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Månsson A, Danielsson AK, Sjöqvist H, Glatz T, Lundin A, Wallhed Finn S. Pharmacotherapy for alcohol use disorder among adults with medical disorders in Sweden. Addict Sci Clin Pract 2024; 19:41. [PMID: 38764075 PMCID: PMC11103816 DOI: 10.1186/s13722-024-00471-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 05/06/2024] [Indexed: 05/21/2024] Open
Abstract
BACKGROUND Alcohol-attributable medical disorders are prevalent among individuals with alcohol use disorder (AUD). However, there is a lack of research on prescriptions of pharmacological treatment for AUD in those with comorbid conditions. This study aims to investigate the utilization of pharmacological treatment (acamprosate, disulfiram and naltrexone) in specialist care among patients with AUD and comorbid medical diagnoses. METHODS This was a descriptive register-based Swedish national cohort study including 132,728 adults diagnosed with AUD (N = 270,933) between 2007 and 2015. The exposure was alcohol-attributable categories of comorbid medical diagnoses. Odds ratios (OR) were calculated using mixed-effect logistic regression analyses for any filled prescription of acamprosate, disulfiram or oral naltrexone within 12 months post AUD diagnosis. RESULTS Individuals with comorbid alcohol-attributable medical diagnoses had lower odds of filling prescriptions for any type of AUD pharmacotherapy compared to those without such comorbidities. Cardiovascular (OR = 0.41 [95% CI: 0.39-0.43]), neurological (OR = 0.52 [95% CI: 0.48-0.56]) and gastrointestinal (OR = 0.57 [95% CI: 0.54-0.60]) diseases were associated with the lowest rates of prescription receipt. The presence of diagnoses which are contraindications to AUD pharmacotherapy did not fully explain the low prescription rate. CONCLUSION There is a substantial underutilization of AUD pharmacotherapy in patients with AUD and comorbid medical disorders in specialist care. Increasing the provision of pharmacotherapy to this group of patients is essential and may prevent morbidity and mortality. There is a need to further understand barriers to medical treatment both from the patient and prescriber perspective.
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Affiliation(s)
- Anastasia Månsson
- Department of Global Public Health, Karolinska Institutet, Stockholm, 171 77, Sweden.
| | - Anna-Karin Danielsson
- Department of Global Public Health, Karolinska Institutet, Stockholm, 171 77, Sweden
| | - Hugo Sjöqvist
- Department of Global Public Health, Karolinska Institutet, Stockholm, 171 77, Sweden
| | - Toivo Glatz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Public Health, Charitéplatz 1, Berlin, 10117, Germany
| | - Andreas Lundin
- Department of Global Public Health, Karolinska Institutet, Stockholm, 171 77, Sweden
- Centre for Epidemiology and Community Medicine, Stockholm Region, Stockholm, 171 77, Sweden
| | - Sara Wallhed Finn
- Department of Global Public Health, Karolinska Institutet, Stockholm, 171 77, Sweden
- Mottagningen för alkohol och hälsa, Stockholm Center for Dependency Disorders, Health Care Services, Riddargatan 1, 114 35, Stockholm, Sweden
- Unit of Clinical Alcohol Research (UCAR), University of Southern Denmark, J.B. Winsløws Vej 20, entrance. 220 B, Odense, 5000, Denmark
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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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Danovitch I, Korouri S, Kaur H, Messineo G, Nuckols T, Ishak WW, Ober A. The addiction consultation service for hospitalized patients with substance use disorder: An integrative review of the evidence. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 163:209377. [PMID: 38657952 DOI: 10.1016/j.josat.2024.209377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/10/2024] [Accepted: 04/10/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION The Addiction Consultation Service has emerged as a model of care for hospitalized patients with substance use disorder. The aim of this integrative review is to characterize the Addiction Consultation Service in general hospital settings, assess its impact on clinical outcomes, identify knowledge gaps, and offer guidance for implementation. METHODS We conducted an integrative review of studies from January 2002 to August 2023, applying specific inclusion criteria to collect study design, service characteristics, staffing models, utilization, and health outcomes. Additionally, a comprehensive quality appraisal was conducted for all studies considered for inclusion. RESULTS Findings from 41 studies meeting inclusion criteria were synthesized and tabulated. Study designs included six reports from three randomized controlled trials, five descriptive studies, and 30 observational studies. The most common study setting was the urban academic medical center. Studies evaluated the structure, process, and outcomes of the Addiction Consultation Service. A majority of studies, particularly those utilizing more rigorous designs, reported positive outcomes involving medication initiation, linkage to post-discharge care, and utilization outcomes. CONCLUSIONS The Addiction Consultation Service care model improves quality of care for hospitalized patients with substance use disorder. Additional research is needed to assess its effectiveness across diverse medical settings, determine the effectiveness of varying staffing models, demonstrate impactful outcomes, and establish funding mechanisms to support sustainability.
