Hospital admissions among patients with Comorbid Substance Use disorders: a secondary analysis of predictors from the NavSTAR Trial.

BACKGROUND: Individuals with substance use disorders (SUDs) frequently use acute hospital services. The Navigation Services to Avoid Rehospitalization (NavSTAR) trial found that a patient navigation intervention for hospitalized patients with comorbid SUDs reduced subsequent inpatient admissions compared to treatment-as-usual (TAU). METHODS: This secondary analysis extends previous findings from the NavSTAR trial by examining whether selected patient characteristics independently predicted hospital service utilization and moderated the effect of the NavSTAR intervention. Participants were 400 medical/surgical hospital patients with comorbid SUDs. We analyzed 30- and 90-day inpatient readmissions (one or more readmissions) and cumulative incidence of inpatient admissions through 12 months using multivariable logistic and negative binomial regression, respectively. RESULTS: Consistent with primary findings and controlling for patient factors, NavSTAR participants were less likely than TAU participants to be readmitted within 30 (P = 0.001) and 90 (P = 0.03) days and had fewer total readmissions over 12 months (P = 0.008). Hospitalization in the previous year (P < 0.001) was associated with cumulative readmissions over 12 months, whereas Medicaid insurance (P = 0.03) and index diagnoses of infection (P = 0.001) and injuries, poisonings, or procedural complications (P = 0.004) were associated with fewer readmissions. None of the selected covariates moderated the effect of the NavSTAR intervention. CONCLUSIONS: Previous findings showed that patient navigation could reduce repeat hospital admissions among patients with comorbid SUDs. Several patient factors were independently associated with readmission. Future research should investigate risk factors for hospital readmission among patients with comorbid SUDs to optimize interventions. TRIAL REGISTRATION: NIH ClinicalTrials.gov NCT02599818, Registered November 9, 2015 https://classic. CLINICALTRIALS: gov/ct2/show/NCT02599818 .

"I want to stay here": Patient and staff perspectives on transitioning from a low-threshold buprenorphine program to clinic-based care.

BACKGROUND: The Project Connections At Re-Entry (PCARE) Van is a low-threshold buprenorphine program operating outside the Baltimore City Detention Center. Like other low-threshold programs, PCARE seeks to engage a vulnerable population in care, stabilize patients, then transition patients to longer-term care; however, <10% of patients transition to clinic-based buprenorphine treatment. Our goal was to better understand these low transition rates and center patient perspectives in discussion of broader low-threshold program design. METHODS: From December 2022 to June 2023, semi-structured interviews were conducted with 20 former and current PCARE patients and 6 staff members. We used deductive and inductive coding followed by thematic content analysis to identify themes around treatment experiences and care preferences. RESULTS: There were strong preferences among current and former patients for continuing buprenorphine treatment at the PCARE Van. Several themes emerged from the data that explained patient preferences, including both advantages to continuing care at the van (preference for continuity, feeling respected by the program's structure and philosophy) and disadvantages to transitioning to a clinic (perceived harms associated with rigid or punitive care models). Staff noted limited program capacity, and patients expressed that if needed, they would transition to a clinic for altruistic reasons. Staff expressed varied perspectives on low-threshold care, emphasizing both larger systems factors, as well as beliefs about individual patient responsibility. CONCLUSIONS: While many low-threshold care settings are designed as transitional bridge models, this research highlights patient preference for long-term care at low-threshold programs and supports efforts to adapt low-threshold models to be sustainable as longitudinal care.

Polysubstance use and post-discharge mortality risk among hospitalized patients with opioid use disorder.

Polysubstance use is becoming increasingly common and presents several harms. This study aimed to examine the association of comorbid cocaine, alcohol (binge drinking), and sedative use with mortality among hospitalized patients with opioid use disorder (OUD). A subsample of adult medical/surgical hospital patients with OUD who were seen by a hospital addiction consultation service in Baltimore City and enrolled in a randomized trial of a patient navigation intervention were included in this study (N = 314; 45 % female; 48 % White; mean age = 44). Death certificate data from the Maryland Division of Vital Records was used, covering 3.3-5.5 years post-discharge. Multivariable proportional hazards Cox regression and competing risks regression were used to estimate all-cause mortality and overdose mortality, respectively, as a function of concurrent use of cocaine, alcohol (binge drinking), and non-prescribed sedatives at baseline. In the 30 days prior to hospital admission, 230 (73 %) participants used cocaine, 64 (20 %) binge drank, and 45 (14 %) used non-prescribed sedatives. Nearly one-third (N = 98; 31 %) died during the observation period. Drug overdose caused 53 % (N = 52) of deaths. Older age (HR = 1.03 [1.01,1.05]; P = 0.001), less than high school education (HR = 0.36 [0.24,0.54]; P < 0.001), and past 30-day sedative use (HR = 2.05 [1.20,3.50]; P = 0.008) were significantly associated with all-cause mortality. The risk of overdose mortality was 62 % lower (HR = 0.38 [0.22,0.66]; P = 0.001) for those who completed high school. No other characteristics were significantly associated with overdose mortality. The concurrent use of opioids and sedatives increases the post-discharge mortality risk among hospitalized patients with OUD. Interventions are needed to prevent mortality among this high-risk population.

