Building Outreach and Diversity in the Field of Addictions

Medication for Opioid Use Disorder for Hospitalized Patients at Six New York City Public Hospitals with an Addiction Consult Service

OBJECTIVES

We explored medications for opioid use disorder treatment (MOUD) utilization in six New York City public hospitals that implemented the "Consultation for Addiction Care and Treatment in Hospitals (CATCH)" program.

METHODS

CATCH rolled out between October 2018 and February 2020. Data from the electronic health record were analyzed for the first year post-implementation. Eligible cases included adults with an opioid-related diagnosis admitted to inpatient departments served by CATCH, with a stay of ≥1 night. Patients were classified as receiving an MOUD order if there was at least 1 order of buprenorphine, methadone, or naltrexone. Logistic regression modeled the impact of CATCH consults on MOUD orders, controlling for demographic and clinical characteristics with hospital as a random effect.

RESULT

Among 2117 eligible patients, 71.4% were male, with a mean age of 51.2 years, and 27.2% identified as Black, 21.2% as White, and 34.5% as Hispanic. MOUD was ordered in 60.9% of admissions, and 41.5% had a completed CATCH consult. Patients identified as Black had lower odds of receiving a MOUD order than those identified as White (OR: 0.52, 95% CI: 0.38-0.71; P < 0.001). Patients with a CATCH consult had higher odds of receiving a MOUD order (OR: 3.22, 95% CI: 2.54-4.07; P < 0.001).

CONCLUSION

Majority of patients in our sample received a MOUD order, with higher odds among those with a CATCH consult. Further research is needed on the drivers of racial disparities in MOUD, and other contextual, organizational, and population-specific barriers and facilitators contributing to receipt of hospital-based addiction consult services and MOUD.

Addressing Racial and Ethnic Inequities in Opioid Overdose Mortality: Strategies for Equitable Interventions and Structural Change

PURPOSE OF REVIEW

This review synthetizes findings reflecting the increasing racial and ethnic inequities in opioid overdose mortality and emphasizes the necessity for tailored interventions as well as other policy-level and structural strategies to stem this trend.

RECENT FINDINGS

Factors contributing to inequities in overdose mortality include changes in drug supply, persistent social-structural vulnerabilities stemming from structural racism, and inequities in access to medication for opioid use disorder and harm reduction services. Key strategies to address these inequities include the cultural adaptation of evidence-based interventions within an equity-based framework, integrating social determinants of health into addiction treatment, centering anti-racism praxis in addiction research, diversifying the addiction workforce, and integrating structural competency as a tool to restructure education and inform practice. Structural racism must be recognized as a key driver of inequities in substance use outcomes, and this understanding must be integrated into existing models of substance use disorder prevention, treatment, and research.

Identifying the Heterogeneity in the Association between Workforce Diversity and Retention in Opioid Treatment among Black clients

Background

This study investigates the impact of workforce diversity, specifically staff identified as Black/African American, on retention in opioid use disorder (OUD) treatment, aiming to enhance patient outcomes. Employing a novel machine learning technique known as 'causal forest,' we explore heterogeneous treatment effects on retention.

Methods

We relied on four waves of the National Drug Abuse Treatment System Survey (NDATSS), a nationally representative longitudinal dataset of treatment programs. We analyzed OUD program data from the years 2000, 2005, 2014 and 2017 (n = 627). Employing the 'causal forest' method, we analyzed the heterogeneity in the relationship between workforce diversity and retention in OUD treatment. Interviews with program directors and clinical supervisors provided the data for this study.

Results

The results reveal diversity-related variations in the association with retention across 61 out of 627 OUD treatment programs (less than 10%). These programs, associated with positive impacts of workforce diversity, were more likely private-for-profit, newer, had lower percentages of Black and Latino clients, lower staff-to-client ratios, higher proportions of staff with graduate degrees, and lower percentages of unemployed clients.

