During his residency at Boston Medical Center in the 1980s, Jeffrey Samet, FACP, wanted to do more to help opioid-dependent patients connect with treatment after discharge. It drove him crazy to see addicts admitted for various medical problems, placed on low-dose methadone to manage withdrawal symptoms, then released to resume their old behaviors.
“I knew we were dropping the ball,” said Dr. Samet, now chief of general internal medicine at Boston Medical Center (BMC) and professor at Boston University School of Medicine.
From Dr. Samet's experience sprang BMC's Transitional Opioid Program, a low-threshold methadone pilot initiative for people at point of discharge. It's based on the theory that hospitalization is a “reachable moment” to identify addicts admitted for other medical problems and link them with long-term treatment. Data from the three-year pilot are encouraging: 82% of enrolled patients presented to the methadone clinic after discharge, and 59% of those continued into long-term treatment. Dr. Samet and colleagues published the pilot's results in the August Journal of General Internal Medicine.
Despite these findings, and successful programs at a few other hospitals across the country, routine screening and treatment coordination for substance abuse are relatively rare. Yet substance abuse is one of the most common problems seen in the emergency department (ED). According to the most recent statistics from the Agency for Healthcare Research and Quality, substance abuse—alone or combined with a mental health condition—accounts for 4.5% of all ED visits.
In light of these numbers and some evidence that screening and brief intervention can be effective, The Joint Commission last year approved a draft set of Tobacco and Alcohol Measures (TAM) to encourage assessment and treatment of tobacco, alcohol and other drug use for all adult hospitalized patients. A six-month pilot test of the measures was recently completed in 26 hospitals around the country and, if deemed successful, these measures could become one of the sets that hospitals can select to meet accreditation requirements, according to Nancy K. Lawler, associate project director for The Joint Commission.
While the measure set does not require screening for drug use, if a patient is identified as drug-dependent, either a referral for addictions treatment or a prescription for an appropriate medication would be required by the measure set, Ms. Lawler said.
The TAM measure is aimed at identifying adults who use alcohol in an unhealthy manner as well as those who may be dependent, said Larry M. Gentilello, MD, a surgeon at the University of Texas Southwestern Medical Center in Dallas who serves on the Commission's Technical Advisory Committee for TAM. The attending physician would determine whether a patient is an unhealthy user—in which case he or she would be referred for brief counseling—or dependent and in need of treatment. Typically, only a small percentage of patients meet the criteria for dependency and are candidates for treatment, he said.
“Surveys consistently show a willingness on the part of doctors and nurses to do something about their patients' substance abuse, and a Joint Commission endorsement will make it a standard of care,” said Dr. Gentilello. “It makes sense to have an intervention be the standard considering that [substance abuse] is more common [in the hospital] than high blood pressure or diabetes.”
Barriers to screening
In a recent survey by Kaiser Permanente, physicians cited three main reasons for not screening for substance abuse: don't have time, don't know how, and don't like to work with addicts, said David Pating, MD, chief of addiction medicine for Kaiser San Francisco. Educating physicians about substance abuse, and its potential remedies, can help with both the second and third objections.
“Untreated, people will accumulate more medical consequences…and hospitalists are seeing all the downstream consequences” without seeing the potential benefits of intervention and treatment, said Dr. Pating, who is also regional chair of addiction medicine for Kaiser's Northern California region. “We want to teach them that this is a disease that is treatable and curable.”
As for the first objection, taking action doesn't have to be time-consuming or difficult, he added. For example, just one question about a patient's recent alcohol use can identify potential problems. If a female patient has had four or more drinks in one day over the past year and a man has had five or more, he or she may be at risk of developing dependence.
The new screening and intervention measures aim to help doctors recognize the nature of a patient's problem and recommend next steps, before the patient becomes dependent, Dr. Gentilello said. “The role of the hospitalist is to take those patients who are not dependent and increase their motivation to change by discussing how their substance abuse impacts their health and led to their current hospitalization.”
Many hospitalists think addiction medicine is outside of their purview when in reality, “hospitalists have an enormous role to play” in detection and brief intervention, he continued. “The average hospitalist says, ‘I'm not working at a treatment center; I'm here to treat their gastritis or headache.’ They're right that they cannot do addiction medicine, but they can provide brief intervention for people who are not dependent.”
