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Study Overview
Objective. To evaluate the impact of addiction consultation during hospitalization on addiction severity and self-reported abstinence at 30 days post discharge.
Design. Prospective quasi-experimental study.
Setting and participants. 399 adults admitted to an urban academic medical center between 1 April 2015 and 1 April 2016 who screened as high risk for having an alcohol or drug use disorder (using the Alcohol Use Disorders Identification Test–Consumption and the National Institute on Drug Abuse single-question screen for drug use) or who were clinically identified by the primary nurse as having a substance use disorder. Pregnant patients, those who were unable to be interviewed due to medical reasons, and those who screened solely for marijuana use were excluded.
Intervention. The intervention was a multidisciplinary addiction consult team (ACT) comprising a psychiatrist, an internist with addiction expertise, advanced practice nurses, 3 social workers, a clinical pharmacist, a recovery coach, and a resource specialist. The ACT provided patients with a diagnosis and longitudinal management plan begun in the hospital including pharmacotherapy initiation when appropriate, motivational counseling, treatment planning, and direct linkage to ongoing addiction treatment upon discharge. The ACT was available to patients on 12 of the hospital’s 14 floors. Patients on the 2 floors where ACT was not implemented and patients who were eligible for inpatient addiction consults but did nor receive them served as controls. Control patients received access to a general psychiatry consult liaison team and floor social work, and management of control patients included withdrawal treatment and referral to outpatient addiction care.
Main outcome measures. The primary outcomes were change in Addiction Severity Index (ASI) composite score for alcohol and drug use and self-reported abstinence at 30 days post discharge compared to baseline. The ASI is a standardized instrument for assessing the severity of problems for patients with substance use disorder. Participants were assessed at enrollment (baseline) and at 30 and 90 days post discharge.
Main results. 256 patients received the intervention and 143 did not (control). Of the 399 participants, 265 completed the 30-day assessment, which showed that patients in the intervention group (n = 165) had a greater reduction in the ASI composite score for alcohol and drug use than patients in the control group (n = 100), with mean ASI-alcohol and ASI-drug decreases of 0.24 (vs 0.08, P < 0.001) and 0.05 (vs 0.02, P = 0.003), respectively. The intervention group also had a greater increase in number of days of abstinence than the control group (12.7 days vs 5.6 days, P < 0.001). These differences all remained statistically significant after controlling for age, gender, employment status, smoking status, and baseline addiction severity. The increase in abstinence days and reduction in alcohol use severity remained significantly greater in the intervention group 90 days after discharge.
Conclusion. Inpatient addiction consultation reduced alcohol and drug addiction severity and increased the number of days of abstinence in the 30 days following discharge.
Commentary
In the United States, national mortality rates due to unintentional overdose, driven largely by opioid misuse and abuse, have surpassed mortality due to HIV and motor vehicle accidents [1]. Individuals with substance use disorder frequently use hospital services for management of acute problems, and up to 1 in 7 hospitalized patients has an active substance use disorder [2]. Hospitalization thus provides an opportunity to engage these patients in addiction treatment. Evidence supports the use of several interventions for patients with substance use disorders in the general medical setting [2–5], but implementation of these interventions in clinical practice remains limited.
This study adds to the literature demonstrating the efficacy of hospital-based interventions for substance abuse disorders. The authors note that the ACT intervention combined pharmacotherapy and behavioral interventions that were shown in prior studies to improve treatment retention, decrease substance use, and reduce hospital readmission. In addition to reducing alcohol/drug addiction severity and increasing days of abstinence at 1 month follow-up, the ACT intervention also reduced the number of self-reported hospital and emergency department visits by treated patients for substance use issues. The effects of the intervention on abstinence days and alcohol use severity were still evident after 3 months, suggesting that similar interventions can have benefits over the long term.
The authors highlighted several limitations of this study, including lack of randomization, which led to differences between the 2 groups on several variables. They controlled for these differences in their analysis, but there is still the potential for confounding. Also, the outcomes data was gathered through patient self-reporting without biological confirmation; however, as the authors note, this approach is widely used and self-report of substance use has shown good agreement with biological measures.
