Outpatient treatment entry and health care utilization after a combined medical/substance abuse intervention for hospitalized medical patients

Clinic-based treatment of opioid-dependent HIV-infected patients versus referral to an opioid treatment program: A randomized trial

BACKGROUND

Opioid dependence is common in HIV clinics. Buprenorphine-naloxone (BUP) is an effective treatment of opioid dependence that may be used in routine medical settings.

OBJECTIVE

To compare clinic-based treatment with BUP (clinic-based BUP) with case management and referral to an opioid treatment program (referred treatment).

DESIGN

Single-center, 12-month randomized trial. Participants and investigators were aware of treatment assignments. (ClinicalTrials.gov registration number: NCT00130819)

SETTING

HIV clinic in Baltimore, Maryland.

PATIENTS

93 HIV-infected, opioid-dependent participants who were not receiving opioid agonist therapy and were not dependent on alcohol or benzodiazepines.

INTERVENTION

Clinic-based BUP included BUP induction and dose titration, urine drug testing, and individual counseling. Referred treatment included case management and referral to an opioid-treatment program.

MEASUREMENTS

Initiation and long-term receipt of opioid agonist therapy, urine drug test results, visit attendance with primary HIV care providers, use of antiretroviral therapy, and changes in HIV RNA levels and CD4 cell counts.

RESULTS

The average estimated participation in opioid agonist therapy was 74% (95% CI, 61% to 84%) for clinic-based BUP and 41% (CI, 29% to 53%) for referred treatment (P < 0.001). Positive test results for opioids and cocaine were significantly less frequent in clinic-based BUP than in referred treatment, and study participants receiving clinic-based BUP attended significantly more HIV primary care visits than those receiving referred treatment. Use of antiretroviral therapy and changes in HIV RNA levels and CD4 cell counts did not differ between the 2 groups.

LIMITATION

This was a small single-center study, follow-up was only moderate, and the study groups were unbalanced in terms of recent drug injections at baseline.

CONCLUSION

Management of HIV-infected, opioid-dependent patients with a clinic-based BUP strategy facilitates access to opioid agonist therapy and improves outcomes of substance abuse treatment.

PRIMARY FUNDING SOURCE

Health Resources and Services Administration Special Projects of National Significance program.

Medical and Mental Health Status Among Drug Dependent Patients Participating in a Smoking Cessation Treatment Study

Substance Abusers have a large number of medical and psychiatric problems, and 70-90% are smokers. The aim of this analysis was to examine the prevalence and correlates of medical and psychiatric problems in this sample of drug dependent patients who were participants in a multi-site study of smoking cessation interventions while engaged in substance abuse treatment. Descriptive analyses showed at baseline, 72.8% of participants had at least one medical problem and 64.1% had at least one psychiatric diagnosis. Medical problems correlated strongly with age, smoking severity, and pack-years; Psychiatric problems correlated with gender and ethnicity. Smoking cessation treatment was associated with a moderate reduction in the ASI Medical composite score. More research is needed on the possible effects of combined treatment of substance abuse and concurrent medical and psychiatric problems. Offering smoking cessation in conjunction with primary care may be a way to address the health needs of this population.

The effect of integrated medical-substance abuse treatment during an acute illness on subsequent health services utilization

BACKGROUND

The acute care hospital provides a context for engaging difficult to reach patients in substance abuse treatment (SAT); however, little is known regarding the effects of such engagement on subsequent health services utilization. We examined whether a structured day hospital (DH) intervention integrating SAT and medical care during an acute medical hospitalization would reduce subsequent emergency department (ED) use and rehospitalization compared with a control group receiving usual medical care and referral to intensive outpatient SAT.