The effect of a non-congregate, integrated care shelter on health: A qualitative study.

OBJECTIVE: To describe the experiences of unstably housed, medically vulnerable residents living at the Haven, a novel, non-congregate integrated care shelter operating in a historic hotel during the COVID-19 pandemic. DESIGN: A qualitative descriptive design. SAMPLE/MEASUREMENT: Semi-structured qualitative interviews were conducted in February and March 2022 with a purposive sample of 20 residents living in the integrated care shelter. Data were analyzed in May and June 2022 using the thematic analysis methods described by Braun and Clarke. RESULTS: Six women and 14 men, ages 23-71 (M = 50, SD = 14), were interviewed. Lengths of stay at the time of the interview ranged from 74 to 536 days (M = 311 days). Medical co-morbidities and substance use details were collected at baseline. Three themes were identified: (1) Autonomy, (2) supportive environments, and (3) stability and the need for permanent housing. Participants characterized the integrated care, non-congregate model as having multiple advantages over traditional shelter systems. Participants emphasized the role of nurses and case managers in providing a respectful, caring environment in the integrated shelter model. CONCLUSION: Participants described acute physical and mental health needs which were largely met by the innovative integrated shelter care model. The effect of homelessness and housing insecurity on health is well documented, but few solutions exist that promote autonomy. Participants in this qualitative study emphasized the benefits of living in a non-congregate integrated care shelter and the services which promoted their self-management of chronic diseases. PATIENT OR PUBLIC CONTRIBUTION: Patients were the participants in the study, but were not involved in the design, analysis of interpretation of the data, or preparation of the manuscript. Due to this project's small scope, we could not involve patients or the public after the study concluded data collection.

Higher buprenorphine dose associated with increased treatment retention at low threshold buprenorphine clinic: A retrospective cohort study.

INTRODUCTION: Controversy exists regarding effective sublingual buprenorphine dosing for treatment of opioid use disorder (OUD), leading to dose caps of 16 mg per day. The Project Connections at Re-Entry (PCARE) program is a low-threshold buprenorphine clinic that provides medication for OUD to vulnerable populations in Baltimore City. OBJECTIVES: To compare retention in care based on treatment dose of buprenorphine, and to examine associated population characteristics. METHODS: This analysis includes clinical patients who received buprenorphine treatment at PCARE between January and July 2021. The study categorized patients into two dosing groups (16 mg or >16 mg). We conducted chi-square tests of independence for categorical variables and independent sample t-tests for continuous variables to evaluate any significant differences in demographic and clinical characteristics by dosing category. To examine differences in 30- and 90-day retention, we conducted multivariable logistic regression analyses with the outcome variable defined as successful retention (at 30 and 90 days, respectively) controlling for demographic and clinical characteristics. RESULTS: In the study period, 566 patients received buprenorphine treatment at the PCARE van. Patients were primarily male (70.9 %), Black (89.4 %), had a mean age of 46.3 years (SD = 11.5), and a mean opioid use of 22.1 years (SD = 13.5). The majority had previous criminal justice involvement (73.9 %), Medicaid insurance coverage (75.4 %), and were unemployed (69.6 %). Nearly half of the sample had reported a previous overdose event (48.4 %). The study found no significant demographic differences between patients receiving 16 mg of buprenorphine per day compared to patients receiving >16 mg. Patients receiving >16 mg had significantly higher rates of treatment retention at 30 and 90 days: 95.4 % vs 86.7 % (p = 0.001), and 82.7 % vs. 67.6 % (p < 0.001) than those receiving 16 mg, respectively. In a multivariable logistic regression controlling for demographic and drug use characteristics, odds of 30-day (Adjusted Odds Ratio [AOR] = 3.98, 95 % Confidence Interval [CI] = 1.92, 8.74, p < 0.001) and 90-day retention (AOR = 2.56, 95 % CI = 1.55, 4.22, p < 0.001) were greater among patients receiving >16 mg daily compared to 16 mg. CONCLUSIONS: In this study examining patients with OUD in a low-threshold buprenorphine clinic, we observed higher rates of treatment retention with buprenorphine doses >16 mg.

