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McNeely J, Wang SS, Rostam Abadi Y, Barron C, Billings J, Tarpey T, Fernando J, Appleton N, Fawole A, Mazumdar M, Weinstein ZM, Kalyanaraman Marcello R, Dolle J, Cooke C, Siddiqui S, King C. Addiction Consultation Services for Opioid Use Disorder Treatment Initiation and Engagement: A Randomized Clinical Trial. JAMA Intern Med 2024; 184:1106-1115. [PMID: 39073796 PMCID: PMC11287446 DOI: 10.1001/jamainternmed.2024.3422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 05/29/2024] [Indexed: 07/30/2024]
Abstract
Importance Medications for opioid use disorder (MOUD) are highly effective, but only 22% of individuals in the US with opioid use disorder receive them. Hospitalization potentially provides an opportunity to initiate MOUD and link patients to ongoing treatment. Objective To study the effectiveness of interprofessional hospital addiction consultation services in increasing MOUD treatment initiation and engagement. Design, Setting, and Participants This pragmatic stepped-wedge cluster randomized implementation and effectiveness (hybrid type 1) trial was conducted in 6 public hospitals in New York, New York, and included 2315 adults with hospitalizations identified in Medicaid claims data between October 2017 and January 2021. Data analysis was conducted in December 2023. Hospitals were randomized to an intervention start date, and outcomes were compared during treatment as usual (TAU) and intervention conditions. Bayesian analysis accounted for the clustering of patients within hospitals and open cohort nature of the study. The addiction consultation service intervention was compared with TAU using posterior probabilities of model parameters from hierarchical logistic regression models that were adjusted for age, sex, and study period. Eligible participants had an admission or discharge diagnosis of opioid use disorder or opioid poisoning/adverse effects, were hospitalized at least 1 night in a medical/surgical inpatient unit, and were not receiving MOUD before hospitalization. Interventions Hospitals implemented an addiction consultation service that provided inpatient specialty care for substance use disorders. Consultation teams comprised a medical clinician, social worker or addiction counselor, and peer counselor. Main Outcomes and Measures The dual primary outcomes were (1) MOUD treatment initiation during the first 14 days after hospital discharge and (2) MOUD engagement for the 30 days following initiation. Results Of 2315 adults, 628 (27.1%) were female, and the mean (SD) age was 47.0 (12.4) years. Initiation of MOUD was 11.0% in the Consult for Addiction Treatment and Care in Hospitals (CATCH) program vs 6.7% in TAU, engagement was 7.4% vs 5.3%, respectively, and continuation for 6 months was 3.2% vs 2.4%. Patients hospitalized during CATCH had 7.96 times higher odds of initiating MOUD (log-odds ratio, 2.07; 95% credible interval, 0.51-4.00) and 6.90 times higher odds of MOUD engagement (log-odds ratio, 1.93; 95% credible interval, 0.09-4.18). Conclusions This randomized clinical trial found that interprofessional addiction consultation services significantly increased postdischarge MOUD initiation and engagement among patients with opioid use disorder. However, the observed rates of MOUD initiation and engagement were still low; further efforts are still needed to improve hospital-based and community-based services for MOUD treatment. Trial Registration ClinicalTrials.gov Identifier: NCT03611335.
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Affiliation(s)
- Jennifer McNeely
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Scarlett S. Wang
- New York University Robert F. Wagner Graduate School of Public Service, New York
| | - Yasna Rostam Abadi
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Charles Barron
- Office of Behavioral Health, New York City Health + Hospitals, New York, New York
| | - John Billings
- New York University Robert F. Wagner Graduate School of Public Service, New York
| | - Thaddeus Tarpey
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Jasmine Fernando
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Noa Appleton
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Adetayo Fawole
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Medha Mazumdar
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Zoe M. Weinstein
- Department of Medicine, Boston University Chobanian and Avedesian School of Medicine, Boston Medical Center, Boston, Massachusetts
| | | | - Johanna Dolle
- Office of Population Health, New York City Health + Hospitals, New York, New York
| | - Caroline Cooke
- Office of Population Health, New York City Health + Hospitals, New York, New York
| | - Samira Siddiqui
- Office of Behavioral Health, New York City Health + Hospitals, New York, New York
| | - Carla King
- Department of Population Health, New York University Grossman School of Medicine, New York
- Office of Behavioral Health, New York City Health + Hospitals, New York, New York
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Piland R, Jenkins RJ, Darwish D, Kram B, Karamchandani K. Substance-Use Disorders in Critically Ill Patients: A Narrative Review. Anesth Analg 2024:00000539-990000000-00898. [PMID: 39116017 DOI: 10.1213/ane.0000000000007078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
Substance-use disorders (SUDs) represent a major public health concern. The increased prevalence of SUDs within the general population has led to more patients with SUD being admitted to intensive care units (ICUs) for an SUD-related condition or with SUD as a relevant comorbidity. Multiprofessional providers of critical care should be familiar with these disorders and their impact on critical illness. Management of critically ill patients with SUDs is complicated by both acute exposures leading to intoxication, the associated withdrawal syndrome(s), and the physiologic changes associated with chronic use that can cause, predispose patients to, and worsen the severity of other medical conditions. This article reviews the epidemiology of substance use in critically ill patients, discusses the identification and treatment of common intoxication and withdrawal syndromes, and provides evidence-based recommendations for the management of patients exposed to chronic use.
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Affiliation(s)
- Rebecca Piland
- From the Division of Critical Care, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Russell Jack Jenkins
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Dana Darwish
- From the Division of Critical Care, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bridgette Kram
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina
| | - Kunal Karamchandani
- From the Division of Critical Care, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
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Shearer RD, Hernandez E, Beebe TJ, Virnig BA, Bart G, Winkelman TNA, Bazzi AR, Shippee ND. Providers' Experiences and Perspectives in Treating Patients With Co-Occurring Opioid and Stimulant Use Disorders in the Hospital. SUBSTANCE USE & ADDICTION JOURNAL 2024; 45:250-259. [PMID: 38258816 PMCID: PMC11151687 DOI: 10.1177/29767342231221060] [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] [Indexed: 01/24/2024]
Abstract
BACKGROUND The overdose crisis is increasingly characterized by opioid and stimulant co-use. Despite effective pharmacologic treatment for both opioid use disorder (OUD) and contingency management for stimulant use disorders, most individuals with these co-occurring conditions are not engaged in treatment. Hospitalization is an important opportunity to engage patients and initiate treatment, however existing hospital addiction care is not tailored for patients with co-use and may not meet the needs of this population. METHODS Semi-structured interviews were conducted with hospital providers about their experiences and perspectives treating patients with opioid and stimulant co-use. We used directed content analysis to identify common experiences and opportunities to improve hospital-based treatment for patients with co-use. RESULTS From qualitative interviews with 20 providers, we identified 4 themes describing how co-use complicated hospital-based substance use treatment: (1) patients' unstable circumstances impacting the treatment plan, (2) co-occurring withdrawals are difficult to identify and treat, (3) providers holding more stigmatizing views of patients with co-use, and (4) stimulant use is often "ignored" in the treatment plans. Participants also described a range of potential opportunities to improve hospital-based treatment of co-use that fall into 3 categories: (1) provider practice changes, (2) healthcare system changes, and (3) development and validation of clinical tools and treatment approaches. CONCLUSIONS We identified unique challenges providing hospital addiction medicine care to patients who use both opioids and stimulants. These findings inform the development, implementation, and testing of hospital-based interventions for patients with co-use.
