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Calcaterra SL, Dafoe A, Tietbohl C, Thurman L, Bredenberg E. Unintended consequences of methadone regulation for opioid use disorder treatment among hospitalized patients. J Hosp Med 2024; 19:460-467. [PMID: 38507276 DOI: 10.1002/jhm.13329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/29/2024] [Accepted: 03/07/2024] [Indexed: 03/22/2024]
Abstract
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.
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Affiliation(s)
- Susan L Calcaterra
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Coloroda, USA
| | - Ashley Dafoe
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Coloroda, USA
| | - Caroline Tietbohl
- Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Coloroda, USA
| | - Lindsay Thurman
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Erin Bredenberg
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Evans SK, Ober AJ, Korn AR, Peltz A, Friedmann PD, Page K, Murray-Krezan C, Huerta S, Ryzewicz SJ, Tarhuni L, Nuckols TK, E Watkins K, Danovitch I. Contextual barriers and enablers to establishing an addiction-focused consultation team for hospitalized adults with opioid use disorder. Addict Sci Clin Pract 2024; 19:31. [PMID: 38671482 PMCID: PMC11046820 DOI: 10.1186/s13722-024-00461-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 04/02/2024] [Indexed: 04/28/2024] Open
Abstract
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.
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Affiliation(s)
- Sandra K Evans
- RAND Corporation, 1776 Main Street, 90407‑2138, Santa Monica, CA, P.O. Box 2138, USA.
| | - Allison J Ober
- RAND Corporation, 1776 Main Street, 90407‑2138, Santa Monica, CA, P.O. Box 2138, USA
| | - Ariella R Korn
- RAND Corporation, 1776 Main Street, 90407‑2138, Santa Monica, CA, P.O. Box 2138, USA
| | - Alex Peltz
- RAND Corporation, 1776 Main Street, 90407‑2138, Santa Monica, CA, P.O. Box 2138, USA
| | - Peter D Friedmann
- Department of Medicine, University of Massachusetts Chan Medical School-Baystate and Baystate Health, 3601 Main Street, 3rd Floor, 01107, Springfield, MA, USA
| | - Kimberly Page
- University of New Mexico Health Sciences Center, 1 University, MSC10 5550, 87133, Albuquerque, NM, USA
| | - Cristina Murray-Krezan
- Departement of Medicine, University of Pittsburgh School of Medicine, 200 Meyran Ave, Suite 300, 15213, Pittsburgh, PA, USA
| | - Sergio Huerta
- University of New Mexico Health Sciences Center, 1 University, MSC10 5550, 87133, Albuquerque, NM, USA
| | - Stephen J Ryzewicz
- Department of Medicine, University of Massachusetts Chan Medical School-Baystate and Baystate Health, 3601 Main Street, 3rd Floor, 01107, Springfield, MA, USA
| | - Lina Tarhuni
- University of New Mexico Health Sciences Center, 1 University, MSC10 5550, 87133, Albuquerque, NM, USA
| | - Teryl K Nuckols
- RAND Corporation, 1776 Main Street, 90407‑2138, Santa Monica, CA, P.O. Box 2138, USA
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, 90048, West Hollywood, CA, USA
| | - Katherine E Watkins
- RAND Corporation, 1776 Main Street, 90407‑2138, Santa Monica, CA, P.O. Box 2138, USA
| | - Itai Danovitch
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, 90048, West Hollywood, CA, USA
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Babbel DM, Liu P, Chen DR, Vaughn VM, Zickmund S, Bloomquist K, Zickmund T, Howell EF, Johnson SA. Inpatient opioid withdrawal: a qualitative study of the patient perspective. Intern Emerg Med 2024:10.1007/s11739-024-03604-9. [PMID: 38642310 DOI: 10.1007/s11739-024-03604-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 04/02/2024] [Indexed: 04/22/2024]
Abstract
Opioid withdrawal is common among hospitalized patients. Those with substance use disorders exhibit higher rates of patient-directed discharge. The literature lacks information regarding the patient perspective on opioid withdrawal in the hospital setting. In this study, we aimed to capture the patient-reported experience of opioid withdrawal during hospitalization and its impact on the desire to continue treatment for opioid use disorder after discharge. We performed a single-center qualitative study involving semi-structured interviews of hospitalized patients with opioid use disorder (OUD) experiencing opioid withdrawal. Investigators conducted in-person interviews utilizing a combination of open-ended and dichotomous questions. Interview transcripts were then analyzed with open coding for emergent themes. Nineteen interviews were performed. All participants were linked to either buprenorphine (79%) or methadone (21%) at discharge. Eight of nineteen patients (42%) reported a patient-directed discharge during prior hospitalizations. Themes identified from the interviews included: (1) opioid withdrawal was well-managed in the hospital; (2) patients appreciated receiving medication for opioid use disorder (MOUD) for withdrawal symptoms; (3) patients valued and felt cared for by healthcare providers; and (4) most patients had plans to follow-up for opioid use disorder treatment after hospitalization. In this population with historically high rates of patient-directed discharge, patients reported having a positive experience with opioid withdrawal management during hospitalization. Amongst our hospitalized patients, we observed several different individualized MOUD induction strategies. All participants were offered MOUD at discharge and most planned to follow-up for further treatment.
