Counseling Veterans with Chronic Pain During the COVID-19 Pandemic: A Secondary Analysis of a Randomized Controlled Trial.

INTRODUCTION: Veterans with chronic pain could be vulnerable during the COVID-19 pandemic. We qualitatively explored the impact of the COVID-19 pandemic on a sample of veterans receiving brief counseling focused on pain management in an ongoing clinical trial and discuss how the pandemic affected the process of motivating veterans with chronic pain to engage in interdisciplinary multimodal pain treatment at the Department of Veteran Affairs. METHODS: Segments of audio-recorded counseling sessions containing content about the pandemic were transcribed and coded to identify key concepts emerging from individual counselor-participant transactions. Themes that emerged were examined with constant comparison analysis. RESULTS: Three major themes emerged. 1) The pandemic caused a disruption in pain management service delivery, resulting in changes to the way veterans receive services or manage their pain symptoms. 2) The pandemic offered opportunities for resilience and personal growth as veterans with chronic pain reflected on their lives and personal goals. 3) The pandemic brought veterans' mental health issues to the forefront, and these should be addressed as part of a comprehensive pain management approach. DISCUSSION: Discussion of the COVID-19 pandemic during pain treatment counseling sessions highlighted negative and positive ways participants were affected by the pandemic. These discussions provided counselors with a unique opportunity to facilitate behavior change by focusing on characteristics of resilience to motivate individuals with chronic pain to adapt and adopt positive behaviors and outlooks to improve their pain experience and quality of life. CONCLUSIONS: Counselors can leverage feelings of resilience and personal growth to motivate veterans' use of adaptive coping skills and a wider array of pain management services.

The acceptability and feasibility of screening, brief intervention, and referral to treatment for pain management among new England veterans with chronic pain: A pilot study.

OBJECTIVES: Musculoskeletal disorders often lead to chronic pain in Veterans. Chronic pain puts sufferers at risk for substance misuse, and early intervention is needed for both conditions. This pilot study tested the feasibility and acceptability of a Screening, Brief Intervention, and Referral to Treatment for Pain Management intervention (SBIRT-PM) to help engage Veterans seeking disability compensation for painful musculoskeletal disorders in multimodal pain treatment and to reduce risky substance use, when indicated. METHODS: This pilot study enrolled 40 Veterans from 8 medical centers across New England in up to 4 sessions of telephone-based counseling using a motivational interviewing framework. Counseling provided education about, and facilitated engagement in, multimodal pain treatments. Study eligibility required Veterans be engaged in no more than 2 Veteran Affairs (VA) pain treatment modalities, and study participation involved a 12-week postassessment and semistructured interview about the counseling process. RESULTS: Majorities of enrolled Veterans screened positive for comorbid depression and problematic substance use. Regarding the offered counseling, 80% of participants engaged in at least one session, with a mean of 3 sessions completed. Ninety percent of participants completed the postassessment. Numerically, most measures improved slightly from baseline to week 12. In semistructured interviews, participants described satisfaction with learning about new pain care services, obtaining assistance connecting to services, and receiving support from their counselors. DISCUSSION: It was feasible to deliver SBIRT-PM to Veterans across New England to promote engagement in multimodal pain treatment and to track study outcomes over 12 weeks. Preliminary results suggest SBIRT-PM was well-received and has promise for the targeted outcomes.

The intertwined expansion of telehealth and buprenorphine access from a prescriber hub.

In this manuscript, we describe how efforts to increase access to buprenorphine for Opioid Use Disorder (OUD) through a telemedicine hub before and since the COVID-19 pandemic have played out in the Veterans Healthcare Administration (VHA) in New England. We look at how the COVID-19 pandemic and subsequent spike in opioid overdoses tilted the risk: benefit calculation for tele-prescribing a controlled substance such as buprenorphine toward expanding access to tele-buprenorphine. We conclude that there is a need for tele-buprenorphine hubs that can fill gaps in geographically dispersed healthcare systems.

Screening, Brief Intervention, and Referral to Treatment for Pain Management for Veterans Seeking Service-Connection Payments for Musculoskeletal Disorders: SBIRT-PM Study Protocol.