Opioid Use Disorder Treatment Linkage at Strategic Touchpoints Using Buprenorphine (OUTLAST-B): Rationale, Design, and Evolution of a Randomized Controlled Trial.

Background: Despite the effectiveness and growing availability of treatment for opioid use disorder (OUD) with buprenorphine, many people with OUD do not access treatment services. This article describes the rationale, methodological design, evolution, and progress of an ongoing clinical trial of treatment linkage strategies for people with untreated OUD. Methods: The study, titled Opioid Use Disorder Treatment Linkage at Strategic Touchpoints using Buprenorphine (OUTLAST-B), uses "strategic touchpoints", initially sexual health clinics and subsequently broadened to other service venues and participant social networks, for recruitment and screening. Adults with untreated OUD (target N = 360) are randomized to one of the three arms: Usual Care (UC, enhanced with overdose education and naloxone distribution), Patient Navigation (PN), or Patient Navigation with an immediate short-term bridge prescription for buprenorphine (PN + BUP). In the PN and PN + BUP arms, the Patient Navigator works with participants for 2 months to facilitate treatment entry and early retention, resolve barriers (e.g., ID cards, transportation), and provide motivational support. Results: The primary outcome is OUD treatment entry within 30 days of enrollment. Participants are assessed at baseline and followed at 3- and 6-months post-enrollment on measures of healthcare utilization, substance use, and general functioning. Challenges and recruitment adaptations pursuant to the COVID-19 pandemic are discussed. Conclusions: This study could provide insights on how to reach people with untreated OUD and link them to care through non-traditional routes. Trial Registration: The study is registered at ClinicalTrials.gov (NCT04991974).

Real-Time Monitoring of Cannabis and Prescription Opioid Co-Use Patterns, Analgesic Effectiveness, and the Opioid-Sparing Effect of Cannabis in Individuals With Chronic Pain.

Despite a rapid expansion of cannabis use for pain management, how cannabis and prescription opioids are co-used and whether co-use improves analgesia and promotes reduction of opioid use in the daily lives of individuals with chronic pain is poorly understood. Based upon ecological momentary assessment (EMA), the present study examined 1) how pain and use of opioids and/or cannabis in the previous moment is associated with individuals' choice of opioids and/or cannabis in the next moment, 2) the effects of co-use on pain severity and pain relief, and 3) whether daily total opioid consumption differs on days when people only used opioids versus co-used. Adults with chronic pain (N = 46) using both opioids and cannabis who were recruited online completed a 30-day EMA. Elevated pain did not increase the likelihood of co-use in subsequent momentary assessments. Switching from sole use of either opioids and cannabis to co-use was common. Neither co-use nor sole use of either cannabis or opioids were associated with reductions in pain in the next moment. However, participants reported the highest daily perceived pain relief from co-use compared to cannabis and opioid use only. Post hoc analysis suggested recall bias as a potential source of this discrepant findings between momentary versus retrospective assessment. Lastly, there was no evidence of an opioid-sparing effect of cannabis in this sample. The present study shows preliminary evidence on cannabis and opioid co-use patterns, as well as the effects of co-use on pain and opoid dose in the real-world setting. PERSPECTIVE: This article presents the overall patterns and effects of co-using cannabis and prescription opioids among individuals with chronic pain employing ecological momentary assessment. There were conflicting findings on the association between co-use and analgesia. Co-use was not associated with a reduction in daily opioid consumption in this sample.

Cost and Cost Savings of Navigation Services to Avoid Rehospitalization for a Comorbid Substance Use Disorder Population.