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Affiliation(s)
- Danielle M Babbel
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N. Mario Capecchi Drive, 3rd Floor South, Salt Lake City, UT, 84112, USA.
| | - Patricia Liu
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Section of Addiction Medicine, Oregon Health and Science University, Portland, OR, USA
| | - David R Chen
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N. Mario Capecchi Drive, 3rd Floor South, Salt Lake City, UT, 84112, USA
| | - Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N. Mario Capecchi Drive, 3rd Floor South, Salt Lake City, UT, 84112, USA
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Susan Zickmund
- Informatics, Decision-Enhancement and Analytic Sciences Center, VA Salt Lake City Healthcare System, University of Utah, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Kennedi Bloomquist
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Tobias Zickmund
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Elizabeth F Howell
- Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Stacy A Johnson
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 30 N. Mario Capecchi Drive, 3rd Floor South, Salt Lake City, UT, 84112, USA
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Shearer RD, Hernandez E, Beebe TJ, Virnig BA, Bart G, Winkelman TNA, Bazzi AR, Shippee ND. Providers' Experiences and Perspectives in Treating Patients With Co-Occurring Opioid and Stimulant Use Disorders in the Hospital. SUBSTANCE USE & ADDICTION JOURNAL 2024; 45:250-259. [PMID: 38258816 PMCID: PMC11151687 DOI: 10.1177/29767342231221060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
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.
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Affiliation(s)
- Riley D Shearer
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
- Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Edith Hernandez
- Department of Pharmacology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Timothy J Beebe
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Beth A Virnig
- College of Public Health and Health Professions, University of Florida, Gainsville, FL, USA
| | - Gavin Bart
- Division of Addiction Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Tyler N A Winkelman
- Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
- Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA
| | - Angela R Bazzi
- Herbert Wertheim School of Public Health, University of California San Diego, La Jolla, CA, USA
| | - Nathan D Shippee
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
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Calcaterra SL, Saunders S, Grimm E, Maki-Gianani E, Keniston A, Wold A, Bonaguidi A. In-Hospital Methadone Enrollment: a Novel Program to Facilitate Linkage from the Hospital to the Opioid Treatment Program for Vulnerable Patients with Opioid Use Disorder. J Gen Intern Med 2024; 39:385-392. [PMID: 37715094 PMCID: PMC10897082 DOI: 10.1007/s11606-023-08411-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/01/2023] [Indexed: 09/17/2023]
Abstract
INTRODUCTION Methadone ameliorates opioid withdrawal among hospitalized patients with opioid use disorder (OUD). To continue methadone after hospital discharge, patients must enroll in an opioid treatment program (OTP) per federal regulations. Uncontrolled opioid withdrawal is a barrier to linkage from hospital to OTP. AIM Describe a federally compliant In-Hospital Methadone Enrollment Team (IN-MEET) that enrolls hospitalized patients with OUD into an OTP with facilitated hospital to OTP linkage. SETTING Seven hundred-bed university hospital in Aurora, CO. PROGRAM DESCRIPTION A physician dually affiliated with a hospital's addiction consultation service and a community OTP completes an in-hospital, face-to-face medical assessment required by federal law and titrates methadone to comfort. An OTP-affiliated nurse with hospital privileges completes a psychosocial evaluation and provides case management by arranging transportation and providing weekly telephone check-ins. PROGRAM EVALUATION METRICS IN-MEET enrollments completed, hospital to OTP linkage, and descriptive characteristics of patients who completed IN-MEET enrollments compared to patients who completed community OTP enrollments. RESULTS Between April 2019 and April 2023, our team completed 165 IN-MEET enrollments. Among a subset of 73 IN-MEET patients, 56 (76.7%) presented to the OTP following hospital discharge. Compared to community OTP enrolled patients (n = 1687), a higher percentage of IN-MEET patients were older (39.7 years, standard deviation [SD] 11.2 years vs. 36.1 years, SD 10.6 years) and were unhoused (n = 43, 58.9% vs. n = 199, 11.8%). Compared to community OTP enrolled patients, a higher percentage of IN-MEET patients reported heroin or fentanyl as their primary substance (n = 53, 72.6% vs. n = 677, 40.1%), reported methamphetamine as their secondary substance (n = 27, 37.0% vs. n = 380, 22.5%), and reported they injected their primary substance (n = 46, 63.0% vs. n = 478, 28.3%). CONCLUSION IN-MEET facilitates hospital to OTP linkage among a vulnerable population. This model has the potential to improve methadone access for hospitalized patients who may not otherwise seek out treatment.