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Affiliation(s)
- Riley D Shearer
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
- Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Edith Hernandez
- Department of Pharmacology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Timothy J Beebe
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Beth A Virnig
- College of Public Health and Health Professions, University of Florida, Gainsville, FL, USA
| | - Gavin Bart
- Division of Addiction Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Tyler N A Winkelman
- Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
- Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Angela R Bazzi
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
| | - Nathan D Shippee
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
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Liu P, Korthuis PT, Buchheit BM. Novel Therapeutic and Program-Based Approaches to Opioid Use Disorders. Annu Rev Med 2024; 75:83-97. [PMID: 37827194 DOI: 10.1146/annurev-med-050522-033924] [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: 10/14/2023]
Abstract
Opioid use disorder continues to drive overdose deaths in many countries, including the United States. Illicit fentanyl and its analogues have emerged as key contributors to the complications and mortality associated with opioid use disorder. Medications for opioid use disorder treatment, such as methadone and buprenorphine, are safe and substantially reduce opioid use, infectious complications, and mortality risk, but remain underutilized. Polysubstance use and emerging substances such as xylazine and designer benzodiazepines create additional treatment challenges. Recent clinical and policy innovations in treatment delivery, including telemedicine, bridge clinics, and expanded models for accessing methadone have the potential to increase access to life-saving care for people living with opioid use disorder.
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Affiliation(s)
- Patricia Liu
- Section of Addiction, Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA;
| | - P Todd Korthuis
- Section of Addiction, Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA;
- Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon, USA
| | - Bradley M Buchheit
- Section of Addiction, Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA;
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, USA
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Hochstatter KR, Nordeck C, Mitchell SG, Schwartz RP, Welsh C, Gryczynski J. Polysubstance use and post-discharge mortality risk among hospitalized patients with opioid use disorder. Prev Med Rep 2023; 36:102494. [PMID: 38116282 PMCID: PMC10728463 DOI: 10.1016/j.pmedr.2023.102494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 12/21/2023] Open
Abstract
Polysubstance use is becoming increasingly common and presents several harms. This study aimed to examine the association of comorbid cocaine, alcohol (binge drinking), and sedative use with mortality among hospitalized patients with opioid use disorder (OUD). A subsample of adult medical/surgical hospital patients with OUD who were seen by a hospital addiction consultation service in Baltimore City and enrolled in a randomized trial of a patient navigation intervention were included in this study (N = 314; 45 % female; 48 % White; mean age = 44). Death certificate data from the Maryland Division of Vital Records was used, covering 3.3-5.5 years post-discharge. Multivariable proportional hazards Cox regression and competing risks regression were used to estimate all-cause mortality and overdose mortality, respectively, as a function of concurrent use of cocaine, alcohol (binge drinking), and non-prescribed sedatives at baseline. In the 30 days prior to hospital admission, 230 (73 %) participants used cocaine, 64 (20 %) binge drank, and 45 (14 %) used non-prescribed sedatives. Nearly one-third (N = 98; 31 %) died during the observation period. Drug overdose caused 53 % (N = 52) of deaths. Older age (HR = 1.03 [1.01,1.05]; P = 0.001), less than high school education (HR = 0.36 [0.24,0.54]; P < 0.001), and past 30-day sedative use (HR = 2.05 [1.20,3.50]; P = 0.008) were significantly associated with all-cause mortality. The risk of overdose mortality was 62 % lower (HR = 0.38 [0.22,0.66]; P = 0.001) for those who completed high school. No other characteristics were significantly associated with overdose mortality. The concurrent use of opioids and sedatives increases the post-discharge mortality risk among hospitalized patients with OUD. Interventions are needed to prevent mortality among this high-risk population.
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Steel TL, Bhatraju EP, Hills-Dunlap K. Critical care for patients with substance use disorders. Curr Opin Crit Care 2023; 29:484-492. [PMID: 37641506 DOI: 10.1097/mcc.0000000000001080] [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: 08/31/2023]
Abstract
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.
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Affiliation(s)
- Tessa L Steel
- Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine
| | - Elenore P Bhatraju
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Kelsey Hills-Dunlap
- University of Colorado Anschutz Medical Campus, Division of Pulmonary Sciences & Critical Care, Department of Medicine, University of Colorado, Aurora, Colorado, USA
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Edelman EJ, Rojas-Perez OF, Nich C, Corvino J, Frankforter T, Gordon D, Jordan A, Paris M, Weimer MB, Yates BT, Williams EC, Kiluk BD. Promoting alcohol treatment engagement post-hospitalization with brief intervention, medications and CBT4CBT: protocol for a randomized clinical trial in a diverse patient population. Addict Sci Clin Pract 2023; 18:55. [PMID: 37726823 PMCID: PMC10510167 DOI: 10.1186/s13722-023-00407-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 08/15/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Alcohol use disorder (AUD) commonly causes hospitalization, particularly for individuals disproportionately impacted by structural racism and other forms of marginalization. The optimal approach for engaging hospitalized patients with AUD in treatment post-hospital discharge is unknown. We describe the rationale, aims, and protocol for Project ENHANCE (ENhancing Hospital-initiated Alcohol TreatmeNt to InCrease Engagement), a clinical trial testing increasingly intensive approaches using a hybrid type 1 effectiveness-implementation approach. METHODS We are randomizing English and/or Spanish-speaking individuals with untreated AUD (n = 450) from a large, urban, academic hospital in New Haven, CT to: (1) Brief Negotiation Interview (with referral and telephone booster) alone (BNI), (2) BNI plus facilitated initiation of medications for alcohol use disorder (BNI + MAUD), or (3) BNI + MAUD + initiation of computer-based training for cognitive behavioral therapy (CBT4CBT, BNI + MAUD + CBT4CBT). Interventions are delivered by Health Promotion Advocates. The primary outcome is AUD treatment engagement 34 days post-hospital discharge. Secondary outcomes include AUD treatment engagement 90 days post-discharge and changes in self-reported alcohol use and phosphatidylethanol. Exploratory outcomes include health care utilization. We will explore whether the effectiveness of the interventions on AUD treatment engagement and alcohol use outcomes differ across and within racialized and ethnic groups, consistent with disproportionate impacts of AUD. Lastly, we will conduct an implementation-focused process evaluation, including individual-level collection and statistical comparisons between the three conditions of costs to providers and to patients, cost-effectiveness indices (effectiveness/cost ratios), and cost-benefit indices (benefit/cost ratios, net benefit [benefits minus costs). Graphs of individual- and group-level effectiveness x cost, and benefits x costs, will portray relationships between costs and effectiveness and between costs and benefits for the three conditions, in a manner that community representatives also should be able to understand and use. CONCLUSIONS Project ENHANCE is expected to generate novel findings to inform future hospital-based efforts to promote AUD treatment engagement among diverse patient populations, including those most impacted by AUD. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT05338151.
