The Substance Use Intervention Team: A Preliminary Analysis of a Population-level Strategy to Address the Opioid Crisis at an Academic Health Center.

OBJECTIVE: In 2017, an academic health center in Chicago launched the multidisciplinary Substance Use Intervention Team (SUIT) to address opioid misuse across 18 inpatient units and in a new outpatient addiction medicine clinic. This report assesses the first 5 months of implementation and associations with patient health and healthcare utilization. METHODS: Patient demographic and screening data were extracted from the administrative data warehouse of the electronic health record (EHR) infrastructure. Distribution of sample characteristics for positive initial screens for opioid misuse was tested against those of all patients screened using a 2-tailed test of proportions (P < 0.05). A second analysis compared length of stay and 30-day readmissions within a cohort of patients with a secondary diagnosis of substance use disorder. RESULTS: Between November, 2017 and March, 2018, 76% of 15,054 unique patients were screened, 578 had positive scores on the Alcohol Use Disorders Identification Test and Drug Abuse Screening Test, 131 had positive scores for opioid misuse, and 52 patients initiated medication treatment. Patients with a secondary diagnosis of substance use disorder who received a SUIT consult (n = 161), compared with those who did not (n = 612), had a shorter average length of stay (5.91 vs 6.73 days) and lower 30-day readmission rate (13.6% vs 15.7%). CONCLUSION: Leveraging the EHR to conduct standardized screenings and treatment has helped identify an at-risk population-disproportionately younger, black, and male-and treat new cases of opioid and substance misuse. The intervention indicates trends toward a shortened length of stay, reduced 30-day readmissions, and has linked patients to outpatient care.

Subtypes in patients with opioid misuse: A prognostic enrichment strategy using electronic health record data in hospitalized patients.

BACKGROUND: Approaches are needed to better delineate the continuum of opioid misuse that occurs in hospitalized patients. A prognostic enrichment strategy with latent class analysis (LCA) may facilitate treatment strategies in subtypes of opioid misuse. We aim to identify subtypes of patients with opioid misuse and examine the distinctions between the subtypes by examining patient characteristics, topic models from clinical notes, and clinical outcomes. METHODS: This was an observational study of inpatient hospitalizations at a tertiary care center between 2007 and 2017. Patients with opioid misuse were identified using an operational definition applied to all inpatient encounters. LCA with eight class-defining variables from the electronic health record (EHR) was applied to identify subtypes in the cohort of patients with opioid misuse. Comparisons between subtypes were made using the following approaches: (1) descriptive statistics on patient characteristics and healthcare utilization using EHR data and census-level data; (2) topic models with natural language processing (NLP) from clinical notes; (3) association with hospital outcomes. FINDINGS: The analysis cohort was 6,224 (2.7% of all hospitalizations) patient encounters with opioid misuse with a data corpus of 422,147 clinical notes. LCA identified four subtypes with differing patient characteristics, topics from the clinical notes, and hospital outcomes. Class 1 was categorized by high hospital utilization with known opioid-related conditions (36.5%); Class 2 included patients with illicit use, low socioeconomic status, and psychoses (12.8%); Class 3 contained patients with alcohol use disorders with complications (39.2%); and class 4 consisted of those with low hospital utilization and incidental opioid misuse (11.5%). The following hospital outcomes were the highest for each subtype when compared against the other subtypes: readmission for class 1 (13.9% vs. 10.5%, p<0.01); discharge against medical advice for class 2 (12.3% vs. 5.3%, p<0.01); and in-hospital death for classes 3 and 4 (3.2% vs. 1.9%, p<0.01). CONCLUSIONS: A 4-class latent model was the most parsimonious model that defined clinically interpretable and relevant subtypes for opioid misuse. Distinct subtypes were delineated after examining multiple domains of EHR data and applying methods in artificial intelligence. The approach with LCA and readily available class-defining substance use variables from the EHR may be applied as a prognostic enrichment strategy for targeted interventions.

Ranking the harm of non-medically used prescription opioids in the UK.

A panel of nine experts applied multi-criteria decision analysis (MCDA) to determine the relative overall harm to users and harms to others of street heroin (injected and smoked) and eleven non-medically used prescription opioids. The experts assessed harm scores for each of the 13 opioids on each of 20 harm criteria, weighted the criteria and explored the resulting weighted harm scores for each opioid. Both forms of heroin scored very high: overall harm score of 99 for injected heroin and 72 for smoked heroin on a scale of 0-100. The main feature that distinguishes both forms of street heroin use is that their harm to others is more than five times that of the other eleven opioids. The overall harm score of fentanyl (including injection of fentanyl extracted from patches) and diamorphine (medically prescribed form of heroin) was 54 and 51, respectively, whereas that of orally used opioids ranged from 32 (pethidine) to 11 (codeine-containing pharmaceuticals). Injected street heroin, fentanyl and diamorphine emerged as most harmful to users, with the latter two very low in harm to others. Pethidine, methadone, morphine and oxycodone are also low in harm to others, while moderate in harm to users. We conclude that the overall harms of non-medically used prescription opioids are less than half that of injected street heroin. These data may give a basis for precautionary regulatory measures that should be considered if the rising trend in non-medical use of prescription opioids were to become evident in the UK.

Classification and definition of misuse, abuse, and related events in clinical trials: ACTTION systematic review and recommendations.

