Faculty Bibliography

INTRODUCTION/BACKGROUND:Screening for unhealthy alcohol and drug use is recommended in primary care, and effective implementation requires understanding patients' perspectives. Failure to identify and address potential differences in attitudes toward screening across demographic groups may result in care gaps, but research examining this is limited. METHODS:We surveyed 977 adult patients in 9 primary care clinics that participated in a screening implementation study. The survey collected demographics and attitudes toward screening/discussion of alcohol/drug use in primary care. We described responses overall and compared across age, gender, race, and ethnicity using Chi-square/Fisher's exact tests. RESULTS:Mean age was 51.1 years, and the sample was 39% male, 61% female, 72% White non-Hispanic, 11% Hispanic, 10% Black non-Hispanic, and 6% other/unknown race non-Hispanic. Most participants across all demographic groups reported supportive attitudes. Comfort reporting drug use was lower among young, male, Black non-Hispanic, and Hispanic patients, and comfort with screening overall was lower among middle-aged, Black non-Hispanic, and Hispanic patients. CONCLUSIONS:Results suggest that screening/discussion of alcohol/drug use in primary care is generally highly acceptable to patients across demographic groups. Strategies are needed to increase comfort and alleviate concerns about how medical information will be used, particularly among middle-aged, Black, and Hispanic patients.

While approximately one in five Americans with substance use disorder (SUD) receives treatment in addiction treatment programs, a majority have seen a primary care medical provider in the past year. Recognizing the critical role of primary care in addressing prevention and treatment of unhealthy substance use, for over a decade the National Drug Abuse Treatment Clinical Trials Network (CTN) has supported research to build the tools and evidence needed to support the integration of SUD care, while remaining realistic about the barriers to doing so. Authored by primary care and addiction medicine physician researchers, this commentary provides an overview of CTN primary care-focused research, from developing and implementing substance use screening tools to advancing evidence-based SUD treatment delivery in primary care settings. We identify three priority areas for research and practice innovations: 1) identifying effective treatment interventions to address polysubstance use; 2) improved screening and treatment for cannabis use; and 3) building the evidence base for substance use interventions among non-treatment seeking patients who have unhealthy drug use identified through screening. Addressing these areas can help primary care fulfill its potential as a key component of the substance use services continuum of care.

IMPORTANCE/UNASSIGNED:With acute care utilization and mortality rates increasing among people with opioid use disorder, hospital addiction consult services can provide an important touchpoint for care, potentially leading to improved outcomes. OBJECTIVE/UNASSIGNED:To study the effectiveness of interprofessional hospital addiction consultation services on postdischarge acute care utilization and mortality. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:In this pragmatic stepped-wedge cluster randomized implementation and effectiveness (hybrid type 1) clinical trial, 6 New York City public hospitals were randomized to an intervention start date, and outcomes were compared during treatment as usual (TAU) and intervention conditions. Participants included adults with hospitalizations identified in Medicaid claims data between October 2017 and January 2021. Eligible patients had an admission or discharge diagnosis of opioid use disorder or opioid poisoning or adverse effects, were hospitalized at least 1 night in a medical or surgical inpatient unit, and were not receiving medication for opioid use disorder before hospitalization. INTERVENTION/UNASSIGNED:Hospitals implemented the Consult for Addiction Treatment and Care in Hospitals (CATCH) program, an interprofessional inpatient addiction consult service providing specialty care for substance use disorders, with teams consisting of a medical clinician, social worker or addiction counselor, and peer counselor. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Acute care utilization (hospitalizations and emergency department [ED] visits) and mortality rates (all-cause deaths, overdose deaths, and opioid-involved overdose deaths) 1 year after hospital discharge. Data for the eligible patients were analyzed July 2023 to September 2024. RESULTS/UNASSIGNED:In total, 1355 eligible admissions were identified (968 [71.4%] men; mean [SD] age, 46.6 [12.4] years). A majority of patients (835 [61.5%]) had at least 1 subsequent hospitalization or ED visit. There were 113 deaths, including 34 overdose deaths (30.1%), of which 28 (82.4%) involved opioids. ED admissions were lower in the intervention period compared with TAU (incidence rate ratio, 0.79 [95% CI, 0.72-0.88]; P < .001). There were no statistically significant differences between CATCH and TAU periods in numbers of hospitalizations (incidence rate ratio, 0.99 [95% CI, 0.87-1.13]) or mortality (eg, hazard ratio for all-cause death, 1.14 [95% CI, 0.98-1.92]). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this prespecified secondary analysis of a cluster randomized clinical trial, postdischarge ED visits decreased with the CATCH program, highlighting the potential of hospital-based addiction consult services to address needs of patients with opioid use. Nonetheless, high rates of acute care utilization and mortality persisted, underscoring the need for comprehensive care strategies that extend beyond the hospital walls, and addressing the complex health and social needs of individuals with opioid use. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT03611335.

