Social factors are critical determinants of the chronic pain experience. Despite this, psychological interventions for pain largely ignore them as meaningful therapeutic targets. Relational demand, the tendency to prioritize the needs of others over self, is a barrier to effective pain self-management, particularly among women. CONNECT, a remote reciprocal peer support pain intervention tailored for women Veterans and based on cognitive behavioral principles, was enhanced to target relational demand via psychoeducational content and self-management strategies. The additional content is not commonly addressed in behavioral pain interventions. Thus, CONNECT was designed to bolster skills related to improvements in pain (intensity, interference) and relational demand. CONNECT used ecological momentary assessment (EMA) to measure demand-pain associations before, during and after the intervention among women Veterans with back pain. A mixed method design leveraging thrice daily momentary assessments over three two-week observation periods (N = 22) was used to (a) quantify the associations between relational demand and pain relevant variables (e.g., pain intensity, pain interference and mood) (b) estimate within-time associations among demand-pain variables to determine whether CONNECT attenuates them, c), explore changes in pain and relational demand following CONNECT and d) qualitatively elucidate the implications of relational factors in the experience of women Veterans with back pain. Relational demand was significantly and moderately correlated with pain intensity (r = .41, p = .006), pain interference (r = .45, p < .001) and mood (positive affect r = − .41, p = .006; negative affect r = .48, p < .001), at baseline. There was no evidence of a statistically significant change in the strength of these associations across the three observation periods. Exploratory analyses revealed a 24

Introduction: Social adversity is associated with hypertension (HTN) risk across the lifespan. Yet, it remains unclear whether area-based deprivation or individual-level social vulnerability (SV; from childhood and adulthood) has a stronger association. In women, HTN risk rises sharply post-menopause, but less is known about how social factors influence HTN in premenopausal women. The objective was to assess if area- and individual-level social factors are differentially associated with HTN risk in premenopausal women and same-aged men. Hypotheses: Area-based deprivation and individual-level SV would each be associated with greater risk of HTN, and associations would differ by sex. Methods: We used data from the CARDIA study, which recruited a biracial sample aged 18-30 in 1985-86, followed for 30 years. To target midlife, the baseline was set at Year 15, with up to 15 years of follow-up. Exclusions were prior HTN, cardiovascular disease, or menopause. The sample was 2196 adults (median age: 40 [IQR: 37,43], 59% women, 43% Black). HTN was defined as blood pressure ≥140 or ≥90 mmHg or antihypertensive use. Proportional hazards regression models for interval-censored data assessed prospective relations of the Area Deprivation Index (ADI; Census-level disadvantage), and SV (z-scored composite of early life trauma, discrimination, healthcare access, social support, neighborhood cohesion, and chronic burden), with incident HTN. ADI and SV were divided into quartiles (Q1=low, Q4=high), and analyses were sex-stratified. Covariates were CARDIA center, age, race, smoking, and body mass index (from Year 15). Results: Overall, 35% of men and 23% of women developed HTN over 5.7 and 5.5 average years. In unadjusted ADI analyses, men in Q3 had 38% greater HTN risk vs Q1, and women in Q2 and Q4 had 40% and 88% greater risk than those in Q1 (Table 1). After adjustment, ADI was only significant for women, as Q4 was associated with 73% greater HTN risk than Q1. In SV models, men in Q3 and Q4 had 80-90% greater HTN risk vs Q1; and women in Q4 had 50% greater risk vs Q1. After adjustment, SV Q3 and Q4 were still associated with 70-76% greater HTN risk for men, but not for women. Adding ADI to SV models did not alter results. Conclusions: Ultimately, area-based deprivation influenced midlife HTN risk in women, while individual-level SV factors were influential for men. Our findings feature the value of exploring sex-specific pathways linking social adversity to HTN.

