Time to address addiction treatment inequality in hospital settings

Improving assessment and management of suicide risk among people who inject drugs: A mixed methods study conducted at the Medically Supervised Injecting Centre, Sydney

INTRODUCTION

People who inject drugs are 13 times more likely to die by suicide than the general population. Guidelines for responding to risk in this population are limited. Harm reduction services attended by people who inject drugs require targeted strategies to address the complexities of suicide risk among this population.

METHODS

Co-design, engaging health professionals and people with lived experience informed the study. Mixed methods were used to understand the experience of managing suicide risk among clients attending the Medically Supervised Injecting Centre (MSIC) in Sydney. A survey was administered to assess staff confidence in managing risk. Focus groups were conducted with health professionals and MSIC clients to explore experiences of suicide management, response and opportunities for improvement.

RESULTS

Half (N = 17) the MSIC staff surveyed reported over 10 years' experience working with this population. Confidence in managing suicide risk was low. Three key themes emerged from focus groups (N = 17): (i) Autonomy and the need to involve clients in the assessment process; (ii) Trust between clients and health professionals, and transparency in decision-making; and (iii) System barriers, described by health professionals as inadequate referral pathways for clients in distress, and by clients as negative experiences of care, including involuntary admission and not receiving medication (e.g. methadone).

DISCUSSION AND CONCLUSIONS

Revised assessment guidelines and a tailored safety plan were developed. These resources are also suitable for other alcohol and other drug services. The challenge in managing suicide risk in harm reduction services is balancing duty of care with staff-client relationships and client engagement.

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.

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

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.

The Impact of Stigma on People with Opioid Use Disorder, Opioid Treatment, and Policy

Illicit drug use disorders are the most stigmatised health conditions worldwide, and stigma acts as a meaningful barrier to treatment entry and treatment provision. In the context of dramatically rising opioid-related harms, it is critical that we understand the drivers of stigma and how it affects opioid use disorder treatment and policy. The aim of this narrative review is to discuss how opioid-related stigma impacts treatment provision and harm reduction, and provide potential strategies to reduce stigma at a social and structural level. We used the Framework for Integrating Normative Influences on Stigma (FINIS) to identify sources of opioid-related stigma at the macro (structural stigma), meso (public stigma) and micro (internalised stigma) levels. Reducing stigma requires strategies that target multiple levels, however addressing inequity in the laws, regulations, and rules that segregate people with opioid and other substance use disorders from mainstream society is essential.