Addiction Treatment Services Research Articles

Mortality Risk for Individuals With Cocaine Use Disorders: Clients and Non-Clients of Public Treatment Centres for Drug Addiction

BACKGROUND: This study targeted individuals who turned for the first time to health services following problems caused by cocaine use (CUD). Our aim was to estimate mortality risk for individuals who were clients of PATS (public addiction treatment services) and never-PATS (those who were not). METHOD: Follow-up study. People resident in Emilia Romagna Region (Northern Italy), aged 18 years and older who for the first time turned to a HOS (hospital ward), an ED (emergency department), a MHS (community mental health centre) or to a PATS for cocaine use disorder were selected. The reference period was between 01/01/2009 and 31/12/2019 and the territory was the metropolitan area of Bologna. CMR (Crude mortality rates) per 1000 PY (Person Years) and SMRs (standardized mortality ratios) were calculated. RESULTS: The cohort was made up of 3,196 subjects. CMR was 4.5 (95% CI 3.6-6.6) per thousand patient/years, SMRs were 4.3 (95% CI 3.5-5.4). The results highlight high CMRs (5.5, 95% CI 3.8-8.1) and SMRs (4.7, 95% CI 3.2-6.9) for individuals who never accessed PATS. Higher and statistically significant incidence rate ratios were found from the multivariate analysis among females and natives, in patients never accessed to PATS, aged more than 35 years and reporting using alcohol or opioids at first admission. CONCLUSIONS: Innovative strategies to facilitate the reduction of barriers to access and to facilitate taking charge in PATS for people with cocaine use disorders must be identified.

Engagement in substance use disorder treatment after an emergency department visit among persons at high risk of opioid overdose: A prediction analysis

BackgroundCertified peer recovery specialists (CPRS) and licensed clinical social workers (LCSWs) can facilitate substance use disorder (SUD) treatment engagement for emergency department (ED) patients at risk for overdose. Predictors of treatment engagement after such behavioral services are unknown. MethodsThis secondary analysis included Rhode Island ED patients at high risk for opioid overdose participating in a randomized controlled trial comparing the effectiveness of CPRS and LCSWs services (2018–2021). SUD treatment engagement within 90 days post-discharge was identified using statewide administrative data. Potential predictors were obtained from baseline questionnaires. Classification and regression trees (CART) were used to identify predictors of treatment engagement. ResultsIn the ED, 323 and 325 participants received CPRS and LCSWs services, respectively, among whom 141 (43.7 %) and 137 (42.2 %) engaged in SUD treatment within 90 days post-discharge. For the CPRS group, predictors of treatment engagement included unhealthy alcohol use, prescription opioid or benzodiazepine use in past 6 months, and lifetime history of: unstable housing, barriers to treatment, bipolar disorder diagnosis, addiction treatment, and recovery services. In the LCSW group, predictors included health insurance, current pain, opioid overdose in past year, and lifetime history of anxiety disorder diagnosis and mental illness treatment. However, CART had low predictive accuracy (CPRS: 60.9 %, LCSW: 54.8 %). ConclusionsAmong ED patients at high risk of opioid overdose receiving behavioral services, 90-day SUD treatment engagement was high. Sociobehavioral and clinical patient characteristics did not accurately predict treatment engagement. Behavioral services should be offered to all ED patients at high risk of opioid overdose.

Psychometric evaluation of the Dutch version of the patient-reported experience measure for addiction treatment (PREMAT-NL).

