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Szpak V, Prostko S, Weiss RD, Suzuki J. Developing a remotely delivered intensive outpatient program adapted for hospitalized patients with opioid use disorder: A qualitative study. Addict Behav Rep 2024; 19:100546. [PMID: 38680207 PMCID: PMC11046241 DOI: 10.1016/j.abrep.2024.100546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 04/01/2024] [Accepted: 04/17/2024] [Indexed: 05/01/2024] Open
Abstract
Introduction Individuals with opioid use disorder (OUD) who inject drugs have an elevated risk of experiencing serious injection-related infections. While such infections can be treated, treatment for the underlying OUD is often limited. One potential strategy for more intensive addiction treatment is to offer a remotely delivered intensive outpatient program (IOP), adapted from an existing remote IOP ("Smart IOP"). We aimed to conduct a qualitative study to gather feedback on Smart IOP and identify adaptations needed for hospitalized patients. Methods Individuals with OUD and a history of serious injection-related infections completed a semi-structured interview and were shown samples of the videos and program content. The interviews were transcribed verbatim and coded to conduct a thematic analysis. Results Seventeen individuals participated. The mean age was 40.8 years and 70.6 % were men. Participants reported that IOP during the hospitalization would have been helpful to their recovery. The themes that emerged were the importance of medications for OUD, having a relapse prevention plan, engaging with a recovery coach, and ensuring treatment linkage post-discharge. Other themes included the recognition of the severity of one's illness and the emotional experiences related to the hospitalization. Conclusions Participants expressed the value of an IOP during hospitalization and provided insights into the support needed while hospitalized. The tailored IOP is now being developed and will undergo a pilot feasibility trial.
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Affiliation(s)
- Veronica Szpak
- Department of Psychiatry, Brigham and Women’s Hospital, Boston, MA, United States
| | - Sara Prostko
- Department of Psychiatry, Brigham and Women’s Hospital, Boston, MA, United States
| | - Roger D. Weiss
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
- Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA, United States
| | - Joji Suzuki
- Department of Psychiatry, Brigham and Women’s Hospital, Boston, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
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Franz B, Cronin CE, Lindenfeld Z, Pagan JA, Lai AY, Krawczyk N, Rivera BD, Chang JE. Rural-urban disparities in the availability of hospital-based screening, medications for opioid use disorder, and addiction consult services. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 160:209280. [PMID: 38142042 PMCID: PMC11060933 DOI: 10.1016/j.josat.2023.209280] [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: 07/29/2023] [Revised: 10/07/2023] [Accepted: 12/15/2023] [Indexed: 12/25/2023]
Abstract
INTRODUCTION Hospitals are an ideal setting to stage opioid-related interventions with patients who are hospitalized due to overdose or other substance use-related complications. Transitional opioid programs-which initiate care and provide linkages upon discharge, such as screening, initiation of medications for opioid use disorder, and addiction consult services-have become the gold standard, but implementation has been uneven. The purpose of this study was to assess disparities in the availability of hospital-based transitional opioid programs, across rural and urban hospital settings in the United States. METHODS Using hospital administrative data paired with county-level demographic data, we conducted bivariate and regression analyses to assess rural-urban differences in the availability of transitional opioid services including screening, addiction consult services, and MOUD in U.S general medical centers, controlling for hospital- and community-level factors. Our sample included 2846 general medical hospitals that completed the 2021 American Hospital Association (AHA) Annual Survey of Hospitals. Our primary outcomes were five self-reported measures: whether the hospital provided screening in the ED; provided screening in the inpatient setting; whether the hospital provided addiction consult services in the ED; provided addiction consult services in the inpatient setting; and whether the hospital provided medications for opioid use disorder. RESULTS Rural hospitals did not have lower odds of screening for OUD or other SUDs than urban hospitals, but both micropolitan rural counties and noncore rural counties had significantly lower odds of having addiction consult services in either the ED (OR: 0.74, 95 % CI: 0.58, 0.95; OR: 0.68, 95 % CI: 0.50, 0.91) or inpatient setting (OR: 0.76, 95 % CI: 0.59, 0.97; OR: 0.68, 95 % CI: 0.50, 0.93), respectively, or of offering MOUD (OR: 0.69, 95 % CI: 0.52, 0.90; OR: 0.52, 95 % CI: 0.37, 0.74). CONCLUSIONS Our study suggests that evidence-based interventions, such as medications for opioid use disorder and addiction consult services, are less often available in rural hospitals, which may contribute to rural-urban disparities in health outcomes secondary to OUD. A priority for population health improvement should be developing implementation strategies to support rural hospital adoption of transitional opioid programs.
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Affiliation(s)
- Berkeley Franz
- Ohio University Heritage College of Osteopathic Medicine, Appalachian Institute to Advance Health Equity Science (ADVANCE), United States of America.
| | - Cory E Cronin
- Ohio University College of Social and Public Health, Appalachian Institute to Advance Health Equity Science (ADVANCE), United States of America
| | - Zoe Lindenfeld
- New York University College of Global Public Health, United States of America
| | - Jose A Pagan
- New York University College of Global Public Health, United States of America
| | - Alden Yuanhong Lai
- New York University College of Global Public Health, United States of America
| | - Noa Krawczyk
- New York University Grossman School of Medicine, United States of America
| | - Bianca D Rivera
- New York University Grossman School of Medicine, United States of America
| | - Ji E Chang
- New York University College of Global Public Health, United States of America
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Kuye IO, Prichett LM, Stewart RW, Berkowitz SA, Buresh ME. The association between opioid use disorder and skilled nursing facility acceptances: A multicenter retrospective cohort study. J Hosp Med 2024; 19:377-385. [PMID: 38458154 DOI: 10.1002/jhm.13302] [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: 10/15/2023] [Revised: 01/21/2024] [Accepted: 01/31/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Prior single-hospital studies have documented barriers to acceptance that hospitalized patients with opioid use disorder (OUD) face when referred to skilled nursing facilities (SNFs). OBJECTIVE To examine the impact of OUD on the number of SNF referrals and the proportion of referrals accepted. DESIGN, SETTINGS, AND PARTICIPANTS A retrospective cohort study of hospitalizations with SNF referrals in 2019 at two academic hospitals in Baltimore, MD. EXPOSURE OUD status was determined by receipt of medications for OUD during admission, upon discharge, or the presence of a diagnosis code for OUD. KEY RESULTS The cohort included 6043 hospitalizations (5440 hospitalizations of patients without OUD and 603 hospitalizations of patients with OUD). Hospitalizations of patients with OUD had more SNF referrals sent (8.9 vs. 5.6, p < .001), had a lower proportion of SNF referrals accepted (31.3% vs. 46.9%, p < .001), and were less likely to be discharged to an SNF (65.6% vs. 70.3%, p = .003). The effect of OUD status on the number of SNF referrals and the proportion of referrals accepted remained significant in multivariable analyses. Our subanalysis showed that reduced acceptances were driven by the hospitalizations of patients discharged without medications for OUD and those receiving methadone. Hospitalizations of patients discharged on buprenorphine were accepted at the same rates as hospitalizations of patients without OUD. CONCLUSIONS This multicenter retrospective cohort study found that hospitalizations of patients with OUD had more SNF referrals sent and fewer referrals accepted. Further work is needed to address the limited discharge options for patients with OUD.
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Affiliation(s)
- Ifedayo O Kuye
- Division of Hospital Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Laura M Prichett
- Biostatistics, Epidemiology and Data Management Core, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rosalyn W Stewart
- Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Scott A Berkowitz
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Megan E Buresh
- Division of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Nordeck CD, Kelly SM, Schwartz RP, Mitchell SG, Welsh C, O'Grady KE, Gryczynski J. Hospital admissions among patients with Comorbid Substance Use disorders: a secondary analysis of predictors from the NavSTAR Trial. Addict Sci Clin Pract 2024; 19:33. [PMID: 38678216 PMCID: PMC11056040 DOI: 10.1186/s13722-024-00463-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 04/09/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Individuals with substance use disorders (SUDs) frequently use acute hospital services. The Navigation Services to Avoid Rehospitalization (NavSTAR) trial found that a patient navigation intervention for hospitalized patients with comorbid SUDs reduced subsequent inpatient admissions compared to treatment-as-usual (TAU). METHODS This secondary analysis extends previous findings from the NavSTAR trial by examining whether selected patient characteristics independently predicted hospital service utilization and moderated the effect of the NavSTAR intervention. Participants were 400 medical/surgical hospital patients with comorbid SUDs. We analyzed 30- and 90-day inpatient readmissions (one or more readmissions) and cumulative incidence of inpatient admissions through 12 months using multivariable logistic and negative binomial regression, respectively. RESULTS Consistent with primary findings and controlling for patient factors, NavSTAR participants were less likely than TAU participants to be readmitted within 30 (P = 0.001) and 90 (P = 0.03) days and had fewer total readmissions over 12 months (P = 0.008). Hospitalization in the previous year (P < 0.001) was associated with cumulative readmissions over 12 months, whereas Medicaid insurance (P = 0.03) and index diagnoses of infection (P = 0.001) and injuries, poisonings, or procedural complications (P = 0.004) were associated with fewer readmissions. None of the selected covariates moderated the effect of the NavSTAR intervention. CONCLUSIONS Previous findings showed that patient navigation could reduce repeat hospital admissions among patients with comorbid SUDs. Several patient factors were independently associated with readmission. Future research should investigate risk factors for hospital readmission among patients with comorbid SUDs to optimize interventions. TRIAL REGISTRATION NIH ClinicalTrials.gov NCT02599818, Registered November 9, 2015 https://classic. CLINICALTRIALS gov/ct2/show/NCT02599818 .
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Affiliation(s)
- Courtney D Nordeck
- Friends Research Institute, 1040 Park Avenue #103, Baltimore, MD, USA, 21201.
| | - Sharon M Kelly
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert P Schwartz
- Friends Research Institute, 1040 Park Avenue #103, Baltimore, MD, USA, 21201
| | - Shannon G Mitchell
- Friends Research Institute, 1040 Park Avenue #103, Baltimore, MD, USA, 21201
| | | | | | - Jan Gryczynski
- Friends Research Institute, 1040 Park Avenue #103, Baltimore, MD, USA, 21201
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Babbel DM, Liu P, Chen DR, Vaughn VM, Zickmund S, Bloomquist K, Zickmund T, Howell EF, Johnson SA. Inpatient opioid withdrawal: a qualitative study of the patient perspective. Intern Emerg Med 2024:10.1007/s11739-024-03604-9. [PMID: 38642310 DOI: 10.1007/s11739-024-03604-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 04/02/2024] [Indexed: 04/22/2024]
Abstract
Opioid withdrawal is common among hospitalized patients. Those with substance use disorders exhibit higher rates of patient-directed discharge. The literature lacks information regarding the patient perspective on opioid withdrawal in the hospital setting. In this study, we aimed to capture the patient-reported experience of opioid withdrawal during hospitalization and its impact on the desire to continue treatment for opioid use disorder after discharge. We performed a single-center qualitative study involving semi-structured interviews of hospitalized patients with opioid use disorder (OUD) experiencing opioid withdrawal. Investigators conducted in-person interviews utilizing a combination of open-ended and dichotomous questions. Interview transcripts were then analyzed with open coding for emergent themes. Nineteen interviews were performed. All participants were linked to either buprenorphine (79%) or methadone (21%) at discharge. Eight of nineteen patients (42%) reported a patient-directed discharge during prior hospitalizations. Themes identified from the interviews included: (1) opioid withdrawal was well-managed in the hospital; (2) patients appreciated receiving medication for opioid use disorder (MOUD) for withdrawal symptoms; (3) patients valued and felt cared for by healthcare providers; and (4) most patients had plans to follow-up for opioid use disorder treatment after hospitalization. In this population with historically high rates of patient-directed discharge, patients reported having a positive experience with opioid withdrawal management during hospitalization. Amongst our hospitalized patients, we observed several different individualized MOUD induction strategies. All participants were offered MOUD at discharge and most planned to follow-up for further treatment.
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Affiliation(s)
- Danielle M Babbel
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N. Mario Capecchi Drive, 3rd Floor South, Salt Lake City, UT, 84112, USA.
| | - Patricia Liu
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Section of Addiction Medicine, Oregon Health and Science University, Portland, OR, USA
| | - David R Chen
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N. Mario Capecchi Drive, 3rd Floor South, Salt Lake City, UT, 84112, USA
| | - Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N. Mario Capecchi Drive, 3rd Floor South, Salt Lake City, UT, 84112, USA
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Susan Zickmund
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Healthcare System, University of Utah, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Kennedi Bloomquist
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Tobias Zickmund
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Elizabeth F Howell
- Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Stacy A Johnson
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N. Mario Capecchi Drive, 3rd Floor South, Salt Lake City, UT, 84112, USA
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Bart G, Korthuis PT, Donohue JM, Hagedorn HJ, Gustafson DH, Bazzi AR, Enns E, McNeely J, Ghitza UE, Magane KM, Baukol P, Vena A, Harris J, Voronca D, Saitz R. Exemplar Hospital initiation trial to Enhance Treatment Engagement (EXHIT ENTRE): protocol for CTN-0098B a randomized implementation study to support hospitals in caring for patients with opioid use disorder. Addict Sci Clin Pract 2024; 19:29. [PMID: 38600571 PMCID: PMC11007900 DOI: 10.1186/s13722-024-00455-9] [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: 02/10/2024] [Accepted: 03/20/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Hospitalizations involving opioid use disorder (OUD) are increasing. Medications for opioid use disorder (MOUD) reduce mortality and acute care utilization. Hospitalization is a reachable moment for initiating MOUD and arranging for ongoing MOUD engagement following hospital discharge. Despite existing quality metrics for MOUD initiation and engagement, few hospitals provide hospital based opioid treatment (HBOT). This protocol describes a cluster-randomized hybrid type-2 implementation study comparing low-intensity and high-intensity implementation support strategies to help community hospitals implement HBOT. METHODS Four state implementation hubs with expertise in initiating HBOT programs will provide implementation support to 24 community hospitals (6 hospitals/hub) interested in starting HBOT. Community hospitals will be randomized to 24-months of either a low-intensity intervention (distribution of an HBOT best-practice manual, a lecture series based on the manual, referral to publicly available resources, and on-demand technical assistance) or a high-intensity intervention (the low-intensity intervention plus funding for a hospital HBOT champion and regular practice facilitation sessions with an expert hub). The primary efficacy outcome, adapted from the National Committee on Quality Assurance, is the proportion of patients engaged in MOUD 34-days following hospital discharge. Secondary and exploratory outcomes include acute care utilization, non-fatal overdose, death, MOUD engagement at various time points, hospital length of stay, and discharges against medical advice. Primary, secondary, and exploratory outcomes will be derived from state Medicaid data. Implementation outcomes, barriers, and facilitators are assessed via longitudinal surveys, qualitative interviews, practice facilitation contact logs, and HBOT sustainability metrics. We hypothesize that the proportion of patients receiving care at hospitals randomized to the high-intensity arm will have greater MOUD engagement following hospital discharge. DISCUSSION Initiation of MOUD during hospitalization improves MOUD engagement post hospitalization. Few studies, however, have tested different implementation strategies on HBOT uptake, outcome, and sustainability and only one to date has tested implementation of a specific type of HBOT (addiction consultation services). This cluster-randomized study comparing different intensities of HBOT implementation support will inform hospitals and policymakers in identifying effective strategies for promoting HBOT dissemination and adoption in community hospitals. TRIAL REGISTRATION NCT04921787.
