The Confederated Tribes of the Grand Ronde Community of Oregon began a Mobile Medication Unit (MMU) as part of their Great Circle Recovery Opioid Treatment Program (OTP) to address elevated rates of ...opioid use disorder (OUD) among American Indians and Alaska Natives in Oregon. The MMU provides methadone or buprenorphine for individuals with OUD, enrolled in the OTP, who are living either on the reservation or in surrounding rural communities. An implementation study describes the service through document review and qualitatively assesses patient and staff experiences and the perceived barriers and facilitators to mobile services.
Semi-structured qualitative interviews with patients (
= 11), MMU staff (
= 5), and the state opioid treatment authority (
= 1) gathered details on the initiative's development and operations. Provider interviews probed implementation experiences. Patient interviews focused on their experiences with the MMU and staff, changes in quality of life and recommendations for enhancing treatment. Interviews were transcribed and analysed using a Thematic Analysis approach.
Staff themes identified two driving forces (i.e. staff desire for an inclusive approach to wellness that is accessible to all community members; the catalysts for the MMU), two steps toward MMU development (i.e. Tribal approvals and support; the construction and maintenance of community relationships) and two perspectives on MMU implementation and impact (i.e. initial implementation barriers; facilitators and observations of how the MMU reduced stigma associated with agonist therapy). Patients' themes noted the MMU's professional and 'caring' environment, accessible rural locations and general suggestions including culturally responsive ancillary services.
The Great Circle MMU enhanced access to opioid agonist therapy for people with OUD (i.e. American Indians/Alaska Natives, and non-natives) living in rural communities. The Confederated Tribes of Grand Ronde operates the first Tribally owned OTP MMU, grounded in cultural humility and committed to Tribal members and the great circle of the larger community.
IMPORTANCE: Effective prevention strategies for HIV infection are an important public health priority. Preexposure prophylaxis (PrEP) involves use of antiretroviral therapy (ART) daily or before and ...after sex to decrease risk of acquiring HIV infection. OBJECTIVE: To synthesize the evidence on the benefits and harms of PrEP, instruments for predicting incident HIV infection, and PrEP adherence to inform the US Preventive Services Task Force. DATA SOURCES: Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and EMBASE through June 2018, with surveillance through January 2019. STUDY SELECTION: English-language placebo-controlled randomized clinical trials of oral PrEP with tenofovir disoproxil fumarate/emtricitabine or tenofovir disoproxil fumarate monotherapy; studies on the diagnostic accuracy of instruments for predicting incident HIV infection; and studies on PrEP adherence. DATA EXTRACTION AND SYNTHESIS: Dual review of titles and abstracts, full-text articles, study quality, and data abstraction. Data were pooled using the Dersimonian and Laird random-effects model for effects of PrEP on HIV infection, mortality, and harms. MAIN OUTCOMES AND MEASURES: HIV acquisition, mortality, and harms; adherence to PrEP; and diagnostic test accuracy and discrimination. RESULTS: Fourteen RCTs (N = 18 837), 8 observational studies (N = 3884), and 7 studies of diagnostic accuracy (N = 32 279) were included. PrEP was associated with decreased risk of HIV infection vs placebo or no PrEP after 4 months to 4 years (11 trials; relative risk RR, 0.46 95% CI, 0.33-0.66; I2 = 67%; absolute risk reduction ARD, −2.0% 95% CI, −2.8% to −1.2%). Greater adherence was associated with greater efficacy (RR with adherence ≥70%, 0.27 95% CI, 0.19-0.39; I2 = 0%) in 6 trials. PrEP was associated with an increased risk of renal adverse events (12 trials; RR, 1.43 95% CI, 1.18-1.75; I2 = 0%; ARD, 0.56% 95% CI, 0.09%-1.04%) and gastrointestinal adverse events (12 trials; RR, 1.63 95% CI, 1.26-2.11; I2 = 43%; ARD, 1.95% 95% CI, 0.48%-3.43%); most adverse events were mild and reversible. Instruments for predicting incident HIV infection had moderate discrimination (area under the receiver operating characteristic curve, 0.49-0.72) and require further validation. Adherence to PrEP in the United States in men who have sex with men varied widely (22%-90%). CONCLUSIONS AND RELEVANCE: In adults at increased risk of HIV infection, PrEP with oral tenofovir disoproxil fumarate monotherapy or tenofovir disoproxil fumarate/emtricitabine was associated with decreased risk of acquiring HIV infection compared with placebo or no PrEP, although effectiveness decreased with suboptimal adherence.
Background
Individuals with substance use disorders (SUD) have high rates of chronic illness and readmission, yet few are engaged in addiction treatment. Hospitalization may be a reachable moment for ...initiating and coordinating addiction care, but little is known about motivation for change in the inpatient setting.
Objective
To explore the experiences of hospitalized adults with SUD and to better understand patient and system level factors impacting readiness for change.
Design
We performed a qualitative study using individual interviews. The study was nested within a larger mixed-methods needs assessment.