Conclusions

While workforce diversity is crucial, our findings underscore that it alone is insufficient for improving retention in addiction health services research. Programs with characteristics typically linked to positive outcomes are better positioned to maximize the benefits of a diverse workforce in client retention. This research has implications for policy and program design, guiding decisions on resource allocation and workforce diversity to enhance retention rates among Black clients with OUDs.

Recruiting and Retaining a Diverse and Skilled Addiction Treatment Workforce

National drug overdose deaths have been rising for decades, with particularly significant increases in recent years among populations of color. There is an urgent need for timely, accessible substance use disorder treatment, but workforce shortages across roles and settings impede the ability of the treatment system to meet the rising and evolving demand. In this Commentary, the authors discuss reasons for workforce shortages across roles, and offer recommendations for 8 areas of investment to grow and sustain a substance use and addiction care workforce prepared to address the overdose crisis in a racially equitable manner.

Structural Racism in Psychiatric Research Careers: Eradicating Barriers to a More Diverse Workforce

Investigators from minoritized backgrounds are underrepresented in psychiatric research. That underrepresentation contributes to disparities in outcomes of access to mental health care. Drawing on lived experience, scholarly qualitative reports, and empirical data, the authors review how the underrepresentation of minoritized researchers arises from interlocking, self-reinforcing effects of structural biases in our research training and funding institutions. Minoritized researchers experience diminished early access to advanced training and opportunities, stereotype threats and microaggressions, isolation due to lack of peers and senior mentors, decreased access to early funding, and unique community and personal financial pressures. These represent structural racism-a system of institutional assumptions and practices that perpetuates race-based disparities, in spite of those institutions' efforts to increase diversity and in contradiction to the values that academic leaders outwardly espouse. The authors further review potential approaches to reversing these structural biases, including undergraduate-focused research experiences, financial support for faculty who lead training/mentoring programs, targeted mentoring through scholarly societies, better use of federal diversity supplement funding, support for scientific reentry, cohort building, diversity efforts targeting senior leadership, and rigorous examination of hiring, compensation, and promotion practices. Several of these approaches have empirically proven best practices and models for dissemination. If implemented alongside outcome measurement, they have the potential to reverse decades of structural bias in psychiatry and psychiatric research.

Integrating Ambulatory Addiction Consultation Service Into a Community Mental Health Center

Despite the escalation in substance related overdose mortality-culminating in more than 100,000 deaths in each of the first 2 years of the COVID-19 pandemic-healthcare systems have not kept up with the demands for care among people who use drugs. There remains a significant gap in access to evidence-based treatment. The addiction consult services has served to address this gap, as a critical intervention that engages mostly hospitalized patients and initiate addiction treatment in acute settings, but little is known about addiction consult services in ambulatory settings. This model of care could potentially serve to scale up the care for people who use drugs in the community by embedding the limited number of addiction professionals within existing ambulatory systems, thus extending their reach. We describe here an innovative, yet simple and potentially replicable model for an ambulatory addiction consultation service in a large, advanced community mental health center.

Comparative Safety Analysis of Opioid Agonist Treatment in Pregnant Women with Opioid Use Disorder: A Population-Based Study

INTRODUCTION AND OBJECTIVE

Receipt of opioid agonist treatment during early and late pregnancy for opioid use disorder may relate to varying perinatal risks. We aimed to assess the effect of time-varying prenatal exposure to opioid agonist treatment using buprenorphine or methadone on adverse neonatal and pregnancy outcomes.

METHODS

We conducted a retrospective cohort study of pregnant women with opioid use disorder using Rhode Island Medicaid claims data and vital statistics during 2008-16. Time-varying exposure was evaluated in early (0-20 weeks) and late (≥ 21 weeks) pregnancy. Marginal structural models with inverse probability of treatment weighting were applied.

