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OBJECTIVE: The goal of this study was to (1) Describe the patient population of a newly implemented addiction medicine consult service (AMCS); (2) Evaluate referrals to community-based addiction support services and acute health service use, over time; (3) Provide lessons learned. METHODS: A retrospective observational analysis was conducted at Health Sciences North in Sudbury, Ontario, Canada, with a newly implemented AMCS from November 2018 and July 2021. Data were collected using the hospital's electronic medical records. The outcomes measured included the number of emergency department visits, inpatient admissions, and re-visits over time. An interrupted time-series analysis was performed to measure the effect of AMCS implementation on acute health service use at Health Sciences North. RESULTS: A total of 833 unique patients were assessed through the AMCS. A total of 1,294 referrals were made to community-based addiction support services, with the highest proportion of referrals between August and October 2020. The post-intervention trend for ED visits, ED re-visits, ED length of stay, inpatient visits, re-visits, and inpatient length of stay did not significantly differ from the pre-intervention period. CONCLUSION: Implementation of an AMCS provides a focused service for patients using with substance use disorders. The service resulted in a high referral rate to community-based addiction support services and limited changes in health service usage.
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Addiction Medicine , COVID-19 , Humans , COVID-19/epidemiology , Inpatients , Ontario , Preliminary Data , Referral and Consultation , Retrospective StudiesABSTRACT
Substance-use disorders (SUDs) and drug addiction are not only national, but also global health concerns that have worsened during and after the COVID-19 pandemic. Acupuncture augments the endogenous opioid system and, therefore, has a theoretical basis as a treatment for opioid use disorders (OUDs). The basic science of acupuncture, its clinical research in addiction medicine, and decades of success of the National Acupuncture Detoxification Association protocol offer positive findings supporting this protocol's utility for treating SUDs. Considering the mounting opioid/substance-use concerns and deficiencies in SUD treatment availability in the United States, acupuncture can be a safe, feasible treatment option and adjunct in addiction medicine. Furthermore, large governmental agencies are lending support to acupuncture for treating acute and chronic pain, which, in turn, could translate to prevention of SUDs and addictions. This article is a narrative review of the background, the basic science and clinical research, and future direction of acupuncture in addiction medicine.
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Introduction and Objectives: Limited healthcare access and resource inequities pose significant barriers to care, all of which have been amplified during the COVID-19 pandemic. DFUs represent an especially challenging medical problem to prevent and treat due to the resource intensive care required. We sought to evaluate the feasibility of multidisciplinary, mobile, DFU outreach clinics to improve access to care. Method(s): Our clinic model focused on creating mobile diabetic foot clinics staffed by volunteer clinical providers who specialize in Vascular Surgery, Diabetes, and Podiatry. We recruited volunteer healthcare providers from an academic medical center. We partnered with local community centers with established programs providing services to unhoused individuals. Result(s): Between June 2020 and August 2022, a total of 130 unhoused individuals were seen at four mobile clinics set up at different locations. Diabetic foot care was provided by volunteers from seven departments: Endocrinology/Diabetes, Vascular Surgery and Vascular Lab, Podiatry, Addiction Medicine, Smoking Cessation, and Financial. On average, 32 healthcare provider volunteers participated at each clinic. Services provided include: vitals, blood glucose, HgA1c, lipid panel testing, ankle-brachial index, podiatric exam, wound care, medical education, COVID vaccination/booster, insurance enrollment, and new socks and shoes. Of 130 unhoused patients, 29% had hypertension (38), 34% had abnormal ABI (44), and 14% had diabetes (18). Fifteen patients were further identified as high risk for developing DFU-associated amputation (12%) and were provided with ambulatory follow-ups. Conclusion(s): In our pilot experience, it is feasible to provide consistent comprehensive DFU care through mobile outreach clinics. By using the infrastructure of partner organizations and healthcare expertise of an academic center, our clinics could integrate into existing community services. [Formula presented]Copyright © 2022
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Background. The U.S. is facing a steep increase in infectious consequences of intravenous drug use due to the ongoing opioid crisis, surging methamphetamine use, and health care disruptions caused by COVID-19. We hypothesize that the sociodemographic and clinical outcomes of persons who inject drugs (PWID) differ based on their drug of choice (opioids, methamphetamines). Further, we hypothesize that the OUD (opioid use disorder) continuum, including linkage and retention inOUD treatment, will vary depending on co-occurring methamphetamine use. By elucidating differences in these groups, we aim to identify opportunities for interventions along the care continuum. Methods. This is a retrospective study of hospitalized PWID receiving care at the University of Alabama at Birmingham Hospital for a serious injection related infection (SIRI) between 1/11/2016 and 4/24/2021. We queried the EMR for clinical data and health outcomes. We extracted data on substance use disorder(s), treatments, and linkage to care through review of primary and addiction medicine consultation notes. Using statistical measures of association, we compared demographic factors and clinical outcomes among groups;delineating between those with and without methamphetamine use, and without OUD. When appropriate, additional comparisons were made to detect statistical differences between factors and those with and without methamphetamine use. Results. Of 370 PWID, 286 had OUD, 94 had OUD and methamphetamine use, and 84 had another substance use disorder. There were significant differences according to drug use disorder with patients with OUD and meth use being mostly White (99%), 42% female, and younger relative to those who use opioids only. Patient directed discharge was most common among those with OUD plus meth use, but death was highest for those with OUD only. The OUD care continuum was similar and alarming for both groups with many gaps in care. (Table Presented) Conclusion. PWID with SIRI are a diverse group with significant differences based on substance of choice, but all experience suboptimal hospital outcomes. There are opportunities to improve linkage and retention across the care continuum, most noticeably outpatient linkage.
