Trauma-Informed Training for Veterans Treatment Court Professionals: Program Development and Initial Feedback.

Background: Justice-involved veterans demonstrate greater mental health and psychosocial needs relative to justice-involved nonveterans and veterans without a criminal history. Veterans treatment courts (VTCs) serve as an alternative to incarceration for veterans whose criminogenic risk is believed to be related to mental health symptoms. Despite observed improvements in functioning and recidivism risk following successful VTC completion, little is known about factors that impede engagement with VTCs. This paper describes a trauma-informed training program that included psychoeducation, skills training, and consultation and was developed for court professionals to facilitate veteran engagement in VTCs. Observations: Needs assessments and court observations informed program development. Based on identified needs, the training incorporated skills from dialectical behavior therapy, acceptance and commitment therapy, and motivational interviewing. Two VTCs in the Rocky Mountain region participated in the pilot trauma-informed training, each lasting about 90 to 120 minutes. Feedback from attendees indicated that the focus on skills training-specifically, managing intense emotions, addressing ambivalence, and approaching sanctions and rewards-was uniquely helpful. The function of posttraumatic stress disorder symptoms and structure of evidence-based treatments were identified as useful educational components. Conclusions: Veterans Health Administration mental health professionals can serve an important role in facilitating effective practices for professionals working within VTCs. This pilot program provided preliminary support for skills-based training to bolster communication, motivation, distress tolerance, and engagement among veterans court participants. Future directions of this program may include expanding the training into a full-day workshop, conducting comprehensive needs assessments, and examining program outcomes.

Suicide risk among veterans using VHA justice-involved services: a latent class analysis.

BACKGROUND: Justice-involved Veterans experience notable risk for psychosocial stressors (e.g., homelessness) and psychiatric multimorbidity, which can result in complex clinical presentations. However, research examining how such factors coalesce to impact risk for suicide remains limited. METHODS: We conducted a latent class analysis of 180,454 Veterans accessing Veterans Health Administration (VHA) justice-related services from 2005 to 2018. RESULTS: A four-model class membership solution was identified. Among these classes, risk for suicide was highest among Veterans with greater psychiatric burden, with risk most notable among those with high VA service use. Veterans seeking healthcare primarily focused on substance use disorders or with low psychiatric burden and service use had a lower risk for suicide. CONCLUSIONS: Psychiatric multimorbidity is salient as it relates to suicide among Veterans accessing VHA justice-related services. Further evaluation of existing VHA services for this population and methods of augmenting and enhancing care for justice-involved Veterans with histories of co-occurring psychiatric conditions may be beneficial in facilitating suicide prevention efforts.

Understanding the Intersection of Homelessness and Justice Involvement: Enhancing Veteran Suicide Prevention Through VA Programming.

BACKGROUND: Veterans with a history of homelessness and justice involvement are at greater risk for mental health sequelae, including suicide. OBSERVATIONS: A bidirectional relationship exists between criminal justice involvement and housing instability (ie, the institutional circuit). Homelessness and justice involvement often represent a vicious cycle that is difficult to escape. The US Department of Veterans Affairs (VA) has a number of programs focused on connecting homeless and justice-involved veterans to health and social services. This paper reviews existing programing and initiatives within such services to detect risk for suicide and connect these veterans to appropriate evidence-based mental health care. CONCLUSIONS: The VA currently has several programs focused on enhancing care for homeless and justice-involved veterans, many of which currently incorporate suicide prevention initiatives. Understanding of factors that may impact health service delivery of suicide risk assessment and intervention may be beneficial in order to enhance veteran suicide prevention efforts.

A national survey of barriers and facilitators to medications for opioid use disorder among legal-involved veterans in the Veterans Health Administration.