Applications for Clinical Practice
Hospitalization represents an opportunity to engage persons with substance abuse disorders in addiction treatment. This study demonstrates the effectiveness of a comprehensive inpatient substance use disorder intervention in improving substance-use–related outcomes in the first month after discharge. Further study of similar interventions in other care settings and for a longer duration is warranted.
—Ajay Dharod, MD, Wake Forest School of Medicine
Winston-Salem, NC
1. Voon P, Karamouzian M, Kerr T. Chronic pain and opioid misuse: a review of reviews. Subst Abuse Treat Prev Policy 2017;12:36.
2. Trowbridge P, Weinstein ZM, Roy P, et al. Addiction consultation services - Linking hospitalized patients to outpatient addiction treatment. J Subst Abuse Treat 2017;79:1–5.
3. Shanahan CW, Beers D, Alford DP, et al. A transitional opioid program to engage hospitalized drug users. J Gen Intern Med 2010;25:803–8.
4. McQueen J, Howe TE, Allan L, et al. Brief interventions for heavy alcohol users admitted to general hospital wards.Cochrane Database Syst Rev 2011;(8):CD005191.
5. Wei J, Defries T, Lozada M, et al. An inpatient treatment and discharge planning protocol for alcohol dependence: efficacy in reducing 30-day readmissions and emergency department visits. J Gen Intern Med 2015;30:365–70.
Study Overview
Objective. To evaluate the impact of addiction consultation during hospitalization on addiction severity and self-reported abstinence at 30 days post discharge.
Design. Prospective quasi-experimental study.
Setting and participants. 399 adults admitted to an urban academic medical center between 1 April 2015 and 1 April 2016 who screened as high risk for having an alcohol or drug use disorder (using the Alcohol Use Disorders Identification Test–Consumption and the National Institute on Drug Abuse single-question screen for drug use) or who were clinically identified by the primary nurse as having a substance use disorder. Pregnant patients, those who were unable to be interviewed due to medical reasons, and those who screened solely for marijuana use were excluded.
Intervention. The intervention was a multidisciplinary addiction consult team (ACT) comprising a psychiatrist, an internist with addiction expertise, advanced practice nurses, 3 social workers, a clinical pharmacist, a recovery coach, and a resource specialist. The ACT provided patients with a diagnosis and longitudinal management plan begun in the hospital including pharmacotherapy initiation when appropriate, motivational counseling, treatment planning, and direct linkage to ongoing addiction treatment upon discharge. The ACT was available to patients on 12 of the hospital’s 14 floors. Patients on the 2 floors where ACT was not implemented and patients who were eligible for inpatient addiction consults but did nor receive them served as controls. Control patients received access to a general psychiatry consult liaison team and floor social work, and management of control patients included withdrawal treatment and referral to outpatient addiction care.
Main outcome measures. The primary outcomes were change in Addiction Severity Index (ASI) composite score for alcohol and drug use and self-reported abstinence at 30 days post discharge compared to baseline. The ASI is a standardized instrument for assessing the severity of problems for patients with substance use disorder. Participants were assessed at enrollment (baseline) and at 30 and 90 days post discharge.
Main results. 256 patients received the intervention and 143 did not (control). Of the 399 participants, 265 completed the 30-day assessment, which showed that patients in the intervention group (n = 165) had a greater reduction in the ASI composite score for alcohol and drug use than patients in the control group (n = 100), with mean ASI-alcohol and ASI-drug decreases of 0.24 (vs 0.08, P < 0.001) and 0.05 (vs 0.02, P = 0.003), respectively. The intervention group also had a greater increase in number of days of abstinence than the control group (12.7 days vs 5.6 days, P < 0.001). These differences all remained statistically significant after controlling for age, gender, employment status, smoking status, and baseline addiction severity. The increase in abstinence days and reduction in alcohol use severity remained significantly greater in the intervention group 90 days after discharge.
Conclusion. Inpatient addiction consultation reduced alcohol and drug addiction severity and increased the number of days of abstinence in the 30 days following discharge.
