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Peters H, Liaukovich A, Grace N, Ausman C, Kiepek N. Opportunities to improve inpatient services and reduce rates of patient-direct discharge among people who use substances. Hosp Pract (1995) 2024; 52:64-76. [PMID: 39081137 DOI: 10.1080/21548331.2024.2386924] [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] [Received: 05/21/2024] [Accepted: 07/29/2024] [Indexed: 08/06/2024]
Abstract
PURPOSE Patients who use substances (PWUS) report experiencing stigmatizing encounters and undertreatment of pain and withdrawal symptoms that increase the likelihood of patient-directed discharge (PDD). This scoping review examines North American literature to gain insights about how institutional factors intersect with patient experiences and contribute to PDD. METHODS A scoping review was conducted using MEDLINE, CINAHL, Scopus, and EMBASE databases. Screening was completed by two reviewers. A data extraction tool developed by the research team was used to collect demographic information and explore patients' experiences and reasons for PDD. RESULTS We present four themes related to PDD: i) effective management of pain and withdrawal symptoms, ii) therapeutic alliance with healthcare providers, iii) hospital policies, protocols, and procedures, and iv) recommendations. Notably, all patients in all qualitative studies reported predominant experiences of uncaring, stigmatizing interactions with healthcare providers. DISCUSSION Findings suggest that transformations are required at individual and institutional levels. At an individual level, to provide equitable care to all patients, healthcare providers in all practice settings should be competent to effectively and compassionately care for PWUS. At an institutional level, policies need to be re-envisioned to support the implementation of effective practices. CONCLUSION Hospitals are faced with the challenges to ensure respectful care environments guided by harm reduction policies that will improve engagement of PWUS in services.
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Affiliation(s)
- Hannah Peters
- School of Occupational Therapy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Alex Liaukovich
- School of Occupational Therapy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Nardeen Grace
- School of Occupational Therapy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Christine Ausman
- School of Occupational Therapy, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Niki Kiepek
- School of Occupational Therapy, Dalhousie University, Halifax, Nova Scotia, Canada
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Sharp A, Sorokopud-Jones M, Haworth-Brockman M, Kasper K, MacKenzie L, Ireland L, Gawlik K, Lopez L, Vanegas JM, Bullard J, Boodman C, Sanguins J, Payne M, Templeton K, Keynan Y, Rueda ZV. Sex differences in houselessness, injection drug use, and mental health conditions among people newly diagnosed with HIV in Manitoba, Canada from 2018 to 2021: a retrospective cohort study. LANCET REGIONAL HEALTH. AMERICAS 2024; 36:100805. [PMID: 38912328 PMCID: PMC11192788 DOI: 10.1016/j.lana.2024.100805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 04/22/2024] [Accepted: 05/22/2024] [Indexed: 06/25/2024]
Abstract
Background Manitoba saw the highest number of new HIV diagnoses in the province's history in 2021 and is the only Canadian province not meeting any of the previous UNAIDS 90-90-90 targets. Our goal was to describe sex differences and syndemic conditions within an incident HIV cohort in Manitoba, and the HIV treatment initiation and undetectable viral load outcomes. Methods This was a retrospective cohort study of all people 18 years and older newly diagnosed with HIV in Manitoba, Canada between January 1st, 2018 and December 31st, 2021. Data was collected as follows: before HIV diagnosis: chlamydia, gonorrhoea, syphilis, and/or hepatitis C antibodies. At the time of HIV diagnosis: age, sex, gender, race/ethnicity, sexual orientation. During follow-up: CD4 counts, viral load, HIV treatment, hospitalizations, and number of visits to HIV care. Main exposures evaluated: methamphetamine use, injection drug use, houselessness, and mental health conditions. Outcomes: started antiretroviral treatment and achieved an undetectable viral load. A descriptive statistical analysis was used. Findings There were 404 new HIV diagnoses in Manitoba from 2018 to 2021; 44.8% were female, 55.2% male; 76.% self-identified as Indigenous, 13.4% white/European, 4.7% African/black; 86.6% cis-gender; 60.9% heterosexual, 13.4% gay, bisexual and men who have sex with men, and 1.7% lesbian. Injection drug use was reported by 71.8% and 43.5% of females and males respectively. Methamphetamine was the most frequently injected drug (62.4%). Amongst females, 81.8% experienced at least one of the following: houselessness (43.1%), mental health comorbidities (46.4%), and injection drug use (71.8%). Only 64.9% of all individuals had an undetectable viral load (61.1% females and 67.9% males), 56.5% among people experiencing houselessness, 59% among young people (≤29 years), and 60.1% among people who inject drugs. Interpretation People newly diagnosed with HIV in Manitoba are disproportionately experiencing houselessness, mental illness, and injection drug use (mostly methamphetamine). This pattern is more pronounced for female individuals. These findings highlight the need for syndemic and gender-specific approaches, simultaneously addressing social and health conditions, to treat HIV. Funding This work was supported by the Canadian Institutes of Health Research, The Manitoba Medical Service Foundation, The James Farley Memorial Fund and the Canada Research Chairs Program.
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Affiliation(s)
- Alexander Sharp
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | | | - Margaret Haworth-Brockman
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
- National Collaborating Centre for Infectious Diseases, Winnipeg, Canada
| | - Ken Kasper
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
- Manitoba HIV Program, Winnipeg, Canada
- Health Science Centre Winnipeg, Shared Health, Winnipeg, Canada
| | - Lauren MacKenzie
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
- Manitoba HIV Program, Winnipeg, Canada
| | - Laurie Ireland
- Manitoba HIV Program, Winnipeg, Canada
- Nine Circles Community Health Centre, Winnipeg, Canada
- Department of Family Medicine, University of Manitoba Rady Faculty of Health Sciences, Winnipeg, MB, R3E 0J9, Canada
| | - Kathy Gawlik
- Health Science Centre Winnipeg, Shared Health, Winnipeg, Canada
| | - Lucelly Lopez
- Public Health Research Group, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellin, Colombia
| | - Johanna Marcela Vanegas
- Public Health Research Group, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellin, Colombia
| | - Jared Bullard
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada
- Section of Pediatric Infectious Diseases, Department of Pediatrics and Child Health, Winnipeg, Canada
- Cadham Provincial Laboratory, Winnipeg, Canada
| | - Carl Boodman
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - Julianne Sanguins
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Mike Payne
- Manitoba HIV Program, Winnipeg, Canada
- Nine Circles Community Health Centre, Winnipeg, Canada
| | | | - Yoav Keynan
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
- National Collaborating Centre for Infectious Diseases, Winnipeg, Canada
| | - Zulma Vanessa Rueda
- Public Health Research Group, Facultad de Medicina, Universidad Pontificia Bolivariana, Medellin, Colombia
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Figgatt MC, Rosen DL, Chu VH, Wu LT, Schranz AJ. Long-term Risk of Serious Infections and Mortality Among Patients Surviving Drug Use-Associated Infective Endocarditis. Clin Infect Dis 2024; 79:56-59. [PMID: 38642403 PMCID: PMC11259212 DOI: 10.1093/cid/ciae214] [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: 01/10/2024] [Revised: 04/10/2024] [Accepted: 04/17/2024] [Indexed: 04/22/2024] Open
Abstract
Among a statewide cohort of 1874 patients surviving hospitalization for drug use-associated endocarditis during 2017-2020, the 3-year risk of death or future hospitalization was 38% (16% for death before later infection, 14% for recurrent endocarditis, 14% for soft tissue, 9% for bacteremia, 5% for bone/joint, and 4% for spinal infections).
