Lightning Strike Injuries.

Lightning is a common environmental hazard, and is a significant cause of global injury and death. Care and evaluation should follow general trauma guidelines, but several unique aspects of lightning injuries necessitate deviations from standard care that can improve survival and overall outcomes. When evaluating lightning strike patients, some common injury patterns are pathognomonic for lightning strikes and easy to recognize, while others are subtle and require heightened awareness. While most lightning-related injuries resolve spontaneously, some may have significant long-term symptoms. Anticipatory guidance and specialty referral may be needed for appropriate follow-up, evaluation, and treatment.

Impact of SARS-CoV-2 Infection on Long-Term Depression Symptoms among Veterans.

BACKGROUND: Prior research demonstrates that SARS-COV-2 infection can be associated with a broad range of mental health outcomes including depression symptoms. Veterans, in particular, may be at elevated risk of increased depression following SARS-COV-2 infection given their high rates of pre-existing mental and physical health comorbidities. However, few studies have tried to isolate SARS-COV-2 infection associations with long term, patient-reported depression symptoms from other factors (e.g., physical health comorbidities, pandemic-related stress). OBJECTIVE: To evaluate the association between SARS-COV-2 infection and subsequent depression symptoms among United States Military Veterans. DESIGN: Survey-based non-randomized cohort study with matched comparators. PARTICIPANTS: A matched-dyadic sample from a larger, stratified random sample of participants with and without known to SARS-COV-2 infection were invited to participate in a survey evaluating mental health and wellness 18-months after their index infection date. Sampled participants were stratified by infection severity of the participant infected with SARS-COV-2 (hospitalized or not) and by month of index date. A total of 186 participants in each group agreed to participate in the survey and had sufficient data for inclusion in analyses. Those in the uninfected group who were later infected were excluded from analyses. MAIN MEASURES: Participants were administered the Patient Health Questionnaire-9 as part of a phone interview survey. Demographics, physical and mental health comorbidities were extracted from VHA administrative data. KEY RESULTS: Veterans infected with SARS-COV-2 had significantly higher depression symptoms scores compared with those uninfected. In particular, psychological symptoms (e.g., low mood, suicidal ideation) scores were elevated relative to the comparator group (MInfected = 3.16, 95%CI: 2.5, 3.8; MUninfected = 1.96, 95%CI: 1.4, 2.5). Findings were similar regardless of history of depression. CONCLUSION: SARS-COV-2 infection was associated with more depression symptoms among Veterans at 18-months post-infection. Routine evaluation of depression symptoms over time following SARS-COV-2 infection is important to facilitate adequate assessment and treatment.

Buprenorphine Receipt and Retention for Opioid Use Disorder Following an Initiative to Increase Access in Primary Care.

OBJECTIVES: Buprenorphine, a medication for opioid use disorder (OUD), is underutilized in general medical settings. Further, it is inequitably received by racialized groups and persons with comorbidities. The Veterans Health Administration launched an initiative to increase buprenorphine receipt in primary care. The project's objective was to identify patient-related factors associated with buprenorphine receipt and retention in primary care clinics (n = 18) participating in the initiative. METHODS: Retrospective cohort quality improvement evaluation of patients 18 years or older with 2 or more primary care visits in a 1-year period and an OUD diagnosis in the year before the first primary care visit (index date). Buprenorphine receipt was the proportion of patients with OUD who received 1 or more buprenorphine prescriptions from primary care providers during the post-index year and retention the proportion who received buprenorphine for 180 days or longer. RESULTS: Of 2880 patients with OUD seen in primary care, 11.7% (95% confidence interval [CI], 10.6%-12.9%) received buprenorphine in primary care, 58.2% (95% CI, 52.8%-63.3%) of whom were retained on buprenorphine for 180 days or longer. Patients with alcohol use disorder (adjusted odds ratio [AOR], 0.39; 95% CI, 0.27-0.57), nonopioid drug use disorder (AOR, 0.64; 95% CI, 0.45-0.93), and serious mental illness (AOR, 0.60; 95% CI, 0.37-0.97) had lower buprenorphine receipt. Those with an anxiety disorder had higher buprenorphine receipt (AOR, 1.42; 95% CI, 1.04-1.95). Buprenorphine receipt (AOR, 0.55; 95% CI, 0.35-0.87) and 180-day retention (AOR, 0.40; 95% CI, 0.19-0.84) were less likely among non-Hispanic Black patients. CONCLUSIONS: Further integration of addiction services in primary care may be needed to enhance buprenorphine receipt for patients with comorbid substance use disorders, and interventions are needed to address disparities in receipt and retention among non-Hispanic Black patients.

