"It's been an Experience, a Life Learning Experience": A Qualitative Study of Hospitalized Patients with Substance Use Disorders

"Every Time I Go in There, It Gives Me Time to Reflect": A Qualitative Study of Patient Perspectives on Substance Use, Medications for Opioid Use Disorder, and Harm Reduction Following Hospitalization for Serious Injection-Related Infection

Background

Serious injection-related infections (SIRIs) have high morbidity and mortality, in part from incomplete antibiotic treatment, ongoing substance use and reinfection. Understanding how hospitalizations for SIRIs affect patient perspectives on substance use, harm reduction, and medications for opioid use disorder (MOUD) in the era of hospital-based addiction services will inform efforts to improve care.

Methods

We conducted qualitative interviews at Boston Medical Center with individuals hospitalized with SIRIs between 2020 and 2024. To ensure diverse experiences, we recruited qualifying participants based on record of SIRI International Classification of Diseases, 10th Revision, codes, presence on the outpatient parenteral antibiotic program list, during hospitalizations, and from a drop-in harm reduction program. Interviews were transcribed, coded inductively, and analyzed for key themes.

Results

Participants with SIRIs (n = 30) had the following characteristics: Most had endocarditis (n = 10) or osteomyelitis (n = 9) and had completed the recommended antibiotics (n = 24); the mean age was 39; most were male (n = 19), White (n = 21), and housed (n = 18). Three key themes emerged after SIRI hospitalization: (1) reduced substance use and adoption of harm reduction practices were common; (2) perspectives on MOUD varied, but negative experiences and medication stigma persisted; and (3) SIRI hospitalizations were viewed as an opportunity for reflection on substance use and health.

Conclusions

SIRI hospitalizations and the postdischarge period are opportunities to engage patients in addiction and infectious disease care. Participants expressed ambivalence about MOUD despite access to robust hospital-based addiction medicine services. Longitudinal support that explicitly includes harm reduction and MOUD, both linkage and retention, is needed to improve care for people with SIRIs.

Understanding parents' experience navigating substance use treatment and the child welfare system

INTRODUCTION

Substance use is a common reason for involvement in the child welfare system and associated with poor outcomes for families, such as repeat maltreatment and loss of parental rights; however, rates of substance use treatment engagement among parents in child welfare are low. The current study examines the role and impact of substance use on parents' experiences with the child welfare system and substance use treatment.

METHODS

The study conducted semi-structured interviews with parents currently or recently involved in child welfare and substance use treatment (N = 29; 86.2 % female; 75.9 % White).

RESULTS

Themes from qualitative analyses related to (1) the role of substance use in child welfare cases, (2) the challenges of managing substance use treatment and child welfare requirements, and (3) perspectives on the role of parenting in substance use treatment and recovery.

CONCLUSIONS

Parents with substance use involved in child welfare face unique challenges when addressing substance use and child welfare requirements. Findings underscore the importance of involving those with lived experience in policy and decision-making; ensuring evidence-based practices specifically targeting parents with substance use are available; and ensuring child welfare personnel receive training and education in addiction and substance use.

Forging hospital and community partnerships to enable care coordination for opioid use disorder

BACKGROUND

Programs that aim to increase access to substance use disorder (SUD) treatment in hospital-based settings have proliferated in recent years. These efforts include transitional opioid programs (TOPs), which navigate patients to community-based SUD treatment programs post-discharge. Successful navigation from TOPs to outpatient treatment hinges on effective coordination between hospitals and post-discharge endpoints, yet it is unclear how hospitals can best develop effective partnerships with outpatient treatment organizations. The objective of this study is to synthesize the common themes underpinning the development of partnerships to facilitate care transitions between TOPs and ongoing SUD treatment.

METHODS

Qualitative study with staff and providers from hospitals affiliated with four safety-net health systems (n = 21) and leaders from community-based organizations (CBOs) and treatment facilities that had established referral partnerships with one of the four health systems in our study (n = 4).

RESULTS

Analysis of interview transcripts revealed seven common themes that underpinned the development of care transitions partnerships: (1) Active, intentional outreach; (2) Responding to a community need; (3) External Enabling Factors; (4) Leveraging reputations and community connections; (5) Focusing on operations; (6) Reciprocal relationships; and (7) Building Infrastructure and Processes to Ensure Collaboration. The seven identified themes were categorized into three groups corresponding to different partnership development stages. The first group revolves around the initial stage of meeting and developing a relationship (themes #1-4). The second set focuses on navigating and resolving challenges that arise in the partnership (themes #5-6). Lastly, the third group pertains to sustaining a partnership long-term (theme #7).

CONCLUSIONS

This study identifies seven core themes underlying the development of care transition partnerships for SUD patients within four safety net health systems and their CBO partners. These themes demonstrate how partner organizations can establish the trust, reciprocity, and commitment necessary to support patients through the critical transition period.

Advancing Health Equity Through Substance Use Medical Record Data Sharing: Insights from Healthcare Providers

BACKGROUND

Better care is delivered when patients and providers share health information. Unfortunately, critical health data are often unavailable due to fragmentation within healthcare systems. Sensitive health information, like substance use disorder, is often sequestered in ways that do not meet patient data privacy choices and provider data access needs. This study explored healthcare providers' perspectives on barriers and facilitators to substance use data sharing and its impact on care.

METHODS

Focus groups were conducted with 31 healthcare providers from four treatment facilities. Discussions focused on privacy concerns, data-sharing workflows, and scenarios involving four Healthcare Effectiveness Data and Information Set (HEDIS) substance use disorder specific metrics. Open coding identified key concepts, and thematic analysis was employed to identify barriers and facilitators influencing data sharing and care outcomes.

RESULTS

Providers identified five main barriers: patient reluctance to share (48%), data access challenges (42%), poor provider coordination (29%), incomplete health information (26%), and complexity of privacy regulations (23%). Key facilitators included patient understanding (26%), patient-provider relationship (16%), and reliability of health information systems (16%).

DISCUSSION

This study sets the stage for understanding and addressing sensitive healthcare data access and privacy concerns through improved care coordination, systems interoperability, education, and policy reform.

Using inpatient addiction consult service via telehealth to improve pharmacotherapy initiation: An observational study

IntroductionThe COVID-19 pandemic exacerbated existing challenges in treating substance use disorders. This study explores the impact of telehealth on addiction consult services (ACS) medication initiation in hospitalized patients with alcohol and opioid use disorders (AUD and OUD).MethodsWe retrospectively analyzed data from adult patients who received their first ACS consultation in-person (pre-pandemic) and telehealth ACS consultation (during the pandemic). We compared medication initiation rates for AUD and OUD before and after ACS consultation.ResultsThe ACS completed 398 in-person consults and 473 telehealth consults. In-person ACS consultation increased the medication initiation rates from 3.41% for AUD in hospitalized patients without an ACS consult, to 45.45% for AUD after an ACS consult. For OUD pharmacotherapy initiation, an ACS consultation increased medication rates from 6.94% to 41.67% for OUD. Telehealth ACS consultation increased medication initiation rates from 5.16% to 66.20% for AUD and from 7.53% to 67.74% for OUD. Buprenorphine and naltrexone were the most commonly initiated medications for OUD and AUD, respectively.DiscussionThe adoption of telehealth by the hospital ACS during the pandemic effectively increased medication initiation rates for AUD and OUD, consistent with pre-pandemic, demonstrating its potential to expand access to addiction services. This approach could address the current shortage of addiction providers and serve underserved populations.

Early Leaves from Inpatient Care Among Individuals with Traumatic Life Events in Ontario, Canada

Psychological trauma is a prevalent mental health concern, with most individuals experiencing at least one traumatic event in their lifetime. Early leaves from inpatient settings are a pertinent challenge among persons who have experienced trauma and may reflect unmet care needs. This study examined patterns of early leaves among persons with trauma from inpatient care in Ontario, Canada. All records for individuals who have experienced trauma with an index admission of over 72 h between January 1, 2015 and December 31, 2019 were included (N = 11,043). Logistic regression using generalized equation estimation was used to assess the association between demographic and clinical characteristics, substance use, social relationships, staff dynamics, and control interventions with the outcome of early leaves. In the final model, alcohol (OR: 1.83, 95% CI: 1.27-2.64), other substances (OR: 2.15, 95% CI: 1.34-3.46), and poly substance use (OR: 2.46, 95% CI: 1.82-3.31) all increased the odds of early leaves after considering possible facility effects, and after adjusting for other demographic and clinical factors. Being older, employed, and having mood disorders reduced odds of early leaves. Early leaves are important within treatment planning, particularly in relation to addressing complex traumas. While challenges related to substance use may be driving some of the early leaves, there may also be challenges to providing complex care within acute mental health settings. Further exploration of policies and practices to prevent early leaves are necessary, including the potential need for longer-term specialized treatment programs.

Exploring Preferences for Communication and Care among Hospitalized Patients with Opioid Use Disorder: A Qualitative Descriptive Study

OBJECTIVE

The aim of the study was to explore hospitalized patient priorities for effective communication and care in opioid use disorder (OUD).

