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Screening for homelessness among individuals initiating medication-assisted treatment for opioid use disorder in the Veterans Health Administration
Abstract
Objective:
To determine the prevalence of homelessness and risk for homelessness among veterans with opioid use disorder initiating treatment.
Setting:
Addiction treatment programs operated by the US Department of Veterans Affairs (VA).
Participants:
All veterans initiating treatment with methadone or buprenorphine for opioid use disorder between October 1, 2013 and September 30, 2014 (n = 2,699) who were administered the VA's national homelessness screener.
Main outcome measures:
Self-reported homelessness or imminent risk of homelessness.
Results:
The prevalence of homelessness was 10.2 percent and 5.3 percent were at risk for homelessness. Compared to male veterans, women veterans were less likely to report homelessness (8.9 percent vs 10.3 percent) but more likely to be at risk (11.8 percent vs 4.9 percent). By age group, veterans aged 18-34 and 45-54 years most frequently reported homelessness (12.0 and 11.7 percent, respectively) and veterans aged 45-54 and 55-64 years most frequently reported risk for homelessness (6.5 and 6.8 percent, respectively).
Conclusions:
The prevalence of homelessness in this population is approximately 10 times that of the general veteran population accessing care at VA. Screening identified a substantial number of veterans who could benefit from VA housing assistance and had not received it recently. Programs to address veteran homelessness should engage with veterans seeking addiction treatment. Integration of homelessness services into addiction treatment settings may, in turn, improve outcomes.
... The research included in this review spans three decades, throughout which an association between SU and housing stability is repeatedly confirmed. Specifically, we observed a pattern of SU impacting veterans' ability to maintain safe and stable housing as well as the inverse of homelessness inhibiting veterans' access to services to address their SUDs and other health concerns (Bachhuber et al., 2015;Tsai & Rosenheck, 2013;Winer et al., 2021). Veterans who lacked stable housing frequently turned to EDs to meet their health needs, given that they lacked access to regular preventive care for SUDs and other comorbidities LePage et al., 2014;O'Toole et al., 2013). ...
... The retained literature presents several characteristics of female veterans and comparisons with male counterparts. The literature indicates that female veterans are less likely to be homeless than male veterans (Bachhuber et al., 2015;Byrne et al., 2016;Tsai et al., 2012), yet simultaneously are at greater risk of homelessness (Bachhuber et al., 2015;Byrne et al., 2013) and are overrepresented in adult female homeless populations (Byrne et al., 2013). ...
... The retained literature presents several characteristics of female veterans and comparisons with male counterparts. The literature indicates that female veterans are less likely to be homeless than male veterans (Bachhuber et al., 2015;Byrne et al., 2016;Tsai et al., 2012), yet simultaneously are at greater risk of homelessness (Bachhuber et al., 2015;Byrne et al., 2013) and are overrepresented in adult female homeless populations (Byrne et al., 2013). ...
The high prevalence of military veteran substance use (SU) when compared to their nonveteran counterparts has been described as an urgent public health issue. The commonality of severe mental and physical health comorbidities in this population affects their ability to recover and relates to the onset and maintenance of homelessness. While veteran-targeted housing and SU interventions exist, they are being underutilized. This scoping review synthesizes published peer-reviewed articles from 1990 to 2021 at the intersections of housing, substance abuse, and service utilization by homeless veterans. Qualitative thematic analysis of 119 retained peer-reviewed articles revealed five key themes: (1) the association between SU and housing stability, (2) gendered comparisons with service needs and provision, (3) consideration for comorbidities, (4) social support and relationship-centered interventions, and (5) barriers to health care services. This review offers a series of concerns, outcomes, and recommendations that might be valuable for practitioners, health care providers, and community stakeholders when implementing or re-evaluating new or existing homeless veteran treatment programs.
... There has yet to be a consensus on an accepted definition for housing-related social risks, nor a gold standard screening tool [3]. Effective screening is a crucial first step for the successful implementation of any [4, 6, 7, 10-12, 19, 21] 4 [4] Veterans, primary care [4, 6, 10-12, 19, 21] Not specified [4,6,10,19], Physicians [11,12,21], Behavioral Health or Social Service Providers [12,21], Nurses [11,12,21], Physician Assistants [12,21], Advanced Practice Nurses [11,12], Nurse Practitioners [11,21], Multiple/other [21] Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool [3, 9, 13-15, 18, 23] 2 [26] Adults/children and their caregivers [3,9,13] Not specified ...
... We identified 31 relevant screening tools from the 22 studies included in this narrative literature review. All of the included studies were from the United States (US) [3,4,[6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25]. Healthcare settings included Veterans Health Administration (VHA) outpatient clinics [4,6,8,[10][11][12][19][20][21], primary care clinics [3, 9, 13-15, 22, 23, 25], emergency departments [3,9,13,25], specialty outpatient clinics [15,24,25], inpatient hospital care [15], home-visiting programs [25], community health centers [18,25], and veteran homeless center programs [17]. ...
... All of the included studies were from the United States (US) [3,4,[6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25]. Healthcare settings included Veterans Health Administration (VHA) outpatient clinics [4,6,8,[10][11][12][19][20][21], primary care clinics [3, 9, 13-15, 22, 23, 25], emergency departments [3,9,13,25], specialty outpatient clinics [15,24,25], inpatient hospital care [15], home-visiting programs [25], community health centers [18,25], and veteran homeless center programs [17]. The organizations involved were serving financially disadvantaged patients [3,13,18,23], pediatric patients [22,25] and rural patients [16]. ...
Objectives: To describe existing tools for screening patients for unstable housing in a healthcare setting.
