Psychiatric diagnoses, somatic disorders, and emergency dispatches among individuals who used a national suicide crisis line.

Crisis line responders initiate emergency dispatches by activating 911 or other local emergency services when individuals are determined to be at imminent risk for undesired outcomes. This study examined the association of characteristics, psychiatric diagnoses, and somatic symptoms with emergency dispatches in a national sample. Veterans Crisis Line data were used to identify contacts (i.e., calls, texts, chats, emails) that were linked with medical records and had a medical encounter in the year prior to contact. Hierarchical logistic regression clustered by responders was used to identify the association among demographics, psychiatric diagnoses, and somatic disorders, and emergency dispatches. Analyses examined 247,340 contacts from 2017 to 2020, with 27,005 (10.9%) emergency dispatches. Odds of an emergency dispatch increased with each diagnosis (three diagnoses Adjusted Odds Ratio [AOR] (95% CI) = 1.88 [1.81,1.95]). Odds were highest among individuals with substance use disorders (SUD) (alcohol AOR (95% CI) = 1.85 [1.80,1.91]; drugs AOR (95% CI) = 1.63 [1.58, 1.68]), which may be a result of intoxication or overdose during contact, requiring further research. Having more psychiatric and somatic conditions was associated with greater odds of an emergency dispatch, indicating that comorbidity contributed to the need for acute care.

What Happens Next? Maintenance of Gains After Discharge From VA Residential PTSD Treatment.

ABSTRACT: Residential posttraumatic stress disorder (PTSD) treatment in the Department of Veterans Affairs is helpful for many Veterans, yet the majority experience symptom rebound after discharge. This study examined a national cohort of Veterans (n = 1872) who completed VA residential PTSD treatment and identified factors associated with maintenance of gains from discharge to 4-month follow-up. We generated three logistic regression models based on response profiles during residential treatment. In the "marginal responders" group, 1-3 "booster" sessions of PTSD treatment were associated with decreased odds of maintenance of gains (odds ratio [OR], 0.42), whereas in the "clinically significant responders" group, these sessions were associated with increased odds of maintenance of gains (OR, 2.89). Greater pain severity was associated with decreased odds of maintenance of gains in the "clinically significant responder" group (OR, 0.90). Results demonstrate several avenues for intervention including targeting pain severity and matching aftercare psychotherapy to Veteran residential treatment response.

Reasons for contacting a crisis line and the initiation of emergency dispatches.

OBJECTIVE: To better understand processes of mental health crisis line utilization by examining associations between reasons for contacting a crisis line with the initiation of emergency dispatches (i.e., activation of 911 or local emergency services) in a national sample. METHODS: Contacts (i.e., calls, texts, email, and chats) to the Veterans Crisis Line (VCL) across 2017-2020 were used to examine associations among stated reasons for the contact and the use of an emergency dispatch. Hierarchical logistic regression models were used to determine the odds of an emergency dispatch by reason for the contact. RESULTS: Suicidal thoughts/crisis were present in 61.5% of contacts that ended in emergency dispatches and were associated with the largest adjusted odds of a dispatch, (Adjusted Odds Ratio [AOR] [95% CI] = 9.34 [9.21, 9.48]), followed by homicidal thoughts/crisis (AOR [95% CI] = 3.84 [3.73, 3.95]), and third-party concerns (AOR [95% CI] = 2.42 [2.37, 2.47]). Substance use/ addiction (AOR [95% CI] = 2.14 [2.10, 2.18]), abuse and violence (AOR [95% CI] = 1.89 [1.82, 1.96]), and physical health (AOR [95% CI] = 1.87 [1.84, 1.91]) were also associated with increased odds of a dispatch. CONCLUSIONS: Emergency dispatches are primarily used in response to imminent suicide risk but are also used in other potentially violent or lethal circumstances such as homicides, violence or abuse, and other crises. These findings highlight the role that crisis lines play in emergency service delivery, and the need to better understand how they are utilized under real world circumstances.