Patient-centred care has become increasingly important in health care. Patient-reported experience measures (PREM) are used to measure patient experiences in health care, but the availability of psychometrically validated PREMs is limited. The Patient Reported Experience Measure in Addiction Treatment (PREMAT) is a PREM developed with extensive service user input to assess the experiences of people in residential addiction treatment services. In this study we aimed to evaluate the psychometric properties of the Dutch translation of the PREMAT, the PREMAT-NL. Ninety-three participants completed the PREMAT-NL approximately 45 days after starting addiction treatment as part of a naturalistic prospective multi-centre study in Belgium. We examined the factorial structure using principal component analysis with Promax oblique rotation and assessed the internal consistencies of the subscales and total score using Cronbach's α. Additionally, we explored the relationship of PREMAT-NL scores with demographic and clinical variables. The PREMAT-NL had a four-factor structure, with good internal consistencies of the subscales (Cronbach's α >0.70) and excellent internal consistency of the total score (Cronbach's α = 0.94). The PREMAT-NL total score was negatively skewed, and four score categories were proposed based on z-scores. PREMAT-NL scores correlated weakly with the type of treatment centre (r = 0.21, p < 0.05) and with previously received treatment for addiction (r = -0.25, p < 0.05). Although the factor structure and thus the appropriate use of subscales need further investigation, the findings of this study support the use of the PREMAT-NL total score as a valid and reliable PREM to evaluate residential addiction treatment services.

Road to Recovery: protocol for a mixed-methods prospective cohort study evaluating the impact of a new model of substance use care in a Canadian setting

IntroductionThe Road to Recovery (R2R) Initiative is an innovative model of substance use care that seeks to increase treatment capacity by creating approximately 100 new addiction treatment beds to provide...

Law enforcement-led, pre-arrest diversion-to-treatment may reduce crime recidivism, incarceration, and overdose deaths: Program evaluation outcomes

IntroductionSubstance use disorder (SUD), overdose, and drug use-related crime continue to increase in the U.S. Pre-arrest diversion-to-treatment programs may decrease crime recidivism and overdose deaths. We assessed the impact of a community-wide diversion-to-treatment initiative on crime, incarceration, and overdose. MethodsThis article reports on the prospective evaluation of a law enforcement-led, pre-arrest diversion-to-treatment program on crime, incarceration, and overdose deaths compared between participants who did not engage (non-engaged; n = 103), engaged but did not complete (non-completers; n = 60) and completed (completers; n = 100) the program. Participants included 263 adults apprehended by police officers for low-level, drug use-related crimes between September 1, 2017 and August 31, 2020. The program offered eligible persons participation in a six-month program consisting of a clinical assessment, referral to addiction treatment services based on each individual's needs, connection to recovery peer support, and treatment engagement monitoring. Completers had their initial criminal charges ‘voided,’ while non-engaged and non-Completer participants had their original charges filed with local prosecutors. The project collected participant-level data on arrests and incarceration within 12 months before and 12 months after program enrollment and data on fatal overdose within 12 months after program enrollment. Logistic regression predicted outcomes using baseline demographics (sex, age, race, housing status) and pre-index crime arrest and incarceration indices as covariates. ResultsAfter accounting for baseline demographics and pre-enrollment arrest/incarceration history, logistic regression models found that the non-engaged and the non-Completer groups were more likely than completers to be arrested (odds ratios [ORs]: 3.9 [95 % CI, 2.0–7.7] and 3.6 [95 % CI, 1.7–7.5], respectively) and incarcerated (ORs: 10.3 [95 % CI, 5.0–20.8] and 21.0 [95 % CI, 7.9–55.7], respectively) during the 12-month follow-up. Rates of overdose deaths during the 12-month follow-up were greatest in non-engaged (6/103, 5.8 %) and non-Completer (2/60, 3.3 %) groups; completers had the lowest rate (2/100, 2.0 %), with all deaths occurring after completion of the six-month treatment/monitoring program. ConclusionsCollaboration between law enforcement, clinicians, researchers, and the broader community to divert adults who commit a low-level, drug use-related crime from criminal prosecution to addiction treatment may effectively reduce crime recidivism, incarceration, and overdose deaths.

W118 - Co-Use of Harm Reduction and Addiction Treatment Services Associated With Decreased Non-Fatal Overdose in Catalonia

W118 - Co-Use of Harm Reduction and Addiction Treatment Services Associated With Decreased Non-Fatal Overdose in Catalonia

Mobile addiction treatment and harm reduction services as tools to address health inequities: a community case study of the Brockton Neighborhood Health Center mobile unit.

