Intensive Case Management for Addiction to promote engagement with care of people with severe mental and substance use disorders: an observational study

Motivations for Misusing Opioids Among African Americans

BACKGROUND

A wide range of opioid misuse motives have been documented in the literature, including to relieve physical pain, feel good/get high, relax, manage feelings/emotions, sleep, and moderate the effects of other substances. Despite a rise in opioid misuse among African Americans over the last 2 decades, their motivations for misuse remain unclear. Much of the research on opioid misuse motivations either rely on samples with little racial diversity or do not stratify their findings by race. As a result, less is known about the specific reasons why African Americans engage in opioid misuse. The objective of this study, therefore, was to identify and explain the most common motives for misusing opioids among African Americans. Qualitative interview data are also presented to explain/contextualize the most prevalent motivations.

METHODS

This study used data from the Florida Minority Health Survey, a mixed-methods project that included online surveys (n = 303) and qualitative in-depth interviews (n = 30) of African Americans. Data collection was conducted from August 2021 to February 2022 throughout Southwest Florida.

RESULTS

Analyses revealed that while some (33.9%) misused opioids for purposes of recreation/sensation seeking (eg, feel good/get high), the majority (66.1%) were attempting to self-treat perceived medical symptoms (eg, physical pain, anxiety/trauma, withdrawals, insomnia).

CONCLUSIONS

This study contributes to a better understanding of why some African Americans engage in opioid misuse and findings highlight the need for interventions to be trauma informed and address unmanaged physical pain among African Americans. Given that most studies on motivations are quantitative in nature, the study contributes to the literature by capturing the voices of African Americans who use drugs.

Profiles of patients with substance-related disorders who dropped out or not from addiction treatment

This longitudinal study identified profiles of patients with substance-related disorders (SRD) who did or did not drop out of specialized addiction treatment, integrating various patterns of outpatient service use. Medical administrative databases of Quebec (Canada) were used to investigate a cohort of 16,179 patients with SRD who received specialized addiction treatment. Latent class analysis identified patient profiles, based on multi-year outpatient service use. Four patient profiles related to treatment dropout were identified: patients who did not drop out and were low service users (Profile 1); patients who did not drop out and were high service users (Profile 2); patients who dropped out and were low service users (Profile 3); patients who dropped out and were high service users (Profile 4). Profile 1 had the best health and social conditions, while Profile 4 had the worst. The risks of being frequent emergency department users, being hospitalized or dying were highest in Profile 4, followed by Profiles 3, 2 and 1. Assertive treatment programs may be suited to Profile 4 and intensive case management programs to Profile 3. Collaborative care with higher psychosocial interventions and regularity of care may be extended to Profile 2 and interventions integrating motivational treatment to Profile 1.

Predictors of dropout from treatment among patients using specialized addiction treatment centers

OBJECTIVES

This study investigated the use of outpatient care, and sociodemographic and clinical characteristics of patients with substance-related disorders (SRD) to predict treatment dropout from specialized addiction treatment centers. The study also explored risks of adverse outcomes, frequent emergency department (ED) use (3+ visits/year), and death, associated with treatment dropout within the subsequent 12 months.

METHODS

The study examined a cohort of 16,179 patients who completed their last treatment episode for SRD between 2012 and 13 and 2014-15 (financial years: April 1 to March 31) in 14 specialized addiction treatment centers using Quebec (Canada) health administrative databases. We used multivariable logistic regressions to measure risk of treatment dropout (1996-96 to 2014-15), while we used survival analysis controlling for sex and age to assess the odds of frequent ED use and death in 2015-16.

RESULTS

Of the 55 % of patients reporting dropout from SRD treatment over the 3-year period, 17 % were frequent ED users, and 1 % died in the subsequent 12 months. Patients residing in the most socially deprived areas, having polysubstance-related disorders or personality disorders, and having previously dropped out from specialized addiction treatment centers had increased odds of current treatment dropout. Older patients, those with a history of homelessness, past SRD treatment, or more concurrent outpatient care outside specialized addiction treatment centers had decreased odds of treatment dropout. Patients who dropped out were subsequently at higher risk of frequent ED use and death.

