Research: Palliative Care Needs and Models of Care for People Who Use Drugs and/or Alcohol: A mixed methods systematic review
Author: Olivia Cook, et al.
Abstract/Extract: C-L psychiatrists are often involved in the care of patients with drugs or alcohol misuse and who are approaching end-of-life. Focusing on creating a trusting relationship, utilizing a harm-reduction model, and involving different specialties in the care of these patients will help improve their outcomes and promote quality of life.
Reviewed by Barbara Lubrano di Ciccone, MD, in the latest quarterly Annotations on the ACLP website, the research describes models of care for people who use drugs and/or alcohol and identifies three key palliative care needs:
Interpersonal/organisational relationships. Patients are reticent to engage in advance care planning and require discussions within a trusted relationship. And a perception that mainstream palliative care services are quiet and serene inhibit access to people who use drugs and/or alcohol, who sense they do not fit in because of their incompatible lifestyle.
Holistic care. Enforced abstinence from drugs and/or alcohol at the end of life may be unrealistic and potentially inhibits access to essential end-of-life care. A harm-reduction model is suggested as more appropriate. Clinicians need to tolerate a level of drug or alcohol use in order to provide individuals with a better sense of security and achieve better outcomes.
Collaborating with other services and training/education. Providing timely end-of-life care is compounded by the presence of difficult behaviours, multiple comorbidities, and/or mental illness. Working alongside different specialties increases the likelihood of an out-of-hospital death and improved quality of life.
Importance: Despite end-of-life needs of this population being different to others, challenges include creating inclusive policies, sensitising staff to distinctive individual needs, and training exchanges for staff working in both drug and alcohol services and palliative care.
Research: Educating the Community About the Opioid Epidemic and Medications for Opioid Use Disorder
Author: Jill Williams, MD, et al.
Abstract/Extract: Graduate students in health sciences are being trained to successfully teach the public about the opioid crisis and the usefulness of medications for opioid use disorder. To date, 120 students at Rutgers University have participated and delivered 59 presentations to more than 1,065 community members. Students named the program RIOT (Rutgers Interdisciplinary Opioid Trainers).
The program has had a significant impact on the knowledge of community members, say researchers. Importantly, there has been a statistically significant increase in community members taking part in the program who endorse that medications are often necessary for successful treatment of opioid use disorders. Most have felt more positive about such medications as a result of attending the students’ presentations. 20% of attendees had a family member with an opioid use disorder.
“Despite overwhelming evidence of benefit, medications for opioid use disorder remain stigmatizing and more efforts are needed to educate health care professionals and the general public,” say the research team.
Importance: Drug overdose deaths in the US have risen to historic levels, with more than 93,331 deaths in 2020, and 700,000 in the last 20 years. The federal response has included changing prescriber behavior to use fewer opioid medications, distributing naloxone to the general public for overdose reversal, and supporting the increased use of medications for opioid use disorder.
Medications for opioid use disorder (MOUD) refers to the use of Food and Drug Administration-approved medications for the maintenance treatment of opioid use disorder and includes methadone, buprenorphine, and naltrexone.
But the use of MOUD remains stigmatizing. Patients, families and health care providers can have negative attitudes and beliefs about MOUD, which may be worse for methadone and buprenorphine treatments that have the potential for misuse. An abstinence-only approach (counseling without medication) is not recommended for opioid use disorder, yet negative attitudes persist even among substance abuse treatment providers and individuals in recovery.
Less than half of individuals with opioid use disorder who are eligible ever receive MOUD. Long-term compliance with treatment is poor, with more than half of individuals discontinuing treatment within six months, contributing to relapse and death. Discontinuation of MOUD even after extended treatment periods (18 months) is associated with a high risk for adverse effects including emergency department visits, hospitalizations, and drug overdose.
“By mobilizing a large group of students, we could hope to have a broader reach,” say the researchers. “It is imperative that we educate future health care professionals how to treat patients with opioid use disorder and RIOT is a model that can be implemented at other universities.”
Availability: Pre-publication in The American Journal on Addictions.
Research: Factors Associated with Readmission to Alcohol and Opioid Detoxification in the Alaska Interior
Authors: Ursula Running Bear, PhD, et al.