BACKGROUND: Veterans with significant chronic pain from musculoskeletal disorders are at risk of substance misuse. Veterans whose condition is the result of military service may be eligible for a disability pension. Department of Veterans Affairs compensation examinations, which determine the degree of disability and whether it was connected to military service, represent an opportunity to engage Veterans in pain management and substance use treatments. A multisite randomized clinical trial is testing the effectiveness and cost-effectiveness of Screening, Brief Intervention, and Referral to Treatment for Pain Management (SBIRT-PM) for Veterans seeking compensation for musculoskeletal disorders. This telephone-based intervention is delivered through a hub-and-spoke configuration. DESIGN: This study is a two-arm, parallel-group, 36-week, multisite randomized controlled single-blind trial. It will randomize 1,100 Veterans experiencing pain and seeking service-connection for musculoskeletal disorders to either SBIRT-PM or usual care across eight New England VA medical centers. The study balances pragmatic with explanatory methodological features. Primary outcomes are pain severity and number of substances misused. Nonpharmacological pain management and substance use services utilization are tracked in the trial. SUMMARY: Early trial enrollment targets were met across sites. SBIRT-PM could help Veterans, at the time of their compensation claims, use multimodal pain treatments and reduce existing substance misuse. Strategies to address COVID-19 pandemic impacts on the SBIRT-PM protocol have been developed to maintain its pragmatic and exploratory integrity.

Sensitivity, specificity, and discordance with self-report of nail sample testing for alcohol and cannabis.

BACKGROUND: Nails accumulate the alcohol metabolite, ethyl glucuronide (ETG), and the cannabis metabolite, carboxy- delta-9-THC over 3-6 months. Few studies have examined nail toxicology testing's sensitivity and specificity and the agreement between nail testing and self-reported alcohol and marijuana use. METHODS: In an ongoing clinical trial, 1101 veterans completed initial telephone questionnaires and were then asked to mail nail clippings for substance use analysis. We examined sensitivity and specificity of ETG and carboxy- delta-9-THC in nails compared to self-report of alcohol use patterns (the AUDIT-C) and substance-related harms (alcohol and THC subscales of the ASSIST). We then examined factors associated with discordance between nails and self-report. RESULTS: Almost two-thirds (707/1101) of respondents mailed in nail clippings. Those with returned nails were disproportionately married, white race, older, and less depressed. At a threshold of 8pg/mg, sensitivity was only.50 to detect risky alcohol use and.49 to detect alcohol-related issues. Sensitivity for marijuana issues was only.61. Specificity was greater than.77 for all measures. Factors associated with positive nails/negative self-report (i.e. false positives) for risky alcohol use on the Audit-C included more pain and being unmarried; false positive nails for alcohol-related issues on the ASSIST were associated with being unmarried and non-Hispanic ethnicity. False positive nails for THC-related issues on the ASSIST were associated with being African American, Hispanic, and having had legal issues. CONCLUSIONS: At standard cut-offs, nail measures had low sensitivity and higher specificity. The groups who disproportionately submit positive nails/negative self-report could have substance use patterns not adequately captured by self-report, inaccurate self-report due to social pressures, or distinct drug metabolism.

Economic evaluation of pharmaco- and behavioral therapies for smoking cessation: a critical and systematic review of empirical research.

Economic evaluations are an important tool to improve our understanding of the costs and effects of health care services and to create sustainable health care systems. This article critically assesses empirical evidence from economic evaluations of pharmaco- and behavioral therapies for smoking cessation. A comprehensive literature review of PubMed and the British National Health Service Economic Evaluation Database was conducted. The search identified 15 articles on nicotine-based pharmacotherapies, 12 articles on nonnicotine based pharmacotherapies, no articles on selegiline, and 10 articles on brief counseling for smoking cessation treatment. Results show that both pharmaco- and behavioral therapies for smoking cessation are cost-effective or even cost-saving. The review highlights several shortcomings in methodology and a lack of standardization of current economic evaluations. Efforts to improve methodology will help make future studies more comparable and increase the evidence base so that such evaluations can be more useful to public health practitioners and policy makers.

Understanding opportunities and challenges with telemedicine-delivered buprenorphine during the COVID-19 pandemic.