Background: Medications for opioid use disorder (MOUD) are clinically effective at treating OUD among legal-involved populations. However, research shows that legal-involved veterans who receive care through the VHA have lower rates of MOUD use compared to non-legal-involved veterans. Education may be a key factor in intervention strategies to improve MOUD access. This study was a national survey of VHA staff to identify barriers to and facilitators of MOUD, as well as MOUD-related education needs for VHA staff, community partners, criminal justice partners, and legal-involved veterans. Method: A 98-item online survey was conducted to examine VHA staff perspectives (N = 218) around needed education, barriers to, and facilitators of MOUD for legal-involved veterans. Descriptive statistics were conducted and linear regression analyses were used to evaluate differences in perceptions by respondents' current position at the VHA and their VHA facility's rate of provision of MOUD among legal-involved veterans. Results: Respondents endorsed a need for education in all areas of MOUD (e.g., existing medications for the treatment of OUD) for VHA staff and providers, community partners, criminal justice partners, and legal-involved veterans. VHA staff perceived barriers to MOUD for legal-involved veterans to include stigma and complicated guidelines around MOUD and OUD treatment. Facilities with low rates of MOUD use highlighted barriers including MOUD conflicting with the philosophy of the local VHA facility and provider stigma toward patients with OUD. Perceptions of efficacy of MOUD differed by respondents' current position at the VHA such that substance use disorder treatment providers perceived buprenorphine and methadone as more effective compared to Veterans Justice Specialists. Conclusion: The results of this study suggest a need for an educational intervention emphasizing the evidence supporting use of MOUD as a lack of knowledge about these medications was considered a barrier to access, whereas gaining education about MOUD was a facilitator to access. Education strategies specifically tailored to address VHA facility-level differences may help address barriers to MOUD experienced by legal-involved veterans.

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.

Strategies to improve implementation of medications for opioid use disorder reported by veterans involved in the legal system: A qualitative study.

BACKGROUND: Veterans involved in the legal system have a high risk of overdose mortality but limited utilization of medications for opioid use disorder (MOUD). To increase the use of MOUD in Veterans Health Administration (VHA) facilities and reduce overdose mortality, the VHA should incorporate strategies identified by legal-involved veterans to improve quality of care and ensure that their patients' experiences are integrated into care delivery. This study aims to determine strategies to increase use of MOUD from the perspective of legal-involved veterans with a history of opioid use or opioid use disorder (OUD). METHODS: Between February 2018 and March 2019, we conducted semistructured interviews with 18 veterans with a history of opioid use or OUD and legal involvement (15 men and 3 women; mean age 41, standard deviation 13, range 28-61). Veterans were from 9 geographically dispersed United States VHA facilities. The study analyzed verbatim transcripts using the framework method. The primary focus was themes that represented legal-involved veteran-identified strategies to improve the use of MOUD. RESULTS: The 18 veterans interviewed had legal involvement directly related to their opioid use and most (n = 15; 83%) had previously used MOUD. Veteran-identified strategies to improve access to and use of MOUD included: (1) VHA should provide transportation or telehealth services; (2) legal agencies should increase access to MOUD during incarceration; (3) the VHA should reduce physician turnover; (4) the VHA should improve physician education to deliver compassionate, patient-centered treatment; (5) the VHA should improve veteran education about MOUD; and (6) the VHA should provide social support opportunities to veterans. CONCLUSIONS: Legal-involved veterans provided strategies that can inform and expand MOUD to better meet their needs and the treatment needs of all patients with OUD. The VHA should consider incorporating these strategies into care, and should evaluate their impact on patients' experience, initiation of and retention on medications, and overdose rates.

Facilitating Successful Reentry Among Justice-involved Veterans: The Role of Veteran and Offender Identity.

Reentry courts facilitate successful offender reintegration into the community following release from incarceration, and many justice-involved veterans may benefit from such services given their elevated risk for deleterious outcomes postrelease. However, effectively engaging court participants is a crucial foundation to achieve the goals of recidivism reduction and global psychosocial improvement. This conceptual article presents an overview of factors that may interfere with a veteran's engagement in reentry court through the lens of both veteran and offender identity. Recommendations for reentry court personnel based on justice-involved veterans' experiences, identity, and unique needs are presented. Careful consideration of these factors and associated practice adaptations may facilitate rapport between reentry court personnel and veteran participants, foster engagement, and ultimately improve outcomes among this unique, at-risk population.

Disparities in Access to Medications for Opioid Use Disorder in the Veterans Health Administration.