Study Protocol for the Healing Opioid Misuse and Pain Through Engagement Trial: Integrated Treatment for Individuals With Co-occurring Chronic Pain and Opioid Use Disorder.

Chronic pain and opioid use disorder (OUD) are public health crises and their co-occurrence has led to further complications and public health impacts. Provision of treatments for comorbid chronic pain and OUD is paramount to address these public health crises. Medications for OUD (MOUD) are gold standard treatments for OUD that have also demonstrated benefit in pain management. However, clinics that provide MOUD for chronic pain or OUD often lack behavioral treatments to address the challenges experienced by individuals with both conditions. Developing and implementing a behavioral treatment that complements MOUD may better equip clinics to provide comprehensive care to the growing proportion of clients who present with comorbid chronic pain and OUD. In the Healing Opioid misuse and Pain through Engagement (HOPE) Trial, we are using an effectiveness-implementation hybrid design to examine the benefits of an integrated behavioral treatment and to determine the feasibility of implementing the integrated treatment into clinics that provide MOUD. The treatment integrated 2 evidence-based treatments-Acceptance and Commitment Therapy and Mindfulness-Based Relapse Prevention-to target the emotional, behavioral, and physiological sequelae of OUD and chronic pain. Implementation feasibility will include assessing changes in implementation readiness and identifying facilitators and barriers to implementing the integrated treatment among all personnel employed in clinics that provide MOUD. This commentary offers an overview of the study and design and details adaptations we made to our study protocol, based largely on clinic personnel time constraints and variable clinic procedures during the COVID-19 pandemic.

Cognitive behavioral therapy for suicide prevention among Veterans receiving substance use disorder treatment: Results from a randomized trial.

Veterans receiving substance use disorder (SUD) treatment are at a clear elevated risk for engaging in suicidal behaviors. Intervening to reduce suicide risk during an episode of SUD treatment could meaningfully target a key high-risk group of Veterans. Cognitive Behavioral Therapy for Suicide Prevention (CBT-SP) was developed to reduce the frequency and duration of suicidal ideation, as well as decrease suicidal behaviors. The form of CBT-SP in this study progressed from building an understanding of the cognitive model to practicing new skills, and highlighted the links between substance use, craving, self-efficacy and suicidal ideation and attempts. CBT-SP was compared to an attention matched 8-session control condition (termed Supportive Psychoeducational Control [SPC]) during a multi-site randomized controlled trial for 299 Veterans receiving outpatient SUD treatment services within the Veterans Health Administration. The frequency of suicidal ideation remained relatively constant over 24-months of follow-up, however the duration of suicidal ideation decreased, and suicide attempts decreased relative to baseline in both conditions. Forty-two participants (14%) reported at least one suicide attempt during the 2-year follow-up period. No statistically significant differences were found between CBT-SP and SPC on any of these outcomes. Analyses of secondary outcomes indicate that preparatory behaviors for suicide were less common among those in the CBT-SP condition than SPC across the 24-month follow-up (OR, 95%CI = 0.44 (0.25, 0.79); p = 0.02). Veterans in SUD treatment are a high-risk group and delivery of suicide-specific interventions is feasible during SUD care. However, results did not indicate that CBT-SP was superior to SPC on any primary outcomes, underscoring the importance of identifying and testing alternative approaches that support suicide reduction in this group.

Assessing the diagnostic utility of the Cannabis Use Disorder Identification Test - Revised (CUDIT-R) among veterans with medical and non-medical cannabis use.