METHODS

In this qualitative descriptive study, we conducted semistructured interviews from April to August 2022 focusing on communication values with inpatient care teams among hospitalized patients with OUD in Philadelphia, PA. Interviews were recorded, transcribed, and analyzed with thematic content analysis.

RESULTS

We identified 3 key themes in the communication and care planning preferences of the 21 patients we interviewed: effectiveness, reciprocity, and empathy. Patients emphasized the need for clear, reliable, and frequent communication from healthcare providers, valuing collaborative dialog, shared decision making, and empathic nonstigmatized interactions that incorporated their prior experiences, full personhood, and current symptoms. Participants reported negative experiences with inconsistent or dismissive communication but appreciated care that incorporated their input and was nonjudgmental, fostering a sense of trust in their healthcare teams.

CONCLUSIONS

Effective, empathic communication, and shared decision making were favored by hospitalized patients with OUD and may be a way to improve treatment for hospitalized patients with OUD. Our findings underscore the need for stigma reduction strategies in clinical education and the expansion of both generalist resources for the treatment of OUD and specialized addiction care services.

Initiation of buprenorphine in the emergency department or emergency out-of-hospital setting: A mixed-methods systematic review

INTRODUCTION

People who use substances increasingly access healthcare primarily through emergency medical services (EMS) and emergency departments (EDs). To meet the needs of these patients, EMS and EDs have become access points for medications for opioid use disorder (OUD), specifically buprenorphine. This systematic review aimed to quantify the efficacy of these programs, examining retention in treatment for OUD, rates of re-presentation to ED or EMS, and rates of precipitated withdrawal, as well as summarise clinician and patient perspectives on buprenorphine initiation in these settings.

METHODS

This review considered studies including patients with OUD receiving, and providers initiating, buprenorphine in an ED or EMS setting. A convergent, segregated approach to mixed-methods review was used as recommended by the Joanna Briggs Institute. A search was conducted of MEDLINE, CINAHL, EMBASE, and the Cochrane Library. Where relevant, meta-analyses of odds ratios and proportions were conducted.

FINDINGS

In both randomised (OR 5.97, 95 %CI 2.52-14.14, 227 participants, I2 16.93 %) and observational (OR 4.28, 95 %CI 2.45-7.48, 779 participants, I2 66.97 %) research, buprenorphine in the ED or EMS setting was associated with increased odds of treatment engagement at 30 days. Rates of retention in treatment varied across measured time points, from 77 % (95 %CI 74-80 %, 763 participants, I2 0.01 %) within 24 h, to 35 % (95 %CI 29-40 %) at 12 months. A low rate of precipitated withdrawal was reported (0.00 %, 95 %CI 0.00-1.00 %, 851 participants, I2 0.00 %). Clinicians and patients were generally supportive of ED-initiated buprenorphine, while identifying the initiation buprenorphine as one component of a longitudinal care path for people with OUD. Patients valued clinicians engaging in shared decision-making, while clinicians identified the environment of the ED often made this challenging.

CONCLUSION

The initiation of buprenorphine in the ED setting is associated with higher odds of short and medium-term treatment engagement. Further research is required into EMS-initiated buprenorphine, as well as patient perspectives of ED- and EMS-initiated buprenorphine.

mHealth Incentivized Adherence Plus Patient Navigation (MIAPP): protocol for a pilot randomized controlled trial to improve linkage and retention on buprenorphine for hospitalized patients with methamphetamine use and opioid use disorder

BACKGROUND

Initiation of buprenorphine for treatment of opioid use disorder (OUD) in acute care settings improves access and outcomes, however patients who use methamphetamine are less likely to link to ongoing treatment. We describe the intervention and design from a pilot randomized controlled trial of an intervention to increase linkage to and retention in outpatient buprenorphine services for patients with OUD and methamphetamine use who initiate buprenorphine in the hospital.

METHODS

The study is a two-arm pilot randomized controlled trial (N = 40) comparing the mHealth Incentivized Adherence Plus Patient Navigation (MIAPP) intervention to treatment as usual. Development of the MIAPP intervention was guided by the information-motivation-behavioral skills model and combines financial rewards via mobile health-based adherence monitoring with the "human touch" of a patient navigator. Participants receive financial incentives for submitting videos of themselves taking buprenorphine via smartphone. The Patient Navigator reviews videos and provides treatment adherence coaching, care coordination and motivational enhancement. The intervention is introduced prior to hospital discharge and is offered for 30 days. The primary outcome is linkage to outpatient buprenorphine care within 30 days of hospital discharge. Secondary outcomes include retention on buprenorphine 90 days post discharge, hospital readmissions, and past 30-day methamphetamine use.

DISCUSSION

Interventions are needed to increase linkage and retention to outpatient buprenorphine among hospitalized patients with OUD, especially for people who co-use methamphetamine. We will examine the MIAPP intervention to improve buprenorphine adherence and linkage to outpatient treatment in a pilot randomized controlled trial which will provide valuable insights about research approaches for hospitalized patients with substance use disorder.

TRIAL REGISTRATION NUMBER

NCT06027814. Date of Initial Release: 08/30/2023.

PROTOCOL VERSION

03/21/2024.

"Just Be Relentless," Lessons Learned from In-Hospital Addiction Consult Service Implementation

BACKGROUND

Hospitalization is a "reachable" moment to engage people in addiction care. Addiction consult services (ACSs) have been shown to improve outcomes for hospitalized patients with substance use disorders (SUDs). Despite this, most hospital systems do not provide hospital-based addiction care or have an ACS.

OBJECTIVE

Characterize implementation barriers, lessons learned, and opportunities for future support of ACS implementation.

DESIGN AND PARTICIPANTS

Semi-structured qualitative interviews with 17 "champions" leading ACS implementation at 11 institutions across the U.S.

APPROACH

Interviews explored evolution of ACSs, including staffing, service delivery, strategic planning, and barriers and facilitators to implementation. Reflexive thematic analysis was applied to identify emergent themes.

KEY RESULTS

Five dominant themes characterize ACS implementation: (1) how champions obtain buy-in from hospital leadership. Participants described the impression that ACSs are not revenue-generators as a barrier to implementation and found ways to capture monetary and non-monetary outcomes to demonstrate value; (2) specific attributes are common to ACS champions including persistence, good communication, and leadership skills. ACS champions described needing to communicate strategically with multiple stakeholders across their institution and often pitched their case multiple times before obtaining funding; (3) reliance on external resources. This included informal coaching from other ACS leaders and formal tools such as telementoring networks and published literature to learn to engage leadership and present a business case; (4) ACSs are important drivers of cultural change within institutions in the face of significant stigma and; (5) planning for sustainability. This included demonstrating improved quality of care and patient and provider satisfaction to obtain ongoing support for ACS.

CONCLUSIONS

Barriers to ACS implementation are common and significant and the process of obtaining leadership support for implementation is often long and iterative. Broad adoption of ACSs will require support from hospital systems and policymakers including incentives, funding, and infrastructure to support clinical champions.

Staff perspectives of barriers and facilitators to implementation of the Consult for Addiction Treatment and Care in Hospitals (CATCH) program in New York City safety net hospitals

BACKGROUND

In response to the heavy burden of untreated substance use disorders (SUD) in hospital patients, many health systems are implementing addiction consult services staffed by interprofessional teams that diagnose SUD, make recommendations for SUD care in the hospital, and link patients to post-discharge treatment. In 2018, the New York City public hospital system began rolling out the Consult for Addiction Treatment and Care in Hospitals (CATCH) program in six hospitals. CATCH teams are comprised of an addiction-trained medical provider, social worker or addiction counselor, and peer counselor.

METHODS

The study conducted qualitative interviews with CATCH staff at all six participating hospitals as part of a pragmatic trial studying the effectiveness and implementation of CATCH. The Consolidated Framework for Implementation Research (CFIR) framework guided interviews conducted from 2018 to 2021 with 26 staff at the start of implementation and with 33 staff 9-12 months post-implementation. The study team created a codebook a priori and further refined it through additional coding of initial interviews. Codes were systematically analyzed using the CFIR.

RESULTS

Barriers and facilitators spanned four CFIR domains: inner setting, outer setting, process, and individual characteristics. Barriers identified were primarily related to the outer and inner settings, including patient characteristics and limited resources (e.g. medical comorbidities, homelessness), insurance, CATCH team role confusion, and infrastructure deficits (e.g., availability of physical space). Additional barriers related to process (workload burden), and characteristics of individuals (stigma and lack of comfort treating SUD among medical teams). Facilitators were mostly related to the characteristics of individuals on the CATCH team (advantages and expertise of the CATCH peer counselor, CATCH team communication and cohesiveness) and inner setting (CATCH team relationships with hospital staff, hospital leadership buy-in and support, and infrastructure). Community networks (outer setting) and CATCH training resources (process) were also facilitators of program implementation.

