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Kim HK, Kaduri P, Buckley L, Tang VM, Beyraghi N. Factors associated with presentation to the emergency department during an intensive post-discharge intervention in patients with substance use disorders. J Psychiatr Res 2024; 178:278-282. [PMID: 39173452 DOI: 10.1016/j.jpsychires.2024.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 08/02/2024] [Accepted: 08/14/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND Early identification of patients with substance use disorders (SUDs) with a higher risk of emergency department (ED) presentations after being discharged can be useful. We performed a chart review of patients from the Intensive Recovery Discharge Team (IRDT) program, which provides two weeks of outpatient support for patients with SUDs discharged from a mental health hospital. METHOD Demographic, service utilization, and clinical data from 716 patients enrolled in IRDT from February 2021-February 2023 were extracted from electronic health records. Receiver operating characteristic (ROC) analysis was performed to identify risk factors associated with increased ED presentations during the two weeks of IRDT follow-up with five-fold cross validation. RESULTS In two years, 10.7% of IRDT patients presented to the ED during the 2 weeks of follow-up. Having been enrolled in IRDT more than once, not having opioid use disorder (OUD), and self-identifying as male was associated with ED presentations, where an average of 20.1% of patients with all three risk factors presented to the ED. The presence of comorbid mental disorders did not emerge as a significant predictor. DISCUSSION Our results suggest that patients who had previous inpatient admissions, a SUD other than OUD, and/or self-identify as male have a higher risk of presenting to the ED post-discharge and may benefit from more intensive follow-up. Larger studies involving multiple sites are required to validate the generalizability of our findings. Findings from our study can be used to guide future studies examining post-discharge programs in patients with SUDs with and without comorbid mental disorders.
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Affiliation(s)
- Helena K Kim
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Pamela Kaduri
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Addictions Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Leslie Buckley
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Addictions Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Victor M Tang
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Addictions Division, Centre for Addiction and Mental Health, Toronto, ON, Canada; Institute for Medical Science, Temerty Faculty of Medicine, University of Toronto, Canada; Centre for Addiction and Mental Health, Campbell Family Mental Health Research Institute, Toronto, ON, Canada; Centre for Addiction and Mental Health, Temerty Centre for Therapeutic Brain Intervention, Toronto, ON, Canada; Institute of Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Narges Beyraghi
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Addictions Division, Centre for Addiction and Mental Health, Toronto, ON, Canada.
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Stubbs JM, Chong S, Achat HM. Identifying Patients at Risk of Not Receiving Timely Community Mental Health Follow-Up After Psychiatric Hospitalisation Using Linked Routinely Collected Data. J Behav Health Serv Res 2024:10.1007/s11414-024-09910-6. [PMID: 39317857 DOI: 10.1007/s11414-024-09910-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2024] [Indexed: 09/26/2024]
Abstract
Timely receipt of community-based follow-up after inpatient psychiatric discharge is associated with positive outcomes. This retrospective cross-sectional study aimed to identify socio-demographic and clinical factors associated with failure to receive community mental health follow-up within 7 days. Routinely collected hospital and community mental health data were linked for all inpatients discharged with a mental health condition in 2017 to 2019 in a local health district in New South Wales, Australia. Of the 8780 patients discharged, 28% (n = 2466) did not have 7-day follow-up. Males were significantly more likely than females to fail follow-up. Adjusted logistic regression analyses revealed that both male and female patients aged 65 years and older were generally less likely to fail follow-up than those who were younger; conversely, patients referred to a hospital by a law enforcement agency and those who left the hospital at their own risk were more likely to fail follow-up. Other factors significantly related to failure to follow-up varied between the sexes. Improved outcomes may be achieved by enhancing the transition from inpatient to outpatient care through targeted strategies aimed at patients who are more likely to disengage with care.
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Affiliation(s)
- Joanne M Stubbs
- Epidemiology and Health Analytics, Research and Education Network, Western Sydney Local Health District, New South Wales, 5 Fleet Street, North Parramatta, 2151, Australia.
| | - Shanley Chong
- Epidemiology and Health Analytics, Research and Education Network, Western Sydney Local Health District, New South Wales, 5 Fleet Street, North Parramatta, 2151, Australia
| | - Helen M Achat
- Epidemiology and Health Analytics, Research and Education Network, Western Sydney Local Health District, New South Wales, 5 Fleet Street, North Parramatta, 2151, Australia
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Shearer RD, Bart G, Beebe TJ, Virnig BA, Shippee ND, Winkelman TNA. Cross sectional analysis of an addiction consultation service, substance co-use patterns, and receipt of medications for opioid use disorder during hospitalization. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 167:209505. [PMID: 39241929 DOI: 10.1016/j.josat.2024.209505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 06/19/2024] [Accepted: 08/27/2024] [Indexed: 09/09/2024]
Abstract
INTRODUCTION Despite effective medications for opioid use disorder (MOUD), treatment engagement remains low. As the overdose crisis is increasingly characterized by opioids co-used with other substances, it is important to understand whether existing models effectively support treatment for patients who use multiple substances. Hospital-based addiction consultation services (ACS) have shown promise at increasing MOUD initiation and treatment engagement, but the effectiveness for patients with specific co-use patterns remains unknown. METHODS Using 2016-2023 admissions data from a large safety net hospital, we estimated a random-effects logistic regression model to determine whether specific co-use (methamphetamine, cocaine, alcohol, sedative, and other) moderated the effect of being seen by ACS on the receipt of MOUD. Adjusting for patient sociodemographic, health, and admission characteristics we estimated the proportion of patients who received MOUD across specific co-use groups. RESULTS Of 7679 total admissions indicating opioid use, of which 5266 (68.6 %) indicated co-use of one or more substances and 2387 (31.1 %) were seen by the ACS. Among admissions not seen by the ACS, a smaller proportion of admissions with any co-use received MOUD (23.5 %; 95 % CI: 21.9-25.1) compared to admissions with opioid use alone (34.0 %; 95 % CI: 31.9-36.1). However, among admissions seen by the ACS a similar proportion of admissions with any co-use received MOUD (57.8 %; 95 % CI: 55.5-60.1) as admissions with opioid use alone (56.2 %; 95 % CI: 52.2-60.2). The increase in proportion of admissions receiving MOUD associated with being seen by the ACS was larger for admissions with methamphetamine (38.6 percentage points; 95 % CI: 34.6-42.6) or cannabis co-use (39.0 percentage points; 95 % CI: 32.9-45.1) compared to admissions without methamphetamine (25.7 percentage points; 95 % CI: 22.2-29.2) or cannabis co-use (29.1 percentage points; 95 % CI: 26.1-32.1). CONCLUSIONS The ACS is an effective hospital-based treatment model for increasing the proportion of admissions which receive MOUD. This study shows that ACSs are also able to support increased receipt of MOUD for patients who use other substances in addition to opioids. Future research is needed to further understand what transition strategies best support treatment linkage for patients who use multiple substances.
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Affiliation(s)
- Riley D Shearer
- University of Minnesota School of Public Health, 420 Delaware St SE, Mayo Building B681, Minneapolis, MN 55455, USA; Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, 701 Park Ave., Suite PP7.700, Minneapolis, MN 55415, USA.
| | - Gavin Bart
- Division of Addiction Medicine, Department of Medicine, Hennepin Healthcare, 900 S 8(th) St, Minneapolis, MN 55415, USA
| | - Timothy J Beebe
- University of Minnesota School of Public Health, 420 Delaware St SE, Mayo Building B681, Minneapolis, MN 55455, USA
| | - Beth A Virnig
- College of Public Health and Health Professions, University of Florida, 1225 Center Drive, Gainsville, FL 32611, USA
| | - Nathan D Shippee
- University of Minnesota School of Public Health, 420 Delaware St SE, Mayo Building B681, Minneapolis, MN 55455, USA
| | - Tyler N A Winkelman
- Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, 701 Park Ave., Suite PP7.700, Minneapolis, MN 55415, USA; Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, 716 S 7(th) St, Minneapolis, MN 55415, USA
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Incze MA, Huebler S, Szczotka K, Grant S, Kertesz SG, Gordon AJ. Expert Panel Consensus on the Effectiveness and Implementation of Models to Support Posthospitalization Care Transitions for People With Substance Use Disorders. J Addict Med 2024:01271255-990000000-00371. [PMID: 39221815 DOI: 10.1097/adm.0000000000001369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
OBJECTIVES Hospitals are increasingly offering treatment for substance use disorders (SUDs) during medical admissions. However, there is a lack of consensus on the best approach to facilitating a successful transition to long-term medical and SUD care after hospitalization. We aimed to establish a hierarchy of existing SUD care transition models in 2 categories-effectiveness and implementation-using an expert consensus approach. METHODS We conducted a modified online Delphi study that convened 25 interdisciplinary clinicians with experience facilitating posthospitalization care transitions for patients with SUD. Panelists rated 10 prespecified posthospitalization care transition models according to 6 criteria concerning each model's anticipated effectiveness (eg, linkage to care, treatment retention) and implementation (eg, feasibility, acceptability). Ratings were made on a 9-point bidirectional scale. Group consensus was determined using the interpercentile range adjusted for symmetry. RESULTS After 3 rounds of the Delphi process (96% retention across all 3 rounds), consensus was reached on all 60 rating criteria. Interdisciplinary addiction consult teams (ACTs) and in-reach from partnering outpatient clinics were rated highest for effectiveness. Interdisciplinary ACTs and bridge clinics were rated highest for implementation. Screening, brief intervention, and referral to treatment; protocol implementation; and postdischarge outreach received the lowest ratings overall. Feasibility of implementation was perceived as the largest challenge for all highly rated models. CONCLUSIONS An expert consensus approach including diverse clinician stakeholders found that interdisciplinary ACT, in-reach from partnering outpatient clinics, and bridge clinics had the greatest potential to enhance posthospitalization care transitions for patients with SUD when considering both perceived effectiveness and implementation.
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Affiliation(s)
- Michael A Incze
- From the Division of General Internal Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT (MAI); Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA); Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT (MAI, SH, KS, AJG); Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT (SH, KS, AJG); University of Oregon, Eugene, OR (SG); and Birmingham Alabama Veterans Affairs Health Care System and University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL (SGK)
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McNeely J, Wang SS, Rostam Abadi Y, Barron C, Billings J, Tarpey T, Fernando J, Appleton N, Fawole A, Mazumdar M, Weinstein ZM, Kalyanaraman Marcello R, Dolle J, Cooke C, Siddiqui S, King C. Addiction Consultation Services for Opioid Use Disorder Treatment Initiation and Engagement: A Randomized Clinical Trial. JAMA Intern Med 2024; 184:1106-1115. [PMID: 39073796 PMCID: PMC11287446 DOI: 10.1001/jamainternmed.2024.3422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 05/29/2024] [Indexed: 07/30/2024]
Abstract
Importance Medications for opioid use disorder (MOUD) are highly effective, but only 22% of individuals in the US with opioid use disorder receive them. Hospitalization potentially provides an opportunity to initiate MOUD and link patients to ongoing treatment. Objective To study the effectiveness of interprofessional hospital addiction consultation services in increasing MOUD treatment initiation and engagement. Design, Setting, and Participants This pragmatic stepped-wedge cluster randomized implementation and effectiveness (hybrid type 1) trial was conducted in 6 public hospitals in New York, New York, and included 2315 adults with hospitalizations identified in Medicaid claims data between October 2017 and January 2021. Data analysis was conducted in December 2023. Hospitals were randomized to an intervention start date, and outcomes were compared during treatment as usual (TAU) and intervention conditions. Bayesian analysis accounted for the clustering of patients within hospitals and open cohort nature of the study. The addiction consultation service intervention was compared with TAU using posterior probabilities of model parameters from hierarchical logistic regression models that were adjusted for age, sex, and study period. Eligible participants had an admission or discharge diagnosis of opioid use disorder or opioid poisoning/adverse effects, were hospitalized at least 1 night in a medical/surgical inpatient unit, and were not receiving MOUD before hospitalization. Interventions Hospitals implemented an addiction consultation service that provided inpatient specialty care for substance use disorders. Consultation teams comprised a medical clinician, social worker or addiction counselor, and peer counselor. Main Outcomes and Measures The dual primary outcomes were (1) MOUD treatment initiation during the first 14 days after hospital discharge and (2) MOUD engagement for the 30 days following initiation. Results Of 2315 adults, 628 (27.1%) were female, and the mean (SD) age was 47.0 (12.4) years. Initiation of MOUD was 11.0% in the Consult for Addiction Treatment and Care in Hospitals (CATCH) program vs 6.7% in TAU, engagement was 7.4% vs 5.3%, respectively, and continuation for 6 months was 3.2% vs 2.4%. Patients hospitalized during CATCH had 7.96 times higher odds of initiating MOUD (log-odds ratio, 2.07; 95% credible interval, 0.51-4.00) and 6.90 times higher odds of MOUD engagement (log-odds ratio, 1.93; 95% credible interval, 0.09-4.18). Conclusions This randomized clinical trial found that interprofessional addiction consultation services significantly increased postdischarge MOUD initiation and engagement among patients with opioid use disorder. However, the observed rates of MOUD initiation and engagement were still low; further efforts are still needed to improve hospital-based and community-based services for MOUD treatment. Trial Registration ClinicalTrials.gov Identifier: NCT03611335.
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Affiliation(s)
- Jennifer McNeely
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Scarlett S. Wang
- New York University Robert F. Wagner Graduate School of Public Service, New York
| | - Yasna Rostam Abadi
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Charles Barron
- Office of Behavioral Health, New York City Health + Hospitals, New York, New York
| | - John Billings
- New York University Robert F. Wagner Graduate School of Public Service, New York
| | - Thaddeus Tarpey
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Jasmine Fernando
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Noa Appleton
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Adetayo Fawole
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Medha Mazumdar
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Zoe M. Weinstein
- Department of Medicine, Boston University Chobanian and Avedesian School of Medicine, Boston Medical Center, Boston, Massachusetts
| | | | - Johanna Dolle
- Office of Population Health, New York City Health + Hospitals, New York, New York
| | - Caroline Cooke
- Office of Population Health, New York City Health + Hospitals, New York, New York
| | - Samira Siddiqui
- Office of Behavioral Health, New York City Health + Hospitals, New York, New York
| | - Carla King
- Department of Population Health, New York University Grossman School of Medicine, New York
- Office of Behavioral Health, New York City Health + Hospitals, New York, New York
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Kast KA, Le TDV, Stewart LS, Wiese AD, Reddy IA, Smith J, Marcovitz DE, Reese TJ. Impact of inpatient addiction psychiatry consultation on opioid use disorder outcomes. Am J Addict 2024; 33:543-550. [PMID: 38546154 DOI: 10.1111/ajad.13540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 02/01/2024] [Accepted: 03/13/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Addiction consultation services provide access to specialty addiction care during general hospital admission. This study assessed opioid use disorder (OUD) outcomes associated with addiction consultation. METHODS Retrospective cohort study of individuals with OUD admitted to an academic medical center between 2018 and 2023. The exposure was addiction consultation. Outcomes included initiating medication for OUD (MOUD), hospital length of stay, before-medically-advised (BMA) discharge, and 30- and 90-day postdischarge acute care utilization. RESULTS Of 26,766 admissions (10,501 patients) with OUD, 2826 addiction consultations were completed. Consultation cohort was more likely to be young, male, and White than controls. Consultation was associated with greater MOUD initiation (adjusted odds ratio [aOR], 5.07; 95% confidence interval [CI], 4.41-5.82), fewer emergency department visits at 30 (aOR, 0.78; 95% CI, 0.67-0.92) and 90 (aOR, 0.79; 95% CI, 0.69-0.89) days, and fewer hospitalizations at 30 (aOR, 0.65; 95% CI, 0.56 to 0.76) and 90 (aOR, 0.67; 95% CI, 0.59-0.76) days. Additionally, consultation patients were more likely to have a longer hospital stay and leave BMA. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE Addiction consultation was associated with increased MOUD initiation and reduced postdischarge acute care utilization. This is the largest study to date showing a significant association between addiction psychiatry consultation and improved OUD outcomes when compared to controls. The observed reduction in postdischarge acute care utilization remains even after adjusting for MOUD initiation. Disparities in access to addiction consultation warrant further study.