BACKGROUND: Few studies examine the utility of the Cannabis Use Disorder Identification Test - Revised (CUDIT-R) in relation to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5) criteria for cannabis use disorder (CUD). This study assesses the performance of the CUDIT-R among a sample of Veterans with and without medical cannabis use. METHODS: We approached and consented primary care patients presenting to one of three Department of Veterans Affairs (VA) Medical Centers. Veterans with at least monthly cannabis use and complete CUD data at baseline were included in this analysis (n=234). CUDIT-R scores were compared against Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 (DSM-5) CUD as the standard to calculate measures of validity (sensitivity, specificity), identify optimal CUDIT-R cutoff values, and assess the diagnostic proficiency of the CUDIT-R using receiver operating characteristic (ROC) curves. We further stratified analyses by active medical cannabis card holder status and DSM-5 CUD severity (any, moderate, and severe). RESULTS: Among the entire sample, 38.9% qualified for any DSM-5 CUD, with 10.7% and 3.0% meeting criteria for moderate and severe CUD, respectively. We identified optimal CUDIT-R scores at 10 for any DSM-5 CUD (sensitivity=0.58; specificity=0.80), at 12 for moderate CUD (sensitivity=0.72; specificity=0.82), and at 14 for severe CUD (sensitivity=0.71; specificity=0.87). ROC curves showed higher CUDIT-R validity among non-card holders compared with medical cannabis card holders. CONCLUSION: The present study identified optimal CUDIT-R cutoff scores for Veterans who use cannabis. Varying DSM-5 validity measures inform the need for population-specific CUDIT-R cutoff values.

Analysis of veterans crisis line data: Temporal factors associated with the initiation of emergency dispatches.

PURPOSE: To identify temporal patterns of emergency dispatches as initiated by Veteran Crisis Line (VCL) responders and among moderate- and high-risk contacts. METHODS: Incidence rate ratios (IRRs) were used to examine the incidence of emergency dispatches among all 1,437,543 VCL contacts across 2019-2020. RESULTS: Emergency dispatches were initiated in 57,077 (4.0%) contacts. IRRs were elevated during Labor Day, IRR (95% CI) = 1.33 (1.15-1.54), and Independence Day, IRR (95% CI) = 1.22 (1.05-1.43), weekends, Saturdays, IRR (95% CI) = 1.04 (1.01-1.08), Sunday (reference), and 6 pm to 11:59 pm, IRR (95% CI) = 1.06 (1.04-1.09). IRRs for moderate- and high-risk contacts were higher on Memorial Day, IRR (95% CI) = 1.16 (1.00-1.33), Sunday (reference), and 6 pm to 11:59 pm (reference). CONCLUSIONS: The initiation of emergency dispatches fluctuates over time and were highest during Labor Day and Independence Day, weekends, and evenings. Moderate- and high-risk contact also fluctuate over time and were highest on Memorial Day, Sundays, and midnight to 5:59 am. VCL policy makers can use knowledge of temporal fluctuations to allocate public health resources for increased efficiency and greatest impact; however, additional research on temporal stability and generalizability is needed.

Cognitive behavioral therapy for insomnia to reduce cannabis use: Results from a pilot randomized controlled trial.

BACKGROUND: Individuals with regular cannabis use demonstrate adverse health outcomes, yet infrequently seek treatment. Insomnia, a common co-occurring complaint, could be targeted to reduce cannabis use and improve functioning in these individuals. In an intervention development study, we refined and tested the preliminary efficacy of a telemedicine-delivered CBT for insomnia tailored to individuals with regular cannabis use for sleep (CBTi-CB-TM). METHODS: In this single-blind randomized trial, fifty-seven adults (43 women, mean age 37.6 ± 12.8 years) with chronic insomnia and cannabis use for sleep ≥3 times/week received CBTi-CB-TM (n = 30) or sleep hygiene education (SHE-TM, n = 27). Participants completed self-reported assessments of insomnia (Insomnia Severity Index [ISI]) and cannabis use (Timeline Followback [TLFB] and daily diary data) at pre-treatment, post-treatment, and 8-week follow-up. RESULTS: ISI scores improved significantly more in the CBTi-CB-TM compared to SHE-TM condition (ß = -2.83, se=0.84, P = 0.004, d=0.81). At 8-week follow-up, 18/30 (60.0 %) CBTi-CB-TM compared to 4/27 (14.8 %) SHE-TM participants were in remission from insomnia (X2 =12.8, P = 0.0003). The TLFB showed a small reduction in past 30-day cannabis use for both conditions (ß = -0.10, se=0.05, P = 0.026); CBTi-CB-TM participants demonstrated greater post-treatment reductions in the % of days cannabis was used within 2 h of bedtime (-29.1 ± 7.9 % fewer days vs. 2.6 ± 8.0 % more days, P = 0.008). CONCLUSIONS: CBTi-CB-TM is feasible, acceptable, and demonstrated preliminary efficacy for improving sleep and cannabis-related outcomes among non-treatment-seeking individuals with regular cannabis use for sleep. Although sample characteristics limit generalizability, these findings support the need for adequately powered randomized controlled trials with longer follow-up periods.

