Prescription opioid duration of action and the risk of unintentional overdose among patients receiving opioid therapy.

Importance: The unprecedented increase in unintentional overdose events that has occurred in tandem with escalating sales of prescription opioids over the past 2 decades has raised concerns about whether the therapeutic use of opioids has contributed to increases in overdose injury. Few controlled studies have examined the extent to which ecologic measures of increases in opioid prescribing and overdose injuries reflect risk among patients prescribed opioids, let alone whether some opioid regimens are safer than others.

Objective: To examine whether the risk of unintentional overdose injury is associated with the duration of opioid action (ie, long-acting vs short-acting formulations).

Drinking goal choice and outcomes in a Web-based alcohol intervention: results from VetChange.

Objectives: The objectives of the paper are to describe characteristics of participants who chose moderation and abstinence drinking goals, and to examine post-treatment drinking outcomes based on patterns of goal choice during a Web-based alcohol intervention for returning U.S. Veterans.

Retention of black and white participants in the selenium and vitamin E cancer prevention trial (SWOG-coordinated intergroup study S0000).

Background: Disproportionally low retention of minority populations can adversely affect the generalizability of clinical research trials. We determine the overall retention rates for White and Black participants from the Selenium and Vitamin E Cancer Prevention Trial (SELECT) and explore participant and site characteristics associated with retention failure (study disengagement) for these groups.

Methods: A secondary analysis of 28,118 White (age ≥55), and 4,322 Black (age ≥ 50) SELECT participants used multivariate Cox regression to estimate overall retention rates and to calculate HRs and 95% confidence intervals (CI).

Incident severe thrombocytopenia in veterans treated with pegylated interferon plus ribavirin for chronic hepatitis C infection.

Purpose: We sought to determine the incidence and risks for severe thrombocytopenia (platelets < 50,000/μL) in United States Veteran patients treated with pegylated interferon (PEG-IFN) plus ribavirin for hepatitis C virus-positive (HCV) chronic liver disease (CLD).

Methods: Using a retrospective, observational cohort study design to analyze databases from the New England Veterans Healthcare System, we identified 979 patients diagnosed with HCV-positive CLD treated solely with PEG-IFN plus ribavirin. The cohort was stratified by pre-treatment platelet counts of 50,000-100,000/μL (N = 90), >100,000-150,000/μL (N = 162), and >150,000μL (N = 727).

Thrombocytopenia and bleeding in veterans with non-hepatitis C-related chronic liver disease.

Background: Thrombocytopenia in chronic liver disease (CLD) typically reflects disease severity and may indicate an increased risk for bleeding.

Aims: To describe the longitudinal course of thrombocytopenia and risks for bleeding in veteran patients with non-hepatitis C-related CLD.

Methods: We identified 2,349 patients with non-hepatitis C-related CLD from databases of the New England Veterans Healthcare System between 1999 and 2008.

A randomized placebo-controlled trial of D-cycloserine and exposure therapy for posttraumatic stress disorder.

D-Cycloserine (DCS) is a partial NMDA receptor agonist that has been shown to enhance therapeutic response to exposure-based treatments for anxiety disorders, but has not been tested in the treatment of combat-related posttraumatic stress disorder (PTSD). The aim of this randomized, double-blind, placebo-controlled trial was to determine whether DCS augments exposure therapy for PTSD in veterans returning from Iraq and Afghanistan and to test whether a brief six-session course of exposure therapy could effectively reduce PTSD symptoms in returning veterans. In contrast to previous trials using DCS to enhance exposure therapy, results indicated that veterans in the exposure therapy plus DCS condition experienced significantly less symptom reduction than those in the exposure therapy plus placebo condition over the course of the treatment.

Risk of community-acquired pneumonia in veteran patients to whom proton pump inhibitors were dispensed.

Background: Observational studies linking proton pump inhibitor (PPI) exposure with community-acquired pneumonia (CAP) have reported either modest or no associations. Accordingly, we studied PPI exposure and CAP in veteran patients, using a retrospective, nested case-control design.

Methods: From linked pharmacy and administrative databases of the New England Veterans Healthcare System, we identified 71985 outpatients newly prescribed PPIs between 1998 and 2007; 1544 patients met criteria for CAP subsequent to PPI initiation; 15440 controls were matched through risk-set sampling by age and time under observation.

Proton pump inhibitor discontinuation in long-term care.

Objectives: To determine factors associated with proton pump inhibitor (PPI) discontinuation in long-term care.

Design: Retrospective cohort analysis.

Setting: Veterans Affairs (VA) long-term care facilities.

A point-of-care clinical trial comparing insulin administered using a sliding scale versus a weight-based regimen.

Background: Clinical trials are widely considered the gold standard in comparative effectiveness research (CER) but the high cost and complexity of traditional trials and concerns about generalizability to broad patient populations and general clinical practice limit their appeal. Unsuccessful implementation of CER results limits the value of even the highest quality trials. Planning for a trial comparing two standard strategies of insulin administration for hospitalized patients led us to develop a new method for a clinical trial designed to be embedded directly into the clinical care setting thereby lowering the cost, increasing the pragmatic nature of the overall trial, strengthening implementation, and creating an integrated environment of research-based care.

Proton pump inhibitors and risk for recurrent Clostridium difficile infection.