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Affiliation(s)
- Kristopher A Kast
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Thao D V Le
- School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Lisa S Stewart
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andrew D Wiese
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - India A Reddy
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan Smith
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David E Marcovitz
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Thomas J Reese
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Piland R, Jenkins RJ, Darwish D, Kram B, Karamchandani K. Substance-Use Disorders in Critically Ill Patients: A Narrative Review. Anesth Analg 2024:00000539-990000000-00898. [PMID: 39116017 DOI: 10.1213/ane.0000000000007078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Substance-use disorders (SUDs) represent a major public health concern. The increased prevalence of SUDs within the general population has led to more patients with SUD being admitted to intensive care units (ICUs) for an SUD-related condition or with SUD as a relevant comorbidity. Multiprofessional providers of critical care should be familiar with these disorders and their impact on critical illness. Management of critically ill patients with SUDs is complicated by both acute exposures leading to intoxication, the associated withdrawal syndrome(s), and the physiologic changes associated with chronic use that can cause, predispose patients to, and worsen the severity of other medical conditions. This article reviews the epidemiology of substance use in critically ill patients, discusses the identification and treatment of common intoxication and withdrawal syndromes, and provides evidence-based recommendations for the management of patients exposed to chronic use.
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Affiliation(s)
- Rebecca Piland
- From the Division of Critical Care, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Russell Jack Jenkins
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Dana Darwish
- From the Division of Critical Care, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bridgette Kram
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina
| | - Kunal Karamchandani
- From the Division of Critical Care, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
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Babbel DM, Liu P, Chen DR, Vaughn VM, Zickmund S, Bloomquist K, Zickmund T, Howell EF, Johnson SA. Inpatient opioid withdrawal: a qualitative study of the patient perspective. Intern Emerg Med 2024; 19:1291-1298. [PMID: 38642310 PMCID: PMC11365782 DOI: 10.1007/s11739-024-03604-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 04/02/2024] [Indexed: 04/22/2024]
Abstract
Opioid withdrawal is common among hospitalized patients. Those with substance use disorders exhibit higher rates of patient-directed discharge. The literature lacks information regarding the patient perspective on opioid withdrawal in the hospital setting. In this study, we aimed to capture the patient-reported experience of opioid withdrawal during hospitalization and its impact on the desire to continue treatment for opioid use disorder after discharge. We performed a single-center qualitative study involving semi-structured interviews of hospitalized patients with opioid use disorder (OUD) experiencing opioid withdrawal. Investigators conducted in-person interviews utilizing a combination of open-ended and dichotomous questions. Interview transcripts were then analyzed with open coding for emergent themes. Nineteen interviews were performed. All participants were linked to either buprenorphine (79%) or methadone (21%) at discharge. Eight of nineteen patients (42%) reported a patient-directed discharge during prior hospitalizations. Themes identified from the interviews included: (1) opioid withdrawal was well-managed in the hospital; (2) patients appreciated receiving medication for opioid use disorder (MOUD) for withdrawal symptoms; (3) patients valued and felt cared for by healthcare providers; and (4) most patients had plans to follow-up for opioid use disorder treatment after hospitalization. In this population with historically high rates of patient-directed discharge, patients reported having a positive experience with opioid withdrawal management during hospitalization. Amongst our hospitalized patients, we observed several different individualized MOUD induction strategies. All participants were offered MOUD at discharge and most planned to follow-up for further treatment.
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Affiliation(s)
- Danielle M Babbel
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N. Mario Capecchi Drive, 3rd Floor South, Salt Lake City, UT, 84112, USA.
| | - Patricia Liu
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Section of Addiction Medicine, Oregon Health and Science University, Portland, OR, USA
| | - David R Chen
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N. Mario Capecchi Drive, 3rd Floor South, Salt Lake City, UT, 84112, USA
| | - Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N. Mario Capecchi Drive, 3rd Floor South, Salt Lake City, UT, 84112, USA
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Susan Zickmund
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Healthcare System, University of Utah, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Kennedi Bloomquist
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Tobias Zickmund
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Elizabeth F Howell
- Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Stacy A Johnson
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N. Mario Capecchi Drive, 3rd Floor South, Salt Lake City, UT, 84112, USA
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Danovitch I, Korouri S, Kaur H, Messineo G, Nuckols T, Ishak WW, Ober A. The addiction consultation service for hospitalized patients with substance use disorder: An integrative review of the evidence. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 163:209377. [PMID: 38657952 DOI: 10.1016/j.josat.2024.209377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/10/2024] [Accepted: 04/10/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION The Addiction Consultation Service has emerged as a model of care for hospitalized patients with substance use disorder. The aim of this integrative review is to characterize the Addiction Consultation Service in general hospital settings, assess its impact on clinical outcomes, identify knowledge gaps, and offer guidance for implementation. METHODS We conducted an integrative review of studies from January 2002 to August 2023, applying specific inclusion criteria to collect study design, service characteristics, staffing models, utilization, and health outcomes. Additionally, a comprehensive quality appraisal was conducted for all studies considered for inclusion. RESULTS Findings from 41 studies meeting inclusion criteria were synthesized and tabulated. Study designs included six reports from three randomized controlled trials, five descriptive studies, and 30 observational studies. The most common study setting was the urban academic medical center. Studies evaluated the structure, process, and outcomes of the Addiction Consultation Service. A majority of studies, particularly those utilizing more rigorous designs, reported positive outcomes involving medication initiation, linkage to post-discharge care, and utilization outcomes. CONCLUSIONS The Addiction Consultation Service care model improves quality of care for hospitalized patients with substance use disorder. Additional research is needed to assess its effectiveness across diverse medical settings, determine the effectiveness of varying staffing models, demonstrate impactful outcomes, and establish funding mechanisms to support sustainability.
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Affiliation(s)
- Itai Danovitch
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, United States of America.
| | - Samuel Korouri
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, United States of America.
| | - Harlene Kaur
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, United States of America.
| | - Gabrielle Messineo
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, United States of America.
| | - Teryl Nuckols
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, United States of America; RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, United States of America.
| | - Waguih W Ishak
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, United States of America.
| | - Allison Ober
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, United States of America.
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Willing L, Schreiber J. Using Advocacy to Address the Crisis of Children's Mental Health. Child Adolesc Psychiatr Clin N Am 2024; 33:319-330. [PMID: 38823806 DOI: 10.1016/j.chc.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2024]
Abstract
Children and youth in the United States are experiencing a mental health crisis that predates the COVID-19 pandemic. Child and adolescent psychiatrists have the knowledge and skillset to advocate for improving the pediatric mental health care system at the local, state, and federal levels. Child psychiatrists can use their knowledge and expertise to advocate legislatively or through regulatory advocacy to improve access to mental health care for youth. Further, including advocacy education in psychiatry and child psychiatry graduate medical education would help empower child psychiatrists to make an impact through their advocacy efforts.
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Affiliation(s)
- Laura Willing
- Children's National Hospital and George Washington University School of Medicine, 6833 4th Street NW Washington, DC 20012, USA.
| | - Justin Schreiber
- University of Pittsburgh Medical Center, Western Psychiatric Hospital, UPMC Children's Hospital of Pittsburgh, Lawrenceville Medical Building, 4117 Penn Avenue, 3rd Floor- 3111, Pittsburgh, PA 15224, USA
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Timko C, Macia K, Lewis M, Lor MC, Blonigen D, Jannausch M, Ilgen M. Medical-surgical patients with untreated hazardous drinking: Randomized controlled trial of the DO-MoST intervention to improve health outcomes over 12-month follow-up. Drug Alcohol Depend 2024; 258:111259. [PMID: 38503244 DOI: 10.1016/j.drugalcdep.2024.111259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 03/21/2024]
Abstract
INTRODUCTION High prevalence and harmful consequences of hazardous drinking among medical-surgical patients underscore the importance of intervening with drinking to improve patients' health. This study evaluated a novel intervention, "Drinking Options - Motivate, Shared Decisions, Telemonitor" (DO-MoST). METHODS In a randomized design, 155 medical-surgical patients with untreated hazardous drinking were assigned to enhanced usual care or DO-MoST, and followed 3, 6, and 12 months later. We conducted intent-to-treat and per-protocol analyses. RESULTS For the primary outcome, percent days of alcohol abstinence in the past 30 days, intent-to-treat analyses did not find superior effectiveness of DO-MoST. However, per-protocol analyses found abstinence increased between 3 and 12 months among participants assigned to DO-MoST who engaged with the intervention (n=46). Among DO-MoST-assigned participants who did not engage (n=27), abstinence stayed stable during follow-up. Group comparisons showed an advantage on abstinence for Engaged compared to Non-Engaged participants on change over time. Intent-to-treat analyses found that DO-MoST was superior to usual care on the secondary outcome of physical health at 12 months; per-protocol analyses found that Engaged DO-MoST-assignees had better physical health at 12 months than Non-Engaged DO-MoST-assignees. DO-MoST-assignees had lower odds of receiving substance use care during follow-up than usual care-assignees. DISCUSSION Patients engaged in DO-MoST showed a greater degree of abstinence and better physical health relative to the non-engaged or usual care group. DO-MoST may be a source of alcohol help in itself rather than only a linkage intervention. Work is needed to increase DO-MoST engagement among medical-surgical patients with untreated hazardous drinking.
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Affiliation(s)
- Christine Timko
- Center for Innovation to Implementation, Department of Veterans Affairs Health Care System, Palo Alto, CA 94304, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | - Kathryn Macia
- Center for Innovation to Implementation, Department of Veterans Affairs Health Care System, Palo Alto, CA 94304, USA; National Center for PTSD Dissemination & Training Division, VA Palo Alto Health Care System, Menlo Park, CA 94304, USA
| | - Mandy Lewis
- Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, 2800 Plymouth Road, Building 16, Ann Arbor, MI 48109, USA; Department of Psychiatry, University of Michigan School of Medicine, 4250 Plymouth Road, Ann Arbor, MI 48109, USA
| | - Mai Chee Lor
- Center for Innovation to Implementation, Department of Veterans Affairs Health Care System, Palo Alto, CA 94304, USA
| | - Daniel Blonigen
- Center for Innovation to Implementation, Department of Veterans Affairs Health Care System, Palo Alto, CA 94304, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Mary Jannausch
- Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, 2800 Plymouth Road, Building 16, Ann Arbor, MI 48109, USA; Department of Psychiatry, University of Michigan School of Medicine, 4250 Plymouth Road, Ann Arbor, MI 48109, USA
| | - Mark Ilgen
- Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, 2800 Plymouth Road, Building 16, Ann Arbor, MI 48109, USA; Department of Psychiatry, University of Michigan School of Medicine, 4250 Plymouth Road, Ann Arbor, MI 48109, USA.
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12
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Nordeck CD, Kelly SM, Schwartz RP, Mitchell SG, Welsh C, O'Grady KE, Gryczynski J. Hospital admissions among patients with Comorbid Substance Use disorders: a secondary analysis of predictors from the NavSTAR Trial. Addict Sci Clin Pract 2024; 19:33. [PMID: 38678216 PMCID: PMC11056040 DOI: 10.1186/s13722-024-00463-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 04/09/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Individuals with substance use disorders (SUDs) frequently use acute hospital services. The Navigation Services to Avoid Rehospitalization (NavSTAR) trial found that a patient navigation intervention for hospitalized patients with comorbid SUDs reduced subsequent inpatient admissions compared to treatment-as-usual (TAU). METHODS This secondary analysis extends previous findings from the NavSTAR trial by examining whether selected patient characteristics independently predicted hospital service utilization and moderated the effect of the NavSTAR intervention. Participants were 400 medical/surgical hospital patients with comorbid SUDs. We analyzed 30- and 90-day inpatient readmissions (one or more readmissions) and cumulative incidence of inpatient admissions through 12 months using multivariable logistic and negative binomial regression, respectively. RESULTS Consistent with primary findings and controlling for patient factors, NavSTAR participants were less likely than TAU participants to be readmitted within 30 (P = 0.001) and 90 (P = 0.03) days and had fewer total readmissions over 12 months (P = 0.008). Hospitalization in the previous year (P < 0.001) was associated with cumulative readmissions over 12 months, whereas Medicaid insurance (P = 0.03) and index diagnoses of infection (P = 0.001) and injuries, poisonings, or procedural complications (P = 0.004) were associated with fewer readmissions. None of the selected covariates moderated the effect of the NavSTAR intervention. CONCLUSIONS Previous findings showed that patient navigation could reduce repeat hospital admissions among patients with comorbid SUDs. Several patient factors were independently associated with readmission. Future research should investigate risk factors for hospital readmission among patients with comorbid SUDs to optimize interventions. TRIAL REGISTRATION NIH ClinicalTrials.gov NCT02599818, Registered November 9, 2015 https://classic. CLINICALTRIALS gov/ct2/show/NCT02599818 .
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Affiliation(s)
- Courtney D Nordeck
- Friends Research Institute, 1040 Park Avenue #103, Baltimore, MD, USA, 21201.
| | - Sharon M Kelly
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert P Schwartz
- Friends Research Institute, 1040 Park Avenue #103, Baltimore, MD, USA, 21201
| | - Shannon G Mitchell
- Friends Research Institute, 1040 Park Avenue #103, Baltimore, MD, USA, 21201
| | | | | | - Jan Gryczynski
- Friends Research Institute, 1040 Park Avenue #103, Baltimore, MD, USA, 21201
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Evans SK, Ober AJ, Korn AR, Peltz A, Friedmann PD, Page K, Murray-Krezan C, Huerta S, Ryzewicz SJ, Tarhuni L, Nuckols TK, E Watkins K, Danovitch I. Contextual barriers and enablers to establishing an addiction-focused consultation team for hospitalized adults with opioid use disorder. Addict Sci Clin Pract 2024; 19:31. [PMID: 38671482 PMCID: PMC11046820 DOI: 10.1186/s13722-024-00461-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 04/02/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Hospitalization presents an opportunity to begin people with opioid use disorder (OUD) on medications for opioid use disorder (MOUD) and link them to care after discharge; regrettably, people admitted to the hospital with an underlying OUD typically do not receive MOUD and are not connected with subsequent treatment for their condition. To address this gap, we launched a multi-site randomized controlled trial to test the effectiveness of a hospital-based addiction consultation team (the Substance Use Treatment and Recovery Team (START)) consisting of an addiction medicine specialist and care manager team that provide collaborative care and a specified intervention to people with OUD during the inpatient stay. Successful implementation of new practices can be impacted by organizational context, though no previous studies have examined context prior to implementation of addiction consultation services (ACS). This study assessed pre-implementation context for implementing a specialized ACS and tailoring it accordingly. METHODS We conducted semi-structured interviews with hospital administrators, physicians, physician assistants, nurses, and social workers at the three study sites between April and August 2021 before the launch of the pragmatic trial. Using an analytical framework based on the Consolidated Framework for Implementation Research, we completed a thematic analysis of interview data to understand potential barriers or enablers and perceptions about acceptability and feasibility. RESULTS We interviewed 28 participants across three sites. The following themes emerged across sites: (1) START is an urgently needed model for people with OUD; (2) Intervention adaptations are recommended to meet local and cultural needs; (3) Linking people with OUD to community clinicians is a highly needed component of START; (4) It is important to engage stakeholders across departments and roles throughout implementation. Across sites, participants generally saw a need for change from usual care to support people with OUD, and thought the START was acceptable and feasible to implement. Differences among sites included tailoring the START to support the needs of varying patient populations and different perceptions of the prevalence of OUD. CONCLUSIONS Hospitals planning to implement an ACS in the inpatient setting may wish to engage in a systematic pre-implementation contextual assessment using a similar framework to understand and address potential barriers and contextual factors that may impact implementation. Pre-implementation work can help ensure the ACS and other new practices fit within each unique hospital context.