The association between cannabis use and subjective memory complaints in older adults in the United States.

OBJECTIVE: The U.S. population is aging and increasing numbers of older adults are using cannabis. Cognitive decline is common in older age and subjective memory complaints (SMC) have been associated with increased risk for dementia. While residual cognitive effects of cannabis use at younger ages are well understood, the links between cannabis use and cognition in older adults is less clear. The present study represents the first population-level analysis of cannabis use and SMC in older adults in the U.S. METHOD: We used the National Survey of Drug Use and Health (NSDUH) dataset to evaluate SMC in respondents over age 50 (N = 26,399) according to past-year cannabis use. RESULTS: Results revealed that 13.2% (95%CI: 11.5%-15.0%) of those who reported cannabis use also reported SMC, compared to 6.4% (95%CI: 6.1%-6.8%) among individuals with no cannabis use. Logistic regression revealed a two-fold increase (OR = 2.21, 95%CI: 1.88-2.60) of reporting SMC in respondents who had used cannabis in the past year, which was attenuated (OR = 1.38, 95%CI: 1.10-1.72) when controlling for additional factors. Other covariates, including physical health conditions, misuse of other substances, and mental illness also significantly contributed to SMC outcomes. CONCLUSIONS: Cannabis use represents a modifiable lifestyle factor that has potential for both risk and protective properties that may impact the trajectory of cognitive decline in older age. These hypothesis generating results are important for characterizing and contextualizing population-level trends related to cannabis use and SMC in older adults.

Encouraging the use of the Veterans Crisis Line among high-risk Veterans: A randomized trial of a Crisis Line Facilitation intervention.

The Veterans Crisis Line (VCL) is a core component of VA's suicide prevention strategy. Despite the availability and utility of the VCL, many Veterans do not utilize this resource during times of crisis. A brief, psychoeducational behavioral intervention (termed Crisis Line Facilitation [CLF]) was developed to increase utilization of the VCL and reduce suicidal behaviors in high-risk Veterans. The therapist-led session includes educational information regarding the VCL, as well as a chance to discuss the participant's perceptions of contacting the VCL during periods of crisis. The final component of the session is a practice call placed to the VCL by both the therapist and the participant. The CLF intervention was compared to Enhanced Usual Care (EUC) during a multi-site randomized clinical trial for 307 Veteran participants recently hospitalized for a suicidal crisis who reported no contact with the VCL in the prior 12 months. Initial analyses indicated that participants randomized to the CLF intervention were less likely to report suicidal behaviors, including suicide attempts compared to participants randomized to receive EUC over 12-months of follow-up (χ2 = 18.48/p < 0.0001), however this effect was not sustained when analyses were conducted on an individual level. No significant differences were found between conditions on VCL utilization. Initial evidence suggests a brief CLF intervention has an impact on preventing suicidal behaviors in Veterans treated in inpatient mental health programs; however, it may not change use of the VCL. This brief intervention could be easily adapted into clinical settings to be delivered by standard clinical staff.

Crisis service utilization following completion of a suicide safety plan for Veterans with and without affective and nonaffective psychosis.

