Rural-urban disparities in the availability of hospital-based screening, medications for opioid use disorder, and addiction consult services

INTRODUCTION

Hospitals are an ideal setting to stage opioid-related interventions with patients who are hospitalized due to overdose or other substance use-related complications. Transitional opioid programs-which initiate care and provide linkages upon discharge, such as screening, initiation of medications for opioid use disorder, and addiction consult services-have become the gold standard, but implementation has been uneven. The purpose of this study was to assess disparities in the availability of hospital-based transitional opioid programs, across rural and urban hospital settings in the United States.

METHODS

Using hospital administrative data paired with county-level demographic data, we conducted bivariate and regression analyses to assess rural-urban differences in the availability of transitional opioid services including screening, addiction consult services, and MOUD in U.S general medical centers, controlling for hospital- and community-level factors. Our sample included 2846 general medical hospitals that completed the 2021 American Hospital Association (AHA) Annual Survey of Hospitals. Our primary outcomes were five self-reported measures: whether the hospital provided screening in the ED; provided screening in the inpatient setting; whether the hospital provided addiction consult services in the ED; provided addiction consult services in the inpatient setting; and whether the hospital provided medications for opioid use disorder.

RESULTS

Rural hospitals did not have lower odds of screening for OUD or other SUDs than urban hospitals, but both micropolitan rural counties and noncore rural counties had significantly lower odds of having addiction consult services in either the ED (OR: 0.74, 95 % CI: 0.58, 0.95; OR: 0.68, 95 % CI: 0.50, 0.91) or inpatient setting (OR: 0.76, 95 % CI: 0.59, 0.97; OR: 0.68, 95 % CI: 0.50, 0.93), respectively, or of offering MOUD (OR: 0.69, 95 % CI: 0.52, 0.90; OR: 0.52, 95 % CI: 0.37, 0.74).

CONCLUSIONS

Our study suggests that evidence-based interventions, such as medications for opioid use disorder and addiction consult services, are less often available in rural hospitals, which may contribute to rural-urban disparities in health outcomes secondary to OUD. A priority for population health improvement should be developing implementation strategies to support rural hospital adoption of transitional opioid programs.

An acute phase reaction from zoledronate mimicking symptoms seen in opioid withdrawal: a case report

BACKGROUND

Zoledronate, a bisphosphonate, is a potent first-line treatment for osteoporosis. It is also a preferred treatment for hypercalcemia especially when unresponsive to intravenous fluids. Bisphosphonates can cause acute phase reactions that mimic opioid withdrawal symptoms, which can confound provider decision-making. Our case highlights cognitive bias involving a patient with opioid use disorder who received zoledronate for hypercalcemia secondary to immobilization and significant bone infection.

CASE PRESENTATION

A 41-year-old male is admitted with a past medical history of active intravenous opioid use complicated by group A streptococcal bacteremia with L5-S1 discitis and osteomyelitis, L2-L3 osteomyelitis, and left ankle abscess/septic arthritis status post left ankle washout. His pain was well-controlled by acute pain service with ketamine infusion (discontinued earlier), opioids, acetaminophen, buprenorphine-naloxone, cyclobenzaprine, gabapentin, and naproxen. Intravenous opioids were discontinued, slightly decreasing the opioid regimen. A day later, the patient reported tachycardia, diaphoresis, myalgias, and chills, which the primary team reconsulted acute pain service for opioid withdrawal. However, the patient received a zoledronate infusion for hypercalcemia, on the same day intravenous opioids were discontinued. He had no other medications known to cause withdrawal-like symptoms per chart review. Therefore, it was suspected that an acute phase reaction occurred, commonly seen within a few days of bisphosphonate use.

CONCLUSION

Zoledronate, well known for causing acute phase reactions, was likely the cause of withdrawal-like symptoms. Acute phase reactions with bisphosphonates mostly occur in the first infusion, and the incidence decreases with subsequent infusions. Symptoms typically occur 24-72 h post-infusion, and last at most for 72 h. Cognitive bias led the primary team to be concerned with opioid withdrawal rather than investigating other causes for the patient's presentation. Therefore, providers should thoroughly investigate potential etiologies and rule them out accordingly to provide the best care. Health care providers should also be aware of the implicit biases that potentially impact the quality of care they provide to patients.

Association of hospital-based substance use supports on emergency department revisits: a retrospective cohort study in Sudbury, Canada from 2018 to 2022

BACKGROUND

This study compares emergency department (ED) revisits for patients receiving hospital-based substance-use support compared to those who did not receive specialized addiction services at Health Sciences North in Sudbury, Ontario, Canada.

METHODS

The study is a retrospective observational study using administrative data from all patients presenting with substance use disorder (SUD) at Health Sciences North from January 1, 2018, and August 31, 2022 with ICD-10 codes from the Discharge Abstract Database (DAD) and the National Ambulatory Care Database (NACRS). There were two interventions under study: addiction medicine consult services (AMCS group), and specialized addiction medicine unit (AMU group). The AMCS is a consult service offered for patients in the ED and those who are admitted to the hospital. The AMU is a specialized inpatient medical unit designed to offer addiction support to stabilize patients that operates under a harm-reduction philosophy. The primary outcome was all cause ED revisit within 30 days of the index ED or hospital visit. The secondary outcome was all observed ED revisits in the study period. Kaplan-Meier curves were used to measure the proportion of 30-day revisits by exposure group. Odds ratios and Hazard Ratios were calculated using logistic regression models with random effects and Cox-proportional hazard model respectively.

RESULTS

A total of 5,367 patients with 10,871 ED index visits, and 2,127 revisits between 2018 and 2022 are included in the study. 45% (2,340/5,367) of patient were not admitted to hospital. 30-day revisits were less likely among the intervention group: Addiction Medicine Consult Services (AMCS) in the ED significantly reduced the odds of revisits (OR 0.53, 95% CI 0.39-0.71, p < 0.01) and first revisits (OR 0.42, 95% CI 0.33-0.53, p < 0.01). The AMU group was associated with lower revisits odds (OR 0.80, 95% CI 0.66-0.98, p = 0.03). For every additional year of age, the odds of revisits slightly decreased (OR 0.99, 95% CI 0.98-1.00, p = 0.01) and males were found to have an increased risk compared to females (OR 1.50, 95% CI 1.35-1.67, p < 0.01).

INTERPRETATION

We observe statistically significant differences in ED revisits for patients receiving hospital-based substance-use support at Health Sciences North. Hospital-based substance-use supports could be applied to other hospitals to reduce 30-day revisits.

Pain and its Perceived Relatedness to the Onset, Maintenance, and Relapse of Opioid use Disorder: A Descriptive Study of Non-Treatment-Seeking Individuals

Background

Previous research has found chronic pain to be prevalent among individuals with opioid use disorder (OUD). The perception that pain is related to OUD onset, maintenance, relapse, and treatment delay has been noted in this population. However, prior works primarily involved treatment-engaged populations. Scant research describes such perceptions among non-treatment-seeking individuals.

Aims

This study describes pain burden and perceptions regarding the role of pain in OUD onset, maintenance, relapse, and addiction treatment delay in a sample of individuals with untreated OUD.

Methods

This cross-sectional study surveyed syringe exchange participants (n = 141). Participants responded to a survey including Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition OUD criteria, pain survey scales, demographic characteristics, and questions regarding pain and its perceived relatedness to aspects of OUD.

Results

Most participants reported pain within the past 4 weeks (127, 91.4%). Data displayed a skew toward more intense pain ratings, with 120 reporting their pain as greater than mild (86.3%). A majority of participants agreed that pain was responsible for their OUD onset (79, 56.4%), maintenance (76, 54.3%), past relapse experience (82, 57.9%), and treatment delay (81, 57.9%). Correlative analyses revealed that pain severity and interference measures displayed moderate and statistically significant associations with extent of perceived relatedness of pain to these aspects of OUD.

Conclusions

Among this sample of individuals with untreated OUD, pain and pain interference were prevalent. Pain was perceived to be related to OUD onset, maintenance, relapse, and treatment delay by a majority of the sample. These findings are in accordance with and expand upon prior works.

Abbreviations

OUD: opioid use disorder; DSM-5: Diagnostic and Statistical Manual 5; BPI: Brief Pain Inventory; NIDA: National Institute on Drug Abuse; IASP: International Association for the Study of Pain; MOUD: Medications for Opioid Use Disorder; IQR: Interquartile Range.

