Are gaps in rates of retention on buprenorphine for treatment of opioid use disorder closing among veterans across different races and ethnicities? A retrospective cohort study.

INTRODUCTION: The U.S. Veterans Health Administration has undertaken several initiatives to improve veterans' access to and retention on buprenorphine because it prevents overdose and reduces drug-related morbidity. We aimed to determine whether improvements in retention duration over time was equitable across veterans of different races and ethnicities. METHODS: This retrospective cohort study was conducted among veterans who initiated buprenorphine from federal fiscal years (FY) 2006 to 2020 after diagnosis of opioid use disorder. Using an accelerated failure time model, we estimated the association between time to buprenorphine discontinuation and FY of initiation, race and ethnicity, and other control covariates. We followed veterans from buprenorphine initiation until they discontinued or had a censoring event. We then estimated the predicted median days retained on buprenorphine, the average marginal effect of initiating in a later FY, the same measure by race and ethnicity, the incremental effect of the various racial and ethnic identities in contrast to non-Hispanic White, and the total change in the size of the gap over the 15 years of the study between veterans with a minoritized racial or ethnic identity compared to non-Hispanic White veterans. RESULTS: Most of the 31,797 veterans in the sample were non-Hispanic White (74.5 %), from urban areas (83.5 %), male (92.0 %), and had significant comorbidities, most frequently anxiety disorders (51.0 %) and depression (63.0 %). Overall, 49.8 % of veterans were retained at least 180 days. The average marginal effect of FY was 7.0 days [95%CI:5.3, 8.8] but was significantly smaller among veterans identifying as Black or African American [3.2 days; 95%CI:2.4, 4.1] or Asian [3.6 days; 95%CI:1.6, 5.7] compared to veterans who identify as non-Hispanic White [7.9 days; 95%CI:5.9, 9.9]. Additional measures of change were significant for veterans identifying as Hispanic White or with two or more races. CONCLUSION: Although buprenorphine retention in OUD treatment improved for all veterans over the 15-year study period, veterans from most minoritized racial and ethnic groups fell further behind as gains in duration on therapy accrued primarily to non-Hispanic White veterans. Targeted interventions addressing specific challenges experienced by veterans with minoritized identities are needed to close gaps in retention on buprenorphine.

Average Daily Dose Trajectories for Episodes of Buprenorphine Treatment for Opioid Use Disorder.

BACKGROUND: High-dose (≥24 mg) buprenorphine daily doses (BDD) may be important in treating patients with opioid use disorder (OUD) to improve retention and prevent overdose, particularly in the context of increased illicit fentanyl use. This study sought to: (1) identify trajectories for average BDD among patients initiating buprenorphine treatment for OUD and (2) assess patient characteristics associated with these identified trajectories. METHODS: Buprenorphine treatment episodes among patients in the US Veterans Healthcare Administration (VHA) from federal fiscal years 2006 to 2020 were identified. Group-based trajectory modeling (GBTM) was used to identify BDD trajectories based on weekly averages of BDD over the 180 days after buprenorphine episode initiation. RESULTS: A total of 79 303 buprenorphine treatment episodes among 44 583 patients were included in the analytic sample. GBTM identified 9 latent trajectories for BDD: (1) moderate dose, early discontinuation (10.1%), (2) moderate dose, delayed discontinuation (4.5%), (3) moderate dose, moderate-paced discontinuation (5.2%), (4) low-moderate dose, delayed discontinuation (7.0%), and (5) low-moderate dose, early discontinuation (21.1%), (6) low dose retention (9.6%), (7) low-moderate dose retention (16.7%), (8) moderate dose retention (18.6%), and (9) high dose retention (7.4%). Patient BDD can broadly be characterized as low [2-4 mg/day], low-moderate (6-8 mg/day), moderate (12-18 mg/day), and high dose (≥ 24 mg/day). Patients with episodes in the high BDD trajectory have the lowest social risk (eg, lowest rate of past-year history of homelessness) and the lowest diagnosed rate of physical and mental health-related comorbidities compared to those following other trajectories. CONCLUSIONS: BDD ranges widely and patient characteristics are significantly different between those episodes following differing BDD trajectories. Future research on the association between BDD and subsequent patient outcomes (eg, overdose) needs to carefully consider these differences in baseline characteristics.

