Prescription Opioid Dose Change Prior to Fatal Opioid-Detected Overdose.

BACKGROUND: The opioid overdose crisis continues within the U.S., and the role of prescribed opioids and prescribing patterns in overdose deaths remains an important area of research. This study investigated patterns of prescription opioids dispensed in the 12 months prior to opioid-detected overdose death in Connecticut between May 8th, 2016 and January 2nd, 2018, considering differences by demographic characteristics. METHODS: The sample included decedents who had an opioid dispensed within 30 days preceding death. Using multilevel modeling, we estimated the slope of change in mean morphine equivalent (MME) daily dose over 12 months prior to death, considering linear and quadratic effects of time. We estimated the main effects of age, sex, race, and ethnicity and their interactions with time on MME. A sensitivity analysis examined how excluding decedents who did not receive long-term (≥90 days) opioid therapy affected mean MME slopes. Secondary analysis explored differences by toxicology results. RESULTS: Among 1,580 opioid-detected deaths, 179 decedents had prescribed opioids dispensed within 30 days preceding death. Decedents' mean age was 47.3 years (±11.5), 65.5% were male, 81% White non-Hispanic, 9.5% Black non-Hispanic, and 9.5% Hispanic. In the time-only model, linear (ß=6.25, p<0.01) and quadratic (ß=0.49, p=0.02) effects of time were positive, indicating exponentially increasing dose prior to death. Linear change in MME was significantly attenuated in men compared to women (ß=-4.87, p=0.03); however, men were more likely to have non-prescription opioids in their toxicology results (p=0.02). Sensitivity analysis results supported primary findings. CONCLUSION: Rapid dose increases in dispensed opioids may be associated with opioid-detected overdose deaths, especially among women.

Pain Care at Home to Amplify Function: Protocol Article.

Guidelines recommend strategies to optimize opioid medication safety, including frequent reassessment of the benefits and harms of long-term opioid therapy. Prescribers, who are predominantly primary care providers (PCPs), may lack the training or resources to implement these guideline-concordant practices. Two interventions have been designed to assist PCPs and tested within the Veterans Health Administration (VHA). Telemedicine Collaborative Management (TCM) provides primarily medication management support via care manager-prescriber teams. Cooperative Pain Education and Self-Management (COPES) promotes self-management strategies for chronic pain via cognitive behavior therapy techniques. Each intervention has been shown to improve prescribing and/or patient outcomes. The added value of combining these interventions is untested. With funding and central coordination by the Integrative Management of Chronic Pain and Opioid Use Disorder for Whole Recovery (IMPOWR) Network of the National Institutes of Health Helping to End Addiction Long-term (HEAL) Initiative, we will conduct a multisite patient-level randomized hybrid II effectiveness-implementation trial within VHA to compare TCM to TCM + COPES on the primary composite outcome of pain interference and opioid safety, secondary outcomes of alcohol use, anxiety, depression, and sleep, and other consensus IMPOWR Network measures. Implementation facilitation strategies informed by interviews with healthcare providers will target site-specific needs. The impact of these strategies on TCM implementation will be assessed via established formative and summative evaluation techniques. Economic analyses will evaluate intervention cost-effectiveness.

Military sexual trauma-related posttraumatic stress disorder service-connection: Characteristics of claimants and award denial across gender, race, and compared to combat trauma.

The current study characterizes a cohort of veteran claims filed with the Veterans Benefits Administration for posttraumatic stress disorder secondary to experiencing military sexual trauma, compares posttraumatic stress disorder service-connection award denial for military sexual trauma-related claims versus combat-related claims, and examines military sexual trauma -related award denial across gender and race. We conducted analyses on a retrospective national cohort of veteran claims submitted and rated between October 2017-May 2022, including 102,409 combat-related claims and 31,803 military sexual trauma-related claims. Descriptive statistics were calculated, logistic regressions assessed denial of service-connection across stressor type and demographics, and odds ratios were calculated as effect sizes. Military sexual trauma-related claims were submitted primarily by White women Army veterans, and had higher odds of being denied than combat claims (27.6% vs 18.2%). When controlling for age, race, and gender, men veterans had a 1.78 times higher odds of having military sexual trauma-related claims denied compared to women veterans (36.6% vs. 25.4%), and Black veterans had a 1.39 times higher odds of having military sexual trauma-related claims denied compared to White veterans (32.4% vs. 25.3%). Three-fourths of military sexual trauma-related claims were awarded in this cohort. However, there were disparities in awarding of claims for men and Black veterans, which suggest the possibility of systemic barriers for veterans from underserved backgrounds and/or veterans who may underreport military sexual trauma.

