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Hayes CJ, Raciborski RA, Martin BC, Gordon AJ, Hudson TJ, Brown CC, Pro G, Cucciare MA. Are gaps in rates of retention on buprenorphine for treatment of opioid use disorder closing among veterans across different races and ethnicities? A retrospective cohort study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 166:209461. [PMID: 39067770 PMCID: PMC11392633 DOI: 10.1016/j.josat.2024.209461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 05/05/2024] [Accepted: 07/11/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION The U.S. Veterans Health Administration has undertaken several initiatives to improve veterans' access to and retention on buprenorphine because it prevents overdose and reduces drug-related morbidity. We aimed to determine whether improvements in retention duration over time was equitable across veterans of different races and ethnicities. METHODS This retrospective cohort study was conducted among veterans who initiated buprenorphine from federal fiscal years (FY) 2006 to 2020 after diagnosis of opioid use disorder. Using an accelerated failure time model, we estimated the association between time to buprenorphine discontinuation and FY of initiation, race and ethnicity, and other control covariates. We followed veterans from buprenorphine initiation until they discontinued or had a censoring event. We then estimated the predicted median days retained on buprenorphine, the average marginal effect of initiating in a later FY, the same measure by race and ethnicity, the incremental effect of the various racial and ethnic identities in contrast to non-Hispanic White, and the total change in the size of the gap over the 15 years of the study between veterans with a minoritized racial or ethnic identity compared to non-Hispanic White veterans. RESULTS Most of the 31,797 veterans in the sample were non-Hispanic White (74.5 %), from urban areas (83.5 %), male (92.0 %), and had significant comorbidities, most frequently anxiety disorders (51.0 %) and depression (63.0 %). Overall, 49.8 % of veterans were retained at least 180 days. The average marginal effect of FY was 7.0 days [95%CI:5.3, 8.8] but was significantly smaller among veterans identifying as Black or African American [3.2 days; 95%CI:2.4, 4.1] or Asian [3.6 days; 95%CI:1.6, 5.7] compared to veterans who identify as non-Hispanic White [7.9 days; 95%CI:5.9, 9.9]. Additional measures of change were significant for veterans identifying as Hispanic White or with two or more races. CONCLUSION Although buprenorphine retention in OUD treatment improved for all veterans over the 15-year study period, veterans from most minoritized racial and ethnic groups fell further behind as gains in duration on therapy accrued primarily to non-Hispanic White veterans. Targeted interventions addressing specific challenges experienced by veterans with minoritized identities are needed to close gaps in retention on buprenorphine.
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Affiliation(s)
- Corey J Hayes
- Department of Biomedical Informatics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Institute for Digital Health and Innovation, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA.
| | - Rebecca A Raciborski
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA; Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA; Evidence, Policy, and Implementation Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
| | - Bradley C Martin
- Division of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Healthcare System, Salt Lake City, UT, USA; Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Teresa J Hudson
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA; Center for Health Services Research, Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Clare C Brown
- Department of Health Policy and Management, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - George Pro
- Department of Health Behavior and Health Education, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Michael A Cucciare
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA; Center for Health Services Research, Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
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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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Calcaterra SL, Dafoe A, Tietbohl C, Thurman L, Bredenberg E. Unintended consequences of methadone regulation for opioid use disorder treatment among hospitalized patients. J Hosp Med 2024; 19:460-467. [PMID: 38507276 PMCID: PMC11282870 DOI: 10.1002/jhm.13329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/29/2024] [Accepted: 03/07/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND In the United States, there are no federal restrictions on the use of methadone to manage opioid withdrawal symptoms when patients are hospitalized with a medical or surgical condition other than addiction. In contrast, in an outpatient setting, methadone for opioid use disorder (OUD) is highly regulated by federal and state governments and can only be dispensed from an opioid treatment program (OTP). Discrepancies in regulatory requirements across these settings may lead to barriers in care for patients with OUD. OBJECTIVE Identify how methadone regulation impacts the care of patients with OUD during hospitalization, care transitions, and in the OTP setting. METHODS We completed 26 interviews with clinicians and social workers working on hospital-based addiction consultation services across the United States. Study findings are the result of a secondary content analysis of interviews to identifying the word "methadone" and construct themes resulting from the data. RESULTS We identified three major themes related to "methadone" for OUD treatment, all of which impacted patient care: (1) limited OTP hours leads to tenuous or delayed hospital discharges; (2) inadequate information-sharing between hospitals and OTPs leads to delays in care; and (3) methadone regulations create treatment barriers for the most vulnerable patients. CONCLUSION Strict methadone regulations have resulted in unintended consequences for patients with OUD in the hospital setting, during care transitions, and in the OTP setting. Recent and ongoing federal efforts to reform methadone provision may improve some of the reported challenges, but significant hurdles remain in providing safe, equitable care to hospitalized patients with OUD.