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Affiliation(s)
- Gavin Bart
- Department of Medicine, Hennepin Healthcare and University of Minnesota, 701 Park Avenue, Minneapolis, MN, 55415, USA.
| | - P Todd Korthuis
- Department of Medicine, Addiction Medicine Section, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, 97239-3098, Portland, OR, USA
| | - Julie M Donohue
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA, 15261, USA
| | - Hildi J Hagedorn
- Center for Care Delivery & Outcomes Research, Minneapolis VA Health Care System, University of Minnesota, 1 Veterans Drive, Minneapolis, MN, 55417, USA
| | - Dave H Gustafson
- Center for Health Enhancement Systems Studies, University of Wisconsin, 1513 University Ave., Madison, WI, 53706, USA
| | - Angela R Bazzi
- Herbert Wertheim School of Public Health, University of California, San Diego; La Jolla, CA, USA
- Boston University School of Public Health, 801 Massachusetts Ave, Suite 431, Boston, MA, 02118, USA
| | - Eva Enns
- Division of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware St. SE, Minneapolis, MN, 55408, USA
| | - Jennifer McNeely
- Department of Population Health, Section on Alcohol, Tobacco and Drug Use, NYU School of Medicine, 180 Madison Avenue, 17th floor, New York, NY, 10016, USA
- Department of Medicine, Division of General Internal Medicine and Clinical Innovation, NYU School of Medicine, 462 1st Avenue, New York, NY, 10016, USA
| | - Udi E Ghitza
- National Institute on Drug Abuse (NIDA) Center for the Clinical Trials Network (CCTN), Bethesda, MD, 20892, USA
| | - Kara M Magane
- Boston University School of Public Health, 801 Massachusetts Ave, Suite 431, Boston, MA, 02118, USA
| | - Paulette Baukol
- Berman Center for Outcomes & Clinical Research, 701 Park Ave, Ste. PP7.700, Minneapolis, MN, 55415, USA
| | - Ashley Vena
- The Emmes Company, LLC, 401 N. Washington St. #700, Rockville, MD, 20850, USA
| | - Jacklyn Harris
- The Emmes Company, LLC, 401 N. Washington St. #700, Rockville, MD, 20850, USA
| | - Delia Voronca
- The Emmes Company, LLC, 401 N. Washington St. #700, Rockville, MD, 20850, USA
- Currently: Regeneron Pharmaceuticals, Inc, 777 Old Saw Mill River Rd, Tarrytown, Deceased, NY, 10591-6707, USA
| | - Richard Saitz
- Boston University School of Public Health, 801 Massachusetts Ave, Suite 431, Boston, MA, 02118, USA
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Stern SJ, D’Orazio JL, Work BD, Calcaterra SL, Thakrar AP. Point/counterpoint: Should full agonist opioid medications be offered to hospitalized patients for management of opioid withdrawal? J Hosp Med 2024; 19:339-343. [PMID: 38030816 PMCID: PMC10987259 DOI: 10.1002/jhm.13238] [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: 03/22/2023] [Revised: 10/22/2023] [Accepted: 11/04/2023] [Indexed: 12/01/2023]
Affiliation(s)
- Sam J. Stern
- Division of Hospital Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
- Lewis Katz School of Medicine, Center for Urban Bioethics, Philadelphia, Pennsylvania, USA
| | - Joseph L. D’Orazio
- Cooper Center for Healing, Camden, New Jersey, USA
- Department of Emergency Medicine, Division of Toxicology and Addiction Medicine, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Brian D. Work
- Division of Hospital Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
- Prevention Point Philadelphia, Philadelphia, Pennsylvania, USA
| | - Susan L. Calcaterra
- Division of General Internal Medicine and Hospital Medicine, University of Colorado, Aurora, Colorado, USA
| | - Ashish P. Thakrar
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Bradford W, Akselrod H, Bassler J, Gagnon KW, Burkholder G, Carpenter JE, Steck A, Catalanotti J, Kuo I, McGonigle K, Mai W, Notis M, Brokus C, Kattakuzhy S, Rosenthal E, Eaton EF. Hospitalization is a missed opportunity for HIV screening, pre-exposure prophylaxis, and treatment. Addict Sci Clin Pract 2024; 19:22. [PMID: 38528590 PMCID: PMC10964564 DOI: 10.1186/s13722-024-00451-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 03/12/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Hospitalization is a "reachable moment" for people who inject drugs (PWID), but preventive care including HIV testing, prevention and treatment is rarely offered within inpatient settings. METHODS We conducted a multisite, retrospective cohort study of patients with opioid use disorder with infectious complications of injection drug use hospitalized between 1/1/2018-12/31/2018. We evaluated HIV care continuum outcomes using descriptive statistics and hypothesis tests for intergroup differences. RESULTS 322 patients were included. Of 300 patients without known HIV, only 2 had a documented discussion of PrEP, while only 1 was prescribed PrEP on discharge. Among the 22 people with HIV (PWH), only 13 (59%) had a viral load collected during admission of whom all were viremic and 10 (45%) were successfully linked to care post-discharge. Rates of readmission, Medicaid or uninsured status, and unstable housing were high in both groups. DISCUSSION We observed poor provision of HIV testing, PrEP and other HIV services for hospitalized PWID across multiple U.S. medical centers. Future initiatives should focus on providing this group with comprehensive HIV testing and treatment services through a status neutral approach.
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Affiliation(s)
- William Bradford
- Division of Infectious Diseases, University of Alabama at Birmingham, Boshell Building 8th Floor 1808 7th Ave S, Birmingham, AL, 35233, USA.
| | - Hana Akselrod
- Department of Medicine, The George Washington School of Medicine and Health Sciences, Washington, USA
| | - John Bassler
- School of Public Health, University of Alabama at Birmingham, Birmingham, USA
| | - Kelly W Gagnon
- Division of Infectious Diseases, University of Alabama at Birmingham, Boshell Building 8th Floor 1808 7th Ave S, Birmingham, AL, 35233, USA
| | - Greer Burkholder
- Division of Infectious Diseases, University of Alabama at Birmingham, Boshell Building 8th Floor 1808 7th Ave S, Birmingham, AL, 35233, USA
| | | | - Alaina Steck
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, USA
| | - Jillian Catalanotti
- Department of Medicine, The George Washington School of Medicine and Health Sciences, Washington, USA
| | - Irene Kuo
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington, USA
| | - Keanan McGonigle
- Department of Medicine, The George Washington School of Medicine and Health Sciences, Washington, USA
| | - William Mai
- Department of Medicine, The George Washington School of Medicine and Health Sciences, Washington, USA
| | - Melissa Notis
- Department of Medicine, The George Washington School of Medicine and Health Sciences, Washington, USA
| | - Christopher Brokus
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, USA
| | - Sarah Kattakuzhy
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, USA
| | - Elana Rosenthal
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, USA
| | - Ellen F Eaton
- Division of Infectious Diseases, University of Alabama at Birmingham, Boshell Building 8th Floor 1808 7th Ave S, Birmingham, AL, 35233, USA
- Division of Infectious Diseases, University of Alabama at Birmingham, Boshell Building 8th Floor 1808 7th Ave S, Birmingham, AL, 35233, USA
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Shearer RD, Shippee ND, Virnig BA, Beebe TJ, Winkelman TN. Characteristics and co-morbidities associated with hospital discharges for opioid and methamphetamine co-use, United States 2016-2019. DRUG AND ALCOHOL DEPENDENCE REPORTS 2024; 10:100219. [PMID: 38356919 PMCID: PMC10864835 DOI: 10.1016/j.dadr.2024.100219] [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: 01/30/2024] [Accepted: 02/02/2024] [Indexed: 02/16/2024]
Abstract
Introduction The US overdose crisis is increasingly characterized by opioid and methamphetamine co-use. Hospitalization is an important opportunity to engage patients in substance use treatment. Understanding characteristics of co-use-related hospital stays can inform the development of services to better support this growing patient population. Methods We used 2016-2019 National Inpatient Sample data to conduct a cross sectional analysis of hospitalizations involving use of opioids, methamphetamine, or both. We used bivariate analysis to compare patient demographics. We then used multinomial logistic regressions to compare the proportion of hospital stays which indicated co-morbid diagnosis. To account for correlated data, we used generalized linear models to compare outcomes in hospital mortality, patient-directed discharge, and length of stay. Results Co-use-related stays had a higher proportion of co-morbid mental health (60.7%; 95% CI: 59.9-61.4%) and infectious diseases (41.5%; 95% CI: 40.8-42.2%), than opioid- or methamphetamine-related stays. Co-use-related stays increased between 2016 and 2019 and were associated with a higher proportion of patient directed discharge (10.7%; 95% CI: 10.4-11.0%) and longer length of stay (6.3 days; 95% CI: 6.2-6.4 days) compared to opioid (8.1%; 95% CI: 7.9-8.3% and 5.8 days; 95% CI: 5.8-5.9 days) and methamphetamine-related stays (6.5%; 95% CI: 6.3-6.6% and 5.5 days; 95% CI: 5.4-5.5 days). Conclusion Patients discharged with co-use differ from patients with opioid or methamphetamine use alone, representing a range of challenges and opportunities. In addition to offering treatment for both substance use disorders, hospital-based services that address co-occurring conditions may better support patients with co-use through targeted and tailored approaches.
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Affiliation(s)
- Riley D. Shearer
- University of Minnesota School of Public Health, 420 Delaware St SE, Mayo Building B681, Minneapolis, MN, 55455 USA
- Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, 701 Park Ave., Suite PP7.700, Minneapolis, MN, 55415, USA
| | - Nathan D. Shippee
- University of Minnesota School of Public Health, 420 Delaware St SE, Mayo Building B681, Minneapolis, MN, 55455 USA
| | - Beth A. Virnig
- College of Public Health and Health Professions, University of Florida, 1225 Center Drive, Gainsville, FL, 32611, USA
| | - Timothy J. Beebe
- University of Minnesota School of Public Health, 420 Delaware St SE, Mayo Building B681, Minneapolis, MN, 55455 USA
| | - Tyler N.A. Winkelman
- Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, 701 Park Ave., Suite PP7.700, Minneapolis, MN, 55415, USA
- Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, 716 S 7th St, Minneapolis, MN, 55415, USA
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Moyo P, Nishar S, Merrick C, Streltzov N, Asiedu E, Roma C, Vanjani R, Soske J. Perspectives on Admissions and Care for Residents With Opioid Use Disorder in Skilled Nursing Facilities. JAMA Netw Open 2024; 7:e2354746. [PMID: 38315484 PMCID: PMC10844991 DOI: 10.1001/jamanetworkopen.2023.54746] [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: 10/24/2023] [Accepted: 12/13/2023] [Indexed: 02/07/2024] Open
Abstract
Importance Skilled nursing facilities (SNFs) are being referred more individuals with opioid use disorder (OUD), even when their medical needs are not directly associated with OUD. Objective To characterize factors that influence SNF admission for individuals with OUD and identify strategies for providing medications for OUD (MOUD) in SNFs. Design, Setting, and Participants In this semistructured qualitative study, interviews were conducted with SNF administrators from 27 SNFs in Rhode Island from November 5, 2021, to April 27, 2022. Data analysis occurred from August 22, 2022, to May 31, 2023. Main Outcomes and Measures Themes and subthemes on administrator perspectives on admissions and care for people with OUD in SNFs. Audio interviews were transcribed, coded, and analyzed using codebook thematic analysis and guided by community-engaged and participatory research principles. Results The study included 29 participants representing 27 SNFs in Rhode Island. Participant roles were administrators (17 participants [59%]), directors of nursing (6 participants [21%]), directors of admissions (5 participants [17%]), and unit managers (1 participant [3%]). Participants described active substance use, Medicaid insurance, housing instability, and younger age as potential barriers to SNF admission for individuals with OUD. The lack of formal guidelines for OUD management, staff shortages, facility liability, state regulations, and skills and training deficits among staff were cited among challenges of effectively meeting the needs of residents with OUD. Many participants reported inadequate institutional capacity as a source of negative outcomes for people with OUD yet expressed their concerns by characterizing individuals with OUD as potentially violent, nonadherent, or likely to bring undesirable elements into facilities. Participants also shared strategies they used to better serve residents with OUD, including providing transportation to support group meetings in the community, delivery in advance of resident arrival of predosed methadone, and telemedicine through the state's hotline to prescribe buprenorphine. Conclusions and Relevance In this qualitative study of administrator perspectives about admissions and care for individuals with OUD in SNFs, gaps in institutional capacity overlapped with stigmatizing beliefs about OUD; such beliefs perpetuate discrimination of individuals with OUD. Adequate SNF funding and staffing combined with OUD-specific interventions (eg, antistigma training, community partnerships for MOUD and recovery support) could incentivize SNFs to serve individuals with OUD and facilitate OUD care consistent with practice guidelines.
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Affiliation(s)
- Patience Moyo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Shivani Nishar
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Charlotte Merrick
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Nicholas Streltzov
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Emmanuella Asiedu
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Corinne Roma
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Rahul Vanjani
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Amos House, Providence, Rhode Island
| | - Jon Soske
- Division of Addiction Medicine, Rhode Island Hospital, Providence, Rhode Island
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11
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Russo TA, Ritchie HR, Schimmel JJ, Lorenzo MP. Dalbavancin Use in Persons Who Use Drugs May Increase Adherence Without Increasing Cost. J Pharm Technol 2024; 40:3-9. [PMID: 38318254 PMCID: PMC10838542 DOI: 10.1177/87551225231205738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
Abstract
Background: Dalbavancin (DAL) may obviate concerns regarding misuse of IV access in persons who use drugs (PWUD) completing treatment for infections in an outpatient setting. However, hesitancy to adopt its use exists due to the cost-prohibitive nature of DAL and perceived issues with insurance reimbursement. Our study looks to determine the financial impact of DAL use in actual, measured cost, and health care utilization, data as well as the effect on treatment completion rates. Methods: This is a retrospective cohort comparing cost information and treatment completion rates of patients who received DAL to a random sample of patients with Staphylococcus aureus bacteremia prior to the institutional availability of DAL. Results: From June 2020 to January 2022, 29 PWUD received DAL. Dalbavancin use resulted in the completion of intended duration in 19 patients (66%) compared with 11 (55%) without DAL. The contribution margin with DAL use was $7180 compared with $6655 without; this was not statistically significant (P = 0.47). Conclusion: Dalbavancin use in PWUD may increase treatment completion, with no statistically significant difference in contribution margins.