"The Only Reason I Am Willing to Do It at All": Evaluation of VA's SUpporting Primary care Providers in Opioid Risk reduction and Treatment (SUPPORT) Center.

OBJECTIVES: Medication treatment for opioid use disorder (MOUD) is effective and recommended for outpatient settings. We implemented and evaluated the SUpporting Primary care Providers in Opioid Risk reduction and Treatment (SUPPORT) Center-a quality improvement partnership to implement stepped care for MOUD in 2 Veterans Health Administration (VA) primary care (PC) clinics. METHODS: SUPPORT provided a dedicated clinical team (nurse practitioner prescriber and social worker) and stepped care ([1] identification, assessment, referral; [2] MOUD induction; [3] stabilization; and [4] maintenance supporting PC providers [PCPs] to initiate and/or sustain treatment) coupled with ongoing internal facilitation (consultation, trainings, informatics support). Qualitative interviews with stakeholders (PCPs and patients) and meeting notes identified barriers and facilitators to implementation. Electronic health record and patient tracking data measured reach, adoption, and implementation outcomes descriptively. RESULTS: SUPPORT's implementation barriers included the need for an X-waiver, VA's opioid tapering policies, patient and PCP knowledge gaps and PCP discomfort, and logistical compatibility and sustainability challenges for clinics. SUPPORT's dedicated clinical staff, ongoing internal facilitation, and high patient and PCP satisfaction were key facilitators. SUPPORT (January 2019 to September 2021) trained 218 providers; 63 received X-waivers, and 23 provided MOUD (10.5% of those trained). SUPPORT provided care to 167 patients, initiated MOUD for 33, and provided education and naloxone to 72 (all = 0 in year before launch). CONCLUSIONS: SUPPORT reached many PCPs and patients and resulted in small increases in MOUD prescribing and high levels of stakeholder satisfaction. Dedicated clinical staff was key to observed successes. Although resource-intensive, SUPPORT offers a potential model for outpatient MOUD provision.

Risk of Suicide-Related Outcomes After SARS-COV-2 Infection: Results from a Nationwide Observational Matched Cohort of US Veterans.

BACKGROUND: Negative mental health-related effects of SARS-COV-2 infection are increasingly evident. However, the impact on suicide-related outcomes is poorly understood, especially among populations at elevated risk. OBJECTIVE: To determine risk of suicide attempts and other self-directed violence (SDV) after SARS-COV-2 infection in a high-risk population. DESIGN: We employed an observational design supported by comprehensive electronic health records from the Veterans Health Administration (VHA) to examine the association of SARS-COV-2 infection with suicide attempts and other SDV within one year of infection. Veterans with SARS-COV-2 infections were matched 1:5 with non-infected comparators each month. Three periods after index were evaluated: days 1-30, days 31-365, and days 1-365. PARTICIPANTS: VHA patients infected with SARS-COV-2 between March 1, 2020 and March 31, 2021 and matched non-infected Veteran comparators. MAIN MEASURES: Suicide attempt and other SDV events for the COVID-19 and non-infected comparator groups were analyzed using incidence rates per 100,000 person years and hazard ratios from Cox regressions modeling time from matched index date to first event. Subgroups were also examined. KEY RESULTS: 198,938 veterans with SARS-COV-2 (COVID-19 group) and 992,036 comparators were included. Unadjusted one-year incidence per 100,000 for suicide attempt and other SDV was higher among the COVID-19 group: 355 vs 250 and 327 vs 235, respectively. The COVID-19 group had higher risk than comparators for suicide attempts: days 1-30 hazard ratio (HR) = 2.54 (CI:2.05, 3.15), days 31-365 HR = 1.30 (CI:1.19, 1.43) and days 1-365 HR = 1.41 (CI:1.30, 1.54), and for other SDV: days 1-30 HR = 1.94 (CI:1.51, 2.49), days 31-365 HR = 1.32 (CI:1.20, 1.45) and days 1-365 HR = 1.38 (CI:1.26, 1.51). CONCLUSIONS: COVID-19 patients had higher risks of both suicide attempts and other forms of SDV compared to uninfected comparators, which persisted for at least one year after infection. Results support suicide risk screening of those infected with SARS-COV-2 to identify opportunities to prevent self-harm.

