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Andersen A, Milefchik E, Papworth E, Penaluna B, Dawes K, Moody J, Weeks G, Froehlich E, deBlois K, Long JD, Philibert R. ZSCAN25 methylation predicts seizures and severe alcohol withdrawal syndrome. Epigenetics 2024; 19:2298057. [PMID: 38166538 PMCID: PMC10766392 DOI: 10.1080/15592294.2023.2298057] [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: 08/26/2023] [Accepted: 12/11/2023] [Indexed: 01/04/2024] Open
Abstract
Currently, clinicians use their judgement and indices such as the Prediction of Alcohol Withdrawal Syndrome Scale (PAWSS) to determine whether patients are admitted to hospitals for consideration of withdrawal syndrome (AWS). However, only a fraction of those admitted will experience severe AWS. Previously, we and others have shown that epigenetic indices, such as the Alcohol T-Score (ATS), can quantify recent alcohol consumption. However, whether these or other alcohol biomarkers, such as carbohydrate deficient transferrin (CDT), could identify those at risk for severe AWS is unknown. To determine this, we first conducted genome-wide DNA methylation analyses of subjects entering and exiting alcohol treatment to identify loci whose methylation quickly reverted as a function of abstinence. We then tested whether methylation at a rapidly reverting locus, cg07375256, or other existing metrics including PAWSS scores, CDT levels, or ATS, could predict outcome in 125 subjects admitted for consideration of AWS. We found that PAWSS did not significantly predict severe AWS nor seizures. However, methylation at cg07375256 (ZSCAN25) and CDT strongly predicted severe AWS with ATS (p < 0.007) and cg07375256 (p < 6 × 10-5) methylation also predicting AWS associated seizures. We conclude that epigenetic methods can predict those likely to experience severe AWS and that the use of these or similar Precision Epigenetic approaches could better guide AWS management.
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Affiliation(s)
- Allan Andersen
- Department of Psychiatry, University of Iowa, Iowa City, IA, USA
| | - Emily Milefchik
- Department of Psychiatry, University of Iowa, Iowa City, IA, USA
| | - Emma Papworth
- Department of Psychiatry, University of Iowa, Iowa City, IA, USA
| | - Brandan Penaluna
- Department of Psychiatry, University of Iowa, Iowa City, IA, USA
| | - Kelsey Dawes
- Department of Psychiatry, University of Iowa, Iowa City, IA, USA
- Behavioral Diagnostics LLC, Coralville, IA, USA
| | - Joanna Moody
- Department of Psychiatry, University of Iowa, Iowa City, IA, USA
| | - Gracie Weeks
- Department of Psychiatry, University of Iowa, Iowa City, IA, USA
| | - Ellyse Froehlich
- Department of Psychiatry, University of Iowa, Iowa City, IA, USA
| | - Kaitlyn deBlois
- Department of Psychiatry, University of Iowa, Iowa City, IA, USA
| | - Jeffrey D Long
- Department of Psychiatry, University of Iowa, Iowa City, IA, USA
- Department of Biostatistics, University of Iowa, Iowa City, IA, USA
| | - Robert Philibert
- Department of Psychiatry, University of Iowa, Iowa City, IA, USA
- Behavioral Diagnostics LLC, Coralville, IA, USA
- Department of Biomedical Engineering, University of Iowa, Iowa City, IA, 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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Incze MA, Huebler S, Grant S, Gordon AJ. Using the Delphi Process to Prioritize an Agenda for Care Transition Research for Patients With Substance Use Disorders. SUBSTANCE USE & ADDICTION JOURNAL 2024; 45:523-528. [PMID: 38622904 DOI: 10.1177/29767342241246762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Medical hospitalizations are increasingly recognized as important opportunities to engage individuals with substance use disorders (SUD) and offer treatment. While a growing number of hospitals have instituted interventions to support the provision of SUD care during medical admissions, post-hospitalization transitions of care remain a challenge for patients and clinicians and an understudied area of SUD care. Evidence is lacking on the most effective and feasible models of care to improve post-hospitalization care transitions for people with SUD. In the absence of strong empirical evidence to guide practice and policy, consensus-based research methods such as the Delphi process can play an important role in efficiently prioritizing existing models of care for future study and implementation. We conducted a Delphi study that convened a group of 25 national interdisciplinary experts with direct clinical experience facilitating post-hospitalization care transitions for people with SUD. Our panelists rated 10 existing care transition models according to anticipated effectiveness and facility of implementation based on the GRADE Evidence to Decision framework. Qualitative data on each care model were also gathered through comments and an online moderated discussion board. Our results help establish a hierarchy of SUD care transition models to inform future study and program development.
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Affiliation(s)
- Michael A Incze
- Division of General Internal Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Program of 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, USA
| | - Sophia Huebler
- Program of 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, USA
| | | | - Adam J Gordon
- Program of 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, USA
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
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Gottlieb M, Chien N, Long B. Managing Alcohol Withdrawal Syndrome. Ann Emerg Med 2024; 84:29-39. [PMID: 38530674 DOI: 10.1016/j.annemergmed.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/28/2024]
Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL.
| | - Nicholas Chien
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX
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Lindenfeld Z, Franz B, Lai AY, Pagán JA, Fenstemaker C, Cronin CE, Chang JE. Barriers and Facilitators to Establishing Partnerships for Substance Use Disorder Care Transitions Between Safety-Net Hospitals and Community-Based Organizations. J Gen Intern Med 2024:10.1007/s11606-024-08883-8. [PMID: 38937366 DOI: 10.1007/s11606-024-08883-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 06/11/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND The effectiveness of hospital-based transitional opioid programs (TOPs), which aim to connect patients with substance use disorders (SUD) to ongoing treatment in the community following initiation of medication for opioid use disorder (MOUD) treatment in the hospital, hinges on successful patient transitions. These transitions are enabled by strong partnerships between hospitals and community-based organizations (CBOs). However, no prior study has specifically examined barriers and facilitators to establishing SUD care transition partnerships between hospitals and CBOs. OBJECTIVE To identify barriers and facilitators to developing partnerships between hospitals and CBOs to facilitate care transitions for patients with SUDs. DESIGN Qualitative study using semi structured interviews conducted between November 2022-August 2023. PARTICIPANTS Staff and providers from hospitals affiliated with four safety-net health systems (n=21), and leaders and staff from the CBOs with which they had established partnerships (n=5). APPROACH Interview questions focused on barriers and facilitators to implementing TOPs, developing partnerships with CBOs, and successfully transitioning SUD patients from hospital settings to CBOs. KEY RESULTS We identified four key barriers to establishing transition partnerships: policy and philosophical differences between organizations, ineffective communication, limited trust, and a lack of connectivity between data systems. We also identified three facilitators to partnership development: strategies focused on building partnership quality, strategic staffing, and organizing partnership processes. CONCLUSIONS Our findings demonstrate that while multiple barriers to developing hospital-CBO partnerships exist, stakeholders can adopt implementation strategies that mitigate these challenges such as using mediators, cross-hiring, and focusing on mutually beneficial services, even within resource-limited safety-net settings. Policymakers and health system leaders who wish to optimize TOPs in their facilities should focus on adopting implementation strategies to support transition partnerships such as inadequate data collection and sharing systems.
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Affiliation(s)
- Zoe Lindenfeld
- Edward J. Bloustein School of Planning and Public Policy, Rutgers University, New Brunswick, NJ, 08901, USA.
| | - Berkeley Franz
- Heritage College of Osteopathic Medicine, The Institute to Advance Health Equity, Ohio University, 1 Ohio University, Athens, OH, 45701, USA
| | - Alden Yuanhong Lai
- Department of Public Health Policy and Management, School of Global Public Health, New York University, 708 Broadway, New York, NY, 10003, USA
| | - José A Pagán
- Department of Public Health Policy and Management, School of Global Public Health, New York University, 708 Broadway, New York, NY, 10003, USA
| | - Cheyenne Fenstemaker
- Heritage College of Osteopathic Medicine, The Institute to Advance Health Equity, Ohio University, 1 Ohio University, Athens, OH, 45701, USA
| | - Cory E Cronin
- College of Health Sciences and Professions, The Institute to Advance Health Equity, Ohio University, 1 Ohio University, Athens, OH, 45701, USA
| | - Ji Eun Chang
- Department of Public Health Policy and Management, School of Global Public Health, New York University, 708 Broadway, New York, NY, 10003, USA
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Abiri P, Jeong ISD, Verdell A, Shah S, Entabi R, Nguyen H. Improvement in inpatient discharge planning for patients with alcohol use disorder with the implementation of a team-based multidisciplinary workflow. PLoS One 2024; 19:e0306066. [PMID: 38917202 PMCID: PMC11198838 DOI: 10.1371/journal.pone.0306066] [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: 11/22/2023] [Accepted: 06/10/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Alcohol use disorder (AUD) is a major economic and healthcare burden in the United States. While there is evidence-based medication-assisted treatment (MAT) for AUD, few physicians implement these therapies on a regular basis. OBJECTIVE To determine the impact of a pharmacy-guided AUD discharge planning workflow on the rate of MAT prescriptions and inpatient readmissions. METHODS This was a single-centered pre-and-post intervention study over a 6-month period, with a 90-day pre-intervention period and a 90-day post-intervention period. The study included all patients over the age of 18 years admitted to a medicine or surgery floor bed who presented with alcohol withdrawal at any point during their hospital course. The intervention involved a pharmacy workflow, in which a list of patients admitted with alcohol withdrawal was automatically generated and referred to pharmacists, who then provided recommendations to the primary physician regarding prescriptions for naltrexone, acamprosate, and/or gabapentin. The patients were then contacted within 30 days after discharge for post-hospitalization follow-up. Our outcome measures were change in prescription rate of MATs, change in total and alcohol-related 90-day readmission rates, and change in total and alcohol-related 90-day emergency department (ED) visit rates. RESULTS The pre-intervention period consisted of 49 patients and the post-intervention period consisted of 41 patients. Our workflow demonstrated a 195% increase in the prescription rate of MATs at discharge (p < 0.001), 61% reduction in 90-day total readmission rate (p < 0.05), 40% reduction in 90-day total ED visit rate (p = 0.09), 92% reduction in 90-day alcohol-related readmission rate (p < 0.05), and 88% reduction in 90-day alcohol-related ED visit rate (p < 0.05). CONCLUSIONS Our intervention demonstrated that a pharmacy-based AUD discharge planning workflow has the potential to reduce inpatient readmissions and ED visits for patients with AUD, thus demonstrating improved patient outcomes with the potential to reduce healthcare costs.
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Affiliation(s)
- Parinaz Abiri
- Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, United States of America
| | - Il Seok Daniel Jeong
- Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, United States of America
| | - Amber Verdell
- Department of Pharmacy, Olive View-UCLA Medical Center, Sylmar, CA, United States of America
| | - Shivani Shah
- Department of Pharmacy, Olive View-UCLA Medical Center, Sylmar, CA, United States of America
| | - Rana Entabi
- Department of Pharmacy, Olive View-UCLA Medical Center, Sylmar, CA, United States of America
| | - Hoanglong Nguyen
- Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA, United States of America
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America
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Lin JS, Won P, Lin ME, Ayo-Ajibola O, Luu NN, Markarian A, Moayer R. Factors Associated With Head and Neck Polytrauma Presentation and Admissions at Emergency Departments of Varying Sizes. J Craniofac Surg 2024:00001665-990000000-01667. [PMID: 38830051 DOI: 10.1097/scs.0000000000010371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 05/04/2024] [Indexed: 06/05/2024] Open
Abstract
Timely diagnosis of acute head and neck polytrauma presenting to emergency departments (EDs) optimizes outcomes. Since ED capacity influences triage and admission, the authors utilized the National Electronic Injury Surveillance System database to understand how ED size and trauma characteristics affect head and neck polytrauma presentation and admissions. Demographics and injury characteristics from the National Electronic Injury Surveillance System database from 2018 to 2021 were analyzed to delineate factors contributing to polytrauma presence and admission through multivariable logistic regressions. The authors' 207,951-patient cohort was primarily females (48.6%), non-Hispanic (62.4%), and white (51.4%) people who averaged 57.2 years old. Nonspecific head injuries were predominant (59.7%), followed by facial trauma (22.6%) with rare substance involvement (alcohol, 6.3%; drugs, 4.1%) presenting to high-volume EDs (48.5%). Of the patients, 20% were admitted, whereas 31.1% sustained polytrauma. Substance use [alcohol, odds ratio (OR) = 4.44; drugs, OR = 2.90] increased polytrauma likelihood; neck (OR = 1.35), face (OR = 1.14), and eye (OR = 1.26) associated with polytrauma more than head injuries. Burns (OR = 1.38) increased polytrauma likelihood more than internal organ injuries. Black patients sustained higher polytrauma when presented to non-small EDs (OR = 1.41-1.90) than white patients showed to small EDs. Admissions were higher for males (OR = 1.51). Relative to small EDs, large EDs demonstrated a higher increase in admissions (OR = 2.42). Neck traumas were more likely admitted than head traumas (OR = 1.71). Fractures (OR = 2.21) and burns (OR = 2.71) demonstrated an increased admission likelihood than internal organ injuries. Polytrauma presence and admissions likelihood are site, injury, and substance dependent. Understanding the impact of factors influencing polytrauma presence or admission will enhance triage to optimize outcomes.
