Addressing Multimorbidity among Veterans with Stimulant Use Disorders

About This Grant

Background: There have been sharp increases in stimulant use disorder among Veterans nationally over the past twenty years, including co-occurring opioid and methamphetamine use disorder. Our previous research shows a high prevalence of multimorbidity among people who use stimulants, which has important implications for delivering healthcare for this high-risk population. Since 2011, the Veterans Health Administration (VHA) has prioritized the availability of contingency management (CM) programs for all Veterans with a stimulant use disorder as a standard of care. Meanwhile, several recent studies have been conducted or are being done to examine how CM may improve other health outcomes. However, limited work has been done to consider CM as a method for delivering integrated care for patients with multimorbidity. This study will fill this knowledge gap by examining patterns of multimorbidity and healthcare utilization among Veterans with stimulant use disorders to develop an integrated intervention to improve health outcomes for this population. Significance: Given the elevated risks of poor health outcomes among Veterans with stimulant use disorders, VHA must provide integrated interventions to address the complex needs of this population. This study directly responds to multiple priorities of the VHA, Health Systems Research, Office of Mental Health and Suicide Prevention, and Veterans Justice Programs (VJP) to improve the health delivery of this high-risk population. Innovation & Impact: Addressing multimorbidity among high-risk patient populations necessitates an integrated approach to care rather than disease-specific treatment. Veterans with stimulant use disorders have unique health needs, given the complex interplay between substance use disorders, mental illness, and medical multimorbidity. Improving health outcomes for this population involves innovative approaches that must be patient-centered and recognize the stigma related to SUDs. This study will utilize multidisciplinary expertise in geriatric and addiction medicine to develop innovative interventions to improve a vulnerable population's health and healthcare delivery. Specific Aims: The three aims are scientifically important and reflect input from Veterans and VHA staff: (1) To describe the prevalence and predictors of multiple chronic conditions, outpatient care fragmentation, and high acute healthcare utilization among Veterans with stimulant use disorders; (2) Adapt VA contingency management (CM) programs to integrate team-based intensive chronic disease management to improve health outcomes and reduce acute healthcare utilization among Veterans with stimulant use disorders; (3) Pilot test an intervention that integrates CM with intensive chronic disease management. Methodology: In Aim 1, we will conduct a retrospective longitudinal cohort study using VHA national data to describe comorbidities and identify predictors for high acute healthcare utilization among Veterans with stimulant use disorders (n=~177,714). For Aim 2, we will conduct qualitative interviews with 35 Veterans with stimulant use disorders and 45 VHA staff and providers and elicit expert feedback from our VHA operational partners to develop an intervention. Finally, Aim 3 will involve pilot testing an intervention coupled with CM programs for the treatment of stimulant use disorders. Next Steps/Implementation: The goal is to have a fully developed protocol for use in a multi-site randomized trial of an integrated model of care intervention to improve health outcomes among Veterans with stimulant use disorders within the VHA that will be evaluated in a subsequent IIR. An evidence-based integrated intervention to address multimorbidity among a high-risk Veteran patient population will have important implications for sustained care delivery for a high-risk patient population.