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Affiliation(s)
- Sandra K Evans
- RAND Corporation, 1776 Main Street, 90407‑2138, Santa Monica, CA, P.O. Box 2138, USA.
| | - Allison J Ober
- RAND Corporation, 1776 Main Street, 90407‑2138, Santa Monica, CA, P.O. Box 2138, USA
| | - Ariella R Korn
- RAND Corporation, 1776 Main Street, 90407‑2138, Santa Monica, CA, P.O. Box 2138, USA
| | - Alex Peltz
- RAND Corporation, 1776 Main Street, 90407‑2138, Santa Monica, CA, P.O. Box 2138, USA
| | - Peter D Friedmann
- Department of Medicine, University of Massachusetts Chan Medical School-Baystate and Baystate Health, 3601 Main Street, 3rd Floor, 01107, Springfield, MA, USA
| | - Kimberly Page
- University of New Mexico Health Sciences Center, 1 University, MSC10 5550, 87133, Albuquerque, NM, USA
| | - Cristina Murray-Krezan
- Departement of Medicine, University of Pittsburgh School of Medicine, 200 Meyran Ave, Suite 300, 15213, Pittsburgh, PA, USA
| | - Sergio Huerta
- University of New Mexico Health Sciences Center, 1 University, MSC10 5550, 87133, Albuquerque, NM, USA
| | - Stephen J Ryzewicz
- Department of Medicine, University of Massachusetts Chan Medical School-Baystate and Baystate Health, 3601 Main Street, 3rd Floor, 01107, Springfield, MA, USA
| | - Lina Tarhuni
- University of New Mexico Health Sciences Center, 1 University, MSC10 5550, 87133, Albuquerque, NM, USA
| | - Teryl K Nuckols
- RAND Corporation, 1776 Main Street, 90407‑2138, Santa Monica, CA, P.O. Box 2138, USA
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, 90048, West Hollywood, CA, USA
| | - Katherine E Watkins
- RAND Corporation, 1776 Main Street, 90407‑2138, Santa Monica, CA, P.O. Box 2138, USA
| | - Itai Danovitch
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, 90048, West Hollywood, CA, USA
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14
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Bart G, Korthuis PT, Donohue JM, Hagedorn HJ, Gustafson DH, Bazzi AR, Enns E, McNeely J, Ghitza UE, Magane KM, Baukol P, Vena A, Harris J, Voronca D, Saitz R. Exemplar Hospital initiation trial to Enhance Treatment Engagement (EXHIT ENTRE): protocol for CTN-0098B a randomized implementation study to support hospitals in caring for patients with opioid use disorder. Addict Sci Clin Pract 2024; 19:29. [PMID: 38600571 PMCID: PMC11007900 DOI: 10.1186/s13722-024-00455-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 03/20/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Hospitalizations involving opioid use disorder (OUD) are increasing. Medications for opioid use disorder (MOUD) reduce mortality and acute care utilization. Hospitalization is a reachable moment for initiating MOUD and arranging for ongoing MOUD engagement following hospital discharge. Despite existing quality metrics for MOUD initiation and engagement, few hospitals provide hospital based opioid treatment (HBOT). This protocol describes a cluster-randomized hybrid type-2 implementation study comparing low-intensity and high-intensity implementation support strategies to help community hospitals implement HBOT. METHODS Four state implementation hubs with expertise in initiating HBOT programs will provide implementation support to 24 community hospitals (6 hospitals/hub) interested in starting HBOT. Community hospitals will be randomized to 24-months of either a low-intensity intervention (distribution of an HBOT best-practice manual, a lecture series based on the manual, referral to publicly available resources, and on-demand technical assistance) or a high-intensity intervention (the low-intensity intervention plus funding for a hospital HBOT champion and regular practice facilitation sessions with an expert hub). The primary efficacy outcome, adapted from the National Committee on Quality Assurance, is the proportion of patients engaged in MOUD 34-days following hospital discharge. Secondary and exploratory outcomes include acute care utilization, non-fatal overdose, death, MOUD engagement at various time points, hospital length of stay, and discharges against medical advice. Primary, secondary, and exploratory outcomes will be derived from state Medicaid data. Implementation outcomes, barriers, and facilitators are assessed via longitudinal surveys, qualitative interviews, practice facilitation contact logs, and HBOT sustainability metrics. We hypothesize that the proportion of patients receiving care at hospitals randomized to the high-intensity arm will have greater MOUD engagement following hospital discharge. DISCUSSION Initiation of MOUD during hospitalization improves MOUD engagement post hospitalization. Few studies, however, have tested different implementation strategies on HBOT uptake, outcome, and sustainability and only one to date has tested implementation of a specific type of HBOT (addiction consultation services). This cluster-randomized study comparing different intensities of HBOT implementation support will inform hospitals and policymakers in identifying effective strategies for promoting HBOT dissemination and adoption in community hospitals. TRIAL REGISTRATION NCT04921787.
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Affiliation(s)
- Gavin Bart
- Department of Medicine, Hennepin Healthcare and University of Minnesota, 701 Park Avenue, Minneapolis, MN, 55415, USA.
| | - P Todd Korthuis
- Department of Medicine, Addiction Medicine Section, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, 97239-3098, Portland, OR, USA
| | - Julie M Donohue
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA, 15261, USA
| | - Hildi J Hagedorn
- Center for Care Delivery & Outcomes Research, Minneapolis VA Health Care System, University of Minnesota, 1 Veterans Drive, Minneapolis, MN, 55417, USA
| | - Dave H Gustafson
- Center for Health Enhancement Systems Studies, University of Wisconsin, 1513 University Ave., Madison, WI, 53706, USA
| | - Angela R Bazzi
- Herbert Wertheim School of Public Health, University of California, San Diego; La Jolla, CA, USA
- Boston University School of Public Health, 801 Massachusetts Ave, Suite 431, Boston, MA, 02118, USA
| | - Eva Enns
- Division of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware St. SE, Minneapolis, MN, 55408, USA
| | - Jennifer McNeely
- Department of Population Health, Section on Alcohol, Tobacco and Drug Use, NYU School of Medicine, 180 Madison Avenue, 17th floor, New York, NY, 10016, USA
- Department of Medicine, Division of General Internal Medicine and Clinical Innovation, NYU School of Medicine, 462 1st Avenue, New York, NY, 10016, USA
| | - Udi E Ghitza
- National Institute on Drug Abuse (NIDA) Center for the Clinical Trials Network (CCTN), Bethesda, MD, 20892, USA
| | - Kara M Magane
- Boston University School of Public Health, 801 Massachusetts Ave, Suite 431, Boston, MA, 02118, USA
| | - Paulette Baukol
- Berman Center for Outcomes & Clinical Research, 701 Park Ave, Ste. PP7.700, Minneapolis, MN, 55415, USA
| | - Ashley Vena
- The Emmes Company, LLC, 401 N. Washington St. #700, Rockville, MD, 20850, USA
| | - Jacklyn Harris
- The Emmes Company, LLC, 401 N. Washington St. #700, Rockville, MD, 20850, USA
| | - Delia Voronca
- The Emmes Company, LLC, 401 N. Washington St. #700, Rockville, MD, 20850, USA
- Currently: Regeneron Pharmaceuticals, Inc, 777 Old Saw Mill River Rd, Tarrytown, Deceased, NY, 10591-6707, USA
| | - Richard Saitz
- Boston University School of Public Health, 801 Massachusetts Ave, Suite 431, Boston, MA, 02118, USA
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15
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Incze MA, Kelley AT, James H, Nolan S, Stofko A, Fordham C, Gordon AJ. Post-hospitalization Care Transition Strategies for Patients with Substance Use Disorders: A Narrative Review and Taxonomy. J Gen Intern Med 2024; 39:837-846. [PMID: 38413539 PMCID: PMC11043281 DOI: 10.1007/s11606-024-08670-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/30/2024] [Indexed: 02/29/2024]
Abstract
Hospitalizations represent important opportunities to engage individuals with substance use disorders (SUD) in treatment. For those who engage with SUD treatment in the hospital setting, tailored supports during post-discharge transitions to longitudinal care settings may improve care linkages, retention, and treatment outcomes. We updated a recent systematic review search on post-hospitalization SUD care transitions through a structured review of published literature from January 2020 through June 2023. We then added novel sources including a gray literature search and key informant interviews to develop a taxonomy of post-hospitalization care transition models for patients with SUD. Our updated literature search generated 956 abstracts not included in the original systematic review. We selected and reviewed 89 full-text articles, which yielded six new references added to 26 relevant articles from the original review. Our search of five gray literature sources yielded four additional references. Using a thematic analysis approach, we extracted themes from semi-structured interviews with 10 key informants. From these results, we constructed a taxonomy consisting of 10 unique SUD care transition models in three overarching domains (inpatient-focused, transitional, outpatient-focused). These models include (1) training and protocol implementation; (2) screening, brief intervention, and referral to treatment; (3) hospital-based interdisciplinary consult team; (4) continuity-enhanced interdisciplinary consult team; (5) peer navigation; (6) transitional care management; (7) outpatient in-reach; (8) post-discharge outreach; (9) incentivizing follow-up; and (10) bridge clinic. For each model, we describe design, scope, approach, and implementation strategies. Our taxonomy highlights emerging models of post-hospitalization care transitions for patients with SUD. An established taxonomy provides a framework for future research, implementation efforts, and policy in this understudied, but critically important, aspect of SUD care.
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Affiliation(s)
- Michael A Incze
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Greater Intermountain Node, National Institute on Drug Abuse Clinical Trial Network, Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), , Salt Lake City, UT, USA.
| | - A Taylor Kelley
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Greater Intermountain Node, National Institute on Drug Abuse Clinical Trial Network, Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), , Salt Lake City, UT, USA
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Patient-Aligned Care Team, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Hannah James
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Seonaid Nolan
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Andrea Stofko
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Greater Intermountain Node, National Institute on Drug Abuse Clinical Trial Network, Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), , Salt Lake City, UT, USA
| | - Cole Fordham
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Greater Intermountain Node, National Institute on Drug Abuse Clinical Trial Network, Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), , Salt Lake City, UT, USA
| | - Adam J Gordon
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Greater Intermountain Node, National Institute on Drug Abuse Clinical Trial Network, Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), , Salt Lake City, UT, USA
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Patient-Aligned Care Team, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
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16
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Treitler P, Crystal S, Cantor J, Chakravarty S, Kline A, Morton C, Powell KG, Borys S, Cooperman NA. Emergency Department Peer Support Program and Patient Outcomes After Opioid Overdose. JAMA Netw Open 2024; 7:e243614. [PMID: 38526490 PMCID: PMC10964115 DOI: 10.1001/jamanetworkopen.2024.3614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 01/30/2024] [Indexed: 03/26/2024] Open
Abstract
Importance Patients treated in emergency departments (EDs) for opioid overdose often need drug treatment yet are rarely linked to services after discharge. Emergency department-based peer support is a promising approach for promoting treatment linkage, but evidence of its effectiveness is lacking. Objective To examine the association of the Opioid Overdose Recovery Program (OORP), an ED peer recovery support service, with postdischarge addiction treatment initiation, repeat overdose, and acute care utilization. Design, Setting, and Participants This intention-to-treat retrospective cohort study used 2014 to 2020 New Jersey Medicaid data for Medicaid enrollees aged 18 to 64 years who were treated for nonfatal opioid overdose from January 2015 to June 2020 at 70 New Jersey acute care hospitals. Data were analyzed from August 2022 to November 2023. Exposure Hospital OORP implementation. Main Outcomes and Measures The primary outcome was medication for opioid use disorder (MOUD) initiation within 60 days of discharge. Secondary outcomes included psychosocial treatment initiation, medically treated drug overdoses, and all-cause acute care visits after discharge. An event study design was used to compare 180-day outcomes between patients treated in OORP hospitals and those treated in non-OORP hospitals. Analyses adjusted for patient demographics, comorbidities, and prior service use and for community-level sociodemographics and drug treatment access. Results A total of 12 046 individuals were included in the study (62.0% male). Preimplementation outcome trends were similar for patients treated in OORP and non-OORP hospitals. Implementation of the OORP was associated with an increase of 0.034 (95% CI, 0.004-0.064) in the probability of 60-day MOUD initiation in the half-year after implementation, representing a 45% increase above the preimplementation mean probability of 0.075 (95% CI, 0.066-0.084). Program implementation was associated with fewer repeat medically treated overdoses 4 half-years (-0.086; 95% CI, -0.154 to -0.018) and 5 half-years (-0.106; 95% CI, -0.184 to -0.028) after implementation. Results differed slightly depending on the reference period used, and hospital-specific models showed substantial heterogeneity in program outcomes across facilities. Conclusions and Relevance In this cohort study of patients treated for opioid overdose, OORP implementation was associated with an increase in MOUD initiation and a decrease in repeat medically treated overdoses. The large variation in outcomes across hospitals suggests that treatment effects were heterogeneous and may depend on factors such as implementation success, program embeddedness, and availability of other hospital- and community-based OUD services.
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Affiliation(s)
- Peter Treitler
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
- Boston University School of Social Work, Boston, Massachusetts
| | - Stephen Crystal
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
- School of Social Work, Rutgers University, New Brunswick, New Jersey
- School of Public Health, Rutgers University, Piscataway, New Jersey
| | - Joel Cantor
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
| | - Sujoy Chakravarty
- Department of Health Sciences, Rutgers University, Camden, New Jersey
| | - Anna Kline
- Department of Psychiatry, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey
| | - Cory Morton
- School of Social Work, Rutgers University, New Brunswick, New Jersey
- Center for Prevention Science, Rutgers University, New Brunswick, New Jersey
- Northeast and Caribbean Prevention Technology Transfer Center, Rutgers University, New Brunswick, New Jersey
| | - Kristen Gilmore Powell
- School of Social Work, Rutgers University, New Brunswick, New Jersey
- Center for Prevention Science, Rutgers University, New Brunswick, New Jersey
- Northeast and Caribbean Prevention Technology Transfer Center, Rutgers University, New Brunswick, New Jersey
| | - Suzanne Borys
- Division of Mental Health and Addiction Services, New Jersey Department of Human Services, Trenton
| | - Nina A. Cooperman
- Department of Psychiatry, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey
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Timko C, Lewis M, Lor MC, Aldaco-Revilla L, Blonigen D, Ilgen M. Hazardous Drinking Interventions Delivered During Medical-Surgical Care: Patient and Provider Views. J Clin Psychol Med Settings 2024; 31:224-235. [PMID: 36959430 PMCID: PMC10035972 DOI: 10.1007/s10880-023-09954-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 03/25/2023]
Abstract
Addressing hazardous drinking during medical-surgical care improves patients' health. This formative evaluation examined patients' consideration of options to change drinking and engage in treatment. It explored whether interventions such as "DO-MoST" overcome treatment barriers. We interviewed 20 medical-surgical patients with hazardous drinking in a trial of DO-MoST, and 16 providers. Analyses used a directed content approach. Patients were receptive to and comfortable discussing drinking during medical-surgical care. Interventions like DO-MoST (patient-centered, motivational approach to shared decision making) addressed some treatment barriers. Patients and providers viewed such interventions as helpful by building a relationship with a psychologist who facilitated self-awareness of drinking behaviors, and discussing connections between alcohol- and physical health-related problems and potential strategies to address drinking. However, both groups expressed concerns about individual and system-level barriers to long-term change. Interventions like DO-MoST bridge the gap between the patient's medical treatment episode and transition to other health care settings. TRIAL REGISTRATION: The study is registered on ClinicalTrials.gov (ID: NCT03258632).
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Affiliation(s)
- Christine Timko
- Department of Veterans Affairs, Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Rd. (152-MPD), Menlo Park, CA, 94025, USA.
