced Ca2+-release mechanisms significantly lowered elevated [Ca2+]i in DFP neurons. Significant reductions in the protein levels of the ryanodine receptor (RyR) stabilizing protein Calstabin2 were also noted. Such a posttranslational modification would render RyR "leaky" resulting in sustained DFP [Ca2+]i elevations. Antagonism of RyR with levetiracetam significantly lower elevated [Ca2+]i in DFP neurons and improved GWI-like behavioral symptoms. Since Ca2+ is a major second messenger molecule, such chronic increases in its levels could underlie pathological synaptic plasticity that expresses itself as GWI morbidities. Our studies show that treatment with drugs targeted at blocking intracellular Ca2+ release could be effective therapies for GWI neurological morbidities.

Hypothermia Reduces Mortality, Prevents the Calcium Plateau, and Is Neuroprotective Following Status Epilepticus in Rats.

Status Epilepticus (SE) is a major neurological emergency and is considered a leading cause of Acquired Epilepsy (AE). We have shown that SE produces neuronal injury and prolonged alterations in hippocampal calcium levels ([Ca2+]i) that may underlie the development of AE. Interventions preventing the SE-induced Ca2+ plateau could therefore prove to be beneficial in lowering the development of AE after SE. Hypothermia is used clinically to prevent neurological complications associated with Traumatic Brain Injury, cardiac arrest, and stroke. Here, we investigated whether hypothermia prevented the development of Ca2+ plateau following SE. SE was induced in hippocampal neuronal cultures (HNC) by exposing them to no added MgCl2 solution for 3 h. To terminate SE, low Mg2+ solution was washed off with 31°C (hypothermic) or 37°C (normothermic) physiological recording solution. [Ca2+]i was estimated with ratiometric Fura-2 imaging. HNCs washed with hypothermic solution exhibited [Ca2+]i ratios, which were significantly lower than ratios obtained from HNCs washed with normothermic solution. For in vivo SE, the rat pilocarpine (PILO) model was used. Moderate hypothermia (30-33°C) in rats was induced at 30-min post-SE using chilled ethanol spray in a cold room. Hypothermia following PILO-SE significantly reduced mortality. Hippocampal neurons isolated from hypothermia-treated PILO SE rats exhibited [Ca2+]i ratios which were significantly lower than ratios obtained from PILO SE rats. Hypothermia also provided significant neuroprotection against SE-induced delayed hippocampal injury as characterized by decreased FluoroJade C labeling in hypothermia-treated PILO SE rats. We previously demonstrated that hypothermia reduced Ca2+ entry via N-methyl-D-aspartate and ryanodine receptors in HNC. Together, our studies indicate that by targeting these two receptor systems hypothermia could interfere with epileptogenesis and prove to be an effective therapeutic intervention for reducing SE-induced AE.

Chronic Neurological Morbidities and Elevated Hippocampal Calcium Levels in a DFP-Based Rat Model of Gulf War Illness.

Over 20 yr have elapsed since the end of the First Gulf War, yet approximately one-third of the veterans exhibit Gulf War Illness (GWI) symptoms, particularly depression and memory impairments. Exposure to organophosphate (OP) compounds is implicated for GWI development. The role of calcium (Ca2+) signaling in learning, memory, and mood is well established and disruptions in Ca2+ homeostasis are observed in many neurological disorders. However, the status of Ca2+ homeostasis in the development of GWI behavioral impairments is not known. Male Sprague-Dawley rats were exposed to OP agent diisopropyl fluorophosphate (DFP; 0.5 mg/kg, s.c. 5 days), and at 6 mo post-DFP exposure, rats were subjected to behavioral assays for the determination of GWI neurological morbidities. Fura-2AM loaded acutely isolated hippocampal neurons were used for [Ca2+]i estimations. We observed chronic depressive symptoms and cognitive deficits in rats exposed to repeated low-dose DFP. The GWI rats also manifested elevations in hippocampal [Ca2+]i along with a significant increase in the number of neurons displaying these elevations. As Ca2+ is a major second-messenger molecule, such sustained increases in its levels could activate multiple signaling cascades and alter gene expression of proteins involved in synaptic plasticity and possibly underlie the neuronal injury and chronic morbidities in GWI.

Pain and psychiatric comorbidities among two groups of Iraq and Afghanistan era Veterans.

This study aimed to (1) identify the prevalence and severity of pain and psychiatric comorbidities among personnel who had been deployed during Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) and (2) assess whether the Department of Veterans Affairs (VA) Polytrauma System of Care and an OIF/OEF/OND registry reflect real differences among patients. Participants (N = 359) were recruited from two VA hospitals. They completed a clinical interview, structured diagnostic interview, and self-report measures. Results indicated pain was the most common complaint, with 87 percent experiencing pain during the prior week and 56 percent reporting moderate or severe pain. Eighty percent of participants met criteria for at least one of seven assessed comorbid problems (moderate or severe pain, postconcussional disorder, posttraumatic stress disorder [PTSD], anxiety disorder, mood disorder, substance use disorder, psychosis), and 59 percent met criteria for two or more problems. PTSD and postconcussional disorder rarely occurred in the absence of pain or other comorbidities (0.3% and 0%, respectively). The Polytrauma group had more comorbid psychiatric conditions (χ(2) = 48.67, p < 0.05) and reported greater severity of symptoms (p < 0.05) than the Registry group. This study confirmed the high prevalence of pain and concurrent mental health problems among personnel returning from military deployment.