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Affiliation(s)
| | - Hannah R. Ritchie
- Department of Pharmacy, Baystate Medical Center, Springfield, MA, USA
| | - Jennifer J. Schimmel
- Department of Infectious Diseases, Baystate Medical Center, Springfield, MA, USA
- University of Massachusetts Chan Medical School, Worcester, MA, USA
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12
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French R, Boccelli A, Valosky K, Oliver E, Uritsky T, McCullion J, Zwiebel S, Andrews T. A Promising Approach to Addressing the Needs of Patients with Endocarditis Secondary to Injection Drug Use: A Case Report. HEALTH & SOCIAL WORK 2024; 49:55-58. [PMID: 38124507 DOI: 10.1093/hsw/hlad036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 04/28/2023] [Indexed: 12/23/2023]
Affiliation(s)
- Rachel French
- PhD, RN, is a registered nurse and postdoctoral fellow, Center for Mental Health, University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104, USA
| | - Amanda Boccelli
- LCSW of advanced practice providers, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Kathryn Valosky
- LCSW of advanced practice providers, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Emilie Oliver
- LCSW, are social workers of advanced practice providers, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Tanya Uritsky
- PharmD, CPE, is pharmacist of advanced practice providers, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jessica McCullion
- BSN, RN, is registered nurse of advanced practice providers, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Samantha Zwiebel
- MD, is psychiatrist of advanced practice providers, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Tracy Andrews
- DNP, ACNP, APRN-BC, is manager of advanced practice providers, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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13
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Byrne KA, Roth PJ, Cumby S, Goodwin E, Herbert K, Schmidt WM, Worth S, Connolly K, Uzor O, Eiff B, Black D. Recovery Barrier Characterizations by Hospitalized Patients with Substance Use Disorders: Results from a Randomized Clinical Study on Inpatient Peer Recovery Coaching. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:93. [PMID: 38248556 PMCID: PMC10815630 DOI: 10.3390/ijerph21010093] [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: 11/08/2023] [Revised: 01/03/2024] [Accepted: 01/08/2024] [Indexed: 01/23/2024]
Abstract
Patients hospitalized with medical complications from substance use disorder (SUD) encounter unique health problems that may complicate their recovery. Recovery barriers are not well understood in this population. The study objective is to characterize recovery barriers in this patient population. Participants (n = 96) in this six-month longitudinal study were randomized to a peer recovery coaching intervention or standard of care. The primary outcome measures were qualitative, open-ended questions addressing factors interfering with participants' recovery. Data were analyzed using content analysis. Themes were identified a priori using past research on recovery capital domains; these seven barriers were (1) psychological health difficulties, (2) physical health challenges, (3) lack of social support, (4) insufficient treatment or recovery support to maintain sobriety, (5) environmental and housing concerns, (6) deficits in coping skills, and (7) lack of meaningful activities. At baseline, the most common recovery barriers were in the environment and housing (28.1%), psychological health (27.1%), and social support (22.9%) domains. At six-month follow-up, participants were asked to describe barriers they felt they had made improvement in over the last six months. The primary themes that participants reported improvements in were treatment and recovery support to maintain sobriety (52.1%), coping skills (35.4%), and social support (27.1%). Hospitalization and participation in a randomized controlled trial may be a turning point in which to address recovery barriers for patients hospitalized with complications from SUD.
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Affiliation(s)
- Kaileigh A. Byrne
- Department of Psychology, Clemson University, Clemson, SC 29634, USA; (B.E.)
| | - Prerana J. Roth
- Greenville Memorial Hospital, Prisma Health, Greenville, SC 29605, USA
| | - Sam Cumby
- Greenville Campus, University of South Carolina School of Medicine, Greenville, SC 29605, USA; (S.C.); (W.M.S.); (S.W.)
| | - Eli Goodwin
- Greenville Campus, University of South Carolina School of Medicine, Greenville, SC 29605, USA; (S.C.); (W.M.S.); (S.W.)
| | - Kristin Herbert
- Greenville Campus, University of South Carolina School of Medicine, Greenville, SC 29605, USA; (S.C.); (W.M.S.); (S.W.)
| | - William Michael Schmidt
- Greenville Campus, University of South Carolina School of Medicine, Greenville, SC 29605, USA; (S.C.); (W.M.S.); (S.W.)
| | - Samantha Worth
- Greenville Campus, University of South Carolina School of Medicine, Greenville, SC 29605, USA; (S.C.); (W.M.S.); (S.W.)
| | - Kyleigh Connolly
- Greenville Campus, University of South Carolina School of Medicine, Greenville, SC 29605, USA; (S.C.); (W.M.S.); (S.W.)
| | - Onye Uzor
- Greenville Campus, University of South Carolina School of Medicine, Greenville, SC 29605, USA; (S.C.); (W.M.S.); (S.W.)
| | - Brandi Eiff
- Department of Psychology, Clemson University, Clemson, SC 29634, USA; (B.E.)
| | - Dominique Black
- Department of Psychology, Clemson University, Clemson, SC 29634, USA; (B.E.)
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Attwood LO, O'Keefe D, Higgs P, Vujovic O, Doyle JS, Stewardson AJ. Epidemiology of acute infections in people who inject drugs in Australia. Drug Alcohol Rev 2024; 43:304-314. [PMID: 37995135 PMCID: PMC10952783 DOI: 10.1111/dar.13772] [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: 03/05/2023] [Revised: 08/23/2023] [Accepted: 10/20/2023] [Indexed: 11/25/2023]
Abstract
ISSUES People who inject drugs are at risk of acute infections, such as skin and soft tissue infections, infective endocarditis, bone and joint infections and bloodstream infections. There has been an increase in these infections in people who inject drugs internationally over the past 10 years. However, the local data regarding acute infections in Australia has not been well described. APPROACH We review the epidemiology of acute infections and associated morbidity and mortality amongst people who inject drugs in Australia. We summarise risk factors for these infections, including the concurrent social and psychological determinants of health. KEY FINDINGS The proportion of people who report having injected drugs in the prior 12 months in Australia has decreased over the past 18 years. However, there has been an increase in the burden of acute infections in this population. This increase is driven largely by skin and soft tissue infections. People who inject drugs often have multiple conflicting priorities that can delay engagement in care. IMPLICATIONS Acute infections in people who inject drugs are associated with significant morbidity and mortality. Acute infections contribute to significant bed days, surgical requirements and health-care costs in Australia. The increase in these infections is likely due to a complex interplay of microbiological, individual, social and environmental factors. CONCLUSION Acute infections in people who inject drugs in Australia represent a significant burden to both patients and health-care systems. Flexible health-care models, such as low-threshold wound clinics, would help directly target, and address early interventions, for these infections.
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Affiliation(s)
- Lucy O. Attwood
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical SchoolMonash UniversityMelbourneAustralia
| | | | - Peter Higgs
- Burnet InstituteMelbourneAustralia
- Department of Public HealthLa Trobe UniversityMelbourneAustralia
| | - Olga Vujovic
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical SchoolMonash UniversityMelbourneAustralia
| | - Joseph S. Doyle
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical SchoolMonash UniversityMelbourneAustralia
- Burnet InstituteMelbourneAustralia
| | - Andrew J. Stewardson
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical SchoolMonash UniversityMelbourneAustralia
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15
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French R, Compton P, Clapp J, Buttenheim A, Schachter A, Uhley O, Mandell D. Opportunities to improve opioid use disorder care for hospitalised patients with endocarditis. BMJ Open Qual 2023; 12:e002420. [PMID: 38114244 DOI: 10.1136/bmjoq-2023-002420] [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: 05/16/2023] [Accepted: 12/06/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Driven by increased injection opioid use, rates of hospitalisation for infective endocarditis, an infection associated with injection drug use, are increasing. In the USA, 1 in 10 hospitalised patients for opioid use disorder-associated infective endocarditis (OUD-IE) die in the hospital and 1 in 20 have a patient-directed discharge. Emerging models of care reveal opportunities for healthcare systems to meet the complex care needs of these patients. We characterised promising practices of staff who care for these patients and identified areas for improvement. METHODS We conducted a qualitative study with 1-hour semistructured virtual interviews between October 2021 and March 2022. Participants included 26 healthcare staff who care for patients with OUD-IE at the Hospital of the University of Pennsylvania. We used thematic analysis of interviews guided by an abductive approach. Interviews were digitally recorded and transcribed and analysed using NVivo software. RESULTS Interviews were characterised by three major themes: (1) care rooted in interdisciplinary collaboration; (2) managing OUD and its sequelae in a setting not designed to treat OUD; and (3) clinician needs and barriers to change. CONCLUSIONS These findings highlight the facilitators of high-quality treatment for patients with OUD-IE, as well as the key areas for improvement. Findings add context to the complexity that both the healthcare staff and patients navigate during and following hospitalisation for OUD-IE. Needed changes include training staff to talk with patients about preparing for a return to drug use following hospitalisation, and changing discharge facilities' practices that hinder access for patients with OUD-IE.
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Affiliation(s)
- Rachel French
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peggy Compton
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Justin Clapp
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alison Buttenheim
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Allison Schachter
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Olivia Uhley
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Mandell
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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16
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Bork JT, Heil EL. What Is Left to Tackle in Inpatient Antimicrobial Stewardship Practice and Research. Infect Dis Clin North Am 2023; 37:901-915. [PMID: 37586930 DOI: 10.1016/j.idc.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Despite widespread uptake of antimicrobial stewardship in acute care hospitals, there is ongoing need for innovation and optimization of ASPs. This article discusses current antimicrobial stewardship practice challenges and ways to improve current antimicrobial stewardship workflows. Additionally, we propose new workflows that further engage front line clinicians in optimizing their own antibiotic decision making.
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Affiliation(s)
- Jacqueline T Bork
- Division of Infectious Diseases, Institute of Human Virology in the Department of Medicine, University of Maryland, School of Medicine, 22 S Greene Street, Baltimore, MD 21201, USA
| | - Emily L Heil
- Department of Practice, Sciences, and Health-Outcomes Research, University of Maryland, School of Pharmacy, 20 N Pine Street, Baltimore, MD 21201, USA.
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17
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Rosenthal ES, Brokus C, Sun J, Carpenter JE, Catalanotti J, Eaton EF, Steck AR, Kuo I, Burkholder GA, Akselrod H, McGonigle K, Moran T, Mai W, Notis M, Del Rio C, Greenberg A, Saag MS, Kottilil S, Masur H, Kattakuzhy S. Undertreatment of opioid use disorder in patients hospitalized with injection drug use-associated infections. AIDS 2023; 37:1799-1809. [PMID: 37352497 PMCID: PMC10481931 DOI: 10.1097/qad.0000000000003629] [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: 03/24/2023] [Revised: 06/06/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVE To evaluate the association between medication for opioid use disorder (MOUD) initiation and addiction consultation and outcomes for patients hospitalized with infectious complications of injecting opioids. METHOD This was a retrospective cohort study performed at four academic medical centers in the United States. The participants were patients who had been hospitalized with infectious complications of injecting opioids in 2018. Three hundred and twenty-two patients were included and their individual patient records were manually reviewed to identify inpatient receipt of medication for opioid use disorder (MOUD), initiation of MOUD, and addiction consultation. The main outcomes of interest were premature discharge, MOUD on discharge, linkage to outpatient MOUD, one-year readmission and death. RESULTS Three hundred and twenty-two patients were predominately male (59%), white (66%), and median age 38 years, with 36% unstably housed, and 30% uninsured. One hundred and forty-five (45%) patients received MOUD during hospitalization, including only 65 (28%) patients not on baseline MOUD. Discharge was premature for 64 (20%) patients. In the year following discharge, 27 (9%) patients were linked to MOUD, and 159 (50%) patients had at least one readmission. Being on MOUD during hospitalization was significantly associated with higher odds of planned discharge [odds ratio (OR) 3.87, P < 0.0001], MOUD on discharge (OR 129.7, P < 0.0001), and linkage to outpatient MOUD (OR 1.25, P < 0.0001), however, was not associated with readmission. Study limitations were the retrospective nature of the study, so post-discharge data are likely underestimated. CONCLUSION There was dramatic undertreatment with MOUD from inpatient admission to outpatient linkage, and high rates of premature discharge and readmission. Engagement in addiction care during hospitalization is a critical first step in improving the care continuum for individuals with opioid use disorder; however, additional interventions may be needed to impact long-term outcomes like readmission.
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Affiliation(s)
- Elana S. Rosenthal
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore
| | - Christopher Brokus
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Joseph E. Carpenter
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jillian Catalanotti
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Ellen F. Eaton
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama
| | - Alaina R. Steck
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Irene Kuo
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington DC
| | - Greer A. Burkholder
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama
| | - Hana Akselrod
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Keanan McGonigle
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Timothy Moran
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - William Mai
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Melissa Notis
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Carlos Del Rio
- Rollins School of Public Health and Emory School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Alan Greenberg
- Department of Epidemiology, Milken Institute School of Public Health, The George Washington University, Washington DC
| | - Michael S. Saag
- Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama
| | - Shyamasundaran Kottilil
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore
| | - Henry Masur
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Sarah Kattakuzhy
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore
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Brothers TD, Bonn M, Lewer D, Comeau E, Kim I, Webster D, Hayward A, Harris M. Social and structural determinants of injection drug use-associated bacterial and fungal infections: A qualitative systematic review and thematic synthesis. Addiction 2023; 118:1853-1877. [PMID: 37170877 DOI: 10.1111/add.16257] [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: 10/03/2022] [Accepted: 04/28/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND AND AIMS Injection drug use-associated bacterial and fungal infections are increasingly common, and social contexts shape individuals' injecting practices and treatment experiences. We sought to synthesize qualitative studies of social-structural factors influencing incidence and treatment of injecting-related infections. METHODS We searched PubMed, EMBASE, Scopus, CINAHL and PsycINFO from 1 January 2000 to 18 February 2021. Informed by Rhodes' 'risk environment' framework, we performed thematic synthesis in three stages: (1) line-by-line coding; (2) organizing codes into descriptive themes, reflecting interpretations of study authors; and (3) consolidating descriptive themes into conceptual categories to identify higher-order analytical themes. RESULTS We screened 4841 abstracts and included 26 qualitative studies on experiences of injecting-related bacterial and fungal infections. We identified six descriptive themes organized into two analytical themes. The first analytical theme, social production of risk, considered macro-environmental influences. Four descriptive themes highlighted pathways through which this occurs: (1) unregulated drug supply, leading to poor drug quality and solubility; (2) unsafe spaces, influenced by policing practices and insecure housing; (3) health-care policies and practices, leading to negative experiences that discourage access to care; and (4) restrictions on harm reduction programmes, including structural barriers to effective service provision. The second analytical theme, practices of care among people who use drugs, addressed protective strategies that people employ within infection risk environments. Associated descriptive themes were: (5) mutual care, including assisted-injecting and sharing sterile equipment; and (6) self-care, including vein health and self-treatment. Within constraining risk environments, some protective strategies for bacterial infections precipitated other health risks (e.g. HIV transmission). CONCLUSIONS Injecting-related bacterial and fungal infections are shaped by modifiable social-structural factors, including poor quality unregulated drugs, criminalization and policing enforcement, insufficient housing, limited harm reduction services and harmful health-care practices. People who inject drugs navigate these barriers while attempting to protect themselves and their community.
