Whole Health

Black AC, Zeliadt SB, Kerns RD, Skanderson M, Wang R, Gelman H, Douglas JH, Becker WC. Association Between Exposure to Complementary and Integrative Therapies and Opioid Analgesic Daily Dose Among Patients on Long-term Opioid Therapy. Clin J Pain. 2022 Jun 1.

OBJECTIVES

To describe the association between exposure to selected complementary and integrative health (CIH) modalities and the trajectory of prescribed opioid analgesic dose within a national cohort of patients receiving long-term opioid therapy (LTOT) in the Veterans Health Administration (VHA).

MATERIALS AND METHODS

Using national data from VHA electronic health records between October 1, 2017 and September 30, 2019, CIH use was analyzed among 57,437 patients receiving LTOT within 18 VHA facilities serving as evaluation sites of VHA's Whole Health System of Care. Using linear mixed effects modeling controlling for covariates, opioid dose was modeled as a function of time, CIH exposure, and their interaction.

RESULTS

Overall, 11.91% of patients on LTOT used any of the focus CIH therapies; 43.25% of those had 4 or more encounters. Patients used acupuncture, chiropractic care, and meditation modalities primarily. CIH use was associated with being female, Black, having a mental health diagnosis, obesity, pain intensity, and baseline morphine-equivalent daily dose. Mean baseline morphine-equivalent daily dose was 40.81 milligrams and dose decreased on average over time. Controlling for covariates, patients with any CIH exposure experienced 38% faster dose tapering, corresponding to a mean difference in 12-month reduction over patients not engaging in CIH of 2.88 milligrams or 7.06% of the mean starting dose.

DISCUSSION

Results support the role of CIH modalities in opioid tapering. The study design precludes inference about the causal effects of CIH on tapering. Analyses did not consider the trend in opioid dose before cohort entry nor the use of other nonopioid treatments for pain. Future research should address these questions and consider tapering-associated adverse events.

Carey EP, Nolan C, Kerns RD, Ho PM, Frank JW. Association Between Facility-Level Utilization of Non-pharmacologic Chronic Pain Treatment and Subsequent Initiation of Long-Term Opioid Therapy. J Gen Intern Med. 2018 May;33(Suppl 1):38-45.

BACKGROUND

Expert guidelines recommend non-pharmacologic treatments and non-opioid medications for chronic pain and recommend against initiating long-term opioid therapy (LTOT).

OBJECTIVE

We examined whether veterans with incident chronic pain receiving care at facilities with greater utilization of non-pharmacologic treatments and non-opioid medications are less likely to initiate LTOT.

DESIGN

Retrospective cohort study PARTICIPANTS: Veterans receiving primary care from a Veterans Health Administration facility with incident chronic pain between 1/1/2010 and 12/31/2015 based on either of 2 criteria: (1) persistent moderate-to-severe patient-reported pain and (2) diagnoses "likely to represent" chronic pain.

MAIN MEASURES

The independent variable was facility-level utilization of pain-related treatment modalities (non-pharmacologic, non-opioid medications, LTOT) in the prior calendar year. The dependent variable was patient-level initiation of LTOT (≥ 90 days within 365 days) in the subsequent year, adjusting for patient characteristics.

KEY RESULTS

Among 1,094,569 veterans with incident chronic pain from 2010 to 2015, there was wide facility-level variation in utilization of 10 pain-related treatment modalities, including initiation of LTOT (median, 16%; range, 5-32%). Veterans receiving care at facilities with greater utilization of non-pharmacologic treatments were less likely to initiate LTOT in the year following incident chronic pain. Conversely, veterans receiving care at facilities with greater non-opioid and opioid medication utilization were more likely to initiate LTOT; this association was strongest for past year facility-level LTOT initiation (adjusted rate ratio, 2.10; 95% confidence interval, 2.06-2.15, top vs. bottom quartile of facility-level LTOT initiation in prior calendar year).

Chang BH, Sommers E. Acupuncture and relaxation response for craving and anxiety reduction among military veterans in recovery from substance use disorder. Am J Addict. 2014 Mar-Apr;23(2):129-36.

BACKGROUND AND OBJECTIVES

Substance use disorder (SUD) is a major health issue, especially among military veterans. We previously reported the effects of auricular acupuncture and the relaxation response (RR) on reducing craving and anxiety following 10-week interventions among veterans who were in recovery from SUDs. Our current analysis examines effects following each intervention session and RR daily practice.

METHODS

We conducted a three-arm randomized controlled trial on residents of a homeless veteran rehabilitation program. Sixty-Seven enrolled participants were randomly assigned to acupuncture (n=23), RR (n=23), or usual care (n=21). Participants in the two intervention groups rated their degree of craving for substance on a scale of 1-10 and anxiety levels on a scale of 1-4 (total score 20-80) before and after each intervention session. Mixed effects regression models were used for analysis.

