Peer recovery coaches in general medical settings: Changes in utilization, treatment engagement, and opioid use.

Recovery coaches, trained peers with a history of substance use disorder (SUD) who are formally embedded in the health care team, may be a cost-effective approach to support outpatient management of SUD treatment. Although recovery coach programs are scaling nationwide, limited data exist to support their impact on costs or clinical outcomes. This study aimed to evaluate the integration of peer recovery coaches in general medical settings. Staff hired and trained nine recovery coaches as a part of a health system-wide effort to redesign SUD care. We examined reductions in acute care utilization and increases in outpatient treatment utilization among patients connected to a recovery coach. Additionally, we examined buprenorphine treatment engagement and opioid abstinence among a subset of patients who initiated buprenorphine prior to or within 30 days of their first recovery coach contact. We hypothesized recovery coach contact would strengthen outpatient SUD treatment and be associated with reductions in SUD severity and preventable acute care utilization. We included patients with an initial recovery coach contact between January 2015 and September 2017 in the main analyses (N = 1171). We assessed utilization outcomes via medical records over one year, comparing the six months before and after first recovery coach contact. We used chart review to extract toxicology results and buprenorphine treatment engagement for the subset of patients initiated on buprenorphine (n = 135). In the six months following recovery coach contact, there was a 44% decrease in patients hospitalized and a 9% decrease in patients with an ED visit. There was a 66% increase in outpatient utilization across primary care, community health center visits, mental health, and laboratory visits. Among patients who initiated buprenorphine, current recovery coach contact was associated with significantly increased odds of buprenorphine treatment engagement (OR = 1.89; 95% CI: 1.49-2.39; p < 0.001) and opioid abstinence (OR = 1.32; 95% CI: 1.02-1.70; p < 0.001). Recovery coaches may be an impactful and potentially cost-effective addition to an SUD care team, but future research is needed that uses a matched comparison condition.

The effectiveness of post-discharge navigation added to an inpatient addiction consultation for patients with substance use disorder; a randomized controlled trial.

Background: It is unknown whether post-discharge navigation enhances the impact of hospital-initiated addiction care. This study tested the incremental benefit of telephonic linkage to a post-discharge navigator for patients who received an addiction consultation during hospitalization. Methods: A two-arm, randomized controlled trial of 395 hospitalized adults with substance use disorder who received an addiction consultation. The intervention group received post-discharge phone calls from a navigator to review the recommended treatment plan and address barriers to engagement on days 3, 7, 14, and 21. The primary outcome was days of alcohol or drug use in the past 30 assessed by Timeline Follow-back at 1 month. Results: Follow-up assessment completion rates were 46% at 1 month, and 41%, at 2 months. At baseline, intervention and control groups did not differ in substance use patterns; 45% reported primary alcohol use, 43% drugs, and 12% both. Heroin was the most common drug. At baseline, mean days of past 30-day alcohol or drug use were 13.6 in the intervention and 14.9 in the control group. The median number of navigation calls completed was 3 out of 4. At 1 month, both groups reported less use (decrease of 4.8 in intervention vs. 4.2 days in control group, p = 0.49). There were no differences between groups at 2 months. Compared to controls, participants who received all four calls had a greater decrease in use with a mean 8.6 days decrease from baseline (difference of 4.4 days, p = 0.0009). Conclusion: Post-discharge telephonic patient navigation did not further improve substance use outcomes following addiction consultation.

Effect of Integrating Substance Use Disorder Treatment into Primary Care on Inpatient and Emergency Department Utilization.

BACKGROUND: Components of substance use disorder (SUD) treatment have been shown to reduce inpatient and emergency department (ED) utilization. However, integrated treatment using pharmacotherapy and recovery coaches in primary care has not been studied. OBJECTIVE: To determine whether integrated addiction treatment in primary care reduces inpatient and ED utilization and improves outpatient engagement. DESIGN: A retrospective cohort study comparing patients in practices with and without integrated addiction treatment including pharmacotherapy and recovery coaching during a staggered roll-out period. PARTICIPANTS: A propensity score matched sample of 2706 adult primary care patients (1353 matched pairs from intervention and control practices) with a SUD diagnosis code, excluding cannabis or tobacco only, matched on baseline utilization. INTERVENTION: A multi-modal strategy that included forming interdisciplinary teams of local champions, access to addiction pharmacotherapy, counseling, and recovery coaching. Control practices could refer patients to an addiction treatment clinic offering pharmacotherapy and behavioral interventions. MAIN MEASURES: The number of inpatient admissions, hospital bed days, ED visits, and primary care visits. KEY RESULTS: During the follow-up period, there were fewer inpatient days among the intervention group (997 vs. 1096 days with a mean difference of 7.3 days per 100 patients, p = 0.03). The mean number of ED visits was lower for the intervention group (36.2 visits vs. 42.9 per 100 patients, p = 0.005). There was no difference in the mean number of hospitalizations. The mean number of primary care visits was higher for the intervention group (317 visits vs. 270 visits per 100 patients, p < 0.001). Intervention practices had a greater increase in buprenorphine and naltrexone prescribing. CONCLUSIONS: In a non-randomized retrospective cohort study, integrated addiction pharmacotherapy and recovery coaching in primary care resulted in fewer hospital days and ED visits for patients with SUD compared to similarly matched patients receiving care in practices without these services.

Inpatient Addiction Consultation for Hospitalized Patients Increases Post-Discharge Abstinence and Reduces Addiction Severity.

BACKGROUND: Alcohol and drug use results in substantial morbidity, mortality, and cost. Individuals with alcohol and drug use disorders are overrepresented in general medical settings. Hospital-based interventions offer an opportunity to engage with a vulnerable population that may not otherwise seek treatment. OBJECTIVE: To determine whether inpatient addiction consultation improves substance use outcomes 1 month after discharge. DESIGN: Prospective quasi-experimental evaluation comparing 30-day post-discharge outcomes between participants who were and were not seen by an addiction consult team during hospitalization at an urban academic hospital. PARTICIPANTS: Three hundred ninety-nine hospitalized adults who screened as high risk for having an alcohol or drug use disorder or who were clinically identified by the primary nurse as having a substance use disorder. INTERVENTION: Addiction consultation from a multidisciplinary specialty team offering pharmacotherapy initiation, motivational counseling, treatment planning, and direct linkage to ongoing addiction treatment. MAIN MEASURES: Addiction Severity Index (ASI) composite score for alcohol and drug use and self-reported abstinence at 30 days post-discharge. Secondary outcomes included 90-day substance use measures and self-reported hospital and ED utilization. KEY RESULTS: Among 265 participants with 30-day follow-up, a greater reduction in the ASI composite score for drug or alcohol use was seen in the intervention group than in the control group (mean ASI-alcohol decreased by 0.24 vs. 0.08, p < 0.001; mean ASI-drug decreased by 0.05 vs. 0.02, p = 0.003.) There was also a greater increase in the number of days of abstinence in the intervention group versus the control group (+12.7 days vs. +5.6, p < 0.001). The differences in ASI-alcohol, ASI-drug, and days abstinent all remained statistically significant after controlling for age, gender, employment status, smoking status, and baseline addiction severity (p = 0.018, 0.018, and 0.02, respectively). In a sensitivity analysis, assuming that patients who were lost to follow-up had no change from baseline severity, the differences remained statistically significant. CONCLUSIONS: In a non-randomized cohort of medical inpatients, addiction consultation reduced addiction severity for alcohol and drug use and increased the number of days of abstinence in the first month after hospital discharge.