RESULTS

Of 400 eligible pregnancies, 85 and 137 individuals received buprenorphine and methadone, respectively, during early pregnancy. Compared with 152 untreated pregnancies with opioid use disorders, methadone exposure in both periods was associated with an increased risk of preterm birth (adjusted odds ratio [aOR]: 2.52; 95% confidence interval [CI] 1.07-5.95), low birth weight (aOR: 2.99; 95% CI 1.34-6.66), neonatal intensive care unit admission (aOR, 5.04; 95% CI 2.49-10.21), neonatal abstinence syndrome (aOR: 11.36; 95% CI 5.65-22.82), respiratory symptoms (aOR, 2.71; 95% CI 1.17-6.24), and maternal hospital stay > 7 days (aOR, 14.51; 95% CI 7.23-29.12). Similar patterns emerged for buprenorphine regarding neonatal abstinence syndrome (aOR: 10.27; 95% CI 4.91-21.47) and extended maternal hospital stay (aOR: 3.84; 95% CI 1.83-8.07). However, differences were found favoring the use of buprenorphine for preterm birth versus untreated pregnancies (aOR: 0.17; 95% CI 0.04-0.77), and for several outcomes versus methadone.

CONCLUSIONS

Methadone and buprenorphine prescribed for the treatment of opioid use disorder during pregnancy are associated with varying perinatal risks. However, buprenorphine may be preferred in the setting of pregnancy opioid agonist treatment. Further research is necessary to confirm our findings and minimize residual confounding.

Psychotic Misdiagnosis of Racially Minoritized Patients: A Case-Based Ethics, Equity, and Educational Exploration

The overdiagnosis and misdiagnosis of racially minoritized groups as having a primary psychotic disorder is one of psychiatry's longest-standing inequities born of real-time clinician racial bias. Evidence suggests that providers assign a diagnosis of schizophrenia and/or schizoaffective disorder according to race more than any other demographic variable, and this inequity persists even in the absence of differences in clinician symptom ratings. This case report describes the journey of one young Black woman through her racialized misdiagnosis of schizophrenia and the process by which interdisciplinary, health equity-minded providers across the spectrum of medical education and practice joined together to provide a culturally informed, systematic rediagnosis of major depressive disorder and post-traumatic stress disorder. Expert discussion is provided by three Black academic psychiatrists with expertise in social justice and health equity. We provide an evidence-based exploration of mechanisms of clinician racial bias and detail how the psychosis misdiagnosis of racially minoritized groups fails medical ethics and perpetuates iatrogenic harm to patients who truly need help with primary mood, trauma, and substance use disorders.

Alcohol use disorder conceptualizations and diagnoses reflect their sociopolitical context

The present paper highlights how alcohol use disorder (AUD) conceptualizations and resulting diagnostic criteria have evolved over time in correspondence with interconnected sociopolitical influences in the United States. We highlight four illustrative examples of how DSM-defined alcoholism, abuse/dependence, and AUD have been influenced by sociopolitical factors. In doing so, we emphasize the importance of recognizing and understanding such sociopolitical factors in the application of AUD diagnoses. Last, we offer a roadmap to direct the process of future efforts toward the improved diagnosis of AUD, with an emphasis on pursuing falsifiability, acknowledging researchers' assumptions about human behavior, and collaborating across subfields. Such efforts that center the numerous mechanisms and functions of behavior, rather than signs or symptoms, have the potential to minimize sociopolitical influences in the development of diagnostic criteria and maximize the treatment utility of diagnoses.

Evaluating ACGME-accredited addiction psychiatry fellowship online content: A critical analysis of addiction psychiatry fellowship program websites in the US