Impact of an intervention to implement provision of opioid use disorder medication among patients with and without co-occurring substance use disorders.

INTRODUCTION: Co-occurring substance use disorders (SUDs) are common among people with opioid use disorder (OUD) and known to hinder receipt of medications for OUD (MOUD). It is important to understand how MOUD care implemented outside of SUD specialty settings impacts access for patients with co-occurring SUDs. The Veterans Health Administration's (VA) Stepped Care for Opioid Use Disorder Train the Trainer (SCOUTT) initiative was implemented in primary care, mental health, and pain clinics in 18 VA facilities, and was found to increase MOUD receipt. This study assessed the SCOUTT initiative's impact among patients with and without co-occurring SUDs. METHODS: This study used a controlled interrupted time series design. We extracted electronic health record data for patients with OUD with visits in SCOUTT intervention or matched comparison clinics during the post-implementation year (9/1/2018-8/31/2019). We examined the monthly proportion of patients who received MOUD in SCOUTT intervention or comparison clinics (primary care, mental health, and pain clinics), or in a VA SUD specialty clinic (where patients may have been referred), during the pre- and post-implementation years. Segmented logistic regression models estimated pre-post changes in outcomes (immediate level change from the final month of the pre-implementation period to the first month of the post-implementation period, change in trend/slope) in intervention vs. comparison facilities, adjusting for patient characteristics and pre-implementation trends. We stratified analyses by the presence of co-occurring SUDs. RESULTS: Among patients without co-occurring SUDs, the pre-post trend/slope change in MOUD received in SCOUTT intervention or comparison clinics was greater in intervention vs. comparison facilities (adjusted odds ratio [aOR]: 1.06, 95% confidence interval [CI]: 1.02-1.10), and the immediate increase in MOUD received in SUD clinics was greater in intervention vs. comparison facilities (aOR: 1.12, 95% CI: 1.02-1.22). These changes did not significantly differ in intervention vs. comparison facilities among patients with co-occurring SUDs. CONCLUSIONS: The SCOUTT initiative may have increased MOUD receipt primarily among patients without co-occurring SUDs. Focusing on increasing MOUD receipt for patients with co-occurring SUDs may improve the overall effectiveness of MOUD implementation efforts.

Towards shortening the Brief Addiction Monitor-Revised (BAM-R).

Introduction: The Brief Addiction Monitor-Revised (BAM-R) is a widely used, 17-item assessment of substance use, risk, and protective factors associated with recovery from substance use disorders. Despite wide adoption in the U.S. Department of Veterans Affairs (VA) and recommendations for use in measurement-based care (MBC), administration may not be feasible in many MBC settings due to time constraints. The purpose of this study was to derive a shortened version of the BAM-R for use in fast-paced healthcare settings. Methods: BAM-R data from 32,002 Veterans were obtained through the VA's Corporate Data Warehouse. We used logistic regression models to identify items for removal based on prediction of two clinical outcomes (90-day substance use disorder (SUD) treatment retention and 12-month mortality) and item-level sensitivity to change during substance use treatment. Results: Although no intake BAM-R items predicted SUD treatment retention or mortality, effect sizes for item-level sensitivity to change during substance use treatment varied from small to large. Seven items were judged as relevant for MBC of SUD. Among all BAM-R items, Heavy Alcohol Use, Self-Help, Drug Use, Craving, and Mood items demonstrated the greatest magnitude of sensitivity to change. Conclusions: Although additional research is recommended before a shortened BAM-R can be implemented in non-specialty MBC settings, we identified 5 BAM-R items with perceived clinical utility and scores that demonstrated evidence of sensitivity to change. Shortening the BAM-R increases feasibility of use, though more work is needed to optimize measurement for SUD MBC.