RESULTS

Craving and anxiety levels decreased significantly following one session of acupuncture (-1.04, p=.0001; -8.83, p<.0001) or RR intervention (-.43, p=.02; -4.64, p=.03). The level of craving continued to drop with additional intervention sessions (regression coefficient b=-.10, p=.01, and b=-.10, p=.02 for acupuncture and RR groups, respectively). Number of daily practice days of RR-eliciting techniques is also associated with reduction in craving ratings (b=-.02, p=.008).

CONCLUSIONS

Findings demonstrate the value of attending regular acupuncture and RR-eliciting intervention sessions, as well as the daily practice of RR-eliciting techniques.

Scientific significance: Substance addiction is a complex disease and effective treatment remains a challenge. Our study findings add to the scientific evidence of these two non-pharmaceutical approaches for SUD.

Chang ET, Oberman RS, Cohen AN, Taylor SL, Gumm E, Mardian AS, Toy S, Revote A, Lewkowitz B, Yano EM. Increasing Access to Medications for Opioid Use Disorder and Complementary and Integrative Health Services in Primary Care. J Gen Intern Med. 2020 Dec;35(Suppl 3):918-926.

OBJECTIVES

Evidence-based therapies for opioid use disorder (OUD) and chronic pain, such as medications for OUD (MOUD) and complementary and integrative health (CIH; e.g., acupuncture and meditation) therapies, exist. However, their adoption has been slow, particularly in primary care, due to numerous implementation challenges. We sought to expand the use of MOUD and CIH within primary care by using an evidence-based quality improvement (EBQI) implementation strategy.

METHODS

We used EBQI to engage two facilities in the Veterans Health Administration (VHA) from June 2018 to September 2019. EBQI included multilevel stakeholder engagement, with external facilitators providing technical support, practice facilitation, and routine data feedback. We established a quality improvement (QI) team at each facility with diverse stakeholders (e.g., primary care, addiction, pain, nursing, pharmacy). We met monthly with regional stakeholders to address implementation barriers. We also convened an advisory board to ensure alignment with national priorities.

RESULTS

Pre-implementation interviews indicated facility-level and provider-level barriers to prescribing buprenorphine, including strong primary care provider resistance. Both facilities developed action plans. They both conducted educational meetings (e.g., Grand Rounds, MOUD waiver trainings). Facility A also offered clinical preceptorships for newly trained primary care prescribers. Facility B used mass media and mailings to educate patients about MOUD and CIH options and dashboards to identify potential candidates for MOUD. After 15 months, both facilities increased their OUD treatment rates to the ≥ 90th percentile of VHA medical centers nationally. Exit interviews indicated an attitudinal shift in MOUD delivery in primary care. Stakeholders valued the EBQI process, particularly cross-site collaboration.

IMPLICATIONS

Despite initial implementation barriers, we effectively engaged stakeholders using EBQI strategies. Local QI teams used an assortment of QI interventions and developed tools to catapult their facilities to among the highest performers in VHA OUD treatment.

IMPACTS

EBQI is an effective strategy to partner with stakeholders to implement MOUD and CIH therapies.

Crawford P, Penzien DB, Coeytaux R. Reduction in Pain Medication Prescriptions and Self-Reported Outcomes Associated with Acupuncture in a Military Patient Population. Med Acupunct. 2017 Aug 1;29(4):229-231. doi: 10.1089/acu.2017.1234. PubMed PMID: 28874924; PubMed Central PMCID: PMC5580367

BACKGROUND

Acupuncture is being offered to patients as part of routine medical care in selected military bases in the United States. There is little published information about the clinical outcomes associated with acupuncture in these clinical settings. OBJECTIVE The goal of this research was to assess clinical outcomes observed among adult patients who received acupuncture treatments at a United States Air Force medical center. Materials and

METHODS

This retrospective chart review was performed at the Nellis Family Medicine Residency in the Mike O'Callaghan Military Medical Center at Nellis Air Force Base in Las Vegas, NV. The charts were from 172 consecutive patients who had at least 4 acupuncture treatments within 1 year. The main outcome measures were prescriptions for opioid medications, muscle relaxants, benzodiazepines, and nonsteroidal anti-inflammatory drugs (NSAIDS) in the 60 days prior to the first acupuncture session and in the corresponding 60 days 1 year later; and Measure Yourself Medical Outcome Profile (MYMOP2) values for symptoms, ability to perform activities, and quality of life.

RESULTS

Opioid prescriptions decreased by 45%, muscle relaxants by 34%, NSAIDs by 42%, and benzodiazepines by 14%. MYMOP2 values decreased 3.50-3.11 (P < 0.002) for question 1, 4.18-3.46 (P < 0.00001) for question 3, and 2.73-2.43 (P < 0.006) for question 4.

CONCLUSIONS

In this military patient population, the number of opioid prescriptions decreased and patients reported improved symptom control, ability to function, and sense of well-being after receiving courses of acupuncture by their primary care physicians.

Garland EL, Fix ST, Hudak JP, Bernat EM, Nakamura Y, Hanley AW, Donaldson GW, Marchand WR, Froeliger B. Mindfulness-Oriented Recovery Enhancement remediates anhedonia in chronic opioid use by enhancing neurophysiological responses during savoring of natural rewards. Psychol Med. 2023 Apr;53(5):2085-2094.

