Which patients receive an addiction consult? A preliminary analysis of the INREACH (INpatient REadmission post-Addiction Consult Help) study

The addiction consultation service for hospitalized patients with substance use disorder: An integrative review of the evidence

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.

Medical Student Attitudes Toward Patients With Substance Use Disorder After Experiential Learning on an Addiction Psychiatry Consultation-Liaison Service: A Pilot Study

BACKGROUND

Stigma surrounding substance use disorder (SUD) is highly prevalent in health care. Negative attitudes toward patients with SUD have been shown to negatively impact patient care. Addressing SUD stigma in medical students is a promising approach, however, few curricula include experiential learning on addiction psychiatry clinical services. We describe a medical student rotation on an addiction psychiatry clinical service and examine its effect on attitudes toward patients with SUD.

METHODS

Medical students were integrated onto an addiction psychiatry consultation-liaison service serving medically/surgically hospitalized patients with co-occurring SUD and other psychiatric disorders. Students learned and practiced in-person assessment of patients and received instruction on basic principles of psychiatry and evaluation and management of SUD. A targeted anti-stigma curriculum was included. Attitudes toward patients with SUD were measured with the Medical Condition Regard Scale (MCRS) before and after the experience. Each item of the MCRS and an overall composite attitude score were analyzed.

RESULTS

Of the 36 students on the clinical rotation, 33 completed the survey. Attitudes showed widespread improvement toward patients with SUD. Mann-Whitney U tests showed significant improvement in most items of the MCRS. Further analysis of composite scores showed an improvement in overall attitudes toward patients with SUD.

CONCLUSIONS

Inclusion of medical students on an addiction psychiatry consult service as part of the core psychiatry clerkship may hold promise for helping improve student attitudes and decrease stigma toward patients with SUD. Controlled study is needed to compare other clinical experiences and determine specific causative effects.

Characteristics and co-morbidities associated with hospital discharges for opioid and methamphetamine co-use, United States 2016-2019

Introduction

The US overdose crisis is increasingly characterized by opioid and methamphetamine co-use. Hospitalization is an important opportunity to engage patients in substance use treatment. Understanding characteristics of co-use-related hospital stays can inform the development of services to better support this growing patient population.

Methods

We used 2016-2019 National Inpatient Sample data to conduct a cross sectional analysis of hospitalizations involving use of opioids, methamphetamine, or both. We used bivariate analysis to compare patient demographics. We then used multinomial logistic regressions to compare the proportion of hospital stays which indicated co-morbid diagnosis. To account for correlated data, we used generalized linear models to compare outcomes in hospital mortality, patient-directed discharge, and length of stay.

Results

Co-use-related stays had a higher proportion of co-morbid mental health (60.7%; 95% CI: 59.9-61.4%) and infectious diseases (41.5%; 95% CI: 40.8-42.2%), than opioid- or methamphetamine-related stays. Co-use-related stays increased between 2016 and 2019 and were associated with a higher proportion of patient directed discharge (10.7%; 95% CI: 10.4-11.0%) and longer length of stay (6.3 days; 95% CI: 6.2-6.4 days) compared to opioid (8.1%; 95% CI: 7.9-8.3% and 5.8 days; 95% CI: 5.8-5.9 days) and methamphetamine-related stays (6.5%; 95% CI: 6.3-6.6% and 5.5 days; 95% CI: 5.4-5.5 days).

Conclusion

Patients discharged with co-use differ from patients with opioid or methamphetamine use alone, representing a range of challenges and opportunities. In addition to offering treatment for both substance use disorders, hospital-based services that address co-occurring conditions may better support patients with co-use through targeted and tailored approaches.

Hospital Addiction Medicine Consultation Service Orders and Outcomes by Patient Race and Ethnicity in an Urban, Safety-Net Hospital

BACKGROUND

Hospital admissions involving substance use disorders are increasing and represent an opportunity to engage patients in substance use treatment. Addiction medicine consultation services improve access to medications for opioid use disorder (MOUD) and patient outcomes. However, as hospitals continue to adopt addiction medicine consultation services it is important to identify where disparities may emerge in the process of care.