Receipt of opioid use disorder treatments prior to fatal overdoses and comparison to no treatment in Connecticut, 2016-17.

OBJECTIVE: To determine the relative risk of death following exposure to treatments for OUD compared to no treatment. METHODS: In this retrospective cohort study we compiled and merged state agency data on accidental and undetermined opioid overdose deaths in 2017 and exposures to OUD treatment in the prior six months to determine incidence rates following exposure to different treatment modalities. These rates were compared to the estimated incidence among those exposed to no treatment to determine relative risk of death for each treatment exposure. RESULTS: Incidence rates for opioid poisoning deaths for those exposed to treatment ranged from 6.06±1.40 per 1000 persons exposed to methadone to 17.36±3.22 per 1000 persons exposed to any non-medication treatment. The estimated incidence rate for those not exposed to treatment was 9.80±0.72 per 1000 persons. With no exposure to treatment as referent, exposure to methadone or buprenorphine reduced the relative risk by 38% or 34%, respectively; the relative risk of non-medication treatments was equal to or worse than no exposure to treatment (RR = 1.27-1.77). PRINCIPAL CONCLUSIONS: Exposure to non-MOUD treatments provided no protection against fatal opioid poisoning whereas the relative risk was reduced following exposures to MOUD treatment, even if treatment was not continued. Population level efforts to reduce opioid overdose deaths need to focus on expanding access to agonist-based MOUD treatments and are unlikely to succeed if access to non-MOUD treatments is made more available.

Changes in opioid prescribing in veterans with headache during the COVID-19 pandemic: A regression discontinuity in time analysis.

OBJECTIVE: To determine changes in opioid prescribing among veterans with headaches during the coronavirus disease of 2019 (COVID-19) pandemic by comparing the stay-at-home phase (March 15 to May 30, 2020) and the reopening phase (May 31 to December 31, 2020). BACKGROUND: Opioid prescribing for chronic pain has declined substantially since 2016; however, changes in opioid prescribing during the COVID-19 pandemic among veterans with headaches remain unknown. METHODS: This retrospective cohort study utilized regression discontinuity in time and difference-in-differences design to analyze veterans aged ≥18 years with a previous diagnosis of headache disorders and an outpatient visit to the Veterans Health Administration (VHA) during the study period. We measured the weekly number of opioid prescriptions, the number of days supplied, the daily dose in morphine milligram equivalents (MMEs), and the number of prescriptions with ≥50 morphine equivalent daily doses (MEDD). RESULTS: A total of 81,376 veterans were analyzed with 589,950 opioid prescriptions. The mean (SD) age was 51.6 (13.5) years, 57,242 (70.3%) were male, and 53,464 (65.7%) were White. During the pre-pandemic period, 323.6 opioid prescriptions (interquartile range 292.1-325.8) were dispensed weekly, with an median (IQR) of 24.1 (24.0-24.4) days supplied and 31.8 (31.2-32.5) MMEs. Transition to stay-at-home was associated with a 7.7% decrease in the number of prescriptions (incidence rate ratio [IRR] 1.077, 95% confidence interval [CI] 0.866-0.984) and a 9.8% increase in days supplied (IRR 1.098, 95% CI 1.078-1.119). Similar trends were observed during the reopening period. Subgroup analysis among veterans on long-term opioid therapy also revealed 1.7% and 1.4% increases in days supplied during the stay-at-home (IRR 1.017, 95% CI 1.009-1.025) and reopening phase (IRR 1.014, 95% CI 1.007-1.021); however, changes in the total number of prescriptions, MME/day, or the number of prescriptions >50 MEDD were insignificant. CONCLUSION: Prescription opioid access was maintained for veterans within VHA during the pandemic. The de-escalation of opioid prescribing observed prior to the pandemic was not seen in our study.