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Affiliation(s)
- Itai Danovitch
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, United States of America.
| | - Samuel Korouri
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, United States of America.
| | - Harlene Kaur
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, United States of America.
| | - Gabrielle Messineo
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, United States of America.
| | - Teryl Nuckols
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, United States of America; RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, United States of America.
| | - Waguih W Ishak
- Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, United States of America.
| | - Allison Ober
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, United States of America.
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Jiao S, Bungay V, Jenkins E, Gagnon M. How an emergency department is organized to provide opioid-specific harm reduction and facilitators and barriers to harm reduction implementation: a systems perspective. Harm Reduct J 2023; 20:139. [PMID: 37735432 PMCID: PMC10515241 DOI: 10.1186/s12954-023-00871-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/13/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND The intersection of dual public health emergencies-the COVID-19 pandemic and the drug toxicity crisis-has led to an urgent need for acute care based harm reduction for unregulated opioid use. Emergency Departments (EDs) as Complex Adaptive Systems (CASs) with multiple, interdependent, and interacting elements are suited to deliver such interventions. This paper examines how the ED is organized to provide harm reduction and identifies facilitators and barriers to implementation in light of interactions between system elements. METHODS Using a case study design, we conducted interviews with Emergency Physicians (n = 5), Emergency Nurses (n = 10), and clinical leaders (n = 5). Nine organizational policy documents were also collected. Interview data were analysed using a Reflexive Thematic Analysis approach. Policy documents were analysed using a predetermined coding structure pertaining to staffing roles and responsibilities and the interrelationships therein for the delivery of opioid-specific harm reduction in the ED. The theory of CAS informed data analysis. RESULTS An array of system agents, including substance use specialist providers and non-specialist providers, interacted in ways that enable the provision of harm reduction interventions in the ED, including opioid agonist treatment, supervised consumption, and withdrawal management. However, limited access to specialist providers, when coupled with specialist control, non-specialist reliance, and concerns related to safety, created tensions in the system that hinder harm reduction provision with resulting implications for the delivery of care. CONCLUSIONS To advance harm reduction implementation, there is a need for substance use specialist services that are congruent with the 24 h a day service delivery model of the ED, and for organizational policies that are attentive to discourses of specialized practice, hierarchical relations of power, and the dynamic regulatory landscape. Implementation efforts that take into consideration these perspectives have the potential to reduce harms experienced by people who use unregulated opioids, not only through overdose prevention and improving access to safer opioid alternatives, but also through supporting people to complete their unique care journeys.
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Affiliation(s)
- Sunny Jiao
- School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
| | - Vicky Bungay
- School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada.