BACKGROUND: A randomized clinical trial found that patient navigation for hospital patients with comorbid substance use disorders (SUDs) reduced emergency department (ED) and inpatient hospital utilization compared with treatment-as-usual. OBJECTIVE: To compare the cost and calculate any cost savings from the Navigation Services to Avoid Rehospitalization (NavSTAR) intervention over treatment-as-usual. RESEARCH DESIGN: This study calculates activity-based costs from the health care providers and uses a net benefits approach to calculate the cost savings generated from NavSTAR. NavSTAR provided patient navigation focused on engagement in SUD treatment, starting before hospital discharge and continuing for up to 3 months postdischarge. SUBJECTS: Adult hospitalized medical/surgical patients with comorbid SUD for opioids, cocaine, and/or alcohol. COST MEASURES: Cost of the 3-month NavSTAR patient navigation intervention and the cost of all inpatient days and ED visits over a 12-month period. RESULTS OF BASE CASE ANALYSIS: NavSTAR generated $17,780 per participant in cost savings. Ninety-seven percent of bootstrapped samples generated positive cost savings, and our sensitivity analyses did not change our results. LIMITATIONS: Participants were recruited at one hospital in Baltimore, MD through the hospital's addiction consultation service. Findings may not generalize to the broader population. Outpatient health care cost data was not available through administrative records. CONCLUSION: Our findings show that patient navigation interventions should be considered by payors and policy makers to reduce the high hospital costs associated with comorbid SUD patients.

Patients with substance use disorders receiving continued care in skilled nursing facilities following hospitalization.

Background: As hospitals in the US face pressures to reduce lengths of stay, healthcare systems are increasingly utilizing skilled nursing facilities (SNFs) to continue treating patients stable enough to leave the hospital, but not to return home. Substance use disorder (SUD) can complicate care of patients transferred to SNFs. The objective of this paper is to understand SNF experiences for this population of patients with comorbid SUD transferred to SNFs and examine care experiences in these facilities. Methods: This secondary mixed-methods analysis focuses on SNF experiences from a clinical trial of patient navigation services for medically-hospitalized adults with comorbid opioid, cocaine, and/or alcohol use disorder. This study compared baseline assessments and medical record review for participants (N = 400) with vs. without SNF transfer, and analyzed semi-structured qualitative interviews with a subsample of 15 participants purposively selected based on their transfer to a SNF. Results: Over 1 in 4 participants had a planned discharged to a SNF (26.8% sub-acute, 3.3% acute). Compared to participants with other types of discharge, participants discharged to a SNF had longer initial hospitalizations (4.9 vs. 11.8 days, p < 0.001), and were more likely to be White (38.6 vs. 50.8%; p = 0.02), female (38.9 vs. 52.5%; p = 0.01), have opioid use disorder (75.7 vs. 85.0%, p = 0.03), and be hospitalized for infection (43.6 vs. 58.3%; p = 0.007), and less likely to have worked prior to hospitalization (24.3 vs. 12.5%; p = 0.006). Qualitative narratives identified several themes from the SNF experience, including opioid analgesic dosing issues, challenges to the use of opioid agonist treatment of OUD, illicit opioid dealing/use, and limited access to addiction recovery support services during and following the SNF stay. Conclusions: SNFs are a common disposition for patients in need of subacute services following hospitalization but may be ill-equipped to properly manage patients in need of new or continuing SUD treatment.

Sexually Transmitted Infection Testing After Brief Intervention for Risk Behaviors in School-Based Health Centers.

PURPOSE: The initiation and escalation of substance use and sex behaviors is prevalent during adolescence. School-based health centers (SBHCs) are well-equipped to provide interventions for risky behaviors and offer sexually transmitted infection (STI) testing services. This study examined receipt of STI testing following brief intervention (BI) among sexually active adolescents. METHODS: This is a secondary analysis of data from a randomized trial comparing computer versus nurse practitioner-delivered BI approaches among adolescents (ages 14-18) with risky alcohol and/or cannabis use at two SBHCs within two urban high schools. Associations were examined among receipt of STI testing and participant characteristics, BI format, site, and frequency of substance use/sexual behaviors. RESULTS: Among sexually active participants (N = 254), 64.2% received STI testing at their SBHC within 6 months of receiving a BI. Participants receiving nurse practitioner-delivered BI had higher odds of getting STI testing than participants receiving computer-delivered BI (adjusted odds ratio 2.51, 95% confidence interval 1.41-4.47, p = .002). Other variables associated with STI testing in multivariable logistic regression included female sex (p = .001), being in a serious relationship (p = .018), and SBHC site (p < .001). Frequency of substance use and sexual risk behaviors were not independently associated with receipt of STI testing services. CONCLUSION: Sexually active adolescents who received in-person BI from a nurse practitioner were more likely to get STI testing than adolescents who received BI via computer. Nurse practitioners working in SBHCs can successfully engage adolescents in additional sexual health services subsequent to BI for risky behaviors.