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Introduction: In January 2018, the Michigan Department of Health and Human Services convened a meeting of the Deans of the seven medical schools to discuss opioid-related training in undergraduate medical education (UME). At that time six of the seven medical schools in Michigan did not have board-certified addiction physicians on their core faculty. UME curriculum is critical to teaching and training of physicians. It empowers their ability to deliver quality and effective addiction treatment. A current challenge is that the number of curricular hours devoted to addiction medicine training is just a fraction of the time dedicated to other chronic diseases. To bridge this gap, MI CARES set out to recruit and retain a physician(s) from each of the seven medical schools to become board-certified in addiction medicine. This collaboration has had significant implications. There is now a board-eligible or a board-certified addiction medicine specialist on core faculty at each university. In early 2020, medical students at Michigan State University College of Human Medicine (MSU-CHM) teamed up to advocate for an elective in addiction medicine. This effort signaled an unmet need in the current curriculum. Implementing addiction medicine curriculum during medical school can boost students' confidence in their ability to screen, manage, and treat people with substance use disorders. Method(s): In May of 2021, during the COVID-19 pandemic, MSU launched a 4-week addiction medicine 75.5-hour elective. To reduce Zoom fatigue amongst students and faculty, the course used active learning, including problem-based learning (PBL), team-based learning (TBL), and peer instruction (PI). An advisory committee of college leadership, medical students, and staff met bi-monthly to discuss implementation, content, and intersession approval. The curriculum was made available as asynchronous online modules combined with guided didactics for small groups, including student and faculty resources, and large group meetings with expert and patient panels. Online asynchronous modules provided background didactics with advanced addiction topics as PBLs for TBL. Result(s): As part of the course requirements, students were asked to complete pre-post self-reported attitudes survey, adopted from the substance abuse attitudes survey (saas). The statements were closed-ended and consisted of Likert scale responses. The survey included statements regarding permissiveness, treatment intervention, treatment optimism and non-moralism. Students were surveyed prior to the first day of class, 3-months and 6-months later.When asked if substance use disorder is a treatable disease in the pre intersession survey, 61% of students agreed and 31% strongly agreed;in the post intersession survey, 28% agreed and 67% strongly agreed;in the 6-month follow-up, 21% agree and 79% strongly agreed. The pre-intersession survey indicated that 64% agreed and 33% strongly agreed that alcohol use disorder is a treatable disease;in the post survey 28% of students agreed and 67% strongly agreed;in the 6-month follow-up, 21% agree and 79% strongly agreed. The survey asked how much they agreed that a person with a substance use disorder is unpleasant to work with as patients. The pre-survey showed that 57% strongly disagreed and 43% strongly disagreed;in the post survey, 61% strongly disagree, 31% disagree, and 8% are neutral;in the 6-month follow-up, 64% strongly disagree, 21% disagree and 14% are neutral.