BACKGROUND

Neuropsychopharmacologic effects of long-term opioid therapy (LTOT) in the context of chronic pain may result in subjective anhedonia coupled with decreased attention to natural rewards. Yet, there are no known efficacious treatments for anhedonia and reward deficits associated with chronic opioid use. Mindfulness-Oriented Recovery Enhancement (MORE), a novel behavioral intervention combining training in mindfulness with savoring of natural rewards, may hold promise for treating anhedonia in LTOT.

METHODS

Veterans receiving LTOT (N = 63) for chronic pain were randomized to 8 weeks of MORE or a supportive group (SG) psychotherapy control. Before and after the 8-week treatment groups, we assessed the effects of MORE on the late positive potential (LPP) of the electroencephalogram and skin conductance level (SCL) during viewing and up-regulating responses (i.e. savoring) to natural reward cues. We then examined whether these neurophysiological effects were associated with reductions in subjective anhedonia by 4-month follow-up.

RESULTS

Patients treated with MORE demonstrated significantly increased LPP and SCL to natural reward cues and greater decreases in subjective anhedonia relative to those in the SG. The effect of MORE on reducing anhedonia was statistically mediated by increases in LPP response during savoring.

CONCLUSIONS

MORE enhances motivated attention to natural reward cues among chronic pain patients on LTOT, as evidenced by increased electrocortical and sympathetic nervous system responses. Given neurophysiological evidence of clinical target engagement, MORE may be an efficacious treatment for anhedonia among chronic opioid users, people with chronic pain, and those at risk for opioid use disorder.

Gellad WF, Good CB, Shulkin DJ. Addressing the Opioid Epidemic in the United States: Lessons From the Department of Veterans Affairs. JAMA Intern Med. 2017 May 1;177(5):611-612. doi: 10.1001/jamainternmed.2017.0147. PubMed PMID: 28288245.

Over the past 15 years, more than 165 000 people in the United States have died from overdoses related to prescription opioids,1 and millions more have suffered adverse consequences. The misuse and abuse of prescription opioids have contributed to a precipitous increase in heroin and fentanyl overdoses.

Patients treated in the health care system of the Department of Veterans Affairs (VA) are part of this epidemic. Chronic pain impacts half of veterans using the VA, complicated by high rates of psychiatric comorbidities such as substance use disorder and posttraumatic stress disorder.4 In 2009, the VA established a national office to coordinate and improve pain management practices, and in 2011, developed standardized metrics for opioid use across the system. Nonetheless, by 2012, nearly 25% of veterans receiving outpatient care in the VA were receiving an opioid.

Giannitrapani KF, Ackland PE, Holliday J, Zeliadt S, Olson J, Kligler B, Taylor SL. Provider Perspectives of Battlefield Acupuncture: Advantages, Disadvantages and Its Potential Role in Reducing Opioid Use for Pain. Med Care. 2020 Sep;58 Suppl 2 9S(2 9 Suppl):S88-S93.

OBJECTIVES

Nonpharmacological options to treat pain are in demand, in part to address the opioid crisis. One such option is acupuncture. Battlefield acupuncture (BFA) is an auricular needling protocol currently used to treat pain in the Veterans Health Administration. We aimed to identify the advantages and disadvantages of BFA from providers' perspectives.

METHODS

We rely on an inductive qualitative approach to explore provider perceptions through thematic analysis of semistructured interviews with 43 BFA providers across the nation.

RESULTS

We identified the following themes. Disadvantages included: (1) clinical guidelines are insufficient; (2) patients often request multiple BFA visits from providers; (3) BFA can be uncomfortable; (4) BFA may not be an effective treatment option unless it can be provided "on demand"; and (5) BFA can promote euphoria, which can have deleterious consequences for patient self-care. Perceived advantages included: (1) BFA can simultaneously effectively control pain while reducing opioid use; (2) BFA may alleviate the pain that has been unsuccessfully treated by conventional methods; (3) BFA gives providers a treatment option to offer patients with substance use disorder; (4) BFA helps build a trusting patient-provider relationship; (5) BFA can create the opportunity for hope.

CONCLUSIONS

Providers perceive BFA to have many benefits, both clinical and relational, including ways in which it may have utility in addressing the current opioid crisis. BFA is easy to deliver and has potential clinical and relational utility. Efforts to better understand effectiveness are warranted.

Gibson CJ, Grasso J, Li Y, Purcell N, Tighe J, Zamora K, Nicosia F, Seal KH. An Integrated Pain Team Model: Impact on Pain-Related Outcomes and Opioid Misuse in Patients with Chronic Pain. Pain Med. 2020 Feb 25. pii: pnaa003.

OBJECTIVE

Biopsychosocial integrated pain team (IPT) care models are being implemented in Veterans Health Administration (VA) and other health care systems to address chronic pain and reduce risks related to long-term opioid therapy, with little evaluation of effectiveness to date. We examined whether IPT improves self-reported pain-related outcomes and opioid misuse.

DESIGN

Single-group quality improvement study.

Setting: Large VA health care system.

Subjects: Veterans with chronic pain (N = 99, 84% male, mean age [SD] = 60 [13] years).

