Publications by authors named "Zoe M Weinstein"

21 Publications

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Shorter outpatient wait-times for buprenorphine are associated with linkage to care post-hospital discharge.

Drug Alcohol Depend 2021 Jul 20;224:108703. Epub 2021 Apr 20.

Department of Medicine, Boston University School of Medicine, 801 Massachusetts Ave, Boston, MA, 02118, USA.

Background: Inpatient addiction consult services (ACS) lower barriers to accessing medications for opioid use disorder (MOUD), however not every patient recommended for MOUD links to outpatient care. We hypothesized that fewer days between discharge date and outpatient appointment date was associated with improved linkage to buprenorphine treatment among patients evaluated by an ACS.

Methods: We extracted appointment and demographic data from electronic medical records and conducted retrospective chart review of adults diagnosed with opioid use disorder (OUD) evaluated by an ACS in Boston, MA between July 2015 and August 2017. These patients were initiated on or recommended buprenorphine treatment on discharge and provided follow-up appointment at our hospital post-discharge. Multivariable logistic regression assessed whether arrival to the appointment post-discharge was associated with shorter wait-times (0-1 vs. 2+ days).

Results: In total, 142 patients were included. Among patients who had wait-times of 0-1 day, 63 % arrived to their appointment compared to wait-times of 2 or more days (42 %). There were no significant differences between groups based on age, gender, distance of residence from the hospital, insurance status, co-occurring alcohol use disorder diagnosis, or discharge with buprenorphine prescription. After adjusting for covariates, patients with 0-1 day of wait-time had 2.6 times the odds of arriving to their appointment [95 % CI 1.3-5.5] compared to patients who had 2+ days of wait-time.

Conclusion: For hospitalized patients with OUD evaluated for initiating MOUD, same- and next-day appointments are associated with increased odds of linkage to outpatient MOUD care post-discharge compared to waiting two or more days.
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http://dx.doi.org/10.1016/j.drugalcdep.2021.108703DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8180499PMC
July 2021

Adapting inpatient addiction medicine consult services during the COVID-19 pandemic.

Addict Sci Clin Pract 2021 02 24;16(1):13. Epub 2021 Feb 24.

Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA.

Background: We describe addiction consult services (ACS) adaptations implemented during the Novel Coronavirus Disease 2019 (COVID-19) pandemic across four different North American sites: St. Paul's Hospital in Vancouver, British Columbia; Oregon Health & Sciences University in Portland, Oregon; Boston Medical Center in Boston, Massachusetts; and Yale New Haven Hospital in New Haven, Connecticut.

Experiences: ACS made system, treatment, harm reduction, and discharge planning adaptations. System changes included patient visits shifting to primarily telephone-based consultations and ACS leading regional COVID-19 emergency response efforts such as substance use treatment care coordination for people experiencing homelessness in COVID-19 isolation units and regional substance use treatment initiatives. Treatment adaptations included providing longer buprenorphine bridge prescriptions at discharge with telemedicine follow-up appointments and completing benzodiazepine tapers or benzodiazepine alternatives for people with alcohol use disorder who could safely detoxify in outpatient settings. We believe that regulatory changes to buprenorphine, and in Vancouver other medications for opioid use disorder, helped increase engagement for hospitalized patients, as many of the barriers preventing them from accessing care on an ongoing basis were reduced. COVID-19 specific harm reductions recommendations were adopted and disseminated to inpatients. Discharge planning changes included peer mentors and social workers increasing hospital in-reach and discharge outreach for high-risk patients, in some cases providing prepaid cell phones for patients without phones.

Recommendations For The Future: We believe that ACS were essential to hospitals' readiness to support patients that have been systematically marginilized during the pandemic. We suggest that hospitals invest in telehealth infrastructure within the hospital, and consider cellphone donations for people without cellphones, to help maintain access to care for vulnerable patients. In addition, we recommend hospital systems evaluate the impact of such interventions. As the economic strain on the healthcare system from COVID-19 threatens the very existence of ACS, overdose deaths continue rising across North America, highlighting the essential nature of these services. We believe it is imperative that health care systems continue investing in hospital-based ACS during public health crises.
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http://dx.doi.org/10.1186/s13722-021-00221-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903401PMC
February 2021

PRimary Care Opioid Use Disorders treatment (PROUD) trial protocol: a pragmatic, cluster-randomized implementation trial in primary care for opioid use disorder treatment.

Addict Sci Clin Pract 2021 01 31;16(1). Epub 2021 Jan 31.

Kaiser Permanente Northwest, Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97227-1098, USA.

Background: Most people with opioid use disorder (OUD) never receive treatment. Medication treatment of OUD in primary care is recommended as an approach to increase access to care. The PRimary Care Opioid Use Disorders treatment (PROUD) trial tests whether implementation of a collaborative care model (Massachusetts Model) using a nurse care manager (NCM) to support medication treatment of OUD in primary care increases OUD treatment and improves outcomes. Specifically, it tests whether implementation of collaborative care, compared to usual primary care, increases the number of days of medication for OUD (implementation objective) and reduces acute health care utilization (effectiveness objective). The protocol for the PROUD trial is presented here.