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Affiliation(s)
- Thomas D Brothers
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, UK
- Department of Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Matthew Bonn
- Canadian Association of People who Use Drugs (CAPUD), Dartmouth, Canada
| | - Dan Lewer
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Emilie Comeau
- Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Inhwa Kim
- Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Duncan Webster
- Department of Medicine, Faculty of Medicine, Dalhousie University, Halifax, Canada
- Division of Infectious Diseases, Saint John Regional Hospital, Saint John, Canada
| | - Andrew Hayward
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Magdalena Harris
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, UK
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Suzuki J, Martin B, Loguidice F, Smelson D, Liebschutz JM, Schnipper JL, Weiss RD. A Peer Recovery Coach Intervention for Hospitalized Patients with Opioid Use Disorder: A Pilot Randomized Controlled Trial. J Addict Med 2023; 17:604-607. [PMID: 37788617 PMCID: PMC10544697 DOI: 10.1097/adm.0000000000001162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
OBJECTIVES Patients with opioid use disorder (OUD) are increasingly being hospitalized for acute medical illnesses. Despite initiation of medications for OUD (MOUDs), many discontinue treatment after discharge. To evaluate whether a psychosocial intervention can improve MOUD retention after hospitalization, we conducted a pilot randomized controlled trial of a peer recovery coach intervention. METHODS An existing peer recovery coach intervention was adapted for this trial. Hospitalized adults with OUD receiving MOUD treatment were randomized to receive either a recovery coach intervention or treatment-as-usual. For those in the intervention arm, the coach guided the participant to complete a relapse prevention plan, maintained contact throughout the 6-month follow-up period, encouraged MOUD continuation, and helped to identify community resources. Those receiving treatment-as-usual were discharged with a referral to outpatient treatment. Primary outcome was retention in MOUD treatment at 6 months. Secondary outcomes were the proportion of participants readmitted to the hospital and the number of days until treatment discontinuation and to hospital readmission. RESULTS Twenty-five individuals who provided consent and randomized to the recovery coach intervention (n = 13) or treatment-as-usual (n = 12) were included in the analysis. No significant differences were found in the proportion of participants retained in MOUD treatment at 6 months (38.5% vs 41.7%, P = 0.87), proportion of participants readmitted at 6 months (46.2% vs 41.2%, P = 0.82), or the time to treatment discontinuation (log-rank P = 0.92) or readmission (log-rank P = 0.85). CONCLUSIONS This pilot trial failed to demonstrate that a recovery coach intervention improved MOUD treatment retention compared with treatment-as-usual among hospitalized individuals with OUD.
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Affiliation(s)
- Joji Suzuki
- Department of Psychiatry, Brigham and Women’s Hospital, Boston MA
- Harvard Medical School, Boston MA
| | - Bianca Martin
- Department of Psychiatry, Brigham and Women’s Hospital, Boston MA
| | - Frank Loguidice
- Department of Psychiatry, Brigham and Women’s Hospital, Boston MA
| | - David Smelson
- Department of Psychiatry, University of Massachusetts Chan Medical School, Worcester, MA
| | - Jane M. Liebschutz
- Division of General Internal Medicine, University of Pittsburgh, UPMC, Pittsburgh, PA
| | - Jeffrey L. Schnipper
- Harvard Medical School, Boston MA
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston MA
| | - Roger D. Weiss
- Harvard Medical School, Boston MA
- McLean Hospital, Belmont MA 02478
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20
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Jimenez Ruiz F, Warner NS, Acampora G, Coleman JR, Kohan L. Substance Use Disorders: Basic Overview for the Anesthesiologist. Anesth Analg 2023; 137:508-520. [PMID: 37590795 DOI: 10.1213/ane.0000000000006281] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
Substance use disorders (SUDs) represent a current major public health concern in the United States and around the world. Social and economic stressors secondary to the coronavirus disease 2019 (COVID-19) pandemic have likely led to an increase in SUDs around the world. This chronic, debilitating disease is a prevalent health problem, and yet many clinicians do not have adequate training or clinical experience diagnosing and treating SUDs. Anesthesiologists and other perioperative medical staff frequently encounter patients with co-occurring SUDs. By such, through increased awareness and education, physicians and other health care providers have a unique opportunity to positively impact the lives and improve the perioperative outcomes of patients with SUDs. Understanding commonly used terms, potentially effective perioperative screening tools, diagnostic criteria, basics of treatment, and the perioperative implications of SUDs is essential to providing adequate care to patients experiencing this illness.
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Affiliation(s)
- Federico Jimenez Ruiz
- From the Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Nafisseh S Warner
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gregory Acampora
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - John R Coleman
- From the Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Lynn Kohan
- From the Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
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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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French R, McFadden R, Stewart R, Christian H, Compton P. "I Just Need Proper Treatment": Being Hospitalized for Endocarditis among Individuals Who Inject Drugs Being Hospitalized for Endocarditis. J Gen Intern Med 2023; 38:2470-2477. [PMID: 36941420 PMCID: PMC10465454 DOI: 10.1007/s11606-023-08133-3] [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: 09/28/2022] [Accepted: 03/01/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Rates of hospitalization for injection drug use-associated infective endocarditis (IDU-IE) are increasing. Much is known about the poor outcomes of patients with IDU-IE; less is known about the patient experience during hospitalization. OBJECTIVE To explore the experience of being hospitalized for endocarditis among individuals who inject drugs, providing a foundation on which to develop strategies to improve care for these patients. DESIGN Qualitative interviews with hospitalized patients undergoing cardiothoracic surgery with a history of injection drug use between February 2021 and May 2022 at the Hospital of the University of Pennsylvania. PARTICIPANTS Cardiothoracic surgery patients with a documented history of injection drug use and the ability to speak English were recruited during their hospital stay. APPROACH Thematic analysis of interviews guided by phenomenology and harm reduction theory was used to identify recurrent themes. Interviews were digitally recorded and transcribed and analyzed using NVIVO software. KEY RESULTS Interviews from 13 participants resulted in four major themes around Hospital Experience: (1) Kindness as an Antidote to Dehumanizing Treatment; (2) Relationships with the Care Team; (3) Withdrawal and Pain Management; and (4) Anticipating and Experiencing the Transition out the Hospital. Participants recounted long histories of dehumanizing care during previous hospitalizations, noted the value of open, sincere, and non-judgmental communication with clinical teams, expressed overall satisfaction with the management of their symptoms during the current hospitalization, reported self-discharging during previous hospitalizations due to undertreated pain and withdrawal, and noted significant challenges around discharge planning and execution. CONCLUSIONS Participants noted structural (e.g., discharge planning) and interpersonal (e.g., stigma from care team) barriers to quality hospital care. They also noted that expressions of kindness from hospital staff were meaningful and comforting. Patients with IDU-IE face multi-dimensional challenges in the hospital. Their perspectives can meaningfully inform programs and initiatives to improve their outcomes and support recovery.
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Affiliation(s)
- Rachel French
- University of Pennsylvania School of Nursing, Philadelphia, PA, 19104, USA.
| | - Rachel McFadden
- Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Rebecca Stewart
- Center for Mental Health, University of Pennsylvania School of Medicine, Philadelphia, PA, 19104, USA
| | - Hanna Christian
- Center for Mental Health, University of Pennsylvania School of Medicine, Philadelphia, PA, 19104, USA
| | - Peggy Compton
- University of Pennsylvania School of Nursing, Philadelphia, PA, 19104, USA
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23
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Nolan NS, Fracasso Francis SM, Marks LR, Beekmann SE, Polgreen PM, Liang SY, Durkin MJ. Harm Reduction: A Missing Piece to the Holistic Care of Patients Who Inject Drugs. Open Forum Infect Dis 2023; 10:ofad402. [PMID: 37593531 PMCID: PMC10428197 DOI: 10.1093/ofid/ofad402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/24/2023] [Indexed: 08/19/2023] Open
Abstract
Background The rise in injection drug use (IDU) has led to an increase in drug-related infections. Harm reduction is an important strategy for preventing infections among people who inject drugs (PWID). We attempted to evaluate the harm reduction counseling that infectious diseases physicians provide to PWID presenting with infections. Methods An electronic survey was distributed to physician members of the Emerging Infections Network to inquire about practices used when caring for patients with IDU-related infections. Results In total, 534 ID physicians responded to the survey. Of those, 375 (70%) reported routinely caring for PWID. Most respondents report screening for human immunodeficiency virus (HIV) and viral hepatitis (98%) and discussing the risk of these infections (87%); 63% prescribe immunization against viral hepatitis, and 45% discuss HIV preexposure prophylaxis (PrEP). However, 55% of respondents (n = 205) reported not counseling patients on safer injection strategies. Common reasons for not counseling included limited time and a desire to emphasize antibiotic therapy/medical issues (62%), lack of training (55%), and believing that it would be better addressed by other services (47%). Among respondents who reported counseling PWID, most recommended abstinence from IDU (72%), handwashing and skin cleansing before injection (62%), and safe disposal of needles/drug equipment used before admission (54%). Conclusions Almost all ID physicians report screening PWID for HIV and viral hepatitis and discussing the risks of these infections. Despite frequently encountering PWID, fewer than half of ID physicians provide safer injection advice. Opportunities exist to standardize harm reduction education, emphasizing safer injection practices in conjunction with other strategies to prevent infections (eg, HIV PrEP or hepatitis A virus/hepatitis B virus vaccination).
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Affiliation(s)
- Nathanial S Nolan
- Division of Infectious Disease, VA St Louis Health Care, St Louis, Missouri, USA
- Division of Infectious Disease, Washington University School of Medicine, St Louis, Missouri, USA
| | | | - Laura R Marks
- Division of Infectious Disease, Washington University School of Medicine, St Louis, Missouri, USA
| | - Susan E Beekmann
- Division of Infectious Disease, Carver College of Medicine, Iowa City, Iowa, USA
| | - Philip M Polgreen
- Division of Infectious Disease, Carver College of Medicine, Iowa City, Iowa, USA
| | - Stephen Y Liang
- Division of Infectious Disease, Washington University School of Medicine, St Louis, Missouri, USA
- Department of Emergency Medicine, Washington University School of Medicine, St Louis Missouri, USA
| | - Michael J Durkin
- Division of Infectious Disease, Washington University School of Medicine, St Louis, Missouri, USA
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Rolová G, Eide D, Gabrhelík R, Odsbu I, Clausen T, Skurtveit S. Gender differences in physical morbidity in opioid agonist treatment patients: population-based cohort studies from the Czech Republic and Norway. Subst Abuse Treat Prev Policy 2023; 18:47. [PMID: 37507709 PMCID: PMC10385939 DOI: 10.1186/s13011-023-00557-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 07/25/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Physical diseases represent a significant burden for opioid agonist treatment (OAT) patients. This study described physical morbidity in two national cohorts of OAT patients focusing on gender differences. METHODS This population-based cohort study linking multiple health registers investigated physical diseases (ICD-10) in patients receiving OAT in the Czech Republic (N = 4,280) and Norway (N = 11,389) during 2010-2019. Gender-stratified analysis was performed. RESULTS Overall, we found a large burden of physical morbidity across gender groups in OAT patients. In the Czech Republic and Norway, women in OAT had a significantly higher prevalence of physical diseases across most diagnostic chapters, notably genitourinary diseases and neoplasms. Injuries/external causes and infectious/parasitic diseases were among the most common diseases in both women and men. Viral hepatitis accounted for over half of infectious morbidity in women and men in both cohorts. CONCLUSIONS Our findings support the need for early screening, detection, and treatment of diseases and conditions across organ systems and the integration of health promotion activities to reduce physical morbidity in OAT patients. The gender differences underline the need for a tailored approach to address specific medical conditions.
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Affiliation(s)
- Gabriela Rolová
- First Faculty of Medicine, Department of Addictology, Charles University, Prague, Czech Republic.
- Department of Addictology, General University Hospital, Prague, Czech Republic.
| | - Desiree Eide
- University of Oslo, Norwegian Centre for Addiction Research, Oslo, Norway
| | - Roman Gabrhelík
- First Faculty of Medicine, Department of Addictology, Charles University, Prague, Czech Republic
- Department of Addictology, General University Hospital, Prague, Czech Republic
| | - Ingvild Odsbu
- First Faculty of Medicine, Department of Addictology, Charles University, Prague, Czech Republic
- Norwegian Institute of Public Health, Oslo, Norway
| | - Thomas Clausen
- University of Oslo, Norwegian Centre for Addiction Research, Oslo, Norway
| | - Svetlana Skurtveit
- University of Oslo, Norwegian Centre for Addiction Research, Oslo, Norway
- Norwegian Institute of Public Health, Oslo, Norway
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Chang JE, Cronin CE, Pagán JA, Simon J, Lindenfeld Z, Franz B. Trends in the Prioritization and Implementation of Substance Use Programs by Nonprofit Hospitals: 2015-2021. J Addict Med 2023; 17:e217-e223. [PMID: 37579091 DOI: 10.1097/adm.0000000000001128] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Hospitalizations are an important opportunity to address substance use through inpatient services, outpatient care, and community partnerships, yet the extent to which nonprofit hospitals prioritize such services across time remains unknown. The objective of this study is to examine trends in nonprofit hospitals' prioritization and implementation of substance use disorder (SUD) programs. METHODS We assessed trends in hospital prioritization of substance use as a top five community need and hospital implementation of SUD programing at nonprofit hospitals between 2015 and 2021 using two waves (wave 1: 2015-2018; wave 2: 2019-2021) by examining hospital community benefit reports. We utilized t or χ 2 tests to understand whether there were significant differences in the prioritization and implementation of SUD programs across waves. We used multilevel logistic regression to evaluate the relation between prioritization and implementation of SUD programs, hospital and community characteristics, and wave. RESULTS Hospitals were less likely to have prioritized SUD but more likely to have implemented SUD programs in the most recent 3 years compared, even after adjusting for the local overdose rate and hospital- and community-level variables. Although most hospitals consistently prioritized and implemented SUD programs during the 2015-2021 period, a 11% removed and 15% never adopted SUD programs at all, despite an overall increase in overdose rates. CONCLUSIONS Our study identified gaps in hospital SUD infrastructure during a time of elevated need. Failing to address this gap reflects missed opportunities to engage vulnerable populations, provide linkages to treatment, and prevent complications of substance use.
