Jodie Trafton

• Ph.D. Neuroscience
• Managing Director at U.S. Department of Veterans Affairs

Objective. This study aims to determine 1) the epidemiology of perioperative opioid use; and 2) the association between patterns of preoperative opioid use and time-to-cessation of postoperative opioids. Design. Retrospective, cohort study. Setting. National, population-level study of Veterans Healthcare Administration (VHA) electronic clinical dat...

Background and aims: Chronic pain is difficult to treat in individuals with substance use disorders and, when not resolved, can have a negative impact on substance use disorder treatment outcomes. This study tested the efficacy of a psychosocial pain management intervention, ImPAT (improving pain during addiction treatment), that combines pain man...

In light of recent data demonstrating large variability in the diagnosis of cannabis use disorders (CUDs) within the Veterans Affairs Health Care System (VA), it is important to elucidate VA-specific barriers and facilitators to CUD diagnosis and treatment engagement. This issue is particularly salient among veterans with posttraumatic stress disor...

BACKGROUND: In order to monitor and ultimately improve the quality of addiction treatment, professional societies, health care systems, and addiction treatment programs must establish clinical practice standards and then operationalize these standards into reliable, valid, and feasible quality measures. Before being implemented, quality measures sh...

Background: Though a growing number of U.S. Veterans are being diagnosed with cannabis use disorders, with posttraumatic stress disorder (PTSD) observed as the most frequently co-occurring psychiatric disorder among this population, no research has investigated the impact of PTSD diagnosis on cannabis quit success. Objectives: The present study so...

Preoperative determinants of pain duration following surgery are poorly understood. We identified preoperative predictors of prolonged pain after surgery in a mixed surgical cohort. We conducted a prospective longitudinal study of patients undergoing mastectomy, lumpectomy, thoracotomy, total knee replacement, or total hip replacement. We measured...

Background In fiscal year (FY) 2008, 133,658 patients were provided services within substance use disorders treatment programs (SUDTPs) in the U.S. Department of Veterans Affairs (VA) health care system. To improve the effectiveness and cost-effectiveness of SUDTPs, we analyze the impacts of staffing mix on the benefits and costs of specialty SUD s...

Due to the Affordable Care Act and other recent laws and regulations, funding for substance use disorder (SUD) treatment is on the rise. In the 2000s, the Veterans Health Administration (VA) implemented several initiatives that increased funding for SUD treatment during a period of growth in demand for it. A key question is whether access to and in...

Patients receiving opioid therapy are at elevated risk of attempting suicide. Guidelines recommend practices to mitigate risk, but it is not known whether these are effective. Our aim was to examine associations between the receipt of guideline-recommended care for opioid therapy and risk of suicide attempt. This was a retrospective analysis of adm...

Accurate operationalization is a major challenge in developing quality measures for substance use disorder treatment. Specification validity is a term used to describe whether a quality measure is operationalized such that it captures the intended care processes and patients. This study assessed the specification validity of the 2009 Healthcare Eff...

Objectives: The purpose of this study was to determine baseline adherence to key recommendations from the 2010 VA/DOD Clinical Practice Guideline for Opioid Therapy for Chronic Pain at Veterans Health Administration (VA) facilities. We hoped to understand practice patterns at the time of guideline release to guide quality improvement and implement...

We longitudinally investigated coping among male military veterans (n = 98) with Posttraumatic Stress Disorder (PTSD) symptomatology and a co-occurring substance use disorder (SUD) who participated in a randomized controlled trial of Seeking Safety (SS). Participants were randomized to SS or intensive treatment-as-usual (TAU) for SUD. Coping (activ...

Background Women experience chronic pain and use pain-related health care at higher rates than men. It is not known whether the pain-related health care female veterans receive is consistent with clinical practice guideline recommendations or whether receipt of this care differs between men and women.Objective The aim of this study was to identify...