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Introduction: School based health centers (SBHCs) are comprehensive primary care facilities that reduce barriers to education by providing in-school access to healthcare. Students enrolled in SBHCs can access confidential healthcare independently during school hours - making SBHCs an ideal setting to address substance use. SBHC providers report lack of time, training, and treatment access as implementation barriers to screening, brief intervention, and referral to treatment (SBIRT) for alcohol and other substance use. We describe the implementation of a novel telemedicine-based adolescent addiction medicine consult service for middle and high school students within SBHCs. Method(s): In January 2020, the Yale Program in Addiction Medicine, Fair Haven Community Health Care (FHCHC;a federally qualified health center), and Yale Department of Pediatrics partnered to integrate substance use screening, treatment, and prevention services into pediatric primary care. FHCHC provides medical and behavioral healthcare to over 18,000 pediatric patients across 14 sites, including 6 middle and high school based SBHCs. From January to March 2020, the SBHC providers, leadership from pediatrics, and a pediatrician board certified in addiction-medicine used a partnered, consensus building approach to establish an SBHC-integrated adolescent addiction medicine outpatient consult service. Protocols were created to standardize: 1) Referral criteria (at risk for suspension due to substance use (including vaping), positive screen for substance use, >= monthly use of any substance);2) referral and scheduling (EHR-based referral system, direct scheduling of appointments);3) overall principles of care (up to 6 sessions of voluntary and confidential care, encouraging parental involvement and linkage to ongoing mental health and substance use treatment services);4) infrastructure needs (tele-video enabled, internet-connected device, private room in the SBHC for patient);5) staffing needs (one pediatric addiction medicine specialist, one SBHC healthcare provider, and one support staff );and 6) SBHC training needs (education on best practices for screening, how to describe service to students, parents and administrators). Given the ongoing COVID-19 pandemic and local addiction medicine workforce capacity, the service was designed to occur via telemedicine with a pediatrician board-certified in addiction medicine or a family-medicine-trained addiction medicine fellow. Result(s): Starting in March 2020, Adolescent Addiction Medicine Tele-Consult Services were available during one four-hour block/week when school was in session. Between March 2020 and December 2021, the service completed 57 encounters with 25 adolescents aged 13-18 years. Telemedicine encounters lasted 20-40 minutes and the student completed the visit in a private room within the SBHC during school hours. Services included: diagnosis of substance use disorders, psychoeducation, referral to and coordination with mental health services, nicotine use disorder treatment with medications, harm reduction and return to use prevention counseling. Diagnoses included: Nicotine use disorder (vaping) (n = 9 patients), cannabis use disorder (n = 5), alcohol use (n = 7), nicotine use (n = 8), cannabis use (n = 11) and prescription opioid misuse (n = 2). Conclusion(s): Here we describe the development and early implementation of an Adolescent Addiction Medicine Tele-Consult Service within SBHCs. Next steps for program development include formal tracking of patient-level outcomes, evaluations of acceptability among adolescents, SBHCs and schools, and further development of training opportunities for residents and fellows.
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The proceedings contain 113 papers. The topics discussed include: a multipronged approach to improving linkage to outpatient substance use treatment;adolescent addiction medicine tele-consult services within school-based health centers;adolescent substance use: a mixed methods assessment;adopting a buprenorphine precision dosing approach treatment for Hispanic Puerto Ricans;advancing patient-centered research and care through journey mapping: EMPOWER project;buprenorphine treatment disparities: the role of the specialty system and insurance status;cannabis legalization and adolescent substance use;community-based interventions for OUD in black churches: a qualitative study;comparing in-person and remote substance use treatment outcomes before and during COVID-19;and COVID-19 implications in mental health and opioid use disorder treatment: qualitative study.
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Background: The role of telehealth expanded during the initial phases of the COVID pandemic. A prior demonstrated that toxicologist's use of telehealth during this time was fairly limited including in total number of consultations performed and billing. This follow up aims to explore how toxicologists use of telehealth evolved over the last 1.5 years as the pandemic changed and telehealth use became more normalized by the medical community. Method(s): The ToxIC Core Registry is a database of patients evaluated at the bedside by medical toxicologists. ToxIC includes cases from 38 sites across the US and 4 sites internationally. A new set of telehealth questions were added to the registry on April 1, 2020. We searched the ToxIC registry from April 2020 to March 2022 to determine how medical toxicologists were using telehealth. Only cases receiving a telehealth evaluation were included. Data collected included: Description of telehealth encounter (video/internet, phone, chart review);the reason telehealth was used;and if the consultation was billed. Data from the registry was downloaded from the REDCap ToxIC Core Registry database and analyzed using simple, descriptive statistics. Result(s): Toxicologists performed 278 telehealth consults from April 2020 to March 2022. There were 144 performed in 2020, 123 in 2021, and 11 through March of 2022. The average patient age was 38 with 51% (n=141) being male. Most referrals came from the emergency department (n=139;50%) or the admitting service (n=95;34%). While consults occurred in the clinic, emergency department, and wards, none occurred in the intensive care unit. Similar number of evaluations were done in 2020 and 2021 over the phone (16 and 14 respectively) and via video (54 and 55 respectively) while fewer chart reviews were done (73 and 52 respectively). In 2020 and 2021, concern for the patient being infectious was a common reason for the evaluation to be performed via telehealth. Ten consults were performed via telehealth because the toxicologist did not have admitting or bedside privileges. In 2020, 74 consults were billed while 94 were billed in 2021 and 6 in 2022. Most patients were evaluated following an intentional exposure to a medication or drug. Few addiction medicine evaluations were completed via telehealth, seven in 2020 and 14 in 2021. However, four consults were done for opioid and ethanol withdrawal in 2020 while 17 were completed in 2021. Conclusion(s): Telehealth appears to be infrequently used by medical toxicologists with fewer telehealth evaluations occurring in 2021 than in 2020. More consults were billed in 2021 than were billed in 2020. Toxicologists could increase the number of addiction medicine evaluations performed via telehealth as a means to increase patient and billing volume.
