Time to address addiction treatment inequality in hospital settings

Injection drug use, and substance use more broadly, places an enormous health and economic burden on society. In North America, opioid-related deaths have continued to increase year-on-year for a decade. Annual US drug overdose deaths rose nearly 30% in 2020, to 93 331, the highest number on record, 75% of which involved opioids.1US Centers for Disease Control and PreventionDrug overdose deaths in the US up 30% in 2020.https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20210714.htmDate: July 14, 2021Date accessed: November 15, 2021Google Scholar Tragically, many of these deaths are preventable. Although we have treatments that work, there continue to be many missed opportunities for intervention, highlighting the need to prioritise access to evidence-based treatments within all health-care settings. A key opportunity to prevent death from substance use disorders is to initiate evidence-based treatments opportunistically during hospital encounters.2D'Onofrio G O'Connor P Bernstein S et al.Models of ED-initiated treatment protocols for opioid dependent patients.Acad Emerg Med. 2014; 21: S305Google Scholar, 3Chen Y Wang Y Nielsen S Kuhn L Lam T A systematic review of opioid overdose interventions delivered within emergency departments.Drug Alcohol Depend. 2020; 213108009Crossref PubMed Scopus (15) Google Scholar In The Lancet Public Health, Joshua Barocas and colleagues4Barocas JA Savinkina A Adams J et al.Clinical impact, costs, and cost-effectiveness of hospital-based strategies for addressing the US opioid epidemic: a modelling study.Lancet Public Health. 2021; (published online Nov 30.)http://doi.org/10.1016/S2468-2667(21)00248-6Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar examine the clinical impact, costs, and cost-effectiveness of hospital-based strategies for addressing the US opioid epidemic through a modelling study that explored different simulations of implementing addiction consultant services and expanded prescribing of medications for opioid use disorder. The focus of this study was on people who inject drugs and the study considered the outcomes of hospitalisation and overdose death. The research contributes to the literature by showing that these strategies could be cost-effective and save lives. It is perhaps unsurprising that providing greater access to evidence-based medications, such as methadone and buprenorphine, is lifesaving, especially given the extensive literature supporting this approach.5Sordo L Barrio G Bravo MJ et al.Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies.BMJ. 2017; 357j1550Crossref PubMed Scopus (659) Google Scholar There are a range of other treatment options, such as detoxification and psychological interventions, but as real-world evidence in the USA has shown, only methadone and buprenorphine are associated with reduced opioid-related overdose.6Wakeman SE Larochelle MR Ameli O et al.Comparative effectiveness of different treatment pathways for opioid use disorder.JAMA Netw Open. 2020; 3e1920622Crossref PubMed Scopus (131) Google Scholar It is perhaps surprising then, that in 2021, after an almost decade-long opioid epidemic in the USA, additional studies are still required to show the value of clinical models that increase access to these evidence-based treatments, and to justify the funding of addiction specialists within the hospital system. Although there have been multiple initiatives to increase provision of these treatments outside specialist systems, it is a disappointing and well understood fact that they are underused in many parts of the globe, even where they are available. Many non-specialists do not see it as their role to prescribe opioid agonist treatment.7Louie DL Assefa MT McGovern MP Attitudes of primary care physicians toward prescribing buprenorphine: a narrative review.BMC Fam Pract. 2019; 20: 157Crossref PubMed Scopus (11) Google Scholar This failing underscores why having addiction consultation services is an important part of the equation. In the study by Barocas and colleagues,4Barocas JA Savinkina A Adams J et al.Clinical impact, costs, and cost-effectiveness of hospital-based strategies for addressing the US opioid epidemic: a modelling study.Lancet Public Health. 2021; (published online Nov 30.)http://doi.org/10.1016/S2468-2667(21)00248-6Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar the modelled outcomes were limited to direct patient benefits, but expanding addiction consult services would likely have a much broader beneficial impact on health systems and society. Expanding these services would build addiction medicine capability more broadly within the hospital system, which in turn might lead to reduced readmission rates, length of hospital stays, and use of emergency care. Such a strategy could also contribute to broader social and economic benefits from effectively treating alcohol and drug use disorders. Providing comprehensive addiction training during medical school or residency, through placements and opportunities for patient contact, has been found to decrease stigma and increase confidence and interest in providing evidence-based treatments for opioid dependence in later practice.8Ayu AP van der Ven M Suryani E et al.Improving medical students' attitude toward patients with substance use problems through addiction medicine education.Subst Abus. 2020; (published online Feb 27.)https://doi.org/10.1080/08897077.2020.1732512Crossref PubMed Scopus (3) Google Scholar Formalised addiction consultation services provide critical opportunities for medical and nursing students and residents and nursing staff, in addition to making expertise accessible to other departments, including pharmacies and allied health. It is important to question why these services are not already in existence. One key barrier appears to be structural stigma, where inequitable allocation of resources means that people face greater barriers to accessing appropriate care for substance use disorders than they do for other health needs.9Livingston JD Structural stigma in health-care Contexts for people with mental health and substance use issues. Mental Health Commission of Canada, Ottawa2020Google Scholar The lack of specialists within hospitals in particular can contribute to fragmented care and poorer health outcomes.9Livingston JD Structural stigma in health-care Contexts for people with mental health and substance use issues. Mental Health Commission of Canada, Ottawa2020Google Scholar Hospitals provide a key opportunity for initiation of treatment, with numerous studies showing that initiating opioid agonist treatment in hospital leads to a greater likelihood that people will continue with treatment after discharge.2D'Onofrio G O'Connor P Bernstein S et al.Models of ED-initiated treatment protocols for opioid dependent patients.Acad Emerg Med. 2014; 21: S305Google Scholar In addition to having addiction medicine specialists in hospitals, we should also explore other strategies that increase engagement with evidence-based treatments. These include peer-recovery coaches and low threshold treatment clinics, with evidence also supporting their cost-effectiveness in inpatient and general medical settings.10Magidson JF Regan S Powell E et al.Peer recovery coaches in general medical settings: Changes in utilization, treatment engagement, and opioid use.J Subst Abuse Treat. 2021; 122108248Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar Given the decade of markedly increasing opioid-related deaths in many parts of the world, and the well-established burden of disease associated with alcohol and drug use, it is time that addiction medicine is considered as essential as any other medical speciality, and to address structural stigma in funding models that prevent access to timely and high-quality care. SN has received untied educational research funding from Seqirus and is a named investigator on a buprenorphine depot implementation study funded by Indivior. DIL has previously received speaking honoraria from AstraZeneca, Camurus AB, Indivior, Janssen, and Lundbeck, and has provided consultancy advice to Lundbeck and Indivior. DL and AB have received research funding from Camurus AB. SN and DL are supported by National Health and Medical Research Council Grants ( 1163961 and 1196892 ). These funding sources had no role in or knowledge of this submission. Clinical impact, costs, and cost-effectiveness of hospital-based strategies for addressing the US opioid epidemic: a modelling studyThe combined interventions of expanding hospital-based prescribing of medications for opioid use disorder and implementing addiction consult services could improve life expectancy, be cost-effective, and could be the basis for a comprehensive hospital-based strategy for addressing the opioid epidemic in the USA and countries with similar opioid epidemics. Full-Text PDF Open Access

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