Opioid agonist treatment initiation and linkage for hospitalized patients seen by a substance use disorder consultation service.

Background: Facilitating opioid agonist treatment (OAT) for opioid use disorder (OUD) is an important role of hospital substance use disorder (SUD) consultation services. In the NavSTAR trial, hospital patients receiving SUD consultation who were randomly assigned to patient navigation services for 3 months post-discharge had fewer readmissions compared to usual care. Methods: This secondary analysis examined hospital-based OAT initiation (pre-randomization) and community-based OAT linkage (post-discharge) among NavSTAR trial participants with OUD (N=314). Associations between OAT initiation and linkage, and patient demographics, housing status, comorbid SUD diagnoses, recent substance use, and study condition were examined using multinomial and dichotomous logistic regression. Results: Overall, 57.6% initiated OAT during hospitalization (36.3% methadone, 21.3% buprenorphine). Compared to participants not initiating OAT, participants who received methadone were more likely to be female (Relative Risk Ratio [RRR]=2.05, 95% CI=1.11, 3.82, p=0.02), while participants who received buprenorphine were more likely to report homelessness (RRR=2.57, 95% CI=1.24, 5.32, p=0.01). Compared to participants initiating methadone, participants initiating buprenorphine were more likely to be non-White (RRR=3.89; 95% CI=1.55, 9.70; p=0.004) and to report prior buprenorphine treatment (RRR=2.57; 95% CI=1.27, 5.20; p=0.009). OAT linkage within 30-days post-discharge was associated with hospital-based buprenorphine initiation (Adjusted Odds Ratio [AOR]=3.86, 95% CI=1.73, 8.61, p=0.001) and patient navigation intervention (AOR=2.97, 95% CI=1.60, 5.52, p=0.001). Conclusions: OAT initiation differed by sex, race, and housing status. Hospital-based OAT initiation and patient navigation were independently associated with linkage to community-based OAT. Hospitalization is a reachable moment to begin OAT to alleviate withdrawal and facilitate treatment continuity post-discharge.

Changes in drinking days among United States adults during the COVID-19 pandemic.

AIMS: To examine changes in drinking behavior among United States (US) adults between March 10 and July 21, 2020, a critical period during the COVID-19 pandemic. DESIGN: Longitudinal, internet-based panel survey. SETTING: The Understanding America Study (UAS), a nationally representative panel of US adults age 18 or older. PARTICIPANTS: A total of 4298 US adults who reported alcohol use. MEASUREMENTS: Changes in number of reported drinking days from March 11, 2020 through July 21, 2020 in the overall sample and stratified by sex, age, race/ethnicity, household structure, poverty status, and census region. FINDINGS: Compared with March 11, the number of drinking days per week was significantly higher on April 1 by an average of 0.36 days (95% CI = 0.30, 0.43), on May 1 by an average of 0.55 days (95% CI = 0.47, 0.63), on June 1 by an average of 0.41 days (95% CI = 0.33, 0.49), and on July 1 by an average of 0.39 days (95% CI = 0.31, 0.48). Males, White participants, and older adults reported sustained increases in drinking days, whereas female participants and individuals living under the federal poverty line had attenuated drinking days in the latter part of the study period. CONCLUSIONS: Between March and mid-July 2020, adults in the United States reported increases in the number of drinking days, with sustained increases observed among males, White participants, and older adults.

Trends in cannabis use among U.S. adults amid the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has had an impact on mental health and alcohol use in the US, however there is little research on its impacts on cannabis use. Considering the role of cannabis as a coping strategy or self-medicating behavior, there is a need to understand how individuals who use cannabis have adapted their use amid the pandemic. Therefore, this study examined changes in self-reported cannabis use among US adults in the context of COVID-19 pandemic by (1) describing trends of use during the first 8 months of the pandemic among adults who used cannabis in this period; and (2) characterizing trends of use within sociodemographic subgroups and by state cannabis policy status. METHODS: The sample consisted of 1,761 US adults who used cannabis at least once during the 8-month study period from the nationally representative Understanding America Study. Linear mixed-effect models were used to model changes in the number of days of past-week cannabis use across 16 waves from March 10, 2020, to November 11, 2020. RESULTS: Compared to early March, the number of days cannabis was used per week was significantly higher at the start of April (ß=0.11, 95% CI=0.03, 0.18) and May (ß=0.21,95% CI=0.05, 0.36). In subsequent months (June - November), the number of days of cannabis use attenuated to levels comparable to March. Trends of cannabis use across the study period generally did not differ across sociodemographic characteristics and state cannabis policy status. CONCLUSION: Though increases in use were marginal among many groups, the evolving pandemic and the growing concern for the mental health of segments of the U.S. population warrant close monitoring of coping behaviors, including substance use.