Problematic alcohol use has been shown to negatively impact cognitive functions germane to achieving optimal HIV health outcomes. The present study, a secondary data analysis, examined the impact of problematic alcohol use on aspects of everyday memory functioning in a sample of 172 HIV-infected individuals (22 % female; M age = 48.37 years, SD = 8...

Objective We previously reported that increased preoperative Beck Depression Inventory II (BDI-II) scores were associated with a 47% (95% CI 24%–64%) reduction in the rate of opioid cessation following surgery. We aimed to identify the underlying factors of the BDI-II (affective/cognitive vs somatic) associated with a decreased rate of opioid cessa...

Occasional cannabis use has been associated with increased antiretroviral therapy (ART) adherence and relief of HIV symptoms, while heavy use has been associated with low ART adherence and negative psychological symptoms. The purpose of the present study was to investigate differences between non-cannabis use (NC), non-dependent cannabis use (C), a...

Opioid-related mortality has increased in the United States in the past decade. The purpose of this study was to examine trends and regional variation in opioid prescribing and overdose rates in a national health system, the Veterans Health Administration (VHA). Annual cohorts of VHA patients were identified based on medical records and overdose mo...

The volume of opioid medications being prescribed in the US is increasing rapidly. Problems associated with the misuse of opioid medications are also increasing, in part because of medication diversion from legitimate prescriptions. However, little is known about what patients do with any unused opioid medications. This paper uses a qualitative ana...

The present study sought to extend prior work, showing an association between self-reported distress tolerance and self-reported antiretroviral treatment (ART) adherence, by conducting a multimethod test of the association between distress tolerance and objective measures of ART adherence among a sample of 140 individuals (23.6% female) with human...

Substance use disorders (SUDs) are a substantial problem in the United States (U.S.), affecting far more people than receive treatment. This is true broadly and within the U.S. military veteran population, which is our focus. To increase funding for treatment, the Veterans Health Administration (VA) has implemented several initiatives over the past...

Clinics licensed to provide pharmacotherapy for opiate dependence disorder are required to perform random urine drug screen (RUDS) tests. The results provide the empirical basis of individual treatment and programmatic effectiveness, and public health policy. Patients consent to witnessed testing but most tests are unwitnessed. The purpose of the p...

Background: Opioid agonist therapy (OAT) through addiction specialty clinic settings (clinic-based OAT) using methadone or buprenorphine or office-based settings using buprenorphine (office-based OAT) is an evidence-based treatment for opioid dependence. The low number of clinic-based OATs available to veterans (N = 53) presents a barrier to OAT a...

: To describe the design and deployment of health information technology to support implementation of mental health services policy requirements in the Veterans Health Administration (VHA). : Using administrative and self-report survey data, we developed and fielded metrics regarding implementation of the requirements delineated in the VHA Uniform...

Although access to and consideration of pharmacological treatments for alcohol dependence are consensus standards of care, receipt of these medications by patients is generally rare and highly variable across treatment settings. The goal of the present project was to survey and interview the clinicians, managers, and pharmacists affiliated with add...

This study evaluated the prevalence and types of criminal arrest among 99,512 male veterans in substance use disorder (SUD) treatment across 150 VA facilities from 1998 to 2001. Participants were assessed with the Addiction Severity Index (ASI), which includes detailed information about lifetime criminal activity. A majority of the patients (58.2%)...

The present investigation sought to document current rates and trends of cannabis use disorder (CUD) diagnoses among patients of the Veterans Affairs Health Care System (VA) during fiscal years 2002, 2008, and 2009. Results indicated that the prevalence of CUD diagnoses within VA has increased more than 50% (from 0.66% to 1.05%) over the past 7 yea...

Recent evidence suggests that rates of cannabis use disorders are significantly lower among military veterans within the Veterans Affairs Health Care System (VA) than the general U.S. population. However, prevalence rates obtained from the VA rely on clinician diagnosis, which have been shown to be underrepresentative of actual disorder rates. The...

Determinants of the duration of opioid use after surgery have not been reported. We hypothesized that both preoperative psychological distress and substance abuse would predict more prolonged opioid use after surgery. Between January 2007 and April 2009, a prospective, longitudinal inception cohort study enrolled 109 of 134 consecutively approached...