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Affiliation(s)
- Joshua S Lin
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California
| | - Paul Won
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Matthew E Lin
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | - Neil N Luu
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California
| | - Alexander Markarian
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California
| | - Roxana Moayer
- Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California
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Gaspar N, Kilarski LL, Rosen H, Huppertz M, Philipsen A, Rohner H. Attention Deficit Hyperactivity Disorder: A Risk Factor for Premature Discontinuation of Inpatient Opioid Withdrawal Treatment. J Clin Med 2024; 13:3301. [PMID: 38893012 PMCID: PMC11173055 DOI: 10.3390/jcm13113301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/11/2024] [Accepted: 05/31/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Substance use disorders present a tremendous challenge within contemporary healthcare systems. Specifically, in the domain of opioid use disorders (OUDs), several foundational elements are crucial for the efficacious management of afflicted individuals. Regrettably, the premature discontinuation of inpatient opioid withdrawal treatment is a prevalent phenomenon. This study aims to elucidate the prevalence of the premature termination of inpatient opioid withdrawal treatment among patients with comorbid ADHD. Methods: We conducted a comprehensive assessment of all participants currently undergoing inpatient opioid withdrawal treatment. Our assessment protocol included the administration of the ADHD Self-Report Scale (ADHD-SR) and the Wender Utah Rating Scale (WURS-k). Additionally, participants who met the thresholds on one or both questionnaires underwent further evaluation using the Diagnostic Interview for ADHD in Adults (DIVA-2.0). Results: The prevalence of individuals diagnosed with ADHD within the studied cohort was determined to be 29.3%. Among the subset of participants identified as ADHD-positive, a notable 54.5% prematurely ceased therapy. In contrast, among those identified as ADHD-negative, the premature discontinuation rate was substantially lower at 28.3%. Conclusions: In summary, the impact of ADHD as a comorbid condition on the efficacy of inpatient opioid withdrawal treatment has been underscored. By identifying comorbid ADHD early in the treatment process, tailored therapeutic approaches may help to maximize the effectiveness of interventions and may improve patient outcomes. This underscores the importance of proactive screening for ADHD as a psychiatric comorbidity in optimizing the management of individuals undergoing inpatient opioid withdrawal treatment.
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Affiliation(s)
- Nikolas Gaspar
- Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Bonn, 53111 Bonn, Germany
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Francis E. Implementing a Screening Tool and Referral Process for Substance Use Disorders in the Emergency Department: A Quality Improvement Project. J Emerg Nurs 2024:S0099-1767(24)00103-X. [PMID: 38795095 DOI: 10.1016/j.jen.2024.04.004] [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: 02/19/2024] [Revised: 04/22/2024] [Accepted: 04/28/2024] [Indexed: 05/27/2024]
Abstract
INTRODUCTION Substance misuse in the United States has continuously proven to be a public health issue. The impact of substance use disorder and the injury and illness it produces creates challenges in the public health sector. This quality improvement project aimed to increase screening and referral rates in a rural emergency department. METHODS The CAGE-AID screening tool was implemented into the triage process in the Meditech Expanse system; 1077 patients were included in this quality improvement project. This initiative used Plan-Do-Study-Act cycles, collecting data weekly. RESULTS There were 1077 patients available for the new screening process. This included 468 males (43.5%) and 609 females (56.5%). Of the 1077 patients, all (100%) were screened with the leading question. All patients (100%) were subsequently screened with the 4-item CAGE-AID tool if they answered "yes" to the leading question. Of these patients, 962 screened negative (89.3%) and 115 screened positive (10.7%). For those 115 positive screens, 63 denied referrals (54.8%) and 52 (45.2%) accepted referral. Of those 52 who accepted referral, 9 (17.3%) scheduled themselves for a follow-up appointment within 30 days of the new process going live. CONCLUSION It is possible for substance use disorder screening and referral to be implemented in every emergency department across the nation and beyond to help identify patients struggling with substance misuse and refer them to the appropriate treatment upon discharge. Substance use disorder screening and referral are an evidence-based method, and sufficient evidence supports the current practice of emergency departments implementing routine substance use disorder screening and referral as standard of care.
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Balmuth EA, Iyer S, Scales DA, Avery J. Perspectives and Recommendations from Hospitalized Patients with Substance Use Disorders: A Qualitative Study. J Gen Intern Med 2024:10.1007/s11606-024-08745-3. [PMID: 38698295 DOI: 10.1007/s11606-024-08745-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/25/2024] [Indexed: 05/05/2024]
Abstract
BACKGROUND Individuals with substance use disorders (SUDs) are hospitalized in growing numbers. Stigma is pervasive among their hospital providers, and SUD management during medical admissions is often inadequate. However, little is known about how these patients perceive their care quality. In particular, few studies have explored their positive care perceptions or recommendations for improvement. OBJECTIVE To explore perspectives on positive aspects, negative aspects, and consequences of care, as well as recommendations for improvement among hospitalized patients with SUDs. DESIGN AND PARTICIPANTS We conducted semi-structured, in-depth bedside interviews (n = 15) with patients who have been diagnosed with a SUD and were admitted to medical or surgical floors of an urban academic medical center. APPROACH Interviews explored patients' hospital experiences and recommendations for improvement. The interviews were audio-recorded, transcribed verbatim, and imported into NVivo software. Two reviewers independently coded the transcripts using interpretative phenomenological analysis and inductive thematic analysis according to grounded theory, and recurring themes were identified from the data. Patients' demographic and clinical data were analyzed with descriptive statistics. KEY RESULTS Perceived clinical and emotional proficiency were the most important components of positive experiences, whereas perceived bias and stigmatized attitudes, clinical improficiency, and inhumane treatment were characteristic of negative experiences. Such care components were most consequential for patients' emotional well-being, trust, and care quality. Recommendations for improving care included specific suggestions for initiating and promoting continued recovery, educating, and partnering in compassionate care. CONCLUSIONS Hospitalized patients with SUDs often experience lower quality and less compassionate care linked to pervasive stigma and poor outcomes. Our study highlights under-recognized perspectives from this patient population, including socioemotional consequences of care and recommendations grounded in lived experiences. By striving to advance our care in accordance with patients' viewpoints, we can turn hospitalizations into opportunities for engagement and promoting recovery.
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Affiliation(s)
| | - Sonali Iyer
- Weill Cornell Medical College, New York, NY, USA
| | - David A Scales
- Department of Medicine, Division of General Internal Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA
| | - Jonathan Avery
- Department of Psychiatry, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA
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11
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Forsgren E, Steiger A, Perez Y, Salazar D, McCollough M, Taira BR. Patient perspectives on emergency department initiation of medication for alcohol use disorder. Acad Emerg Med 2024; 31:471-480. [PMID: 37326129 DOI: 10.1111/acem.14758] [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: 03/17/2023] [Revised: 05/17/2023] [Accepted: 06/02/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVE Alcohol use disorder (AUD) is a leading cause of preventable death and is a frequent diagnosis in the emergency department (ED). Treatment in the ED, however, typically focuses on managing the sequelae of AUD, such as acute withdrawal, rather than addressing the underlying addiction. For many patients, these ED encounters are a missed opportunity to connect with medication for AUD. In 2020, our ED created a pathway to offer patients with AUD treatment with naltrexone (NTX) during their ED visit. The aim of this study was to identify what barriers and facilitators patients perceive to NTX initiation in the ED. METHODS Adopting the theoretical framework of the behavior change wheel (BCW), we conducted qualitative interviews with patients to elicit their perspectives on ED initiation of NTX. Interviews were coded and analyzed using both inductive and deductive approaches. Themes were categorized according to patients' capabilities, opportunities, and motivations. Barriers were then mapped through the BCW to design interventions that will improve our treatment pathway. RESULTS Twenty-eight patients with AUD were interviewed. Facilitators of accepting NTX included having recently experienced sequelae of AUD, rapid management of withdrawal symptoms by the ED provider, having a choice between intramuscular and oral formulations of the medication, and experiencing positive interactions in the ED that destigmatized the patient's AUD. Barriers to accepting treatment included lack of provider knowledge about NTX, dependence on alcohol as self-treatment for psychiatric trauma and physical pain, perceived discriminatory treatment and stigma about AUD, aversion to potential side effects, and lack of access to continued treatment. CONCLUSIONS Initiation of treatment of AUD with NTX in the ED is acceptable to patients and can be facilitated by knowledgeable ED providers who create a destigmatizing environment, effectively manage withdrawal symptoms, and connect patients to providers who will continue treatment.
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Affiliation(s)
- Ethan Forsgren
- Department of Emergency Medicine, Olive View-UCLA Medical Center, Sylmar, California, USA
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Athreya Steiger
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Yesenia Perez
- Department of Emergency Medicine, Olive View-UCLA Medical Center, Sylmar, California, USA
| | - David Salazar
- Department of Emergency Medicine, Olive View-UCLA Medical Center, Sylmar, California, USA
| | - Maureen McCollough
- Department of Emergency Medicine, Olive View-UCLA Medical Center, Sylmar, California, USA
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Breena R Taira
- Department of Emergency Medicine, Olive View-UCLA Medical Center, Sylmar, California, USA
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Punia K, Scott W, Manuja K, Sabbineni M, Campbell K, Balodis IM, MacKillop J. SAEM GRACE: Anti-craving medications for alcohol use disorder treatment in the emergency department: A systematic review of direct evidence. Acad Emerg Med 2024; 31:504-514. [PMID: 37735346 DOI: 10.1111/acem.14806] [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: 04/14/2023] [Revised: 08/11/2023] [Accepted: 08/14/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVES Alcohol-related concerns commonly present to the emergency department (ED), with a subset of individuals experiencing the symptoms of an alcohol use disorder (AUD). As such, examining the efficacy of pharmacological anti-craving treatment for AUD in the ED is of increasing interest. The objective of this systematic review was to evaluate the direct evidence assessing the efficacy of providing anti-craving medications for AUD treatment in the ED. METHODS A systematic search was conducted according to the patient-intervention-control-outcome question: (P) adults (≥18 years old) presenting to the ED with an AUD (including suspected AUD); (I) anti-craving medications (i.e., naltrexone, acamprosate, gabapentin); (C) no prescription or placebo; (O) reduction of repeat ED visits, engagement in addiction services, reductions in heavy drinking days, reductions in any drinking and amount consumed (or abstinence), and in relapse. Two reviewers independently assessed articles for inclusion and conducted risk of bias assessments for included studies. RESULTS From 143 potentially relevant articles, 6 met inclusion criteria: 3 clinical trials, and 3 case studies. The clinical trials identified evaluated oral versus extended-release naltrexone, monthly extended-release naltrexone injections, and disulfiram. Both oral and extended-release naltrexone resulted in decreased alcohol consumption. Monthly extended-release naltrexone injections resulted in significant improvements in drinking and quality of life. Although out of scope, the disulfiram studies identified did not result in an improvement in drinking in comparison to no medication. CONCLUSIONS Overall, there are few studies directly examining the efficacy of anti-craving medications for AUD in the ED, although the limited evidence that exists is supportive of naltrexone pharmacotherapy, particularly extended-release injection formulation. Additional randomized controlled trials are necessary for substantive direct evidence on anti-craving medication initiation in the ED.
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Affiliation(s)
- Kiran Punia
- Department of Psychology, Neuroscience, and Behaviour, McMaster University, Hamilton, Ontario, Canada
- Peter Boris Centre for Addictions Research, St. Joseph's Healthcare, Hamilton/McMaster University, Hamilton, Ontario, Canada
| | - William Scott
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kriti Manuja
- Peter Boris Centre for Addictions Research, St. Joseph's Healthcare, Hamilton/McMaster University, Hamilton, Ontario, Canada
| | - Monica Sabbineni
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Iris M Balodis
- Peter Boris Centre for Addictions Research, St. Joseph's Healthcare, Hamilton/McMaster University, Hamilton, Ontario, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Centre for Medicinal Cannabis Research, McMaster University/St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - James MacKillop
- Peter Boris Centre for Addictions Research, St. Joseph's Healthcare, Hamilton/McMaster University, Hamilton, Ontario, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Centre for Medicinal Cannabis Research, McMaster University/St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
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Duvalyan E, Falade I, Fan W, Foe M, Mvemba A, Zussman JW, Geier C, LeSaint KT, Graglia S. Implementation and analysis of a multifaceted intervention for alcohol use disorder from a single academic urban emergency department. Acad Emerg Med 2024; 31:456-462. [PMID: 38380769 DOI: 10.1111/acem.14860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 11/11/2023] [Accepted: 12/27/2023] [Indexed: 02/22/2024]
Abstract
BACKGROUND From 2006 to 2014, alcohol-related visits to the emergency department (ED) increased by 76% in the United States, highlighting the need for improved ED-driven interventions addressing alcohol use disorder (AUD). Naltrexone is an FDA-approved medication for AUD shown to decrease craving and self-administration of alcohol. While oral naltrexone and extended-release naltrexone have been long utilized in primary care and inpatient hospital settings, the use of naltrexone in the ED is limited. METHODS This study implemented and analyzed a multifaceted intervention regarding ED naltrexone prescribing at a large safety net, academic, urban hospital. A baseline assessment of preintervention conditions and perspectives on naltrexone prescribing was conducted through a chart review and standardized interviews with ED providers, respectively. The interview results guided design of interventions that addressed identified barriers. These included provider education, prescribing aids, and zero-cost naltrexone tablets supplied by the ED pharmacy to patients upon discharge. RESULTS Between September 1, 2019, and August 31, 2020, of 753 unique patients who had a primary diagnosis or chief complaint containing the word "alcohol," only five (0.66%) were prescribed naltrexone. ED providers identified lack of training regarding naltrexone, lack of a prescribing protocol, and limited patient and provider education materials as barriers to prescribing naltrexone. Following the intervention, among 278 eligible patients, 11 oral naltrexone prescriptions were written (3.96%) between April 13, 2021, and August 1, 2021. This represents a sixfold increase over the preintervention period. CONCLUSIONS An intervention to increase ED oral naltrexone prescriptions for AUD was successfully implemented, addressing lack of provider education, lack of prescribing resources, and patient barriers to accessing prescribed medications. Longer-term follow-up is needed to assess the efficacy and sustainability of these interventions. Nevertheless, ED clinicians are well positioned to initiate naltrexone prescriptions for patients presenting with AUD.