Commentary
In the United States, national mortality rates due to unintentional overdose, driven largely by opioid misuse and abuse, have surpassed mortality due to HIV and motor vehicle accidents [1]. Individuals with substance use disorder frequently use hospital services for management of acute problems, and up to 1 in 7 hospitalized patients has an active substance use disorder [2]. Hospitalization thus provides an opportunity to engage these patients in addiction treatment. Evidence supports the use of several interventions for patients with substance use disorders in the general medical setting [2–5], but implementation of these interventions in clinical practice remains limited.
This study adds to the literature demonstrating the efficacy of hospital-based interventions for substance abuse disorders. The authors note that the ACT intervention combined pharmacotherapy and behavioral interventions that were shown in prior studies to improve treatment retention, decrease substance use, and reduce hospital readmission. In addition to reducing alcohol/drug addiction severity and increasing days of abstinence at 1 month follow-up, the ACT intervention also reduced the number of self-reported hospital and emergency department visits by treated patients for substance use issues. The effects of the intervention on abstinence days and alcohol use severity were still evident after 3 months, suggesting that similar interventions can have benefits over the long term.
The authors highlighted several limitations of this study, including lack of randomization, which led to differences between the 2 groups on several variables. They controlled for these differences in their analysis, but there is still the potential for confounding. Also, the outcomes data was gathered through patient self-reporting without biological confirmation; however, as the authors note, this approach is widely used and self-report of substance use has shown good agreement with biological measures.
Applications for Clinical Practice
Hospitalization represents an opportunity to engage persons with substance abuse disorders in addiction treatment. This study demonstrates the effectiveness of a comprehensive inpatient substance use disorder intervention in improving substance-use–related outcomes in the first month after discharge. Further study of similar interventions in other care settings and for a longer duration is warranted.
—Ajay Dharod, MD, Wake Forest School of Medicine
Winston-Salem, NC
Study Overview
Objective. To evaluate the impact of addiction consultation during hospitalization on addiction severity and self-reported abstinence at 30 days post discharge.
Design. Prospective quasi-experimental study.
Setting and participants. 399 adults admitted to an urban academic medical center between 1 April 2015 and 1 April 2016 who screened as high risk for having an alcohol or drug use disorder (using the Alcohol Use Disorders Identification Test–Consumption and the National Institute on Drug Abuse single-question screen for drug use) or who were clinically identified by the primary nurse as having a substance use disorder. Pregnant patients, those who were unable to be interviewed due to medical reasons, and those who screened solely for marijuana use were excluded.
Intervention. The intervention was a multidisciplinary addiction consult team (ACT) comprising a psychiatrist, an internist with addiction expertise, advanced practice nurses, 3 social workers, a clinical pharmacist, a recovery coach, and a resource specialist. The ACT provided patients with a diagnosis and longitudinal management plan begun in the hospital including pharmacotherapy initiation when appropriate, motivational counseling, treatment planning, and direct linkage to ongoing addiction treatment upon discharge. The ACT was available to patients on 12 of the hospital’s 14 floors. Patients on the 2 floors where ACT was not implemented and patients who were eligible for inpatient addiction consults but did nor receive them served as controls. Control patients received access to a general psychiatry consult liaison team and floor social work, and management of control patients included withdrawal treatment and referral to outpatient addiction care.
Main outcome measures. The primary outcomes were change in Addiction Severity Index (ASI) composite score for alcohol and drug use and self-reported abstinence at 30 days post discharge compared to baseline. The ASI is a standardized instrument for assessing the severity of problems for patients with substance use disorder. Participants were assessed at enrollment (baseline) and at 30 and 90 days post discharge.
Main results. 256 patients received the intervention and 143 did not (control). Of the 399 participants, 265 completed the 30-day assessment, which showed that patients in the intervention group (n = 165) had a greater reduction in the ASI composite score for alcohol and drug use than patients in the control group (n = 100), with mean ASI-alcohol and ASI-drug decreases of 0.24 (vs 0.08, P < 0.001) and 0.05 (vs 0.02, P = 0.003), respectively. The intervention group also had a greater increase in number of days of abstinence than the control group (12.7 days vs 5.6 days, P < 0.001). These differences all remained statistically significant after controlling for age, gender, employment status, smoking status, and baseline addiction severity. The increase in abstinence days and reduction in alcohol use severity remained significantly greater in the intervention group 90 days after discharge.