BACKGROUND:A majority of the 8.9 million Americans with opioid misuse have mild or no symptoms of opioid use disorder (OUD), but they may be at elevated risk of developing more severe OUD, overdose, or other health consequences of opioid use. The "Subthreshold Opioid Use Disorder Prevention"(STOP) Trial is evaluating a collaborative care intervention for risky opioid use in primary care. Here, we describe baseline characteristics of participants to understand their needs and assess the generalizability of the sample. METHODS:Recruitment at five primary care sites spanned March 2021-May 2023. Adult patients who screened positive for subthreshold OUD (current illicit or non-medical opioid use without meeting DSM-5 criteria for moderate-severe OUD) were eligible. Baseline assessments measured self-reported demographic characteristics, other substance use, pain, and physical and mental health symptoms. Descriptive statistics summarize characteristics of the enrolled sample across sites. RESULTS:Among the 202 participants, the majority identified as female (63.4%), white (70.8%), and non-Hispanic (96.5%), with mean age 55.7 (SD: 12.7) years. Nearly half (49.0%) had problem or high-risk use of prescription opioids, and most received a prescription for opioid medication in the past six months (74.8%). Many participants reported current problem use or high-risk use of alcohol (47.0%) or cannabis (31.2%). Approximately one-third endorsed mental health symptoms, including moderate-severe anxiety (35.6%), depression (31.2%), or sleep disturbance (29.7%), and 20.3% reported a past suicide attempt. In the prior six months, 14.7% had experienced a nonfatal overdose. Moderate-severe pain was reported by 63.4%, and 60.4% rated their general health as fair or poor. CONCLUSIONS:Patients with subthreshold OUD had high rates of polysubstance use and comorbidities that may present challenges to reducing risky opioid use. The STOP trial presents an opportunity to detect and address subthreshold OUD in a cohort with considerable medical and social needs, within primary care settings. CLINICAL TRIALS REGISTRATION/BACKGROUND:ClinicalTrials.gov NCT04218201.

BACKGROUND:The Tobacco, Alcohol, Prescription Medication, and Other Substance (TAPS) tool is a screening and brief assessment instrument to identify unhealthy tobacco, alcohol, drug use, and prescription medication use in primary care patients. This secondary analysis compares the TAPS tool to the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) for alcohol screening. METHODS:Adult primary care patients (1124 female, 874 male) completed the TAPS tool followed by AUDIT-C. Performance of each instrument was evaluated against a reference standard measure, the modified World Mental Health Composite International Diagnostic Interview, to identify problem use and alcohol use disorder (AUD). Area under the curve (AUC) appraised discrimination, and sensitivity and specificity were calculated for Youden optimal score thresholds. RESULTS:For identifying problem use: On the AUDIT-C, AUC was 0.90 (95% Confidence Interval: 0.86-0.92) for females and 0.91 (0.89-0.93) for males. Sensitivity and specificity for females were 0.89 (0.83-0.93) and 0.78 (0.75-0.80), respectively, and for males were 0.84 (0.79-0.88) and 0.82 (0.79-0.85). On the TAPS tool, AUC was 0.82 (0.79-0.86) for females and 0.81 (0.78-0.84) for males. Sensitivity and specificity for females were 0.78 (0.72-0.84) and 0.78 (0.75-0.81), respectively, and for males were 0.76 (0.71-0.81) and 0.76 (0.72-0.79). For AUD: On the AUDIT-C, AUC was 0.90 (0.88-0.93) for both females and males. Sensitivity and specificity for females were 0.83 (0.74-0.90) and 0.83 (0.80-0.85), respectively, while for males, they were 0.81 (0.74-0.87) and 0.84 (0.81-0.87). On the TAPS tool, AUC was 0.84 (0.80-0.89) for females and 0.82 (0.78-0.86) for males. Sensitivity and specificity for females were 0.73 (0.63-0.81) and 0.85 (0.83-0.88), respectively, while for males, they were 0.75 (0.68-0.81) and 0.84 (0.81-0.86). CONCLUSION/CONCLUSIONS:The AUDIT-C performed somewhat better than the TAPS tool for alcohol screening. However, the TAPS tool had an acceptable level of performance for alcohol screening and may be advantageous in practice settings seeking to identify alcohol and other substance use with a single instrument.