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Affiliation(s)
- Eva Duvalyan
- School of Medicine, University of California, San Francisco, California, USA
| | - Israel Falade
- School of Medicine, University of California, San Francisco, California, USA
| | - Winnie Fan
- School of Medicine, University of California, San Francisco, California, USA
| | - Meghan Foe
- School of Medicine, University of California, San Francisco, California, USA
| | - Audrey Mvemba
- School of Medicine, University of California, San Francisco, California, USA
| | - Jay W Zussman
- School of Medicine, University of California, San Francisco, California, USA
| | - Curtis Geier
- Department of Clinical Pharmacy, Department of Emergency Medicine, University of California, San Francisco, California, USA
| | - Kathy T LeSaint
- Department of Emergency Medicine, University of California, San Francisco, California, USA
| | - Sally Graglia
- Department of Emergency Medicine, University of California, San Francisco, California, USA
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14
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Watson DP, Swartz JA, Magee LA, Bray BC, Phalen P, Medcalf S, McGuire AB. Latent class analysis of emergency department patients engaged in telehealth peer recovery support services and associations of identified classes with post-discharge outcomes. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 160:209282. [PMID: 38135121 PMCID: PMC11060927 DOI: 10.1016/j.josat.2023.209282] [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: 08/05/2023] [Revised: 10/23/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND People with substance use disorders (SUDs) frequently use emergency department (ED) services. Despite evidence demonstrating that post-discharge SUD treatment linkage effectively reduces the number of ED re-presentations, relatively few hospitals have implemented interventions to identify and connect patients with SUDs to appropriate care. ED-based peer recovery support specialist (PRSS) interventions have emerged as a promising approach for hospitals, but more research is needed to understand the extent to which these interventions meet the needs of patients who present to the ED for different reasons and with various underlying concerns. METHOD A retrospective cohort analysis used data from a telehealth PRSS program in 15 EDs within one Indiana hospital system. The study included 2950 ED patients who engaged with telehealth PRSS services between September 2018 and September 2021. Latent class analysis identified patterns of patient characteristics associated with post-discharge PRSS engagement and ED re-presentations. Covariate predictors and distal outcomes were assessed to examine the associations between class membership, demographic factors, and patient outcomes. RESULTS The study team selected a six-class model as the best fit for the data. Class 1, representing patients with opioid use disorder and mental health diagnoses who presented to the ED for an opioid overdose, was used as the reference class for all other statistical tests. Multinomial logistic regression analysis demonstrated significant associations between covariate predictors, outcomes, and class membership. Regression results also demonstrate PRSSs had greater success contacting patients with prior year ED use and patients with a successful post-discharge PRSS contact were less likely to re-present to the ED. CONCLUSION Results highlight the heterogeneity of patients with SUDs and emphasize the need for tailored interventions to address patient-specific needs more effectively. They also provide support for the perceived utility of PRSS engagement for ED patients.
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Affiliation(s)
- Dennis P Watson
- Chestnut Health Systems, Lighthouse Institute, 221 W. Walton Street, Chicago, IL 60610, USA.
| | - James A Swartz
- Jane Addams College of Social Work, University of Illinois Chicago, 1040 W. Harrison Street, Chicago, IL 60607, USA
| | - Lauren A Magee
- Paul H. O'Neill School of Environmental and Public Affairs, Indiana University - Purdue University Indianapolis, 801 W. Michigan Street, Indianapolis, IN 46202, USA
| | - Bethany C Bray
- Institute for Health Research and Policy, The University of Illinois at Chicago, 1747 W. Roosevelt Road, Chicago, IL 60608, USA
| | - Peter Phalen
- Division of Psychiatric Services Research, University of Maryland School of Medicine, 655 W. Baltimore Street, Baltimore, MD 21201, USA
| | - Spencer Medcalf
- Indiana University Health, 950 N Meridian Street, Suite 900, Indianapolis, IN 46204, USA
| | - Alan B McGuire
- Indiana University Richard M. Fairbanks School of Public Health, Department of Social and Behavioral Sciences, 1050 Wishard Boulevard, Indianapolis, IN 46202, USA; Richard L. Roudebush VAMC, Health Services Research and Development, 1481 W. 10(th) Street (11H) Room C8108, Indianapolis, IN 46202, USA
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15
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Anderson ES, Frazee BW. The Intersection of Substance Use Disorders and Infectious Diseases in the Emergency Department. Emerg Med Clin North Am 2024; 42:391-413. [PMID: 38641396 DOI: 10.1016/j.emc.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
Substance use disorders (SUDs) intersect clinically with many infectious diseases, leading to significant morbidity and mortality if either condition is inadequately treated. In this article, we will describe commonly seen SUDs in the emergency department (ED) as well as their associated infectious diseases, discuss social drivers of patient outcomes, and introduce novel ED-based interventions for co-occurring conditions. Clinicians should come away from this article with prescriptions for both antimicrobial medications and pharmacotherapy for SUDs, as well as an appreciation for social barriers, to care for these patients.
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Affiliation(s)
- Erik S Anderson
- Department of Emergency Medicine, Alameda Health System, Wilma Chan Highland Hospital, 1411 East 31st Street, Oakland, CA 94602, USA; Division of Addiction Medicine, Highland Hospital, Alameda Health System, 1411 East 31st Street, Oakland, CA 94602, USA.
| | - Bradley W Frazee
- Department of Emergency Medicine, Alameda Health System, Wilma Chan Highland Hospital, 1411 East 31st Street, Oakland, CA 94602, USA
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Punia K, Scott W, Manuja K, Campbell K, Balodis IM, MacKillop J. SAEM GRACE: Phenobarbital for alcohol withdrawal management in the emergency department: A systematic review of direct evidence. Acad Emerg Med 2024; 31:481-492. [PMID: 37589203 DOI: 10.1111/acem.14788] [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: 01/23/2023] [Revised: 06/19/2023] [Accepted: 07/02/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVES Alcohol withdrawal syndrome (AWS) is a commonly presenting condition in the emergency department (ED) and can have severe complications, including mortality. Benzodiazepines are first-line medications for treating AWS but may be unavailable or insufficient. This systematic review evaluates the direct evidence assessing the utility of phenobarbital for treating AWS in the ED. METHODS A systematic search was conducted and designed according to the patient-intervention-comparator-outcome (PICO) question: (P) adults (≥18 years old) presenting to the ED with alcohol withdrawal; (I) phenobarbital (including adjunctive); (C) benzodiazepines or no intervention; and (O) AWS complications, admission to a monitored setting, control of symptoms, adverse effects, and adjunctive medications. Two reviewers independently assessed articles for inclusion and conducted risk of bias assessments for included studies. RESULTS From 70 potentially relevant articles, seven studies met inclusion criteria: three retrospective cohort studies, two retrospective chart reviews, and two randomized controlled trials (RCTs), one examining phenobarbital monotherapy and one examining adjunctive phenobarbital. Across the retrospective cohort studies, treatment of AWS with phenobarbital resulted in lower odds of a subsequent ED visit. The retrospective chart reviews indicated that phenobarbital was associated with higher discharge rate compared to benzodiazepine-only treatments. For the two RCTs, phenobarbital did not differ significantly from benzodiazepine for most outcomes, although concomitant treatment with phenobarbital was associated with lower benzodiazepine use and intensive care unit admission. The heterogeneous designs and small number of studies prevented quantitative synthesis. CONCLUSIONS Relatively few studies provide direct evidence on the utility of phenobarbital for AWS in the ED, but the evidence that exists generally suggests that it is a reasonable and appropriate approach. Additional RCTs and other methodologically rigorous investigations are needed for more definitive direct evidence.
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Affiliation(s)
- Kiran Punia
- Department of Psychology, Neuroscience, and Behaviour, McMaster University, Ontario, Hamilton, Canada
- Peter Boris Centre for Addictions Research, St. Joseph's Healthcare Hamilton/McMaster University, Hamilton, Ontario, Canada
| | - William Scott
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kriti Manuja
- Peter Boris Centre for Addictions Research, St. Joseph's Healthcare Hamilton/McMaster University, Hamilton, Ontario, Canada
| | | | - Iris M Balodis
- Peter Boris Centre for Addictions Research, St. Joseph's Healthcare Hamilton/McMaster University, Hamilton, Ontario, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Centre for Medicinal Cannabis Research (CMCR), McMaster University, Hamilton, Ontario, Canada
| | - James MacKillop
- Peter Boris Centre for Addictions Research, St. Joseph's Healthcare Hamilton/McMaster University, Hamilton, Ontario, Canada
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
- Michael G. DeGroote Centre for Medicinal Cannabis Research (CMCR), McMaster University, Hamilton, Ontario, Canada
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Riser E, Kennedy AG, Holterman LA, Brooklyn J, Maruti S, Sobel HG. Preparing Medical Students to Care for Patients with Opioid Use Disorder: Buprenorphine Waiver Training in Undergraduate Medical Education. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2024:10.1007/s40596-024-01968-w. [PMID: 38684575 DOI: 10.1007/s40596-024-01968-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 04/04/2024] [Indexed: 05/02/2024]
Affiliation(s)
- Elly Riser
- The Robert Larner, MD College of Medicine at the University of Vermont, Burlington, VT, USA.
| | - Amanda G Kennedy
- The Robert Larner, MD College of Medicine at the University of Vermont, Burlington, VT, USA
| | - Leigh Ann Holterman
- The Robert Larner, MD College of Medicine at the University of Vermont, Burlington, VT, USA
| | - John Brooklyn
- The Robert Larner, MD College of Medicine at the University of Vermont, Burlington, VT, USA
| | - Sanchit Maruti
- The Robert Larner, MD College of Medicine at the University of Vermont, Burlington, VT, USA
| | - Halle G Sobel
- The Robert Larner, MD College of Medicine at the University of Vermont, Burlington, VT, USA
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Moe J, Koh J, Ma JA, Pei LX, MacLean E, Keech J, Maguire K, Ronsley C, Doyle-Waters MM, Brubacher JR. Screening for harmful substance use in emergency departments: a systematic review. Int J Emerg Med 2024; 17:52. [PMID: 38584266 PMCID: PMC11000386 DOI: 10.1186/s12245-024-00616-2] [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: 09/24/2023] [Accepted: 03/15/2024] [Indexed: 04/09/2024] Open
Abstract
BACKGROUND Substance use-related emergency department (ED) visits have increased substantially in North America. Screening for substance use in EDs is recommended; best approaches are unclear. This systematic review synthesizes evidence on diagnostic accuracy of ED screening tools to detect harmful substance use. METHODS We included derivation or validation studies, with or without comparator, that included adult (≥ 18 years) ED patients and evaluated screening tools to identify general or specific substance use disorders or harmful use. Our search strategy combined concepts Emergency Department AND Screening AND Substance Use. Trained reviewers assessed title/abstracts and full-text articles for inclusion, extracted data, and assessed risk of bias (QUADAS-2) independently and in duplicate. Reviewers resolved disagreements by discussion. Primary investigators adjudicated if necessary. Heterogeneity precluded meta-analysis. We descriptively summarized results. RESULTS Our search strategy yielded 2696 studies; we included 33. Twenty-one (64%) evaluated a North American population. Fourteen (42%) applied screening among general ED patients. Screening tools were administered by research staff (n = 21), self-administered by patients (n = 10), or non-research healthcare providers (n = 1). Most studies evaluated alcohol use screens (n = 26), most commonly the Alcohol Use Disorders Identification Test (AUDIT; n = 14), Cut down/Annoyed/Guilty/Eye-opener (CAGE; n = 13), and Rapid Alcohol Problems Screen (RAPS/RAPS4/RAPS4-QF; n = 12). Four studies assessing six tools and screening thresholds for alcohol abuse/dependence in North American patients (AUDIT ≥ 8; CAGE ≥ 2; Diagnostic and Statistical Manual of Mental Disorders, 4th Edition [DSM-IV-2] ≥ 1; RAPS ≥ 1; National Institute on Alcohol Abuse and Alcoholism [NIAAA]; Tolerance/Worry/Eye-opener/Amnesia/K-Cut down [TWEAK] ≥ 3) reported both sensitivities and specificities ≥ 83%. Two studies evaluating a single alcohol screening question (SASQ) (When was the last time you had more than X drinks in 1 day?, X = 4 for women; X = 5 for men) reported sensitivities 82-85% and specificities 70-77%. Five evaluated screening tools for general substance abuse/dependence (Relax/Alone/Friends/Family/Trouble [RAFFT] ≥ 3, Drug Abuse Screening Test [DAST] ≥ 4, single drug screening question, Alcohol, Smoking and Substance Involvement Screening Test [ASSIST] ≥ 42/18), reporting sensitivities 64%-90% and specificities 61%-100%. Studies' risk of bias were mostly high or uncertain. CONCLUSIONS Six screening tools demonstrated both sensitivities and specificities ≥ 83% for detecting alcohol abuse/dependence in EDs. Tools with the highest sensitivities (AUDIT ≥ 8; RAPS ≥ 1) and that prioritize simplicity and efficiency (SASQ) should be prioritized.