Conclusion. Inpatient addiction consultation reduced alcohol and drug addiction severity and increased the number of days of abstinence in the 30 days following discharge.
Commentary
In the United States, national mortality rates due to unintentional overdose, driven largely by opioid misuse and abuse, have surpassed mortality due to HIV and motor vehicle accidents [1]. Individuals with substance use disorder frequently use hospital services for management of acute problems, and up to 1 in 7 hospitalized patients has an active substance use disorder [2]. Hospitalization thus provides an opportunity to engage these patients in addiction treatment. Evidence supports the use of several interventions for patients with substance use disorders in the general medical setting [2–5], but implementation of these interventions in clinical practice remains limited.
This study adds to the literature demonstrating the efficacy of hospital-based interventions for substance abuse disorders. The authors note that the ACT intervention combined pharmacotherapy and behavioral interventions that were shown in prior studies to improve treatment retention, decrease substance use, and reduce hospital readmission. In addition to reducing alcohol/drug addiction severity and increasing days of abstinence at 1 month follow-up, the ACT intervention also reduced the number of self-reported hospital and emergency department visits by treated patients for substance use issues. The effects of the intervention on abstinence days and alcohol use severity were still evident after 3 months, suggesting that similar interventions can have benefits over the long term.
The authors highlighted several limitations of this study, including lack of randomization, which led to differences between the 2 groups on several variables. They controlled for these differences in their analysis, but there is still the potential for confounding. Also, the outcomes data was gathered through patient self-reporting without biological confirmation; however, as the authors note, this approach is widely used and self-report of substance use has shown good agreement with biological measures.
Applications for Clinical Practice
Hospitalization represents an opportunity to engage persons with substance abuse disorders in addiction treatment. This study demonstrates the effectiveness of a comprehensive inpatient substance use disorder intervention in improving substance-use–related outcomes in the first month after discharge. Further study of similar interventions in other care settings and for a longer duration is warranted.
—Ajay Dharod, MD, Wake Forest School of Medicine
Winston-Salem, NC
1. Voon P, Karamouzian M, Kerr T. Chronic pain and opioid misuse: a review of reviews. Subst Abuse Treat Prev Policy 2017;12:36.
2. Trowbridge P, Weinstein ZM, Roy P, et al. Addiction consultation services - Linking hospitalized patients to outpatient addiction treatment. J Subst Abuse Treat 2017;79:1–5.
3. Shanahan CW, Beers D, Alford DP, et al. A transitional opioid program to engage hospitalized drug users. J Gen Intern Med 2010;25:803–8.
4. McQueen J, Howe TE, Allan L, et al. Brief interventions for heavy alcohol users admitted to general hospital wards.Cochrane Database Syst Rev 2011;(8):CD005191.
5. Wei J, Defries T, Lozada M, et al. An inpatient treatment and discharge planning protocol for alcohol dependence: efficacy in reducing 30-day readmissions and emergency department visits. J Gen Intern Med 2015;30:365–70.
1. Voon P, Karamouzian M, Kerr T. Chronic pain and opioid misuse: a review of reviews. Subst Abuse Treat Prev Policy 2017;12:36.
2. Trowbridge P, Weinstein ZM, Roy P, et al. Addiction consultation services - Linking hospitalized patients to outpatient addiction treatment. J Subst Abuse Treat 2017;79:1–5.
3. Shanahan CW, Beers D, Alford DP, et al. A transitional opioid program to engage hospitalized drug users. J Gen Intern Med 2010;25:803–8.
4. McQueen J, Howe TE, Allan L, et al. Brief interventions for heavy alcohol users admitted to general hospital wards.Cochrane Database Syst Rev 2011;(8):CD005191.
5. Wei J, Defries T, Lozada M, et al. An inpatient treatment and discharge planning protocol for alcohol dependence: efficacy in reducing 30-day readmissions and emergency department visits. J Gen Intern Med 2015;30:365–70.