Treatment of alcohol use disorder in patients with alcohol-associated liver disease: Innovative approaches and a call to action

Alcohol-associated liver disease is currently the leading cause of liver transplantation and liver deaths both in Europe and the United States. Efficacious treatments exist for alcohol use disorder, but they are seldomly prescribed for patients who need them. Besides, the presence of liver cirrhosis can complicate pharmacological treatment choices. In this review, we discuss established and innovative treatment strategies to treat unhealthy alcohol use in patients with alcohol-associated liver disease. We also describe the experience of our own institutions, Hospital Universitari Germans Trias i Pujol in Badalona (Spain) and Yale-New Haven Health and Yale Medicine (Connecticut. United States of America).

The burden of skin and soft tissue, bone and joint infections in an Australian cohort of people who inject drugs

INTRODUCTION

There are currently limited data regarding the clinical and economic significance of skin and soft tissue infections (SSTI) and bone and joint infections in Australian people who inject drugs (PWID).

METHODS

Retrospective cohort study in adult PWID admitted to Monash Health, a large heath care network with six hospitals in Victoria, Australia. Inpatients were identified using administrative datasets and International Classification of Disease (ICD-10) coding for specific infection-related conditions. Cost analysis was based on mean ward, intensive care and hospital-in-the-home (HITH) lengths of stay. Spinal infections and endocarditis were excluded as part of previous studies.

RESULTS

A total of 185 PWID (61 female, 124 male, median age 37) meeting the study criteria were admitted to Monash Health between January 2010 and January 2021. Admitting diagnoses included 78 skin abscesses, 80 cellulitis, 17 septic arthritis, 4 osteomyelitis, 3 thrombophlebitis and 1 each of necrotising fasciitis, vasculitis and myositis. Pain (87.5%) and swelling (75.1%) were the most common presenting complaints. Opioids (67.4%) and methamphetamine (37.5%) were the most common primary drugs injected. Almost half (46.5%) of patients had concurrent active hepatitis C (HCV) infection on admission. Hepatitis B (HBV) and Human Immunodeficiency Virus (HIV) were uncommon. The most significant causative organism was methicillin-susceptible Staphylococcus aureus (24.9%). In 40.0% (74/185) no organism was identified. Patients required a median acute hospital stay of 5 days (2-51 days). There were 15 patients admitted to the intensive care unit (ICU) with median duration 2 days. PICC line insertion for antibiotics was required in 16.8% of patients, while 51.4% required surgical intervention. Median duration of both oral and IV antibiotic therapy was 11 days. Almost half (48.6%) of patients were enrolled in an opioid maintenance program on discharge. Average estimated expenditure was AUD $16, 528 per admission.

CONCLUSION

Skin and soft tissue and joint infections are a major cause of morbidity for PWID. Admission to hospital provides opportunistic involvement of addiction specialty services.

Feeling safer: effectiveness, feasibility, and acceptability of continuous pulse oximetry for people who smoke opioids at overdose prevention services in British Columbia, Canada

BACKGROUND

Smoking is the most common mode of unregulated opioid consumption overall and implicated in fatal overdoses in British Columbia (BC). In part, perception of decreased risk (e.g., fewer who smoke carry naloxone kits) and limited smoking-specific harm reduction services contribute to overdose deaths. Overdose prevention services (OPS) offer supervised settings for drug use. Continuous pulse oximetry, common in acute care, allows real-time, remote oxygen monitoring. We evaluated the effectiveness of a novel continuous pulse oximetry protocol aimed at allowing physical distancing (as required by COVID-19, secluded spaces, and to avoid staff exposure to vaporized opioids), its feasibility, and acceptability at OPS for people who smoke opioids.

METHODS

This was a mixed methods survey study. We developed a continuous pulse oximetry protocol in collaboration with clinical experts and people with lived/living experience of substance use. We implemented our protocol from March to August 2021 at four OPS in BC permitting smoking. We included adults (≥ 18 years) presenting to OPS to smoke opioids. Peer researchers collected demographic, health, and substance use information, and conducted structured observations. OPS clients participating in our study, OPS staff, and peer researchers completed post-monitoring surveys. We analyzed responses using a thematic inductive approach and validated themes with peer researchers.

RESULTS

We included 599 smoking events. OPS clients participating in our study had a mean age of 38.5 years; 73% were male. Most (98%) reported using "down", heroin, or fentanyl; 48% concurrently used other substances (32% of whom reported stimulants); 76% reported smoking alone in the last 3 days; and 36% reported an overdose while smoking. Respondents reported that the protocol facilitated physical distancing, was easy to use, high satisfaction, improved confidence, improved sense of safety, and that they would use it again.

CONCLUSIONS

Continuous pulse oximetry allowed safe physical distancing, was feasible, and acceptable in monitoring people who smoke opioids at OPS.

Overview of best practices for buprenorphine initiation in the emergency department

In recent decades, opioid overdoses have increased dramatically in the United States and peer countries. Given this, emergency medicine physicians have become adept in reversing and managing complications of acute overdose. However, many remain unfamiliar with initiating medication for opioid use disorder such as buprenorphine, a high-affinity partial opioid agonist. Emergency department-based buprenorphine initiation is supported by a significant body of literature demonstrating a marked reduction in mortality in addition to increased engagement in care. Buprenorphine initiation is also safe, given both the pharmacologic properties of buprenorphine that reduce the risk of diversion or recreational use, and previously published literature demonstrating low rates of respiratory depression, sedation, and precipitated withdrawal. Further, barriers to emergency department-based initiation have been reduced in recent years, with publicly available dosing and up-titration schedules, numerous publications overviewing best practices for managing precipitated withdrawal, and removal of USA policies previously restricting patient access and provider prescribing, with the removal of the X-waiver via the Medication Access and Training Expansion Act. Despite reductions in barriers, buprenorphine initiation in the emergency room remains underutilized. Poor uptake has been attributed to numerous individual and systemic barriers, including inadequate education, provider stigma, and insufficient access to outpatient follow-up care. The following practice innovation aims to summarize previously published evidence-based best practices and provide an accessible, user-friendly initiation guide to increase emergency physician comfortability with buprenorphine initiation going forward.

How I manage severe bacterial infections in people who inject drugs

BACKGROUND

Injecting drug use is a risk factor for severe bacterial infection, but there is limited high-quality evidence to guide clinicians providing care to people who inject drugs. Management can be complicated by mistrust, stigma, and competing patient priorities.

OBJECTIVES

To review the management of severe infections in people who inject drugs, using an illustrative clinical scenario of complicated Staphylococcus aureus bloodstream infection.

SOURCES

The discussion is based on recent literature searches of relevant topics. Very few randomized clinical trials have focussed specifically on the management of severe bacterial infections among people who inject drugs. Most recommendations are, therefore, based on observational studies, extrapolation from other patient groups, and the experience and opinions of the authors.

CONTENT

We discuss evidence and options regarding the following management issues for severe bacterial infections among people who inject drugs: initial management of sepsis; indications for surgical management; assessment and management of substance dependence; approaches to antibiotic administration following clinical stability; opportunistic health promotion; and secondary prevention of bacterial infections. Throughout, we highlight the importance of harm reduction and strategies to optimize patient engagement in care through a patient-centred approach.

IMPLICATIONS

We advocate for a multi-disciplinary trauma-informed approach to the management of severe bacterial infection among people who inject drugs. We emphasize the need for pragmatic trials to inform management guidelines, including those that are co-designed with the community. In particular, research is needed to establish the comparative effectiveness, safety, and cost-effectiveness of inpatient intravenous antibiotics vs. early oral antibiotic switch, outpatient parenteral therapy, and long-acting lipoglycopeptide antibiotics in this scenario.

Buprenorphine misinformation and willingness to treat patients with opioid use disorder among primary care-aligned health care professionals

BACKGROUND

Buprenorphine is a highly effective medication for opioid use disorder that is underused by health care professionals (HCPs). Medications for opioid use disorder (MOUD) misinformation may be an important barrier to buprenorphine access, but most implementation strategies have aimed to reduce negative attitudes towards patients with opioid use disorder (OUD) rather than misinformation specific to buprenorphine use. In this study, we assessed the degree to which HCPs endorsed misinformation related to buprenorphine, and whether this is associated with willingness to provide care to patients with OUD.

METHODS

In September-December of 2022, we surveyed HCPs practicing in Ohio (n = 409). Our primary outcomes included a previously validated 5-item measure of HCP willingness to treat patients with OUD, and three other measures of willingness. Our key independent variable was a study-developed 5-item measure of endorsement of misinformation related to buprenorphine, which assessed beliefs in buprenorphine's efficacy in managing withdrawal symptoms and reducing overdose deaths as well as beliefs about the role of buprenorphine in achieving remission. We computed descriptive and bivariable statistics and fit regression models predicting each outcome of interest.