Opioid overdose deaths continue to increase in the US. Recent data show disproportionately high and increasing overdose death rates among Black, Latine, and Indigenous individuals, and people experiencing homelessness. Medications for opioid use disorder (MOUD) can be lifesaving; however, only a fraction of eligible individuals receive them. Our goal was to describe our experience promoting equitable MOUD access using a mobile delivery model. We implemented a mobile MOUD unit aiming to improve equitable access in Brockton, a racially diverse, medium-sized city in Massachusetts. Brockton has a relatively high opioid overdose death rate with increasingly disproportionate death rates among Black residents. Brockton Neighborhood Health Center (BNHC), a community health center, provides brick-and-mortar MOUD access. Through the Communities That HEAL intervention as part of the HEALing Communities Study (HCS), Brockton convened a community coalition with the aim of selecting evidence-based practices to decrease overdose deaths. BNHC leadership and coalition members recognized that traditional brick-and-mortar treatment locations were inaccessible to marginalized populations, and that a mobile program could increase MOUD access. In September 2021, with support from the HCS coalition, BNHC launched its mobile initiative - Community Care-in-Reach® - to bring low-threshold buprenorphine, harm reduction, and preventive care to high-risk populations. During implementation, the team encountered several challenges including: securing local buy-in; navigating a complex licensure process; maintaining operations throughout the COVID-19 pandemic; and finally, planning for sustainability. In two years of operation, the mobile team cared for 297 unique patients during 1,286 total visits. More than one-third (36%) of patients received buprenorphine prescriptions. In contrast to BNHC's brick-and-mortar clinics, patients with OUD seen on the mobile unit were more representative of historically marginalized racial and ethnic groups, and people experiencing homelessness, evidencing improved, equitable addiction care access for these historically disadvantaged populations. Offering varied services on the mobile unit, such as wound care, syringe and safer smoking supplies, naloxone, and other basic medical care, was a key engagement strategy. This on-demand mobile model helped redress systemic disadvantages in access to addiction treatment and harm reduction services, reaching diverse individuals to offer lifesaving MOUD at a time of inequitable increases in overdose deaths.

The Cumulative Effect of Expanding the Breadth and Scope of Coverage for Substance Use Disorder Treatment on Behavioral Health Acute Inpatient Admissions: Evidence from Virginia Medicaid.

We evaluated the impact of Medicaid policies in Virginia (VA), namely the Addiction and Recovery Treatment Services (ARTS) program and Medicaid expansion, on the number of behavioral health acute inpatient admissions from 2016 to 2019. We used Poisson fixed-effect event study regression and compared average proportional differences in admissions over three time periods: (1) prior to ARTS; (2) following ARTS but before Medicaid expansion; (3) post-Medicaid expansion. The number of behavioral health acute inpatient admissions decreased by 2.6% (95% CI [-5.1, -0.2]) in the first quarter of 2018 and this decrease gradually intensified by 4.9% (95% CI [-7.5, -2.4]) in the fourth quarter of 2018 compared to the second quarter of 2017 (beginning of ARTS) in VA relative to North Carolina (NC). Following the first quarter of 2019 (beginning of Medicaid expansion), decreases in VA admissions became larger relative to NC. The average proportional difference in admissions estimated a decrease of 2.7% (95% CI, [-4.1, -0.8]) after ARTS but before Medicaid expansion and a decrease of 2.9% (95% CI, [-6.1, 0.4]) post-Medicaid expansion compared to pre-ARTS in VA compared to NC. Behavioral health acute inpatient admissions in VA decreased following ARTS implementation, and the decrease became larger after Medicaid expansion.

Exploring help-seeking pathways and disparities in substance use disorder care in India: A multicenter cross-sectional study.