Compensation and Pension Exams for Military Sexual Trauma-Related Posttraumatic Stress Disorder: Examiner Perspectives, Clinical Impacts on Veterans, and Strategies.

BACKGROUND: It is estimated that in one in three women veterans experience military sexual trauma (MST), which is strongly associated with posttraumatic stress disorder (PTSD). A 2018 report indicated the Veterans Benefits Administration (VBA) processed approximately 12,000 disability claims annually for PTSD related to MST, most of which are filed by women. Part of the VBA adjudication process involves reviewing information from a Compensation and Pension (C&P) exam, a forensic diagnostic evaluation that helps determine the relationship among military service, diagnoses, and current psychosocial functioning. The quality and outcome of these exams may affect veteran well-being and use of Veterans Health Administration (VHA) mental health care, but no work has looked at examiner perspectives of MST C&P exams and their potential clinical impacts on veteran claimants. METHODS: Thirteen clinicians ("examiners") who conduct MST C&P exams through VHA were interviewed. Data were analyzed using rapid qualitative methods. RESULTS: Examiners described MST exams as more clinically and diagnostically complex than non-MST PTSD exams. Examiners noted that assessing "markers" of MST (indication that MST occurred) could make veterans feel disbelieved; others raised concerns related to malingered PTSD symptoms. Examiners identified unique challenges for veterans who underreport MST (e.g., men and lesbian, gay, bisexual, transgender, and queer [LGBTQ+] veterans), and saw evaluations as a conduit to psychotherapy referrals and utilization of VHA mental health care. Last, examiners used strategies to convey respect and minimize retraumatization, including a standardized process and validating the difficulty of the process. CONCLUSIONS: Examiners' responses offer insight into a process entered by thousands of veterans annually with PTSD. Strengthening the MST C&P process is a unique opportunity to enhance trust in the VBA claims process and increase likelihood of using VHA mental health care, especially for women veterans.

Concordance between controlled substance receipt and post-mortem toxicology in opioid-detected overdose deaths: A statewide analysis.

BACKGROUND: Opioid overdoses are a leading cause of preventable death in the United States. There is limited research linking decedents' receipt of controlled substances and presence of controlled substances on post-mortem toxicology (PMT). METHODS: We linked data on opioid-detected deaths in Connecticut between May 3, 2016, and December 31, 2017 from the Office of the Chief Medical Examiner, Department of Consumer Protection, and Department of Mental Health and Addiction Services. Exposure was defined as receipt of an opioid or benzodiazepine prescription within 90 days prior to death. Our primary outcome was concordance between medication received and metabolites in PMT. RESULTS: Our analysis included 1412 opioid-detected overdose deaths. 47 % received an opioid or benzodiazepine 90 days prior to death; 36 % received an opioid and 27 % received a benzodiazepine. Concordance between receipt of an opioid or benzodiazepine and its presence in PMT was observed in 30 % of opioid-detected deaths. Concordance with an opioid was present in 17 % of opioid-detected deaths and concordance with a benzodiazepine was present in 21 % of opioid-detected deaths. Receipt of an opioid or benzodiazepine and concordance with PMT were less common in fentanyl or heroin-detected deaths and more common in pharmaceutical opioid-detected deaths. DISCUSSION: Our results suggest medically supplied opioids and benzodiazepines potentially contributed to a substantial number, though minority, of opioid-detected deaths during the study period. Efforts to reduce opioid and benzodiazepine prescribing may reduce risk of opioid-detected deaths in this group, but other approaches will be needed to address most opioid-detected deaths that involved non-pharmaceutical opioids.