Predictors of concerned others' mental health and quality of life over 12 months following adults' entry into treatment for an alcohol use disorder.

INTRODUCTION: People in treatment for alcohol use disorders (AUDs) can negatively impact their Concerned Others (COs). This longitudinal study examined patient and CO characteristics associated with CO outcomes. METHOD: Participants were 279 dyads of patients entering residential treatment and their CO. Outcomes were COs' mental health and quality of life. The study collected patient and CO predictors and CO outcomes at baseline and 3-, 6-, and 12-month follow-ups as part of a randomized controlled trial. In the first set of models, the analytic approach identified baseline patient predictors associated with COs' outcomes measured at baseline and follow-ups. In the second set of models, we examined whether those effects remained after adding baseline CO characteristics. RESULTS: In the first set of models, COs of older age and whose patient reported less CO-patient relationship stress had better mental health. Also, married COs and those with higher income and whose patient reported no violence in the CO-patient relationship had better quality of life. In the second set of models, COs whose patient entered treatment due to criminal justice involvement, with more social support, less reported stigma, and less use of avoidance coping had better mental health. Also, married COs, those with higher income, and less reported discrimination stigma had better quality of life. CONCLUSIONS: Understanding patient and CO characteristics that are associated with COs' outcomes may inform AUD treatment programs' efforts to help COs. Identifying modifiable determinants of CO outcomes is important to clinical practice regardless of whether the patient chooses to obtain treatment.

For whom are treatments for criminal recidivism effective? Moderator effects from a randomized controlled trial of justice-involved veterans.

OBJECTIVE: In a recent trial, moral reconation therapy (MRT)-a cognitive-behavioral intervention for criminal recidivism-was not more effective than usual care (UC) for veterans in behavioral health treatment. To determine for whom treatments of recidivism are most effective, we tested if recency of criminal history or psychopathic traits moderated MRT's effects on outcomes. METHOD: In a multisite trial, 341 veterans (95.3% male; 57.8% White/Non-Hispanic) with a criminal history who were admitted to behavioral health treatment programs were randomly assigned to UC or UC + MRT and followed at 6- and 12-months. Incarceration (yes/no) or criminal conviction (yes/no) in the year prior to enrollment and psychopathic traits at baseline (median split) were prespecified as moderators of treatment effects on primary (criminal thinking, criminal associations) and secondary outcomes (legal, employment, and family/social problems; substance use problems and days of use). RESULTS: Among veterans incarcerated in the year prior to enrollment, MRT (vs. UC) was associated with greater reductions in criminal associations (6 months) and days drinking or using drugs (12 months). Among those convicted in the year prior to enrollment, MRT (vs. UC) was associated with greater reductions in employment problems (12 months) and days drinking or using drugs at each follow-up. For those high in psychopathic traits, MRT (vs. UC) was associated with greater reductions in days drinking or using drugs at each follow-up. CONCLUSIONS: For veterans in behavioral health treatment with recent criminal histories and high in psychopathic traits, MRT may be effective for reducing risk for criminal recidivism. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Trust and perceived mental health access: Exploring the relationship between perceived access barriers and veteran-reported trust.

The importance of patients' trust in health care is well known. However, identifying actionable access barriers to trust is challenging. The goal of these exploratory analyses is to identify actionable access barriers that correlate with and predict patients' lack of trust in providers and in the health care system. This article combines existing data from three studies regarding perceived access to mental health services to explore the relationship between provider and system trust and other access barriers. Data from the Perceived Access Inventory (PAI) were analyzed from three studies that together enrolled a total of 353 veterans who screened positive for a mental health problem and had a VA mental health encounter in the previous 12 months. The PAI includes actionable barriers to accessing VA mental health services. The data are cross-sectional, and analyses include Spearman rank correlations of PAI access barriers and provider and system trust, and linear regressions examining the effect of demographic, clinical, and PAI barriers on lack of trust in VA mental health providers and in the VA health care system. Age, depression, and anxiety symptoms and PAI items demonstrated statistically significant bivariate correlations with provider and system trust. However, in multivariate linear regressions, only PAI items remained statistically significant. The PAI items that predicted provider and system trust could be addressed in interventions to improve provider- and system-level trust. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Adapting an Alcohol Care Linkage Intervention to US Military Veterans Presenting to Primary Care with Hazardous Drinking and PTSD and/or Depression Symptoms: A Qualitative Study.

