Hospital-Based Addiction Medicine Healthcare Providers: High Demand, Short Supply Substance use disorders account for a significant burden of disease and place an enormous strain on the health care system in the United States and beyond. Despite death tolls climbing, a myriad of evidence-based medications exist to effectively treat many substance use disorders including nicotine, alcohol, and opioid use disorders. To date, hospitals have largely been overlooked as a setting ripe for the delivery of specialized addiction care. This occurs despite a high lifetime prevalence of a substance use disorder (50%) occurring among hospitalized individuals. A potential barrier to this is the lack of addiction medicine training that currently exists in undergraduate and graduate medical education. Consequently, a paucity of existing physicians report feeling competent to adequately screen for, diagnose or treat substance use disorders. Given the prevalence, cost and potentially lethal consequences of substance use disorders, a critical need exists to improve its identification and evidence-based management in hospital settings.

Impact of Fentanyl Use on Buprenorphine Treatment Retention and Opioid Abstinence Objectives: There has been a rapid increase in the presence of illicitly manufactured fentanyl in the heroin drug supply. Buprenorphine is an effective treatment for heroin and prescription opioid use disorder; however, little is known about treatment outcomes among people using fentanyl. We compared 6-month treatment retention and opioid abstinence among people initiating buprenorphine treatment who had toxicology positive for heroin compared to fentanyl at baseline. Methods: Retrospective cohort study of 251 adult patients initiating office-based buprenorphine treatment who had available toxicology testing across an academic health system between August 2016 and July 2017. Exposure was assessed at baseline before initiating buprenorphine and was categorized as negative toxicology (n = 184) versus fentanyl positive toxicology (n = 48) versus heroin positive toxicology (n = 19). Results: Six-month treatment retention rates were not different between the fentanyl positive and heroin positive groups [38% (n = 18) vs 47% (n = 9); P = 0.58], or between the fentanyl positive and the negative toxicology group [38% (n = 18) vs 51% (n = 93); P = 0.14]. Opioid abstinence at 6 months among those who had testing did not differ between the fentanyl positive and the heroin positive group [55% (n = 6) vs 60% (n = 6); P = 0.99]. The fentanyl positive group had a lower abstinence rate at 6 months compared to those with negative toxicology at baseline [55% (n = 6) vs 93% (n = 63); P = 0.004]. Mean initial buprenophine dosage did not differ between groups. Conclusions: Buprenorphine treatment retention and abstinence among those retained in treatment is not worse between people using fentanyl compared to heroin at treatment initiation. Both groups have lower abstinence rates at 6 months compared to individuals with negative toxicology at baseline. These findings suggest that people exposed to fentanyl still benefit from buprenorphine treatment.

Obstetric and Pediatric Provider Perspectives on Mandatory Reporting of Prenatal Substance Use Objective: In many states, health care providers are legally required to report pregnant women who use substances, or infants affected by prenatal substance use, to child welfare authorities. The objective of this study was to characterize obstetric and pediatric providers’ perceptions of and experiences with policies requiring mandatory reporting of prenatal substance use to child welfare authorities. Methods: We conducted a qualitative interview study among 20 obstetric and pediatric providers to elicit participants’ perspectives about and experience with current policy requiring mandatory reporting of prenatal substance use. Two investigators used an iterative content analysis approach to code interview transcripts and identify themes. Results: Study participants included obstetrician/gynecologists (N = 7), midwives (N = 5), and pediatricians (N = 8). Providers noted that implementation of the policy was often targeted and that targeted screening can be biased. Most providers reported that they incorporated information about mandatory reporting policies into patient counseling about substance use. They described not knowing what happens to patients after mandatory reporting and concerns regarding unintended consequences. Providers indicated that changes are needed to improve outcomes for patients and their families and suggested increased research into best practices, more funding for social services, and eliminating the policy altogether. Conclusions: Health care providers expressed concern about the targeted screening process used to identify women with substance use whose children are reported to child welfare authorities. Most providers believed that mandatory reporting processes could be modified in ways that would support the health of women and children.

“I didn’t want to be on Suboxone at first…” – Ambivalence in Perinatal Substance Use Treatment Objectives: The objectives of this article are to present findings from recent qualitative research with patients in a combined perinatal substance use treatment program in Central Appalachia, and to describe and analyze participants’ ambivalence about medication-assisted treatment for opioid use disorder (OUD), in the context of widespread societal stigma and judgement. Methods: We conducted research in a comprehensive outpatient perinatal substance use treatment program housed in a larger obstetric practice serving a large rural, Central Appalachian region. The program serves patients across the spectrum of substance use disorders but specifically offers medication-assisted treatment to perinatal patients with OUD. We purposively and opportunistically sampled patients receiving prescriptions for buprenorphine or buprenorphine-naloxone dual product, along with prenatal care and other services. Through participant-observation and semi-structured interviews, we gathered qualitative data from 27 participants, in a total of 31 interviews. We analyzed transcripts of interviews and fieldnotes using modified Grounded Theory. Results: Participants in a combined perinatal substance use treatment program value supportive, non-judgmental care but report ambivalence about medication, within structural and institutional contexts of criminalized, stigmatized substance use and close scrutiny of their pregnancies. Women are keenly aware of the social and public consequences for themselves and their parenting, if they begin or continue medication treatment for OUD. Conclusions: Substance use treatment providers should consider the social consequences of medication treatment, as well as the clinical benefits, when presenting treatment options and recommendations to patients. Patient-centered care must include an understanding of larger social and structural contexts.