Methods: A literature search was completed to retrieve articles published in the last 10 years on screening patients for unstable housing in a healthcare setting.
Results: The current literature on screening patients for homelessness in healthcare settings describes a variety of tools administered by a range of healthcare providers, but all are based in the United States.
Conclusion: The studies revealed the potential for effective screening in healthcare settings and positive engagement of patients and providers with screening. Key areas for future research include innovative methods of screening and evaluation of reliability and validity for a broader range of tools.
... OUD continues to cause substantial personal and societal harms. Examples of personal harms include death from overdose (from opioid use alone or polysubstance use) [1,4,5], medical and psychiatric comorbidities (e.g., human immunodeficiency virus (HIV), hepatitis C virus (HCV), cardiopulmonary disease, depression, and anxiety) [6][7][8][9][10][11], problems with employment and social relationships [12][13][14][15], as well as criminal justice involvement [16,17]. OUD also causes societal harm by disrupting the lives of those connected to persons with OUD [18] and by generating substantial economic burden; i.e., the annual cost of OUD was recently estimated to be $1.5 trillion in the USA [19], related to lost economic productivity, increased healthcare utilization, criminal justice involvement, and use of social services. ...
... Each participant's percentage abstinence was calculated after the first (weeks 10-25), second (weeks [14][15][16][17][18][19][20][21][22][23][24][25], and third (weeks 18-25) maintenance doses as the proportion (%) of negative opioid use results among the corresponding 16, 12, and 8 weekly assessments, respectively. Missing UDS or self-report at a specific visit (or both as a result of study discontinuation) were treated as positive for opioid use for that week ( Table 2). ...
... Harm Reduction Journal (2023) 20:173 Table 1 Baseline characteristics by the most frequent opioid use route and maintenance dosage groups Shown for the efficacy analysis set (participants who received at least one maintenance dose (BUP-XR 300 mg vs. 100 mg). Q, quartile; SD, standard deviation; UDS, urine drug screen a Based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria [35] b Self-reported cocaine use history or self-reported cocaine use within one week prior to screen or UDS-detected cocaine use at screen visit c Self-reported polydrug use history or UDS-detected Meth/amphetamine, cocaine metabolites, benzodiazepines, cannabinoids, or phencyclidine use at screen visit Each participant's percentage abstinence was calculated after the first (weeks 10-25), second (weeks [14][15][16][17][18][19][20][21][22][23][24][25], and third (weeks 18-25) maintenance doses as the proportion (%) of negative opioid use results among the corresponding 16, 12, and 8 weekly assessments, respectively. Missing = Positive: the missing UDS or missing self-report for illicit opioid use at a specific scheduled visit was imputed as positive for that visit. ...
Background
BUP-XR (SUBLOCADE ® ) is the first buprenorphine extended-release subcutaneous injection approved in the USA for monthly treatment of moderate-to-severe opioid use disorder (OUD). Among patients with OUD, those who inject or use high doses of opioids likely require higher doses of buprenorphine to maximize treatment efficacy. The objective of this analysis was to compare the efficacy and safety of 100-mg versus 300-mg maintenance doses of BUP-XR in OUD patients who inject opioids.
Methods
This was a secondary analysis of a randomized, double-blind, placebo-controlled study in which adults with moderate or severe OUD received monthly injections of BUP-XR (2 × 300-mg doses, then 4 × 100-mg or 300-mg maintenance doses) or placebo for 24 weeks. Abstinence was defined as opioid-negative urine drug screens combined with negative self-reports collected weekly. Each participant’s percentage abstinence was calculated after the first, second, and third maintenance doses in opioid-injecting and non-injecting participants. The proportion of participants achieving opioid abstinence in each group was also calculated weekly. Treatment retention rate following the first maintenance dose was estimated for opioid-injecting participants with Kaplan–Meier method. Risk-adjusted comparisons were made via inverse propensity weighting using propensity scores. Buprenorphine plasma concentration–time profiles were compared between injecting and non-injecting participants. The percentages of participants reporting treatment-emergent adverse events were compared between maintenance dose groups within injecting and non-injecting participants separately.
Results
BUP-XR 100-mg and 300-mg maintenance doses were equally effective in non-injecting participants. However, in opioid-injecting participants, the 300-mg maintenance dose delivered clinically meaningful improvements over the 100-mg maintenance dose for treatment retention and opioid abstinence. Exposure–response analyses confirmed that injecting participants would require higher buprenorphine plasma concentrations compared to non-injecting opioid participants to achieve similar efficacy in terms of opioid abstinence. Importantly, both 100- and 300-mg maintenance doses had comparable safety profiles, including hepatic safety events.
Conclusions
These analyses show clear benefits of the 300-mg maintenance dose in injecting participants, while no additional benefit was observed in non-injecting participants relative to the 100-mg maintenance dose. This is an important finding as opioid-injecting participants represent a high-risk and difficult-to-treat population. Optimal buprenorphine dosing in this population might facilitate harm reduction by improving abstinence and treatment retention.
Trial registration: ClinicalTrials.gov, NCT02357901.
... Despite the afore mentioned associations of OUD with both the risk of homelessness and other adverse outcomes among homeless adults, (Bachhuber et al., 2015;Doran et al., 2018;Midboe et al., 2019;Tsai and Rosenheck, 2015) there is limited research on the complex relationship between OUD, homelessness and other shared sociodemographic and medical risk factors. To our knowledge, no studies have attempted to systematically evaluate the association of OUD and homelessness net of other factors such as low income, racial minority status, as well as other SUDs, psychiatric and medical disorders that are themselves associated with both OUD and homelessness. ...