There is a critical need to improve linkage to alcohol care for veterans in primary care with hazardous drinking and PTSD and/or depression symptoms (A-MH). We adapted an alcohol care linkage intervention, "Connect to Care" (C2C), for this population. We conducted separate focus groups with veterans with A-MH, providers, and policy leaders. Feedback centered on how psychologists and other providers can optimally inform veterans about their care options and alcohol use, and how to ensure C2C is accessible. Participants reported that veterans with A-MH may not view alcohol use as their primary concern but rather as a symptom of a potential co-occurring mental health condition. Veterans have difficulty identifying and accessing existing alcohol care options within the Veterans Health Administration. C2C was modified to facilitate alcohol care linkage for this population specific to their locality, provide concrete support and education, and offer care options to preserve privacy.

Connect To Care (C2C): protocol for two-site randomized controlled pilot trial to improve outcomes for patients with hazardous drinking and PTSD and/or depression symptoms.

BACKGROUND: In studies of the general population and of military veterans, many primary care patients with hazardous drinking and PTSD and/or depression (abbreviated here as HD +) do not initiate or engage with alcohol-related care. To address this gap in care, we identified and will pilot test a promising evidence-based intervention, Connect To Care (C2C). C2C is a strengths-based approach, delivered by a Care Coach by telephone and/or video, with four components: (1) identifying and leveraging patient strengths to facilitate care initiation, (2) collaborative decision-making around a menu of care options, (3) identifying and resolving barriers to care, and (4) monitoring and facilitating progress toward care initiation by, for example, checking on barriers, identifying solutions, and revisiting care options. METHODS/DESIGN: Aim 1 will involve adapting C2C for use in Veterans Affairs' (VA) primary care. We will use an iterative process that includes focus groups and semi-structured interviews with key stakeholders (patients, primary care providers, and VA national policy leaders). In Aim 2, we will conduct a two-site, pilot randomized controlled trial to determine the feasibility of conducting a larger scale trial to test C2C's effectiveness, ascertain the acceptability of C2C among primary care patients with HD + , and explore the efficacy of C2C to improve veteran patients' initiation of and engagement in alcohol care, and their alcohol and mental health (PTSD, depression) outcomes, at 3-month follow-up. We will explore explanatory mechanisms by which C2C is effective. DISCUSSION: Study findings are likely to have implications for clinical practice to enhance current approaches to linking patients with HD + to alcohol care by applying a practical intervention such as C2C. The results may improve treatment outcomes for people with HD + by drawing on patients' strengths to problem-solve barriers to care following a process of shared decision-making with a coach. In addition to possibly accelerating the translation of C2C into practice, study findings will also support additional research in terms of a planned effectiveness-implementation hybrid trial, adding to this study's potential for high impact. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05023317.

Patient-Concerned Other Dyads' 12-Step Involvement and Patients' Substance Use: A Latent Class Growth Model Analysis.

OBJECTIVE: This study aimed to inform clinical practice by identifying subgroups of patient-concerned other (CO) dyads. Patients with alcohol use disorders (AUDs) were characterized on Alcoholics Anonymous (AA) involvement and substance use together with COs' Al-Anon involvement. Predictors and recovery maintenance outcomes of subgroup membership were examined. METHOD: Participants were 279 patient-CO dyads. Patients were in residential treatment for AUD. Parallel latent class growth model analysis characterized 12-step involvement and substance use at treatment entry and 3-, 6-, and 12-month follow-ups. RESULTS: Three classes were as follows: 38% Low AA/Low Al-Anon (patients' low AA and COs' low Al-Anon involvement, and patients' high-to-moderate substance use), 10% High AA/High Al-Anon (patients' high AA and COs' high Al-Anon involvement, and patients' moderate-to-low substance use), and 52% High AA/Low Al-Anon (patients' high AA and COs' low Al-Anon involvement, and patients' moderate-to-low substance use). At follow-up, the Low AA/Low Al-Anon classes' patients were less likely to have spirituality as recovery support, confidence about staying abstinent, and satisfaction with recovery progress. The High AA classes' COs had less concern about patients' drinking and scored higher on positive aspects of relationships with patients. CONCLUSIONS: Clinicians should encourage patients' and COs' 12-step group involvement (12-step practices' engagement). Among patients treated for AUD, AA involvement was related to better outcomes, and to COs' lessened concern about the patients' drinking. COs' Al-Anon involvement was associated with having a more positive view of their relationship with the patient. That more than one third of dyads had low 12-step group involvement suggests that treatment programs may need to facilitate involvement in non-12-step mutual-help groups.