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Background: As we continue to treat patients during the ongoing opioid overdose epidemic, it is ever more important that providers have adequate experience in understanding and treating patients with addiction, substance use disorder and withdrawal states. Additionally, throughout the COVID-19 pandemic, there have been numerous reports demonstrating that substance use is exponentially increasing. This increases the likelihood that addiction medicine will occupy a more prominent position in our medical field. Until recently, addiction medicine education was not an ACGME program requirement for medical toxicology fellowship programs. We aimed to evaluate the percentage of bedside medical toxicology consultations addressing addiction-related issues, over time, at a tertiary care hospital system. Method(s): We reviewed bedside toxicology consults performed by a tertiary care hospital system's Division of Medical Toxicology consultation service between January 2017 and December 2021 for addiction, substance use, and withdrawal-related cases. Consultation data is entered by bedside toxicologists and maintained in a secure database. Descriptive statistics were analyzed for various variables and were compared between years, utilizing SPSS28. Result(s): Over the 5-year period, the toxicology service was consulted on a total of 4733 patients, of which, 2549 were addiction- related (53.9%). The majority of consults were male (65.6%), with 1 transgender (male-to-female) patient treated during this time. The proportion of addiction medicine consults increased steadily over the five-year time period. In 2017, there were 345 total consults, with 88 addiction-related (25.5%). In 2018, the service was consulted on 509 patients, of which 168 were addiction related (33%). In 2019, this trend continued to increase, with addiction medicine consults accounting for 52.8% of the total consults (478 of 905 consults). 58.7% of the toxicology services' consults were addiction related in 2020 (627 of 1069). As of this past year, of the 1905 total consults, 1188 were for addiction or substance-use complaints (62.4%). The most common primary reason for a medical toxicologist consult, was alcohol withdrawal (803 cases, 31.5%). In 2021, alcohol withdrawal accounted for 44.2% of the total consults, which was a 25.7% increase from pre-pandemic levels. Opioid withdrawal as the primary reason for consultation accounted for 9.1% of total consults across the time-period. In 2017, opioid withdrawal accounted for 2.3% of consults, but increased to 13.0% of the consultations by 2021. Opioid agonist therapy (buprenorphine, methadone) was initiated in 12.7% of total consults. In 2017, there were no cases where opioid agonist therapy was a topic of consultation, but this increased to 12.0% of consults throughout 2021. Conclusion(s): At a tertiary care hospital system, addiction medicine consults by bedside medical toxicologists have continued to increase disproportionately compared to other consults. As of this past year, addiction related complaints made up roughly two-thirds of all medical toxicology consults, increasing almost 40% over 5-years. This single center phenomenon could represent a national trend;however, larger-scale studies would need to assess this pattern. This data further supports the recent ACGME medical toxicology program requirement changes, emphasizing the importance of addiction medicine and its relationship to medical toxicology.
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SESSION TITLE: What's New in Critical Care? SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Alcohol withdrawal syndrome (AWS) is a common etiology of intensive care unit (ICU) admission(Vigouroux et al 2021). Emergency Department (ED) related alcohol visits have increased in incidence dramatically since the beginning of the SARS-CoV2 pandemic. A median ICU length of stay (LOS) of 8 days for severe AWS has been previously reported. The increase in substance abuse observed during the pandemic may prolong future patients’ LOS. Pandemic staffing and bed shortages have made it even more evident the need to research efficient and safe treatment options of common hospital admission diagnosis such as AWS. Current national guidelines recommend benzodiazepines as first-line therapy for inpatient management of AWS (American Society of Addiction Medicine Clinical Practice Guidelines). However, historically phenobarbital (PB) and other barbiturates have been utilized with varying success. Recent evidence has demonstrated phenobarbital loading followed by symptom-triggered benzodiazepines may reduce LOS and ICU admission (Rosenson et al 2012). We retrospectively evaluated ED and ICU data to further guide our future research on PB in AWS, specifically;LOS, location of admission, and high risk side effects frequently associated with PB such as intubation. METHODS: Patients admitted for AWS and who received PB from 8/1/2021 to 02/01/2022 were identified. Subsequently, these subjects were then matched to themselves for historical AWS admissions without receipt of PB. Exclusion criteria included: admission with concomitant diagnosis with expected admission LOS longer than AWS treatment course;no separate admission for AWS. Pertinent patient demographics were collected including cumulative dosing of benzodiazepines, disposition from the ED, hospital LOS, ICU LOS, relative hypotension, and intubation. Data was analyzed using descriptive statistics and one-sided Student T-test. RESULTS: Total of 16 patients received PB during the six month identification period. Six were excluded due to lack of previous admission for AWS. Three were excluded for previous admissions with concomitant disease states requiring prolonged admissions. These