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Affiliation(s)
- Susan L Calcaterra
- Division of Hospital Medicine, Department of Medicine, University of Colorado, Aurora, CO, USA.
- Division of General Internal Medicine, University of Colorado, Aurora, CO, USA.
| | - Scott Saunders
- Division of Hospital Medicine, Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Eric Grimm
- Division of Hospital Medicine, Department of Medicine, University of Colorado, Aurora, CO, USA
| | | | - Angela Keniston
- Division of Hospital Medicine, Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Angi Wold
- Department of Psychiatry, University of Colorado, Aurora, CO, USA
| | - Angela Bonaguidi
- Department of Psychiatry, University of Colorado, Aurora, CO, USA
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Skogrand E, Sharpe J, Englander H. Dispensing Methadone at Hospital Discharge: One Hospital's Approach to Implementing the "72-hour Rule" Change. J Addict Med 2024; 18:71-74. [PMID: 37994453 PMCID: PMC10873107 DOI: 10.1097/adm.0000000000001246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
OBJECTIVES Methadone for opioid use disorder treatment in ambulatory settings is restricted to federally licensed opioid treatment programs (OTPs) in the United States. However, these restrictions do not apply during hospitalization. A recent change to the rule governing methadone in non-OTP settings created an opportunity to dispense methadone at hospital discharge for up to 72 hours. METHODS Here, we describe one hospital's approach to dispensing methadone at discharge in alignment with the "72-hour rule," including implementation challenges and considerations for other hospitals planning on adopting this practice. Implementation included creating a workflow and detailed documents outlining dispensing procedure, educating interprofessional staff, and coordinating with local OTPs. RESULTS Our experiences highlight the importance of pharmacy champions to support implementation and interdisciplinary staff education, the need to consider electronic health record capabilities, and the importance of having policies and practices that support appropriate interpretation of the "72-hour rule" renewal timeline. CONCLUSIONS Exceptions to federal regulations allow greater flexibility in discharge planning for patients with opioid use disorder; however, dispensation workflow falls outside standard hospital care and may be challenging to implement.