Substance use and criminogenic thinking: Longitudinal latent class analysis of veterans with criminal histories.

INTRODUCTION: The objective of this study was to inform clinical practice by identifying distinct subgroups of US veterans with criminal histories in residential mental health treatment. The study characterized veteran patients on their alcohol and drug use and criminogenic thinking. We also examined predictors and outcomes of subgroup membership. METHODS: Participants were 341 veterans with a criminal history in residential mental health care. A parallel latent growth trajectory model characterized participants' alcohol and drug use and criminogenic thinking at treatment entry and at 6- and 12-month follow-ups. RESULTS: The study identified four distinct classes: 53 % Normative Improvement, 27 % High Criminogenic Thinking, 11 % High Recurrence (of substance use), and 9 % High Drug Use. Compared to the Normative Improvement class, prior to treatment entry, patients in the High Recurrence class were less likely to be on parole or probation, and patients in the High Criminogenic Thinking class were more likely to be chronically homeless. Compared to the Normative Improvement class, at follow-ups, patients in the High Drug Use and High Criminogenic Thinking classes were more likely to recidivate, and patients in the High Drug Use class were more likely to report unstable housing. Depression scores were higher (nearly double) in the High Drug Use, High Recurrence, and High Criminogenic Thinking classes at follow-ups compared to the Normative Improvement class. CONCLUSIONS: That the Normative Improvement class entered mental health residential treatment with relatively low alcohol and drug use and criminogenic thinking, and sustained these low levels, suggests that treatment does not need to be broadened or intensified to improve these domains for these patients with criminal histories. In contrast, findings for the High Drug Use, High Recurrence, and High Criminogenic Thinking classes, which composed 47 % of the sample, suggest that more integrated and sustained treatment may be needed to reduce recidivism, depression, and homelessness among these patients.

Adapting the Eliminating Medications Through Patient Ownership of End Results Protocol to Promote Benzodiazepine Cessation Among US Military Veterans: Focus Group Study With US Military Veterans and National Veterans Health Administration Leaders.

BACKGROUND: Long-term dependence on prescribed benzodiazepines is a public health problem. Eliminating Medications Through Patient Ownership of End Results (EMPOWER) is a promising self-management intervention, delivered directly to patients as a printed booklet, that is effective in promoting benzodiazepine reduction and cessation in older adults. EMPOWER has high potential to benefit large health care systems such as the US Veterans Health Administration (VHA), which cares for many veterans who use benzodiazepines for extended periods. OBJECTIVE: We aimed to adapt the original EMPOWER booklet materials for electronic delivery and for use among US military veterans receiving VHA care who were long-term benzodiazepine users. METHODS: We used elements of Analysis, Design, Development, Implementation, and Evaluation, a framework commonly used in the field of instructional design, to guide a qualitative approach to iteratively adapting EMPOWER Electronic Delivery (EMPOWER-ED). We conducted 3 waves of focus groups with the same 2 groups of VHA stakeholders. Stakeholders were VHA-enrolled veterans (n=16) with medical chart evidence of long-term benzodiazepine use and national VHA leaders (n=7) with expertise in setting VHA policy for prescription benzodiazepine use and developing electronically delivered educational tools for veterans. Qualitative data collected from each wave of focus groups were analyzed using template analysis. RESULTS: Themes that emerged from the initial focus groups included veterans' anxiety about self-tapering from benzodiazepines and prior negative experiences attempting to self-taper without support. Participants also provided feedback on the protocol's look and feel, educational content, the tapering protocol, and website functionality; for example, feedback from policy leaders included listing, on the cover page, the most commonly prescribed benzodiazepines to ensure that veterans were aware of medications that qualify for self-taper using the EMPOWER-ED protocol. Both groups of stakeholders identified the importance of having access to supportive resources to help veterans manage sleep and anxiety in the absence of taking benzodiazepines. Both groups also emphasized the importance of ensuring that the self-taper could be personalized and that the taper instructions were clear. The policy leaders emphasized the importance of encouraging veterans to notify their provider of their decision to self-taper to help facilitate provider assistance, if needed, with the taper process and to help prevent medication stockpiling. CONCLUSIONS: EMPOWER-ED is the first direct-to-patient electronically delivered protocol designed to help US military veterans self-taper from long-term benzodiazepine use. We used the Analysis, Design, Development, Implementation, and Evaluation framework to guide the successful adaption of the original EMPOWER booklet for use with this population and for electronic delivery. The next step in this line of research is to evaluate EMPOWER-ED in a randomized controlled trial.

