Journal Article Annotations
2024, 2nd Quarter
Annotations by Julian J. Raffoul, MD, PhD
July, 2024
The finding:
Addiction consultation services are emerging service lines that offer evidence-based interventions to patients with substance use disorders in the general hospital setting. Patients with opioid use disorder (OUD) who receive a consultation with an addiction psychiatrist experience a higher rate of medications for OUD (MOUD) initiation and lower post-discharge healthcare utilization compared to those without a consultation.
Strength and weaknesses:
This retrospective cohort study compares rates of MOUD prescribing for individuals with and without a specialty addiction consultation in a general hospital, while also reporting associated post-discharge acute care utilization and other relevant patient care outcomes. This is the largest study evaluating the impact of an addiction consultation service compared to a control condition on an OUD patient population. Additional unique factors of this study that may have contributed to the added benefits of consultation, includes the presence of addiction psychiatrists and psychiatric advanced practice providers on the studied service line, the presence of a rapid access post-acute care Bridge Clinic for continued MOUD management, and the inclusion of specialized social work and peer recovery support embedded within the addiction consultation team. Limitations of the study include healthcare data limited to one academic healthcare system, limiting visibility into post-discharge utilization at community facilities outside the studied electronic health record; using diagnostic codes to identify the control group with OUD may exclude patients with undiagnosed OUD; a potential confounding variable is the decision to request an addiction consultation by a patient’s primary medical team possibly representing a higher baseline motivation for change that may explain the finding of improved outcomes with consultation; lastly, the studied addiction service line included providers well-versed in addressing psychiatric problems and not all addiction consultation services have access to this, which may limit the generalizability to all addiction consult services.
Relevance:
The C-L psychiatrist will frequently encounter patients with substance use and related disorders and will likely offer MOUD, such as buprenorphine and methadone. Initiation of MOUD during general hospital admission increases the likelihood of linkage to outpatient care while mitigating risk of relapse, overdose, and all-cause mortality. Given that most individuals with SUD in the U.S. do not receive specialty addiction treatment, i.e., approximately 80%–90% of the total population with SUD, the presence of an addiction consult service or C-L service staffed with psychiatrists comfortable evaluating and managing substance use disorders is imperative for health care systems to provide life-saving treatment for these vulnerable patient populations.
The finding:
Hospitalizations involving patients with opioid use disorder (OUD) result in substantial costs and burdens on health care systems. With the number of overdose deaths in the U.S. now at record levels (105,452 in 2022, 48% higher than in 2019), addressing the current U.S. overdose crisis is paramount. This randomized clinical trial sought to determine whether referring inpatients with OUD from a hospital addiction consultation service to a co-located outpatient bridge clinic influenced hospital length of stay (LOS) compared with usual care. Among inpatients with OUD, bridge clinic referrals did not improve hospital LOS. Although referrals did improve outpatient metrics and increased resource use and expenditures, likely mitigating OUD overdoses, bending the cost curve may require broader community and regional partnerships.
Strength and weaknesses:
This study is a pragmatic randomized trial in a tertiary care hospital with an addiction consult team and its co-located hospital bridge clinic that demonstrated median length of stay, the primary outcome, did not differ between the groups and at 16 weeks, those referred to the bridge clinic had fewer hospital-free days, more readmissions to the study hospital, and higher care costs. Although there were no differences in emergency department visits or deaths between groups, those in the bridge clinic group were more likely to receive self-reported MOUD clinician linkage, had more MOUD refills, and were less likely to experience an overdose. Multiple key outcomes over the 16-week follow-up were improved, e.g., they were more likely to link to the bridge clinic, had more MOUD refills, and were less likely to experience an overdose—likely due to MOUD’s life-saving impact, likely due to the enhanced case management during hospitalization and bridge staff introductions prior to discharge. Although randomization should have led to an even distribution of differences, this study did not systematically capture the severity of OUD or the nature of co-occurring disorders at enrollment, limiting the ability to account for the heterogeneity of treatment effect. It is also possible that 16 weeks was too short a window to show improvements in patient-centered outcomes and lack of information about recurrent use of acute care in settings outside a single center. Finally, because this trial was part of routine clinical care and was not blinded, it is possible that ACS medical professionals approached patients randomized to the bridge clinic and patients receiving usual care differently, leading to nonspecific effects favoring one condition or another.
Relevance:
As the number of overdose deaths in the U.S. continue to rise at alarming rates, substance use disorder (SUD)–related admissions are going to rise concomitantly. Already representing 20% to 30% of general hospital admissions, patients with SUD will continue to need specialized care from the C-L psychiatrist. Hospitals have already witnessed increases in hospitalizations associated with complex, injection drug–related infections, sometimes prolonged due to difficulty placing patients for parenteral antibiotics and finding options for patients to continue the benefits of OUD treatment after hospitalization. C-L psychiatrists can lead the change by assisting with transitions of care by creating multiple interventions to improve care for these patients, including addiction consult teams and linkage supports (e.g., peer support specialists and social workers).