Methods: PROUD is a hybrid type III cluster-randomized implementation trial in six health care systems. The intervention consists of three implementation strategies: salary for a full-time NCM, training and technical assistance for the NCM, and requiring that three primary care providers have DEA waivers to prescribe buprenorphine. Within each health system, two primary care clinics are randomized: one to the intervention and one to Usual Primary Care. The sample includes all patients age 16-90 who visited the randomized primary care clinics from 3 years before to 2 years after randomization (anticipated to be > 170,000). Quantitative data are derived from existing health system administrative data, electronic medical records, and/or health insurance claims ("electronic health records," [EHRs]). Anonymous staff surveys, stakeholder debriefs, and observations from site visits, trainings and technical assistance provide qualitative data to assess barriers and facilitators to implementation. The outcome for the implementation objective (primary outcome) is a clinic-level measure of the number of patient days of medication treatment of OUD over the 2 years post-randomization. The patient-level outcome for the effectiveness objective (secondary outcome) is days of acute care utilization [e.g. urgent care, emergency department (ED) and/or hospitalizations] over 2 years post-randomization among patients with documented OUD prior to randomization.

Discussion: The PROUD trial provides information for clinical leaders and policy makers regarding potential benefits for patients and health systems of a collaborative care model for management of OUD in primary care, tested in real-world diverse primary care settings. Trial registration # NCT03407638 (February 28, 2018); CTN-0074 https://clinicaltrials.gov/ct2/show/NCT03407638?term=CTN-0074&draw=2&rank=1.
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http://dx.doi.org/10.1186/s13722-021-00218-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7849121PMC
January 2021

A Pilot Study of Automated Pupillometry in the Treatment of Opioid Use Disorder.

J Addict Med 2020 Dec 15;Publish Ahead of Print. Epub 2020 Dec 15.

Department of Ophthalmology, Boston Medical Center, Boston University School of Medicine, Boston, MA (CEP, MG, NS, SS, NT, MGF), Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA (CEP), Department of Biostatistics, Boston Medical Center, Boston University School of Medicine, Boston, MA (HC), Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA (MKP-O, ZMW).

Introduction/background: A rough, visual estimate of pupil size is used in grading the severity of opioid withdrawal. Few studies have examined the clinical utility of more precise automated pupillometry measurements.

Methods: This prospective cohort study enrolled 27 patients receiving opioid agonist therapy (OAT) to treat cravings or withdrawal during an acute hospitalization. Six sets of automated pupillometry measurements were obtained at regular intervals before and after administration of OAT. Clinical Opiate Withdrawal Scale measurements were performed pre and post OAT. Primary outcomes included pupil size in dark and bright illumination (mm). Latency of the pupillary light response (s), constriction and dilation velocity (mm/s), and percent constriction (%) were secondary outcomes.

Results: The mean predosing pupil size in dark and bright illumination was 4.33 ± 1.40 mm and 2.96 ± 0.79 mm, respectively. A significantly decreased mean pupil size was first detected at 15 minutes postdosing (4.01 ± 1.34 mm, P = 0.0115 for dark illumination; 2.71 ± 0.72 mm, P = 0.0003 for bright illumination) and this reduction in pupil size persisted at later postdosing timepoints. Those with Clinical Opiate Withdrawal Scale <5 after dosing had a greater decrease in dark pupil size (10.6% ± 13.2 vs 3.2% ± 3.2, P = 0.043). There was no significant change in the remaining pupil reactivity parameters.

Conclusions: Automated pupillometry demonstrated a small but significant change in mean pupil size that occurred within 15 minutes of OAT dosing and was associated with low withdrawal scores. This pilot may inform future work to incorporate pupillometry measurement into OAT dosing assessments.
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http://dx.doi.org/10.1097/ADM.0000000000000794DOI Listing
December 2020

Inpatient addiction consultation and post-discharge 30-day acute care utilization.

Drug Alcohol Depend 2020 May 25;213:108081. Epub 2020 May 25.

Boston University School of Medicine, 72 East Concord St., Boston, MA 02118, United States; Boston Medical Center Grayken Center for Addiction, Department of Medicine, Section of General Internal Medicine, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, United States.

Background: Addiction Consult Services care for hospitalized patients with substance use disorders (SUD), who frequently utilize costly medical services. This study evaluates whether an addiction consult is associated with 30-day acute care utilization.

Methods: This was a retrospective cohort study of 3905 inpatients with SUD. Acute care utilization was defined as any emergency department visit or re-hospitalization within 30 days of discharge. Inverse probability of treatment weighted generalized estimating equations logistic regression models were used to evaluate the relationship between receipt of an addiction consult and 30-day acute care utilization. Exploratory subgroup analyses were performed to describe whether this association differed by type of SUD and discharge on medication for addiction treatment.