| | - Emily Jenkins
- School of Nursing, University of British Columbia, T201-2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
| | - Marilou Gagnon
- School of Nursing, University of Victoria, 3800 Finnerty Road, HSD Building A402a, Victoria, BC, V8P 5C2, Canada
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Ober AJ, Osilla KC, Klein DJ, Burgette LF, Leamon I, Mazer MW, Messineo G, Collier S, Korouri S, Watkins KE, IsHak W, Nuckols T, Danovitch I. Pilot randomized controlled trial of a hospital-based substance use treatment and recovery team (START) to improve initiation of medication for alcohol or opioid use disorder and linkage to follow-up care. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 150:209063. [PMID: 37156424 DOI: 10.1016/j.josat.2023.209063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 12/06/2022] [Accepted: 05/01/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVES We conducted a pilot randomized controlled trial (RCT) to explore whether a hospital inpatient addiction consult team (Substance Use Treatment and Recovery Team [START]) based on collaborative care was feasible, acceptable to patients, and whether it could improve uptake of medication in the hospital and linkage to care after discharge, as well as reduce substance use and hospital readmission. The START consisted of an addiction medicine specialist and care manager who implemented a motivational and discharge planning intervention. METHODS We randomized inpatients age ≥ 18 with a probable alcohol or opioid use disorder to receive START or usual care. We assessed feasibility and acceptability of START and the RCT, and we conducted an intent-to-treat analysis on data from the electronic medical record and patient interviews at baseline and 1-month postdischarge. The study compared RCT outcomes (medication for alcohol or opioid use disorder, linkage to follow-up care after discharge, substance use, hospital readmission) between arms by fitting logistic and linear regression models. FINDINGS Of 38 START patients, 97 % met with the addiction medicine specialist and care manager; 89 % received ≥8 of 10 intervention components. All patients receiving START found it to be somewhat or very acceptable. START patients had higher odds of initiating medication during the inpatient stay (OR 6.26, 95 % CI = 2.38-16.48, p < .001) and being linked to follow-up care (OR 5.76, 95 % CI = 1.86-17.86, p < .01) compared to usual care patients (N = 50). The study found no significant differences between groups in drinking or opioid use; patients in both groups reported using fewer substances at the 1-month follow-up. CONCLUSIONS Pilot data suggest START and RCT implementation are feasible and acceptable and that START may facilitate medication initiation and linkage to follow-up for inpatients with an alcohol or opioid use disorder. A larger trial should assess effectiveness, covariates, and moderators of intervention effects.
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Affiliation(s)
- Allison J Ober
- RAND Corporation, Santa Monica, CA, United States of America.
| | - Karen C Osilla
- Stanford University School of Medicine, Palo Alto, CA, United States of America
| | - David J Klein
- RAND Corporation, Santa Monica, CA, United States of America
| | - Lane F Burgette
- RAND Corporation, Santa Monica, CA, United States of America
| | - I Leamon
- RAND Corporation, Santa Monica, CA, United States of America
| | - Mia W Mazer
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | | | - Stacy Collier
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Samuel Korouri
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | | | - Waghui IsHak
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Teryl Nuckols
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Itai Danovitch
- Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
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Bardwell G, Bowles JM, Mansoor M, Werb D, Kerr T. Access to tablet injectable opioid agonist therapy in rural and smaller urban settings in British Columbia, Canada: a qualitative study. Subst Abuse Treat Prev Policy 2023; 18:14. [PMID: 36869358 PMCID: PMC9984129 DOI: 10.1186/s13011-023-00525-2] [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: 01/06/2023] [Accepted: 02/24/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND Rural and smaller urban settings in Canada are disproportionately impacted by the overdose crisis, highlighting the need for novel public health interventions within these jurisdictions. Tablet injectable opioid agonist therapy (TiOAT) programs have been implemented in select rural communities as a means to address drug-related harms. However, little is known about the accessibility of these novel programs. Therefore, we conducted this study to understand the rural context and factors that affected access of TiOAT programs. METHODS Between October 2021 to April 2022, individual qualitative semi-structured interviews were conducted with 32 individuals enrolled in a TiOAT program at participating rural and smaller urban sites in British Columbia, Canada. Interview transcripts were coded using NVivo 12 and data were analyzed thematically. RESULTS TiOAT access varied considerably. TiOAT delivery in rural settings is complicated due to geographic challenges. Participants who were homeless and staying at a nearby shelter or those in centrally-located supportive housing had minimal issues compared to those living in more affordable housing on the outskirts of town with limited transportation options. Dispensing policies that required daily-witnessed ingestion multiple times daily were challenging for most. Only one site provided evening take-home doses whereas participants at the other site could only resort to the illicit opioid supply to address withdrawal outside of program hours. Participants described the clinics as providing a positive and familial social environment compared to experiences of stigma elsewhere. Medication interruptions did occur when participants were in hospital and custodial settings, leading to withdrawal, program discontinuation, and overdose risk. CONCLUSIONS This study highlights the beneficial ways in which health services tailored for people who use drugs can create a stigma-free environment with an emphasis on social bonds. Other factors such as transportation access, dispensing policies, and access in rural hospitals and custodial settings produced unique challenges for rural people who use drugs. Public health authorities in rural and smaller settings should consider these factors when designing, implementing, and scaling up future substance use services, including TiOAT programs.