Unique characteristics and service exposures of the post-9/11 cohort of U.S. Veterans can influence their sleep health and associated comorbidities. The objectives of this study were to learn about men and women post-9/11 Veterans' and "front line" VA providers' knowledge about sleep and experiences with Veterans Health Administration (VA) sleep management. One sample included post-9/11 Veterans who received VA care (n=23; 60% women; Mage: 45 y). To complement those views, primary care and mental health providers were recruited from VA medical centers (n=27). Semistructured qualitative interviews were conducted using Microsoft Teams. Questions pertained to sleep knowledge, care practices, and perceived barriers to sleep-related VA care. Interview data were synthesized with content analysis and inductive coding to characterize major themes. Four main themes emerged: (1) Sleep is viewed as foundational but Veterans and providers often have limited related knowledge and more routine education is needed. (2) Men and women have distinct sleep management needs. Relative to men, women are more likely to advocate for sleep assessment and for behavioral versus pharmacological treatment. (3) Sleep management practices vary considerably between clinics and providers. (4) Veterans and their providers each experience unique barriers to sleep management. Post-9/11 Veterans and providers view sleep as critical. Yet, VA sleep management needs to be more uniform. Providers are motivated to assess sleep but require standardized education and low-burden opportunities to incorporate sleep into their practice, perhaps with mental health screening. Ultimately, more specialized care is required to meet the responsibility of Veterans' sleep health.

Rationale: Veterans from contemporary conflicts faced numerous airborne particulate matter exposures. Assessments of the impact of these exposures on asthma prevalence and management and differences by sex are urgently needed. Among Veterans with an asthma diagnosis, we compared medication prescriptions, asthma-related comorbidities and 1-year emergency department (ED) visits by sex. Methods: In a national cohort of Veterans Affairs patients utilizing primary care between FY16-FY23, we identified patients with asthma via principal ICD-10 codes (J45.XX those with concurrent COPD diagnosis (J41-J44) were excluded. Demographics, medication prescription, smoking status, and comorbidities associated with asthma (i.e., allergic conditions, psychiatric diagnoses, gastrointestinal reflux disease (GERD)/esophagitis) were compared using descriptive statistics. Long-acting inhalers were categorized as “controller” medications; we also included biologics and oral medications used for asthma treatment. Our primary outcome was 1-year asthma-related ED visit using logistic regression, adjusting for relevant covariates. Results: Of 296,948 Veterans with asthma, 22% were women. Compared with men, women were younger (mean age 48 (SD=13) vs. 56 (SD=16) years), more likely to be black (33% vs. 19%), and more likely to be never-smokers (63% vs. 45%). Women were more likely to have allergies (21% vs. 15%), depression (32% vs. 18%), and PTSD (30% vs 21%). There was no difference by sex in GERD (19% for both). Women were statistically less likely to receive inhaled corticosteroid controllers than men, though the difference was small (43% vs. 45%), and more likely to receive leukotriene inhibitors (24% vs. 17%) (all p<0.0001). Use of any biologic was low (and did not vary with sex (0.5%). Women had more 1-year all-cause (33% vs. 25%) and asthma-specific ED visits (7% vs. 5%).Adjusting for age, race, smoking, and allergy-related diagnoses and medications, women had 33% increased risk for an ED visit (Odds ratio (OR) 1.33, 95% confidence limits [1.30-1.35]) (Table). Conclusion: Compared to men, women Veterans with asthma had more all-cause and asthma-specific ED visits, but were less likely to be on ICS medications. Suboptimal asthma treatment in women may contribute to increased ED utilization. Use of biologics was low in both sexes, suggesting underutilization in this cohort. Future work will evaluate how asthma severity, comorbidities, and the temporal relationship between treatments and ED visits modify these associations as well as factors associated with biologic prescription and how they vary by sex.

