Divergent trends in accidental deaths since return from an Afghanistan/Iraq deployment among army soldiers.

PURPOSE: Accidental death is a leading cause of mortality among military members and Veterans; however, knowledge is limited regarding time-dependent risk following deployment and if there are differences by type of accidental death. METHODS: Longitudinal cohort study (N = 860,930) of soldiers returning from Afghanistan/Iraq deployments in fiscal years 2008-2014. Accidental deaths (i.e., motor vehicle accidents [MVA], accidental overdose, other accidental deaths), were identified through 2018. Crude and age-adjusted mortality rates, rate ratios, time-dependent hazard rates and trends postdeployment were compared across demographic and military characteristics. RESULTS: During the postdeployment observation period, over one-third of deaths were accidental; most were MVA (46.0 %) or overdoses (37.9 %). Across accidental mortality categories (all, MVA, overdose), younger soldiers (18-24, 25-29) were at higher risk compared to older soldiers (40+), and females at lower risk than males. MVA death rates were highest immediately postdeployment, with a significant decreasing hazard rate over time (annual percent change [APC]: -6.5 %). Conversely, accidental overdose death rates were lowest immediately following deployment, with a significant increasing hazard rate over time (APC: 9.9 %). CONCLUSIONS: Observed divergent trends in risk for the most common types of accidental deaths provide essential information to inform prevention and intervention planning for the immediate postdeployment transition and long-term.

Opioid Prescription Clusters Associated With Early or Unplanned Military Separation.

INTRODUCTION: Early/unplanned military separation in Active Component U.S. service members can result in reduced readiness during periods of high-tempo combat and increased demand for health care services within the Military Health System and Veterans Administration. Although current assessment tools leverage prescription data to determine deployment-limiting medication receipt and the need for interventions or waivers, there is a lack of understanding regarding opioid prescription patterns and subsequent early/unplanned military separation after return from deployment. As such, understanding these relationships could support future tool development and strategic resourcing. Therefore, the goal of the present study was to identify unique 12-month opioid prescription patterns and evaluate their relationship with early/unplanned military separation in Active Component service members who returned from deployment. MATERIALS AND METHODS: This retrospective, IRB-approved cohort study included data from 137,654 Active Component Army service members who returned from deployment between 2007 and 2013, received a post-deployment (index) opioid prescription, and had at least 1 year of Active Component service post-opioid initiation. A k-means clustering analysis identified clusters using opioid prescription frequency, median dose, median days supply, and prescription breaks (≥30 days) over the 12-month post-initiation (monitoring) period. A generalized additive model examined whether cluster membership and additional covariates were associated with early/unplanned separation. RESULTS: In addition to the single opioid prescription (38%), the cluster analysis identified five clusters: brief/moderate dose (25%), recurrent breaks (16%), brief/high dose (11%), long/few prescriptions (8%), and high prescription frequency (2%). In the generalized additive model, the probability of early/unplanned military separation was higher for the high prescription frequency cluster (74%), followed by recurrent breaks (45%), long/few prescriptions (37%), brief/moderate dose (30%), and brief/high dose (29%) clusters, relative to the single prescription (21%) cluster. The probability of early/unplanned separation was significantly higher for service members with documented substance use disorders, mental health conditions, or traumatic brain injuries during the monitoring periods. Service members assigned male were more likely to have an early/unplanned separation relative to service members assigned female. Latinx service members and service members whose race was listed as Other were less likely to experience early/unplanned separation relative to white service members. Relative to Junior Officers, Junior Enlisted and Senior Enlisted service members were more likely to experience early/unplanned separation, but Senior Officers were less likely. CONCLUSIONS: Further evaluation to support the integration of longitudinal opioid prescription patterns into existing tools (e.g., a screening tool for deployment-limiting prescriptions) may enable more timely intervention and support service delivery to mitigate the probability and impact of early/unplanned separation.

Healthcare utilization and readiness outcomes among soldiers with post-deployment at-risk drinking, by multimorbidity class.

