Highlights • Supervised injection services (SISs) aim to reduce harm among drug users. • SISs have also been accused of fostering drug use and drug trafficking. • All studies converged to find that ...SISs fulfilled their harm-reduction objectives. • SISs were not found to increase drug use or crime. • 85% of the studies of the literature originated from Vancouver or Sydney.
ABSTRACT
BACKGROUND
Alcohol dependence results in multiple hospital readmissions, but no discharge planning protocol has been studied to improve outcomes. The inpatient setting is a frequently missed ...opportunity to discuss treatment of alcohol dependence and initiate medication-assisted treatment, which is effective yet rarely utilized.
AIM
Our aim was to implement and evaluate a discharge planning protocol for patients admitted with alcohol dependence.
SETTING
The study took place at the San Francisco General Hospital (SFGH), a university-affiliated, large urban county hospital.
PARTICIPANTS
Learner participants included Internal Medicine residents at the University of California, San Francisco (UCSF) who staff the teaching service at SFGH. Patient participants included inpatients with alcohol dependence admitted to the Internal Medicine teaching service.
PROGRAM DESCRIPTION
We developed and implemented a discharge planning protocol for patients admitted with alcohol dependence that included eligibility assessment and initiation of medication-assisted treatment.
PROGRAM EVALUATION
Rates of medication-assisted treatment increased from 0 % to 64 % (p value < 0.001). All-cause 30-day readmission rates to SFGH decreased from 23.4 % to 8.2 % (p value = 0.042). All-cause emergency department visits to SFGH within 30 days of discharge decreased from 18.8 % to 6.1 % (p value = 0.056).
DISCUSSION
Through implementation of a discharge planning protocol by Internal Medicine residents for patients admitted with alcohol dependence, there was a statistically significant increase in medication-assisted treatment and a statistically significant decrease in both 30-day readmission rates and emergency department visits.
We examined options and need for women-centered substance use disorder treatment in the United States between 2002 and 2009.
We obtained characteristics of facilities from the National Survey of ...Substance Abuse Treatment Services and treatment need data from the National Survey on Drug Use and Health. We also examined differences in provision of women-centered programs by urbanization level in data from the National Center for Health Statistics 2006 Rural-Urban County Continuum.
Of the 13 000 facilities surveyed annually, the proportion offering women-centered services declined from 43% in 2002 to 40% in 2009 (P < .001). Urban location, state population size, and Medicaid payment predicted provision of such services as trauma-related and domestic violence counseling, child care, and housing assistance (all, P < .001). Prevalence of women with unmet need ranged from 81% to 95% across states.
Change in availability of women-centered drug treatment services was minimal from 2002 to 2009, even though need for treatment was high in all states.
We modeled the impact of changing Specialist Treatment Access Rates to different treatment pathways on the future prevalence of alcohol dependence, treatment outcomes, service capacity, costs, and ...mortality.
Local Authority numbers and the prevalence of people "potentially in need of assessment for and treatment in specialist services for alcohol dependence" (PINASTFAD) are estimated by mild, moderate, severe, and complex needs. Administrative data were used to estimate the Specialist Treatment Access Rate per PINASTFAD person and classify 22 different treatment pathways. Other model inputs include natural remission, relapse after treatment, service costs, and mortality rates. "What-if" analyses assess changes to Specialist Treatment Access Rates and treatment pathways. Model outputs include the numbers and prevalence of people who are PINASTFAD, numbers treated by 22 pathways, outcomes (successful completion with abstinence, successfully moderated nonproblematic drinking, re-treatment within 6 months, dropout, transfer, custody), mortality rates, capacity requirements (numbers in contact with community services or staying in residential or inpatient places), total treatment costs, and general health care savings. Five scenarios illustrate functionality: (a) no change, (b) achieve access rates at the 70th percentile nationally, (c) increase access by 25%, (d) increase access to Scotland rate, and (e) reduce access by 25%.