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Affiliation(s)
- E Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, 367 Cedar Street, ES Harkness Memorial Hall, Suite 401, New Haven, CT, 06510, USA.
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, USA.
- Department of Social and Behavioral Sciences, Yale School of Medicine, New Haven, CT, USA.
| | | | - Charla Nich
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Joanne Corvino
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Tami Frankforter
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Derrick Gordon
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- The Consultation Center, New Haven, CT, USA
| | - Ayana Jordan
- Department of Psychiatry, NYU Langone Health, New York, NY, USA
| | - Manuel Paris
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Hispanic Clinic, Connecticut Mental Health Center, New Haven, CT, USA
| | - Melissa B Weimer
- Department of Internal Medicine, Yale School of Medicine, 367 Cedar Street, ES Harkness Memorial Hall, Suite 401, New Haven, CT, 06510, USA
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - Brian T Yates
- Department of Psychology, American University, Washington, DC, USA
| | - Emily C Williams
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
- Health Services Research and Development Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Health Administration (VA), Seattle, WA, USA
| | - Brian D Kiluk
- Yale Program in Addiction Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
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Muller M, Weyer G, Zakrison T, Ari M. Impact of an opioid use disorder consult service on hospitalized trauma patients with opioid use disorder. J Trauma Acute Care Surg 2023; 95:226-233. [PMID: 36914601 DOI: 10.1097/ta.0000000000003965] [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: 03/16/2023]
Abstract
BACKGROUND Opioid use disorder (OUD) is common in the hospitalized trauma population, being a comorbid diagnosis in approximately 1% of operative trauma cases. The impact of an addiction consult service in this population has been less well studied but may lead to increased provision of evidence-based OUD treatment and improved postdischarge outcomes. METHODS One hundred thirteen patients with an International Classification of Diseases diagnosis of OUD who were admitted to the trauma service at a single academic hospital between January 2020 to December 2021 were included in a retrospective chart review. Wilcoxon rank-sum tests were used to evaluate differences between patients who received an OUD consult and those who did not. Regression analysis was used to assess differences in postdischarge acute care utilization, attendance of follow-up appointments, initiation of and discharge on medication for opioid use disorder (MOUD), naloxone prescribing at discharge, and length of stay (LOS) between the consult and no-consult groups. RESULTS Eighty-one patients in the study population received a consult and 32 did not. Patients in the consult group were more likely to have started MOUD during their admission (odds ratio [OR], 2.09; p < 0.001), be discharged with naloxone (OR, 1.89; p < 0.001), have a plan in place for continued OUD treatment at discharge (OR, 1.43; p < 0.001), and attend scheduled follow-up appointments with the trauma team (OR, 1.76; p = 0.02). Differences in acute care utilization and LOS between the two groups were not statistically significant. CONCLUSION An OUD consult service can provide benefit to hospitalized trauma patients by increasing likelihood of starting MOUD, of discharging with MOUD and naloxone, and of attending trauma follow-up appointments without increasing LOS or acute care utilization. Thus, addiction consult service interventions during hospital admissions for trauma may serve to facilitate both evidence-based OUD care and posthospitalization trauma care. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Megan Muller
- From the Pritzker School of Medicine (M.M.), Department of Medicine (G.W., M.A.), and Department of Surgery (T.Z.), The University of Chicago, Chicago, Illinois
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Chang JE, Franz B, Pagán JA, Lindenfeld Z, Cronin CE. Substance Use Disorder Program Availability in Safety-Net and Non-Safety-Net Hospitals in the US. JAMA Netw Open 2023; 6:e2331243. [PMID: 37639270 PMCID: PMC10463097 DOI: 10.1001/jamanetworkopen.2023.31243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 07/23/2023] [Indexed: 08/29/2023] Open
Abstract
Importance Safety-net hospitals (SNHs) are ideal sites to deliver addiction treatment to patients with substance use disorders (SUDs), but the availability of these services within SNHs nationwide remains unknown. Objective To examine differences in the delivery of different SUD programs in SNHs vs non-SNHs across the US and to determine whether these differences are increased in certain types of SNHs depending on ownership. Design, Setting, and Participants This cross-sectional analysis used data from the 2021 American Hospital Association Annual Survey of Hospitals to examine the associations of safety-net status and ownership with the availability of SUD services at acute care hospitals in the US. Data analysis was performed from January to March 2022. Main Outcomes and Measures This study used 2 survey questions from the American Hospital Association survey to determine the delivery of 5 hospital-based SUD services: screening, consultation, inpatient treatment services, outpatient treatment services, and medications for opioid use disorder (MOUD). Results A total of 2846 hospitals were included: 409 were SNHs and 2437 were non-SNHs. The lowest proportion of hospitals reported offering inpatient treatment services (791 hospitals [27%]), followed by MOUD (1055 hospitals [37%]), and outpatient treatment services (1087 hospitals [38%]). The majority of hospitals reported offering consultation (1704 hospitals [60%]) and screening (2240 hospitals [79%]). In multivariable models, SNHs were significantly less likely to offer SUD services across all 5 categories of services (screening odds ratio [OR], 0.62 [95% CI, 0.48-0.76]; consultation OR, 0.62 [95% CI, 0.47-0.83]; inpatient services OR, 0.73 [95% CI, 0.55-0.97]; outpatient services OR, 0.76 [95% CI, 0.59-0.99]; MOUD OR, 0.6 [95% CI, 0.46-0.78]). With the exception of MOUD, public or for-profit SNHs did not differ significantly from their non-SNH counterparts. However, nonprofit SNHs were significantly less likely to offer all 5 SUD services compared with their non-SNH counterparts (screening OR, 0.52 [95% CI, 0.41-0.66]; consultation OR, 0.56 [95% CI, 0.44-0.73]; inpatient services OR, 0.45 [95% CI, 0.33-0.61]; outpatient services OR, 0.58 [95% CI, 0.44-0.76]; MOUD OR, 0.61 [95% CI, 0.46-0.79]). Conclusions and Relevance In this cross-sectional study of SNHs and non-SNHs, SNHs had significantly lower odds of offering the full range of SUD services. These findings add to a growing body of research suggesting that SNHs may face additional barriers to offering SUD programs. Further research is needed to understand these barriers and to identify strategies that support the adoption of evidence-based SUD programs in SNH settings.