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Rd, Stanford, CA, 94305, USA.
| | - Mandy Lewis
- VA Center for Clinical Management Research (CCMR), North Campus Research Complex, 2800 Plymouth Rd., Building 16, Ann Arbor, MI, 48109, USA
- Department of Psychiatry, North Campus Research Complex, University of Michigan, 2800 Plymouth Rd., Building 16, Ann Arbor, MI, 48109, USA
| | - Mai Chee Lor
- Department of Veterans Affairs, Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Rd. (152-MPD), Menlo Park, CA, 94025, USA
| | - Laura Aldaco-Revilla
- VA Center for Clinical Management Research (CCMR), North Campus Research Complex, 2800 Plymouth Rd., Building 16, Ann Arbor, MI, 48109, USA
- Department of Psychiatry, North Campus Research Complex, University of Michigan, 2800 Plymouth Rd., Building 16, Ann Arbor, MI, 48109, USA
| | - Daniel Blonigen
- Department of Veterans Affairs, Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Rd. (152-MPD), Menlo Park, CA, 94025, USA
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Rd, Stanford, CA, 94305, USA
| | - Mark Ilgen
- VA Center for Clinical Management Research (CCMR), North Campus Research Complex, 2800 Plymouth Rd., Building 16, Ann Arbor, MI, 48109, USA
- Department of Psychiatry, North Campus Research Complex, University of Michigan, 2800 Plymouth Rd., Building 16, Ann Arbor, MI, 48109, USA
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18
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Marcovitz D, Dear ML, Donald R, Edwards DA, Kast KA, Le TDV, Shah MV, Ferrell J, Gatto C, Hennessy C, Buie R, Rice TW, Sullivan W, White KD, Van Winkle G, Wolf R, Lindsell CJ. Effect of a Co-Located Bridging Recovery Initiative on Hospital Length of Stay Among Patients With Opioid Use Disorder: The BRIDGE Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2356430. [PMID: 38411964 PMCID: PMC10900965 DOI: 10.1001/jamanetworkopen.2023.56430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/20/2023] [Indexed: 02/28/2024] Open
Abstract
Importance Co-located bridge clinics aim to facilitate a timely transition to outpatient care for inpatients with opioid use disorder (OUD); however, their effect on hospital length of stay (LOS) and postdischarge outcomes remains unclear. Objective To evaluate the effect of a co-located bridge clinic on hospital LOS among inpatients with OUD. Design, Setting, and Participants This parallel-group randomized clinical trial recruited 335 adult inpatients with OUD seen by an addiction consultation service and without an existing outpatient clinician to provide medication for OUD (MOUD) between November 25, 2019, and September 28, 2021, at a tertiary care hospital affiliated with a large academic medical center and its bridge clinic. Intervention The bridge clinic included enhanced case management before and after hospital discharge, MOUD prescription, and referral to a co-located bridge clinic. Usual care included MOUD prescription and referrals to community health care professionals who provided MOUD. Main Outcomes and Measures The primary outcome was the index admission LOS. Secondary outcomes, assessed at 16 weeks, were linkage to health care professionals who provided MOUD, MOUD refills, same-center emergency department (ED) and hospital use, recurrent opioid use, quality of life (measured by the Schwartz Outcome Scale-10), overdose, mortality, and cost. Analysis was performed on an intent-to-treat basis. Results Of 335 participants recruited (167 randomized to the bridge clinic and 168 to usual care), the median age was 38.0 years (IQR, 31.9-45.7 years), and 194 (57.9%) were male. The median LOS did not differ between arms (adjusted odds ratio [AOR], 0.94 [95% CI, 0.65-1.37]; P = .74). At the 16-week follow-up, participants referred to the bridge clinic had fewer hospital-free days (AOR, 0.54 [95% CI, 0.32-0.92]), more readmissions (AOR, 2.17 [95% CI, 1.25-3.76]), and higher care costs (AOR, 2.25 [95% CI, 1.51-3.35]), with no differences in ED visits (AOR, 1.15 [95% CI, 0.68-1.94]) or deaths (AOR, 0.48 [95% CI, 0.08-2.72]) compared with those receiving usual care. Follow-up calls were completed for 88 participants (26.3%). Participants referred to the bridge clinic were more likely to receive linkage to health care professionals who provided MOUD (AOR, 2.37 [95% CI, 1.32-4.26]) and have more MOUD refills (AOR, 6.17 [95% CI, 3.69-10.30]) and less likely to experience an overdose (AOR, 0.11 [95% CI, 0.03-0.41]). Conclusions and Relevance This randomized clinical trial found that among inpatients with OUD, bridge clinic referrals did not improve hospital LOS. Referrals may improve outpatient metrics but with higher resource use and expenditure. Bending the cost curve may require broader community and regional partnerships. Trial Registration ClinicalTrials.gov Identifier: NCT04084392.
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Affiliation(s)
- David Marcovitz
- Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mary Lynn Dear
- Vanderbilt University School of Medicine, Nashville, Tennessee
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rebecca Donald
- Vanderbilt University School of Medicine, Nashville, Tennessee
- Division of Pain Medicine, Department of Anesthesia, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David A. Edwards
- Vanderbilt University School of Medicine, Nashville, Tennessee
- Division of Pain Medicine, Department of Anesthesia, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kristopher A. Kast
- Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Thao D. V. Le
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mauli V. Shah
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jason Ferrell
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Cheryl Gatto
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Cassandra Hennessy
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Reagan Buie
- Office of Episodes of Care, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd W. Rice
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William Sullivan
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Katie D. White
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Grace Van Winkle
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rachel Wolf
- Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
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19
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Nordeck CD, Sharma A, Terplan M, Dusek K, Gilliams E, Gryczynski J. Opioid Use Disorder Treatment Linkage at Strategic Touchpoints Using Buprenorphine (OUTLAST-B): Rationale, Design, and Evolution of a Randomized Controlled Trial. JOURNAL OF PSYCHIATRY AND BRAIN SCIENCE 2023; 8:e230010. [PMID: 38456042 PMCID: PMC10919199 DOI: 10.20900/jpbs.20230010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Background Despite the effectiveness and growing availability of treatment for opioid use disorder (OUD) with buprenorphine, many people with OUD do not access treatment services. This article describes the rationale, methodological design, evolution, and progress of an ongoing clinical trial of treatment linkage strategies for people with untreated OUD. Methods The study, titled Opioid Use Disorder Treatment Linkage at Strategic Touchpoints using Buprenorphine (OUTLAST-B), uses "strategic touchpoints", initially sexual health clinics and subsequently broadened to other service venues and participant social networks, for recruitment and screening. Adults with untreated OUD (target N = 360) are randomized to one of the three arms: Usual Care (UC, enhanced with overdose education and naloxone distribution), Patient Navigation (PN), or Patient Navigation with an immediate short-term bridge prescription for buprenorphine (PN + BUP). In the PN and PN + BUP arms, the Patient Navigator works with participants for 2 months to facilitate treatment entry and early retention, resolve barriers (e.g., ID cards, transportation), and provide motivational support. Results The primary outcome is OUD treatment entry within 30 days of enrollment. Participants are assessed at baseline and followed at 3- and 6-months post-enrollment on measures of healthcare utilization, substance use, and general functioning. Challenges and recruitment adaptations pursuant to the COVID-19 pandemic are discussed. Conclusions This study could provide insights on how to reach people with untreated OUD and link them to care through non-traditional routes. Trial Registration The study is registered at ClinicalTrials.gov (NCT04991974).
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Affiliation(s)
| | - Anjalee Sharma
- Friends Research Institute, Baltimore, MD 21201, USA
- Behavioral Pharmacology Research Unit, Johns Hopkins School of Medicine, Baltimore, MD 21224, USA
| | | | - Kristi Dusek
- Friends Research Institute, Baltimore, MD 21201, USA
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20
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Crowther D, Curran J, Somerville M, Sinclair D, Wozney L, MacPhee S, Rose AE, Boulos L, Caudrella A. Harm reduction strategies in acute care for people who use alcohol and/or drugs: A scoping review. PLoS One 2023; 18:e0294804. [PMID: 38100469 PMCID: PMC10723714 DOI: 10.1371/journal.pone.0294804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/09/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND People who use alcohol and/or drugs (PWUAD) are at higher risk of infectious disease, experiencing stigma, and recurrent hospitalization. Further, they have a higher likelihood of death once hospitalized when compared to people who do not use drugs and/or alcohol. The use of harm reduction strategies within acute care settings has shown promise in alleviating some of the harms experienced by PWUAD. This review aimed to identify and synthesize evidence related to the implementation of harm reduction strategies in acute care settings. METHODS A scoping review investigating harm reduction strategies implemented in acute care settings for PWUAD was conducted. A search strategy developed by a JBI-trained specialist was used to search five databases (Medline, Embase, CINAHL, PsychInfo and Scopus). Screening of titles, abstracts and full texts, and data extraction was done in duplicate by two independent reviewers. Discrepancies were resolved by consensus or with a third reviewer. Results were reported narratively and in tables. Both patients and healthcare decision makers contributing to the development of the protocol, article screening, synthesis and feedback of results, and the identification of gaps in the literature. FINDINGS The database search identified 14,580 titles, with 59 studies included in this review. A variety of intervention modalities including pharmacological, decision support, safer consumption, early overdose detection and turning a blind eye were identified. Reported outcome measures related to safer use, managed use, and conditions of use. Reported barriers and enablers to implementation related to system and organizational factors, patient-provider communication, and patient and provider perspectives. CONCLUSION This review outlines the types of alcohol and/or drug harm reduction strategies, which have been evaluated and/or implemented in acute care settings, the type of outcome measures used in these evaluations and summarizes key barriers and enablers to implementation. This review has the potential to serve as a resource for future harm reduction evaluation and implementation efforts in the context of acute care settings.
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Affiliation(s)
- Daniel Crowther
- School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Janet Curran
- School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
- Quality and Patient Safety, IWK Health, Halifax, Nova Scotia, Canada
| | - Mari Somerville
- School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
- Quality and Patient Safety, IWK Health, Halifax, Nova Scotia, Canada
| | - Doug Sinclair
- Quality and Patient Safety, IWK Health, Halifax, Nova Scotia, Canada
| | - Lori Wozney
- Mental Health and Addictions Program, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Shannon MacPhee
- Quality and Patient Safety, IWK Health, Halifax, Nova Scotia, Canada
| | | | - Leah Boulos
- The Maritime Strategy for Patient Oriented Research SUPPORT Unit, Halifax, NS, Canada
| | - Alexander Caudrella
- Mental Health and Addictions Service, St Michael’s Hospital, Toronto, Ontario, Canada
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21
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Hochstatter KR, Nordeck C, Mitchell SG, Schwartz RP, Welsh C, Gryczynski J. Polysubstance use and post-discharge mortality risk among hospitalized patients with opioid use disorder. Prev Med Rep 2023; 36:102494. [PMID: 38116282 PMCID: PMC10728463 DOI: 10.1016/j.pmedr.2023.102494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 12/21/2023] Open
Abstract
Polysubstance use is becoming increasingly common and presents several harms. This study aimed to examine the association of comorbid cocaine, alcohol (binge drinking), and sedative use with mortality among hospitalized patients with opioid use disorder (OUD). A subsample of adult medical/surgical hospital patients with OUD who were seen by a hospital addiction consultation service in Baltimore City and enrolled in a randomized trial of a patient navigation intervention were included in this study (N = 314; 45 % female; 48 % White; mean age = 44). Death certificate data from the Maryland Division of Vital Records was used, covering 3.3-5.5 years post-discharge. Multivariable proportional hazards Cox regression and competing risks regression were used to estimate all-cause mortality and overdose mortality, respectively, as a function of concurrent use of cocaine, alcohol (binge drinking), and non-prescribed sedatives at baseline. In the 30 days prior to hospital admission, 230 (73 %) participants used cocaine, 64 (20 %) binge drank, and 45 (14 %) used non-prescribed sedatives. Nearly one-third (N = 98; 31 %) died during the observation period. Drug overdose caused 53 % (N = 52) of deaths. Older age (HR = 1.03 [1.01,1.05]; P = 0.001), less than high school education (HR = 0.36 [0.24,0.54]; P < 0.001), and past 30-day sedative use (HR = 2.05 [1.20,3.50]; P = 0.008) were significantly associated with all-cause mortality. The risk of overdose mortality was 62 % lower (HR = 0.38 [0.22,0.66]; P = 0.001) for those who completed high school. No other characteristics were significantly associated with overdose mortality. The concurrent use of opioids and sedatives increases the post-discharge mortality risk among hospitalized patients with OUD. Interventions are needed to prevent mortality among this high-risk population.
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22
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Patidar KR, Guarnizo Ortiz M, Slaven JE, Nephew LD, Vilar Gomez E, Kettler CD, Ghabril MS, Desai AP, Orman ES, Chalasani N, Gawrieh S. Incidence, clinical characteristics, and risk factors associated with recurrent alcohol-associated hepatitis. Hepatol Commun 2023; 7:e0341. [PMID: 38055648 PMCID: PMC10984669 DOI: 10.1097/hc9.0000000000000341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/25/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Alcohol relapse occurs frequently in alcohol-associated hepatitis (AH) survivors, but data on the frequency and course of recurrent alcohol-associated hepatitis (rAH) are sparse. We investigated the incidence, risk factors, and outcomes of rAH. METHODS Hospitalized patients with AH from 2010 to 2020 at a large health care system were followed until death/liver transplant, last follow-up, or end of study (December 31, 2021). AH was defined by NIAAA Alcoholic Hepatitis Consortium criteria; rAH was defined a priori as a discrete AH episode >6 months from index AH hospitalization with interim >50% improvement or normalization of total bilirubin. Multivariable competing risk analysis was performed to identify factors associated with rAH. Landmark Kaplan-Meier analysis was performed to compare survival between patients who did versus those who did not develop rAH. RESULTS Of 1504 hospitalized patients with AH, 1317 (87.6%) survived and were analyzed. During a 3055 person-year follow-up, 116 (8.8%) developed rAH at an annual incidence rate of 3.8% (95% CI: 2.8-4.8). On multivariable competing risk analysis, marital status [sub-HR 0.54 (95% CI: 0.34, 0.92), p=0.01] and medications for alcohol use disorder [sub-HR 0.56 (95% CI: 0.34, 0.91), p=0.02] were associated with a lower risk for rAH. On landmark Kaplan-Meier analysis, the cumulative proportion surviving at 1 year (75% vs. 90%) and 3 years (50% vs. 78%) was significantly lower in patients who developed rAH compared to those who did not develop rAH (log-rank p<0.001). CONCLUSIONS rAH develops in ~1 in 10 AH survivors and is associated with lower long-term survival. Medications for alcohol use disorder lower the risk for rAH and, therefore, could be a key preventative strategy to improve outcomes.
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Affiliation(s)
- Kavish R. Patidar
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Maria Guarnizo Ortiz
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - James E. Slaven
- Department of Biostatistics and Health Data Science, Indiana University, Indianapolis, Indiana, USA
| | - Lauren D. Nephew
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Eduardo Vilar Gomez
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Carla D. Kettler
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Marwan S. Ghabril
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Archita P. Desai
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Eric S. Orman
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine and Indiana University Health, Indianapolis, Indiana, USA
| | - Samer Gawrieh
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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23
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Krawczyk N, Rivera BD, Chang JE, Grivel M, Chen YH, Nagappala S, Englander H, McNeely J. Strategies to support substance use disorder care transitions from acute-care to community-based settings: a scoping review and typology. Addict Sci Clin Pract 2023; 18:67. [PMID: 37919755 PMCID: PMC10621088 DOI: 10.1186/s13722-023-00422-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 10/17/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Acute-care interventions that identify patients with substance use disorders (SUDs), initiate treatment, and link patients to community-based services, have proliferated in recent years. Yet, much is unknown about the specific strategies being used to support continuity of care from emergency department (ED) or inpatient hospital settings to community-based SUD treatment. In this scoping review, we synthesize the existing literature on patient transition interventions, and form an initial typology of reported strategies. METHODS We searched Pubmed, Embase, CINAHL and PsychINFO for peer-reviewed articles published between 2000 and 2021 that studied interventions linking patients with SUD from ED or inpatient hospital settings to community-based SUD services. Eligible articles measured at least one post-discharge treatment outcome and included a description of the strategy used to promote linkage to community care. Detailed information was extracted on the components of the transition strategies and a thematic coding process was used to categorize strategies into a typology based on shared characteristics. Facilitators and barriers to transitions of care were synthesized using the Consolidated Framework for Implementation Research. RESULTS Forty-five articles met inclusion criteria. 62% included ED interventions and 44% inpatient interventions. The majority focused on patients with opioid (71%) or alcohol (31%) use disorder. The transition strategies reported across studies were heterogeneous and often not well described. An initial typology of ten transition strategies, including five pre- and five post-discharge transition strategies is proposed. The most common strategy was scheduling an appointment with a community-based treatment provider prior to discharge. A range of facilitators and barriers were described, which can inform efforts to improve hospital-to-community transitions of care. CONCLUSIONS Strategies to support transitions from acute-care to community-based SUD services, although critical for ensuring continuity of care, vary greatly across interventions and are inconsistently measured and described. More research is needed to classify SUD care transition strategies, understand their components, and explore which lead to the best patient outcomes.
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Affiliation(s)
- Noa Krawczyk
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, 10065, USA.