CONCLUSIONS

This study highlighted that patients with more severe problems and previous dropout may need more sustained and adequate help to prevent subsequent treatment dropout. Specialized addiction treatment centers may consider enhancing their follow-up care of patients over a longer duration and better integrating their treatment with other outpatient care resources to meet the multiple needs of the more vulnerable patients using their services.

Extended-Release Naltrexone and Case Management for Treatment of Alcohol Use Disorder in the Emergency Department

STUDY OBJECTIVE

To assess the feasibility of initiating treatment for alcohol use disorder with extended-release naltrexone and case management services in the emergency department (ED) and measure the intervention's impact on daily alcohol consumption and quality of life.

METHODS

This is a 12-week prospective open-label single-arm study of a multimodal treatment for alcohol use disorder consisting of monthly extended-release naltrexone injections and case management services initiated at an urban academic ED. Participants were actively drinking adult patients in ED with known or suspected alcohol use disorder and an AUDIT-C score more than 4. The main feasibility outcomes included the rates of participant enrollment, retention in the study, and continuing treatment after study completion. Efficacy outcomes were the change in daily alcohol consumption (drinks per day; 14 g ethanol per drink), measured by a 14-day timeline followback, and the change in quality of life measured with a single-item Kemp quality of life scale.

RESULTS

One hundred seventy-nine patients were approached, and 32 were enrolled (18%). Of the 32 enrolled patients, 25 (78%) completed all visits, and 22 (69%) continued naltrexone after the trial. The mean baseline daily alcohol consumption was 7.6 drinks per day (interquartile range, 4.5, 13.4), and the mean quality of life was 3.6 (SD 1.7) on a 7-point scale. The median daily alcohol consumption change was -7.5 drinks per day (Hodges-Lehmann 95% confidence interval -8.6, -5.9). The mean quality of life change was 1.2 points (95% confidence interval 0.5, 1.9; P<.01).

CONCLUSION

We found that initiation of treatment of alcohol use disorder with extended-release naltrexone and case management is feasible in an ED setting and observed significant reductions in drinking with improved quality of life in the short term. Multicenter randomized controlled trials are needed to further validate these findings.

Profiles of quality of outpatient care use, associated sociodemographic and clinical characteristics, and adverse outcomes among patients with substance-related disorders

BACKGROUND

This study identified patient profiles in terms of their quality of outpatient care use, associated sociodemographic and clinical characteristics, and adverse outcomes based on frequent emergency department (ED) use, hospitalization, and death from medical causes.

METHODS

A cohort of 18,215 patients with substance-related disorders (SRD) recruited in addiction treatment centers was investigated using Quebec (Canada) health administrative databases. A latent class analysis was produced, identifying three profiles of quality of outpatient care use, while multinomial and logistic regressions tested associations with patient characteristics and adverse outcomes, respectively.

RESULTS

Profile 1 patients (47% of the sample), labeled "Low outpatient service users", received low quality of care. They were mainly younger, materially and socially deprived men, some with a criminal history. They had more recent SRD, mainly polysubstance, and less mental disorders (MD) and chronic physical illnesses than other Profiles. Profile 2 patients (36%), labeled "Moderate outpatient service users", received high continuity and intensity of care by general practitioners (GP), while the diversity and regularity in their overall quality of outpatient service was moderate. Compared with Profile 1, they  were older, less likely to be unemployed or to live in semi-urban areas, and most had common MD and chronic physical illnesses. Profile 3 patients (17%), labeled "High outpatient service users", received more intensive psychiatric care and higher quality of outpatient care than other Profiles. Most Profile 3 patients lived alone or were single parents, and fewer lived in rural areas or had a history of homelessness, versus Profile 1 patients. They were strongly affected by MD, mostly serious MD and personality disorders. Compared with Profile 1, Profile 3 had more frequent ED use and hospitalizations, followed by Profile 2. No differences in death rates emerged among the profiles.

