Literature Collection

PURPOSE: The present study examined differences in the mental health outcomes and psychotherapy use of rural Veterans with military sexual trauma (MST), as compared to their urban peers, given rural Veterans' increased risk for delayed or missed care. METHODS: We analyzed Veterans Health Administration (VHA) administrative data for 311,917 Veterans with a history of MST. Veterans were classified as rural/highly rural (30.25%) or urban (69.75%) based on VHA Rural-Urban Commuting Area codes. Rural-urban differences were assessed for mental health disorders and service use across 4 VHA clinic types (i.e., integrated Primary Care-Mental Health Clinic, General Mental Health Clinic, Posttraumatic Stress Disorder Clinical Team, Substance Use Disorder Clinic) using logistic regression models adjusted for age. Analysis of covariance models compared differences in utilization intensity among Veterans with at least 1 encounter in the designated clinic. FINDINGS: Compared to urban Veterans with MST, rural Veterans with MST were more likely to be diagnosed with an anxiety disorder but less likely to be diagnosed with posttraumatic stress disorder, depression, bipolar disorder, alcohol use disorder, and other substance use disorder. As expected, rural Veterans with MST were less likely to receive individual and group psychotherapy services, regardless of the VHA clinic type, than their urban counterparts. Notably, rural Veterans remained in individual and group treatment longer than urban Veterans across nearly all clinics. CONCLUSION: Further investigation into challenges and opportunities to improve mental health care initiation among rural Veterans with MST is a critical next step in optimizing their well-being and quality of life.

OBJECTIVE: Effective treatments for opioid use disorder exist, but rural areas of the United States have a shortage of services offering such treatments. Physician bias toward patients with opioid use disorder can also limit care access, but no studies have assessed whether physician bias is a more acute barrier in rural compared with urban communities. METHODS: In total, 408 board-certified physicians in Ohio, a state with a high rate of opioid overdoses, completed an online survey examining perspectives on clinical care for patients who misuse opioids. Respondents with missing county-level data were excluded, leaving a total sample of 274. The authors used t tests to determine rural-urban differences in bias, key predictors of bias, and availability of opioid services. Multivariable regression modeling was used to estimate rural-urban differences in bias independent of key bias predictors. RESULTS: Physicians in rural areas (N=37) reported higher levels of bias toward patients with opioid use disorder than did their urban counterparts (N=237). This difference remained statistically significant even after accounting for known bias predictors and physician specialty. Physicians specializing in addiction medicine reported lower bias than did physicians not working in this specialty. CONCLUSIONS: Given existing disparities in harm reduction and addiction treatment services in rural areas, increased physician bias in counties lacking these services suggests that rural patients with opioid use disorder face numerous challenges to finding effective treatment. Bias reduction interventions should target health care professionals in rural communities where such efforts may have the most pronounced impact on improving health care access.

The prevalence of opioid use among pregnant people has been increasing over the past few decades, with a parallel increase in the rate of neonatal abstinence syndrome. Opioid agonist treatment (OAT) including methadone and buprenorphine is the recommended management method for opioid use disorders during pregnancy. Methadone has been extensively studied during pregnancy; however, buprenorphine was introduced in the early 2000s with limited data on the use of different preparations during pregnancy. Buprenorphine-naloxone has been incorporated into routine practice; however, only a few studies have investigated the use of this medication during pregnancy. To determine the safety and efficacy of this medication, we conducted a systematic review of maternal and neonatal outcomes among buprenorphine-naloxone-exposed pregnancies. The primary outcomes of interest were birth parameters, congenital anomalies, and severity of neonatal abstinence syndrome. Secondary maternal outcomes included the OAT dose and substance use at delivery. Seven studies met the inclusion criteria. Buprenorphine-naloxone doses ranged between 8 and 20 mg, and there was an associated reduction of opioid use during pregnancy. There were no significant differences in gestational age at delivery, birth parameters, or prevalence of congenital anomalies between buprenorphine-naloxone-exposed neonates and those exposed to methadone, buprenorphine monotherapy, illicit opioids, or no opioids. In studies comparing buprenorphine-naloxone to methadone, there were reduced rates of neonatal abstinence syndrome requiring pharmacotherapy. These studies demonstrate that buprenorphine-naloxone is a safe and effective opioid agonist treatment for pregnant people with OUD. Further large-scale, prospective data collection is required to confirm these findings. Patients and clinicians may be reassured about the use of buprenorphine-naloxone during pregnancy.

INTRODUCTION: Chronic pain is a significant risk factor for suicide, especially among Veterans. The aim of this study is to evaluate the safety (i.e., the occurrence of suicidal behavior after treatment) and tolerability (i.e., treatment completion) of a Brief Cognitive-Behavioral Therapy for Chronic Pain (Brief CBT-CP) group in primary care among a sample of Veterans with chronic noncancer pain deemed to be at an increased risk for suicide. MATERIALS AND METHODS: Chart review was used to assess suicide history and treatment completion among Veterans who participated in a Brief CBT-CP group within a Primary Care-Mental Health Integration Clinic at a Veteran Affairs Medical Center. Suicide risk was stratified into 3 categories: Minimal (no current suicidal ideation or history of suicidal behavior), Elevated (current suicidal ideation or history of suicidal behavior), and High Risk (current suicidal ideation and history of suicidal behavior). Safety was assessed as the absence of suicidal behavior during and after Brief CBT-CP sessions. Tolerability was defined as completion of at least 4/6 sessions. RESULTS: Of the 261 Veterans who participated in a Brief CBT-CP group, 24.9% of Veterans were identified to be at Elevated Risk for suicide, and 1.5% of Veterans were identified to be at High Risk. Brief CBT-CP was identified as safe, as no deaths (by suicide or otherwise) or suicidal behaviors were observed while Veterans engaged in the treatment sessions. In fact, following completion of Brief CBT-CP, a 24.2% reduction in relative risk of suicidal behaviors was observed in the overall sample. Brief CBT-CP was also tolerable, with nearly 90% of Veterans completing at least 4 sessions (n = 229). CONCLUSIONS: Brief CBT-CP appears to be a safe and well-tolerated treatment for Veterans with chronic noncancer pain who are also at risk for suicide.