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, 180 Madison Ave, Room 5-53, New York, USA.
| | - Bianca D Rivera
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, 10065, USA
| | - Ji E Chang
- Department of Public Health Policy and Management, NYU School of Global Public Health, New York, NY, 10003, USA
| | - Margaux Grivel
- Department of Social and Behavioral Sciences, NYU School of Global Public Health, New York, NY, 10003, USA
| | - Yu-Heng Chen
- Department of Criminal Justice, Temple University, Philadelphia, PA, 19102, USA
| | | | - Honora Englander
- Department of Medicine, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Jennifer McNeely
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, 10065, USA
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24
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King C, Douglas D, Avalone L, Appleton N, Linn-Walton R, Barron C, McNeely J. Telephonic Outreach to Engage Patients with Substance Use Disorder Post-Hospitalization During the COVID-19 Pandemic. J Behav Health Serv Res 2023; 50:540-547. [PMID: 37106160 PMCID: PMC10139664 DOI: 10.1007/s11414-023-09837-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2023] [Indexed: 04/29/2023]
Abstract
During the initial COVID-19 surge, one public hospital in NYC updated their post-discharge outreach approach for patients with substance use disorder, as part of the CATCH (Consult for Addiction Treatment and Care in Hospitals) program. Beginning April 1, 2020, three peers and two addiction counselors attempted telephonic outreach to patients who received a CATCH consultation during hospitalization from program launch (October 7, 2019) through March 31, 2020 (n = 329). Outreach calls could include counseling, in-depth peer support, and referrals to substance use services (SUS)-a significant expansion of the services offered via outreach pre-pandemic. CATCH staff successfully reached 29.5% of patients and provided 77.6% of them with supportive counseling and referrals. Thirty percent of unsuccessful calls were due to inactive numbers, and only 8% of patients without housing were reached. Telephonic outreach established a low-barrier connection between patients and SUS that may be valuable during any period, including non-COVID times. Future interventions that address social determinants such as housing and cell phone access concomitantly with substance use should be considered by addiction consultation services to potentially reduce acute care utilization and improve health outcomes.
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Affiliation(s)
- Carla King
- Office of Behavioral Health, NYC Health + Hospitals, NY, New York, USA.
- Department of Population Health, Section On Tobacco, Alcohol, and Drug Use, NYU Grossman School of Medicine, NY, New York, USA.
| | - Drezzell Douglas
- Graduate School of Public Health & Health Policy, City University of New York, New York, NY, USA
| | - Lynsey Avalone
- Office of Behavioral Health, NYC Health + Hospitals, NY, New York, USA
| | - Noa Appleton
- Department of Population Health, Section On Tobacco, Alcohol, and Drug Use, NYU Grossman School of Medicine, NY, New York, USA
| | | | - Charles Barron
- Office of Behavioral Health, NYC Health + Hospitals, NY, New York, USA
| | - Jennifer McNeely
- Department of Population Health, Section On Tobacco, Alcohol, and Drug Use, NYU Grossman School of Medicine, NY, New York, USA
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25
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Rosenthal ES, Brokus C, Sun J, Carpenter JE, Catalanotti J, Eaton EF, Steck AR, Kuo I, Burkholder GA, Akselrod H, McGonigle K, Moran T, Mai W, Notis M, Del Rio C, Greenberg A, Saag MS, Kottilil S, Masur H, Kattakuzhy S. Undertreatment of opioid use disorder in patients hospitalized with injection drug use-associated infections. AIDS 2023; 37:1799-1809. [PMID: 37352497 PMCID: PMC10481931 DOI: 10.1097/qad.0000000000003629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/06/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVE To evaluate the association between medication for opioid use disorder (MOUD) initiation and addiction consultation and outcomes for patients hospitalized with infectious complications of injecting opioids. METHOD This was a retrospective cohort study performed at four academic medical centers in the United States. The participants were patients who had been hospitalized with infectious complications of injecting opioids in 2018. Three hundred and twenty-two patients were included and their individual patient records were manually reviewed to identify inpatient receipt of medication for opioid use disorder (MOUD), initiation of MOUD, and addiction consultation. The main outcomes of interest were premature discharge, MOUD on discharge, linkage to outpatient MOUD, one-year readmission and death. RESULTS Three hundred and twenty-two patients were predominately male (59%), white (66%), and median age 38 years, with 36% unstably housed, and 30% uninsured. One hundred and forty-five (45%) patients received MOUD during hospitalization, including only 65 (28%) patients not on baseline MOUD. Discharge was premature for 64 (20%) patients. In the year following discharge, 27 (9%) patients were linked to MOUD, and 159 (50%) patients had at least one readmission. Being on MOUD during hospitalization was significantly associated with higher odds of planned discharge [odds ratio (OR) 3.87, P < 0.0001], MOUD on discharge (OR 129.7, P < 0.0001), and linkage to outpatient MOUD (OR 1.25, P < 0.0001), however, was not associated with readmission. Study limitations were the retrospective nature of the study, so post-discharge data are likely underestimated. CONCLUSION There was dramatic undertreatment with MOUD from inpatient admission to outpatient linkage, and high rates of premature discharge and readmission. Engagement in addiction care during hospitalization is a critical first step in improving the care continuum for individuals with opioid use disorder; however, additional interventions may be needed to impact long-term outcomes like readmission.
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Affiliation(s)
- Elana S. Rosenthal
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore
| | - Christopher Brokus
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Joseph E. Carpenter
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jillian Catalanotti
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Ellen F. Eaton
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama
| | - Alaina R. Steck
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Irene Kuo
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington DC
| | - Greer A. Burkholder
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama
| | - Hana Akselrod
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Keanan McGonigle
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Timothy Moran
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - William Mai
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Melissa Notis
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Carlos Del Rio
- Rollins School of Public Health and Emory School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Alan Greenberg
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington DC
| | - Michael S. Saag
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama
| | - Shyamasundaran Kottilil
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore
| | - Henry Masur
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Sarah Kattakuzhy
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore
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26
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Jimenez Ruiz F, Warner NS, Acampora G, Coleman JR, Kohan L. Substance Use Disorders: Basic Overview for the Anesthesiologist. Anesth Analg 2023; 137:508-520. [PMID: 37590795 DOI: 10.1213/ane.0000000000006281] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
Substance use disorders (SUDs) represent a current major public health concern in the United States and around the world. Social and economic stressors secondary to the coronavirus disease 2019 (COVID-19) pandemic have likely led to an increase in SUDs around the world. This chronic, debilitating disease is a prevalent health problem, and yet many clinicians do not have adequate training or clinical experience diagnosing and treating SUDs. Anesthesiologists and other perioperative medical staff frequently encounter patients with co-occurring SUDs. By such, through increased awareness and education, physicians and other health care providers have a unique opportunity to positively impact the lives and improve the perioperative outcomes of patients with SUDs. Understanding commonly used terms, potentially effective perioperative screening tools, diagnostic criteria, basics of treatment, and the perioperative implications of SUDs is essential to providing adequate care to patients experiencing this illness.
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Affiliation(s)
- Federico Jimenez Ruiz
- From the Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Nafisseh S Warner
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gregory Acampora
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - John R Coleman
- From the Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Lynn Kohan
- From the Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
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Terasaki D, Hanratty R, Thurstone C. More than MAT: lesser-known benefits of an inpatient addiction consult service. Hosp Pract (1995) 2023; 51:107-109. [PMID: 37314327 DOI: 10.1080/21548331.2023.2225977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 06/13/2023] [Indexed: 06/15/2023]
Affiliation(s)
- Dale Terasaki
- Department of Behavioral Health Services, Denver Health & Hospital Authority, Denver, CO, USA
| | - Rebecca Hanratty
- Department of Ambulatory Care Services, Denver Health & Hospital Authority, Denver, CO, USA
| | - Christian Thurstone
- Department of Behavioral Health Services, Denver Health & Hospital Authority, Denver, CO, USA
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Ascandar N, Vadlakonda A, Verma A, Chervu N, Roberts JS, Sakowitz S, Williamson C, Benharash P. Association of opioid use disorder with outcomes of hospitalizations for acute myocardial infarction in the United States. Clinics (Sao Paulo) 2023; 78:100251. [PMID: 37473624 PMCID: PMC10372160 DOI: 10.1016/j.clinsp.2023.100251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 06/27/2023] [Accepted: 07/03/2023] [Indexed: 07/22/2023] Open
Abstract
OBJECTIVE While Opioid Use Disorder (OUD) has been linked to inferior clinical outcomes, studies examining the clinical outcomes and readmission of OUD patients experiencing Acute Myocardial Infarction (AMI) remain lacking. The authors analyze the clinical and financial outcomes of OUD in a contemporary cohort of AMI hospitalizations. METHODS All non-elective adult (≥ 18 years) hospitalizations for AMI were tabulated from the 2016‒2019 Nationwide Readmissions Database using relevant International Classification of Disease codes. Patients were grouped into OUD and non-OUD cohorts. Bivariate and regression analyses were performed to identify the independent association of OUD with outcomes after non-elective admission for AMI, as well as subsequent readmission. RESULTS Of an estimated 3,318,257 hospitalizations for AMI meeting study criteria, 36,057 (1.1%) had a concomitant diagnosis of OUD. While OUD was not significantly associated with mortality, OUD patients experienced superior cardiovascular outcomes compared to non-OUD. However, OUD was linked to increased odds of non-cardiovascular complications, length of stay, costs, non-home discharge, and 30-day non-elective readmission. CONCLUSIONS Patients with OUD presented with AMI at a significantly younger age than non-OUD. While OUD appears to have a cardioprotective effect, it is associated with several markers of increased resource use, including readmission. The present findings underscore the need for a multifaceted approach to increasing social services and treatment for OUD at index hospitalization.
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Affiliation(s)
- Nameer Ascandar
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Amulya Vadlakonda
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Jacob S Roberts
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Catherine Williamson
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
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Raman SR, Ford CB, Hammill BG, Clark AG, Clifton DC, Jackson GL. Non-overdose acute care hospitalizations for opioid use disorder among commercially-insured adults: a retrospective cohort study. Addict Sci Clin Pract 2023; 18:42. [PMID: 37434260 PMCID: PMC10337199 DOI: 10.1186/s13722-023-00396-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 06/26/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Acute care inpatient admissions outside of psychiatric facilities have been increasingly identified as a critical touchpoint for opioid use disorder (OUD) treatment. We sought to describe non-opioid overdose hospitalizations with documented OUD and examine receipt of post-discharge outpatient buprenorphine. METHODS We examined acute care hospitalizations with an OUD diagnosis in any position within US commercially-insured adults age 18-64 years (IBM MarketScan claims, 2013-2017), excluding opioid overdose diagnoses. We included individuals with ≥ 6 months of continuous enrollment prior to the index hospitalization and ≥ 10 days following discharge. We described demographic and hospitalization characteristics, including outpatient buprenorphine receipt within 10 days of discharge. RESULTS Most (87%) hospitalizations with documented OUD did not include opioid overdose. Of 56,717 hospitalizations (49,959 individuals), 56.8% had a primary diagnosis other than OUD, 37.0% had documentation of an alcohol-related diagnosis code, and 5.8% end in a self-directed discharge. Where opioid use disorder was not the primary diagnosis, 36.5% were due to other substance use disorders, and 23.1% were due to psychiatric disorders. Of all non-overdose hospitalizations who had prescription medication insurance coverage and who were discharged to an outpatient setting (n = 49, 237), 8.8% filled an outpatient buprenorphine prescription within 10 days of discharge. CONCLUSIONS Non-overdose OUD hospitalizations often occur with substance use disorders and psychiatric disorders, and very few are followed by timely outpatient buprenorphine. Addressing the OUD treatment gap during hospitalization may include implementing medication for OUD for inpatients with a broad range of diagnoses.
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Affiliation(s)
- Sudha R Raman
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Suite 210, Durham, NC, 27701, USA.
| | - Cassie B Ford
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Suite 210, Durham, NC, 27701, USA
| | - Bradley G Hammill
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Suite 210, Durham, NC, 27701, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Amy G Clark
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Suite 210, Durham, NC, 27701, USA
| | - Dana C Clifton
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 2301 Erwin Road, Durham, NC, 27710, USA
- Department of Pediatrics, Duke University School of Medicine, 2301 Erwin Road, Durham, NC, 27710, USA
| | - George L Jackson
- Department of Population Health Sciences, Duke University School of Medicine, 215 Morris Street, Suite 210, Durham, NC, 27701, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 2301 Erwin Road, Durham, NC, 27710, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham Veterans Affairs (VA) Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
- Department of Family Medicine and Community Health, Duke University School of Medicine, 2100 Erwin Road, Durham, NC, 27705, USA
- Peter O'Donnell Jr. School of Public Health, University of Texas Southweatern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
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Deaney M, Terasaki D. Intramuscular, extended-release naltrexone inadvertently administered in the deltoid muscle: A case report. J Am Pharm Assoc (2003) 2023; 63:1245-1248. [PMID: 37207707 DOI: 10.1016/j.japh.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/05/2023] [Accepted: 05/06/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Extended-release, intramuscular (IM) naltrexone can be an effective and convenient medication option for alcohol use disorder. We sought to assess the clinical impact of an alternate, if inadvertent, administration of IM naltrexone in the deltoid muscle instead of the recommended gluteal muscle. CASE SUMMARY IM naltrexone was prescribed to a hospitalized 28-year-old man with severe alcohol use disorder as part of an inpatient clinical trial. A nurse unfamiliar with naltrexone administration mistakenly administered the drug to the deltoid instead of the gluteal muscle recommended by the manufacturer. Despite concerns that injection of the large-volume suspension to the smaller muscle would potentially contribute to increased pain and higher chance of adverse events owing to faster medication absorption, the patient experienced only mild discomfort to the deltoid region, without other adverse events on immediate physical and laboratory examinations. The patient later denied additional adverse events in the period after hospitalization, but he did not endorse any anti-craving effect of the medication, resuming drinking alcohol quickly following initial discharge. PRACTICE IMPLICATIONS This case represents a unique procedural challenge of administering a medication in the inpatient setting that is typically given in the outpatient setting. Inpatient staff members frequently rotate and may be relatively unfamiliar with IM naltrexone, so handling should be limited to personnel who have received focused training on its administration. Fortunately, in this case deltoid administration of naltrexone was well-tolerated and even deemed quite "acceptable" to the patient. Clinically, the medication was insufficiently effective, but biopsychosocial context may have made his AUD especially refractory. More research is needed to fully establish whether naltrexone given via deltoid muscle injection has comparable safety and efficacy to gluteal muscle administration.
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Ober AJ, Osilla KC, Klein DJ, Burgette LF, Leamon I, Mazer MW, Messineo G, Collier S, Korouri S, Watkins KE, Ishak W, Nuckols T, Danovitch I. Pilot randomized controlled trial of a hospital-based substance use treatment and recovery team (START) to improve initiation of medication for alcohol or opioid use disorder and linkage to follow-up care. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 150:209063. [PMID: 37156424 PMCID: PMC10330512 DOI: 10.1016/j.josat.2023.209063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 12/06/2022] [Accepted: 05/01/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVES We conducted a pilot randomized controlled trial (RCT) to explore whether a hospital inpatient addiction consult team (Substance Use Treatment and Recovery Team [START]) based on collaborative care was feasible, acceptable to patients, and whether it could improve uptake of medication in the hospital and linkage to care after discharge, as well as reduce substance use and hospital readmission. The START consisted of an addiction medicine specialist and care manager who implemented a motivational and discharge planning intervention. METHODS We randomized inpatients age ≥ 18 with a probable alcohol or opioid use disorder to receive START or usual care. We assessed feasibility and acceptability of START and the RCT, and we conducted an intent-to-treat analysis on data from the electronic medical record and patient interviews at baseline and 1-month postdischarge. The study compared RCT outcomes (medication for alcohol or opioid use disorder, linkage to follow-up care after discharge, substance use, hospital readmission) between arms by fitting logistic and linear regression models. FINDINGS Of 38 START patients, 97 % met with the addiction medicine specialist and care manager; 89 % received ≥8 of 10 intervention components. All patients receiving START found it to be somewhat or very acceptable. START patients had higher odds of initiating medication during the inpatient stay (OR 6.26, 95 % CI = 2.38-16.48, p < .001) and being linked to follow-up care (OR 5.76, 95 % CI = 1.86-17.86, p < .01) compared to usual care patients (N = 50). The study found no significant differences between groups in drinking or opioid use; patients in both groups reported using fewer substances at the 1-month follow-up. CONCLUSIONS Pilot data suggest START and RCT implementation are feasible and acceptable and that START may facilitate medication initiation and linkage to follow-up for inpatients with an alcohol or opioid use disorder. A larger trial should assess effectiveness, covariates, and moderators of intervention effects.