CONCLUSION

Addiction consult services have great potential for improving care for hospital patients with SUD, but as new programs in busy hospital settings they face barriers to implementation that could impact their effectiveness. Barriers may be particularly impactful for programs operating in safety-net hospitals, given limited resources within the health system and the multiple and complex needs of their patients. Understanding the strengths of these programs as well as the barriers to their implementation is critical to utilizing addiction consult services effectively.

Narrative review: Managing buprenorphine and opioid use disorder in the perioperative setting

The opioid epidemic continues to have a staggering impact on millions of individuals and families across all socioeconomic levels and communities. Recent studies suggest high numbers of patients presenting for surgery with reported opioid misuse and/or opioid use disorder (OUD). Anesthesiologists often lack basic education to treat patients suffering with OUD or patients in recovery from this treatable disease. This manuscript will provide a review of the American Society of Anesthesiology and Pain Medicine Multisociety Working Group Practice Advisory recommendations on existing OUD treatment barriers and perioperative management best practices; it will also demonstrate the benefits that greater involvement of the anesthesiologist can have in managing patients with OUD perioperatively.

Caring for patients with substance use disorders: a qualitative investigation of difficulties encountered by hospital-based clinicians

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.

Attributes of higher- and lower-performing hospitals in the Consult for Addiction Treatment and Care in Hospitals (CATCH) program implementation: A multiple-case study

INTRODUCTION

Six hospitals within the New York City public hospital system implemented the Consult for Addiction Treatment and Care in Hospitals (CATCH) program, an interprofessional addiction consult service. A stepped-wedge cluster randomized controlled trial tested the effectiveness of CATCH for increasing initiation and engagement in post-discharge medication for opioid use disorder (MOUD) treatment among hospital patients with opioid use disorder (OUD). The objective of this study was to identify facility characteristics that were associated with stronger performance of CATCH.

METHODS

This study used a mixed methods multiple-case study design. The six hospitals in the CATCH evaluation were each assigned a case rating according to intervention reach. Reach was considered high if ≥50 % of hospitalized OUD patients received an MOUD order. Cross-case rating comparison identified attributes of high-performing hospitals and inductive and deductive approaches were used to identify themes.

RESULTS

Higher-performing hospitals exhibited attributes that were generally absent in lower-performing hospitals, including (1) complete medical provider staffing; (2) designated office space and resources for CATCH; (3) existing integrated OUD treatment resources; and (4) limited overlap between the implementation period and COVID-19 pandemic.

CONCLUSIONS

Hospitals with attributes indicative of awareness and integration of OUD services into general care were generally higher performing than hospitals that had siloed OUD treatment programs. Future implementations of addiction consult services may benefit from an increased focus on hospital- and community-level buy-in and efforts to integrate MOUD treatment into general care.

Nonprescribed Substance Use in the General Hospital: A Retrospective Study

BACKGROUND

Nonprescribed substance use (NPSU) is a recognized phenomenon exhibited by patients with substance use disorders while admitted to inpatient hospitals. What factors distinguish patients who engage in NPSU, or how their hospitalizations and outcomes differ, remains to be understood in full.

OBJECTIVES

Our study describes a cohort of medically admitted patients with substance use disorders with behaviors concerning for NPSU during their hospitalization.

METHODS

We extracted electronic health record data for all hospital encounters when an addiction consult was documented (n = 3100). We defined NPSU cases during a clinical, interdisciplinary case review in which patients were deemed high risk based on team members' observations of one or more behaviors described in the NPSU Checklist. These individuals were placed on a "NPSU Protocol," which was implemented for optimization of care, destigmatization, and risk mitigation (n = 61). We compared clinical characteristics, resource utilization, and treatment outcomes among the NPSU cohort to addiction consult patients without suspicion of NPSU but with stimulant or opioid use disorder diagnoses.

RESULTS

Patients on the NPSU protocol were younger and had higher rates of infectious disease diagnoses reported during hospitalization than patients without concern for NPSU. Hospitalizations for individuals suspected of NPSU were longer, had higher rates of before medically advised discharge, as well as discharges without medications for opioid use disorder. These outcome differences were also observed when analysis was restricted to hospitalizations in which an infectious disease was diagnosed.

CONCLUSIONS

Our study characterizes a population of people who exhibited behaviors concerning for NPSU and highlights key outcome disparities. To our knowledge, this study is the first to show a direct correlation between infectious disease diagnosis and NPSU, as well as a direct correlation between suspected NPSU and outcomes such as before medically advised discharge and discharge without medications for opioid use disorder, irrespective of infectious disease diagnosis. Further study is necessary to determine interventions to reduce poor outcomes among hospitalized patients with NPSU.

Cross sectional analysis of an addiction consultation service, substance co-use patterns, and receipt of medications for opioid use disorder during hospitalization

INTRODUCTION

Despite effective medications for opioid use disorder (MOUD), treatment engagement remains low. As the overdose crisis is increasingly characterized by opioids co-used with other substances, it is important to understand whether existing models effectively support treatment for patients who use multiple substances. Hospital-based addiction consultation services (ACS) have shown promise at increasing MOUD initiation and treatment engagement, but the effectiveness for patients with specific co-use patterns remains unknown.

METHODS

Using 2016-2023 admissions data from a large safety net hospital, we estimated a random-effects logistic regression model to determine whether specific co-use (methamphetamine, cocaine, alcohol, sedative, and other) moderated the effect of being seen by ACS on the receipt of MOUD. Adjusting for patient sociodemographic, health, and admission characteristics we estimated the proportion of patients who received MOUD across specific co-use groups.

RESULTS

Of 7679 total admissions indicating opioid use, of which 5266 (68.6 %) indicated co-use of one or more substances and 2387 (31.1 %) were seen by the ACS. Among admissions not seen by the ACS, a smaller proportion of admissions with any co-use received MOUD (23.5 %; 95 % CI: 21.9-25.1) compared to admissions with opioid use alone (34.0 %; 95 % CI: 31.9-36.1). However, among admissions seen by the ACS a similar proportion of admissions with any co-use received MOUD (57.8 %; 95 % CI: 55.5-60.1) as admissions with opioid use alone (56.2 %; 95 % CI: 52.2-60.2). The increase in proportion of admissions receiving MOUD associated with being seen by the ACS was larger for admissions with methamphetamine (38.6 percentage points; 95 % CI: 34.6-42.6) or cannabis co-use (39.0 percentage points; 95 % CI: 32.9-45.1) compared to admissions without methamphetamine (25.7 percentage points; 95 % CI: 22.2-29.2) or cannabis co-use (29.1 percentage points; 95 % CI: 26.1-32.1).

CONCLUSIONS

The ACS is an effective hospital-based treatment model for increasing the proportion of admissions which receive MOUD. This study shows that ACSs are also able to support increased receipt of MOUD for patients who use other substances in addition to opioids. Future research is needed to further understand what transition strategies best support treatment linkage for patients who use multiple substances.

Correlates of post-hospitalization naltrexone adherence for alcohol use disorder

INTRODUCTION

Hospitalizations present an opportunity to initiate naltrexone for patients with alcohol use disorder (AUD). Understanding factors associated with post-hospitalization adherence could inform practice.

METHODS

This study is a secondary analysis of a clinical trial in which patients with AUD were randomized to oral (PO) versus long-acting injectable (LAI) naltrexone at hospital discharge. The outcome of this secondary analysis was naltrexone adherence 3 months after discharge, defined as receipt of at least 2 out of 3 monthly injections or the equivalent days of self-reported PO medication use (60 out of 90). We used baseline socio-demographics, substance use history, health status, healthcare utilization, and randomization arm to construct multivariable logistic regression models to identify correlates of adherence.

RESULTS

We evaluated patients who initiated naltrexone treatment, 124 randomized to PO and 120 to LAI (overall mean age 49 years, 80 % male, 51 % Black, 47 % unhoused, and 91 % with severe AUD). At 3 months, 50 % of patients were adherent. LAI naltrexone (aOR 3.88; 95 % CI 2.17-7.13), recent office visit (aOR 2.01; 95 % CI 1.10-3.72), and age (aOR per 10-year increase 1.37; 95 % CI 1.02-1.88) were associated with increased odds of adherence. Unhoused status (aOR 0.54; 95 % CI 0.30-0.98) and cocaine use (aOR 0.35; 95 % CI 0.17-0.71) were associated with decreased odds of adherence.

CONCLUSIONS

LAI naltrexone for AUD at hospital discharge was associated with better adherence at 3 months vs PO. Access to LAI naltrexone and targeted interventions for patients with cocaine use or who are unhoused hold potential to improve naltrexone adherence.

Addiction Consultation Services for Opioid Use Disorder Treatment Initiation and Engagement: A Randomized Clinical Trial

Importance

Medications for opioid use disorder (MOUD) are highly effective, but only 22% of individuals in the US with opioid use disorder receive them. Hospitalization potentially provides an opportunity to initiate MOUD and link patients to ongoing treatment.

Objective

To study the effectiveness of interprofessional hospital addiction consultation services in increasing MOUD treatment initiation and engagement.

