Integrating substance use peer support and screening brief intervention and referral to treatment services in the emergency department: a descriptive study of the ED leads program

BACKGROUND

The ED Leads program was introduced to 11 emergency departments (EDs) within New York City public hospitals from 2018 to 2019 to address a need for addiction support services in the ED. The purpose of this study is to (i) describe the ED Leads blended licensed-clinician and peer counselor team model in the ED at three hospitals, (ii) provide a descriptive analysis of patient engagement and referrals to substance use disorder (SUD) care post-intervention, and (iii) highlight potential barriers and facilitators to implementing the model.

METHODS

The program intended to combine Screening Brief Intervention and Referral to Treatment and peer support services. The authors analyzed electronic medical records data for patients encountered by ED Leads in the first 120 days of program launch. Data included the outcome of an encounter when a patient was engaged with one or both staff types, and 7-day attendance at an SUD treatment appointment when a patient accepted a referral within the 11-hospital system.

RESULTS

There were 1785 patients approached by ED Leads staff during the study period. Engagement differed by staff type and patient demographics, and encounter outcomes varied significantly by hospital. Eighty-four percent (N = 1503) of patients who were approached engaged with at least one staff type, and 6% (N = 86) engaged with both. Patients were predominantly male (N = 1438, 81%) with an average age of 45 (SD = 13), and enrolled in Medicaid (N = 1062, 59%). A majority (N = 801, 45%) had alcohol use disorder. Of the patients who accepted a referral within the system (N = 433), 63% received treatment services within 7 days of the ED Leads encounter, a majority at detoxification treatment (N = 252, 58%).

CONCLUSIONS

This study describes the potential value and challenges of implementing a blended peer counselor and licensed clinician model in the ED to provide SUD services. While teams provided a high volume of referrals and the analysis of post-intervention treatment follow up is promising, the blended team model was not fully realized, making it difficult to assess the benefits of this combined service. Further research might examine patient outcomes among ED patients who are offered services by both a peer counselor and licensed clinician.

ED-Home: Pilot feasibility study of a targeted homelessness prevention intervention for emergency department patients with drug or unhealthy alcohol use

BACKGROUND

Housing insecurity is prevalent among emergency department (ED) patients. Despite a surge of interest in screening for patients' social needs including housing insecurity, little research has examined ED social needs interventions. We worked together with government and community partners to develop and pilot test a homelessness prevention intervention targeted to ED patients with drug or unhealthy alcohol use.

METHODS

We approached randomly sampled patients at an urban public hospital ED, May to August 2019. Adult patients were eligible if they were medically stable, not incarcerated, spoke English, had unhealthy alcohol or any drug use, and were not currently homeless but screened positive for risk of future homelessness using a previously developed risk screening tool. Participants received a three-part intervention: (1) brief counseling and referral to treatment for substance use delivered through a preexisting ED program; (2) referral to Homebase, an evidence-based community homelessness prevention program; and (3) up to three troubleshooting phone calls by study staff. Participants completed surveys at baseline and 6 months.

RESULTS

Of 2183 patients screened, 51 were eligible and 40 (78.4%) participated; one later withdrew, leaving 39 participants. Participants were diverse in age, gender, race, and ethnicity. Of the 32 participants reached at 6 months, most said it was very or extremely helpful to talk to someone about their housing situation (n = 23, 71.9%) at the baseline ED visit. Thirteen (40.6%) said their housing situation had improved in the past 6 months and 16 (50.0%) said it had not changed. Twenty participants (62.5%) had made contact with a Homebase office. Participants shared ideas of how to improve the intervention.

CONCLUSIONS

This pilot intervention was feasible and well received by participants though it required a large amount of screening to identify potentially eligible patients. Our findings will inform a larger future trial and may be informative for others seeking to develop similar interventions.

Association of Urbanicity With Psychosis in Low- and Middle-Income Countries

Importance

Urban residence is one of the most well-established risk factors for psychotic disorder, but most evidence comes from a small group of high-income countries.

Objective

To determine whether urban living is associated with greater odds for psychosis in low- and middle-income countries (LMICs).

Design, Setting, and Participants

This international population-based study used cross-sectional survey data collected as part of the World Health Organization (WHO) World Health Survey from May 2, 2002, through December 31, 2004. Participants included nationally representative general population probability samples of adults (≥18 years) residing in 42 LMICs (N = 215 682). Data were analyzed from November 20 through December 5, 2017.

Exposures

Urban vs nonurban residence, determined by the WHO based on national data.

Main Outcomes and Measures

Psychotic experiences, assessed using the WHO Composite International Diagnostic Interview psychosis screen, and self-reported lifetime history of a diagnosis of a psychotic disorder.

Results

Among the 215 682 participants (50.8% women and 49.2% men; mean [SD] age, 37.9 [15.7] years), urban residence was not associated with psychotic experiences (odds ratio [OR], 0.99; 95% CI, 0.89-1.11) or psychotic disorder (OR, 0.89; 95% CI, 0.76-1.06). Results of all pooled analyses and meta-analyses of within-country effects approached a null effect, with an overall OR of 0.97 (95% CI, 0.87-1.07), OR for low-income countries of 0.98 (95% CI, 0.82-1.15), and OR for middle-income countries of 0.96 (95% CI, 0.84-1.09) for psychotic experiences and an overall OR of 0.92 (95% CI, 0.73-1.16), OR for low-income countries of 0.92 (95% CI, 0.66-1.27), and OR for middle-income countries of 0.92 (95% CI, 0.67-1.27) for psychotic disorder.

Conclusions and Relevance

Our results provide evidence that urbanicity, a well-established risk factor for psychosis, may not be associated with elevated odds for psychosis in developing countries. This finding may provide better understanding of the mechanisms by which urban living may contribute to psychosis risk in high-income countries, because urban-rural patterns of cannabis use, racial discrimination, and socioeconomic disparities may vary between developing and developed nations.

Characteristics associated with synthetic cannabinoid use among patients treated in a public psychiatric emergency setting

BACKGROUND

Growing evidence of adverse outcomes following synthetic cannabinoid use has engendered interest into populations at risk. The existing literature reports that synthetic cannabinoid use is predominant among young, white males. However, reports from local Departments of Health have found contrary evidence, showing that synthetic cannabinoid use is prevalent in populations other than those of young, white men.

OBJECTIVES

This study sought to examine sociodemographic characteristics associated with self-reported synthetic cannabinoid use among a clinical psychiatric population within a public hospital in New York City.

METHODS

A cross-sectional medical record review was conducted on synthetic cannabinoid users and non-users in an emergency psychiatric setting. A total of 948 patients who presented at the emergency psychiatric setting in 2014 were included in this sample, 110 (11.6%) of whom were synthetic cannabinoid users. Logistic regressions were used to determine the sociodemographic correlates of synthetic cannabinoid use.

RESULTS

The most prominent correlate of synthetic cannabinoid use was homelessness/residing in a shelter during time of treatment (AOR = 17.77, 95% CI = 9.74-32.5). Male (AOR = 5.37, 95% CI = 2.04-14.1), non-white (AOR = 2.74, 95% CI = 1.36-5.54), and younger age (AOR = .961, 95% CI = .940-.980) were also significant correlates of synthetic cannabinoid use.

CONCLUSION

Synthetic cannabinoid use among the homeless and mentally ill is a growing public health concern, representing a population with unique clinical and social needs. Areas and populations with high rates of homelessness should be targeted for synthetic cannabinoid prevention and treatment efforts, particularly in urban and racial/ethnic minority communities.