OBJECTIVE

To describe addiction medicine consultation service use by race and ethnicity as well as substance to identify opportunities to reduce substance use treatment disparities.

DESIGN

Retrospective cohort study using 2016-2021 Electronic Health Record data from a large Midwest safety-net hospital.

PARTICIPANTS

Hospitalized adults aged 18 or older, with one or more substance use disorders.

MAIN MEASURES

Consultation orders placed, patient seen by consult provider, and receipt of MOUD by self-reported race.

KEY RESULTS

Between 2016 and 2021, we identified 16,895 hospitalized patients with a substance use disorder. Consultation orders were placed for 6344 patients and 2789 were seen by the consult provider. Black patients were less likely (aOR = 0.58; 95% CI: 0.53-0.63) to have an addiction medicine consultation order placed and, among patients with a consultation order, were less likely (aOR = 0.74; 95% CI: 0.65-0.85) to be seen by the consult provider than White patients. Overall, Black patients with OUD were also less likely to receive MOUD in the hospital (aOR = 0.63; 95% CI: 0.50-0.79) compared to White patients. However, there were no differences in MOUD receipt among Black and White patients seen by the consult provider.

CONCLUSIONS

Using Electronic Health Record data, we identified racial and ethnic disparities at multiple points in the inpatient addiction medicine consultation process. Addressing these disparities may support more equitable access to MOUD and other substance use treatment in the hospital setting.

A Taxonomy of Hospital-Based Addiction Care Models: a Scoping Review and Key Informant Interviews

BACKGROUND

There is pressing need to improve hospital-based addiction care. Various models for integrating substance use disorder care into hospital settings exist, but there is no framework for describing, selecting, or comparing models. We sought to fill that gap by constructing a taxonomy of hospital-based addiction care models based on scoping literature review and key informant interviews.

METHODS

Methods included a scoping review of the literature on US hospital-based addiction care models and interventions for adults, published between January 2000 and July 2021. We conducted semi-structured interviews with 15 key informants experienced in leading, implementing, evaluating, andpracticing hospital-based addiction care to explore model characteristics, including their perceived strengths, limitations, and implementation considerations. We synthesized findings from the literature review and interviews to construct a taxonomy of model types.

RESULTS

Searches identified 2,849 unique abstracts. Of these, we reviewed 280 full text articles, of which 76 were included in the final review. We added 8 references from reference lists and informant interviews, and 4 gray literature sources. We identified six distinct hospital-based addiction care models. Those classified as addiction consult models include (1) interprofessional addiction consult services, (2) psychiatry consult liaison services, and (3) individual consultant models. Those classified as practice-based models, wherein general hospital staff integrate addiction care into usual practice, include (4) hospital-based opioid treatment and (5) hospital-based alcohol treatment. The final type was (6) community-based in-reach, wherein community providers deliver care. Models vary in their target patient population, staffing, and core clinical and systems change activities. Limitations include that some models have overlapping characteristics and variable ways of delivering core components.

DISCUSSION

A taxonomy provides hospital clinicians and administrators, researchers, and policy-makers with a framework to describe, compare, and select models for implementing hospital-based addiction care and measure outcomes.

The Substance Use Treatment and Recovery Team (START) study: protocol for a multi-site randomized controlled trial evaluating an intervention to improve initiation of medication and linkage to post-discharge care for hospitalized patients with opioid use disorder

BACKGROUND

People with opioid use disorder experience high burden of disease from medical comorbidities and are increasingly hospitalized with medical complications. Medications for opioid use disorder are an effective, life-saving treatment, but patients with an opioid use disorder admitted to the hospital seldom initiate medication for their disorder while in the hospital, nor are they linked with outpatient treatment after discharge. The inpatient stay, when patients may be more receptive to improving their health and reducing substance use, offers an opportunity to discuss opioid use disorder and facilitate medication initiation and linkage to treatment after discharge. An addiction-focus consultative team that uses evidence-based tools and resources could address barriers, such as the need for the primary medical team to focus on the primary health problem and lack of time and expertise, that prevent primary medical teams from addressing substance use.