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Affiliation(s)
- Emily Skogrand
- Department of Pharmacy, Oregon Health & Science University, Portland Oregon
| | - Jackie Sharpe
- Department of Pharmacy, Oregon Health & Science University, Portland Oregon
| | - Honora Englander
- Section of Addiction Medicine, Department of Medicine, Oregon Health & Science University, Portland Oregon
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Martin M, Englander H, Calcaterra SL. Things We Do for No Reason™: Avoiding methadone for opioid withdrawal. J Hosp Med 2023; 18:1034-1037. [PMID: 37244869 PMCID: PMC10870273 DOI: 10.1002/jhm.13138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 04/26/2023] [Accepted: 05/10/2023] [Indexed: 05/29/2023]
Affiliation(s)
- Marlene Martin
- Department of Medicine, Division of Hospital Medicine, San Francisco General Hospital, University of California, San Francisco, California, USA
| | - Honora Englander
- Department of Medicine, Section of Addiction Medicine in Division of General Internal Medicine & Geriatrics, Oregon Health & Science University, Oregon, Portland, USA
- Department of Medicine, Division of Hospital Medicine, Oregon Health & Science University, Oregon, Portland, USA
| | - Susan L. Calcaterra
- Department of Medicine, Divisions of Hospital Medicine and General Internal Medicine, University of Colorado Hospital, Aurora, Colorado, USA
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Severson MA, Onanong S, Dolezal A, Bartelt-Hunt SL, Snow DD, McFadden LM. Analysis of Wastewater Samples to Explore Community Substance Use in the United States: Pilot Correlative and Machine Learning Study. JMIR Form Res 2023; 7:e45353. [PMID: 37883150 PMCID: PMC10636622 DOI: 10.2196/45353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 08/17/2023] [Accepted: 09/01/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND Substance use disorder and associated deaths have increased in the United States, but methods for detecting and monitoring substance use using rapid and unbiased techniques are lacking. Wastewater-based surveillance is a cost-effective method for monitoring community drug use. However, the examination of the results often focuses on descriptive analysis. OBJECTIVE The objective of this study was to explore community substance use in the United States by analyzing wastewater samples. Geographic differences and commonalities of substance use were explored. METHODS Wastewater was sampled across the United States (n=12). Selected drugs with misuse potential, prescriptions, and over-the-counter drugs and their metabolites were tested across geographic locations for 7 days. Methods used included wastewater assessment of substances and metabolites paired with machine learning, specifically discriminant analysis and cluster analysis, to explore similarities and differences in wastewater measures. RESULTS Geographic variations in the wastewater drug or metabolite levels were found. Results revealed a higher use of methamphetamine (z=-2.27, P=.02) and opioids-to-methadone ratios (oxycodone-to-methadone: z=-1.95, P=.05; hydrocodone-to-methadone: z=-1.95, P=.05) in states west of the Mississippi River compared to the east. Discriminant analysis suggested temazepam and methadone were significant predictors of geographical locations. Precision, sensitivity, specificity, and F1-scores were 0.88, 1, 0.80, and 0.93, respectively. Finally, cluster analysis revealed similarities in substance use among communities. CONCLUSIONS These findings suggest that wastewater-based surveillance has the potential to become an effective form of surveillance for substance use. Further, advanced analytical techniques may help uncover geographical patterns and detect communities with similar needs for resources to address substance use disorders. Using automated analytics, these advanced surveillance techniques may help communities develop timely, tailored treatment and prevention efforts.
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Affiliation(s)
- Marie A Severson
- Division of Basic Biomedical Sciences, University of South Dakota, Vermillion, SD, United States
| | - Sathaporn Onanong
- Water Sciences Laboratory & Nebraska Water Center, part of the Daugherty Water for Food Global Institute, University of Nebraska-Lincoln, Lincoln, NE, United States
| | - Alexandra Dolezal
- Division of Basic Biomedical Sciences, University of South Dakota, Vermillion, SD, United States
| | - Shannon L Bartelt-Hunt
- Department of Civil and Environmental Engineering, University of Nebraska-Lincoln, Lincoln, NE, United States
| | - Daniel D Snow
- Water Sciences Laboratory & Nebraska Water Center, part of the Daugherty Water for Food Global Institute, University of Nebraska-Lincoln, Lincoln, NE, United States
| | - Lisa M McFadden
- Division of Basic Biomedical Sciences, University of South Dakota, Vermillion, SD, United States
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Calcaterra SL, Lockhart S, Natvig C, Mikulich S. Barriers to initiate buprenorphine and methadone for opioid use disorder treatment with postdischarge treatment linkage. J Hosp Med 2023; 18:896-907. [PMID: 37608527 PMCID: PMC10592161 DOI: 10.1002/jhm.13193] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/27/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Hospitals are an essential site of care for people with opioid use disorder (OUD). Buprenorphine and methadone are underutilized in the hospital. OBJECTIVES Characterize barriers to in-hospital buprenorphine or methadone initiation to inform implementation strategies to increase OUD treatment provision. DESIGN, SETTINGS, AND PARTICIPANTS Survey of hospital-based clinicians' perceptions of OUD treatment from 12 hospitals conducted between June 2022 and August 2022. MEASURES Survey questions were grouped into six domains: (1) evidence to treat OUD, (2) hospital processes to treat OUD, (3) buprenorphine or methadone initiation, (4) clinical practices to treat OUD, (5) leadership prioritization of OUD treatment, and (6) job satisfaction. Likert responses were dichotomized and associations between "readiness" to initiate buprenorphine or methadone and each domain were assessed. RESULTS Of 160 respondents (60% response rate), 72 (45%) reported higher readiness to initiate buprenorphine compared to methadone, 55 (34%). Respondents with higher readiness to initiate medications for OUD were more likely to perceive that evidence supports the use of buprenorphine and methadone to treat OUD (p < .001), to perceive fewer barriers to treat OUD (p < .001), to incorporate OUD treatment into their clinical practice (p < .001), to perceive leadership support for OUD treatment (p < .007), and to have great job satisfaction (p < .04). Clinicians reported that OUD treatment protocols with treatment linkage, increased education, and addiction specialist support would facilitate OUD treatment provision. CONCLUSION Interventions that incorporate protocols to initiate medications for OUD, include addiction specialist support and education, and ensure postdischarge OUD treatment linkage could facilitate hospital-based OUD treatment provision.
