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Fredericksen RJ, Mixson LS, Estadt AT, Leichtling G, Bresett J, Zule W, Walters SM, Friedmann PD, Romo E, Whitney BM, Delaney JAC, Crane HM, Tsui JI, Young A, Seal D, Stopka TJ. Barriers to retention in inpatient and residential drug treatment among persons who use opioids and/or injection drugs living in the rural U.S. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 165:209453. [PMID: 39033853 PMCID: PMC11347080 DOI: 10.1016/j.josat.2024.209453] [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: 01/25/2024] [Revised: 05/30/2024] [Accepted: 07/02/2024] [Indexed: 07/23/2024]
Abstract
AIM Barriers to retention in inpatient and residential care for persons who use drugs are understudied in the rural context. We sought to better understand barriers to retention in inpatient and residential drug treatment in a large, multi-site, geographically diverse sample of persons who use opioids and/or injection drugs in the rural U.S. METHODS We conducted semi-structured individual interviews with persons currently using opioids and/or injection drugs in 9 U.S. states, including Illinois, Kentucky, Massachusetts, North Carolina, New Hampshire, Ohio, Oregon, Vermont, and Wisconsin. Content areas included substance use history and experiences with all modalities of drug treatment. We performed initial structural coding followed by an iterative "open-coding" process of itemizing and categorizing content within each code, and a multi-coder memoing process to summarize themes. We identified themes using three levels of the Social-Ecological Model (SEM): individual, interpersonal, and facility-level (organizational) barriers. RESULTS Among 304 interviewed, over half (n = 166, 54 %) reported having experienced inpatient and residential treatment. Lack of treatment retention was driven by interrelated factors at all levels of the SEM. Person-level factors inhibiting retention included lack of readiness to stop using, which was particularly true for court-ordered treatment, and dislike of "freedom limitations". The sole interpersonal-level factor was the influence of other patients on re-initiation of drug use. Facility-level barriers included unaddressed withdrawal symptoms and lack of access to MOUD, staff relatability, inadequate staff training, and, particularly in residential treatment, lack of structure and supervision. Lack of preparation for coping with real-world triggers was seen as a barrier to engagement in ongoing treatment. CONCLUSION Barriers to retention in inpatient and residential substance use treatment were present at three levels of the SEM. Interviews suggest much room for improvement in inpatient and residential drug treatment programs with respect to improving access to MOUD, tailoring content to better address social challenges in the rural context, and improving quality control measures with respect to staff and resident supervision.
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Affiliation(s)
- R J Fredericksen
- University of Washington, Department of Medicine, Seattle, WA, USA.
| | - L S Mixson
- University of Washington, Department of Medicine, Seattle, WA, USA
| | - A T Estadt
- Ohio State University, College of Public Health, Columbus, OH, USA
| | | | - J Bresett
- Southern Illinois University, School of Human Sciences, Carbondale, IL, USA
| | - W Zule
- RTI International, Durham, NC, USA
| | - S M Walters
- New York University, School of Global Public Health, New York, NY, USA
| | - P D Friedmann
- University of Massachusetts, Department of Medicine, Springfield, MA, USA
| | - E Romo
- University of Massachusetts, Clinical and Population Health Research, Springfield, MA, USA
| | - B M Whitney
- University of Washington, Department of Medicine, Seattle, WA, USA
| | - J A C Delaney
- University of Washington, Department of Medicine, Seattle, WA, USA
| | - H M Crane
- University of Washington, Department of Medicine, Seattle, WA, USA
| | - J I Tsui
- University of Washington, Department of Medicine, Seattle, WA, USA
| | - A Young
- University of Kentucky, Department of Epidemiology, Lexington, KY, USA
| | - D Seal
- Tulane University, School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - T J Stopka
- Tufts University, Department of Public Health and Community Medicine, Boston, MA, USA
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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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Goodman-Meza D, Goto M, Salimian A, Shoptaw S, Bui AAT, Gordon AJ, Goetz MB. Impact of Potential Case Misclassification by Administrative Diagnostic Codes on Outcome Assessment of Observational Study for People Who Inject Drugs. Open Forum Infect Dis 2024; 11:ofae030. [PMID: 38379573 PMCID: PMC10878055 DOI: 10.1093/ofid/ofae030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/12/2024] [Indexed: 02/22/2024] Open
Abstract