Introduction: There is an extreme shortage of addiction psychiatrists and a lack of representation of addiction psychiatry (ADP) fellows from racial/ethnic minoritized backgrounds. ADP fellowship websites are integral in engaging potential applicants. It is therefore critical to understand the quality of engagement that trainees are having with ADP fellowship websites. The aim of this study was to investigate the accessibility and content of ADP fellowship program websites in the U.S. Methods: A list of ADP Fellowship programs was obtained from the Accreditation Council for Graduate Medical Education. A critical textual analysis of 42 unique factors within four categories (accessibility, recruitment, education, and health equity) was performed for each ADP fellowship website. Results: Of 51 ADP fellowships, 47 (92.2%) had websites. Information about social media accounts was largely missing from ADP fellowship websites. For recruitment, program description (95.7%) and program director name (76.6%) were most readily available, while interview day (0.00%) and vacation details (10.6%) were least available. For education, a list of rotations (55.3%) and didactics/lectures (40.4%) were most readily available, while post fellowship placement (6.4%), call schedule (4.3%), and responsibility progression (2.1%) were least available. The most prevalent health equity factors were gender-inclusive language (100%) and an absence of stigmatizing addiction language (100%). The least listed were statements of commitment to health equity (0.0%), antiracism training (2.1%), and harm-reduction strategies (4.3%). Conclusions: There are considerable gaps in the amount and types of information provided by ADP fellowship websites. Many existing websites are poorly interfacing with potential leaders in the field. The development of ADP fellowship websites could serve as a low-cost recruitment tool to engage potential addiction specialists. Our findings underscore the need for ADP fellowships to optimize their websites to engage bourgeoning leaders in addiction and optimize access to more comprehensive information.

Gender and Racial Disparity among Addiction Psychiatry Fellows in the United States

The United States (US) has a culturally diverse population. However, the percentage of underrepresented minorities (URMs) and women in healthcare does not fully reflect their current and future demographics. Our objective was to explore and forecast the gender and racial trends in the US addiction psychiatry fellowship programs. A retrospective analysis was performed using data from Accreditation Council for Graduate Medical Education (ACGME) Resource Books which encompassed US addiction psychiatry fellows from 2007 to 2020. Simple linear and multiple regression were used to predict the 2030 addiction psychiatry workforce. White (Non-Hispanic) and Asian/Pacific Islander had a relative change of -2.8% and -26.1% from 2011 to 2020, respectively. Black (non-Hispanic) had a relative change of + 5.2%. Hispanic and Native American/Alaskan had no relative change during this time. From 2007 to 2020, women's representation relatively decreased by 10.9%. Statistically, these dynamic trends of the addiction psychiatry workforce will continue to exist in 2030. Women and URM addiction psychiatrists play an effective role in addressing substance use disorders (SUD). Unfortunately, the current gender and racial disparities in addiction psychiatry will exist in the future. Understanding the continued gender and racial bias in addiction psychiatry fellowships and devising appropriate recommendations can help mitigate the existing disparities.

Gender and Racial Disparity Among US Forensic Psychiatry Fellows: Broken System by Default

Diversity enhances the performance of the healthcare system by providing better patient outcomes and reducing physician burnout. In this study, we explored the gender and racial trends in the recruitment of women and racial minorities into forensic psychiatry fellowship programs in the US. Retrospective data analysis was performed by utilizing the data from the Accreditation Council for Graduate Medical Education (ACGME)'s annual Data Resource Books from the year 2007 to 2021. Demographic data, including gender and race, were extracted for forensic psychiatry fellows. The number of female trainees increased significantly to become a majority, i.e., 58.8% of all forensic psychiatry trainees in 2020-2021 were female compared to 27.78% of women forensic psychiatry fellows in 2007-08. Between 2011-12 and 2020-2021, there was a relative increase in White (Non-Hispanic), Asian/Pacific Islander and Black (Non-Hispanic) forensic psychiatry fellows, by 54.75%, 114.4%, and 0.36% respectively. Despite the overall increase in the numbers of ethnic minorities in US psychiatry residency and fellowship programs, racial minorities remain significantly under-represented in forensic psychiatry fellowship programs. We need to revise policies to promote underrepresented minorities in medicine (URMM) in forensic psychiatry.