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Affiliation(s)
- Susan L. Calcaterra
- Department of Medicine, Divisions of General Internal Medicine and Hospital Medicine, Univeristy of Colorado, Aurora, CO, USA
- Adult and Child Center for Health Outcomes Research and Delivery Service, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - Steven Lockhart
- Adult and Child Center for Health Outcomes Research and Delivery Service, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - Crystal Natvig
- Department of Psychiatry, Univeristy of Colorado, Aurora, CO, USA
| | - Susan Mikulich
- Department of Psychiatry, Univeristy of Colorado, Aurora, CO, USA
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Muller M, Weyer G, Zakrison T, Ari M. Impact of an opioid use disorder consult service on hospitalized trauma patients with opioid use disorder. J Trauma Acute Care Surg 2023; 95:226-233. [PMID: 36914601 DOI: 10.1097/ta.0000000000003965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Opioid use disorder (OUD) is common in the hospitalized trauma population, being a comorbid diagnosis in approximately 1% of operative trauma cases. The impact of an addiction consult service in this population has been less well studied but may lead to increased provision of evidence-based OUD treatment and improved postdischarge outcomes. METHODS One hundred thirteen patients with an International Classification of Diseases diagnosis of OUD who were admitted to the trauma service at a single academic hospital between January 2020 to December 2021 were included in a retrospective chart review. Wilcoxon rank-sum tests were used to evaluate differences between patients who received an OUD consult and those who did not. Regression analysis was used to assess differences in postdischarge acute care utilization, attendance of follow-up appointments, initiation of and discharge on medication for opioid use disorder (MOUD), naloxone prescribing at discharge, and length of stay (LOS) between the consult and no-consult groups. RESULTS Eighty-one patients in the study population received a consult and 32 did not. Patients in the consult group were more likely to have started MOUD during their admission (odds ratio [OR], 2.09; p < 0.001), be discharged with naloxone (OR, 1.89; p < 0.001), have a plan in place for continued OUD treatment at discharge (OR, 1.43; p < 0.001), and attend scheduled follow-up appointments with the trauma team (OR, 1.76; p = 0.02). Differences in acute care utilization and LOS between the two groups were not statistically significant. CONCLUSION An OUD consult service can provide benefit to hospitalized trauma patients by increasing likelihood of starting MOUD, of discharging with MOUD and naloxone, and of attending trauma follow-up appointments without increasing LOS or acute care utilization. Thus, addiction consult service interventions during hospital admissions for trauma may serve to facilitate both evidence-based OUD care and posthospitalization trauma care. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Megan Muller
- From the Pritzker School of Medicine (M.M.), Department of Medicine (G.W., M.A.), and Department of Surgery (T.Z.), The University of Chicago, Chicago, Illinois
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Santo T, Gisev N, Campbell G, Nelson E, Degenhardt L. The effects of childhood trauma and mental disorders on treatment engagement, contact with the criminal justice system, and mortality among people with opioid dependence. Drug Alcohol Depend 2023; 243:109734. [PMID: 36549227 DOI: 10.1016/j.drugalcdep.2022.109734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 12/02/2022] [Accepted: 12/08/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Childhood trauma and mental disorders increase the risk of opioid dependence. We aimed to examine whether childhood trauma and mental disorders are associated with opioid agonist treatment (OAT) engagement, contact with the criminal justice system, and mortality among people with opioid dependence. METHODS This observational study linked survey data from 1482 people receiving OAT in Sydney, Australia (2004-2008) to administrative data on OAT, crime, and mortality through 2017. We used survey data to assess childhood trauma, depression, panic disorder, post-traumatic stress disorder (PTSD), borderline personality disorder, anti-social personality disorder (ASPD), and comorbid substance dependence. We used discrete-time analysis to examine time from opioid dependence onset to OAT entry and mortality. Poisson regressions