Although alcohol use disorder (AUD) regularly co-occurs with other conditions, there has not been investigation of specific multimorbidity classes among military members with at-risk alcohol use. We used latent class analysis (LCA) to cluster 138,929 soldiers with post-deployment at-risk drinking based on their co-occurring psychological and physical health conditions and indicators of alcohol severity. We examined the association of these multimorbidity classes with healthcare utilization and military readiness outcomes. Latent class analysis was conducted on 31 dichotomous indicators capturing alcohol use severity, mental health screens, psychological and physical health diagnoses, and tobacco use. Longitudinal survival analysis was used to examine the relative hazards of class membership regarding healthcare utilization (e.g., emergency department visit, inpatient stay) and readiness outcomes (e.g., early separation for misconduct). Latent class analysis identified five classes: Class 1 -Relatively Healthy (51.6 %); Class 2 - Pain/Tobacco (17.3 %); Class 3 - Heavy Drinking/Pain/Tobacco (13.1 %); Class 4 - Mental Health/Pain/Tobacco (12.7 %); and Class 5 - Heavy Drinking/Mental Health/Pain/Tobacco (5.4 %). Musculoskeletal pain and tobacco use were prevalent in all classes, though highest in Classes 2, 4, and 5. Classes 4 and 5 had the highest hazards of all outcomes. Class 5 generally exhibited slightly higher hazards of all outcomes than Class 4, demonstrating the exacerbation of risk among those with heavy drinking/AUD in combination with mental health conditions and other multimorbidity. This study provides new information about the most common multimorbidity presentations of at-risk drinkers in the military so that targeted, individualized care may be employed. Future research is needed to determine whether tailored prevention and treatment approaches for soldiers in different multimorbidity classes is associated with improved outcomes.

Clinician approaches to new spine pain cases in primary care: Balance of opioid prescribing and early linkage to exercise therapy and spinal manipulation.

RATIONALE, AIMS AND OBJECTIVES: Spine pain (SP) is common and often disabling. Clinical practice guidelines discourage opioid treatment and outline the value of varied nonpharmacologic therapies (NPTs). This study elucidates the amount of variability in primary-care clinicians' (PCPs') prescribing of opioids and in their cases' receipt of the two most common NPTs (exercise therapy and spinal manipulation). METHOD: The design was a retrospective cohort study examining variation in the treatment of PCPs' new SP cases, classified by receipt of (a) prescription of an opioid at the initial visit; (b) exercise therapy and/or spinal manipulation within 30 days of initial visit. The study was set in the primary care clinics at military treatment facilities of the US Military Health System in the period between October 2011 and September 2016. RESULTS: The majority of cases did not receive a study treatment (66.3%); 19.6% of cases received only NPT within 30 days of initial visit; 11.5% were prescribed only an opioid at the initial visit with receipt of both NPT and opioid during early treatment rare (2.6%). Exercise therapy within 30 days exhibited more than a twofold difference in interquartile percentile rates (IQR) (median provision 15.8%, IQR 9.8%-22.1%). The other treatments exhibited even greater variation; specifically, spinal manipulation (median 8.5%, IQR 3.3%-15.8%), and opioid at initial visit (median 10.3%, IQR 4.4%-18.2%). The availability of physical therapists and doctors of chiropractic had significant association with several clinical provision rates. CONCLUSION: Among providers of spine care for a sample of Army soldiers, there was substantial variation in the early provision of exercise therapy, spinal manipulation, and opioid prescriptions. The magnitude of the case-mix adjusted variation and its association with facility availability of providers suggests that quality of care initiatives may help reduce this variation.

Associations of Military-Related Traumatic Brain Injury With New-Onset Mental Health Conditions and Suicide Risk.