CONCLUSIONS

Frequent ED use and hospitalization were strongly related to patient clinical and sociodemographic profiles, and the quality of outpatient services received to the severity of their conditions. Outreach strategies more responsive to patient needs may include motivational interventions and prevention of risky behaviors for Profile 1 patients, collaborative GP-psychiatrist care for Profile 2 patients, and GP care and intensive specialized treatment for Profile 3 patients.

Effectiveness of crisis resolution home treatment for the management of acute psychiatric crises in Southern Switzerland: a natural experiment based on geography

BACKGROUND

Crisis Resolution Home Treatment (CRHT) is an alternative to inpatient treatment for acute psychiatric crises management. However, evidence on CRHT effectiveness is still limited. In the Canton of Ticino (Southern Switzerland), in 2016 the regional public psychiatric hospital replaced one acute ward with a CRHT. The current study was designed within this evaluation setting to assess the effectiveness of CRHT compared to standard inpatient treatment.

METHODS

CRHT was offered to patients aged 18 to 65 with an acute psychiatric crisis that would have required hospitalization. We used a natural experiment based on geography, where intervention and control groups were formed according to the place of residence. Primary endpoints were reduction of psychiatric symptoms at discharge measured using the Health of the Nation Outcome Scales, treatment duration in days, and rate and length of readmissions during a two-year follow-up period after discharge. Safety during the treatment period was measured with the number of serious adverse events (suicide/suicide attempts, major self-harm episodes, acute alcohol/drug intoxications, aggressions to caregivers or family members). We used linear, log-linear and logistic regression models with propensity scores for the main analysis.

RESULTS

We enrolled 321 patients; 67 were excluded because the treatment period was too short and 17 because they were transferred before the end of the treatment. Two hundred thirty-seven patients were available for data analysis, 93 in the intervention group and 144 in the control group. No serious adverse event was observed during the treatment period in both groups. Reduction of psychiatric symptoms at discharge (p-value = 0.359), readmission rates (p-value = 0.563) and length of readmissions (p-value = 0.770) during the two-year follow-up period did not differ significantly between the two groups. Treatment duration was significantly higher in the treatment group (+ 29.6% on average, p-value = 0.002).

CONCLUSIONS

CRHT was comparable to standard hospitalization in terms of psychiatric symptoms reduction, readmission rates and length of readmissions, but it was also characterized by a longer first treatment period. However, observational evidence following the study indicated that CRHT duration constantly lowered over time since its introduction in 2016 and became comparable to hospitalization, showing therefore to be an effective alternative also in terms of treatment length.

TRIAL REGISTRATION

ISRCTN38472626 (17/11/2020, retrospectively registered).

Patterns of Service Use in Intensive Case Management: A Six Year Longitudinal Study

An Intensive Case Management (ICM) intervention has been developed in Lausanne, Switzerland. It aims to promote access to care for people with severe mental disorders who have difficulties to engage with mental health services because of the severity of their disorders and/or their marginality. ICM embrace components of assertive community treatment and critical time intervention. It is time limited and focused on critical phases of recovery. The goal of this study was to examine the heterogeneity of service use patterns of people who required ICM interventions and identify differences in patterns of duration and timing of the intervention. Records of 471 patients from the Department of Psychiatry of Lausanne University Hospital for whom the ICM team intervention was requested were analysed over a 6 year period with discrete sequential-state analysis. Trajectories could be split between six meaningful clusters including service light use and critical time intervention (58.0%), transition to long-term regular ambulatory-care (11.3%), partial transition to ambulatory care (14.4%), alternative to hospitalization (10.4%), continued ICM (4.9%) and long hospital stays (1.1%). Diagnoses of substance abuse were overrepresented among heavy users and diagnoses of schizophrenia were the most frequent diagnostic overall. Profiles of service use for ICM patients were very diverse. Long term interventions were frequently not necessary. A time-limited intervention was likely sufficient to stabilize the situation and/or engage the patient in care. A small number of situations required a sustained and long-term investment and did not always allowed for a reduction in the need for hospitalization. A general reflection on alternatives to hospitalization must be pursued, in particular for these patients.