Introduction:Comorbid insomnia and obstructive sleep apnea (OSA, i.e., COMISA) are associated with cardiovascular disease (CVD) among older adults. It is unknown how the comorbidity is related to cardiovascular risk among younger military Veterans, who show a greater risk for hypertension and CVD than non-Veterans, and if associations differ by sex. Thus, we examined whether COMISA is associated with incident hypertension and CVD risk in younger men and women Veterans. Methods:The cohort included post-9/11 Veterans who enrolled in Veterans Health Administration care from 2001 to 2021. Administrative and electronic health record data were merged. Insomnia and OSA were defined by 2 outpatient International Classification of Diseases, 9 or 10 diagnoses. Hypertension was defined by ≥2 outpatient-coded diagnoses or ≥1 antihypertensive medication fill. CVD was defined by 1≥ inpatient or ≥2 outpatient diagnoses. Time-varying Cox proportional hazard models were adjusted for demographics, behavioral, and clinical factors and conducted overall and by sex. Results:Analyses included 937,598 Veterans (12% women; median age: 41 years). Greater hypertension risk was observed overall (adjusted hazard ratio [aHR]:2.43: 95%CI:2.36-2.50), for men (aHR:2.09, 95%CI:2.02-2.16) and women with COMISA (aHR:2.20, 95%CI:2.00-2.42), insomnia only (aHRs:1.27-1.44), and OSA only (aHRs:2.00-2.26) versus no sleep disorder. For incident CVD, COMISA was again associated with risk overall (aHR:3.81, 95%CI:3.64-3.99), in men (aHR:3.81, 95%CI:3.63-4.00), and women (aHR:3.44, 95%CI:2.98-3.98), as were insomnia (aHRs:1.36-1.37) and OSA (aHRs:3.32-2.62). Conclusions:For post-9/11 Veterans, COMISA was associated with the greatest risk of hypertension and CVD. Identifying disordered sleep among men and women should be a cardiovascular prevention priority.

BACKGROUND:Unique characteristics and service exposures of the post-9/11 cohort of U.S. Veterans can influence their sleep health and associated comorbidities. The objectives of this study were to learn about men and women post-9/11 Veterans' and "front line" VA providers' knowledge about sleep and experiences with Veterans Health Administration (VA) sleep management. RESEARCH DESIGN:One sample included post-9/11 Veterans who received VA care (n=23; 60% women; Mage: 45 y). To complement those views, primary care and mental health providers were recruited from VA medical centers (n=27). Semistructured qualitative interviews were conducted using Microsoft Teams. Questions pertained to sleep knowledge, care practices, and perceived barriers to sleep-related VA care. Interview data were synthesized with content analysis and inductive coding to characterize major themes. RESULTS:Four main themes emerged: (1) Sleep is viewed as foundational but Veterans and providers often have limited related knowledge and more routine education is needed. (2) Men and women have distinct sleep management needs. Relative to men, women are more likely to advocate for sleep assessment and for behavioral versus pharmacological treatment. (3) Sleep management practices vary considerably between clinics and providers. (4) Veterans and their providers each experience unique barriers to sleep management. CONCLUSIONS:Post-9/11 Veterans and providers view sleep as critical. Yet, VA sleep management needs to be more uniform. Providers are motivated to assess sleep but require standardized education and low-burden opportunities to incorporate sleep into their practice, perhaps with mental health screening. Ultimately, more specialized care is required to meet the responsibility of Veterans' sleep health.

Sleep disorders and chronic conditions that are comorbid with disordered sleep represent a high burden to the U.S. population, and Veterans have a particularly high risk for disordered sleep. Sleep disorders also present differently by sex and there is a rapidly growing proportion of women Veterans. Among the most recent Veteran cohort (i.e., discharged post-9/11), the extent of sleep disorders and how those conditions are managed is unknown. The objectives were to characterize the frequency of sleep assessment, diagnosis, and treatment among post-9/11 Veterans served by the Veterans Health Administration (VA), the timing of sleep management, and to determine if there were sex-based disparities in all sleep care. This prospective cohort study included all post-9/11 Veterans who enrolled in VA care, and completed ≥ 1 outpatient encounter, 10/1/2001–9/30/2021. Diagnostic and procedural codes, health factors, and dates were used to extract variables for assessment (e.g., behavioral, polysomnography), diagnoses (i.e., insomnia, sleep-related breathing [SRBD], comorbid insomnia and SRBD [COMISA], sleep-related movement [SRMD], or Other disorders), treatment of insomnia or SRBD, and time to sleep assessment, diagnosis, and treatment. Logistic regressions assessed likelihood of sleep care by sex. The final sample included 1,113,633 patients (12