BACKGROUND:Individuals with opioid use disorder have high rates of hospital admissions, which represent a critical opportunity to engage patients and initiate medications for opioid use disorder (MOUD). However, few patients receive MOUD and, even if MOUD is initiated in the hospital, patients may encounter barriers to continuing MOUD in the community. OBJECTIVE:Describe hospital providers' experiences and perspectives to inform initiatives and policies that support hospital-based MOUD initiation and continuation in community treatment programs. DESIGN/METHODS:As part of a broader implementation study focused on inpatient MOUD (NCT#04921787), we conducted semi-structured interviews with hospital providers. PARTICIPANTS/METHODS:Fifty-seven hospital providers from 12 community hospitals. APPROACH/METHODS:Thematic analysis examined an emergent topic on challenges transitioning patients to outpatient MOUD treatment and related impacts on MOUD initiation by inpatient providers. KEY RESULTS/RESULTS:Participants described structural barriers to transitioning hospitalized patients to continuing outpatient MOUD including (a) limited outpatient buprenorphine prescriber availability, (b) the siloed nature of addiction treatment, and (c) long wait times. As a result of observing these structural barriers, participants experienced a sense of futility that deterred them from initiating MOUD. Participants proposed strategies that could better support these patient transitions, including developing partnerships between hospitals and outpatient addiction treatment and supporting in-reach services from community providers. CONCLUSIONS:We identified concerns about inadequate and inaccessible community-based care and transition pathways that discouraged hospital providers from prescribing MOUD. As hospital-based opioid treatment models continue to expand, programmatic and policy strategies to support inpatient transitions to outpatient addiction treatment are needed. NCT TRIAL NUMBER/UNASSIGNED:04921787.

OBJECTIVE:This analysis evaluated the validation results of the Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) tool for older adults. METHODS:We performed a subgroup analysis of older adults aged ≥65 (n = 184) from the TAPS tool validation study conducted in 5 primary care clinics. We compared the interviewer and self-administered versions of the TAPS tool at a cutoff of ≥1 for identifying problem use with a reference standard measure, the modified World Mental Health Composite International Diagnostic Interview. RESULTS:The mean age was 70.6 ± 5.9 years, 52.7% were female, and 49.5% were non-Hispanic Black. For identifying problem use, the self-administered TAPS tool had sensitivity of 0.91 (95% CI: 0.75-0.98) and specificity of 0.91 (95% CI: 0.85-0.95) for tobacco; sensitivity of 0.68 (95% CI: 0.45-0.86) and specificity of 0.88 (95% CI: 0.82-0.93) for alcohol; and sensitivity 0.86 (95% CI: 0.42-1.00) and specificity 0.94 (95% CI: 0.90-0.97) for cannabis. The interviewer-administered TAPS tool had similar results. We were unable to evaluate its performance for identifying problem use of individual classes of drugs other than cannabis in this population due to small sample sizes. CONCLUSIONS:While the TAPS had excellent sensitivity and specificity for identifying tobacco use among older adults, the results for other substances lack precision, and we were unable to evaluate its performance for prescription medications and individual illicit drugs in this sample. This analysis underlines the critical need to adapt and validate screening tools for unhealthy substance use, specifically for older populations who have unique risks.