... US military veterans appear to have similar or somewhat greater rates of homelessness than the general population (Balshem et al., 2011a;Tsai et al., 2016;Tsai and Rosenheck, 2015), and the prevalence of SUD including OUD among homeless veterans also appears to be as elevated as it is among homeless non-veterans (Balshem et al., 2011b;O'Toole et al., 2003;Tsai and Rosenheck, 2015;Winkleby and Fleshin, 1993). The combination of OUD and homelessness is a vexing clinical problem among veterans as in the general population, but has yet to be examined in a systematic study addressing the many factors involved in the linkage between OUD and homelessness (Bachhuber et al., 2015;Doran et al., 2018;Midboe et al., 2019). The Veterans Health Administration (VHA) is the largest integrated national health system in the US and its clinical activities, and specifically its provision of services to homeless veterans, have been comprehensively documented through its electronic health record . ...
... Other studies have explored some aspects of the relationship between OUD and homelessness, although not the direct association between the two net of other factors. For example, Bachhuber et al. found that veterans on medication treatment for OUD had greater homelessness prevalence than other veterans (Bachhuber et al., 2015). Another study reported a higher adjusted risk of homelessness associated with OUD, similar to our study, and higher risk of prior overdose events associated with homelessness but used a more limited sample of patients presenting to emergency rooms and did not elaborate on the involvement of sociodemographic and clinical factors in the relationship (Doran et al., 2018). ...
Background:
Substance use disorder (SUD) is a major risk factor for homelessness, but the specific association of opioid use disorder (OUD) and homelessness in the context of their shared risk factors has not been the focus of prior studies. We used national data from the United States Veterans Health Administration (VHA) to examine the association of OUD and homelessness in the context of shared risk factors.
Methods:
In this cross-sectional analysis of veterans who received VHA care during Fiscal Year 2012 (N = 5,450,078), we compared the prevalence of OUD and other sociodemographic, and clinical factors among homeless and non-homeless veterans. We estimated the odds ratio for homelessness associated with OUD alone, and after adjusting for other factors through multivariate logistic regression.
Results:
Homeless veterans had substantially higher prevalence of OUD than other VHA patients (7.7 % Vs 0.6 %) and OUD was associated with 13 times higher unadjusted odds of homelessness (Odds Ratio [OR] 13.36, 95 % CI 13.09-13.62), which decreased with adjustment for sociodemographic factors (black race, mean income and age), other SUD, medical, and psychiatric diagnoses (final OR 1.57, 95 % CI 1.53-1.61). Other SUDs (alcohol, cannabis, cocaine, and hallucinogens) showed similar or slightly higher odds of homelessness as OUD in the final model.
Conclusions:
OUD was strongly associated with homelessness among US veterans although this association was largely but not entirely attenuated by shared sociodemographic and co-morbid risk factors including several other SUDs. Treatment of homeless veterans with OUD should address socio-economic vulnerabilities and other co-morbidities in addition to treatments for OUD.
... Of the sixty included studies, twenty-seven reported on opioid use treatment access and engagement among PEH (Amodeo et al., 2004;Bachhuber et al., 2015;Bauer et al., 2016;Corsi et al., 2007;Daniulaityte et al., 2019;Deck and Carlson, 2004;Dunn et al., 2019;Englander et al., 2020;Eyrich-Garg et al., 2008;Hoffman et al., 2019;Kelly et al., 2018;Krawczyk et al., 2020;Krull et al., 2011;Lundgren et al., 2003;Masson et al., 2002;Midboe et al., 2019;Nyamathi et al., 2004;Patel et al., 2020;Reynoso-Vallejo et al., 2008;Rivers et al., 2006;Robbins et al., 2010;Royse et al., 2000;Shah et al., 2000;Simon et al., 2017;Timko et al., 2016;Upshur et al., 2018;Van Ness et al., 2004). While most were conducted among general populations of people who use opioids, five evaluated characteristics of treatment engagement exclusively among homeless-experienced populations (Bauer et al., 2016;Midboe et al., 2019;Nyamathi et al., 2004;Robbins et al., 2010;Upshur et al., 2018). ...
... A retrospective analysis found that PEH were less likely to have received OAT in the context of outpatient treatment admissions for OUD (Krawczyk et al., 2020). Moreover, the prevalence of homelessness among veterans initiating methadone or buprenorphine treatment was only 10.2 % in 2012 (Bachhuber et al., 2015), despite 34.6 % of veterans with OUD being homeless in the following two years (Iheanacho et al., 2018). PEH were also less likely to receive OAT than housed individuals in detoxification settings (Dunn et al., 2019), though they were more likely to receive XR-NTX than OAT and no treatment in a sample of veterans in 2012 (Kelly et al., 2018). ...
Background
The opioid-related overdose epidemic remains a persistent public health problem in the United States and has been accelerated by the 2019 coronavirus disease pandemic. Existing, evidence-based treatment options for opioid use disorder (OUD) are broadly underutilized, particularly by people experiencing homelessness (PEH). PEH are also more likely to misuse and overdose on opioids. To better understand current gaps and disparities in OUD treatment experienced by PEH and efforts to address them, we synthesized the literature reporting on the intersection of housing status and OUD treatment.
Methods
We conducted a scoping review of the literature from the electronic databases MEDLINE, Embase, PsycINFO, and Web of Science Core Collection. We included studies describing treatment-related outcomes specific to PEH and articles assessing OUD treatment interventions tailored to this population. Relevant findings were compiled via thematic analysis and narratively synthesized.
Results
We included 60 articles, including 43 descriptive and 17 intervention-focused studies. These studies demonstrated that PEH experience more barriers to OUD treatment than their housed counterparts and access inpatient and detoxification treatment more commonly than pharmacotherapy. However, the reviewed literature indicated that PEH have similar outcomes once engaged in pharmacotherapy. Efficacious interventions for PEH were low-barrier and targeted, with housing interventions also demonstrating benefit.