METHODS

Using paired t tests and Wilcoxon matched-pairs signed-ranks tests, we examined pain experience (Brief Pain Inventory, Pain Catastrophizing Scale), opioid misuse (Current Opioid Misuse Measure), treatment satisfaction (Pain Treatment Satisfaction Scale), and pain management strategies among patients with chronic pain before and after three or more IPT encounters.

RESULTS

After an average (SD) of 14.3 (9) weeks engaged in IPT, patients reported improvement in pain interference (mean [SD] = 46.0 [15.9] vs 40.5 [16.2], P < 0.001), pain catastrophizing (mean [SD] = 22.9 [13.0] vs 19.3 [14.1], P = 0.01), treatment satisfaction (i.e., "very satisfied" = 13.1% at baseline vs 25.3% at follow-up, P = 0.01), and reduced opioid misuse (mean [SD] = 11.0 [7.5] vs 8.2 [6.1], P = 0.01). Patients reported increased use of integrative (i.e., acupuncture, 11% at baseline vs 26% at follow-up, P < 0.01) and active pain management strategies (i.e., exercise, 8% at baseline vs 16% at follow-up, P < 0.01) and were less likely to use only pharmacological pain management strategies after IPT engagement (19% at baseline vs 5% at follow-up, P < 0.01).

CONCLUSIONS

Biopsychosocial, integrated pain care may improve patient-centered outcomes related to opioid misuse and the subjective experience and nonpharmacological self-management of chronic pain.

Hadlandsmyth K, Mosher H, Vander Weg MW, Lund BC. Decline in Prescription Opioids Attributable to Decreases in Long-Term Use: A Retrospective Study in the Veterans Health Administration 2010-2016. J Gen Intern Med. 2018 Jun;33(6):818-824.

BACKGROUND

Improved understanding of temporal trends in short- and long-term opioid prescribing may inform efforts to curb the opioid epidemic.

OBJECTIVE

To characterize the prevalence of short- and long-term opioid prescribing in the Veterans Health Administration (VHA) from 2010 to 2016.

DESIGN

Observational cohort study using VHA databases.

Participants: All patients receiving at least one outpatient prescription through the VHA during calendar years 2010 through 2016.

MAIN MEASURES

Prevalence of opioid use from 2010 through 2016, stratified by short-term, intermediate-term, and long-term use. Temporal trends in discontinuation among existing long-term users and initiation of new long-term use and the net impact on rates of long-term opioid use. Relative likelihood of transitioning to long-term opioid use contrasted with use patterns in the prior year.

KEY RESULTS

The prevalence of opioid prescribing was 20.8% in 2010, peaked at 21.2% in 2012, and declined annually to 16.1% in 2016. Between 2010 and 2016, reductions in long-term opioid prescribing accounted for 83% of the overall decline in opioid prescription fills. Comparing data from 2010-2011 to data from 2015-2016, declining rates in new long-term use accounted for more than 90% of the decreasing prevalence of long-term opioid use in the VHA, whereas increases in cessation among existing long-term users accounted for less than 10%. The relative risk of transitioning to long-term use during 2016 was 6.5 (95% CI: 6.4, 6.7) among short-term users and 35.5 (95% CI: 34.8, 36.3) among intermediate users, relative to patients with no opioid prescriptions filled during 2015.

CONCLUSIONS

Opioid prescribing trends followed similar trajectories in VHA and non-VHA settings, peaking around 2012 and subsequently declining. However, changes in long-term opioid prescribing accounted for most of the decline in the VHA. Recent VA opioid initiatives may be preventing patients from initiating long-term use. This may offer valuable lessons generalizable to other healthcare systems.

Killeen TK, Baker NL, Davis LL, Bowen S, Brady KT. Efficacy of mindfulness-based relapse prevention in a sample of veterans in a substance use disorder aftercare program: A randomized controlled trial. J Subst Use Addict Treat. 2023 Sep;152:209116.

BACKGROUND

Complementary integrative medicine, such as mindfulness-based interventions, (MBI) have demonstrated efficacy in the treatment of depression, anxiety, substance use disorders (SUDs), and pain. Mindfulness-based relapse prevention (MBRP) is an aftercare intervention targeting SUD relapse that integrates cognitive-behavioral relapse prevention and mindfulness meditation practices, raising awareness of substance use triggers and reactive behavioral patterns. This study evaluated the efficacy of MBRP in reducing relapse in veterans following completion of an SUD treatment program.

METHODS

This study was a two-site, randomized controlled trial comparing MBRP to 12-step facilitation (TSF) aftercare in military veterans following completion of intensive treatment for SUDs. The 8 weeks of 90-minute, group-based MBRP or TSF sessions were followed by 3-, 6- and 10-month follow-up periods with assessments of alcohol/substance use and secondary outcomes of depression, anxiety, and mindfulness.