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Affiliation(s)
- Mary C Figgatt
- Department of Medicine, University of Alabama, Birmingham, Alabama, USA
| | - David L Rosen
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Vivian H Chu
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Li-Tzy Wu
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Asher J Schranz
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
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4
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Kimmel SD, Walley AY, White LF, Yan S, Grella C, Majeski A, Stein MD, Bettano A, Bernson D, Drainoni ML, Samet JH, Larochelle MR. Medication for Opioid Use Disorder After Serious Injection-Related Infections in Massachusetts. JAMA Netw Open 2024; 7:e2421740. [PMID: 39046742 PMCID: PMC11270137 DOI: 10.1001/jamanetworkopen.2024.21740] [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: 01/08/2024] [Accepted: 05/10/2024] [Indexed: 07/25/2024] Open
Abstract
Importance Serious injection-related infections (SIRIs) cause significant morbidity and mortality. Medication for opioid use disorder (MOUD) improves outcomes but is underused. Understanding MOUD treatment after SIRIs could inform interventions to close this gap. Objectives To examine rehospitalization, death rates, and MOUD receipt for individuals with SIRIs and to assess characteristics associated with MOUD receipt. Design, Setting, and Participants This retrospective cohort study used the Massachusetts Public Health Data Warehouse, which included all individuals with a claim in the All-Payer Claims Database and is linked to individual-level data from multiple government agencies, to assess individuals aged 18 to 64 years with opioid use disorder and hospitalization for endocarditis, osteomyelitis, epidural abscess, septic arthritis, or bloodstream infection (ie, SIRI) between July 1, 2014, and December 31, 2019. Data analysis was performed from November 2021 to May 2023. Exposure Demographic and clinical factors potentially associated with posthospitalization MOUD receipt. Main Outcomes and Measures The main outcome was MOUD receipt measured weekly in the 12 months after hospitalization. We used zero-inflated negative binomial regression to examine characteristics associated with any MOUD receipt and rates of treatment in the 12 months after hospitalization. Secondary outcomes were receipt of any buprenorphine formulation, methadone, and extended-release naltrexone examined individually. Results Among 8769 individuals (mean [SD] age, 43.2 [12.0] years; 5066 [57.8%] male) who survived a SIRI hospitalization, 4305 (49.1%) received MOUD, 5919 (67.5%) were rehospitalized, and 973 (11.1%) died within 12 months. Of those treated with MOUD in the 12 months after hospitalization, the mean (SD) number of MOUD initiations during follow-up was 3.0 (1.7), with 956 of 4305 individuals (22.2%) receiving treatment at least 80% of the time. MOUD treatment after SIRI hospitalization was significantly associated with MOUD in the prior 6 months (buprenorphine: adjusted odds ratio [AOR], 16.51; 95% CI, 13.81-19.74; methadone: AOR, 28.46; 95% CI, 22.41-36.14; or naltrexone: AOR, 2.05; 95% CI, 1.56-2.69). Prior buprenorphine (incident rate ratio [IRR], 1.17; 95% CI, 1.11-1.24) or methadone (IRR, 1.89; 95% CI, 1.79-2.01) use was associated with higher treatment rates after hospitalization, and prior naltrexone use (IRR, 0.86; 95% CI, 0.77-0.95) was associated with lower rates. Conclusions and Relevance This study found that in the year after a SIRI hospitalization in Massachusetts, mortality and rehospitalization were common, and only half of patients received MOUD. Treatment with MOUD before a SIRI was associated with posthospitalization MOUD initiation and time receiving MOUD. Efforts are needed to initiate MOUD treatment during SIRI hospitalizations and subsequently retain patients in treatment.
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Affiliation(s)
- Simeon D. Kimmel
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
- Section of Infectious Diseases, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Alexander Y. Walley
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Laura F. White
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Shapei Yan
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Christine Grella
- Semel Institute of Neuroscience and Human Behavior, David Geffen School of Medicine, University of California, Los Angeles
- Lighthouse Institute, Chestnut Health Systems, Chicago, Illinois
| | - Adam Majeski
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Michael D. Stein
- Department of Health, Law and Policy, Boston University School of Public Health, Boston, Massachusetts
| | - Amy Bettano
- Office of Population Health, Department of Public Health, Commonwealth of Massachusetts, Boston
| | - Dana Bernson
- Office of Population Health, Department of Public Health, Commonwealth of Massachusetts, Boston
| | - Mari-Lynn Drainoni
- Section of Infectious Diseases, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
- Department of Health, Law and Policy, Boston University School of Public Health, Boston, Massachusetts
- Evans Center for Implementation and Improvement Sciences, Boston University, Boston, Massachusetts
| | - Jeffrey H. Samet
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Marc R. Larochelle
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
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Fabricant SA, Abramson EL, Hutchings K, Vien A, Scherer M, Kapadia SN. PICC Your Poison: Resident Beliefs and Attitudes Regarding Discharge Parenteral Antibiotics for Patients Who Inject Drugs. Open Forum Infect Dis 2024; 11:ofae364. [PMID: 38994443 PMCID: PMC11237634 DOI: 10.1093/ofid/ofae364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 06/26/2024] [Indexed: 07/13/2024] Open
Abstract
Background Serious injection-related infections (SIRIs) in people who inject drugs often lead to prolonged hospitalizations or premature discharges. This may be in part due to provider reluctance to place peripherally inserted central catheters (PICCs) for outpatient parenteral antibiotic therapy in this population. Because internal medicine (IM) residents are often frontline providers in academic centers, understanding their perspectives on SIRI care is important to improve outcomes. Methods We surveyed IM residents in a large urban multicenter hospital system about SIRI care with a novel case-based survey that elicited preferences, comfort, experience, and stigma. The survey was developed using expert review, cognitive interviewing, and pilot testing. Results are reported with descriptive statistics and linear regression. Results Of 116 respondents (response rate 34%), most (73%) were uncomfortable discharging a patient with active substance use home with a PICC, but comfortable (87%) with discharge to postacute facilities. Many (∼40%) endorsed high levels of concern for PICC misuse or secondary line infections, but larger numbers cited concerns about home environment (50%) or loss to follow-up (68%). While overall rates were low, higher stigma was associated with more concerns around PICC use (r = -0.3, P = .002). A majority (58%) believed hospital policies against PICC use in SIRI may act as a barrier to discharge, and 74% felt initiation of medications for opioid use disorder (MOUD) would increase their comfort discharging with a PICC. Conclusions Most IM residents endorsed high levels of concern about PICC use for SIRI, related to patient outcomes and perceived institutional barriers, but identified MOUD as a mitigating factor.