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Affiliation(s)
- Ji E. Chang
- Department of Public Health Policy and Management, School of Global Public Health, New York University, New York, New York
| | - Berkeley Franz
- Heritage College of Osteopathic Medicine, Ohio University, Athens
| | - José A. Pagán
- Department of Public Health Policy and Management, School of Global Public Health, New York University, New York, New York
| | - Zoe Lindenfeld
- Department of Public Health Policy and Management, School of Global Public Health, New York University, New York, New York
| | - Cory E. Cronin
- College of Health Sciences and Professions, Ohio University, Athens
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Ober AJ, Osilla KC, Klein DJ, Burgette LF, Leamon I, Mazer MW, Messineo G, Collier S, Korouri S, Watkins KE, Ishak W, Nuckols T, Danovitch I. Pilot randomized controlled trial of a hospital-based substance use treatment and recovery team (START) to improve initiation of medication for alcohol or opioid use disorder and linkage to follow-up care. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 150:209063. [PMID: 37156424 PMCID: PMC10330512 DOI: 10.1016/j.josat.2023.209063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 12/06/2022] [Accepted: 05/01/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVES We conducted a pilot randomized controlled trial (RCT) to explore whether a hospital inpatient addiction consult team (Substance Use Treatment and Recovery Team [START]) based on collaborative care was feasible, acceptable to patients, and whether it could improve uptake of medication in the hospital and linkage to care after discharge, as well as reduce substance use and hospital readmission. The START consisted of an addiction medicine specialist and care manager who implemented a motivational and discharge planning intervention. METHODS We randomized inpatients age ≥ 18 with a probable alcohol or opioid use disorder to receive START or usual care. We assessed feasibility and acceptability of START and the RCT, and we conducted an intent-to-treat analysis on data from the electronic medical record and patient interviews at baseline and 1-month postdischarge. The study compared RCT outcomes (medication for alcohol or opioid use disorder, linkage to follow-up care after discharge, substance use, hospital readmission) between arms by fitting logistic and linear regression models. FINDINGS Of 38 START patients, 97 % met with the addiction medicine specialist and care manager; 89 % received ≥8 of 10 intervention components. All patients receiving START found it to be somewhat or very acceptable. START patients had higher odds of initiating medication during the inpatient stay (OR 6.26, 95 % CI = 2.38-16.48, p < .001) and being linked to follow-up care (OR 5.76, 95 % CI = 1.86-17.86, p < .01) compared to usual care patients (N = 50). The study found no significant differences between groups in drinking or opioid use; patients in both groups reported using fewer substances at the 1-month follow-up. CONCLUSIONS Pilot data suggest START and RCT implementation are feasible and acceptable and that START may facilitate medication initiation and linkage to follow-up for inpatients with an alcohol or opioid use disorder. A larger trial should assess effectiveness, covariates, and moderators of intervention effects.
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Affiliation(s)
- Allison J Ober
- RAND Corporation, Santa Monica, CA, United States of America.
| | - Karen C Osilla
- Stanford University School of Medicine, Palo Alto, CA, United States of America
| | - David J Klein
- RAND Corporation, Santa Monica, CA, United States of America
| | - Lane F Burgette
- RAND Corporation, Santa Monica, CA, United States of America
| | - Isabel Leamon
- RAND Corporation, Santa Monica, CA, United States of America
| | - Mia W Mazer
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | | | - Stacy Collier
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Samuel Korouri
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | | | - Waguih Ishak
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Teryl Nuckols
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Itai Danovitch
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
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Englander H. Reply to: "Co-use of Methamphetamine Is Associated With Lower Rates of Linkage to Outpatient Treatment for Hospitalized Patients Who Initiate Buprenorphine". J Addict Med 2023; 17:492-493. [PMID: 37579120 DOI: 10.1097/adm.0000000000001130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Honora Englander
- Section of Addiction Medicine in Division of General Internal Medicine and Geriatrics, Department of Medicine, Oregon Health and Science University, Portland, OR; and Division of Hospital Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR
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12
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Addiction Services for Veterans: Opportunities in Acute Care. J Addict Med 2023; 17:42-46. [PMID: 35914119 DOI: 10.1097/adm.0000000000001026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This study aimed to estimate the proportion of total hospital discharges that involved a primary or secondary substance-related diagnosis code (SubDx) on inpatient medicine, psychiatry, and surgery services as part of a needs assessment for inpatient addiction consultation at our large, academic-affiliated Veterans Affairs (VA) hospital. METHODS We first calculated the percentage of total and service-specific discharges with a primary or secondary substance-related International Classification of Disease, Tenth Revision , code on all inpatient services (medicine, psychiatry, and surgery) in Fiscal Year 2017, 2018, and 2019, using facility-level data. Second, we calculated the proportion of total discharges that involved alcohol- and opioid-related diagnoses. RESULTS Over the 3 years studied, 29% of total discharges had a SubDx (4469 of 15,575). The proportion of total discharges that involved a SubDx was 23% (1246 of 5449) in 2017, 31% (1664 of 5332) in 2018, and 33% in 2019 (1559 of 4794), a statistically significant increase ( P < 0.001). As a percentage of service-specific discharges, 65% of discharges from psychiatry (1446 of 2217) had a SubDx, compared with 25% from medicine (2469 of 9713), and 15% from surgery (554 of 3645). Medicine services had the most discharges with SubDx, with a year-over-year increase in the number of discharges with SubDx. The percentage of total discharges that involved alcohol- and opioid-related diagnoses was 14% and 4%, respectively. CONCLUSIONS Substance-related diagnoses are prevalent at our hospital and are increasing over time. The largest number of discharges with SubDx was found on medicine services. Alcohol-related diagnoses were nearly 4 times more prevalent than opioid-related diagnoses. We found focused need around alcohol use and alcohol withdrawal.