Delphi study to explore a new diagnosis for "ineffective" long-term opioid therapy for chronic pain.

ABSTRACT: A challenge in clinical, research, and policy spheres is determining whether and how to apply the Diagnostic and Statistical Manual-5 Opioid Use Disorder criteria to patients receiving long-term opioid therapy (LTOT) for the management of chronic pain. This study explored perspectives on the merits of creating a new diagnostic entity to characterize the problems that arise for certain patients prescribed LTOT and develop consensus on its definition and diagnostic criteria. We conducted 3 rounds of online surveys and held one discussion-based workshop to explore a new diagnostic entity and generate consensus with subject matter experts (n = 51) in pain and opioid use disorder, including a wide range of professional disciplines. The first survey included open-ended questions and rapid qualitative analysis to identify potential diagnostic criteria. Rounds 2 and 3 involved rating potential diagnostic criteria on a Likert-type scale to achieve consensus. The workshop was a facilitated conversation aimed at further refining criteria. Three-quarters of Delphi panelists were in favor of a new diagnostic entity; consensus was reached for 19 potential diagnostic criteria including benefits of LTOT no longer outweighing harms and a criterion related to difficulty tapering. A subgroup of expert panelists further refined the new diagnostic entity definition and criteria. Consensus on potential criteria for the new diagnostic entity was reached and further refined by a subgroup of experts. This Delphi study represents the opinions of a small group of subject matter experts; perspectives from other experts and additional stakeholder groups (including patients) are warranted.

Long-term opioid therapy trajectories and overdose in patients with and without cancer.

Objective: Pain is experienced by most patients with cancer and opioids are a cornerstone of management. Our objectives were (1) to identify patterns or trajectories of long-term opioid therapy (LTOT) and their correlates among patients with and without cancer and (2) to assess the association between trajectories and risk for opioid overdose, considering the potential moderating role of cancer. Methods and Analysis: We conducted a retrospective cohort study among individuals in the US Veterans Health Administration (VHA) database with incident LTOT with and without cancer (N=44,351; N=285,772, respectively) between 2010-2017. We investigated the relationship between LTOT trajectory and all International Classification of Diseases-9 and 10-defined accidental and intentional opioid-related overdoses. Results: Trajectories of opioid receipt observed in patients without cancer and replicated in patients with cancer were: low-dose/stable trend, low-dose/de-escalating trend, moderate-dose/stable trend, moderate-dose/escalating with quadratic downturn trend, and high-dose/escalating with quadratic downturn trend. Time to first overdose was significantly predicted by higher-dose and escalating trajectories; the two low-dose trajectories conferred similar, lower risk. Conditional hazard ratios (99% CI) for the moderate-dose, moderate-dose/escalating with quadratic downturn and high-dose/escalating with quadratic downturn trends were 1·84 (1·18, 2·85), 2·56 (1·54, 4·25), and 2·41 (1·37, 4·26), respectively. Effects of trajectories on time to overdose did not differ by presence of cancer; inferences were replicated when restricting to patients with stage 3/4 cancer. Conclusion: Patients with cancer face opioid overdose risks like patients without cancer. Future studies should seek to expand and address our knowledge about opioid risk in cancer patients. Trial registration: None.

Self-reported Use of Prescribed Buprenorphine Among US Adults With Nonmedical Use of Prescription Opioids Motivated by Pain.

This cross-sectional study of US adults examines the prevalence of and characteristics associated with prescribed buprenorphine use among US adults with pain-motivated nonmedical use of prescription opioids.

Profiles of substance use related protective and risk factors and their associations with alcohol and tobacco use initiation among black adolescents.

