Relationships between insomnia and alcohol and cocaine use frequency with aggression among veterans engaged in substance use treatment.

BACKGROUND: Veterans with substance use problems have rates of partner and non-partner violence that typically exceed the general population. Sleep problems may exacerbate violence and maintain addictive behaviors in non-veterans, but requires study in veterans. Therefore, we examine the interrelationships between substance use, insomnia, and violence in veterans. METHODS: Veterans (N = 762) screened for a randomized controlled trial at veterans affairs mental health and substance use clinics. Participants completed modified Conflict Tactics Scales to quantify past-year violence and the Insomnia Symptom Questionnaire to assess sleep disturbance. We evaluated associations between substance use and sleep in predicting the target of aggression (partner or non-partner) and degree of violence (aggression or injury) using binomial logistic regressions. RESULTS: Half of participants endorsed symptoms suggestive of insomnia, 23.2% endorsed physical aggression toward partners (PA-P) and 33.9% non-partners (PA-NP), and 9.7% endorsed physical injury of partners (PI-P) and 17.6% of non-partners (PI-NP). Regressions revealed significant models for PA-P, PA-NP, and PI-NP, whereas the PI-P model was not significant. PA-P was higher among non-Caucasian race and older veterans. PA-NP was more common in those with insomnia and increased with frequency of cocaine use. Insomnia moderated the relationship between cocaine use and PA-NP; there was a weaker relationship between cocaine use and PA-NP in those with insomnia. PI-NP was more common with higher frequency of alcohol and cocaine use, and in those with insomnia. CONCLUSIONS: This study finds sleep disturbances are meaningful predictors of violence among veterans with differential relationships with aggression severity, victims, and substance use concurrence.

A randomized controlled trial for aggression and substance use involvement among Veterans: Impact of combining Motivational Interviewing, Cognitive Behavioral Treatment and telephone-based Continuing Care.

Physical aggression (towards partners or non-partners) is common among patients in treatment for substance use disorders (SUDs), including among Veteran samples; however, few treatment programs provide adjunct intervention approaches targeting reduction or prevention of aggression. The primary objectives of this comparative efficacy study were to examine the impact of adjunct aggression interventions delivered during treatment on aggression and substance use outcomes, including: a) an acute treatment phase 6-session integrated Motivational Interviewing-Cognitive Behavioral Treatment intervention (MI-CBT) for aggression and substance use prevention, b) MI-CBT plus a 12-week telephone-based Continuing Care (MI-CBT + CC) intervention, and c) an acute phase single session control condition [including some discussion of violence prevention and local violence prevention resources (Enhanced Treatment as Usual (E-TAU))]. Participants (N = 180; 165 males and 15 females) were Veterans with SUD problems and past-year severe aggression who were randomized to one of three conditions: MI-CBT, MI-CBT + CC, or E-TAU. Primary 12-month outcomes included physical aggression and injury to partners, non-partners, and total aggression (collapsing across partner and non-partner relationships). Substance use outcomes included heavy drinking, marijuana use, cocaine use, and overall illicit substance use. Due to low representation in the sample (n = 4 women in each group at follow-up), women were excluded from primary analyses. According to unadjusted analyses of male participants, all groups showed similar significant declines in aggression over time, with the MI-CBT and MI-CBT + CC groups showing significant reductions in more substance use outcomes (heavy drinking, cocaine use, overall illicit drug use) than the E-TAU group. The only significant group x time interaction was for partner physical aggression by men (those in the MI-CBT + CC group showed a significantly greater decrease from baseline to follow-up). Also, neither the MI-CBT nor MI-CBT + CC groups reported any injuring of partners during the follow-up. For heavy drinking, cocaine, marijuana and overall illicit drug use, there were significant reductions over time, but no group by time interaction effects. The findings illustrate significant reductions in aggression and substance use over time for those involved in VA SUD treatment, and a potential modest benefit of additional integrated treatment approaches (MI-CBT, MI-CBT + CC) on reducing aggression. Future studies should examine dissemination efforts in the VA, cost-effectiveness, and moderators of outcome.

Veterans with recent substance use and aggression: PTSD, substance use, and social network behaviors.