included endoscopy, long-bone fracture, and subdural hematoma. Seven patients (14 unique admissions) met inclusion criteria. Patients were all male with a mean age of 58. Compared to non-PB admissions a trend in mean reduction of hospital LOS was 39.3 hours shorter in the PB cohort (p-value=0.068). Mean benzodiazepine reduction (lorazepam equivalents) was 26.3mg less in the PB cohort (p-value = 0.064). No intubations or hypotensive events were observed in either cohort. CONCLUSIONS: When PB was utilized there was reduction in total hospital LOS with no increase in intubations. Preliminary patient matched data of PB in AWS appears efficacious and safe. CLINICAL IMPLICATIONS: PB may decrease overall hospital LOS in AWS. DISCLOSURES: No relevant relationships by Yara Albair No relevant relationships by Nicholas Barreras No relevant relationships by Jessica Kim No relevant relationships by Marc McDowell No relevant relationships by Joshua Posner No relevant relationships by Mariana Silva
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Symposium summary: Over the last few decades, the medical concept of addiction disorders has undergone tremendous development. Addictive disorders are currently considered a multifactorial chronic disease and have become a significant cause of global health problems and other psychiatric disorders. Not only drug addiction but also the number of behavioral addiction patients continues to increase. The outbreak of Coronavirus Disease 2019 (COVID-19) spread across the entire world has curtailed most individuals' daily activities and movements. In response, the COVID-19 pandemic lets individuals engage more with technology use, providing escapism to several activities (e.g., shopping, eating, gambling, gaming, doing physical exercise, watching pornography). These activities allow them to find some acute emotional relief, albeit pathologically. These behaviors happened by accessibility, availability, and the absence of prevention and management programs for excess use. The COVID-19 pandemic and the lockdown policies in several countries have created a new paradigm regarding the prevention of specific strategies for behavioral addiction, primarily due to the increase in internet use that leads to addiction. A standard is needed to manage behavioral addiction, both pharmacological and non-pharmacological, in a holistic and comprehensive manner. Besides, an instrument is needed to distinguish healthy gamers, problematic gamers, and gaming disorders in order to prevent overdiagnosis. Notably, the symposium will highlight the emerging issue of behavioral addiction such as gambling, gaming, and pornography in Low Middle-Income Countries during the pandemic, exploring global solutions to international problems in the field of addiction medicine. In this symposium, there will be one chair and four speakers.
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BACKGROUND: Methadone reduces opioid-related harms and overdose deaths in those with opioid use disorder (OUD) yet in the US is restricted to federal and state-regulated opioid treatment programs (OTPs). Methadone access remains limited, particularly in rural settings. We sought to determine prescriber and practice characteristics associated with support for provision of methadone through office-based settings. METHODS: We performed a secondary analysis of the Opioid Use Disorder Provider COVID-19 Survey, a survey collaboratively developed with multistakeholder input to explore the impact of COVID-19-related practice changes among X-waivered buprenorphine prescribers. Data were collected from July to August 2020 electronically and analyses herein were restricted to prescribers who provided outpatient, longitudinal care for adults with OUD. The outcome variable was selecting “The opportunity for patients to receive office-based methadone” when asked “Which of the pandemic-related federal policy changes or new policy changes would you like to be continued after the pandemic?” Sequential multivariable logistic regression analyses were performed to determine prescriber and practice characteristics associated with support for the opportunity for patients to receive office-based methadone. RESULTS: Among invited participants, 1,900 initiated and completed the survey. Among the 739 respondents included in the analysis, 52% were men, 60% were ≥50 years old, 81% were White, 39% were board certified in Addiction Medicine/Psychiatry, 44% were practicing in family medicine or internal medicine, and 20% in psychiatry. Nineteen percent had prescribed medications to treat OUD (MOUD) for ≥15 years, 20% had ordered methadone previously, and 21% worked in OTPs. Twenty-nine percent indicated support for office-based methadone. In sequential multivariable logistic regression models, factors associated with support for office-based methadone, compared to being White, were being Asian (AOR=2.23;95% [CI] = 1.01, 5.04), Black/African-American (AOR=3.36;95% [CI] = 1.30, 8.71);having prescribed MOUD for ≥15 years (OR=2.06;95% [CI] = 1.15, 3.66) compared to 0-5 years;having ordered methadone previously (AOR=1.71;95% [CI] = 1.03, 2.83) or having prescribed injectable naltrexone previously (AOR=1.70;95% [CI] = 1.14, 2.56) compared to not prescribing MOUD previously;and working in an academic medical center (AOR=1.87;95% [CI] = 1.11, 3.14) compared to working in other clinical practice settings. CONCLUSIONS: Nearly a third of X-waivered buprenorphine prescribers supported provision of office-based methadone, specifically prescribers of Asian, Black, or African-American backgrounds, who had spent a longer time treating OUD, and had experience providing methadone. Future efforts should explore pathways to include office-based methadone to improve access to OUD treatment.