Design, Setting, and Participants

This pragmatic stepped-wedge cluster randomized implementation and effectiveness (hybrid type 1) trial was conducted in 6 public hospitals in New York, New York, and included 2315 adults with hospitalizations identified in Medicaid claims data between October 2017 and January 2021. Data analysis was conducted in December 2023. Hospitals were randomized to an intervention start date, and outcomes were compared during treatment as usual (TAU) and intervention conditions. Bayesian analysis accounted for the clustering of patients within hospitals and open cohort nature of the study. The addiction consultation service intervention was compared with TAU using posterior probabilities of model parameters from hierarchical logistic regression models that were adjusted for age, sex, and study period. Eligible participants had an admission or discharge diagnosis of opioid use disorder or opioid poisoning/adverse effects, were hospitalized at least 1 night in a medical/surgical inpatient unit, and were not receiving MOUD before hospitalization.

Interventions

Hospitals implemented an addiction consultation service that provided inpatient specialty care for substance use disorders. Consultation teams comprised a medical clinician, social worker or addiction counselor, and peer counselor.

Main Outcomes and Measures

The dual primary outcomes were (1) MOUD treatment initiation during the first 14 days after hospital discharge and (2) MOUD engagement for the 30 days following initiation.

Results

Of 2315 adults, 628 (27.1%) were female, and the mean (SD) age was 47.0 (12.4) years. Initiation of MOUD was 11.0% in the Consult for Addiction Treatment and Care in Hospitals (CATCH) program vs 6.7% in TAU, engagement was 7.4% vs 5.3%, respectively, and continuation for 6 months was 3.2% vs 2.4%. Patients hospitalized during CATCH had 7.96 times higher odds of initiating MOUD (log-odds ratio, 2.07; 95% credible interval, 0.51-4.00) and 6.90 times higher odds of MOUD engagement (log-odds ratio, 1.93; 95% credible interval, 0.09-4.18).

Conclusions

This randomized clinical trial found that interprofessional addiction consultation services significantly increased postdischarge MOUD initiation and engagement among patients with opioid use disorder. However, the observed rates of MOUD initiation and engagement were still low; further efforts are still needed to improve hospital-based and community-based services for MOUD treatment.

Trial Registration

ClinicalTrials.gov Identifier: NCT03611335.

Why do men with drinking problems change their behavior? A qualitative study nested in a randomized controlled trial in India

The aim of this qualitative study, nested in a randomized controlled trial, was to assess the mechanisms of the effects in both arms through examining perceptions of the participants about changes in their drinking behavior and their attributions for any perceived changes. We conducted semi-structured interviews with a sub-sample of trial participants. We used thematic analysis to analyze the data. Self-perceived change, mostly positive, was reported regardless of the objectively measured remission status. Participating in the trial itself was a major catalyst for change. Participants in both arms used a variety of similar strategies to make these changes; additionally, for those who received the intervention, both the style of the counselor (for example, the non-judgmental stance) as well as specific elements of the intervention were seen to influence change in drinking behavior. Absence of self-reported change was relatively uncommon and primarily related to the felt need for alcohol (e.g., drinking was perceived to be necessary to maintain good health), or the belief that one did not need to or want to change. Experiences of participating in a trial, the counselor style, and specific elements of a brief psychological treatment, play a role in influencing change in harmful drinking behaviors.

Inpatient opioid withdrawal: a qualitative study of the patient perspective

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.

Opportunities to improve inpatient services and reduce rates of patient-direct discharge among people who use substances

PURPOSE

Patients who use substances (PWUS) report experiencing stigmatizing encounters and undertreatment of pain and withdrawal symptoms that increase the likelihood of patient-directed discharge (PDD). This scoping review examines North American literature to gain insights about how institutional factors intersect with patient experiences and contribute to PDD.

METHODS

A scoping review was conducted using MEDLINE, CINAHL, Scopus, and EMBASE databases. Screening was completed by two reviewers. A data extraction tool developed by the research team was used to collect demographic information and explore patients' experiences and reasons for PDD.

RESULTS

We present four themes related to PDD: i) effective management of pain and withdrawal symptoms, ii) therapeutic alliance with healthcare providers, iii) hospital policies, protocols, and procedures, and iv) recommendations. Notably, all patients in all qualitative studies reported predominant experiences of uncaring, stigmatizing interactions with healthcare providers.

DISCUSSION

Findings suggest that transformations are required at individual and institutional levels. At an individual level, to provide equitable care to all patients, healthcare providers in all practice settings should be competent to effectively and compassionately care for PWUS. At an institutional level, policies need to be re-envisioned to support the implementation of effective practices.

CONCLUSION

Hospitals are faced with the challenges to ensure respectful care environments guided by harm reduction policies that will improve engagement of PWUS in services.

Perspectives and Recommendations from Hospitalized Patients with Substance Use Disorders: A Qualitative Study

BACKGROUND

Individuals with substance use disorders (SUDs) are hospitalized in growing numbers. Stigma is pervasive among their hospital providers, and SUD management during medical admissions is often inadequate. However, little is known about how these patients perceive their care quality. In particular, few studies have explored their positive care perceptions or recommendations for improvement.

OBJECTIVE

To explore perspectives on positive aspects, negative aspects, and consequences of care, as well as recommendations for improvement among hospitalized patients with SUDs.

DESIGN AND PARTICIPANTS

We conducted semi-structured, in-depth bedside interviews (n = 15) with patients who have been diagnosed with a SUD and were admitted to medical or surgical floors of an urban academic medical center.

APPROACH

Interviews explored patients' hospital experiences and recommendations for improvement. The interviews were audio-recorded, transcribed verbatim, and imported into NVivo software. Two reviewers independently coded the transcripts using interpretative phenomenological analysis and inductive thematic analysis according to grounded theory, and recurring themes were identified from the data. Patients' demographic and clinical data were analyzed with descriptive statistics.

KEY RESULTS

Perceived clinical and emotional proficiency were the most important components of positive experiences, whereas perceived bias and stigmatized attitudes, clinical improficiency, and inhumane treatment were characteristic of negative experiences. Such care components were most consequential for patients' emotional well-being, trust, and care quality. Recommendations for improving care included specific suggestions for initiating and promoting continued recovery, educating, and partnering in compassionate care.

CONCLUSIONS

Hospitalized patients with SUDs often experience lower quality and less compassionate care linked to pervasive stigma and poor outcomes. Our study highlights under-recognized perspectives from this patient population, including socioemotional consequences of care and recommendations grounded in lived experiences. By striving to advance our care in accordance with patients' viewpoints, we can turn hospitalizations into opportunities for engagement and promoting recovery.

Medical training to effectively support patients who use substances across practice settings: a scoping review of recommended competencies

Background

The responsibility for addressing the healthcare needs of PWUS is the responsibility of all physicians. Within the healthcare system, research consistently reveals inequitable experiences in healthcare with people who use substances (PWUS) reporting stigmatization, marginalization, and a lack of compassion.

Objectives

The aim of this scoping review was to find and describe competencies being taught, developed, and fostered within medical education and then to provide recommendations to improve care for this population of patients.

Results

Nineteen articles were included. Recommended knowledge competencies tend to promote understanding neurophysiological changes caused by substances, alongside knowing how to evaluate of 'risky' behaviours. Commonly recommended skills relate to the screening and management of substance use disorders. Recommended attitude competencies include identifying personal bias and establishing a patient-centered culture among practice teams. The disease model of addiction informed all papers, with no acknowledgement of potential beneficial or non-problematic experiences of substance use. To enhance knowledge-type competencies, medical education programs are advised to include addiction specialists as educators and prevent stigmatization through the hidden curriculum.

Conclusion

To reduce experiences of stigmatization and marginalization among patients who use illicit substances and to improve quality of care, knowledge, skills, and attitudes competencies can be more effectively taught in medical education programs.Résumé.

Substance use during hospitalisation requiring an urgent clinical response: an opportunity for intervention

BACKGROUND

There are few reports on drug use in patients while hospitalised and none regarding management or clinical outcomes.

AIMS

To describe cases of drug use by inpatients requiring an urgent clinical response.

METHODS

We retrospectively reviewed cases at a teaching hospital in Sydney, Australia, from February 2019 to March 2021.

RESULTS

Thirty cases were identified, with no deaths. Two patient groups were identified: (i) substance use disorders, using illicit drugs and (ii) self-harm history, using prescribed or over-the-counter drugs. Management involved cardiac monitoring (40%), intensive care (30%), charcoal (20%), antidotes (20%) and intubation (13%). Discharge was planned in 22 of 30 patients, against medical advice in four and directed by medical staff in four.

CONCLUSIONS

Inpatient drug use requiring an urgent clinical response was infrequently recognised but presents a risk of harm to patients and staff and increases service utilisation and costs. Both harm reduction and systematic approaches guided by institutional policy are recommended. Using these events as reachable moments to address driving factors may modify patients' risk from future events.