Promoting benzodiazepine cessation through an electronically-delivered patient self-management intervention (EMPOWER-ED): Randomized controlled trial protocol.

Background: Long-term benzodiazepine dependence carries significant health risks which might be reduced with low-cost patient self-management interventions. A booklet version of one such intervention (Eliminating Medications Through Patient Ownership of End Results; EMPOWER) proved effective in a Canadian clinical trial with older adults. Digitizing such an intervention for electronic delivery and tailoring it to different populations could expand its reach. Accordingly, this article describes the protocol for a randomized controlled trial to test the effectiveness of an electronically-delivered, direct-to-patient benzodiazepine cessation intervention tailored to U.S. military veterans. Methods: Design: Two-arm individually randomized controlled trial. Setting: US Veterans Health Administration primary care clinics. Participants: Primary care patients taking benzodiazepines for three or more months and having access to a smartphone, tablet or desktop computer. Intervention and comparator: Participants will be randomized to receive either the electronically-delivered EMPOWER (EMPOWER-ED) protocol or asked to continue to follow provider recommendations regarding their benzodiazepine use (treatment-as-usual). Measurements: The primary outcomes are complete benzodiazepine cessation and 25% dose reduction, assessed using administrative and self-report data, between baseline and six-month follow-up. Secondary outcomes are self-reported anxiety symptoms, sleep quality, and overall health and quality of life, measured at baseline and 6-month follow-up, and benzodiazepine cessation at 12-month follow-up. Comments: This randomized controlled trial will evaluate whether the accessibility and effectiveness of a promising intervention for benzodiazepine cessation can be improved through digitization and population tailoring.

Caregivers of people with substance use or mental health disorders in the US.

Background: Caregiving for persons with substance use and/or mental health disorders (SU/MHD) and other conditions places significant strains on caregivers. Methods: The present study used Behavioral Risk Factor Surveillance System (a US health survey) data to (1) compare caregivers of recipients with SU/MHD to those of recipients with other conditions on demographic and caregiving characteristics and health outcomes and (2) examine demographic and caregiving characteristics that were associated with poorer health outcomes among caregivers of persons with SU/MHD. Results: Caregivers of people with SU/MHD were more likely than other caregiver groups (of recipients with medical, cognitive, developmental disability, and old age-related conditions) to report poor general health, physical health, and mental health, as well as activities limitations, having been diagnosed with depression, and binge drinking. Among the group of caregivers of recipients with SU/MHD, those caring for a parent were more likely to report poor physical health, poor mental health, depression, and binge drinking than those caring for a friend, relative, child, or spouse. In addition, caregivers who provided SU/MHD-related caregiving for a longer duration and for whom caregiving included household help were less likely to report poor mental health, depression, or binge drinking. Conclusions: Findings underscore the importance of the substance use disorder treatment system developing improved institutional and structural support for caregivers of recipients with SU/MHD.