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SETTING AND PARTICIPANTS: Montefiore Health System is the largest health care provider in Bronx, New York, a community that is disproportionately impacted by substance use disorders (SUDs). To better prepare resident physicians to care for patients with SUDs, we developed a novel addiction medicine rotation required for internal medicine residents. DESCRIPTION: The 2-week rotation includes inpatient and outpatient clinical experiences. During the inpatient week, residents rotate on the Addiction Consult Service, staffed by an addiction medicine attending, a fellow, and a peer navigator. Residents attend a weekly interdisciplinary meeting with the Psychiatry Consult Service to discuss cases. During the outpatient week, residents rotate through an opioid treatment program, an intensive outpatient substance use treatment program, and an addiction medicine “Bridge” clinic, which links patients with SUDs to primary care post- hospitalization. Residents also complete a self-study curriculum that includes addiction-focused readings and podcasts as well as the 8-hour online buprenorphine waiver training. All residents participate in Addiction Medicine Rounds, a weekly case conference and journal club led by addiction medicine faculty and trainees. EVALUATION: Between July and November 2021, 22 internal medicine residents participated in the rotation and 12 (55%) completed formal evaluations. All residents rated the overall rotation to be valuable for their education, with 33% in strong agreement based on a 4-point scale from strongly disagree to strongly agree. All residents also agreed (with 42% strongly agreed) that the rotation increased their knowledge and skills in diagnosing SUDs, and managing medication treatment for SUDs. One resident summarized: “This rotation is one of the best rotations I have experienced during my time as a resident. After completing this rotation, I felt very confident in my ability to diagnose, navigate, and manage the complexities of addiction related illness.” DISCUSSION / REFLECTION / LESSONS LEARNED: The Addiction Medicine Rotation was well-received in its first months of implementation. The experience on the Addiction Consult Service stood out as high-yield training, building on residents' familiarity with hospital-based care and leveraging multidisciplinary partnerships with psychiatry, pharmacy, and nursing departments. Providing rigorous inpatient training in addiction medicine is a unique feature of this rotation, as addiction consult services are not the mainstay in most hospitals. The “Bridge” clinic has also been valuable in training residents to provide medication treatment for SUDs within primary care. However, the outpatient experience in specialty care settings faced many scheduling challenges related to the COVID-19 pandemic, with reduced availability of preceptors, decreased number of in-person visits, and suspended group treatment. Optimizing outpatient addiction medicine training will be an ongoing goal in future rotation iterations. ONLINE RESOURCE URL: Rotation document: https://tinyurl.com/ MontefioreAddMedRotation.
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Objective The global COVID-19 pandemic has imposed challenges on healthcare systems and professionals worldwide and introduced a 'maelstrom' of ethical dilemmas. How ethically demanding situations are handled affects employees' moral stress and job satisfaction. The aim of this study was to describe priority-setting dilemmas, moral distress and support experienced by nurses and physicians across medical specialties in the early phase of the COVID-19 pandemic in Western Norway. Methods A cross-sectional hospital-based survey was conducted from 23 April to 11 May 2020. Results Among the 1606 respondents, 67% had experienced priority-setting dilemmas the previous two weeks. Healthcare workers who were directly involved in COVID-19 care, were redeployed or worked in psychiatry/addiction medicine experienced it more often. Although 59% of the respondents had seen adverse consequences due to resource scarcity, severe consequences were rare. Moral distress levels were generally low (2.9 on a 0-10 scale), but higher in selected groups (redeployed, managers and working in psychiatry/addiction medicine). Backing from existing collegial and managerial structures and routines, such as discussions with colleagues and receiving updates and information from managers that listened and acted upon feedback, were found more helpful than external support mechanisms. Priority-setting guidelines were also helpful. Conclusion By including all medical specialties, nurses and physicians, and various institutions, the study provides information on how the COVID-19 mitigation also influenced those not directly involved in the COVID-19 treatment of patients. In the next stages of the pandemic response, support for healthcare professionals directly involved in outbreakaffected patients, those redeployed or those most impacted by mitigation strategies must be a priority.