Results: The 30-day acute care utilization rate was 39.5 % among patients with a consult and 36.0 % among those without. Addiction consults were not significantly associated with care utilization (Adjusted Odds Ratio 1.02; 0.82, 1.28). No significant differences were detected in subgroup analyses; however, the decreased odds among patients with OUD given medication was clinically notable (AOR 0.69; 0.47, 1.02).

Discussion: Repeat acute care utilization is common among hospitalized patients with SUD, particularly those seen by the addiction consult services. While this study did not detect a significant association between addiction consults and 30-day acute care utilization, this relationship merits further evaluation using prospective studies, controlling for key confounders and with a focus on the impact of medications for opioid use disorder.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108081DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371521PMC
May 2020

Which patients receive an addiction consult? A preliminary analysis of the INREACH (INpatient REadmission post-Addiction Consult Help) study.

J Subst Abuse Treat 2019 11 20;106:35-42. Epub 2019 Aug 20.

Boston University School of Medicine, 72 East Concord St., Boston, MA 02118, United States; Boston Medical Center Grayken Center for Addiction, Department of Medicine, Section of General Internal Medicine, 801 Massachusetts Avenue, 2nd floor, Boston, MA 02118, United States. Electronic address:

Introduction: Despite the high prevalence and significant health risks of substance use disorders (SUDs), a minority of individuals with SUDs receive treatment of any kind. The aims of this study are to describe inpatients with an SUD who receive an addiction consult at a large urban safety net hospital and explore characteristics associated with receiving an addiction consult.

Methods: This is a retrospective cohort study of all adult patients with a discharge diagnosis of an SUD from July 2015 to July 2016. A generalized estimating equation (GEE) logistic regression model was used to explore patient factors associated with receipt of an addiction consult, such as demographics, social, medical, and SUD characteristics.

Results: A total of 3905 patients with SUD diagnoses with 5979 hospitalization encounters were included in this study. There were 694 addiction consults (11.6%, 95% CI: 10.71% to 12.5%) across all of the encounters and 576 unique patients that received consults. Patients with opioid use disorder had higher odds of receiving a consult (Adjusted Odds Ratio: 6.39, 95% CI 5.14-7.94), as did patients with acute complications from their substance use (AOR: 1.64, 95% CI 1.34-2.02), patients with human immunodeficiency virus (HIV) (AOR: 2.06, 95% CI 1.59-2.67), and homeless patients (AOR: 1.31, 95% CI 1.08-1.59). Patients with a psychiatry consult had higher odds of receiving an addiction consult (AOR: 1.75, 95% CI 1.37-2.23), and so did patients receiving benzodiazepines and/or phenobarbital (AOR: 1.88, 95% CI 1.55-2.28). Older patients (AOR: 0.82, 95% CI 0.76-0.88 per 10 year increase) had lower odds of receiving a consult, as did patients with an overdose diagnosis (AOR: 0.71, 95% CI 0.53-0.96).

Conclusion: A minority of inpatients with SUD received an addiction consult, however, inpatients with opioid use disorder, acute complications (medical, mental health) and homelessness had higher odds of receiving an addiction consult. Patients surviving overdose, a severe acute complication of substance use, had lower odds of receiving a consult and, thus, warrant development of care pathways to provide overdose prevention and addiction treatment engagement.
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http://dx.doi.org/10.1016/j.jsat.2019.08.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6756179PMC
November 2019

Neurological Complications of Endocarditis: A Multidisciplinary Review with Focus on Surgical Decision Making.

Semin Neurol 2019 08 18;39(4):495-506. Epub 2019 Sep 18.

Department of Neurology, Boston Medical Center, Boston, Massachusetts.

Infective endocarditis (IE) is a systemic disease with many potential neurologic manifestations including ischemic and hemorrhagic strokes, cerebral microbleeding, infectious intracranial aneurysms, meningitis, brain abscesses, and encephalopathy. The majority of left-sided (heart) IE patients have brain lesions that may alter management decisions, warranting the systematic use of magnetic resonance imaging. Many patients require surgical treatment of valvular disease, and central nervous system lesions weigh into decision making. Data regarding the timing of surgery are conflicting, but earlier surgery appears to be safe in most ischemic strokes, while ideally surgery should be delayed for 3 to 4 weeks in patients with hemorrhagic strokes. IE requires a multidisciplinary team to collaboratively care for the patient. In this article, we review the current understanding and management of the neurological complications of IE and their impact on the performance and timing of cardiac surgery.
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http://dx.doi.org/10.1055/s-0039-1688826DOI Listing
August 2019

Patient and Physician Perspectives on Treating Tobacco Dependence in Hospitalized Smokers With Substance Use Disorders: A Mixed Methods Study.

J Addict Med 2019 Sep/Oct;13(5):338-345

The Pulmonary Center, Boston University School of Medicine, Boston, MA (HK, VC, EDH, RSW); Division of General Internal Medicine, Boston University School of Medicine, Boston, MA (RGS, MG); Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, Boston University School of Medicine/Boston Medical Center, Boston, MA (ZMW); Center for Healthcare Organization & Implementation Research, ENRM VA Hospital, Bedford, MA (RSW).

