Design and Implementation of a Curriculum for Emergency Medicine Residents to Address Medications and Treatment Referral for Opioid Use Disorder.

Background: Medications for Opioid Use Disorder (MOUD) are recognized as successful treatments for Opioid Use Disorder (OUD). The Emergency Department is well situated to initiate MOUD and begin the referral process. Unfortunately, uptake of this practice among Emergency Medicine (EM) physicians has been slow. EM physicians may feel inadequately prepared to provide MOUD and addiction referral services due to lack of previous training and experience. The goal of this pilot study was to create, implement, and evaluate an OUD management curriculum for EM residents and measure impact on knowledge, practice, and empathy. Methods: A 4.5-hour curriculum was developed, incorporating the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment mission statement as well as the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine resident physician milestones. The curriculum was inserted into an existing EM residency didactic block at an urban, tertiary care, residency program. Surveys were obtained pre- and post-intervention. Results: Post curriculum surveys demonstrated improved knowledge of buprenorphine/naloxone including indications, clinical effects and side-effects (p < 0.05). Surveys also noted increased comfort prescribing buprenorphine/naloxone for opioid withdrawal and misuse and instructing patients on home induction (p < 0.05). Additionally, residents responded positively regarding the impact of the curriculum on their understanding of the topic and their subsequent confidence in managing patients with OUD in the ED setting. Conclusion: A dedicated brief MOUD and referral curriculum can be effectively integrated into EM resident education to provide valuable clinical knowledge that may affect clinical practice.

An Integrated Hospital Protocol for Persons With Injection-Related Infections May Increase Medications for Opioid Use Disorder Use but Challenges Remain.

BACKGROUND: Hospital-based strategies that link persons with infectious complications of opioid use disorder (OUD) to medications for OUD (MOUD) are of great interest. The objective of this study is to determine whether a hospital-based protocol would increase the use of MOUD and to identify barriers to MOUD during admission and at the time of discharge. METHODS: This study included participants with a documented or suspected history of injection drug usage receiving care for an infection at the University of Alabama at Birmingham Hospital from 2015 to 2018. The protocol, the intravenous antibiotic and addiction team (IVAT), included Addiction Medicine and Infectious Diseases consultation and a 9-item risk assessment. We quantified MOUD use before and after IVAT and used logistic regression to determine factors associated with MOUD. We explored barriers to MOUD uptake using chart review. RESULTS: A total of 37 and 98 patients met criteria in the pre- and post-IVAT periods, respectively. With IVAT, the percentage with OUD receiving MOUD significantly increased (29% pre-IVAT and 37% post-IVAT; P = .026) and MOUD use was higher in "high risk" participants (62%). Clinical and sociodemographic factors were not associated with MOUD receipt. CONCLUSIONS: A hospital-based protocol may increase the use of MOUD; however, the uptake of MOUD remains suboptimal (<50%).

A 9-Point Risk Assessment for Patients Who Inject Drugs and Require Intravenous Antibiotics: Focusing Inpatient Resources on Patients at Greatest Risk of Ongoing Drug Use.

A 9-point risk assessment identified persons with a history of injection drug use who were safe for discharge. "Low-risk" patients were discharged with outpatient antibiotics; others continued inpatient treatment. Use of the assessment reduced the mean length of stay by 20 days and total direct cost by 33%, creating capacity for an additional 333 patients.

Opioid Detoxification in Pregnancy: Systematic Review and Meta-Analysis of Perinatal Outcomes.

OBJECTIVE: We sought to compare the efficacy and safety of detoxification from opioids compared with opioid replacement therapy (ORT) during pregnancy. STUDY DESIGN: We searched PubMed, Embase, Cochrane Library, and ClinicalTrials.gov from inception to June 2017 for English-language randomized-controlled trials or cohort studies that compared detoxification with ORT. We sought studies with outcomes data on maternal abstinence at the time of delivery, neonatal abstinence syndrome (NAS), stillbirth, and preterm birth (PTB). We calculated pooled relative risks (RRs) with a random-effects model, assessed heterogeneity using the chi-square test for heterogeneity, and quantified heterogeneity using the I 2 test. We assessed publication bias using funnel plots and the Harbord test. RESULTS: Three cohort studies met the inclusion criteria; eligible studies included 235 women with opioid use disorder in pregnancy. Maternal detoxification was associated with increased risk of relapse (RR = 1.91; 95% confidence interval [CI] = 1.14-3.21); however, no treatment differences were observed for the rates of NAS (RR = 0.99; 95% CI = 0.38-2.53) or PTB (RR = 0.39; 95% CI = 0.10-1.60). CONCLUSION: Our findings suggest an increased risk of relapse with detoxification treatment compared with ORT; however, detoxification does not alter the risk of PTB or NAS. Further studies should confirm our findings and explore mechanisms to fight the current opioid epidemic.

In-Hospital Illicit Drug Use and Patient-Directed Discharge: Barriers to Care for Patients With Injection-Related Infections.

BACKGROUND: Hospitalized persons who inject drugs are at a greater risk of adverse hospital outcomes including discharge against medical advice, inpatient illicit drug use, overdose, and death. However, there are limited data on the frequency and outcomes of these events in the United States. METHODS: This retrospective analysis included patients with injection-related infections receiving a protocol for injection drug use (IDU) at University of Alabama at Birmingham Hospital from 2016 to 2017. In-hospital IDU was suspected or reported drug usage plus confirmatory drug screen, and documented discharges "against medical advice" were deemed patient-directed discharges (PDD). We analyzed the frequency of and associations between in-hospital IDU, PDD, 30-day readmission, and deaths (between 2016 and 2019) using McNemar's tests. Logistic regression models evaluated the association between PDD, in-hospital IDU, readmission, and death. RESULTS: Overall, 83 patients met inclusion criteria: 28 (34%) with in-hospital IDU, 12 (14%) PDD, 9 (11%) died, and 12 (14%) 30-day readmission. In-hospital IDU was significantly associated with PDD (P = .003), 30-day readmission (P = .005), and death (P = .0003). Patient-directed discharges and 30-day readmission were not significantly associated with death nor with each other. CONCLUSIONS: In a cohort of patients receiving inpatient care for injection-related infections, illicit drug use, PDD, 30-day readmissions, and death were common. Furthermore, patients who use illicit drugs while hospitalized are significantly more likely to leave early, be readmitted, and/or die. We must design models of care that prevent adverse outcomes, including drug use and PDD, to reduce barriers to evidence-based treatment of infections.