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RATIONALE: Investigations show that medications for alcohol use disorders (MAUD) reduce heavy drinking and relapses. However, only 1.6% of individuals with alcohol use disorders (AUD) receive MAUD across care settings. The epidemiology of MAUD prescribing in the acute care setting is incompletely described. We hypothesized that MAUD would be under prescribed in inpatient acute care hospital settings compared to the outpatient, emergency department (ED), and inpatient substance use treatment settings. METHODS: We evaluated electronic health record (EHR) data from adult patients with an International Classification of Diseases, 10th revision (ICD-10) alcohol-related diagnosis in the University of Colorado Health (UCHealth) system between January 1, 2016 and 31 December, 2019. Data from patients with an ICD-10 diagnosis code for opioid use disorder and those receiving MAUD prior to their first alcohol-related episode were excluded. The primary outcome was prescribing of MAUD, defined by prescription of naltrexone, acamprosate, and/or disulfiram. We performed bivariate and multivariate analyses to identify independent predictors of MAUD prescribing at UCHealth. RESULTS: We identified 48,421 unique patients with 136,205 alcohol-related encounters at UCHealth. Encounters occurred in the ED (42%), inpatient acute care (17%), inpatient substance use treatment (18%), or outpatient primary care (12%) settings. Only 2270 (5%) patients received MAUD across all settings. Female sex and addiction medicine consults positively predicted MAUD prescribing. In contrast, encounters outside inpatient substance use treatment, Hispanic ethnicity, and black or non-white race were negative predictors of MAUD prescribing. Compared to inpatient substance use treatment, inpatient acute care hospitalizations for AUD was associated with a 93% reduced odds of receiving MAUD. CONCLUSIONS: AUD-related ED and inpatient acute care hospital encounters in our healthcare system were common. Nevertheless, prescriptions for MAUD were infrequent in this population, particularly in inpatient settings. Our findings suggest that the initiation of MAUD for patients with alcohol-related diagnoses in acute care settings deserves additional evaluation.
Subject(s)
Alcoholism , Opioid-Related Disorders , Adult , Alcoholism/drug therapy , Alcoholism/epidemiology , Colorado/epidemiology , Delivery of Health Care , Ethanol/therapeutic use , Female , Humans , Naltrexone/therapeutic useABSTRACT
SETTING: Substance use remains a pervasive public health issue throughout Canada, exerting substantial economic, social, and political pressure on health care systems, while impacting lives of affected individuals. The advent of COVID-19 has been doubly perilous; it restricts existing programming, while exacting a worsening toll on mental health and substance use fronts across the demographic landscape. INTERVENTION: In response to the crisis, the Mobile Withdrawal Management Service (MWMS) was established in 2019 through a Winnipeg-based community health centre. MWMS is a community-based outreach withdrawal service that supports individuals for up to 30 days. Clients may choose where services are accessed in the community, including their own home. For those without safe housing, short-term accommodation is offered. Additionally, Indigenous cultural support, peer support, trauma counselling, and linkage to primary care are available. OUTCOMES: The MWMS approach is resolutely patient-centred. The program meets people where they are at, both figuratively and literally. Agility and adaptability-particularly in the context of substance use treatment-is uniquely advantageous in maintaining service delivery to the broad demographic cross-section revealed in the data. Moreover, relative to inpatient detoxification services, MWMS holds significant potential for system-wide cost savings. IMPLICATIONS: The presented approach addresses a significant gap in addiction services. There is substantial capacity for both increased access and system savings with implementation of this approach. Furthermore, the principles behind the program are readily transferable to different contexts and easily modifiable to local conditions. There is particular potential for servicing hard-to-reach populations, with respect to both physical and social geography.
RéSUMé: LIEU: L'usage de substances demeure un problème de santé publique omniprésent au Canada; en plus de son impact sur la vie des personnes touchées, il exerce une pression économique, sociale et politique considérable sur les systèmes de soins de santé. L'avènement de la COVID-19 a été doublement périlleux : il a limité les programmes existants tout en aggravant le bilan en matière de santé mentale et d'usage de substances dans toutes les couches de la société. INTERVENTION: En réponse à la crise, un service mobile de sevrage contrôlé (Mobile Withdrawal Management Service MWMS) a été créé en 2019 par un centre de santé communautaire de Winnipeg. Le MWMS est un service de sevrage de proximité qui offre une aide individuelle pendant une période pouvant aller jusqu'à 30 jours. Les usagères et usagers peuvent choisir l'endroit où recevoir ces services dans la communauté, y compris à leur domicile. Un hébergement à court terme est offert aux personnes sans logement sûr. Du soutien culturel aux personnes autochtones, du soutien par les pairs, du counseling traumatologique et un aiguillage vers les soins primaires sont aussi disponibles. RéSULTATS: La démarche du MWMS est résolument centrée sur la personne. Le programme rejoint les gens là où ils se trouvent, au propre et au figuré. Son agilité et son adaptabilitéparticulièrement dans le contexte du traitement de l'usage de substanceslui procurent un avantage unique lorsqu'il s'agit de maintenir la prestation de services au large spectre démographique révélé dans les données. De plus, comparé aux services de désintoxication en établissement, le MWMS peut générer des économies considérables à l'échelle du système. CONSéQUENCES: La démarche présentée comble une lacune importante dans les services d'aide aux toxicomanes. Sa mise en Åuvre permettrait d'élargir l'accès aux services et de réaliser des économies à l'échelle du système. De plus, les principes qui sous-tendent le programme sont faciles à transférer à d'autres contextes et à modifier en fonction des conditions locales. C'est aussi une démarche qui revêt l'intérêt particulier de pouvoir joindre les populations difficiles à atteindre, tant sur le plan de la géographie physique que sociale.