At baseline, 14,581 people are PINASTFAD (2.43% of adults) and the Specialist Treatment Access Rate is 10.84%. The 5-year impact of scenarios on PINASTFAD numbers (vs. no change) are (B) reduced by 191 (-1.3%), (C) reduced by 477 (-3.3%), (D) reduced by almost 2,800 (-19.2%), and (E) increased by 533 (+3.6%). The relative impact is similar for other outputs.
Decision makers can estimate the potential impact of changing Specialist Treatment Access Rates for alcohol dependence.
: The COVID-19 health crisis joined, rather than supplanted, the opioid crisis as the most acutely pressing threats to US public health. In the setting of COVID-19, opioid use disorder treatment ...paradigms are being disrupted, including the fact that methadone clinics are scrambling to give "take-home" doses where they would typically not. The rapid transition away from in-person examination, dosing and group therapy in an era of social isolation calls for adjustments to clinical practice, including emphasizing patient-provider communication, favoring new inductees on buprenorphine and leveraging technology to optimize safety of medication treatment.
•Review provides a comprehensive update on evidence base for residential treatment.•Of 23 studies, 10 were rated as methodologically strong, 5 as moderate and 8 as weak.•Results provide moderate ...evidence for the effectiveness of residential treatment.•Effectiveness evident for substance use and other life outcomes.•Best practice integrates mental health treatment and provides continuity of care.
Residential treatment is a standard treatment for individuals with severe and complex substance use problems. However, there is limited evidence on best practice approaches to treatment in these settings. This review provides a comprehensive update on the evidence base for residential treatment, and directions for future research and clinical practice.
A systematic review of all studies published between January 2013 and December 2018 was conducted. Public health and psychology databases (Medline, CINAHL, PsycARTICLES and PsycINFO) were systematically searched, and forward and backward snowballing were used to identify additional studies. Studies were included if they were quantitative, assessed the effectiveness of residential substance treatment programs for adults, were published in the English language and in peer-reviewed journals. The Effective Public Health Practice Project’s Quality Assessment Tool for Quantitative Studies was used to assess methodological quality.
Our search identified 23 studies. Eight were rated as methodologically strong, five as moderate and ten rated as weak. Quality ratings were impacted by attrition at follow-up and research design. Despite limitations, results provide moderate quality evidence for the effectiveness of residential treatment in improving outcomes across a number of substance use and life domains.
With caution, results suggest that best practice rehabilitation treatment integrates mental health treatment and provides continuity of care post-discharge. Future research and practice should focus on better collection of outcome data and conducting data linkage of key health, welfare and justice agency administrative data to enhance understanding of risk and recovery trajectories.
Background
Many concerns about liver transplantation in alcoholic patients are related to the risk of alcohol recidivism. Starting from 2002, an Alcohol Addiction Unit (AAU) was formed within the ...liver transplant center for the management of alcoholic patients affected by end‐stage liver disease and included in the waiting list for transplantation. We evaluated retrospectively the impact of the AAU on alcohol recidivism after transplantation. The relationship between alcohol recidivism and the duration of alcohol abstinence before transplant was evaluated as well.
Methods
Between 1995 and 2010, 92 cirrhotic alcoholic patients underwent liver transplantation. Clinical evaluation and management of alcohol use in these patients was provided by psychiatrists with expertise in addiction medicine not affiliated to the liver transplant center before 2002 (n = 37; group A), or by the clinical staff of the AAU within the liver transplant center starting from 2002 (n = 55; group B).
Results
Group B, as compared with group A, showed a significantly lower prevalence of alcohol recidivism (16.4 vs. 35.1%; p = 0.038) and a significantly lower mortality (14.5 vs. 37.8%; p = 0.01). Furthermore, an analysis of group B patients with either ≥6 or <6 months of alcohol abstinence before transplantation showed no difference in the rate of alcohol recidivism (21.1 vs. 15.4%; p = ns).
Conclusions
The presence of an AAU within a liver transplant center reduces the risk of alcohol recidivism after transplantation. A pretransplant abstinence period <6 months might be considered, at least in selected patients managed by an AAU.
To quantify the availability of telehealth services at substance use treatment facilities in the U.S. at the beginning of the COVID-19 pandemic, and determine whether telehealth is available at ...facilities in counties with the greatest amount of social distancing.