Clinician Perspectives on Delivering Medication Treatment for Opioid Use Disorder during the COVID-19 Pandemic: A Qualitative Evaluation.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic necessitated changes in opioid use disorder care. Little is known about COVID-19's impact on general healthcare clinicians' experiences providing medication treatment for opioid use disorder (MOUD). This qualitative evaluation assessed clinicians' beliefs about and experiences delivering MOUD in general healthcare clinics during COVID-19. METHODS: Individual semistructured interviews were conducted May through December 2020 with clinicians participating in a Department of Veterans Affairs initiative to implement MOUD in general healthcare clinics. Participants included 30 clinicians from 21 clinics (9 primary care, 10 pain, and 2 mental health). Interviews were analyzed using thematic analysis. RESULTS: The following 4 themes were identified: overall impact of the pandemic on MOUD care and patient well-being, features of MOUD care impacted, MOUD care delivery, and continuance of telehealth for MOUD care. Clinicians reported a rapid shift to telehealth care, resulting in few changes to patient assessments, MOUD initiations, and access to and quality of care. Although technological challenges were noted, clinicians highlighted positive experiences, including treatment destigmatization, more timely visits, and insight into patients' environments. Such changes resulted in more relaxed clinical interactions and improved clinic efficiency. Clinicians reported a preference for in-person and telehealth hybrid care models. CONCLUSIONS: After the quick shift to telehealth-based MOUD delivery, general healthcare clinicians reported few impacts on quality of care and highlighted several benefits that may address common barriers to MOUD care. Evaluations of in-person and telehealth hybrid care models, clinical outcomes, equity, and patient perspectives are needed to inform MOUD services moving forward.

Associations Between Distinct Co-occurring Substance Use Disorders and Receipt of Medications for Opioid Use Disorder in the Veterans Health Administration.

OBJECTIVES: Among people with opioid use disorder (OUD), having a co-occurring substance use disorder (SUD) is associated with lower likelihood of receiving OUD treatment medications (MOUD). However, it is unclear how distinct co-occurring SUDs are associated with MOUD receipt. This study examined associations of distinct co-occurring SUDs with initiation and continuation of MOUD among patients with OUD in the national Veterans Health Administration (VA). METHODS: Electronic health record data were extracted for outpatients with OUD who received care August 1, 2016, to July 31, 2017. Analyses were conducted separately among patients without and with prior-year MOUD receipt to examine initiation and continuation, respectively. SUDs were measured using diagnostic codes; MOUD receipt was measured using prescription fills/clinic visits. Adjusted regression models estimated likelihood of following-year MOUD receipt for patients with each co-occurring SUD relative to those without. RESULTS: Among 23,990 patients without prior-year MOUD receipt, 12% initiated in the following year. Alcohol use disorder (adjusted incidence rate ratio [aIRR], 0.80; 95% confidence interval [CI], 0.72-0.90) and cannabis use disorder (aIRR, 0.78; 95% CI, 0.70-0.87) were negatively associated with initiation. Among 11,854 patients with prior-year MOUD receipt, 83% continued in the following year. Alcohol use disorder (aIRR, 0.94; 95% CI, 0.91-0.97), amphetamine/other stimulant use disorder (aIRR, 0.94; 95% CI, 0.90-0.99), and cannabis use disorder (aIRR, 0.95; 95% CI, 0.93-0.98) were negatively associated with continuation. CONCLUSIONS: In this study of national VA outpatients with OUD, those with certain co-occurring SUDs were less likely to initiate or continue MOUD. Further research is needed to identify barriers related to specific co-occurring SUDs.

Treating opioid use disorder in veterans with co-occurring substance use: a qualitative study with buprenorphine providers in primary care, mental health, and pain settings.