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Affiliation(s)
- Scott A Fabricant
- Department of Medicine, New York–Presbyterian, New York, New York, USA
| | - Erika L Abramson
- Department of Pediatrics, Weill Cornell Medicine, New York, New York, USA
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Kayla Hutchings
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Alexis Vien
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Matthew Scherer
- Division of Infectious Diseases, Columbia University Medical Center, New York, New York, USA
| | - Shashi N Kapadia
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
- Division of Infectious Diseases, Weill Cornell Medicine, New York, New York, USA
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Incze MA, Kelley AT, James H, Nolan S, Stofko A, Fordham C, Gordon AJ. Post-hospitalization Care Transition Strategies for Patients with Substance Use Disorders: A Narrative Review and Taxonomy. J Gen Intern Med 2024; 39:837-846. [PMID: 38413539 PMCID: PMC11043281 DOI: 10.1007/s11606-024-08670-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/30/2024] [Indexed: 02/29/2024]
Abstract
Hospitalizations represent important opportunities to engage individuals with substance use disorders (SUD) in treatment. For those who engage with SUD treatment in the hospital setting, tailored supports during post-discharge transitions to longitudinal care settings may improve care linkages, retention, and treatment outcomes. We updated a recent systematic review search on post-hospitalization SUD care transitions through a structured review of published literature from January 2020 through June 2023. We then added novel sources including a gray literature search and key informant interviews to develop a taxonomy of post-hospitalization care transition models for patients with SUD. Our updated literature search generated 956 abstracts not included in the original systematic review. We selected and reviewed 89 full-text articles, which yielded six new references added to 26 relevant articles from the original review. Our search of five gray literature sources yielded four additional references. Using a thematic analysis approach, we extracted themes from semi-structured interviews with 10 key informants. From these results, we constructed a taxonomy consisting of 10 unique SUD care transition models in three overarching domains (inpatient-focused, transitional, outpatient-focused). These models include (1) training and protocol implementation; (2) screening, brief intervention, and referral to treatment; (3) hospital-based interdisciplinary consult team; (4) continuity-enhanced interdisciplinary consult team; (5) peer navigation; (6) transitional care management; (7) outpatient in-reach; (8) post-discharge outreach; (9) incentivizing follow-up; and (10) bridge clinic. For each model, we describe design, scope, approach, and implementation strategies. Our taxonomy highlights emerging models of post-hospitalization care transitions for patients with SUD. An established taxonomy provides a framework for future research, implementation efforts, and policy in this understudied, but critically important, aspect of SUD care.
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Affiliation(s)
- Michael A Incze
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Greater Intermountain Node, National Institute on Drug Abuse Clinical Trial Network, Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), , Salt Lake City, UT, USA.
| | - A Taylor Kelley
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Greater Intermountain Node, National Institute on Drug Abuse Clinical Trial Network, Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), , Salt Lake City, UT, USA
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Patient-Aligned Care Team, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Hannah James
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Seonaid Nolan
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Andrea Stofko
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Greater Intermountain Node, National Institute on Drug Abuse Clinical Trial Network, Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), , Salt Lake City, UT, USA
| | - Cole Fordham
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Greater Intermountain Node, National Institute on Drug Abuse Clinical Trial Network, Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), , Salt Lake City, UT, USA
| | - Adam J Gordon
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Greater Intermountain Node, National Institute on Drug Abuse Clinical Trial Network, Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), , Salt Lake City, UT, USA
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Patient-Aligned Care Team, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
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Warp PV, Hauschild M, Serota DP, Ciraldo K, Cruz I, Bartholomew TS, Tookes HE. A confirmed case of xylazine-induced skin ulcers in a person who injects drugs in Miami, Florida, USA. Harm Reduct J 2024; 21:64. [PMID: 38491467 PMCID: PMC10941577 DOI: 10.1186/s12954-024-00978-z] [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: 07/22/2023] [Accepted: 03/01/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Xylazine is an alpha-2 adrenergic receptor agonist that has emerged as a contaminant in the illicit drug supply of fentanyl. Xylazine use may be suspected in naloxone-resistant overdoses and atypical, chronic wounds in people who use drugs (PWUD). This case is unique because it is the first case to our knowledge describing wound care for a xylazine-induced wound with a confirmatory xylazine test strip (XTS) in the setting of a syringe services program (SSP) and in the state of Florida. CASE PRESENTATION A 43-year-old woman with a past medical history of severe opioid use disorder and stimulant use disorder presented to a student-run clinic at a Miami SSP for wound care. She had multiple ulcerations diffusely over her bilateral forearms with surrounding erythema and warmth. Seven weeks later, she presented to clinic again for wound care because her wounds had progressed. At this visit, a XTS was used to confirm the presence of xylazine in her urine. Wound care management and harm reduction strategies employed at both visits were informed by best clinical judgement due to lack of formal guidelines at the time. Wound outcomes are unknown as the patient has not returned to clinic. CONCLUSIONS Many PWUD at highest risk for acute and chronic health consequences of xylazine-adulterated fentanyl do not have access to healthcare outside of low barrier clinics and SSPs due to lack of insurance or mistrust of the traditional healthcare system due to stigma. There is an urgent need for access to XTS for PWUD and clinical practice guidelines for the treatment of xylazine-related wounds in outpatient clinics.
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Affiliation(s)
- Peyton V Warp
- Department of Medical Education, University of Miami Miller School of Medicine, 1600 NW 10th Ave, Suite 1149, Miami, FL, 33136, USA.