Insufficient attention to protective and risk factors of particular salience for Black youth (e.g., racial identity and racial discrimination) in population-based substance use studies has left gaps in our understanding of alcohol and tobacco use development in Black adolescents. The current study aimed to capture the clustering of such understudied factors and their collective influence on alcohol and tobacco use initiation among Black adolescents. Data were drawn from The National Survey of American Life (n = 1,170; age range = 13-17; 6.9% Afro Caribbean, 93.1% African American; 50.0% female). Latent profile analysis applied to 11 indicators representing family, community, and individual level protective and risk factors revealed (1) High Vulnerability (high risk, low protective factors; 17.5%), (2) Moderate Vulnerability (moderate on both; 63.2%), and (3) Low Vulnerability (high protective, low risk factors; 19.3%) classes. Classes differed significantly by religious community support, school bonding, quality of relationship with mother, religious involvement, and interpersonal trauma. Relative to Class 2, Class 1 had higher odds of alcohol (OR = 1.518, CI:1.092-2.109) and tobacco use (OR = 1.998, CI:1.401-2.848); Class 3 had lower odds of alcohol (OR = 0.659, CI:0.449-0.968) but not tobacco use (OR = 0.965, CI:0.611-1.523). Findings suggest that alcohol and tobacco use initiation among Black adolescents is shaped by the collective influence of community and family level support, with commonly experienced risk factors such as non-interpersonal trauma distinguishing liability to a lesser degree. The equally modest prevalence of tobacco use among low and moderate vulnerability classes further indicates that fostering these connections may be especially effective in reducing tobacco use risk.

Association Between Exposure to Complementary and Integrative Therapies and Opioid Analgesic Daily Dose Among Patients on Long-term Opioid Therapy.

OBJECTIVES: To describe the association between exposure to selected complementary and integrative health (CIH) modalities and the trajectory of prescribed opioid analgesic dose within a national cohort of patients receiving long-term opioid therapy (LTOT) in the Veterans Health Administration (VHA). MATERIALS AND METHODS: Using national data from VHA electronic health records between October 1, 2017 and September 30, 2019, CIH use was analyzed among 57,437 patients receiving LTOT within 18 VHA facilities serving as evaluation sites of VHA's Whole Health System of Care. Using linear mixed effects modeling controlling for covariates, opioid dose was modeled as a function of time, CIH exposure, and their interaction. RESULTS: Overall, 11.91% of patients on LTOT used any of the focus CIH therapies; 43.25% of those had 4 or more encounters. Patients used acupuncture, chiropractic care, and meditation modalities primarily. CIH use was associated with being female, Black, having a mental health diagnosis, obesity, pain intensity, and baseline morphine-equivalent daily dose. Mean baseline morphine-equivalent daily dose was 40.81 milligrams and dose decreased on average over time. Controlling for covariates, patients with any CIH exposure experienced 38% faster dose tapering, corresponding to a mean difference in 12-month reduction over patients not engaging in CIH of 2.88 milligrams or 7.06% of the mean starting dose. DISCUSSION: Results support the role of CIH modalities in opioid tapering. The study design precludes inference about the causal effects of CIH on tapering. Analyses did not consider the trend in opioid dose before cohort entry nor the use of other nonopioid treatments for pain. Future research should address these questions and consider tapering-associated adverse events.

Classification of Patients for Whom Benefit of Long-term Opioid Therapy No Longer Outweighs Harm: Protocol for a Delphi Study.

BACKGROUND: Patients with chronic pain prescribed long-term opioid therapy may come to a point where the benefits of the therapy are outweighed by the risks and tapering is indicated. At the 2019 Veterans Health Administration State of the Art Conference, there was an acknowledgment of a lack of clinical guidance with regard to treating this subset of patients. Some of the participants believed clinicians and patients would both benefit from a new diagnostic entity describing this situation. OBJECTIVE: The aim of this study was to determine if a new diagnostic entity was needed and what the criteria of the diagnostic entity would be. Given the ability of the Delphi method to synthesize input from a broad range of experts, we felt this technique was the most appropriate for this study. METHODS: We designed a modified Delphi technique involving 3 rounds. The first round is a series of open-ended questions asking about the necessity of this diagnostic entity, how this condition is different from opioid use disorder, and what its possible diagnostic criteria would be. After synthesizing the responses collected, a second round will be conducted to ask participants to rate the different responses offered by their peers. These ratings will be collected and analyzed, and will generate a preliminary definition for this clinical phenomena. In the third round, we will circulate this definition with the aim of achieving consensus. RESULTS: The modified Delphi study was initiated in July of 2020 and analysis is currently underway. CONCLUSIONS: This protocol has been approved by the Internal Review Board at the Connecticut Veterans Affairs and the study is in process. This protocol may assist other researchers conducting similar studies. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/33310.