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Affiliation(s)
- Ji Eun Chang
- From the Department of Public Health Policy and Management, School of Global Public Health, New York University, New York, NY (JEC, JAP, ZL); College of Health Sciences and Professions, Ohio University, Athens, OH (CC); Heritage College of Osteopathic Medicine, Ohio University, Athens, OH (JS, BF); and Ohio University Appalachian Institute to Advance Health Equity Science (BF, CEC)
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26
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Ober AJ, Osilla KC, Klein DJ, Burgette LF, Leamon I, Mazer MW, Messineo G, Collier S, Korouri S, Watkins KE, Ishak W, Nuckols T, Danovitch I. Pilot randomized controlled trial of a hospital-based substance use treatment and recovery team (START) to improve initiation of medication for alcohol or opioid use disorder and linkage to follow-up care. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 150:209063. [PMID: 37156424 PMCID: PMC10330512 DOI: 10.1016/j.josat.2023.209063] [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: 09/23/2022] [Revised: 12/06/2022] [Accepted: 05/01/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVES We conducted a pilot randomized controlled trial (RCT) to explore whether a hospital inpatient addiction consult team (Substance Use Treatment and Recovery Team [START]) based on collaborative care was feasible, acceptable to patients, and whether it could improve uptake of medication in the hospital and linkage to care after discharge, as well as reduce substance use and hospital readmission. The START consisted of an addiction medicine specialist and care manager who implemented a motivational and discharge planning intervention. METHODS We randomized inpatients age ≥ 18 with a probable alcohol or opioid use disorder to receive START or usual care. We assessed feasibility and acceptability of START and the RCT, and we conducted an intent-to-treat analysis on data from the electronic medical record and patient interviews at baseline and 1-month postdischarge. The study compared RCT outcomes (medication for alcohol or opioid use disorder, linkage to follow-up care after discharge, substance use, hospital readmission) between arms by fitting logistic and linear regression models. FINDINGS Of 38 START patients, 97 % met with the addiction medicine specialist and care manager; 89 % received ≥8 of 10 intervention components. All patients receiving START found it to be somewhat or very acceptable. START patients had higher odds of initiating medication during the inpatient stay (OR 6.26, 95 % CI = 2.38-16.48, p < .001) and being linked to follow-up care (OR 5.76, 95 % CI = 1.86-17.86, p < .01) compared to usual care patients (N = 50). The study found no significant differences between groups in drinking or opioid use; patients in both groups reported using fewer substances at the 1-month follow-up. CONCLUSIONS Pilot data suggest START and RCT implementation are feasible and acceptable and that START may facilitate medication initiation and linkage to follow-up for inpatients with an alcohol or opioid use disorder. A larger trial should assess effectiveness, covariates, and moderators of intervention effects.
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Affiliation(s)
- Allison J Ober
- RAND Corporation, Santa Monica, CA, United States of America.
| | - Karen C Osilla
- Stanford University School of Medicine, Palo Alto, CA, United States of America
| | - David J Klein
- RAND Corporation, Santa Monica, CA, United States of America
| | - Lane F Burgette
- RAND Corporation, Santa Monica, CA, United States of America
| | - Isabel Leamon
- RAND Corporation, Santa Monica, CA, United States of America
| | - Mia W Mazer
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | | | - Stacy Collier
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Samuel Korouri
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | | | - Waguih Ishak
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Teryl Nuckols
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Itai Danovitch
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
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Seval N, Nunez J, Roth PMD, Meredith S, Strong M, Frank CA, Litwin AH, Levin FR, Brady KT, Nunes EV, Springer SA. Inpatient Low-dose Transitions From Full Agonist Opioids Including Methadone Onto Long-acting Depot Buprenorphine: Case Series From a Multicenter Clinical Trial. J Addict Med 2023; 17:e232-e239. [PMID: 37579095 PMCID: PMC10368784 DOI: 10.1097/adm.0000000000001136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Persons with opioid use disorder (OUD) suffer disproportionately from morbidity and mortality related to serious addiction-related infections requiring hospitalization. Long-acting buprenorphine (LAB) is an underused medication for OUD that may facilitate linkage to care and treatment retention when administered before hospital discharge. Transition onto buprenorphine in the inpatient setting is often complicated by pain, active infection management, potential surgical interventions, and risk of opioid withdrawal in transition from full agonists to a partial agonist. METHODS The COMMIT Trial is a randomized controlled trial evaluating LAB administered by infectious disease physicians and hospitalists compared with treatment as usual for persons with OUD hospitalized with infections. We report a case series of participants on full agonist opioids including methadone who were transitioned to sublingual buprenorphine using low-dose ( microdosing ) strategies followed by LAB injection. RESULTS Seven participants with current opioid use disorder and life-threatening infections, all with significant concurrent pain and many requiring surgical intervention, underwent low-dose transitions starting at buccal buprenorphine doses ranging from 225 μg to 300 μg 3 times a day on the first day. All were well tolerated with average time to LAB injection of 7.5 days (range, 5-10 days). CONCLUSIONS Inpatient low-dose buprenorphine transition from full agonist opioids including methadone onto LAB is feasible even in those with complex hospitalizations for concurrent infections and/or surgery. This strategy facilitates dosing of LAB before hospital discharge when risk of opioid relapse and overdose are significant.
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Affiliation(s)
- Nikhil Seval
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Disease. Yale AIDS Program. New Haven, CT
| | - Johnathan Nunez
- Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Division of Infectious Diseases and Epidemiology, Department of Medicine. Hershey, PA
| | - Prerana MD Roth
- Prisma Health, Department of Internal Medicine, Addiction Medicine Center, Greenville, SC
| | - Schade Meredith
- Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Division of Infectious Diseases and Epidemiology, Department of Medicine. Hershey, PA
| | - Michelle Strong
- Prisma Health, Department of Internal Medicine, Addiction Medicine Center, Greenville, SC
| | - Cynthia A. Frank
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Disease. Yale AIDS Program. New Haven, CT
| | - Alain H. Litwin
- Prisma Health, Department of Internal Medicine, Addiction Medicine Center, Greenville, SC
- University of South Carolina School of Medicine – Greenville, Greenville, SC
| | - Frances R. Levin
- Columbia University Irving Medical Center, Department of Psychiatry and New York State Psychiatric Institute
| | - Kathleen T. Brady
- Medical University of South Carolina, Clinical Neuroscience Division, Department of Psychiatry and Behavioral Sciences. Charleston, SC
| | - Edward V. Nunes
- University of South Carolina School of Medicine – Greenville, Greenville, SC
| | - Sandra A. Springer
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Disease. Yale AIDS Program. New Haven, CT
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Paroz S, Monnat M, Panese F, Saraga M, Daeppen JB. Caring for patients with substance use disorders: a qualitative investigation of difficulties encountered by hospital-based clinicians. J Addict Dis 2023:1-12. [PMID: 37369578 DOI: 10.1080/10550887.2023.2227307] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Background: Caring for patients with substance use disorders (SUD) is held in low regard and many clinicians resist treating them. To address this situation, numerous research projects assessed training program gaps and professional attitudes. In contrast, this study explored the actual clinical difficulties that a variety of hospital-based professionals encounter when treating patients with SUD. Methods: Qualitative multiple method design including: (1) individual semi-structured interviews with SUD experts and educators; (2) video-elicited, cross self-confrontation interviews with clinicians working in a specialist addiction unit; (3) paired semi-structured interviews with clinicians working in non-specialist units. Participants were recruited within one university hospital. Data collected at stages (1) and (3) relied on an interview guide and were analyzed using conventional content analyses. Data collected at stage (2) consisted of discussions of video recorded clinical interviews and were analyzed based on a participatory approach. Results: Twenty-three clinicians from seven hospital units participated. Forty-four difficulties were reported that we classified into six categories: knowledge-based; moral; technical; relational; identity-related; institutional. We identified seven cross-category themes as key features of SUD clinical complexity: exacerbation of patient characteristics; multiplication of medical issues; hybridity and specificity of medical discipline; experiences of stalemate, adversity, and role reversal. Conclusions: Our study, providing a comprehensive analysis of the difficulties of caring for patients with SUD, reveals a highly challenging clinical practice for a diversity of healthcare providers. They represent a complementary approach to addressing resistance as an important feature of a complex clinical system, and valuable material to discussing professional preparedness.
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Affiliation(s)
- Sophie Paroz
- Service of Addictions Medicine, Lausanne University Hospital and University of Lausanne, Canton of Vaud, Switzerland
| | - Martine Monnat
- Service of Community Psychiatry, Lausanne University Hospital and University of Lausanne, Canton of Vaud, Switzerland
- Public Health Service of Canton de Vaud, Department of Health and Social Action, Canton of Vaud, Lausanne, Switzerland
| | - Francesco Panese
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Canton of Vaud, Switzerland
- Institute of Social Sciences, University of Lausanne, Canton of Vaud, Switzerland
| | - Michael Saraga
- Service of General Psychiatry, Lausanne University Hospital and University of Lausanne, Canton of Vaud, Switzerland
| | - Jean-Bernard Daeppen
- Service of Addictions Medicine, Lausanne University Hospital and University of Lausanne, Canton of Vaud, Switzerland
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Harvey LH, Sliwinski SK, Flike K, Boudreau J, Gifford AL, Branch-Elliman W, Hyde J. The integration of harm reduction services in the Veterans Health Administration (VHA): a qualitative analysis of barriers and facilitators. J Addict Dis 2023:1-9. [PMID: 37154222 PMCID: PMC10630529 DOI: 10.1080/10550887.2023.2210021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Substance use is common among U.S. military veterans and veterans are at high risk for negative consequences associated with substance use, such as injection-related infections and overdose. Although harm reduction services (HRS) are highly evidence-based, implementation in traditional healthcare settings has been limited. This formative, qualitative study sought to identify barriers and facilitators to the integration of HRS and identify appropriate implementation strategies to support the optimized integration of a comprehensive bundle of HRS in the Veterans Health Administration (VHA). METHODS Semi-structured interviews explored how harm reduction is currently understood by VHA providers and elicited input on perceived facilitators and barriers to implementation. Data were analyzed using a directed content analysis and the Practical, Robust Implementation and Sustainability Model (PRISM) implementation framework was used to organize findings. Results were then mapped to relevant implementation strategies using the Consolidated Framework for Implementation Research - Expert Recommendations for Implementing Change (CFIR - ERIC) tool. RESULTS 15 interviews with VHA providers were conducted across 5 sites. Respondents reported that current HRS are fragmented and dependent on the knowledge, time, and comfort level of individual providers. Stigma around substance use at the patient, provider, and institutional levels was noted to be a key barrier to HRS adoption. Based on identified barriers and facilitators, strategies that may be effective for increasing adoption of HRS include engagement of champions, communication and educational strategies, and adaptation of existing infrastructure. CONCLUSIONS Many of the barriers identified in this formative study may be addressed using evidence-based implementation strategies. Additional research is needed to identify implementation strategies that are effective for addressing stigma, which is perceived to be a persistent challenge to the provision of integrated harm reduction services.
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Affiliation(s)
- Leah H Harvey
- Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Samantha K Sliwinski
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
| | - Kimberlee Flike
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Jacqueline Boudreau
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Allen L Gifford
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
| | - Westyn Branch-Elliman
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Veterans Affairs Boston Healthcare System, Department of Medicine, Boston, MA, USA
| | - Justeen Hyde
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
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Racha S, Patel SM, Bou Harfouch LT, Berger O, Buresh ME. Safety of rapid inpatient methadone initiation protocol: A retrospective cohort study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 148:209004. [PMID: 36931605 DOI: 10.1016/j.josat.2023.209004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 12/01/2022] [Accepted: 02/27/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Current methadone titration guidelines recommend low initial doses (15-40 mg) and slow increases (10-20 mg every 3 to 7 days) to prevent dose accumulation and oversedation until reaching a target therapeutic dose between 60 and 120 mg. These guidelines were created primarily for outpatient settings in the pre-fentanyl era. Methadone initiations are becoming more common in hospitals, but no titration guidelines exist specific to this treatment setting, which has capacity for increased monitoring. Our objective was to assess the safety of rapid inpatient methadone initiation with regard to mortality, overdose, and serious adverse outcomes both in-hospital and postdischarge. METHODS This is a retrospective, observational, cohort study conducted at an urban, academic medical center in the United States. We queried our electronic medical record for hospitalized adults with moderate to severe opioid use disorder admitted between July 1, 2018, and November 30, 2021. Included patients were rapidly initiated on methadone with 30 mg as the initial dose and 10 mg increases daily until reaching 60 mg. The study extracted thirty-day post-discharge opioid overdose and mortality data from the CRISP database. RESULTS Twenty-five hospitalized patients received rapid methadone initiation during the study period. The study had no major adverse events including in-hospital or thirty-day post-discharge overdoses or deaths. The study did have two instances of sedation, but neither led to methadone dose holds. There were no instances of QTc prolongation. The study had one patient-directed discharge. CONCLUSIONS This study demonstrated that a small subset of hospitalized patients tolerated rapid methadone initiation. More rapid titrations can be utilized in a monitored inpatient setting to retain patients in the hospital and allow providers to account for increased tolerance in the fentanyl era. Guidelines should be updated to reflect the capabilities of inpatient settings to safely initiate and rapidly titrate methadone. Further work should determine optimal methadone initiation protocols in the fentanyl era.
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Affiliation(s)
- Savitha Racha
- Department of Medicine, Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America.
| | - Sapan M Patel
- Department of Medicine, Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America; Johns Hopkins University, Krieger School of Arts and Sciences, United States of America.
| | - Layal T Bou Harfouch
- Department of Medicine, Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America; Johns Hopkins University, Krieger School of Arts and Sciences, United States of America.
| | - Olivia Berger
- Department of Pharmacy, Johns Hopkins Bayview Medical Center, Baltimore, MD, United States of America.
| | - Megan E Buresh
- Department of Medicine, Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America.
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Attwood LO, Bryant M, Lee SJ, Vujovic O, Higgs P, Doyle JS, Stewardson AJ. Epidemiology and Management of invasive infections among people who Use drugs (EMU): protocol for a prospective, multicentre cohort study. BMJ Open 2023; 13:e070236. [PMID: 37012020 PMCID: PMC10083776 DOI: 10.1136/bmjopen-2022-070236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2023] Open
Abstract
INTRODUCTION People who inject drugs (PWID) are at risk of invasive infections such as bloodstream infections, endocarditis, osteomyelitis and septic arthritis. Such infections require prolonged antibiotic therapy, but there is limited evidence about the optimal care model to deliver to this population. The Epidemiology and Management of invasive infections among people who Use drugs (EMU) study aims to (1) describe the current burden, clinical spectrum, management and outcomes of invasive infections in PWID; (2) determine the impact of currently available models of care on completion of planned antimicrobials for PWID admitted to hospital with invasive infections and (3) determine postdischarge outcomes of PWID admitted with invasive infections at 30 and 90 days. METHODS AND ANALYSIS EMU is a prospective multicentre cohort study of Australian public hospitals who provide care to PWIDs with invasive infections. All patients who have injected drugs in the previous six months and are admitted to a participating site for management of an invasive infection are eligible. EMU has two components: (1) EMU-Audit will collect information from medical records, including demographics, clinical presentation, management and outcomes; (2) EMU-Cohort will augment this with interviews at baseline, 30 and 90 days post-discharge, and data linkage examining readmission rates and mortality. The primary exposure is antimicrobial treatment modality, categorised as inpatient intravenous antimicrobials, outpatient antimicrobial therapy, early oral antibiotics or lipoglycopeptide. The primary outcome is confirmed completion of planned antimicrobials. We aim to recruit 146 participants over a 2-year period. ETHICS AND DISSEMINATION EMU has been approved by the Alfred Hospital Human Research Ethics Committee (Project number 78815.) EMU-Audit will collect non-identifiable data with a waiver of consent. EMU-Cohort will collect identifiable data with informed consent. Findings will be presented at scientific conferences and disseminated by peer-review publications. TRIAL REGISTRATION NUMBER ACTRN12622001173785; Pre-results.
