Department of Population Health, New York University Grossman School of Medicine, New York.
New York University Robert F. Wagner Graduate School of Public Service, New York.
JAMA Intern Med. 2024 Sep 1;184(9):1106-1115. doi: 10.1001/jamainternmed.2024.3422.
Medications for opioid use disorder (MOUD) are highly effective, but only 22% of individuals in the US with opioid use disorder receive them. Hospitalization potentially provides an opportunity to initiate MOUD and link patients to ongoing treatment.
To study the effectiveness of interprofessional hospital addiction consultation services in increasing MOUD treatment initiation and engagement.
DESIGN, SETTING, AND PARTICIPANTS: This pragmatic stepped-wedge cluster randomized implementation and effectiveness (hybrid type 1) trial was conducted in 6 public hospitals in New York, New York, and included 2315 adults with hospitalizations identified in Medicaid claims data between October 2017 and January 2021. Data analysis was conducted in December 2023. Hospitals were randomized to an intervention start date, and outcomes were compared during treatment as usual (TAU) and intervention conditions. Bayesian analysis accounted for the clustering of patients within hospitals and open cohort nature of the study. The addiction consultation service intervention was compared with TAU using posterior probabilities of model parameters from hierarchical logistic regression models that were adjusted for age, sex, and study period. Eligible participants had an admission or discharge diagnosis of opioid use disorder or opioid poisoning/adverse effects, were hospitalized at least 1 night in a medical/surgical inpatient unit, and were not receiving MOUD before hospitalization.
Hospitals implemented an addiction consultation service that provided inpatient specialty care for substance use disorders. Consultation teams comprised a medical clinician, social worker or addiction counselor, and peer counselor.
The dual primary outcomes were (1) MOUD treatment initiation during the first 14 days after hospital discharge and (2) MOUD engagement for the 30 days following initiation.
Of 2315 adults, 628 (27.1%) were female, and the mean (SD) age was 47.0 (12.4) years. Initiation of MOUD was 11.0% in the Consult for Addiction Treatment and Care in Hospitals (CATCH) program vs 6.7% in TAU, engagement was 7.4% vs 5.3%, respectively, and continuation for 6 months was 3.2% vs 2.4%. Patients hospitalized during CATCH had 7.96 times higher odds of initiating MOUD (log-odds ratio, 2.07; 95% credible interval, 0.51-4.00) and 6.90 times higher odds of MOUD engagement (log-odds ratio, 1.93; 95% credible interval, 0.09-4.18).
This randomized clinical trial found that interprofessional addiction consultation services significantly increased postdischarge MOUD initiation and engagement among patients with opioid use disorder. However, the observed rates of MOUD initiation and engagement were still low; further efforts are still needed to improve hospital-based and community-based services for MOUD treatment.
ClinicalTrials.gov Identifier: NCT03611335.
阿片类药物使用障碍（MOUD）的药物治疗非常有效，但美国只有 22%的阿片类药物使用障碍患者接受了这种治疗。住院治疗可能提供了一个启动 MOUD 并将患者与持续治疗联系起来的机会。
研究多专业医院成瘾咨询服务在增加 MOUD 治疗开始和参与方面的有效性。
设计、设置和参与者：这是一项实用的分步楔形集群随机实施和有效性（混合 1 型）试验，在纽约市的 6 家公立医院进行，纳入了 2017 年 10 月至 2021 年 1 月期间医疗补助索赔数据中确定的 2315 名住院成年人。数据分析于 2023 年 12 月进行。医院被随机分配到干预开始日期，在常规治疗（TAU）和干预条件下比较结果。贝叶斯分析考虑了患者在医院内的聚类和研究的开放队列性质。成瘾咨询服务干预与 TAU 进行了比较，使用分层逻辑回归模型中的模型参数的后验概率，该模型根据年龄、性别和研究期间进行了调整。符合条件的参与者有住院或出院诊断为阿片类药物使用障碍或阿片类药物中毒/不良反应，在医疗/外科住院病房至少住院 1 晚，并且在住院前未接受 MOUD 治疗。
医院实施了成瘾咨询服务，为物质使用障碍提供住院专科护理。咨询团队由一名医疗临床医生、社会工作者或成瘾顾问以及同伴顾问组成。
双重主要结果是（1）出院后 14 天内 MOUD 治疗的开始，（2）开始治疗后 30 天内 MOUD 的参与。
在 2315 名成年人中，628 名（27.1%）为女性，平均（SD）年龄为 47.0（12.4）岁。在 CATCH 项目中，MOUD 的起始率为 11.0%，而 TAU 为 6.7%，参与率分别为 7.4%和 5.3%，6 个月的持续率分别为 3.2%和 2.4%。在 CATCH 住院的患者启动 MOUD 的可能性高 7.96 倍（对数优势比，2.07；95%可信区间，0.51-4.00），MOUD 参与的可能性高 6.90 倍（对数优势比，1.93；95%可信区间，0.09-4.18）。
这项随机临床试验发现，多专业成瘾咨询服务显著增加了阿片类药物使用障碍患者出院后 MOUD 的启动和参与。然而，观察到的 MOUD 起始和参与率仍然很低；仍需努力改善 MOUD 治疗的基于医院和社区的服务。
ClinicalTrials.gov 标识符：NCT03611335。