OBJECTIVE: Violence is a salient concern among veterans, yet relationships between psychiatric comorbidity, social networks, and aggression are poorly understood. We examined associations between biopsychosocial factors (substance use, posttraumatic stress disorder [PTSD], and social network behaviors) with aggression. METHOD: We recruited veterans endorsing past-year aggression and substance use (N = 180) from Department of Veterans Affairs outpatient treatment clinics. Main and interaction effects between probable PTSD, substance use, social network violence and substance use, and veteran violence were examined with negative binomial regressions-specifically, physical aggression toward a relationship partner (PA-P), physical injury of a partner (PI-P), physical aggression toward nonpartners (PA-NP), and physical injury of nonpartners (PI-NP). RESULTS: Alcohol use yielded consistent main effects. PTSD and social network violence demonstrated main effects for PA-NP and PI-NP. PTSD and social network violence interacted to predict PA-P such that social network violence appeared salient only in the context of PTSD. PTSD was associated with PI-P, PA-NP, and PI-NP in social network substance use models. In the PA-P model including social network substance use, veterans with PTSD reported greater PA-P in the context of greater social network substance use, whereas veterans without PTSD endorsed PA-P concurrent with greater alcohol frequency. For PI-P, PTSD interacted with alcohol to predict a greater likelihood of partner injury in the context of social network substance use. CONCLUSIONS: Investigated variables demonstrated unique associations within the context of specific relationships and the severity of behaviors. Overall, the findings underscore the importance of biopsychosocial models for understanding veteran violence. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Substance use consequences, mental health problems, and readiness to change among Veterans seeking substance use treatment.

Individuals seeking substance use treatment who have one or more co-occurring mental health problems tend to have lower treatment engagement, higher rates of attrition, and poorer treatment outcomes. Readiness to change (RTC) is an integral construct in the recovery process, with higher RTC associated with improved treatment outcomes. However, the impact of psychiatric symptoms on RTC is not fully understood, especially among specialty subpopulations, such as military Veterans. Therefore, the aim of the present study was to examine the associations of mental health problems with RTC in a sample of Veterans initiating outpatient substance use treatment. The present sample was comprised of 278 Veterans (12% women, Mage = 48.22, SD = 14.06) who completed self-report intake measures assessing past month substance use frequency, substance-related consequences, symptoms of insomnia, depression, and anxiety, and importance and confidence to change one's substance use. Four separate canonical correlation analyses focusing on RTC alcohol, opioid, cannabis, and nicotine use were conducted. Veterans' inclusion in each analysis was not mutually exclusive. Results indicated that greater depression, anxiety, consequences, and frequency of alcohol use corresponded with greater importance to change alcohol use. Likewise, greater depression, anxiety, and insomnia symptoms along with frequency of use and consequences related to greater importance and confidence to change one's opioid use. In contrast, greater anxiety, depression, insomnia, and frequency of use were associated with less confidence in one's ability to change cannabis use. None of these variables were related to one's RTC nicotine use. Findings highlight the importance of assessing mental health problems at outset of substance use treatment, as they may be an indication of RTC and could be used as a catalyst to advance Veterans forward in the process of behavior change.

A randomized clinical trial of motivational enhancement therapy for alcohol problems in partner violent men.

This study examined the efficacy of brief alcohol intervention in the context of community-based treatment for partner violence. In a randomized clinical trial, 228 partner-violent men with hazardous or problem drinking were recruited at three Intimate Partner Violence (IPV) treatment agencies and randomly assigned to receive one of two 4-session alcohol interventions: Motivational Enhancement Therapy (MET: N = 110) or Alcohol Education (AE: N = 118). After completing alcohol intervention, participants received standard agency counseling services for IPV. Participants completed assessments of alcohol use, drug use, and IPV at pre-treatment, post-alcohol intervention, and quarterly follow-ups for 12 months. At the end of the 4-session alcohol intervention, MET participants displayed greater acknowledgment of problems with alcohol than AE participants (Partial ή2 = 0.039, p = 0.006). Significant changes from baseline across treatment conditions (at p < 0.001) were observed for percent days of alcohol abstinence [95% empirical CI for Partial ή2 =0.226, 0.296], heavy drinking [0.292, 0.349], illicit drug use [0.096, 0.156] and partner violence [0.282, 0.334]. No significant condition differences (treatment by time interactions) were found for alcohol abstinence [95% empirical CI for Partial ή2 = 0.007, 0.036], heavy drinking [0.016, 0.055], illicit drug use [0.005, 0.035] or partner violence [0.001, 0.004]. Results encourage continued use of brief alcohol interventions in community IPV services, but do not provide evidence of a unique benefit of MET in reducing alcohol use in this population.