Adaptations to Opioid Use Disorder Care During the COVID-19 Pandemic: A National Survey of Prescribers.

OBJECTIVES: Among opioid use disorder (OUD)-treating providers, to characterize adaptations used to provide medications for OUD (MOUD) and factors associated with desire to continue virtual visits post-COVID-19 pandemic. METHODS: In a national electronic survey of OUD-treating prescribers (July-August 2020), analyses restricted to X-waivered buprenorphine prescribers providing outpatient, longitudinal care for adults with OUD, quantitative and qualitative analyses of survey items and free text responses were conducted. RESULTS: Among 797 respondents, 49% were men, 57% ≥50 years, 76% White, 68% physicians. Respondents widely used virtual visits to continue prescribing existing MOUD regimens (79%), provide behavioral healthcare (71%), and initiate new MOUD prescriptions (49%). Most prescribers preferred to continue/expand use of virtual visits after COVID-19. In multivariable models, factors associated with preference to continue/expand virtual visits to initiate MOUD postpandemic were treating a moderate number of patients prepandemic (aOR = 1.67; 95%[CI] = 1.06,2.62) and practicing in an urban setting (aOR = 2.17; 95%[CI] = 1.48,3.18). Prescribing buprenorphine prepandemic (aOR = 2.06; 95%[CI] = 1.11,3.82) and working in an academic medical center (aOR = 2.47; 95%[CI] = 1.30,4.68) were associated with preference to continue/expand use of virtual visits to continue MOUD postpandemic. Prescribing naltrexone extended-release injection prepandemic was associated with preference to continue/expand virtual visits to initiate and continue MOUD (aOR = 1.51; 95%[CI] = 1.10,2.07; aOR = 1.74; 95%[CI] = 1.19,2.54). Qualitative findings suggest that providers appreciated virtual visits due to convenience and patient accessibility, but were concerned about liability and technological barriers. CONCLUSIONS: Surveyed prescribers widely used virtual visits to provide MOUD with overall positive experiences. Future studies should evaluate the impact of virtual visits on MOUD access and retention and clinical outcomes.

Well-Being of Health Care Professionals Treating Opioid Use Disorder During the COVID-19 Pandemic: Results From a National Survey.

OBJECTIVE: The COVID-19 pandemic has dramatically affected health care delivery, effects that are juxtaposed with health care professional (HCP) burnout and mental distress. The Opioid Use Disorder Provider COVID-19 Survey was conducted to better understand the impact of COVID-19 on clinical practice and HCP well-being. METHODS: The cross-sectional survey was e-mailed to listservs with approximately 157,000 subscribers of diverse professions between July 14 and August 15, 2020. Two dependent variables evaluated HCP functioning and work-life balance. Independent variables assessed organizational practices and HCP experiences. Covariates included participant demographic characteristics, addiction board certification, and practice setting. Multilevel multivariate logistic regression models were used. RESULTS: Among 812 survey respondents, most were men, White, and physicians, with 46% located in urban settings. Function-impairing anxiety was reported by 17%, and 28% reported more difficulty with work-life balance. Difficulty with functioning was positively associated with having staff who were sick with COVID-19 and feeling close to patients, and was negatively associated with being male and having no staff changes. Difficulty with work-life balance was positively associated with addiction board certification; working in multiple settings; having layoffs, furloughs, or reduced hours; staff illness with COVID-19; and group well-being check-ins. It was negatively associated with male gender, older age, and no staff changes. CONCLUSIONS: Demographic, provider, and organizational-practice variables were associated with reporting negative measures of well-being during the COVID-19 pandemic. These results should inform HCPs and their organizations on factors that may lead to burnout, with particular focus on gender and age-related concerns and the role of well-being check-ins.

