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1.  Predictors of Improvements in Pain Intensity in a National Cohort of Older Veterans with Chronic Pain 
Little is known about the factors associated with pain-related outcomes in older adults. In this observational study, we sought to identify patient factors associated with improvements in pain intensity in a national cohort of older veterans with chronic pain. We included 12,924 veterans receiving treatment from the Veterans Health Administration with persistently elevated numeric rating scale scores in 2010 who had not been prescribed opioids in the prior 12 months. We examined 1) percentage decrease over 12 months in average pain intensity scores relative to average baseline pain intensity score; and 2) time to sustained improvement in average pain intensity scores, defined as a 30% reduction in 3-month scores compared to baseline. Average relative improvement in pain intensity scores from baseline ranged from 25% to 29%; almost two-thirds met criteria for sustained improvement during the 12-month follow-up period. In models, higher baseline pain intensity and older age were associated with greater likelihood of improvement in pain intensity, while VA service-connected disability, mental health, and certain pain-related diagnoses were associated with lower likelihood of improvement. Opioid prescription initiation during follow-up was associated with lower likelihood of sustained improvement. The findings call for further characterization of heterogeneity in pain outcomes in older adults as well as further analysis of the relationship between prescription opioids and treatment outcomes.
doi:10.1016/j.jpain.2016.03.006
PMCID: PMC4925248  PMID: 27058162
Chronic pain; Veterans; Numeric Rating Scale; Aged; Analgesics; opioid
2.  Correlates of Suicide Among Veterans Treated in Primary Care: Case–Control Study of a Nationally Representative Sample 
Journal of General Internal Medicine  2014;29(Suppl 4):853-860.
ABSTRACT
BACKGROUND
Veterans receiving Veterans Affairs (VA) healthcare have increased suicide risk compared to the general population. Many patients see primary care clinicians prior to suicide. Yet little is known about the correlates of suicide among patients who receive primary care treatment prior to death.
OBJECTIVE
Our aim was to describe characteristics of veterans who received VA primary care in the 6 months prior to suicide; and to compare these to characteristics of control patients who also received VA primary care.
DESIGN
This was a retrospective case–control study.
SUBJECTS
The investigators partnered with VA operations leaders to obtain death certificate data from 11 states for veterans who died by suicide in 2009. Cases were matched 1:2 to controls based on age, sex, and clinician.
MAIN MEASURES
Demographic, diagnosis, and utilization data were obtained from VA’s Corporate Data Warehouse. Additional clinical and psychosocial context data were collected using manual medical record review. Multivariate conditional logistic regression was used to examine associations between potential predictor variables and suicide.
KEY RESULTS
Two hundred and sixty-nine veteran cases were matched to 538 controls. Average subject age was 63 years; 97 % were male. Rates of mental health conditions, functional decline, sleep disturbance, suicidal ideation, and psychosocial stressors were all significantly greater in cases compared to controls. In the final model describing men in the sample, non-white race (OR = 0.51; 95 % CI = 0.27–0.98) and VA service-connected disability (OR = 0.54; 95 % CI = 0.36–0.80) were associated with decreased odds of suicide, while anxiety disorder (OR = 3.52; 95 % CI = 1.79–6.92), functional decline (OR = 2.52; 95 % CI = 1.55–4.10), depression (OR = 1.82; 95 % CI = 1.07–3.10), and endorsement of suicidal ideation (OR = 2.27; 95 % CI = 1.07–4.83) were associated with greater odds of suicide.
CONCLUSIONS
Assessment for anxiety disorders and functional decline in addition to suicidal ideation and depression may be especially important for determining suicide risk in this population. Continued development of interventions that support identifying and addressing these conditions in primary care is indicated.
doi:10.1007/s11606-014-3028-1
PMCID: PMC4239287  PMID: 25355088
mental health; veterans; primary care; health services research
3.  Short-term Variability in Outpatient Pain Intensity Scores in a National Sample of Older Veterans with Chronic Pain 
Pain medicine (Malden, Mass.)  2014;16(5):855-865.
