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.

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.

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.

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 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.

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.

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.

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.

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.

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.

Influences of poly-victimization on adolescents' pre-treatment cognitive motivations and post-treatment outcomes.

INTRODUCTION: Substance use treatment outcomes are challenging to predict: myriad potentially relevant factors influence outcomes, including age, sex, motivations, and history of victimization. METHODS: The current study seeks to assess these factors in adolescents through an evaluation of the relationship between distinct victimization profiles, sex, and cognitive factors related to substance use treatment outcomes-specifically motivation, self-efficacy, and reasons for quitting-and the relationship between these factors and posttreatment outcomes. We report sex differences in the prevalence of specific types of victimization; females are more likely than males to report poly-victimization alongside higher levels of traumagenic characteristics such as fearing for your life, chronic abuse, abuse by a trusted individual, or negative reactions to disclosure. RESULTS: Adolescents who endorsed high levels of poly-victimization and high traumagenic characteristics reported a) higher motivation for treatment, b) more reasons for quitting substance use, c) lower self-efficacy, and d) fewer adjusted days abstinent posttreatment relative to their peers. We report several sex differences: emergent poly-victimization profiles are different for males and females, class membership has a differential proportion, and, last, associations between class membership and pre-treatment cognitive motivations and posttreatment outcomes vary by sex. CONCLUSION: Clinicians working with adolescents who report poly-victimization should aim to leverage their motivation and reasons for quitting, as these factors are traditionally associated with positive outcomes. Last, interventions aimed at fostering self-efficacy may also be particularly important to improve long-term outcomes, specifically among adolescents with a history of poly-victimization.

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.

What's sleep got to do with it? Longitudinal associations between insomnia, PTSD, and alcohol use among U.S. Veterans.

U.S. veterans are at risk for insomnia, which often co-occurs with symptoms of posttraumatic stress disorder (PTSD) and alcohol use. Much of the research on veterans and these three constructs is cross-sectional and focused on unidirectional pathways. Recent theoretical and empirical evidence suggests a dynamic interplay between insomnia, PTSD, and alcohol use, yet few longitudinal studies exist. A clearer understanding of these pathways is needed to help inform integrated treatments. Using a sample of 1,230 post-9/11 veterans assessed over four time points across 12 months, we used a latent difference score modeling approach to examine proportional and dynamic change between insomnia, PTSD, and alcohol. Results revealed a complex interplay between all three constructs. Higher prior levels of both PTSD and alcohol use were associated with greater subsequent changes in insomnia symptoms (i.e., worse sleep). Moreover, although veterans drank less frequently as their insomnia symptoms worsened over time, greater changes in insomnia symptoms (i.e., worse symptoms) was a mechanism linking PTSD and more frequent drinking. As the research on interventions addressing insomnia, PTSD, and alcohol is limited, there are opportunities for researchers and clinicians to develop programs that effectively target all three in integrated treatments.

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.

Effects of an integrated mindfulness intervention for veterans with diabetes distress: a randomized controlled trial.

INTRODUCTION: US military veterans have disproportionately high rates of diabetes and diabetes-related morbidity in addition to being at risk of comorbid stress-related conditions. This study aimed to examine the effects of a technology-supported mindfulness intervention integrated into usual diabetes care and education on psychological and biobehavioral outcomes. RESEARCH DESIGN AND METHODS: Veterans (N=132) with type 1 or 2 diabetes participated in this two-arm randomized controlled efficacy trial. The intervention arm received a one-session mindfulness intervention integrated into a pre-existing program of diabetes self-management education and support (DSMES) plus one booster session and 24 weeks of home practice supported by a mobile application. The control arm received one 3-hour comprehensive DSMES group session. The primary outcome was change in diabetes distress (DD). The secondary outcomes were diabetes self-care behaviors, diabetes self-efficacy, post-traumatic stress disorder (PTSD), depression, mindfulness, hemoglobin A1C (HbA1C), body weight, and blood pressure. Assessments were conducted at baseline, 12 weeks, and 24 weeks. Participant satisfaction and engagement in home practice were assessed in the intervention group at 12 and 24 weeks. RESULTS: Intention-to-treat group by time analyses showed a statistically significant improvement in DD in both arms without significant intervention effect from baseline to 24 weeks. Examination of distal effects on DD between weeks 12 and 24 showed significantly greater improvement in the intervention arm. Improvement in DD was greater when baseline HbA1C was <8.5%. A significant intervention effect was also shown for general dietary behaviors. The secondary outcomes diabetes self-efficacy, PTSD, depression, and HbA1C significantly improved in both arms without significant intervention effects. Mindfulness and body weight were unchanged in either group. CONCLUSIONS: A technology-supported mindfulness intervention integrated with DSMES showed stronger distal effects on DD compared with DSMES control. Examination of longer-term outcomes, underlying mechanisms, and the feasibility of virtual delivery is warranted. TRIAL REGISTRATION NUMBER: NCT02928952.