Substance use disorders (SUDs) are among the leading causes of morbidity in the population. In low- and medium-income countries like India, there is a wide treatment gap for SUD. A multicentric study on the care pathways for SUD in India can help to understand service provision, service utilization, and challenges to improve existing SUD care in India. We aimed to map pathways to care in SUD. We compared the clinical and demographic characteristics of patients who first consulted specialized services versus other medical services. This was a cross-sectional study of consecutive, consenting adults (18-65 years) with SUD registered to each of the nine participating addiction treatment services distributed across five Indian regions. We adapted the World Health Organization's pathway encounter form. Of the 998 participants, 98% were males, 49.4% were rural, and 20% were indigenous population. Addiction services dominated initial (50%) and subsequent (60%) healthcare contacts. One in five contacted private for-profit healthcare. Primary care contact was rare (5/998). Diverse approaches included traditional healers (4-6%) and self-medication (2-8%). There was a 3-year delay in first contact; younger, educated individuals with opioid dependence preferred specialized services. There is a need to strengthen public healthcare infrastructure and delivery systems and integrate SUD treatment into public healthcare.

A quality assurance study of the development of quality of care in outpatient clinics for treatment of addiction in Greenland

Introduction In 2016, a new addiction treatment service, Allorfik, was introduced in Greenland. Allorfik has, throughout the implementation and after, used auditing of patient records with feedback to develop the quality of care in treatment. Audits and feedback are routinely done in each treatment center. This study wishes to investigate the development of the quality of treatment through the case notes from the journal audits. Methodology This study is based on case notes audits from 2019, 2020 and 2021. In the audits, the focus has been on the quality of documentation and content for ten specific areas in each patient record. Each area was scored on a Likert scale of 0–4 for both outcomes. Statistical analyses were done using Stata 17, and P-values < 0.05 were considered statistically significant. We present baseline characteristics for patients and illustrate the development of quality for both outcomes as time trends with scatter plots. Results The analysis was based on data from 454 patients and audits of their case notes. The mean number of weeks in treatment is 12.72, and the mean age for the people in the audited case notes is 39. Time had a positive effect on both outcomes, and so each month, documentation increased by 0.21 points (p-value = <0.001), and content increased by 0.27 points (p-value = <0.001). Conclusion For documentation and content, the quality level has increased significantly with time, and the quality of case notes is at an excellent level at the final audits of all treatment centers.

An International, Multidisciplinary Consensus Set of Patient-Centered Outcome Measures for Substance-Related and Addictive Disorders.

Background: In 1990, the United States' Institute of Medicine promoted the principles of outcomes monitoring in the alcohol and other drugs treatment field to improve the evidence synthesis and quality of research. While various national outcome measures have been developed and employed, no global consensus on standard measurement has been agreed for addiction. It is thus timely to build an international consensus. Convened by the International Consortium for Health Outcomes Measurement (ICHOM), an international, multi-disciplinary working group reviewed the existing literature and reached consensus for a globally applicable minimum set of outcome measures for people who seek treatment for addiction. Methods: To this end, 26 addiction experts from 11 countries and 5 continents, including people with lived experience (n = 5; 19%), convened over 16 months (December 2018-March 2020) to develop recommendations for a minimum set of outcome measures. A structured, consensus-building, modified Delphi process was employed. Evidence-based proposals for the minimum set of measures were generated and discussed across eight videoconferences and in a subsequent structured online consultation. The resulting set was reviewed by 123 professionals and 34 people with lived experience internationally. Results: The final consensus-based recommendation includes alcohol, substance, and tobacco use disorders, as well as gambling and gaming disorders in people aged 12 years and older. Recommended outcome domains are frequency and quantity of addictive disorders, symptom burden, health-related quality of life, global functioning, psychosocial functioning, and overall physical and mental health and wellbeing. Standard case-mix (moderator) variables and measurement time points are also recommended. Conclusions: Use of consistent and meaningful outcome measurement facilitates carer-patient relations, shared decision-making, service improvement, benchmarking, and evidence synthesis for the evaluation of addiction treatment services and the dissemination of best practices. The consensus set of recommended outcomes is freely available for adoption in healthcare settings globally.