Unintended consequences of methadone regulation for opioid use disorder treatment among hospitalized patients

BACKGROUND

In the United States, there are no federal restrictions on the use of methadone to manage opioid withdrawal symptoms when patients are hospitalized with a medical or surgical condition other than addiction. In contrast, in an outpatient setting, methadone for opioid use disorder (OUD) is highly regulated by federal and state governments and can only be dispensed from an opioid treatment program (OTP). Discrepancies in regulatory requirements across these settings may lead to barriers in care for patients with OUD.

OBJECTIVE

Identify how methadone regulation impacts the care of patients with OUD during hospitalization, care transitions, and in the OTP setting.

METHODS

We completed 26 interviews with clinicians and social workers working on hospital-based addiction consultation services across the United States. Study findings are the result of a secondary content analysis of interviews to identifying the word "methadone" and construct themes resulting from the data.

RESULTS

We identified three major themes related to "methadone" for OUD treatment, all of which impacted patient care: (1) limited OTP hours leads to tenuous or delayed hospital discharges; (2) inadequate information-sharing between hospitals and OTPs leads to delays in care; and (3) methadone regulations create treatment barriers for the most vulnerable patients.

CONCLUSION

Strict methadone regulations have resulted in unintended consequences for patients with OUD in the hospital setting, during care transitions, and in the OTP setting. Recent and ongoing federal efforts to reform methadone provision may improve some of the reported challenges, but significant hurdles remain in providing safe, equitable care to hospitalized patients with OUD.

Caring for Hospitalized Adults With Opioid Use Disorder in the Era of Fentanyl: A Review

Importance

The rise of fentanyl and other high-potency synthetic opioids across US and Canada has been associated with increasing hospitalizations and unprecedented overdose deaths. Hospitalization is a critical touchpoint to engage patients and offer life-saving opioid use disorder (OUD) care when admitted for OUD or other medical conditions.

Observations

Clinical best practices include managing acute withdrawal and pain, initiating medication for OUD, integrating harm reduction principles and practices, addressing in-hospital substance use, and supporting hospital-to-community care transitions. Fentanyl complicates hospital OUD care. Fentanyl's high potency intensifies pain, withdrawal, and cravings and increases the risk for overdose and other harms. Fentanyl's unique pharmacology has rendered traditional techniques for managing opioid withdrawal and initiating buprenorphine and methadone inadequate for some patients, necessitating novel strategies. Further, co-use of opioids with stimulants drugs is common, and the opioid supply is unpredictable and can be contaminated with benzodiazepines, xylazine, and other substances. To address these challenges, clinicians are increasingly relying on emerging practices, such as low-dose buprenorphine initiation with opioid continuation, rapid methadone titration, and the use of alternative opioid agonists. Hospitals must also reconsider conventional approaches to in-hospital substance use and expand clinicians' understanding and embrace of harm reduction, which is a philosophy and set of practical strategies that supports people who use drugs to be safer and healthier without judgment, coercion, or discrimination. Hospital-to-community care transitions should ensure uninterrupted access to OUD care after discharge, which requires special consideration and coordination. Finally, improving hospital-based addiction care requires dedicated infrastructure and expertise. Preparing hospitals across the US and Canada to deliver OUD best practices requires investments in clinical champions, staff education, leadership commitment, community partnerships, quality metrics, and financing.

Conclusions and Relevance

The findings of this review indicate that fentanyl creates increased urgency and new challenges for hospital OUD care. Hospital clinicians and systems have a central role in addressing the current drug crisis.

Developing a remotely delivered intensive outpatient program adapted for hospitalized patients with opioid use disorder: A qualitative study

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.

Contextual barriers and enablers to establishing an addiction-focused consultation team for hospitalized adults with opioid use disorder

BACKGROUND

Hospitalization presents an opportunity to begin people with opioid use disorder (OUD) on medications for opioid use disorder (MOUD) and link them to care after discharge; regrettably, people admitted to the hospital with an underlying OUD typically do not receive MOUD and are not connected with subsequent treatment for their condition. To address this gap, we launched a multi-site randomized controlled trial to test the effectiveness of a hospital-based addiction consultation team (the Substance Use Treatment and Recovery Team (START)) consisting of an addiction medicine specialist and care manager team that provide collaborative care and a specified intervention to people with OUD during the inpatient stay. Successful implementation of new practices can be impacted by organizational context, though no previous studies have examined context prior to implementation of addiction consultation services (ACS). This study assessed pre-implementation context for implementing a specialized ACS and tailoring it accordingly.

METHODS

We conducted semi-structured interviews with hospital administrators, physicians, physician assistants, nurses, and social workers at the three study sites between April and August 2021 before the launch of the pragmatic trial. Using an analytical framework based on the Consolidated Framework for Implementation Research, we completed a thematic analysis of interview data to understand potential barriers or enablers and perceptions about acceptability and feasibility.

RESULTS

We interviewed 28 participants across three sites. The following themes emerged across sites: (1) START is an urgently needed model for people with OUD; (2) Intervention adaptations are recommended to meet local and cultural needs; (3) Linking people with OUD to community clinicians is a highly needed component of START; (4) It is important to engage stakeholders across departments and roles throughout implementation. Across sites, participants generally saw a need for change from usual care to support people with OUD, and thought the START was acceptable and feasible to implement. Differences among sites included tailoring the START to support the needs of varying patient populations and different perceptions of the prevalence of OUD.

CONCLUSIONS

Hospitals planning to implement an ACS in the inpatient setting may wish to engage in a systematic pre-implementation contextual assessment using a similar framework to understand and address potential barriers and contextual factors that may impact implementation. Pre-implementation work can help ensure the ACS and other new practices fit within each unique hospital context.

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

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.

Providers' Experiences and Perspectives in Treating Patients With Co-Occurring Opioid and Stimulant Use Disorders in the Hospital

BACKGROUND

The overdose crisis is increasingly characterized by opioid and stimulant co-use. Despite effective pharmacologic treatment for both opioid use disorder (OUD) and contingency management for stimulant use disorders, most individuals with these co-occurring conditions are not engaged in treatment. Hospitalization is an important opportunity to engage patients and initiate treatment, however existing hospital addiction care is not tailored for patients with co-use and may not meet the needs of this population.

METHODS

Semi-structured interviews were conducted with hospital providers about their experiences and perspectives treating patients with opioid and stimulant co-use. We used directed content analysis to identify common experiences and opportunities to improve hospital-based treatment for patients with co-use.

RESULTS

From qualitative interviews with 20 providers, we identified 4 themes describing how co-use complicated hospital-based substance use treatment: (1) patients' unstable circumstances impacting the treatment plan, (2) co-occurring withdrawals are difficult to identify and treat, (3) providers holding more stigmatizing views of patients with co-use, and (4) stimulant use is often "ignored" in the treatment plans. Participants also described a range of potential opportunities to improve hospital-based treatment of co-use that fall into 3 categories: (1) provider practice changes, (2) healthcare system changes, and (3) development and validation of clinical tools and treatment approaches.

CONCLUSIONS

We identified unique challenges providing hospital addiction medicine care to patients who use both opioids and stimulants. These findings inform the development, implementation, and testing of hospital-based interventions for patients with co-use.

Attending to Marginalization in The Chronic Pain Literature: A Scoping Review

Background

There has been a recent and, for many within the chronic pain space, long-overdue increase in literature that focuses on equity, diversity, inclusion, and decolonization (EDI-D) to understand chronic pain among people who are historically and structurally marginalized.

Aims

In light of this growing attention in chronic pain research, we undertook a scoping review of studies that focus on people living with chronic pain and marginalization to map how these studies were carried out, how marginalization was conceptualized and operationalized by researchers, and identify suggestions for moving forward with marginalization and EDI-D in mind to better support people living with chronic pain.

Methods

We conducted this scoping review using critical analysis in a manner that aligns with dominant scoping review frameworks and recent developments made to scoping review methodology as well as reporting guidelines.

Results

Drawing on 67 studies, we begin with a descriptive review of the literature followed by a critical review that aims to identify fissures within the field through the following themes: (1) varying considerations of sociopolitical and socioeconomic contexts, (2) conceptual conflations between sex and gender, and (3) differing approaches to how people living with chronic pain and marginalization are described.

Conclusion

By identifying strengths and limitations in the research literature, we aim to highlight opportunities for researchers to contribute to a more comprehensive understanding of marginalization in chronic pain experiences.

Forgone healthcare for medically vulnerable groups during the pandemic era: experiences of family caregivers of young adults with substance use disorders in Zambia

Introduction

Scholars worldwide have defined the COVID-19 pandemic as a mass-disabling event of our time. The situation is grave for families experiencing financial hurdles while caring for young adults in recovery from addiction problems.

Methods

Using semi-structured interviews with 30 purposively selected family caregivers (FCGs) of young adults with substance use disorders (SUDs) in Lusaka, Zambia, this study reveals several factors influencing forgone healthcare for this medically vulnerable group.