Naloxone Availability and Pharmacy Staff Knowledge of Standing Order for Naloxone in Pennsylvania Pharmacies Objective: To assess the availability and price of naloxone as well as pharmacy staff knowledge of the standing order for naloxone in Pennsylvania pharmacies. Methods: We conducted a telephone audit study from December 2016 to April 2017 in which staff from Pennsylvania pharmacies were surveyed to evaluate naloxone availability, staff understanding of the naloxone standing order, and out-of-pocket cost of naloxone. Results: Responses were obtained from 682 of 758 contacted pharmacies (90% response rate). Naloxone was stocked (ie, available for dispensing) in 306 (45%) pharmacies surveyed. Of the 376 (55%) pharmacies that did not stock naloxone, 118 (31%) stated that they could place an order for naloxone for pickup within 1 business day. Responses by pharmacy staff to questions about key components of the standing order for naloxone were collected from 581 of the 682 pharmacies who participated in the survey (85%). Of the 581 pharmacy staff members who stated that they either stocked or could order naloxone, 64% correctly answered all questions pertaining to understanding of the naloxone standing order. The respective median out-of-pocket prices stated in the audit varied by formulation and ranged from $50 to $4000. Staff from national pharmacies were significantly more likely than staff from regional/local chain and non-chain pharmacies to correctly answer that a prescription was not required to obtain naloxone (68.5%, 57.7%, and 52.4% respectively, (P = 0.0045). Conclusions: Multiple barriers to naloxone access exist in pharmacies across a large, diverse state, despite the presence of a standing order to facilitate such access. Limited availability of naloxone in pharmacies, lack of knowledge or understanding by pharmacy staff of the standing order, and variability in out-of-pocket cost for this drug are among these potential barriers. Regulatory or legal incentives for pharmacies or drug manufacturers, education efforts directed toward pharmacy staff members, or other interventions may be needed to increase naloxone availability in pharmacies.

Technology Use Patterns Among Patients Enrolled in Inpatient Detoxification Treatment Background: Technology-based interventions offer a practical, low-cost, and scalable approach to optimize the treatment of substance use disorders (SUDs) and related comorbidities (HIV, hepatitis C infection). This study assessed technology use patterns (mobile phones, desktop computers, internet, social media) among adults enrolled in inpatient detoxification treatment. Methods: A 49-item, quantitative and qualitative semi-structured survey assessed for demographic characteristics, technology use patterns (ie, mobile phone, text messaging [TM], smart phone applications, desktop computer, internet, and social media use), privacy concerns, and barriers to technology use. We used multivariate logistic regression models to assess the association between respondent demographic and clinical characteristics and their routine use of technologies. Results: Two hundred and six participants completed the survey. Nearly all participants reported mobile phone ownership (86%). Popular mobile phone features included TM (96%), web-browsers (81%), and accessing social media (61%). There was high mobile phone (3.3 ± 2.98) and phone number (2.6 ± 2.36) turnover in the preceding 12 months. Nearly half described daily or weekly access to desktop computers (48%) and most reported internet access (67%). Increased smartphone ownership was associated with higher education status (P = 0.022) and homeless respondents were less likely to report mobile phone ownership (P = 0.010) compared to participants with any housing status (ie, own apartment, residing with friends, family, or in a halfway house). Internet search engines were used by some participants (39.4%, 71/180) to locate 12 step support group meetings (37%), inpatient detoxification programs (35%), short- or long-term rehabilitation programs (32%), and outpatient treatment programs (4%). Conclusions: Technology use patterns among this hard-to-reach sample of inpatient detoxification respondents suggest high rates of mobile phone ownership, TM use, and moderate use of technology to facilitate linkage to addiction treatment services.

Opioid and Cannabis Co-Use among Adults With Chronic Pain: Relations to Substance Misuse, Mental Health, and Pain Experience Objectives: Opioid misuse constitutes a significant public health problem and is associated with a host of negative outcomes. Despite efforts to curb this increasing epidemic, opioids remain the most widely prescribed class of medications. Prescription opioids are often used to treat chronic pain despite the risks associated with use, and chronic pain remains an important factor in understanding this epidemic. Cannabis is another substance that has recently garnered attention in the chronic pain literature, as increasing numbers of individuals use cannabis to manage chronic pain. Importantly, the co-use of substances generally is associated with poorer outcomes than single substance use, yet little work has examined the impact of opioid-cannabis co-use. Methods: The current study examined the use of opioids alone, compared to use of opioid and cannabis co-use, among adults (n = 450) with chronic pain on mental health, pain, and substance use outcomes. Results: Results suggest that, compared to opioid use alone, opioid and cannabis co-use was associated with elevated anxiety and depression symptoms, as well as tobacco, alcohol, cocaine, and sedative use problems, but not pain experience. Conclusions: These findings highlight a vulnerable population of polysubstance users with chronic pain, and indicates the need for more comprehensive assessment and treatment of chronic pain.

