Buprenorphine Treatment for Hospitalized, Opioid-Dependent Patients

IMPORTANCE

Buprenorphine opioid agonist treatment (OAT) has established efficacy for treating opioid dependency among persons seeking addiction treatment. However, effectiveness for out-of-treatment, hospitalized patients is not known.

OBJECTIVE

To determine whether buprenorphine administration during medical hospitalization and linkage to office-based buprenorphine OAT after discharge increase entry into office-based OAT, increase sustained engagement in OAT, and decrease illicit opioid use at 6 months after hospitalization.

DESIGN, SETTING, AND PARTICIPANTS

From August 1, 2009, through October 31, 2012, a total of 663 hospitalized, opioid-dependent patients in a general medical hospital were identified. Of these, 369 did not meet eligibility criteria. A total of 145 eligible patients consented to participation in the randomized clinical trial. Of these, 139 completed the baseline interview and were assigned to the detoxification (n = 67) or linkage (n = 72) group.

INTERVENTIONS

Five-day buprenorphine detoxification protocol or buprenorphine induction, intrahospital dose stabilization, and postdischarge transition to maintenance buprenorphine OAT affiliated with the hospital’s primary care clinic (linkage).

MAIN OUTCOMES AND MEASURES

Entry and sustained engagement with buprenorphine OAT at 1, 3, and 6 months (medical record verified) and prior 30-day use of illicit opioids (self-report).

RESULTS

During follow-up, linkage participants were more likely to enter buprenorphine OAT than those in the detoxification group (52 [72.2%] vs 8 [11.9%], P < .001). At 6 months, 12 linkage participants (16.7%) and 2 detoxification participants (3.0%) were receiving buprenorphine OAT (P = .007). Compared with those in the detoxification group, participants randomized to the linkage group reported less illicit opioid use in the 30 days before the 6-month interview (incidence rate ratio, 0.60; 95% CI, 0.46-0.73; P < .01) in an intent-to-treat analysis.

CONCLUSIONS AND RELEVANCE

Compared with an inpatient detoxification protocol, initiation of and linkage to buprenorphine treatment is an effective means for engaging medically hospitalized patients who are not seeking addiction treatment and reduces illicit opioid use 6 months after hospitalization. However, maintaining engagement in treatment remains a challenge.

LEVEL OF EVIDENCE:

Level 3 Prognostic.

Below:  Distribution of Rates of Illicit Opioid Use During Follow-up Assessment by Intervention in 116 Individuals. 

A, Detoxification group; B, linkage group. To facilitate description, rates were calculated as days of illicit opioid use per 30 follow-up days using all available data, including the mean of all assessments for each study participant with multiple follow-up data or any follow-up time point for participants with one time point.

Full article at:   http://goo.gl/zwTQgS

By:  Jane M. Liebschutz, MD, MPH, Denise Crooks, MPH, Debra Herman, PhD, Bradley Anderson, PhD, Judith Tsui, MD, MPH, Lidia Z. Meshesha, BA, Shernaz Dossabhoy, BA, and Michael Stein, MD

Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts (Liebschutz, Crooks, Tsui, Dossabhoy); Department of Medicine, Boston University School of Medicine, Boston, Massachusetts (Liebschutz, Tsui); Department of General Internal Medicine, Butler Hospital, Providence, Rhode Island (Herman, Anderson, Stein); Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island (Herman, Anderson, Stein); Department of Psychology, The University of Memphis, Memphis, Tennessee (Meshesha).

Corresponding Author: Jane M. Liebschutz, MD, MPH, Boston Medical Center, 801 Massachusetts Ave, Second Floor, Boston, MA 02118 

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

What do we know about the risks for young people moving into, through and out of inpatient mental health care? Findings from an evidence synthesis

Background

Young people with complex or severe mental health needs sometimes require care and treatment in inpatient settings. There are risks for young people in this care context, and this study addressed the question: ‘What is known about the identification, assessment and management of risk in young people (aged 11–18) with complex mental health needs entering, using and exiting inpatient child and adolescent mental health services in the UK?’