INTRODUCTION: Opioid use disorder (OUD) is a debilitating illness that remains a serious public health issue in the United States. Use of telemedicine to deliver medications for the treatment of OUD (MOUD) was limited until the confluence of the COVID-19 and opioid addiction epidemics in spring 2020. Starting in spring 2020, the Department of Veterans Health Affairs (VHA) transitioned from in-person to mostly telemedicine-delivered OUD care to reduce COVID-19 transmission among veterans and providers. To gain a nuanced understanding of provider perspectives on MOUD care delivery using telemedicine, we conducted semi-structured interviews with VHA providers who were using telehealth to deliver MOUD care. METHODS: We conducted semi-structed Zoom interviews with VA clinicians at nine VA Medical Centers (VAMCs) in eight states. Potential study participants were identified as providers who were involved in referrals and provision of buprenorphine treatment for chronic pain and opioid addiction. Audio-recordings of all interviews were transcribed and entered into Atlas. Ti qualitative analysis software. The study team analyzed the transcripts for major themes related to tele-prescribing practices for buprenorphine. RESULTS: Twenty-three VA providers participated in the study, representing 32% of all providers invited to participate in the study. The research team identified the following four themes: (1) COVID-19 spurred a seismic shift in OUD treatment; (2) Video calls provided a rare window into veterans' lives; (3) Providers experienced numerous challenges to virtual visits; and (4) Providers wrestled with paternalism and trust. CONCLUSIONS: The pandemic accelerated the movement toward harm reduction approaches. Prior to the pandemic, stringent requirements existed for patients receiving MOUD care. Providers in this study reflected on the need for these requirements (e.g., in-person visits, toxicology screens) and how reducing this monitoring implied more trust in patients' autonomous decisions. Providers' observation that videoconferencing offered them a window into patients' lives may offer some ways to improve rapport, and research should explore how best to incorporate the additional information conveyed in virtual visits.

Micro-costing in health and medicine: a critical appraisal.

BACKGROUND: Concerns about rising health care costs require rigorous economic study to inform clinical and policy decision-making. Micro-costing is a cost estimation methodology employing detailed resource utilization and unit cost data to generate precise estimates of economic costs. Micro-costing studies have not been critically appraised. METHODS: Critical appraisal of micro-costing studies in English. Studies fully or predominantly employing micro-costing were appraised for methodological and reporting quality through economic evaluation guidelines (Evers, Drummond, Consolidated Health Economic Evaluation Reporting Standards (CHEERS), Fukuda and Imanaka checklists). Following the Panel on Cost Effectiveness in Health and Medicine, micro-costing studies were defined as involving "direct enumeration and costing out of every input consumed in the treatment of a particular patient." RESULTS: Full or predominant micro-costing studies included  neoplasms (18.5%), infectious and parasitic diseases (17.9%), and diseases of circulatory systems (10.8%) as the  most studied diseases. 36.9% were in the United States and 34.9% were in Europe. 33.8% did not report analytic perspective, 32.8% did not report price year, 3.6% did not inflation adjust cost data, and 44.1% did not specify inflation adjustment. 86.2% did not separately report unit costs and resource utilization quantity, 14.9 and 19.5% did not provide sufficient detail to assess appropriateness of measured physical units or valued costs. CONCLUSIONS: Micro-costing studies vary widely in methodological and reporting quality, highlighting the need to standardize methods and reporting of micro-costing studies and develop tools for their evaluation.

Practices and policies of providers testing school-aged children for tuberculosis, Connecticut, 2008.

This study identified current practices and policies related to testing school children for latent tuberculosis infection (LTBI) in Connecticut. A cross-sectional survey was mailed to a random sample of community pediatricians and family practitioners in Connecticut who provide health care services to children aged 4-18 years. The main outcome measure was adherence to national guidelines for tuberculosis (TB) testing of school-aged children. The response rate was 66.3% (345 of 520), 258 of whom provided services to children. Responses showed that 60% (152 of 252) of replying providers read the American Academy of Pediatrics (AAP) published guidelines, and 85% routinely assess children for TB risk before skin testing although only a minority (22%) use a written questionnaire. Of 153 responding providers, 130 (85%) report that schools require formal TB risk assessments at mandated school physical examinations or at school entry. Results also showed providers who read AAP-published guidelines and who are trained in the United States are more likely to follow the national guidelines for TB testing of children. The majority of health care providers reported following AAP-published guidelines for screening school-aged children for LTBI and TB disease; however, an important number of providers still do not follow recommended guidelines. Public health officials should make efforts to increase provider awareness of, and adherence to, guidelines. School districts also should take steps to ensure the appropriate level of testing of children for TB disease and LTBI.