Background: Proton pump inhibitors (PPIs) are widely used gastric acid suppressants, but they are often prescribed without clear indications and may increase risk of Clostridium difficile infection (CDI). We sought to determine the association between PPI use and the risk of recurrent CDI.

Methods: Retrospective, cohort study using administrative databases of the New England Veterans Healthcare System from October 1, 2003, through September 30, 2008.

Impact of supplemental site grants to increase African American accrual for the Selenium and Vitamin E Cancer Prevention Trial.

Background: African American accrual to prevention trials at rates representative of the disease burden experienced by this population requires additional resources and focused efforts.

Purpose: To describe the rationale, context, and criteria for selection of sites that received Minority Recruitment Enhancement Grants (MREGs) to increase African American recruitment to the Selenium and Vitamin E Cancer Prevention Trial (SELECT). To determine if African American accrual was higher among the 15 MREG sites when compared with similar nonawarded sites.

Does opioid therapy affect quality of care for diabetes mellitus?

Objective: To examine whether veterans who received chronic opioid therapy had worse diabetes performance measures than patients who did not receive opioids.

Study Design: Retrospective cohort study.

Methods: We identified all patients with diabetes mellitus receiving care in US Department of Veterans Affairs facilities during 2004.

Early Age-of-onset Drinking Predicts Prescription Drug Misuse Among Teenagers and Young Adults: Results from a National Survey.

Early age-of-onset drinking is associated with alcohol problems and related, high-risk behaviors. We analyzed data from 18- to 34-year-old respondents from the 2001 to 2002 National Epidemiological Survey on Alcohol and Related Conditions (NESARC) to determine to what extent early age-of-onset drinking increased risks for prescription drug misuse (PDM), defined as 1 or more positive responses to: "ever having misused sedatives, tranquilizers, painkillers or stimulants, obtained either as prescriptions or from indirect sources." Lifetime prevalence of PDM was 15.

Association of elevated alanine aminotransferase with BMI and diabetes in older veteran outpatients.

Aims: We determined age-stratified associations of elevated alanine aminotransferase (ALAT), as a likely indicator of non-alcoholic steatonecrosis (NASH), with body mass index (BMI) and diabetes among older male, veteran outpatients.

Methods: Administrative files at three, urban Veteran Administration Healthcare Systems were surveyed. 47.

Long-term, high-dose benzodiazepine prescriptions in veteran patients with PTSD: influence of preexisting alcoholism and drug-abuse diagnoses.

Databases from the New England Veterans Integrated Service Network were analyzed to determine factors associated with long-term, high-dose anxiolytic benzodiazepine prescriptions dispensed to patients with posttraumatic stress disorder (PTSD) and existing alcoholism and/or drug abuse diagnoses. Among 2,183 PTSD patients, 234 received the highest 10% average daily doses for alprazolam, clonazepam, diazepam, or lorazepam, doses above those typically recommended. Highest doses were more commonly prescribed to patients with existing drug abuse diagnoses.

Characterizations of long-term anxiolytic benzodiazepine prescriptions in veteran patients.

To characterize long-term prescriptions for commonly prescribed anxiolytic benzodiazepines to veteran patients and to identify factors associated with high daily doses, we analyzed the linked pharmacy and administrative databases from New England Veterans Healthcare System (VISN 1). We analyzed treatment episodes of 3 months or longer with the 4 most commonly prescribed agents: alprazolam, clonazepam, diazepam, and lorazepam. Descriptive statistics and univariate and multivariate analyses described the sample and tested associations of pharmacological and clinical variables for patients prescribed the top 5% of average daily doses ("high-dose" prescriptions).

Conceptual bases of Christian, faith-based substance abuse rehabilitation programs: qualitative analysis of staff interviews.

Faith-based substance abuse rehabilitation programs provide residential treatment for many substance abusers. To determine key governing concepts of such programs, we conducted semi-structured interviews with sample of eleven clinical and administrative staff referred to us by program directors at six, Evangelical Christian, faith-based, residential rehabilitation programs representing two large, nationwide networks. Qualitative analysis using grounded theory methods examined how spirituality is incorporated into treatment and elicited key theories of addiction and recovery.

Characterizations of long-term oxycodone/acetaminophen prescriptions in veteran patients.

Background: Long-term management of chronic pain with opioids may be stable over time or may be complicated by problematic dose increases, drug dependencies, and toxic effects. To determine clinical contexts in which stability or problems may occur, we examined the pharmacologic and clinical correlates of long-term prescriptions of oxycodone/acetaminophen, a commonly prescribed short-acting opioid formulation.

Methods: We analyzed linked, archival outpatient pharmacy and clinical databases from the New England Veterans Integrated Service Network between January 1, 1998, and June 30, 2001.

Patterns of dispensed disulfiram and naltrexone for alcoholism treatment in a veteran patient population.

Background: Short-term treatment trials indicate that two Food and Drug Administration-approved agents, disulfiram and naltrexone, may each curtail alcohol consumption, but two large 1-year Veterans Administration cooperative studies showed no long-term benefits for these agents over placebo. To assess whether these agents are being prescribed for extended periods, as an indicator of long-term use in nonexperimental settings, we compared dispensing patterns in a veteran patient population.

Methods: The New England Veterans Integrated Service Network outpatient pharmacy files between January 1, 1998, and June 30, 2001, were analyzed; only patients with prescriptions on or after March 1, 1998, were included.