Longitudinal Military Health System data were analyzed from redeployed active duty Army service members (n=15,544) who were assigned to Warrior Transition Units (WTUs), FY2008-2015, to identify factors predicting OUD treatment.

1. Longitudinal Analysis of Factors Predicting Receipt of Treatment for Opioid Use Disorder in Redeployed
Army Service Members assigned to Warrior Transition Units, FY2008-2015
Nikki R. Wooten, PhD, LISW-CP1 , Akhtar Hossain, MS2, Diana D. Jeffery, PhD3, Christopher Spevak, MD, MPH, JD4,5, Mary Jo Larson, PhD6
1College of Social Work, University of South Carolina, Columbia SC. 2Arnold School of Public Health, University of South Carolina, Columbia SC. 3Defense Health Agency, U. S. Department of Defense, Falls Church, VA.
4Walter Reed National Military Medical Center, Bethesda MD. 5Georgetown University School of Medicine, Washington DC. 6Institute of Behavioral Health, Brandeis University, Waltham MA.
Funded by the National Institute on Drug Abuse #K01DA037412
 Military service members deployed to Afghanistan and Iraq may return with
severe physical injuries requiring pain management with prescription opioids.
 Service members who return from deployment with debilitating physical and
psychological injuries requiring health care for 30 days or more receive
comprehensive care, patient-centered care coordination, and complex case
management in Warrior Transition Units (WTUs), which are co-located with
major military treatment facilities (e.g. Walter Reed National Military Medical
Center). WTUs provide a Triad of Care involving a primary care physician,
nurse case manager, and a military leadership team.
 Service members receiving comprehensive health care in WTUs may be at
increased risk for opioid use disorder (OUD) and need treatment for opioid
use disorder (OUDT) if they have multiple injuries, comorbid conditions, and
prescription drug polypharmacy.
 The need for OUDT is a significant concern for the Military Health System
(MHS) given the potential for OUD to result in physical and psychological
impairment, opioid overdose, and accidental death. OUDT is also associated
with increased health care costs and health service utilization.
 Identifying physical and behavioral health factors predicting receipt of OUDT
among WTU members is critical to ensuring military and deployment
readiness, and preventing opioid overdose and opioid-related mortality.
 This study identified factors predicting receipt of treatment for opioid use
disorder by Army service members who were assigned to WTUs after
returning from Operations Enduring Freedom or Iraqi Freedom (OEF/OIF)
deployments between FY2008-2015.
BACKGROUND
This study was funded by the National Institute on Drug Abuse (NIDA
#K01DA037412, PI: Dr. Wooten, nwooten@sc.edu). Data are from the
Department of Defense Military Health System Data Repository. Dr.
Jeffery is the Defense Health Agency’s project officer who sponsored
access to these data. Laura Hopkins of Kennell & Associates, Inc.
created data extracts utilized for this study. The opinions and assertions
herein are those of the authors and do not necessarily reflect the official
views of the U. S. Department of Defense, NIDA, the Defense Health
Agency, or the National Institutes of Health.
ACKNOWLEDGEMENTS
 A small proportion of Army service members
received OUDT during post-deployment
while assigned to a WTU. However, they
were frequent users of OP and costly ED
services and those diagnosed with PTSD
were often treated for comorbid conditions.
 An overwhelming majority received a
behavioral health diagnosis (91.1%) and/or
behavioral health treatment (82.5%) prior to
WTU assignment. They also had high rates
of adjustment, anxiety, and drug use
disorders, musculoskeletal injuries, and
prescription opioid polypharmacy use.
 These ill and injured WTU members received
opioid polypharmacy and thus, benefit from
comprehensive care, case management, and
specialty substance abuse treatment.
 Targeted prevention strategies and enhanced
monitoring protocols for high risk opioid use
and opioid polypharmacy designed for WTU
members with a history of OUD, chronic
pain, DUD, and hospitalizations may result in
early identification of prescription opioid
misuse and reduce their need OUDT.
 MHS opioid safety initiatives involving more
frequent monitoring of opioid therapy and
polypharmacy after hospital discharge may
also be a preventive measure. Training of
Warrior Transition Clinic health care teams in
clinical decision making protocols for high
risk polypharmacy and chronic pain in WTU
members at risk for or diagnosed with OUD
may also result in early intervention.
 Having TRICARE coverage for more than 10
years and being deployed for less than 12
months during OEF/OIF may be factors that
reduce odds of receiving OUDT while
assigned to a WTU during post-deployment.
Increasing access to military health care may
be a preventive measure for Army National
Guard and Reservists who may have
received TRICARE for 9 months or more for
the first time in their military career after
being activated for OEF/OIF.
DISCUSSION
 Sample: All MHS medical claims between WTU begin and end dates for a
retrospective cohort of Army service members who were assigned to WTUs
after returning from OEF/OIF deployments between FY2008-2015.
 Outcome: Receipt of OUDT was identified if OUD was the primary diagnosis
on a MHS medical claim for any inpatient (IP), outpatient (OP), or emergency
department (ED) visit between WTU begin and end dates for each member.