Characteristics and clinical treatment of tobacco smokers enrolled in a VA substance use disorders clinic.

Individuals with a substance use disorder (SUD) diagnosis are more than twice as likely to smoke cigarettes as the general population. Emerging research has suggested that treating a substance use disorder simultaneously with tobacco use leads to a higher rate of treatment success for both substances. Despite this, substance use treatment protocols tend not to focus on tobacco use; in fact, traditional substance use treatments often discourage patients from attempting to quit smoking. One rationale is that patients may not be motivated to quit smoking. In the current study, data from veterans enrolled in outpatient treatment for a SUD were examined to assess for general characteristics of smokers as compared to non-smokers as well as to examine motivation to quit smoking. Baseline (i.e., pre-treatment) data from 277 Veterans were used. Charts of smokers in the SUD clinic (SUDC) were reviewed to assess how smoking is handled by SUDC providers, and if smokers attempt cessation. Of 277, 163 (59%) SUDC patients reported that they currently smoke cigarettes (M=16.3 cigarettes per day, SD=11.1). Smokers in the clinic reported greater general impairment than nonsmokers on the Short Index of Problems, F(1248)=8.9, p=0.003, as well as greater specific impairment: Physical Problems, F(1258)=13.5, p=0.000; Interpersonal Problems, F(1262)=5.6, p=0.019; Intrapersonal Problems, F(1260)=6.5, p=0.011, and Social Responsibility, F(1262)=14.7, p=0.000. Smokers in the sample were marginally more anxious than their non-smoking counterparts as measured by the GAD-7, F(1254)=4.6, p=0.053, though they were not significantly more depressed (p=0.19). On a 1-10 scale, smokers reported moderate levels of importance (M=5.4, SD=3.1), readiness (M=5.6, SD=3.2), and confidence (M=5.0, SD=3.0) regarding quitting smoking. Review of smokers' medical records reveal that while SUDC providers assess tobacco use at intake (90%) and offer treatment (86.5%), a substantially small portion of smokers attempt cessation (41.1%) while enrolled in SUDC. Moreover, no patients were enrolled in smoking-specific behavioral interventions while in SUDC, though 78 patients did obtain nicotine replacement or another smoking cessation medication (41% were prescribed by a SUDC provider). Contrary to the belief that treatment-seeking substance users are not motivated to quit smoking, these preliminary analyses demonstrate that Veterans were at least contemplating quitting smoking while they were enrolled in substance use treatment. Further, there is evidence that cigarette smokers have greater impairment caused by substance use, suggesting that this subgroup is of particular high need. Specific treatment recommendations are discussed, including how behavioral health providers in SUD clinics may be better able to capitalize on patients' moderate motivation to quit at intake.

Binge-drinking and non-partner aggression are associated with gambling among Veterans with recent substance use in VA outpatient treatment.

BACKGROUND: Gambling is relatively under-assessed in Veterans Affairs (VA) substance use disorder (SUD) treatment settings, yet shared characteristics with substance addiction suggest the importance of understanding how gambling behaviors present in Veterans seeking SUD care. METHOD: We evaluated substance use, mental health, and violence-related correlates of past 30-day gambling among 833 Veterans (93% male, M age 48years, 72% Caucasian) seeking treatment in VA outpatient mental health and SUD clinics who completed screening for a randomized clinical trial. RESULTS: A total of 288 (35%) Veterans reported past 30-day gambling. Among those who gambled, 79% had cravings/urges to gamble, whereas between 20%-27% of gamblers reported perceived relationship, legal, and daily life problems related to gambling, as well as difficulty controlling gambling. A logistic regression analysis revealed that age, recent binge-drinking, and non-partner physical aggression were associated with recent gambling. CONCLUSIONS: Gambling was associated with binge-drinking and non-partner physical aggression, supporting potential shared characteristics among these behaviors such as impulsivity and risk-taking, which may complicate SUD treatment engagement and effectiveness. Findings support the need to screen for gambling in the VA, and to adapt treatments to include gambling as a potential behavioral target or relapse trigger, particularly among heavy drinking patients.