| | - Maia Hauschild
- Department of Medical Education, University of Miami Miller School of Medicine, 1600 NW 10th Ave, Suite 1149, Miami, FL, 33136, USA
| | - David P Serota
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Katrina Ciraldo
- Department of Family Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Irasema Cruz
- IDEA Exchange, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Tyler S Bartholomew
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hansel E Tookes
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
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Thakarar K, Appa A, Abdul Mutakabbir JC, Goff A, Brown J, Tuell C, Fairfield K, Wurcel A. Frame Shift: Focusing on Harm Reduction and Shared Decision Making for People Who Use Drugs Hospitalized With Infections. Clin Infect Dis 2024; 78:e12-e26. [PMID: 38018174 DOI: 10.1093/cid/ciad664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Indexed: 11/30/2023] Open
Affiliation(s)
- Kinna Thakarar
- Tufts University School of Medicine, Boston, Massachusetts, USA
- Center for Interdisciplinary Population & Health Research, MaineHealth Institute for Research, Portland, Maine, USA
- Department of Medicine, Maine Medical Center, Portland, Maine, USA
| | - Ayesha Appa
- Division of HIV, Infectious Diseases, and Global Medicine at San Francisco General Hospital, University of California-San Francisco, San Francisco, California, USA
| | - Jacinda C Abdul Mutakabbir
- Division of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California-San Diego, La Jolla, California, USA
- Division of the Black Diaspora and African American Studies, University of California-San Diego, La Jolla, California, USA
| | - Amelia Goff
- Section of Addiction Medicine, Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Jessica Brown
- Department of Care Management, Oregon Health and Science University, Portland, Oregon, USA
| | | | - Kathleen Fairfield
- Tufts University School of Medicine, Boston, Massachusetts, USA
- Center for Interdisciplinary Population & Health Research, MaineHealth Institute for Research, Portland, Maine, USA
- Department of Medicine, Maine Medical Center, Portland, Maine, USA
| | - Alysse Wurcel
- Tufts University School of Medicine, Boston, Massachusetts, USA
- Department of Medicine, Division of Geographic Medicine and Infectious Diseases, Tufts Medicine, Boston, Massachusetts, USA
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9
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Figgatt MC, Hincapie-Castillo JM, Schranz AJ, Dasgupta N, Edwards JK, Jackson BE, Marshall SW, Golightly YM. Medications for Opioid Use Disorder and Mortality and Hospitalization Among People With Opioid Use-related Infections. Epidemiology 2024; 35:7-15. [PMID: 37820243 PMCID: PMC10841877 DOI: 10.1097/ede.0000000000001681] [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: 10/13/2023]
Abstract
BACKGROUND Severe skin and soft tissue infections related to injection drug use have increased in concordance with a shift to heroin and illicitly manufactured fentanyl. Opioid agonist therapy medications (methadone and buprenorphine) may improve long-term outcomes by reducing injection drug use. We aimed to examine the association of medication use with mortality among people with opioid use-related skin or soft tissue infections. METHODS An observational cohort study of Medicaid enrollees aged 18 years or older following their first documented medical encounters for opioid use-related skin or soft tissue infections during 2007-2018 in North Carolina. The exposure was documented medication use (methadone or buprenorphine claim) in the first 30 days following initial infection compared with no medication claim. Using Kaplan-Meier estimators, we examined the difference in 3-year incidence of mortality by medication use, weighted for year, age, comorbidities, and length of hospital stay. RESULTS In this sample, there were 13,286 people with opioid use-related skin or soft tissue infections. The median age was 37 years, 68% were women, and 78% were white. In Kaplan-Meier curves for the total study population, 12 of every 100 patients died during the first 3 years. In weighted models, for every 100 people who used medications, there were four fewer deaths over 3 years (95% confidence interval = 2, 6). CONCLUSION In this study, people with opioid use-related skin and soft tissue infections had a high risk of mortality following their initial healthcare visit for infections. Methadone or buprenorphine use was associated with reductions in mortality.
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Affiliation(s)
- Mary C Figgatt
- University of North Carolina at Chapel Hill Gillings School of Global Public Health Department of Epidemiology, 135 Dauer Drive, Chapel Hill, North Carolina, USA, 27599
- University of North Carolina Injury Prevention Research Center, 725 Martin Luther King Jr Blvd, Chapel Hill, North Carolina, USA, 27599
| | - Juan M Hincapie-Castillo
- University of North Carolina at Chapel Hill Gillings School of Global Public Health Department of Epidemiology, 135 Dauer Drive, Chapel Hill, North Carolina, USA, 27599
- University of North Carolina Injury Prevention Research Center, 725 Martin Luther King Jr Blvd, Chapel Hill, North Carolina, USA, 27599
| | - Asher J Schranz
- University of North Carolina at Chapel Hill School of Medicine Division of Infectious Diseases, Chapel Hill, 130 Mason Farm Road, Chapel Hill, North Carolina, USA, 27599
| | - Nabarun Dasgupta
- University of North Carolina Injury Prevention Research Center, 725 Martin Luther King Jr Blvd, Chapel Hill, North Carolina, USA, 27599
- University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Drive, Chapel Hill, North Carolina, USA, 27599
| | - Jessie K Edwards
- University of North Carolina at Chapel Hill Gillings School of Global Public Health Department of Epidemiology, 135 Dauer Drive, Chapel Hill, North Carolina, USA, 27599
| | - Bradford E Jackson
- University of North Carolina Lineberger Cancer Center Cancer Information and Population Health Resource, 101 East Weaver St, Chapel Hill, North Carolina, USA, 27599
| | - Stephen W Marshall
- University of North Carolina at Chapel Hill Gillings School of Global Public Health Department of Epidemiology, 135 Dauer Drive, Chapel Hill, North Carolina, USA, 27599
- University of North Carolina Injury Prevention Research Center, 725 Martin Luther King Jr Blvd, Chapel Hill, North Carolina, USA, 27599
| | - Yvonne M Golightly
- University of North Carolina at Chapel Hill Gillings School of Global Public Health Department of Epidemiology, 135 Dauer Drive, Chapel Hill, North Carolina, USA, 27599
- University of Nebraska Medical Center College of Allied Health Professions, 42 and Emilie St, Omaha, Nebraska, USA, 68198
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10
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Clingan SE, Cousins SJ, Lin C, Nguyen TE, Hser YI, Mooney LJ. Perceptions of COVID-19 risk during the pandemic: perspectives from people seeking medication for opioid use disorder. Ann Med 2023; 55:480-489. [PMID: 36692029 PMCID: PMC9879168 DOI: 10.1080/07853890.2023.2169342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION The Coronavirus Disease 2019 (COVID-19) pandemic has had devastating consequences for persons with opioid use disorder (OUD). Yet, little is known about how people seeking treatment for OUD perceive the risks of COVID-19 and how their perception interplays with their health behaviours. METHODS In-depth interviews were conducted from September 2021 to March 2022 with 32 patients seeking medication treatment for OUD (MOUD) in Southern California. All interviews were conducted virtually and lasted between one and two hours. Interviews were recorded and transcribed verbatim. Two qualitative researchers independently conducted a content analysis of the transcripts to identify themes. RESULTS Three primary themes were identified: (1) perceptions and beliefs about COVID-19 susceptibility and severity; (2) perceptions of COVID-19 risk compared to substance use behaviours; and (3) vaccine hesitancy. Participants were mixed in their beliefs of susceptibility to contracting COVID-19 and the severity of the disease if contracted. Some participants reported taking precautions to mitigate their chances of acquiring COVID-19, and other participants reported that COVID was not a big concern as substance use took priority. For many of the participants, COVID-19 concerns were overshadowed by the risk of overdosing on substances and other risky substance use behaviour. Most of the participants (n = 23; 72%) had received at least one COVID-19 vaccine by the time of the interview, but over half (n = 19; 59%) expressed vaccine hesitancy. Vaccine hesitancy was driven by concerns about the unknown long-term side effects and potential interactions of the vaccine with MOUD. CONCLUSIONS Our study provides insight into COVID-19 prevention measures as well as vaccination perceptions and hesitancy among people who received treatment for OUD.Key messagesParticipants expressed diverse perceptions of the seriousness of COVID-19, with some taking precautions to mitigate their chances of acquiring COVID-19 and others perceiving that the risk of contracting COVID-19 was less than the risk of overdosing.Substance use, social isolation, vaccine hesitancy and COVID-19 risk behaviours should be studied as co-occurring phenomena that have potentially overlapping relationships that can influence behaviours that impact health and well-being.