Perinatal mental health conditions have been associated with adverse pregnancy outcomes, including maternal death. This quality improvement project analyzed pregnancy-associated death among veterans with mental health conditions in order to identify opportunities to improve healthcare and reduce maternal deaths. Pregnancy-associated deaths among veterans using Veterans Health Administration (VHA) maternity care benefits between fiscal year 2011 and 2020 were identified from national VHA databases. Deaths among individuals with active mental health conditions underwent individual chart review using a standardized abstraction template adapted from the Centers for Disease Control and Prevention (CDC). Thirty-two pregnancy-associated deaths were identified among 39,720 paid deliveries with 81% ( n = 26) occurring among individuals with an active perinatal mental health condition. In the perinatal mental health cohort, most deaths ( n = 16, 62%) occurred in the late postpartum period and 42% ( n = 11) were due to suicide, homicide, or overdose. Opportunities to improve care included addressing (1) racial disparities, (2) mental health effects of perinatal loss, (3) late postpartum vulnerability, (4) lack of psychotropic medication continuity, (5) mental health conditions in intimate partners, (6) child custody loss, (7) lack of patient education or stigmatizing patient education, and (8) missed opportunities for addressing reproductive health concerns in mental health contexts. Pregnancy-associated deaths related to active perinatal mental health conditions can be reduced. Mental healthcare clinicians, clinical teams, and healthcare systems have opportunities to improve care for individuals with perinatal mental health conditions.

Objective: There is ample evidence for associations among childhood family violence and adult intimate partner violence (IPV) use. This study was designed to examine potential differential associations between childhood physical abuse, childhood sexual abuse, witnessing parental IPV, posttraumatic stress symptom (PTSS) severity, and IPV use for veteran men and women. Method: Survey data from 825 veterans who participated in a longitudinal multisite investigation of post-9/11 veterans who completed measures of childhood family violence history, PTSS, IPV use, and experiences were used. Moderation analysis in hierarchical linear regression tested whether veteran men with childhood family violence had higher rates of IPV use than veteran women. A gender-stratified causal mediation was conducted to test whether PTSS severity mediated the relationships among childhood family violence types and IPV use for men and women. Results: Veteran women reported significantly higher rates of all forms of childhood family violence than men, but there were no significant gender differences in rates of reported IPV use. PTSS severity did not mediate the association between childhood family violence types and adult IPV use for men or women. For men PTSS severity was the only factor significantly positively associated with IPV use. Childhood sexual abuse was the only factor significantly positively associated with IPV use for women. Conclusions: These differential findings for veteran men and women support screening and intervention based on gender for veterans accessing the Veterans Affairs health care and the need for interventions that address childhood trauma, PTSS, and IPV within the Veterans Affairs health care system.

Background: Women veterans who experience certain conditions during pregnancy, such as gestational hypertension, pre-eclampsia, and gestational diabetes, are at increased risk of developing cardiovascular disease (CVD) later in life. Many women are unaware of this risk. Furthermore, women often face financial, socioeconomic, or physical challenges when trying to make healthy behavior modifications to reduce CVD risk.Objective: To examine Veterans' pregnancy-related cardiovascular (CV) risk conditions, risk identification, and risk communication with primary care providers.Research Design: Telephone/video interviews were conducted with female Veterans who had experienced at least one sex-specific CV risk condition during pregnancy. Interviews were recorded, transcribed, and analyzed using content analysis techniques. Major themes and representative quotes were derived.Results: Twenty-eight women Veterans participated in the study, conducted between October and December 2023. A majority of participants were racial/ethnic minorities, and the average age was 38. Four themes arose: (1) Veterans Affairs (VA) medical records may contain limited information regarding CV risk factors experienced during pregnancy; (2) strong relationships between Veterans and their VA primary care providers can facilitate management of CV risk factors following pregnancy; (3) some Veterans receive vague and/or conflicting recommendations for CV risk reduction following pregnancy; and (4) social determinants of health may play a key role in Veterans' ability to follow recommended CV risk reduction behaviors.Conclusions: Women Veterans with pregnancy-related CV risk conditions may not know that they are at increased risk of developing future CVD conditions, often because VA providers receive limited records from outside providers. Those who are aware often receive conflicting or vague recommendations to address these risk factors. When trying to follow CV health recommendations, many women have difficulty due to lack of finances, childcare, or safe areas. Future interventions should be aimed at improving access to medical records between outside and VA providers, patient education, and access to heart-healthy resources.