RESULTS

On average, HCPs scored 2.34 out of 5.00 (SD = 0.80) on the composite measure of buprenorphine misinformation. 48.41% of participants endorsed at least one piece of misinformation. The most endorsed items were that buprenorphine is ineffective at reducing overdose deaths (M = 2.75, SD =0 .98), and that its use substitutes one drug for another (M = 2.41, SD = 1.25). HCP endorsement of buprenorphine misinformation significantly and negatively predicted willingness to work with patients with OUD (b = - 0.34; 95% CI - 0.46, - 0.21); intentions to increase time spent with this patient population (b = - 0.36; 95% CI - 5.86, - 1.28); receipt of an X-waiver (OR = 0.54, 95% CI 0.38, 0.77); and intention to get an X-waiver (OR: 0.56; 95% CI: 0.33-0.94).

CONCLUSIONS

Misinformation is common among HCPs and associated with lower willingness to treat patients with OUD. Implementation strategies to increase MOUD use among HCPs should specifically counter misinformation related to buprenorphine.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, NCT05505227. Registered 17 August 2022, https://clinicaltrials.gov/ct2/show/NCT05505227.

The Perceived Role of Withdrawal in Maintaining Opioid Addiction among Adults with Untreated Opioid Use Disorder: A Survey of Syringe Exchange Program Participants

Background: Withdrawal is believed to play a central role in the brain disease model of addiction. However, little research describes withdrawal-motives among untreated individuals in community settings. Methods: This cross-sectional study surveyed syringe exchange program participants (n = 139) with untreated opioid use disorder (OUD) in Columbus, Ohio from January 10th to March 25th, 2023, to assess their perceptions of the role of withdrawal in OUD maintenance, treatment delay, and OUD's refractoriness to buprenorphine. Participants responded to a survey including DSM-5 OUD criteria, demographics, and questions about substance use and opioid withdrawal. Participant ages ranged from 21 to 65 years with a mean age of 37.5 years and standard deviation of 8.1. The racial distribution of the sample was as follows: 81% White/Caucasian, 12% Black/African American, 3% Native American or Alaskan Native. Results: Sixty-six percent of participants agreed, or strongly agreed that opioid withdrawal was "the most important reason" they had been unable to stop using opioids. Almost seventy-one percent agreed, or strongly agreed that worry about opioid withdrawal had caused them to "put off or delay" OUD treatment. Although all participants had active, untreated OUD at the time of recruitment, most (85%) had previously tried buprenorphine, and the majority (78%) reported having experienced buprenorphine-precipitated withdrawal. Conclusions: Among this community sample of individuals with untreated OUD, withdrawal was perceived to have an important role in maintaining OUD, including by motivating OUD treatment delay. Prior buprenorphine-precipitated withdrawal was common, suggesting aversion to withdrawal might possibly be associated with OUD's refractoriness to buprenorphine.

Differences in buprenorphine prescribing readiness among primary care professionals with and without X-waiver training in the US

BACKGROUND

Medications for opioid use disorder (OUD) are effective at preventing overdose and infectious disease but are vastly under-prescribed in the US. For decades, prescribers faced additional training and regulation to prescribe buprenorphine which stigmatized the medication and lessened support for a harm reduction approach to treating opioid use disorder. The Drug Enforcement Administration removed the X-waiver requirement for prescribing buprenorphine in late 2022, which removed stigma and lessened important barriers to prescribing but also left training at the discretion of individual organizations. Our study aimed to assess differences in knowledge, confidence, and stigma regarding buprenorphine between those who went through the X-waiver training and those who did not, among practicing primary care providers (PCPs).

METHODS

We assessed buprenorphine prescribing readiness among primary care aligned outpatient providers in Ohio, USA. Using survey data, we conducted bivariate and regression analyses predicting primary prescribing outcomes. Primary outcomes measured knowledge of and confidence in buprenorphine, as well as perceived adequacy of one's training. Secondary outcomes were attitudes toward patients with OUD, including bias toward OUD patients, stress when working with them, and empathy toward them. Participants (n = 403) included physicians, nurse practitioners, and physician assistants practicing in primary care aligned disciplines.

RESULTS

Survey data showed that PCPs who received X-waiver training were more likely to understand and have confidence in the mechanism of buprenorphine, and consider their training on treating OUD to be adequate. PCPs with an X-waiver showed more empathy, less negative bias, and experienced less stress when working with patients with OUD.

CONCLUSION

Removing restrictive policies for prescribing buprenorphine is an important step to expanding access and reducing the stigma associated with opioid use disorder treatment. Yet, our findings suggest that the training received alongside regulation may be important for improving prescribing confidence and reducing stigma. Strategies to increase buprenorphine prescribing are unlikely to be effective without also expanding access to prescribing support for primary care providers across the career course.

Positive contact and empathy as predictors of primary care providers' willingness to prescribe medications for opioid use disorder

Introduction

Patients with opioid use disorder (OUD) have a heightened need for quality health care, including access to evidence-based medications to reduce cravings and prevent overdose. However, primary care providers (PCPs) are reluctant to work with patients with OUD and implement medication prescribing into primary care practice. Previous studies have sought to identify potential ways to overcome these barriers, but often utilize interventions that facilitate both positive contact with as well as empathy for patients with OUD. In this study, we jointly assess positive contact and empathy to determine their unique impact on treatment attitudes and behaviors among PCPs, after controlling for other known predictors.

Methods

We surveyed 409 PCPs currently practicing in Ohio in 2022. Our primary dependent variables were willingness to work with patients with OUD, receipt of an X-waiver to prescribe buprenorphine, and interest in receiving an X-waiver. Our primary independent variables were positive contact and empathy toward patients with OUD. We computed bivariate correlations and multivariable linear regression (for continuous dependent variables) and logistic regression (for binary dependent variables) to understand the relationship between positive contact, empathy, and our outcome variables while accounting for other known predictors and relevant participant demographics.

Results

Positive contact was positively correlated with willingness to work with patients with OUD, receipt of the X-waiver, an interest in receiving the X-waiver, more frequent checking with patients about the need for naloxone, and higher odds of naloxone prescribing. These relationships held after accounting for PCP demographics, explicit bias toward patients with OUD, and overall levels of contact with patients with OUD. Empathy, conversely, was not a significant predictor of any treatment outcomes in the fully adjusted models.

Conclusion

Interventions and medical education programs aimed at improving treatment outcomes for patients with OUD should facilitate positive contact between PCPs and patients with OUD.

Evaluating an addiction medicine unit in Sudbury, Ontario Canada: a mixed-methods study protocol

BACKGROUND

In response to the escalating global prevalence of substance use and the specific challenges faced in Northern Ontario, Canada, an Addiction Medicine Unit (AMU) was established at Health Sciences North (HSN) in Sudbury. This protocol outlines the approach for a comprehensive evaluation of the AMU, with the aim of assessing its impact on patient outcomes, healthcare utilization, and staff perspectives.

METHODS

We conducted a parallel mixed-method study that encompassed the analysis of single-center-level administrative health data and primary data collection, including a longitudinal observational study (target n = 1,200), pre- and post-admission quantitative interviews (target n = 100), and qualitative interviews (target n = 25 patients and n = 15 staff). We implemented a participatory approach to this evaluation, collaborating with individuals who possess lived or living expertise in drug use, frontline staff, and decision-makers across the hospital. Data analysis methods encompass a range of statistical techniques, including logistic regression models, Cox proportional hazards models, Kaplan-Meier curves, Generalized Estimating Equations (GEE), and thematic qualitative analysis, ensuring a robust evaluation of patient outcomes and healthcare utilization.

DISCUSSION

This protocol serves as the foundation for a comprehensive assessment designed to provide insights into the AMU's effectiveness in addressing substance use-related challenges, reducing healthcare disparities, and improving patient outcomes. All study procedures have been meticulously designed to align with the ethical principles outlined in the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans. The findings will be disseminated progressively through committees and working groups established for this research, and subsequently published in peer-reviewed journals. Anticipated outcomes include informing evidence-based healthcare decision-making and driving improvements in addiction treatment practices within healthcare settings.

Evidence of telescoping in females across two decades of US treatment admissions for injection drug use: 2000-2020

Background

People who inject drugs (PWID) have an increased risk of soft tissue infection, drug overdose and death. Females may be particularly vulnerable due to barriers to substance use disorder (SUD) treatment entry, stigma, and telescoping, or the greater severity in substance use-related comorbidity and consequences despite a shorter history of use. We set out to identify sex differences in United States injection drug use (IDU).

Methods

The Treatment Episode Dataset-Admission (2000-2020) provided data to identify PWID undergoing their initial SUD treatment admission. Mann-Whitney U test, chi-square, and Spearman correlations were used for ordinal variables, categorical variables, and to assess similarity of male/female trends over the 21 years, respectively. The probabilistic index (PI) and Cramer's V provided effect sizes for Mann-Whitney U tests and chi-square tests, respectively.