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Affiliation(s)
- Jessica Moe
- Department of Emergency Medicine, University of British Columbia, Diamond Health Care Centre, 11 Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
| | - Justin Koh
- Department of Emergency Medicine, Queen's University, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada
| | - Jennifer A Ma
- Department of Emergency Medicine, University of Manitoba, S203 Medical Sciences Building, 750 Bannatyne Avenue, Winnipeg, MB, R3E 0W2, Canada
| | - Lulu X Pei
- Department of Emergency Medicine, University of British Columbia, Diamond Health Care Centre, 11 Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - Eleanor MacLean
- Department of Emergency Medicine, University of British Columbia, Diamond Health Care Centre, 11 Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - James Keech
- School of Medicine, Queen's University, 15 Arch Street, Kingston, ON, K7L 3N6, Canada
| | - Kaitlyn Maguire
- Department of Emergency Medicine, University of British Columbia, Diamond Health Care Centre, 11 Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - Claire Ronsley
- Department of Emergency Medicine, University of British Columbia, Diamond Health Care Centre, 11 Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - Mary M Doyle-Waters
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, 7th Floor, 828 West 10th Avenue, Research Pavilion, Vancouver, BC, V5Z 1M9, Canada
| | - Jeffrey R Brubacher
- Department of Emergency Medicine, University of British Columbia, Diamond Health Care Centre, 11 Floor - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
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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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20
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Phillips AZ, Wang Y, Allen NB. Patterns of health care interactions of individuals with alcohol use disorder: A latent class analysis. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 159:209251. [PMID: 38072388 PMCID: PMC11005937 DOI: 10.1016/j.josat.2023.209251] [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: 04/20/2023] [Revised: 09/29/2023] [Accepted: 11/30/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Given the high rates at which individuals with alcohol use disorder (AUD) utilize health care for co-existing conditions, health systems are promising venues for interventions that will facilitate access to AUD treatment. However, how individuals with AUD interact with such systems and, thus, how systems should intervene is unclear. In this study, we seek to identify patterns in how individuals diagnosed with AUD within an academic health system interacted with the system prior to diagnosis. METHODS We use electronic health records from a single academic health system in a major US metropolitan area to create a deidentified retrospective cohort including all individuals age 18+ diagnosed with AUD 2010-2019 (n = 26,899). Latent class analysis (LCA) identified subgroups defined by aspects of previous system interaction and health status, including having an in-system primary care provider, previous utilization of primary and specialty care, diagnosis setting, payer, and presence of other chronic conditions. We then assessed subgroup differences in demographics and associations with in-system AUD treatment receipt in the year following diagnosis, adjusting for demographics. RESULTS The population was on average 38.6 years old (standard deviation = 15.4) and predominantly male (66.1 %), White (64.5 %), and not of Hispanic/Latino ethnicity (87.8 %). Only 4.7 % received in-system treatment following diagnosis. We deemed the four-class model the optimal LCA model. This model identified subgroups that can be described as 1) average utilization (20.7 % of population), 2) low utilization (54.5 %), 3) high health burden and low utilization (14.2 %), and 4) high health burden and high utilization (10.6 %). Predicted membership in the high health burden and high utilization subgroup and low utilization subgroup were associated with higher and lower odds of treatment receipt, respectively, compared with predicted membership in the average utilization subgroup (odds ratio (OR) for high/high subgroup = 1.21, 95 % confidence interval (CI) = 1.01, 1.27; OR for low subgroup = 0.29 95 % CI = 0.24, 0.34). CONCLUSION Individuals diagnosed with AUD within a health system interact with that system in markedly different ways and are unlikely to benefit uniformly from system-based interventions to facilitate treatment. Group-tailored interventions are more likely to have impact and provide returns on investments for systems.
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Affiliation(s)
- Aryn Z Phillips
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL 60611, USA; Department of Health Policy and Management, University of Maryland School of Public Health, 4200 Valley Drive, College Park, MD 20742, USA.
| | - Yaojie Wang
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL 60611, USA.
| | - Norrina B Allen
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL 60611, USA.
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Incze MA, Huebler S, Chen D, Stofko A, Wu C, Baylis JD, Wells C, Babbel D. Hospitalists' Attitudes and Experiences With Posthospitalization Care Transitions for Patients With Substance Use Disorders: A Cross-sectional Analysis. J Addict Med 2024:01271255-990000000-00297. [PMID: 38498626 DOI: 10.1097/adm.0000000000001305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
BACKGROUND Medical hospitalizations are relatively common among individuals who have substance use disorders (SUDs) and represent opportunities for patient engagement and treatment. Posthospitalization transitions of care are an important element of providing full-spectrum inpatient SUD care; however, little is known about clinicians' experiences with postdischarge care transitions. METHODS We conducted a cross-sectional study surveying hospital-based medical clinicians (ie, "hospitalists") across 2 large health systems in the state of Utah to assess current practices, barriers, facilitators, and perceptions toward posthospitalization care transitions for patients with SUDs. We used Wilcoxon signed-rank tests to identify the most impactful barriers and facilitators among all respondents. We used logistic regression models to explore the influence of hospitalists' attitudes toward providing SUD care on perceived barriers and facilitators. RESULTS The survey was distributed to 429 individuals across 15 hospitals. Eighty-two hospitalists responded to the survey (response rate, 21.4%). Most respondents frequently cared for hospitalized patients with SUDs (n = 63, 77%) and prescribed medications for SUDs (n = 44, 56%). Four respondents (5%) felt that patients received adequate support during care transitions. Lack of social support (P < 0.001) and social factors such as lack of transportation (P < 0.001) were perceived as the largest barriers to successful care transitions. Conversely, a partnering outpatient clinic/clinician (P < 0.001) and outpatient-based care coordination (P < 0.001) were perceived as the strongest facilitators. Respondents' attitudes toward people with SUDs had a modest effect on perceived barriers and facilitators. CONCLUSIONS Hospitalists perceived increased outpatient SUD treatment infrastructure and transitional care supports as most important in facilitating posthospitalization care transitions for patients with SUDs.
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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, DC, DB); Program of Addiction Research, Clinical Care, Knowledge, and Advocacy, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT (MAI, SH, JDB); Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT (CW); Intermountain Health Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT (SH); Division of Hospital Medicine, Intermountain Health, Salt Lake City, UT (AS, CW)
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22
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Lindenfeld Z, Chen K, Kapur S, Chang JE. Comparing Rates of Undiagnosed Hypertension and Diabetes in Patients With and Without Substance Use Disorders. J Gen Intern Med 2024:10.1007/s11606-024-08718-6. [PMID: 38467919 DOI: 10.1007/s11606-024-08718-6] [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: 10/11/2023] [Accepted: 03/01/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Individuals with substance use disorders (SUDs) have increased risk for developing chronic conditions, though few studies assess rates of diagnosis of these conditions among patients with SUDs. OBJECTIVE To compare rates of undiagnosed hypertension and diabetes among patients with and without an SUD. DESIGN Cross-sectional analysis using electronic health record (EHR) data from 58 primary care clinics at a large, urban, healthcare system in New York. PARTICIPANTS Patients who had at least two primary care visits from 2019-2022 were included in our patient sample. Patients without an ICD-10 hypertension diagnosis or prescribed hypertension medications and with at least two blood pressure (BP) readings ≥ 140/90 mm were labeled 'undiagnosed hypertension,' and patients without a diabetes diagnosis or prescribed diabetes medications and with A1C/hemoglobin ≥ 6.5% were labeled 'undiagnosed diabetes.' MAIN MEASURES We calculated the mean number of patients with and without an ICD-10 SUD diagnosis who were diagnosed and undiagnosed for each condition. We used multivariate logistic regression to assess the association between being undiagnosed for each condition, and having an SUD diagnosis, patient demographic characteristics, clinical characteristics (body mass index, Elixhauser comorbidity count, diagnosed HIV and psychosis), the percentage of visits without a BP screening, and the total number of visits during the time period. KEY RESULTS The percentage of patients with undiagnosed hypertension (2.74%) and diabetes (22.98%) was higher amongst patients with SUD than patients without SUD. In multivariate models, controlling for other factors, patients with SUD had significantly higher odds of having undiagnosed hypertension (OR: 1.81; 95% CI: 1.48, 2.20) and undiagnosed diabetes (OR: 1.93; 1.72, 2.16). Being younger, female, and having an HIV diagnosis was also associated with significantly higher odds for being undiagnosed. CONCLUSIONS We found significant disparities in rates of undiagnosed chronic diseases among patients with SUDs, compared with patients without SUDs.
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Affiliation(s)
- Zoe Lindenfeld
- Department of Public Health Policy and Management, School of Global Public Health, New York University, New York, NY, USA.
| | - Kevin Chen
- Office of Ambulatory Care and Population Health, New York City Health + Hospitals, New York, NY, USA
- Division of General Internal Medicine and Clinical Innovation, New York University Grossman School of Medicine, New York, NY, USA
| | - Supriya Kapur
- Department of Public Health Policy and Management, School of Global Public Health, New York University, New York, NY, USA
| | - Ji E Chang
- Department of Public Health Policy and Management, School of Global Public Health, New York University, New York, NY, USA
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23
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Krawczyk N, Rivera BD, Chang JE, Lindenfeld Z, Franz B. Initiatives to Support the Transition of Patients With Substance Use Disorders From Acute Care to Community-based Services Among a National Sample of Nonprofit Hospitals. J Addict Med 2024; 18:115-121. [PMID: 38015653 PMCID: PMC10939963 DOI: 10.1097/adm.0000000000001250] [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] [Indexed: 11/30/2023]
Abstract
BACKGROUND Hospitals are a key touchpoint to reach patients with substance use disorders (SUDs) and link them with ongoing community-based services. Although there are many acute care interventions to initiate SUD treatment in hospital settings, less is known about what services are offered to transition patients to ongoing care after discharge. In this study, we explore what SUD care transition strategies are offered across nonprofit US hospitals. METHODS We analyzed administrative documents from a national sample of US hospitals that indicated SUD as a top 5 significant community need in their Community Health Needs Assessment reports (2019-2021). Data were coded and categorized based on the nature of described services. We used data on hospitals and characteristics of surrounding counties to identify factors associated with hospitals' endorsement of transition interventions for SUD. RESULTS Of 613 included hospitals, 313 prioritized SUD as a significant community need. Fifty-three of these hospitals (17%) offered acute care interventions to support patients' transition to community-based SUD services. Most (68%) of the 53 hospitals described transition strategies without further detail, 23% described scheduling appointments before discharge, and 11% described discussing treatment options before discharge. No hospital characteristics were associated with offering transition interventions, but such hospitals were more likely to be in the Northeast, in counties with higher median income, and states that expanded Medicaid. CONCLUSIONS Despite high need, most US hospitals are not offering interventions to link patients with SUD from acute to community care. Efforts to increase acute care interventions for SUD should identify and implement best practices to support care continuity.
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Affiliation(s)
- Noa Krawczyk
- Center for Opioid Epidemiology and Policy, Department of Population Health, New York University Grossman School of Medicine
| | - Bianca D. Rivera
- Center for Opioid Epidemiology and Policy, Department of Population Health, New York University Grossman School of Medicine
| | - Ji E. Chang
- Department of Public Health Policy and Management, New York University School of Global Public Health
| | - Zoe Lindenfeld
- Department of Public Health Policy and Management, New York University School of Global Public Health
| | - Berkeley Franz
- Ohio University Heritage College of Osteopathic Medicine; Appalachian Institute to Advance Health Equity Science (ADVANCE)
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Thakarar K, Appa A, Abdul Mutakabbir JC, Goff A, Brown J, Tuell C, Fairfield K, Wurcel A. Frame Shift: Focusing on Harm Reduction and Shared Decision Making for People Who Use Drugs Hospitalized With Infections. Clin Infect Dis 2024; 78:e12-e26. [PMID: 38018174 DOI: 10.1093/cid/ciad664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Indexed: 11/30/2023] Open
Affiliation(s)
- Kinna Thakarar
- Tufts University School of Medicine, Boston, Massachusetts, USA
- Center for Interdisciplinary Population & Health Research, MaineHealth Institute for Research, Portland, Maine, USA
- Department of Medicine, Maine Medical Center, Portland, Maine, USA
| | - Ayesha Appa
- Division of HIV, Infectious Diseases, and Global Medicine at San Francisco General Hospital, University of California-San Francisco, San Francisco, California, USA
| | - Jacinda C Abdul Mutakabbir
- Division of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California-San Diego, La Jolla, California, USA
- Division of the Black Diaspora and African American Studies, University of California-San Diego, La Jolla, California, USA
| | - Amelia Goff
- Section of Addiction Medicine, Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Jessica Brown
- Department of Care Management, Oregon Health and Science University, Portland, Oregon, USA
| | | | - Kathleen Fairfield
- Tufts University School of Medicine, Boston, Massachusetts, USA
- Center for Interdisciplinary Population & Health Research, MaineHealth Institute for Research, Portland, Maine, USA
- Department of Medicine, Maine Medical Center, Portland, Maine, USA
| | - Alysse Wurcel
- Tufts University School of Medicine, Boston, Massachusetts, USA
- Department of Medicine, Division of Geographic Medicine and Infectious Diseases, Tufts Medicine, Boston, Massachusetts, USA
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25
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Makutonin M, Ramdin C, Meltzer A, Mazer-Amirshahi M, Nelson L. Concurrent Alcohol and Opioid Intoxication in Emergency Department Patients Leads to Greater Resource Utilization. Subst Use Misuse 2024; 59:616-621. [PMID: 38192231 DOI: 10.1080/10826084.2023.2294963] [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: 01/10/2024]
Abstract
Background: Concurrent alcohol intoxication can complicate emergency department (ED) presentations for opioid-related adverse events. We sought to determine if there was a difference in resource utilization among patients who presented to the ED with concurrent opioid and alcohol intoxication compared to opioid intoxication alone. Methods: Using linked state-wide databases from the Maryland Healthcare Cost and Utilization Project (HCUP), we identified patients with a diagnosis of opioid intoxication treated in the ED from 2016 to 2018. We measured healthcare utilization for each patient in the ED settings for one year after the initial ED visit and estimated direct costs. We performed logistic regression comparing patients presented with co-intoxication to those without. Results: Of 12,295 patients who presented to the ED for opioid intoxication during the study period, 703 (5.7%) had concurrent alcohol intoxication. Patients with co-intoxication had more recurrent ED visits (340 vs 247.4 per 1000 patients, p < 0.05), higher index ED visit admission rates (26.9% vs 19.4%, p < 0.001), but similar overall costs ($3736 vs $2861, p < 0.05) at one year. Co-intoxication was associated with suicidal ideation (OR = 1.58, 95% CI 1.51-1.65), high zip code income (OR = 1.16, 95% CI 1.12-1.21), and higher rates of intoxication with all classes of drugs analyzed (p < 0.001). Conclusion: Our study demonstrated that mental health disorders, socioeconomic status, and increased ED utilization are associated with co-intoxication of opioids and alcohol presenting to the ED. Further research is needed to elucidate factors responsible for the increased resource use in this population.