OBJECTIVES/OBJECTIVE:We explored medications for opioid use disorder treatment (MOUD) utilization in six New York City public hospitals that implemented the "Consultation for Addiction Care and Treatment in Hospitals (CATCH)" program. METHODS:CATCH rolled out between October 2018 and February 2020. Data from the electronic health record were analyzed for the first year post-implementation. Eligible cases included adults with an opioid-related diagnosis admitted to inpatient departments served by CATCH, with a stay of ≥1 night. Patients were classified as receiving an MOUD order if there was at least 1 order of buprenorphine, methadone, or naltrexone. Logistic regression modeled the impact of CATCH consults on MOUD orders, controlling for demographic and clinical characteristics with hospital as a random effect. RESULT/RESULTS:Among 2117 eligible patients, 71.4% were male, with a mean age of 51.2 years, and 27.2% identified as Black, 21.2% as White, and 34.5% as Hispanic. MOUD was ordered in 60.9% of admissions, and 41.5% had a completed CATCH consult. Patients identified as Black had lower odds of receiving a MOUD order than those identified as White (OR: 0.52, 95% CI: 0.38-0.71; P < 0.001). Patients with a CATCH consult had higher odds of receiving a MOUD order (OR: 3.22, 95% CI: 2.54-4.07; P < 0.001). CONCLUSION/CONCLUSIONS:Majority of patients in our sample received a MOUD order, with higher odds among those with a CATCH consult. Further research is needed on the drivers of racial disparities in MOUD, and other contextual, organizational, and population-specific barriers and facilitators contributing to receipt of hospital-based addiction consult services and MOUD.

BACKGROUND:In response to the heavy burden of untreated substance use disorders (SUD) in hospital patients, many health systems are implementing addiction consult services staffed by interprofessional teams that diagnose SUD, make recommendations for SUD care in the hospital, and link patients to post-discharge treatment. In 2018, the New York City public hospital system began rolling out the Consult for Addiction Treatment and Care in Hospitals (CATCH) program in six hospitals. CATCH teams are comprised of an addiction-trained medical provider, social worker or addiction counselor, and peer counselor. METHODS:The study conducted qualitative interviews with CATCH staff at all six participating hospitals as part of a pragmatic trial studying the effectiveness and implementation of CATCH. The Consolidated Framework for Implementation Research (CFIR) framework guided interviews conducted from 2018 to 2021 with 26 staff at the start of implementation and with 33 staff 9-12 months post-implementation. The study team created a codebook a priori and further refined it through additional coding of initial interviews. Codes were systematically analyzed using the CFIR. RESULTS:Barriers and facilitators spanned four CFIR domains: inner setting, outer setting, process, and individual characteristics. Barriers identified were primarily related to the outer and inner settings, including patient characteristics and limited resources (e.g. medical comorbidities, homelessness), insurance, CATCH team role confusion, and infrastructure deficits (e.g., availability of physical space). Additional barriers related to process (workload burden), and characteristics of individuals (stigma and lack of comfort treating SUD among medical teams). Facilitators were mostly related to the characteristics of individuals on the CATCH team (advantages and expertise of the CATCH peer counselor, CATCH team communication and cohesiveness) and inner setting (CATCH team relationships with hospital staff, hospital leadership buy-in and support, and infrastructure). Community networks (outer setting) and CATCH training resources (process) were also facilitators of program implementation. CONCLUSION/CONCLUSIONS:Addiction consult services have great potential for improving care for hospital patients with SUD, but as new programs in busy hospital settings they face barriers to implementation that could impact their effectiveness. Barriers may be particularly impactful for programs operating in safety-net hospitals, given limited resources within the health system and the multiple and complex needs of their patients. Understanding the strengths of these programs as well as the barriers to their implementation is critical to utilizing addiction consult services effectively.