How Physician Workforce Shortages Are Hampering the Response to the Opioid Crisis

The United States is experiencing an unprecedented opioid crisis, with a record of about 93,000 opioid-involved overdose deaths in 2020, which requires rapid and substantial scaling up of access to effective treatment for opioid use disorder. Only 18% of individuals with opioid use disorder receive evidence-based treatment, and strategies to increase access are hindered by a lack of treatment providers. Using a case study from the largest municipal hospital system in the United States, the authors describe the effects of a workforce shortage on health system responses to the opioid crisis. This national problem demands a multipronged approach, including federal programs to grow and diversify the pipeline of addiction providers, medical education initiatives, and enhanced training and mentorship to increase the capacity of allied clinicians to treat patients who have an opioid use disorder. Workforce development should be combined with structural reforms for integrating addiction treatment into mainstream medical care and with new treatment models, including telehealth, which can lower patient barriers to accessing treatment.

Group-based medical mistrust and care expectations among black patients seeking addiction treatment

Background

Black patients seeking addiction care experience poorer treatment access, retention, and outcomes when compared to White counterparts. Black patients may have elevated group-based medical mistrust, which has been associated with poorer health outcomes and increased experiences of racism across multiple healthcare contexts. The relationship between group-based medical mistrust and expectations for addiction treatment among Black individuals remains untested.

Methods

A total of 143 Black participants were recruited from two addiction treatment centers in Columbus, Ohio. Participants completed the Group Based Medical Mistrust Scale (GBMMS) and answered questions related to expectations of addiction treatment. Descriptive analysis and Spearman's rho correlations were performed to assess for relationships between group-based medical mistrust and expectations of care.

Results

Group-based medical mistrust in Black patients was associated with self-reported delay in accessing addiction treatment, anticipation of racism during addiction treatment, non-adherence and discrimination-precipitated relapse. However, non-adherence to treatment was least strongly correlated with group-based medical mistrust demonstrating an opportunity for engagement.

Conclusion

Group-based medical mistrust is associated with Black patients' care expectations when seeking addiction treatment. Use of the GBMMS within addiction medicine to address themes of mistrust in patients, and potential biases in providers, may improve treatment access and outcomes.

Perceptions on navigating ACGME-accredited addiction psychiatry fellowship program websites: A thematic analysis across a race- and gender-diverse pool of potential applicants

Background: There is an alarming shortage of addiction psychiatrists in the United States. To promote interest in addiction psychiatry (ADP), it is essential to maximize resources available through ADP fellowship websites. The aim of this study was to investigate the perceived adequacy and accessibility of content on ADP fellowship websites and discover what further information is considered important among trainees interested in becoming addiction specialists. Methods: Three virtual focus groups were conducted between January and February 2021 among medical students and residents in diverse geographic regions. Participants were asked about the availability of information on ADP fellowship program websites and other material they would like to see available. Focus groups were recorded, with data transcribed and coded using NVivo 11 and Dedoose. A coding scheme was deductively developed based on the core research questions. Results: The majority of participants (N = 27) identified areas of dissatisfaction with the content currently available on ADP websites. The sample was highly representative of racial and ethnic minoritized trainees (n = 12) and genderqueer/non-binary participants (n = 3). Three major themes were identified and durable across all focus groups: lack of emphasis on diversity/health equity, lack of portrayal of everyday life and activities of fellows, and inadequate representation of curricula. Overwhelmingly, participants identified a dedication to health equity (for example, working with minoritized populations) as a key deciding factor in whether to apply to a particular ADP fellowship. Conclusions: ADP fellowship websites are perceived to have considerable variability in the amount and quality of information. Many do not appear to provide the full spectrum of content desired by diverse potential applicants, such as information regarding current fellows and community-centered initiatives. This is concerning, as it suggests ADP fellowships may be interfacing poorly with burgeoning leaders, especially those from race and gender minoritized backgrounds, neglecting potential opportunities to develop future addiction specialists.

Disparities in Addiction Treatment: Learning from the Past to Forge an Equitable Future

The Half-Century long problem of addiction treatment disparities. We cannot imagine addressing disparities in addiction treatment without first acknowledging and deconstructing the etiology of this inequity. This article examines the history of addiction treatment disparities beginning with early twentieth-century drug policies. We begin by discussing structural racism, its contribution to treatment disparities, using opioid use disorder as a case study to highlight the importance of a structural competency framework in obtaining care. We conclude by discussing diversity in the workforce as an additional tool to minimizing disparities. Addiction treatment should be aimed at addressing care delivery in the context of the social, economic, and political determinants of health, which require appreciation of their historical origins to move toward equitable treatment.