BACKGROUND: Most people with opioid use disorder (OUD) have co-occurring substance use, which is associated with lower receipt of OUD medications (MOUD). Expanding MOUD provision and care linkage outside of substance use disorder (SUD) specialty settings is a key strategy to increase access. Therefore, it is important to understand how MOUD providers in these settings approach care for patients with co-occurring substance use. This qualitative study of Veterans Health Administration (VA) clinicians providing buprenorphine care in primary care, mental health, and pain settings aimed to understand (1) their approach to addressing OUD in patients with co-occurring substance use, (2) perspectives on barriers/facilitators to MOUD receipt for this population, and (3) support needed to increase MOUD receipt for this population. METHODS: We interviewed a purposive sample of 27 clinicians (12 primary care, 7 mental health, 4 pain, 4 pharmacists) in the VA northwest network. The interview guide assessed domains of the Tailored Implementation for Chronic Diseases Checklist. Interviews were transcribed and qualitatively analyzed using inductive content analysis. RESULTS: Participants reported varied approaches to identifying co-occurring substance use and addressing OUD in this patient population. Although they reported that this topic was not clearly addressed in clinical guidelines or training, participants generally felt that patients with co-occurring substance use should receive MOUD. Some viewed their primary role as providing this care, others as facilitating linkage to OUD care in SUD specialty settings. Participants reported multiple barriers and facilitators to providing buprenorphine care to patients with co-occurring substance use and linking them to SUD specialty care, including provider, patient, organizational, and external factors. CONCLUSIONS: Efforts are needed to support clinicians outside of SUD specialty settings in providing buprenorphine care to patients with co-occurring substance use. These could include clearer guidelines and policies, more specific training, and increased care integration or cross-disciplinary collaboration. Simultaneously, efforts are needed to improve linkage to specialty SUD care for patients who would benefit from and are willing to receive this care, which could include increased service availability and improved referral/hand-off processes. These efforts may increase MOUD receipt and improve OUD care quality for patients with co-occurring substance use.

Risk Factors for Chronic Prescription Opioid Use in Multiple Sclerosis.

OBJECTIVE: To characterize patterns of prescription opioid use among individuals with multiple sclerosis (MS) and identify risk factors associated with chronic use. DESIGN: Retrospective longitudinal cohort study examining US Department of Veterans Affairs electronic medical record data of Veterans with MS. The annual prevalence of prescription opioid use by type (any, acute, chronic, incident chronic) was calculated for each study year (2015-2017). Multivariable logistic regression was used to identify demographics and medical, mental health, and substance use comorbidities in 2015-2016 associated with chronic prescription opioid use in 2017. SETTING: US Department of Veterans Affairs, Veteran's Health Administration. PARTICIPANTS: National sample of Veterans with MS (N=14,974). MAIN OUTCOME MEASURE: Chronic prescription opioid use (≥90 days). RESULTS: All types of prescription opioid use declined across the 3 study years (chronic opioid use prevalence=14.6%, 14.0%, and 12.2%, respectively). In multivariable logistic regression, prior chronic opioid use, history of pain condition, paraplegia or hemiplegia, post-traumatic stress disorder, and rural residence were associated with greater risk of chronic prescription opioid use. History of dementia and psychotic disorder were both associated with lower risk of chronic prescription opioid use. CONCLUSION: Despite reductions over time, chronic prescription opioid use remains common among a substantial minority of Veterans with MS and is associated with multiple biopsychosocial factors that are important for understanding risk for long-term use.

Stand Down-Think Before You Drink: protocol for an effectiveness-implementation trial of a mobile application for unhealthy alcohol use with and without peer support.