Objective: Individuals with substance use disorders have a high prevalence of smoking cigarettes. Hospitalization represents an opportunity to deliver concurrent treatment for tobacco and other substances. Using a sequential explanatory mixed methods design, we characterized practices and perspectives of patients and physicians about smoking cessation counseling during inpatient addiction medicine consultations.

Methods: We abstracted data from 694 consecutive inpatient addiction consult notes to quantify how often physicians addressed tobacco dependence using the guideline-recommended 5As framework. We conducted semi-structured interviews with 9 addiction medicine physicians and 20 hospitalized smokers with substance use disorders. We analyzed transcripts to explore physicians' and patients' perspectives on smoking cessation conversations during inpatient addiction consultations, physician-perceived barriers and facilitators to engaging inpatients in tobacco treatment, and strategies to improve tobacco treatment in this context.

Results: 75.5% (522/694) of hospitalized substance use disorder patients were current smokers. Among smokers, 20.9% (109/522) were offered nicotine replacement while hospitalized, but only 5.4% (28/522) received the full guideline-recommended 5As. Patients and physicians reported minimal discussion about tobacco addiction during hospitalization. Physicians cited tobacco not being an immediate health threat and the perception that quitting tobacco is not a priority to patients as barriers, often limiting thorough counseling to patients with smoking-related admissions. Physicians and patients offered strategies to integrate treatment of tobacco dependence and other substances.

Conclusions: Inpatient addiction consultations represent a missed opportunity to counsel patients with substance use disorders to quit smoking. System-level changes are needed to coordinate treatment of tobacco and other drug dependence in hospitalized smokers.
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http://dx.doi.org/10.1097/ADM.0000000000000503DOI Listing
July 2020

Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort.

Drug Alcohol Depend 2019 07 3;200:34-39. Epub 2019 May 3.

Department of Medicine, Section of Infectious Diseases, Boston Medical Center, 801 Massachusetts Avenue Boston, MA, 02118, USA; Department of Epidemiology, Boston University School of Public Health, 801 Massachusetts Avenue Boston, MA, 02118, USA.

Background And Aims: Despite the growing opioid overdose crisis, medication treatment for opioid use disorder remains uncommon. The comparative effectiveness of buprenorphine and naltrexone treatment in reducing overdose and the comparative risks of discontinuing treatment in the real world, remain uncertain. Our aim was to examine the effectiveness of medications for opioid use disorder in preventing opioid-related overdose.

Design: Retrospective cohort study SETTING: United States.

Patients: 46,846 commercially insured individuals diagnosed with opioid use disorder and initiating medication treatment between 2010 and 2016.

Measurements: Opioid-related overdose identified by International Classification of Diseases, Ninth and Tenth Revisions.

Findings: In our sample, 1386 individuals were prescribed extended-release injectable naltrexone (median filled prescriptions = 9 months), 7782 were prescribed oral naltrexone (5 months), and 40,441 were prescribed buprenorphine (19 months) at least once during follow-up. Individuals receiving buprenorphine therapy were at significantly reduced risk of opioid-related overdose compared to no treatment (adjusted hazard ratio (HR) = 0.40, 95% CI 0.35-0.46), while a significant association was not observed in extended-release injectable (HR = 0.74, 95% CI 0.42-1.31) or oral (HR = 0.93, 95% CI 0.71-1.22) naltrexone. We found no association with opioid overdose within four weeks of discontinuation of any medication.

Conclusion: Among commercially-insured patients who initiate medications for opioid use disorder, buprenorphine, but not naltrexone, was associated with lower risk of overdose during active treatment compared to post-discontinuation. More research is needed to understand the benefits and risks unique to each treatment option to better tailor therapies to patients with opioid use disorder.
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http://dx.doi.org/10.1016/j.drugalcdep.2019.02.031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6613830PMC
July 2019

Perceived barriers to quitting cigarettes among hospitalized smokers with substance use disorders: A mixed methods study.

Addict Behav 2019 08 18;95:41-48. Epub 2019 Feb 18.

The Pulmonary Center, Boston University School of Medicine, Boston, MA, United States of America; Center for Healthcare Organization & Implementation Research, ENRM VA Hospital, Bedford, MA, United States of America.

Aims: Smoking cessation may promote long-term recovery in patients with substance use disorders (SUD). Yet smoking rates remain alarmingly high in this population. Using a sequential explanatory mixed methods approach, we examined smoking rates among hospitalized patients with SUD at a large safety-net hospital, and then characterized factors associated with smoking behaviors both quantitatively and qualitatively.

Method: We abstracted data from all hospital admissions (7/2016-6/2017) and determined demographics, substance use type, and other characteristics associated with cigarette use among those with SUD. We then conducted semi-structured qualitative interviews with 20 hospitalized SUD smokers. We analyzed transcripts to characterize factors that affect patients' smoking habits, focusing on the constructs of the Health Belief Model.