Importance: Research to identify the direct and indirect associations of military-related traumatic brain injury (TBI) with suicide has been complicated by a range of data-related challenges. Objective: To identify differences in rates of new-onset mental health conditions (ie, anxiety, mood, posttraumatic stress, adjustment, alcohol use, and substance use disorders) among soldiers with and without a history of military-related TBI and to explore the direct and indirect (through new-onset mental health disorders) associations of TBI with suicide. Design, Setting, and Participants: This retrospective cohort study used data from the Substance Use and Psychological Injury Combat Study (SUPIC) database. Demographic, military, and health data from the Department of Defense within SUPIC were compiled and linked with National Death Index records to identify deaths by suicide. Participants included US Army soldiers who returned from an Afghanistan or Iraq deployment. Data were analyzed from September to December 2022. Exposures: Military-related TBI. Main Outcomes and Measures: The outcome of interest was suicide. Secondary outcomes were incidence of new-onset mental health conditions. Mediation analyses consisted of accelerated failure time (AFT) models in conjunction with the product of coefficients method. The 6 new-onset mental health diagnosis categories and the 2 or more categories variable were each considered separately as potential mediators; therefore, a total of 14 models plus the overall AFT model estimating the total effect associated with TBI in suicide risk were fit. Results: The study included 860 892 soldiers (320 539 soldiers [37.2%] aged 18-24 at end of index deployment; 766 454 [89.0%] male), with 108 785 soldiers (12.6%) with at least 1 documented TBI on their military health record. Larger increases in mental health diagnoses were observed for all conditions from before to after documented TBI, compared with the matched dates for those without a history of TBI, with increases observed for mood (67.7% vs 37.5%) and substance use (100% vs 14.5%). Time-to-suicide direct effect estimates for soldiers with a history of TBI were similar across mediators. For example, considering new-onset adjustment disorders, time-to-suicide was 16.7% faster (deceleration factor, 0.833; 95% CI, 0.756-0.912) than for soldiers without a history of TBI. Indirect effect estimates of associations with TBI were substantial and varied across mediators. The largest indirect effect estimate was observed through the association with new-onset substance use disorder, with a time to suicide 63.8% faster (deceleration factor, 0.372; 95% CI, 0.322-0.433) for soldiers with a history of TBI. Conclusions and Relevance: In this longitudinal cohort study of soldiers, rates of new-onset mental health conditions were higher among individuals with a history of TBI compared with those without. Moreover, risk for suicide was both directly and indirectly associated with history of TBI. These findings suggest that increased efforts are needed to conceptualize the accumulation of risk associated with multiple military-related exposures and identify evidence-based interventions that address mechanisms associated with frequently co-occurring conditions.

Trends in suicide rates by race and ethnicity among members of the United States Army.

Efforts were focused on identifying differences in suicide rates and time-dependent hazard rate trends, overall and within age groups, by race and ethnicity among United States Army members who returned from an index deployment (October 2007 to September 2014). This retrospective cohort study was conducted using an existing longitudinal database, the Substance Use and Psychological Injury Combat Study (SUPIC). Demographic (e.g., race and ethnicity) and military data from the Department of Defense compiled within SUPIC, as well as Department of Veterans Affairs data were linked with National Death Index records (through 2018) to identify deaths by suicide including those that occurred after military service. The cohort included 860,930 Army Service members (Active Duty, National Guard, and Reserve). Age-adjusted (using the direct standardization method) and age-specific suicide rates per 100,000 person years were calculated and rate ratios (RR) were used for comparisons. Trends were evaluated using hazard rates over time since the end of individuals' index deployments. Among those aged 18-29 at the end of their index deployment, the suicide rate for American Indian/Alaskan Native (AI/AN) individuals was 1.51 times higher (95% confidence interval [CI]: 1.03, 2.14) compared to White non-Hispanic individuals (WNH), and lower for Hispanic and Black non-Hispanic (BNH) than for WNH individuals (RR = 0.65 [95% CI: 0.55, 0.77] and RR = 0.71 [95% CI: 0.61, 0.82], respectively). However, analyses revealed increasing trends in hazard rates post-deployment (≤ 6.5 years) within groups of Hispanic and BNH individuals (Average Annual Percent Change [APC]: 12.1% [95% CI: 1.3%, 24.1%] and 11.4% [95% CI: 6.9%, 16.0%], respectively) with a smaller, increase for WNH individuals (APC: 3.1%; 95% CI: 0.1%, 6.1%). Findings highlight key subgroups at risk for post-deployment suicide (i.e., WNH, AI/AN and younger individuals), as well as heterogeneous trends overtime, with rates and trends varying within race and ethnic groups by age groups. Post-deployment suicide prevention efforts that address culturally relevant factors and social determinants of health associated with health inequities are needed.