Conclusions
PEH have diminished access to evidence-based OUD treatment, particularly medications, and require targeted approaches to improve engagement and retention. To mitigate the disproportionate opioid-related morbidity and mortality PEH experience, innovative, flexible, and interdisciplinary OUD treatment models are necessary, with housing support playing an important role.
... We did not account for stimulant use as our data focused on 2016, likely preceding this "fourth wave." Lastly, homelessness is a major problem among patients with OUD, which could affect discharge decisions and access to PAC facilities and could lengthen hospital stays [51][52][53]. We sought to adjust for this by running a sensitivity analysis using homelessness as a covariate as described above, which did not significantly affect our results. ...
Background
Patients with opioid use disorder (OUD) who are hospitalized for serious infections requiring prolonged intravenous antibiotics may face barriers to discharge, which could prolong hospital length of stay (LOS) and increase financial burden. We investigated differences in LOS, discharge disposition, and charges between hospitalizations for serious infections in patients with and without OUD.
Methods and findings
We utilized the 2016 National Inpatient Sample—a nationally representative database of all discharges from US acute care hospitals. The population of interest was all hospitalizations for infective endocarditis, epidural abscess, septic arthritis, or osteomyelitis. The exposure was OUD, and the primary outcome was LOS until discharge, assessed by using a competing risks analysis to estimate adjusted hazard ratios (aHRs). Adjusted odds ratio (aOR) of discharge disposition and adjusted differences in hospital charges were also reported. Of 95,470 estimated hospitalizations for serious infections (infective endocarditis, epidural abscess, septic arthritis, and osteomyelitis), the mean age was 49 years and 35% were female. 46% had Medicare (government-based insurance coverage for people age 65+ years), and 70% were non-Hispanic white. After adjustment for potential confounders, OUD was associated with a lower probability of discharge at any given LOS (aHR 0.61; 95% CI 0.59–0.63; p < 0.001). OUD was also associated with lower odds of discharge to home (aOR 0.38; 95% CI 0.33–0.43; p < 0.001) and higher odds of discharge to a post-acute care facility (aOR 1.85; 95% CI 1.57–2.17; p < 0.001) or patient-directed discharge (also referred to as “discharge against medical advice”) (aOR 3.47; 95% CI 2.80–4.29; p < 0.001). There was no significant difference in average total hospital charges, though daily hospital charges were significantly lower for patients with OUD. Limitations include the potential for unmeasured confounders and the use of billing codes to identify cohorts.
Conclusions
Our findings suggest that among hospitalizations for some serious infections, those involving patients with OUD were associated with longer LOS, higher odds of discharge to post-acute care facilities or patient-directed discharge, and similar total hospital charges, despite lower daily charges. These findings highlight opportunities to improve care for patients with OUD hospitalized with serious infections, and to reduce the growing associated costs.
... In addition to the role of the provider, the type of clinic where a Veteran responds to the HSCR also appears to be important, although it is difficult to interpret this finding given that the category of "other" has the only significant effect. Analyses of HSCR data have found that rates of positive screens are significantly higher in specialty clinicsparticularly for mental health and substance use (Montgomery 2016) as well as methadone maintenance (Bachhuber et al. 2015)-than in primary care clinics, and providers who participated in this study suggest that psychiatrists are often better connected with resources. Similarly, providers in specialty clinics may have more experience working with patients with higher social needs and may therefore be more experienced at responding to Veterans' needs when they screen positive for housing instability. ...
This study aims to explore the relationship between the context of screening for housing instability and Veterans’ access to services, with the goal of ensuring effective processes to address housing instability among Veterans. This study used administrative data from 100,022 Veterans’ electronic medical records and qualitative data collected during in-depth interviews with 22 health care providers and six Homeless Program staff. A mixed effects logistic regression assessed the relationship between Veterans’ screening experiences and connection with services; qualitative data were analyzed using a grounded theory approach to present providers’ reflections on administering screening for housing instability and responding to Veterans’ positive screens with needed resources. We observed a significant relationship between providers’ roles and location of screening with patients’ timely linkage with services. Providing additional training related to how to conduct the screen and provide required resources, shifting screening responsibilities to providers with more flexibility to address these needs, and embedding supportive services in the care team may improve post-screening linkage with services.
... Opioid use disorder (OUD) is associated with significant societal, physical, psychological, and economic burden (Bachhuber, Roberts, Metraux, & Montgomery, 2015;D'Onofrio et al., 2015;Fisher et al., 2014;Han et al., 2017;Stein et al., 2017). For people seeking treatment for OUD, medication-assisted treatment with buprenorphine, methadone, or naltrexone may be an option. ...
Introduction:
The physical, social, psychological, and economic burden of opioid use disorder (OUD) is substantial. As of the year 2019, the predominant focus of OUD research was outcomes such as retention and abstinence. We report herein the effects of extended-release buprenorphine (BUP-XR), the first FDA-approved subcutaneously injected, monthly treatment for OUD, on patient-centered outcomes.
Materials and methods:
Patient-centered outcomes were collected during an open-label safety study of participants with OUD (NCT# 02510014) evaluating BUP-XR. Measures collected during the study included the EQ-5D-5L, SF-36v2, Treatment Effectiveness Assessment (TEA), Addiction Severity Index-Lite (ASI-Lite), employment/insurance status questionnaire, and Medication Satisfaction Questionnaire (MSQ). Changes from baseline to end of study week 49 were analyzed using mixed models for repeated measures. "Baseline" was defined as the value collected prior to the first BUP-XR injection. Results presented are for those participants who initiated treatment on BUP-XR during the open-label study and were eligible to receive up to 12 injections.