RESULTS

Forty-seven percent of veterans attended ≥75 % of sessions. Veterans in both the MBRP and TSF aftercare groups maintained reductions in alcohol and illicit substance use during the aftercare treatment. Nineteen participants (11 %; 19/174) reported returning to alcohol use during the study treatment period and the study found no difference between study groups [MBRP: 9 % vs. TSF 13 %; p = 0.42]. Thirteen participants (7.5 %; 13/174) reported a return to illicit substance use during study treatment [MBRP: 5.4 % vs. TSF 10.3 % p = 0.34]. The number of days of drinking and illicit substance use was not different between groups (alcohol, p = 0.53; illicit substance use, p = 0.28).Conclusion: Although retention in treatment limits interpretation of the findings, both MBRP and TSF were effective in maintenance of treatment gains following an intensive treatment program for veterans with SUDs. Future studies should focus on strategies to improve treatment participation.

Lehmann LP, Detweiler JG, Detweiler MB.  Veterans in substance abuse treatment program self-initiate box gardening as a stress reducing therapeutic modality. Complement Ther Med. 2018 Feb;36:50-53. doi: 10.1016/j.ctim.2017.10.013. Epub 2017 Oct 31.

OBJECTIVES

To assess the experiences of a veteran initiated horticultural therapy garden during their 28-day inpatient Substance Abuse Residential Rehabilitation Treatment Program (SARRTP).

DESIGN

Retrospective study.

SETTING

Veterans Affairs Medical Center (VAMC), Salem, Virginia, USA INTERVENTIONS: Group interviews with veterans from the last SARRTP classes and individual interviews with VAMC greenhouse staff in summer of 2016.

OUTCOME MEASURES

Time spent in garden, frequency of garden visits, types of passive and active garden activities, words describing the veterans' emotional reactions to utilizing the garden.

RESULTS

In 3 summer months of 2016, 50 percent of the 56 veterans interviewed visited and interacted with the gardens during their free time. Frequency of visits generally varied from 3 times weekly to 1-2 times a day. Amount of time in the garden varied from 10min to 2h. The veterans engaged in active and/or passive gardening activities during their garden visits. The veterans reported feeling "calm", "serene", and "refreshed" during garden visitation and after leaving the garden.

CONCLUSIONS

Although data was secured only at the end of the 2016 growing season, interviews of the inpatient veterans revealed that they used their own initiative and resources to continue the horticulture therapy program for 2 successive growing years after the original pilot project ended in 2014. These non-interventionist, therapeutic garden projects suggest the role of autonomy and patient initiative in recovery programs for veterans attending VAMC treatment programs and they also suggest the value of horticulture therapy as a meaningful evidence- based therapeutic modality for veterans.

Lisi AJ, Corcoran KL, DeRycke EC, Bastian LA, Becker WC, Edmond SN, Goertz CM, Goulet JL, Haskell SG, Higgins DM, Kawecki T, Kerns RD, Mattocks K, Ramsey C, Ruser CB, Brandt CA. Opioid Use Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care. Pain Med. 2018 Sep 1;19(suppl_1):S54-S60. doi: PubMed PMID: 30203014.

OBJECTIVE

To examine patient sociodemographic and clinical characteristics associated with opioid use among Veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who receive chiropractic care, and to explore the relationship between timing of a chiropractic visit and receipt of an opioid prescription.

METHODS

Cross-sectional analysis of administrative data on OEF/OIF/OND veterans who had at least one visit to a Veterans Affairs (VA) chiropractic clinic between 2004 and 2014. Opioid receipt was defined as at least one prescription within a window of 90 days before to 90 days after the index chiropractic clinic visit.

RESULTS

We identified 14,025 OEF/OIF/OND veterans with at least one chiropractic visit, and 4,396 (31.3%) of them also received one or more opioid prescriptions. Moderate/severe pain (odds ratio [OR] = 1.87, 95% confidence interval [CI] = 1.72-2.03), PTSD (OR = 1.55, 95% CI = 1.41-1.69), depression (OR = 1.40, 95% CI = 1.29-1.53), and current smoking (OR = 1.39, 95% CI = 1.26-1.52) were associated with a higher likelihood of receiving an opioid prescription. The percentage of veterans receiving opioid prescriptions was lower in each of the three 30-day time frames assessed after the index chiropractic visit than before.

CONCLUSIONS

Nearly one-third of OEF/OIF/OND veterans receiving VA chiropractic services also received an opioid prescription, yet the frequency of opioid prescriptions was lower after the index chiropractic visit than before. Further study is warranted to assess the relationship between opioid use and chiropractic care.

Lovejoy TI, Morasco BJ, Demidenko MI, Meath THA, Dobscha SK. Clinician Referrals for Non-opioid Pain Care Following Discontinuation of Long-term Opioid Therapy Differ Based on Reasons for Discontinuation. J Gen Intern Med. 2018 May;33(Suppl 1):24-30.

OBJECTIVE

This study aimed to compare rates of non-opioid analgesic pharmacotherapy initiation and clinician referrals for non-pharmacologic pain treatment, complementary and integrative pain therapies, and specialty mental health and substance use disorder treatment between patients discontinued from opioid therapy due to aberrant behaviors versus other reasons.

DESIGN

The design included retrospective manual electronic health record review and administrative data abstraction.