Results

A total of 13,612,978 records existed for cases entering their initial treatment. Mapping to a history of IDU left 1,458,695 (561,793 females). Females had a higher prevalence among PWID across all 21 years; IDU trends were essentially identical between males and females (r = 0.97). Females endorsed beginning their primary substance later in life (PI = 0.47, p < 0.0001) and entered treatment after a shorter period of substance use (PI = 0.57, p < 0.0001).

Conclusions

We saw evidence of telescoping among PWID with a SUD entering their initial episode of treatment. Interventions should be implemented prior to the transition to IDU, and this window of opportunity is shortened in females. Utilizing gender-responsive treatment options may be a way to increase treatment-seeking earlier in the disease course.

Evaluation of a student clinical research education program in addiction medicine

OBJECTIVE

To evaluate an experiential student clinical addiction research program by analyzing its components, evaluation survey data, and scientific outputs.

METHODS

In 1995, we established a summer research program supporting trainees to gain exposure to clinical addiction research careers. This curriculum employed a three-pronged approach that combined mentored research training, didactic education, and clinical observerships for medical students and other trainees to acquire experience with addiction medicine and research. Utilizing the Kirkpatrick model as program evaluation framework, we analyzed evaluation data from programmatic surveys (didactic seminar evaluations, overall program surveys) and conducted qualitative feedback exploration.

RESULTS

Between 2007 and 2019, 56 trainees and 26 faculty mentors participated in the curriculum. To date, 25 students published 38 papers with their faculty mentor. Analysis of the past 12 years of program evaluation data demonstrated that students highly valued individually-mentored research experiences. They indicated that seminars familiarized them with the foundations of different clinical care models and career trajectories in addiction medicine. Clinical observerships provided students with patient contacts in various multidisciplinary addiction treatment settings. These experiences, perhaps most importantly hearing about patients' lived experiences, meaningfully informed various research and didactic activities.

CONCLUSIONS

This summer student research program successfully introduced students to addiction medicine and research, manifested by high peer-reviewed publication productivity. While our program engaged and involved committed mentors and inspired mentees to pursue professional paths in addiction research, it did not specifically incorporate attention to equity and diversity into program planning and implementation. Going forward, the program will improve equity by increasing the recruitment of trainees from disadvantaged groups and engaging underrepresented faculty.KEY MESSAGESSummer programs can be effective in engaging medical students and trainees in research early in their trajectory and inspire them to incorporate research into their careers.Programs that integrate experiential addiction research learning, i.e. mentored research activities, didactic sessions, and clinical observerships, can provide trainees with a profound understanding of substance use disorder treatment and research.

A Novel Approach to Addiction Medicine Education for Undergraduate Medical Students

A virtual addiction medicine elective was developed using interactive multimedia modules, active learning strategies, and patient-based cases. Student had opportunities for professional networking and interacting with physicians and patients. The elective was successful in boosting Year-1 medical students' confidence to screen, manage, and treat patients with substance abuse disorder.

Implementation of an online and in-person addiction medicine course and its impact on medical students' knowledge on substance use disorders

BACKGROUND

Substance use is a public health crisis that requires improved education on substance use disorders (SUDs) in medical school curriculum to ensure that the future generation of physicians is prepared to care for this growing patient population.

OBJECTIVES

This study evaluates how the implementation of an online and in-person addiction medicine course impacted medical students' knowledge on SUD and caring for patients with SUD.

METHODS

86 third-year and fourth-year medical students participated in either an online or in-person elective course on addiction medicine. Students learned about SUDs through various modalities, such as online SUD modules, clinical encounters, movies, books, participation in support group meetings and learning evidence-based tools to screen or treat patients. To assess the impact of the course curriculum on students' knowledge in treating SUDs, a pre and post survey was administered and analyzed.

RESULTS

After completing the SUD course, students showed significant improvement (P < 0.01) in caring for SUD patients. Specifically, they improved in the areas of: assessing a patient with SUD, comfort and knowledge in using motivational interviewing to affect behavior change in a patient with a SUD, and knowledge of community resources related to SUD. Students also showed a significant improvement (P < 0.01) in the number of unique SUDs (such as opioids or alcohol) they felt knowledgeable about and in the number of treatment modalities for unique SUDs.

CONCLUSIONS

Implementation of an addiction medicine course that utilizes various teaching modalities can significantly improve medical students' fundamental knowledge on SUD.

Clinical guidance for e-cigarette (vaping) cessation: Results from a modified Delphi panel approach

Individuals seek help to stop their use of e-cigarettes from their healthcare practitioners. However, there is a paucity of published work addressing e-cigarette cessation methods empirically, and what evidence that is available is weak. Therefore, we developed an expert informed clinical resource to guide practitioners helping their clients quit using e-cigarettes. We conducted a modified Delphi process between September and December 2021 to reach consensus on clinical recommendations for e-cigarette cessation. Expert and Peer Panel members (n = 28) voted and provided feedback on the recommendations through three rounds of structured surveys, a discussion board, and one intermediate survey. The penultimate knowledge products underwent usability testing and were finalized based on user feedback. The Expert Panel maintained a 100% response rate for rounds 1 and 2 and 96% for round 3; the Peer Panel achieved a 100% response rate for all three rounds of the modified Delphi process. Consensus was reach on 24 recommendations and 2 statements spanning eight domains: severity and dependence; general approaches; treatment approaches; dual use; pharmacotherapy strategies; behavioural therapy strategies; harm reduction; and relapse prevention. Two additional 'no agreement' statements that did not reach consensus are included in the guidance resource. The recommendations were also contextualized for the following groups: adults; youth; people who are pregnant, breastfeeding and/or chestfeeding; and people with mental illness and/or substance use issues. The recommendations listed in the resource provide general clinical guidance on e-cigarette cessation to assist healthcare practitioners in the treatment planning process.

Kappa opioid receptor in nucleus accumbens regulates depressive-like behaviors following prolonged morphine withdrawal in mice

Prolonged withdrawal from opioids leads to negative emotions. Kappa opioid receptor (KOR) plays an important role in opioid addiction and affective disorders. However, the underlying mechanism of KOR in withdrawal-related depression is still lacking. We found that escitalopram treatment had a limited effect in improving depression symptoms in heroin-dependent patients. In mice, we demonstrated prolonged (4 weeks) but not acute (24 h) withdrawal from morphine induced depressive-like behaviors. The number of c-Fos positive cells and the expression of KOR in the nucleus accumbens (NAc), were significantly increased in the prolonged morphine withdrawal mice. Conditional KOR knockdown in NAc significantly improved depressive-like behaviors. Repeated but not acute treatment with the KOR antagonist norBNI improved depressive-like behaviors and reversed PSD95, synaptophysin, p-ERK, p-CREB, and BDNF in NAc. This study demonstrated the important role of striatal KOR in morphine withdrawal-related depressive-like behaviors and offered therapeutic potential for the treatment of withdrawal-related depression.

Polysubstance addiction patterns among 7,989 individuals with cocaine use disorder

To characterize polysubstance addiction (PSA) patterns of cocaine use disorder (CoUD), we performed a latent class analysis (LCA) in 7,989 participants with a lifetime DSM-5 diagnosis of CoUD. This analysis identified three PSA subgroups among CoUD participants (i.e., low, 17%; intermediate, 38%; high, 45%). While these subgroups varied by age, sex, and racial-ethnic distribution (p < 0.001), there was no difference with respect to education or income (p > 0.05). After accounting for sex, age, and race-ethnicity, the CoUD subgroup with high PSA had higher odds of antisocial personality disorder (OR = 21.96 vs. 6.39, difference-p = 8.08✕10-6), agoraphobia (OR = 4.58 vs. 2.05, difference-p = 7.04✕10-4), mixed bipolar episode (OR = 10.36 vs. 2.61, difference-p = 7.04✕10-4), posttraumatic stress disorder (OR = 11.54 vs. 5.86, difference-p = 2.67✕10-4), antidepressant medication use (OR = 13.49 vs. 8.02, difference-p = 1.42✕10-4), and sexually transmitted diseases (OR = 5.92 vs. 3.38, difference-p = 1.81✕10-5) than the low-PSA CoUD subgroup. These findings underscore the importance of modeling PSA severity and comorbidities when examining the clinical, molecular, and neuroimaging correlates of CoUD.

Low dose IV buprenorphine inductions for patients with opioid use disorder and concurrent pain: a retrospective case series

BACKGROUND

Hospitalizations are a vital opportunity for the initiation of life-saving opioid agonist therapy (OAT) for patients with opioid use disorder. A novel approach to OAT initiation is the use of IV buprenorphine for low dose induction, which allows patients to immediately start buprenorphine at any point in a hospitalization without stopping full agonist opioids or experiencing significant withdrawal.