The present study describes intimate partner violence (IPV) perpetration and victimization alongside theoretically associated variables in a sample of lesbian, gay, and bisexual veterans. We conducted bivariate analyses (chi-square tests and independent t test) to examine whether the frequencies of IPV perpetration and victimization varied by demographic characteristics, military sexual trauma, alcohol use, and mental health symptoms. Out of the 69 lesbian, gay, and bisexual (LGB) veterans who answered the questions on IPV, 16 (23.2%) reported some form of IPV victimization in the past year, and 38 (55.1%) reported past-year perpetration. Among the 43 veterans who reported psychological IPV, roughly half (48.9%) reported bidirectional psychological IPV, 39.5% reported perpetration only, and 11.6% reported victimization only. LGB veterans who reported bidirectional psychological IPV in their relationships were younger and reported greater symptoms of posttraumatic stress disorder symptoms and depression. The results presented here call for universal screening of IPV perpetration and victimization to both accurately assess and ultimately intervene among all veterans. Inclusive interventions are needed for all genders and sexual orientations, specifically interventions that do not adhere to gendered assumptions of perpetrators and victims. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The majority of intimate partner violence (IPV) research is unidirectional, focusing on IPV use (i.e., perpetration) or experience (i.e., victimization). However, when IPV use and experience data are simultaneously included in analyses, bidirectional IPV often emerges as a common IPV pattern. The objective of this study was to examine patterns of IPV use and experience, risk factors that may be associated with these patterns, and potential gender differences within a sample of post-9/11 Veterans. This study included a national sample of post-9/11 Veterans ( N = 1,150; 50.3% women) who completed self-report measures at two timepoints. We performed a latent class analysis (LCA) to determine the appropriate number of IPV classes, conducted sensitivity analyses, and examined factors potentially associated with IPV class membership. We identified three distinct classes of IPV: Low to no IPV, Bidirectional Psychological IPV, and Bidirectional Multiform IPV. Men and women reported similar rates of IPV use and experience, and there were no gender differences in the LCA model. However, race and ethnicity, employment status, children in the household, marital status, child abuse or witnessing family violence, lifetime physical assault, posttraumatic stress symptoms, and binge drinking were differentially associated with class membership. This study extends existing knowledge on patterns of IPV among Veterans and factors associated with these patterns. Bidirectional IPV was the most common IPV pattern, underscoring the importance of examining IPV use and experience concurrently within research and clinical samples, and developing comprehensive IPV screening and treatment strategies that incorporate bidirectional IPV in work to advance relationship health and safety among Veterans.