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King CA, Cook R, Korthuis PT, McCarty D, Morris CD, Englander H. Expanding Inpatient Addiction Consult Services Through Accountable Care Organizations for Medicaid Enrollees: A Modeling Study. J Addict Med 2022; 16:570-576. [PMID: 35135988 PMCID: PMC9357852 DOI: 10.1097/adm.0000000000000972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Addiction consult services (ACS) care for hospitalized patients with substance use disorder, including opioid use disorder (OUD). Medicaid Accountable Care Organizations (ACOs) could enhance access to ACS. This study extends data from Oregon's only ACS to Oregon's 15 regional Medicaid Coordinated Care Organizations (CCOs) to illustrate the potential value of enhanced in- and out-patient care for hospitalized patients with OUD. The study objectives were to estimate the effects of (1) expanding ACS care through CCOs in Oregon, and (2) increasing community treatment access within CCOs, on post-discharge OUD treatment engagement. METHODS We used a validated Markov model, populated with Oregon Medicaid data from April 2015 to December 2017, to estimate study objectives. RESULTS Oregon Medicaid patients hospitalized with OUD with care billed to a CCO (n = 5878) included 1298 (22.1%) patients engaged in post-discharge OUD treatment. Simulation of referral to an ACS increased post-discharge OUD treatment engagement to 47.0% (95% confidence interval [CI] 45.7%, 48.3%), or 2684 patients (95% CI 2610, 2758). Ten of fifteen (66.7%) CCOs had fewer than 20% of patients engage in post-discharge OUD care. Without ACS, increasing outpatient treatment such that 20% of patients engage increased the patients engaging in post-discharge OUD care from 12.9% or 296 patients in care at baseline to 20% (95% CI 18.1%, 21.4%) or 453 (95% CI 416, 491). DISCUSSION ACOs can improve care for patients hospitalized with OUD. Implementing ACS in ACO networks can potentially improve post-discharge OUD treatment engagement, but community treatment systems must be prepared to accept more patients as inpatient addiction care improves.
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Affiliation(s)
- Caroline A King
- From the Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR (CAK); Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR (RC, PTK, HE); School of Public Health, Oregon Health & Science University - Portland State University, Portland, OR (DM); Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR (CDM); Department of Medicine, Division of Hospital Medicine, Oregon Health & Science University, Portland, OR (HE)
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Englander H, Jones A, Krawczyk N, Patten A, Roberts T, Korthuis PT, McNeely J. A Taxonomy of Hospital-Based Addiction Care Models: a Scoping Review and Key Informant Interviews. J Gen Intern Med 2022; 37:2821-2833. [PMID: 35534663 PMCID: PMC9411356 DOI: 10.1007/s11606-022-07618-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/12/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND There is pressing need to improve hospital-based addiction care. Various models for integrating substance use disorder care into hospital settings exist, but there is no framework for describing, selecting, or comparing models. We sought to fill that gap by constructing a taxonomy of hospital-based addiction care models based on scoping literature review and key informant interviews. METHODS Methods included a scoping review of the literature on US hospital-based addiction care models and interventions for adults, published between January 2000 and July 2021. We conducted semi-structured interviews with 15 key informants experienced in leading, implementing, evaluating, andpracticing hospital-based addiction care to explore model characteristics, including their perceived strengths, limitations, and implementation considerations. We synthesized findings from the literature review and interviews to construct a taxonomy of model types. RESULTS Searches identified 2,849 unique abstracts. Of these, we reviewed 280 full text articles, of which 76 were included in the final review. We added 8 references from reference lists and informant interviews, and 4 gray literature sources. We identified six distinct hospital-based addiction care models. Those classified as addiction consult models include (1) interprofessional addiction consult services, (2) psychiatry consult liaison services, and (3) individual consultant models. Those classified as practice-based models, wherein general hospital staff integrate addiction care into usual practice, include (4) hospital-based opioid treatment and (5) hospital-based alcohol treatment. The final type was (6) community-based in-reach, wherein community providers deliver care. Models vary in their target patient population, staffing, and core clinical and systems change activities. Limitations include that some models have overlapping characteristics and variable ways of delivering core components. DISCUSSION A taxonomy provides hospital clinicians and administrators, researchers, and policy-makers with a framework to describe, compare, and select models for implementing hospital-based addiction care and measure outcomes.
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Affiliation(s)
- Honora Englander
- Section of Addiction Medicine in Division of General Internal Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
- Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Amy Jones
- School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Noa Krawczyk
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Alisa Patten
- Section of Addiction Medicine in Division of General Internal Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Timothy Roberts
- NYU Health Sciences Library, New York University Grossman School of Medicine, New York, NY, USA
| | - P Todd Korthuis
- Section of Addiction Medicine in Division of General Internal Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jennifer McNeely
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
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King C, Cook R, Korthuis PT, Morris CD, Englander H. Causes of Death in the 12 Months After Hospital Discharge Among Patients With Opioid Use Disorder. J Addict Med 2022; 16:466-469. [PMID: 34510087 PMCID: PMC8907339 DOI: 10.1097/adm.0000000000000915] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Patients with substance use disorders are seven times more likely hospitalized than the general population. However, causes of death for recently hospitalized patients with Opioid Use Disorder (OUD) are not well described. This study describes causes of death in the year post-discharge among hospitalized patients with OUD. METHODS We analyzed data from participants who were at least 18 years old, with Medicaid insurance, and had a diagnosis of OUD during a general hospital admission in Oregon between April 2015 and December 2017. RESULTS During the study window, 6,654 Oregon Medicaid patients with an OUD diagnosis were hospitalized. Patients were predominately female (56.7%) and White (72.2%), an average age of 44.2 years (SD = 15.4 years) and average hospital length of stay of 6.5 days (SD = 10.9 days). In the 12 months post-discharge, 522 patients died (7.8%); 301 patients from a drug or substance related cause (4.5%), including 71 from drug overdose (1.1%). Stated another way, of those who died within 12 months, 58% of deaths were attributed to drug-related causes, including 13.6% of deaths attributed to overdose; 42% died of non-drug related causes. Drug-related death was the most frequent cause of mortality. CONCLUSIONS Hospitalized patients with OUD are at high risk of death, from drug and non-drug related causes, in the year after discharge. Future research should consider not only overdose, but a more comprehensive definition of drug-related death in understanding post-discharge mortality among hospitalized patients with OUD, and care systems should work to mitigate the risk of death in this population.