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Affiliation(s)
- Sarah E. Clingan
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
| | - Sarah J. Cousins
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Community Health Sciences, University of California, Los Angeles, Los Angeles, CA, USA
| | - Chunqing Lin
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
| | - Tram E. Nguyen
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
- Department of Community Health Sciences, University of California, Los Angeles, Los Angeles, CA, USA
| | - Yih-Ing Hser
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
| | - Larissa J. Mooney
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Warp PV, Hauschild M, Tookes HE, Ciraldo K, Serota DP, Cruz I. A Confirmed Case of Xylazine-Induced Skin Ulcers in a Person Who Injects Drugs in Miami, Florida, USA. RESEARCH SQUARE 2023:rs.3.rs-3194876. [PMID: 37547000 PMCID: PMC10402246 DOI: 10.21203/rs.3.rs-3194876/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Background Xylazine is an alpha-2 adrenergic receptor agonist that has emerged as a contaminant in the street drug supply of fentanyl. Xylazine use may be suspected in naloxone-resistant overdoses and atypical, chronic wounds in people who inject drugs (PWID). This case is unique because it is the first case to our knowledge describing wound care for a xylazine-induced wound with a confirmatory xylazine test strip (XTS) in the setting of a syringe services program (SSP) and in the state of Florida. Case Presentation A 43-year-old woman with a past medical history of severe opioid use disorder and stimulant use disorder presented to a student-run clinic at the IDEA Miami SSP for wound care. She had multiple ulcerations diffusely over her bilateral forearms with surrounding erythema and warmth. Seven weeks later, she presented to clinic again for wound care because her wounds had progressed. At this visit, a XTS was used to confirm the presence of xylazine in her urine. Wound care management and harm reduction strategies employed at both visits are discussed below. Wound outcomes are unknown as the patient has not returned to clinic. Conclusions Many PWID at highest risk for acute and chronic health consequences of xylazine-adulterated fentanyl do not have access to healthcare outside of low barrier clinics and SSPs due to lack of insurance or mistrust of the traditional healthcare system. There is an urgent need for access to XTS for PWID and clinical practice guidelines for the treatment of xylazine-related wounds in outpatient clinics.
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Affiliation(s)
| | | | - Hansel E Tookes
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine
| | - Katrina Ciraldo
- Department of Family Medicine, University of Miami Miller School of Medicine
| | - David P Serota
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine
| | - Irasema Cruz
- IDEA Exchange, University of Miami Miller School of Medicine
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12
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Schranz AJ, Tak C, Wu LT, Chu VH, Wohl DA, Rosen DL. The Impact of Discharge Against Medical Advice on Readmission After Opioid Use Disorder-Associated Infective Endocarditis: a National Cohort Study. J Gen Intern Med 2023; 38:1615-1622. [PMID: 36344644 PMCID: PMC10212894 DOI: 10.1007/s11606-022-07879-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 10/24/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Hospitalizations for infective endocarditis (IE) associated with opioid use disorder (O-IE) have increased in the USA and have been linked to high rates of discharge against medical advice (DAMA). DAMA represents a truncation of care for a severe infection, yet patient outcomes after DAMA are unknown. OBJECTIVE This study aimed to assess readmissions following O-IE and quantify the impact of DAMA on outcomes. DESIGN A retrospective study of a nationally representative dataset of persons' inpatient discharges in the USA in 2016 PARTICIPANTS: A total of 6018 weighted persons were discharged for O-IE, stratified by DAMA vs. other discharge statuses. Of these, 1331 (22%) were DAMA. MAIN MEASURES The primary outcome of interest was 30-day readmission rates, stratified by discharge type. We also examined the total number of hospitalizations during the year and estimated the effect of DAMA on readmission. KEY RESULTS Compared with non-DAMA, those experiencing DAMA were more commonly female, resided in metropolitan areas, lower income, and uninsured. Crude 30-day readmission following DAMA was 50%, compared with 21% for other discharge types. DAMA was strongly associated with readmission in an adjusted logistic regression model (OR 3.72, CI 3.02-4.60). Persons experiencing DAMA more commonly had ≥2 more hospitalizations during the period (31% vs. 18%, p<0.01), and were less frequently readmitted at the same hospital (49% vs 64%, p<0.01). CONCLUSIONS DAMA occurs in nearly a quarter of patients hospitalized for O-IE and is strongly associated with short-term readmission. Interventions to address the root causes of premature discharges will enhance O-IE care, reduce hospitalizations and improve outcomes.
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Affiliation(s)
- Asher J Schranz
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA.
| | - Casey Tak
- Department of Pharmacotherapy, University of Utah, Salt Lake City, UT, USA
| | - Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Vivian H Chu
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - David A Wohl
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - David L Rosen
- Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
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13
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Yang WT, Dombrowski JC, Glick SN, Kim HN, Beieler AM, Lan KF, Dhanireddy S. Partial-Oral Antibiotic Therapy for Bone and Joint Infections in People With Recent Injection Drug Use. Open Forum Infect Dis 2023; 10:ofad005. [PMID: 36726538 PMCID: PMC9887258 DOI: 10.1093/ofid/ofad005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/05/2023] [Indexed: 01/09/2023] Open
Abstract
Background Limited outcome data exist regarding partial-oral antibiotic therapy, defined as oral antibiotics as part of a patient's treatment, for bone and joint infections (BJIs) in people who inject drugs (PWID). Methods We conducted a retrospective study of all PWID reporting drug use within 3 months and BJIs requiring ≥6 weeks of antibiotics in an urban safety-net hospital between February 1, 2019, and February 1, 2021. Treatment outcomes were assessed by chart review. Rates of failure, defined as death, symptoms, or signs concerning for worsening or recurrent infections, were assessed 90 and 180 days after completion of antibiotics. Univariate logistic regression was used to explore the association between covariates and failure. Results Of 705 patients with BJI, 88 (13%) were PWID. Eighty-six patients were included in the final cohort. Forty-four (51%) were homeless, 50 (58%) had spine infection, 68 (79%) had surgery, and 32 of 68 (47%) had postoperatively retained hardware. Twelve (14%) of 86 patients received exclusively intravenous (IV) antibiotics, and 74 (86%) received partial-oral antibiotics. Twelve (14%) of 86 patients had patient-directed discharge. In those who received partial-oral antibiotics, the failure rate was 20% at 90 days and 21% at 180 days after completion of intended treatment. Discharge to a medical respite and follow-up with infectious diseases (ID) or surgery were negatively associated with odds of failure. Conclusions Partial-oral treatment of BJI in PWID was a common practice and often successful when paired with medical respite and follow-up with ID or surgery.