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Affiliation(s)
- Allison J Ober
- RAND Corporation, Santa Monica, CA, United States of America.
| | - Karen C Osilla
- Stanford University School of Medicine, Palo Alto, CA, United States of America
| | - David J Klein
- RAND Corporation, Santa Monica, CA, United States of America
| | - Lane F Burgette
- RAND Corporation, Santa Monica, CA, United States of America
| | - Isabel Leamon
- RAND Corporation, Santa Monica, CA, United States of America
| | - Mia W Mazer
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | | | - Stacy Collier
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Samuel Korouri
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | | | - Waguih Ishak
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Teryl Nuckols
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Itai Danovitch
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
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Englander H. Reply to: "Co-use of Methamphetamine Is Associated With Lower Rates of Linkage to Outpatient Treatment for Hospitalized Patients Who Initiate Buprenorphine". J Addict Med 2023; 17:492-493. [PMID: 37579120 DOI: 10.1097/adm.0000000000001130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Honora Englander
- Section of Addiction Medicine in Division of General Internal Medicine and Geriatrics, Department of Medicine, Oregon Health and Science University, Portland, OR; and Division of Hospital Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR
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Jakubowski A, Singh-Tan S, Torres-Lockhart K, Nahvi S, Stein M, Fox AD, Lu T. Hospital-based clinicians lack knowledge and comfort in initiating medications for opioid use disorder: opportunities for training innovation. Addict Sci Clin Pract 2023; 18:31. [PMID: 37198707 PMCID: PMC10193697 DOI: 10.1186/s13722-023-00386-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 05/01/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Hospital-based clinicians infrequently initiate medications for opioid use disorder (MOUD) for hospitalized patients. Our objective was to understand hospital-based clinicians' knowledge, comfort, attitudes, and motivations regarding MOUD initiation to target quality improvement initiatives. METHODS General medicine attending physicians and physician assistants at an academic medical center completed questionnaires eliciting barriers to MOUD initiation, including knowledge, comfort, attitudes and motivations regarding MOUD. We explored whether clinicians who had initiated MOUD in the prior 12 months differed in knowledge, comfort, attitudes, and motivations from those who had not. RESULTS One-hundred forty-three clinicians completed the survey with 55% reporting having initiated MOUD for a hospitalized patient during the prior 12 months. Common barriers to MOUD initiation were: (1) Not enough experience (86%); (2) Not enough training (82%); (3) Need for more addiction specialist support (76%). Overall, knowledge of and comfort with MOUD was low, but motivation to address OUD was high. Compared to MOUD non-initiators, a greater proportion of MOUD initiators answered knowledge questions correctly, agreed or strongly agreed that they wanted to treat OUD (86% vs. 68%, p = 0.009), and agreed or strongly agreed that treatment of OUD with medication was more effective than without medication (90% vs. 75%, p = 0.022). CONCLUSIONS Hospital-based clinicians had favorable attitudes toward MOUD and are motivated to initiate MOUD, but they lacked knowledge of and comfort with MOUD initiation. To increase MOUD initiation for hospitalized patients, clinicians will need additional training and specialist support.
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Affiliation(s)
- Andrea Jakubowski
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY 10467 USA
| | - Sumeet Singh-Tan
- Department of Medicine, Hospital Division, Albert Einstein College of Medicine/Montefiore Medical Center, 111 E. 210 St, Bronx, NY 10467 USA
| | - Kristine Torres-Lockhart
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY 10467 USA
| | - Shadi Nahvi
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY 10467 USA
| | - Melissa Stein
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY 10467 USA
| | - Aaron D. Fox
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY 10467 USA
| | - Tiffany Lu
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY 10467 USA
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Luo AL, Ravi A, Arvisais-Anhalt S, Muniyappa AN, Liu X, Wang S. Development and Internal Validation of an Interpretable Machine Learning Model to Predict Readmissions in a United States Healthcare System. INFORMATICS 2023. [DOI: 10.3390/informatics10020033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
(1) One in four hospital readmissions is potentially preventable. Machine learning (ML) models have been developed to predict hospital readmissions and risk-stratify patients, but thus far they have been limited in clinical applicability, timeliness, and generalizability. (2) Methods: Using deidentified clinical data from the University of California, San Francisco (UCSF) between January 2016 and November 2021, we developed and compared four supervised ML models (logistic regression, random forest, gradient boosting, and XGBoost) to predict 30-day readmissions for adults admitted to a UCSF hospital. (3) Results: Of 147,358 inpatient encounters, 20,747 (13.9%) patients were readmitted within 30 days of discharge. The final model selected was XGBoost, which had an area under the receiver operating characteristic curve of 0.783 and an area under the precision-recall curve of 0.434. The most important features by Shapley Additive Explanations were days since last admission, discharge department, and inpatient length of stay. (4) Conclusions: We developed and internally validated a supervised ML model to predict 30-day readmissions in a US-based healthcare system. This model has several advantages including state-of-the-art performance metrics, the use of clinical data, the use of features available within 24 h of discharge, and generalizability to multiple disease states.
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Anderson ES, Rusoja E, Luftig J, Ullal M, Shardha R, Schwimmer H, Friedman A, Hailozian C, Herring AA. Effectiveness of Substance Use Navigation for Emergency Department Patients With Substance Use Disorders: An Implementation Study. Ann Emerg Med 2023; 81:297-308. [PMID: 36402631 DOI: 10.1016/j.annemergmed.2022.09.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/07/2022] [Accepted: 09/28/2022] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE We implemented a whole person care-informed intervention delivered by substance use navigators (SUN) for emergency department (ED) patients with substance use disorders. METHODS This was an implementation study of adult patients discharged from 3 public hospital EDs between September 1, 2021 through January 31, 2022 with cocaine, methamphetamine, alcohol, and opioid use-related diagnoses. The primary effectiveness outcome was treatment engagement within 30 days of ED discharge among patients with and without the SUN intervention. We used logistic regression and nearest neighbor propensity score matching without replacement to control for confounding effects. RESULTS There were 1,328 patients in the cohort, and 119 (9.0%) received the SUN intervention; 50.4% of patients in the SUN intervention group and 15.9% of patients without the SUN intervention were engaged in outpatient treatment within 30 days of ED discharge (difference in proportions: 34.5%, 95% confidence interval [CI] 25.3% to 43.8%). In the unadjusted analysis, the SUN intervention was associated with higher rates of treatment engagement after ED discharge for patients with alcohol, opioid, and cocaine-related diagnoses; patients with methamphetamine-related diagnoses had low engagement rates with or without the SUN intervention. In addition, the SUN intervention was associated with higher odds of treatment engagement in the multivariable model (aOR 3.7, 95% CI 2.4 to 5.8) and in the propensity score-matched analysis (OR 2.1, 95% CI 1.2 to 3.5). CONCLUSION A whole person care-informed intervention delivered by SUNs for ED patients with substance use disorders was strongly associated with higher engagement rates in addiction treatment after discharge.
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Affiliation(s)
- Erik S Anderson
- Department of Emergency Medicine, Highland Hospital - Alameda Health System, Oakland, CA; Substance Use Disorder Program, Highland Hospital - Alameda Health System, Oakland, CA.
| | - Evan Rusoja
- Department of Emergency Medicine, Highland Hospital - Alameda Health System, Oakland, CA; Quality and Performance Improvement Program, Highland Hospital - Alameda Health System, Oakland, CA
| | - Joshua Luftig
- Department of Emergency Medicine, Highland Hospital - Alameda Health System, Oakland, CA
| | - Monish Ullal
- Substance Use Disorder Program, Highland Hospital - Alameda Health System, Oakland, CA; Division of Hospital Medicine, Department of Medicine, Highland Hospital - Alameda Health System, Oakland, CA
| | - Ranjana Shardha
- Division of Hospital Medicine, Department of Medicine, Highland Hospital - Alameda Health System, Oakland, CA
| | - Henry Schwimmer
- Department of Emergency Medicine, Highland Hospital - Alameda Health System, Oakland, CA
| | - Alexandra Friedman
- Department of Emergency Medicine, Highland Hospital - Alameda Health System, Oakland, CA
| | - Christian Hailozian
- School of Pharmacy, University of California San Francisco, San Francisco, CA
| | - Andrew A Herring
- Department of Emergency Medicine, Highland Hospital - Alameda Health System, Oakland, CA; Substance Use Disorder Program, Highland Hospital - Alameda Health System, Oakland, CA
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Goldfarb SS, Graves K, Geletko K, Hansen MD, Kinsell H, Harman J. Racial and Ethnic Differences in Emergency Department Wait Times for Patients with Substance Use Disorder. J Emerg Med 2023; 64:481-487. [PMID: 36997432 DOI: 10.1016/j.jemermed.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 02/03/2023] [Accepted: 02/17/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Substance use-related morbidity and mortality rates are at an all-time high in the United States, yet there remains significant stigma and discrimination in emergency medicine about patients with this condition. OBJECTIVES The purpose of this study was to determine whether there are racial and ethnic differences in emergency department (ED) wait times among patients with substance use disorder. METHODS The study uses pooled data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2016 to 2018. The dependent variable is length of time the patient with a diagnosis of substance use disorder waited in the ED before being admitted for care. The independent variable is patient race and ethnicity. Adjusted analyses were conducted using a generalized linear model. RESULTS There were a total of 3995 reported ED events among patients reporting a substance use disorder in the NHAMCS sample between 2016 and 2018. After adjusting for covariates, Black patients with substance use disorder were significantly more likely to wait longer in the ED (35% longer) than White patients with substance use disorder (p < 0.01). CONCLUSIONS The findings showed that Black patients with substance use disorder are waiting 35% longer, on average, than White patients with the same condition. This is concerning, given that emergency medicine is a critical frontline of care, and often the only source of care, for these patients. Furthermore, longer wait times can increase the likelihood of leaving the ED without being seen. Programs and policies should address potential stigma and discrimination among providers, and EDs should consider adding people with lived experiences to the staff to serve as peer recovery specialists and bridge the gap for care.
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Affiliation(s)
- Samantha Sittig Goldfarb
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee
| | - Katelyn Graves
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee
| | - Karen Geletko
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee
| | - Megan Deichen Hansen
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee
| | - Heidi Kinsell
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee
| | - Jeff Harman
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee
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James H, Morgan J, Ti L, Nolan S. Transitions in care between hospital and community settings for individuals with a substance use disorder: A systematic review. Drug Alcohol Depend 2023; 243:109763. [PMID: 36634575 DOI: 10.1016/j.drugalcdep.2023.109763] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 12/28/2022] [Accepted: 01/03/2023] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND AIMS Individuals with a substance use disorder (SUD) have high rates of hospital service utilization including emergency department (ED) presentations and hospital admissions. Acute care settings offer a critical opportunity to engage individuals in addiction care and improve health outcomes especially given that the period of transition from hospital to community is challenging. This review summarizes literature on interventions for optimizing transitions in care from hospital to community for individuals with a SUD. METHODS The literature search focused on key terms associated with transitions in care and SUD. The search was conducted on three databases: MEDLINE, CINAHL, and PsychInfo. Eligible studies evaluated interventions acting prior to or during transitions in care from hospital to community and reported post-discharge engagement in specialized addiction care and/or return to hospital and were published since 2010. RESULTS Title and abstract screening were conducted for 2337 records. Overall, 31 studies met inclusion criteria, including 7 randomized controlled trials and 24 quasi-experimental designs which focused on opioid use (n = 8), alcohol use (n = 5), or polysubstance use (n = 18). Interventions included pharmacotherapy initiation (n = 7), addiction consult services (n = 9), protocol implementation (n = 3), screening, brief intervention, and referral to treatment (n = 2), patient navigation (n = 4), case management (n = 1), and recovery coaching (n = 3). CONCLUSIONS Both pharmacologic and psychosocial interventions implemented around transitions from acute to community care settings can improve engagement in care and reduce hospital readmission and ED presentations. Future research should focus on long-term health and social outcomes to improve quality of care for individuals with a SUD.
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Affiliation(s)
- Hannah James
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC V6H 0A5, Canada
| | - Jeffrey Morgan
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6Z 1Z3, Canada
| | - Lianping Ti
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC V6H 0A5, Canada
| | - Seonaid Nolan
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, 2775 Laurel Street, Vancouver, BC V6H 0A5, Canada.
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Serota DP, Rosenbloom L, Hervera B, Seo G, Feaster DJ, Metsch LR, Suarez E, Chueng TA, Hernandez S, Rodriguez AE, Tookes HE, Doblecki-Lewis S, Bartholomew TS. Integrated Infectious Disease and Substance Use Disorder Care for the Treatment of Injection Drug Use-Associated Infections: A Prospective Cohort Study With Historical Control. Open Forum Infect Dis 2023; 10:ofac688. [PMID: 36632415 PMCID: PMC9830545 DOI: 10.1093/ofid/ofac688] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Background To address the infectious disease (ID) and substance use disorder (SUD) syndemic, we developed an integrated ID/SUD clinical team rooted in harm reduction at a county hospital in Miami, Florida. The Severe Injection-Related Infection (SIRI) team treats people who inject drugs (PWID) and provides medical care, SUD treatment, and patient navigation during hospitalization and after hospital discharge. We assessed the impact of the SIRI team on ID and SUD treatment and healthcare utilization outcomes. Methods We prospectively collected data on patients seen by the SIRI team. A diagnostic code algorithm confirmed by chart review was used to identify a historical control group of patients with SIRI hospitalizations in the year preceding implementation of the SIRI team. The primary outcome was death or readmission within 90 days post-hospital discharge. Secondary outcomes included initiation of medications for opioid use disorder (MOUD) and antibiotic course completion. Results There were 129 patients included in the study: 59 in the SIRI team intervention and 70 in the pre-SIRI team control group. SIRI team patients had a 45% risk reduction (aRR, 0.55 [95% confidence interval CI, .32-.95]; 24% vs 44%) of being readmitted in 90 days or dying compared to pre-SIRI historical controls. SIRI team patients were more likely to initiate MOUD in the hospital (93% vs 33%, P < .01), complete antibiotic treatment (90% vs 60%, P < .01), and less likely to have patient-directed discharge (17% vs 37%, P = .02). Conclusions An integrated ID/SUD team was associated with improvements in healthcare utilization, MOUD initiation, and antibiotic completion for PWID with infections.
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Affiliation(s)
- David P Serota
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Liza Rosenbloom
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Belén Hervera
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Grace Seo
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Daniel J Feaster
- Division of Biostatistics, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Lisa R Metsch
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Edward Suarez
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Teresa A Chueng
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Salma Hernandez
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Allan E Rodriguez
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Hansel E Tookes
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Susanne Doblecki-Lewis
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Tyler S Bartholomew
- Division of Health Services Research and Policy, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
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Implementation of an integrated infectious disease and substance use disorder team for injection drug use-associated infections: a qualitative study. Addict Sci Clin Pract 2023; 18:8. [PMID: 36747268 PMCID: PMC9902242 DOI: 10.1186/s13722-023-00363-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 01/25/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Hospitalizations for severe injection drug use-related infections (SIRIs) are characterized by high costs, frequent patient-directed discharge, and high readmission rates. Beyond the health system impacts, these admissions can be traumatizing to people who inject drugs (PWID), who often receive inadequate treatment for their substance use disorders (SUD). The Jackson SIRI team was developed as an integrated infectious disease/SUD treatment intervention for patients hospitalized at a public safety-net hospital in Miami, Florida in 2020. We conducted a qualitative study to identify patient- and clinician-level perceived implementation barriers and facilitators to the SIRI team intervention. METHODS Participants were patients with history of SIRIs (n = 7) and healthcare clinicians (n = 8) at one implementing hospital (Jackson Memorial Hospital). Semi-structured qualitative interviews were performed with a guide created using the Consolidated Framework for Implementation Research (CFIR). Interviews were transcribed, double coded, and categorized by study team members using CFIR constructs. RESULTS Implementation barriers to the SIRI team intervention identified by participants included: (1) complexity of the SIRI team intervention; (2) lack of resources for PWID experiencing homelessness, financial insecurity, and uninsured status; (3) clinician-level stigma and lack of knowledge around addiction and medications for opioid use disorder (OUD); and (4) concerns about underinvestment in the intervention. Implementation facilitators of the intervention included: (1) a non-judgmental, harm reduction-oriented approach; (2) the team's advocacy for PWID as a means of institutional culture change; (3) provision of close post-hospital follow-up that is often inaccessible for PWID; (4) strong communication with patients and their hospital physicians; and (5) addressing diverse needs such as housing, insurance, and psychological wellbeing. CONCLUSION Integration of infectious disease and SUD treatment is a promising approach to managing patients with SIRIs. Implementation success depends on institutional buy-in, holistic care beyond the medical domain, and an ethos rooted in harm reduction across multilevel (inner and outer) implementation contexts.