 WTU index deployment was identified by the deployment with an end date
immediately prior to the first WTU begin date. WTU assignment timing was
relative to the WTU index deployment end date (before deployment end date,
<90 days post-deployment, >90 days post-deployment). Time was measured
from WTU begin date to each medical visit during WTU assignment.
 Diagnoses before WTU begin date: Any mental health disorder; alcohol
use, opioid use, or drug use (minus OUD) disorders defined by ICD-9 codes.
 Variables measured at WTU begin date: Demographics (sex, age, race,
marital and single parent status). Military factors (military service component,
military rank, total number of years of TRICARE coverage since FY2002).
Deployment factor (total number of months deployed since FY2002).
 Diagnoses within 90 days after WTU begin date: Physical health included
any diagnoses for sleep, chronic pain, musculoskeletal injuries, amputations,
blindness, traumatic brain injury, and overdose. Behavioral health included
adjustment, mood, PTSD, and anxiety. Service use during WTU assignment
included opioid polypharmacy use (>4 prescriptions including >1 opioid
prescriptions in the past 30 days at each visit) and visit type (IP, OP, ED).
 A total of 25,385 patients and 4,660,064 visits were included in analyses.
Both patients (descriptives) and visits (GEE model) were units of analysis.
METHODS
RESULTS
530 (2.1%) of redeployed Army service members who were assigned to a WTU between FY2008-2015 received OUDT during 8,648 MHS visits. They averaged 5.5 (sd=6.8) ED
visits/year, 1.6 (sd=2) hospitalizations/year, and 20.7 (sd=8.4) OP visits/month. Of these Army WTU members, 28.1% received an OUD diagnosis before WTU assignment and
38.7% received an OUD diagnosis within 90 days after WTU assignment. Most were Active duty (67.2%), male (94.5%), White (93.4%), ages 18-39 (86.6%), enlisted (96%), had
deployed for 12 months or more during OEF/OIF (53.6%), and were assigned to a WTU more than 90 days after their WTU index deployment ended (54.9%).
Adjustment (71.7%) and anxiety (78.1%) disorders were the most prevalent mental health diagnoses and musculoskeletal injuries (88.9%) were the most prevalent physical
health diagnoses received within 90 days after WTU assignment. Only 3.6% were treated for an overdose, but 68.7% had prescription opioid polypharmacy use. Almost all had
either a mental health or substance use disorder (91.1%) prior to WTU assignment and 82.5% had received behavioral health treatment prior to WTU assignment. A substantial
proportion had comorbid conditions, which included PTSD and prescription opioid polypharmacy use (35.7%), PTSD and drug use disorder (DUD; 34.7%), chronic pain and
prescription opioid polypharmacy use (33.0%), PTSD and mood disorders (32.1%), and PTSD and OUD (24.7%).
71.7
78.1
46.6 50.9
55.7
26
62.6
39.3
88.9
39.3
0
10
20
30
40
50
60
70
80
90
100
ADJUSTMENT ANXIETY MOOD PTSD SLEEP ALCOHOL USE DX DRUG USE DX TBI MUSCULOSKELETAL CHRONIC PAIN
GENERALIZED ESTIMATING EQUATIONS PREDICTING TREATMENT FOR OPIOID USE DISORDER IN ARMY SERVICE MEMBERS ASSIGNED TO
WARRIOR TRANSITION UNITS
% of U. S. Army WTU
members receiving
OUDT, FY2008-2015
 Being deployed for 12 months or more
during OEF/OIF increased odds of OUDT
by 84% (OR: 1.84, 95% CI: 1.04-3.25)
compared to being deployed for less
than 12 months during OEF/OIF.
 TRICARE coverage for 4 years or less
during OEF/OIF resulted in 3.71 greater
odds of receiving OUDT than having
TRICARE coverage for 10+ years.
 Being hospitalized while assigned to a
WTU or being diagnosed with a DUD
within 90 days after WTU assignment
resulted in more than twice the odds of
receiving OUDT than not having this
history.
 Receiving behavioral health treatment
prior to WTU assignment reduced the
likelihood of receiving OUDT than not
having this treatment history.
 Being treated for OUD before WTU
assignment along with treatment for
chronic pain within 90 days after WTU
assignment resulted in 3.60 greater odds
of receiving OUDT compared to not
having this treatment history.
 For every month of treatment while
assigned to a WTU, being treated for
PTSD within 90 days after WTU
assignment reduced odds (OR: 0.97,
95% CI: 0.95-0.99) of receiving OUDT
and OUDT before WTU assignment
increased odds (OR: 1.05, 95% CI: 1.01-
1.09) of receiving OUDT while in a WTU
compared to not having this history.
PHYSICAL & BEHAVIORAL HEALTH DIAGNOSES WITHIN 90 DAYS AFTER WARRIOR TRANSITION UNIT ASSIGNMENT IN ARMY MEMBERS RECEIVING TREATMENT FOR OPIOID USE DISORDER
DESCRIPTION OF ARMY MEMBERS RECEIVING TREATMENT FOR OPIOID USE DISORDER WHILE ASSIGNED TO WARRIOR TRANSITON UNITS
***p < .0001. **p < .005. *p < .05.
GEE model also adjusted for race, military rank, marital status, single parent, and any mental health disorder before WTU assignment.
***p < .0001. **p < .005. *p < .05.
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