Access to Pain Care From Compensation Clinics: A Relational Coordination Perspective.

BACKGROUND: The Compensation and Pension (C&P) determination process is a potential gateway to accessing pain treatment in the Veterans Health Administration (VHA). However, attitudes about C&P as a gateway and about collaboration with C&P clinics among VHA staff are unknown. METHODS: In preparation for an initiative to link veterans seeking compensation for musculoskeletal disorders to treatment, clinical and administrative staff from the 8 VHA medical centers in New England were invited to complete a relational coordination survey that examined how different workgroups collaborate (communication and relationships) to provide pain care to veterans. A subset of those staff also participated in a semistructured interview about pain treatment referral practices within their medical centers. VHA staff were from primary care, administration, pain management, and C&P teams. RESULTS: Eighty-three VHA staff were invited to complete the relational coordination survey; 66 completed the survey and 39 participated in the semistructured interview. Most C&P staff interviewed thought of the compensation examination as a forensic process and that C&P-based efforts to engage veterans might interfere with the examination or were not their responsibility. However, some examiners described their efforts to determine new veterans' eligibility for VHA care and to connect them to specific treatments. VHA staff reported that there was little communication between the C&P team and other teams. The survey results supported this finding. The C&P group's relational coordination composite scores were lower than any other workgroup. CONCLUSION: Outreach to veterans at New England C&P clinics was inconsistent, and C&P teams rated low on a measure of coordination with workgroups involved in pain treatment. Compensation examinations appear to be underused opportunities to help veterans access treatment. C&P-based treatment engagement is feasible; it is being done by some Compensation teams.

Perceptions of People Living with HIV and HIV Healthcare Providers on Real-Time Measuring and Monitoring of Antiretroviral Adherence Using Ingestible Sensors: A Qualitative Study.

OBJECTIVE: To describe and analyze the perception and attitudes of people living with HIV (PLWH) and HIV HCPs towards medication adherence with a focus on a digital medicine program (DMP) with ingestible sensors (ISs). METHODS: This is a qualitative analysis pilot study of PLWH who were using DMP recruited by purposive sampling. A convenience sample of HCPs was interviewed. Semistructured interviews were conducted, and thematic analysis was performed. RESULTS: Fifteen PLWH were interviewed, and thematic analysis resulted in three main themes: self-identified medication adherence patterns, experiences with the DMP, and recommending the DMP to others. Six health care providers (HCPs) described barriers and facilitators to adherence, as well as advantages and disadvantages of using or recommending the DMP to PLWH. CONCLUSION: This study evaluated participant and provider responses to DMP, which is a novel technology for real-time measuring and monitoring adherence with the IS. Participant and provider responses were mixed, highlighting both the advantages and limitations of the technology. Practice Implications. Taking PLWH experiences into consideration will enhance the development of this and other useful tools that clinicians and researchers can use for enhanced patient care.

Consideration of substance use in compensation and pension examinations of veterans filing PTSD claims.

Veterans filing claims that service-induced PTSD impairs them worry that claims examiners may attribute their difficulties to conditions other than PTSD, such as substance use. Substance use commonly co-occurs with PTSD and complicates establishing a PTSD diagnosis because symptoms may be explained by PTSD alone, PTSD-induced substance use, or by a substance use condition independent of PTSD. These alternative explanations of symptoms lead to different conclusions about whether a PTSD diagnosis can be made. How substance use impacts an examiner's diagnosis of PTSD in a Veteran's service-connection claim has not been previously studied. In this study, we tested the hypothesis that mention of risky substance use in the Compensation & Pension (C&P) examination would result in a lower likelihood of service-connection award, presumably because substance use reflected an alternative explanation for symptoms. Data were analyzed from 208 Veterans' C&P examinations, medical records, and confidentially-collected research assessments. In this sample, 165/208 (79%) Veterans' claims were approved for a mental health condition; 70/83 (84%) with risky substance use mentioned and 95/125 (76%) without risky use mentioned (p = .02). Contrary to the a priori hypothesis, Veterans with risky substance use were more likely to get a service-connection award, even after controlling for baseline PTSD severity and other potential confounds. They had almost twice the odds of receiving any mental health award and 2.4 times greater odds of receiving an award for PTSD specifically. These data contradict assertions of bias against Veterans with risky substance use when their claims are reviewed. The data are more consistent with substance use often being judged as a symptom of PTSD. The more liberal granting of awards is consistent with literature concerning comorbid PTSD and substance use, and with claims procedures that make it more likely that substance use will be attributed to trauma exposure than to other causes.

