Post-hospitalization Care Transition Strategies for Patients with Substance Use Disorders: A Narrative Review and Taxonomy

Incze, Michael A.; Kelley, A. Taylor; James, Hannah; Nolan, Seonaid; Stofko, Andrea; Fordham, Cole; Gordon, Adam J.

doi:10.1007/s11606-024-08670-5

Cited by 3 publications

(5 citation statements)

References 54 publications

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“…Although outcomes associated with methadone and buprenorphine are similar, there are multiple complexities related to starting methadone in the hospital, including the need to establish linkage to an outpatient treatment program that dispenses methadone. These challenges are not insurmountable, and there is a framework for hospitals to guide implementation . Different than methadone, buprenorphine can be prescribed and dispensed at commercial pharmacies, although access varies.…”

Section: Discussioncontrasting

confidence: 75%

“…These challenges are not insurmountable, and there is a framework for hospitals to guide implementation. 32 , 33 Different than methadone, buprenorphine can be prescribed and dispensed at commercial pharmacies, although access varies. The recent abolishment of the buprenorphine X-waiver may encourage more prescribers to provide this medication to their patients, but barriers at pharmacies remain.…”

Section: Discussionmentioning

confidence: 99%

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Opioid Overdose After Medication for Opioid Use Disorder Initiation Following Hospitalization or ED Visit

Weiner,

Little,

Yoo

et al. 2024

JAMA Netw Open

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ImportanceHospitalizations related to opioid use disorder (OUD) represent an opportunity to initiate medication for OUD (MOUD).ObjectiveTo assess whether starting MOUD after a hospitalization or emergency department (ED) visit is associated with the odds of fatal and nonfatal opioid overdose at 6 and 12 months.Design, Setting, and ParticipantsThis population-based cohort study used data from the Oregon Comprehensive Opioid Risk Registry, which links all payer claims data to other administrative health datasets, for individuals aged 18 years or older who had diagnosis codes related to OUD recorded at an index ED visit or hospitalization from January 2017 to December 2019. Data were analyzed between May 2023 and January 2024.ExposuresReceipt of MOUD within the 7 days after an OUD-related hospital visit.Main Outcomes and MeasuresThe primary outcome was fatal or nonfatal overdose at 6 and 12 months after discharge. Sample characteristics, including age, sex, insurance plan, number of comorbidities, and opioid-related overdose events, were stratified by receipt or nonreceipt of MOUD within 7 days after an OUD-related hospital visit. A logistic regression model was used to investigate the association between receipt of MOUD and having an opioid overdose event.ResultsThe study included 22 235 patients (53.1% female; 25.0% aged 25-39 years) who had an OUD-related hospital visit during the study period. Overall, 1184 patients (5.3%) received MOUD within 7 days of their ED visit or hospitalization. Of these patients, 683 (57.7%) received buprenorphine, 463 (39.1%) received methadone, and 46 (3.9%) received long-acting injectable naltrexone. Patients who received MOUD within 7 days after discharge had lower adjusted odds of fatal or nonfatal overdose at 6 months compared with those who did not (adjusted odds ratio [AOR], 0.63; 95% CI, 0.41-0.97). At 12 months, there was no difference in adjusted odds of fatal or nonfatal overdose between these groups (AOR, 0.79; 95% CI, 0.58-1.08). Patients had a lower risk of fatal or nonfatal overdose at 6 months associated with buprenorphine use (AOR, 0.50; 95% CI, 0.27-0.95) but not with methadone use (AOR, 0.57; 95% CI, 0.28-1.17).Conclusions and RelevanceIn this cohort study of individuals with an OUD-related hospital visit, initiation of MOUD was associated with reduced odds of opioid-related overdose at 6 months. Hospitals should consider implementing programs and protocols to offer initiation of MOUD to patients with OUD who present for care.

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Section: Discussioncontrasting

confidence: 75%

Section: Discussionmentioning

confidence: 99%

Opioid Overdose After Medication for Opioid Use Disorder Initiation Following Hospitalization or ED Visit

Weiner,

Little,

Yoo

et al. 2024

JAMA Netw Open

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“…Specifically, we aimed to explore consensus among a diverse group of SUD experts on the anticipated effectiveness and implementation of 10 post-hospitalization SUD care transition models generated from a recent narrative review. 3 To achieve this, we designed a Delphi study that convened 25 interdisciplinary clinicians with diverse experience orchestrating SUD care transitions. We created a rating system for each model evaluating anticipated effectiveness and implementation using the GRADE Evidence to Decision framework.…”