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Affiliation(s)
- Michael Makutonin
- Department of Emergency Medicine, George Washington University School of Medicine, Washington, District of Columbia, USA
| | - Christine Ramdin
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Andrew Meltzer
- Department of Emergency Medicine, George Washington University School of Medicine, Washington, District of Columbia, USA
| | | | - Lewis Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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26
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Fraimow-Wong L, Martín M, Thomas L, Giuliano R, Nguyen OK, Knight K, Suen LW. Patient and Staff Perspectives on the Impacts and Challenges of Hospital-Based Harm Reduction. JAMA Netw Open 2024; 7:e240229. [PMID: 38386317 PMCID: PMC10884877 DOI: 10.1001/jamanetworkopen.2024.0229] [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] [Indexed: 02/23/2024] Open
Abstract
Importance Harm reduction is associated with improved health outcomes among people who use substances. As overdose deaths persist, hospitals are recognizing the need for harm reduction services; however, little is known about the outcomes of hospital-based harm reduction for patients and staff. Objective To evaluate patient and staff perspectives on the impact and challenges of a hospital-based harm reduction program offering safer use education and supplies at discharge. Design, Setting, and Participants This qualitative study consisted of 40-minute semistructured interviews with hospitalized patients receiving harm reduction services and hospital staff at an urban, safety-net hospital in California from October 2022 to March 2023. Purposive sampling allowed inclusion of diverse patient racial and ethnic identities, substance use disorders (SUDs), and staff roles. Exposure Receipt of harm reduction education and/or supplies (eg, syringes, pipes, naloxone, and test strips) from an addiction consult team, or providing care for patients receiving these services. Main Outcomes and Measures Interviews were analyzed using thematic analysis to identify key themes. Results A total of 40 participants completed interviews, including 20 patients (mean [SD] age, 43 [13] years; 1 American Indian or Alaska Native [5%], 1 Asian and Pacific Islander [5%], 6 Black [30%]; 6 Latine [30%]; and 6 White [30%]) and 20 staff (mean [SD] age 37 [8] years). Patients were diagnosed with a variety of SUDs (7 patients with opioid and stimulant use disorder [35%]; 7 patients with stimulant use disorder [35%]; 3 patients with opioid use disorder [15%]; and 3 patients with alcohol use disorder [15%]). A total of 3 themes were identified; respondents reported that harm reduction programs (1) expanded access to harm reduction education and supplies, particularly for ethnically and racially minoritized populations; (2) built trust by improving the patient care experience and increasing engagement; and (3) catalyzed culture change by helping destigmatize care for individuals who planned to continue using substances and increasing staff fulfillment. Black and Latine patients, those who primarily used stimulants, and those with limited English proficiency (LEP) reported learning new harm reduction strategies. Program challenges included hesitancy regarding regulations, limited SUD education among staff, remaining stigma, and the need for careful assessment of patient goals. Conclusions and Relevance In this qualitative study, patients and staff believed that integrating harm reduction services into hospital care increased access for populations unfamiliar with harm reduction, improved trust, and reduced stigma. These findings suggest that efforts to increase access to harm reduction services for Black, Latine, and LEP populations, including those who use stimulants, are especially needed.
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Affiliation(s)
| | - Marlene Martín
- University of California, San Francisco, School of Medicine
- Division of Hospital Medicine at San Francisco General Hospital, University of California, San Francisco
| | - Laura Thomas
- San Francisco AIDS Foundation, San Francisco, California
| | - Ro Giuliano
- San Francisco AIDS Foundation, San Francisco, California
| | - Oanh Kieu Nguyen
- University of California, San Francisco, School of Medicine
- Division of Hospital Medicine at San Francisco General Hospital, University of California, San Francisco
| | - Kelly Knight
- University of California, San Francisco, School of Medicine
- Department of Humanities and Social Sciences, University of California San Francisco
| | - Leslie W Suen
- University of California, San Francisco, School of Medicine
- Division of General Internal Medicine at San Francisco General Hospital, University of California, San Francisco
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27
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Bolshakova M, González JL, Thompson T, Schneberk T, Sussman S, Unger JB, Bluthenthal RN. A qualitative analysis of internal medicine residents' experience with substance use disorder education and training: a pilot study. J Addict Dis 2024; 42:63-70. [PMID: 36330994 DOI: 10.1080/10550887.2022.2139580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Lack of education and training on caring for patients with substance use disorder (SUD) is common among healthcare providers, often resulting in clinicians feeling unprepared to treat patients with SUD. OBJECTIVES This study explored resident physicians' experiences with SUD education throughout medical school and residency and qualitatively evaluated whether a SUD initiative improved resident's knowledge and efficacy of treating various SUDs. METHODS We implemented a brief (seven hours total) educational initiative focused on treating SUDs virtually over the course of an academic year for residents enrolled in the University of Southern California Internal Medicine Residency program. Semi-structured interviews were conducted with residents after completion of the initiative. A thematic analysis was conducted to identify common themes that emerged from the qualitative data. RESULTS Every resident noted receiving insufficient training for the treatment of SUDs prior to the initiative. The initiative was viewed favorably, and participants particularly appreciated having an introduction to prescribing medication for the treatment of SUD such as buprenorphine. Despite the perceived success of the initiative in increasing awareness of treatment modalities for SUD, residents expressed a lack of comfort in handling SUD cases and desired additional practical lectures and application of knowledge through increased experiential training. CONCLUSIONS SUD education and training appears to be a useful constituent of resident training and should be included in the standard curriculum and rotations. Residency programs should consider including formal education, hands-on practice, and providing adequate resources for residents to develop their capabilities to care for patients with SUD.
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Affiliation(s)
- Maria Bolshakova
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - José Luis González
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- LAC + USC Medical Center, Los Angeles, CA, USA
| | - Tiana Thompson
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Steve Sussman
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jennifer B Unger
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ricky N Bluthenthal
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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28
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Smith CJ, Payne VM. Epidemiology studies on effects of lithium salts in pregnancy are confounded by the inability to control for other potentially teratogenic factors. Hum Exp Toxicol 2024; 43:9603271241236346. [PMID: 38394684 DOI: 10.1177/09603271241236346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
INTRODUCTION In bipolar women who took lithium during pregnancy, several epidemiology studies have reported small increases in a rare fetal cardiac defect termed Ebstein's anomaly. METHODS Behavioral, environmental, and lifestyle-associated risk factors associated with bipolar disorder and health insurance status were determined from an Internet search. The search was conducted from October 1, 2023, through October 14, 2023. The search terms employed included the following: bipolar, bipolar disorder, mood disorders, pregnancy, congenital heart defects, Ebstein's anomaly, diabetes, hypertension, Medicaid, Medicaid patients, alcohol use, cigarette smoking, marijuana, cocaine, methamphetamine, narcotics, nutrition, diet, obesity, body mass index, environment, environmental exposures, poverty, socioeconomic status, divorce, unemployment, and income. No quotes, special fields, truncations, etc., were used in the searches. No filters of any kind were used in the searches. RESULTS Women who remain on lithium in the United States throughout their pregnancy are likely to be experiencing mania symptoms and/or suicidal ideation refractory to other drugs. Pregnant women administered the highest doses of lithium salts would be expected to have been insufficiently responsive to lower doses. Any small increases in the retrospectively determined risk of fetal cardiac anomalies in bipolar women taking lithium salts cannot be disentangled from potential developmental effects resulting from very high rates of cigarette smoking, poor diet, alcohol abuse, ingestion of illegal drugs like cocaine or opioids, marijuana smoking, obesity, and poverty. CONCLUSIONS The small risks in fetal cardiac abnormalities reported in the epidemiology literature do not establish a causal association for lithium salts and Ebstein's anomaly.
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Affiliation(s)
- Carr J Smith
- Department of Alzheimer's Section, Society for Brain Mapping and Therapeutics, Mobile, AL, USA
| | - Victoria M Payne
- Psychiatric Associates of North Carolina Professional Association, Raleigh, NC, USA
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29
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Koens S, Klein J, Scherer M, Strauß A, Härter M, Schäfer I, Lüdecke D, von dem Knesebeck O. Perceived treatment urgency of common mental disorders in the German population. Sci Rep 2023; 13:22711. [PMID: 38123622 PMCID: PMC10733386 DOI: 10.1038/s41598-023-49969-3] [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: 08/28/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023] Open
Abstract
Perceived treatment urgency of mental disorders are important as they determine utilization of health care. The aim was to analyze variations in perceived treatment urgency in cases of psychosis (adolescents), alcoholism (adults), and depression (older adults) with two levels of severity each by characteristics of the case and the respondents. A telephone survey (N = 1200) with vignettes describing cases of psychosis, alcoholism, and depression was conducted in Hamburg, Germany. Vignettes varied by symptom severity and sex. Perceived treatment urgency was assessed by three items. A sum scale was calculated. Linear regression models were computed to analyze differences in perceived urgency by characteristics of the case (severity, sex) and the respondents (sex, age, education, migration background, illness recognition, personal affliction). Perceived treatment urgency was significantly higher in severe cases and varied by education. Additionally, regarding psychosis, estimated urgency varied significantly by correct illness recognition. With regard to depression, perceived urgency differed significantly by age and correct illness recognition. Interaction effects between case severity and sociodemographic characteristics of the respondents, personal affliction, and correct recognition of the disorder were found. The identified differences should be considered in the development of interventions on mental health literacy with regard to adequate urgency assessment.
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Affiliation(s)
- Sarah Koens
- Institute of Medical Sociology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Jens Klein
- Institute of Medical Sociology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Martin Scherer
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Annette Strauß
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Martin Härter
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Ingo Schäfer
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Daniel Lüdecke
- Institute of Medical Sociology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Olaf von dem Knesebeck
- Institute of Medical Sociology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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Rajab D, Fujioka JK, Walker M, Bartels SA, MacKenzie M, Purkey E. Emergency department care experiences among people who use substances: a qualitative study. Int J Equity Health 2023; 22:248. [PMID: 38049838 PMCID: PMC10696685 DOI: 10.1186/s12939-023-02050-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: 08/21/2023] [Accepted: 11/02/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND People who use substances (PWUS) encounter significant barriers to accessing care for their complex health needs. As a result, emergency departments (EDs) often become the first point of healthcare access for many PWUS and are a crucial setting for the study of health inequities. This study aimed to understand the ED healthcare experiences of PWUS with the intent of informing ways of improving the delivery of equitable care. METHODS This qualitative study was part of a larger cross-sectional, mixed-methods study that examined ED experiences among diverse underserved and equity-deserving groups (EDGs) within Kingston, Ontario, Canada. Participants shared and self-interpreted a story about a memorable ED or UCC visit within the preceding 24 months. Data from participants who self-identified as having substance use experiences was analyzed through inductive thematic analysis. RESULTS Of the 1973 unique participants who completed the survey, 246 participants self-identified as PWUS and were included in the analysis. Most participants were < 45 years of age (61%), male (53%), and white/European (57%). 45% identified as a person with a disability and 39% frequently struggled to make ends meet. Themes were determined at the patient, provider, and system levels. PATIENT history of substance use and experience of intersectionality negatively influenced participants' anticipation and perception of care. Provider: negative experiences were linked to assumption making, feelings of stigma and discrimination, and negative perceptions of provider care. Whereas positive experiences were linked to positive perceptions of provider care. System: timeliness of care and the perception of inadequate mental health resources negatively impacted participants' care experience. Overall, these themes shaped participants' trust of ED staff, their desire to seek care, and their perception of the care quality received. CONCLUSIONS PWUS face significant challenges when seeking care in the ED. Given that EDs are a main site of healthcare utilization, there is an urgent need to better support staff in the ED to improve care experiences among PWUS. Based on the findings, three recommendations are proposed: (1) Integration of an equity-oriented approach into the ED, (2) Widespread training on substance use, and (3) Investment in expert resources and services to support PWUS.