Ohio START: An adaption of the National Sobriety Treatment and Recovery Teams model

BackgroundThe Sobriety Treatment and Recovery Teams (START) model is an evidence-supported intervention for families with at least one child under age 6 involved in the child welfare system due to substance misuse. The hallmark of the START model is early identification and linkage to addiction treatment services. To address the dual problem of heightened need for addiction treatment services and limited treatment availability in the wake of the opioid epidemic, Ohio’s adaptation extended the model to serve all eligible families regardless of the age of children in the household. ObjectiveTo investigate the delivery of the START model for parents and caregivers of older youth (age 6–18) only as compared to the population for which it was originally intended. MethodsWe used data from 40 counties and with parents as the unit of analysis (N = 714). We used multilevel models to estimate the relationship between the age of children in the home and 1) meeting fidelity for timely access to treatment services and 2) successful completion of the model. ResultsThere was no statistically significant difference in the likelihood of meeting fidelity requirement for timely access to treatment services, nor in successful completion for families with older children as compared to those with at least one child aged 0–5. ConclusionsThese results lend support to the use of the START model for all eligible families, regardless of the children’s ages. Future studies can examine more nuanced relationships to include the role of specific substances, child placement, and the role of family peer mentors.

A qualitative study of the implementation and organization of the national Greenlandic addiction treatment service.

Alcohol and cannabis use constitutes the major public health problems in Greenland. Thus, it is important to assess if Allorfik, a new national outpatient addiction treatment service introduced in 2016, was implemented successfully and how it is perceived. Allorfik introduced local treatment centers offering a treatment methodology (motivational interviewing and cognitive therapy) new to addiction treatment in Greenland with limited evidence from Indigenous populations such as the Greenlandic. The present study investigates the implementation of Allorfik from the perspective of those engaged in the process and the field. Data consisted of transcribed interviews with 23 individuals from both Allorfik and organizations collaborating with or supposed to collaborate with Allorfik. The theme of the interviews was their perspectives on the implementation process, enablers, and obstacles in the process and how Allorfik was performing at the time of the interview. The interview guide was informed by implementation theory. The transcribed material was analyzed using a general inductive approach. The analysis resulted in three overall and interconnected themes, namely, implementation, collaborations, and challenges. The implementation was overall considered a success by the interviewees as all components were implemented as planned with a few adaptions, e.g., a treatment guideline update. The collaborations are considered challenging but important to all interviewees. Collaborations seem to rely on personal commitment as opposed to well-defined structures, making it unstable and vulnerable to changes in staff. One of the main challenges highlighted by the interviewees is the number of problems other than addiction among people in treatment, which makes addiction treatment and recovery difficult to achieve. Nevertheless, the high levels of other problems being treated in Allorfik highlights the need for easily accessible therapy as many find that Allorfik is the only place to turn to in times of crisis. Allorfik seems to have been implemented in accordance with original intentions and plans for addiction treatment service but has also become more than just a service for addiction treatment with easy access in a country with vast distances and limited resources.

For addicted teens, residential treatment is scarce and expensive

Residential addiction treatment for teens is limited and expensive, according to a study published in Health Affairs last month. For the study, “Treatment In The US: Uneven Access, Waitlists, And High Costs” — which was funded by the National Institute on Drug Abuse (NIDA) — Caroline King, M.D., and colleagues used the FindTreatment.gov database maintained by the Substance Abuse and Mental Health Services Administration (SAMHSA) and a search analytics company to find 354 centers that claim to provide residential addiction treatment services to people under age 18. The researchers then contacted them.