Section: Our Approachmentioning

confidence: 99%

“…These include residual symptoms and complications from their medical illness, the clinical features of SUD itself, new medications and appointments, social barriers such as housing and transportation, insurance limitations, and inadequate local treatment infrastructure. Several care models, [2][3][4] including hospital in-reach from partnering SUD treatment programs, 5,6 peer navigation, 7,8 and intensive care management, 9 have shown promise in improving linkage to follow-up care after hospitalization; however, these interventions have generally been evaluated in small, single-site trials, 4 and no studies have rigorously evaluated the comparative effectiveness of existing SUD care transition models. Given the urgent need for research to inform best clinical practices related to posthospitalization SUD care transitions, alternative study designs are needed that can help prioritize existing interventions for future research and clinical implementation.…”

mentioning

confidence: 99%

Using the Delphi Process to Prioritize an Agenda for Care Transition Research for Patients With Substance Use Disorders

Incze,

Huebler,

Grant

et al. 2024

Substance Use & Addiction Journal

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Medical hospitalizations are increasingly recognized as important opportunities to engage individuals with substance use disorders (SUD) and offer treatment. While a growing number of hospitals have instituted interventions to support the provision of SUD care during medical admissions, post-hospitalization transitions of care remain a challenge for patients and clinicians and an understudied area of SUD care. Evidence is lacking on the most effective and feasible models of care to improve post-hospitalization care transitions for people with SUD. In the absence of strong empirical evidence to guide practice and policy, consensus-based research methods such as the Delphi process can play an important role in efficiently prioritizing existing models of care for future study and implementation. We conducted a Delphi study that convened a group of 25 national interdisciplinary experts with direct clinical experience facilitating post-hospitalization care transitions for people with SUD. Our panelists rated 10 existing care transition models according to anticipated effectiveness and facility of implementation based on the GRADE Evidence to Decision framework. Qualitative data on each care model were also gathered through comments and an online moderated discussion board. Our results help establish a hierarchy of SUD care transition models to inform future study and program development.

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“…While hospital-based teams can coordinate care and help anticipate and address post–acute care needs, such as transportation or insurance barriers, they have limited ability to influence often stringent community treatment requirements, such as daily in-person visits for methadone, frequent drug testing, mandatory counseling, and abstinence as a condition of treatment. Nevertheless, there is a valuable role for transitional care interventions to link patients to posthospital OUD care after hospitalization . Such interventions have potential to address some but not all patient-level needs and, if designed to do so, could play a critical role in driving improvement across siloed OUD care settings.…”

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confidence: 99%

Opioid Use Disorder Medications After Hospitalization—Rethinking Engagement in Care

Englander

2024

JAMA Intern Med

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Increasingly, health systems are recognizing hospitals as a critical touchpoint in the opioid use disorder (OUD) care continuum. Rapidly emerging evidence from observational studies show that interprofessional hospital-based addiction consultation services (ACS) c an mitigate stigma toward people who use drugs, increase patients' trust in hospital clinicians, increase in-hospital use of methadone and buprenorphine, reduce patient-directed discharges, educate a hospital workforce, transform health systems, and reduce mortality after hospital discharge. 1 Hospitalized people with OUD experience disproportionately high morbidity and mortality. 2 Methadone and buprenorphine are lifesaving and the most effective treatment for OUD, yet most hospitalized patients who need them do not access them. 3 This real-world, step-wedge cluster randomized clinical trial by McNeely and colleagues 4 compares outcomes in 6 New York City hospitals during a period of treatment as usual with a period when the hospitals provided interprofessional ACS intended to facilitate posthospital treatment initiation and engagement with medication for OUD (MOUD), including methadone, buprenorphine, and extended-release naltrexone, for patients with OUD. The authors found that admission to a hospital with an ACS was associated with 8-fold higher odds of MOUD initiation in the 14 days after discharge and almost 7-fold higher odds of engagement in the subsequent 30 days. This study is the most rigorous evaluation of interprofessional ACS to date and provides more compelling evidence for hospitals, health systems, and payers to adopt and expand ACS.While the relative odds of initiating and engaging in MOUD after discharge between hospitals with ACS are impressive, the absolute effect size was modest; even in hospitals with ACS, only 11% of people not taking MOUD at admission initiated MOUD after discharge, and 7.4% sustained engagement in the subsequent 30 days. This raises important questions. It is possible that in New York City, with a relatively high density of available treatment, patients who want MOUD are already taking it. In the study by McNeely et al, 4 42% of otherwise eligible patients were excluded because they had received MOUD in the 30 days before admission; among patients not taking MOUD, 6.7% of people admitted to hospitals without ACS initiated MOUD. This differs greatly from previous estimates in other regions;

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Post-hospitalization Care Transition Strategies for Patients with Substance Use Disorders: A Narrative Review and Taxonomy

Cited by 3 publications

References 54 publications

Opioid Overdose After Medication for Opioid Use Disorder Initiation Following Hospitalization or ED Visit

Opioid Overdose After Medication for Opioid Use Disorder Initiation Following Hospitalization or ED Visit

Using the Delphi Process to Prioritize an Agenda for Care Transition Research for Patients With Substance Use Disorders

Opioid Use Disorder Medications After Hospitalization—Rethinking Engagement in Care

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