Facilitators and barriers to initiating change in medical intensive care unit survivors with alcohol use disorders: a qualitative study

Critical care for patients with substance use disorders

PURPOSE OF REVIEW

To examine the impact of substance use disorders (SUDs) on critical illness and the role of critical care providers in treating SUDs. We discuss emerging evidence supporting hospital-based addiction treatment and highlight the clinical and research innovations needed to elevate the standards of care for patients with SUDs in the intensive care unit (ICU) amidst staggering individual and public health consequences.

RECENT FINDINGS

Despite the rapid increase of SUDs in recent years, with growing implications for critical care, dedicated studies focused on ICU patients with SUDs remain scant. Available data demonstrate SUDs are major risk factors for the development and severity of critical illness and are associated with poor outcomes. ICU patients with SUDs experience mutually reinforcing effects of substance withdrawal and pain, which amplify risks and consequences of delirium, and complicate management of comorbid conditions. Hospital-based addiction treatment can dramatically improve the health outcomes of hospitalized patients with SUDs and should begin in the ICU.

SUMMARY

SUDs have a significant impact on critical illness and post-ICU outcomes. High-quality cohort and treatment studies designed specifically for ICU patients with SUDs are needed to define best practices and improve health outcomes in this vulnerable population.

Medication prescribing for alcohol use disorders during alcohol-related encounters in a Colorado regional healthcare system

RATIONALE

Investigations show that medications for alcohol use disorders (MAUD) reduce heavy drinking and relapses. However, only 1.6% of individuals with alcohol use disorders (AUD) receive MAUD across care settings. The epidemiology of MAUD prescribing in the acute care setting is incompletely described. We hypothesized that MAUD would be under prescribed in inpatient acute care hospital settings compared to the outpatient, emergency department (ED), and inpatient substance use treatment settings.

METHODS

We evaluated electronic health record (EHR) data from adult patients with an International Classification of Diseases, 10th revision (ICD-10) alcohol-related diagnosis in the University of Colorado Health (UCHealth) system between January 1, 2016 and 31 December, 2019. Data from patients with an ICD-10 diagnosis code for opioid use disorder and those receiving MAUD prior to their first alcohol-related episode were excluded. The primary outcome was prescribing of MAUD, defined by prescription of naltrexone, acamprosate, and/or disulfiram. We performed bivariate and multivariate analyses to identify independent predictors of MAUD prescribing at UCHealth.

RESULTS

We identified 48,421 unique patients with 136,205 alcohol-related encounters at UCHealth. Encounters occurred in the ED (42%), inpatient acute care (17%), inpatient substance use treatment (18%), or outpatient primary care (12%) settings. Only 2270 (5%) patients received MAUD across all settings. Female sex and addiction medicine consults positively predicted MAUD prescribing. In contrast, encounters outside inpatient substance use treatment, Hispanic ethnicity, and black or non-white race were negative predictors of MAUD prescribing. Compared to inpatient substance use treatment, inpatient acute care hospitalizations for AUD was associated with a 93% reduced odds of receiving MAUD.

CONCLUSIONS

AUD-related ED and inpatient acute care hospital encounters in our healthcare system were common. Nevertheless, prescriptions for MAUD were infrequent in this population, particularly in inpatient settings. Our findings suggest that the initiation of MAUD for patients with alcohol-related diagnoses in acute care settings deserves additional evaluation.

Staff experiences of encountering and treating outpatients with substance use disorder in the psychiatric context: a qualitative study

Background

High comorbidity exists between mental illness and substance use disorders (SUD). Patients in psychiatry living with problematic alcohol or drug consumption can experience a sense of exclusion, where seeking help for SUD can be perceived as stigmatizing. The aim of this study is to illuminate staff experiences of encountering patients with SUD within the psychiatric outpatient context.

Methods

The study was exploratory, with a qualitative design. Interviews with outpatient psychiatry managers and focus groups with clinical staff focused on the experience of encountering patients with SUD. Data were evaluated using content analysis inspired by phenomenological-hermeneutic methodology.