Participants: Patients were sampled from a national cohort of US Department of Veterans Affairs patients prescribed continuous opioid therapy in 2011 who subsequently discontinued opioid therapy in 2012. The study sample comprised 509 patients discontinued from LTOT by opioid-prescribing clinicians.

Main Measures: The primary independent variable was reason for discontinuation of LTOT (aberrant behaviors versus other reasons). Pain care dichotomous outcomes included clinician use of an opioid taper; initiating new non-opioid analgesic pharmacotherapy; and referrals for non-pharmacologic pain treatment, complementary and integrative pain therapies, and specialty mental health and substance use disorder treatment.

KEY RESULTS

We observed low rates of opioid taper (15% of patients), initiations of new or modifications of existing non-opioid analgesic pharmacotherapy (45% of patients), and clinician referrals for non-pharmacologic pain treatment (58% of patients) and complementary and integrative therapies (25% of patients). Patients discontinued due to aberrant behaviors, relative to patients discontinued for other reasons, were more likely to receive opioid tapers (adjusted OR = 5.60, 95% CI = 2.10-14.93), receive new non-opioid analgesic medications or dose changes to an existing non-opioid analgesic medications (adjusted OR = 2.61, 95% CI = 1.59-4.29), or be referred for specialty substance use disorder treatment (adjusted OR = 7.39, 95% CI = 3.76-14.53).

CONCLUSIONS

These findings highlight the variability in referral rates for different types of non-opioid pain treatments and challenges accessing specific types of pain care.

Marchand WR, Klinger W, Block K, VerMerris S, Herrmann TS, Johnson C, Paradiso N, Scott M, Yabko B. Mindfulness Training plus Nature Exposure for Veterans with Psychiatric and Substance Use Disorders: A Model Intervention. Int J Environ Res Public Health. 2019 Nov 27;16(23).

There is a need to develop novel complementary interventions aimed at enhancing treatment engagement and/or response for veterans with psychiatric and substance use disorders. There is evidence that both mindfulness training and nature exposure (MT/NE) may be beneficial for this population and that combining the two approaches into one intervention might result in synergistic benefit. However, to date, the MT/NE concept has not been tested. This article reports a pilot feasibility and acceptability study of MT/NE which was, in this case, provided via recreational sailing. The primary aim of this project was to develop a model intervention and evaluation process that could be used for future studies of MT/NE interventions using a variety of methods of nature exposure (e.g., hiking, skiing, mountain biking). Results indicate preliminary evidence that it is feasible to utilize MT/NE interventions for the population studied and that the MT/NE model described can serve as a template for future investigations. Further, there were significant pre- to post-intervention decreases in state anxiety, as well as increases in trait mindfulness. Three psychological instruments were identified that might be used in future studies to evaluate MT/NE outcomes. Results from this project provide a model MT/NE intervention template along with evaluation metrics for use in future studies.

Marchand WR, Klinger W, Block K, VerMerris S, Herrmann TS, Johnson C, Shubin E, Sheppard S. Safety and psychological impact of sailing adventure therapy among Veterans with substance use disorders. Complement Ther Med. 2018 Oct;40:42-47. doi:

OBJECTIVES

Many Veterans suffer from substance use disorders (SUDs). Treatment challenges include poor treatment engagement and high relapse rates. Complementary interventions have the potential to enhance both. This study was a preliminary evaluation of sailing adventure therapy (SAT) for this population.

DESIGN

Retrospective chart review. Participants in the intervention were 22 Veterans (20 male, 2 female) aged 22-65 who entered a Veterans Administration residential SUD treatment program. All subjects had two or more SUDs, and many had psychiatric (95%) and/or medical (77%) comorbidities. The age, gender and diagnosis-matched control group (n = 22) received residential SUD treatment as usual (TAU) in the same program but without SAT.

Setting

Residential SUD treatment program at a Veterans Administration Medical Center.

Ralevski E, Southwick S, Jackson E, Jane JS, Russo M, Petrakis I. Trauma- and Stress-Induced Response in Veterans with Alcohol Dependence and Comorbid Post-Traumatic Stress Disorder. Alcohol Clin Exp Res. 2016 Aug;40(8):1752-60. 

BACKGROUND

Alcohol dependence (AD) and post-traumatic stress disorder (PTSD) commonly co-occur, and the co-occurrence is associated with worse prognosis than either disorder absent the other. Craving is an important construct related to relapse, but the relationship between PTSD symptoms, craving, and relapse is not well understood. Several studies have documented the relationship between stress and craving in individuals without comorbid PTSD, but the effect on those with comorbid PTSD is not well known. A small literature suggests that trauma imagery affects craving. This is the first study to explore the effects of trauma-induced and stress-induced scripts on alcohol craving, affect, cardiovascular, and cortisol responses in the laboratory.

METHODS

Veterans (n = 25) diagnosed with AD and PTSD who were participating in a randomized clinical treatment trial took part in this laboratory study. Baseline assessment included PTSD symptoms and drinking quantity and frequency over 3 months before study initiation. In the laboratory, participants were exposed to neutral, stressful, and trauma scripts randomly assigned. Main outcomes included craving, anxiety, mood states, salivary cortisol, and cardiovascular responses.