INTRODUCTION: Mobile apps can increase access to alcohol-related care but only if patients actively engage with them. Peers have shown promise for facilitating patients' engagement with mobile apps. However, the effectiveness of peer-based mobile health interventions for unhealthy alcohol use has yet to be evaluated in a randomised controlled trial. The goal of this hybrid I effectiveness-implementation study is to test a mobile app ('Stand Down-Think Before You Drink'), with and without peer support, to improve drinking outcomes among primary care patients. METHODS AND ANALYSIS: In two US Veterans Health Administration (VA) medical centres, 274 primary care patients who screen positive for unhealthy alcohol use and are not currently in alcohol treatment will be randomised to receive usual care (UC), UC plus access to Stand Down (App), or UC plus Peer-Supported Stand Down (PSSD-four peer-led phone sessions over the initial 8 weeks to enhance app engagement). Assessments will occur at baseline and 8-, 20- and 32-weeks postbaseline. The primary outcome is total standard drinks; secondary outcomes include drinks per drinking day, heavy drinking days and negative consequences from drinking. Hypotheses for study outcomes, as well as treatment mediators and moderators, will be tested using mixed effects models. Semi-structured interviews with patients and primary care staff will be analysed using thematic analysis to identify potential barriers and facilitators to implementation of PSSD in primary care. ETHICS AND DISSEMINATION: This protocol is a minimal risk study and has received approval from the VA Central Institutional Review Board. The results have the potential to transform the delivery of alcohol-related services for primary care patients who engage in unhealthy levels of drinking but rarely seek treatment. Study findings will be disseminated through collaborations with healthcare system policymakers as well as publications to scholarly journals and presentations at scientific conferences. TRIAL REGISTRATION NUMBER: NCT05473598.

A controlled examination of acute warning signs for suicide attempts among hospitalized patients.

BACKGROUND: Near-term risk factors for suicidal behavior, referred to as 'warning signs' (WS), distinguish periods of acute heightened risk from periods of lower risk within an individual. No prior published study has examined, using a controlled study design, a broad set of hypothesized WS for suicide attempt. This study addressed this gap through examination of hypothesized behavioral/experiential, cognitive, and affective WS among patients recently hospitalized following a suicide attempt. METHODS: Participants were recruited during hospitalization from five medical centers across the USA including two civilian hospitals and three Veterans Health Administration facilities (n = 349). A within-person case-crossover study design was used, where each patient served as her/his own control. WS were measured by the Timeline Follow-back for Suicide Attempts Interview and were operationalized as factors that were present (v. absent) or that increased in frequency/intensity within an individual during the 6 h preceding the suicide attempt (case period) compared to the corresponding 6 h on the day before (control period). RESULTS: Select WS were associated with near-term risk for suicide attempt including suicide-related communications, preparing personal affairs, drinking alcohol, experiencing a negative interpersonal event, and increases in key affective (e.g. emptiness) and cognitive (e.g. burdensomeness) responses. CONCLUSIONS: The identification of WS for suicidal behavior can enhance risk recognition efforts by medical providers, patients, their families, and other stakeholders that can serve to inform acute risk management decisions.

U.S. veterans' experiences and factors associated with use of a smartphone application to self-manage unhealthy alcohol use.

Unhealthy alcohol use is common among Operations Enduring and Iraqi Freedom (OEF/OIF) veterans, yet barriers discourage treatment-seeking. Mobile applications (apps) that deliver alcohol interventions have potential to address these barriers and increase treatment receipt. Few studies have qualitatively assessed users' experiences with apps to manage alcohol use. We assessed OEF/OIF veterans' experiences with Step Away, an app to reduce alcohol-related risks, to identify factors that may influence engagement. This single-arm pilot study recruited OEF/OIF veterans with positive alcohol screens nationwide using mail/telephone. Veterans aged 18-55 who exceeded drinking guidelines and owned an iPhone were eligible. Twenty-one (16 men, 5 women) of 55 participants completed interviews. Interviews were analyzed using thematic analysis. Participants found Step Away easy to use, although setup was time consuming. Participants reported increased awareness of alcohol use, highlighting daily assessment, weekly feedback, goal setting, and high-risk notification features as helpful and associated awareness with an intent to decrease use. Participants described Step Away as informative, with over half reporting they would use it outside of the study and most recommending it. Suggestions for improvement included greater personalization and control over features. Step Away features appear to influence engagement and increase users' awareness about alcohol consumed and factors associated with drinking, as well as intent to change. Assessment, feedback, and customization features of apps may facilitate app engagement. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Association between clinically recognized suicidality and subsequent initiation or continuation of medications for opioid use disorder.