As the nontherapeutic use of prescription medications escalates, serious associated consequences have also increased. This makes it essential to estimate misuse, abuse, and related events (MAREs) in the development and postmarketing adverse event surveillance and monitoring of prescription drugs accurately. However, classifications and definitions to describe prescription drug MAREs differ depending on the purpose of the classification system, may apply to single events or ongoing patterns of inappropriate use, and are not standardized or systematically employed, thereby complicating the ability to assess MARE occurrence adequately. In a systematic review of existing prescription drug MARE terminology and definitions from consensus efforts, review articles, and major institutions and agencies, MARE terms were often defined inconsistently or idiosyncratically, or had definitions that overlapped with other MARE terms. The Analgesic, Anesthetic, and Addiction Clinical Trials, Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership convened an expert panel to develop mutually exclusive and exhaustive consensus classifications and definitions of MAREs occurring in clinical trials of analgesic medications to increase accuracy and consistency in characterizing their occurrence and prevalence in clinical trials. The proposed ACTTION classifications and definitions are designed as a first step in a system to adjudicate MAREs that occur in analgesic clinical trials and postmarketing adverse event surveillance and monitoring, which can be used in conjunction with other methods of assessing a treatment's abuse potential.

Potentially inappropriate medication use among institutionalized elderly individuals in southeastern Brazil

In recent decades, the elderly population in Brazil has grown rapidly, as has concern for the health of this population. Institutionalization in nursing homes has appeared as an alternative form of health care for frail elderly that live alone. The present study evaluated the pharmacotherapy and inappropriate drug prescriptions for institutionalized elderly patients living in long-term institutions in southeastern Brazil. This research was conducted at five institutions with a total sample of 151 individuals aged at least 60 years. Databases were used to identify drug interactions, defined daily dose and inappropriate prescriptions. The prevalence of drug intake among the elderly was 95.36%, and there were an average of 3.31 ± 1.80 drug prescriptions per individual. Based on Beers criteria, the prevalence of inappropriate prescriptions was 25.83%. In addition, 70.2% of prescriptions were prescribed at a higher dosage than the defined daily dose (ATC/WHO). Potential drug interactions were identified for 54.11% of prescriptions; 81.42% of these were of moderate severity. The main inappropriate drugs were prescribed for cardiovascular and nervous system problems. Institutionalized elderly individuals presented a high consumption and misuse of medications, requiring professional intervention to monitor prescriptions and improve the quality of service for this population.

Nas últimas décadas, o número de idosos no Brasil cresceu rapidamente, bem como, a preocupação com a saúde desta parcela da população. Neste cenário, a institucionalização em casas de repouso aparece como uma alternativa para os cuidados com a saúde dos idosos debilitados ou que vivem sozinhos. O presente estudo avaliou a farmacoterapia e a prescrição inadequada para idosos que residem em instituições de longa permanência no sudeste do Brasil. Esta pesquisa foi realizada em cinco instituições, totalizando uma amostra de 151 indivíduos com idade a partir de 60 anos. O banco de dados foi analisado para identificação de interações medicamentosas, dose diária definida e critérios de Beers. Dentre os indivíduos avaliados, 95,36% consomem algum tipo de medicamento, sendo 3,31 ± 1,80 medicamentos prescritos por indivíduo. Com base nos critérios de Beers, a prevalência de prescrições inapropriadas foi de 25,83%, sendo também encontradas 70,2% das prescrições com doses superiores à dose diária definida (ATC/WHO). Interações medicamentosas potenciais estavam presentes em 54,11% das prescrições, sendo 81,42% com grau moderado de gravidade. Os principais medicamentos inapropriados foram prescritos para problemas cardiovasculares e do sistema nervoso. Os idosos institucionalizados apresentam alto consumo e uso inadequado de medicamentos, sendo necessária a intervenção profissional para monitorar as prescrições médicas e melhorar a qualidade do serviço de distribuição de medicamentos a esta parte da população.

Drug related problems associated with the psychoactive drugs used on geriatric, hospitalized patients

A prospective study was carried out, to identify the drug related problems and to prevent or to solve the negative outcomes associated with medication of the geriatric patients that consumed psychoactive drugs, who were hospitalized. The study was carried out according to the DADER Method of Pharmacotherapy Monitoring, adapted to the Hospital's environment and the theoretical rationale of the Third Consent of Granada was assumed, for the considerations related to the drug related problems and the negative outcomes associated with medication. Thirty five patients were included whose ages ranged between the 60 and 90 years. Thirty six negative associated outcomes were identified, in 34 patients that represented 97.14% incidence. A prevalence of the negative outcomes associated with the necessity was observed, followed by those associated with the security. The inadequate drug uses was the drug related problem that prevailed in the sample. The psychoactive drugs that were related with these results were mainly the anxiolytics, meprobamate and the neuroleptics. Some 82.35% of the interventions were accepted, achieving resolution of 47.06% of the negative outcomes associated with medication.

Foi realizada uma pesquisa de intervenção, prospectiva, a fim de identificar problemas relacionados aos medicamentos e evitar ou resolver resultados negativos daí decorrentes, em pacientes idosos que faziam uso de medicamentos psicotrópicos e que foram internados. O estudo foi realizado de acordo com o método DADER para o acompanhamento farmacoterapêutico e assumiram-se os pressupostos teóricos do III Consenso de Granada, as considerações relacionadas com os problemas dos fármacos e os resultados negativos associados à medicação. Foram incluídos 35 pacientes com idades entre 60 e 90 anos. Trinta e seis RM foram identificados em 34 pacientes representando incidência de 97,14% e a prevalência foi observada para os resultados negativos associados com a necessidade, seguidos por aqueles relacionados à segurança. O uso indevido de fármacos foi os problema mais frequente na amostra. Os psicofármacos mais implicados foram os ansiolíticos, meprobamato e neurolépticos. Das intervenções, 82,35% foram aceitas, alcançando 47,06% de resolução dos resultados negativos associados à medicação.