Results:
Four hundred twelve participants were included in analyses; 206 participants discontinued BUP-XR prematurely. Mean EQ-5D-5L scores remained stable from baseline to end of study. Statistically significant improvements from baseline to end of study were noted for the SF-36v2 mental component summary score (difference = 5.0, 95%CI: 3.5-6.5) and 7 of 8 domain scores (P < .05 for all comparisons); the SF-36v2 physical component summary remained stable from baseline to end of study. The TEA total score (difference = 9.3 points, 95%CI: 8.0-10.5) and 4 of 4 domain scores (difference = 2-3 points per domain) significantly improved from baseline to end of study. Significant improvements (P < .05 for all comparisons) on the ASI-Lite were seen for all problem areas except alcohol use from baseline to end of study. Employment rate increased 7% whereas health insurance status remained stable from baseline to end of study. Medication satisfaction measured using the MSQ was >88% at end of study.
Conclusions:
Treatment with BUP-XR monthly injections for up to 12 months in this cohort of treatment-seeking individuals with OUD led to positive PCOs and high treatment satisfaction, which correspond to personal recovery.
Stable housing is critical for health, employment, education, and other social outcomes. Evictions reflect a form of housing instability that is experienced by millions of Americans each year. Inadequately treated psychiatric disorders have the potential to influence evictions in several ways. For example, these disorders may impede labor market performance and thus the ability to pay rent, or increase the likelihood of risky and/or nuisance behaviors that can lead to a lease violation. We estimate the effect of local access to psychiatric treatment on eviction rates. We combine data on the number of psychiatric treatment centers that offer outpatient and residential care within a county with eviction rates in a two‐way fixed‐effects framework. Our findings imply that 10 additional psychiatric treatment centers in a county lead to a reduction of 2.1% in the eviction rate.
Objective
To examine the extent to which there was any therapeutic relationship between Veterans and their initial buprenorphine provider, and whether presence of this relationship influenced treatment retention.
Data sources
National, secondary administrative data used from the Veterans Health Administration (VHA), 2008-2017.
Study Design
Retrospective cohort study. The primary exposure was a therapeutic relationship between the Veteran and buprenorphine provider, defined as the presence of previous visit or medication prescribed by the provider in the two years preceding buprenorphine treatment initiation. The primary outcome was treatment discontinuation, evaluated as 14 days of absence of medication from initiation through 1 year.
Data Collection/Extraction Methods
Adult Veterans (age ≥18 years) diagnosed with opioid use disorder and treated with buprenorphine or buprenorphine/ naloxone within the VHA system were included in this study. We excluded those receiving buprenorphine patches, those with a documentation of a metastatic tumor diagnosis within two years prior to buprenorphine initiation, and those without geographical information on rurality.
Principal Findings
A total of 28,791 Veterans were included in the study. Within the overall study sample, 56.3% (n=16,206) of Veterans previously had at least one outpatient encounter with their initial buprenorphine provider and 24.9% (n=7,174) of Veterans previously had at least one prescription from that provider in the two years preceding buprenorphine initiation. There was no significant or clinically meaningful association between therapeutic relationship history and treatment retention when defined as visit history (aHR: 0.99; 95%CI: 0.96-1.02) or medication history (aHR: 1.03; 95%CI: 1.00, 1.07).
Conclusions
Veterans initiating buprenorphine frequently did not have a therapeutic history with their initial buprenorphine provider, but this relationship was not associated with treatment retention. Future work should investigate how the quality of Veteran-provider therapeutic relationships influences OUD management, and whether eliminating training requirements for providers might affect access to buprenorphine, and subsequently treatment initiation and retention.
Introduction
Veterans with opioid use disorder have an increased risk of suicide and overdose compared with the general population. Buprenorphine, a U.S. Food and Drug Administration–approved medication to treat opioid use disorder, has shown benefits, including decreased risk of illicit drug use and overdose. This study assesses the mortality outcomes with buprenorphine pharmacotherapy among Veterans up to 5 years from treatment initiation.
Methods
This was a retrospective cohort study of Veterans receiving buprenorphine (2008–2017) across any Veterans Health Administration facility. Buprenorphine pharmacotherapy was evaluated as a time-varying covariate. The primary outcome was death up to 5 years from treatment initiation by suicide and overdose combined; secondary outcomes included suicide, overdose, opioid-specific overdose, and all-cause death. Secondary analyses included evaluating the risk of mortality in recent discontinuation and effect modification by select characteristics. All analyses were conducted in 2020.
Results
Veterans who were not receiving buprenorphine were 4.33 (adjusted hazard ratio; 95% CI=3.60, 5.21) times more likely to die by suicide/overdose than those receiving buprenorphine pharmacotherapy on any given day, with similar protective associations with treatment across secondary outcomes. The risk of suicide/overdose was highest 8–14 days from treatment discontinuation (adjusted hazard ratio=6.54, 95% CI=4.32, 9.91) than in currently receiving buprenorphine pharmacotherapy. There was no evidence of effect modification by the selected covariates.
Conclusions
Mortality risk was greater among Veterans who were not receiving buprenorphine pharmacotherapy than among those who were. Providers should consider whether buprenorphine pharmacotherapy, either intermittent or continuous, may provide health benefits for their patients and prevent mortality.
Addressing homelessness among veterans has been a top policy priority for the U.S. Department of Veterans Affairs (VA) since 2009. Part of the multitiered strategy to prevent and end homelessness among veterans was the implementation of a universal screen for housing instability among all veteran outpatients at VA facilities. Data from more than six million veterans responding to this screen have provided insight into veterans’ housing instability, as well as the characteristics of individuals and structural forces that may influence housing insecurity among veterans; the current article synthesizes these findings. Although the universal screen for housing instability has been effective at linking veterans with needed resources, questions remain regarding the best ways to ensure that they remain in safe, affordable, adequate, and permanent housing.