Dyadic Patterns of Intimate Partner Violence in Early Marriage.

OBJECTIVE: Research examining dyadic patterns of intimate partner violence (IPV) often focuses on static conceptions based on whether either the husband or wife has exhibited any violence. This study examined the dyadic patterns of IPV empirically and traced how these groups change over time. METHOD: Couples (N=634) were assessed with respect to IPV and relationship satisfaction at the time of marriage, and at their first and second anniversaries. Cluster analysis was conducted on Total Aggression, Differential Aggression, and the Aggression Ratio prior to marriage for couples with any violence. RESULTS: This analysis revealed 5 clusters; Very High-Husband to Wife, (High:H>W); Very High-Wife to Husband (High-W>H); Low to Moderate, Husband to Wife (Low:H>W); Low to Moderate, Wife to Husband (Low-W>H); Low to Moderate, Both Aggressive (Low:H=W). The majority (57%) of the aggressive couples were classified in the gender asymmetric groups. Most asymmetric clusters became symmetric over time, but the High:H>W cluster became more asymmetric. By the 2nd anniversary, all clusters were characterized by higher injuries experienced by wives than by husbands. CONCLUSION: These results demonstrate that a considerable amount of IPV that is typically classified as "bidirectional" is gender asymmetric and that these asymmetric patterns tend to converge into more symmetric patterns over time.

Inpatient hospitalization in addiction treatment for patients with a history of suicide attempt: a case of support for treatment performance measures.

This study attempts to validate substance use disorder (SUD) treatment performance measures (PM) in a naturalistic treatment setting. Despite its significance in healthcare systems and in SUD populations, suicidality is one patient characteristic that remains unexplored in the context of SUD PMs. The current study focused on the extent to which the care processes encouraged by SUD PMs were associated with improved outcomes in patients with a prior suicide attempt as compared to those without. We abstracted Addiction Severity Index and health services data from the VA medical record for 381 veterans who initiated outpatient SUD treatment and completed baseline intake measures at a Midwestern VA hospital. Cox proportional hazard regressions examined how baseline characteristics, prior suicide attempts, and PM status predicted the time until hospitalization for psychiatric or substance use problems. Prior suicide attempts significantly interacted with treatment engagement, and hospitalization risk was significantly higher among individuals with a prior suicide attempt who did not meet PMs. This study provides initial observational evidence that past suicide attempts may be a factor that should be considered when defining performance standards that influence the processes of SUD treatment. Future research on PMs should take into account the differences on indicators of high risk and poor treatment outcomes.

Outcome expectancies of partner abuse: assessing perpetrators' expectancies and their associations with readiness to change, abuse, and relevant problems.

Concerns about low motivation to change among perpetrators of intimate partner violence (IPV) have heightened interest employing behavior change models with this population. In the present investigation, a new scale was developed, the Outcome Expectancies for Partner Abuse (OEPA) Scale, assessing the negative and positive outcome expectancies of partner abuse. Items were generated from statements made by IPV offenders during videotaped group therapy sessions. Among a clinical sample of 130 IPV perpetrators, item psychometric properties, factor structure, and subscale validity were examined. Results indicated generally good psychometric properties and a 2-factor solution, with the exception of 4 items subsequently removed from the negative expectancies scale. Significant associations were demonstrated between instrument subscales, readiness to change, and self-reported abusive behavior. Additionally, positive expectancy scores correlated with anger problems and relationship adjustment whereas negative expectancy scores correlated with partner-reported IPV. Potential uses of the OEPA and future directions for psychometric research are discussed.

Treatment needs of men and women with violence problems in substance use disorder treatment.

This study examined treatment needs of men and women in substance use disorder (SUD) treatment. The sample (n = 489) was recruited between 2006 and 2007 from a Midwestern state in the United States, and participants were grouped based on injury occurring in partner and nonpartner relationships in the past year. Rates of injury across relationship types were alarming with over 54.8% reporting injuring another person and 55.4% reporting being injured. Overall, those injuring nonpartners or both partners/nonpartners had more severe problems. Implications of the findings for SUD treatment settings and a model for integrated violence prevention are discussed.