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Affiliation(s)
- Susan L. Calcaterra
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Coloroda, USA
| | - Ashley Dafoe
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Coloroda, USA
| | - Caroline Tietbohl
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Coloroda, USA
| | - Lindsay Thurman
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Erin Bredenberg
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Jalali A. Informing evidence-based medicine for opioid use disorder using pharmacoeconomic studies. Expert Rev Pharmacoecon Outcomes Res 2024; 24:599-611. [PMID: 38696161 PMCID: PMC11389975 DOI: 10.1080/14737167.2024.2350561] [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: 01/11/2024] [Accepted: 04/29/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION The health and economic consequences of inadequately treated opioid use disorder (OUD) are substantial. Healthcare systems in the United States (US) and other countries are facing a growing healthcare crisis due to opioids. Although effective medications for OUD exist, relying solely on clinical information is insufficient for addressing the opioid crisis. AREAS COVERED In this review, the role of pharmacoeconomic studies in informing evidence-based medication treatment for OUD is discussed, with a particular emphasis on the US healthcare system, where the economic burden is significantly higher than the global average. The scope/objective of pharmacoeconomics as a distinct scientific research program is briefly defined, followed by a discussion of existing evidence informed by data from systematic reviews, in addition to a convenience sample of recently published pharmacoeconomic studies and protocols. The review also explores the need for methodological advancements in the field. EXPERT OPINION Despite the potential of pharmacoeconomic research in shaping evidence-based medicine for OUD, significant challenges limiting its real-world application remain. How to address these challenges are explored, including how to combine cost-effectiveness and budget impact analyses to address the needs of the healthcare system as a whole and specific stakeholders interested in adopting new OUD treatment strategies.
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Affiliation(s)
- Ali Jalali
- Department of Population Health Sciences, Division of Comparative Effectiveness & Outcomes Research, Joan and Sanford I. Weill Medical College of Cornell University, New York, NY, USA
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Merz S, Aksakal T, Hibtay A, Yücesoy H, Fieselmann J, Annaç K, Yılmaz-Aslan Y, Brzoska P, Tezcan-Güntekin H. Racism against healthcare users in inpatient care: a scoping review. Int J Equity Health 2024; 23:89. [PMID: 38698455 PMCID: PMC11067303 DOI: 10.1186/s12939-024-02156-w] [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: 01/08/2024] [Accepted: 03/19/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Racism in the healthcare system has become a burgeoning focus in health policy-making and research. Existing research has shown both interpersonal and structural forms of racism limiting access to quality healthcare for racialised healthcare users. Nevertheless, little is known about the specifics of racism in the inpatient sector, specifically hospitals and rehabilitation facilities. The aim of this scoping review is therefore to map the evidence on racial discrimination experienced by people receiving treatment in inpatient settings (hospitals and rehabilitation facilities) or their caregivers in high-income countries, focusing specifically on whether intersectional axes of discrimination have been taken into account when describing these experiences. METHODS Based on the conceptual framework developed by Arksey and O'Malley, this scoping review surveyed existing research on racism and racial discrimination in inpatient care in high-income countries published between 2013 and 2023. The software Rayyan was used to support the screening process while MAXQDA was used for thematic coding. RESULTS Forty-seven articles were included in this review. Specifics of the inpatient sector included different hospitalisation, admission and referral rates within and across hospitals; the threat of racial discrimination from other healthcare users; and the spatial segregation of healthcare users according to ethnic, religious or racialised criteria. While most articles described some interactions between race and other social categories in the sample composition, the framework of intersectionality was rarely considered explicitly during analysis. DISCUSSION While the USA continue to predominate in discussions, other high-income countries including Canada, Australia and the UK also examine racism in their own healthcare systems. Absent from the literature are studies from a wider range of European countries as well as of racialised and disadvantaged groups other than refugees or recent immigrants. Research in this area would also benefit from an engagement with approaches to intersectionality in public health to produce a more nuanced understanding of the interactions of racism with other axes of discrimination. As inpatient care exhibits a range of specific structures, future research and policy-making ought to consider these specifics to develop targeted interventions, including training for non-clinical staff and robust, transparent and accessible complaint procedures.