This chapter explores and discusses veteran health care issues and the long‐term impact that chronic illness and disability has on veteran transition to civilian life. There are multiple roles and responsibilities of government and private healthcare providers to maintain and increase optimal medical, physical, and mental health functioning. A model of psychosocial adjustment and adaptation to disability is offered that will assist clinicians to anticipate and predict the various psychosocial phases that are important for successful veteran reintegration and transition. Guidelines are presented for prevention, coping, and treatment to deal with the multiple complex challenges in veteran medical, physical, and psychological health, vocational and social adjustment, as well as independent functioning. Best practices for long‐term medical, physical, and psychological health are offered to professionals with intention to provide competent and ethical services enhancing optimal veteran wellness.
Background: Emergency department (ED) visits related to substance use are common. ED patients also have high levels of health-related material needs (HRMNs), such as homelessness and food insecurity. However, little research has examined the intersection between ED patient HRMNs and substance use.
Methods: We surveyed a random sample of public hospital ED patients. Surveys included validated single-item screeners for unhealthy alcohol and any drug use and questions on self-reported past-year material needs. We compared individual HRMNs and cumulative number of HRMNs by substance use screening status using bivariate and multivariable analyses.
Results: A total of 2312 surveys were completed. Nearly one third of patients (32.3%, n = 747) screened positive for unhealthy alcohol use, and 21.8% ( n = 503) screened positive for drug use. Prevalence of HRMNs for all patients—including food insecurity (50.8%), inability to meet essential expenses (40.8%), cost barriers to medical care (24.6%), employment issues (23.8%), and homelessness (21.4%)—was high and was significantly higher for patients with unhealthy alcohol use or drug use. In multivariable analyses, homelessness was independently associated with unhealthy alcohol use (adjusted odds ratio [aOR]: 1.61, 95% confidence interval [CI]: 1.24–2.09) and drug use (aOR: 2.30, 95% CI: 1.74–3.05). There was a significant stepwise increase in the odds of patient unhealthy alcohol or drug use as number of HRMNs increased.
Conclusions: ED patients with unhealthy alcohol or drug use have higher prevalence of HRMNs than those without. Our findings suggest that HRMNs may act additively and that homelessness is particularly salient. Patients’ comorbid HRMNs may affect the success of ED-based substance use interventions.
The authors conducted a systematic, critical review of the literature to assess and summarize existing research on homelessness among female veterans. They searched seven electronic databases (ERIC, Proquest Dissertations and Theses, PsycINFO, PubMed, Social Services Abstracts, Social Science Citation Index, and Sociological Abstracts), websites of several government and research organizations, and reference lists of prior studies. They abstracted data on study design, funding source, and topic from studies meeting inclusion criteria and classified each study into one of the following categories: epidemiology, health and other services utilization, and interventions. The authors included both experimental and observational studies of interventions in the review and performed a narrative synthesis for each of the 26 studies identified. No studies were experimental, 20 were observational, and the remainder were either qualitative or descriptive. Of the 26 identified studies, 14 were epidemiologic, 7 focused on the health and additional service utilization, and 5 were intervention studies. Findings provided important baseline epidemiologic information about homelessness among female veterans and indicated that female veterans were at an increased risk of homelessness relative to their male veteran and female non-veteran counterparts. Additional research is needed to develop and implement effective, evidence-based programs to prevent and end homelessness among women veterans. The contents of this article do not necessarily represent the views of the Department of Veterans Affairs or the United States Government.
Methadone substitution therapy is an effective harm reduction treatment method for opioid dependent persons. Ability to retain patients in methadone treatment is an accepted predictor of treatment outcomes.
The current study evaluates the roles of psychiatric comorbidity, medical comorbidity, and sociodemographic characteristics as predictors of retention in methadone treatment utilizing retrospective analysis of data from a nationwide sample of patients in methadone treatment in the VA.
Data were gathered using the VA's national health services use database. A cohort of veterans with a new episode of "opiate substitution" in fiscal year 1999 was identified, and their continuous service use was tracked through fiscal year 2002. The sample included a total of 2,363 patients in 23 VA medical centers. Survival analysis was used to explore factors associated with retention in methadone treatment.
Younger age, having a serious mental illness, being African American, or having race recorded as unknown were associated with lower rates of retention in methadone treatment programs in this population of veterans (controlling for site).
Given that extended methadone treatment is associated with improved outcomes while patients remain in treatment, more longitudinal studies using primary data collection are needed to fully explore factors related to retention. For the VA population specifically, further research is necessary to fully understand the relationship between race/ethnicity and treatment retention.
This is the first retention study the authors are aware of that utilizes data from a nationwide, multisite, population of participants in methadone treatment.
This study identified risk factors for homelessness among indigent urban adults without dependent children and with no history of psychotic illness.
We conducted a matched case-control study, stratified by sex, of 200 newly homeless men and women and 200 indigent men and women with no history of homelessness. Newly homeless case subjects were recruited from shelter assessment centers in New York City. Never-homeless control subjects, selected from public assistance centers, were single adults applying for home relief. Control subjects were matched with case subjects according to ethnicity, age, and sex. Trained interviewers employed standardized research instruments to probe 3 domains of risk factors: symptom severity and substance use disorder, family support and functioning, and prior use of services.
Significant interaction effects by sex were present for symptom severity, heroin use disorder, and prior service use. Greater numbers of the homeless of both sexes lacked a high school diploma and had less income from all sources, including from their families, than of the never homeless.