Time-dependent suicide rates among Army soldiers returning from an Afghanistan/Iraq deployment, by military rank and component.

BACKGROUND: To date, knowledge is limited regarding time-dependent suicide risk in the years following return from deployment and whether such rates vary by military rank (i.e., enlisted, officer) or component (i.e., active duty, National Guard, reserve). To address these gaps in knowledge, the objectives of this study were to determine and compare postdeployment suicide rates and trends (percent change over time), and hazard rates for Army soldiers, by rank and component (measured at the end of the deployment). METHODS: Longitudinal cohort study of 860,930 Army soldiers returning from Afghanistan/Iraq deployment in fiscal years 2008-2014 from the Substance Use and Psychological Injury Combat study. Death by suicide was observed from the end of the first deployment in the study period through 2018 (i.e., the most recently available mortality data) for up to 11 years of follow-up. Analyses were conducted in 2021-2022. RESULTS: Adjusting for age, lowest-ranking Junior Enlisted (E1-E4) soldiers had a suicide rate 1.58 times higher than Senior Enlisted (E5-E9)/Warrant Officers (95% CI [1.24, 2.01]) and 2.41 times higher than Officers (95% CI [1.78, 3.29]). Suicide rates among lower-ranking enlisted soldiers remained elevated for 11 years postdeployment. Overall and annual postdeployment suicide rates did not differ significantly across components. Comparisons across rank and component for females were generally consistent with the full cohort results. CONCLUSIONS: Lower-ranking enlisted soldiers had the highest rate of suicide, underscoring the importance of understanding rank as it relates to social determinants of health. For over a decade following Afghanistan/Iraq deployment, lower-enlisted rank during deployment was associated with an elevated rate of suicide; thereby suggesting that postdeployment prevention interventions targeting lower-ranking military members are warranted.

The relationship between capacity and utilization of nonpharmacologic therapies in the US Military Health System.

BACKGROUND: Nonpharmacologic therapies (NPTs) are recommended as first-line treatments for pain, however the impact of expanding professional capacity to deliver these therapies on use has not been extensively studied. We sought to examine whether an effort by the US Military Health System (MHS) to improve access to NPTs by expanding professional capacity increased NPT utilization in a cohort at higher risk for pain - Army soldiers returning from deployment. METHODS: Our study involved secondary analysis of MHS workforce data derived from the Defense Medical Human Resources System Internet (DMHRSi), and healthcare utilization data obtained from two ambulatory record systems of the Military Health System (MHS) for a sample of 863,855 Army soldiers previously deployed to Iraq or Afghanistan over a 10-year period (2008-2017). We measured clinical provider capacity in three occupational groups responsible for pain management at 130 military treatment facilities (MTFs): physical therapy, chiropractic, and behavioral health, measured annually as full-time equivalence per 100,000 patients served at each MTF. Utilization in both direct and purchased care settings was measured as annual mean NPT users per 1000 sample members and mean encounters per NPT user. Generalized estimating equation models estimated the associations of facility-level occupational capacity measures and facility-level utilization NPT measures. RESULTS: In 2008, nearly all MTFs had some physical therapist and behavioral health provider capacity, but less than half had any chiropractor capacity. The largest increase in capacity from 2008 to 2017 was for chiropractors (89%) followed by behavioral health providers (77%) and physical therapists (37%). Models indicated that increased capacity of physical therapists and chiropractors were associated with significantly increased utilization of six out of seven NPTs. Acupuncture initiation was associated with capacity increases in each occupation. Increased professional capacity in MTFs was associated with limited but positive effects on NPT utilization in purchased care. CONCLUSIONS: Increasing occupational capacity in three professions responsible for delivering NPTs at MTFs were associated with growing utilization of seven NPTs in this Army sample. Despite increasing capacity in MTFs, some positive associations between MTF capacity and purchased care utilization suggest an unmet need for NPTs. Future research should examine if these changes lead to greater receipt of guideline-concordant pain management.

Dose of Exercise Therapy Among Active Duty Soldiers With Chronic Pain Is Associated With Lower Risk of Long-Term Adverse Outcomes After Linking to the Veterans Health Administration.