Beds for teens are scarce and expensive: NIDA study

Residential addiction treatment for teens is limited and expensive, according to a study published in Health Affairs last week. For the study, “Treatment In The US: Uneven Access, Waitlists, And High Costs” — which was funded by the National Institute on Drug Abuse (NIDA) — Caroline King, M.D. and colleagues used the FindTreatment.gov database maintained by the Substance Abuse and Mental Health Services Administration (SAMHSA) and a search analytics company to find 354 centers that claim to provide residential addiction treatment services to people under age 18. The researchers then contacted them.

Prevalence and association between alcohol, tobacco, and COVID-19: a study from a tribal predominant district in eastern India.

Alcohol and tobacco use has been proposed to significantly affect COVID-19 outcomes. The study aimed to estimate the prevalence of alcohol and tobacco use among COVID-19-positive patients and compare it with the general population prevalence rates. It also aimed to assess and determine the association between the severity of COVID-19 illness and the complications with alcohol and tobacco use. For this, a cross-sectional, retrospective, telephone-based study was conducted using a structured questionnaire among COVID-19 diagnosed patients in the district of Deoghar of the Indian state of Jharkhand. A multinomial logistic regression is done to determine the association. Among 1,425 patients interviewed, tobacco and alcohol were used by 22.31 and 9.96%, significantly more than the prevalence of tobacco (Z = 4.9485, p < 0.00001) and alcohol use (Z = 7.118, p < 0.00001), respectively, in the district (tobacco-11.7% and alcohol-4.8%).In a regression model, patients with co-morbidity had higher odds of severe [3.34 (1.99-5.62)] and moderate [2.95 (1.97-4.41)] COVID-19. Young [0.12 (0.04-0.38)] and middle-aged individuals [0.23 (0.13-0.4)], people below the poverty line 0.28 (0.11-0.69) are at lower odds of severe COVID-19. Tobacco users [1.58 (1.16-2.14)], alcohol users [1.53 (1.03-2.28)], incomplete vaccination [3.24 (1.49-7.01)], and patients with comorbidity [3.6 (2.79-4.68)] were found to have higher odds of post-COVID-19 complications. People with COVID-19 in our study population had significantly higher tobacco and alcohol use compared to the general population. Tobacco and alcohol use significantly increases the risk of post-COVID-19 complications. The study highlights the need for addiction treatment services to prevent complications during future pandemics.

Integrated Health and Social Care In A Woman's Shelter and Multi-Service Agency

Introduction: Evidence exists demonstrating that integrated health and social care (IHSC) can support enhanced care for highly vulnerable and marginalized population groups. One such group are homeless women. Street Haven (SH) is a multi-service women’s agency that serves homeless women who suffers from the intersection of critical health, social and financial disadvantages living in one of the poorest urban neighbourhoods in Toronto, Canada. SH provides shelter, supported housing, addictions treatment and training support services. Over the past ten years, client acuity has increased the health and social care needs of vulnerable women. The pandemic has exacerbated this. Clients have experienced chronic homelessness which is connected to trauma. They also suffer from mental illness conditions, and chronic diseases including respiratory illnesses, and gastro-intestinal illness, and diabetes. Street Haven has engaged in integrated health and social care (IHSC) to ensure that more comprehensive care can respond to the increasing client care complexity. &#x0D; Approach: IHSC coordination with community partners have been undertaken in order to address unmet health and social care. Within the SH shelter services, partnerships with primary health care partners, hospital services and community-based crisis and mental health teams have been established. As a result, a primary care physician and psychiatrist can be accessed once weekly on site by clients. Homeless women are then attached to a physician and psychiatrist while accessing SH services. In addition, when clients experience crisis, community-based outreach mental health and crisis teams are dispatched by other organizations to SH locations. The SH addiction treatment residence services also integrate with psychiatry services with a community clinical services agency and with the community crisis team to introduce crisis and psychiatric supports for addiction service clients. Lastly, SH works with community policing to ensure that women who exhibit behaviours stemming from crisis, may have benefit of community policing services that provide SH and client with protection while offering crisis supports at the same time. They help to divert clients from hospital and correctional services.&#x0D; Results: IHSC enables SH to better meet the needs of its highly complex client base within its premises. Several benefits of the IHSC include the identification of unmet health and social care needs of our clients including psychiatric and mental health needs and management of chronic diseases and medication prescription needs; enhanced client community engagement through the referral and coordination of services with community health and social care partner agencies; minimization of crisis events on SH premise sites; and minimizing utilization of acute car and correctional services. The competencies that are absent in the organization are available due to IHSC.&#x0D; Lessons Learned: IHSC can act as a lever for women’s shelter and addiction treatment services to provide more comprehensive health and social care services. IHSC is crucial considering the austerity in government program funding in Toronto and Ontario. IHSC is another means to better serve marginalized, homeless and impoverished women to ensure that they have more equitable access to health and social care services especially where there is a gender-bias against women’s services in Toronto. &#x0D;

