Impact of inpatient addiction psychiatry consultation on opioid use disorder outcomes.

BACKGROUND AND OBJECTIVES: Addiction consultation services provide access to specialty addiction care during general hospital admission. This study assessed opioid use disorder (OUD) outcomes associated with addiction consultation. METHODS: Retrospective cohort study of individuals with OUD admitted to an academic medical center between 2018 and 2023. The exposure was addiction consultation. Outcomes included initiating medication for OUD (MOUD), hospital length of stay, before-medically-advised (BMA) discharge, and 30- and 90-day postdischarge acute care utilization. RESULTS: Of 26,766 admissions (10,501 patients) with OUD, 2826 addiction consultations were completed. Consultation cohort was more likely to be young, male, and White than controls. Consultation was associated with greater MOUD initiation (adjusted odds ratio [aOR], 5.07; 95% confidence interval [CI], 4.41-5.82), fewer emergency department visits at 30 (aOR, 0.78; 95% CI, 0.67-0.92) and 90 (aOR, 0.79; 95% CI, 0.69-0.89) days, and fewer hospitalizations at 30 (aOR, 0.65; 95% CI, 0.56 to 0.76) and 90 (aOR, 0.67; 95% CI, 0.59-0.76) days. Additionally, consultation patients were more likely to have a longer hospital stay and leave BMA. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Addiction consultation was associated with increased MOUD initiation and reduced postdischarge acute care utilization. This is the largest study to date showing a significant association between addiction psychiatry consultation and improved OUD outcomes when compared to controls. The observed reduction in postdischarge acute care utilization remains even after adjusting for MOUD initiation. Disparities in access to addiction consultation warrant further study.

More Effective Communication During Inpatient Addiction Treatment.

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

Assessment of a Naloxone Coprescribing Alert for Patients at Risk of Opioid Overdose: A Quality Improvement Project.

BACKGROUND: Patients taking high doses of opioids, or taking opioids in combination with other central nervous system depressants, are at increased risk of opioid overdose. Coprescribing the opioid-reversal agent naloxone is an essential safety measure, recommended by the surgeon general, but the rate of naloxone coprescribing is low. Therefore, we set out to determine whether a targeted clinical decision support alert could increase the rate of naloxone coprescribing. METHODS: We conducted a before-after study from January 2019 to April 2021 at a large academic health system in the Southeast. We developed a targeted point of care decision support notification in the electronic health record to suggest ordering naloxone for patients who have a high risk of opioid overdose based on a high morphine equivalent daily dose (MEDD) ≥90 mg, concomitant benzodiazepine prescription, or a history of opioid use disorder or opioid overdose. We measured the rate of outpatient naloxone prescribing as our primary measure. A multivariable logistic regression model with robust variance to adjust for prescriptions within the same prescriber was implemented to estimate the association between alerts and naloxone coprescribing. RESULTS: The baseline naloxone coprescribing rate in 2019 was 0.28 (95% confidence interval [CI], 0.24-0.31) naloxone prescriptions per 100 opioid prescriptions. After alert implementation, the naloxone coprescribing rate increased to 4.51 (95% CI, 4.33-4.68) naloxone prescriptions per 100 opioid prescriptions (P < .001). The adjusted odds of naloxone coprescribing after alert implementation were approximately 28 times those during the baseline period (95% CI, 15-52). CONCLUSIONS: A targeted decision support alert for patients at risk for opioid overdose significantly increased the rate of naloxone coprescribing and was relatively easy to build.

Implementation of a Hub-and-Spoke Partnership for Opioid Use Disorder Treatment in a Medicaid Nonexpansion State.

Hub-and-spoke (H&S) partnerships for managing opioid use disorder vary by U.S. state. This column provides the first description of the development of an H&S partnership in Tennessee, a Medicaid nonexpansion state. Medicaid expansion allows states to fund evidence-based substance use disorder treatment and community-based psychosocial interventions. In an H&S model in a Medicaid nonexpansion context, federal grant support must fund not only treatment itself but also the creation and maintenance of parallel billing and documentation processes for various partners, reducing the funds available for patient care.

Bridging Recovery Initiative Despite Gaps in Entry (BRIDGE): study protocol for a randomized controlled trial of a bridge clinic compared with usual care for patients with opioid use disorder.