Results

Financial challenges and huge out-of-pocket bills; caregivers' perceived far-fetched recovery of the young adult; the cost of medication and transportation; the young adult's little perceived need for healthcare service use, their runaway and treatment elusive tendencies; caregiver concerns about contracting the virus, and the stigma associated with it; and a fragmented child and adolescent mental health system influenced forgone healthcare. The young adults were often unavailable for days and months, posing challenges to the continuity of care. Despite caregivers' acknowledgment of the availability of healthcare professionals, young adults with problematic substance use had limited access to SUD recovery services, resulting in adverse health outcomes. Results also show that most family caregivers encountered challenges in accessing and purchasing psychotropic medications, which were difficult to find during the lockdowns. Some family caregivers lost their sources of income by being laid off from work due to the pandemic and skipping work to attend to caregiving responsibilities. Most of those in self-employment had to close their business and stay home to look after their youth. Several caregivers kept their youth at home because they failed to access private residential SUD recovery services. Family caregivers mostly relied on outpatient public health services, alternative medicine from traditional healers, and faith-based healing, all of which some young adults rarely accessed because of their problematic behaviors of escaping healthcare.

Conclusion

These identifiable risk factors, and their detrimental consequences highlight the need for interventions to improve healthcare access for this vulnerable population. Supporting FCGs of addicted young adults is crucial in ensuring the well-being of both the caregivers and care recipients. Further research is warranted to explore potential solutions, such as peer support programs, policy changes, and education initiatives for carers and recipients in the (post) pandemic era.

Patient and Staff Perspectives on the Impacts and Challenges of Hospital-Based Harm Reduction

Importance

Harm reduction is associated with improved health outcomes among people who use substances. As overdose deaths persist, hospitals are recognizing the need for harm reduction services; however, little is known about the outcomes of hospital-based harm reduction for patients and staff.

Objective

To evaluate patient and staff perspectives on the impact and challenges of a hospital-based harm reduction program offering safer use education and supplies at discharge.

Design, Setting, and Participants

This qualitative study consisted of 40-minute semistructured interviews with hospitalized patients receiving harm reduction services and hospital staff at an urban, safety-net hospital in California from October 2022 to March 2023. Purposive sampling allowed inclusion of diverse patient racial and ethnic identities, substance use disorders (SUDs), and staff roles.

Exposure

Receipt of harm reduction education and/or supplies (eg, syringes, pipes, naloxone, and test strips) from an addiction consult team, or providing care for patients receiving these services.

Main Outcomes and Measures

Interviews were analyzed using thematic analysis to identify key themes.

Results

A total of 40 participants completed interviews, including 20 patients (mean [SD] age, 43 [13] years; 1 American Indian or Alaska Native [5%], 1 Asian and Pacific Islander [5%], 6 Black [30%]; 6 Latine [30%]; and 6 White [30%]) and 20 staff (mean [SD] age 37 [8] years). Patients were diagnosed with a variety of SUDs (7 patients with opioid and stimulant use disorder [35%]; 7 patients with stimulant use disorder [35%]; 3 patients with opioid use disorder [15%]; and 3 patients with alcohol use disorder [15%]). A total of 3 themes were identified; respondents reported that harm reduction programs (1) expanded access to harm reduction education and supplies, particularly for ethnically and racially minoritized populations; (2) built trust by improving the patient care experience and increasing engagement; and (3) catalyzed culture change by helping destigmatize care for individuals who planned to continue using substances and increasing staff fulfillment. Black and Latine patients, those who primarily used stimulants, and those with limited English proficiency (LEP) reported learning new harm reduction strategies. Program challenges included hesitancy regarding regulations, limited SUD education among staff, remaining stigma, and the need for careful assessment of patient goals.

Conclusions and Relevance

In this qualitative study, patients and staff believed that integrating harm reduction services into hospital care increased access for populations unfamiliar with harm reduction, improved trust, and reduced stigma. These findings suggest that efforts to increase access to harm reduction services for Black, Latine, and LEP populations, including those who use stimulants, are especially needed.

"Whatever journey you want to take, I'll support you through": a mixed methods evaluation of a peer worker program in the hospital emergency department

BACKGROUND

People who are unhoused, use substances (drugs and/or alcohol), and who have mental health conditions experience barriers to care access and are frequently confronted with discrimination and stigma in health care settings. The role of Peer Workers in addressing these gaps in a hospital-based context is not well characterized. The aim of this evaluation was to 1) outline the role of Peer Workers in the care of a marginalized populations in the emergency department; 2) characterize the impact of Peer Workers on patient care, and 3) to describe how being employed as a Peer Worker impacts the Peer.

METHODS

Through a concurrent mixed methods evaluation, we explore the role of Peer Workers in the care of marginalized populations in the emergency department at two urban hospitals in Toronto, Ontario Canada. We describe the demographic characteristics of patients (n = 555) and the type of supports provided to patients collected through a survey between February and June 2022. Semi-structured, in-depth interviews were completed with Peer Workers (n = 7). Interviews were thematically analyzed using a deductive approach, complemented by an inductive approach to allow new themes to emerge from the data.

RESULTS

Support provided to patients primarily consisted of friendly conversations (91.4%), discharge planning (59.6%), tactics to help the patient navigate their emotions/mental wellbeing (57.8%) and sharing their lived experience (50.1%). In over one third (38.9%) of all patient interactions, Peer Workers shared new information about the patient with the health care team (e.g., obtaining patient identification). Five major themes emerged from our interviews with Peer Workers which include: (1) Establishing empathy and building trust between the patient and their care team through self-disclosure; (2) Facilitating a person-centered approach to patient care through trauma-informed listening and accessible language; (3) Support for patient preferences on harm reduction; (4) Peer worker role facilitating self-acceptance and self-defined recovery; and (5) Importance of supports and resources to help Peer Workers navigate the emotional intensity of the emergency department.

CONCLUSIONS

The findings add to the literature on Peer Worker programs and how such interventions are designed to best meet the needs of marginalized populations.

Recovery Barrier Characterizations by Hospitalized Patients with Substance Use Disorders: Results from a Randomized Clinical Study on Inpatient Peer Recovery Coaching

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.

CE: Reducing Bias Against People with Substance Use Disorders

ABSTRACT

Addiction is a highly misunderstood and stigmatized chronic illness frequently encountered by health care providers during routine medical care. People with substance use disorders, in particular, face extraordinary stigma and bias when interacting with health care providers, including nurses. Stigma associated with addiction contributes to health inequities and is recognized as a significant barrier to people seeking and receiving necessary health care. Since patients often spend the most time with nurses in the clinical setting, nurses are ideally positioned to address addiction stigma. However, many nurses lack knowledge about addiction, stigma, and the impact of the words they use, whether in conversation or in clinical documentation. This article reviews the consequences of addiction stigma (labeling, stereotyping, or discrimination) and the steps nurses can take to reduce biases related to substance use. A case scenario based on our experience will be used to guide a discussion of opportunities for nurses to intervene and improve care.

Addiction Consult Service and Inpatient Outcomes Among Patients with Alcohol Use Disorder

BACKGROUND

Alcohol use disorder (AUD) is the most prevalent substance use disorder, but evidence-based medications to treat AUD (MAUD), including naltrexone and acamprosate, are substantially underutilized. Hospitalization provides an opportunity to start MAUD for patients who may not otherwise seek treatment. Addiction consultation services (ACSs) have been increasingly utilized to ensure appropriate treatment. There is little research examining the effect of an ACS on health outcomes among patients with AUD.

OBJECTIVE

To determine the association between an ACS consultation and provision of MAUD during admission and MAUD at discharge among admissions with AUD.

DESIGN

Retrospective study comparing admissions which received an ACS consult and propensity score-matched historical control admissions. Subjects A total of 215 admissions with a primary or secondary diagnosis of AUD who received an ACS consult and 215 matched historical control admissions. Intervention ACS consultation from a multidisciplinary team offering withdrawal management, substance use disorder treatment, patient-centered counseling, discharge planning, and linkage to outpatient care for patients with substance use disorders, including AUD. Main Measures Primary outcomes were initiation of new MAUD during admission and new MAUD at discharge. Secondary outcomes were patient-directed discharge, time to 7- and 30-day readmission, and time to 7- and 30-day post-discharge ER visit. Key Results Among 430 admissions with AUD, those that received an ACS consultation were significantly more likely to receive new inpatient MAUD (33.0% vs 0.9%; OR 52.5 [CI 12.6-218.6]) and significantly more likely to receive new MAUD at discharge (41.4% vs 1.9%; OR 37.3 [13.3-104.6]), compared with historical controls. ACS was not significantly associated with patient-directed discharge, time to readmission, or time to post-discharge ER visit.

CONCLUSIONS

ACS was associated with a large increase in provision of new inpatient MAUD and new MAUD at discharge when compared to propensity-matched historical controls.

Applying a mutual capacity building model to inform peer provider programs in South Africa and the United States: A combined qualitative analysis

BACKGROUND

Globally, there is a treatment gap for substance use treatment and harm reduction services. As peer-delivered interventions expand to address this gap in both high-income countries (HICs) and low and middle-income countries (LMICs), they provide an opportunity to examine mutual capacity building, the bidirectional exchange of ideas between distinct settings to address common challenges.