Predictors of alcohol use disorder treatment outcomes over 12 months: Role of concerned others' functioning and Al-Anon participation.

BACKGROUND: This study included dyads comprised of adults entering treatment for alcohol use disorder and their Concerned Others (COs) to examine indicators of COs functioning (Al-Anon attendance and involvement, relationship stressors, use of approach coping and stigma) as predictors of patient outcomes (Alcoholics Anonymous (AA) attendance and involvement, abstinence and risk of substance use) over 12 months following adults' entry into AUD treatment. METHODS: Dyads (n = 279) were assessed when patients entered treatment and at 3-, 6- and 12-month follow-ups. Data were collected through participants' self-report. Lagged generalized linear mixed models were used to examine associations between indicators of COs' functioning at baseline, 3- and 6-month follow-ups and patients' outcomes at 3-, 6- and 12-month follow-ups. RESULTS: Patients reported less AA attendance and involvement and likelihood of maintaining abstinence from alcohol use over time. Findings from our multivariate analysis showed that any CO involvement in Al-Anon, relative to none, was associated with more patient AA attendance. In contrast, more stigma (e.g., need to hide patient's drinking) reported by COs was associated with lower patient AA participation and involvement, while more CO use of approach coping was associated with less patient risk for alcohol and drug use. CONCLUSIONS: Findings suggest that COs' functioning can affect longer-term outcomes of adults entering AUD treatment. Treatment programs should increase the availability of help to COs to improve their functioning and patient outcomes.

Using data science to improve outcomes for persons with opioid use disorder.

Medication treatment for opioid use disorder (MOUD) is an effective evidence-based therapy for decreasing opioid-related adverse outcomes. Effective strategies for retaining persons on MOUD, an essential step to improving outcomes, are needed as roughly half of all persons initiating MOUD discontinue within a year. Data science may be valuable and promising for improving MOUD retention by using "big data" (e.g., electronic health record data, claims data mobile/sensor data, social media data) and specific machine learning techniques (e.g., predictive modeling, natural language processing, reinforcement learning) to individualize patient care. Maximizing the utility of data science to improve MOUD retention requires a three-pronged approach: (1) increasing funding for data science research for OUD, (2) integrating data from multiple sources including treatment for OUD and general medical care as well as data not specific to medical care (e.g., mobile, sensor, and social media data), and (3) applying multiple data science approaches with integrated big data to provide insights and optimize advances in the OUD and overall addiction fields.

A randomized controlled trial of moral reconation therapy to reduce risk for criminal recidivism among justice-involved adults in mental health residential treatment.

OBJECTIVE: Moral reconation therapy (MRT) is a cognitive-behavioral intervention to reduce risk for criminal recidivism. Despite being implemented widely in correctional settings, there are no randomized controlled trials of MRT, and its effectiveness for reducing recidivism among justice-involved adults in noncorrectional settings is unknown. METHOD: In a pragmatic trial, 341 justice-involved patients (95.3% male; 57.8% White/non-Hispanic) admitted to one of three mental health residential treatment programs were randomly assigned to usual care (UC) or UC plus two MRT groups per week for 12 weeks. Follow-ups were conducted at 6- and 12-month postbaseline (71.3% and 74.8% retention, respectively). Primary outcomes were criminal thinking and criminal associates. Secondary outcomes were legal problem severity, days incarcerated in the past 30, rearrested/charged (per official records), substance use, and employment and family/social problems. The study design, analysis, and outcomes were preregistered (ClinicalTrials.gov; ID: NCT02524171). RESULTS: Patients in both conditions improved over time on most outcomes. In intent-to-treat analyses, the rate of change in outcomes over time did not differ by condition, nor did the prevalence of being rearrested and charged within 1 year of baseline (UC = 20.2%, MRT = 24.9%; OR = 1.14; 95% CI [0.67, 1.94], p = .63). MRT engagement was low; 37% of those randomized to MRT received a minimum dose-that is, completed at least Step 3. In per-protocol analyses, this subgroup, relative to UC, improved more on criminal associates, days incarcerated, legal problem severity, and alcohol use severity. CONCLUSIONS: In this study, MRT was not more effective than UC at reducing recidivism risk for patients in mental health residential treatment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Leveraging the Prescription Drug Monitoring Program to Curb Opioid Prescribing in Arkansas.