Substance Use/Dependence in Psychiatric Emergency Setting Leading to Hospitalization: Predictors of Continuity of Care

Background: Poor adherence to treatment is a common clinical problem in individuals affected by mental illness and substance use/dependence. In Italy, mental care is organized in a psychiatric service and addiction unit (SERD), characterized by dual independent assets of treatment. This difference, in the Emergency Room setting, leads to a risk of discontinuity of treatment in case of hospitalization. In this study we clinically characterized individuals who decided to attend hospital post-discharge appointments at SERD, in accordance with medical advice. Methods: This is a retrospective study, based on two years of discharged records of patients entering “Versilia Hospital” (Viareggio, Italy) emergency room, with urinalyses testing positive for substance use, and hospitalization after psychiatric consultation. The sample was divided according to the presence or absence of SERD consultation after discharge. Results: In the 2-year period of the present study, 1005 individuals were hospitalized. Considering the inclusion criterion of the study, the sample consisted of 264 individuals. Of these, 128 patients attended post-discharge appointments at SERD showing urinalyses positive to cocaine, opiates, and poly use; they were more frequently diagnosed as personality disorder and less frequently as bipolar disorder. The prediction was higher for patients that had already been treated at SERD, for patients who received SERD consultation during hospitalization, and for patients with positive urinalyses to cocaine and opiates at treatment entry. Conversely, patients who did not attend SERD consultation after discharge were affected by bipolar disorders. Limitations: Small sample size. Demographical data are limited to gender and age due to paucity of data in hospital information systems. SERD is located far from the hospital and is open only on weekdays; thus, it cannot ensure a consultation with all inpatients. Conclusions: Mental illness diagnosis, the set of substance use positivity at hospitalization, and having received SERD consultation during hospitalization appeared to have a critical role in promoting continuity of care. Moreover, to reduce the gap between the need and the provision of the treatment, a more effective personalized individual program of care should be implemented.

Substance Use Disorders as a Critical Element for Decision-Making in Forensic Assertive Community Treatment: A Systematic Review

Introduction: The prevalence of substance use disorders in forensic populations is high. They are an important factor linked to negative outcomes in mentally ill offenders and are detrimental to forensic or non-forensic outcome measures. In contrast, substance use disorders are often underdiagnosed and undertreated, especially in forensic settings. Forensic Assertive Community Treatment is a forensic adaptation of regular assertive community treatment, combined with essential elements of forensic rehabilitation theories. Little is known however on the effectivity of forensic assertive community treatment when it comes to substance use disorders or what their exact role is on the outcome measures. In this paper, we explore how SUD is treated in Forensic assertive community treatment and how it relates to the forensic and non-forensic outcome measures. Methods: We performed a systematic review (PRISMA) of forensic Assertive community treatment teams that followed the main evidence-based principles of regular assertive community treatment and added basic elements of forensic rehabilitation. We analyzed articles the Psychinfo and Medline databases dating from 2005 to 2020. Fifteen studies fit the search criteria and were included in the analysis. The Quality of the studies was assessed using the Newcastle-Ottawa scale. Results: SUD was highly prevalent in all studies. Patients entered FACT through two pathways, either from a care continuum or directly from prison. The severity of SUD at intake emerges as a critical element when deciding which pathway to choose, as a high severity-score at the start of FACT follow-up was linked to recidivism. While differing in method all studies offered integrated SUD treatment. These included evidence-based techniques like CBT, therapeutic communities, and Substance Abuse Management Module. Though results on SUD outcomes were mixed 4 studies mentioned abstinence in 50-75%. The severity of SUD tended to increase initially and to stabilize afterwards. Conclusion: Severity of SUD at intake emerges as a decisive element in decision-making on entering FACT teams directly from prison or through a care-continuum. The ways to provide SUD treatment varied and outcomes for SUD were mixed. SUD was found to be detrimental to forensic and non-forensic outcome measures, such as recidivism or hospitalizations during FACT treatment.