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Affiliation(s)
- Sibille Merz
- Faculty of Health and Education, Alice Salomon University of Applied Sciences, Alice-Salomon-Platz 5, 12627, Berlin, Germany
| | - Tuğba Aksakal
- Faculty of Health, School of Medicine, Witten/Herdecke University, Health Services Research Unit. Alfred-Herrhausen-Straße 50, 58448, Witten, Germany
| | - Ariam Hibtay
- Faculty of Health and Education, Alice Salomon University of Applied Sciences, Alice-Salomon-Platz 5, 12627, Berlin, Germany
| | - Hilâl Yücesoy
- Faculty of Health and Education, Alice Salomon University of Applied Sciences, Alice-Salomon-Platz 5, 12627, Berlin, Germany
| | - Jana Fieselmann
- Faculty of Health, School of Medicine, Witten/Herdecke University, Health Services Research Unit. Alfred-Herrhausen-Straße 50, 58448, Witten, Germany
| | - Kübra Annaç
- Faculty of Health, School of Medicine, Witten/Herdecke University, Health Services Research Unit. Alfred-Herrhausen-Straße 50, 58448, Witten, Germany
| | - Yüce Yılmaz-Aslan
- Faculty of Health, School of Medicine, Witten/Herdecke University, Health Services Research Unit. Alfred-Herrhausen-Straße 50, 58448, Witten, Germany
| | - Patrick Brzoska
- Faculty of Health, School of Medicine, Witten/Herdecke University, Health Services Research Unit. Alfred-Herrhausen-Straße 50, 58448, Witten, Germany.
| | - Hürrem Tezcan-Güntekin
- Faculty of Health and Education, Alice Salomon University of Applied Sciences, Alice-Salomon-Platz 5, 12627, Berlin, Germany
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Lindsay AR, Winkelman TNA, Bart G, Rhodes MT, Shearer RD. Hospital Addiction Medicine Consultation Service Orders and Outcomes by Patient Race and Ethnicity in an Urban, Safety-Net Hospital. J Gen Intern Med 2024; 39:168-175. [PMID: 37552419 PMCID: PMC10853106 DOI: 10.1007/s11606-023-08356-4] [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: 02/13/2023] [Accepted: 07/27/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Hospital admissions involving substance use disorders are increasing and represent an opportunity to engage patients in substance use treatment. Addiction medicine consultation services improve access to medications for opioid use disorder (MOUD) and patient outcomes. However, as hospitals continue to adopt addiction medicine consultation services it is important to identify where disparities may emerge in the process of care. OBJECTIVE To describe addiction medicine consultation service use by race and ethnicity as well as substance to identify opportunities to reduce substance use treatment disparities. DESIGN Retrospective cohort study using 2016-2021 Electronic Health Record data from a large Midwest safety-net hospital. PARTICIPANTS Hospitalized adults aged 18 or older, with one or more substance use disorders. MAIN MEASURES Consultation orders placed, patient seen by consult provider, and receipt of MOUD by self-reported race. KEY RESULTS Between 2016 and 2021, we identified 16,895 hospitalized patients with a substance use disorder. Consultation orders were placed for 6344 patients and 2789 were seen by the consult provider. Black patients were less likely (aOR = 0.58; 95% CI: 0.53-0.63) to have an addiction medicine consultation order placed and, among patients with a consultation order, were less likely (aOR = 0.74; 95% CI: 0.65-0.85) to be seen by the consult provider than White patients. Overall, Black patients with OUD were also less likely to receive MOUD in the hospital (aOR = 0.63; 95% CI: 0.50-0.79) compared to White patients. However, there were no differences in MOUD receipt among Black and White patients seen by the consult provider. CONCLUSIONS Using Electronic Health Record data, we identified racial and ethnic disparities at multiple points in the inpatient addiction medicine consultation process. Addressing these disparities may support more equitable access to MOUD and other substance use treatment in the hospital setting.