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).

Mental health symptoms among American veterans during the COVID-19 Pandemic.

We examined the symptom trajectories of posttraumatic stress disorder (PTSD), depression, and anxiety among 1,230 American veterans assessed online one month prior to the COVID-19 outbreak in the United States (February 2020) through the next year (August 2020, November 2020, February 2021). Veterans slightly increased mental health symptoms over time and those with pre-pandemic alcohol and cannabis use disorders reported greater symptoms compared to those without. Women and racial/ethnic minority veterans reported greater symptoms pre-pandemic but less steep increases over time compared to men and white veterans. Findings point to the continued need for mental health care efforts with veterans.

Associations between symptoms of posttraumatic stress disorder, pain, and alcohol use disorder among OEF/OIF/OND veterans.

BACKGROUND: Alcohol use disorder (AUD) is prevalent among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND) veterans. Pain and posttraumatic stress disorder (PTSD) are highly comorbid and increase risk of AUD. Prior studies linking pain or PTSD to AUD have not explored interactions between pain and PTSD symptoms. METHODS: OEF/OIF/OND veterans (N = 1230) were recruited from social media websites for a cross-sectional study of health behavior. Pain was assessed using the Pain Outcomes Questionnaire. PTSD symptoms and PTSD symptom clusters were assessed using the Posttraumatic Stress Disorder Checklist for DSM-5. AUD symptoms were assessed with the AUD Identification Test. Linear regression models were used to test for main and interaction effects in the full sample and separately by sex. RESULTS: Both pain and PTSD symptoms were associated with increased AUD symptomology, though the relationship between pain and AUD was heighted at relatively low PTSD symptoms. With respect to PTSD symptom clusters, re-experiencing and negative cognitions and mood were associated with increased AUD symptomology. Interactions between pain and re-experiencing as well as pain and avoidance were revealed. Results for men mirrored the full sample, while an interaction between pain and negative cognitions and mood was associated with AUD in women. CONCLUSIONS: Results highlight associations between AUD, PTSD symptoms, and pain among veterans. While the relationship between pain and AUD appeared stronger in the context of low PTSD symptoms, both pain and PTSD symptoms were associated with increased AUD. Clinicians treating veterans with AUD should address the range of potential comorbidities.

Changes in alcohol use during the COVID-19 pandemic among American veterans.

BACKGROUND: The COVID-19 pandemic has had considerable behavioral health implications globally. One subgroup that may be of particular concern is U.S. veterans, who are susceptible to mental health and substance use concerns. The current study aimed to investigate changes in alcohol use and binge drinking before and during the first year of the pandemic among U.S. veterans, and how pre-pandemic mental health disorders, namely posttraumatic stress disorder (PTSD), and COVID-19-related factors like loneliness, negative reactions to COVID-19, and economic hardship influenced alcohol use trends. METHODS: 1230 veterans were recruited in February 2020 as part of a larger survey study on veteran health behaviors. Veterans were asked to complete follow-up assessments throughout the pandemic at 6, 9, and 12- months. RESULTS: Overall, veterans reported a significant decrease in alcohol use (IRR = 0.98) and binge drinking (IRR = 0.11) However, women, racial/ethnic minority veterans, and those with pre-existing PTSD exhibited smaller decreases in alcohol use and binge drinking and overall higher rates of use compared to men, White veterans, and those without PTSD. Both economic hardship and negative reactions to COVID-19 were associated with greater alcohol and binge drinking whereas loneliness showed a negative association with alcohol use and binge drinking. CONCLUSIONS: Veterans reported decreases in alcohol use and binge drinking throughout the pandemic, with heterogeneity in these outcomes noted for higher risk groups. Special research and clinical attention should be given to the behavioral health care needs of veterans in the post-pandemic period.