Introduction: Military sexual trauma (MST) is more common among post-9/11 Veterans and women versus older Veterans and men. Despite mandatory screening, the concordance of electronic health record (EHR) documentation and survey-reported MST, and associations with health care utilization and mental health diagnoses, are unknown for this younger group.Materials and Methods: Veterans' Health Administration (VHA) EHR (2001-2021) were merged with data from the observational, nationwide WomenVeterans Cohort Study (collected 2016-2020, n = 1058; 51% women). Experiencing MST was defined as positive endorsement of sexual harassment and/or assault. From the EHR, we derived Veterans' number of primary care and mental health visits in the initial two years of VHA care and diagnoses of posttraumatic stress disorder (PTSD), depression, and anxiety. First, the concordance of EHR MST screening and survey-reported MST was compared. Next, multivariate analyses tested the cross-sectional associations of EHR screening and survey-reported MST with Veterans' health care utilization, and compared the likelihood of PTSD, depression, and anxiety diagnoses by MST group, while covarying demographics and service-related characteristics. With few MST cases among men, multivariate analyses were only pursued for women.Results: Overall, 29% of women and 2% of men screened positive for MST in the EHR, but 64% of women and 9% of men had survey-reported MST. Primary care utilization was similar between women with concordant, positive MST reports in the EHR and survey versus those with survey-reported MST only. Women with survey-reported MST only were less likely to have a PTSD or depression diagnosis than those with concordant, positive MST reports. There was no group difference in women's likelihood of anxiety.Conclusions: EHR MST documentation is discordant for many post-9/11 Veterans-both for men and women. Improving MST screening and better supporting MST disclosure are each critical to provide appropriate and timely care for younger Veterans, particularly women.

Introduction: Insomnia and obstructive sleep apnea (OSA) each increase risk for hypertension (HTN). Among older adults, there is a negative synergistic association of comorbid insomnia and OSA (i.e., COMISA) on incident cardiovascular disease (CVD) but it is unknown if this comorbidity is associated with HTN risk earlier in the lifespan. Research Questions: 1) Is COMISA associated with incident HTN among younger adults? 2) Do COMISA-HTN associations differ by sex? Hypotheses: We hypothesized that 1) COMISA would be associated with a greater risk of HTN than having no sleep disorder, 2) the hazard would be larger than for insomnia and OSA alone, and 3) distinct COMISA-HTN associations would be observed among men and women, respectively. Methods: Analyses included Veterans who enrolled in Veterans Health Administration (VA) care 2001-2021, a group selected because of its early adult age distribution. We merged administrative data, including outpatient and inpatient encounters, diagnoses, (ICD-9-CM/10 codes/dates) and pharmacy records. Veterans without demographic data, a history of other sleep disorders or CVD, or <2 clinical encounters were excluded. Sleep disorders were defined by 1 inpatient or ≥2 outpatient encounters. HTN was defined by 1 inpatient or ≥2 outpatient encounters and/or ≥1 antihypertensive medication fill. Time-varying Cox proportional hazard models were adjusted for sociodemographic, behavioral/lifestyle, and clinical factors, and stratified analyses by sex. We used multiple imputation to address missing data. Results: Analyses included 1,293,165 Veterans (12% women; mean age 32.8) with an average follow-up of 7.6 years. Men with COMISA showed a 19% greater risk of HTN vs. no sleep diagnosis (95% CL: 1.17-1.20). Risks were slightly lower – but still significant – for men with only insomnia (HR:1.08 [95% CL: 1.06-1.09]) or only OSA (HR:1.15 [95% CL: 1.13-1.16]). Women with COMISA had a 21% greater risk of HTN vs. those without a sleep diagnosis (95% CL: 1.16-1.26), and those with insomnia (HR:1.15 [95% CL: 1.11-1.19]) or OSA (HR:1.13 [95% CL: 1.09-1.17]) showed a lower, though still significant risk. Conclusion: In this younger group, Veterans with COMISA had a 19-21% greater risk of HTN than without a disorder, and this risk was similar by sex and slightly higher than that attributable to insomnia or OSA alone. Increased identification of disordered sleep among younger adults should be a cardiovascular prevention priority.