OBJECTIVE: Psychosis is associated with increased suicide risk. Safety planning is a suicide prevention practice that is associated with decreased suicidal behavior and psychiatric hospitalizations. A common feature of safety planning is listing of crisis line numbers. The primary purpose of this study was to compare Veterans with and without psychosis who completed a safety plan in terms of their next year crisis service use, including Veterans Crisis Line (VCL) calls, and suicidal behavior. METHODS: Data were drawn from the VA San Diego's electronic medical record system for (N = 1602) safety plans from 2018 to 2021. Clinical records of crisis services and suicide attempt/death were recorded for one year after the safety plan. RESULTS: Following completion of a safety plan, Veterans with psychosis were more likely to have a next year psychiatric hospitalization (OR = 4.1), emergency department visit (OR = 2.3), and psychiatric emergency clinic visit (OR = 2.2) than those without psychosis. In contrast, there were no group differences in likelihood of calling the VCL. CONCLUSIONS: Veterans with psychosis who recently completed a safety plan do not show elevated rates of VCL use that are commensurate with increases in crisis service use. Interventions for this high-risk group may focus on understanding the motivation and ability to call the VCL as ways to enhance safety planning.

Suicide theory-guided natural language processing of clinical progress notes to improve prediction of veteran suicide risk: protocol for a mixed-method study.

INTRODUCTION: The state-of-the-art 3-step Theory of Suicide (3ST) describes why people consider suicide and who will act on their suicidal thoughts and attempt suicide. The central concepts of 3ST-psychological pain, hopelessness, connectedness, and capacity for suicide-are among the most important drivers of suicidal behaviour but they are missing from clinical suicide risk prediction models in use at the US Veterans Health Administration (VHA). These four concepts are not systematically recorded in structured fields of VHA's electronic healthcare records. Therefore, this study will develop a domain-specific ontology that will enable automated extraction of these concepts from clinical progress notes using natural language processing (NLP), and test whether NLP-based predictors for these concepts improve accuracy of existing VHA suicide risk prediction models. METHODS AND ANALYSIS: Our mixed-method study has an exploratory sequential design where a qualitative component (aim 1) will inform quantitative analyses (aims 2 and 3). For aim 1, subject matter experts will manually annotate progress notes of clinical encounters with veterans who attempted or died by suicide to develop a domain-specific ontology for the 3ST concepts. During aim 2, we will use NLP to machine-annotate clinical progress notes and derive longitudinal representations for each patient with respect to the presence and intensity of hopelessness, psychological pain, connectedness and capacity for suicide in temporal proximity of suicide attempts and deaths by suicide. These longitudinal representations will be evaluated during aim 3 for their ability to improve existing VHA prediction models of suicide and suicide attempts, STORM (Stratification Tool for Opioid Risk Mitigation) and REACHVET (Recovery Engagement and Coordination for Health - Veterans Enhanced Treatment). ETHICS AND DISSEMINATION: Ethics approval for this study was granted by the Stanford University Institutional Review Board and the Research and Development Committee of the VA Palo Alto Health Care System. Results of the study will be disseminated through several outlets, including peer-reviewed publications and presentations at national conferences.

Telemedicine-delivered cognitive-behavioral therapy for insomnia in alcohol use disorder (AUD): study protocol for a randomized controlled trial.