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Affiliation(s)
- Lucy O Attwood
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Mellissa Bryant
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Sue J Lee
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Olga Vujovic
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Peter Higgs
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
- Department of Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Joseph S Doyle
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Andrew J Stewardson
- Department of Infectious Diseases, the Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Antill Keener T, Tallerico J, Harvath R, Cartwright-Stroupe L, Shafique S, Piamjariyakul U. Nurses' Perception of Caring for Patients With Substance Use Disorder. J Addict Nurs 2023; 34:111-120. [PMID: 37276200 DOI: 10.1097/jan.0000000000000523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
ABSTRACT The objective of this research was to explore the perceptions of nurses regarding patients with substance use disorder (SUD), healthcare provided, and desired resources to care for this population properly. This study used a cross-sectional, descriptive design. Data were collected via an anonymous 12-item survey and three open-ended questions. Data were analyzed using descriptive statistics and conventional content analysis. Nurses with less than 1 year of experience reported more significant challenges when caring for patients with SUD. These challenges included difficulties in managing pain, implementing alternative pain management techniques, and knowing who to contact when problems occur. The study revealed many needs of nurses to provide compassionate care for patients with SUD. Findings indicate a need for education for nurses, especially novice nurses, who care for patients with SUD.
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RE: Maxillofacial Surgeons Beware: Some AHA "Moderate Risk" Patients Develop Endocarditis After Exodontia. J Oral Maxillofac Surg 2023; 81:261. [PMID: 36868680 DOI: 10.1016/j.joms.2022.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 12/12/2022] [Accepted: 12/12/2022] [Indexed: 03/05/2023]
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Nodoushani AY, Wang Y, Datar Y, Mohnot J, Karlson KJ, Edwards NM, Yin K, Dobrilovic N. Association of Intravenous Drug Use and Length of Stay Following Infective Endocarditis. J Surg Res 2023; 282:239-245. [PMID: 36332302 DOI: 10.1016/j.jss.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 09/13/2022] [Accepted: 10/07/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Intravenous drug use (IVDU) and associated infective endocarditis (IE) has been on the rise in the US since the beginning of the opioid epidemic. IVDU-IE has high morbidity and mortality, and treatment can be lengthy. We aim to quantify the association between IVDU and length of stay (LOS) in IE patients. METHODS The National Inpatient Sample database was used to identify IE patients, which was then stratified into IVDU-IE and non-IVDU-IE groups. Weighted values of hospitalizations were used to generate national estimates. Multivariable linear and logistic regression analyses were applied to estimate the effects of IVDU on LOS. RESULTS We identified 1,114,257 adult IE patients, among which 123,409 (11.1%) were IVDU-IE. Compared to non-IVDU-IE patients, IVDU-IE patients were younger, had fewer comorbidities, and had an overall longer LOS (median [interquartile range]: 10 [5-20] versus 7 [4-13] d, P < 0.001), with a greater percentage of patients with a LOS longer than 30 d (13.7% versus 5.7%, P < 0.001). After adjusting for multiple demographic and clinical factors, IVDU was independently associated with a 1.25-d increase in LOS (beta-coefficient = 1.25, 95% confidence interval [CI]: 0.95-1.54, P < 0.001) and 35% higher odds of being hospitalized for more than 30 d (odds ratio = 1.35, 95% CI: 1.27-1.44, P < 0.001). CONCLUSIONS Among IE patients, being IVDU has associated with a longer LOS and a higher risk of prolonged hospital stay. Steps toward the prevention of IE in the IVDU population should be taken to avoid an undue burden on the healthcare system.
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Affiliation(s)
- Ariana Y Nodoushani
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Yunda Wang
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Yesh Datar
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Joy Mohnot
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Karl J Karlson
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Niloo M Edwards
- Division of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Kanhua Yin
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Nikola Dobrilovic
- Division of Cardiac Surgery, NorthShore University HealthSystem, Chicago, Illinois.
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Smart R, Kim JY, Kennedy S, Tang L, Allen L, Crane D, Mack A, Mohamoud S, Pauly N, Perez R, Donohue J. Association of polysubstance use disorder with treatment quality among Medicaid beneficiaries with opioid use disorder. J Subst Abuse Treat 2023; 144:108921. [PMID: 36327615 PMCID: PMC10664516 DOI: 10.1016/j.jsat.2022.108921] [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] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 08/22/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION The opioid crisis is transitioning to a polydrug crisis, and individuals with co-occurring substance use disorder (SUDs) often have unique clinical characteristics and contextual barriers that influence treatment needs, engagement in treatment, complexity of treatment planning, and treatment retention. METHODS Using Medicaid data for 2017-2018 from four states participating in a distributed research network, this retrospective cohort study documents the prevalence of specific types of co-occurring SUD among Medicaid enrollees with an opioid use disorder (OUD) diagnosis, and assesses the extent to which different SUD presentations are associated with differential patterns of MOUD and psychosocial treatments. RESULTS We find that more than half of enrollees with OUD had a co-occurring SUD, and the most prevalent co-occurring SUD was for "other psychoactive substances", indicated among about one-quarter of enrollees with OUD in each state. We also find some substantial gaps in MOUD treatment receipt and engagement for individuals with OUD and a co-occurring SUD, a group representing more than half of individuals with OUD. In most states, enrollees with OUD and alcohol, cannabis, or amphetamine use disorder are significantly less likely to receive MOUD compared to enrollees with OUD only. In contrast, enrollees with OUD and other psychoactive SUD were significantly more likely to receive MOUD treatment. Conditional on MOUD receipt, enrollees with co-occurring SUDs had 10 % to 50 % lower odds of having a 180-day period of continuous MOUD treatment, an important predictor of better patient outcomes. Associations with concurrent receipt of MOUD and behavioral counseling were mixed across states and varied depending on co-occurring SUD type. CONCLUSIONS Overall, ongoing progress toward increasing access to and quality of evidence-based treatment for OUD requires further efforts to ensure that individuals with co-occurring SUDs are engaged and retained in effective treatment. As the opioid crisis evolves, continued changes in drug use patterns and populations experiencing harms may necessitate new policy approaches that more fully address the complex needs of a growing population of individuals with OUD and other types of SUD.
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Affiliation(s)
- Rosanna Smart
- Drug Policy Research Center, RAND Corporation, 1776 Main Street, PO Box 2138, Santa Monica, CA 90407-2138, United States of America.
| | - Joo Yeon Kim
- Department of Health Policy and Management, University of Pittsburgh, 130 DeSoto Street, Crabtree Hall A635, Pittsburgh, PA 15261, United States of America.
| | - Susan Kennedy
- AcademyHealth, 1666 K Street NW, Suite 1100, Washington, DC 20006, United States of America.
| | - Lu Tang
- Department of Biostatistics, University of Pittsburgh, 130 DeSoto Street, Pittsburgh, PA 15261, United States of America.
| | - Lindsay Allen
- Department of Emergency Medicine, Buehler Center for Health Policy & Economics, Northwestern University, 750 N. Lake Shore Drive, Evanston, IL 60611, United States of America.
| | - Dushka Crane
- Government Resource Center, The Ohio State University, 150 Pressey Hall, 1070 Carmack Road, Columbus, OH 43210, United States of America.
| | - Aimee Mack
- Government Resource Center, The Ohio State University, 150 Pressey Hall, 1070 Carmack Road, Columbus, OH 43210, United States of America.
| | - Shamis Mohamoud
- The Hilltop Institute, University of Maryland Baltimore County, Sondheim Hall, Third Floor, 1000 Hilltop Circle, Baltimore, MD 21250, United States of America.
| | - Nathan Pauly
- Manatt Health Strategies, 151 N Franklin Street, Suite 2600, Chicago, IL 60606, United States of America.
| | - Rosa Perez
- The Hilltop Institute, University of Maryland Baltimore County, Sondheim Hall, Third Floor, 1000 Hilltop Circle, Baltimore, MD 21250, United States of America.
| | - Julie Donohue
- Department of Health Policy and Management, University of Pittsburgh, 130 DeSoto Street, Crabtree Hall A635, Pittsburgh, PA 15261, United States of America.
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Implementation of an integrated infectious disease and substance use disorder team for injection drug use-associated infections: a qualitative study. Addict Sci Clin Pract 2023; 18:8. [PMID: 36747268 PMCID: PMC9902242 DOI: 10.1186/s13722-023-00363-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 01/25/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Hospitalizations for severe injection drug use-related infections (SIRIs) are characterized by high costs, frequent patient-directed discharge, and high readmission rates. Beyond the health system impacts, these admissions can be traumatizing to people who inject drugs (PWID), who often receive inadequate treatment for their substance use disorders (SUD). The Jackson SIRI team was developed as an integrated infectious disease/SUD treatment intervention for patients hospitalized at a public safety-net hospital in Miami, Florida in 2020. We conducted a qualitative study to identify patient- and clinician-level perceived implementation barriers and facilitators to the SIRI team intervention. METHODS Participants were patients with history of SIRIs (n = 7) and healthcare clinicians (n = 8) at one implementing hospital (Jackson Memorial Hospital). Semi-structured qualitative interviews were performed with a guide created using the Consolidated Framework for Implementation Research (CFIR). Interviews were transcribed, double coded, and categorized by study team members using CFIR constructs. RESULTS Implementation barriers to the SIRI team intervention identified by participants included: (1) complexity of the SIRI team intervention; (2) lack of resources for PWID experiencing homelessness, financial insecurity, and uninsured status; (3) clinician-level stigma and lack of knowledge around addiction and medications for opioid use disorder (OUD); and (4) concerns about underinvestment in the intervention. Implementation facilitators of the intervention included: (1) a non-judgmental, harm reduction-oriented approach; (2) the team's advocacy for PWID as a means of institutional culture change; (3) provision of close post-hospital follow-up that is often inaccessible for PWID; (4) strong communication with patients and their hospital physicians; and (5) addressing diverse needs such as housing, insurance, and psychological wellbeing. CONCLUSION Integration of infectious disease and SUD treatment is a promising approach to managing patients with SIRIs. Implementation success depends on institutional buy-in, holistic care beyond the medical domain, and an ethos rooted in harm reduction across multilevel (inner and outer) implementation contexts.
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Zavodnick J, Heinsinger NM, Lepore AC, Sterling RC. Medication Initiation, Patient-directed Discharges, and Hospital Readmissions Before and After Implementing Guidelines for Opioid Withdrawal Management. J Addict Med 2023; 17:e57-e63. [PMID: 36001053 PMCID: PMC11002789 DOI: 10.1097/adm.0000000000001053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Rising rates of hospitalization for patients with opioid use disorder (OUD) result in high rates of patient-directed discharge (PDD, also called "discharge against medical advice") and 30-day readmissions. Interdisciplinary addiction consult services are an emerging criterion standard to improve care for these patients, but these services are resource- and expertise-intensive. A set of withdrawal guidelines was developed to guide generalists in caring for patients with opioid withdrawal at a hospital without an addiction consult service. METHODS Retrospective chart review was performed to determine PDD, 30-day readmission, and psychiatry consult rates for hospitalized patients with OUD during periods before (July 1, 2017, to March 31, 2018) and after (January 1, 2019, to July 31, 2019) the withdrawal guidelines were implemented. Information on the provision of opioid agonist therapy (OAT) was also obtained. RESULTS Use of OAT in patients with OUD increased significantly after guideline introduction, from 23.3% to 64.8% ( P < 0.001). Patient-directed discharge did not change, remaining at 14% before and after. Thirty-day readmissions increased 12.4% to 15.7% ( P = 0.05065). Receiving any OAT was associated with increased PDD and readmission, but only within the postintervention cohort. CONCLUSIONS A guideline to facilitate generalist management of opioid withdrawal in hospitalized patients improved the process of care, increasing the use of OAT and decreasing workload on the psychiatry consult services. Although increased inpatient OAT has been previously shown to decrease PDD, in this study PDD and readmission rates did not improve. Guidelines may be insufficient to impact these outcomes.
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Affiliation(s)
- Jillian Zavodnick
- From the Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA (JZ); Department of Neuroscience, Thomas Jefferson University, Philadelphia, PA (NMH, ACL); and Department of Psychiatry, Thomas Jefferson University, Philadelphia, PA (RCS)
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Thakarar K, Kohut M, Stoddard H, Burris D, Chessa F, Sikka MK, Solomon DA, Kershaw CM, Eaton E, Hutchinson R, Fairfield KM, Friedmann P, Stopka TJ. 'I feel like they're actually listening to me': a pilot study of a hospital discharge decision-making conversation guide for patients with injection drug use-associated infections. Ther Adv Infect Dis 2023; 10:20499361231165108. [PMID: 37034032 PMCID: PMC10074622 DOI: 10.1177/20499361231165108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 03/06/2023] [Indexed: 04/07/2023] Open
Abstract
Background The prevalence of injection drug use (IDU)-associated infections and associated hospitalizations has been increasing for nearly two decades. Due to issues ranging from ongoing substance use to peripherally inserted central catheter safety, many clinicians find discharge decision-making challenging. Typically, clinicians advise patients to remain hospitalized for several weeks for intravenous antimicrobial treatment; however, some patients may desire other antimicrobial treatment options. A structured conversation guide, delivered by infectious disease physicians, intended to inform hospital discharge decisions has the potential to enhance patient participation in decisions. We developed a conversation guide in order to: (1) investigate its feasibility and acceptability and (2) examine experiences, outcomes, and lessons learned from use of the guide. Methods We interviewed physicians after they each piloted the conversation guide with two patients. We interviewed patients immediately after the conversation and again 4-6 weeks later. Two analysts indexed transcriptions and used the framework method to identify and organize relevant information. We conducted retrospective chart review to corroborate and contextualize qualitative data. Results Eight patients and four infectious disease physicians piloted the conversation guide. All patients (N = 8) completed antimicrobial treatment. Nearly all participants believed the conversation guide was important for incorporating patient values and preferences. Patients reported an increased sense of autonomy, but felt post-discharge needs could be better addressed. Physician participants identified the guide's long length and inclusion of pain management as areas for improvement. Conclusions A novel conversation guide to inform hospital discharge decision-making for patients with IDU-associated infections was feasible, acceptable, and fostered the incorporation of patient preferences and values into decisions. While we identified areas for improvement, overall participants believed that this novel conversation guide helped to improve patient care and autonomy.