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Affiliation(s)
- Dana Rajab
- Department of Medicine, Queen's University, Kingston, ON, Canada.
| | - Jamie K Fujioka
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Melanie Walker
- Department of Medicine, Queen's University, Kingston, ON, Canada
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Susan A Bartels
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Meredith MacKenzie
- Department of Family Medicine, Queen's University, Kingston, ON, Canada
- Street Health Centre, Kingston Community Health Centres, Kingston, ON, Canada
| | - Eva Purkey
- Department of Family Medicine, Queen's University, Kingston, ON, Canada
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
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31
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Cunningham JK, Solomon TGA, Ritchey J, Weiss BD. Alcohol Use Disorder Visits and Suicide Ideation Diagnosis: Racial/Ethnic Differences at Emergency Departments. Am J Prev Med 2023; 65:1113-1123. [PMID: 37348661 DOI: 10.1016/j.amepre.2023.06.011] [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: 01/22/2023] [Revised: 06/16/2023] [Accepted: 06/18/2023] [Indexed: 06/24/2023]
Abstract
INTRODUCTION Nationally, suicide ideation prevalence is comparable among White, American Indian/Alaska Native, Black, and Hispanic adults experiencing alcohol use disorder. This study examines whether such comparability extends to the probability of receiving a suicide ideation diagnosis when presenting with alcohol use disorder at emergency departments. The probability of hospitalization following such diagnosis is examined as well. METHODS National Emergency Department Sample (2019) data were used. Logistic and multilevel logistic regression analyses were performed in 2022-2023 with suicide ideation diagnosis and subsequent hospitalization as the outcome variables. Control variables included demographics, payor, alcohol use disorder level, comorbidities, and emergency department facility. Adjusted probabilities were computed. RESULTS Age-adjusted probabilities of suicide ideation diagnoses for American Indian/Alaska Native, Black, and Hispanic patients with alcohol use disorder were 5.4%, 6.7%, and 4.9% (95% CIs=3.7, 7.1; 6.0, 7.4; 4.4, 5.4), respectively; all less than that for White counterparts (8.7%; 95% CI=8.2, 9.2). Among patients with alcohol use disorder plus suicide ideation diagnoses, the age-adjusted probability of hospitalization for American Indians/Alaska Natives (32.4%; 95% CI=20.9, 44.0) was less than that for Whites, Blacks, and Hispanics (49.8%, 52.3%, and 49.9%; 95% CIs=46.7, 52.8; 47.1, 57.5; and 43.9, 55.8, respectively). In regressions with multiple control variables, the racial/ethnic differences remained statistically significant (p<0.05). CONCLUSIONS Diagnosis of suicide ideation, a key step in emergency department suicide prevention care, occurred significantly less often for patients of color with alcohol use disorder than for White counterparts. American Indians/Alaska Natives, the racial/ethnic group known to have the nation's highest suicide rate, had the lowest probability of being hospitalized after a diagnosis of alcohol use disorder plus suicide ideation.
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Affiliation(s)
- James K Cunningham
- Department of Family and Community Medicine, The University of Arizona, Tucson, Arizona; American Indian Research Center for Health, The University of Arizona, Tucson, Arizona.
| | - Teshia G Arambula Solomon
- Department of Family and Community Medicine, The University of Arizona, Tucson, Arizona; American Indian Research Center for Health, The University of Arizona, Tucson, Arizona
| | - Jamie Ritchey
- Tribal Epidemiology Center, Inter Tribal Council of Arizona, Inc., Phoenix, Arizona
| | - Barry D Weiss
- Department of Family and Community Medicine, The University of Arizona, Tucson, Arizona
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Lawrence RE, Bernstein A, Jaffe C, Zhao Y, Wang Y, Goldberg TE. Eligibility of emergency psychiatry patients for clinical trials studying depression. J Affect Disord 2023; 342:10-15. [PMID: 37683939 DOI: 10.1016/j.jad.2023.09.010] [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: 05/16/2023] [Revised: 09/04/2023] [Accepted: 09/05/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND Differences often exist between people with depression who are eligible for clinical trials and those seen in clinical practice. The impact of exclusion criteria on eligibility has been previously reported for inpatients and outpatients, but has not been assessed for emergency psychiatry patients; a group that overlaps with inpatients and outpatients but also has important distinctives. Understanding the frequencies of commonly used exclusion criteria in this population could inform interpretation of existing data (generalizability) and highlight opportunities/needs for future trials. METHODS We reviewed 67 clinical trials studying depression using Qualitative Content Analysis to identify common and recurring exclusion criteria. We examined the frequency of these exclusion criteria among a clinical sample of emergency psychiatry patients. RESULTS Most clinical trials had exclusions for basic research requirements, age, symptom severity, psychosis, and substance use. Applying 9 commonly used exclusion criteria to the clinical population resulted in a 3.3 % eligibility rate (95 % CI 1.2 %-7.0 %). Exclusions for psychosis (85.1 % of trials), substance use (83.6 % of trials), and suicide risk (65.7 % of trials) would likely exclude 93 % of emergency psychiatry patients. The prevalence of psychosis, substance use, and suicide risk was much higher among emergency psychiatry patients than among previously studied populations. LIMITATIONS Some eligibility criteria could not be measured. The Qualitative Content Analysis consolidated similar exclusion criteria, losing potentially important nuances in wordings. CONCLUSIONS Exclusion criteria commonly used in contemporary clinical trials of depression limit generalizability to emergency psychiatry patients, due in large part to exclusions for psychosis, substance use, and suicide risk.
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Affiliation(s)
- Ryan E Lawrence
- Department of Psychiatry, Columbia University Medical Center, Director of the Comprehensive Psychiatric Emergency Program at New York - Presbyterian Hospital, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032, United States of America.
| | - Adam Bernstein
- Creedmoor Psychiatric Center, Queens, NY, United States of America.
| | - Chaya Jaffe
- New York State Psychiatric Institute, United States of America.
| | - Yinjun Zhao
- Department of Biostatistics, Mailman School of Public Health, Columbia University, United States of America.
| | - Yuanjia Wang
- Department of Biostatistics, Columbia University, United States of America.
| | - Terry E Goldberg
- Department of Psychiatry, Columbia University, Columbia University Medical Center, United States of America.
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Sokolski E, Buchheit BM, Desai S, Englander H. It's Time to Train Residents in Addiction Medicine. J Grad Med Educ 2023; 15:632-637. [PMID: 38045952 PMCID: PMC10686659 DOI: 10.4300/jgme-d-23-00317.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Affiliation(s)
- Eleasa Sokolski
- Eleasa Sokolski, MD, is Assistant Professor of Medicine and Psychiatry, Division of General Internal Medicine & Geriatrics, Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Bradley M. Buchheit
- Bradley M. Buchheit, MD, MS, is Assistant Professor of Medicine and Family Medicine, Program Director, Oregon Health & Science University Addiction Medicine Fellowship Program, and Medical Director, Harm Reduction and BRidges to Care (HRBR) Clinic, Oregon Health & Science University, Portland, Oregon, USA
| | - Sima Desai
- Sima Desai, MD, MACP, FRCP, is Professor of Medicine Division of Hospital Medicine, Department of Medicine, Program Director, Oregon Health & Science University Internal Medicine Residency Program, and Vice Chair of Education, Department of Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA; and
| | - Honora Englander
- Honora Englander, MD, is Professor of Medicine, Division of General Internal Medicine & Geriatrics, Department of Medicine, Section of Addiction Medicine, and Director/PI Improving Addiction Care Team (IMPACT), Oregon Health & Science University, Portland, Oregon, USA
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Bhondoekhan F, Li Y, Gaither R, Daly MM, Hallowell BD, Chambers LC, Beaudoin FL, Marshall BD. The impact of polysubstance use patterns on engagement of substance use disorder treatment among emergency department patients at high risk of opioid overdose. Addict Behav Rep 2023; 18:100512. [PMID: 37636893 PMCID: PMC10450842 DOI: 10.1016/j.abrep.2023.100512] [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: 04/23/2023] [Revised: 06/30/2023] [Accepted: 08/11/2023] [Indexed: 08/29/2023] Open
Abstract
Background Substance use patterns are diverse, and multiple substances are often involved in fatal and nonfatal overdoses. Additionally, polysubstance use is associated with greater difficulty accessing and remaining in substance use disorder (SUD) treatment. The aim of this study was to identify substance use patterns and determine their association with SUD treatment engagement among emergency department (ED) patients at risk of opioid overdose. Methods This was a sub-analysis of a randomized controlled trial comparing two behavioral interventions for individuals at two EDs in Rhode Island from 2018 to 2021. Past six-month substance use frequency for eight substances plus injection drug use was self-reported at trial enrollment, and SUD treatment engagement within 90 days after enrollment was obtained using administrative data linkages. Latent class analysis identified substance use patterns and multivariable log-binomial models estimated the association with SUD treatment engagement. Results Among 607 participants, there were four substance use patterns: 1) low reported use (n = 295), 2) frequent injection and heroin use (n = 131), 3) high frequency broad polysubstance use (n = 62), and 4) low frequency broad polysubstance use (n = 119). Compared to participants with the low reported use pattern, those with the frequent injection and heroin pattern had a greater likelihood of SUD treatment engagement (adjusted risk ratio = 1.28; 95% confidence interval = 1.02-1.61). Conclusions Distinct and meaningful polysubstance use patterns showed differential SUD treatment engagement after ED discharge. Nuanced relationships between substance use patterns and treatment highlight the necessity for tailored harm reduction, treatment, and recovery services.
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Affiliation(s)
- Fiona Bhondoekhan
- Brown University School of Public Health, Department of Epidemiology, 121 South Main Street, Providence, RI 02903, USA
| | - Yu Li
- Brown University School of Public Health, Department of Epidemiology, 121 South Main Street, Providence, RI 02903, USA
| | - Rachel Gaither
- Brown University School of Public Health, Department of Epidemiology, 121 South Main Street, Providence, RI 02903, USA
| | - Mackenzie M. Daly
- Rhode Island Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, 14 Harrington Rd, Cranston, RI 02920, USA
| | | | - Laura C. Chambers
- Brown University School of Public Health, Department of Epidemiology, 121 South Main Street, Providence, RI 02903, USA
| | - Francesca L. Beaudoin
- Brown University School of Public Health, Department of Epidemiology, 121 South Main Street, Providence, RI 02903, USA
| | - Brandon D.L. Marshall
- Brown University School of Public Health, Department of Epidemiology, 121 South Main Street, Providence, RI 02903, USA
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Lee YK, Trevisan L, S Fuehrlein B. Longitudinal Outcomes of the top 20 Utilizers of VA Connecticut's Psychiatric Emergency Services Between 2010 and 2020. Community Ment Health J 2023; 59:1532-1536. [PMID: 37243739 DOI: 10.1007/s10597-023-01140-y] [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: 10/11/2022] [Accepted: 05/16/2023] [Indexed: 05/29/2023]
Abstract
Frequent utilizers of emergency services represent a clinically important cohort with potentially unmet health care needs despite demanding a high volume of costly services. However, not much is known about their longitudinal course. This study identified the top 20 utilizers of VA Connecticut's psychiatric emergency services and conducted a chart review of their longitudinal outcomes during an 11-year period between 2010 and 2020, including their visit diagnoses, medical and psychiatric comorbidities, and types and frequency of other medical services and supports received. At the index visit, 19 of the 20 patients had substance use disorder and 14 patients had at least one non-substance psychiatric diagnosis. Despite all patients receiving primary care and other services, such as residential treatments, outpatient therapy, and social work consults, 11 of the 12 patients remaining alive and residing in the state continued to utilize psychiatric emergency services in 2020, revealing a pattern of persistent use.
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Affiliation(s)
- Yu Kyung Lee
- Yale School of Medicine, Yale University School of Medicine, New Haven, USA.
| | - Louis Trevisan
- Yale School of Medicine, Yale University School of Medicine, New Haven, USA
- Department of Psychiatry, Creighton University, Omaha, USA
| | - Brian S Fuehrlein
- Yale School of Medicine, Yale University School of Medicine, New Haven, USA
- Department of Psychiatry, Yale University, New Haven, USA
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Myran DT, Harrison LD, Pugliese M, Solmi M, Anderson KK, Fiedorowicz JG, Perlman CM, Webber C, Finkelstein Y, Tanuseputro P. Transition to Schizophrenia Spectrum Disorder Following Emergency Department Visits Due to Substance Use With and Without Psychosis. JAMA Psychiatry 2023; 80:1169-1174. [PMID: 37755727 PMCID: PMC10535000 DOI: 10.1001/jamapsychiatry.2023.3582] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 07/28/2023] [Indexed: 09/28/2023]
Abstract
Importance Episodes of substance-induced psychosis are associated with increased risk of developing a schizophrenia spectrum disorder. However, there are limited data on the transition risk for substance use without psychosis. Objectives To quantify the risk of transition to schizophrenia spectrum disorder following an incident emergency department (ED) visit for (1) substance-induced psychosis and (2) substance use without psychosis and to explore factors associated with transition. Design, Settings, and Participants A population-based retrospective cohort study (January 2008 to March 2022) of all individuals, aged 14 to 65 years, in Ontario, Canada, with no history of a psychotic disorder. Individuals with incident ED visits for substance use with and without psychosis were compared with members of the general population. Main Outcomes and Measures Transition to schizophrenia spectrum disorder using a chart-validated algorithm. Associations between ED visits for substance use and subsequent transition were estimated using cause-specific hazard models. Results The study included 9 844 497 individuals, aged 14 to 65 years (mean [SD] age, 40.2 [14.7] years; 50.2% female) without a history of psychosis. There were 407 737 individuals with an incident ED visit for substance use, of which 13 784 (3.4%) ED visits were for substance-induced psychosis. Individuals with substance-induced psychosis were at a 163-fold (age- and sex-adjusted hazard ratio [aHR], 163.2; 95% CI, 156.1-170.5) increased risk of transitioning, relative to the general population (3-year risk, 18.5% vs 0.1%). Individuals with an ED visit for substance use without psychosis had a lower relative risk of transitioning (aHR, 9.8; 95% CI, 9.5-10.2; 3-year risk, 1.4%), but incurred more than 3 times the absolute number of transitions (9969 vs 3029). Cannabis use had the highest transition risk among visits with psychosis (aHR, 241.6; 95% CI, 225.5-258.9) and the third-highest risk among visits without psychosis (aHR, 14.3; 95% CI, 13.5-15.2). Younger age and male sex were associated with a higher risk of transition, and the risk of male sex was greater in younger compared with older individuals, particularly for cannabis use. Conclusions and Relevance The findings of this cohort study suggest that ED visits for substance use were associated with an increased risk of developing a schizophrenia spectrum disorder. Although substance-induced psychoses had a greater relative transition risk, substance use without psychosis was far more prevalent and resulted in a greater absolute number of transitions. Several factors were associated with higher transition risk, with implications for counseling and early intervention.