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Affiliation(s)
- Geoff Bardwell
- School of Public Health Sciences, Faculty of Health, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada.
- British Columbia Centre On Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, , Vancouver, BC, V6Z 1Y6, Canada.
| | - Jeanette M Bowles
- British Columbia Centre On Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, , Vancouver, BC, V6Z 1Y6, Canada
| | - Manal Mansoor
- British Columbia Centre On Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
| | - Dan Werb
- Centre On Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, 209 Victoria St, Toronto, ON, M5B 1T8, Canada
- Division of Infectious Diseases & Global Public Health, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92023, USA
| | - Thomas Kerr
- British Columbia Centre On Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
- Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, , Vancouver, BC, V6Z 1Y6, Canada
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Inpatient care provider perspectives on the development and implementation of an addiction medicine consultation service in a small urban setting. Subst Abuse Treat Prev Policy 2022; 17:70. [PMID: 36303182 PMCID: PMC9612624 DOI: 10.1186/s13011-022-00497-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND To evaluate provider perspectives on the development and implementation of an inpatient Addiction Medicine Consult Service, including their awareness of the service, its perceived role in the continuum of care, and changes over time in their perceptions of care quality for inpatients with substance use disorders. METHODS Repeated cross-sectional survey of hospital-based physicians, nurses and social workers performed at service launch (April-June, 2017) and 4 years later (March-June, 2021). RESULTS Providers had generally positive perceptions of the service and its impact on care quality, but encountered significant barriers at both time points in meeting patient needs (related to high patient complexity and difficulty connecting patients with community services post-discharge). Relative to physicians and social workers, nurses were less likely to be familiar with the service or see it as beneficial. CONCLUSIONS Findings indicate that the service fills a gap that existed previously in the local system of care; however, numerous opportunities exist to further strengthen the system beyond the hospital setting to promote longer-term health among people who use substances. For nurses in particular, outreach, education, and other resources (e.g., dedicated nursing role support, nurse liaison) are warranted to ensure that nurses feel supported and confident caring for this patient population.
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Calcaterra SL, Lockhart S, Callister C, Hoover K, Binswanger IA. Opioid Use Disorder Treatment Initiation and Continuation: a Qualitative Study of Patients Who Received Addiction Consultation and Hospital-Based Providers. J Gen Intern Med 2022; 37:2786-2794. [PMID: 34981359 PMCID: PMC8722657 DOI: 10.1007/s11606-021-07305-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 11/23/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Hospitalizations related to opioid use disorder (OUD) are rising. Addiction consultation services (ACS) increasingly provide OUD treatment to hospitalized patients, but barriers to initiating and continuing medications for OUD remain. We examined facilitators and barriers to hospital-based OUD treatment initiation and continuation from the perspective of patients and healthcare workers in the context of an ACS. METHODS In this qualitative study, we sought input using key informant interviews and focus groups from patients who received care from an ACS during their hospitalization and from hospitalists, pharmacists, social workers, and nurses who work in the hospital setting. A multidisciplinary team coded and analyzed transcripts using a directed content analysis. FINDINGS We conducted 20 key informant interviews with patients, nine of whom were interviewed following hospital discharge and 12 of whom were interviewed during a rehospitalization. We completed six focus groups and eight key informant interviews with hospitalists and hospital-based medical staff (n = 62). Emergent themes related to hospital-based OUD treatment included the following: the benefit of an ACS to facilitate OUD treatment engagement; expanded use of methadone or buprenorphine to treat opioid withdrawal; the triad of hospitalization, self-efficacy, and easily accessible, patient-centered treatment motivates change in opioid use; adequate pain control and stabilization of mental health conditions among patients with OUD contributed to opioid agonist therapy (OAT) continuation; and stable housing and social support are prerequisites for OAT uptake and continuation. CONCLUSION Modifiable factors which facilitate hospital-based OUD treatment initiation and continuation include availability of in-hospital addiction expertise to offer easily accessible, patient-centered treatment and the use of methadone or buprenorphine to manage opioid withdrawal. Further research and public policy efforts are urgently needed to address reported barriers to hospital-based OUD treatment initiation and continuation which include unstable housing, poorly controlled chronic medical and mental illness, and lack of social support.