We merged county-level measures of social distancing through April 18, 2020 to detailed administrative data on substance use treatment facilities. We then calculated the number and share of treatment facilities that offered telehealth services by whether residents of the county social distanced or not. Finally, we estimated a logistic regression that predicted the offering of telehealth services using both county- and facility-level characteristics.
Approximately 27% of substance use facilities in the U.S. reported telehealth availability at the outset of the pandemic. Treatment facilities in counties with a greater social distancing were less likely to possess telemedicine capability. Similarly, nonopioid treatment programs that offered buprenorphine or vivitrol in counties with a greater burden of COVID-19 were less likely to offer telemedicine when compared to similar facilities in counties with a lower burden of COVID-19.
Relatively few substance use treatment facilities offered telehealth services at the onset of the COVID-19 pandemic. Policymakers and public health officials should do more to support facilities in offering telehealth services.
Backgrounds and aims
Iran has 2.1 and 1.8% of its 15–64‐year‐old population living with illicit substance and opioid use disorders, respectively. To address these problems, Iran has been developing a ...large and multi‐modality addiction treatment system, spanning the time before and after the Islamic Revolution.
Methods
Iran's current drug treatment scene is a combination of services, ranging from medical/harm reduction services to punitive/criminal justice programs. Included in this array of services are drop‐in centers providing low‐threshold harm reduction services, such as distribution of sterile needles and syringes; opioid maintenance treatment clinics providing methadone, buprenorphine and opium tincture; and abstinence‐based residential centers. We will review the evolution of this system in four phases.
Results
In 1980, Iran's revolutionary government shut down all voluntary treatment programs and replaced them with residential correctional programs. The first shift in the addiction treatment policies came 15 years later after facing the negative consequences. Addiction is viewed as a disease, and new voluntary treatment centers offering non‐agonist medications and psychosocial services were established. With an increased number of people who inject drugs and HIV/AIDS epidemics, in the second shift an extensive move towards harm reduction strategies and opioid‐maintenance programs has been implemented to reduce HIV‐related high‐risk behavior. The emergence of a methamphetamine use crisis creating an increased number of socially marginalized addicted people resulted in public and political demands for stricter policies and ended in the third shift starting in 2010, with extended compulsory court‐based residential programs. Currently, there is a new shift towards reducing the severity of criminal penalties for drug use/sales and promoting proposals for opium legalization.
Conclusion
Iran's evolutionary experience in developing a large addiction treatment program in a complex combination of medical/harm reduction and punitive/criminal justice addiction treatment can be examined in its political, clinical and pragmatic context.
Chronically homeless individuals with severe alcohol problems often have multiple medical and psychiatric problems and use costly health and criminal justice services at high rates.
To evaluate ...association of a "Housing First" intervention for chronically homeless individuals with severe alcohol problems with health care use and costs.
Quasi-experimental design comparing 95 housed participants (with drinking permitted) with 39 wait-list control participants enrolled between November 2005 and March 2007 in Seattle, Washington.
Use and cost of services (jail bookings, days incarcerated, shelter and sobering center use, hospital-based medical services, publicly funded alcohol and drug detoxification and treatment, emergency medical services, and Medicaid-funded services) for Housing First participants relative to wait-list controls.
Housing First participants had total costs of $8,175,922 in the year prior to the study, or median costs of $4066 per person per month (interquartile range IQR, $2067-$8264). Median monthly costs decreased to $1492 (IQR, $337-$5709) and $958 (IQR, $98-$3200) after 6 and 12 months in housing, respectively. Poisson generalized estimating equation regressions using propensity score adjustments showed total cost rate reduction of 53% for housed participants relative to wait-list controls (rate ratio, 0.47; 95% confidence interval, 0.25-0.88) over the first 6 months. Total cost offsets for Housing First participants relative to controls averaged $2449 per person per month after accounting for housing program costs.
In this population of chronically homeless individuals with high service use and costs, a Housing First program was associated with a relative decrease in costs after 6 months. These benefits increased to the extent that participants were retained in housing longer.
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