INTRODUCTION: Research in soldiers who had been deployed to Iraq or Afghanistan suggests that nonpharmacological treatments may be protective against adverse outcomes. However, the degree to which exercise therapy received in the U.S. Military Health System (MHS) among soldiers with chronic pain is associated with adverse outcomes after soldiers transition to the Veterans Health Administration (VHA) is unclear. The objective of this study was to determine if exercise therapy received in the MHS among soldiers with chronic pain is associated with long-term adverse outcomes after military separation and enrollment into the VHA and whether this association is moderated by prescription opioid use before starting exercise therapy. MATERIALS AND METHODS: We conducted a longitudinal cohort study of electronic medical records of active duty Army soldiers with documented chronic pain after an index deployment to Iraq or Afghanistan (years 2008-2014) who subsequently enrolled in the VHA (N = 93,967). Coarsened exact matching matched 37,310 soldiers who received exercise therapy and 28,947 soldiers who did not receive exercise therapy in the MHS. Weighted multivariable Cox proportional hazard models tested for differences in adverse outcomes between groups with different exercise therapy exposure vs. no exercise therapy.Exercise therapy was identified by procedure codes on ambulatory records in the MHS and expressed as the number of exercise therapy visits in 1 year after the first diagnosis with a chronic pain condition. The number of visits was then stratified into seven dose groups.The primary outcomes were weighted proportional hazards for: (1) alcohol and drug disorders, (2) suicide ideation, (3) intentional self-injury, and (4) all-cause mortality. Outcomes were determined based on ICD-9 and ICD-10 diagnoses recorded in VHA healthcare records from enrollment till September 30, 2020. RESULTS: Our main analysis indicated significantly lower hazard ratios (HRs) for all adverse outcomes except intentional self-injury, for soldiers with at least eight visits for exercise therapy, compared to soldiers who received no exercise therapy. In the proportional hazard model for any adverse outcome, the HR was 0.91 (95% CI 0.84-0.99) for soldiers with eight or nine exercise therapy visits and 0.91 (95% CI 0.86-0.96) for soldiers with more than nine visits. Significant exercise therapy × prior opioid prescription interactions were observed. In the group that was prescribed opioids before starting exercise therapy, significantly lower HRs were observed for soldiers with more than nine exercise therapy visits, compared to soldiers who received no exercise therapy, for alcohol and drug disorders (HR = 0.85, 95% CI 0.77-0.92), suicide ideation (HR = 0.77, 95% CI 0.66-0.91), and for self-injury (HR = 0.58, 95% CI 0.41-0.83). CONCLUSIONS: Exercise therapy should be considered in the multimodal treatment of chronic pain, especially when pain is being managed with opioids, as it may lower the risk of serious adverse outcomes associated with chronic pain and opioid use. Our findings may generalize only to those active duty soldiers with chronic pain who enroll into VHA after separating from the military.

Adverse childhood experiences are associated with increased overdose risk in predominately Latinx adults seeking treatment for substance use disorders.

Introduction: Almost no previous studies explored the relationship between adverse childhood experiences (ACEs) and overdose risk for individuals with substance use disorders (SUDs), and these did not focus on a Latinx population. This study examined the relationship between ACEs, reporting PTSD symptoms, and lifetime experience of overdose in a sample (n = 149) of primarily Latinx adults seeking treatment for substance use disorder (SUD). Materials and methods: Administrative data from an integrated behavioral health and primary care treatment system in Massachusetts were analyzed through bivariate analyses and multiple logistic regression. The final model examined the association between self-reported ACEs, PTSD screen, and lifetime drug overdose. We controlled for demographic characteristics and heroin use and explored alternative measure specifications. Results: ACEs scores were high with 58% having experienced 4+ ACEs. Female gender was associated with a 24% higher ACE score than male gender (p < 0.01). In the multiple logistic model each additional ACE was associated with 1.3 times greater odds of overdose (p < 0.01). Those reporting heroin use had 8.8 times greater odds of reporting overdose compared to those reporting no heroin use (p < 0.001). Gender, age, Puerto Rican ethnicity, years of cocaine use, receiving public assistance income, and a positive initial PTSD screen were not significant. Findings were robust in sensitivity testing. Discussion and conclusion: We found the number of ACEs and reported heroin use significantly and positively associated with self-report of overdose in both bivariate and multiple logistic regression analyses. In contrast, a positive initial screen for PTSD was only significantly associated with overdose in the bivariate analysis. Increased screening for ACEs is warranted and ACE-specific treatment is suggested for SUD treatment programs offering trauma-informed services for adults.