METHODS

This is a retrospective case series of 33 patients with opioid use disorder concurrently treated with full agonist opioids for pain who voluntarily underwent low dose induction at a tertiary academic medical center. Low dose induction is the process of initiating very low doses of buprenorphine at fixed intervals with gradual dose increases in patients who recently received or are simultaneously treated with full opioid agonists. Our study reports one primary outcome: successful completion of the low dose induction (i.e. transitioned from low dose IV buprenorphine to sublingual buprenorphine-naloxone) and three secondary outcomes: discharge from the hospital with buprenorphine-naloxone prescription, self-reported pain scores, and nursing-assessed clinical opiate withdrawal scale (COWS) scores over a 6-day period, using descriptive statistics. COWS and pain scores were obtained from day 0 (prior to starting the low dose induction) to day 5 to assess the effect on withdrawal symptoms and pain control.

RESULTS

Thirty patients completed the low dose induction (30/33, 90.9%). Thirty patients (30/33, 90.9%) were discharged with a buprenorphine prescription. Pain and COWS scores remained stable over the course of the study period. Mean COWS scores for all patients were 2.6 (SD 2.8) on day 0 and 1.6 (SD 2.6) on day 5. Mean pain scores for all patients were 4.4 (SD 2.1) on day 0 and 3.5 on day 5 (SD 2.1).

CONCLUSIONS

This study found that an IV buprenorphine low dose induction protocol was well-tolerated by a group of 33 hospitalized patients with opioid use disorder with co-occurring pain requiring full agonist opioid therapy. COWS and pain scores improved for the majority of patients. This is the first case series to report mean daily COWS and pain scores over an extended period throughout a low dose induction process.

Grayken lessons: between a rock and a hard place? A 37-year-old man with acute liver injury while enrolled in a managed alcohol program for severe alcohol use disorder

Managed alcohol programs aim to reduce health and social harms associated with severe alcohol use disorder. Here, we describe a young man with severe alcohol use disorder enrolled in a managed alcohol program, who was admitted to hospital with acute liver injury. Fearing that alcohol was contributing, the inpatient care team discontinued the managed alcohol dose in hospital. He was ultimately diagnosed with cephalexin-induced liver injury. After consideration of risks, benefits, and alternative options, the patient and care team jointly decided to restart managed alcohol after hospital discharge. With this case, we describe managed alcohol programs and summarize the emerging evidence-base, including eligibility criteria and outcome measures; we explore clinical and ethical dilemmas in caring for patients with liver disease within managed alcohol programs; and we emphasize principles of harm reduction and patient-centered care when establishing treatment plans for patients with severe alcohol use disorder and unstable housing.

Years of life lost due to unintentional drug overdose relative to the leading underlying causes of death in the United States: a comparative analysis of excess mortality 2017-2019

The present study aims to compare Years of Life Lost for unintentional drug overdose and the leading underlying causes of death in the United States annually from 2017 to 2019. Years of Life Lost provide valuable context to incident deaths when comparing the relative mortality burden of underlying causes of death. Prior research has shown unintentional drug overdose was the third leading cause of Years of Life Lost in the state of Ohio in 2017. However, this finding has yet to be replicated at the national level in the US. Death statistics for 2017-2019 were accessed via CDC WONDER. Years of Life Lost were calculated for unintentional drug overdose and each of the top five causes of incident deaths in the US during the study period. Unintentional drug overdose caused nearly seven million Years of Life Lost in the US during the three-year period of study and was the fourth leading cause of Years of Life Lost after cancer, heart disease and other accidents. Incidence alone provides an incomplete picture of the effect of unintentional drug overdose on overall mortality burden in the US. Years of Life Lost give critical context to the overdose crisis, underscoring unintentional drug overdose as a leading cause of premature mortality.

Emergency department care experiences among members of equity-deserving groups: quantitative results from a cross-sectional mixed methods study

BACKGROUND

Emergency departments (EDs) serve an integral role in healthcare, particularly for vulnerable populations. However, marginalized groups often report negative ED experiences, including stigmatizing attitudes and behaviours. We engaged with historically marginalized patients to better understand their ED care experiences.

METHOD

Participants were invited to complete an anonymous mixed-methods survey about a previous ED experience. We analysed quantitative data including controls and equity-deserving groups (EDGs) - those who self-identified as: (a) Indigenous; (b) having a disability; (c) experiencing mental health issues; (d) a person who uses substances; (e) a sexual and gender minority; (f) a visible minority; (g) experiencing violence; and/or (h) facing homelessness - to identify differences in their perspectives. Differences between EDGs and controls were calculated with chi squared tests, geometric means with confidence ellipses, and the Kruskal-Wallis H test.

RESULTS

We collected a total of 2114 surveys from 1973 unique participants, 949 controls and 994 who identified as equity-deserving. Members of EDGs were more likely to attribute negative feelings to their ED experience (p < 0.001), to indicate that their identity impacted the care received (p < 0.001), and that they felt disrespected and/or judged while in the ED (p < 0.001). Members of EDGs were also more likely to indicate that they had little control over healthcare decisions (p < 0.001) and that it was more important to be treated with kindness/respect than to receive the best possible care (p < 0.001).

CONCLUSION

Members of EDGs were more likely to report negative ED care experiences. Equity-deserving individuals felt judged and disrespected by ED staff and felt disempowered to make decisions about their care. Next steps will include contextualizing findings using participants' qualitative data and identifying how to improve ED care experiences among EDGs to make it more inclusive and better able to meet their healthcare needs.

Long-Acting Injectable Therapy for People with HIV: Looking Ahead with Lessons from Psychiatry and Addiction Medicine

Long-acting injectable antiretroviral medications are new to HIV treatment. People with HIV may benefit from a treatment option that better aligns with their preferences, but could also face new challenges and barriers. Authors from the fields of HIV, substance use treatment, and mental health collaborated on this commentary on the issues surrounding equitable implementation and uptake of LAI ART by drawing lessons from all three fields. We employ a socio-ecological framework beginning at the policy level and moving through the community, organizational, interpersonal, and patient levels. We look at extant literature on the topic as well as draw from the direct experience of our clinician-authors.

Self-Assessment of Addiction Medicine Core Competencies in Four Year Groups of Psychiatrists in Training: Efficacy of the Addiction Medicine Training Needs Assessment Scale in a Local Training Context

BACKGROUND

In addiction medicine training, self-assessment is increasingly used to support self-regulation learning by identifying standards of excellence, competence gaps, and training needs. To ensure psychiatrists in Lithuania also develop specific addiction competencies, the Lithuanian Health Sciences University faculty in Kaunas developed an addiction psychiatry curriculum.

OBJECTIVES

The aim of this research is to explore the efficacy of the AM-TNA scale to measure individual and group differences in proficiency in the core competencies of addiction medicine. A cross-sectional study and a convenience sample were used.

METHOD

We studied the differences in performance in addiction medicine competencies between 4 successive year groups and analysed the variance to determine the statistical differences between the means of 4 year groups with biases, resulting from repeated measurement statistically corrected-for.

RESULTS

Of the psychiatrists in training, 41% or 59% completed the scale. The assessment of competencies suggested that all but 2 competencies differ significantly (p < 0.05) between the 4 groups. The post hoc analyses indicated that mean scores for 24 of the 30 core competencies differed significantly between the year groups (p < 0.05) and showed a gradual increase in scores of self-assessed competencies over the 4 year groups. We found adequate scale variance and a gradual increase in self-assessed competencies between the 4 year groups, suggesting a positive association between the results of incremental professional training and improved self-assessed substance use disorders (SUD) competency scores.

CONCLUSIONS

This study illustrates the efficacy of the AM-TNA scale as an assessment instrument in a local training context. Future research should aim to have larger sample sizes, be longitudinal in design, assess individual progress, and focus on comparing and combining self-reported competencies with validated objective external assessment and feedback.

Early Career Training in Addiction Medicine: A Qualitative Study with Health Professions Trainees Following a Specialized Training Program in a Canadian Setting

Background: There has been a notable deficiency in the implementation of addiction science in clinical practice and many healthcare providers feel unprepared to treat patients with substance use disorders (SUD) following training. However, the perceptions of addiction medicine training by learners in health professions have not been fully investigated. This qualitative study explored perceptions of prior training in SUD care among early-career trainees enrolled in Addiction Medicine fellowships and electives in Vancouver, Canada. Methods: From April 2015 - August 2018, we interviewed 45 early-career physicians, social workers, nurses, and 17 medical students participating in training in addiction medicine. We coded transcripts inductively using qualitative data analysis software (NVivo 11.4.3). Results: Findings revealed six key themes related to early-career training in addiction medicine: (1) Insufficient time spent on addiction education, (2) A need for more structured addictions training, (3) Insufficient hands-on clinical training and skill development, (4) Lack of patient-centeredness and empathy in the training environment, (5) Insufficient implementation of evidence-based medicine, and (6) Prevailing stigmas toward addiction medicine. Conclusion: Early clinical training in addiction medicine appears insufficient and largely focused on symptoms, rather than etiology or evidence. Early career learners in health professions perceived benefit to expanding access to quality education and reported positive learning outcomes after completing structured training programs.