A comprehensive review of prioritised interventions to improve the health and wellbeing of persons with lived experience of homelessness

Background

Homelessness has emerged as a public health priority, with growing numbers of vulnerable populations despite advances in social welfare. In February 2020, the United Nations passed a historic resolution, identifying the need to adopt social-protection systems and ensure access to safe and affordable housing for all. The establishment of housing stability is a critical outcome that intersects with other social inequities. Prior research has shown that in comparison to the general population, people experiencing homelessness have higher rates of infectious diseases, chronic illnesses, and mental-health disorders, along with disproportionately poorer outcomes. Hence, there is an urgent need to identify effective interventions to improve the lives of people living with homelessness.

Objectives

The objective of this systematic review is to identify, appraise, and synthesise the best available evidence on the benefits and cost-effectiveness of interventions to improve the health and social outcomes of people experiencing homelessness.

Search Methods

In consultation with an information scientist, we searched nine bibliographic databases, including Medline, EMBASE, and Cochrane CENTRAL, from database inception to February 10, 2020 using keywords and MeSH terms. We conducted a focused grey literature search and consulted experts for additional studies.

Selection Criteria

Teams of two reviewers independently screened studies against our inclusion criteria. We included randomised control trials (RCTs) and quasi-experimental studies conducted among populations experiencing homelessness in high-income countries. Eligible interventions included permanent supportive housing (PSH), income assistance, standard case management (SCM), peer support, mental health interventions such as assertive community treatment (ACT), intensive case management (ICM), critical time intervention (CTI) and injectable antipsychotics, and substance-use interventions, including supervised consumption facilities (SCFs), managed alcohol programmes and opioid agonist therapy. Outcomes of interest were housing stability, mental health, quality of life, substance use, hospitalisations, employment and income.

Data Collection and Analysis

Teams of two reviewers extracted data in duplicate and independently. We assessed risk of bias using the Cochrane Risk of Bias tool. We performed our statistical analyses using RevMan 5.3. For dichotomous data, we used odds ratios and risk ratios with 95% confidence intervals. For continuous data, we used the mean difference (MD) with a 95% CI if the outcomes were measured in the same way between trials. We used the standardised mean difference with a 95% CI to combine trials that measured the same outcome but used different methods of measurement. Whenever possible, we pooled effect estimates using a random-effects model.

Main Results

The search resulted in 15,889 citations. We included 86 studies (128 citations) that examined the effectiveness and/or cost-effectiveness of interventions for people with lived experience of homelessness. Studies were conducted in the United States (73), Canada (8), United Kingdom (2), the Netherlands (2) and Australia (1). The studies were of low to moderate certainty, with several concerns regarding the risk of bias. PSH was found to have significant benefits on housing stability as compared to usual care. These benefits impacted both high- and moderate-needs populations with significant cimorbid mental illness and substance-use disorders. PSH may also reduce emergency department visits and days spent hospitalised. Most studies found no significant benefit of PSH on mental-health or substance-use outcomes. The effect on quality of life was also mixed and unclear. In one study, PSH resulted in lower odds of obtaining employment. The effect on income showed no significant differences. Income assistance appeared to have some benefits in improving housing stability, particularly in the form of rental subsidies. Although short-term improvement in depression and perceived stress levels were reported, no evidence of the long-term effect on mental health measures was found. No consistent impact on the outcomes of quality of life, substance use, hospitalisations, employment status, or earned income could be detected when compared with usual services. SCM interventions may have a small beneficial effect on housing stability, though results were mixed. Results for peer support interventions were also mixed, though no benefit was noted in housing stability specifically. Mental health interventions (ICM, ACT, CTI) appeared to reduce the number of days homeless and had varied effects on psychiatric symptoms, quality of life, and substance use over time. Cost analyses of PSH interventions reported mixed results. Seven studies showed that PSH interventions were associated with increased cost to payers and that the cost of the interventions were only partially offset by savings in medical- and social-services costs. Six studies revealed that PSH interventions saved the payers money. Two studies focused on the cost-effectiveness of income-assistance interventions. For each additional day housed, clients who received income assistance incurred additional costs of US$45 (95% CI, -$19, -$108) from the societal perspective. In addition, the benefits gained from temporary financial assistance were found to outweigh the costs, with a net savings of US$20,548. The economic implications of case management interventions (SCM, ICM, ACT, CTI) was highly uncertain. SCM clients were found to incur higher costs than those receiving the usual care. For ICM, all included studies suggested that the intervention may be cost-offset or cost-effective. Regarding ACT, included studies consistently revealed that ACT saved payers money and improved health outcomes than usual care. Despite having comparable costs (US$52,574 vs. US$51,749), CTI led to greater nonhomeless nights (508 vs. 450 nights) compared to usual services.