Association between 1-year patient outcomes and opioid-prescribing group of emergency department clinicians: A cohort study with Army active-duty soldiers.

OBJECTIVE: The objective was to examine the association between clinicians' opioid prescribing group and patients' outcomes among patients treated in the emergency department (ED). METHODS: This was a retrospective cohort study. The setting was the EDs of the U.S. Military Health System (MHS). Patients were 181,557 Army active-duty opioid-naïve (no fill in past 180 days) patients with an index encounter to the ED between October 2010 and September 2016. Exposure was patients classified by opioid prescribing tier of the treating ED clinician: top, middle, or bottom third relative to the clinician's peers in the same ED. Follow-up measurement was from 31 to 365 days after the index encounter. The primary outcome was long-term opioid prescriptions (LTOPs) defined as 180 (or more) days' supply within the follow-up window. We also computed the total morphine milligram equivalents (MME) and total opioid days' supply. Secondary measures were any repeat ED encounter, any hospitalization, any sick leave, and any military-duty restriction. RESULTS: We found a 2.5-fold variation in opioid prescribing rates among clinicians in the same MHS ED. Controlling for sample demographics, reason for encounter, and military background, in multivariate analyses the odds of receiving a 180-day opioid supply during follow-up were 1.19 (95% confidence interval [CI] = 1.01 to 1.40, p < 0.05) for the top opioid exposure group and 1.37 (95% CI = 1.19 to 1.57, p < 0.001) for the middle opioid exposure group compared to the bottom exposure group, and there were significant increases in total opioid days' supply and total MME. There were no differences in secondary outcome measures. CONCLUSION: In a relatively healthy sample of Army soldiers, variation in opioid exposure defined by clinician's prescribing history was associated with increased odds of LTOP and increase in opioid volume, but not in functional outcomes.

Predictors of Veterans Health Administration utilization and pain persistence among soldiers treated for postdeployment chronic pain in the Military Health System.

BACKGROUND: Chronic pain presents a significant burden for both federal health care systems designed to serve combat Veterans in the United States (i.e., the Military Health System [MHS] and Veterans Health Administration [VHA]), yet there have been few studies of Veterans with chronic pain that have integrated data from both systems of care. This study examined 1) health care utilization in VHA as an enrollee (i.e., linkage to VHA) after military separation among soldiers with postdeployment chronic pain identified in the MHS, and predictors of linkage, and 2) persistence of chronic pain among those utilizing the VHA. METHODS: Observational, longitudinal study of soldiers returning from a deployment in support of the Afghanistan/Iraq conflicts in fiscal years 2008-2014. The analytic sample included 138,206 active duty soldiers for whom linkage to VHA was determined through FY2019. A Cox proportional hazards model was estimated to examine the effects of demographic characteristics, military history, and MHS clinical characteristics on time to linkage to VHA after separation from the military. Among the subpopulation of soldiers who linked to VHA, we described whether they met criteria for chronic pain in the VHA and pain management treatments received during the first year in VHA. RESULTS: The majority (79%) of soldiers within the chronic pain cohort linked to VHA after military separation. Significant predictors of VHA linkage included: VHA utilization as a non-enrollee prior to military separation, separating for disability, mental health comorbidities, and being non-Hispanic Black or Hispanic. Soldiers that separated because of misconduct were less likely to link than other soldiers. Soldiers who received nonpharmacological treatments, opioids/tramadol, or mental health treatment in the MHS linked earlier to VHA than soldiers who did not receive these treatments. Among those who enrolled in VHA, during the first year after linking to the VHA, 49.7% of soldiers met criteria for persistent chronic pain in VHA. CONCLUSIONS: The vast majority of soldiers identified with chronic pain in the MHS utilized care within VHA after military separation. Careful coordination of pain management approaches across the MHS and VHA is required to optimize care for soldiers with chronic pain.