METHODS

The aim of this study was to explore the perspectives of patients in Cape Town and Baltimore about the acceptability and feasibility of a peer-delivered intervention using a combined qualitative analysis across a HIC and LMIC. Semi-structured qualitative interviews were conducted with participants in pilot trials in Cape Town, South Africa and Baltimore, USA (n=55). Across both trials, participants received a peer-delivered behavioral intervention focused on problem solving strategies for medication adherence, behavioral activation, and other cognitive-behavioral skills. The datasets from each location were merged and analyzed jointly using thematic analysis to develop codes and themes. Transcripts were coded to theoretical saturation (n=21 from Baltimore, n=16 from Cape Town).

RESULTS

Participants highlighted what they valued about the peer-delivered intervention: 1) behavioral skills learned, 2) relationship with the peer, 3) ability to help others based on what they learned, 4) improved adherence to HIV or substance use medications, and 5) changes in substance use behaviors. In Baltimore, participants were typically more focused on their supportive relationship with the peer, which contrasted with many other relationships in their lives. In Cape Town, many participants highlighted the value of the skills they learned, such as mindfulness and activity scheduling.

CONCLUSIONS

Across sites, participants valued that the peer could support them to accomplish meaningful life goals beyond substance use recovery, such as building relationships or health. Differences between settings may highlight the importance of tailoring peer interventions to fill context-specific gaps in available services.

Promoting alcohol treatment engagement post-hospitalization with brief intervention, medications and CBT4CBT: protocol for a randomized clinical trial in a diverse patient population

BACKGROUND

Alcohol use disorder (AUD) commonly causes hospitalization, particularly for individuals disproportionately impacted by structural racism and other forms of marginalization. The optimal approach for engaging hospitalized patients with AUD in treatment post-hospital discharge is unknown. We describe the rationale, aims, and protocol for Project ENHANCE (ENhancing Hospital-initiated Alcohol TreatmeNt to InCrease Engagement), a clinical trial testing increasingly intensive approaches using a hybrid type 1 effectiveness-implementation approach.

METHODS

We are randomizing English and/or Spanish-speaking individuals with untreated AUD (n = 450) from a large, urban, academic hospital in New Haven, CT to: (1) Brief Negotiation Interview (with referral and telephone booster) alone (BNI), (2) BNI plus facilitated initiation of medications for alcohol use disorder (BNI + MAUD), or (3) BNI + MAUD + initiation of computer-based training for cognitive behavioral therapy (CBT4CBT, BNI + MAUD + CBT4CBT). Interventions are delivered by Health Promotion Advocates. The primary outcome is AUD treatment engagement 34 days post-hospital discharge. Secondary outcomes include AUD treatment engagement 90 days post-discharge and changes in self-reported alcohol use and phosphatidylethanol. Exploratory outcomes include health care utilization. We will explore whether the effectiveness of the interventions on AUD treatment engagement and alcohol use outcomes differ across and within racialized and ethnic groups, consistent with disproportionate impacts of AUD. Lastly, we will conduct an implementation-focused process evaluation, including individual-level collection and statistical comparisons between the three conditions of costs to providers and to patients, cost-effectiveness indices (effectiveness/cost ratios), and cost-benefit indices (benefit/cost ratios, net benefit [benefits minus costs). Graphs of individual- and group-level effectiveness x cost, and benefits x costs, will portray relationships between costs and effectiveness and between costs and benefits for the three conditions, in a manner that community representatives also should be able to understand and use.

CONCLUSIONS

Project ENHANCE is expected to generate novel findings to inform future hospital-based efforts to promote AUD treatment engagement among diverse patient populations, including those most impacted by AUD.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT05338151.

Low Dose Buprenorphine Initiation: A Guide for the Inpatient Clinician

Low dose buprenorphine initiation (LDBI) is a dosing strategy used to transition patients from full opioid agonists to buprenorphine. The purpose of LDBI is to circumvent obstacles associated with disruption in analgesia, precipitated withdrawal, and prerequisite opioid withdrawal prior to initiating buprenorphine, as not all patients are able to tolerate physical withdrawal symptoms recommended by national guidelines. No literature exists directly comparing traditional buprenorphine initiation to LDBI. Until information on long-term outcomes is available, these dosing strategies should be reserved for patients unable to tolerate traditional buprenorphine initiation. Available published research suggests LDBI strategies will allow some patients to successfully transition to buprenorphine with minimal or no symptoms of withdrawal. Ensuring access to pharmacotherapy during hospital admission is a crucial time for potential intervention and should be considered when appropriate. This narrative review discusses the background of LDBI strategies as well as practical clinical and operational considerations for the inpatient clinician.

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

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.

Rewriting the Hidden Curriculum via Addiction Consult Services: Meeting Patients Where They Are At

Addiction Consult Services (ACS) deliver evidence-based care for patients with substance use disorder (SUD) during the course of general hospital admissions. Stigma toward patients with SUD is a known phenomenon and is part of the "hidden curriculum" that permeates medical training and healthcare settings. ACS have the potential to rewrite the hidden curriculum around SUD and to teach medical students and other trainees how to compassionately care for this patient population. Here, the authors explore the role of stigma within the hidden curriculum of medical training and outline how ACS can successfully contribute to combatting this stigma. The authors highlight two institutions' approaches to educational initiatives that incorporate health professional trainees into ACS. The authors end by providing a vision of how expansion of ACS can promote interdisciplinary learning for healthcare providers amidst the changing landscape of SUD treatment in the USA.

A scoping review of barriers and facilitators to the integration of substance use treatment services into US mainstream health care

Background

Following the national implementation of the Affordable Care Act (ACA) in 2014, barriers still exist that limit the adoption of substance use treatment (SUT) services in mainstream health care (MHC) settings in the United States. This study provides an overview of current evidence on barriers and facilitators to integrating various SUT services into MHC.

Methods

A systematic search was conducted with the following databases: "PubMed including MEDLINE", "CINAHL", "Web of Science", "ABI/Inform", and "PsycINFO." We identified barriers and/or facilitators affecting patients, providers, and programs/systems.

Results

Of the 540 identified citations, 36 were included. Main barriers were identified for patients (socio-demographics, finances, confidentiality, legal impact, and disinterest), providers (limited training, lack of time, patient satisfaction concerns, legal implications, lack of access to resources or evidence-based information, and lack of legal/regulatory clarity), and programs/systems (lack of leadership support, lack of staff, limited financial resources, lack of referral networks, lack of space, and lack of state-level support). Also, we recognized key facilitators pertaining to patients (trust for providers, education, and shared decision making), providers (expert supervision, use of support team, training with programs like Extension for Community Health Outcomes (ECHO), and receptivity), and programs/systems (leadership support, collaboration with external agencies, and policies e.g., those expanding the addiction workforce, improving insurance access and treatment access).

Conclusions

This study identified several factors influencing the integration of SUT services in MHC. Strategies for improving SUT integration in MHC should address barriers and leverage facilitators related to patients, providers, and programs/systems.

Barriers and facilitators to accessing inpatient and community substance use treatment and harm reduction services for people who use drugs in the Muslim communities: A systematic narrative review of studies on the experiences of people who receive services and service providers

BACKGROUND

The prevalence of drug use in Muslim communities is difficult to estimate due to religious, social, and cultural prohibition toward drug use. With Islam affecting all aspects of life in the Muslim world, people who use drugs do it clandestinely to avoid stigma and exclusion from the community, leading to a low number of them seeking treatment for their drug use. This review explored the barriers and facilitators to accessing inpatient and community substance use treatment and harm reduction services for people who use drugs in Muslim communities.

METHODS

This review was in accordance with PRISMA. Seven databases were systematically searched for qualitative, quantitative, and mixed methods studies conducted in countries where at least 70% of the population were Muslim or where data were presented separately for Muslim communities in other countries. Eligible articles were reviewed, and key qualitative themes were abstracted and compared across studies and settings.

RESULTS

Twenty-four studies were included from Iran, Bangladesh, Afghanistan, Tajikistan, Kazakhstan, Kyrgyzstan, Egypt, Lebanon, and UAE. Two themes were identified: a psychosocial theme included denial of the problem severity, lack of trust in the treatment system, fear of breach in confidentiality and privacy, the need for community support, religion and women who use drugs. Additionally, an organizational theme included affordability, treatment Service characteristics, lack of Awareness, service providers' Attitudes, drug use registration and fear of legal consequences of drug use. Stigma was also identified as an over-arching theme. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of the included studies with where 12 of the studies met all 5 the quality criteria. No studies were excluded for having lower quality scores.

CONCLUSION

This review reflected how diverse the Muslim world is in drug use. It is important to use mosques to raise awareness on people who use drugs and reduce stigma. Providing holistic services for people who use drugs specially women will improve their access to treatment and harm reduction services in the Muslim world.

Evaluating the Impact of Substance Use Disorder Resources on Outcomes of Persons Who Inject Drugs with Infections

OBJECTIVE

The aim of the study is to evaluate the impact of inpatient substance use disorder (SUD) resources on outcomes of persons who inject stimulants and/or opioids (PWIDs) with infections.

