Hospital-Based Services for Opioid Use Disorder: A Study of Supply-Side Attributes

The United States (U.S.) is in the midst of an opioid overdose epidemic. In the U.S., overdose deaths related to opioid exposure are the leading cause of accidental death, yet life-saving treatments, such as methadone or buprenorphine (opioid agonist therapy [OAT]), are underused. OAT underuse is due, in part, to complex regulatory and health services delivery environments. Public health officials and policymakers have focused on expanding OAT access in the community (e.g. office-based buprenorphine treatment, and opioid treatment programs); however, an often-overlooked component of the treatment pathway is the acute care delivery setting, in particular hospitals. Opioid use disorder (OUD)-related hospitalizations are increasing, and incurring significant costs; care delivered in this setting is likely sub-optimal. This study examined hospital-based services for OUD using a conceptual framework based on an interdisciplinary review of policy, organizational behavior, systems science, economics, and health services delivery scholarship. The study’s primary research question was: How do supply-side attributes influence hospital OAT delivery, health outcomes, and health services utilization for persons hospitalized with OUD? Supply-side attributes refer to the contextual elements inside and outside of a hospital that may be associated with hospital OAT delivery performance, such as social structures (e.g., hospital standards of care, societal values) and resources and technologies (e.g., hospital staffing, federal treatment policies). A mixed methods study described, explored, and identified how patients with OUD are cared for in the hospital and the barriers and facilitators to delivering OAT during hospitalization. The sequential mixed methods approach (i.e., qualitative followed by quantitative analyses) included analysis of 17 key informant interviews with addiction medicine physicians from 16 non-federal U.S. hospitals, 25 hospital guidance documents from 10 non-federal U.S. hospitals, and administrative data from 12,407 OUD-related hospital admissions from the Veterans Health Administration (VHA) health system. The findings from the study’s three aims and 16 research sub-questions were integrated to reach seven conclusions: 1) OAT is underused in the hospital; 2) OAT delivery varies within and across hospitals; 3) OAT is used ineffectively; 4) non-OAT modalities are inappropriately used during and after hospitalization; 5) supply-side attributes inside and outside the hospital facilitate and impede hospital OAT delivery; 6) demand-side attributes facilitate and impede hospital OAT delivery; and 7) the hospital is an important service delivery mechanism in the OUD care continuum. The study’s findings could be extrapolated to improve policy and practice by implementing education and health service delivery interventions through regulatory and allocative policy mechanisms focused on physicians, medical trainees, and hospital and health system administrators. Understanding how OAT delivery may be improved within the acute care delivery system is an important element to support efforts to curb the ongoing drug poisoning crisis

Time-to-Completed-Imaging, Survival and Function in Patients with Spinal Epidural Abscess: Description of a Series of 34 Patients, 2015–2018

Introduction: Spinal epidural abscess (SEA) is a rare and life-threatening infection with increasing incidence over the past two decades. Delays in diagnosis can cause significant morbidity and mortality among patients. Objective: The objective of this study was to describe trends in time-to-imaging and intervention, risk factors, and outcomes among patients presenting to the emergency department with SEA at a single academic medical center in Portland, Oregon. Methods: This retrospective cohort study analyzed data from patients with new SEA diagnosis at a single hospital from October 1, 2015 to April 1, 2018. We describe averages to time-to-imaging and interventions, and frequencies of risk factors and outcomes among patients presenting to the emergency department with SEA. Results: Of the 34 patients included, 7 (20%) died or were discharged with plegia during the study period. Those who died or were discharged with plegia (n = 7) had shorter mean time-to-imaging order (20.8 h versus 29.2 h). Patients with a history of intravenous drug use had a longer mean time-to-imaging order (30.2 h versus 23.7 h) as compared to those without intravenous drug use. Patients who died or acquired plegia had longer times from imaging completed to final imaging read (20.9 h versus 7.1 h), but shorter times from final imaging read to surgical intervention among patients who received surgery (4.9 h versus 46.2 h). Further, only three (42.9%) of the seven patients who died or acquired plegia presented with the three-symptom classic triad of fever, neurologic symptoms, and neck or back pain. Conclusions: SEA is a potentially deadly infection that requires prompt identification and treatment. This research provides baseline data for potential quality improvement work at the study site. Future research should evaluate multi-center approaches for identifying and intervening to treat SEA, particularly among patients with intravenous drug use

Patterns of Substance Use Before and After Hospitalization among Patients Seen by an Inpatient Addiction Consult Service: A Latent Transition Analysis

Background and aims: Polysubstance use is common and contributes to morbidity and mortality of hospitalized patients, and yet little is known about patterns of substance use among hospitalized patients, or how an addiction consult service (ACS) might impact polysubstance use after discharge. The objective of this study was to identify patterns of substance use at admission and after discharge among hospitalized patients with substance use disorders who saw an ACS. Design: Prospective cohort study. We used latent transition analysis of substance use scores at the time of hospital admission and 30 to 90 days posthospitalization. Setting: Single, academic health center with an ACS in Portland, Oregon, from 2015 to 2018. Participants/cases: Patients were eligible if they received a consult to the inpatient ACS. Measurements: We used Addiction Severity Index-Lite scores to capture self-reported substance use at baseline and follow-up for heroin, other opioid, alcohol, amphetamine, and cocaine. Findings: From 2015 to 2018, 486 individuals consented to participate. More than half of patients used more than one substance at baseline. Of those reporting any baseline opioid use, nearly three-quarters (n=187, 69.5%) had polysubstance use in the previous 30 days, including alcohol (n=80, 29.7%), cocaine (n=25, 9.3%), or amphetamine use (n=142, 52.8%). We identified three patterns of substance use at baseline: 1) alcohol use dominant, 2) polysubstance use dominant, and 3) heroin and other opioid use dominant. Patients transitioned along five trajectories to three different follow-up profiles that showed lower endorsement of all substances used. Slightly more than 40% (40.1%) of patients newly endorsed abstinence of at least one substance at follow-up. Conclusions: Polysubstance use is common in hospitalized patients with substance use disorders and identifying patterns of polysubstance use can guide clinical management. Hospital providers should prepare to manage polysubstance use during hospitalization and hospitals should broaden care beyond interventions for opioid use disorder

Substance Use Disorders and COVID-19 : Multi-Faceted Problems Which Require Multi-Pronged Solutions

COVID-19 shocked health and economic systems leaving millions of people without employment and safety nets. The pandemic disproportionately affects people with substance use disorders (SUDs) due to the collision between SUDs and COVID-19. Comorbidities and risk environments for SUDs are likely risk factors for COVID-19. The pandemic, in turn, diminishes resources that people with SUD need for their recovery and well-being. This article presents an interdisciplinary and international perspective on how COVID-19 and the related systemic shock impact on individuals with SUDs directly and indirectly. We highlight a need to understand SUDs as biopsychosocial disorders and use evidence-based policies to destigmatize SUDs. We recommend a suite of multi-sectorial actions and strategies to strengthen, modernize and complement addiction care systems which will become resilient and responsive to future systemic shocks similar to the COVID-19 pandemic