Is Capability to Manage Finances Stable Over Time?

Procedures to determine when people receiving disability payments are incapable of managing their money recently have been re-examined by the Social Security Administration. Understanding the time-course of financial capability is necessary because people who are judged capable of managing their funds at one point may go on to need supports in the future, and those judged incapable and assigned a fiduciary will need re-evaluation so they have the most possible autonomy over their funds management. The financial capability of 132 individuals was examined during acute treatment and twenty-four weeks later. The extent to which baseline variables predicted future capability were examined. More participants were assessed as financially incapable at baseline (n=72) than at the twenty-four-week follow-up (n=43). Most participants had stable capability across assessment periods (n=35 remained incapable; n=52 remained capable), however a substantial minority (n=37) moved from incapable to capable. People who transitioned from incapable to capable had greater net reductions in psychiatric distress ratings and days of alcohol use from baseline to follow-up, compared to people who remained incapable. In multivariate analyses, incapability at follow-up was predicted by having been rated incapable at baseline, drug use at baseline, and having a psychotic disorder. The high baseline rate of incapability determinations suggests that admission into intensive psychiatric programs may be a good time to assess an individual's financial capability. However, these findings also suggest the importance of periodically reassessing beneficiaries' capability because high proportions rated incapable were rated to be capable twenty-four weeks later.

Momentary assessment of PTSD symptoms and sexual risk behavior in male OEF/OIF/OND Veterans.

BACKGROUND: Post-traumatic stress disorder (PTSD) in Veterans is associated with increased sexual risk behaviors, but the nature of this association is not well understood. Typical PTSD measurement deriving a summary estimate of symptom severity over a period of time precludes inferences about symptom variability, and whether momentary changes in symptom severity predict risk behavior. METHODS: We assessed the feasibility of measuring daily PTSD symptoms, substance use, and high-risk sexual behavior in Veterans using ecological momentary assessment (EMA). Feasibility indicators were survey completion, PTSD symptom variability, and variability in rates of substance use and sexual risk behavior. Nine male Veterans completed web-based questionnaires by cell phone three times per day for 28 days. RESULTS: Median within-day survey completion rates maintained near 90%, and PTSD symptoms showed high within-person variability, ranging up to 59 points on the 80-point scale. Six Veterans reported alcohol or substance use, and substance users reported use of more than one drug. Eight Veterans reported 1 to 28 high-risk sexual events. Heightened PTSD-related negative affect and externalizing behaviors preceded high-risk sexual events. Greater PTSD symptom instability was associated with having multiple sexual partners in the 28-day period. LIMITATIONS: These results are preliminary, given this small sample size, and multiple comparisons, and should be verified with larger Veteran samples. CONCLUSIONS: Results support the feasibility and utility of using of EMA to better understand the relationship between PTSD symptoms and sexual risk behavior in Veterans. Specific antecedent-risk behavior patterns provide promise for focused clinical interventions.

All-data approach to assessing financial capability in people with psychiatric disabilities.