Feasibility and acceptability of using smartphone-based EMA to assess patterns of prescription opioid and medical cannabis use among individuals with chronic pain.

BACKGROUND: Intensive longitudinal studies are needed to examine the co-use of prescription opioid medication and medical cannabis and their effects on chronic pain. The current study sought to investigate the feasibility and participant compliance with a smartphone-based Ecological Momentary Assessment (EMA) data collection protocol among individuals who use multiple substances and suffer from chronic pain. METHODS: A total of 46 participants (mean age = 44.8 years; 78% female; 85% Non-Hispanic White) were recruited online and completed a 30-day EMA phase where they responded to prompted surveys (four random past-hour surveys and one daily diary per day) about opioid medication use, medical cannabis use, and pain symptoms. Qualitative follow-up interviews were conducted with a subset of 10 participants. Linear and logistic regression models were used to examine baseline participant characteristics in relation to EMA compliance. Qualitative indicators of participant study experience were extracted from interviews. RESULTS: Participants responded to an average of 70% of past-hour surveys and 92% of daily diaries. Female participants were more likely to complete all daily diaries and at least one past-hour survey per day on all 30 days, respectively (OR = 5.60, 95% CI: 1.02-30.77, p < .05; OR = 7.08, 95% CI: 1.28-39.16, p < .05). Female participants were also more likely to complete at least 75% of their prompted past-hour surveys (OR = 4.67, 95% CI: 1.00-21.69, p < .05). Interview participants reported a positive study experience overall, although some mentioned problems related to smartphone notifications, redundant questions, or being prompted when they were not feeling well. Participants also mentioned problems with reporting the amount of medical cannabis used (e.g., milliliters of vaping liquid). CONCLUSIONS: Study results demonstrate both feasibility and acceptability of using EMA methodology to examine use patterns of medical cannabis and prescription opioid medication among individuals with chronic pain.

Preventing Hospital Readmission for Patients With Comorbid Substance Use Disorder : A Randomized Trial.

BACKGROUND: Hospitalized patients with comorbid substance use disorders (SUDs) are at high risk for poor outcomes, including readmission and emergency department (ED) use. OBJECTIVE: To determine whether patient navigation services reduce hospital readmissions. DESIGN: Randomized controlled trial comparing Navigation Services to Avoid Rehospitalization (NavSTAR) versus treatment as usual (TAU). (ClinicalTrials.gov: NCT02599818). SETTING: Urban academic hospital in Baltimore, Maryland, with an SUD consultation service. PARTICIPANTS: 400 hospitalized adults with comorbid SUD (opioid, cocaine, or alcohol). INTERVENTION: NavSTAR used proactive case management, advocacy, service linkage, and motivational support to resolve internal and external barriers to care and address SUD, medical, and basic needs for 3 months after discharge. MEASUREMENTS: Data on inpatient readmissions (primary outcome) and ED visits for 12 months were obtained for all participants via the regional health information exchange. Entry into SUD treatment, substance use, and related outcomes were assessed at 3-, 6-, and 12-month follow-up. RESULTS: Participants had high levels of acute care use: 69% had an inpatient readmission and 79% visited the ED over the 12-month observation period. Event rates per 1000 person-days were 6.05 (NavSTAR) versus 8.13 (TAU) for inpatient admissions (hazard ratio, 0.74 [95% CI, 0.58 to 0.96]; P = 0.020) and 17.66 (NavSTAR) versus 27.85 (TAU) for ED visits (hazard ratio, 0.66 [CI, 0.49 to 0.89]; P = 0.006). Participants in the NavSTAR group were less likely to have an inpatient readmission within 30 days than those receiving TAU (15.5% vs. 30.0%; P < 0.001) and were more likely to enter community SUD treatment after discharge (P = 0.014; treatment entry within 3 months, 50.3% NavSTAR vs. 35.3% TAU). LIMITATION: Single-site trial, which limits generalizability. CONCLUSION: Patient navigation reduced inpatient readmissions and ED visits in this clinically challenging sample of hospitalized patients with comorbid SUDs. PRIMARY FUNDING SOURCE: National Institute on Drug Abuse.