OBJECTIVES: A variety of patients - including women, older, racial/ethnic minority, rural, homeless, and justice-involved patients - are vulnerable to experiencing poor healthcare access and quality, such as lower quality substance use disorder treatment, than other populations. The current study examined receipt of medications for opioid use disorder by vulnerable populations within Veterans Health Administration (VHA) facilities to determine whether there are patient and facility factors that are associated with disparities in care. METHODS: Using national VHA clinical/administrative data from Fiscal Year 2017, we calculated receipt of medications for opioid use disorder using the American Society for Addiction Medicine quality measure specifications. A mixed-effects logistic regression model tested whether patient vulnerability (ie, women, older age, racial/ethnic minority, rural residence, homeless, and justice-involved) and facility (eg, regional location, availability of a methadone clinic) characteristics were associated with medication receipt. RESULTS: Among the 53,568 veterans at VHA facilities diagnosed with opioid use disorder in Fiscal Year 2017, vulnerable populations - including women, older, Black, rural, homeless, and justice-involved veterans - had lower odds of receiving medications for opioid use disorder than their nonvulnerable counterparts. Veterans had higher odds of receiving medications at facilities with a higher proportion of patients with opioid use disorder, but lower odds of receiving medications at facilities in the Southern region compared to the Northeast region of the United States. CONCLUSIONS: Quality improvement efforts targeted at vulnerable populations are needed at the VHA to ensure these groups receive the same quality of substance use disorder treatment as other veterans.

Barriers to Medications for Opioid Use Disorder Among Veterans Involved in the Legal System: a Qualitative Study.

BACKGROUND: Veterans involved in the legal system are at high risk for overdose but have lower receipt of medications for opioid use disorder than other veterans. OBJECTIVE: The study aimed to understand barriers to medication access from the perspective of legally involved veterans with opioid use disorder and people who work with these veterans in the Veterans Health Administration (VHA) and the legal system. DESIGN: This national qualitative study interviewed veterans and stakeholders from 14 geographically diverse VHA facilities to explore perceptions of barriers to medications for opioid use disorder. PARTICIPANTS: Participants included veterans with a history of opioid use disorder and legal involvement (n = 18), VHA Veterans Justice Programs Specialists (n = 15), VHA and community substance use disorder treatment providers (n = 5), and criminal justice staff (n = 12). APPROACH: We conducted interviews based on the Consolidated Framework for Implementation Research. Interview transcripts were analyzed using a team-based approach. KEY RESULTS: Four key barriers, noted by group, were identified: (1) a preference for counseling along with or instead of medications (veterans, Specialists, treatment providers, criminal justice staff); (2) concerns about veterans using medications without a prescription, selling them, or providing them to others (veterans, Specialists, treatment providers, criminal justice staff); (3) concerns about perceived stigma towards medication use (veterans, Specialists, treatment providers, criminal justice staff); and (4) concerns about medication discontinuation after recurrent opioid use (veterans, criminal justice staff). A fifth theme, education, was noted by all stakeholders except providers as important to facilitating use of medications for opioid use disorder. All five themes mapped to the framework construct of knowledge and beliefs about the intervention. CONCLUSIONS: Based on identified barriers, interventions focused on enhancing medication knowledge, reducing stigma towards use of medications, and increasing knowledge that opioid use may recur during treatment may help increase access to medication for veterans with legal involvement.

The impact of substance use disorders on treatment engagement among justice-involved veterans with posttraumatic stress disorder.

Veterans involved with the criminal justice system represent a particularly vulnerable population who experience high rates of both posttraumatic stress disorder (PTSD) and substance use disorders (SUD). This study sought to investigate whether having co-occurring SUD is a barrier to PTSD treatment. This is a retrospective observational study of a national sample of justice-involved veterans served by the Veterans Health Administration Veterans Justice Outreach program who had a diagnosis of PTSD (N = 27,857). Mixed effects logistic regression models with a random effect for facility (N = 141 medical centers) were utilized to estimate the odds of receiving each type of PTSD treatment as a function of having a SUD diagnosis. Results indicate that a majority of veterans with PTSD served by the Veterans Justice Outreach program have an SUD diagnosis (73%), and having a co-occurring SUD was associated with higher odds of receiving PTSD treatment, after adjusting for demographic differences. Although not without limitations, these results suggest that among justice-involved veterans enrolled in the Veterans Health Administration with PTSD, having an SUD comorbidity is not a barrier to PTSD treatment and may in fact facilitate access to PTSD treatment. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Logic Model of the Department of Veterans Affairs' Role in Veterans Treatment Courts.