Introduction Initiation of medications for opioid use disorder (MOUD) within the hospital setting may improve outcomes for people who inject drugs (PWID) hospitalized because of an infection. Many studies used International Classification of Diseases (ICD) codes to identify PWID, although these may be misclassified and thus, inaccurate. We hypothesized that bias from misclassification of PWID using ICD codes may impact analyses of MOUD outcomes. Methods We analyzed a cohort of 36 868 cases of patients diagnosed with Staphylococcus aureus bacteremia at 124 US Veterans Health Administration hospitals between 2003 and 2014. To identify PWID, we implemented an ICD code-based algorithm and a natural language processing (NLP) algorithm for classification of admission notes. We analyzed outcomes of prescribing MOUD as an inpatient using both approaches. Our primary outcome was 365-day all-cause mortality. We fit mixed-effects Cox regression models with receipt or not of MOUD during the index hospitalization as the primary predictor and 365-day mortality as the outcome. Results NLP identified 2389 cases as PWID, whereas ICD codes identified 6804 cases as PWID. In the cohort identified by NLP, receipt of inpatient MOUD was associated with a protective effect on 365-day survival (adjusted hazard ratio, 0.48; 95% confidence interval, .29-.81; P < .01) compared with those not receiving MOUD. There was no significant effect of MOUD receipt in the cohort identified by ICD codes (adjusted hazard ratio, 1.00; 95% confidence interval, .77-1.30; P = .99). Conclusions MOUD was protective of all-cause mortality when NLP was used to identify PWID, but not significant when ICD codes were used to identify the analytic subjects.
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Affiliation(s)
- David Goodman-Meza
- Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Greater Los Angeles Veterans Health Administration, Los Angeles, California, USA
| | - Michihiko Goto
- University of Iowa, Iowa City, Iowa, USA
- Iowa City VA Medical Center, Iowa City, Iowa, USA
| | - Anabel Salimian
- Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Steven Shoptaw
- Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Alex A T Bui
- Medical & Imaging Informatics (MII) Group, Department of Radiological Sciences, UCLA, Los Angeles, California, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Matthew B Goetz
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Greater Los Angeles Veterans Health Administration, Los Angeles, California, USA
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Calcaterra SL, Saunders S, Grimm E, Maki-Gianani E, Keniston A, Wold A, Bonaguidi A. In-Hospital Methadone Enrollment: a Novel Program to Facilitate Linkage from the Hospital to the Opioid Treatment Program for Vulnerable Patients with Opioid Use Disorder. J Gen Intern Med 2024; 39:385-392. [PMID: 37715094 PMCID: PMC10897082 DOI: 10.1007/s11606-023-08411-0] [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: 06/30/2023] [Accepted: 09/01/2023] [Indexed: 09/17/2023]
Abstract
INTRODUCTION Methadone ameliorates opioid withdrawal among hospitalized patients with opioid use disorder (OUD). To continue methadone after hospital discharge, patients must enroll in an opioid treatment program (OTP) per federal regulations. Uncontrolled opioid withdrawal is a barrier to linkage from hospital to OTP. AIM Describe a federally compliant In-Hospital Methadone Enrollment Team (IN-MEET) that enrolls hospitalized patients with OUD into an OTP with facilitated hospital to OTP linkage. SETTING Seven hundred-bed university hospital in Aurora, CO. PROGRAM DESCRIPTION A physician dually affiliated with a hospital's addiction consultation service and a community OTP completes an in-hospital, face-to-face medical assessment required by federal law and titrates methadone to comfort. An OTP-affiliated nurse with hospital privileges completes a psychosocial evaluation and provides case management by arranging transportation and providing weekly telephone check-ins. PROGRAM EVALUATION METRICS IN-MEET enrollments completed, hospital to OTP linkage, and descriptive characteristics of patients who completed IN-MEET enrollments compared to patients who completed community OTP enrollments. RESULTS Between April 2019 and April 2023, our team completed 165 IN-MEET enrollments. Among a subset of 73 IN-MEET patients, 56 (76.7%) presented to the OTP following hospital discharge. Compared to community OTP enrolled patients (n = 1687), a higher percentage of IN-MEET patients were older (39.7 years, standard deviation [SD] 11.2 years vs. 36.1 years, SD 10.6 years) and were unhoused (n = 43, 58.9% vs. n = 199, 11.8%). Compared to community OTP enrolled patients, a higher percentage of IN-MEET patients reported heroin or fentanyl as their primary substance (n = 53, 72.6% vs. n = 677, 40.1%), reported methamphetamine as their secondary substance (n = 27, 37.0% vs. n = 380, 22.5%), and reported they injected their primary substance (n = 46, 63.0% vs. n = 478, 28.3%). CONCLUSION IN-MEET facilitates hospital to OTP linkage among a vulnerable population. This model has the potential to improve methadone access for hospitalized patients who may not otherwise seek out treatment.
