More than MAT: lesser-known benefits of an inpatient addiction consult service

KEYWORDS:

• addiction
• hospital utilization
• quality improvement
• education
• consultative medicine

Introduction

Substance use disorders (SUDs) are ubiquitous among medical, surgical, and psychiatric admissions in hospitals across the United States, and many staff are not specifically trained to provide trauma-informed, evidence-based SUD care. To address this need, some hospitals – particularly in urban, academic institutions – have implemented an inpatient addiction consult service (ACS). These specialized, multidisciplinary teams can provide timely pharmacologic, psychotherapeutic, and care-linkage interventions during the ‘reachable’ moment of hospitalization [1]. In the August 2022 edition of the New England Journal of Medicine, authors Englander & Davis published a thorough and mobilizing call for hospitals and policymakers to establish a new standard of care for patients with SUDs, including via support for inpatient ACS teams [2]. Patient care outcomes such as addiction severity [3], readmission risk [4], treatment follow-up [5], evidence-based medication initiation [6], and inpatient antibiotic treatment completion [6] have been shown to improve with ACS involvement – in no small part related to medications for addiction treatment (MAT).

But there are also many benefits to an ACS that extend beyond patient care outcomes. In this article, we highlight our first-hand experience at a safety-net hospital that expanded its ACS to great effect, particularly in terms of 1) staff recruitment and retention, 2) widespread trainee education, 3) quality improvement, and 4) pragmatic clinical research. Direct quotations from key informants are included (with explicit permission when possible) as well as results from a staff survey regarding perceptions of the ACS.

Team structure

Our team is generally comprised of two physician attendings (one trained in addiction medicine and one in addiction psychiatry) and two social workers, with a morning census ranging between 20 to 50 patients (new consults plus follow-ups). We receive consult orders from all admitting services in the hospital, including from a specialized eating disorder unit, from obstetrics, from a correctional care medical unit, and from adolescent and adult psychiatry. Consultations generally include evaluation of SUD diagnosis, withdrawal management, pharmacotherapy initiation, brief psychotherapeutic interventions (including motivational interviewing), harm reduction activities (e.g. disease screening and overdose prevention counseling), and linkage to services/treatment.

Staff recruitment and retention

Multiple recent physicians have been hired at our institution who have received addiction specialty training. The opportunity to rotate with our service has been offered as an incentive for enhanced clinical variety and career development. One addiction-trained, internal medicine hire stated via e-mail, ‘I was searching for opportunities to work a few weeks a year on addiction consults … Being an effective addiction medicine provider necessitates an understanding of the system you practice in, for which becoming familiar with inpatient care and post-acute care transitions is helpful. A decent amount of my fellowship was spent on inpatient consults, so it was a skill set I hoped to maintain.’

Additional physicians from primary care and psychiatry have requested ACS rotations to facilitate obtaining their practice-pathway board-certification [7] in addiction medicine. This has enhanced both knowledge of SUD care among these guest providers as well as knowledge of within-institution linkage pathways among usual ACS providers. A recent guest psychiatrist stated via e-mail, ‘I had limited real-world experience managing opioid use disorder, particularly complex buprenorphine and methadone inductions, and wanted to learn more … I met my goal.’

Moreover, in 2022 an anonymous staff survey was distributed electronically to evaluate perceptions of the ACS. Over 300 individuals from internal medicine, family medicine, pediatrics, obstetrics, surgery, nursing, and care management responded. On a 1–5 Likert scale, some 95% agreed (i.e. scored a 4 or 5) that the ACS is valuable to the hospital, 92% agreed that the ACS is integral to providing comprehensive care, 89% agreed that our services are distinct from those offered by a psychiatry consult service, and 88% agreed that the ACS ought to expand its coverage further (i.e. to weekends). A recently hired care manager stated in the survey, ‘Thanks again for all your team does to help the community I grew up in. This service is one of the reasons I am proud to work here.’ A recently hired internal medicine physician stated in the survey, ‘[I] could not imagine my job without the help of [the] addiction med consult service!’

With upwards of 63% of physicians showing manifestations of burnout across the country [8], we posit that addiction consult services may be an underrecognized tool to improve retention, both among those who rotate with the service and among all inpatient clinical staff whose patients benefit from ACS intervention. Beyond developing additional expertise and supporting additional certifications, consult services are likely to reduce burnout by addressing moral injury [9] (e.g. when clinicians feel powerless to alter the course of a patient’s SUD), by better aligning meaning, efficiency, and resources [10] (e.g. allowing some hospital providers to prioritize the acute medical concerns they are most skilled at addressing without neglecting SUD evaluation and treatment), and by promoting a mission-based culture [10] (i.e. one that values equity and combating disease-related stigma).