Objective
The Department of Veterans Affairs (VA) uses the 11-point pain numeric rating scale (NRS) to gather pain intensity information from veterans at outpatient appointments. Yet, little is known about how NRS scores may vary over time within individuals; NRS variability may have important ramifications for treatment planning. Our main objective was to describe variability in NRS scores within a one-month timeframe, as obtained during routine outpatient care in older patients with chronic pain treated in VA hospitals. A secondary objective was to explore for patient characteristics associated with within-month NRS score variability.
Design
Retrospective cohort study.
Subjects
National sample of veterans 65 years or older seen in VA in 2010 who had multiple elevated NRS scores indicating chronic pain.
Methods
VA datasets were used to identify the sample and demographic and clinical variables including NRS scores. For the main analysis, we identified subjects with 2 or more NRS scores obtained in each of 2 or more months in a 12 month period; we examined ranges in NRS scores across the first 2 qualifying months.
Results
Among 4,336 individuals in the main analysis cohort, the mean and median of the average NRS score range across the two months were 2.7 and 2.5, respectively. In multivariable models, main significant predictors of within-month NRS score variability were baseline pain intensity, overall medical comorbidity, and being divorced/separated.
Conclusions
The majority of patients in the sample had clinically meaningful variation in pain scores within a given month. This finding highlights the need for clinicians and their patients to consider multiple NRS scores when making chronic pain treatment decisions.
doi:10.1111/pme.12643
PMCID: PMC4439348  PMID: 25545398
Chronic pain; Veterans; Numeric Rating Scale; Aged
4.  Impact of Research Network Participation on the Adoption of Buprenorphine for Substance Abuse Treatment 
Addictive behaviors  2014;39(5):889-896.
There is a growing body of research supporting the use of buprenorphine and other medication assisted treatments (MATs) for the rapidly accelerating opioid epidemic in the United States. Despite numerous advantages of buprenorphine (accessible in primary care, no daily dosing required, minimal stigma), implementation has been slow. As the field progresses, there is a need to understand the impact of participation in practitioner-scientist research networks on acceptance and uptake of buprenorphine. This paper examines the impact of research network participation on counselor attitudes toward buprenorphine addressing both counselor-level characteristics and program-level variables using hierarchical linear modeling (HLM) to account for nesting of counselors within treatment programs. Using data from the National Treatment Center Study, this project compares privately funded treatment programs (n=345) versus programs affiliated with the National Institute on Drug Abuse Clinical Trials Network (CTN) (n=198). Models included 922 counselors in 172 CTN programs and 1,203 counselors in 251 private programs. Results of two-level HLM logistic (Bernoulli) models revealed that counselors with higher levels of education, larger caseloads, more buprenorphine-specific training, and less preference for 12-step treatment models were more likely to perceive buprenorphine as acceptable and effective. Furthermore, buprenorphine was 50% more likely to be perceived as effective among counselors working in CTN-affiliated programs as compared to private programs. This study suggests that research network affiliation positively impacts counselors’ acceptance and perceptions of buprenorphine. Thus, research network participation can be utilized as a means to promote positive attitudes toward the implementation of innovations including medication assisted treatment.
doi:10.1016/j.addbeh.2014.01.016
PMCID: PMC4063285  PMID: 24594902
Buprenorphine; research network participation; implementation
5.  Employing Policy and Purchasing Levers to Increase the Use of Evidence-Based Practices in Community-Based Substance Abuse Treatment Settings: Reports from Single State Authorities 
Evaluation and program planning  2011;34(4):366-374.
State public health authorities are critical to the successful implementation of science based addiction treatment practices by community-based providers. The literature to date, however, lacks examples of state level policy strategies that promote evidence-based practices (EBPs). This mixed-methods study documents changes in two critical state-to-provider strategies aimed at accelerating use of evidence-based practices: purchasing levers (financial incentives and mechanisms) and policy or regulatory levers. A sample of 51 state representatives was interviewed. Single State Authorities for substance abuse treatment (SSAs) that fund providers directly or through managed care were significantly more likely to have contracts that required or encouraged evidence-based interventions, as compared to SSAs that fund providers indirectly through sub-state entities. Policy levers included EBP-related legislation, language in rules and regulations, and evidence-based criteria in state plans and standards. These differences in state policy are likely to result in significant state level variations regarding both the extent to which EBPs are implemented by community-based treatment providers and the quality of implementation.