Adapting a Low-threshold Buprenorphine Program for Vulnerable Populations During the COVID-19 Pandemic.

OBJECTIVES: To examine patient characteristics and outcomes among opioid use disorder patients enrolled in low-threshold buprenorphine treatment during the COVID-19 pandemic. METHODS: This paper describes the adaptation of the Project Connections (PC) program, a low-threshold buprenorphine program in Baltimore, in response to the COVID-19 pandemic. This paper examines patient characteristics and initial outcomes of patients served during a rapid protocol shift to telehealth that allowed buprenorphine initiation without an in-person encounter following a state-mandated stay-at-home order. Patient characteristics were compared to a subsample of patients enrolled in the program before the COVID-19 pandemic. RESULTS: In March 2020, there was a sharp increase in new enrollments to the PC program. A total of 143 patients completed an intake assessment between March and May 2020 and 140 began treatment with buprenorphine/naloxone. Those who completed an intake assessment were primarily male (68.5%), Black (83.2%), had a mean age of 43.2 years (SD = 11.7), and reported a mean of 17.0 years of opioid use (SD = 12.9). The majority of patients were unemployed (72.7%) and reported previous criminal justice involvement (69.2%). Of those who completed an intake assessment, 96.5% returned for a second visit. Among those for whom 30-day retention data was available (n = 113), 63.7% were engaged for 30 days or longer. CONCLUSIONS: The PC program illustrates that offering on-demand, flexible treatment is an opportunity to increase opioid use disorder treatment access, even during a public health emergency that disrupted access to services. Relaxation of buprenorphine telehealth regulations allowed for flexibility in treatment and benefits vulnerable populations.

Leveraging health information exchange for clinical research: Extreme underreporting of hospital service utilization among patients with substance use disorders.

BACKGROUND: Substance use disorders are associated with inefficient and fragmented use of healthcare services. The Chesapeake Regional Information System for Our Patients, Inc. (CRISP) is a Health Information Exchange (HIE) linking disparate systems of care in the mid-Atlantic region. METHODS: This article describes applications of HIE for tracking hospital service utilization in substance use disorder clinical and services research, drawing upon data from one of the first studies approved to access the CRISP HIE. Participants were 200 medical/surgical inpatients with comorbid opioid, cocaine, and/or alcohol use disorder (45.5 % female; 56.5 % black; 77.5 % opioid use disorder; 42.0 % homeless). This study compared HIE-identified hospital service utilization with conventional methods of participant self-report during in-person research follow-ups (3-, 6-, and 12-months post-discharge) and electronic health record (EHR) review from the hospital system of the index admission. RESULTS: This sample exhibited high levels of hospital utilization, which would have been underestimated using conventional methods. Relying exclusively on self-report in the 12-month observation period would have identified only 33.8 % of 429 inpatient hospitalizations and 9.0 % of 1,287 ED visits, due to both loss-to-follow-up and failure to report events. Even combining self-report with single-system EHR review identified only 66.2 % of inpatient hospitalizations and 59.8 % of ED visits. CONCLUSIONS: CRISP HIE data were superior to conventional methods for ascertaining hospital service utilization in this sample of patients exhibiting high-volume and fragmented care. The use of HIE holds implications for improving rigor, safety, and efficiency in research studies.

Comparison of timeline follow-back self-report and oral fluid testing to detect substance use in adult primary care patients.

BACKGROUND: Timeline Follow-back (TLFB) interviews using self-report are often used to assess substance use. Oral fluid testing (OFT) offers an objective measure of substance use. There are limited data on the agreement between TLFB and OFT. METHODS: In this secondary analysis from a multisite study in five primary care sites, self-reported TLFB and OFT data collected under confidential conditions were compared to assess concordance (N=1799). OFT samples were analyzed for marijuana, heroin, cocaine, and non-medical use of prescription opioids. Demographic differences in discordance relative to TLFB and OFT concordant results for marijuana, the only substance with an adequate sample size in this analysis, were examined using multinomial logistic regression. RESULTS: Overall concordance rates between TLFB and OFT were 94.9 % or higher for each substance, driven by large subgroups with no use. Among participants with discordant use, marijuana was the only substance with lower detection on OFT than self-report (27.6 % OFT-positive only vs 32.2 % TLFB-positive only), whereas cocaine (65.6 % vs 8.6 %), prescription opioids (90.4 % vs 6.0 %), and heroin (40.7 % vs 26.0 %) all had higher detection via OFT than TLFB. Participants who reported marijuana use but had a negative OFT were more likely to be younger, Hispanic, and White compared to those with TLFB and OFT concordant positive results. CONCLUSIONS: TLFB and OFT show disparate detection of different substances. Researchers should consider the implications of using either self-report or oral fluid testing in isolation, depending on the substance and collection setting. Triangulating multiple sources of information may improve detection of drug use.