METHODS

This study is a pragmatic randomized controlled trial that will evaluate whether a consultative team, called the Substance Use Treatment and Recovery Team (START), increases initiation of any US Food and Drug Administration approved medication for opioid use disorder (buprenorphine, methadone, naltrexone) during the hospital stay and increases linkage to treatment after discharge compared to patients receiving usual care. The study is being conducted at three geographically distinct academic hospitals. Patients are randomly assigned within each hospital to receive the START intervention or usual care. Primary study outcomes are initiation of medication for opioid use disorder in the hospital and linkage to medication or other opioid use disorder treatment after discharge. Outcomes are assessed through participant interviews at baseline and 1 month after discharge and data from hospital and outpatient medical records.

DISCUSSION

The START intervention offers a compelling model to improve care for hospitalized patients with opioid use disorder. The study could also advance translational science by identifying an effective and generalizable approach to treating not only opioid use disorder, but also other substance use disorders and behavioral health conditions.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT05086796, Registered on 10/21/2021. https://www.

CLINICALTRIALS

gov/ct2/results?recrs=ab&cond=&term=NCT05086796&cntry=&state=&city=&dist  = .

Partnering With State Health Departments to Address Injection-Related Infections During the Opioid Epidemic: Experience at a Safety Net Hospital

Massachusetts is one of the epicenters of the opioid epidemic and has been severely impacted by injection-related viral and bacterial infections. A recent increase in newly diagnosed human immunodeficiency virus (HIV) infections among persons who inject drugs in the state highlights the urgent need to address and bridge the overlapping epidemics of opioid use disorder (OUD) and injection-related infections. Building on an established relationship between the Massachusetts Department of Public Health and Boston Medical Center, the Infectious Diseases section has contributed to the development and implementation of a cohesive response involving ambulatory, inpatient, emergency department, and community-based services. We describe this comprehensive approach including the rapid delivery of antimicrobials for the prevention and treatment of HIV, sexually transmitted diseases, systemic infections such as endocarditis, bone and joint infections, as well as curative therapy for chronic hepatitis C virus in a manner that is accessible to patients on the addiction-recovery continuum. We also provide an overview of programs that provide access to medications for OUD, harm reduction services including overdose education, and distribution of naloxone. Finally, we outline lessons learned to inform initiatives in other settings.

Preventing Hospital Readmission for Patients With Comorbid Substance Use Disorder : A Randomized Trial

BACKGROUND

Hospitalized patients with comorbid substance use disorders (SUDs) are at high risk for poor outcomes, including readmission and emergency department (ED) use.

OBJECTIVE

To determine whether patient navigation services reduce hospital readmissions.

DESIGN

Randomized controlled trial comparing Navigation Services to Avoid Rehospitalization (NavSTAR) versus treatment as usual (TAU). (ClinicalTrials.gov: NCT02599818).

SETTING

Urban academic hospital in Baltimore, Maryland, with an SUD consultation service.

PARTICIPANTS

400 hospitalized adults with comorbid SUD (opioid, cocaine, or alcohol).

INTERVENTION

NavSTAR used proactive case management, advocacy, service linkage, and motivational support to resolve internal and external barriers to care and address SUD, medical, and basic needs for 3 months after discharge.

MEASUREMENTS

Data on inpatient readmissions (primary outcome) and ED visits for 12 months were obtained for all participants via the regional health information exchange. Entry into SUD treatment, substance use, and related outcomes were assessed at 3-, 6-, and 12-month follow-up.