BACKGROUND: Patients with substance use disorders are overrepresented among general hospital inpatients, and their admissions are associated with longer lengths of stay and increased readmission rates. Amid the national opioid crisis, increased attention has been given to the integration of addiction with routine medical care in order to better engage such patients and minimize fragmentation of care. General hospital addiction consultation services and transitional, hospital-based "bridge" clinics have emerged as potential solutions. We designed the Bridging Recovery Initiative Despite Gaps in Entry (BRIDGE) trial to determine if these clinics are superior to usual care for these patients. METHODS: This single-center, pragmatic, randomized controlled clinical trial is enrolling hospitalized patients with opioid use disorder (OUD) who are initiating medication for OUD (MOUD) in consultation with the addiction consult service. Patients are randomized for referral to a co-located, transitional, multidisciplinary bridge clinic or to usual care, with the assignment probability being determined by clinic capacity. The primary endpoint is hospital length of stay. Secondary endpoints include quality of life, linkage to care, self-reported buprenorphine or naltrexone fills, rate of known recurrent opioid use, readmission rates, and costs. Implementation endpoints include willingness to be referred to the bridge clinic, attendance rates among those referred, and reasons why patients were not eligible for referral. The main analysis will use an intent-to-treat approach with full covariate adjustment. DISCUSSION: This ongoing pragmatic trial will provide evidence on the effectiveness of proactive linkage to a bridge clinic intervention for hospitalized patients with OUD initiating evidence-based pharmacotherapy in consultation with the addiction consult service. TRIAL REGISTRATION: ClinicalTrials.gov NCT04084392 . Registered on 10 September 2019. The study has been approved by the Vanderbilt Institutional Review Board. The current approved protocol is dated version May 12, 2021.

Overlapping Mechanisms of Recovery Between Professional Psychotherapies and Alcoholics Anonymous.

BACKGROUND: Much research over the past 25 years has focused on elucidating the mechanisms by which Alcoholics Anonymous (AA) affects behavioral change in its participants. In addition to research on the spiritual mechanisms for which AA is best known in the popular conception, research on mechanisms of recovery (MOR) has predominantly supported social, cognitive, and affective mechanisms that are also present in many professional psychotherapies. AIM: This paper compares and contrasts the theorized MOR of AA with those found in several common professional psychotherapies to illustrate analogous elements. METHODS: Literature review, summary, and synthesis of studies examining the MOR of both AA and common psychotherapies including analytic/dynamic therapies, cognitive-behavioral therapies, and acceptance and mindfulness-based therapies. RESULTS: There exists a significant overlap in theorized MOR of AA and mainstream, professional psychotherapies. Mechanisms with the greatest overlap include those mobilizing stress and coping theory, behavioral choice theory, and social learning theory, while mechanisms more unique to AA compared to professional psychotherapies mobilize social control theory to a greater degree. CONCLUSIONS: In caring for patients with addiction, practicing clinicians will find it useful to be aware of overlapping analogous elements found in the AA program and professional psychotherapies and how they can complement one another.

Correlates of Opioid Abstinence in a 42-Month Posttreatment Naturalistic Follow-Up Study of Prescription Opioid Dependence.

OBJECTIVE: The natural course of prescription opioid use disorder has not been examined in longitudinal studies. The current study examined correlates of opioid abstinence over time after completion of a treatment trial for prescription opioid dependence. METHODS: The multisite Prescription Opioid Addiction Treatment Study examined different durations of buprenorphine-naloxone treatment and different intensities of counseling to treat prescription opioid dependence, as assessed by DSM-IV; following the clinical trial, a longitudinal study was conducted from March 2009-January 2013. At 18, 30, and 42 months after treatment entry, telephone interviews were conducted (N = 375). In this exploratory, naturalistic study, logistic regression analyses examined the association between treatment modality (including formal treatment and mutual help) and opioid abstinence rates at the follow-up assessments. RESULTS: At the 3 follow-up assessments, approximately half of the participants reported engaging in current substance use disorder treatment (47%-50%). The most common treatments were buprenorphine maintenance (27%-35%) and mutual-help group attendance (27%-30%), followed by outpatient counseling (18%-23%) and methadone maintenance (4%). In adjusted analyses, current opioid agonist treatment showed the strongest association with current opioid abstinence (odds ratios [ORs] = 5.4, 4.6, and 2.8 at the 3 assessments), followed by current mutual-help attendance (ORs = 2.2, 2.7, and 1.9); current outpatient counseling was not significantly associated with abstinence in the adjusted models. CONCLUSIONS: While opioid agonist treatment was most strongly associated with opioid abstinence among patients with prescription opioid dependence over time, mutual-help group attendance was independently associated with opioid abstinence. Clinicians should consider recommending both of these interventions to patients with opioid use disorder. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00316277​.