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Affiliation(s)
- Susan L Calcaterra
- Division of Hospital Medicine, Department of Medicine, University of Colorado, Aurora, CO, USA.
- Division of General Internal Medicine, University of Colorado, Aurora, CO, USA.
| | - Scott Saunders
- Division of Hospital Medicine, Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Eric Grimm
- Division of Hospital Medicine, Department of Medicine, University of Colorado, Aurora, CO, USA
| | | | - Angela Keniston
- Division of Hospital Medicine, Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Angi Wold
- Department of Psychiatry, University of Colorado, Aurora, CO, USA
| | - Angela Bonaguidi
- Department of Psychiatry, University of Colorado, Aurora, CO, USA
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Gopaldas M, Wenzel K, Campbell ANC, Jalali A, Fishman M, Rotrosen J, Nunes EV, Murphy SM. Impact of Medication-Based Treatment on Health Care Utilization Among Individuals With Opioid Use Disorder. Psychiatr Serv 2023; 74:1227-1233. [PMID: 37337675 PMCID: PMC10730760 DOI: 10.1176/appi.ps.20220549] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
OBJECTIVE This study evaluated the association between medication for opioid use disorder (MOUD) and health care utilization over time among a sample of treatment-seeking individuals with opioid use disorder. In contrast to previous studies, this study used a novel measure of MOUD adherence, more comprehensive utilization data, and analyses that controlled for detailed individual and social determinants of health. METHODS This study was a secondary analysis of a comparative effectiveness trial (N=570) of extended-release naltrexone versus buprenorphine-naloxone. The outcome of interest was usage of nonstudy acute care, inpatient and outpatient addiction services, and other outpatient services across 36 weeks of assessment. Adherence (percentage of days taking MOUD) was defined as low (<20%), medium (≥20% but <80%), or high (≥80%). A two-part model evaluated the probability of utilizing a resource and the quantity (utilization days) of the resource consumed. A time-varying approach was used to examine the effect of adherence in a given month on utilization in the same month, with analyses controlling for a wide range of person-level characteristics. RESULTS Participants with high adherence (vs. low) were significantly less likely to use inpatient addiction (p<0.001) and acute care (p<0.001) services and significantly more likely to engage in outpatient addiction (p=0.045) and other outpatient (p=0.042) services. CONCLUSIONS These findings reinforce the understanding that greater MOUD adherence is associated with reduced usage of high-cost health services and increased usage of outpatient care. The results further suggest the need for enhanced access to MOUD and for interventions that improve adherence.