Navigation Services to Avoid Rehospitalization among Medical/Surgical Patients with Comorbid Substance Use Disorder: Rationale and Design of a Randomized Controlled Trial.

Substance use disorders (SUDs) are associated with significant morbidity and mortality and contribute to inefficient use of healthcare services. Hospitalized medical/surgical patients with comorbid SUD are at elevated risk of hospital readmission and poor outcomes. Thus, effective interventions are needed to help such patients during hospitalization and post-discharge. This article reports the rationale, methodological design, and progress to date on a randomized trial comparing the effectiveness of Navigation Services to Avoid Rehospitalization (NavSTAR) vs Treatmentas-Usual (TAU) for hospital medical/surgical patients with comorbid SUD (N = 400). Applying Andersen's theoretical model of health service utilization, NavSTAR employed Patient Navigation and motivational interventions to promote entry into SUD treatment, facilitate adherence to recommendations for medical follow-up and self-care, address basic needs, and prevent the recurrent use of hospital services. As part of the NavSTAR service model, Patient Navigators embedded within the SUD consultation service at a large urban hospital delivered patient-centered, proactive navigation and motivational services initiated during the hospital stay and continued for up to 3 months post-discharge. Participants randomized to TAU received usual care from the hospital and the SUD consultation service, which included referral to SUD treatment but no continued contact post-hospital discharge. Hospital service utilization will be determined via review of electronic health records and the regional Health Information Exchange. Participants were assessed at baseline and again at 3-, 6-, and 12-month follow-up on various measures of healthcare utilization, substance use, and functioning. The primary outcome of interest is time-to-rehospitalization through 12 months. In addition, a range of secondary outcomes spanning the medical and SUD service areas will be assessed. The study will include a health economic evaluation of NavSTAR. If NavSTAR proves to be effective and cost-effective in this high-risk patient group, it would have important implications for addressing the needs of hospital patients with comorbid SUD, designing hospital discharge planning services, informing cost containment initiatives, and improving public health.

Rehospitalization and substance use disorder (SUD) treatment entry among patients seen by a hospital SUD consultation-liaison service.

BACKGROUND: Substance use disorders (SUD) are associated with non-adherence to medical care and high utilization of hospital services. This study characterized patterns and correlates of rehospitalization among patients seen by a hospital-based SUD consultation-liaison (CL) team. METHODS: This study was a retrospective medical record review of patients in a large urban academic hospital who received SUD consultation and were diagnosed with opioid, cocaine, and/or alcohol use disorder (N = 267). Data were collected on patient characteristics, substance-specific SUD diagnoses (opioids, cocaine, and alcohol), opioid agonist treatment (OAT) with methadone or buprenorphine (treatment status at admission; in-hospital initiation of OAT), and rehospitalization through 180 days post-discharge. Associations with rehospitalization were examined using bivariate tests of independence and multivariate logistic regression, with patient background and medical characteristics, substance-specific SUD diagnoses, and OAT status (at admission and in-hospital initiation) as predictors. RESULTS: Rehospitalization rates were higher among patients with current opioid (38% vs. 24%; p < .05) and cocaine use disorders (39% vs. 26%; p < .05) compared to patients without these diagnoses. In multivariate logistic regression analysis, the number of medical comorbidities [Adjusted Odds Ratio (AOR) = 1.2; p < .01] and opioid use disorder (AOR = 2.4, p < .05) were independently associated with rehospitalization. CONCLUSIONS: In this sample of hospital patients receiving SUD CL services, the risk of rehospitalization differed by type of SUD diagnosis. In-hospital initiation of OAT is promising for facilitating treatment linkage post-discharge, but this small study did not show differences in rehospitalization based on OAT initiation. These findings could inform services for hospital patients with comorbid SUDs.