RESULTS

Participants had high levels of acute care use: 69% had an inpatient readmission and 79% visited the ED over the 12-month observation period. Event rates per 1000 person-days were 6.05 (NavSTAR) versus 8.13 (TAU) for inpatient admissions (hazard ratio, 0.74 [95% CI, 0.58 to 0.96]; P = 0.020) and 17.66 (NavSTAR) versus 27.85 (TAU) for ED visits (hazard ratio, 0.66 [CI, 0.49 to 0.89]; P = 0.006). Participants in the NavSTAR group were less likely to have an inpatient readmission within 30 days than those receiving TAU (15.5% vs. 30.0%; P < 0.001) and were more likely to enter community SUD treatment after discharge (P = 0.014; treatment entry within 3 months, 50.3% NavSTAR vs. 35.3% TAU).

LIMITATION

Single-site trial, which limits generalizability.

CONCLUSION

Patient navigation reduced inpatient readmissions and ED visits in this clinically challenging sample of hospitalized patients with comorbid SUDs.

PRIMARY FUNDING SOURCE

National Institute on Drug Abuse.

Refusal to accept emergency medical transport following opioid overdose, and conditions that may promote connections to care

BACKGROUND

Opioid overdose is a leading cause of death in the United States. Emergency medical services (EMS) encounters following overdose may serve as a critical linkage to care for people who use drugs (PWUD). However, many overdose survivors refuse EMS transport to hospitals, where they would presumably receive appropriate follow-up services and referrals. This study aims to (1) identify reasons for refusal of EMS transport after opioid overdose reversal; (2) identify conditions under which overdose survivors might be more likely to accept these services; and (3) describe solutions proposed by both PWUD and EMS providers to improve post-overdose care.

METHODS

The study comprised 20 semi-structured, qualitative in-depth interviews with PWUD, followed by two semi-structured focus groups with eight EMS providers.

RESULTS

PWUD cited intolerable withdrawal symptoms; anticipation of inadequate care upon arrival at the hospital; and stigmatizing treatment by EMS and hospital providers as main reasons for refusal to accept EMS transport. EMS providers corroborated these descriptions and offered solutions such as titration of naloxone to avoid harsh withdrawal symptoms; peer outreach or community paramedicine; and addressing provider burnout. PWUD stated they might accept EMS transport after overdose reversal if they were offered ease for withdrawal symptoms, at either a hospital or non-hospital facility, and treated with respect and empathy.

CONCLUSION

Standard of care by EMS and hospital providers following overdose reversal should include treatment for withdrawal symptoms, including buprenorphine induction; patient-centered communication; and effective linkage to prevention, treatment, and harm reduction services.

Inpatient addiction consultation and post-discharge 30-day acute care utilization

BACKGROUND

Addiction Consult Services care for hospitalized patients with substance use disorders (SUD), who frequently utilize costly medical services. This study evaluates whether an addiction consult is associated with 30-day acute care utilization.

METHODS

This was a retrospective cohort study of 3905 inpatients with SUD. Acute care utilization was defined as any emergency department visit or re-hospitalization within 30 days of discharge. Inverse probability of treatment weighted generalized estimating equations logistic regression models were used to evaluate the relationship between receipt of an addiction consult and 30-day acute care utilization. Exploratory subgroup analyses were performed to describe whether this association differed by type of SUD and discharge on medication for addiction treatment.

RESULTS

The 30-day acute care utilization rate was 39.5 % among patients with a consult and 36.0 % among those without. Addiction consults were not significantly associated with care utilization (Adjusted Odds Ratio 1.02; 0.82, 1.28). No significant differences were detected in subgroup analyses; however, the decreased odds among patients with OUD given medication was clinically notable (AOR 0.69; 0.47, 1.02).

DISCUSSION

Repeat acute care utilization is common among hospitalized patients with SUD, particularly those seen by the addiction consult services. While this study did not detect a significant association between addiction consults and 30-day acute care utilization, this relationship merits further evaluation using prospective studies, controlling for key confounders and with a focus on the impact of medications for opioid use disorder.