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Affiliation(s)
- Caroline King
- Dept. of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR
- Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR
| | - Ryan Cook
- Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR
| | - P. Todd Korthuis
- Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR
| | - Cynthia D. Morris
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR
| | - Honora Englander
- Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR
- Department of Medicine, Division of Hospital Medicine, Oregon Health & Science University, Portland, OR
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Diagnosis and Management of Infective Endocarditis in People Who Inject Drugs: JACC State-of-the-Art Review. J Am Coll Cardiol 2022; 79:2037-2057. [PMID: 35589166 DOI: 10.1016/j.jacc.2022.03.349] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 12/16/2022]
Abstract
The incidence of injection drug use-associated infective endocarditis has been increasing rapidly over the last decade. Patients with drug use-associated infective endocarditis present an increasingly common clinical challenge with poor long-term outcomes and high reinfection and readmission rates. Their care raises issues unique to this population, including antibiotic selection and administration, indications for and ethical issues surrounding surgical intervention, and importantly management of the underlying substance use disorder to minimize the risk of reinfection. Successful treatment of these patients requires a broad understanding of these concerns. A multidisciplinary, collaborative approach providing a holistic approach to treating both the acute infection along with effectively addressing substance use disorder is needed to improve short-term and longer-term outcomes.
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17
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Button D, Hartley J, Robbins J, Levander XA, Smith NJ, Englander H. Low-dose Buprenorphine Initiation in Hospitalized Adults With Opioid Use Disorder: A Retrospective Cohort Analysis. J Addict Med 2022; 16:e105-e111. [PMID: 34001775 PMCID: PMC8595358 DOI: 10.1097/adm.0000000000000864] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Patients with opioid use disorder (OUD) can initiate buprenorphine without requiring a withdrawal period through a low-dose (sometimes referred to as "micro-induction") approach. Although there is growing interest in low-dose buprenorphine initiation, current evidence is limited to case reports and small case series. METHODS We performed a retrospective cohort study of patients with OUD seen by a hospital-based addiction medicine consult service who underwent low-dose buprenorphine initiation starting during hospital admission. We then integrated our practice-based experiences with results from the existing literature to create practice considerations. RESULTS Sixty-eight individuals underwent 72 low-dose buprenorphine initiations between July 2019 and July 2020. Reasons for low-dose versus standard buprenorphine initiation included co-occurring pain (91.7%), patient anxiety around the possibility of withdrawal (69.4%), history of precipitated withdrawal (9.7%), opioid withdrawal intolerance (6.9%), and other reason/not specified (18.1%). Of the 72 low-dose buprenorphine initiations, 50 (69.4%) were completed in the hospital, 9 (12.5%) transitioned to complete as an outpatient, and 13 (18.1%) were terminated early. We apply our experiences and findings from literature to recommendations for varied clinical scenarios, including acute illness, co-occurring pain, opioid withdrawal intolerance, transition from high dose methadone to buprenorphine, history of precipitated withdrawal, and rapid hospital discharge. We share a standard low-dose initiation protocol with potential modifications based on above scenarios. CONCLUSIONS Low-dose buprenorphine initiation offers a well-tolerated and versatile approach for hospitalized patients with OUD. We share lessons from our experiences and the literature, and provide practical considerations for providers.
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Affiliation(s)
- Dana Button
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University
| | | | - Jonathan Robbins
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University
| | - Ximena A. Levander
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University
| | - Natashia J. Smith
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University
| | - Honora Englander
- Division of General Internal Medicine & Geriatrics, Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University
- Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University
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Opioid agonist treatment initiation and linkage for hospitalized patients seen by a substance use disorder consultation service. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 2:100031. [PMID: 36845893 PMCID: PMC9948812 DOI: 10.1016/j.dadr.2022.100031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 02/02/2022] [Accepted: 02/02/2022] [Indexed: 11/20/2022]
Abstract
Background Facilitating opioid agonist treatment (OAT) for opioid use disorder (OUD) is an important role of hospital substance use disorder (SUD) consultation services. In the NavSTAR trial, hospital patients receiving SUD consultation who were randomly assigned to patient navigation services for 3 months post-discharge had fewer readmissions compared to usual care. Methods This secondary analysis examined hospital-based OAT initiation (pre-randomization) and community-based OAT linkage (post-discharge) among NavSTAR trial participants with OUD (N=314). Associations between OAT initiation and linkage, and patient demographics, housing status, comorbid SUD diagnoses, recent substance use, and study condition were examined using multinomial and dichotomous logistic regression. Results Overall, 57.6% initiated OAT during hospitalization (36.3% methadone, 21.3% buprenorphine). Compared to participants not initiating OAT, participants who received methadone were more likely to be female (Relative Risk Ratio [RRR]=2.05, 95% CI=1.11, 3.82, p=0.02), while participants who received buprenorphine were more likely to report homelessness (RRR=2.57, 95% CI=1.24, 5.32, p=0.01). Compared to participants initiating methadone, participants initiating buprenorphine were more likely to be non-White (RRR=3.89; 95% CI=1.55, 9.70; p=0.004) and to report prior buprenorphine treatment (RRR=2.57; 95% CI=1.27, 5.20; p=0.009). OAT linkage within 30-days post-discharge was associated with hospital-based buprenorphine initiation (Adjusted Odds Ratio [AOR]=3.86, 95% CI=1.73, 8.61, p=0.001) and patient navigation intervention (AOR=2.97, 95% CI=1.60, 5.52, p=0.001). Conclusions OAT initiation differed by sex, race, and housing status. Hospital-based OAT initiation and patient navigation were independently associated with linkage to community-based OAT. Hospitalization is a reachable moment to begin OAT to alleviate withdrawal and facilitate treatment continuity post-discharge.
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King CA, Cook R, Wheelock H, Korthuis PT, Leahy JM, Goff A, Morris CD, Englander H. Simulating the impact of Addiction Consult Services in the context of drug supply contamination, hospitalizations, and drug-related mortality. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 100:103525. [PMID: 34837879 PMCID: PMC8810590 DOI: 10.1016/j.drugpo.2021.103525] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/22/2021] [Accepted: 10/29/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Illicitly manufactured fentanyl (IMF) is increasing in international drug supply chains, and IMF-related opioid overdose deaths are rising in North America. Hospitalizations among patients with opioid use disorder (OUD) are also rising; and, hospitalized patients are at increased risk of overdose and death following hospital discharge. Hospitalization is a key opportunity to engage patients with OUD. Addiction consult services (ACS) can provide effective treatment for patients hospitalized with OUD. This study aims to estimate the effect of increasing IMF contamination on drug-related death among patients hospitalized with OUD, and simulate the role of ACS expansion to mitigate these effects. METHODS We used a Markov model to mirror care systems for adult patients hospitalized with OUD in Oregon, from the time of hospital admission through 12-months post-discharge, and simulated patients through modeled care systems to evaluate the expansion of Addiction Consult Services in the context of increasing IMF in the drug supply. RESULTS In a simulated cohort of 10,000 patients, we estimate that 537 patients would die from drug-related causes within 12-months of hospital discharge. In the context of increased IMF in the drug supply, this estimate increased to 913. ACS referral at baseline was 4%; increasing ACS referral to accommodate 10%, 50%, or 100% of hospitalized OUD patients in the state reduces drug-related deaths to 904, 849, and 780, respectively. The number needed to treat for ACS to avoid one drug-related death in the context of increased IMF was 73. CONCLUSIONS Hospitals should expand interventions to help reduce IMF-related opioid overdoses, including through implementation of ACS. In the context of rising IMF-related deaths, ACS expansion could help connect patients to treatment, offer harm reduction interventions, or both, which can help reduce the risk of opioid-related death.