BACKGROUND: Among individuals with opioid use disorder (OUD), medications for OUD (MOUD) may lower suicide risk. Therefore, it is important that individuals with OUD and suicidality receive MOUD. This study examined associations between clinically recognized suicidality and subsequent initiation or continuation of MOUD among patients with OUD in the national Veterans Health Administration (VA). METHODS: Electronic health record data were extracted for outpatients with OUD who received VA care 10/1/2016-7/31/2017. Suicidality was measured using diagnostic codes for suicidal ideation/attempt and patient record flags. Analyses were conducted separately among patients without prior-year MOUD receipt to examine MOUD initiation, and with prior-year MOUD receipt to examine MOUD continuation. Poisson regression models estimated likelihood of MOUD receipt in the following year for patients with prior-year suicidality relative to those without. Models were adjusted for sociodemographic and clinical characteristics. RESULTS: Among 20,085 patients with no prior-year MOUD, 12% had suicidality and 12% received MOUD in the following year. Suicidality was positively associated with MOUD initiation (adjusted incidence rate ratio [aIRR]: 1.15, 95% confidence interval [CI]: 1.04-1.28). Among 10,162 patients with prior-year MOUD, 9% had suicidality and 84% received MOUD in the following year. Suicidality was negatively associated with MOUD continuation (aIRR: 0.95, 95% CI 0.91-0.98). CONCLUSIONS: Among VA patients with OUD, clinically recognized suicidality may increase likelihood of MOUD initiation but decrease likelihood of continuation. Efforts to increase initiation overall and to support retention for patients with suicidality are needed.

Roles and Perceptions of Nurses During Implementation of a Medication Treatment for Opioid Use Disorder National Initiative.

BACKGROUND: In the United States, a national priority exists to improve access to medication treatment for opioid use disorder (MOUD). Nurses can be an essential component of that care. We examined the perceptions and evolving roles of nurses in a national Veterans Health Administration (VHA) initiative designed to improve MOUD access within general medical settings. METHODS: From April 15, 2021, to June 16, 2021, we recruited nurses participating in VHA's Stepped Care for Opioid Use Disorder Train the Trainer Initiative-a national program intending to implement MOUD in general medical settings-to participate in an interview about their roles, perceptions, and experiences. The respondents answered our inquiries through an interview or responded to an email solicitation with written responses, which were then recorded, transcribed, and independently coded to identify themes. RESULTS: Nurses from 10 VHA facilities participated in an interview (n = 7) or completed the questionnaire (n = 4). Inadequate staffing, high patient-to-provider ratios, and time constraints were identified as barriers to MOUD care. Mentorship activities, existing VHA informational resources, and patients' willingness to accept treatment were identified as facilitators of MOUD care. The Stepped Care for Opioid Use Disorder Train the Trainer Initiative processes were acknowledged to promote role confidence, which in turn increased job satisfaction and empowered nurses to become content experts. Respondents often identified nurses as local lead facilitators in MOUD care. CONCLUSIONS: In a national initiative to implement MOUD within general medical settings, nurses identified several barriers and facilitators to MOUD implementation. Nurses play vital collaborative care roles in enhancing access to MOUD.

The impact of military sexual trauma and gender on receipt of evidence-based medication treatment among veterans with opioid use disorder.

INTRODUCTION: Opioid use disorder (OUD), a chronic illness associated with substantial morbidity and mortality, is common in veterans. Despite several national Department of Veteran Affairs (VA) initiatives over the last 15 years to increase access to medications to treat OUD (MOUD), MOUD remain underutilized. Women and veterans with mental health comorbidities are less likely to receive MOUD. The current study evaluated associations between military sexual trauma (MST), one common comorbidity among veterans, and receipt of MOUD among VA outpatients. We also evaluated whether gender moderated the MST-MOUD association and whether mental health conditions were associated with lower rates of MOUD across MST status. METHODS: In a cross-sectional study using a national sample of 80,845 veterans with OUD who sought care at VA facilities from 2009 to 2017, we fit mixed-effects logistic regression models to assess the association between MST and MOUD, adjusting for demographic and clinical characteristics, and with facility modeled as a random effect. Secondary analyses added interaction terms of MST x gender and MST x mental health diagnoses and compared average predicted probabilities to evaluate whether the MST and MOUD association varied by gender or mental health diagnoses. The study used a p-value threshold of .001 to determine significance due to multiple comparisons and large sample size. RESULTS: Overall, 35% of veterans with OUD received MOUD. MST (8.1% overall; 5.2% of men, 48.8% of women) was not significantly associated with receipt of MOUD in a fully adjusted model (OR = 1.08; 99% CI 1.00, 1.17). No significant MST x gender interaction (p = .377) and no significant MST x mental health interaction (p = .722) occurred. CONCLUSIONS: Both men and women veterans with and without a history of MST received MOUD treatment at similar rates. Room for improvement exists in MOUD receipt and future research should continue to assess barriers to MOUD receipt.