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Affiliation(s)
- Wei-Teng Yang
- Correspondence: Wei-Teng Yang, MD, MPH, Section of Addiction Medicine, Division of General Internal Medicine and Geriatrics, Department of Medicine, Oregon Health & Science University, 3181 Southwest Samuel Jackson Park Road, Mail Code UNH30, Portland, OR 97239. E-mail:
| | - Julia C Dombrowski
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA,HIV/STD Program, Public Health-Seattle & King County, Seattle, Washington, USA
| | - Sara N Glick
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA,HIV/STD Program, Public Health-Seattle & King County, Seattle, Washington, USA
| | - H Nina Kim
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | | | - Kristine F Lan
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
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Britton TR, Clague MR, Zagorski CM, Hill LG, Loera LJ. A wound care and immunization needs assessment for participants of a mobile syringe services program in Austin, TX. J Am Pharm Assoc (2003) 2023; 63:361-365.e1. [PMID: 36549930 DOI: 10.1016/j.japh.2022.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/03/2022] [Accepted: 10/16/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND People who inject drugs (PWID) are subject to injection-related harm, including skin and soft tissue infections. Syringe services programs (SSPs) provide sterile syringes, disposal of used syringes, and other supportive services. Given their contact and credibility with PWID, SSPs could facilitate triage and treatment of wounds and access to immunizations for communicable diseases. OBJECTIVE This work aimed to assess wound care and immunization needs among participants accessing mobile SSP services in Austin, TX. METHODS A 21-item mixed-methods survey was created to assess frequency and severity of wounds, wound care approaches, and vaccination status. Participants were included if they reported injection drug use and experienced a related wound in the previous 6 months. Interview sections included screening, demographics, wound care, and immunization status. RESULTS A total of 21 participants completed the semistructured interview. A majority identified as male (n = 13, 61.9%), white (n = 12, 57.1%), and were unhoused (n = 12, 57.1%). The primary drug of injection was heroin alone (n = 14, 66.7%). Many avoided seeking wound care from health care providers (n = 16, 76.2%) owing to stigmatization (n = 13, 61.9%) and previous negative experiences (n = 7, 33.3%). Self-treatment of wounds included over-the-counter medications (n = 10, 47.6%), over-the-counter supplies (n = 10, 47.6%), and antibiotics (n = 9, 42.8%). In the past 5 years, few had received vaccination for hepatitis A and B (n = 3, 14.3%) or tetanus (n = 7, 33.3%), and many expressed interest in receiving vaccinations through the SSP. Interest for other expanded services included access to antibiotics, an on-site provider, wound care supplies, and education. CONCLUSIONS PWID may avoid professional health care for wound care or immunizations owing to perceived stigma. Expanding availability of wound care services and immunizations directly through mobile SSPs is desired by participants and could positively affect public health.
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15
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Serota DP, Rosenbloom L, Hervera B, Seo G, Feaster DJ, Metsch LR, Suarez E, Chueng TA, Hernandez S, Rodriguez AE, Tookes HE, Doblecki-Lewis S, Bartholomew TS. Integrated Infectious Disease and Substance Use Disorder Care for the Treatment of Injection Drug Use-Associated Infections: A Prospective Cohort Study With Historical Control. Open Forum Infect Dis 2023; 10:ofac688. [PMID: 36632415 PMCID: PMC9830545 DOI: 10.1093/ofid/ofac688] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Background To address the infectious disease (ID) and substance use disorder (SUD) syndemic, we developed an integrated ID/SUD clinical team rooted in harm reduction at a county hospital in Miami, Florida. The Severe Injection-Related Infection (SIRI) team treats people who inject drugs (PWID) and provides medical care, SUD treatment, and patient navigation during hospitalization and after hospital discharge. We assessed the impact of the SIRI team on ID and SUD treatment and healthcare utilization outcomes. Methods We prospectively collected data on patients seen by the SIRI team. A diagnostic code algorithm confirmed by chart review was used to identify a historical control group of patients with SIRI hospitalizations in the year preceding implementation of the SIRI team. The primary outcome was death or readmission within 90 days post-hospital discharge. Secondary outcomes included initiation of medications for opioid use disorder (MOUD) and antibiotic course completion. Results There were 129 patients included in the study: 59 in the SIRI team intervention and 70 in the pre-SIRI team control group. SIRI team patients had a 45% risk reduction (aRR, 0.55 [95% confidence interval CI, .32-.95]; 24% vs 44%) of being readmitted in 90 days or dying compared to pre-SIRI historical controls. SIRI team patients were more likely to initiate MOUD in the hospital (93% vs 33%, P < .01), complete antibiotic treatment (90% vs 60%, P < .01), and less likely to have patient-directed discharge (17% vs 37%, P = .02). Conclusions An integrated ID/SUD team was associated with improvements in healthcare utilization, MOUD initiation, and antibiotic completion for PWID with infections.
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Affiliation(s)
- David P Serota
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Liza Rosenbloom
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Belén Hervera
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Grace Seo
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Daniel J Feaster
- Division of Biostatistics, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Lisa R Metsch
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Edward Suarez
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Teresa A Chueng
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Salma Hernandez
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Allan E Rodriguez
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Hansel E Tookes
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Susanne Doblecki-Lewis
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Tyler S Bartholomew
- Division of Health Services Research and Policy, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
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16
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Implementation of an integrated infectious disease and substance use disorder team for injection drug use-associated infections: a qualitative study. Addict Sci Clin Pract 2023; 18:8. [PMID: 36747268 PMCID: PMC9902242 DOI: 10.1186/s13722-023-00363-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 01/25/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Hospitalizations for severe injection drug use-related infections (SIRIs) are characterized by high costs, frequent patient-directed discharge, and high readmission rates. Beyond the health system impacts, these admissions can be traumatizing to people who inject drugs (PWID), who often receive inadequate treatment for their substance use disorders (SUD). The Jackson SIRI team was developed as an integrated infectious disease/SUD treatment intervention for patients hospitalized at a public safety-net hospital in Miami, Florida in 2020. We conducted a qualitative study to identify patient- and clinician-level perceived implementation barriers and facilitators to the SIRI team intervention. METHODS Participants were patients with history of SIRIs (n = 7) and healthcare clinicians (n = 8) at one implementing hospital (Jackson Memorial Hospital). Semi-structured qualitative interviews were performed with a guide created using the Consolidated Framework for Implementation Research (CFIR). Interviews were transcribed, double coded, and categorized by study team members using CFIR constructs. RESULTS Implementation barriers to the SIRI team intervention identified by participants included: (1) complexity of the SIRI team intervention; (2) lack of resources for PWID experiencing homelessness, financial insecurity, and uninsured status; (3) clinician-level stigma and lack of knowledge around addiction and medications for opioid use disorder (OUD); and (4) concerns about underinvestment in the intervention. Implementation facilitators of the intervention included: (1) a non-judgmental, harm reduction-oriented approach; (2) the team's advocacy for PWID as a means of institutional culture change; (3) provision of close post-hospital follow-up that is often inaccessible for PWID; (4) strong communication with patients and their hospital physicians; and (5) addressing diverse needs such as housing, insurance, and psychological wellbeing. CONCLUSION Integration of infectious disease and SUD treatment is a promising approach to managing patients with SIRIs. Implementation success depends on institutional buy-in, holistic care beyond the medical domain, and an ethos rooted in harm reduction across multilevel (inner and outer) implementation contexts.