Do nonpharmacological services offset opioids in pain treatment for soldiers?

OBJECTIVE: To examine the relationships between nonpharmacological treatment (NPT) utilization and opioid prescriptions and doses and whether these relationships vary according to the type of NPT service received. DATA SOURCE: Secondary data from the US Military Health System, nationwide. STUDY DESIGN: Patterns of NPT utilization and opioid prescriptions were analyzed over the 23 months after initial pain treatment (index visit). Regression models were used to examine the relationship between opioid prescription use in a given month and NPT service utilization in the three preceding months, using person fixed effects to control for time-invariant patient characteristics, as well as time fixed effects. Analyses were stratified by whether the patient filled an opioid prescription in the first 30 days post index visit. DATA EXTRACTION METHODS: Administrative data on health care utilization were extracted from the US Military Health System Data Repository for Army service members who returned from deployments in Afghanistan and Iraq that ended in fiscal years 2008 to 2014 and had at least one outpatient visit with a primary diagnosis of musculoskeletal pain in the subsequent year. PRINCIPAL FINDINGS: Utilization of any NPT service in the past 3 months was positively associated with filling an opioid prescription in the given month, regardless of whether the patient was initially prescribed opioids (percentage point difference [PP] =2.87, P < 0.01) or not (PP = 0.83, P < 0.01). However, for those not initially prescribed opioids, use of any NPT service in the past 3 months was negatively associated with mean daily opioid dose in the given month (morphine milligram equivalent dose = -0.4017, P < 0.01). For those initially prescribed opioids, NPT was not associated with opioid dose. CONCLUSIONS: NPT only reduced the prescription opioid daily dose for some patients, whereas the probability of receiving an opioid prescription was positively associated with NPT. Future research should assess whether recent system-level policies and program changes influence referral and opioid prescribing patterns.

The association of engagement in substance use treatment with negative separation from the military among soldiers with post-deployment alcohol use disorder.

BACKGROUND: Alcohol use disorder (AUD) reduces the health of soldiers and the readiness of the Armed Forces. It remains unknown if engagement in substance use treatment in the Military Health System improves retention in the military. METHODS: The sample consisted of active duty soldiers returning from an Afghanistan/Iraq deployment in fiscal years 2008-2010 who received an AUD diagnosis within 150 days of completing a post-deployment health re-assessment survey (n = 4,726). A Heckman probit procedure was used to examine predictors of substance use treatment initiation and engagement in accordance with Healthcare Effectiveness Data and Information Set (HEDIS) criteria. Cox proportional hazard modeling was used to examine the association between treatment engagement and retention, defined as a negative separation for a non-routine cause (e.g., separation due to misconduct, poor performance, disability) from the military in the two years following the index AUD diagnosis. RESULTS: 40 % of soldiers meeting HEDIS AUD criteria initiated and 24 % engaged in substance use treatment. Among soldiers diagnosed with AUD, meeting criteria for treatment engagement was associated with a significantly higher hazard of having a negative separation compared to soldiers who did not engage in treatment. CONCLUSIONS: Rates of initiation and engagement in substance use treatment for post-deployment AUD were relatively low. Soldiers with AUD who engaged in substance use treatment were more likely to have a negative separation from the military than soldiers with AUD who did not engage. Our findings imply that in the study cohort, treatment did not mitigate negative career consequences of AUD.

Opioid and Nonpharmacologic Treatments Among Soldiers With Chronic Pain and Posttraumatic Stress Disorder.