Effective means of accurately identifying problematic opioid prescribing are needed. Using an iterative approach with the Arkansas State Medical Board Pain Subcommittee, we modified existing opioid prescriber criteria to create seven metrics to be deployed in Arkansas. These included metrics of dose and days' supply, concomitant use of opioid and benzodiazepines, solid dosage units, and numbers of opioid patients and certain opioid prescriptions. Two of these metrics (average MME daily dose per prescription and total oxycodone 30 mg or hydromorphone prescriptions) were weighted by 2, creating a maximum score of 9 of which each prescriber could receive. Twenty prescribers with a score of 7 or greater were identified and referred to the Arkansas State Medical Board Pain Subcommittee for review and subsequent investigation if deemed necessary. Of those 20 prescribers, four were previously investigated and under disciplinary action, and three were under current investigation for misconduct related to prescribing practices. Five prescribers had new investigations opened due to the findings from the metrics, and disciplinary action was taken. Therefore, 12 of the 20 prescribers referred to the Arkansas State Medical Board were deemed worthy of investigation and disciplinary action. The Arkansas opioid prescriber metrics are able to accurately identify prescribers with potentially problematic opioid prescribing.

Experiencing Sexual Assault and/or Stalking-Related Behavior is Associated with Binge Drinking and Substance Use Consequences in Deployed U.S. Servicewomen.

BACKGROUND: Being deployed is a risk factor for poor postdeployment mental health outcomes in U.S. servicewomen, including harmful drinking. However, to our knowledge, no studies have examined deployment-related sexual assault and exposure to stalking-related behavior in relation to binge drinking and substance use consequences in this population. METHODS: A community sample of post-9/11 servicewomen from the Midwest, including both veterans and those actively serving (N = 991), completed computer-assisted telephone interviews after deployment. Logistic regression models examined associations between deployment-related sexual assault (attempted or completed) and stalking-related behavior (e.g., being left unwanted things, having property vandalized), and the likelihood of reporting binge drinking and substance use consequences after controlling for covariates. RESULTS: U.S. servicewomen experiencing deployment-related sexual assault and/or stalking-related behavior were more likely to report binge drinking in the past 4 weeks and at least one negative consequence of substance use in the past year. Also, 21.56% of the sample reported experiencing any deployment-related sexual assault and/or stalking-related behavior, 17.34% reported any stalking-related behavior and no sexual assault, 2.42% reported both sexual assault and stalking-related behavior, and 1.80% reported sexual assault and no stalking-related behavior. The most commonly endorsed behaviors were being followed or spied on (9.09%), receiving unsolicited correspondence (8.34%-8.74%), and having someone show up at places you were (6.90%). CONCLUSIONS: U.S. servicewomen experiencing sexual assault and/or stalking-related behavior during deployment may be at higher risk for binge drinking and experiencing negative consequence of substance use when compared with their peers not reporting these stressors.

Implementation Potential of Moral Reconation Therapy for Criminal Recidivism in Mental Health Residential Programs.

OBJECTIVE: Criminal recidivism is common among patients in mental health residential treatment programs. Moral reconation therapy (MRT) has empirical support for reducing criminal recidivism by modifying antisocial cognitions and behaviors; however, its implementation potential in noncorrectional settings has been rarely studied. This potential was examined in a three-site effectiveness-implementation trial of MRT for justice-involved veterans receiving residential mental health treatment in the U.S. Veterans Health Administration. METHODS: Semistructured interviews were conducted with 36 veterans who received MRT and 13 residential program staff who were involved in its implementation during the trial. Interviews were guided by the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework and a focus on patient engagement and context. Content analysis was used to identify facilitators of and barriers to MRT implementation in residential mental health treatment. RESULTS: Participants viewed MRT as unique and complementary to usual residential care, with benefits beyond recidivism reduction. However, time intensity of the MRT curriculum, challenges in adapting its content and format, and long-term costs of maintaining MRT were viewed as barriers to implementation. To facilitate implementation, participants suggested streamlining the MRT curriculum, adding motivational components, and establishing partnerships in- and outside the health care system. CONCLUSIONS: The findings suggest strategies and modifications to MRT, which, if shown to be effective, may facilitate its wider implementation in mental health residential treatment programs.