Role of the calcium plateau in neuronal injury and behavioral morbidities following organophosphate intoxication.

Organophosphate (OP) chemicals include nerve agents and pesticides, and there is a growing concern of OP-based chemical attacks against civilians. Current antidotes are essential in limiting immediate mortality associated with OP exposure. However, further research is needed to identify the molecular mechanisms underlying long-term neurological deficits following survival of OP toxicity in order to develop effective therapeutics. We have developed rat survival models of OP-induced status epilepticus (SE) that mimic chronic mortality and morbidity following OP intoxication. We have observed significant elevations in hippocampal calcium levels after OP SE that persisted for weeks following initial survival. Drugs inhibiting intracellular calcium-induced calcium release, such as dantrolene, levetiracetam, and carisbamate, lowered OP SE-mediated protracted calcium elevations. Given the critical role of calcium signaling in modulating behavior and cell death mechanisms, drugs targeted at preventing the development of the calcium plateau could enhance neuroprotection, help reduce morbidity, and improve outcomes following survival of OP SE.

Pharmacological blockade of the calcium plateau provides neuroprotection following organophosphate paraoxon induced status epilepticus in rats.

Organophosphate (OP) compounds which include nerve agents and pesticides are considered chemical threat agents. Currently approved antidotes are crucial in limiting OP mediated acute mortality. However, survivors of lethal OP exposure exhibit delayed neuronal injury and chronic behavioral morbidities. In this study, we investigated neuroprotective capabilities of dantrolene and carisbamate in a rat survival model of paraoxon (POX) induced status epilepticus (SE). Significant elevations in hippocampal calcium levels were observed 48-h post POX SE survival, and treatment with dantrolene (10mg/kg, i.m.) and carisbamate (90mg/kg, i.m.) lowered these protracted calcium elevations. POX SE induced delayed neuronal injury as characterized by Fluoro Jade C labeling was observed in critical brain areas including the dentate gyrus, parietal cortex, amygdala, and thalamus. Dantrolene and carisbamate treatment provided significant neuroprotection against delayed neuronal damage in these brain regions when administered one-hour after POX-SE. These results indicate that dantrolene or carisbamate could be effective adjuvant therapies to the existing countermeasures to reduce neuronal injury and behavioral morbidities post OP SE survival.

Validity of Center for Epidemiologic Studies Depression (CES-D) scale in a sample of Iraq and Afghanistan Veterans.

OBJECTIVES: Optimal depression screening necessitates measurement tools that are valid across varied populations and in the presence of comorbidities. METHODS: This study assessed the test properties of two versions of the Center for Epidemiologic Studies Depression scale against psychiatric diagnoses established by the Mini International Neuropsychiatric Interview among a clinical sample of US Veterans deployed during Operations Enduring Freedom, Iraqi Freedom, and New Dawn. Participants (N = 359) recruited from two Department of Veterans Affairs hospitals completed a clinical interview, structured diagnostic interview, and self-reported measures. RESULTS: Based on diagnostic interview and the Diagnostic and Statistical Manual of Mental Disorders 4th Edition criteria, 29.5% of the sample met diagnostic criteria for major depressive disorder and 26.5% met diagnostic criteria for post-traumatic stress disorder. Both Center for Epidemiologic Studies Depression-20 and Center for Epidemiologic Studies Depression-10 scales performed well and almost identically against the Mini International Neuropsychiatric Interview-major depressive disorder in identifying Veterans with major depressive disorder (Center for Epidemiologic Studies Depression-20 area under the Receiver Operating Characteristic curve 91%; Center for Epidemiologic Studies Depression-10 area under the ROC curve 90%). Overall, higher cut points for the Center for Epidemiologic Studies Depression scales performed better in correctly identifying true positives and true negatives for major depressive disorder (Center for Epidemiologic Studies Depression-20 cut point 18+ sensitivity 92% specificity 72%; Center for Epidemiologic Studies Depression-10 cut point 10+ sensitivity 92% specificity 69%). CONCLUSIONS: The specificity of the Center for Epidemiologic Studies Depression scales was poor among Veterans with co-occurring post-traumatic stress disorder (13% and 16%). Veterans with post-traumatic stress disorder who have a positive depression screen should have a more thorough assessment of mental health symptoms and comorbidities, rather than immediate diagnosis of and treatment for depression.

Sex differences between Veterans participating in interdisciplinary chronic pain rehabilitation.

The improved management of pain among the growing number of female Veterans receiving care through the Veterans Health Administration has been established as a priority, but studies suggest that females may respond differently to pain treatment. This study explored differences between female and male Veterans engaged in a Chronic Pain Rehabilitation Program and determined how female and male Veterans change following participation. Veterans (N = 324) in a 3 wk inpatient program completed self-report measures at admission, discharge, and 3 mo follow-up. Participants were 21% female (n = 67) and 79% male (n = 257). Compared with males, females were younger and less likely to be white or married/partnered. Females reported shorter pain duration and were more likely to have primary head or limb pain. At admission, fewer females were prescribed opioids than males and at lower doses. After opioid cessation in the program, however, there were no significant differences in use between the sexes at follow-up. Improvements in a range of domains were sustained at follow-up for both sexes, but females did not maintain gains in pain intensity or sleep while males reported more pain-related fear at discharge and follow-up. This study adds to the literature on sex-specific variations in chronic pain and implications for treatment.