OBJECTIVE: This study examined the prevalence of chronic pain alone, posttraumatic stress disorder (PTSD) alone, and both chronic pain and PTSD among U.S. Army soldiers during the postdeployment year. METHODS: The sample was 576,425 active duty soldiers returning from deployment in Afghanistan or Iraq between October 1, 2008, and September 30, 2014. Bivariate statistics were used to compare health care utilization among subgroups. Multivariate logistic regression with additional covariates was used to identify predictors of receiving an opioid days' supply of >30 days in the postdeployment year among soldiers with chronic pain, focusing on the effect of PTSD alone and on an interaction of PTSD with nonpharmacologic treatments (including therapeutic exercise, chiropractic treatment, acupuncture, and biofeedback). RESULTS: In total, 12.2% of the soldiers received a chronic pain diagnosis, 5.1% a PTSD diagnosis, and 1.8% had both. Among soldiers with both conditions, 80.3% received nonpharmacologic treatment, and 31.4% received an opioid days' supply of >30 days. Among soldiers with chronic pain, comorbid PTSD and lack of nonpharmacologic treatment was associated with increased odds of receiving an opioid days' supply of >30 days (odds ratio [OR]=1.4, 95% confidence interval [CI]=1.3-1.6). PTSD combined with specific nonpharmacologic treatment modalities had a variable relationship with opioid receipt, and only PTSD with acupuncture or biofeedback was associated with reduced odds (OR=0.8, 95% CI=0.7-0.9). CONCLUSIONS: Soldiers having both chronic pain and PTSD have significant health care needs. Although these soldiers accessed mental health care and received nonpharmacologic treatment, additional interventions are needed to mitigate protracted opioid utilization.

Opioid prescribing for surgical dental procedures in dental clinics of military treatment facilities.

BACKGROUND: Variation in opioid prescribing rates among geographic regions is well known and, to the authors' knowledge, there have been no studies of variation from 1 dental clinic to another, and such variation might suggest an excess of opioid prescriptions. METHODS: The authors used a retrospective cohort design study of all dental encounter records for 819,453 soldiers in the dental clinics (n = 250) of the US Military Health System during the period from 2008 through 2017. RESULTS: There were 743,459 dental surgical encounters. Opioid prescriptions were filled for 36.7% of these encounters. Multinomial multilevel regression found statistically significant between-facility variance in opioid prescribing, which was partially explained via facility-level characteristics (region, type, and percentage of surgeries for young patients), and practice variables (mean percentage extractions, percentage periodontic surgery, and percentage specialists). CONCLUSIONS: The authors found a substantial variation in opioid prescribing among dental clinics in the US Military Health System. Dentists at 11 of the 30 largest military treatment facilities prescribed at a rate 4 percentage points higher than expected, and dentists at 9 of these military treatment facilities had a rate of 4 percentage points lower than expected. Additional study of the factors allowing the low-prescribing facilities to achieve these rates might lead to an overall decrease in opioid prescribing. PRACTICAL IMPLICATIONS: The authors' findings of dental opioid prescribing in the military can lead to appreciation of the guidelines from the American Dental Association and the American Association of Oral and Maxillofacial Surgeons, which suggest alternatives to opioid prescribing for surgical procedures, particularly for tooth extractions.

Assessing the postdeployment quality of treatment for substance use disorders among Army enlisted soldiers in the Military Health System.

Little is known about the rates and predictors of substance use treatment received in the Military Health System among Army soldiers diagnosed with a postdeployment substance use disorder (SUD). We used data from the Substance Use and Psychological Injury Combat study to determine the proportion of active duty (n = 338,708) and National Guard/Reserve (n = 178,801) enlisted soldiers returning from an Afghanistan/Iraq deployment in fiscal years 2008 to 2011 who had an SUD diagnosis in the first 150 days postdeployment. Among soldiers diagnosed with an SUD, we examined the rates and predictors of substance use treatment initiation and engagement according to the Healthcare Effectiveness Data and Information Set criteria. In the first 150 days postdeployment 3.3% of active duty soldiers and 1.0% of National Guard/Reserve soldiers were diagnosed with an SUD. Active duty soldiers were more likely to initiate and engage in substance use treatment than National Guard/Reserve soldiers, yet overall, engagement rates were low (25.0% and 15.7%, respectively). Soldiers were more likely to engage in treatment if they received their index diagnosis in a specialty behavioral health setting. Efforts to improve substance use treatment in the Military Health System should include initiatives to more accurately identify soldiers with undiagnosed SUD. Suggestions to improve substance use treatment engagement in the Military Health System will be discussed.