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Hugunin J, Davis M, Larkin C, Baek J, Skehan B, Lapane KL. Established Outpatient Care and Follow-Up After Acute Psychiatric Service Use Among Youths and Young Adults. Psychiatr Serv 2023; 74:2-9. [PMID: 36223162 PMCID: PMC9812848 DOI: 10.1176/appi.ps.202200047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE This study explored follow-up after hospitalization and emergency room (ER) use for mental health among youths and young adults with private insurance. METHODS The IBM MarketScan commercial database (2013-2018) was used to identify people ages 12-27 with a mental health hospitalization (N=95,153) or ER use (N=108,576). Factors associated with outpatient mental health follow-up within 7 and 30 days of discharge were determined via logistic models with generalized estimating equations that accounted for state variation. RESULTS Of those hospitalized, 42.7% received follow-up within 7 days (67.4% within 30 days). Of those with ER use, 28.6% received follow-up within 7 days (46.4% within 30 days). Type of established outpatient care predicted follow-up after hospitalization and ER use. Compared with people with no established care, the likelihood of receiving follow-up within 7 days was highest among those with mental health and primary care (hospitalization, adjusted odds ratio [AOR]=2.81, 95% confidence interval [CI]=2.68-2.94; ER use, AOR=4.06, 95% CI=3.72-4.42), followed by those with mental health care only (hospitalization, AOR=2.57, 95% CI=2.45-2.70; ER use, AOR=3.48, 95% CI=3.17-3.82) and those with primary care only (hospitalization, AOR=1.20, 95% CI=1.15-1.26; ER use, AOR=1.22, 95% CI=1.16-1.28). Similar trends were observed within 30 days of discharge. CONCLUSIONS Follow-up rates after acute mental health service use among youths and young adults were suboptimal. Having established mental health care more strongly predicted receiving follow-up than did having established primary care. Improving engagement with outpatient mental health care providers may increase follow-up rates.
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Affiliation(s)
- Julie Hugunin
- Clinical and Population Health Research doctoral program, Morningside Graduate School of Biomedical Sciences (Hugunin, Davis, Larkin, Baek, Lapane); Department of Psychiatry (Davis, Larkin, Skehan); Department of Emergency Medicine (Larkin); Department of Population and Quantitative Health Sciences (Baek, Lapane); and Department of Pediatrics (Skehan), University of Massachusetts Chan Medical School, Worcester
| | - Maryann Davis
- Clinical and Population Health Research doctoral program, Morningside Graduate School of Biomedical Sciences (Hugunin, Davis, Larkin, Baek, Lapane); Department of Psychiatry (Davis, Larkin, Skehan); Department of Emergency Medicine (Larkin); Department of Population and Quantitative Health Sciences (Baek, Lapane); and Department of Pediatrics (Skehan), University of Massachusetts Chan Medical School, Worcester
| | - Celine Larkin
- Clinical and Population Health Research doctoral program, Morningside Graduate School of Biomedical Sciences (Hugunin, Davis, Larkin, Baek, Lapane); Department of Psychiatry (Davis, Larkin, Skehan); Department of Emergency Medicine (Larkin); Department of Population and Quantitative Health Sciences (Baek, Lapane); and Department of Pediatrics (Skehan), University of Massachusetts Chan Medical School, Worcester
| | - Jonggyu Baek
- Clinical and Population Health Research doctoral program, Morningside Graduate School of Biomedical Sciences (Hugunin, Davis, Larkin, Baek, Lapane); Department of Psychiatry (Davis, Larkin, Skehan); Department of Emergency Medicine (Larkin); Department of Population and Quantitative Health Sciences (Baek, Lapane); and Department of Pediatrics (Skehan), University of Massachusetts Chan Medical School, Worcester
| | - Brian Skehan
- Clinical and Population Health Research doctoral program, Morningside Graduate School of Biomedical Sciences (Hugunin, Davis, Larkin, Baek, Lapane); Department of Psychiatry (Davis, Larkin, Skehan); Department of Emergency Medicine (Larkin); Department of Population and Quantitative Health Sciences (Baek, Lapane); and Department of Pediatrics (Skehan), University of Massachusetts Chan Medical School, Worcester
| | - Kate L Lapane
- Clinical and Population Health Research doctoral program, Morningside Graduate School of Biomedical Sciences (Hugunin, Davis, Larkin, Baek, Lapane); Department of Psychiatry (Davis, Larkin, Skehan); Department of Emergency Medicine (Larkin); Department of Population and Quantitative Health Sciences (Baek, Lapane); and Department of Pediatrics (Skehan), University of Massachusetts Chan Medical School, Worcester
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Levy S, Bassler J, Gagnon K, Prados M, Jeziorski M, McCleskey B, Crockett K, Li L, Bradford D, Cropsey K, Eaton E. Methamphetamines and Serious Injection-Related Infections: Opioid Use Care Continuum and Opportunities to End Alabama's Drug Crisis. Open Forum Infect Dis 2022; 10:ofac708. [PMID: 36726543 PMCID: PMC9879754 DOI: 10.1093/ofid/ofac708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/29/2022] [Indexed: 01/01/2023] Open
Abstract
Background Increasingly, injection opioid use and opioid use disorder (OUD) are complicated by methamphetamine use, but the impact of stimulant use on the care of people who inject drugs (PWID) with serious injection-related infections (SIRIs) is unknown. The objective of this study was to explore hospital outcomes and postdischarge trends for a cohort of hospitalized PWID to identify opportunities for intervention. Methods We queried the electronic medical record for patients hospitalized at the University of Alabama at Birmingham with injection drug use-related infections between 1/11/2016 and 4/24/2021. Patients were categorized as having OUD only (OUD), OUD plus methamphetamine use (OUD/meth), or injection of other substance(s) (other). We utilized statistical analyses to assess group differences across hospital outcomes and postdischarge trends. We determined the OUD continuum of care for those with OUD, with and without methamphetamine use. Results A total of 370 patients met inclusion criteria-many with readmissions (98%) and high mortality (8%). The majority were White, male, and uninsured, with a median age of 38. One in 4 resided outside of a metropolitan area. There were significant differences according to substance use in terms of sociodemographics and hospital outcomes: patients with OUD/meth were more likely to leave via patient-directed discharge, but those with OUD only had the greatest mortality. Comorbid methamphetamine use did not significantly impact the OUD care continuum. Conclusions The current drug crisis in AL will require targeted interventions to engage a young, uninsured population with SIRI in evidence-based addiction and infection services.
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Affiliation(s)
- Sera Levy
- Correspondence: Sera Levy, MS, Department of Psychiatry and Behavioral Neurobiology, Heersink School of Medicine, UAB, The University of Alabama at Birmingham, L107 Volker Hall, 1670 University Blvd, Birmingham, AL 35233 ()
| | - John Bassler
- Division of Infectious Diseases, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kelly Gagnon
- Division of Infectious Diseases, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Myles Prados
- Division of Infectious Diseases, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Madison Jeziorski
- Division of Infectious Diseases, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brandi McCleskey
- Department of Pathology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kaylee Crockett
- Department of Family and Community Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Li Li
- Department of Psychiatry, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Davis Bradford
- Department of Internal Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Karen Cropsey
- Department of Psychiatry and Behavioral Neurobiology, Heersink School of Medicine, UAB, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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Luo Z, Roychoudhury C, Pompos WS, DiMaria J, Robinette CM, Gore PH, Roychoudhury R, Beecroft W. Prevention of 90-day inpatient detoxification readmission for opioid use disorder by a community-based life-changing individualized medically assisted evidence-based treatment (C.L.I.M.B.) program: A quasi-experimental study. PLoS One 2022; 17:e0278208. [PMID: 36520863 PMCID: PMC9754176 DOI: 10.1371/journal.pone.0278208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 11/12/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Evidence for community-based strategies to reduce inpatient detoxification readmission for opioid use disorder (OUD) is scant. A pilot program was designed to provide individualized structured treatment plans, including addressing prolonged withdrawal symptoms, family/systems assessment, and contingency management, to reduce readmission after the index inpatient detoxification. METHODS A non-randomized quasi-experimental design was used to compare the pilot facilities (treatment) and comparison facilities before and after the program started, i.e., a simple difference-in-differences (DID) strategy. Adults 18 years and older who met the Diagnostic and Statistical Manual of Mental Disorders version 5 criteria for OUD and had an inpatient detoxification admission at any OUD treatment facility in two study periods between 7/2016 and 3/2020 were included. Readmission for inpatient detoxification in 90-days after the index stay was the primary outcome, and partial hospitalization, intensive outpatient care, outpatient services, and medications for OUD were the secondary outcomes. Six statistical estimation methods were used to triangulate evidence and adjust for potential confounding factors between treatment and comparison groups. RESULTS A total of 2,320 unique patients in the pilot and comparison facilities with 2,443 index inpatient detoxification admissions in the pre- and post-periods were included. Compared with patients in comparison facilities, patients in the C.L.I.M.B. facilities had higher readmission in the pre-period (unadjusted readmission 17.0% vs. 10.6%), but similar rates in the post-period (12.3% vs. 10.6%) after the implementation of the pilot program. For 90-day readmission, all DID estimates were not statistically significant (adjusted estimates ranged from 6 to 9 percentage points difference favoring the C.L.I.M.B. program). There was no significant improvement in the secondary outcomes of utilizations in lower level of care and medications for OUD in C.L.I.M.B. facilities. CONCLUSIONS We found a reduction in readmission in the pilot facilities between the two periods, but the results were not statistically significant compared with the comparison facilities and the utilization of lower level of care services remained low. Even though providers in the pilot OUD treatment facilities actively worked with health plans to standardize care for patients with OUD, more strategies are needed to improve treatment engagement and retention after an inpatient detoxification.
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Affiliation(s)
- Zhehui Luo
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, United States of America
- * E-mail:
| | - Canopy Roychoudhury
- Health Care Value Business Analytics Services, Blue Cross Blue Shield of Michigan, Detroit, Michigan, United States of America
| | - William S. Pompos
- Behavioral Health Strategy & Planning, Blue Cross Blue Shield of Michigan, Detroit, Michigan, United States of America
| | - James DiMaria
- Health Care Value Business Analytics Services, Blue Cross Blue Shield of Michigan, Detroit, Michigan, United States of America
| | - Cynthia M. Robinette
- Health Care Value Business Analytics Services, Blue Cross Blue Shield of Michigan, Detroit, Michigan, United States of America
| | - Purva H. Gore
- Health Care Value Business Analytics Services, Blue Cross Blue Shield of Michigan, Detroit, Michigan, United States of America
| | - Rohon Roychoudhury
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, United States of America
| | - William Beecroft
- Behavioral Health Strategy & Planning, Blue Cross Blue Shield of Michigan, Detroit, Michigan, United States of America
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Tassey TE, Ott GE, Alvanzo AAH, Peirce JM, Antoine D, Buresh ME. OUD MEETS: A novel program to increase initiation of medications for opioid use disorder and improve outcomes for hospitalized patients being discharged to skilled nursing facilities. J Subst Abuse Treat 2022; 143:108895. [PMID: 36215913 DOI: 10.1016/j.jsat.2022.108895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 08/09/2022] [Accepted: 09/20/2022] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Rates of hospitalizations from medical complications of opioid use disorder (OUD) are rising and many of these patients require post-acute care at skilled nursing facilities (SNFs). However, access to medication for OUD (MOUD) at SNFs remains low and patients with OUD have high rates of patient-directed discharge (PDD) and hospital readmissions. METHODS Opioid Use Disorder Medical Patient Engagement, Enrollment in treatment and Transitional Supports (OUD MEETS) program was a clinical pilot designed to increase initiation of buprenorphine and methadone for hospitalized patients with OUD requiring post-acute care. The program comprises a hospital partnership with two SNFs and two opioid treatment programs (OTPs) to improve recovery supports and access to MOUD for patients discharged to SNF. RESULTS Between August 2019 and August 2020, study staff approached 49 hospitalized patients with OUD for participation in OUD MEETS. Twenty-eight of 30 eligible patients enrolled in the program and initiated buprenorphine or methadone. Twenty-seven (96 %) enrolled patients successfully completed hospital treatment. Twenty-three (85 %) patients successfully completed medical treatment at SNF. Thirteen (46 %) enrolled patients had confirmed linkage to OUD treatment post-SNF. One patient left the hospital (4 %) and four patients left SNF (15 %) via PDD. CONCLUSION OUD MEETS demonstrates feasibility of hospital, SNF, and OTP partnership to integrate MOUD treatment into SNFs, with high rates of completion of medical treatment and low rates of PDD. Future research should find sustainable ways to improve access to MOUD at post-acute care facilities, including through regulatory and policy changes.
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Affiliation(s)
- Theresa E Tassey
- Behavioral Health Systems Baltimore, Baltimore, MD, United States of America
| | - Geoffrey E Ott
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Anika A H Alvanzo
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America; Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Jessica M Peirce
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Denis Antoine
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Megan E Buresh
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America.
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Jack HE, Denisiuk ED, Collins BA, Stephens D, Blalock KL, Klein JW, Bhatraju EP, Merrill JO, Hallgren KA, Tsui JI. Peer providers and linkage with buprenorphine care after hospitalization: A retrospective cohort study. Subst Abus 2022; 43:1308-1316. [PMID: 35896006 PMCID: PMC9586121 DOI: 10.1080/08897077.2022.2095078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Background: People with opioid use disorder (OUD) are increasingly started on buprenorphine in the hospital, yet many patients do not attend outpatient buprenorphine care after discharge. Peer providers, people in recovery themselves, are a growing part of addiction care. We examine whether patients who received a low-intensity, peer-delivered intervention during hospitalization had a greater rate of linking with outpatient buprenorphine care relative to those not seen by a peer. Methods: This was a retrospective cohort study of adults with OUD who were started on buprenorphine during hospitalization. The primary outcome was receipt of a buprenorphine prescription within 30 days of discharge. Secondary outcomes included attendance at a follow-up visit with a buprenorphine provider within 30 days and hospital readmission within 90 days. Modified Poisson regression analyses tested for differences in the rate ratios (RR) of each binary outcome for patients who were versus were not seen by a peer provider. Peer notes in the electronic health record were reviewed to characterize peer activities. Results: 111 patients met the study inclusion criteria, 31.5% of whom saw a peer provider. 55.0% received a buprenorphine prescription within 30 days of hospital discharge. Patients with versus without peer provider encounters did not significantly differ in the rates of receiving a buprenorphine prescription (RR = 1.06, 95% CI: 0.74-1.51), hospital readmission (RR = 1.45, 95% CI: 0.80-2.64), or attendance at a buprenorphine follow-up visit (RR = 1.03, 95% CI: 0.68-1.57). Peers most often listened to or shared experiences with patients (68.6% of encounters) and helped facilitate medical care (60.0% of encounters). Conclusions: There were no differences in multiple measures of buprenorphine follow-up between patients who received this low-intensity peer intervention and those who did not. There is need to investigate what elements of peer provider programs contribute to patient outcomes and what outcomes should be assessed when evaluating peer programs.