Not Just Service Attendance: Associations of Religious Community Social Connections with Alcohol Use among Black Adults Header: Religious Community Social Connections and Alcohol Use among Black Adults.

Background: Religious involvement is a well-documented protective factor against alcohol use among Black adults, but the extent to which social connections to the religious community can explain those effects remains largely unknown. The current study was designed to capture contributions of religious community support and demands - independent of religious service attendance - to alcohol use among three age cohorts of Black adults. Methods: Data were drawn from 18- to 65-year-old Black participants in the National Survey of American Life (n = 4,462; 29.4% Afro Caribbean, 70.6% African American; 63.20% female). Ordinal logistic regression analyses, conducted separately for each age cohort (18-29, 30-44, and 45-65), were used to model frequency of alcohol use as a function of religious community support and demands in two stages: (1) prior to and (2) after accounting for religious service attendance. Results: Religious community support accounted for differences in alcohol use frequency over and above religious service attendance (in Stage 2 models) for adults aged 30-44 (OR = 0.85, CI: 0.74-0.96) and 45-65 (OR = 0.77, CI: 0.64-0.93) but not 18-29 (OR = 0.85, CI: 0.71-1.03). The association of religious community demands with alcohol use frequency was specific to the age 30-44 cohort in both stage models (Stage 2: OR = 1.33, CI: 1.06-1.68). Conclusions: Study findings suggest that in addition to attending religious services regularly, developing supportive social connections to the religious community may reduce risk for frequent drinking among Black adults, particularly during middle adulthood, when demands from the religious community may increase risk.

Comparison of attitudes towards the service connection claims process among veterans filing for PTSD and veterans filing for musculoskeletal disorders.

ABSTRACT: Many veterans have negative views about the service connection claims process for posttraumatic stress disorder (PTSD), which likely impacts willingness to file service connection claims, re-file claims, and use Veterans Healthcare Administration care. Nevertheless, veterans have reported that PTSD claims are important to them for the financial benefits, validation of prior experience and harm, and self-other issues such as pleasing a significant other. It is unknown if reported attitudes are specific to PTSD claimants or if they would be similar to those submitting claims for other disorders, such as musculoskeletal disorders. Therefore, the purpose of this study was to compare attitudes and beliefs about service connection processes between veterans submitting service connection claims for PTSD and musculoskeletal disorders.Participants were Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans filing service connection claims for PTSD (n = 218) or musculoskeletal disorder (n = 257) who completed a modified Disability Application Appraisal Inventory. This secondary data analysis using multiple regression models tested the effect of demographics, clinical characteristics, and claim type on 5 Disability Application Appraisal Inventory subscales: Knowledge about service connection claims, Negative Expectations about the process, and importance of Financial Benefits, importance of Validation of veteran's experience/condition, and importance of Self-Other attitudes.The PTSD group assigned significantly less importance to financial benefits than the musculoskeletal disorder group. In addition, the subset of the PTSD group without depression had significantly more Negative Expectations than musculoskeletal disorder claimants without depression. Negative Expectations did not differ between the PTSD and musculoskeletal disorder groups with depression. Depression was significantly positively associated with Negative Expectations, importance of Financial Benefits, and importance of Validation.Most perceptions around seeking service connection are not specific to PTSD claimants. Depression is associated with having negative expectations about service connection claims and motivations to file claims. Addressing depression and negative expectations during the compensation and pension process might help veterans at this important point of contact with Veterans Healthcare Administration services.

Correspondence Between Retrospective and Momentary Self-Reported Posttraumatic Stress Disorder Symptoms: Evidence for Peak and End Effects in Veterans.