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Affiliation(s)
- Manesh Gopaldas
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
| | - Kevin Wenzel
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
| | - Aimee N C Campbell
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
| | - Ali Jalali
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
| | - Marc Fishman
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
| | - John Rotrosen
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
| | - Edward V Nunes
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
| | - Sean M Murphy
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
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Martin M, Englander H, Calcaterra SL. Things We Do for No Reason™: Avoiding methadone for opioid withdrawal. J Hosp Med 2023; 18:1034-1037. [PMID: 37244869 PMCID: PMC10870273 DOI: 10.1002/jhm.13138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/26/2023] [Accepted: 05/10/2023] [Indexed: 05/29/2023]
Affiliation(s)
- Marlene Martin
- Department of Medicine, Division of Hospital Medicine, San Francisco General Hospital, University of California, San Francisco, California, USA
| | - Honora Englander
- Department of Medicine, Section of Addiction Medicine in Division of General Internal Medicine & Geriatrics, Oregon Health & Science University, Oregon, Portland, USA
- Department of Medicine, Division of Hospital Medicine, Oregon Health & Science University, Oregon, Portland, USA
| | - Susan L. Calcaterra
- Department of Medicine, Divisions of Hospital Medicine and General Internal Medicine, University of Colorado Hospital, Aurora, Colorado, USA
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Calcaterra SL, Lockhart S, Natvig C, Mikulich S. Barriers to initiate buprenorphine and methadone for opioid use disorder treatment with postdischarge treatment linkage. J Hosp Med 2023; 18:896-907. [PMID: 37608527 PMCID: PMC10592161 DOI: 10.1002/jhm.13193] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/27/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Hospitals are an essential site of care for people with opioid use disorder (OUD). Buprenorphine and methadone are underutilized in the hospital. OBJECTIVES Characterize barriers to in-hospital buprenorphine or methadone initiation to inform implementation strategies to increase OUD treatment provision. DESIGN, SETTINGS, AND PARTICIPANTS Survey of hospital-based clinicians' perceptions of OUD treatment from 12 hospitals conducted between June 2022 and August 2022. MEASURES Survey questions were grouped into six domains: (1) evidence to treat OUD, (2) hospital processes to treat OUD, (3) buprenorphine or methadone initiation, (4) clinical practices to treat OUD, (5) leadership prioritization of OUD treatment, and (6) job satisfaction. Likert responses were dichotomized and associations between "readiness" to initiate buprenorphine or methadone and each domain were assessed. RESULTS Of 160 respondents (60% response rate), 72 (45%) reported higher readiness to initiate buprenorphine compared to methadone, 55 (34%). Respondents with higher readiness to initiate medications for OUD were more likely to perceive that evidence supports the use of buprenorphine and methadone to treat OUD (p < .001), to perceive fewer barriers to treat OUD (p < .001), to incorporate OUD treatment into their clinical practice (p < .001), to perceive leadership support for OUD treatment (p < .007), and to have great job satisfaction (p < .04). Clinicians reported that OUD treatment protocols with treatment linkage, increased education, and addiction specialist support would facilitate OUD treatment provision. CONCLUSION Interventions that incorporate protocols to initiate medications for OUD, include addiction specialist support and education, and ensure postdischarge OUD treatment linkage could facilitate hospital-based OUD treatment provision.
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Affiliation(s)
- Susan L. Calcaterra
- Department of Medicine, Divisions of General Internal Medicine and Hospital Medicine, Univeristy of Colorado, Aurora, CO, USA
- Adult and Child Center for Health Outcomes Research and Delivery Service, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - Steven Lockhart
- Adult and Child Center for Health Outcomes Research and Delivery Service, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - Crystal Natvig
- Department of Psychiatry, Univeristy of Colorado, Aurora, CO, USA
| | - Susan Mikulich
- Department of Psychiatry, Univeristy of Colorado, Aurora, CO, USA
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O'Rourke BP, Hogan TH, Teater J, Fried M, Williams M, Miller A, Clark AD, Huynh P, Kauffman E, Hefner JL. Initiation of medication for opioid use disorder across a health system: A retrospective analysis of patient characteristics and inpatient outcomes. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 5:100114. [PMID: 36844164 PMCID: PMC9948916 DOI: 10.1016/j.dadr.2022.100114] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/08/2022]
Abstract
Objectives Medication for opioid use disorder (MOUD) has gained significant momentum as an evidence-based intervention for treating opioid use disorder (OUD). The purpose of this study was to characterize MOUD initiations for buprenorphine and extended release (ER) naltrexone across all care sites at a major health system in the Midwest and determine whether MOUD initiation was associated with inpatient outcomes. Methods The study population comprised patients with OUD in the health system between 2018 and 2021. First, we described characteristics of all MOUD initiations for the study population within the health system. Second, we compared inpatient length of stay (LOS) and unplanned readmission rates between patients prescribed MOUD and patients not prescribed MOUD, including a pre-post comparison of patients prescribed MOUD before versus after initiation. Results The 3,831 patients receiving MOUD were mostly white, non-Hispanic and generally received buprenorphine over ER naltrexone. 65.5% of most recent initiations occurred in an inpatient setting. Compared to those not prescribed MOUD, inpatient encounters where patients received MOUD on or before the admission date were significantly less likely to be unplanned readmissions (13% vs. 20%, p < 0.001) and their LOS was 0.14 days shorter (p = 0.278). Among patients prescribed MOUD, there was a significant reduction in the readmission rate after initiation compared to before (13% vs. 22%, p < 0.001). Conclusions This study is the first to examine MOUD initiations for thousands of patients across multiple care sites in a health system, finding that receiving MOUD is associated with clinically meaningful reductions in readmission rates.