Results: The prevalence of cigarette smoking among hospitalized smokers with SUD was three times higher than those without SUD. Qualitative analyses showed that patients perceived that smoking cigarettes was a less serious concern than other substances. Some patients feared that quitting cigarettes could negatively impact their recovery and perceived that clinicians do not prioritize treating tobacco dependence. Almost all patients with heroin use disorder described how cigarette use potentiated their heroin high. Many SUD patients are turning to vaping and e-cigarettes to quit smoking.

Conclusion: Hospitalized patients with SUD have disproportionately high smoking rates and perceive multiple barriers to quitting cigarettes. When designing and implementing smoking cessation interventions for hospitalized patients with SUD, policymakers should understand and take into account how patients with SUD perceive smoking-related health risks and how that influences their decision to quit smoking.
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http://dx.doi.org/10.1016/j.addbeh.2019.02.017DOI Listing
August 2019

Study protocol for a pragmatic trial of the Consult for Addiction Treatment and Care in Hospitals (CATCH) model for engaging patients in opioid use disorder treatment.

Addict Sci Clin Pract 2019 02 19;14(1). Epub 2019 Feb 19.

Office of Behavioral Health, NYC Health + Hospitals, 125 Worth St, New York, NY, 10013, USA.

Background: Treatment for opioid use disorder (OUD) is highly effective, yet it remains dramatically underutilized. Individuals with OUD have disproportionately high rates of hospitalization and low rates of addiction treatment. Hospital-based addiction consult services offer a potential solution by using multidisciplinary teams to evaluate patients, initiate medication for addiction treatment (MAT) in the hospital, and connect patients to post-discharge care. We are studying the effectiveness of an addiction consult model [Consult for Addiction Treatment and Care in Hospitals (CATCH)] as a strategy for engaging patients with OUD in treatment as the program rolls out in the largest municipal hospital system in the US. The primary aim is to evaluate the effectiveness of CATCH in increasing post-discharge initiation and engagement in MAT. Secondary aims are to assess treatment retention, frequency of acute care utilization and overdose deaths and their associated costs, and implementation outcomes.

Methods: A pragmatic trial at six hospitals, conducted in collaboration with the municipal hospital system and department of health, will be implemented to study the CATCH intervention. Guided by the RE-AIM evaluation framework, this hybrid effectiveness-implementation study (Type 1) focuses primarily on effectiveness and also measures implementation outcomes to inform the intervention's adoption and sustainability. A stepped-wedge cluster randomized trial design will determine the impact of CATCH on treatment outcomes in comparison to usual care for a control period, followed by a 12-month intervention period and a 6- to 18-month maintenance period at each hospital. A mixed methods approach will primarily utilize administrative data to measure outcomes, while interviews and focus groups with staff and patients will provide additional information on implementation fidelity and barriers to delivering MAT to patients with OUD.

Discussion: Because of their great potential to reduce the negative health and economic consequences of untreated OUD, addiction consult models are proliferating in response to the opioid epidemic, despite the absence of a strong evidence base. This study will provide the first known rigorous evaluation of an addiction consult model in a large multi-site trial and promises to generate knowledge that can rapidly transform practice and inform the potential for widespread dissemination of these services.

Trial Registration: NCT03611335.
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http://dx.doi.org/10.1186/s13722-019-0135-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6380041PMC
February 2019

Tapering off and returning to buprenorphine maintenance in a primary care Office Based Addiction Treatment (OBAT) program.

Drug Alcohol Depend 2018 08 19;189:166-171. Epub 2018 Jun 19.

Boston University School of Medicine/Boston Medical Center, Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, 801 Massachusetts Avenue, 2nd Floor, Boston, MA, 02118, United States; Boston University School of Public Health, Department of Community Health Sciences, 801 Massachusetts Avenue, 2nd Floor, Boston, MA, 02118, United States.

Background: Guidelines recommend long-term treatment for opioid use disorder including the use of buprenorphine; however, many patients desire to eventually taper off. This study examines the prevalence and patient characteristics of patients that voluntarily taper off buprenorphine.

Methods: This is a 12-year retrospective cohort study of adults on buprenorphine in a large urban safety-net primary care practice. The primary outcome was completion of a voluntary buprenorphine taper, which was further characterized as a medically supervised or unsupervised taper. The secondary outcome was re-engagement in care after taper. Descriptive statistics and estimated proportions of both taper completion and re-engagement in treatment were calculated using Kaplan-Meier estimates.

Results: The study sample included 1308 patients with a median follow-up time of 316 days; 48 patients were observed to taper off buprenorphine during the study period, with an estimated proportion of 15% (95%CI: 10%-21%) based on Kaplan Meier analyses. Less than half of the tapers, 45.8% (22/48), were medically supervised. Thirteen of the 48 patients subsequently, re-engaged in buprenorphine treatment (estimated proportion 61%, 95%CI: 27%-96%), based on Kaplan-Meier analyses with median follow-up time of 490 days.

