Motivational Interviewing on an Addiction Consult Service: Pearls, Perils, and Educational Opportunities

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.

More Effective Communication During Inpatient Addiction Treatment

In this commentary, the authors argue that historical approaches to inpatient addiction treatment favoring more confrontational, expert-centric, or paternalistic undercurrents continue to permeate the hidden curriculum in medical training. These older approaches unfortunately continue to inform how many trainees learn to approach inpatient addiction treatment. The authors go on to provide several examples of how clinical challenges specific to inpatient addiction treatment can be addressed by employing principles of motivational interviewing, harm reduction, and psychodynamic thought. Key skills are described including accurate reflection, recognition of countertransference, and assisting patients to sit with important dialectics. The authors call for greater training of attending physicians, precepting advanced practice providers, and trainees across these disciplines, as well as further study of whether systematic improvements in such provider communication may alter patient outcomes.

A Taxonomy of Hospital-Based Addiction Care Models: a Scoping Review and Key Informant Interviews

BACKGROUND

There is pressing need to improve hospital-based addiction care. Various models for integrating substance use disorder care into hospital settings exist, but there is no framework for describing, selecting, or comparing models. We sought to fill that gap by constructing a taxonomy of hospital-based addiction care models based on scoping literature review and key informant interviews.

METHODS

Methods included a scoping review of the literature on US hospital-based addiction care models and interventions for adults, published between January 2000 and July 2021. We conducted semi-structured interviews with 15 key informants experienced in leading, implementing, evaluating, andpracticing hospital-based addiction care to explore model characteristics, including their perceived strengths, limitations, and implementation considerations. We synthesized findings from the literature review and interviews to construct a taxonomy of model types.

RESULTS

Searches identified 2,849 unique abstracts. Of these, we reviewed 280 full text articles, of which 76 were included in the final review. We added 8 references from reference lists and informant interviews, and 4 gray literature sources. We identified six distinct hospital-based addiction care models. Those classified as addiction consult models include (1) interprofessional addiction consult services, (2) psychiatry consult liaison services, and (3) individual consultant models. Those classified as practice-based models, wherein general hospital staff integrate addiction care into usual practice, include (4) hospital-based opioid treatment and (5) hospital-based alcohol treatment. The final type was (6) community-based in-reach, wherein community providers deliver care. Models vary in their target patient population, staffing, and core clinical and systems change activities. Limitations include that some models have overlapping characteristics and variable ways of delivering core components.

DISCUSSION

A taxonomy provides hospital clinicians and administrators, researchers, and policy-makers with a framework to describe, compare, and select models for implementing hospital-based addiction care and measure outcomes.

Psychotherapeutic Tools to Enhance the Neurologist-Patient Interaction

Despite providing care for patients with "disturbances of the same organ," the brain, the therapeutic approaches used by neurologists and psychiatrists are, to some extent, distinct. With recognition of the closely coupled relationship between physical health and mental health, there is increased awareness of the need to provide an integrated, neuropsychiatric approach to the care of patients in neurology. In this review article, we provide a broad overview of how neurologists can use psychotherapeutic principles to enhance patient-physician interactions in the neurological setting (e.g., developing a therapeutic alliance; frame/boundary setting; active, empathic listening; acknowledging affect). These practices relate to a broad range of conditions, including, but not necessarily limited to epilepsy, traumatic brain injury, and functional neurological (conversion) disorder. The authors provide practical approaches that a neurologist can learn to leverage psychotherapeutic tools to enhance clinical encounters.