This study assessed changes since 2007 at Veterans Health Administration (VHA) facilities (N=129) in use of the medications approved by the U.S. Food and Drug Administration for treatment of alcohol use disorders. VHA data from fiscal years (FYs) 2008 and 2009 were used to identify patients with a diagnosis of an alcohol use disorder who received o...

The objective of this study was to explore the relationship between patterns of opioid use, pain severity, and pain-related mental health in chronic pain patients prescribed opioids. The study was designed as a one-time patient interview with structured pain and opioid use assessments. The study was set in a tertiary care medical center in the Unit...

The safe and effective prescribing of opioid therapy for chronic pain has become a significant health care priority over the last several years. Substantial research has focused on patient-oriented interventions toward preventing problematic use, but provider and system level factors may be more amenable to quality improvement approaches. Here, we...

Research evidence supports and practice guidelines recommend methadone maintenance treatment (MMT) for opioid dependence, yet it remains controversial and is provided to a minority of based practice guidelines of directors of addiction treatment programs in the Veterans Health Administration (VA). Compared to respondents at programs that did not pr...

Primary care is an optimal place to target modifiable health behavior problems that are linked to increased risk for mortality. The Veterans Administration (VA) has recognized the importance of coordinated, patient-centered care that increases access to health care services and has recently initiated efforts to implement Patient Aligned Care Teams...

The current study examined the impact of BMI and illicit drug use on the ability to inhibit prepotent behaviors. Participants (n=290) completed surveys and behavioral tasks: the Stroop Test and Go/No-Go. After controlling for age and gender, higher BMI was an independent predictor of poorer performance in both the Stroop and Go/No-Go tasks. Illicit...

We reviewed existing methods for identifying patients with neck and back pain in administrative data. We compared these methods using data from the Department of Veterans Affairs. To answer the following questions: (1) what diagnosis codes should be used to identify patients with neck pain and back pain in administrative data; (2) because the major...

Opioid agonist treatment (OAT)-through licensed clinic settings (C-OAT) using methadone or buprenorphine or office-based settings with buprenorphine (O-OAT)-is an evidence-based treatment for opioid dependence. Because of limited availability of on-site C-OAT (n=28 of 128 facilities) in the Veterans Health Administration (VHA), O-OAT use has been e...

Genetic testing is increasingly used as a tool throughout the health care system. In 2011 the number of clinically available genetic tests is approaching 2,000, and wide variation exists between these tests in their sensitivity, specificity, and clinical implications, as well as the potential for discrimination based on the results. As health care...

In patients with HIV/AIDS, chronic pain is common and analgesics pose serious risks. Cognitive-behavioral therapies (CBT) provide an alternative. This study evaluated feasibility and impact of a CBT-based pain management program in three public primary care clinics for HIV patients. The program included a workbook and 12-weeks of group CBT sessions...

To determine whether substituting Seeking Safety (SS), a manualized therapy for comorbid substance use disorders (SUD) and post-traumatic stress disorder (PTSD) for part of treatment-as-usual (TAU) improves substance use outcomes. Randomized controlled effectiveness trial. Out-patient Veterans Administration Health Care System SUD clinic. Ninety-ei...

Opioid dependence is a chronic, relapsing disorder that deleteriously influences the health of those afflicted. Sublingual buprenorphine opioid agonist treatment (OAT) has been shown to be safe, effective, and cost-effective for the treatment of opioid dependence in nonspecialized, office-based settings, including the Veterans Health Administration...

Unlabelled: Non-adherence to opioid prescriptions can decrease the safety and efficacy of opioid therapy. Identifying factors associated with over- and under-use of opioids in patients presenting with pain may improve prescribing and pain management. Patients presenting with pain often also present with somatization, and somatization is associated...

Pain is one of the most common reasons that patients seek treatment from health care professionals, often their primary care providers. One tool for treating pain is opioid therapy, and opioid prescriptions have increased dramatically in recent years in the United States. This article will review recent research about opioids that is most relevant...