The goal of this project was to develop an evidence-based method to assess the ability of disabled persons to manage federal disability payments. This article describes the development of the Financial Incapability Structured Clinical Assessment done Longitudinally (FISCAL) measure of financial capability. The FISCAL was developed by an iterative process of literature review, pilot testing, and expert consultation. Independent assessors used the FISCAL to rate the financial capability of 118 participants (57% female, 58% Caucasian) who received Social Security disability payments, had recently been treated in acute care facilities for psychiatric disorders, and who did not have representative payees or conservators. Altogether, 48% of participants were determined financially incapable by the FISCAL, of whom 60% were incapable because of unmet basic needs, 91% were incapable because of spending that harmed them (e.g., on illicit drugs or alcohol), 56% were incapable because of both unmet needs and harmful spending, and 5% were incapable because of contextual factors. As expected, incapable individuals scored higher on a measure of money mismanagement (p < .001) compared with capable individuals. Interrater reliability for FISCAL capability determinations was very good (κ = .77) and interrater agreement was 89%. In this population, the FISCAL had construct validity; ratings demonstrated good reliability and correlated with a related measure. Potentially, the FISCAL can be used to validate other measures of capability and to help understand how people on limited incomes manage their funds.

Ambiguity in determining financial capability of SSI and SSDI beneficiaries with psychiatric disabilities.

OBJECTIVE: The liberty of individuals who receive Social Security disability payments is constrained if they are judged incapable of managing their payments and are assigned a payee or conservator to manage benefit payments on their behalf. Conversely, beneficiaries' well-being may be compromised if they misspend money that they need to survive. Several studies have shown that determinations of financial capability are made inconsistently and that capability guidelines appear to be applied inconsistently. This article describes ambiguities that remained for individuals even after a comprehensive assessment of financial capability was conducted by independent assessors. METHODS: Trained, experienced assessors rated the financial capability of 118 individuals in intensive outpatient or inpatient psychiatric facilities who received Social Security Disability Insurance or Supplemental Security Income. RESULTS: Ten individuals' cases were determined to be difficult to judge. Six sources of ambiguity were identified by case review: distinguishing incapability from the challenges of navigating poverty, the amount of nonessential spending that indicates incapability, the amount of spending on harmful things that indicates incapability, how to consider intermittent periods of capability and incapability, the relative weighting of past behavior and future plans to change, and discrepancies between different sources of information. CONCLUSIONS: The cases raise fundamental questions about how to define and identify financial incapability, but they also illustrate how detailed consideration of beneficiaries' living situations and decision making can inform the difficult dichotomous decision about capability.

Financial victimization of adults with severe mental illness.

OBJECTIVE: People with severe mental illness are vulnerable to having other people directly take or misappropriate their disability payments. This study investigated the prevalence of different types of financial victimization and the client characteristics associated with being financially victimized. METHODS: Adults (N=122) receiving inpatient or intensive outpatient psychiatric treatment who received Social Security disability payments completed assessments about money management and victimization. A path model was used to estimate the association of victimization with participant characteristics. RESULTS: Seventy percent of participants experienced at least one type of financial victimization in the preceding 28 days; 35% ran out of money because of victimization. Victimization was significantly associated with being younger, having had more psychiatric hospitalizations, having more recent alcohol use, and, most robustly, having problems managing money (ß=.52, p<.01). CONCLUSIONS: Financial victimization of disability recipients in acute care settings is common and more likely among people with recent substance use and difficulty managing their funds.

Economic evaluation of drug abuse treatment and HIV prevention programs in pregnant women: a systematic review.

Drug abuse and transmission of HIV during pregnancy are public health problems that adversely affect pregnant women, their children and surrounding communities. Programs that address this vulnerable population have the ability to be cost-effective due to resulting cost savings for mother, child and society. Economic evaluations of programs that address these issues are an important tool to better understand the costs of services and create sustainable healthcare systems. This study critically examined economic evaluations of drug abuse treatment and HIV prevention programs in pregnant women. A systematic review was conducted using the criteria recommended by the Panel on Cost-Effectiveness in Health and Medicine and the British Medical Journal (BMJ) checklist for economic evaluations. The search identified 6 economic studies assessing drug abuse treatment for pregnant women, and 12 economic studies assessing programs that focus on prevention of mother-to-child transmission (PMTCT) of HIV. Results show that many programs for drug abuse treatment and PMTCT among pregnant women are cost-effective or even cost-saving. This study identified several shortcomings in methodology and lack of standardization of current economic evaluations. Efforts to address methodological challenges will help make future studies more comparable and have more influence on policy makers, clinicians and the public.