Methods

In phase 1 a scoping search of two electronic databases (MEDLINE and PsychINFO) was undertaken. Items included were themed and presented to members of a stakeholder advisory group, who were asked to help prioritise the focus for phase 2. In phase 2, 17 electronic databases (EconLit; ASSIA; BNI; Cochrane Library; CINAHL; ERIC; EMBASE; HMIC; MEDLINE; PsycINFO; Scopus; Social Care Online; Social Services Abstracts; Sociological Abstracts; OpenGrey; TRiP; and Web of Science) were searched. Websites were explored and a call for evidence was circulated to locate items related to the risks to young people in mental health hospitals relating to ‘dislocation’ and ‘contagion’. All types of evidence including research, policies and service and practice responses relating to outcomes, views and experiences, costs and cost-effectiveness were considered. Materials identified were narratively synthesised.

Results

In phase 1, 4539 citations were found and 124 items included. Most were concerned with clinical risks. In phase 2, 15,662 citations were found, and 40 addressing the risks of ‘dislocation’ and ‘contagion’ were included supplemented by 20 policy and guidance documents. The quality of studies varied. Materials were synthesised using the categories: Dislocation: Normal Life; Dislocation: Identity; Dislocation: Friends; Dislocation: Stigma; Dislocation: Education; Dislocation: Families; and Contagion. No studies included an economic analysis. Although we found evidence of consideration of risk to young people in these areas we found little evidence to improve practice and services.

Conclusions

The importance to stakeholders of the risks of ‘dislocation’ and ‘contagion’ contrasted with the limited quantity and quality of evidence to inform policy, services and practice. The risks of dislocation and contagion are important, but new research is needed to inform how staff might identify, assess and manage them.

Below:  Phase 1 themes

Full article at:  http://goo.gl/txXwYG

By:   Deborah Edwards¹, Nicola Evans¹, Elizabeth Gillen², Mirella Longo³, Steven Pryjmachuk⁴,Gemma Trainor⁵ and Ben Hannigan^1*

¹School of Healthcare Sciences, College of Biomedical and Life Sciences, Cardiff University, Cardiff, UK

²Information Services, Cardiff University, Cardiff, UK

³College of Human and Health Sciences, Swansea University, Swansea, UK

⁴School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK

⁵Greater Manchester West Mental Health NHS Foundation Trust, Manchester, UK

 

More at:  https://twitter.com/hiv_insight

And: http://twitter.com/Prison_Health

Rethinking Adolescent Inpatient Psychiatric Care: The Importance of Integrated Interventions for Suicidal Youth with Substance Use Problems

Adolescents psychiatrically hospitalized following a suicide attempt are at high risk for a repeat attempt or suicide completion, and substance use is consistently implicated as a risk factor for continued suicidal behavior in adolescents. Despite this knowledge, there have been few studies that have investigated the effectiveness of combined suicidality and substance use interventions within acute psychiatric care settings for suicidal youth with substance use problems. While social workers are well-positioned to deliver such interventions, greater emphasis on teaching integrated therapeutic techniques in social work curriculum and professional training is needed to ensure their implementation.

Below:  A proposed mechanism of change model for adolescents receiving a brief motivational intervention for substance abuse in a psychiatric hospital following a suicide attempt.

...A significant proportion of adolescents who attempt suicide have a comorbid substance use disorder. Substance use, particularly alcohol use, puts suicidal adolescents at greater risk for repeat suicide attempts and eventual suicide completion. Adolescents with comorbid substance use disorders and suicidality may benefit from the implementation of I-CBT techniques in inpatient psychiatric settings to address the co-occurring problems, especially those that utilize a family component. For adolescents who do not meet full criteria for a substance use disorder, or meet this criteria but are in the pre-contemplation stage of change, MI may be a more feasible and effective intervention to implement during their psychiatric hospitalization, as this inpatient stay can often serve as a critical teaching moment for adolescents who have just attempted suicide. In these teachable moments, interventions such as MI can be useful in helping the adolescents understand the relationship between their substance use and continued suicidal thoughts and behaviors, and in doing so prepare them for change. Social workers are well-positioned to deliver such interventions in acute care settings, but greater devotion to teaching such integrated interventions in social work curriculum and professional training is needed.

Full article at:   http://goo.gl/2weObh

By:   Kimberly H. McManama O'Brien, PhD, LICSW

Kimberly H. McManama O'Brien, Center for Alcohol & Addiction Studies, Brown University, Providence, Rhode Island, USA;

Address correspondence to Kimberly H. McManama O'Brien, PhD, LICSW, Brown University, Center for Alcohol & Addiction Studies, Box G-S121-4, Providence, RI 02912, USA. Email: ude.nworb@neirbo_ylrebmik

 

More at:  https://twitter.com/hiv_insight

And: http://twitter.com/Prison_Health