Changes in buprenorphine waivered provider supply after Virginia Medicaid implements the addiction and recovery treatment services program and Medicaid expansion

BackgroundShortages of providers authorized to prescribe buprenorphine may limit access to buprenorphine, which studies have shown to be effective in the treatment of opioid use disorder (OUD). ObjectiveTo examine whether two state Medicaid policies in Virginia—the Addiction and Recovery Treatment Services (ARTS) program in 2017, and Medicaid expansion in 2019—increased the number of buprenorphine waivered providers (BWP) in Virginia, compared to other southern states in the United States that did not expand Medicaid. MethodsThe study population includes providers authorized to prescribe buprenorphine. We compute the number of BWP per 100,000 people for the study states, overall and for different waiver limits (30, 100 or 275). Using difference-in-difference regression models, we examine changes in BWP rates for Virginia relative to nonexpansion states in the US South between 2015 and 2020. ResultsThe rate of increase in BWP was higher in Virginia after implementation of ARTS and Medicaid expansion (148 %), compared to southern nonexpansion states over the same time period (115 %). Relative to nonexpansion states in the South, BWP with patient limits of 100 or 275 increased by 7 % in Virginia after ARTS implementation in 2017, and by an additional 22 % after Medicaid expansion in 2019 (p < 0.05 each). ConclusionsThe findings suggest that public policies that expand access to OUD treatment services—including buprenorphine treatment—may also increase the supply of providers authorized to prescribe buprenorphine, helping to alleviate shortages of BWP providers and further increasing access to care.

Ambulatory Intensive Care for Medically Complex Patients at a Health Care Clinic for Individuals Experiencing Homelessness