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Affiliation(s)
- Susan L Calcaterra
- Division of General Internal Medicine, University of Colorado, 8th Floor, Academic Office 1, Mailstop B180, 12631 E 17th Ave, Aurora, CO, 80045, USA.
- Division of Hospital Medicine, University of Colorado, Aurora, CO, USA.
| | - Steve Lockhart
- Adult and Child Consortium for Health Outcomes Research and Delivery Service, Univeristy of Colorado, School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | | | - Kaitlyn Hoover
- Clinical Science Graduate Program, University of Colorado, Aurora, CO, USA
| | - Ingrid A Binswanger
- Division of General Internal Medicine, University of Colorado, 8th Floor, Academic Office 1, Mailstop B180, 12631 E 17th Ave, Aurora, CO, 80045, USA
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Colorado Permanente Medical Group, Aurora, CO, USA
- Bernard J. Tyson School of Medicine, Pasadena, CA, USA
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Opioid agonist treatment and risk of death or rehospitalization following injection drug use-associated bacterial and fungal infections: A cohort study in New South Wales, Australia. PLoS Med 2022; 19:e1004049. [PMID: 35853024 PMCID: PMC9295981 DOI: 10.1371/journal.pmed.1004049] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 06/12/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Injecting-related bacterial and fungal infections are associated with significant morbidity and mortality among people who inject drugs (PWID), and they are increasing in incidence. Following hospitalization with an injecting-related infection, use of opioid agonist treatment (OAT; methadone or buprenorphine) may be associated with reduced risk of death or rehospitalization with an injecting-related infection. METHODS AND FINDINGS Data came from the Opioid Agonist Treatment Safety (OATS) study, an administrative linkage cohort including all people in New South Wales, Australia, who accessed OAT between July 1, 2001 and June 28, 2018. Included participants survived a hospitalization with injecting-related infections (i.e., skin and soft-tissue infection, sepsis/bacteremia, endocarditis, osteomyelitis, septic arthritis, or epidural/brain abscess). Outcomes were all-cause death and rehospitalization for injecting-related infections. OAT exposure was classified as time varying by days on or off treatment, following hospital discharge. We used separate Cox proportional hazards models to assess associations between each outcome and OAT exposure. The study included 8,943 participants (mean age 39 years, standard deviation [SD] 11 years; 34% women). The most common infections during participants' index hospitalizations were skin and soft tissue (7,021; 79%), sepsis/bacteremia (1,207; 14%), and endocarditis (431; 5%). During median 6.56 years follow-up, 1,481 (17%) participants died; use of OAT was associated with lower hazard of death (adjusted hazard ratio [aHR] 0.63, 95% confidence interval [CI] 0.57 to 0.70). During median 3.41 years follow-up, 3,653 (41%) were rehospitalized for injecting-related infections; use of OAT was associated with lower hazard of these rehospitalizations (aHR 0.89, 95% CI 0.84 to 0.96). Study limitations include the use of routinely collected administrative data, which lacks information on other risk factors for injecting-related infections including injecting practices, injection stimulant use, housing status, and access to harm reduction services (e.g., needle exchange and supervised injecting sites); we also lacked information on OAT medication dosages. CONCLUSIONS Following hospitalizations with injection drug use-associated bacterial and fungal infections, use of OAT is associated with lower risks of death and recurrent injecting-related infections among people with opioid use disorder.