were used to analyze time receiving OAT and number of charges. RESULTS Participants with extensive childhood trauma histories and ASPD were less likely to enter OAT and those with depression were more likely to enter OAT in any given year after opioid dependence onset. Panic disorder, PTSD, and borderline personality disorder were associated with less time in OAT. Extensive histories of childhood trauma, PTSD, ASPD, and comorbid substance dependence increased risk of charges for any offence. There were no significant associations between the exposure variables and mortality. CONCLUSIONS Our findings suggest that childhood trauma and mental disorders increase the risk of adverse treatment and social outcomes among people with opioid dependence. Interventions that aim to reduce harm among people with opioid dependence may consider the effect of childhood trauma and mental disorders on OAT engagement and crime.
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Affiliation(s)
- Thomas Santo
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney, Australia.
| | - Natasa Gisev
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Gabrielle Campbell
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney, Australia; School of Psychology, University of Queensland, St. Lucia, Queensland, Australia; National Centre for Youth Substance Use Research, University of Queensland, Brisbane, Queensland, Australia
| | - Elliot Nelson
- School of Psychiatry, Washington University, St. Louis, USA
| | - Louisa Degenhardt
- National Drug & Alcohol Research Centre, University of New South Wales, Sydney, Australia
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The Substance Use Treatment and Recovery Team (START) study: protocol for a multi-site randomized controlled trial evaluating an intervention to improve initiation of medication and linkage to post-discharge care for hospitalized patients with opioid use disorder. Addict Sci Clin Pract 2022; 17:39. [PMID: 35902888 PMCID: PMC9331017 DOI: 10.1186/s13722-022-00320-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND People with opioid use disorder experience high burden of disease from medical comorbidities and are increasingly hospitalized with medical complications. Medications for opioid use disorder are an effective, life-saving treatment, but patients with an opioid use disorder admitted to the hospital seldom initiate medication for their disorder while in the hospital, nor are they linked with outpatient treatment after discharge. The inpatient stay, when patients may be more receptive to improving their health and reducing substance use, offers an opportunity to discuss opioid use disorder and facilitate medication initiation and linkage to treatment after discharge. An addiction-focus consultative team that uses evidence-based tools and resources could address barriers, such as the need for the primary medical team to focus on the primary health problem and lack of time and expertise, that prevent primary medical teams from addressing substance use. METHODS This study is a pragmatic randomized controlled trial that will evaluate whether a consultative team, called the Substance Use Treatment and Recovery Team (START), increases initiation of any US Food and Drug Administration approved medication for opioid use disorder (buprenorphine, methadone, naltrexone) during the hospital stay and increases linkage to treatment after discharge compared to patients receiving usual care. The study is being conducted at three geographically distinct academic hospitals. Patients are randomly assigned within each hospital to receive the START intervention or usual care. Primary study outcomes are initiation of medication for opioid use disorder in the hospital and linkage to medication or other opioid use disorder treatment after discharge. Outcomes are assessed through participant interviews at baseline and 1 month after discharge and data from hospital and outpatient medical records. DISCUSSION The START intervention offers a compelling model to improve care for hospitalized patients with opioid use disorder. The study could also advance translational science by identifying an effective and generalizable approach to treating not only opioid use disorder, but also other substance use disorders and behavioral health conditions. TRIAL REGISTRATION Clinicaltrials.gov: NCT05086796, Registered on 10/21/2021. https://www. CLINICALTRIALS gov/ct2/results?recrs=ab&cond=&term=NCT05086796&cntry=&state=&city=&dist = .
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