Intensive primary care interventions have been promoted to reduce hospitalization rates and improve health outcomes for medically complex patients, but evidence of their efficacy is limited. To assess the efficacy of a multidisciplinary ambulatory intensive care unit (A-ICU) intervention on health care utilization and patient-reported outcomes. The Streamlined Unified Meaningfully Managed Interdisciplinary Team (SUMMIT) randomized clinical trial used a wait-list control design and was conducted at a health care clinic for patients experiencing homelessness in Portland, Oregon. The first patient was enrolled in August 2016, and the last patient was enrolled in November 2019. Included patients had 1 or more hospitalizations in the prior 6 months and 2 or more chronic medical conditions, substance use disorder, or mental illness. Data analysis was performed between March and May 2021. The A-ICU included a team manager, a pharmacist, a nurse, care coordinators, social workers, and physicians. Activities included comprehensive 90-minute intake, transitional care coordination, and flexible appointments, with reduced panel size. Enhanced usual care (EUC), consisting of team-based primary care with access to community health workers and mental health, addiction treatment, and pharmacy services, served as the comparator. Participants who received EUC joined the A-ICU intervention after 6 months. The main outcome was the difference in rates of hospitalization (primary outcome), emergency department (ED) visits, and primary care physician (PCP) visits per person over 6 months (vs the prior 6 months). Patient-reported outcomes included changes in patient activation, experience, health-related quality of life, and self-rated health at 6 months (vs baseline). We performed an intention-to-treat analysis using a linear mixed-effects model with a random intercept for each patient to examine the association between study group and outcomes. This study randomized 159 participants (mean [SD] age, 54.9 [9.8] years) to the A-ICU SUMMIT intervention (n = 80) or to EUC (n = 79). The majority of participants were men (102 [65.8%]) and most were White (121 [76.1%]). A total of 64 participants (41.0%) reported having unstable housing at baseline. Six-month hospitalizations decreased in both the A-ICU and EUC groups, with no difference between them (mean [SE], -0.6 [0.5] vs -0.9 [0.5]; difference, 0.3 [95% CI, -1.0 to 1.5]). Emergency department use did not differ between groups (mean [SE], -2.0 [1.0] vs 0.9 [1.0] visits per person; difference, -1.1 [95% CI, -3.7 to 1.6]). Primary care physician visits increased in the A-ICU group (mean [SE], 4.2 [1.6] vs -2.0 [1.6] per person; difference, 6.1 [95% CI, 1.8 to 10.4]). Patients in the A-ICU group reported improved social functioning (mean [SE], 4.7 [2.0] vs -1.1 [2.0]; difference, 5.8 [95% CI, 0.3 to 11.2]) and self-rated health (mean [SE], 0.7 [0.3] vs -0.2 [0.3]; difference, 1.0 [95% CI, 0.1 to 1.8]) compared with patients in the EUC group. No differences in patient activation or experience were observed. The A-ICU intervention did not change hospital or ED utilization at 6 months but increased PCP visits and improved patient well-being. Longer-term studies are needed to evaluate whether these observed improvements lead to eventual changes in acute care utilization. ClinicalTrials.gov Identifier: NCT03224858.

Effectiveness and feasibility of a motivational interviewing intake (MII) intervention for increasing client engagement in outpatient addiction treatment: an effectiveness-implementation hybrid design protocol

BackgroundClient discontinuation from outpatient addiction treatment programs is common, and the initial intake is the service delivery point with the highest attrition rate. Replacing the comprehensive intake assessment with a person-centered Motivational Interviewing (MI) intervention is a potential solution to address provider and client concerns about the disengaging, time-intensive nature of the typical initial intake. It remains unclear whether the use of an alternative to the standard intake at the initial visit can fit within typical organizational reporting requirements, whether it decreases attrition, and whether implementation of person-centered intake procedures within outpatient addiction treatment programs is feasible, acceptable, and can be sustained.PurposeTo describe the methods and design of an effectiveness-implementation hybrid type 1 trial of a Motivational Interviewing at Intake (MII) intervention using the Consolidated Framework for Implementation Research (CFIR).MethodsThe study will determine the effectiveness of two intake conditions: (1) standard comprehensive intake assessment (intake-as-usual [IAU]), and (2) MII consisting of a person-centered discussion between provider and client about the client’s desire and intent to enter treatment. Although both interventions are focused on understanding client presenting complaints and needs for treatment, the delivery differs as the IAU uses a semi-structured assessment guide, while MII applies the theory of MI to have a conversation about treatment engagement. Adults seeking outpatient addiction treatment services will be randomly assigned to the MII condition (n = 75) or the IAU condition (n = 75). Primary outcomes will be client engagement (i.e., treatment entry, attendance, and completion) obtained from the electronic medical record. Secondary outcomes (client motivation and therapeutic alliance) will be putative mechanisms of client engagement assessed immediately before and after the intake. The trial also will explore determinants of effective, sustainable implementation using assessments of organizational readiness and capacity to change, as well as interviews on MII implementation feasibility.ConclusionThis trial of an MII intervention will investigate the feasibility of a motivational intervention as an initial contact with substance use treatment-seeking clients as well as indicators of intervention effectiveness within the systems where it is employed.Trial registration Clinicaltrials.gov identifier: NCT05489068