Veterans Treatment Courts (VTCs) grew exponentially in the last decade with more than 550 courts, dockets and tracks operating in the U.S. Eligibility criteria and operating practices of VTCs vary widely. Existing logic models guide the activities of these courts, but do not explicitly address the distinct missions and priorities of different agencies that support VTCs. To facilitate communication and research to address this gap, we propose a logic model of the Department of Veterans Affairs' (VA) role in VTCs. To construct the VA-VTC logic model, we adapted an existing logic model and held expert panels with VA staff, clinical leaders and researchers to discuss and refine the model. The VA-VTC logic model is a novel contribution to current thinking about VTCs and clarifies the potential resources, activities, outputs, outcomes and population impacts that are under the purview of the VA. Explicitly recognizing the VA as a separate partner in VTCs, this logic model can be a tool for communication with criminal justice agencies to facilitate broader discussions about the mechanisms driving VTC outcomes. This model can also be continuously updated as we learn from research and evaluation efforts about VTCs, ultimate improving the effectiveness of the VA's role in these courts.

Facility-level changes in receipt of pharmacotherapy for opioid use disorder: Implications for implementation science.

BACKGROUND: The U.S. is facing an opioid epidemic, but despite mandates for pharmacotherapy for opioid use disorder to be available at Veterans Health Administration (VHA) facilities, the majority of veterans with opioid use disorder do not receive these medications. In implementation research, facilities are often targeted for qualitative inquiry or quality improvement efforts based on quality measure performance during a one-year period. However, sites that experience quality performance changes from one year to the next may be highly informative because mechanisms that impact facility change may be more discoverable. The current study examined changes in receipt of pharmacotherapy for opioid use disorder in a national healthcare system to determine the extent to which sites fluctuated in performance over a two-year period and illustrate how changes in quality measures over time may be useful for implementation research and healthcare surveillance of quality measures. METHODS: Using national VHA data from Fiscal Years (FY) 2016 and 2017, we calculated quality measure performance as the number of patients who received pharmacotherapy for opioid use disorder (i.e., methadone, buprenorphine, and naltrexone) divided by the number of patients with a current non-remitted opioid use disorder diagnosis for each FY at each facility (n = 129) and examined change from FY16 to FY17. RESULTS: The mean rate of receipt of pharmacotherapy for opioid use disorder was 38% (facility range = 3% to 74%) in FY16 and 41% (facility range = 2% to 76%) in FY17. The average facility-level change in performance was 3% and ranged from -19% to 26%. There were 32 facilities that decreased in provision of pharmacotherapy, 12 facilities with no change, and 85 facilities that increased. CONCLUSIONS: For facilities with average or high performance, it was difficult to maintain their performance over time. Identifying and learning from facilities with recent fluctuations may be more informative to guide the design of future quality improvement efforts than studying facilities with stable high or low performance.

Use of Veterans Health Administration Mental Health and Substance Use Disorder Treatment After Exiting Prison: The Health Care for Reentry Veterans Program.

The Veterans Health Administration (VA) Health Care for Reentry Veterans (HCRV) program links veterans exiting prison with treatment. Among veterans served by HCRV, national VA clinical data were used to describe contact with VA health care, and mental health and substance use disorder diagnoses and treatment use. Of veterans seen for an HCRV outreach visit, 56 % had contact with VA health care. Prevalence of mental health disorders was 57 %; of whom 77 % entered mental health treatment within a month of diagnosis. Prevalence of substance use disorders was 49 %; of whom 37 % entered substance use disorder treatment within a month of diagnosis. For veterans exiting prison, increasing access to VA health care, especially for rural veterans, and for substance use disorder treatment, are important quality improvement targets.

Adolescent attributes and young adult smoking cessation behavior.

This study collected data five times between 1983 and 2002 from 400 participants who originally came from upstate New York. These participants completed structured interviews as did their mothers three times. LISREL analysis generally supported the hypothesized model. The results indicated that having parents who smoked and having low educational aspirations and expectations were associated with being unconventional, which, in turn, was related to having low emotional control and reporting more internalizing behaviors. Internalizing behaviors were directly associated with a lower likelihood of smoking cessation, as was parental smoking. Research and clinical implications are discussed and the limitations noted.

The association between earlier marijuana use and subsequent academic achievement and health problems: a longitudinal study.

In this prospective longitudinal study, the authors investigated the association between marijuana use over a period of 13 years and subsequent health problems at age 27. A community sample of 749 participants from upstate New York was interviewed at mean ages of 14, 16, 22, and 27 years. Marijuana use over time was significantly associated with increased health problems by the late twenties, including respiratory problems, general malaise, neurocognitive problems, and lower academic achievement and functioning. Effective prevention and intervention programs should consider the wide range of adverse physiological and psychosocial outcomes associated with marijuana use over time.