Development of clinical decision support systems (CDSs) has tended to focus on facilitating medication management. An understanding of behavioral medicine perspectives on the usefulness of a CDS for patient care can expand CDSs to improve management of chronic disease. The purpose of this study is to explore feedback from behavioral medicine provid...

The Multisite Opiate Substitution Treatment study compared four opioid substitution programs that were highly concordant with clinical practice guidelines to four programs that were less concordant. Program staff were surveyed, and consenting new patients from highly concordant (n = 164) and less-concordant programs (n = 91) were assessed. After 12...

Using data from the National Comorbidity Survey--Replication, this study examined the timing of onset of self-report comorbid chronic nonarthritis pain and substance use disorders (SUDs) and characteristics associated with different onset patterns. Most individuals (58.2%; N = 351/632) report that the SUD preceded the onset of pain. Relative to tho...

With the growth in opioid therapy for the treatment of chronic pain, health care providers have focused their attention on avoiding over-use of opioid medications, specifically to avoid addiction, dependency, and other misuse. Qualitative and quantitative reviews of medication adherence, in contrast, focus primarily on why patients under-use or do...

Pain Assessment tool. Picture of the pain assessment tool clinicians can interact with and write to the medical record.

Conversion calculator tool. Picture of a conversion calculator tool to support clinicians calculating dose equivalents when converting from one opioid drug to another.

Note in medical record from pain assessment tool. This is a picture of a note written to the electronic medical record when clinicians complete the pain assessment tool.

Opioid prescribing for chronic pain is common and controversial, but recommended clinical practices are followed inconsistently in many clinical settings. Strategies for increasing adherence to clinical practice guideline recommendations are needed to increase effectiveness and reduce negative consequences of opioid prescribing in chronic pain pati...

To develop and evaluate a clinical decision support system (CDSS) named Assessment and Treatment in Healthcare: Evidenced-Based Automation (ATHENA)-Opioid Therapy, which encourages safe and effective use of opioid therapy for chronic, noncancer pain. CDSS development and iterative evaluation using the analysis, design, development, implementation,...

This study examined whether organizational characteristics and quality improvement initiatives were related to HIV and hepatitis C (HCV) testing rates in veterans' substance use disorders programs. Data were collected by surveying 232 program directors at all U.S. Department of Veterans Affairs (VA) substance use disorder programs. Program director...

Although methadone is not a new medication, its use in pain management has increased rapidly over the past decade. This article reviews the unique pharmacologic properties of methadone, including its long-acting nature, highly variable clearance rate, and its antagonism of the N-methyl-D-aspartate receptor. We discuss potential benefits and risks o...

The primary aim of this study was to examine the role of patient characteristics in predicting response to treatment in a sample of HIV-positive patients receiving 12 weekly sessions of a CBT-based pain management protocol. A pre/post test single group design was used. Pain-related functioning was assessed at baseline and 12 weeks post-treatment us...

The present study evaluated the effect of smoking deprivation on a biobehavioral index of distress tolerance, breath-holding duration, among 43 adult smokers in a repeated measures test (Session 1=smoking-as-usual, Session 2=12-h smoking deprivation). We theorized that distress tolerance is a context-dependent individual difference variable whose e...

Background: Misuse of and addiction to prescription medication is a growing problem. Identifying patients who misuse can be difficult and alternative strategies, such as decision support systems and visualization techniques, may help clinicians better detect misuse. Methods: Fifty veterans who received a prescription for an opioid medication...

This study examined the extent to which the timing of last methadone dose moderates the influence of a laboratory stressor on craving for methadone in a sample of methadone maintenance patients. Methadone maintenance patients (N=41) completed a computerized stress manipulation with two levels (low and high stress) on two separate days: (1) immediat...

The purpose of this paper is to describe potential improvements in patient safety resulting from design decisions in the development of a computerized decision support system (DSS) for managing opioid therapy for chronic noncancer pain. ATHENA-DSS is an automated decision support system developed in a collaboration between Stanford University and t...