BACKGROUND: Alcohol use disorder (AUD) is a leading preventable cause of morbidity and mortality, but relapse rates are high even with available treatments. Insomnia is a robust predictor of relapse and pilot studies have shown that CBT for insomnia improves insomnia and daytime functioning in adults with AUD and insomnia. The impact of CBT for insomnia on relapse, however, is unclear. This trial will compare telemedicine-delivered CBT for insomnia (CBT-TM) with sleep hygiene education (SHE-TM) on improving insomnia/sleep, daytime symptom, and drinking outcomes in treatment-seeking AUD adults with insomnia. The study will also determine the effects of treatment on sleep mechanisms and their association with clinical outcomes. METHODS: This is a single-site randomized controlled trial with planned enrollment of 150 adults meeting criteria for both AUD and chronic insomnia. Eligible participants will be randomized 1:1 to 6 sessions of telemedicine-delivered Cognitive Behavioral Therapy for Insomnia (CBT-TM) or Sleep Hygiene Education (SHE-TM) with clinical assessments conducted at pre-treatment, post- treatment, and at 3, 6, and 12 months post-treatment. Overnight polysomnography will be conducted before and after treatment. Primary clinical outcomes will include post-treatment scores on the Insomnia Severity Index and the General Fatigue subscale of the Multidisciplinary Fatigue Inventory, and the percent of days abstinent (PDA) on the interview-administered Time Line Follow Back. EEG delta activity, derived from overnight polysomnography, will be the primary endpoint to assess the sleep homeostasis mechanism. DISCUSSION: This adequately powered randomized controlled trial will provide clinically relevant information about whether targeting insomnia is effective for improving treatment outcomes among treatment-seeking adults with AUD. Additionally, the study will offer new scientific insights on the impact of an evidence-based non-medication treatment for insomnia on a candidate mechanism of sleep dysfunction in this population - sleep homeostasis. TRIAL REGISTRATION: CClinicalTrials.gov NCT # 04457674 . Registered on 07 July 2020.

Methamphetamine use among American Indians and Alaska Natives in the United States.

BACKGROUND: Recent trends show methamphetamine use is increasing in the United States. American Indian and Alaska Native (AI/AN) communities face health disparities compared to the population overall, including some of the highest rates of illegal drug use. Herein, we examined the prevalence of methamphetamine use among AI/ANs and characteristics associated with methamphetamine use among AI/AN people. METHODS: We examined past-year methamphetamine use from 2015 to 2019 between AI/ANs and the general non-institutionalized U.S. population using the National Survey of Drug Use and Health. Then, we identify potential subgroups of AI/AN people at elevated risk of methamphetamine use across factors including demographic, social determinants, mental health, and co-occurring substance use. RESULTS: A total of 214,505 people, aged 18 or older, were surveyed between 2015 and 2019; 3,075 (0.55%) identified as AI/AN. An estimated 26.2 out of every 1000 AI/ANs used methamphetamine compared to 6.8 out of every 1000 in the general U.S. POPULATION: Compared to methamphetamine use in the general population, AI/AN methamphetamine use tends to cluster in rural areas and among those with low income. AI/ANs who use methamphetamine were more likely to be male, middle-aged, low income, have severe mental illness, and misuse other substances than AI/AN people who did not use methamphetamine. DISCUSSION: AI/ANs experience a disproportionate amount of methamphetamine use in the U.S. To address this disparity, multifaceted, broad prevention, harm reduction, and treatment efforts are needed that leverage cultural strengths to mitigate the consequences of methamphetamine use.

Prevalence of cannabis use among individuals with a history of cancer in the United States.

BACKGROUND: Patients with cancer have played a key role in advocating for legal access to cannabis, but little is known about links between cancer and cannabis use or cannabis-related beliefs. The authors used data from a national survey to study these relationships. METHODS: Nationally representative data collected by the National Survey on Drug Use and Health from 2015 to 2019 were acquired. Patterns of cannabis use and cancer history were examined and tested within age group subpopulations via domain analysis using survey weights. RESULTS: Data for 214,505 adults, including 4741 individuals (3.8%) with past (>1 year ago) cancer diagnosis and 1518 individuals (1.2%) with recent (≤1 year ago) cancer diagnosis, were examined. Cannabis use was less common in those with past (8.9%; 95% CI, 8.0%-9.8%) or recent (9.9%; 95% CI, 6.9%-11.1%) cancer diagnosis than in those without a history of cancer (15.9%; 95% CI, 15.7%-16.1%). However, when analyses were stratified by age group, those 18 to 34 years of age were more likely to report past cannabis use, and those 35 to 49 years of age were more likely to report past or recent cannabis use if they had a history of cancer. Younger patients felt that cannabis was more accessible and less risky if they had a history of cancer. CONCLUSIONS: Patients with cancer were less likely to report cannabis use, but there were different cannabis perceptions and use patterns by age. Age should be considered in studies of cannabis and cancer, and policy initiatives may be needed to aid provision of quality information on cannabis risk to those with cancer. LAY SUMMARY: Cannabis (marijuana) use is increasing in the United States, but we do not have much information on the relationship between cannabis use and cancer. We studied information from a representative group of people and found that younger patients generally reported more past and/or recent cannabis use if they had been diagnosed with cancer whereas older individuals did not. Beliefs about cannabis risk and accessibility differed by age. Clinical trials to study cannabis should account for patient age, and accurate information about cannabis should be provided to help patients with cancer make decisions about cannabis use.