Subject(s)
COVID-19 , Substance-Related Disorders , COVID-19/epidemiology , COVID-19/therapy , Community Health Services , Housing , Humans , Program Evaluation/methods , Substance-Related Disorders/epidemiology , Substance-Related Disorders/therapyABSTRACT
Primary care physicians are well-positioned to integrate lifestyle interventions into the management of patients with unhealthy substance use, who may also have mental and physical chronic health comorbidities. However, the COVID-19 pandemic exacerbated the U.S.'s poor state of health, revealing that its current approach to chronic disease management is neither effective nor sustainable. Today's full spectrum comprehensive care model requires an expanded toolkit. Lifestyle interventions broaden current treatment approaches and may enhance Addiction Medicine care. Primary care providers have the potential to have the greatest impact on unhealthy substance use care because they are experts in chronic disease management and their frontline accessibility minimizes healthcare barriers. Individuals with unhealthy substance use are at an increased risk of chronic physical conditions. Incorporating lifestyle interventions with unhealthy substance use care at every level of medicine, from medical school through practice, normalizes both as part of the standard care of medicine and will drive evidence-based best practices to support patients through prevention, treatment, and reversal of chronic diseases.
ABSTRACT
Background and Objectives: Here we aimed to characterize clinical outcomes in those receiving treatment at a Veterans Health Administration (VHA) methadone maintenance treatment program (MMT) during the COVID 19 pandemic in which SAMSHA regulations for MMTs were changed to provide a greater number of methadone allotments and decreased clinic-visit frequency. Methods: We report results of a single-site, pre-post cohort study of urine drug screen data 3 months before and after an increase in allotments of take-home medication from the methadone clinic. One hundred twenty-nine patients met inclusion criteria for this study. The study was reviewed by the NYHHS IRB committee and granted final approval by the Research and Development Committee. Results: The sample was predominately male, average age 66years and average years in most recent treatment is 4.1 years. No statistical significance was found between period 1 and period 2 in the positive test detection for nonprescribed opiates, methadone and illicit substances (P > .05), number of new medical illnesses or overdoses. We controlled for participant age, substance use disorder diagnosis, psychiatric disorder diagnosis, and number of years in treatment. Discussion/Conclusions: The results of the study illustrate the relative safety of the changes made at this particular MMT during the pandemic. Additionally, there was continued adherence to methadone treatment with minimal change in illicit substance use during period 1 and period 2. Scientific Significance: To these authors' knowledge this paper is one of the first to examine clinical outcomes in those with opioid addiction prescribed methadone from MMTs during the COVID 19 pandemic.
ABSTRACT
OBJECTIVE: We describe the planning, process and evaluation of final-year Psychiatry and Addiction Medicine summative assessments in a four-year graduate medical degree program, during a COVID-19 Delta-variant public health stay-at-home lockdown. CONCLUSIONS: We conducted separate written and clinical synchronous (real-time simultaneous) tele-assessments. We used online assessment technology with students, examiners and simulated patients, all in different physical locations. Medical students' examination performance showed a good range. This was comparable to other discipline stations, and performance in previous years. There was no differential performance of students through the day of the assessments.
Subject(s)
Addiction Medicine , COVID-19 , Education, Medical, Undergraduate , Psychiatry , Students, Medical , Addiction Medicine/education , Communicable Disease Control , Educational Measurement , Humans , Psychiatry/educationABSTRACT
Background: Substance use accounts for more than 400,000 deaths annually in the United States and overdose rates surged during the COVID pandemic. While the pandemic created increased pressure for better prepared providers, it simultaneously placed restrictions on medical training programs. The purpose of this educational case series is to assess the feasibility of a virtual addiction medicine training program and conduct a qualitative evaluation of medical student attitudes toward caring for people with substance use disorders, both before and after their addiction medicine training experience. Methods: We conducted a qualitative analysis related to course content focused on strengths and limitations of in-person and virtual training modalities. Individual quotes were evaluated and content themes were developed after a thorough review of all codes and detailed examination of interviewee quotes. Results: The primary themes that emerged were (1) Addiction medicine content is important to improve care of patients with substance disorders and is not fully addressed in undergraduate medical education (2) In-person and virtual training contain unique strengths and weaknesses and (3) Students perceived that both experiences provided positive and needed training in addiction medicine that shifted perspective and enhanced confidence to practice. Conclusions: Remote training via virtual lectures and patient visits may enhance training opportunities for students with limited exposure to addiction medicine patients and faculty with addiction medicine expertise. There is a need to further refine virtual care for patients with SUDs and virtual training to meet the needs of patients and learners across the country.