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Affiliation(s)
- Daniel T. Myran
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Lyndsay D. Harrison
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Michael Pugliese
- ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Marco Solmi
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Psychiatry, University of Ottawa, Ottawa, Ontario, Canada
- Department of Mental Health, The Ottawa Hospital, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
| | - Kelly K. Anderson
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Department of Psychiatry, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- ICES Western, London, Ontario, Canada
| | - Jess G. Fiedorowicz
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Psychiatry, University of Ottawa, Ottawa, Ontario, Canada
- Department of Mental Health, The Ottawa Hospital, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Neurosciences, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Colleen Webber
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Yaron Finkelstein
- Division of Pediatric Emergency Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Pharmacology and Toxicology, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Peter Tanuseputro
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Martin M, Englander H, Calcaterra SL. Things We Do for No Reason™: Avoiding methadone for opioid withdrawal. J Hosp Med 2023; 18:1034-1037. [PMID: 37244869 PMCID: PMC10870273 DOI: 10.1002/jhm.13138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/26/2023] [Accepted: 05/10/2023] [Indexed: 05/29/2023]
Affiliation(s)
- Marlene Martin
- Department of Medicine, Division of Hospital Medicine, San Francisco General Hospital, University of California, San Francisco, California, USA
| | - Honora Englander
- Department of Medicine, Section of Addiction Medicine in Division of General Internal Medicine & Geriatrics, Oregon Health & Science University, Oregon, Portland, USA
- Department of Medicine, Division of Hospital Medicine, Oregon Health & Science University, Oregon, Portland, USA
| | - Susan L. Calcaterra
- Department of Medicine, Divisions of Hospital Medicine and General Internal Medicine, University of Colorado Hospital, Aurora, Colorado, USA
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Knight-Dunn L, Gorchynski J. Alcohol-Related Metabolic Emergencies. Emerg Med Clin North Am 2023; 41:809-819. [PMID: 37758425 DOI: 10.1016/j.emc.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Patients with alcohol use disorders are commonly identified and managed in the emergency department. Although the alcohol-intoxicated patient has a high risk for significant injury and diseases, the majority will be allowed to sober in the emergency department and can be discharged without incident. However, there are metabolic derangements in these patients, such as alcoholic ketoacidosis, Wernicke-Korsakoff, and potomania that very commonly present similar to intoxication and can be misdiagnosed by emergency clinicians.
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Affiliation(s)
| | - Julie Gorchynski
- Department of Emergency Medicine, UT Health San Antonio, 7703 Floyd Curl Drive, Mail Code 7736, San Antonio, TX 78229-3900, USA.
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39
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Stolbach AI, Mazer-Amirshahi M, Cienki J, Dye LR, Nelson LS, Marino R, Weiss ST, Warrick BJ, Wax PM. ACMT Position Statement: Role of the Medical Toxicologist in the Management of Patients with Substance Use Disorder. J Med Toxicol 2023; 19:411-413. [PMID: 37415025 PMCID: PMC10522538 DOI: 10.1007/s13181-023-00945-3] [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: 04/26/2023] [Revised: 04/26/2023] [Accepted: 05/04/2023] [Indexed: 07/08/2023] Open
Affiliation(s)
| | | | | | - Leslie R Dye
- Department of Emergency Medicine, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | | | - Ryan Marino
- Departments of Emergency Medicine & Psychiatry, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Stephanie T Weiss
- National Institute On Drug Abuse, Bethesda, MD, USA
- National Institutes of Health, Bethesda, MD, USA
| | | | - Paul M Wax
- American College of Medical Toxicology, Phoenix, AZ, USA
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Lett E, Tran NK, Nweke N, Nguyen M, Kim JG, Holmboe E, McDade W, Boatright D. Intersectional Disparities in Emergency Medicine Residents' Performance Assessments by Race, Ethnicity, and Sex. JAMA Netw Open 2023; 6:e2330847. [PMID: 37733347 PMCID: PMC10514741 DOI: 10.1001/jamanetworkopen.2023.30847] [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: 01/20/2023] [Accepted: 07/19/2023] [Indexed: 09/22/2023] Open
Abstract
Importance Previous studies have demonstrated sex-specific disparities in performance assessments among emergency medicine (EM) residents. However, less work has focused on intersectional disparities by ethnoracial identity and sex in resident performance assessments. Objective To estimate intersectional sex-specific ethnoracial disparities in standardized EM resident assessments. Design, Setting, and Participants This retrospective cohort study used data from the Association of American Medical Colleges and the Accreditation Council for Graduate Medical Education Milestones (Milestones) assessments to evaluate ratings for EM residents at 128 EM training programs in the US. Statistical analyses were conducted in June 2020 to January 2023. Exposure Training and assessment environments in EM residency programs across comparison groups defined by ethnoracial identity (Asian, White, or groups underrepresented in medicine [URM], ie, African American/Black, American Indian/Alaska Native, Hispanic/Latine, and Native Hawaiian/Other Pacific Islander) and sex (female/male). Main Outcomes and Measures Mean Milestone scores (scale, 0-9) across 6 core competency domains: interpersonal and communications skills, medical knowledge, patient care, practice-based learning and improvement, professionalism, and system-based practice. Overall assessment scores were calculated as the mean of the 6 competency scores. Results The study sample comprised 128 ACGME-accredited programs and 16 634 assessments for 2708 EM residents of which 1913 (70.6%) were in 3-year and 795 (29.4%) in 4-year programs. Most of the residents were White (n = 2012; 74.3%), followed by Asian (n = 477; 17.6%), Hispanic or Latine (n = 213; 7.9%), African American or Black (n = 160; 5.9%), American Indian or Alaska Native (n = 24; 0.9%), and Native Hawaiian or Other Pacific Islander (n = 4; 0.1%). Approximately 14.3% (n = 386) and 34.6% (n = 936) were of URM groups and female, respectively. Compared with White male residents, URM female residents in 3-year programs were rated increasingly lower in the medical knowledge (URM female score, -0.47; 95% CI, -0.77 to -0.17), patient care (-0.18; 95% CI, -0.35 to -0.01), and practice-based learning and improvement (-0.37; 95% CI, -0.65 to -0.09) domains by postgraduate year 3 year-end assessment; URM female residents in 4-year programs were also rated lower in all 6 competencies over the assessment period. Conclusions and Relevance This retrospective cohort study found that URM female residents were consistently rated lower than White male residents on Milestone assessments, findings that may reflect intersectional discrimination in physician competency evaluation. Eliminating sex-specific ethnoracial disparities in resident assessments may contribute to equitable health care by removing barriers to retention and promotion of underrepresented and minoritized trainees and facilitating diversity and representation among the emergency physician workforce.
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Affiliation(s)
- Elle Lett
- Health Systems and Population Health, University of Washington School of Public Health, Seattle
- Center for Anti-Racism and Community Health, University of Washington School of Public Health, Seattle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nguyen Khai Tran
- The PRIDE Study/PRIDEnet, Stanford University School of Medicine, Palo Alto, California
| | - Nkemjika Nweke
- St George’s University School of Medicine, St George, Grenada
| | | | - Jung G. Kim
- Department of Health System Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Eric Holmboe
- Accreditation Council for Graduate Medical Education, Chicago, Illinois
| | - William McDade
- Accreditation Council for Graduate Medical Education, Chicago, Illinois
| | - Dowin Boatright
- Ronald O. Perelman Department of Emergency Medicine, New York University, New York
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Huxley-Reicher Z, Puglisi LB, Tetrault JM, Weimer MB, Stellini M, Bhandary-Alexander J, Thomas KA, Donroe JH. Response to substance use during hospitalization: A survey study of current and ideal policies and practices. J Hosp Med 2023; 18:829-834. [PMID: 37475186 DOI: 10.1002/jhm.13162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/09/2023] [Accepted: 06/20/2023] [Indexed: 07/22/2023]
Abstract
People may use nonprescribed substances during an acute hospitalization. Hospital policies and responses can be stigmatizing, involve law enforcement, and lead to worse patient outcomes, including patient-directed discharge. In the United States, there is currently little data on hospital policies that address the use of substances during hospitalization. In this cross-sectional study, we surveyed clinicians at US hospitals with Accreditation Council of Graduate Medical Education (ACGME)-accredited addiction medicine fellowships about their current practices and policies and what they would include in an ideal policy. We had 77 responses from 55 out of 86 ACGME-addiction medicine fellowships (63.9%). Respondents identified policies at 21.8% of the institutions surveyed. Current responses to inpatient substance use vary, though most do not match what clinicians identify as an ideal response. Our results suggest that the use of nonprescribed substances during a hospitalization may be common, but a majority of hospitals likely do not have patient-centered policies to address this.
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Affiliation(s)
- Zina Huxley-Reicher
- Yale Primary Care Residency Program, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Lisa B Puglisi
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale School of Medicine, Program in Addiction Medicine, Section of General Internal Medicine, New Haven, Connecticut, USA
- Justice at Yale School of Medicine, SEICHE Center for Health, New Haven, Connecticut, USA
| | - Jeanette M Tetrault
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale School of Medicine, Program in Addiction Medicine, Section of General Internal Medicine, New Haven, Connecticut, USA
| | - Melissa B Weimer
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale School of Medicine, Program in Addiction Medicine, Section of General Internal Medicine, New Haven, Connecticut, USA
- Yale School of Public Health, New Haven, Connecticut, USA
| | - Meg Stellini
- Children's Hospital of Philadelphia-Policy Lab, Philadelphia, Pennsylvania, USA
| | | | - Kathryn A Thomas
- Justice at Yale School of Medicine, SEICHE Center for Health, New Haven, Connecticut, USA
- Justice Collaboratory at Yale Law School, New Haven, Connecticut, USA
| | - Joseph H Donroe
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale School of Medicine, Program in Addiction Medicine, Section of General Internal Medicine, New Haven, Connecticut, USA
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Oami T, Yumoto T, Shimazui T, Sarmiento S, Klingensmith NJ, Chen CW, Otani S, Liang Z, Burd EM, Mahdi ZK, Ford ML, Coopersmith CM. CHRONIC ETHANOL USE WORSENS GUT PERMEABILITY AND ALTERS TIGHT JUNCTION EXPRESSION IN A MURINE SEPSIS MODEL. Shock 2023; 60:280-290. [PMID: 37405872 PMCID: PMC10526701 DOI: 10.1097/shk.0000000000002162] [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: 07/07/2023]
Abstract
ABSTRACT Alcohol use disorder is associated with increased mortality in septic patients. Murine studies demonstrate that ethanol/sepsis is associated with changes in gut integrity. This study examined intestinal permeability after ethanol/sepsis and investigated mechanisms responsible for alterations in barrier function. Mice were randomized to drink either 20% ethanol or water for 12 weeks and then were subjected to either sham laparotomy or cecal ligation and puncture (CLP). Intestinal permeability was disproportionately increased in ethanol/septic mice via the pore, leak, and unrestricted pathways. Consistent with increased permeability in the leak pathway, jejunal myosin light chain (MLC) kinase (MLCK) expression and the ratio of phospho-MLC to total MLC were both increased in ethanol/CLP. Gut permeability was altered in MLCK -/- mice in water/CLP; however, permeability was not different between WT and MLCK -/- mice in ethanol/CLP. Similarly, jejunal IL-1β levels were decreased while systemic IL-6 levels were increased in MLCK -/- mice in water/CLP but no differences were identified in ethanol/CLP. While we have previously shown that mortality is improved in MLCK -/- mice after water/CLP, mortality was significantly worse in MLCK -/- mice after ethanol/CLP. Consistent with an increase in the pore pathway, claudin 4 levels were also selectively decreased in ethanol/CLP WT mice. Furthermore, mRNA expression of jejunal TNF and IFN-γ were both significantly increased in ethanol/CLP. The frequency of CD4 + cells expressing TNF and IL-17A and the frequency of CD8 + cells expressing IFN-γ in Peyer's Patches were also increased in ethanol/CLP. Thus, there is an ethanol-specific worsening of gut barrier function after CLP that impacts all pathways of intestinal permeability, mediated, in part, via changes to the tight junction. Differences in the host response in the setting of chronic alcohol use may play a role in future precision medicine approaches toward the treatment of sepsis.
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Affiliation(s)
| | | | | | - Sofia Sarmiento
- Department of Surgery and Emory Critical Care Center, Emory University School of Medicine, Atlanta, Georgia
| | - Nathan J Klingensmith
- Department of Surgery and Emory Critical Care Center, Emory University School of Medicine, Atlanta, Georgia
| | - Ching-Wen Chen
- Department of Surgery and Emory Critical Care Center, Emory University School of Medicine, Atlanta, Georgia
| | | | - Zhe Liang
- Department of Surgery and Emory Critical Care Center, Emory University School of Medicine, Atlanta, Georgia
| | - Eileen M Burd
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Zaid K Mahdi
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Mandy L Ford
- Department of Surgery and Emory Transplant Center, Emory University School of Medicine, Atlanta, Georgia
| | - Craig M Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University School of Medicine, Atlanta, Georgia
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Kratovil A, Schuler MS, Vottero BA, Aryal G. Original Research: Nurses' Self-Assessed Knowledge, Attitudes, and Educational Needs Regarding Patients with Substance Use Disorder. Am J Nurs 2023; 123:26-33. [PMID: 36951342 DOI: 10.1097/01.naj.0000925496.18847.c6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
BACKGROUND Substance use disorder (SUD) is a chronic illness, but it's often seen as an intentional choice rather than as a disease. People with SUD are frequently stigmatized, leading to disparate care. Findings from previous studies have indicated that nurses feel inadequately prepared to care for, and tend to have negative attitudes toward, patients with SUD. But it's unknown what kind of education would better prepare nurses caring for this patient population, or whether these negative attitudes vary across practice settings. PURPOSE AND DESIGN This observational, cross-sectional, mixed-methods study sought to explore nurses' self-assessed knowledge of and attitudes toward caring for patients with SUD (whether formally diagnosed or not) in hospital settings across the United States. A secondary aim was to determine nurses' educational preferences and needs in this area. METHODS Data were collected over a three-month period in early 2020, using the online social networking platform Facebook. All participants were nurses working in hospital settings throughout the United States. Participants were surveyed using two tools: the Drug and Drug Problems Perceptions Questionnaire, and another questionnaire that included open-ended questions regarding nurses' SUD-related education and their experiences and perceived needs in caring for patients with SUD. Quantitative data were analyzed using analysis of variance and post hoc Tukey tests. Qualitative data were analyzed using thematic analysis. RESULTS A total of 691 nurses participated. Nurses reported having been educated in SUD but wanted additional face-to-face education from mental health specialists. The nurses working on mental health units had significantly more positive attitudes toward caring for patients with SUD than nurses on other units. Older nurses had significantly more positive attitudes toward patients with SUD than younger nurses. Qualitative analysis uncovered four themes: unmet needs, personal experiences inform care, personal beliefs inform perceptions, and judgmental attitudes. CONCLUSIONS Study findings indicate that, in general, hospital nurses have negative attitudes toward patients with SUD. The results further reaffirm the need for empathy-based nursing education for nurses who care for these patients. Participants expressed a preference for face-to-face training by mental health specialists experienced in SUD. Given the increasing prevalence of SUD and the expected retirement of older nurses, it is urgent that we prioritize empathy-based nursing education, particularly for newer-to-practice nurses, in order to improve nurses' attitudes and ensure best care for patients with SUD.