Shorter- and Longer-Term Risk for Suicide Among Male US Military Veterans in the Year After Discharge From Psychiatric Hospitalization.

OBJECTIVE: Risk for suicide is highest in the first 3 months (days 1-90) after discharge from acute psychiatric hospitalization yet remains elevated for the remainder of the year (days 91-365). The purpose of this study was to compare risk factors for suicide in the first 90 days to those over the remainder of the year to identify changes across time frames. METHODS: The study included 316,707 male veterans discharged from Veterans Health Administration acute psychiatric inpatient units from 2008 through 2013. Proportional hazard regression models were used to identify predictors of suicide death in the first 90 days and in days 91-365, defined via ICD-10 codes. Adjusted piecewise proportional hazard regression was used to compare risk across time frames. RESULTS: Among the 1,037 veterans (< 1%) who died by suicide, 471 (45%) died between days 1 and 90 and 566 (55%) died between days 91 and 365. There was little change regarding the strength of risk factors over time, with two exceptions: risk increased among those aged 18-29 years compared to those aged ≥ 65 years (days 1-90: hazard ratio [HR] = 0.83; 95% CI, 0.57-1.20 vs days 91-365: HR = 1.42; 95% CI, 1.03-1.97; P < .05), whereas, risk associated with suicidal ideation decreased (days 1-90: HR = 1.89; 95% CI, 1.57-2.28 vs days 91-365: HR = 1.40; 95% CI, 1.17-1.66, P < .05). CONCLUSIONS: The strength of association between common risk factors and suicide remains relatively stable during the year following psychiatric hospitalization. However, risk among veterans aged 19-29 years increased over time, whereas risk among those with suicidal ideation decreased.

Developing and testing Crisis Line Facilitation (CLF) to encourage help-seeking in adults receiving inpatient treatment for a suicidal crisis.

Military Veterans are at overall greater risk of suicide than non-Veterans and have experienced increases in rates of suicide that are on par with or exceed those of the general population. The Department of Veterans Affairs has undertaken several initiatives to reduce suicide among Veterans, including the development and expansion of the Veterans Crisis Line (VCL). The VCL has the potential to reduce suicidal behaviors, but it is likely underutilized by high-risk Veterans. This paper describes the development of Crisis Line Facilitation (CLF) a brief intervention, designed to increase use of the VCL in this high-risk population. In a single session, CLF presents psychoeducational information about the VCL, discusses the participant's perceived barriers and facilitators to future use of the VCL, and culminates in the Veteran calling the VCL with the therapist to provide firsthand experiences that may counter negative impressions of the line. The intervention development process, intervention and control condition, and self-reported change indices are presented. Preliminary results (N = 301) suggest Veterans receiving CLF may experience a significant increase in comfort with, and confidence in, using the VCL during future crises compared to those in the control condition.

Progression of cannabis withdrawal symptoms in people using medical cannabis for chronic pain.