Newly homeless men and women with no history of psychotic illness differed from their never-homeless counterparts in the 3 domains investigated, but socioeconomic factors were also important.
Although office-based opioid treatment with buprenorphine (OBOT-B) has been successfully implemented in primary care settings in the US, its use has not been reported in homeless patients.
To characterize the feasibility of OBOT-B in homeless relative to housed patients.
A retrospective record review examining treatment failure, drug use, utilization of substance abuse treatment services, and intensity of clinical support by a nurse care manager (NCM) among homeless and housed patients in an OBOT-B program between August 2003 and October 2004. Treatment failure was defined as elopement before completing medication induction, discharge after medication induction due to ongoing drug use with concurrent nonadherence with intensified treatment, or discharge due to disruptive behavior.
Of 44 homeless and 41 housed patients enrolled over 12 months, homeless patients were more likely to be older, nonwhite, unemployed, infected with HIV and hepatitis C, and report a psychiatric illness. Homeless patients had fewer social supports and more chronic substance abuse histories with a 3- to 6-fold greater number of years of drug use, number of detoxification attempts and percentage with a history of methadone maintenance treatment. The proportion of subjects with treatment failure for the homeless (21%) and housed (22%) did not differ (P = .94). At 12 months, both groups had similar proportions with illicit opioid use [Odds ratio (OR), 0.9 (95% CI, 0.5-1.7) P = .8], utilization of counseling (homeless, 46%; housed, 49%; P = .95), and participation in mutual-help groups (homeless, 25%; housed, 29%; P = .96). At 12 months, 36% of the homeless group was no longer homeless. During the first month of treatment, homeless patients required more clinical support from the NCM than housed patients.
Despite homeless opioid dependent patients' social instability, greater comorbidities, and more chronic drug use, office-based opioid treatment with buprenorphine was effectively implemented in this population comparable to outcomes in housed patients with respect to treatment failure, illicit opioid use, and utilization of substance abuse treatment.
Homelessness among US veterans has been a focus of research for over 3 decades. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, this is the first systematic review to summarize research on risk factors for homelessness among US veterans and to evaluate the evidence for these risk factors. Thirty-one studies published from 1987 to 2014 were divided into 3 categories: more rigorous studies, less rigorous studies, and studies comparing homeless veterans with homeless nonveterans. The strongest and most consistent risk factors were substance use disorders and mental illness, followed by low income and other income-related factors. There was some evidence that social isolation, adverse childhood experiences, and past incarceration were also important risk factors. Veterans, especially those who served since the advent of the all-volunteer force, were at greater risk for homelessness than other adults. Homeless veterans were generally older, better educated, and more likely to be male, married/have been married, and to have health insurance coverage than other homeless adults. More studies simultaneously addressing premilitary, military, and postmilitary risk factors for veteran homelessness are needed. This review identifies substance use disorders, mental illness, and low income as targets for policies and programs in efforts to end homelessness among veterans.
Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health 2015. This work is written by (a) US Government employee(s) and is in the public domain in the US.
Objectives:
Veterans are overrepresented within the homeless population compared with their non-veteran counterparts, particularly when controlling for poverty. The U.S. Department of Veterans Affairs (VA) aims to prevent new episodes of homelessness by targeting households at greatest risk; however, there are no instruments that systematically assess veterans' risk of homelessness. We developed and tested a brief screening instrument to identify imminent risk of homelessness among veterans accessing VA health care.
Methods:
The study team developed initial assessment items, conducted cognitive interviews with veterans experiencing homelessness, refined pilot items based on veterans' and experts' feedback and results of psychometric analyses, and assigned weights to items in the final instrument to indicate a measure of homelessness risk.
Results:
One-third of veterans who responded to the field instrument reported imminent risk of homelessness (i.e., housing instability in the previous 90 days or expected in the next 90 days). The reliability coefficient for the instrument was 0.85, indicating good internal consistency. Veterans who had a recent change in income, had unpaid housing expenses, were living temporarily with family and friends, needed help to get or keep housing, and had poor rental and credit histories were more likely to report a risk of homelessness than those who did not.
Conclusion:
This study provides the field with an instrument to identify individuals and households at risk of or experiencing homelessness, which is necessary to prevent and end homelessness. In addition, it supports VA's investment in homelessness prevention and rapid rehousing services for veterans who are experiencing or are at risk for homelessness.
Objectives:
We examined whether substance-use disorders and poverty predicted first-time homelessness over 3 years.
Methods:
We analyzed longitudinal data from waves 1 (2001-2002) and 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions to determine the main and interactive effects of wave 1 substance use disorders and poverty on first-time homelessness by wave 2, among those who were never homeless at wave 1 (n = 30,558). First-time homelessness was defined as having no regular place to live or having to live with others for 1 month or more as a result of having no place of one's own since wave 1.
Results:
Alcohol-use disorders (adjusted odds ratio [AOR] = 1.34), drug-use disorders (AOR = 2.51), and poverty (AOR = 1.34) independently increased prospective risk for first-time homelessness, after adjustment for ecological variables. Substance-use disorders and poverty interacted to differentially influence risk for first-time homelessness (P < .05), before, but not after, adjustment for controls.
Conclusions:
This study reinforces the importance of both substance-use disorders and poverty in the risk for first-time homelessness, and can serve as a benchmark for future studies. Substance abuse treatment should address financial status and risk of future homelessness.