Prescription drug abuse is a growing problem. Little is known about factors leading to more persistent opioid use following acute injury. We proposed to use the peri-operative setting to identify psychological risk factors for prolonged opioid use. We conducted a prospective, longitudinal observational study among 77 patients undergoing either: (1)...

To date, numerous studies have investigated the severity of post-operative pain, but few have characterized the duration of pain following surgery. We studied time-to-pain resolution following surgery to establish the natural history of pain cessation following five specific surgeries and to identify factors that predict persistent pain following s...

The Multisite Opiate Substitution Treatment study evaluated whether adhering to clinical-trial-derived practice guidelines improves treatment outcomes of unselected opiate-dependent patients seen in everyday practice. Clinics that were relatively concordant (n = 4) or nonconcordant (n = 4) with guidelines concerning medication dose levels and psych...

Persons recovering from addiction must refrain from drug use even when the opportunity to use exists. Understanding how behavioral response to drug reward opportunities is modified is key to treating addiction. Most effective behavioral therapies encourage patients to increase reinforcement opportunities by engaging unidentified sources of nondrug...

Compared to non-veterans, veterans are disproportionately diagnosed with opioid dependence. Sublingual buprenorphine provides greater access to opioid agonist therapy. To understand the diffusion of this innovative treatment within a large healthcare system, we describe the introduction of buprenorphine within the Veterans Health Administration (VH...

Clinical practice guidelines for opioid substitution treatment (OST) for opioid dependence recommend that patients receive at least 60 mg daily methadone and have access to a broad array of psychosocial services. However, there is still wide variation in clinical practice in OST clinics. In real-world settings, patients could receive lower methadon...

The aim of this study was to determine how the treatment needs and outcomes of polysubstance-using patients entering opioid-substitution treatment (OST) may be affected if the patient had a parent with substance-use problems. This prospective observational study examined outcomes of 255 patients (97% male) entering OST at eight clinics in the Veter...

This study examined interventions for substance use disorders within the Department of Veterans Affairs (VA) psychiatric and primary care settings. National random samples of 83 VA psychiatry program directors and 102 primary care practitioners were surveyed by telephone. The survey assessed screening practices to detect substance use disorders, pr...

To evaluate a 4-item screen for Post-Traumatic Stress Disorder (PTSD) for use with patients diagnosed with substance use disorders, 97 patients were recruited from substance use disorder treatment clinics at a large medical center. Participants completed the self-administered 4-item PTSD screen. Psychologists interviewed patients using the Clinicia...

Retention in Opioid Agonist Therapy (OAT) is associated with reductions in substance use, HIV risk behavior, and criminal activities in opioid dependent patients. To improve the effectiveness of treatment for opioid dependence, it is important to identify predisposing characteristics and provider-related variables that predict retention in OAT. Par...

Both clinicians and researchers have expressed doubt that opiate dependent patients with significant pain can be effectively treated in methadone maintenance treatment (MMT) programs; however, little research exists on this topic. Patients who report significant pain in the month preceding entry to MMT present with a distinct and more severe patter...

The purpose of this study was to determine whether opioid-dependent patients with diagnosed posttraumatic stress disorder (PTSD) have poorer long-term outcomes in opioid substitution treatment than do patients without PTSD. This prospective observational study examined outcomes of 255 opioid-dependent patients (men = 248) entering opioid substituti...

Randomized clinical trials of methadone maintenance have found that on average high daily doses are more effective for reducing heroin use, and clinical practice guidelines recommend 60 mg/d as a minimum dosage. Nevertheless, many clinicians report that some patients can be stably maintained on lower methadone dosages to optimal effect, and clinic...

Sample Consent Form This is a sample of a consent form from one of our eight participating research sites. Consent forms from the other seven participating sites were similar, with minor modifications of formatting and language to comply with local IRB preferences. (76 KB PDF).