Benzodiazepine Treatment and Hospital Course of Medical Inpatients With Alcohol Withdrawal Syndrome in the Veterans Health Administration.

OBJECTIVE: To describe initial benzodiazepine dosing strategies and factors associated with variation in benzodiazepine dosing in a national cohort of hospitalized patients with alcohol withdrawal syndrome (AWS). PATIENTS AND METHODS: This cross-sectional study included adult patients with AWS admitted to medical services and treated with benzodiazepines at 93 Veterans Health Administration hospitals in 2013. Treatment was categorized by initial benzodiazepine dosing strategy-fixed-dose, symptom-triggered, or front-loading. Associations with patient characteristics, facility, and cumulative benzodiazepine exposure, intensive care, and intubation were evaluated. RESULTS: Among 6938 medical inpatients with AWS, 2909 (41.9%), 2829 (40.8%), and 1200 (17.3%) received treatment with symptom-triggered, fixed-dose, and front-loading benzodiazepines, respectively. The magnitude of differences in initial treatment associated with patient characteristics was small compared with differences associated with the predominant practice at a facility. Compared with fixed-dose therapy, symptom-triggered therapy was associated with higher cumulative benzodiazepine exposure (mean, 208-mg vs 182-mg diazepam equivalents) and higher probability of intensive care and intubation (28.2% vs 21.3% and 4.8% vs 3.5%, respectively). CONCLUSION: This study revealed that real-world AWS treatment of medical inpatients was often inconsistent with published guidelines recommending symptom-triggered long-acting benzodiazepines for AWS. The facility where a patient was hospitalized was associated with marked treatment variation. In contrast to prior randomized controlled trials conducted in specialized detoxification units, hospitalized patients who received symptom-triggered therapy in this study had greater cumulative benzodiazepine exposure and higher probability of intensive care and intubation than those receiving fixed-dose therapy.

Are x-waiver trainings enough? Facilitators and barriers to buprenorphine prescribing after x-waiver trainings.

BACKGROUND: In the United States, an x-waiver credential is necessary to prescribe buprenorphine medication treatment for opioid use disorder (B-MOUD). Historically, this process has required certified training, which could be a barrier to obtaining an x-waiver and subsequently prescribing. To address this barrier, the US recently removed the training requirement for some clinicians. We sought to determine if clinicians who attended x-waiver training went on to obtain an x-waiver and prescribe B-MOUD, and to examine what facilitated or impeded B-MOUD prescribing. METHODS: In September 2020, we conducted a cross-sectional, electronic survey of attendees of 15 in-person x-waiver pieces of training from June 2018 to January 2020 within the Veterans Health Administration (VHA). Of the attendees (n = 321), we surveyed current VHA clinicians who recalled taking the training. The survey assessed whether clinicians obtained the x-waiver, had prescribed B-MOUD, and barriers or facilitators that influenced B-MOUD prescribing. RESULTS: Of 251 eligible participants, 62 (24.7%) responded to the survey, including 27 (43.5%) physicians, 16 (25.8%) advanced practice clinicians, and 12 (19.4%) pharmacists. Of the 43 clinicians who could prescribe, 29 (67.4%) had obtained their x-waiver and 16 (37.2%) had reported prescribing B-MOUD. Prominent barriers to prescribing B-MOUD included a lack of supporting clinical staff and competing demands on time. The primary facilitator to prescribing was leadership support. CONCLUSION AND SCIENTIFIC SIGNIFICANCE: Nine months after x-waiver training, two-thirds of clinicians with prescribing credentials had obtained their x-waiver and one-third were prescribing B-MOUD. Removing the x-waiver training may not have the intended policy effect as other barriers to B-MOUD prescribing persist.