Predictors of early dropout in outpatient buprenorphine/naloxone treatment.

BACKGROUND AND OBJECTIVES: Identifying predictors of early drop out from outpatient treatment of opioid use disorder (OUD) with buprenorphine/naloxone (BN) may improve care for subgroups requiring more intensive engagement to achieve stabilization. However, previous research on predictors of dropout among this population has yielded mixed results. The aim of the present study was to elucidate these mixed findings by simultaneously evaluating a range of putative risk factors that may predict dropout in BN maintenance treatment. METHODS: Outpatient medical records and weekly supervised urine toxicology results were retrospectively reviewed for patients at two community psychiatric clinics (n = 202): a private hospital clinic (n = 84) and a federally qualified health center (n = 118). A forward stepwise logistic regression was utilized to investigate the association between early dropout (i.e., discontinuing treatment or buprenorphine non-adherence within the first 3 months of clinic entry) and extracted sociodemographic, clinical, substance use, and treatment history variables. RESULTS: Overall, 56 of 202 participants (27.7%) dropped out of treatment. The multivariable analysis indicated that age under 25 (B = 1.47, SEB = .52, p < .01) and opioid use in month 1 (B = 1.50, SEB = .41, p < .001) were significantly associated with early dropout; those with a history of suicide attempt were significantly less likely to drop out (B = -1.44, SEB = .67, p < .05). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Consistent with previous research, younger age and use of opioids during the first month of treatment predicted early dropout. Having a history of prior suicide attempt was associated with 3-month BN treatment retention, which has not been previously reported. (Am J Addict 2016;25:472-477).

Short, subjective measures of numeracy and general health literacy in an adult emergency department.

OBJECTIVES: The objective was to evaluate the reliability and validity of brief subjective measures of numeracy and general health literacy in the adult emergency department (ED) setting. METHODS: A convenience sample of adult ED patients completed subjective measures of general health literacy (Short Literacy Survey [SLS]) and numeracy (Subjective Numeracy Scale [SNS]). These patients also completed two objective tests of literacy (the Short Test of Functional Health Literacy in Adults [S-TOFHLA] and the Rapid Estimate of Adult Literacy in Medicine [REALM]) and an objective test of numeracy (Wide Range Achievement Test-4 [WRAT4]). Internal reliability of the subjective measures was assessed using Cronbach's alpha. Construct validity of the subjective measures was assessed by correlating them against the S-TOFHLA, REALM, and WRAT4, using Spearman's rank correlation coefficients, receiver operating characteristics (ROC) curves, and hierarchical, multiple linear regression with adjustment for patient age, sex, race, and education. RESULTS: The median age of the 207 patients surveyed was 46 years (interquartile range [IQR] = 32 to 59 years); 27% were African American. Sixty-one percent of patients reported that their highest level of education was high school or below. As measured by the S-TOFHLA and REALM, most patients had adequate literacy levels (89% and 80%, respectively), while 44% of patients had below average numeracy skills on the WRAT4. The median SLS score was 14 (IQR = 12 to 15) on a scale of 3 to 15; the median SNS score was 36 (IQR = 30 to 42) on a scale of 6 to 48. The SLS and SNS had good internal reliability, with Cronbach's alphas of 0.74 and 0.82, respectively. The SLS Spearman's rank order correlation coefficient was 0.33 (95% confidence interval [CI] = 0.20 to 0.45) for the S-TOFHLA, with a standardized beta coefficient of 0.36 (p < 0.05) after adjustment for patient demographics. The SLS correlation coefficient was 0.26 (95% CI = 0.13 to 0.38) for the REALM, with a standardized beta coefficient of 0.38 (p < 0.05) after adjustment for patient demographics. The area under the ROC curve (AUC) for the SLS was 0.74 (95% CI = 0.68 to 0.80) when compared to the S-TOFHLA and 0.72 (95% CI = 0.65 to 0.78) when compared to the REALM. The SNS predicted numeracy well, with a correlation coefficient of 0.57 (95% CI = 0.47 to 0.65) for the WRAT4, a standardized beta coefficient of 0.30 (p < 0.05) after adjustment for patient demographics, and an AUC of 0.77 (95% CI = 0.70 to 0.82). CONCLUSIONS: The SNS and SLS are reliable, valid tests that can be used to rapidly estimate general health literacy and numeracy skill levels in adult ED patients. Continuing work is needed to establish their ability to predict clinical outcomes.