Participants and Setting
Hospitalized adults admitted to medical or surgical units at an urban academic medical center who reported high-risk alcohol or drug use on AUDIT-C or single-item drug use screener.
Approach
We conducted a thematic analysis, using an inductive approach at a semantic level.
Key Results
Thirty-two patients participated. The mean age was 43 years; 75% were men, and 68% identified as white. Participants reported moderate to high-risk alcohol (39%), amphetamine (46%), and opioid (65%) use. Emergent themes highlight the influence of hospitalization at the patient, provider, and health system levels. Many patients experienced hospitalization as a wake-up call, where mortality was motivation for change and hospitalization disrupted substance use. However, many participants voiced complex narratives of social chaos, trauma, homelessness, and chronic pain. Participants valued providers who understood SUD and the importance of treatment choice. Patient experience suggests the importance of peers in the hospital setting, access to medication-assisted treatment, and coordinated care post-discharge.
Conclusions
This study supports that hospitalization offers an opportunity to initiate and coordinate addiction care, and provides insights into patient, provider, and health system factors which can leverage the reachability of this moment.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Injection drug use has far-reaching social, economic, and health consequences. Serious bacterial infections, including skin/soft tissue infections, osteomyelitis, bacteremia, and endocarditis, are ...particularly morbid and mortal consequences of injection drug use.
We conducted a population-based retrospective cohort analysis of hospitalizations among patients with a diagnosis code for substance use and a serious bacterial infection during the same hospital admission using Oregon Hospital Discharge Data. We examined trends in hospitalizations and costs of hospitalizations attributable to injection drug use-related serious bacterial infections from January 1, 2008 through December 31, 2018.
From 2008 to 2018, Oregon hospital discharge data included 4,084,743 hospitalizations among 2,090,359 patients. During the study period, hospitalizations for injection drug use-related serious bacterial infection increased from 980 to 6,265 per year, or from 0.26% to 1.68% of all hospitalizations (P<0.001). The number of unique patients with an injection drug use-related serious bacterial infection increased from 839 to 5,055, or from 2.52% to 8.46% of all patients (P<0.001). While hospitalizations for all injection drug use-related serious bacterial infections increased over the study period, bacteremia/sepsis hospitalizations rose most rapidly with an 18-fold increase. Opioid use diagnoses accounted for the largest percentage of hospitalizations for injection drug use-related serious bacterial infections, but hospitalizations for amphetamine-type stimulant-related serious bacterial infections rose most rapidly with a 15-fold increase. People living with HIV and HCV experienced increases in hospitalizations for injection drug use-related serious bacterial infection during the study period. Overall, the total cost of hospitalizations for injection drug use-related serious bacterial infections increased from $16,305,129 in 2008 to $150,879,237 in 2018 (P<0.001).
In Oregon, hospitalizations for injection drug use-related serious bacterial infections increased dramatically and exacted a substantial cost on the health care system from 2008 to 2018. This increase in hospitalizations represents an opportunity to initiate substance use disorder treatment and harm reduction services to improve outcomes for people who inject drugs.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Background
Hospitalizations due to medical and surgical complications of substance use disorder (SUD) are rising. Most hospitals lack systems to treat SUD, and most people with SUD do not engage in ...treatment after discharge.
Objective
Determine the effect of a hospital-based addiction medicine consult service, the Improving Addiction Care Team (IMPACT), on post-hospital SUD treatment engagement.
Design
Cohort study using multivariable analysis of Oregon Medicaid claims comparing IMPACT patients with propensity-matched controls.
Participants
18–64-year-old Oregon Medicaid beneficiaries with SUD, hospitalized at an Oregon hospital between July 1, 2015, and September 30, 2016. IMPACT patients (
n
= 208) were matched to controls (
n
= 416) using a propensity score that accounted for SUD, gender, age, race, residence region, and diagnoses.
Interventions
IMPACT included hospital-based consultation care from an interdisciplinary team of addiction medicine physicians, social workers, and peers with lived experience in recovery. IMPACT met patients during hospitalization; offered pharmacotherapy, behavioral treatments, and harm reduction services; and supported linkages to SUD treatment after discharge.
Outcomes
Healthcare Effectiveness Data and Information Set (HEDIS) measure of SUD treatment engagement, defined as two or more claims on two separate days for SUD care within 34 days of discharge.
Results
Only 17.2% of all patients were engaged in SUD treatment before hospitalization. IMPACT patients engaged in SUD treatment following discharge more frequently than controls (38.9% vs. 23.3%,
p
< 0.01; aOR 2.15, 95% confidence interval CI 1.29–3.58). IMPACT participation remained associated with SUD treatment engagement when limiting the sample to people who were not engaged in treatment prior to hospitalization (aOR 2.63; 95% CI 1.46–4.72).