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Bartholomew TS, Tookes HE, Spencer EC, Feaster DJ. Application of machine learning algorithms for localized syringe services program policy implementation - Florida, 2017. Ann Med 2022; 54:2137-2150. [PMID: 35900201 PMCID: PMC9341345 DOI: 10.1080/07853890.2022.2105391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND People who inject drugs (PWID) are at an amplified vulnerability for experiencing a multitude of harms related to their substance use, including viral (e.g. HIV, Hepatitis C) and bacterial infections (e.g. endocarditis). Implementation of evidence-based interventions, such as syringe services programs (SSPs), remains imperative, particularly in locations at an increased risk of HIV outbreaks. This study aims to identify communities in Florida that are high-priority locations for SSP implementation by examining state-level data related to the substance use and overdose crises. METHODS State-level surveillance data were aggregated at the ZIP Code Tabulation Area (ZCTA) (n = 983) for 2017. We used confirmed cases of acute HCV infection as a proxy of injection drug use. Least Absolute Selection and Shrinkage Operator (LASSO) regression was used to develop a machine learning model to identify significant indicators of acute HCV infection and high-priority areas for SSP implementation due to their increased vulnerability to an HIV outbreak. RESULTS The final model retained three variables of importance: (1) the number of drug-associated skin and soft tissue infection hospitalizations, (2) the number of chronic HCV infections in people aged 18-39, and 3) the number of drug-associated endocarditis hospitalizations. High-priority SSP implementation locations were identified in both urban and rural communities outside of current Ending the HIV Epidemic counties. CONCLUSION SSPs are long researched, safe, and effective evidence-based programs that offer a variety of services that reduce disease transmission and assist with combating the overdose crisis. Opportunities to increase services in needed regions across the state now exist in Florida as supported by the expansion of the Infectious Disease Elimination Act of 2019. This study provides details where potential areas of concern may be and highlights regions where future evidence-based harm reduction programs, such as SSPs, would be useful to reduce opioid overdoses and disease transmission among PWID.Key messagesThe rate of acute HCV in Florida in 2017 was 1.9 per 100,000, nearly twice the national average.Serious injection related infections among PWID are significant indicators of acute HCV infection.High-priority SSP implementation locations in Florida were identified in both urban and rural communities, including those outside of current Ending the HIV Epidemic counties.
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Affiliation(s)
- Tyler S Bartholomew
- Division of Health Services Research and Policy, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hansel E Tookes
- Department of Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Emma C Spencer
- Florida Department of Health, Division of Disease Control and Health Protection, HIV/AIDS Section, Bureau of Communicable Diseases, Tallahassee, FL, USA
| | - Daniel J Feaster
- Division of Health Services Research and Policy, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
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Morales Y, Smyth E, Zubiago J, Bearnot B, Wurcel AG. "They Just Assume That We're All Going to Do the Wrong Thing With It. It's Just Not True": Stakeholder Perspectives About Peripherally Inserted Central Catheters in People Who Inject Drugs. Open Forum Infect Dis 2022; 9:ofac364. [PMID: 36267246 PMCID: PMC9579457 DOI: 10.1093/ofid/ofac364] [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: 03/30/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background In the absence of adequate harm reduction opportunities, people who inject drugs (PWID) are at increased risk for serious infections. Infectious diseases guidelines recommend extended periods of intravenous antibiotic treatment through peripherally inserted central catheters (PICCs), but PWID are often deemed unsuitable for this treatment. We conducted semi-structured interviews and focus groups to understand the perspectives and opinions of patients and clinicians on the use of PICCs for PWID. Methods We approached patients and clinicians (doctors, nurses, PICC nurses, social workers, and case workers) involved in patient care at Tufts Medical Center (Boston, Massachusetts) between August 2019 and April 2020 for semi-structured interviews and focus groups. Results Eleven of 14 (79%) patients agreed to participate in an in-depth interview, and 5 role-specific clinician focus groups (1 group consisting of infectious diseases, internal medicine, and addiction psychiatry doctors, 2 separate groups of floor nurses, 1 group of PICC nurses, and 1 group of social workers) were completed. Emergent themes included the overall agreement that PICCs improve healthcare, patients' feelings that their stage of recovery from addiction was not taken into consideration, and clinicians' anecdotal negative experiences driving decisions on PICCs. Conclusions When analyzed together, the experiences of PWID and clinicians shed light on ways the healthcare system can improve the quality of care for PWID hospitalized for infections. Further research is needed to develop a system of person-centered care for PWID that meets the specific needs of patients and improves the relationship between them and the healthcare system.
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Affiliation(s)
- Yoelkys Morales
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Emma Smyth
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Julia Zubiago
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Benjamin Bearnot
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
| | - Alysse G Wurcel
- Correspondence: Alysse G. Wurcel, MD, MS, Tufts Medical Center, Department of Geographic Medicine and Infectious Diseases, 800 Washington St, Boston MA 02111, USA ()
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Moore N, Kohut M, Stoddard H, Burris D, Chessa F, Sikka MK, Solomon D, Kershaw CM, Eaton E, Hutchinson R, Fairfield KM, Stopka TJ, Friedmann P, Thakarar K. Health care professional perspectives on discharging hospitalized patients with injection drug use-associated infections. Ther Adv Infect Dis 2022; 9:20499361221126868. [PMID: 36225855 PMCID: PMC9549088 DOI: 10.1177/20499361221126868] [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: 03/04/2022] [Accepted: 08/30/2022] [Indexed: 11/07/2022] Open
Abstract
Background: Patients with injection drug use (IDU)-associated infections traditionally
experience prolonged hospitalizations, which often result in negative
experiences and bad outcomes. Harm reduction approaches that value patient
autonomy and shared decision-making regarding outpatient treatment options
may improve outcomes. We sought to identify health care professionals (HCPs)
perspectives on the barriers to offering four different options to
hospitalized people who use drugs (PWUD): long-term hospitalization, oral
antibiotics, long-acting antibiotics at an infusion center, and outpatient
parenteral antibiotics. Methods: We recruited HCPs (n = 19) from a single tertiary care
center in Portland, Maine. We interviewed HCPs involved with discharge
decision-making and other HCPs involved in the specialized care of PWUD.
Semi-structured interviews elicited lead HCP values, preferences, and
concerns about presenting outpatient antimicrobial treatment options to
PWUD, while support HCPs provided contextual information. We used the
iterative categorization approach to code and thematically analyze
transcripts. Results: HCPs were willing to present outpatient treatment options for patients with
IDU-associated infections, yet several factors contributed to reluctance.
First, insufficient resources, such as transportation, may make these
options impractical. However, HCPs may be unaware of existing community
resources or viable treatment options. They also may believe the hospital
protects patients, and that discharging patients into the community exposes
them to structural harms. Some HCPs are concerned that patients with
substance use disorder will not make ‘good’ decisions regarding outpatient
antimicrobial options. Finally, there is uncertainty about how
responsibility for offering outpatient treatment is shared across changing
care teams. Conclusion: HCPs perceive many barriers to offering outpatient care for people with
IDU-associated infections, but with appropriate interventions to address
their concerns, may be open to considering more options. This study provides
important insights and contextual information that can help inform specific
harm reduction interventions aimed at improving care of people with
IDU-associated infections.