Objective: Failure to "make weight" carries significant consequences for military personnel including additional training burdens, stigma, possible demotion, or even separation from service. The aim of this study was to examine potential gender differences in, and investigate relationships between, military making weight behavior and obesity, eating pathology, and mental health later in life. Method: Iraq and Afghanistan war era Veterans (N = 1,126, 51.8% women) completed the Making Weight Inventory (MWI), a measure of making weight behaviors engaged in during military service, and validated measures of eating behavior and mental health. Analyses compared participants who engaged in at least one making weight behavior (MWI+) versus those who did not (MWI-). Results: Overall, 41% (n = 462) of the sample was categorized as MWI+. The most frequently endorsed making weight behavior was excessive exercise (35.7%). Among those who were MWI+, there was a significantly greater proportion of women (58.2% versus 47.3%, p < 0.001). The MWI+ group had higher rates of obesity (52.4% versus 26.2%) and had significantly higher levels of dietary restraint, emotional eating, food addiction, depression, anxiety, and posttraumatic stress disorder than the MWI- group (p's < 0.001). Conclusions: Military making weight behavior was associated with female gender, higher weight, eating pathology, and mental health later in life. Collectively, these findings suggest these factors may place female service members at a disadvantage for career advancement and salary. Efforts to better understand and address extreme making weight efforts in military populations, particularly in female service members and Veterans, are warranted.

BACKGROUND:Veterans transitioning to civilian life often have chronic pain from service-related musculoskeletal disorders (MSD) with higher risk for substance misuse. Many seek VA (Department of Veterans Affairs) compensation for MSD. Use of Screening, Brief Intervention, and Referral to Treatment for Pain Management (SBIRT-PM) by VA Post-9/11 Military2VA (M2VA) case managers presents an opportunity to engage these veterans in VA pain care and address substance misuse. Implementation facilitation might help case managers use SBIRT-PM and engage veterans in services to improve outcomes. DESIGN:This study is a 2-cohort multisite cluster-randomized hybrid type 2 effectiveness-implementation trial. Within 2 separate cohorts of 14 VA sites each, sites will be allocated to receive an implementation strategy through the use of a constrained randomization procedure: virtual implementation facilitation or training-as-usual. Sites and M2VA case managers will receive the assigned implementation strategy to support use of SBIRT-PM. Recently discharged veterans (n = 1848) claiming service-connected MSD will be recruited, with case managers blind to veterans' study enrollment. The proportion of participants who receive any SBIRT-PM will be the primary implementation outcome. Veteran participants will complete baseline, 12-week, and 36-week assessments, irrespective of whether case managers conduct SBIRT-PM with them (intent-to-treat). Pain intensity and interference will be the primary clinical outcomes. The study emphasizes pragmatic over explanatory methodological features. SUMMARY:This pragmatic trial will examine implementation facilitation versus training-as-usual in implementing SBIRT-PM to promote veteran engagement in nonpharmacological pain services. Using innovative methods to train and support VA case managers in SBIRT-PM, study outcomes could have broad implications for case management systems of care across the VA.

Background Opioids may play a part in the development of atrial fibrillation (AF). Understanding the relationship between opioid exposure and AF can help providers better assess the risk and benefits of prescribing opioids.Objective To assess the incidence of AF as a function of prescribed opioids and opioid type.Design We performed unadjusted and adjusted time-updated Cox regressions to assess the association between opioid exposure and incident AF.Participants The national study sample was comprised of Veterans enrolled in the Veterans Health Administration (VHA) who served in support of post-9/11 operations.Main measures The main predictor of interest was prescription opioid exposure, which was treated as a time-dependent variable. The first was any opioid exposure (yes/no). Secondary was opioid type. The outcome, incident AF, was identified through ICD-9-CM diagnostic codes at any primary care visit after the baseline period.Key results A total of 609,763 veterans (mean age: 34 years and 13.24% female) were included in our study. Median follow-up time was 4.8 years. Within this cohort, 124,395 veterans (20.40%) were prescribed an opioid. A total of 1,455 Veterans (0.24%) were diagnosed with AF. In adjusted time-updated Cox regressions, the risk of incident AF was higher in the veterans prescribed opioids (hazard ratio [HR]: 1.47; 95% confidence interval [CI]: 1.38-1.57). In adjusted time-updated Cox regressions, both immunomodulating and nonimmunomodulating opioid type was associated with increased risk of incident AF (HR: 1.40; 95% CI: 1.25-1.57 and HR: 1.49; 95% CI: 1.39-1.60), compared to no opioid use, respectively.Conclusions Our findings suggest opioid prescription may be a modifiable risk factor for the development of AF. (Am Heart J 2024;268:61-67.)