Trainee education

Our ACS provides clinical supervision and teaching to a near-constant flow of trainees. These include addiction medicine fellows, addiction psychiatry fellows, internal medicine residents, family medicine residents, emergency medicine residents, psychiatry residents, psychology interns, advance practice provider students and fellows, and even pharmacy residents. In 2022, one of the ACS attendings logged over 1600 trainee-hours of supervision.

The expansion of the ACS has come in the midst of a new requirement by the Accreditation Council on Graduate Medical Education for all internal medicine residents to receive addiction medicine training [11]. One internal medicine resident reported (anonymously) in rotation feedback, ‘I felt that prior to this experience I had little knowledge on the treatment of opioid use disorder and did not feel comfortable managing medications such as methadone/[buprenorphine]; however, after this rotation I felt much more equipped to do so.’ ACS teams can play a key role in ensuring a new generation of internists has as much familiarity with SUD treatments as with diabetes or heart failure treatments in the hospital [2].

Quality improvement

‘Our ability to discharge patients in a timely manner is directly linked to [ACS] bandwidth … Anyone who has an interest in improving patient care and admission/discharge flow should support the expansion of ACS,’ reported a survey respondent from the surgery department. Our hospital is a Level 1 Trauma center, and this designation mandates a ‘program for substance abuse [sic] screening and patient intervention.’ [12] We agree with this requirement; the existence of our ACS helps to uphold this ‘program’ to a robust standard for the countless inpatients severely injured related to substance use.

Additionally, our state Medicaid agency implemented an initiative starting in 2020 entitled the ‘Hospital Transformation Program,’ charged with measuring and advancing a range of quality metrics among hospitalized patients, tied directly to provider fee-funded hospital reimbursement [13]. Two intertwined metrics – creating collaborative discharge plans for patients with primary or secondary behavioral health diagnoses, and reducing hospital readmissions – directly involve the ACS for implementation and feedback. In a separate initiative governing regional accountable care in the state, our Medicaid agency established the ‘Behavioral Health Incentive Program,’ which provides value-based payments tied to metrics such as SUD treatment engagement [14]. Our ACS was able to hire full-time social work support to help execute these and other endeavors, and we have already seen myriad process improvements related to care linkage that would not have been possible without the existence of the ACS.

Such linkage to care and treatment for SUD and substance-related withdrawal may also improve patient-reported outcomes on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, results of which are compared between hospitals [15]. Therefore, as value-based care continues to gain traction in hospital systems and payers, ACS teams may have growing quality and monetary impacts through targeting of patients that are inherently high-risk.

Clinical research

Human research in addiction medicine is often conducted in laboratory, outpatient, or residential treatment settings with participants who are medically stable and can reliably provide longitudinal data. However, many patients with the most severe and costly substance use disorders are engaged initially – and sometimes exclusively – in hospitals due to SUD complications. The hospital setting effectively constitutes the highest American Society of Addiction Medicine (ASAM) level of care [16], an opportune environment for intensive intervention along with medical monitoring. Targeting this population with advanced interventions has the potential to vastly decrease system costs and, more importantly, patient morbidity and mortality.

Measurement of research outcomes can be challenging. While not impossible to engage high risk SUD populations in research – as demonstrated by work by Collins et al. [17] who recruited unhoused individuals with alcohol use disorder – many hospitalized patients with SUD quickly relapse or disconnect after discharge. This may be mitigated by intensive engagement efforts, such as leveraging assertive community treatment [18] or peer-navigation initiated pre-discharge [19]. Alternatively, outcomes independent of participant follow-up include hospital readmission or clinic attendance through chart review or insurance claims. Our ACS was able to conduct a small clinical trial with limited resources focusing on readmissions as the outcome, delivering promising data on the use of novel pharmacologic interventions pre-discharge [20]. The ACS offers a robust venue to continue this work.

Conclusion

There are more than 100 acute care hospitals in our state, and – to our knowledge – only 2 have a formal addiction consult service. A patient on our census recently needed to ‘repatriate’ to another hospital due to insurance reasons, but no available in-network hospital could provide specialty addiction care, a critical part of his treatment plan. These types of situations underscore the lack of parity and equity [21] between conventionally physical and so-called ‘behavioral’ health care. We wholeheartedly agree with Englander & Davis on implementing broad changes in policy and practice among America’s acute care hospitals [2], not only for the sake of comprehensive and effective patient care, but also to build and navigate a new infrastructure that can tackle the multiple crises precipitated by SUD proliferation across the country. Dedicated inpatient ACS teams can and should be a part of that future.

Declaration of financial/other interests

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

The authors would like to thank Julie Taub, Jennifer Lyden, Jennifer Brady, Hannan Braun, and Lela Ross for their development of the staff survey and provision of relevant quotations.

Additional information

Funding

This paper was not funded.