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Affiliation(s)
- Amanda Kratovil
- Amanda Kratovil is an assistant professor of nursing and Beth A. Vottero is an associate professor of nursing at the College of Nursing, Purdue University Northwest, Hammond, IN. Monika S. Schuler is an associate professor at the College of Nursing and Health Sciences, University of Massachusetts (UMass) Dartmouth. Gokarna Aryal is a professor of statistics at the College of Engineering and Sciences, Purdue University Northwest. Funding for this study was provided through UMass Dartmouth's University-Industry Collaborative Seed Funding Program. Contact author: Amanda Kratovil, . The authors have disclosed no potential conflicts of interest, financial or otherwise
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Murphy CE, Coralic Z, Wang RC, Montoy JCC, Ramirez B, Raven MC. Extended-Release Naltrexone and Case Management for Treatment of Alcohol Use Disorder in the Emergency Department. Ann Emerg Med 2023; 81:440-449. [PMID: 36328851 DOI: 10.1016/j.annemergmed.2022.08.453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 08/01/2022] [Accepted: 08/25/2022] [Indexed: 11/15/2022]
Abstract
STUDY OBJECTIVE To assess the feasibility of initiating treatment for alcohol use disorder with extended-release naltrexone and case management services in the emergency department (ED) and measure the intervention's impact on daily alcohol consumption and quality of life. METHODS This is a 12-week prospective open-label single-arm study of a multimodal treatment for alcohol use disorder consisting of monthly extended-release naltrexone injections and case management services initiated at an urban academic ED. Participants were actively drinking adult patients in ED with known or suspected alcohol use disorder and an AUDIT-C score more than 4. The main feasibility outcomes included the rates of participant enrollment, retention in the study, and continuing treatment after study completion. Efficacy outcomes were the change in daily alcohol consumption (drinks per day; 14 g ethanol per drink), measured by a 14-day timeline followback, and the change in quality of life measured with a single-item Kemp quality of life scale. RESULTS One hundred seventy-nine patients were approached, and 32 were enrolled (18%). Of the 32 enrolled patients, 25 (78%) completed all visits, and 22 (69%) continued naltrexone after the trial. The mean baseline daily alcohol consumption was 7.6 drinks per day (interquartile range, 4.5, 13.4), and the mean quality of life was 3.6 (SD 1.7) on a 7-point scale. The median daily alcohol consumption change was -7.5 drinks per day (Hodges-Lehmann 95% confidence interval -8.6, -5.9). The mean quality of life change was 1.2 points (95% confidence interval 0.5, 1.9; P<.01). CONCLUSION We found that initiation of treatment of alcohol use disorder with extended-release naltrexone and case management is feasible in an ED setting and observed significant reductions in drinking with improved quality of life in the short term. Multicenter randomized controlled trials are needed to further validate these findings.
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Affiliation(s)
- Charles E Murphy
- Department of Emergency Medicine, University of California, San Francisco, CA.
| | - Zlatan Coralic
- Department of Emergency Medicine, University of California, San Francisco, CA; Department of Pharmacy, University of California, San Francisco, CA
| | - Ralph C Wang
- Department of Emergency Medicine, University of California, San Francisco, CA
| | | | - Bianca Ramirez
- Department of Emergency Medicine, University of California, San Francisco, CA
| | - Maria C Raven
- Department of Emergency Medicine, University of California, San Francisco, CA; Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA
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Hawk KF, D'Onofrio G. Time to Treat Alcohol Use Disorder in the Emergency Department. Ann Emerg Med 2023; 81:450-452. [PMID: 36775724 DOI: 10.1016/j.annemergmed.2022.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/20/2022] [Accepted: 11/14/2022] [Indexed: 02/13/2023]
Affiliation(s)
- Kathryn F Hawk
- Department of Emergency Medicine Yale School of Medicine, New Haven, CT
| | - Gail D'Onofrio
- Department of Emergency Medicine Yale School of Medicine, New Haven, CT.
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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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Miele AS, Fleury MJ, Zeluff H, Mendieta A, Phillips C, Roth A, Basello G, Nienaber C, Crupi R, Brondolo E. Driven by need, shaped by access: Heterogeneity in patient profiles and patterns of service utilization in patients with alcohol use disorders. Drug Alcohol Depend 2023; 246:109825. [PMID: 36924662 DOI: 10.1016/j.drugalcdep.2023.109825] [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: 09/16/2022] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Patients with alcohol-use disorders (AUDs) are highly heterogenous and account for an increasing proportion of general medical hospital visits. However, many patients with AUDs do not present with severe medical or psychiatric needs requiring immediate attention. There may be a mismatch between some patients' needs and the available services, potentially driving re-admissions and re-encounters. The current study aims to identify subgroups of AUD patients and predict differences in patterns of healthcare service use (HSU) over time. METHODS Latent class analysis (LCA) was conducted using hospital data incorporating sociodemographic, health behavior, clinical, and service use variables to identify subtypes of AUD patients, then class membership was used to predict patterns of HSU. RESULTS Four classes were identified with the following characteristics: (1) Patients with acute medical injuries (30 %); (2) Patients with socioeconomic and psychiatric risk factors, (11 %); (3) Patients with chronic AUD with primarily non-psychiatric medical needs (18 %); and (4) Patients with primary AUDs with low medical-treatment complexity (40 %). Negative binomial models showed that Class 4 patients accounted for the highest frequency of service use, including significantly higher rates of emergency department reencounters at 30 days and 12 months. CONCLUSIONS The profile and patterns of HSU exhibited by patients in class 4 suggest that these patients have needs which are not currently being addressed in the emergency department. These have implications for how resources are allocated to meet the needs of patients with AUDs, including those who make frequent visits to the emergency department without high acuity medical needs.
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Affiliation(s)
- Andrew S Miele
- St. John's University Department of Psychology, Queens, NY, USA; Jamaica Hospital Medical Center (JHMC), Queens, NY, USA.
| | - Marie-Josée Fleury
- Douglas Research Center, McGill University Department of Psychiatry, Montreal, Quebec, Canada
| | - Heather Zeluff
- St. John's University Department of Psychology, Queens, NY, USA
| | - Ashley Mendieta
- St. John's University Department of Psychology, Queens, NY, USA
| | | | - Alan Roth
- Jamaica Hospital Medical Center (JHMC), Queens, NY, USA
| | - Gina Basello
- Jamaica Hospital Medical Center (JHMC), Queens, NY, USA
| | | | - Robert Crupi
- Ambulatory Care & Population Health & Palliative Care Services, Weill Cornell Medical College, USA
| | - Elizabeth Brondolo
- St. John's University Department of Psychology, Queens, NY, USA; Jamaica Hospital Medical Center (JHMC), Queens, NY, USA
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Hale EW, Coyle TD. Under-Documented or Under-Recognized? Comorbid ADHD in Emergency Department Patients With Addictive Disorders. J Atten Disord 2023; 27:270-272. [PMID: 36354068 DOI: 10.1177/10870547221135800] [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: 11/11/2022]
Abstract
OBJECTIVES We sought to examine rates of comorbid ADHD and SUD/AUD using a nationally representative dataset, and to compare this data with established estimates. We hoped to increase available research on ADHD within patients with SUD/AUD. METHODS This study is a retrospective secondary analysis of cross-sectional data collected in the National Hospital Ambulatory Medical Care Survey (NHAMCS). RESULTS The data showed less than 1% of comorbid ADHD in either AUD or SUD, and prevalence of 0.6% in patients with both. Our estimated prevalence of ADHD among SUD/AUD patients is more than 30-fold smaller than the 25% consensus. CONCLUSION The stark difference between our data and prior research indicates a need for further examination of the prevalence of ADHD within acute care. This finding of a large reservoir of ADHD that is unrecognized or undocumented indicates a substantive need for ADHD-focused education with opportunity for improvement in patient treatment.
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Fleury MJ, Cao Z, Grenier G, Huỳnh C. Profiles of quality of outpatient care use, associated sociodemographic and clinical characteristics, and adverse outcomes among patients with substance-related disorders. Subst Abuse Treat Prev Policy 2023; 18:5. [PMID: 36641441 PMCID: PMC9840840 DOI: 10.1186/s13011-022-00511-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 12/22/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND This study identified patient profiles in terms of their quality of outpatient care use, associated sociodemographic and clinical characteristics, and adverse outcomes based on frequent emergency department (ED) use, hospitalization, and death from medical causes. METHODS A cohort of 18,215 patients with substance-related disorders (SRD) recruited in addiction treatment centers was investigated using Quebec (Canada) health administrative databases. A latent class analysis was produced, identifying three profiles of quality of outpatient care use, while multinomial and logistic regressions tested associations with patient characteristics and adverse outcomes, respectively. RESULTS Profile 1 patients (47% of the sample), labeled "Low outpatient service users", received low quality of care. They were mainly younger, materially and socially deprived men, some with a criminal history. They had more recent SRD, mainly polysubstance, and less mental disorders (MD) and chronic physical illnesses than other Profiles. Profile 2 patients (36%), labeled "Moderate outpatient service users", received high continuity and intensity of care by general practitioners (GP), while the diversity and regularity in their overall quality of outpatient service was moderate. Compared with Profile 1, they were older, less likely to be unemployed or to live in semi-urban areas, and most had common MD and chronic physical illnesses. Profile 3 patients (17%), labeled "High outpatient service users", received more intensive psychiatric care and higher quality of outpatient care than other Profiles. Most Profile 3 patients lived alone or were single parents, and fewer lived in rural areas or had a history of homelessness, versus Profile 1 patients. They were strongly affected by MD, mostly serious MD and personality disorders. Compared with Profile 1, Profile 3 had more frequent ED use and hospitalizations, followed by Profile 2. No differences in death rates emerged among the profiles. CONCLUSIONS Frequent ED use and hospitalization were strongly related to patient clinical and sociodemographic profiles, and the quality of outpatient services received to the severity of their conditions. Outreach strategies more responsive to patient needs may include motivational interventions and prevention of risky behaviors for Profile 1 patients, collaborative GP-psychiatrist care for Profile 2 patients, and GP care and intensive specialized treatment for Profile 3 patients.
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Affiliation(s)
- Marie-Josée Fleury
- Douglas Hospital Research Centre, 6875 LaSalle Blvd, Montreal, Quebec, H4H 1R3, Canada. .,Department of Psychiatry, McGill University, 1033 Pine Avenue West, Montreal, Quebec, H3A 1A1, Canada.
| | - Zhirong Cao
- grid.412078.80000 0001 2353 5268Douglas Hospital Research Centre, 6875 LaSalle Blvd, Montreal, Quebec H4H 1R3 Canada
| | - Guy Grenier
- grid.412078.80000 0001 2353 5268Douglas Hospital Research Centre, 6875 LaSalle Blvd, Montreal, Quebec H4H 1R3 Canada
| | - Christophe Huỳnh
- grid.459278.50000 0004 4910 4652Institut universitaire sur les dépendances, Centre intégré universitaire de santé et des services sociaux du Centre-Sud-de-l’Île-de-Montréal, 950 Louvain Est, Montreal, Quebec H2M 2E8 Canada
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Rohner H, Gaspar N, Philipsen A, Schulze M. Prevalence of Attention Deficit Hyperactivity Disorder (ADHD) among Substance Use Disorder (SUD) Populations: Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1275. [PMID: 36674031 PMCID: PMC9859173 DOI: 10.3390/ijerph20021275] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/04/2023] [Accepted: 01/09/2023] [Indexed: 06/02/2023]
Abstract
(1) Background: Attention deficit hyperactivity disorder (ADHD) is characterized by a persistent pattern of age-inappropriate levels of inattention and/or hyperactivity/impulsivity that results in functional impairment at work, education, or hobbies and affects family life, social contacts, and self-confidence. ADHD is a comorbid condition associated with a prognosis of severe substance use disorder (SUD) and the early onset of such. The aim of this meta-analysis was to obtain the best estimate of the prevalence of ADHD in SUD populations. (2) Methods: A literature research was conducted using PUBMED® and Web of Science®. The following search terms were used: [ADHD], [prevalence], and [substance use disorder]. RStudio® was used for meta-analysis methods. (3) Results: In total, 31 studies were included. We estimate the prevalence of ADHD among SUD patients at 21%.
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