Validated retrospective self-report symptom rating scales are recommended for posttraumatic stress disorder (PTSD) screening and treatment. However, such reports may be affected by a respondent's most intense ("peak") or most recent ("end") symptoms. The present study evaluated the correspondence between PTSD symptoms assessed using a standard past-month retrospective rating scale and recorded by ecological momentary assessment (EMA) over the same period and tested hypotheses that retrospective scores would be predicted by peak and end-period momentary symptoms. Male U.S. veterans (N = 35) who served post-9/11 completed the PTSD Symptom Checklist for DSM-5 (PCL-5) at baseline and 1 month later. For 28 days during the intervening period, they received quasi-randomly timed text prompts to complete a modified version of the PCL-5 at that moment. Using multiple regression modeling, controlling for the number of completed EMAs and time (days) since the last EMA, we assessed the predictability of follow-up retrospective PCL-5 scores by (a) the mean of all momentary scores and (b) peak and last-day momentary scores. Retrospective PCL-5 scores were closest to peak scores, d = -0.31, and substantially higher than overall mean, d = 0.99, and last-day momentary scores, d = 0.94. In the regression model, peak symptom experiences and last-day momentary symptoms uniquely predicted follow-up PCL-5 scores over and above significant prediction by overall mean momentary symptom scores. In sum, participants' self-reported past-month PTSD symptom severity did not simply reflect an average over time. Additional questioning is needed to understand peak and recent symptom periods reflected in these estimates.

Profiles of Psychosocial Risk and Protective Factors and their Associations with Alcohol Use and Regular Smoking in Black Adults.

INTRODUCTION: This study aimed to identify the clustering of substance use-related psychosocial risk and protective factors (subgroups) and the differential associations of those subgroups with current alcohol use and regular smoking among Black adults. METHODS: Data were drawn from 4462 participants (29% Afro Caribbean, 71% African American; median age = 38; 63% female) in a nationally representative study of social, economic, and structural conditions and health in Black Americans. Latent classes, i.e., subgroups, were derived via latent profile analysis with 10 indicators representing social support and religious involvement (support); demands from family and religious community (demands); and socioeconomic and neighborhood factors and racial discrimination (adversity). Frequency of alcohol use and prevalence of regular smoking were compared across classes using regression analyses. RESULTS: Four classes emerged: (1) high support, low demands and adversity; (2) high support and demands, low-moderate adversity; (3) low support and demands, low-moderate adversity; and (4) low support, high demands and adversity. Relative to Class 1, frequency of alcohol use and regular smoking prevalence were significantly higher only in Class 4. CONCLUSIONS: Results indicate substantive variations in the clustering of substance use-related psychosocial risk and protective factors in Black adults. Furthermore, they suggest that neither the presence of high demands nor the absence of support alone differentiates likelihood of engaging in frequent alcohol use or regular smoking, but adverse experiences such as racial discrimination may be especially impactful.

Themes in experiences of PTSD symptoms and relationships among male veterans with risky sexual behavior.

OBJECTIVE: United States veterans with posttraumatic stress disorder (PTSD) symptoms are at elevated risk for high-risk sexual behavior (HRSB). Although quantitative research has examined relationships between PTSD symptoms and HRSB, qualitative research to understand the lived experiences of veterans with PTSD symptoms and HRSB has not been conducted. METHOD: Qualitative interviews were conducted with N = 29 male veterans of Operation Enduring Freedom or Operation Iraqi Freedom who had PTSD symptoms and reported recent HRSB. The interviews were analyzed using a phenomenological framework. RESULTS: Six themes emerged: (a) avoiding social contact due to feeling different since return from service; (b) effortful self-management; (c) supportive relationships; (d) sex as a means to an end; (e) sex, risk, and intimacy; and (f) responsibility and growth. CONCLUSION: Male veterans with PTSD symptoms and HRSB reported engagement in significant self-management to reengage in life, and still reported high levels of difficulty in relationships. They described both wanting to avoid perceived risk associated with intimate relationships and wanting to take risks that caused them to feel alive. Implications for treatment include increased efforts to facilitate coping, to recognize and moderate risk-taking urges, and to build intimacy and trust. (PsycInfo Database Record (c) 2020 APA, all rights reserved).