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King CA, Cook R, Wheelock H, Korthuis PT, Leahy JM, Goff A, Morris CD, Englander H. Simulating the impact of Addiction Consult Services in the context of drug supply contamination, hospitalizations, and drug-related mortality. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 100:103525. [PMID: 34837879 PMCID: PMC8810590 DOI: 10.1016/j.drugpo.2021.103525] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/22/2021] [Accepted: 10/29/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Illicitly manufactured fentanyl (IMF) is increasing in international drug supply chains, and IMF-related opioid overdose deaths are rising in North America. Hospitalizations among patients with opioid use disorder (OUD) are also rising; and, hospitalized patients are at increased risk of overdose and death following hospital discharge. Hospitalization is a key opportunity to engage patients with OUD. Addiction consult services (ACS) can provide effective treatment for patients hospitalized with OUD. This study aims to estimate the effect of increasing IMF contamination on drug-related death among patients hospitalized with OUD, and simulate the role of ACS expansion to mitigate these effects. METHODS We used a Markov model to mirror care systems for adult patients hospitalized with OUD in Oregon, from the time of hospital admission through 12-months post-discharge, and simulated patients through modeled care systems to evaluate the expansion of Addiction Consult Services in the context of increasing IMF in the drug supply. RESULTS In a simulated cohort of 10,000 patients, we estimate that 537 patients would die from drug-related causes within 12-months of hospital discharge. In the context of increased IMF in the drug supply, this estimate increased to 913. ACS referral at baseline was 4%; increasing ACS referral to accommodate 10%, 50%, or 100% of hospitalized OUD patients in the state reduces drug-related deaths to 904, 849, and 780, respectively. The number needed to treat for ACS to avoid one drug-related death in the context of increased IMF was 73. CONCLUSIONS Hospitals should expand interventions to help reduce IMF-related opioid overdoses, including through implementation of ACS. In the context of rising IMF-related deaths, ACS expansion could help connect patients to treatment, offer harm reduction interventions, or both, which can help reduce the risk of opioid-related death.
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Affiliation(s)
- Caroline A King
- Dept. of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Ryan Cook
- Dept. of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR, USA
| | | | - P Todd Korthuis
- Dept. of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Judith M Leahy
- Oregon Health Authority, Acute and Communicable Disease Prevention, Public Health Division, Oregon Health Authority, Salem, OR, USA
| | - Amelia Goff
- Dept. of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR, USA; Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Cynthia D Morris
- Dept. of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - Honora Englander
- Dept. of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR, USA; Division of Hospital Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
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Brothers TD, Mosseler K, Kirkland S, Melanson P, Barrett L, Webster D. Unequal access to opioid agonist treatment and sterile injecting equipment among hospitalized patients with injection drug use-associated infective endocarditis. PLoS One 2022; 17:e0263156. [PMID: 35081174 PMCID: PMC8791472 DOI: 10.1371/journal.pone.0263156] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 01/12/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Addiction treatment and harm reduction services reduce risks of death and re-infection among patients with injection drug use-associated infective endocarditis (IDU-IE), but these are not offered at many hospitals. Among hospitalized patients with IDU-IE at the two tertiary-care hospitals in the Canadian Maritimes, we aimed to identify (1) the availability of opioid agonist treatment (OAT) and sterile drug injecting equipment, and (2) indicators of potential unmet addiction care needs. METHODS Retrospective review of IDU-IE hospitalizations at Queen Elizabeth II Health Sciences Centre (Halifax, Nova Scotia) and the Saint John Regional Hospital (Saint John, New Brunswick), October 2015 -March 2017. In Halifax, there are no addiction medicine providers on staff; in Saint John, infectious diseases physicians also practice addiction medicine. Inclusion criteria were: (1) probable or definite IE as defined by the modified Duke criteria; and (2) injection drug use within the prior 3 months. RESULTS We identified 38 hospitalizations (21 in Halifax and 17 in Saint John), for 30 unique patients. Among patients with IDU-IE and untreated opioid use disorder, OAT was offered to 36% (5/14) of patients in Halifax and 100% (6/6) of patients in Saint John. Once it was offered, most patients at both sites initiated OAT and planned to continue it after discharge. In Halifax, no patients were offered sterile injecting equipment, and during five hospitalizations staff confiscated patients' own equipment. In Saint John, four patients were offered (and one was provided) injecting equipment in hospital, and during two hospitalizations staff confiscated patients' own equipment. Concerns regarding undertreated pain or opioid withdrawal were documented during 66% (25/38) of hospitalizations, and in-hospital illicit or non-medical drug use during 32% (12/38). Two patients at each site (11%; 4/38) had self-directed discharges against medical advice. CONCLUSIONS Patients with IDU-IE in the Canadian Maritimes have unequal access to evidence-based addiction care depending on where they are hospitalized, which differs from the community-based standard of care. Indicators of potential unmet addiction care needs in hospital were common.