We examined data for all veterans who completed the Veterans Health Administration's national homelessness screening instrument between October 1, 2012, and January 10, 2013. Among veterans who were not engaged with the US Department of Veterans Affairs homeless system and presented for primary care services, the prevalence of recent housing instability or homelessness was 0.9% and homelessness risk was 1.2%. Future research will refine outreach strategies, targeting of prevention resources, and development of novel interventions. (Am J Public Health. Published online ahead of print October 22, 2013: e1-e2. doi:10.2105/AJPH.2013.301398).
The objective of this study was to examine, for a population of 8,258 adult injection drug users (IDUs) who all had entered a Massachusetts licensed methadone maintenance treatment program (MMT) between 1996 and 2002, client factors associated with remaining in MMT for a minimum of 1 year after program entry. Two binomial logistic regression models were developed. The first model examined the association between age, sex, race/ethnicity, parental status, employment status, educational status, health insurance status, homelessness status, having injected drugs in the past month, residential treatment use, number of overall treatment admissions, and whether a client's longest consecutive stay in MMT had lasted for 1 year or more. Second, to examine the stability of the statistical relationships identified in the first logistic regression model, a second logistic regression model examined whether there were significant differences in client level characteristics between those who used MMT for 6 months or less compared with their counterparts. Those who were older, women, those who were not homeless, those who resided with their children, those who had public health insurance, and those who had not used residential treatment were significantly more likely to have stayed in MMT for at least 1 year or more. In contrast, those who were younger, males, homeless, did not live with children, had no insurance, and had used residential treatment were significantly more likely to have stayed in MMT for 6 months or less compared with their counterparts. Those who stayed in MMT for 1 year or more were more likely to have stable lives compared with those who dropped out of MMT before a year. Providing services to improve MMT clients' employment, housing, and family stability may help improve MMT retention rates. Second, clients with a history of having used residential substance abuse treatment were more likely to stay in MMT for a shorter time period compared with their counterparts. The extent to which treatment bifurcation is a matter of choice or related to other factors needs to be further explored.
To assess retention in methadone maintenance treatment for prescription-type opioid primary (PTOP) users compared to heroin users.
A retrospective cohort study was carried out to examine the association between opiate types used on 12-month retention. The study population consisted of adults admitted to one of 11 not-for-profit methadone maintenance clinics in 2004 and 2005 throughout Washington State (n = 2308). Logistic regression analyses with fixed effects for treatment agencies were conducted.
Opiate use type in past 30 days: any heroin use or primary prescription opioid without heroin use. Demographics, other drugs used, self-reported medical and psychiatric concerns, social, familial and legal issues, public assistance type and housing stability were documented at intake using a comprehensive biopsychosocial instrument, the Treatment and Assessment Reports Generation Tool.
The odds of being retained in treatment for PTOP compared to heroin users not adjusting for other factors was 1.33 (95% confidence interval [CI], 1.03, 1.71). In the final logistic regression model the odds of retention for PTOP compared to heroin users was 1.25 (95% CI, 0.93, 1.67), indicating that there was no statistically significant difference in treatment retention by opiate type after adjusting for demographics, treatment agencies, other drug use, public assistance type, medical, psychiatric, social, legal and familial factors.
The findings of this study suggest that PTOP can be treated at methadone maintenance treatment facilities at least as effectively as heroin users in terms of treatment retention.
This study examined temporal relationships between relative onsets of mental illness and homelessness in a cross-sectional study of 900 homeless people compared with a matched, never-homeless sample from the Epidemiologic Catchment Area study. All psychiatric disorders preceded homelessness in the majority. Only one disorder, alcohol use disorder (in men only), had significantly earlier onset in homeless subjects. Regarding number of symptoms or earlier age of onset of psychiatric disorders, earlier onset of homelessness was associated with several diagnoses: schizophrenia, major depression, generalized anxiety disorder, alcohol and drug use disorders, and antisocial personality. In multiple regression models, history of dysfunctional family background and maternal psychiatric illness were also associated with earlier onset of homelessness, whereas education was protective. Chronicity of homelessness was associated with number of symptoms of alcohol use disorder and earlier age of onset of drug use disorder, presence and number of symptoms of schizophrenia and antisocial personality, and earlier onset of major depression and conduct disorder. In multiple regression models, more education, but not family background problems, was associated with shorter lifetime duration of homelessness. These findings provide information relevant to the roles of mental illness and personal vulnerability factors in the onset and chronicity of homelessness.
To determine predictors of injection drug use cessation and subsequent relapse among a cohort of injection drug users (IDUs).
IDUs in Baltimore, MD were recruited through community outreach in 1988-1989. Among IDUs with at least three follow-up visits, parametric survival models for time to injection cessation (>or=6 months) and subsequent relapse were constructed.
Of 1327 IDUs, 94.8% were African American, 77.2% were male, median age was 34 years, and 37.7% were HIV-infected. Among 936 (70.5%) subjects who ceased injection, median time from baseline to cessation was 4.0 years. Three-quarters subsequently resumed injection drug use, among whom median time to relapse was 1.0 year. Factors independently associated with a shorter time to cessation were: age <30 years, stable housing, HIV seropositivity, methadone maintenance treatment, detoxification, abstinence from cigarettes and alcohol, injecting less than daily, not injecting heroin and cocaine together, and not having an IDU sex partner. Factors independently associated with shorter time to injection relapse were male gender, homelessness, HIV seropositivity, use of alcohol, cigarettes, non-injection cocaine, sexual abstinence and having a longer time to the first cessation.
This study provides strong support for targeting cessation efforts among young IDUs and severely dependent, unstably housed, and HIV-infected individuals.
Longitudinal predictors of injection cessation and subsequent relapse among a cohort of injection drug users in
- N G Shah
- N Galai
- D D Celentano
Shah NG, Galai N, Celentano DD, et al. : Longitudinal predictors of injection cessation and
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