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Affiliation(s)
- Kinna Thakarar
- Department of Medicine, Tufts University School
of Medicine, Boston, MA 02111, USA
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
- Divisions of Infectious Disease and Addiction
Medicine, Department of Medicine, Maine Medical Center, 41 Donald B. Dean
Drive, Suite B, South Portland, ME 04106, USA
| | - Michael Kohut
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
| | - Henry Stoddard
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
| | - Deb Burris
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
| | - Frank Chessa
- Department of Medical Ethics, Tufts University
School of Medicine, Boston, MA, USA
| | - Monica K. Sikka
- Division of Infectious Diseases, Oregon Health
& Science University, Portland, OR, USA
| | - Daniel A. Solomon
- Division of Infectious Disease, Brigham and
Women’s Hospital, Boston, MA, USA
| | - Colleen M. Kershaw
- Section of Infectious Disease and
International Health, Dartmouth Hitchcock Medical Center, Lebanon, NH,
USA
- Department of Medicine, Geisel School of
Medicine, Dartmouth College, Hanover, NH, USA
| | - Ellen Eaton
- Division of Infectious Disease, School of
Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rebecca Hutchinson
- Division of Palliative Care, Maine Medical
Center, Portland, ME, USA
- Department of Medical Education, Tufts
University School of Medicine, Boston, MA, USA
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
| | - Kathleen M. Fairfield
- Department of Medicine, Maine Medical Center,
Portland, ME, USA
- Department of Medical Education, Tufts
University School of Medicine, Boston, MA, USA
- Center for Interdisciplinary Population and
Health Research, MaineHealth Institute for Research, Portland, ME, USA
| | - Peter Friedmann
- Office of Research, UMass Chan Medical School,
Worcester, MA, USA
| | - Thomas J. Stopka
- Department of Public Health and Community
Medicine, Tufts University School of Medicine, Boston, MA, USA
- Frank Chessa is also affiliated to Maine
Medical Center, Portland, ME, USA
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Kershaw C, Lurie JD, Brackett C, Loukas E, Smith K, Mullins S, Gooley C, Borrows M, Bardach S, Perry A, Carpenter-Song E, Landsman HS, Pierotti D, Bergeron E, McMahon E, Finn C. Improving care for individuals with serious infections who inject drugs. Ther Adv Infect Dis 2022; 9:20499361221142476. [PMID: 36600726 PMCID: PMC9806364 DOI: 10.1177/20499361221142476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 11/14/2022] [Indexed: 12/28/2022] Open
Abstract
Background Hospitalizations for serious infections requiring long-term intravenous (IV) antimicrobials related to injection drug use have risen sharply over the last decade. At our rural tertiary care center, opportunities for treatment of underlying substance use disorders were often missed during these hospital admissions. Once medically stable, home IV antimicrobial therapy has not traditionally been offered to this patient population due to theoretical concerns about misuse of long-term IV catheters, leading to discharges with suboptimal treatment regimens, lengthy hospital stays, or care that is incongruent with patient goals and preferences. Methods A multidisciplinary group of clinicians and patients set out to redesign and improve care for this patient population through a health care innovation process, with a focus on increasing the proportion of patients who may be discharged on home IV therapy. Baseline assessment of current experience was established through retrospective chart review and extensive stakeholder analysis. The innovation process was based in design thinking and facilitated by a health care delivery improvement incubator. Results The components of the resulting intervention included early identification of hospitalized people who inject drugs with serious infections, a proactive psychiatry consultation service for addiction management for all patients, a multidisciplinary care conference to support decision making around treatment options for infection and substance use, and care coordination/navigation in the outpatient setting with a substance use peer recovery coach and infectious disease nurse for patients discharged on home IV antimicrobials. Patients discharged on home IV therapy followed routine outpatient parenteral antimicrobial therapy (OPAT) protocols and treatment protocols for addiction with their chosen provider. Conclusion An intervention developed through a design-thinking-based health care redesign process improved patient-centered care for people with serious infections who inject drugs.
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Affiliation(s)
| | - Jon D Lurie
- Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA; Dartmouth College Geisel School of Medicine, Hanover, NH, USA,The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH,
USA
| | - Charles Brackett
- Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA,Dartmouth College Geisel School of Medicine,
Hanover, NH, USA
| | - Elias Loukas
- Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA,Dartmouth College Geisel School of Medicine,
Hanover, NH, USA
| | - Katie Smith
- Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA
| | - Sarah Mullins
- Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA
| | | | | | - Shoshana Bardach
- The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH,
USA
| | - Amanda Perry
- The Dartmouth Institute for Health Policy and
Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH,
USA
| | | | - H. Samuel Landsman
- Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA,Dartmouth College Geisel School of Medicine,
Hanover, NH, USA
| | - Danielle Pierotti
- Visiting Nurse and Hospice for Vermont and New
Hampshire, White River Junction, VT, USA,Christine Finn is also affiliated to Dartmouth
College Geisel School of Medicine, Hanover, NH, USA
| | - Ericka Bergeron
- Visiting Nurse and Hospice for Vermont and New
Hampshire, White River Junction, VT, USA,Christine Finn is also affiliated to Dartmouth
College Geisel School of Medicine, Hanover, NH, USA
| | - Erin McMahon
- Visiting Nurse and Hospice for Vermont and New
Hampshire, White River Junction, VT, USA,Christine Finn is also affiliated to Dartmouth
College Geisel School of Medicine, Hanover, NH, USA
| | - Christine Finn
- Dartmouth-Hitchcock Medical Center, Lebanon,
NH, USA,Dartmouth College Geisel School of Medicine,
Hanover, NH, USA
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40
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Narayanan S, Ching PR, Traver EC, George N, Amoroso A, Kottilil S. Predictors of Nonadherence Among Patients With Infectious Complications of Substance Use Who Are Discharged on Parenteral Antimicrobial Therapy. Open Forum Infect Dis 2022; 10:ofac633. [PMID: 36686627 PMCID: PMC9845962 DOI: 10.1093/ofid/ofac633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 11/23/2022] [Indexed: 12/14/2022] Open
Abstract
Background The management of invasive infections related to substance use disorder (SUD) needing parenteral antimicrobial therapy is challenging and may have poor treatment outcomes including nonadherence and lack of completion of parenteral antimicrobial therapy. Methods In this retrospective cohort of 201 patients with invasive infections related to SUD, we looked at frequency and determinants of unfavorable outcomes including nonadherence. Results Seventy-nine percent of patients with SUD-related infection completed parenteral antibiotic therapy in skilled nursing facilities. A total of 21.5% of patient episodes had documentation of nonadherence. Nonadherence was higher in patients with active injection drug use (IDU) (28.5% versus 15% in non IDU; adjusted odds ratio [OR] 2.36; 95% confidence interval [CI], 1.1-5.5; P = .024), patients with active SUD in the prior year (24.5% vs 11%, P = .047), patients with use of more than 1 illicit substance (30.3% vs 17%, P = .031), as well as in people experiencing homelessness (32.8% vs 15.7% in stably housed, P = .005). In a multivariate model, nonadherence was significantly associated with IDU (OR, 2.38; 95% CI, 1.03-5.5) and homelessness (OR, 2.25; 95% CI, 1.01-4.8) Medication for opioid use disorder was prescribed at discharge in 68% of overall cohort and was not associated with improved outcomes for any of the above groups. Conclusions Nonadherence to parenteral antimicrobial therapy is high in the most vulnerable patients with unstable high-risk SUD and adverse social determinants of health.
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Affiliation(s)
- Shivakumar Narayanan
- Correspondence: Shivakumar Narayanan, MD, Institute of Human Virology, University of Maryland School of Medicine, 725 W Lombard St, S211B, Baltimore, MD 21201 ()
| | - Patrick R Ching
- Division of Infectious Diseases, Department of Medicine, Washington UniversitySchool of Medicine, St. Louis, Missouri, USA
| | - Edward C Traver
- University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Nivya George
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Anthony Amoroso
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Tassey TE, Ott GE, Alvanzo AAH, Peirce JM, Antoine D, Buresh ME. OUD MEETS: A novel program to increase initiation of medications for opioid use disorder and improve outcomes for hospitalized patients being discharged to skilled nursing facilities. J Subst Abuse Treat 2022; 143:108895. [PMID: 36215913 DOI: 10.1016/j.jsat.2022.108895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 08/09/2022] [Accepted: 09/20/2022] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Rates of hospitalizations from medical complications of opioid use disorder (OUD) are rising and many of these patients require post-acute care at skilled nursing facilities (SNFs). However, access to medication for OUD (MOUD) at SNFs remains low and patients with OUD have high rates of patient-directed discharge (PDD) and hospital readmissions. METHODS Opioid Use Disorder Medical Patient Engagement, Enrollment in treatment and Transitional Supports (OUD MEETS) program was a clinical pilot designed to increase initiation of buprenorphine and methadone for hospitalized patients with OUD requiring post-acute care. The program comprises a hospital partnership with two SNFs and two opioid treatment programs (OTPs) to improve recovery supports and access to MOUD for patients discharged to SNF. RESULTS Between August 2019 and August 2020, study staff approached 49 hospitalized patients with OUD for participation in OUD MEETS. Twenty-eight of 30 eligible patients enrolled in the program and initiated buprenorphine or methadone. Twenty-seven (96 %) enrolled patients successfully completed hospital treatment. Twenty-three (85 %) patients successfully completed medical treatment at SNF. Thirteen (46 %) enrolled patients had confirmed linkage to OUD treatment post-SNF. One patient left the hospital (4 %) and four patients left SNF (15 %) via PDD. CONCLUSION OUD MEETS demonstrates feasibility of hospital, SNF, and OTP partnership to integrate MOUD treatment into SNFs, with high rates of completion of medical treatment and low rates of PDD. Future research should find sustainable ways to improve access to MOUD at post-acute care facilities, including through regulatory and policy changes.
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Affiliation(s)
- Theresa E Tassey
- Behavioral Health Systems Baltimore, Baltimore, MD, United States of America
| | - Geoffrey E Ott
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, United States of America
| | - Anika A H Alvanzo
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America; Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Jessica M Peirce
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Denis Antoine
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States of America
| | - Megan E Buresh
- Division of Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States of America; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America.
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Schultz JR, Costa SK, Jachak GR, Hegde P, Zimmerman M, Pan Y, Josten M, Ejeh C, Hammerstad T, Sahl HG, Pereira PM, Pinho MG, Dartois V, Cheung A, Aldrich CC. Identification of 5-(Aryl/Heteroaryl)amino-4-quinolones as Potent Membrane-Disrupting Agents to Combat Antibiotic-Resistant Gram-Positive Bacteria. J Med Chem 2022; 65:13910-13934. [PMID: 36219779 PMCID: PMC9826610 DOI: 10.1021/acs.jmedchem.2c01151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Nosocomial infections caused by resistant Gram-positive organisms are on the rise, presumably due to a combination of factors including prolonged hospital exposure, increased use of invasive procedures, and pervasive antibiotic therapy. Although antibiotic stewardship and infection control measures are helpful, newer agents against multidrug-resistant (MDR) Gram-positive bacteria are urgently needed. Here, we describe our efforts that led to the identification of 5-amino-4-quinolone 111 with exceptionally potent Gram-positive activity with minimum inhibitory concentrations (MICs) ≤0.06 μg/mL against numerous clinical isolates. Preliminary mechanism of action and resistance studies demonstrate that the 5-amino-4-quinolones are bacteriostatic, do not select for resistance, and selectively disrupt bacterial membranes. While the precise molecular mechanism has not been elucidated, the lead compound is nontoxic displaying a therapeutic index greater than 500, is devoid of hemolytic activity, and has attractive physicochemical properties (clog P = 3.8, molecular weight (MW) = 441) that warrant further investigation of this promising antibacterial scaffold for the treatment of Gram-positive infections.
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Affiliation(s)
- John R Schultz
- Department of Medicinal Chemistry, University of Minnesota, Minneapolis, Minnesota 55455, United States
| | - Stephen K Costa
- Department of Microbiology & Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire 03755, United States
| | - Gorakhnath R Jachak
- Department of Medicinal Chemistry, University of Minnesota, Minneapolis, Minnesota 55455, United States
| | - Pooja Hegde
- Department of Medicinal Chemistry, University of Minnesota, Minneapolis, Minnesota 55455, United States
| | - Matthew Zimmerman
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey 07110, United States
| | - Yan Pan
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey 07110, United States
| | - Michaele Josten
- Institute for Pharmaceutical Microbiology and Institute for Medical Microbiology, Immunology, and Parasitology, University of Bonn, D-53115 Bonn, Germany
| | - Chinedu Ejeh
- Department of Microbiology & Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire 03755, United States
| | - Travis Hammerstad
- Department of Medicinal Chemistry, University of Minnesota, Minneapolis, Minnesota 55455, United States
| | - Hans Georg Sahl
- Institute for Pharmaceutical Microbiology and Institute for Medical Microbiology, Immunology, and Parasitology, University of Bonn, D-53115 Bonn, Germany
| | - Pedro M Pereira
- Bacterial Cell Biology Laboratory, Instituto de Tecnologia Química e Biológica António Xavier, Universidade Nova de Lisboa, Avenida da República (EAN), 2781-901 Oeiras, Portugal
| | - Mariana G Pinho
- Bacterial Cell Biology Laboratory, Instituto de Tecnologia Química e Biológica António Xavier, Universidade Nova de Lisboa, Avenida da República (EAN), 2781-901 Oeiras, Portugal
| | - Véronique Dartois
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, New Jersey 07110, United States
| | - Ambrose Cheung
- Department of Microbiology & Immunology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire 03755, United States
| | - Courtney C Aldrich
- Department of Medicinal Chemistry, University of Minnesota, Minneapolis, Minnesota 55455, United States
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Morales Y, Smyth E, Zubiago J, Bearnot B, Wurcel AG. "They Just Assume That We're All Going to Do the Wrong Thing With It. It's Just Not True": Stakeholder Perspectives About Peripherally Inserted Central Catheters in People Who Inject Drugs. Open Forum Infect Dis 2022; 9:ofac364. [PMID: 36267246 PMCID: PMC9579457 DOI: 10.1093/ofid/ofac364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 07/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background In the absence of adequate harm reduction opportunities, people who inject drugs (PWID) are at increased risk for serious infections. Infectious diseases guidelines recommend extended periods of intravenous antibiotic treatment through peripherally inserted central catheters (PICCs), but PWID are often deemed unsuitable for this treatment. We conducted semi-structured interviews and focus groups to understand the perspectives and opinions of patients and clinicians on the use of PICCs for PWID. Methods We approached patients and clinicians (doctors, nurses, PICC nurses, social workers, and case workers) involved in patient care at Tufts Medical Center (Boston, Massachusetts) between August 2019 and April 2020 for semi-structured interviews and focus groups. Results Eleven of 14 (79%) patients agreed to participate in an in-depth interview, and 5 role-specific clinician focus groups (1 group consisting of infectious diseases, internal medicine, and addiction psychiatry doctors, 2 separate groups of floor nurses, 1 group of PICC nurses, and 1 group of social workers) were completed. Emergent themes included the overall agreement that PICCs improve healthcare, patients' feelings that their stage of recovery from addiction was not taken into consideration, and clinicians' anecdotal negative experiences driving decisions on PICCs. Conclusions When analyzed together, the experiences of PWID and clinicians shed light on ways the healthcare system can improve the quality of care for PWID hospitalized for infections. Further research is needed to develop a system of person-centered care for PWID that meets the specific needs of patients and improves the relationship between them and the healthcare system.