BACKGROUND AND AIMS: Research from cohorts of individuals with recreational cannabis use indicates that cannabis withdrawal symptoms are reported by more than 40% of those using regularly. Withdrawal symptoms are not well understood in those who use cannabis for medical purposes. Therefore, we prospectively examined the stability of withdrawal symptoms in individuals using cannabis to manage chronic pain. DESIGN, SETTING, PARTICIPANTS: Using latent class analysis (LCA) we examined baseline cannabis withdrawal to derive symptom profiles. Then, using latent transition analysis (LTA) we examined the longitudinal course of withdrawal symptoms across the time points. Exploratory analyses examined demographic and clinical characteristics predictive of withdrawal class and transitioning to more or fewer withdrawal symptoms over time. A cohort of 527 adults with chronic pain seeking medical cannabis certification or re-certification was recruited between February 2014 and June 2015. Participants were recruited from medical cannabis clinic waiting rooms in Michigan, USA. Participants were predominantly white (82%) and 49% identified as male, with an average age of 45.6 years (standard deviation = 12.8). MEASUREMENTS: Baseline, 12-month and 24-month assessments of withdrawal symptoms using the Marijuana Withdrawal Checklist-revised. FINDINGS: A three-class LCA model including a mild (41%), moderate (34%) and severe (25%) symptom class parsimoniously represented withdrawal symptoms experienced by people using medical cannabis. Stability of withdrawal symptoms using a three-class LTA at 12 and 24 months ranged from 0.58 to 0.87, with the most stability in the mild withdrawal class. Younger age predicted greater severity and worsening of withdrawal over time. CONCLUSIONS: Adults with chronic pain seeking medical cannabis certification or re-certification appear to experience mild to severe withdrawal symptoms. Withdrawal symptoms tend to be stable over a 2-year period, but younger age is predictive of worse symptoms and of an escalating withdrawal trajectory.

Polysubstance use and association with opioid use disorder treatment in the US Veterans Health Administration.

AIMS: To understand the role of comorbid substance use disorders (SUDs), or polysubstance use, in the treatment of opioid use disorder (OUD), this study compared patients with OUD only to those with additional SUDs and examined association with OUD treatment receipt. DESIGN, SETTING AND PARTICIPANTS: Retrospective national cohort study of Veterans diagnosed with OUD (n = 65 741) receiving care from the US Veterans Health Administration (VHA) in fiscal year (FY) 2017. MEASUREMENTS: Patient characteristics were compared among those diagnosed with OUD only versus those with one other SUD (OUD + 1 SUD) and with multiple SUDs (OUD + ≥ 2 SUDs). The study examined the relationship between comorbid SUDs and receipt of buprenorphine, methadone and SUD outpatient treatment during 1-year follow-up, adjusting for patient demographic characteristics and clinical conditions. FINDINGS: Among the 65 741 Veterans with OUD in FY 2017, 41.2% had OUD only, 22.9% had OUD + 1 SUD and 35.9% had OUD + ≥ 2 SUDs. Common comorbid SUDs included alcohol use disorder (41.3%), cocaine/stimulant use disorder (30.0%) and cannabis use disorder (22.4%). Adjusting for patient characteristics, patients with OUD + 1 SUD [adjusted odds ratio (aOR) = 0.87, 95% confidence interval (CI) = 0.82-0.93] and patients with OUD +≥ 2 SUDs (aOR = 0.65, 95% CI = 0.61-0.69) had lower odds of receiving buprenorphine compared with OUD only patients. There were also lower odds of receiving methadone for patients with OUD + 1 SUD (aOR = 0.91, 95% CI = 0.86-0.97)and for those with OUD + ≥2 SUDs (aOR = 0.79, 95% CI = 0.74-0.84). Patients with OUD + 1 SUD (aOR = 1.85, 95% CI = 1.77-1.93) and patients with OUD + ≥2 SUDs (aOR = 3.25, 95% CI = 3.103.41) were much more likely to have a SUD clinic visit. CONCLUSIONS: The majority of Veterans in the US Veterans Health Administration diagnosed with opioid use disorder appeared to have at least one comorbid substance use disorder and many have multiple substance use disorders. Despite the higher likelihood of a substance use disorder clinic visit, having a non-opioid substance use disorder is associated with lower likelihood of buprenorphine treatment, suggesting the importance of addressing polysubstance use within efforts to expand treatment for opioid use disorder.