Growing racial/ethnic disparities in overdose mortality before and during the COVID-19 pandemic in California

As overdose mortality is spiking during the COVID-19 pandemic, few race/ethnicity-stratified trends are available. This is of particular concern as overdose mortality was increasing most rapidly in Black and Latinx communities prior to the pandemic. We used quarterly, age-standardized overdose mortality rates from California to assess trends by race/ethnicity and drug involved over time. Rates from 2020 Q2-Q4 were compared to expected trends based on ARIMA forecasting models fit using data from 2006 to 2020 Q1. In 2020 Q2-Q4 overdose death rates rose by 49.8% from 2019, exceeding an expected increase of 11.5% (95%CI: 0.5%-22.5%). Rates significantly exceeded forecasted trends for all racial/ethnic groups. Black/African American individuals saw an increase of 52.4% from 2019, compared to 42.6% among their White counterparts. The absolute Black-White overdose mortality gap rose from 0.7 higher per 100,000 for Black individuals in 2018 to 4.8 in 2019, and further increased to 9.9 during the pandemic. Black overdose mortality in California was therefore 34.3% higher than that of White individuals in 2020 Q2-Q4. This reflects growing methamphetamine-, cocaine-, and fentanyl-involved deaths among Black communities. Growing racial disparities in overdose must be understood in the context of the unequal social and economic fallout from the COVID-19 pandemic, during which time Black communities have been subjected to the dual burden of disproportionate COVID-19 deaths and rising overdose mortality. Increased investments are required to ameliorate racial/ethnic disparities in substance use treatment, harm reduction, and the structural drivers of overdose, as part of the COVID-19 response and post-pandemic recovery efforts.

Exploring Gender and Racial Disparity in Child and Adolescent Psychiatry: A Step Toward Diversity

A diverse medical workforce is pivotal for the provision of high-quality healthcare services to the US population.¹ Currently, women comprise 50% of all medical students in the United States, whereas only 35.2% of the physician workforce is represented by women.² The under-represented minority (URM) physicians are significantly lower in number compared to the White physicians.¹ Women and the URM workforce are less represented at leadership and faculty levels.³ Although female residents have gradually increased, recruitment of URM residents in psychiatry continues to be low.³ The field of child and adolescent psychiatry has faced numerous challenges in recruitment and representation of URM residents.⁴ In 2017, among 134 child and adolescent psychiatry programs, 535 fellows (64.5%) were women.⁵ Considering racial trends, there were 383 White, 282 Asian, 78 African American/Black, and 2 American Indian child and adolescent psychiatry fellows.⁵.

The rise of illicit fentanyls, stimulants and the fourth wave of the opioid overdose crisis

PURPOSE OF REVIEW

This review provides an update on recently published literature on the rise of illicit fentanyls, risks for overdose, combinations with other substances, e.g. stimulants, consequences, and treatment.

RECENT FINDINGS

Overdose due to illicit synthetic opioids (e.g. fentanyl and fentanyl analogs) continues to rise in the US both preceding and during the COVID-19 pandemic. Fentanyl-related overdose is rising in new geographic areas e.g. the western USA. Stimulant-related overdose is also increasing nationwide driven by methamphetamine and cocaine. Polysubstance use, e.g. the use of a stimulant along with an opioid is driving stimulant-related overdose. Other medical consequences of injection drug use are rising including HIV and hepatitis C infections. Medication approaches to treating opioid use disorder remain the standard of care and there are new promising pharmacological approaches to treating methamphetamine use disorder.

SUMMARY

A 'fourth wave' of high mortality involving methamphetamine and cocaine use has been gathering force in the USA. Availability and use of illicit fentanyls are still the major drivers of overdose deaths and the current rise in stimulant-related deaths appears entwined with the ongoing opioid epidemic.