RESULTS

Both stress and trauma scripts produced greater increases in craving, negative affect, and cardiovascular reactivity, compared to neutral scripts. Trauma scripts produced significantly stronger craving for alcohol and greater cardiovascular reactivity than stress scripts. Also, trauma-induced but not stress-induced craving was positively correlated with baseline levels of drinking. There were no changes in cortisol levels from pre- to postexposure of any scripts.

CONCLUSIONS

The results highlight that trauma cues are more salient in inducing alcohol craving than stress cues and higher reactivity is related to more baseline drinking. This finding is consistent with clinical observations that show an association between PTSD symptoms and alcohol relapse. It also underscores the importance of adequate treatment of PTSD as reactivity related to trauma cues and reminders may be an important factor in craving and relapse.

Reddy S, Dick AM, Gerber MR, Mitchell K. The effect of a yoga intervention on alcohol and drug abuse risk in veteran and civilian women with posttraumatic stress disorder. J Altern Complement Med. 2014 Oct;20(10):750-6. doi: 10.1089/acm.2014.0014. Epub 2014 Sep 11. PubMed PMID: 25211372; PubMed Central PMCID: PMC4195227

BACKGROUND

Individuals with posttraumatic stress disorder (PTSD) often exhibit high-risk substance use behaviors. Complementary and alternative therapies are increasingly used for mental health disorders, although evidence is sparse.

OBJECTIVES

Investigate the effect of a yoga intervention on alcohol and drug abuse behaviors in women with PTSD. Secondary outcomes include changes in PTSD symptom perception and management and initiation of evidence-based therapies.

MATERIALS AND METHODS

The current investigation analyzed data from a pilot randomized controlled trial comparing a 12-session yoga intervention with an assessment control for women age 18 to 65 years with PTSD. The Alcohol Use Disorder Identification Test (AUDIT) and Drug Use Disorder Identification Test (DUDIT) were administered at baseline, after the intervention, and a 1-month follow-up. Linear mixed models were used to test the significance of the change in AUDIT and DUDIT scores over time. Treatment-seeking questions were compared by using Fisher exact tests.

RESULTS

The mean AUDIT and DUDIT scores decreased in the yoga group; in the control group, mean AUDIT score increased while mean DUDIT score remained stable. In the linear mixed models, the change in AUDIT and DUDIT scores over time did not differ significantly by group. Most yoga group participants reported a reduction in symptoms and improved symptom management. All participants expressed interest in psychotherapy for PTSD, although only two participants, both in the yoga group, initiated therapy.

CONCLUSIONS

Results from this pilot study suggest that a specialized yoga therapy may play a role in attenuating the symptoms of PTSD, reducing risk of alcohol and drug use, and promoting interest in evidence-based psychotherapy. Further research is needed to confirm and evaluate the strength of these effects.

Tick H, Nielsen A, Pelletier KR, Bonakdar R, Simmons S, Glick R, Ratner E, Lemmon RL, Wayne P, Zador V; Pain Task Force of the Academic Consortium for Integrative Medicine and Health.  Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper. Explore (NY). 2018 May - Jun;14(3):177-211.

Medical pain management is in crisis; from the pervasiveness of pain to inadequate pain treatment, from the escalation of prescription opioids to an epidemic in addiction, diversion and overdose deaths. The rising costs of pain care and managing adverse effects of that care have prompted action from state and federal agencies including the DOD, VHA, NIH, FDA and CDC. There is pressure for pain medicine to shift away from reliance on opioids, ineffective procedures and surgeries toward comprehensive pain management that includes evidence-based nonpharmacologic options. This White Paper details the historical context and magnitude of the current pain problem including individual, social and economic impacts as well as the challenges of pain management for patients and a healthcare workforce engaging prevalent strategies not entirely based in current evidence. Detailed here is the evidence-base for nonpharmacologic therapies effective in postsurgical pain with opioid sparing, acute non-surgical pain, cancer pain and chronic pain. Therapies reviewed include acupuncture therapy, massage therapy, osteopathic and chiropractic manipulation, meditative movement therapies Tai chi and yoga, mind body behavioral interventions, dietary components and self-care/self-efficacy strategies. Transforming the system of pain care to a responsive comprehensive model necessitates that options for treatment and collaborative care must be evidence-based and include effective nonpharmacologic strategies that have the advantage of reduced risks of adverse events and addiction liability. The evidence demands a call to action to increase awareness of effective nonpharmacologic treatments for pain, to train healthcare practitioners and administrators in the evidence base of effective nonpharmacologic practice, to advocate for policy initiatives that remedy system and reimbursement barriers to evidence-informed comprehensive pain care, and to promote ongoing research and dissemination of the role of effective nonpharmacologic treatments in pain, focused on the short- and long-term therapeutic and economic impact of comprehensive care practices.

Turner AP, Edwards KA, Jensen MP, Ehde DM, Day MA, Williams RM. Effects of hypnosis, mindfulness meditation, and education for chronic pain on substance use in veterans: A supplementary analysis of a randomized clinical trial. Rehabil Psychol. 2023 Aug;68(3):261-270.