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Affiliation(s)
- Helen E. Jack
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Eric D. Denisiuk
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Brett A. Collins
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Dan Stephens
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Kendra L. Blalock
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Jared W. Klein
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Elenore P. Bhatraju
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Joseph O. Merrill
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Kevin A. Hallgren
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Judith I. Tsui
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
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O'Rourke BP, Hogan TH, Teater J, Fried M, Williams M, Miller A, Clark AD, Huynh P, Kauffman E, Hefner JL. Initiation of medication for opioid use disorder across a health system: A retrospective analysis of patient characteristics and inpatient outcomes. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 5:100114. [PMID: 36844164 PMCID: PMC9948916 DOI: 10.1016/j.dadr.2022.100114] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/08/2022]
Abstract
Objectives Medication for opioid use disorder (MOUD) has gained significant momentum as an evidence-based intervention for treating opioid use disorder (OUD). The purpose of this study was to characterize MOUD initiations for buprenorphine and extended release (ER) naltrexone across all care sites at a major health system in the Midwest and determine whether MOUD initiation was associated with inpatient outcomes. Methods The study population comprised patients with OUD in the health system between 2018 and 2021. First, we described characteristics of all MOUD initiations for the study population within the health system. Second, we compared inpatient length of stay (LOS) and unplanned readmission rates between patients prescribed MOUD and patients not prescribed MOUD, including a pre-post comparison of patients prescribed MOUD before versus after initiation. Results The 3,831 patients receiving MOUD were mostly white, non-Hispanic and generally received buprenorphine over ER naltrexone. 65.5% of most recent initiations occurred in an inpatient setting. Compared to those not prescribed MOUD, inpatient encounters where patients received MOUD on or before the admission date were significantly less likely to be unplanned readmissions (13% vs. 20%, p < 0.001) and their LOS was 0.14 days shorter (p = 0.278). Among patients prescribed MOUD, there was a significant reduction in the readmission rate after initiation compared to before (13% vs. 22%, p < 0.001). Conclusions This study is the first to examine MOUD initiations for thousands of patients across multiple care sites in a health system, finding that receiving MOUD is associated with clinically meaningful reductions in readmission rates.
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Affiliation(s)
- Brian P. O'Rourke
- The Division of Health Services Management and Policy, College of Public Health, The Ohio State University, 1841 Neil Ave Rm 250, Columbus, OH 43210, USA,Corresponding author.
| | - Tory H. Hogan
- The Division of Health Services Management and Policy, College of Public Health, The Ohio State University, 1841 Neil Ave Rm 250, Columbus, OH 43210, USA
| | - Julie Teater
- The Department of Psychiatry and Behavioral Health, College of Medicine, The Ohio State University, 370 W. 9th Avenue, Columbus, OH 43210, USA
| | - Martin Fried
- The Division of General Internal Medicine, College of Medicine, The Ohio State University, 370 W. 9th Avenue, Columbus, OH 43210, USA
| | - Margaret Williams
- The Division of Hospital Medicine, College of Medicine, The Ohio State University, 370 W. 9th Avenue, Columbus, OH 43210, USA
| | - Alison Miller
- Neurological Institute, The Ohio State University Wexner Medical Center, 410 W. 10th Ave, Columbus, OH 43210, USA
| | - Aaron D. Clark
- The Department of Family and Community Medicine, College of Medicine, The Ohio State University, 370 W. 9th Avenue, Columbus, OH 43210, USA
| | - Phuong Huynh
- The Department of Family and Community Medicine, College of Medicine, The Ohio State University, 370 W. 9th Avenue, Columbus, OH 43210, USA
| | - Emily Kauffman
- The Division of General Internal Medicine, College of Medicine, The Ohio State University, 370 W. 9th Avenue, Columbus, OH 43210, USA,Department of Emergency Medicine, College of Medicine, The Ohio State University, 370 W. 9th Avenue, Columbus, OH 43210, USA
| | - Jennifer L. Hefner
- The Division of Health Services Management and Policy, College of Public Health, The Ohio State University, 1841 Neil Ave Rm 250, Columbus, OH 43210, USA,The Department of Family and Community Medicine, College of Medicine, The Ohio State University, 370 W. 9th Avenue, Columbus, OH 43210, USA
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Jimenez AE, Cicalese KV, Chakravarti S, Porras JL, Azad TD, Jackson CM, Gallia G, Bettegowda C, Weingart J, Mukherjee D. Substance Use Disorders Are Independently Associated with Hospital Readmission Among Patients with Brain Tumors. World Neurosurg 2022; 166:e358-e368. [PMID: 35817348 DOI: 10.1016/j.wneu.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/02/2022] [Accepted: 07/04/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Research on the effects of substance use disorders (SUDs) on postoperative outcomes within neurosurgical oncology has been limited. Therefore, the present study sought to quantify the effect of having a SUD on hospital length of stay, postoperative complication incidence, discharge disposition, hospital charges, 90-day readmission rates, and 90-day mortality rates following brain tumor surgery. METHODS The present study used data from patients who received surgical resection for brain tumor at a single institution between January 1, 2017, and December 31, 2019. The Mann-Whitney U test was used for bivariate analysis of continuous variables and Fisher exact test was used for bivariate analysis of categorical variables. Multivariate analysis was conducted using logistic regression models. RESULTS Our study cohort included a total of 2519 patients, 124 (4.9%) of whom had at least 1 SUD. More specifically, 90 (3.6%) patients had an alcohol use disorder, 27 (1.1%) had a cannabis use disorder, and 12 (0.5%) had an opioid use disorder. On bivariate analysis, 90-day hospital readmission was the only postoperative outcome significantly associated with a SUD (odds ratio 2.21, P = 0.0011). When controlling for patient age, sex, race, marital status, insurance, brain tumor diagnosis, 5-factor modified frailty index score, American Society of Anesthesiologists score, and surgery number, SUDs remained significantly and independently associated with 90-day readmission (odds ratio 1.82, P = 0.013). CONCLUSIONS In patients with brain tumor, SUDs significantly and independently predict 90-day hospital readmission after surgery. Targeted management of patients with SUDs before and after surgery can optimize patient outcomes and improve the provision of high-value neurosurgical care.
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Affiliation(s)
- Adrian E Jimenez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kyle V Cicalese
- Department of Neurosurgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Sachiv Chakravarti
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jose L Porras
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tej D Azad
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gary Gallia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jon Weingart
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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47
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Englander H, Jones A, Krawczyk N, Patten A, Roberts T, Korthuis PT, McNeely J. A Taxonomy of Hospital-Based Addiction Care Models: a Scoping Review and Key Informant Interviews. J Gen Intern Med 2022; 37:2821-2833. [PMID: 35534663 PMCID: PMC9411356 DOI: 10.1007/s11606-022-07618-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/12/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND There is pressing need to improve hospital-based addiction care. Various models for integrating substance use disorder care into hospital settings exist, but there is no framework for describing, selecting, or comparing models. We sought to fill that gap by constructing a taxonomy of hospital-based addiction care models based on scoping literature review and key informant interviews. METHODS Methods included a scoping review of the literature on US hospital-based addiction care models and interventions for adults, published between January 2000 and July 2021. We conducted semi-structured interviews with 15 key informants experienced in leading, implementing, evaluating, andpracticing hospital-based addiction care to explore model characteristics, including their perceived strengths, limitations, and implementation considerations. We synthesized findings from the literature review and interviews to construct a taxonomy of model types. RESULTS Searches identified 2,849 unique abstracts. Of these, we reviewed 280 full text articles, of which 76 were included in the final review. We added 8 references from reference lists and informant interviews, and 4 gray literature sources. We identified six distinct hospital-based addiction care models. Those classified as addiction consult models include (1) interprofessional addiction consult services, (2) psychiatry consult liaison services, and (3) individual consultant models. Those classified as practice-based models, wherein general hospital staff integrate addiction care into usual practice, include (4) hospital-based opioid treatment and (5) hospital-based alcohol treatment. The final type was (6) community-based in-reach, wherein community providers deliver care. Models vary in their target patient population, staffing, and core clinical and systems change activities. Limitations include that some models have overlapping characteristics and variable ways of delivering core components. DISCUSSION A taxonomy provides hospital clinicians and administrators, researchers, and policy-makers with a framework to describe, compare, and select models for implementing hospital-based addiction care and measure outcomes.
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Affiliation(s)
- Honora Englander
- Section of Addiction Medicine in Division of General Internal Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
- Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Amy Jones
- School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Noa Krawczyk
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Alisa Patten
- Section of Addiction Medicine in Division of General Internal Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Timothy Roberts
- NYU Health Sciences Library, New York University Grossman School of Medicine, New York, NY, USA
| | - P Todd Korthuis
- Section of Addiction Medicine in Division of General Internal Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jennifer McNeely
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
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48
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Orme S, Zarkin GA, Dunlap LJ, Nordeck CD, Schwartz RP, Mitchell SG, Welsh C, O’Grady KE, Gryczynski J. Cost and Cost Savings of Navigation Services to Avoid Rehospitalization for a Comorbid Substance Use Disorder Population. Med Care 2022; 60:631-635. [PMID: 35687900 PMCID: PMC9382857 DOI: 10.1097/mlr.0000000000001743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A randomized clinical trial found that patient navigation for hospital patients with comorbid substance use disorders (SUDs) reduced emergency department (ED) and inpatient hospital utilization compared with treatment-as-usual. OBJECTIVE To compare the cost and calculate any cost savings from the Navigation Services to Avoid Rehospitalization (NavSTAR) intervention over treatment-as-usual. RESEARCH DESIGN This study calculates activity-based costs from the health care providers and uses a net benefits approach to calculate the cost savings generated from NavSTAR. NavSTAR provided patient navigation focused on engagement in SUD treatment, starting before hospital discharge and continuing for up to 3 months postdischarge. SUBJECTS Adult hospitalized medical/surgical patients with comorbid SUD for opioids, cocaine, and/or alcohol. COST MEASURES Cost of the 3-month NavSTAR patient navigation intervention and the cost of all inpatient days and ED visits over a 12-month period. RESULTS OF BASE CASE ANALYSIS NavSTAR generated $17,780 per participant in cost savings. Ninety-seven percent of bootstrapped samples generated positive cost savings, and our sensitivity analyses did not change our results. LIMITATIONS Participants were recruited at one hospital in Baltimore, MD through the hospital's addiction consultation service. Findings may not generalize to the broader population. Outpatient health care cost data was not available through administrative records. CONCLUSION Our findings show that patient navigation interventions should be considered by payors and policy makers to reduce the high hospital costs associated with comorbid SUD patients.
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Affiliation(s)
- Stephen Orme
- RTI International, 3040 East Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709
| | - Gary A. Zarkin
- RTI International, 3040 East Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709
| | - Laura J. Dunlap
- RTI International, 3040 East Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709
| | | | - Robert P. Schwartz
- Friends Research Institute, 1040 Park Avenue Suite 103. Baltimore, MD 21201
| | | | - Christopher Welsh
- University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201
| | - Kevin E. O’Grady
- Department of Psychology, University of Maryland, College Park, 4094 Campus Drive, College Park, MD 20742
| | - Jan Gryczynski
- Friends Research Institute, 1040 Park Avenue Suite 103. Baltimore, MD 21201
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49
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Cupp JA, Byrne KA, Herbert K, Roth PJ. Acute Care Utilization After Recovery Coaching Linkage During Substance-Related Inpatient Admission: Results of Two Randomized Controlled Trials. J Gen Intern Med 2022; 37:2768-2776. [PMID: 35296984 PMCID: PMC8926086 DOI: 10.1007/s11606-021-07360-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 12/16/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND For patients with substance use disorder (SUD), a peer recovery coach (PRC) intervention increases engagement in recovery services; effective support services interventions have occasionally demonstrated cost savings through decreased acute care utilization. OBJECTIVE Examine effect of PRCs on acute care utilization. DESIGN Combined results of 2 parallel 1:1 randomized controlled trials. PARTICIPANTS Inpatient adults with substance use disorder INTERVENTIONS: Inpatient PRC linkage and follow-up contact for 6 months vs usual care (providing contact information for SUD resources and PRCs) MAIN MEASURES: Acute care encounters (emergency and inpatient) 6 months before and after enrollment; encounter type by primary diagnosis code category (mental/behavioral vs medical); 30-day readmissions with Lace+ readmission risk scores. KEY RESULTS A total of 193 patients were randomized: 95 PRC; 98 control. In the PRC intervention, 66 patients had a pre-enrollment acute care encounter and 56 had an encounter post-enrollment, compared to the control group with 59 pre- and 62 post-enrollment (odds ratio [OR] = -0.79, P = 0.11); there was no significant effect for sub-groups by encounter location (emergency vs inpatient). There was a significant decrease in mental/behavioral ED visits (PRC: pre-enrollment 17 vs post-enrollment 10; control: pre-enrollment 13 vs post-enrollment 16 (OR = -2.62, P = 0.02)) but not mental/behavioral inpatient encounters or medical emergency or inpatient encounters. There was no significant difference in 30-day readmissions corrected for Lace+ scores (15.8% PRC vs 17.3% control, OR = 0.19, P = 0.65). CONCLUSIONS PRCs did not decrease overall acute care utilization but may decrease emergency encounters related to substance use. TRIAL REGISTRATION ClinicalTrials.gov (NCT04098601, NCT04098614).
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Affiliation(s)
| | | | - Kristin Herbert
- University of South Carolina School of Medicine-Greenville, Greenville, USA
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50
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Ober AJ, Murray-Krezan C, Page K, Friedmann PD, Chan Osilla K, Ryzewicz S, Huerta S, Mazer MW, Leamon I, Messineo G, Watkins KE, Nuckols T, Danovitch I. The Substance Use Treatment and Recovery Team (START) study: protocol for a multi-site randomized controlled trial evaluating an intervention to improve initiation of medication and linkage to post-discharge care for hospitalized patients with opioid use disorder. Addict Sci Clin Pract 2022; 17:39. [PMID: 35902888 PMCID: PMC9331017 DOI: 10.1186/s13722-022-00320-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND People with opioid use disorder experience high burden of disease from medical comorbidities and are increasingly hospitalized with medical complications. Medications for opioid use disorder are an effective, life-saving treatment, but patients with an opioid use disorder admitted to the hospital seldom initiate medication for their disorder while in the hospital, nor are they linked with outpatient treatment after discharge. The inpatient stay, when patients may be more receptive to improving their health and reducing substance use, offers an opportunity to discuss opioid use disorder and facilitate medication initiation and linkage to treatment after discharge. An addiction-focus consultative team that uses evidence-based tools and resources could address barriers, such as the need for the primary medical team to focus on the primary health problem and lack of time and expertise, that prevent primary medical teams from addressing substance use. METHODS This study is a pragmatic randomized controlled trial that will evaluate whether a consultative team, called the Substance Use Treatment and Recovery Team (START), increases initiation of any US Food and Drug Administration approved medication for opioid use disorder (buprenorphine, methadone, naltrexone) during the hospital stay and increases linkage to treatment after discharge compared to patients receiving usual care. The study is being conducted at three geographically distinct academic hospitals. Patients are randomly assigned within each hospital to receive the START intervention or usual care. Primary study outcomes are initiation of medication for opioid use disorder in the hospital and linkage to medication or other opioid use disorder treatment after discharge. Outcomes are assessed through participant interviews at baseline and 1 month after discharge and data from hospital and outpatient medical records. DISCUSSION The START intervention offers a compelling model to improve care for hospitalized patients with opioid use disorder. The study could also advance translational science by identifying an effective and generalizable approach to treating not only opioid use disorder, but also other substance use disorders and behavioral health conditions. TRIAL REGISTRATION Clinicaltrials.gov: NCT05086796, Registered on 10/21/2021. https://www. CLINICALTRIALS gov/ct2/results?recrs=ab&cond=&term=NCT05086796&cntry=&state=&city=&dist = .
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Affiliation(s)
- Allison J Ober
- RAND Corporation, 1776 Main St, Santa Monica, CA, 90407-2138, USA.
| | | | - Kimberly Page
- University of New Mexico Hospital, Albuquerque, NM, USA
| | - Peter D Friedmann
- University of Massachusetts Chan Medical School-Baystate, Springfield, MA, USA
| | | | - Stephen Ryzewicz
- University of Massachusetts Chan Medical School-Baystate, Springfield, MA, USA
| | | | - Mia W Mazer
- Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Isabel Leamon
- RAND Corporation, 1776 Main St, Santa Monica, CA, 90407-2138, USA
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