METHODS

Between October 2001 and June 2002, we enrolled 390 hospitalized substance using patients in a nonrandomized clinical trial. Once stabilized, patients were assigned to either the DH intervention (n = 63) or usual care control group (n = 327). Baseline interview and chart review collected data on demographics, substance use, and acute and chronic medical conditions. Subsequent chart review collected data on ED, hospital and ambulatory care utilization in the 6 months pre-enrollment and 6 months postdischarge. Univariate and multiple logistic regression methods were used to assess the independent effects of the DH intervention on postdischarge health care utilization.

RESULTS

Overall 25%, 48%, and 42% reported > or =3 ED episodes, > or =1 rehospitalization, and > or =1 ambulatory care visit during the postdischarge period. Subjects who completed the DH intervention were significantly less likely to have > or =3 ED episodes (AOR = 0.27; 95% CI, 0.08-0.89) and more likely to have > or =1 ambulatory care visit (AOR = 4.05; 95% CI, 1.44-11.37) than the usual care group. No similarly beneficial effects were seen for patients who initiated but did not complete the DH intervention.

CONCLUSIONS

: A DH model that engages acutely ill substance using patients in integrated medical and substance abuse treatment can positively influence subsequent health care seeking behavior.

Effectiveness of low-dose naltrexone in the post-detoxification treatment of opioid dependence

BACKGROUND

The clinical use of naltrexone (NTX) in the treatment of opioid dependence has been limited because of poor compliance and inconsistent outcomes. In particular, the therapeutic benefit of extended treatment with NTX after opioid detoxification is unclear. The present study evaluated whether the augmentation with low-dose NTX during the post-detoxification treatment of opioid dependence would improve outcomes.

METHODS

In an open-label naturalistic design, 435 opioid-dependent patients who had completed inpatient detoxification were offered the choice of entering 1 of the 2 outpatient treatment arms: clonidine extended treatment (CET) (clonidine + psychosocial treatment), or enhanced extended treatment (EET) (oral NTX [1-10 mg/d] + CET) for 21 days. The primary outcome measure was retention in treatment. Secondary outcomes included abstinence from opioids, dropouts, and adherence to postdischarge care.

RESULTS

One hundred sixty-two patients (37.2%) accepted EET. Subjects receiving EET stayed longer in the program (F = 64.4; P = 0.000), were less likely to drop out, used less opioids, and followed through with referral to long-term outpatient treatment in a higher number, compared with patients in the CET arm (P = 0.000 in each case). The NTX + clonidine combination was safe and well tolerated.

CONCLUSIONS

This preliminary study indicates the potential benefit of augmentation with low-dose NTX to improve outcomes after opioid detoxification for a preferred group of patients. Randomized controlled trials are necessary to further evaluate the role of low-dose NTX in the outpatient treatment of opioid dependence.

Factors identifying high-frequency and low-frequency health service utilization among substance-using adults

Understanding why substance-using patients seek care at emergency departments (EDs) and who utilizes such service at high rates is important in tailoring and targeting interventions. We conducted a retrospective/prospective cohort study of 326 medically ill substance-using adults to identify factors associated with 12-month high-frequency utilization of ambulatory care, ED, and inpatient medical care. The majority were actively using heroin (74.6%), cocaine (62.4%), and alcohol (54.4%); 94.8% had a chronic medical condition; and 53.8% reported a chronic mental health condition. High-frequency use of ED (> or = 3 visits) was independently associated with being female (adjusted odds ratio [AOR] = 1.88; 95% confidence interval [95% CI] = 1.12, 3.17), being African American (AOR = 2.36; 95% CI = 1.30, 4.29), being homeless (AOR = 2.07; 95% CI = 1.08, 3.96), a history of > 1 substance abuse treatment episode (AOR = 4.10; 95% CI = 3.28, 10.87), and > or = 1 ambulatory care visit (AOR = 8.94; 95% CI = 3.28, 24.41). However, the combination of having certain chronic conditions (seizure disorder, hepatitis B, and hepatitis C) and accessing ambulatory care was protective against high-frequency use of ED. In contrast, high-frequency use of ambulatory care (> or = 3 visits) was independently associated with having insurance (Medicare/Medicaid: AOR = 2.39; 95% CI = 1.31, 4.69), having HIV/AIDS (AOR = 3.15; 95% CI = 1.70, 5.85), and receiving substance abuse treatment during the study period (AOR = 3.58; 95% CI = 1.61, 7.98) Efforts to redirect medical care to more subacute settings will likely require both capacity building and addressing a client's underlying needs, including homelessness, access to substance abuse treatment, and chronic disease management.