METHODS

This retrospective cohort evaluated PWIDs hospitalized from July 1, 2020, to May 31, 2021, and prescribed an antimicrobial course. The patients were compared based on inpatient implementation of SUD resources, including consultation of addiction medicine/behavioral health, implementation of an opioid withdrawal treatment protocol, or continuation/initiation of medications for opioid use disorder. The primary outcome was a composite of antibiotic completion, no unplanned discharge, and no 30-day readmission. Notable secondary outcomes included length of stay and presence of stigmatizing language in the electronic medical record.

RESULTS

A total of 119 patients were analyzed-74 (62.2%) received SUD resources. The primary outcome was met by 43 patients with SUD resources implemented (58.1%) and 19 patients without resources (42.2%, P = 0.093). After adjustment for infection type, implementation of SUD resources (adjusted odds ratio, 2.593; 95% confidence interval, 1.162-5.789) was independently associated with primary outcome success. The patients who received SUD resources had a median length of stay of 7 days (4-13.3) compared with 4 days (2-6.5) in those without resources ( P < 0.001). Stigmatizing language was present in 98% of patient electronic medical records.

CONCLUSIONS

Patient care provided to PWIDs with infections is optimized when SUD resources are implemented. This study further supports the necessity of improving SUD management when PWIDs are admitted to healthcare facilities.

Overcoming challenges in acute care hospitalizations for patients with opioid use disorder

BACKGROUND

Hospitalized patients with opioid use disorder (OUD) present unique challenges and opportunities for inpatient medical teams. Having the ability to initiate medications for opioid use disorder (MOUD) and linkage to outpatient treatment are key to improve inpatient care of patients with OUD.

OBJECTIVE

This study aimed to describe the process taken by a multidisciplinary work group to improve the acute care management of patients with OUD.

PRACTICE DESCRIPTION

In 2018, we identified that inpatient care teams at the University of Chicago Medicine (UCM) lacked a standardized approach to the management of hospitalized patients with OUD and that the care typically did not include evidence-based therapies. Herein, we describe the process taken to develop the OUD workgroup and the work completed by the workgroup.

PRACTICE INNOVATION

The OUD workgroup spearheaded the development of an OUD consult service, formulary revisions, education for health care workers (inpatient nurse training and X-waiver training for prescribers), and outpatient partnerships. Pharmacy-led initiatives included formulary management, electronic medication orders, naloxone co-prescribing decision support, and MOUD education.

EVALUATION METHODS

The OUD consult service was granted an Institutional Review Board exemption for quality improvement analysis through UCM. A data analytics dashboard was built to track consult service volumes and outcomes.

RESULTS

From July 2020 to April 2021, 296 OUD consults occurred. In total, 103 consult patients (35%) received and were discharged with buprenorphine. An additional 118 patients (40%) were managed with methadone and linked to outpatient care. Naloxone dispensing at discharge increased to over 65%, which did not include patients who opted out or were discharged to a facility.

CONCLUSION

The ongoing OUD epidemic presents a need for the development of services to improve management of patients with OUD in the acute care setting. The OUD workgroup has improved the management of patients admitted with OUD. Pharmacy-based initiatives are key to the development of safe and effective management of OUD in hospitalized patients.

Medication Initiation, Patient-directed Discharges, and Hospital Readmissions Before and After Implementing Guidelines for Opioid Withdrawal Management

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.

Peer providers and linkage with buprenorphine care after hospitalization: A retrospective cohort study

Background: People with opioid use disorder (OUD) are increasingly started on buprenorphine in the hospital, yet many patients do not attend outpatient buprenorphine care after discharge. Peer providers, people in recovery themselves, are a growing part of addiction care. We examine whether patients who received a low-intensity, peer-delivered intervention during hospitalization had a greater rate of linking with outpatient buprenorphine care relative to those not seen by a peer. Methods: This was a retrospective cohort study of adults with OUD who were started on buprenorphine during hospitalization. The primary outcome was receipt of a buprenorphine prescription within 30 days of discharge. Secondary outcomes included attendance at a follow-up visit with a buprenorphine provider within 30 days and hospital readmission within 90 days. Modified Poisson regression analyses tested for differences in the rate ratios (RR) of each binary outcome for patients who were versus were not seen by a peer provider. Peer notes in the electronic health record were reviewed to characterize peer activities. Results: 111 patients met the study inclusion criteria, 31.5% of whom saw a peer provider. 55.0% received a buprenorphine prescription within 30 days of hospital discharge. Patients with versus without peer provider encounters did not significantly differ in the rates of receiving a buprenorphine prescription (RR = 1.06, 95% CI: 0.74-1.51), hospital readmission (RR = 1.45, 95% CI: 0.80-2.64), or attendance at a buprenorphine follow-up visit (RR = 1.03, 95% CI: 0.68-1.57). Peers most often listened to or shared experiences with patients (68.6% of encounters) and helped facilitate medical care (60.0% of encounters). Conclusions: There were no differences in multiple measures of buprenorphine follow-up between patients who received this low-intensity peer intervention and those who did not. There is need to investigate what elements of peer provider programs contribute to patient outcomes and what outcomes should be assessed when evaluating peer programs.

Availability of medications for opioid use disorder in outpatient and inpatient pharmacies in South Florida: a secret shopper survey

Background

Despite the proven efficacy of medications for opioid use disorder (MOUD) and recent reduction in barriers to prescribers, numerous obstacles exist for patients seeking MOUD. Prior studies have used telephone surveys to investigate pharmacy-related barriers to MOUD. We applied this methodology to evaluate inpatient and outpatient pharmacy barriers to MOUD in South Florida.

Methods

Randomly selected pharmacies in South Florida (Miami-Dade, Broward, and Palm Beach Counties) were called using a standardized script with a “secret shopper” approach until 200 successful surveys had been completed. The primary outcome was the availability of any buprenorphine products. Second, a list of all 48 acute care hospitals within the aforementioned counties was compiled, and hospitals were contacted by telephone using a second structured script.

Results

A total of 1374 outpatient pharmacies and 48 inpatient pharmacies were identified. 378 randomly selected outpatient pharmacies were contacted to accrue 200 successful calls (53% success rate). All 48 inpatient pharmacies were contacted to successfully complete 25 inpatient surveys (52%). Of the 200 outpatient pharmacies contacted, 38% had any buprenorphine available. There was a significant difference in buprenorphine availability by county, with Miami-Dade having the least availability and Palm Beach having the most availability (27% vs. 47%, respectively; p = 0.04). Of the 38% with buprenorphine available, 82% had a sufficient supply for a two-week prescription of buprenorphine 8 mg twice daily. Of the pharmacies that did not have buprenorphine, 55% would be willing to order with a median estimated time to receive an order of 2 days (IQR 1.25–3 days). Of the 25 surveyed inpatient pharmacies, 88% reported having buprenorphine on inpatient formulary, and 55% of hospitals had at least one restriction on ordering of buprenorphine beyond federal regulations.

Conclusions

The results of this study highlight significant pharmacy-related barriers to comprehensive OUD treatment across the healthcare system including both acute care hospital pharmacies and outpatient community pharmacies. Despite efforts to increase the number of MOUD providers, there still remain downstream obstacles to MOUD access.

Acute injection-related infections requiring hospitalisation among people who inject drugs: Clinical features, microbiology and management

INTRODUCTION

People who inject drugs are at risk of hospitalisation with injection-related infections (IRI). We audited the clinical features, microbiology and management of IRI at a tertiary service in Melbourne to describe the burden and identify quality improvement opportunities.

METHODS

We performed retrospective review of IRI admissions from January 2017 to April 2019. We extracted admissions where ICD-10 codes or triage text suggested injecting drug use, and the diagnosis suggested IRI. We reviewed these for eligibility and extracted data using a standardised form. We performed mixed-effects logistic regression to determine predictors of unplanned discharge.

RESULTS

From 574 extracted candidate admissions, 226 were eligible, representing 178 patients. Median age was 41 years (interquartile range 36-47), 66% (117/178) male and 49% (111/226) had unstable housing. Over 50% (96/178) had a psychiatric diagnosis and 35% (62/178) were on opioid agonist therapy (OAT) on admission. Skin and soft tissue infection was the most common IRI (119/205, 58%), followed by bacteraemia (36/205, 18%) and endocarditis (26/205, 13%). Management included addictions review (143/226, 63%), blood-borne virus screening (115/226, 51%), surgery (77/226, 34%) and OAT commencement (68/226, 30%). Aggression events (54/226, 15%) and unplanned discharge (69/226, 30%) complicated some admissions. Opioid use without OAT was associated with almost 3-fold increased odds of unplanned discharge compared to no opioid use (odds ratio 2.90, 95% confidence interval 1.23, 6.85, p = 0.015).

DISCUSSION AND CONCLUSION

Comorbidities associated with IRI may be amenable to opportunistic intervention during hospitalisation. Further research is needed to develop optimal models of care for this vulnerable patient group.