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Affiliation(s)
- Brian P. O'Rourke
- The Division of Health Services Management and Policy, College of Public Health, The Ohio State University, 1841 Neil Ave Rm 250, Columbus, OH 43210, USA,Corresponding author.
| | - Tory H. Hogan
- The Division of Health Services Management and Policy, College of Public Health, The Ohio State University, 1841 Neil Ave Rm 250, Columbus, OH 43210, USA
| | - Julie Teater
- The Department of Psychiatry and Behavioral Health, College of Medicine, The Ohio State University, 370 W. 9th Avenue, Columbus, OH 43210, USA
| | - Martin Fried
- The Division of General Internal Medicine, College of Medicine, The Ohio State University, 370 W. 9th Avenue, Columbus, OH 43210, USA
| | - Margaret Williams
- The Division of Hospital Medicine, College of Medicine, The Ohio State University, 370 W. 9th Avenue, Columbus, OH 43210, USA
| | - Alison Miller
- Neurological Institute, The Ohio State University Wexner Medical Center, 410 W. 10th Ave, Columbus, OH 43210, USA
| | - Aaron D. Clark
- The Department of Family and Community Medicine, College of Medicine, The Ohio State University, 370 W. 9th Avenue, Columbus, OH 43210, USA
| | - Phuong Huynh
- The Department of Family and Community Medicine, College of Medicine, The Ohio State University, 370 W. 9th Avenue, Columbus, OH 43210, USA
| | - Emily Kauffman
- The Division of General Internal Medicine, College of Medicine, The Ohio State University, 370 W. 9th Avenue, Columbus, OH 43210, USA,Department of Emergency Medicine, College of Medicine, The Ohio State University, 370 W. 9th Avenue, Columbus, OH 43210, USA
| | - Jennifer L. Hefner
- The Division of Health Services Management and Policy, College of Public Health, The Ohio State University, 1841 Neil Ave Rm 250, Columbus, OH 43210, USA,The Department of Family and Community Medicine, College of Medicine, The Ohio State University, 370 W. 9th Avenue, Columbus, OH 43210, USA
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Associations Between Inpatient Induction on Medications for Opioid Use Disorder and Postdischarge Medications for Opioid Use Disorder Adherence, Overdose, and Service Use. J Addict Med 2022:01271255-990000000-00096. [PMID: 36255110 DOI: 10.1097/adm.0000000000001092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study aimed to examine outcomes of a pilot program designed to increase inpatient medications for opioid use disorder (MOUD) induction and to support MOUD adherence after discharge. METHODS This retrospective cohort analysis examined Medicaid adults diagnosed with opioid use disorder discharged from 2 freestanding inpatient withdrawal management facilities between October 1, 2018, and December 31, 2019. Participants had ≥90 days of continuous Medicaid enrollment before and after admission. Odds ratios (ORs) examined associations of inpatient MOUD induction with discharge against medical advice, 7- and 30-day all-cause hospital readmission, and postdischarge MOUD adherence. Mixed-effect models examined changes associated with MOUD induction and postdischarge MOUD adherence in acute service utilization and opioid overdose in the 90-day postdischarge period. RESULTS Of the 2332 patients discharged, 493 started MOUD inpatient care (21.1%), with most initiating buprenorphine (76.5%). Induction of MOUD was associated with a lower likelihood of discharge against medical advice (OR, 0.49; 95% confidence interval [CI], 0.37-0.64), 30-day all-cause hospital readmission (OR, 0.61; 95% CI, 0.47-0.80), and higher odds of postdischarge MOUD adherence (OR, 3.83; 95% CI, 3.06-4.81). In the 90 days after discharge, MOUD adherent patients had significant reductions in emergency department visits for behavioral health, inpatient days, withdrawal management episodes, and opioid overdoses compared with the 90-day preadmission period. CONCLUSIONS Inpatient MOUD induction is associated with a higher likelihood of short-term MOUD adherence after discharge, which in turn is associated with significant reductions in short-term service utilization and opioid overdose after discharge.