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Affiliation(s)
- Caroline A King
- Dept. of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Ryan Cook
- Dept. of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR, USA
| | | | - P Todd Korthuis
- Dept. of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Judith M Leahy
- Oregon Health Authority, Acute and Communicable Disease Prevention, Public Health Division, Oregon Health Authority, Salem, OR, USA
| | - Amelia Goff
- Dept. of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR, USA; Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Cynthia D Morris
- Dept. of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - Honora Englander
- Dept. of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR, USA; Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
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20
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King C, Collins D, Patten A, Nicolaidis C, Englander H. Trust in Hospital Physicians Among Patients With Substance Use Disorder Referred to an Addiction Consult Service: A Mixed-methods Study. J Addict Med 2022; 16:41-48. [PMID: 33577229 PMCID: PMC8349928 DOI: 10.1097/adm.0000000000000819] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Trust is essential in patient-physician relationships. Hospitalized patients with substance use disorders (SUDs) often experience stigma and trauma in the hospital, which can impede trust. Little research has explored the role of hospital-based addictions care in creating trusting relationships with patients with SUDs. This study describes how trust in physicians changed among hospitalized people with SUDs who were seen by an interprofessional addiction medicine service. METHODS We analyzed data from hospitalized patients with SUD seen by an addiction consult service from 2015 to 2018. Participants completed surveys at baseline and 30 to 90 days after hospital discharge. Follow-up assessments included open-ended questions exploring participant experiences with hospitalization and the addiction consult service. We measured provider trust using the Wake Forest Trust scale. We modeled trust trajectories using discrete mixture modeling, and sampled qualitative interviews from those trust trajectories. RESULTS Of 328 participants with SUD who had prior hospitalizations but had not previously been seen by an addiction consult service, 196 (59.8%) had both baseline and follow-up trust scores. We identified 3 groups of patients: Persistent-Low Trust, Increasing Trust, and Persistent-High Trust and 4 qualitative themes around in-hospital trust: humanizing care, demonstrating addiction expertise, reliability, and granting agency. CONCLUSIONS Most participants retained or increased to high trust levels after hospitalization with an addiction consult service. Addiction consult services can create environments where healthcare providers build trust with, and humanize care for, hospitalized patients with SUD, and can also mitigate power struggles that hospitalized patients with SUD frequently experience.
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Affiliation(s)
- Caroline King
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR
- MD/PhD Program, School of Medicine, Oregon Health & Science University, Portland, OR
| | | | - Alisa Patten
- Department of Medicine, Oregon Health & Science University
| | - Christina Nicolaidis
- Department of Medicine, Oregon Health & Science University
- School of Social Work, Portland State University
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King CA, Englander H, Korthuis PT, Barocas JA, McConnell KJ, Morris CD, Cook R. Designing and validating a Markov model for hospital-based addiction consult service impact on 12-month drug and non-drug related mortality. PLoS One 2021; 16:e0256793. [PMID: 34506517 PMCID: PMC8432751 DOI: 10.1371/journal.pone.0256793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 08/16/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Addiction consult services (ACS) engage hospitalized patients with opioid use disorder (OUD) in care and help meet their goals for substance use treatment. Little is known about how ACS affect mortality for patients with OUD. The objective of this study was to design and validate a model that estimates the impact of ACS care on 12-month mortality among hospitalized patients with OUD. METHODS We developed a Markov model of referral to an ACS, post-discharge engagement in SUD care, and 12-month drug-related and non-drug related mortality among hospitalized patients with OUD. We populated our model using Oregon Medicaid data and validated it using international modeling standards. RESULTS There were 6,654 patients with OUD hospitalized from April 2015 through December 2017. There were 114 (1.7%) drug-related deaths and 408 (6.1%) non-drug related deaths at 12 months. Bayesian logistic regression models estimated four percent (4%, 95% CI = 2%, 6%) of patients were referred to an ACS. Of those, 47% (95% CI = 37%, 57%) engaged in post-discharge OUD care, versus 20% not referred to an ACS (95% CI = 16%, 24%). The risk of drug-related death at 12 months among patients in post-discharge OUD care was 3% (95% CI = 0%, 7%) versus 6% not in care (95% CI = 2%, 10%). The risk of non-drug related death was 7% (95% CI = 1%, 13%) among patients in post-discharge OUD treatment, versus 9% not in care (95% CI = 5%, 13%). We validated our model by evaluating its predictive, external, internal, face and cross validity. DISCUSSION Our novel Markov model reflects trajectories of care and survival for patients hospitalized with OUD. This model can be used to evaluate the impact of other clinical and policy changes to improve patient survival.
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Affiliation(s)
- Caroline A. King
- Dept. of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - Honora Englander
- Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - P. Todd Korthuis
- Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - Joshua A. Barocas
- Section of Infectious Diseases, Boston University School of Medicine and Boston Medical Center, Boston, MA, United States of America
| | - K. John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States of America
| | - Cynthia D. Morris
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, United States of America
| | - Ryan Cook
- Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR, United States of America
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Sikka MK, Gore S, Vega T, Strnad L, Gregg J, Englander H. "OPTIONS-DC", a feasible discharge planning conference to expand infection treatment options for people with substance use disorder. BMC Infect Dis 2021; 21:772. [PMID: 34372776 PMCID: PMC8351414 DOI: 10.1186/s12879-021-06514-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 07/30/2021] [Indexed: 11/10/2022] Open
Abstract
Background Serious bacterial infections associated with substance use often result in long hospitalizations, premature discharges, and high costs. Out-of-hospital treatment options in people with substance use disorder (SUD) are often limited. Methods We describe a novel multidisciplinary and interprofessional care conference, “OPTIONS-DC,” to identify treatment options agreeable to both patients and providers using the frameworks of harm reduction and patient-centered care. We retrospectively reviewed charts of patients who had an OPTIONS-DC between February 2018 and July 2019 and used content analysis to understand the conferences’ effects on antibiotic treatment options. Results Fifty patients had an OPTIONS-DC during the study window. Forty-two (84%) had some intravenous (IV) substance use and 44 (88%) had an active substance use disorder. Participants’ primary substances included opioids (65%) or methamphetamines (28%). On average, conferences lasted 28 min. OPTIONS-DC providers recommended out-of-hospital antibiotic treatment options for 34 (68%) of patients. OPTIONS-DC recommended first line therapy of IV antibiotics for 35 (70%) patients, long-acting injectable antibiotics for 14 (28%), and oral therapy for 1 (2%). 35 (70%) patients that had an OPTIONS-DC completed an antibiotic course and 6 (12%) left the hospital prematurely. OPTIONS-DC expanded treatment options by exposing and contextualizing SUD, psychosocial risk and protective factors; incorporating patient preferences; and allowing providers to tailor antibiotic and SUD recommendations. Conclusions OPTIONS-DC is a feasible intervention that allows providers to integrate principles of harm reduction and offer patient-centered choices among patients needing prolonged antibiotic treatment. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06514-9.