Discussion: Despite the fact that many patients desire to discontinue buprenorphine, a minority had a documented taper. Among those who tapered, more than half did so unsupervised by the clinic and a majority of those who tapered off returned to buprenorphine treatment within two years. As many patients are unable to successfully taper off buprenorphine, the medical community must work to address any barriers to long-term maintenance.
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http://dx.doi.org/10.1016/j.drugalcdep.2018.05.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6139651PMC
August 2018

Inpatient Addiction Consult Service: Expertise for Hospitalized Patients with Complex Addiction Problems.

Med Clin North Am 2018 Jul;102(4):587-601

British Columbia Centre on Substance Use, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 553B-1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada.

Substance use disorders are highly prevalent and are a large driver of costly inpatient medical care; however, historically the substance use disorder has gone unaddressed during an inpatient stay. Inpatient addiction consult services are an important intervention to use the reachable moment of hospitalization to engage patients and initiate addiction treatment. Addiction consultation involves taking an addiction-specific history, motivational interviewing, withdrawal symptom management, and initiation of long-term pharmacotherapy. Addiction consult services have the potential to decrease readmissions and utilization costs for medical systems and improve substance-related outcomes for patients.
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http://dx.doi.org/10.1016/j.mcna.2018.03.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6750950PMC
July 2018

A police-led addiction treatment referral program in Gloucester, MA: Implementation and participants' experiences.

J Subst Abuse Treat 2017 11 9;82:41-47. Epub 2017 Sep 9.

Department of Health Law, Policy, and Management, Boston University School of Public Health, 715 Albany Street, T3W, Boston, MA, 02118, United States.

Background: The increasing rates of opioid use disorder and resulting overdose deaths are a public health emergency, yet only a fraction of individuals in need receive treatment.

Objective: To describe the implementation of and participants' experiences with a novel police-led addiction treatment referral program.

Methods: Follow-up telephone calls to participants in the Gloucester Police Department's Angel Program from June 2015-May 2016. Open-ended survey questionnaires assessed experiences of program participants and their close contacts, confirmed police-reported placement, and queried self-reported substance use and treatment outcomes.

Results: Surveys were completed by 198 of 367 individuals (54% response rate) who participated 214 times. Reasons for participation included: the program was a highly-visible entry point to the treatment system, belief that placement would be obtained, poor prior treatment system experiences, and external pressure to seek treatment. Most participants reported positive experiences citing the welcoming, non-judgmental services. In 75% (160/214) of the encounters, entry into referral placement was confirmed. Participants expressed frustration when they did not meet program entry requirements and had difficulty finding sustained treatment following initial program placement. At a mean follow-up time of 6.7months, 37% of participants reported abstinence since participation, with no differences between participants who entered referral placement versus those who did not.

Conclusions: A police-led referral program was feasible to implement and acceptable to participants. The program was effective in finding initial access to treatment, primarily through short-term detoxification services. However, the program was not able to overcome a fragmented treatment system focused on acute episodic care which remains a barrier to long-term recovery.
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http://dx.doi.org/10.1016/j.jsat.2017.09.003DOI Listing
November 2017

Very early disengagement and subsequent re-engagement in primary care Office Based Opioid Treatment (OBOT) with buprenorphine.

J Subst Abuse Treat 2017 08 16;79:12-19. Epub 2017 May 16.

Boston University School of Medicine/Boston Medical Center, Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, United States; Boston University School of Public Health, Department of Community Health Sciences, 801 Massachusetts Avenue, 4th Floor, Boston, MA 02118, United States. Electronic address:

Introduction: Patients with opioid use disorder often require multiple treatment attempts before achieving stable recovery. Rates of disengagement from buprenorphine are highest in the first month of treatment and termination of buprenorphine therapy results in return to use rates as high as 90%. To better characterize these at-risk patients, this study aims to describe: 1) the frequency and characteristics of patients with very early disengagement (≤1month) from Office Based Opioid Treatment (OBOT) with buprenorphine and 2) the frequency and characteristics of patients who re-engage in care at this same OBOT clinic within 2years, among the subset of very early disengagers.

Methods: This is a retrospective cohort study of adult patients enrolled in a large urban OBOT program. Descriptive statistics were used to characterize the sample and the proportion of patients with very early (≤1month) disengagement and their re-engagement. Multivariable logistic regression models were used to identify patient characteristics associated with the outcomes of very early disengagement and re-engagement. Potential predictors included: sex, age, race/ethnicity, education, employment, opioid use history, prior substance use treatments, urine drug testing, and psychiatric diagnoses.

Results: Overall, very early disengagement was unusual, with only 8.4% (104/1234) of patients disengaging within the first month. Among the subset of very early disengagers with 2years of follow-up, the proportion who re-engaged with this OBOT program in the subsequent 2years was 11.9% (10/84). Urine drug test positive for opiates within the first month (AOR: 2.01, 95% CI: 1.02-3.93) was associated with increased odds of very early disengagement. Transferring from another buprenorphine prescriber (AOR: 0.09, 95% CI: 0.01-0.70) was associated with decreased odds of very early disengagement. No characteristics were significantly associated with re-engagement.