Conclusions
Hospital-based addiction medicine consultation can improve SUD treatment engagement, which is associated with reduced substance use, mortality, and other important clinical outcomes. National expansion of such models represents an opportunity to address an enduring gap in the SUD treatment continuum.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Greater integration of medication-assisted treatment (MAT) for opioid use disorder (OUD) in U.S. primary care settings would expand access to treatment for this condition. Models for integrating MAT ...into primary care vary in structure. This article summarizes findings of a technical report for the Agency for Healthcare Research and Quality describing MAT models of care for OUD, based on a literature review and interviews with key informants in the field. The report describes 12 representative models of care for integrating MAT into primary care settings that could be considered for adaptation across diverse health care settings. Common components of existing care models include pharmacotherapy with buprenorphine or naltrexone, provider and community education, coordination and integration of OUD treatment with other medical and psychological needs, and psychosocial services and interventions. Models vary in how each component is implemented. Decisions about adopting MAT models of care should be individualized to address the unique milieu of each implementation setting.
Background
There is pressing need to improve hospital-based addiction care. Various models for integrating substance use disorder care into hospital settings exist, but there is no framework for ...describing, selecting, or comparing models. We sought to fill that gap by constructing a taxonomy of hospital-based addiction care models based on scoping literature review and key informant interviews.
Methods
Methods included a scoping review of the literature on US hospital-based addiction care models and interventions for adults, published between January 2000 and July 2021. We conducted semi-structured interviews with 15 key informants experienced in leading, implementing, evaluating, andpracticing hospital-based addiction care to explore model characteristics, including their perceived strengths, limitations, and implementation considerations. We synthesized findings from the literature review and interviews to construct a taxonomy of model types.
Results
Searches identified 2,849 unique abstracts. Of these, we reviewed 280 full text articles, of which 76 were included in the final review. We added 8 references from reference lists and informant interviews, and 4 gray literature sources. We identified six distinct hospital-based addiction care models. Those classified as addiction consult models include (1) interprofessional addiction consult services, (2) psychiatry consult liaison services, and (3) individual consultant models. Those classified as practice-based models, wherein general hospital staff integrate addiction care into usual practice, include (4) hospital-based opioid treatment and (5) hospital-based alcohol treatment. The final type was (6) community-based in-reach, wherein community providers deliver care. Models vary in their target patient population, staffing, and core clinical and systems change activities. Limitations include that some models have overlapping characteristics and variable ways of delivering core components.
Discussion
A taxonomy provides hospital clinicians and administrators, researchers, and policy-makers with a framework to describe, compare, and select models for implementing hospital-based addiction care and measure outcomes.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Addiction consult services (ACS) engage hospitalized patients with opioid use disorder (OUD) in care and help meet their goals for substance use treatment. Little is known about how ACS affect ...mortality for patients with OUD. The objective of this study was to design and validate a model that estimates the impact of ACS care on 12-month mortality among hospitalized patients with OUD.
We developed a Markov model of referral to an ACS, post-discharge engagement in SUD care, and 12-month drug-related and non-drug related mortality among hospitalized patients with OUD. We populated our model using Oregon Medicaid data and validated it using international modeling standards.
There were 6,654 patients with OUD hospitalized from April 2015 through December 2017. There were 114 (1.7%) drug-related deaths and 408 (6.1%) non-drug related deaths at 12 months. Bayesian logistic regression models estimated four percent (4%, 95% CI = 2%, 6%) of patients were referred to an ACS. Of those, 47% (95% CI = 37%, 57%) engaged in post-discharge OUD care, versus 20% not referred to an ACS (95% CI = 16%, 24%). The risk of drug-related death at 12 months among patients in post-discharge OUD care was 3% (95% CI = 0%, 7%) versus 6% not in care (95% CI = 2%, 10%). The risk of non-drug related death was 7% (95% CI = 1%, 13%) among patients in post-discharge OUD treatment, versus 9% not in care (95% CI = 5%, 13%). We validated our model by evaluating its predictive, external, internal, face and cross validity.
Our novel Markov model reflects trajectories of care and survival for patients hospitalized with OUD. This model can be used to evaluate the impact of other clinical and policy changes to improve patient survival.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Treatment for opioid use disorder in the United States evolved in response to changing federal policy and advances in science. Inpatient care began in 1935 with the US Public Health Service Hospitals ...in Lexington, Kentucky, and Fort Worth, Texas. Outpatient clinics emerged in the 1960s to provide aftercare. Research advances led to opioid agonist and opioid antagonist therapies. When patients complete opioid withdrawal, return to use is often rapid and frequently deadly. US and international authorities recommend opioid agonist therapy (i.e., methadone or buprenorphine). Opioid antagonist therapy (i.e., extended-release naltrexone) may also inhibit return to use. Prevention efforts emphasize public and prescriber education, use of prescription drug monitoring programs, and safe medication disposal options. Overdose education and naloxone distribution promote access to rescue medication and reduce opioid overdose fatalities. Opioid use disorder prevention and treatment must embrace evidence-based care and integrate with physical and mental health care.
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