Where it's working: in-house consults
Once a patient has been identified as having a substance abuse problem, there must be a process in place to connect him or her with treatment options, experts said. Some hospitals, such as Meriter Hospital in Madison, Wis., have established in-house consult services that work with general hospitalists to ensure that addicts are transitioned into treatment at discharge.
Psychiatrist Michael M. Miller, MD, who specializes in inpatient addiction medicine at Meriter, developed one of the few addiction consult services based in a hospital. The 20-year-old consult service—made up of two full-time physicians and six full-time nurses—works closely with the hospital's 24-physician internal medicine consult service and cross-refers patients daily, said Dr. Miller.
“[The internal medicine service] sees patients for us that have a significant medical complication we need them to manage, and they consult with us to help with detox management and discharge planning,” he said.
For example, a hospitalist on the medical service might consult Dr. Miller or another addiction specialist about a patient with agitated behavior due to opioid withdrawal or alcohol delirium tremens. The addiction specialists work with general hospitalists and intensivists to manage alcohol withdrawal in critical or intermediate care settings while nurses on both services coordinate on bedside management.
Prior to discharge, a nurse from Meriter's consult service determines the patient's insurance coverage and sets him or her up in an outside treatment program, typically one run by a community nonprofit.
In some hospitals, screening and early intervention occur when a patient is admitted to the ED. In 2005, Poudre Valley Hospital in Larimer County, Colo. established a 24/7 Crisis Assessment Center within its ED to provide mental health and substance abuse assessments, admissions to inpatient care, and next-day placements at community outpatient providers.
“We realized there was no clear entryway into hospital emergency services, that people who had a substance abuse emergency ended up in the ED, but doctors there were already overloaded with emergencies and didn't have the ability to deal with addiction issues,” said Lin Wilder, director of community impact for the Health District of Northern Larimer County, which coordinated the project through the Community Mental Health and Substance Abuse Partnership. “Now, when someone with a substance abuse emergency shows up, they have immediate entry and can bypass the ED.”
The ED model is based on integrated care between the hospital and the community, said Ms. Wilder. Bringing mental health and substance abuse professionals into the ED takes pressure off busy physicians and ensures that patients are connected with the services they need.
“[The crisis center] is a win-win for doctors, the hospital, clients, and the police because people know you can bring people with addiction emergencies to the hospital and they will receive the services they need,” she said.
Continuum of care
Kaiser Permanente is widely considered a model of how to coordinate care for substance abuse both inside and outside the hospital. The California-based heath maintenance organization offers immediate access to a continuum of care with unlimited benefits for its members, said Dr. Pating. If addicts are identified in the ED, for example, the goal is to get them into care within 48 hours and connect them with long-term services that are fully covered for up to two years or longer, depending on the individual situation.
“We've been able to show through our research that when we offer integrated care, within six months, the cost of hospitalization comes down so much that the savings pay for the treatment,” said Dr. Pating. By integrating medical and psychiatric care, he said, Kaiser was able to reduce its ED costs from $60 to $35 per member per month, and from $509 to $232 per member per month for high-risk patients with medical and psychiatric substance abuse issues.
Murtuza Ghadiali, MD, a hospitalist who splits his time between Kaiser's San Francisco hospital and its chemical dependency clinic, sees that integration in play every day. Dr. Ghadiali acts as a bridge for patients going from the hospital to the dependency clinic and gets called in for consults on addiction cases by attending doctors or social workers.
He also collaborates with ED physicians on patients who have been identified as chronically inebriated or considered at high risk for addiction. An ED doctor might call Dr. Ghadiali to arrange for triage of a known addict directly to the clinic, or a therapist from the clinic might visit a high-risk patient in the ED to discuss treatment options.
The dependency clinic provides structure for a patient seeking recovery by offering access to in-house services like detox appointments, psychiatrists and group therapy, as well as referrals to community resources. A patient might transition to using mainly community resources but can return to the clinic whenever necessary, said Dr. Ghadiali.
“The most important thing for us is no matter what stage of change you are in your addictive cycle, you have a place to come when the consequences get severe,” he said.
That guaranteed access is at the heart of Kaiser's success in treating addiction, added Dr. Pating. “The best evidence-based treatments don't work unless they are accessible and available.”