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Affiliation(s)
- Monica K Sikka
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, L457, Portland, OR, 97239-3098, USA.
| | - Sara Gore
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, L457, Portland, OR, 97239-3098, USA
| | - Taylor Vega
- School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Luke Strnad
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, L457, Portland, OR, 97239-3098, USA.,Epidemiology Programs, School of Public Health, Oregon Health and Science University and Portland State University, Portland, OR, USA
| | - Jessica Gregg
- Section of Addiction Medicine, Division of General Internal Medicine, Department of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, BTE 119, Portland, OR, 97239-3098, USA.,Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Honora Englander
- Section of Addiction Medicine, Division of General Internal Medicine, Department of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, BTE 119, Portland, OR, 97239-3098, USA. .,Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
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23
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Levander XA, Vega TA, Seaman A, Korthuis PT, Englander H. Exploring how hospitalization can alter hepatitis c virus treatment prioritization and trajectories in people who use drugs: A qualitative analysis. Subst Abus 2021; 43:245-252. [PMID: 34161198 PMCID: PMC8695635 DOI: 10.1080/08897077.2021.1932699] [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: 01/03/2023]
Abstract
Background: People who use drugs (PWUD) have high rates of hepatitis C virus (HCV) infection. Hospitalization can be a time for PWUD to engage in addiction treatment, but little is known about how hospitalization shapes HCV treatment readiness. We aimed to describe how hospitalization and addiction medicine consult service (AMCS) can alter HCV prioritization of inpatient PWUD with HCV. Methods: We conducted a qualitative study consisting of semi-structured interviews (n = 27) of hospitalized adults with addiction and HCV infection seen by an AMCS at a single, urban, academic center. Interviews were audio-recorded, transcribed, and coded iteratively at the semantic level, and analyzed for themes. Results: Of the 27 participants, most identified as Caucasian (85%), male gender (67%), and they primarily used opioids (78%); approximately half (48%) reported HCV diagnosis over 5 years ago. We identified three main themes around hospitalization altering the prioritizations and HCV treatment preferences for PWUD: (1) HCV treatment non-engaged (2) HCV treatment urgency, and (3) HCV treatment in the future. Those wanting to treat HCV-whether urgently or in the future-shared the overlapping theme of hospitalization as a reachable moment for their addiction and HCV. These participants recognized the long-term benefits of addressing HCV and connected their hospitalization to substance use. Conclusion: In our study, PWUD with HCV expressed varying and competing priorities and life circumstances contributing to three main HCV treatment trajectories. Our results suggest ways hospitalization can serve as an HCV touchpoint for PWUD, especially in the context of addressing substance use, and could be used when designing and implementing targeted interventions to improve the HCV care continuum for PWUD.
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Affiliation(s)
- Ximena A. Levander
- Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Department of Medicine Oregon Health and Science University, Portland, OR, USA
| | - Taylor A. Vega
- School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Andrew Seaman
- Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Department of Medicine Oregon Health and Science University, Portland, OR, USA
- Central City Concern, Portland, OR, USA
| | - P. Todd Korthuis
- Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Department of Medicine Oregon Health and Science University, Portland, OR, USA
| | - Honora Englander
- Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Department of Medicine Oregon Health and Science University, Portland, OR, USA
- Division of Hospital Medicine, Department of Medicine, Oregon Health and Science University, Portland, OR, USA
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24
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Spreading Addictions Care Across Oregon's Rural and Community Hospitals: Mixed-Methods Evaluation of an Interprofessional Telementoring ECHO Program. J Gen Intern Med 2021; 36:100-107. [PMID: 32885371 PMCID: PMC7859151 DOI: 10.1007/s11606-020-06175-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/20/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Despite evidence of effectiveness, most US hospitals do not deliver hospital-based addictions care. ECHO (Extension for Community Healthcare Outcomes) is a telementoring model for providers across diverse geographic areas. We developed and implemented a substance use disorder (SUD) in hospital care ECHO to support statewide dissemination of best practices in hospital-based addictions care. OBJECTIVES Assess the feasibility, acceptability, and effects of ECHO and explore lessons learned and implications for the spread of hospital-based addictions care. DESIGN Mixed-methods study with a pre-/post-intervention design. PARTICIPANTS Interprofessional hospital providers and administrators across Oregon. INTERVENTION A 10-12-week ECHO that included participant case presentations and brief didactics delivered by an interprofessional faculty, including peers with lived experience in recovery. APPROACH To assess feasibility and acceptability, we collected enrollment, attendance, and participant feedback data. To evaluate ECHO effects, we used pre-/post-ECHO assessments and performed a thematic analysis of open-ended survey responses and participant focus groups. KEY RESULTS We recruited 143 registrants to three cohorts between January and September 2019, drawing from 32 of Oregon's 62 hospitals and one southwest Washington hospital. Ninety-six (67.1%) attended at least half of ECHO sessions. Participants were highly satisfied with ECHO. After ECHO, participants were more prepared to treat SUD; however, prescribing did not change. Participants identified substantial gains in knowledge and skills, particularly regarding the use of medications for opioid use disorder; patient-centered communication with people who use drugs; and understanding harm reduction as a valid treatment approach. ECHO built a community of practice and reduced provider isolation. Participants recognized the need for supportive hospital leadership, policies, and SUD resources to fully implement and adopt hospital-based SUD care. CONCLUSIONS A statewide, interprofessional SUD hospital care ECHO was feasible and acceptable. Findings may be useful to health systems, states, and regions looking to expand hospital-based addictions care.
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