In 2014, as a hospitalist in Portland, Honora L. Englander, MD, FACP, found that she was caring for increasing numbers of young people who were dying secondary to their substance use disorders. “We were already investing so many resources and care for this really vulnerable population; we just weren't doing it in the best way,” she said. “So I reached out to OHSU leadership and basically said, ‘I think we have an opportunity to redesign care and do better for folks.’”
That led to a needs assessment, which found that some of the biggest gaps were lack of clinician expertise around addiction and prolonged wait times for opioid use disorder treatment in the community. To address these issues, Dr. Englander and colleagues developed the Improving Addiction Care Team (IMPACT), an interprofessional addiction medicine consult service that treats hospitalized adults with substance use disorders. The team also developed partnerships with community organizations to allow for rapid-access pathways to treatment.
How it works
IMPACT, which started seeing patients in July 2015, currently includes physicians (a mix of addiction medicine-boarded physicians and general internists), a nurse practitioner, a physician assistant, two social workers, and three peer recovery mentors with lived experience in recovery. “Peers help engage patients, many of whom have experienced significant trauma and may have had negative experiences in hospitals,” noted Dr. Englander, who is principal investigator and director of IMPACT and an associate professor of medicine at OHSU. Inpatient clinicians refer to IMPACT patients with known or suspected substance use disorders.
During its first three years, the service consulted on more than 800 patients with 1,025 hospitalizations: 60% opioid use disorder, 45% stimulant use disorder, and 42% alcohol use disorder, according to a commentary in the Journal of Addiction Medicine in December 2018. Of these patients, 60% had medication for substance use disorder started in the hospital, and 75% had planned linkage to treatment after hospitalization.
Before IMPACT, the hospital's clinicians who cared for patients with substance use disorder largely believed that hospitalization did not address addiction and led to untreated withdrawal and patients leaving against medical advice, according to a study published in the November 2018 Journal of Hospital Medicine. After exposure to IMPACT, the surveyed clinicians reported that the intervention reframed addiction as a treatable chronic disease, humanized care, and improved patient engagement and communication. The project has also improved patient outcomes. In newer, unpublished research, “We found substantially improved rates of substance use treatment after hospitalization in IMPACT patients compared with controls,” said Dr. Englander.
At the start, there was a range of responses to the project. Surgeons working on heart valves, for example, were initially concerned about the potential effects of a medication like buprenorphine in the perioperative setting, Dr. Englander said. There were also questions about the legality of methadone in the hospital. “We had to create a policy so that all of the providers would have something that we can point to right away and say, ‘Nope, this is policy, and this is legal,’” she said. Finally, while peer recovery mentors remain a valuable part of the intervention, there can be challenges in integrating them into hospital settings, Dr. Englander said. For example, peers might have different expectations than hospital staff regarding professional boundaries and sharing personal information, she said.
Many people with addiction are desperate to quit, but others are not. Dr. Englander recently saw a man who was diagnosed with metastatic cancer, had longstanding heroin use, and was facing homelessness, but was not ready to quit. The team struggled with what to do, and she decided to have a conversation with the patient.
Dr. Englander asked him, “Why don't we just work with the assumption that you're going to continue to use? How can we support you, and what matters to you?” Appreciative of somebody acknowledging his experience, the man let his guard down and began to cry, she said. “So it's not all about connecting people to treatment, though it's a big part of what we do.”
IMPACT is now focusing on disseminating best practices. In January 2019, OHSU launched training through Project ECHO to provide clinician education and system-level support for hospitals across Oregon, she said. The curriculum, which targets hospital staff, including hospitalists, nurses, and social workers, focuses on substance use disorder diagnosis, buprenorphine and methadone, and trauma-informed care.