Conclusions: Early disengagement is uncommon; however, continued opioid use appeared to be associated with higher odds of treatment disengagement and these patients may warrant additional support. Re-engagement was uncommon, suggesting the need for a more formal explicit system to encourage and facilitate re-engagement among patients who disengage.
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http://dx.doi.org/10.1016/j.jsat.2017.05.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5522736PMC
August 2017

Addiction consultation services - Linking hospitalized patients to outpatient addiction treatment.

J Subst Abuse Treat 2017 08 11;79:1-5. Epub 2017 May 11.

Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston University School of Medicine & Boston Medical Center, 801 Massachusetts Avenue, Boston, USA.

Background: Approximately 15% of hospitalized patients have an active substance use disorder (SUD). Starting treatment for SUD, including medications, during acute hospitalizations can engage patients in addiction care. In July 2015, the Boston Medical Center Addiction Consult Service (ACS), began providing inpatient diagnostic, management, and discharge linkage consultations. We describe this implementation.

Methods: The ACS staff recorded SUDs diagnoses and medication recommendations and tracked follow-up data for affiliated outpatient office-based addiction clinics and methadone maintenance programs. We assessed the number of consults, SUDs diagnoses, medications recommended and initiated, and outpatient addiction clinic follow-up.

Results: Over 26weeks, the BMC ACS completed 337 consults: 78% had an opioid use disorder (UD), 37% an alcohol UD, 28% a cocaine UD, 9% a benzodiazepine UD, 3% a cannabinoid (including K2) UD, and <1% a methamphetamine UD. Methadone was initiated in 70 inpatients and buprenorphine in 40 inpatients. Naltrexone was recommended 45 times (for opioid UD, alcohol UD, or both). Of the patients initiated on methadone, 76% linked to methadone clinic, with 54%, 39%, and 29% still retained at 30, 90, and 180days, respectively. For buprenorphine, 49% linked to clinic, with 39%, 27%, and 18% retained at 30, 90, and 180days, respectively. For naltrexone, 26% linked to clinic, all with alcohol UD alone.

Conclusions: A new inpatient addiction consultation service diagnosed and treated hospitalized patients with substance use disorders and linked them to outpatient addiction treatment care. Initiating addiction medications, particularly opioid agonists, was feasible in the inpatient setting. Optimal linkage and retention of hospitalized patients to post-discharge addiction care warrants further innovation and program development.
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http://dx.doi.org/10.1016/j.jsat.2017.05.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6035788PMC
August 2017

Long-term retention in Office Based Opioid Treatment with buprenorphine.

J Subst Abuse Treat 2017 03 30;74:65-70. Epub 2016 Dec 30.

Boston University School of Medicine/Boston Medical Center, Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, United States; Boston University School of Public Health, Department of Community Health Sciences, 801 Massachusetts Avenue, 4th Floor, Boston, MA 02118, United States.

Background: Guidelines recommend long-term treatment for opioid use disorder with buprenorphine; however, little is known about patients in long-term treatment. The aim of this study is to examine the prevalence and patient characteristics of long-term treatment retention (≥1year) in an Office Based Opioid Treatment (OBOT) program with buprenorphine.

Methods: This is a retrospective cohort study of adults on buprenorphine from January 2002 to February 2014 in a large urban safety-net primary care OBOT program. The primary outcome was retention in OBOT for at least one continuous year. Potential predictors included age, race, psychiatric diagnoses, hepatitis C, employment, prior buprenorphine, ever heroin use, current cocaine, benzodiazepine and alcohol use on enrollment. Factors associated with ≥1year OBOT retention were identified using generalized estimating equation logistic regression models. Patients who re-enrolled in the program contributed repeated observations.

Results: There were 1605 OBOT treatment periods among 1237 patients in this study. Almost half, 45% (717/1605), of all treatment periods were ≥1year and a majority, 53.7% (664/1237), of patients had at least one ≥1year period. In adjusted analyses, female gender (Adjusted Odds Ratio [AOR] 1.55, 95% CI [1.20, 2.00]) psychiatric diagnosis (AOR 1.75 [1.35, 2.27]) and age (AOR 1.19 per 10year increase [1.05, 1.34]) were associated with greater odds of ≥1year retention. Unemployment (AOR 0.72 [0.56, 0.92]), Hepatitis C (AOR 0.59 [0.45, 0.76]), black race/ethnicity (AOR 0.53 [0.36, 0.78]) and Hispanic race/ethnicity (AOR 0.66 [0.48, 0.92]) were associated with lower odds of ≥1year retention.

Conclusions: Over half of patients who presented to Office Based Opioid Treatment with buprenorphine were ultimately successfully retained for ≥1year. However, significant disparities in one-year treatment retention were observed, including poorer retention for patients who were younger, black, Hispanic, unemployed, or with hepatitis C.
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http://dx.doi.org/10.1016/j.jsat.2016.12.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5312773PMC
March 2017

Psychoactive medications and disengagement from office based opioid treatment (obot) with buprenorphine.