A novel home- and community-based mobile outreach detoxification service for individuals identifying problematic substance use: implementation and program evaluation

SETTING

Substance use remains a pervasive public health issue throughout Canada, exerting substantial economic, social, and political pressure on health care systems, while impacting lives of affected individuals. The advent of COVID-19 has been doubly perilous; it restricts existing programming, while exacting a worsening toll on mental health and substance use fronts across the demographic landscape.

INTERVENTION

In response to the crisis, the Mobile Withdrawal Management Service (MWMS) was established in 2019 through a Winnipeg-based community health centre. MWMS is a community-based outreach withdrawal service that supports individuals for up to 30 days. Clients may choose where services are accessed in the community, including their own home. For those without safe housing, short-term accommodation is offered. Additionally, Indigenous cultural support, peer support, trauma counselling, and linkage to primary care are available.

OUTCOMES

The MWMS approach is resolutely patient-centred. The program meets people where they are at, both figuratively and literally. Agility and adaptability-particularly in the context of substance use treatment-is uniquely advantageous in maintaining service delivery to the broad demographic cross-section revealed in the data. Moreover, relative to inpatient detoxification services, MWMS holds significant potential for system-wide cost savings.

IMPLICATIONS

The presented approach addresses a significant gap in addiction services. There is substantial capacity for both increased access and system savings with implementation of this approach. Furthermore, the principles behind the program are readily transferable to different contexts and easily modifiable to local conditions. There is particular potential for servicing hard-to-reach populations, with respect to both physical and social geography.

Evaluation of an experiential clinical learning option during pandemic teaching suspensions

BACKGROUND

As students' direct patient contact was suspended because of COVID-19-related restrictions, we revised our clinical addiction medicine curriculum for students to learn about the different multidisciplinary clinical models delivered at our hospital and in community settings. Our aim was to provide an overview of clinical modalities and familiarize learners with clinician and patient experiential perspectives.

METHODS

We implemented a multi-pronged approach, offering an overview of clinical care programs through remote panels involving care providers at the clinics where students had previously been scheduled for in-person rotations. This included inpatient and office-based addiction services, addiction treatment program for adolescents and young adults, integrated addiction care and HIV primary care clinic, and opioid use urgent care clinic. Beyond having them join outpatient telehealth clinic visits, students also participated in an online panel involving patients in recovery to gain familiarity with their care perspectives; and joined a panel with recovery coaches to get further insights into patient challenges in clinical settings. Students further participated in remote opioid treatment trainings and observed clinical rounds of inpatient addiction consults and adolescent clinic team meetings.

RESULTS

With this revised curriculum, students learned about the variety of clinical modalities at the height of our hospital's COVID-19 pandemic burden. The evaluation suggested that students appreciated the authenticity of accounts from patients and providers about their challenges and satisfaction related to clinical care. While in a remote learning setting, students overall wished for more personal interaction with patients and providers. They also noted a lack of group cohesion and connection that they felt would otherwise have been met in an in-person program.

CONCLUSIONS

Remote learning allowed our program to connect trainees to the multidisciplinary field of addiction medicine despite the COVID-19 pandemic. In future program iterations, we will consider hybrid formats of in-person learning experiences with direct patient and faculty contact where possible, combined with online provider and patient panels possibly, in addition to virtual breakout formats to facilitate more personal student-patient and student-faculty interactions.

Strategic planning for addiction programs within academic medical centers: Examples from the Yale Program in Addiction Medicine

Background Addiction programs at academic medical centers must navigate complex, multidisciplinary environments as they work to advance the field and improve substance use treatment access and outcomes. Programs can employ strategic planning processes to identify goals and strategies for success. Methods: The Yale Program in Addiction Medicine began a series of strategic planning activities in February 2020 with the primary aims of (1) conducting a point-in-time needs assessment for the Program and (2) identifying goals for Program improvement and expansion. Drawing upon a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis framework and the Delphi method for group decision-making, these strategic planning activities were implemented in four steps involving multimodal engagement and iterative feedback amongst Program faculty and selected stakeholders. Results: Primary deliverables included four overarching programmatic goals, associated action items, strategies for success, a proposed implementation timeline, and a revised Mission, Vision, and Values statement for the Program. Conclusion: Methodologic considerations and environmental factors offer insight into the strengths, limitations, and adaptive potential of this approach as well as others described in the literature. Key outputs highlight the benefits and timeliness of strategic planning for addiction programs, as heightened interest and investment in substance use treatment, prevention, and harm reduction paves the way for opportunity and innovation.

The Development and Current Status of Subspecialty Training and Certification in Addiction Psychiatry

OBJECTIVE

This article describes the evolution of subspecialty training and certification in addiction psychiatry. The impact of the newer subspecialty in addiction medicine is also addressed.

METHODS

Information about programs and trainees was obtained from records of the Accreditation Council for Graduate Medical Education. Information about addiction psychiatry certification was obtained from the records of the American Board of Psychiatry and Neurology (ABPN). Information about the addiction medicine subspecialty was obtained from the American Board of Preventive Medicine.

RESULTS

In AY 2020-2021, there were 53 addiction psychiatry programs with 92 fellows, and the numbers of each have increased over the past 5 academic years. The total number of addiction psychiatry certificates awarded through 2020 was 2806. Three years after addiction medicine programs were first accredited, there were 83 programs with 149 fellows. Thus far, 3282 addiction medicine certificates have been awarded, 1275 (38.8%) of them to ABPN diplomates.

CONCLUSIONS

In the 30 years since addiction psychiatry received subspecialty recognition, the numbers of training programs and fellows have grown steadily and are continuing to increase. Recently, the numbers of training programs and fellows in the newer subspecialty of addiction medicine have grown rapidly with substantial psychiatry involvement in addiction medicine training and certification programs. Nonetheless, it is apparent that the need for specialists with expertise in substance use disorders will far exceed the supply for the foreseeable future.

Health care workers' perspectives on care for patients with injection drug use associated infective endocarditis (IDU-IE)

Background

Despite high morbidity and mortality, patients with injection drug use associated infective endocarditis (IDU-IE) lack standardized care, and experience prolonged hospitalization and variable substance use disorder (SUD) management.

Our study’s objective was to elicit perspectives of health care workers (HCWs) who deliver care to this population by understanding their perceived patient, provider, and system-level resources and barriers.

Methods

This qualitative study included interviews of HCWs providing care to patients with IDU-IE from January 2017 to December 2019 at a single Midwest academic center. Based on electronic medical record queries to determine high and low rates of referral to SUD treatment, HCWs were selected using stratified random sampling followed by convenience sampling of non-physician HCWs and a patient. Study participants were recruited via email and verbal consent was obtained. The final sample included 11 hospitalists, 3 specialists (including 2 cardiovascular surgery providers), 3 case managers, 2 social workers, 1 nurse, and 1 patient. Qualitative semi-structured interviews explored challenges and resources related to caring for this population. Qualitative Data Analysis (QDA) Minor Lite was used for thematic data using an inductive approach.

Results

Three major thematic categories emerged relative to patient-level barriers (e.g., pain control, difficult patient interactions, social determinants of health), provider-level barriers (e.g., inequity, expectations for recovery, varying levels of hope, communication style, prescribing medication for SUD), and system-level barriers (e.g., repeat surgery, placement, resources for SUD and mental health). The need to address underlying SUD was a prominent theme.

Conclusion

Practical steps we can take to improve treatment for this population include training and coaching HCWs on a more person-centered approach to communication and transparent decision-making around pain management, surgery decisions, and expectations for SUD treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08121-z.

A case of buprenorphine-precipitated withdrawal managed with high-dose buprenorphine

BACKGROUND

Buprenorphine-naloxone has a very high affinity for the mu-receptor and can cause precipitated opioid withdrawal, typically more severe than withdrawal that occurs naturally, when administered while a full mu-opioid receptor agonist remains in a person's system. To avoid precipitated withdrawal, one needs to be in mild to moderate opioid withdrawal at the time of buprenorphine-naloxone induction. Recently, there have been reported cases of precipitated withdrawal occurring in patients taking fentanyl knowingly or unknowingly, despite them being in adequate opioid withdrawal at the time of induction. When this occurs, the current recommendation is to provide 2 mg of buprenorphine-naloxone every 1-2 hours.

OBJECTIVES

Describe a case of successful management of buprenorphine-precipitated withdrawal with escalation of the dose of buprenorphine and highlight implications for future management.