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Affiliation(s)
- Amber R Lindsay
- Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Tyler N A Winkelman
- Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA
- Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Gavin Bart
- Division of Addiction Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Michael T Rhodes
- Division of Hospital Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Riley D Shearer
- Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, USA.
- Division of Health Policy and Management, School of Public Health, University of Minnesota Medical School, 420 Delaware St. Minneapolis, Minneapolis, DE, 55455, USA.
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Alrawashdeh M, Rhee C, Klompas M, Larochelle MR, Poland RE, Guy JS, Kimmel SD. Association of Early Opioid Withdrawal Treatment Strategy and Patient-Directed Discharge Among Hospitalized Patients with Opioid Use Disorder. J Gen Intern Med 2023; 38:2289-2297. [PMID: 36788169 PMCID: PMC10406767 DOI: 10.1007/s11606-023-08059-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 01/26/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Medical hospitalizations for people with opioid use disorder (OUD) frequently result in patient-directed discharges (PDD), often due to untreated pain and withdrawal. OBJECTIVE To investigate the association between early opioid withdrawal management strategies and PDD. DESIGN Retrospective cohort study using three datasets representing 362 US hospitals. PARTICIPANTS Adult patients hospitalized between 2009 and 2015 with OUD (as identified using ICD-9-CM codes or inpatient buprenorphine administration) and no PDD on the day of admission. INTERVENTIONS Opioid withdrawal management strategies were classified based on day-of-admission receipt of any of the following treatments: (1) medications for OUD (MOUD) including methadone or buprenorphine, (2) other opioid analgesics, (3) adjunctive symptomatic medications without opioids (e.g., clonidine), and (4) no withdrawal treatment. MAIN MEASURES PDD was assessed as the main outcome and hospital length of stay as a secondary outcome. KEY RESULTS Of 6,715,286 hospitalizations, 127,158 (1.9%) patients had OUD and no PDD on the day of admission, of whom 7166 (5.6%) had a later PDD and 91,051 (71.6%) patients received some early opioid withdrawal treatment (22.3% MOUD; 43.4% opioid analgesics; 5.9% adjunctive medications). Compared to no withdrawal treatment, MOUD was associated with a lower risk of PDD (adjusted odds ratio [aOR] = 0.73, 95%CI 0.68-0.8, p < .001), adjunctive treatment alone was associated with higher risk (aOR = 1.13, 95%CI: 1.01-1.26, p = .031), and treatment with opioid analgesics alone was associated with similar risk (aOR 0.95, 95%CI: 0.89-1.02, p = .148). Among those with PDD, both MOUD (adjusted incidence rate ratio [aIRR] = 1.24, 95%CI: 1.17-1.3, p < .001) and opioid analgesic treatments (aIRR = 1.39, 95%CI: 1.34-1.45, p < .001) were associated with longer hospital stays. CONCLUSIONS MOUD was associated with decreased risk of PDD but was utilized in < 1 in 4 patients. Efforts are needed to ensure all patients with OUD have access to effective opioid withdrawal management to improve the likelihood they receive recommended hospital care.
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Affiliation(s)
- Mohammad Alrawashdeh
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.
- Jordan University of Science and Technology, Irbid, Jordan.