doi:10.1016/j.evalprogplan.2011.02.003
PMCID: PMC3670771  PMID: 21371753
evidence-based practices; implementation; evaluation; purchasing; policy
6.  Implementation of Evidence-Based Practices for Treatment of Alcohol and Drug Disorders: The Role of the State Authority 
The current climate of increasing performance expectations and diminishing resources, along with innovations in evidence-based practices (EBPs), creates new dilemmas for substance abuse treatment providers, policymakers, funders, and the service delivery system. This paper describes findings from baseline interviews with representatives from 49 state substance abuse authorities (SSAs). Interviews assessed efforts aimed at facilitating EBP adoption in each state and the District of Columbia. Results suggested that SSAs are concentrating more effort on EBP implementation strategies such as education, training, and infrastructure development, and less effort on financial mechanisms, regulations, and accreditation. The majority of SSAs use EBPs as a criterion in their contracts with providers, and just over half reported that EBP use is tied to state funding. To date, Oregon remains the only state with legislation that mandates treatment expenditures for EBPs; North Carolina follows suit with legislation that requires EBP promotion within current resources.
doi:10.1007/s11414-008-9122-6
PMCID: PMC3666827  PMID: 18543111
7.  Counselor Attitudes toward the Use of Buprenorphine in Substance Abuse Treatment: A Multi-level Modeling Approach 
In spite of evidence that buprenorphine is effective, safe, and offers greater access as compared with methadone, implementation for treatment of opiate dependence continues to be weak. Research indicates that legal and regulatory factors, state policies, and organizational and provider variables affect adoption of buprenorphine. This study uses hierarchical linear modeling (HLM) to examine National Treatment Center Study (NTCS) data to identify counselor characteristics (attitudes, training, beliefs) and organizational factors (accreditation, caseload, access to buprenorphine and other evidence-based practices) that influence implementation of buprenorphine for treatment of opiate dependence. Analyses showed that provider training about buprenorphine, higher prevalence of opiate dependent clients, and less treatment program emphasis on a 12-step model predicted greater counselor acceptance and perceived effectiveness of buprenorphine. Results also indicate that program use of buprenorphine for any treatment purpose (detoxification, maintenance, and/or pain management) and time (calendar year in data collection) were associated with increased diffusion of knowledge about buprenorphine among counselors and with more favorable counselor attitudes toward buprenorphine.
doi:10.1016/j.jsat.2011.05.005
PMCID: PMC3486698  PMID: 21821379
8.  Counselor Attitudes Toward the Use of Naltrexone in Substance Abuse Treatment: A Multi-level Modeling Approach 
Addictive behaviors  2011;36(6):576-583.
Although alcohol use disorders (AUDs) continue to be one of the most pervasive and costly of the substance use disorders (SUDs), evidence suggests that new medications provide effective treatment. However, adoption rates of these evidence-based practices (EBPs) remain low and have been explained by characteristics of treatment organizations and individual counselor’s attitudes and behaviors. Few studies have simultaneously examined the impact of organizational-level and counselor-level characteristics on counselor perceptions of EBPs. To address this gap in the literature, we use data from a national sample of 1,178 counselors employed in 209 privately funded treatment organizations to examine the effects of organizational and individual counselor characteristics on counselor attitudes toward tablet and injectable naltrexone. Results of hierarchical linear modeling (HLM) show that organizational characteristics (use of tablet/injectable naltrexone in the program, 12-step orientation) were associated with counselor perceptions of naltrexone. Net of organizational characteristics, several counselor level characteristics were associated with attitudes toward tablet and injectable naltrexone including gender, tenure in the field, recovery status, percentage of AUD patients, and receipt of medication-specific training. These findings reveal that counselor receptiveness toward naltrexone is shaped in part by the organizational context in which counselors are embedded.
doi:10.1016/j.addbeh.2011.01.030
PMCID: PMC3070850  PMID: 21382667
TABLET NALTREXONE; INJECTABLE NALTREXONE; ALCOHOL USE DISORDERS; MULTILEVEL MODELING

Results 1-8 (8)