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Englander H, Jones A, Krawczyk N, Patten A, Roberts T, Korthuis PT, McNeely J. A Taxonomy of Hospital-Based Addiction Care Models: a Scoping Review and Key Informant Interviews. J Gen Intern Med 2022; 37:2821-2833. [PMID: 35534663 PMCID: PMC9411356 DOI: 10.1007/s11606-022-07618-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/12/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND There is pressing need to improve hospital-based addiction care. Various models for integrating substance use disorder care into hospital settings exist, but there is no framework for describing, selecting, or comparing models. We sought to fill that gap by constructing a taxonomy of hospital-based addiction care models based on scoping literature review and key informant interviews. METHODS Methods included a scoping review of the literature on US hospital-based addiction care models and interventions for adults, published between January 2000 and July 2021. We conducted semi-structured interviews with 15 key informants experienced in leading, implementing, evaluating, andpracticing hospital-based addiction care to explore model characteristics, including their perceived strengths, limitations, and implementation considerations. We synthesized findings from the literature review and interviews to construct a taxonomy of model types. RESULTS Searches identified 2,849 unique abstracts. Of these, we reviewed 280 full text articles, of which 76 were included in the final review. We added 8 references from reference lists and informant interviews, and 4 gray literature sources. We identified six distinct hospital-based addiction care models. Those classified as addiction consult models include (1) interprofessional addiction consult services, (2) psychiatry consult liaison services, and (3) individual consultant models. Those classified as practice-based models, wherein general hospital staff integrate addiction care into usual practice, include (4) hospital-based opioid treatment and (5) hospital-based alcohol treatment. The final type was (6) community-based in-reach, wherein community providers deliver care. Models vary in their target patient population, staffing, and core clinical and systems change activities. Limitations include that some models have overlapping characteristics and variable ways of delivering core components. DISCUSSION A taxonomy provides hospital clinicians and administrators, researchers, and policy-makers with a framework to describe, compare, and select models for implementing hospital-based addiction care and measure outcomes.
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Affiliation(s)
- Honora Englander
- Section of Addiction Medicine in Division of General Internal Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
- Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Amy Jones
- School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Noa Krawczyk
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Alisa Patten
- Section of Addiction Medicine in Division of General Internal Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Timothy Roberts
- NYU Health Sciences Library, New York University Grossman School of Medicine, New York, NY, USA
| | - P Todd Korthuis
- Section of Addiction Medicine in Division of General Internal Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jennifer McNeely
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
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Calcaterra SL, Lockhart S, Callister C, Hoover K, Binswanger IA. Opioid Use Disorder Treatment Initiation and Continuation: a Qualitative Study of Patients Who Received Addiction Consultation and Hospital-Based Providers. J Gen Intern Med 2022; 37:2786-2794. [PMID: 34981359 PMCID: PMC8722657 DOI: 10.1007/s11606-021-07305-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 11/23/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Hospitalizations related to opioid use disorder (OUD) are rising. Addiction consultation services (ACS) increasingly provide OUD treatment to hospitalized patients, but barriers to initiating and continuing medications for OUD remain. We examined facilitators and barriers to hospital-based OUD treatment initiation and continuation from the perspective of patients and healthcare workers in the context of an ACS. METHODS In this qualitative study, we sought input using key informant interviews and focus groups from patients who received care from an ACS during their hospitalization and from hospitalists, pharmacists, social workers, and nurses who work in the hospital setting. A