Results

Three themes were identified and each illuminated by two sub-themes. Bridging the organizational gap included sub-themes of having an established collaboration and facing difficulties in the collaboration; Having beliefs about the patient you encounter included sub-themes of working with patients who are exposed to prejudicial thoughts and expressing prejudicial thoughts about the patient. Striving to achieve a therapeutic alliance included sub-themes of having a feeling of developing together and supporting the patient towards recovery.

Conclusion

A life-world perspective, used to interpret results, indicated that caring for patients with SUD in psychiatry was perceived as difficult, where collaboration between psychiatry and addiction care was often experienced as problematic. Based on these findings, we believe that the current gap between the psychiatry and addiction care could be reduced to some extent by offering patients digital treatment for SUD. In this way, patients could remain under the care of their regular psychiatric clinic without having to physically visit SUD services. Thus, a virtual bridge could be established to bring psychiatry and addiction care closer to each other for the patients’ benefit.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-021-00235-9.

A qualitative study of the perceived effects of alcohol on depressive symptoms among undergraduates who drink to cope with depression

INTRODUCTION AND AIMS

Heavy drinking is prevalent among undergraduate students and is linked with drinking to cope with depression motives for drinking. Drinking to cope with depression remains poorly understood given that alcohol has been shown to have adverse effects on mood when consumed at high doses. Using semi-structured qualitative interviews, the present study examined the perceived effects of alcohol on depressive symptoms as reported by undergraduate students who endorse high levels of drinking to cope with depression.

DESIGN AND METHODS

Sixteen undergraduate coping-with-depression-motivated (CWDM) drinkers (nine women, seven men), identified using the Modified Drinking Motives Questionnaire-Revised [1], reported on their experiences of drinking to cope with depression. Thematic analysis was conducted to identify themes and subthemes in the data.

RESULTS

Undergraduate students reported several effects of alcohol on affective, cognitive and behavioural depressive symptoms. While most of the perceived alcohol effects they described involved relief from depressive symptoms, some perceived effects involved worsening depressive symptoms.

DISCUSSION AND CONCLUSIONS

The study generated several hypotheses to explain drinking to cope with depression, some of which might be testable in future experimental work. Overall, findings suggest the mood-altering effects of alcohol do not fully explain why depression and alcohol use are frequently co-morbid. Indeed, effects of alcohol on cognitive and behavioural depressive symptoms might be particularly reinforcing for CWDM drinkers. Interventions that target co-morbid depression and alcohol use might be improved by teaching CWDM drinkers skills to reduce depressive cognitions and to improve interpersonal interactions outside of drinking contexts.

Pilot Randomized Trial of a Recovery Navigator Program for Survivors of Critical Illness With Problematic Alcohol Use

Many survivors of critical illness have problematic alcohol use, associated with risk of death and hospital readmission. We tested the feasibility, acceptability, treatment fidelity, and potential efficacy of a customized alcohol intervention for patients in ICUs. The intervention was delivered by a Recovery Navigator using principles of motivational interviewing and shared decision-making.

DESIGN

Pilot randomized trial.

SETTING

Two urban ICUs in Denver, CO.

PATIENTS

Patients with problematic alcohol use were enrolled prior to hospital discharge.

INTERVENTIONS

Patients were randomly assigned to usual care, single-session motivational interviewing and shared decision-making, or multisession motivational interviewing and shared decision-making.

MEASUREMENTS AND MAIN RESULTS

We assessed feasibility via enrollment and attrition, acceptability via patient satisfaction (Client Satisfaction Questionnaire-8), fidelity via observation and questionnaires, and potential efficacy via group means and CIs on measures of alcohol use, psychiatric symptoms, cognition, and other alcohol-related problems. Over 18 months, we offered the study to 111 patients, enrolled 47, and randomized 36; refusals were mainly due to stigma or patients' desire to handle problems on their own. Groups were similar at baseline, and 67% of patients met criteria for alcohol use disorder. Average patient satisfaction was high (mean = 28/32) regardless of group assignment. Sessions were delivered with 98% adherence to motivational interviewing principles and excellent motivational interviewing spirit; patients perceived the intervention to be more autonomy supportive than usual care. Group means after 6 months suggested that patients receiving the intervention might improve on measures such as alcohol use, psychiatric symptoms, legal problems, and days of paid work; however, they did not receive more substance use treatment. All results were nonsignificant due to small sample size.