METHODS

We present a case of a patient with a history of opioid use disorder who was in moderate opioid withdrawal at the time of buprenorphine-naloxone induction and experienced precipitated withdrawal after buprenorphine-naloxone administration.

RESULTS

High-dose buprenorphine-naloxone was given to the patient and precipitated withdrawal subsided after receiving a total of 20 mg. On the next day, the patient had no symptoms of opioid withdrawal and is currently maintained on 16 mg/day.

CONCLUSION

With the rising prevalence of fentanyl-laced drugs, increased instances of precipitated withdrawal are likely to be encountered. In cases of precipitated withdrawal, giving a high dose of buprenorphine-naloxone rapidly is safe and will allow rapid reversal of withdrawal symptoms.

Preparing for the future of medical education: A case series of traditional and virtual clinical rotations in addiction medicine spanning the COVID pandemic

Background: Substance use accounts for more than 400,000 deaths annually in the United States and overdose rates surged during the COVID pandemic. While the pandemic created increased pressure for better prepared providers, it simultaneously placed restrictions on medical training programs. The purpose of this educational case series is to assess the feasibility of a virtual addiction medicine training program and conduct a qualitative evaluation of medical student attitudes toward caring for people with substance use disorders, both before and after their addiction medicine training experience. Methods: We conducted a qualitative analysis related to course content focused on strengths and limitations of in-person and virtual training modalities. Individual quotes were evaluated and content themes were developed after a thorough review of all codes and detailed examination of interviewee quotes. Results: The primary themes that emerged were (1) Addiction medicine content is important to improve care of patients with substance disorders and is not fully addressed in undergraduate medical education (2) In-person and virtual training contain unique strengths and weaknesses and (3) Students perceived that both experiences provided positive and needed training in addiction medicine that shifted perspective and enhanced confidence to practice. Conclusions: Remote training via virtual lectures and patient visits may enhance training opportunities for students with limited exposure to addiction medicine patients and faculty with addiction medicine expertise. There is a need to further refine virtual care for patients with SUDs and virtual training to meet the needs of patients and learners across the country.

Rural opioid treatment program patient perspectives on take-home methadone policy changes during COVID-19: a qualitative thematic analysis

BACKGROUND

In the United States, methadone for opioid use disorder (OUD) is highly regulated. Federal agencies announced guidelines in March 2020 allowing for relaxation of take-home methadone dispensing at opioid treatment programs (OTPs) to improve treatment access and reduce COVID-19 transmission risk during the public health emergency. We explored patient perspectives at three OTPs serving rural communities on how take-home policy changes were received and implemented and how these changes impacted their addiction treatment and recovery.

METHODS

We completed semi-structured individual qualitative interviews in 2 phases: (1) August-October 2020 and (2) November 2020-January 2021 (total n = 46), anticipating possible policy changes as the pandemic progressed. We interviewed patients with OUD enrolled at 3 rural OTPs in Oregon. Participants received varying take-home methadone allowances following the COVID-19-related policy changes. All interviews were conducted via phone, audio-recorded, and transcribed. We conducted a thematic analysis, iteratively coding transcripts, and deductively and inductively generating codes.

RESULTS

The 46 participants included 50% women and 89% had Medicaid insurance. Three main themes emerged in the analysis, with no differences between study phases: (1) Adapting to changing OTP policies throughout the pandemic; (2) Recognizing the benefits, and occasional struggles, with increased take-home methadone dosing; and (3) Continuing policies and procedures post-pandemic. Participants described fears and anxieties around ongoing methadone access and safety concerns prior to OTP policy changes, but quickly adapted as protocols soon seemed "natural." The majority of participants acknowledged significant benefits to increased take-homes independent of reducing COVID-19 infection risk including feeling "more like a normal person," improved recovery support, reduced time traveling, and having more time with family and for work. Looking to a post-pandemic future, participants thought some COVID-19-related safety protocols should continue that would reduce risk of other infections, make OTP settings less stressful, and result in more individualized care.

CONCLUSIONS

As the pandemic progressed, study participants adapted to rapidly changing OTP policies. Participants noted many unanticipated benefits to increased take-home methadone and other COVID-19 protocols including strengthened self-efficacy and recovery and reduced interpersonal conflict, with limited evidence of diversion. Patient perspectives should inform future policies to better address the ongoing overdose epidemic.

The development and implementation of a "B-Team" (buprenorphine team) to treat hospitalized patients with opioid use disorder

IMPLEMENTATION INSIGHTS.

Investigating interventions that lead to the highest treatment retention for emerging adults with substance use disorder: A systematic review

BACKGROUND AND AIMS

Emerging adults (age 18-25) have the highest rate of substance use disorders (SUD) and often drop out of treatment earlier than those age twenty six or older. In order to increase treatment retention in emerging adults, there needs to be a better understanding of which SUD treatment interventions work best for this population. The purpose of this systematic review was to evaluate treatment interventions for emerging adults with SUD and identify which interventions show promise for retention in treatment.

METHODS

Following the PRISMA guidelines, Medline, PsycInfo, CINAHL (all via EBSCO), and Embase were systematically searched for articles that evaluated treatment interventions for emerging adults with SUD. From here, the authors identified treatment interventions that showed promise for retention in treatment.

RESULTS

Nine studies were included. The main findings indicate (1) behavioral therapy such as cognitive behavioral therapy and contingency management for cannabis and alcohol use disorders, or (2) cognitive behavioral therapy paired with opioid-agonist-therapy for opioid use disorder demonstrate the most promise for retention in treatment.

CONCLUSION

The interventions identified that show promise for emerging adults was similar to studies evaluating interventions for all ages. Given that retention rates are often lower in emerging adults despite the application of the full range of effective adult treatments, this review suggests they may require something different. While further studies are warranted to determine with more certainty what works best to keep emerging adults in treatment, some tentative suggestions are included.

[Kratom - a short review for pain medicine]

Hintergrund

Der Konsum des psychotrop wirksamen Kratoms (botanischer Name: Mitragyna speciosa) erfolgt teilweise zum Zweck der Selbstmedikation bei chronischen und akuten Schmerzen. Eine zunehmende Verbreitung des Konsums in Deutschland ist in Zukunft möglich.

Ziele der Arbeit

Diese Übersicht vermittelt daher Schmerztherapeuten pharmakologische Aspekte sowie Essenzielles zur psychischen Wirkung, zur Wirkung auf Schmerzen und zu den Risiken von Kratom, inkl. Abhängigkeit.

Material und Methoden

Es erfolgte eine strukturierte Literaturrecherche in PubMed bis Mitte Januar 2021. Wir fanden 426 relevante Literaturstellen. Acht davon beschäftigten sich spezifisch mit Kratom und Schmerz.

Ergebnisse

Neben weiteren Alkaloiden enthält Kratom das an Opioidrezeptoren wirksame (7-Hydroxy‑)Mitragynin. Der Konsum birgt Risiken, u. a. aufgrund nichtstandardisierter Verabreichung, aber auch durch direkte gesundheitliche Schäden bis hin zur möglichen Entwicklung einer Abhängigkeit.

Diskussion

Aktuell kann evidenzbasiert keine Empfehlung zur Nutzung von Kratom als Analgetikum gegeben werden. Für Schmerztherapeuten ist es wichtig, einen eventuellen Kratomkonsum zu erfragen und den Patienten über die potenziellen Risiken von Kratom zu informieren.

"I'm pretty sure it's either food poisoning or Covid-19": Lived experience versus medical knowledge in diagnosing substance use problems

People who use drugs, or who have in the past, often report that doctors and/or treatment providers devalue, or are unwilling to believe their claims in regards to substance use issues, in particular the presence and severity of withdrawal. In the case of benzodiazepine withdrawal this can not only lead to significant discomfort, frustration, and trauma for patients, but can lead to serious medical problems. This commentary uses the authors’ recent first-person experience with a disbelieving doctor in order to illustrate the lack of value often given to the claims and narratives of people with lived substance use experience. I outline some of the potential problems with this approach, including the effects on patients themselves and the loss of an important source of evidence-based knowledge. It also discusses potential risks associated with the recent increase in benzodiazepine prescription due to Covid-19 and offers suggestions for improving treatment outcomes.

Smoking cessation or initiation: The paradox of vaping

In recent years, there has been a rapid expansion of the vaping market which has led many to question whether vaping can assist people in smoking cessation, or if it in fact paves the way for new smokers. While there has not been conclusive evidence regarding vaping as a smoking cessation tool, there is striking evidence that vaping is linked to new smoking addictions, especially in teenagers and young adults. Despite the prevalent belief that tobacco is more harmful to the body, early research on vaping has already shown very detrimental effects, and the comprehensive effects may become much clearer in the years to come. To curtail the rapidly increasing number of teenagers and young adults vaping, strict action must be taken. Legalization with tight control of vaping products would focus the efforts on those attempting to quit, while helping to prevent acquisition by teenagers and young adults that are not of legal age. In the years to come, vaping controls should be carefully considered to ensure that the purported benefits of helping those overcome a smoking addiction are not outweighed by the unintended consequences of creating a teenage demographic addicted to vaping.