Authors' Conclusions

PSH interventions improved housing stability for people living with homelessness. High-intensity case management and income-assistance interventions may also benefit housing stability. The majority of included interventions inconsistently detected benefits for mental health, quality of life, substance use, employment and income. These results have important implications for public health, social policy, and community programme implementation. The COVID-19 pandemic has highlighted the urgent need to tackle systemic inequality and address social determinants of health. Our review provides timely evidence on PSH, income assistance, and mental health interventions as a means of improving housing stability. PSH has major cost and policy implications and this approach could play a key role in ending homelessness. Evidence-based reviews like this one can guide practice and outcome research and contribute to advancing international networks committed to solving homelessness.

Recovery opioid overdose team (ROOT) pilot program evaluation: A community-wide post-overdose response strategy

BACKGROUND

Effective interventions for overdose survivors are needed in the emergency departments (EDs). One promising model is the use of peer recovery coaches to engage with survivors in EDs, followed by partnering with community case management navigators to connect survivors to recovery support and treatment services. This paper describes the evaluation of a pilot program, the Recovery Opioid Overdose Team (ROOT), a warm hand-off system that links survivors to treatment services post-ED discharge. Methods: The ROOT program is composed of a peer recovery coach who is in long-term recovery, and a case management navigator who specializes in mental health care and provides guidance for accessing community services. After an overdose reversal, law enforcement contacts a county 24/7 Crisis Team, who then notifies ROOT. The peer recovery coach engages with the survivor in the ED, and then follow up continues with the case management navigator and the peer recovery coach for up to 90 days post-ED discharge. Retrospective chart reviews were conducted to evaluate ROOT in two Midwest EDs from September 2017 through March 2019. Results: Of the 122 referrals, 77.0% (n = 94) of the survivors initially engaged with ROOT in the ED or in the community. The remaining 23.0% (n = 28) left the ED against medical advice or were unengaged. The majority of overdose survivors were male (63.9%; n = 78), White (43.4%; n = 53), had housing (80.2%; n = 48), and access to transportation (48.4%; n = 59). From the 122 referrals, 33.6% (n = 41) received ongoing treatment services (n = 20 outpatient, n = 17 residential, n = 2 detoxification facility, n = 1 recovery housing, n = 1 medication treatment for opioid use disorder), 2.5% (n = 3) were incarcerated, 2.5% (n = 3) died, and 61.5% (n = 75) declined services. Conclusions: The ROOT, a community-wide coordinated program in the EDs, shows promise in linking overdose survivors to recovery support and treatment services post-overdose.

Accountability and participation: how to overcome the tutelary character in the psychosocial care center for alcohol and drug users?

OBJECTIVE

Analyze the degree of accountability and participation of user under treatment at the Psychosocial Care Center for Alcohol and Drug Users (CAPS-ad) from the harm reduction policy perspective.

METHODS

It is a qualitative approach study, case study type, with 12 users and four professionals from CAPS-ad in a county of Minas Gerais state. Data were collected from April to September 2017, by means of semi-structured interview, participant observation and documental analysis.

RESULTS

Based on content analysis, information was organized in two thematic categories: treatment objectives and motivation for treatment. Conclusions: the study's findings revealed that users should be more held accountable and empowered with regard to their treatment.

CONCLUSIONS

More professional listening is suggested, favoring the constructions of goals befitting users' interests, as contracts.