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Affiliation(s)
- Nichole Moore
- Tufts University School of Medicine, Boston,
MA, USA
| | - Michael Kohut
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
| | - Henry Stoddard
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
| | - Debra Burris
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
| | - Frank Chessa
- Tufts University School of Medicine, Boston,
MA, USA
| | - Monica K. Sikka
- Division of Infectious Diseases, Department of
Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Daniel Solomon
- Division of Infectious Disease, Brigham and
Women’s Hospital, Boston, MA, USA
| | - Colleen M. Kershaw
- Section of Infectious Disease and International
Health, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA,Geisel School of Medicine at Dartmouth,
Hanover, NH, USA
| | - Ellen Eaton
- Division of Infectious Disease, The University
of Alabama at Birmingham, Birmingham, AL, USA
| | - Rebecca Hutchinson
- Tufts University School of Medicine, Boston,
MA, USA,Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA,Maine Medical Center, Portland, ME, USA
| | - Kathleen M. Fairfield
- Tufts University School of Medicine, Boston,
MA, USA,Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA,Maine Medical Center, Portland, ME, USA
| | - Thomas J. Stopka
- Department of Public Health & Community
Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Peter Friedmann
- Office of Research, UMass Chan Medical
School-Baystate, Springfield, MA, USA,Frank Chessa is also affiliated to MaineHealth
Institute for Research, Portland, ME, USA; Maine Medical Center, Portland,
ME, USA
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20
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Brothers TD, Lewer D, Jones N, Colledge-Frisby S, Farrell M, Hickman M, Webster D, Hayward A, Degenhardt L. Opioid agonist treatment and risk of death or rehospitalization following injection drug use-associated bacterial and fungal infections: A cohort study in New South Wales, Australia. PLoS Med 2022; 19:e1004049. [PMID: 35853024 PMCID: PMC9295981 DOI: 10.1371/journal.pmed.1004049] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 06/12/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Injecting-related bacterial and fungal infections are associated with significant morbidity and mortality among people who inject drugs (PWID), and they are increasing in incidence. Following hospitalization with an injecting-related infection, use of opioid agonist treatment (OAT; methadone or buprenorphine) may be associated with reduced risk of death or rehospitalization with an injecting-related infection. METHODS AND FINDINGS Data came from the Opioid Agonist Treatment Safety (OATS) study, an administrative linkage cohort including all people in New South Wales, Australia, who accessed OAT between July 1, 2001 and June 28, 2018. Included participants survived a hospitalization with injecting-related infections (i.e., skin and soft-tissue infection, sepsis/bacteremia, endocarditis, osteomyelitis, septic arthritis, or epidural/brain abscess). Outcomes were all-cause death and rehospitalization for injecting-related infections. OAT exposure was classified as time varying by days on or off treatment, following hospital discharge. We used separate Cox proportional hazards models to assess associations between each outcome and OAT exposure. The study included 8,943 participants (mean age 39 years, standard deviation [SD] 11 years; 34% women). The most common infections during participants' index hospitalizations were skin and soft tissue (7,021; 79%), sepsis/bacteremia (1,207; 14%), and endocarditis (431; 5%). During median 6.56 years follow-up, 1,481 (17%) participants died; use of OAT was associated with lower hazard of death (adjusted hazard ratio [aHR] 0.63, 95% confidence interval [CI] 0.57 to 0.70). During median 3.41 years follow-up, 3,653 (41%) were rehospitalized for injecting-related infections; use of OAT was associated with lower hazard of these rehospitalizations (aHR 0.89, 95% CI 0.84 to 0.96). Study limitations include the use of routinely collected administrative data, which lacks information on other risk factors for injecting-related infections including injecting practices, injection stimulant use, housing status, and access to harm reduction services (e.g., needle exchange and supervised injecting sites); we also lacked information on OAT medication dosages. CONCLUSIONS Following hospitalizations with injection drug use-associated bacterial and fungal infections, use of OAT is associated with lower risks of death and recurrent injecting-related infections among people with opioid use disorder.
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Affiliation(s)
- Thomas D. Brothers
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, Australia
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
- Department of Medicine, Dalhousie University, Halifax, Canada
| | - Dan Lewer
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, Australia
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Nicola Jones
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, Australia
| | | | - Michael Farrell
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, Australia
| | - Matthew Hickman
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Duncan Webster
- Department of Medicine, Dalhousie University, Halifax, Canada
- Division of Infectious Diseases, Saint John Regional Hospital, Saint John, Canada
| | - Andrew Hayward
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, Australia
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21
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Brothers TD, Mosseler K, Kirkland S, Melanson P, Barrett L, Webster D. Unequal access to opioid agonist treatment and sterile injecting equipment among hospitalized patients with injection drug use-associated infective endocarditis. PLoS One 2022; 17:e0263156. [PMID: 35081174 PMCID: PMC8791472 DOI: 10.1371/journal.pone.0263156] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 01/12/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Addiction treatment and harm reduction services reduce risks of death and re-infection among patients with injection drug use-associated infective endocarditis (IDU-IE), but these are not offered at many hospitals. Among hospitalized patients with IDU-IE at the two tertiary-care hospitals in the Canadian Maritimes, we aimed to identify (1) the availability of opioid agonist treatment (OAT) and sterile drug injecting equipment, and (2) indicators of potential unmet addiction care needs. METHODS Retrospective review of IDU-IE hospitalizations at Queen Elizabeth II Health Sciences Centre (Halifax, Nova Scotia) and the Saint John Regional Hospital (Saint John, New Brunswick), October 2015 -March 2017. In Halifax, there are no addiction medicine providers on staff; in Saint John, infectious diseases physicians also practice addiction medicine. Inclusion criteria were: (1) probable or definite IE as defined by the modified Duke criteria; and (2) injection drug use within the prior 3 months. RESULTS We identified 38 hospitalizations (21 in Halifax and 17 in Saint John), for 30 unique patients. Among patients with IDU-IE and untreated opioid use disorder, OAT was offered to 36% (5/14) of patients in Halifax and 100% (6/6) of patients in Saint John. Once it was offered, most patients at both sites initiated OAT and planned to continue it after discharge. In Halifax, no patients were offered sterile injecting equipment, and during five hospitalizations staff confiscated patients' own equipment. In Saint John, four patients were offered (and one was provided) injecting equipment in hospital, and during two hospitalizations staff confiscated patients' own equipment. Concerns regarding undertreated pain or opioid withdrawal were documented during 66% (25/38) of hospitalizations, and in-hospital illicit or non-medical drug use during 32% (12/38). Two patients at each site (11%; 4/38) had self-directed discharges against medical advice. CONCLUSIONS Patients with IDU-IE in the Canadian Maritimes have unequal access to evidence-based addiction care depending on where they are hospitalized, which differs from the community-based standard of care. Indicators of potential unmet addiction care needs in hospital were common.
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Affiliation(s)
- Thomas D. Brothers
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- UCL Collaborative Centre for Inclusion Heath, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Kimiko Mosseler
- Dalhousie Medicine New Brunswick, Dalhousie University, Saint John, New Brunswick, Canada
| | - Susan Kirkland
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Patti Melanson
- Mobile Outreach Street Health (MOSH), Halifax, Nova Scotia, Canada
| | - Lisa Barrett
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Division of Infectious Diseases, Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Duncan Webster
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Division of Infectious Diseases, Saint John Regional Hospital and Dalhousie University, Saint John, New Brunswick, Canada
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