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Marc R Larochelle
- Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Russell E Poland
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
- HCA Healthcare, Nashville, TN, USA
| | | | - Simeon D Kimmel
- Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
- Section of Infectious Diseases, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
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Wang J, Claman A, Singh S, Sidelnik SA, Arshed A. Best Practices in Substance Use Disorders to Achieve Treatment Equity in Consultation-Liaison Psychiatry. Psychiatr Ann 2023. [DOI: 10.3928/00485713-20230103-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Calcaterra SL, Bottner R, Martin M, Englander H, Weinstein ZM, Weimer MB, Lambert E, Ronan MV, Huerta S, Zaman T, Ullal M, Peterkin AF, Torres-Lockhart K, Buresh M, O’Brien MT, Snyder H, Herzig SJ. Management of opioid use disorder, opioid withdrawal, and opioid overdose prevention in hospitalized adults: A systematic review of existing guidelines. J Hosp Med 2022; 17:679-692. [PMID: 35880821 PMCID: PMC9474657 DOI: 10.1002/jhm.12908] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/11/2022] [Accepted: 05/22/2022] [Indexed: 12/20/2022]
Abstract
BACKGROUND Hospitalizations related to the consequences of opioid use are rising. National guidelines directing in-hospital opioid use disorder (OUD) management do not exist. OUD treatment guidelines intended for other treatment settings could inform in-hospital OUD management. OBJECTIVE Evaluate the quality and content of existing guidelines for OUD treatment and management. DATA SOURCES OVID MEDLINE, PubMed, Ovid PsychINFO, EBSCOhost CINHAL, ERCI Guidelines Trust, websites of relevant societies and advocacy organizations, and selected international search engines. STUDY SELECTION Guidelines published between January 2010 to June 2020 addressing OUD treatment, opioid withdrawal management, opioid overdose prevention, and care transitions among adults. DATA EXTRACTION We assessed quality using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. DATA SYNTHESIS Nineteen guidelines met the selection criteria. Most recommendations were based on observational studies or expert consensus. Guidelines recommended the use of nonstigmatizing language among patients with OUD; to assess patients with unhealthy opioid use for OUD using the Diagnostic Statistical Manual of Diseases-5th Edition criteria; use of methadone or buprenorphine to treat OUD and opioid withdrawal; use of multimodal, nonopioid therapy, and when needed, short-acting opioid analgesics in addition to buprenorphine or methadone, for acute pain management; ensuring linkage to ongoing methadone or buprenorphine treatment; referring patients to psychosocial treatment; and ensuring access to naloxone for opioid overdose reversal. CONCLUSIONS Included guidelines were informed by studies with various levels of rigor and quality. Future research should systematically study buprenorphine and methadone initiation and titration among people using fentanyl and people with pain, especially during hospitalization.
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Affiliation(s)
- Susan L. Calcaterra
- Department of Medicine, Division of General Internal Medicine and Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
| | - Richard Bottner
- Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, TX, USA
| | - Marlene Martin
- Department of Medicine, Division of Hospital Medicine, University of California San Francisco and San Francisco General Hospital, San Francisco, CA, USA
| | - Honora Englander
- Section of Addiction Medicine and Division of Hospital Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Zoe M. Weinstein
- Boston University School of Medicine, Boston Medical Center, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, Boston, MA, USA
| | | | - Eugene Lambert
- Harvard Medical School, Boston, MA and Massachusetts General Hospital, Medicine, Charlestown, MA, USA
| | - Matthew V. Ronan
- Harvard Medical School, Boston, MA and Massachusetts General Hospital, Medicine, Charlestown, MA, USA
- Department of Medicine, VA Boston Healthcare System, West Roxbury, MA, USA
| | - Sergio Huerta
- Department of Internal Medicine, Division of Hospital Medicine, University of New Mexico School of Medicine, NM, USA
| | - Tauheed Zaman
- San Francisco VA Medical Center, San Francisco, CA, USA
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Monish Ullal
- Department of Internal Medicine at Highland Hospital, Alameda Health System, Oakland, CA, USA
| | - Alyssa F. Peterkin
- Boston University School of Medicine, Boston Medical Center, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, Boston, MA, USA
| | | | - Megan Buresh
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Meghan T. O’Brien
- Department of Medicine, Division of Hospital Medicine, University of California San Francisco and San Francisco General Hospital, San Francisco, CA, USA
| | - Hannah Snyder
- Family Community Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Shoshana J. Herzig
- Harvard Medical School, Boston, MA and Massachusetts General Hospital, Medicine, Charlestown, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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