Prevalence, Incidence, and Factors Associated With Substance Use Among Medical Students: A 2-Year Longitudinal Study Objectives: Although there are a number of studies about substance use by medical students, the majority are still cross-sectional. We aimed to investigate prevalence, 2-year incidence, and factors associated with substance use during medical training. Methods: This longitudinal study included medical students in 4 different waves (with each wave equaling 1 semester). Socio-demographic data, Duke Religion Index (DUREL), DASS-21, and the “Alcohol, Smoking and Substance Involvement Screening Test” (ASSIST) were used. Results: A total of 327 (56.2%) medical students were followed for 2 years. Prevalence of lifetime substance use was 89.9% for alcohol, 34.5% for cannabis, and 17.1% for sedatives. Tobacco had the greatest incidence of use over the 2 years (16.4%), followed by alcohol (13.8%) and cannabis (13.8%). At least 24% of the students would need an intervention for alcohol use, 11.4% for tobacco, and 6.5% for cannabis. Alcohol use during wave 4 was associated with organizational religiosity, and alcohol and tobacco use at the baseline; tobacco use during wave 4 was associated with age, non-organizational religiosity, and cannabis and tobacco use at the baseline; and cannabis use during wave 4 was associated with cannabis and tobacco use at the baseline. Conclusions: Our results indicate an increase in the incidence of lifetime substance use during medical training. Prior use of substance was associated with a higher chance of use after 2 years, while age and religiousness seem to reduce the chance of use.

Recovery Goals and Long-term Treatment Preference in Persons Who Engage in Nonmedical Opioid Use Background: While most opioid use disorder (OUD) treatment providers consider opioid abstinence to be the preferred outcome, little is known about the treatment preferences of the larger population of individuals who engage in nonmedical opioid use and have not yet sought treatment. This study sought to descriptively quantify the proportion of out-of-treatment individuals with nonmedical opioid use that have abstinent and nonabstinent recovery goals. Methods: Participants (N = 235) who engage in nonmedical opioid use and met self-reported criteria for OUD were recruited online and participated in a cross-sectional survey on recovery goals and treatment perceptions. Participants were dichotomized as having either abstinent (70.6%) or nonabstinent (29.4%) recovery goals. Participants were presented with 13 treatment options and asked which treatment they would “try first” and which treatment they thought would be the best option for long-term recovery. Results: Persons in the nonabstinent group were more likely to want to continue use of prescription opioids as prescribed by a physician compared with the abstinent group (χ2[1] = 9.71, P = 0.002). There were no group differences regarding preference for individual OUD treatments. The most frequently endorsed treatments that participants would “try first” were physician visits (23.4%), one-on-one counseling (18.7%), and 12-step groups (13.2%), whereas the most frequently endorsed treatments for long-term recovery were one-on-one counseling (17.4%), residential treatment (16.7%), and buprenorphine (15.3%). Conclusion: Public health initiatives to engage out-of-treatment individuals should take into account recovery goals and treatment preferences to maximize treatment initiation and retention.

Predictors for 30-Day and 90-Day Hospital Readmission Among Patients With Opioid Use Disorder Objectives: To identify the incidence, characteristics, and predictors for 30 and 90-day readmission among acutely hospitalized patients with opioid use disorder (OUD). Methods: This retrospective, cohort study evaluated consecutive adults with OUD admitted to an academic medical center over a 5-year period (10/1/11 to 9/30/16). Multivariable logistic regression was used to determine independent predictors for 30 and 90-day readmissions based on pertinent admission, hospital, and discharge variables collected via chart review and found to be different (with a P < 0.10) on univariate analysis. Results: Among the 470 adults (mean age 43.1 ± 12.8 years, past heroin use 77.9%; admission opioid agonist therapy use [buprenorphine 22.6%; methadone 27.0%]; medical [vs surgical] admission 75.3%, floor [vs ICU] admission 93.0%, in-hospital mortality 0.9%), 85 (18.2%) and 151 (32.1%) were readmitted within 30 and 90 days, respectively. Among the 90-day readmitted patients, median time to first readmission was 26 days. Buprenorphine use (vs no use) at index hospital admission was independently associated with reduced 30-day (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.24–0.93) and 90-day (OR 0.57, 95% CI 0.34–0.96) readmission; prior heroin (vs prescription opioid) use was associated with reduced 90-day readmission (OR 0.59, 95% CI 0.37–0.94) and length of hospital stay was associated with both greater 30-day (OR 1.02, 95% CI 1.01–1.05) and 90-day (OR 1.04, 95% CI 1.01–1.06) readmission rates. Conclusions: Among patients with OUD taking buprenorphine at the time of hospital admission, 30-day and 90-day hospital readmission was reduced by 53% and 43%, respectively.