Drug Alcohol Depend 2017 Jan 5;170:9-16. Epub 2016 Nov 5.

Boston University School of Medicine/Boston Medical Center, Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, United States; Boston University School of Public Health, Department of Community Health Sciences, 801 Massachusetts Avenue, Boston, MA 02118, United States.

Background: The prevalence of psychoactive medications (PAMs) use in patients enrolled in Office Based Opioid Treatment (OBOT) and its association with engagement in this care is largely unknown.

Objective: To describe the use of PAMs, including those medications with emerging evidence of misuse ("emerging PAMs" - gabapentin, clonidine and promethazine) among patients on buprenorphine, and its association with disengagement from OBOT.

Methods: This is a retrospective cohort study of adults on buprenorphine from January 2002 to February 2014. The association between use of PAMs and 6-month disengagement from OBOT was examined using multivariable logistic regression models. A secondary analysis exploring time-to-disengagement was conducted using Cox regression models.

Results: At OBOT entry, 43% of patients (562/1308) were prescribed any PAM; including 17% (223/1308) on an emerging PAM. In separate adjusted analyses, neither the presence of any PAM (adjusted odds ratio [AOR] 1.07, 95% CI [0.78, 1.46]) nor an emerging PAM (AOR 1.28 [0.95, 1.74]) was significantly associated with 6-month disengagement. The results were similar for the Cox model (any PAM (adjusted hazard ratio [AHR] 1.16, 95% CI [1.00, 1.36]), emerging PAM (AHR 1.18 [0.98, 1.41])). Exploratory analyses suggested gabapentin (AHR 1.30 [1.05-1.62]) and clonidine (AHR 1.33 [1.01-1.73]) specifically, may be associated with an overall shorter time to disengagement.

Conclusions: Psychoactive medication use is common among patients in buprenorphine treatment. No significant association was found between the presence of any psychoactive medications, including medications with emerging evidence of misuse, and 6-month disengagement from buprenorphine treatment.
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http://dx.doi.org/10.1016/j.drugalcdep.2016.10.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5183557PMC
January 2017

Factors Associated with Adherence to Routine Screening Mammography in HIV-Infected Women.

J Womens Health (Larchmt) 2016 05 26;25(5):473-9. Epub 2016 Jan 26.

3 Division of Infectious Diseases and HIV Medicine, Department of Medicine, Drexel University College of Medicine , Philadelphia, Pennsylvania.

Background: Both HIV-infected women and minority women have historically lower rates of screening mammography. The objective of this study was to identify factors related to adherence to routine screening mammography in a diverse inner-city cohort of HIV-infected women, to inform future work on targeted interventions to address disparities.

Materials And Methods: This retrospective cohort study reviewed the electronic medical record of HIV-infected women aged 40 and older engaged in care between October 1, 2003 and March 31, 2008 at a large urban safety-net HIV clinic. Analyses included chi square testing and multivariate logistic regression to assess for patient-specific factors associated with adherence to breast cancer screening, defined as obtaining a screening mammogram within 2 years of engaging in care.

Results: The 292 women were a racially diverse group, with 70% black, 11% Hispanic, and 42% foreign born. There was suboptimal HIV control, with only 33% having an undetectable viral load (VL). One hundred forty-six (50%) were adherent to screening mammography. In multivariate analysis, women who were foreign born (OR 2.65 [CI 1.52-4.64]) had not completed high school (OR 1.77 [CI 1.06-2.95]) or had an undetectable VL (OR 2.51 [CI 1.44-4.40]) had increased odds of obtaining a mammogram.

Conclusions: Among a racially diverse urban population of HIV-infected women engaged in care, only half had a mammogram. Foreign-born women had higher odds of undergoing mammography, suggesting that nativity status and social determinants of health are under-recognized drivers of adherence in this population. Future programs targeting screening must be mindful of the multiple predictors of adherence.
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http://dx.doi.org/10.1089/jwh.2015.5430DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4876520PMC
May 2016

Optimising health and safety of people who inject drugs during transition from acute to outpatient care: narrative review with clinical checklist.

Postgrad Med J 2016 Jun 22;92(1088):356-63. Epub 2016 Mar 22.

Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts, USA.

The opioid epidemic in the USA continues to worsen. Medical providers are faced with the challenge of addressing complications from opioid use disorders and associated injection drug use. Unsafe injection practices among people who inject drugs (PWID) can lead to several complications requiring acute care encounters in the emergency department and inpatient hospital. Our objective is to provide a narrative review to help medical providers recognise and address key health issues in PWID, who are being released from the emergency department and inpatient hospital. In the midst of rises in overdose deaths and infections such as hepatitis C, we highlight several health issues for PWID, including overdose and infection prevention. We provide a clinical checklist of actions to help guide providers in the care of these complex patients. The clinical checklist includes strategies also applicable to low-resource settings, which may lack addiction treatment options. Our review and clinical checklist highlight key aspects of optimising the health and safety of PWID.
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http://dx.doi.org/10.1136/postgradmedj-2015-133720DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4967553PMC
June 2016