PURPOSE/OBJECTIVE

To examine the impact of three behavioral interventions for chronic pain on substance use.Research method/design: Participants were 328 Veterans with chronic pain receiving care at one of two Veterans Affairs Medical Centers in the northwest United States. Participants were randomly assigned to one of three 8-week manualized in-person group treatments: (a) hypnosis (HYP), (b) mindfulness meditation (MM), or (c) active education control (ED). Substance use frequency was assessed using 10 individual items from the WHO-ASSIST, administered at baseline prior to randomization and at 3- and 6-month posttreatment.

RESULTS

Baseline substance use (i.e., any use) in the past 3 months was reported by 22% (tobacco), 27% (cannabis), and 61% (alcohol) of participants. Use of all other substances assessed was reported by < 7% of participants. Results showed that MM, as compared to ED, significantly reduced risk of daily cannabis use by 85% and 81% at the 3- and 6-month posttreatment follow-ups, respectively, after adjusting for baseline use. HYP, as compared to ED, significantly reduced risk of daily cannabis use by 82% at the 6-month posttreatment follow-up after adjusting for baseline use. There was no intervention effect on tobacco or alcohol use at either posttreatment follow-up.Conclusions/implications: HYP and MM for chronic pain may facilitate reductions in cannabis use, even when reducing such use is not a focus of treatment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Vanneman, M, Mary Jo Larson, Cheng Chen, Rachel Sayko Adams, Thomas V. Williams, Esther Meerwijk, Alex H.S. Harris. Treatment of Low Back Pain with Opioids and Non-pharmacologic Treatment Modalities for Army Veterans.  Med Care. 2018 Oct; 56(10): 855–861

OBJECTIVES

To describe overall and facility-level variation in the extent to which specific NPT modalities are used in VHA for LBP, either alone or as adjuncts to opioid medications, and to understand associations between veterans' clinical and demographic characteristics and type of treatment.

RESEARCH DESIGN

Our retrospective cohort study examined use of opioids and 21 specific NPT modalities used by veterans.

SUBJECTS

VHA-enrolled Iraq and Afghanistan veterans who utilized care in ("linked" to) 130 VHA facilities within 12 months after their separation from the Army between fiscal years 2008–11, and who were diagnosed with LBP within 12 months after linkage (n=49,885).

MEASURES

Measures included per patient: days' supply of opioids, number of visits for NPT modalities, and pain scores within one year after a LBP diagnosis.

RESULTS

Thirty-four percent of veterans filled a prescription for opioids, 35% utilized at least one NPT modality, and 15% used both within the same year. Most patients with LBP receiving NPT, on average, had moderate pain (36%), followed by low pain (27%), and severe pain (15%), no pain (11%). Eleven percent had no pain scores recorded.

CONCLUSIONS

About 65% of VHA patients with a LBP diagnosis did not receive NPT, and about 43% of NPT users also were prescribed an opioid. Understanding utilization patterns and their relationship with patient characteristics can guide pain management decisions and future study.

Zeliadt SB, Douglas JH, Gelman H, Coggeshall S, Taylor SL, Kligler B, Bokhour BG. Effectiveness of a whole health model of care emphasizing complementary and integrative health on reducing opioid use among patients with chronic pain. BMC Health Serv Res. 2022 Aug 17;22(1):1053.

BACKGROUND

The opioid crisis has necessitated new approaches to managing chronic pain. The Veterans Health Administration (VHA) Whole Health model of care, with its focus on patient empowerment and emphasis on nonpharmacological approaches to pain management, is a promising strategy for reducing patients' use of opioids. We aim to assess whether the VHA's Whole Health pilot program impacted longitudinal patterns of opioid utilization among patients with chronic musculoskeletal pain.

METHODS

A cohort of 4,869 Veterans with chronic pain engaging in Whole Health services was compared with a cohort of 118,888 Veterans receiving conventional care. All patients were continuously enrolled in VHA care from 10/2017 through 3/2019 at the 18 VHA medical centers participating in the pilot program. Inverse probability of treatment weighting and multivariate analyses were used to adjust for observable differences in patient characteristics between exposures and conventional care. Patients exposed to Whole Health services were offered nine complementary and integrative health therapies alone or in combination with novel Whole Health services including goal-setting clinical encounters, Whole Health coaching, and personal health planning.

Main measures

The main measure was change over an 18-month period in prescribed opioid doses starting from the six-month period prior to qualifying exposure.

RESULTS

Prescribed opioid doses decreased by -12.0% in one year among Veterans who began complementary and integrative health therapies compared to similar Veterans who used conventional care; -4.4% among Veterans who used only Whole Health services such as goal setting and coaching compared to conventional care, and -8.5% among Veterans who used both complementary and integrative health therapies combined with Whole Health services compared to conventional care.

CONCLUSIONS

VHA's Whole Health national pilot program was associated with greater reductions in prescribed opioid doses compared to secular trends associated with conventional care, especially when Veterans were connected with complementary and integrative health therapies.