Al-Anon Intensive Referral to facilitate concerned others' participation in Al-Anon Family Groups: a randomized controlled trial.

AIMS: To test the effectiveness of an intervention, Al-Anon Intensive Referral (AIR), to facilitate participation in Al-Anon Family Groups (Al-Anon). DESIGN, SETTING AND PARTICIPANTS: Multi-site, randomized controlled trial of AIR versus usual care (UC), with follow-up assessments at 3, 6 and 12 months. The 12-month follow-up rate was 74%. Residential alcohol use disorder (AUD) treatment programs in three US locations. Concerned others (COs) of patients in treatment for AUD. COs were mainly women (77%) who were patients' spouses (33%) or parents (25%). INTERVENTION AND COMPARATOR: AIR (n = 128) consisted of four sessions over 3 months with an Al-Anon coach. UC (n = 151) was the treatment program's offer of educational sessions for COs. MEASUREMENTS: Primary outcome: COs' self-reports of any Al-Anon attendance (yes or no) at 3 months. SECONDARY OUTCOMES: number of Al-Anon meetings and the CO-patient relationship (stressors, resources). Potential predictors of outcomes examined in generalized linear mixed models were their baseline value, time, CO-patient relationship type (marital or non-marital), treatment program and condition. FINDINGS: There was no effect of condition for the primary outcome (28% in AIR, 21% in UC; Bayes factor = 1.86). Relationship stressors at follow-ups were more severe for COs in a marital relationship with the patient than for COs in a non-marital relationship [ß = 2.19, 95% confidence interval (CI) = 1.07, 3.32]. For CO-patient relationship resources at follow-ups, the main effect for condition was significant (ß = 1.33, 95% CI = 0.04, 2.61). COs assigned to the AIR condition had more resources than COs who were in the UC condition. CONCLUSIONS: Relative to usual care, Al-Anon Intensive Referral was not associated with increases in participation of concerned others in Al-Anon, but was associated with more resources in the concerned other-patient relationship.

Al-Anon Intensive Referral (AIR): A qualitative formative evaluation for implementation.

INTRODUCTION: The Al-Anon mutual-help program helps concerned others (COs; e.g., families, friends) of persons with excessive alcohol use. Despite widespread availability of Al-Anon meetings, participation is limited and little is known about how to best facilitate engagement. Al-Anon Intensive Referral (AIR) was developed to facilitate COs' engagement in Al-Anon and is being tested in a randomized controlled trial (RCT). Toward the end of the recruitment for the RCT, a qualitative formative evaluation was conducted to learn about facilitators, barriers, and recommendations for AIR implementation in substance use disorder (SUD) treatment clinics. METHODS: Thirty-one directors and staff at ten VA and community SUD clinics were interviewed. Semi-structured interviews were based on the Consolidated Framework for Implementation Research and were thematically analyzed to identify facilitators, barriers, and recommendations for AIR implementation. RESULTS: Perceived facilitators of AIR implementation included AIR's face validity, adaptability, and alignment with staff values and skills, requiring only minimal training. Several interviewees in community settings thought AIR would fit with their current practices (e.g., family groups), and some clinics reported having sufficient staff available for delivering AIR. Perceived barriers included limited staff time, and VA clinics having limited resources for providing services to COs. Furthermore, many clients have no COs, or COs who are unwilling or unable to engage with them. Recommendations included fitting AIR within existing workflows and focusing on COs with highest readiness to receive support. Interviewees also thought AIR could be adapted to a website format or smartphone app, which may expand its reach while decreasing staff burden and cost; however, it may not be as effective and appealing to some demographic groups (e.g., older COs). CONCLUSIONS: AIR has strong potential for implementation in SUD treatment settings, but clinics vary on implementation capacity. Most clinics could implement AIR partially (e.g., case-by-case basis) while clinics with sufficient capacity (e.g., staff time) could implement it more fully. These findings can also inform implementation of other interventions for concerned others.