Legal System Involvement and Opioid-Related Overdose Mortality in U.S. Department of Veterans Affairs Patients.

INTRODUCTION: Opioid-related overdose risks are elevated after incarceration. The rates of opioid-related overdose mortality have risen in recent years, including among Veterans Health Administration patients. To inform Veteran overdose prevention, this study evaluates whether opioid-related overdose risks differ for Veterans Health Administration patients with versus those without indicators of legal system involvement. METHODS: This retrospective national cohort study, conducted in 2019-2021, used Veterans Health Administration electronic health records and death certificate data from the Department of Veterans Affairs/Department of Defense Mortality Data Repository to examine opioid-related overdose mortality from January 1, 2013 through December 31, 2017. The cohort included 5,390,902 Veterans with Veterans Health Administration inpatient or outpatient encounters in 2012 who were alive as of January 1, 2013, of whom 32,284 (0.60%) patients had legal system involvement in 2012, indicated by Veterans Justice Programs outpatient encounters. Cox proportional hazards regression models assessed the associations between legal involvement and risk of opioid-related overdose mortality. RESULTS: There were 4,670 opioid-related overdose deaths, including 295 (6.31%) among legal-involved Veterans. Veterans with legal involvement had a higher opioid-related overdose mortality rate per 100,000 person-years (191.22, 95% CI=169.40, 213.04 vs 17.76, 95% CI=17.23, 18.29, p<0.001) and an elevated risk of opioid-related overdose mortality (adjusted hazard ratio=1.38, 95% CI=1.22, 1.57, p<0.001) compared with those without. CONCLUSIONS: Among Veterans receiving Veterans Health Administration care in 2012, documented legal system involvement was associated with an increased risk of opioid-related overdose mortality. Targeting overdose education and naloxone distribution programs and integrating opioid overdose prevention efforts into mental health care may reduce opioid overdose deaths among Veterans with legal involvement.

Ascertainment of Patient Suicides by Veterans Affairs Facilities and Associations With Veteran, Clinical, and Suicide Characteristics.

Objectives. To evaluate the sensitivity of health care facility documentation of suicide deaths among US veterans with recent Veterans Health Administration (VHA) care and assess variation in identification by veteran, clinical, and suicide death characteristics. Methods. Cross-sectional analyses included 11 148 veterans who died by suicide in 2013 to 2017, per National Death Index death certificate information, with VHA encounters in the year of death or the previous year. Facility suicide ascertainment was assessed per site reports in the VHA Suicide Prevention Applications Network. Bivariate and multivariable analyses assessed ascertainment by decedent demographic, clinical, utilization, and method of suicide characteristics. Results. Site reports identified 3667 suicide decedents (32.9%). Veteran suicide decedents identified by facilities were more likely to be younger and with clinical risk factors and more recent VHA encounters. Suicide deaths involving poisoning were less likely to be identified than deaths involving other methods. Conclusions. VHA facility ascertainment of suicide deaths among recent patients was neither comprehensive nor representative. Findings will inform efforts to enhance facility suicide surveillance and veteran suicide prevention.

Veterans Justice Programs: Assessing Population Risks for Suicide Deaths and Attempts.

OBJECTIVES: Understanding suicide risks among Veteran subpopulations is a national priority. This study assessed risks of suicide, suicide attempts, and other-cause mortality among recipients of Veterans Health Administration (VHA) Veterans Justice Program services as compared to other Veteran VHA users. METHODS: Per VHA records, the cohort included 5,401,192 Veterans alive as of January 1, 2013 and with VHA utilization in 2012. Receipt of Veterans Justice Outreach (VJO) or Health Care for Reentry Veterans (HCRV) services in 2012 was assessed using encounter codes. Multivariable proportional hazards regression assessed risks of suicide (per National Death Index search results from the VA/DoD Mortality Data Repository) and attempts (per diagnoses and site reports) in 2013-2016, adjusting for demographic and clinical indicators. RESULTS: Compared to other patients, Veterans with VJO encounters had greater risk of suicide (unadjusted HR = 2.80, 95% confidence interval [CI] = 2.30-3.40; adjusted HR = 1.25, 95% CI = 1.02-1.53) and attempts (unadjusted HR = 8.88, 95% CI = 8.45-9.35; adjusted HR = 1.06, 95% CI = 1.00-1.11). Veterans with HCRV encounters had elevated risk of suicide attempts (unadjusted HR = 4.56, 95% CI = 4.00-5.20; adjusted HR = 1.42, 95% CI = 1.24-1.62). Risks were also elevated for other external causes of mortality. CONCLUSIONS: Findings document increased risk of suicidal behavior among Veterans Justice Program recipients. These results have informed VHA suicide prevention activities.

Modern 'junk food' and minimally-processed 'natural food' cafeteria diets alter the response to sweet taste but do not impair flavor-nutrient learning in rats.

Animals learn to prefer and increase consumption of flavors paired with postingestive nutrient sensing. Analogous effects have been difficult to observe in human studies. One possibility is experience with the modern, processed diet impairs learning. Food processing manipulates flavor, texture, sweetness, and nutrition, obscuring ordinary correspondences between sensory cues and postingestive consequences. Over time, a diet of these processed 'junk' foods may impair flavor-nutrient learning. This 'flavor-confusion' hypothesis was tested by providing rats long-term exposure to cafeteria diets of unusual breadth (2 or 3 foods per day, 96 different foods over 3 months, plus ad libitum chow). One group was fed processed foods (PF) with added sugars/fats and manipulated flavors, to mimic the sensory-nutrient properties of the modern processed diet. Another group was fed only 'natural' foods (NF) meaning minimally-processed foods without manipulated flavors or added sugars/fats (e.g., fresh fruits, vegetables, whole grains) ostensibly preserving the ordinary correspondence between flavors and nutrition. A CON group was fed chow only. In subsequent tests of flavor-nutrient learning, PF and NF rats consistently acquired strong preferences for novel nutrient-paired flavors and PF rats exhibited enhanced learned acceptance, contradicting the 'flavor-confusion' hypothesis. An unexpected finding was PF and NF diets both caused lasting reduction in ad lib sweet solution intake. Groups did not differ in reinforcing value of sugar in a progressive ratio task. In lick microstructure analysis the NF group paradoxically showed increased sucrose palatability relative to PF and CON, suggesting the diets have different effects on sweet taste evaluation.