multidisciplinary team coded and analyzed transcripts using a directed content analysis. FINDINGS We conducted 20 key informant interviews with patients, nine of whom were interviewed following hospital discharge and 12 of whom were interviewed during a rehospitalization. We completed six focus groups and eight key informant interviews with hospitalists and hospital-based medical staff (n = 62). Emergent themes related to hospital-based OUD treatment included the following: the benefit of an ACS to facilitate OUD treatment engagement; expanded use of methadone or buprenorphine to treat opioid withdrawal; the triad of hospitalization, self-efficacy, and easily accessible, patient-centered treatment motivates change in opioid use; adequate pain control and stabilization of mental health conditions among patients with OUD contributed to opioid agonist therapy (OAT) continuation; and stable housing and social support are prerequisites for OAT uptake and continuation. CONCLUSION Modifiable factors which facilitate hospital-based OUD treatment initiation and continuation include availability of in-hospital addiction expertise to offer easily accessible, patient-centered treatment and the use of methadone or buprenorphine to manage opioid withdrawal. Further research and public policy efforts are urgently needed to address reported barriers to hospital-based OUD treatment initiation and continuation which include unstable housing, poorly controlled chronic medical and mental illness, and lack of social support.
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Affiliation(s)
- Susan L Calcaterra
- Division of General Internal Medicine, University of Colorado, 8th Floor, Academic Office 1, Mailstop B180, 12631 E 17th Ave, Aurora, CO, 80045, USA.
- Division of Hospital Medicine, University of Colorado, Aurora, CO, USA.
| | - Steve Lockhart
- Adult and Child Consortium for Health Outcomes Research and Delivery Service, Univeristy of Colorado, School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | | | - Kaitlyn Hoover
- Clinical Science Graduate Program, University of Colorado, Aurora, CO, USA
| | - Ingrid A Binswanger
- Division of General Internal Medicine, University of Colorado, 8th Floor, Academic Office 1, Mailstop B180, 12631 E 17th Ave, Aurora, CO, 80045, USA
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Colorado Permanente Medical Group, Aurora, CO, USA
- Bernard J. Tyson School of Medicine, Pasadena, CA, USA
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Methadone treatment and patient-directed hospital discharges among patients with opioid use disorder: Observations from general medicine services at an urban, safety-net hospital. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 3:100066. [PMID: 36845982 PMCID: PMC9949313 DOI: 10.1016/j.dadr.2022.100066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/13/2022] [Accepted: 05/11/2022] [Indexed: 11/22/2022]
Abstract
Introduction People with opioid use disorder (OUD) have high rates of discharge against medical advice from the hospital. Interventions for addressing these patient-directed discharges (PDDs) are lacking. We sought to explore the impact of methadone treatment for OUD on PDD. Methods Using electronic record and billing data from an urban safety-net hospital, we retrospectively examined the first hospitalization on a general medicine service for adults with OUD from January 2016 through June 2018. Associations with PDD compared to planned discharge were examined using multivariable logistic regression. Administration patterns of maintenance therapy versus new in-hospital initiation of methadone were examined using bivariate tests. Results During the study time period, 1,195 patients with OUD were hospitalized. 60.6% of patients received medication for OUD, of which 92.8% was methadone. Patients who received no treatment for OUD had a 19.1% PDD rate while patients initiated on methadone in-hospital had a 20.5% PDD rate and patients on maintenance methadone during the hospitalization had a 8.6% PDD rate. In multivariable logistic regression, methadone maintenance was associated with lower odds of PDD compared to no treatment (aOR 0.53, 95% CI 0.34-0.81), while methadone initiation was not (aOR 0.89, 95% CI 0.56-1.39). About 60% of patients initiated on methadone received 30 mg or less per day. Conclusions In this study sample, maintenance methadone was associated with nearly a 50% reduction in the odds of PDD. More research is needed to assess the impact of higher hospital methadone initiation dosing on PDD and if there is an optimal protective dose.
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