CONCLUSIONS

A Recovery Navigator intervention was feasible and acceptable for delivering high-fidelity brief interventions to ICU patients. Changes in alcohol-related problems with motivational interviewing and shared decision-making were nonsignificant but clinically meaningful in size. A full-scale randomized trial of motivational interviewing and shared decision-making is warranted.

The Experience of Patients with Alcohol Misuse after Surviving a Critical Illness. A Qualitative Study

RATIONALE

Alcohol misuse is common in patients admitted to the intensive care unit (ICU), but there is currently no evidence-based approach to address drinking in ICU survivors.

OBJECTIVES

We sought to describe the experience of ICU survivors with alcohol misuse during their hospitalization and the 3 months after hospital discharge to inform an alcohol-specific intervention for this unique population.

METHODS

We conducted a descriptive qualitative study of ICU survivors from medical ICUs in three separate hospitals with a positive screening result on the Alcohol Use Disorders Identification Test. Semistructured interviews were conducted 3 months after hospital discharge of patients. Patients were also allowed to nominate up to two friends or family members for enrollment to provide additional perspective on the patient's experience.

RESULTS

We enrolled 50 patients and 22 of their friends and/or family members. The average APACHE II score was 23, 80% of patients were male, and the average age was 50 years; 70% of patients and 77% of friends/family members completed the semistructured interview 3 months after hospital discharge. We identified three domains that could inform an alcohol-specific intervention, each with multiple themes: motivation with complications (anxiety and depression, critical illness as a catalyst, delirium and cognitive impairment); therapeutic alliance (autonomy, failure and opportunities to build a therapeutic alliance); and the return to the home milieu (lack of screening for depression and anxiety, social network support for drinking, social isolation, social network support for abstinence, lack of available and affordable treatment, and negative experiences with Alcoholics Anonymous).

CONCLUSIONS

An alcohol intervention for ICU survivors would account for the context in which patients are making a decision about their drinking and optimize the patient-provider interaction. Contrary to current paradigms that focus on addressing alcohol consumption only during a hospitalization, an intervention for ICU survivors should continue as patients transition from the hospital to home.

Motivation to change and factors influencing motivation in alcohol dependence syndrome in a tertiary care hospital

CONTEXT

Motivation plays an important role in the treatment of alcohol dependence syndrome (ADS) by influencing the patient to seek and comply with treatment as well as make successful long term changes.

AIM

The aim of this study is to study the motivation for change in inpatients with ADS.

SETTINGS AND DESIGN

One hundred consecutive patients admitted for the treatment of ADS in a medical college hospital were evaluated.

MATERIALS AND METHODS

The International Classification of Disease 10^th Revision - AM symptom checklist for mental disorders screener and appropriate modules were used to establish ADS. The assessment of motivation was done using the University of Rhode Island Change Assessment scale at baseline and after 2 weeks of admission. The Severity of Alcohol Dependence Questionnaire and Kuppuswamy's scale for socioeconomic status were used.

STATISTICAL ANALYSIS

Paired and unpaired t-test, Fisher's exact test, and Wilcoxon signed-rank test were used to analyze data.

RESULTS

The assessment of motivation showed 60% of patients in precontemplation (PC) stage at baseline, compared to 34% of the patients in PC, 57% in contemplation, and 9% in action stage after 2 weeks of inpatient stay. A highly significant change was seen in the levels of motivation toward contemplation and action stage after 2 weeks of inpatient stay (Z = 5.745, P < 0.001). Motivation to change had a significant association with complications of alcohol use, medical comorbidity, onset and severity of alcohol dependence, socioeconomic status, religion, and mode of referral.

CONCLUSIONS

The study concludes that certain patients with ADS may have low pretreatment levels of motivation, with significant improvement in the motivation levels after a short duration of inpatient treatment.

Alcohol screening scores and the risk of intensive care unit admission and hospital readmission

BACKGROUND

The association between alcohol misuse and the need for intensive care unit admission as well as hospital readmission among those discharged from the hospital following a critical illness is unclear. This study sought to determine whether alcohol misuse was associated with (1) admission to an intensive care unit (ICU) among a cohort of patients receiving outpatient care and (2) hospital readmission among those discharged from the hospital following critical illness.