Abstract/Extract: A ‘revolving door’ of repeated admissions to detoxification treatment facilities has long plagued alcohol and drug use patients, yet few studies examine factors associated with readmission. This study examined risk factors for readmission to alcohol and opioid detoxification in a sample from the Alaska Interior.
“The ‘revolving door’ phenomenon was reported more than four decades ago but still persists today,” say the researchers. “It impacts both patients and health care systems. A large proportion of detoxification patients who do not transition to treatment are at high risk for readmission and remain vulnerable to poor health, experience more physical and psychiatric comorbidities, and have more withdrawal symptoms.”
Data from 1989 in the US indicates the average cost for an inpatient detoxification stay for patients with mild to moderate withdrawal exceeded $3,300. Though not specific to inpatient detoxification, the average cost per episode of adult residential treatment was $9,426 in 2003.
“Although these studies are dated, the statistics hint at the staggering costs of treating patients caught in the ‘revolving door,’” say the researchers. “In Alaska, this phenomenon may be even more burdensome because only two detoxification facilities exist within the state, resulting in a limited number of beds to treat withdrawal. Additionally, Alaska experiences a shortage of health care providers, including substance use treatment providers. These combined conditions may contribute to an increased strain on the health care system in Alaska.”
The researchers’ prior work from a detoxification facility in Southcentral Alaska found 42% of Alaska Native/American Indian people admitted to an inpatient alcohol detoxification program were readmitted within one year of their admission.
This latest study also found lower levels of social, occupational, and psychological functioning and worse withdrawal severity were associated with readmission to detoxification among these people. Other associations with readmission to detoxification included unemployment and homelessness. The Alaska Native/American Southcentral readmission rate is higher than the readmission rate found in a sample of the general US population where 26% were readmitted within one year.
Importance: This study is the first to examine both alcohol and opioid use risk and protective factors in the Alaska Interior. The results can be used in the development of interventions for subpopulations with high detoxification readmission rates.
But the longstanding ‘revolving door’ pattern points to a system in need of reform. “Attempting to solve a complex problem like the detoxification ‘revolving door’ by addressing only the individual or health care influences may be too simplistic,” say the researchers. “We have yet to address the societal factors that either encourage or inhibit the ‘revolving door’ such as societal attitudes and beliefs, policy, and funding for this vulnerable population.”
Availability: Pre-publication in The American Journal on Addictions.
Research: Cognitive Dysfunction, Psychiatric Distress, and Functional Decline After COVID-19
Authors: Tracy Vannorsdall, PhD, et al.
Abstract/Extract: At approximately four months after acute illness, two-thirds of COVID-19 patients presenting to a post-COVID-19 clinic showed impairment in one or more domains of cognition.
Cognitive deficits were widespread in those with and without ICU stays and occurred most commonly on measures of oral processing speed and verbal fluency as well as learning and memory.
Patients requiring at least 48 hours of ICU care demonstrated poorer global cognition and also demonstrated more frequent impairment in executive functioning and working memory relative to those requiring less intensive treatment.
Psychiatric distress and functional decline were also common, with 35% of COVID-19 survivors producing at least one moderately elevated score across measures of anxiety, depression, trauma, and functional decline. One in four patients requiring treatment in the ICU reported trauma-related distress. Severity of psychiatric distress and functional decline were similar among patients requiring more and less intense COVID-19 treatment and were unrelated to cognitive functioning.
“Our understanding of post-acute cognitive and mental health functioning remains in the early stages and is limited to a handful of studies that vary with respect to patient characteristics, COVID-19 severity, the time in which testing occurred relative to infection, and the breadth and depth of cognitive assessment,” say the researchers.
Their study was of patients in the Johns Hopkins Post-Acute COVID-19 Team Pulmonary Clinic who underwent a clinical telephone-based assessment of cognition, depression, anxiety, trauma, and function. Patients spanned a wide age range and were of diverse racial and ethnic backgrounds. They varied in disease severity and level of care required during the acute phase of illness.
Importance: Findings highlight the need for multidisciplinary integrated care teams aimed at providing comprehensive survivorship care for COVID-19 survivors throughout the recovery process. They also serve as a foundation for the longitudinal assessment of cognitive and mental health outcomes among COVID-19 survivors of different demographic backgrounds and illness characteristics.
Availability: Published in the Journal of the Academy of Consultation-Liaison Psychiatry (JACLP).
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