IRB Approval Letter from the Stanford University IRB for Oversight of the MOST Study at the VA Palo Alto (182 KB PDF).

Several theories of opioid tolerance predict that the magnitude of micro opioid receptor (MOR) internalization in response to ligand changes in the setting of morphine tolerance. Here we show that in rats rendered tolerant to the analgesic action of morphine, cross-tolerance to the analgesic action of intrathecally administered [d-Ala2,N-MePhe4,Gly...

Although pain problems are prevalent in substance use disorder (SUD) patients, the special treatment needs of SUD patients with pain have not been investigated. This study examines the problems and behaviors associated with reported pain among veterans treated at eight opioid substitution treatment clinics. Patients reporting pain had more severe m...

Opioid compounds have powerful analgesic properties when administered to the spinal cord. These effects are exerted through mu and delta opioid receptors, and both pre- and postsynaptic mechanisms have been implicated. To specifically address the relative pre- and postsynaptic contribution to spinal opioid analgesia, we have quantitatively assessed...

Although the tachykinins substance P (SP) and neurokinin A (NKA) are coreleased from primary afferent nociceptors and act via neurokinin (NK) receptors, their differential effects in vivo are not known. Despite pharmacological evidence that NKA preferentially binds NK-2 receptors, this receptor is not found in spinal cord neurons. Thus, in the pres...

Internalization of spinal cord neurokinin-1 receptors following noxious stimulation provides a reliable measure of tachykinin signaling. In the present study, we examined the contribution of GABAergic mechanisms to the control of nociceptor processing involving tachykinins. Spinal administration of the GABAB receptor agonist R(+)-baclofen in the ra...

Although both pre- and postsynaptic mechanisms have been implicated in the analgesia produced by μ-opioids at the spinal cord, it is not known under what conditions these different controls come into play. Because the μ-opioid receptor (MOR) can be visualized in individual lamina II excitatory interneurons and internalizes into endosomes on ligand...

Discovery of the occurrence of neurokinin-1 (NK-1) receptor internalization in response to agonist activation has provided researchers with a new tool for studying tachykinin actions. Using the readily observable end point of NK-1 receptor internalization as an activity marker, this observation has allowed for more detailed study of tachykinin syst...

The capsaicin (vanilloid) receptor VR1 is a cation channel expressed by primary sensory neurons of the “pain” pathway. Heterologously expressed VR1 can be activated by vanilloid compounds, protons, or heat (>43°C), but whether this channel contributes to chemical or thermal sensitivity in vivo is not known. Here, we demonstrate that sensory neurons...

The relative contribution of pre- and postsynaptic controls to the flow of nociceptive information at the level of the spinal cord has been one of Ron Melzack's longstanding interests and a key issue in the formulation of the gate control theory. The authors review their own studies, in which they monitored internalization of the neurokinin-1 recep...

Although opioids can reduce stimulus-evoked efflux of Substance P (SP) from nociceptive primary afferents, the consequences of this reduction on spinal cord nociceptive processing has not been studied. Rather than assaying SP release, in the present study we examined the effect of opioids on two postsynaptic measures of SP release, Fos expression a...

Although the neurokinin-1 (NK-1)/substance P (SP) receptor is expressed by neurons throughout the spinal dorsal horn, nox- ious chemical stimulation in the normal rat only induces inter- nalization of the receptor in cell bodies and dendrites of lamina I. Here we compared the effects of mechanical and thermal stimulation in normal rats and in rats...

Acidosis has traditionally been considered to mediate certain types of hypoxic-ischemic injury to the brain. However, the recent demonstration that moderate acidosis will reduce NMDA-mediated currents suggested that acidity could actually protect against types of ischemia and excitotoxicity, and in vitro studies now support this idea. Prompted by t...

Recent publications have reported calcium level determinations in slices of brain using imaging techniques and the dye fura-2AM. In general these studies ignore or deal only perfunctorily with the problem of autofluorescence in slices. This confound, which is a result of the pyridine nucleotides that are normally present in tissue, has been previou...