METHODS

This was a retrospective cohort study conducted with data from 24 Veterans Affairs (VA) health care facilities between 2004 and 2007. Scores on the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire were used to identify patients with past-year abstinence, lower-risk alcohol use, moderate alcohol misuse, or severe alcohol misuse. The primary outcome was admission to a VA intensive care unit within the year following administration of the AUDIT-C. In an analysis focused on patients discharged from the ICU, the 2 main outcomes were hospital readmission within 1 year and within 30 days.

RESULTS

Among 486,115 veterans receiving outpatient care, the adjusted probability of ICU admission within 1 year was 2.0% (95% confidence interval [CI]: 1.7%-2.3%) for abstinent patients, 1.6% (95% CI: 1.3%-1.8%) for patients with lower-risk alcohol use, 1.8% (1.4%-2.3%) for patients with moderate alcohol misuse, and 2.5% (2.0%-2.9%) for patients with severe alcohol misuse. Among the 9,030 patients discharged from an ICU, the adjusted probability of hospital readmission within 1 year was 48% (46%-49%) in abstinent patients, 44% (42%-45%) in patients with lower-risk alcohol use, 42% (39%-45%) in patients with moderate alcohol misuse, and 55% (49%-60%) in patients with severe alcohol misuse.

CONCLUSIONS

Alcohol misuse may represent a modifiable risk factor for a cycle of ICU admission and subsequent hospital readmission.

Health and social consequences of an alcohol-related admission to critical care: a qualitative study

OBJECTIVE

To examine the impact of critical care on future alcohol-related behaviour. Further, it aimed to explore patterns of recovery for patients with and without alcohol use disorders beyond the hospital environment.

DESIGN

In-depth, semistructured interviews with participants (patients) 3-7 months post intensive care discharge.

SETTING

The setting for this study was a 20-bedded mixed intensive care unit (ICU), in a large teaching hospital in Scotland. On admission, patients were allocated to one of the three alcohol groups: low risk, harmful/hazardous and alcohol dependency.

PARTICIPANTS

21 participants who received mechanical ventilation for greater than 3 days were interviewed between March 2013 and June 2014.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Four themes which impacted on recovery from ICU were identified in this patient group: psychological resilience, support for activities of daily living, social support and cohesion and the impact of alcohol use disorders on recovery. Participants also discussed the importance of personalised goal setting and appropriate and timely rehabilitation for alcohol-related behaviours during the critical care recovery period.

CONCLUSIONS

There is a significant interplay between alcohol misuse and recovery from critical illness. This study has demonstrated that at present, there is a haphazard approach to rehabilitation for patients after ICU. A more targeted rehabilitation pathway for patients leaving critical care, with specific emphasis on alcohol misuse if appropriate, requires to be generated.

Do alcohol use disorders impact on long term outcomes from intensive care?

Introduction

There is limited evidence regarding the impact of alcohol use disorders on long term outcomes from intensive care. The aims of this study were to analyse the nature and complications of alcohol related admissions to intensive care and determine whether alcohol use disorders impact on survival at six months post ICU discharge.

Method

This was an 18 month prospective observational cohort study in a 20 bedded mixed ICU, in a large teaching hospital in Scotland. On admission patients were allocated to one of three alcohol groups: low risk, harmful/hazardous, or alcohol dependency.

Results

34.4% of patients were admitted with an alcohol use disorder. Those with an alcohol related admission (either harmful/hazardous or alcohol dependent) had an increased odds of developing septic shock during their admission, compared with the low risk group (OR 1.67; 95% CI 1.13-2.47, p = 0.01). After adjustment for all lifestyle factors which were significantly different between the groups, alcohol dependence was associated with more than a twofold increased odds of ICU mortality (OR 2.28; 95% CI 1.2-4.69, p = 0.01) and hospital mortality (OR 2.43; 95% CI 1.28-4.621, p = 0.004). After adjustment for deprivation category and age, alcohol dependence was associated with an almost two fold increased odds of mortality at six months post ICU discharge (HR 1.86; CI 1.30-2.70, p = 0.001).

Conclusion

Alcohol use disorders are a significant risk factor for the development of septic shock in intensive care. Further, alcohol dependency is independently associated with poorer long term outcomes from intensive care.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0909-6) contains supplementary material, which is available to authorized users.