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Affiliation(s)
- Thomas D. Brothers
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- UCL Collaborative Centre for Inclusion Heath, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Kimiko Mosseler
- Dalhousie Medicine New Brunswick, Dalhousie University, Saint John, New Brunswick, Canada
| | - Susan Kirkland
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Patti Melanson
- Mobile Outreach Street Health (MOSH), Halifax, Nova Scotia, Canada
| | - Lisa Barrett
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Division of Infectious Diseases, Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Duncan Webster
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Division of Infectious Diseases, Saint John Regional Hospital and Dalhousie University, Saint John, New Brunswick, Canada
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Callister C, Lockhart S, Holtrop JS, Hoover K, Calcaterra SL. Experiences with an addiction consultation service on care provided to hospitalized patients with opioid use disorder: a qualitative study of hospitalists, nurses, pharmacists, and social workers. Subst Abuse 2022; 43:615-622. [PMID: 34666634 PMCID: PMC8888039 DOI: 10.1080/08897077.2021.1975873] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: In response to the opioid epidemic, addiction consultation services (ACS) increasingly provide dedicated hospital-based addiction treatment to patients with substance use disorder. We assessed hospitalist and medical staff perceptions of how the presence of 2 hospitals' ACS impacted care for hospitalized patients with opioid use disorder (OUD). We inquired about ongoing challenges in caring for this patient population.Methods: We conducted a qualitative study of hospital-based providers utilizing focus groups and key informant interviews for data collection. Transcripts were analyzed using a mixed inductive-deductive approach. Emergent themes were identified through an iterative, multidisciplinary team-based process using a directed content analysis approach.Results: Hospitalists (n = 20), nurses (n = 13), social workers (n = 11), and pharmacists (n = 18) from a university hospital and a safety-net hospital in Colorado participated in focus groups or key informant interviews. In response to the availability of an ACS, hospitalists described increased confidence using methadone and buprenorphine to treat opioid withdrawal, which they perceived as contributing to improved patient outcomes and greater job satisfaction. Participants expressed concern about inconsistent care provided to patients with OUD that varied by the admitting team's specialty and the physician's background and training. Nurses and hospitalists reported frustrations with achieving adequate pain control among patients with OUD. Last, pharmacists reported practice variations when physicians dosed buprenorphine for acute pain among patients with OUD. A lack of standardized dosing led to concerns of inadequate analgesia or return to opioid use following hospital discharge.Conclusions: An ACS reportedly supports hospitalists and medical staff to best care for hospitalized patients with OUD. Notably, care provided to patients with OUD may not be uniform depending on various physician-level factors. Future work to address the concerns reported by study participants may include education for OUD treatment, early involvement of the ACS, and incorporation of buprenorphine prescribing algorithms to standardize care.
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Affiliation(s)
- Catherine Callister
- Division of Hospital Medicine, University of Colorado, Aurora, Colorado, USA
| | - Steven Lockhart
- Adult and Child Consortium for Health Outcomes Research and Delivery Service, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado, USA
| | | | - Kaitlyn Hoover
- Clinical Science Graduate Program, University of Colorado, Aurora, Colorado, USA
| | - Susan L. Calcaterra
- Division of Hospital Medicine, University of Colorado, Aurora, Colorado, USA,Division of General Internal Medicine, University of Colorado, Aurora, Colorado, USA
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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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