Psychological aggression, physical aggression, and injury in nonpartner relationships among men and women in treatment for substance-use disorders.

OBJECTIVE: This study focused on the prevalence and predictors of psychological aggression, physical aggression, and injury rates in nonintimate partner relationships in a substance-use disorder treatment sample. METHOD: The sample included 489 (76% men, 24% women) participants who completed screening measures for inclusion in a randomized control trial for an aggression-prevention treatment. Primary outcome measures included rates of past-year psychological aggression, physical aggression, and injury (both from the participant to nonpartners and from nonpartners to the participant). Potential predictors included individual factors (e.g., age, gender), developmental factors (e.g., family history of drug use, childhood physical abuse), and recent factors (e.g., depression, cocaine use). RESULTS: Rates of participant-to nonpartner psychological aggression (83%), physical aggression (61%), and injury (47%) were high, as were rates of nonpartner-to-participant aggression. Bivariate analyses revealed significant relationships between the aggression outcomes and most of the individual, developmental, and recent factors. However, multivariate analyses (zero-inflated Poisson regression) revealed that age, treatment status, current symptoms of depression, heavy periods of drinking, and cocaine use were related most frequently to the occurrence of aggression to and from nonpartners. CONCLUSIONS: Nonpartner aggression may be as common within a substance-use disorder sample as partner aggression, and it is associated with heavy drinking episodes, cocaine use, and depressive symptoms. The findings highlight the need for the development of effective violence interventions addressing violence in nonpartner relationship types.

ED visits by older adults for ambulatory care-sensitive and supply-sensitive conditions.

OBJECTIVES: The aim of this study was to examine the effect of advanced age on ED outcomes, including hospitalization for any reason, ambulatory care-sensitive hospitalizations (ACSHs), and supply-sensitive hospitalizations. METHODS: A secondary data analysis of the National Hospital Ambulatory Care Survey was conducted. National estimates of patient visits were obtained using available sampling weights from National Hospital Ambulatory Care Survey, and population estimates were calculated using estimates published by the US Census Bureau. RESULTS: Older adults made 48 million patient visits to ED between 2000 and 2002. Overall, 20.3% was for an ambulatory care-sensitive condition, yielding 5 million ACSH, whereas 62% was for a supply-sensitive condition, yielding 9.5 million supply-sensitive hospitalizations. Residents from nursing homes and patients aged 85 years or older were more likely to be hospitalized for any reason, for ACSH, and for supply-sensitive conditions. CONCLUSIONS: Further research is needed to understand how comorbidity contributes to increasing ED and hospital use among older adults.

Alcohol consumption and intimate partner violence by alcoholic men: comparing violent and nonviolent conflicts.

Alcoholic men and their relationship partners were interviewed about a conflict in which physical assault occurred and 1 in which psychological aggression occurred without physical assault. The interview assessed the quantity of alcohol consumed prior to each conflict, other drug use, and the topics, location, timing, duration, and speed of escalation for each conflict. The number of standard drinks consumed by the husband in the previous 12 hr was significantly higher prior to violent versus nonviolent conflicts for both self- and collateral reports, as was blood alcohol concentration estimated from self-report. Other drug use was not significantly different. Greater drinking by wives prior to violent conflicts was found in some analyses. These within-subject comparisons help to rule out individual difference explanations for the alcohol-violence association and indicate that alcohol consumption is a proximal risk factor for partner violence in alcoholic men.

Behavioral couples therapy for female substance-abusing patients: effects on substance use and relationship adjustment.

Married or cohabiting female drug-abusing patients (N = 75) were randomly assigned to either a behavioral couples therapy condition (BCT; n = 37), which consisted of group, individual, and behavioral couples therapy sessions, or to an equally intensive individual-based treatment condition (IBT; n = 38), which consisted of group and individual counseling. During most of the 1-year follow-up, compared with participants who received IBT, those who received BCT reported (a) fewer days of substance use, (b) longer periods of continuous abstinence, (c) lower levels of alcohol, drug, and family problems, and (d) higher relationship satisfaction. However, differences in relationship satisfaction and number of days of substance use dissipated over the course of the posttreatment follow-up period and were not significantly different by the end of 1 year.