Mixed methods feasibility study for the surviving opioid overdose with naloxone education and resuscitation (SOONER) trial

Aim

We plan to conduct a randomised clinical trial among people likely to witness opioid overdose to compare the educational effectiveness of point-of-care naloxone distribution with best-available care, by observing participants’ resuscitation skills in a simulated overdose. This mixed methods feasibility study aims to assess the effectiveness of recruitment and retention strategies and acceptability of study procedures.

Methods

We implemented candidate-driven recruitment strategies with verbal consent and destigmatizing study materials in a family practice, emergency department, and addictions service. People ≥16 years of age who are likely to witness overdose were randomized to point-of-care naloxone distribution or referral to an existing program. We evaluated participant skills as a responder to a simulated overdose 3–14 days post-recruitment. Retention strategies included flexible scheduling, reminders, cash compensation and refreshments. The primary outcome was recruitment and retention feasibility, defined as the ability to recruit 28 eligible participants in 28 days, with <50% attrition at the outcome simulation. Acceptability of study procedures and motivations for participation were assessed in a semi-structured interview.

Results

We enrolled 30 participants over 24 days, and retained 21 participants (70%, 95%CI 56.7–100). The most common motivation for participation was a desire to serve the community or loved ones in distress. Participants reported that study procedures were acceptable and that the outcome simulation provided a supportive and affirming environment.

Conclusion

The planned trial is ready for implementation. Recruitment and retention is feasible and study processes are acceptable for people who are likely to witness overdose. (Registration: NCT03821649).

Hospital admissions and mortality due to complications of injection drug use in two hospitals in Regina, Canada: retrospective chart review

BACKGROUND

Infectious complications of injection drug use (IDU) often require lengthy inpatient treatment. Our objective was to identify the number of admissions related to IDU in Regina, Canada, as well as describe patient demographics and comorbidities, yearly mortality, readmission rate, and cumulative cost of these hospitalizations between January 1 and December 31, 2018. Additionally, we sought to identify factors that increased risk of death or readmission.

METHODS

This study is a retrospective chart review conducted at the two hospitals in Regina. Eligible study cases were identified by querying the discharge database for predetermined International Classification of Diseases code combinations. Electronic medical records were reviewed to assess whether each admission met inclusion criteria, and hospitalization and patient data were subsequently extracted for all included admissions. Mortality data were gleaned from hospital and Ministry of Health databases. Data were analyzed using Excel and IBM SPSS Statistics to identify common comorbidities, admission diagnoses, and costs, as well as to compare patients with a single admission during the study period to those with multiple admissions. Logistic regression analysis was used to identify the relationship between individual variables and in- and out-of-hospital annual mortality.

RESULTS

One hundred and forty-nine admissions were included, with 102 unique patients identified. Common comorbidities included hepatitis C (47%), human immunodeficiency virus (HIV) (25%), and comorbid psychiatric disorders (19%). In 23% of all admissions, patients left hospital prior to treatment completion, and 27% of patients experienced multiple admissions. Female patients and those with chronic pain were more likely to be readmitted (p = 0.024 and p = 0.029, respectively). Patients admitted with infective endocarditis were more likely to die during hospitalization (p = 0.0001). The overall mortality was 15% in our cohort. The estimated cumulative cost of inpatient treatment of complications of IDU in Regina was $3.7 million CAD in 2018.

CONCLUSION

Patients with history of IDU and hospital admission experience high mortality rates in Regina, a city with paucity of inpatient supports for persons who use injection drugs. Needle syringe programs, opioid agonist therapy, and safe consumption sites have been shown to improve outcomes as well as reduce healthcare costs for this patient population. We will use our findings to advocate for increased access to these harm reduction strategies in Regina, particularly for inpatients.

Integrating DATA 2000 waiver training into undergraduate medical education: The time is now

Background: Medications for opioid use disorder (MOUD) significantly reduce morbidity and mortality from opioid use disorder (OUD). To prescribe MOUD, physicians must obtain a DEA waiver through requirements outlined in the Drug Addiction Treatment Act of 2000 (DATA 2000). We developed an Addiction Medicine curriculum that features DATA 2000 waiver training at the Robert Larner, MD College of Medicine (LCOM). Methods: All third-year medical students completed a virtual DATA 2000 waiver training at the commencement of clinical clerkships. We conducted a curriculum needs assessment followed by pre- and post-training surveys to evaluate MOUD pharmacology knowledge and best prescribing practices. Results: Of LCOM students surveyed, 77.6% reported interest in being waivered to prescribed MOUD for OUD treatment. Third-year medical students demonstrated increases in both MOUD Pharmacology Knowledge from 64.2% to 84.8% (chi-squared = 40.8; p < .001) and MOUD Best Prescribing Practices from 55.9% to 75.2% (chi-squared = 29.9; p < .001). Discussion: Surveys showed the majority of students felt waiver training was relevant to their future practice. An online DATA 2000 waiver training format effectively improved student knowledge of MOUD. Conclusion: This curriculum exposed medical students to DATA 2000 waiver training, MOUD pharmacology and best practices, and increased the number of future physicians eligible to treat OUD using MOUD.

Street-drug lethality index: A novel methodology for predicting unintentional drug overdose fatalities in population research

BACKGROUND

Emerging evidence suggests the composition of local illicit drug markets varies over time and the availability and relative lethality of illicit drugs may contribute to temporal trends in overdose mortality. Law enforcement drug seizures represent a unique opportunity to sample the makeup of local drug markets. Prior research has associated shifts in the types of drugs seized and trends in unintentional drug overdose mortality. The present report builds on this work by demonstrating a novel methodology, the Street-Drug Lethality Index, which may serve as a low-lag predictor of unintentional overdose deaths.

METHODS

Data included administrative records of law enforcement drug seizures and unintentional drug overdose deaths in Ohio from 2009 -to- 2018. Death records and lab results from drug seizures occurring during the calendar year 2017 were transformed via the described procedure to create lethality indices for individual drugs. These indices were then summed annually to create the independent variable for a linear regression model predicting unintentional overdose deaths for all years during the study period.

RESULTS

The regression model explained 93 % of the year-to-year variance in unintentional overdose fatalities (slope = 0.009480; CI = 0.007369 to 0.011590; t10 = 10.355942; P = 0.000007; Y = 11.808982 + 0.009480X, r2 = 0.931).

CONCLUSION

These findings contribute to a growing body of evidence that changes in the composition of the drug supply may predict trends in unintentional overdose mortality. The proposed methodology might inform future overdose prevention and response efforts as well as research.

An international consultation on case reports in addiction medicine

BACKGROUND

A Case Report (CR) is a scientific documentation of a single clinical observation which serves to inform but also to educate the reader. Case reports help to compliment clinical critical thinking in Addiction Medicine (AM) when there is limited evidence base. Aim: This study aims to analyze how international clinical and research leaders in Addiction Medicine view Case Reports and their relevance to bridge the gap between evidence and practice. Methods: A semi-structured, audio-recorded interviews were conducted with 12 international Addiction Medicine scholars. Thematic content analysis was used to code the transcribed interview data. Results: Interviewees showed a positive view toward publishing Case Reports in Addiction Medicine. They found that medical students and clinicians working in the field of Addiction Medicine should be encouraged to share and record cases of clinical interaction. To aid this process (1) formal supervised training in case reporting within an academic environment must be facilitated. And (2) journals should also offer a place to publish Case Reports. Conclusion: The international scholars agree that Case Reports are important for the development of Addiction Medicine and that they can contribute to a better understanding of patients with substance use disorder.

Addiction psychiatry and addiction medicine - Strange bedfellows or separated at birth?

Substance use disorders (SUDs) are major causes of morbidity and mortality in the United States. SUDs commonly co-occur with other psychiatric and physical illness and often require management by an addiction specialist to comprehensively address patients' complex needs. The American Board of Medical Specialties (ABMS) offers two pathways leading to addiction subspecialty board certification: addiction psychiatry (American Board of Psychiatry and Neurology) and addiction medicine (American Board of Preventive Medicine). We explore the history of the distinct but overlapping practices of addiction medicine and addiction psychiatry and describe the unique contributions of each field. Specifically, we review skill sets, specialty training, and career outcomes for physicians specializing in the assessment and management of SUDs. We conclude by highlighting collaboration between the two specialties and offer a shared vision for the future of addiction specialty care.