Does this patient really want treatment? Factors associated with baseline and evolving readiness for change among hospitalized substance using adults interested in treatment

Little is known about motivation for treatment and readiness for change during an acute medical event. We present data from a cohort of 353 actively substance abusing adults assessed at baseline and every three days during their hospital admission for readiness to change substance use behaviors (URICA), self-reported motivations for substance abuse treatment, and pain and withdrawal symptoms. Factors independently associated with being in a higher (i.e., contemplation or action) stage of change included female sex (AOR=2.33; 95% CI: 1.42, 3.81), being on probation or parole (AOR=2.55; 95% CI: 1.32, 4.93), bipolar disorder (AOR 2.60; 95% CI: 1.20, 5.63), believing they would get sick again if drug use continued (AOR=2.24; 95% CI: 1.36, 3.70), being "tired of using" (AOR=2.91; 95% CI: 1.21, 6.96) and family concerns (AOR=1.78; 95% CI: 1.08, 2.96). During their hospitalization 43.6% increased from precontemplation or contemplation to a higher stage or remained in the action stage. Believing one would get sick again if substance use continued (AOR=2.42; 95% CI: 1.07, 5.48), physical health concerns (AOR=5.28; 95% CI: 1.36, 20.44) and citing "tired of using" as a primary motivator (AOR=2.88; 95% CI: 1.10, 7.54) were independently associated with increased stage of change.

Admission to acute care hospitals for adolescent substance abuse: a national descriptive analysis

BACKGROUND

Use of alcohol and illicit drugs by adolescents remains a problem in the U.S. Case identification and early treatment can occur within a broad variety of healthcare and non-healthcare settings, including acute care hospitals. The objective of this study is to describe the extent and nature of adolescent admissions to the acute inpatient setting for substance abuse (SA). We use the Agency for Healthcare Research and Quality (AHRQ) 2000 Healthcare Cost and Utilization Project Kids Inpatient Database (HCUP-KID) which includes over 2.5 million admissions for youth age 20 and under to 2,784 hospitals in 27 states in the year 2000. Specifically, this analysis estimates national number of admissions, mean total charges, and mean lengths of stay for adolescents between the ages of 12 and 17 admitted to an acute care hospital for the following diagnostic categories from the AHRQ's Clinical Classifications Software categories: "alcohol-related mental disorders" and "substance-related mental disorders". Frequency and percentage of total admissions were calculated for demographic variables of age, gender and income and for hospital characteristic variables of urban/rural designation and children's hospital designation.

RESULTS

SA admissions represented 1.25 percent of adolescent admissions to acute care hospitals. Nearly 90 percent of the admission occurred in non-Children's hospitals. Most were for drug dependence (38%) or non-dependent use of alcohol or drugs (35%). Costs were highest for drug dependence admissions. Nearly half of admissions had comorbid mental health diagnoses. Higher rates of admission were seen in boys, in older adolescents, and in "self-pay" patients. Alcohol and drug rehabilitation/detoxification, alone or in combination with psychological and psychiatric evaluation and therapy, was documented for 38 percent of admissions. Over 50 percent of cases had no documentation of treatment specific to substance use behavior.

CONCLUSION

General acute care hospitals have a significant and important opportunity to recognize, treat, and refer adolescents with substance abuse problems. These results suggest that inpatient facilities should develop and implement policies and processes to ensure that adolescent substance abusers admitted to their institutions receive appropriate care during the admission and appropriate referral to community care resources.