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Affiliation(s)
- Yoelkys Morales
- Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Emma Smyth
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Julia Zubiago
- Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Benjamin Bearnot
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA,Harvard Medical School, Boston, Massachusetts, USA
| | - Alysse G Wurcel
- Correspondence: Alysse G. Wurcel, MD, MS, Tufts Medical Center, Department of Geographic Medicine and Infectious Diseases, 800 Washington St, Boston MA 02111, USA ()
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Factors Associated With Severe Bacterial Infections in People Who Inject Drugs: A Single-center Observational Study. J Addict Med 2022:01271255-990000000-00097. [PMID: 36256703 DOI: 10.1097/adm.0000000000001099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND People who inject drugs are at increased risk for several bacterial infections such as bacteremia, endocarditis, and osteomyelitis resulting in severe morbidity and high care costs. Limited data exist surrounding the injection drug use practices and behaviors that may increase the risk of these infections. METHODS Individuals admitted to a single hospital in New York City with severe bacterial infection, between August 2020 and June 2021, were recruited to partake in an in-depth survey examining potential factors, both demographic and injection drug use behavioral, associated with severe bacterial infections. RESULTS Thirty-four participants were recruited with injection drug use-associated severe bacterial infection. The mean age was 36.5 years; 21 (62%) were currently homeless, with 19 (56%) patients admitted for infective endocarditis. The mean length of hospital stay of all participants was 32.2 days; 94% received medication for opioid use disorder while admitted, whereas 35% left before treatment completion with a patient-directed discharge or elopement. Eight-two percent of participants were injected daily in the prior 30 days, with an average of 276 injections per participant. Fifty percent of participants reported requiring multiple sticks per injection event "always" or "very often," with 94% reporting reuse of syringes in the prior month. CONCLUSIONS Severe bacterial infections in people who inject drugs resulted in prolonged and complex hospitalization that culminate in suboptimal outcomes despite aggressive measures to engage patients in medication for opioid use disorder. Numerous nonsterile injection drug use practices were identified, indicating a gap in current infection prevention harm reduction messaging.
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Baddour LM, Weimer MB, Wurcel AG, McElhinney DB, Marks LR, Fanucchi LC, Esquer Garrigos Z, Pettersson GB, DeSimone DC. Management of Infective Endocarditis in People Who Inject Drugs: A Scientific Statement From the American Heart Association. Circulation 2022; 146:e187-e201. [PMID: 36043414 DOI: 10.1161/cir.0000000000001090] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The American Heart Association has sponsored both guidelines and scientific statements that address the diagnosis, management, and prevention of infective endocarditis. As a result of the unprecedented and increasing incidence of infective endocarditis cases among people who inject drugs, the American Heart Association sponsored this original scientific statement. It provides a more in-depth focus on the management of infective endocarditis among this unique population than what has been provided in prior American Heart Association infective endocarditis-related documents. METHODS A writing group was named and consisted of recognized experts in the fields of infectious diseases, cardiology, addiction medicine, and cardiovascular surgery in October 2021. A literature search was conducted in Embase on November 19, 2021, and multiple terms were used, with 1345 English-language articles identified after removal of duplicates. CONCLUSIONS Management of infective endocarditis in people who inject drugs is complex and requires a unique approach in all aspects of care. Clinicians must appreciate that it requires involvement of a variety of specialists and that consultation by addiction-trained clinicians is as important as that of more traditional members of the endocarditis team to improve infective endocarditis outcomes. Preventive measures are critical in people who inject drugs and are cured of an initial bout of infective endocarditis because they remain at extremely high risk for subsequent bouts of infective endocarditis, regardless of whether injection drug use is continued.
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Ginther J, Chipps E, Landers T, Sinnott L, Overcash J. The Complexity of Educating Acute Care Nurses on Opioid Use Disorder: A Quality Improvement Project. J Addict Nurs 2022; 33:299-308. [PMID: 37140417 DOI: 10.1097/jan.0000000000000496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
BACKGROUND Opioid use disorder (OUD) is a public health crisis, yet most acute care nurses are not educated to deliver evidence-based OUD care. Hospitalization provides a unique opportunity to initiate and coordinate OUD care in people presenting for other medical-surgical reasons. The aim of this quality improvement project was to determine the impact of an educational program on self-reported competencies of medical-surgical nurses caring for people with OUD at a large academic medical center in the Midwestern United States. METHOD Data were collected from two time points using a quality survey examining self-reported nurse competencies related to (a) assessment, (b) intervention, (c) treatment recommendation, (d) resource use, (e) beliefs, and (f) attitudes toward caring for people with OUD. RESULTS Nurses surveyed before education (T1G1, N = 123) and, after education, those who received the intervention (T2G2, N = 17) and those who did not (T2G3, N = 65) were included. Resource use subscores increased over time (T1G1: x = 3.83, T2G3: x = 4.07, p = .006). Results from the two measurement points found no difference in mean total scores (T1G1: x = 3.53, T2G3: x = 3.63, p = .09). Comparison of mean total scores of nurses who directly received the educational program with those who did not during the second time point showed no improvement (T2G2: x = 3.52, T2G3: x = 3.63, p = .30). CONCLUSIONS Education alone was insufficient in improving self-reported competencies of medical-surgical nurses caring for people with OUD. Findings can be used to inform efforts to increase nurse knowledge and understanding of OUD and to decrease negative attitudes, stigma, and discriminatory behaviors perpetuating care.
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Azzoni L, Giron LB, Vadrevu S, Zhao L, Lalley-Chareczko L, Hiserodt E, Fair M, Lynn K, Trooskin S, Mounzer K, Abdel-Mohsen M, Montaner LJ. Methadone use is associated with increased levels of sCD14, immune activation, and inflammation during suppressed HIV infection. J Leukoc Biol 2022; 112:733-744. [PMID: 35916053 DOI: 10.1002/jlb.4a1221-678rr] [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: 12/06/2021] [Revised: 07/10/2022] [Accepted: 07/11/2022] [Indexed: 11/10/2022] Open
Abstract
Opioid use has negative effects on immune responses and may impair immune reconstitution in persons living with HIV (PLWH) infection undergoing antiretroviral treatment (ART). The effects of treatment with μ opioid receptor (MOR) agonists (e.g., methadone, MET) and antagonists (e.g., naltrexone, NTX) on immune reconstitution and immune activation in ART-suppressed PLWH have not been assessed in-depth. We studied the effects of methadone or naltrexone on measures of immune reconstitution and immune activation in a cross-sectional community cohort of 30 HIV-infected individuals receiving suppressive ART and medications for opioid use disorder (MOUD) (12 MET, 8 NTX and 10 controls). Plasma markers of inflammation and immune activation were measured using ELISA, Luminex, or Simoa. Plasma IgG glycosylation was assessed using capillary electrophoresis. Cell subsets and activation were studied using whole blood flow cytometry. Individuals in the MET group, but no in the NTX group, had higher plasma levels of inflammation and immune activation markers than controls. These markers include soluble CD14 (an independent predictor of morbidity and mortality during HIV infection), proinflammatory cytokines, and proinflammatory IgG glycans. This effect was independent of time on treatment. Our results indicate that methadone-based MOUD regimens may sustain immune activation and inflammation in ART-treated HIV-infected individuals. Our pilot study provides the foundation and rationale for future longitudinal functional studies of the impact of MOUD regimens on immune reconstitution and residual activation after ART-mediated suppression.
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Affiliation(s)
- Livio Azzoni
- Vaccine and Immunotherapy Center, The Wistar Institute, Philadelphia, Pennsylvania, USA
| | - Leila B Giron
- Vaccine and Immunotherapy Center, The Wistar Institute, Philadelphia, Pennsylvania, USA
| | - Surya Vadrevu
- Vaccine and Immunotherapy Center, The Wistar Institute, Philadelphia, Pennsylvania, USA
| | - Ling Zhao
- Perelman School of Medicine - University of PA, Philadelphia, Pennsylvania, USA
| | | | - Emily Hiserodt
- Philadelphia FIGHT Community Health Centers, Philadelphia, Pennsylvania, USA
| | - Matthew Fair
- Vaccine and Immunotherapy Center, The Wistar Institute, Philadelphia, Pennsylvania, USA
| | - Kenneth Lynn
- Perelman School of Medicine - University of PA, Philadelphia, Pennsylvania, USA
| | - Stacey Trooskin
- Philadelphia FIGHT Community Health Centers, Philadelphia, Pennsylvania, USA
| | - Karam Mounzer
- Philadelphia FIGHT Community Health Centers, Philadelphia, Pennsylvania, USA
| | - Mohamed Abdel-Mohsen
- Vaccine and Immunotherapy Center, The Wistar Institute, Philadelphia, Pennsylvania, USA
| | - Luis J Montaner
- Vaccine and Immunotherapy Center, The Wistar Institute, Philadelphia, Pennsylvania, USA
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Falker CG, Stefanovics EA, Rhee TG, Rosenheck RA. Women's Use of Substance Use Disorder Treatment Services: Rates, Correlates, and Comparisons to Men. Psychiatr Q 2022; 93:737-752. [PMID: 35661318 DOI: 10.1007/s11126-022-09989-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/07/2022] [Indexed: 10/18/2022]
Abstract
In spite of evidence of increasing prevalence of substance use disorders (SUDs) among women, there is little information on gender differences in SUD treatment use. Nationally representative survey data were used to compare specialized SUD treatment among women and men with past-year DSM-5 SUD diagnoses (N = 5,789, 42.8% women). An estimated 10.7% of women and 9.9% of men (p = 0.45) received SUD treatment. Those who received treatment among both men and women had more problems than others. Five variables were independently associated with receipt of past-year treatment in both women and men and while five others were independently associated with receipt of treatment for only one gender. Interaction analysis, however, revealed no statistically significant gender differences in any correlate of treatment receipt. Although men were more likely to have SUDs than women, there were no significant differences by gender in rates or correlates of service use.
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Affiliation(s)
- Caroline G Falker
- U.S. Department of Veterans Affairs Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, USA.,Department of Internal Medicine, Yale School of Medicine, 300 George Street, Suite 901, New Haven, CT, 06511, USA.,Department of Public Health Sciences, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT, USA
| | - Elina A Stefanovics
- U.S. Department of Veterans Affairs Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, USA.,Mental Illness Research, Education and Clinical Center, 950 Campbell Avenue, CT, West Haven, USA.,Department of Psychiatry, Yale School of Medicine, 300 George Street, Suite 901, New Haven, CT, 06511, USA.,Department of Public Health Sciences, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT, USA
| | - Taeho Greg Rhee
- Mental Illness Research, Education and Clinical Center, 950 Campbell Avenue, CT, West Haven, USA.,Department of Psychiatry, Yale School of Medicine, 300 George Street, Suite 901, New Haven, CT, 06511, USA.,Department of Public Health Sciences, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT, USA
| | - Robert A Rosenheck
- U.S. Department of Veterans Affairs Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT, USA. .,Mental Illness Research, Education and Clinical Center, 950 Campbell Avenue, CT, West Haven, USA. .,Department of Psychiatry, Yale School of Medicine, 300 George Street, Suite 901, New Haven, CT, 06511, USA. .,Department of Public Health Sciences, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT, USA.
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King CA, Cook R, Korthuis PT, McCarty D, Morris CD, Englander H. Expanding Inpatient Addiction Consult Services Through Accountable Care Organizations for Medicaid Enrollees: A Modeling Study. J Addict Med 2022; 16:570-576. [PMID: 35135988 PMCID: PMC9357852 DOI: 10.1097/adm.0000000000000972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Addiction consult services (ACS) care for hospitalized patients with substance use disorder, including opioid use disorder (OUD). Medicaid Accountable Care Organizations (ACOs) could enhance access to ACS. This study extends data from Oregon's only ACS to Oregon's 15 regional Medicaid Coordinated Care Organizations (CCOs) to illustrate the potential value of enhanced in- and out-patient care for hospitalized patients with OUD. The study objectives were to estimate the effects of (1) expanding ACS care through CCOs in Oregon, and (2) increasing community treatment access within CCOs, on post-discharge OUD treatment engagement. METHODS We used a validated Markov model, populated with Oregon Medicaid data from April 2015 to December 2017, to estimate study objectives. RESULTS Oregon Medicaid patients hospitalized with OUD with care billed to a CCO (n = 5878) included 1298 (22.1%) patients engaged in post-discharge OUD treatment. Simulation of referral to an ACS increased post-discharge OUD treatment engagement to 47.0% (95% confidence interval [CI] 45.7%, 48.3%), or 2684 patients (95% CI 2610, 2758). Ten of fifteen (66.7%) CCOs had fewer than 20% of patients engage in post-discharge OUD care. Without ACS, increasing outpatient treatment such that 20% of patients engage increased the patients engaging in post-discharge OUD care from 12.9% or 296 patients in care at baseline to 20% (95% CI 18.1%, 21.4%) or 453 (95% CI 416, 491). DISCUSSION ACOs can improve care for patients hospitalized with OUD. Implementing ACS in ACO networks can potentially improve post-discharge OUD treatment engagement, but community treatment systems must be prepared to accept more patients as inpatient addiction care improves.
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Affiliation(s)
- Caroline A King
- From the Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR (CAK); Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR (RC, PTK, HE); School of Public Health, Oregon Health & Science University - Portland State University, Portland, OR (DM); Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR (CDM); Department of Medicine, Division of Hospital Medicine, Oregon Health & Science University, Portland, OR (HE)
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Prevalence and factors associated with hospitalisation for bacterial skin infections among people who inject drugs: The ETHOS Engage Study. Drug Alcohol Depend 2022; 237:109543. [PMID: 35772249 DOI: 10.1016/j.drugalcdep.2022.109543] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/15/2022] [Accepted: 06/17/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Injecting-related skin and soft tissue infections (SSTIs) are a preventable cause of inpatient hospitalisation among people who inject drugs (PWID). This study aimed to determine the prevalence of hospitalisation for SSTIs among PWID, and identify similarities and differences in factors associated with hospitalisation for SSTIs versus non-bacterial harms related to injecting drug use. METHODS We performed cross-sectional analyses of baseline data from an observational cohort study of PWID attending drug treatment clinics and needle and syringe programs in Australia. Logistic regression models were used to identify factors associated with self-reported hospitalisation for (1) SSTIs (abscess and/or cellulitis), and (2) non-bacterial harms related to injecting drug use (e.g., non-fatal overdose; hereafter referred to as non-bacterial harms), both together and separately. RESULTS 1851 participants who injected drugs in the previous six months were enrolled (67% male; 85% injected in the past month; 42% receiving opioid agonist treatment [OAT]). In the previous year, 40% (n = 737) had been hospitalised for drug-related causes: 20% (n = 377) and 29% (n = 528) of participants were admitted to hospital for an SSTI and non-bacterial harm, respectively. Participants who were female (adjusted odds ratio [aOR]: 1.53, 95% CI: 1.19-1.97) or homeless (aOR: 1.59, 95% CI: 1.16-2.19) were more likely to be hospitalised for an SSTI, but not a non-bacterial harm. Both types of hospitalisation were more likely among people recently released from prison. CONCLUSIONS Hospitalisation for SSTIs is common among PWID. Community-based interventions to prevent SSTIs and subsequent hospitalisation among PWID will require targeting of at-risk groups, including women, people experiencing homelessness, and incarcerated people upon prison release.
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