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Associated Difficulties for Patients With Injection-Related Infections

In an addiction treatment desert like Alabama, in-hospital injection drug use and patient-directed discharge can be common.

Illicit drug use, patient-directed discharges (PDD), 30-day readmissions and death were common among patients receiving inpatient care for injection-related infections, according to a new study in Open Forum Infectious Diseases.

Investigators from the University of Alabama at Birmingham conducted a retrospective analysis of 83 patients in order to determine the frequency of and associations between in-hospital injection drug use (IDU), PDD, 30-day readmission and deaths. The patients were treated at the hospital between October 2016 and December 2017, but the investigators only included the first hospitalization during the study period in their analysis.

Typically, hospitalizations for these patients who inject drugs is described as a “reachable” moment, where they have access to medical care and services, the study authors said. However, as much as a third of those patients leave the hospital early against medical advice.

The rural state of Alabama has one of the highest opioid prescribing rates in the nation, without access to Medicaid expansion. Study author Ellen Eaton MD, MSPH, of the University of Alabama at Birmingham Division of Infectious Diseases told Contagion® it was “an addiction treatment desert,” with few addiction medicine providers and even fewer who see uninsured patients.

The median age among the patients was 36 years, about half were male, almost all were Caucasian, and about half were uninsured. A majority (82%) reported illicit opioid use prior to admission, though there were reports of methamphetamine use (34%) and polysubstance abuse (33%) as well.

Of the 83 patients in the analysis, 28 were found to have in-hospital illicit drug use, 12 had PDD, and 9 patients died. A dozen patients experienced 30-day readmission, the investigators found.

“We knew that inpatient illicit drug use (the use of illicit drugs while hospitalized) was common, but we were surprised to see just how common it was in our cohort (34%),” Eaton said. “It is also sobering to think that more than 1 in 10 of our hospitalized patients will die within a couple of years of their admission (11%), and these are really young patients often with young children. So, having a tool to predict the most vulnerable patients has us thinking about ways to intervene on day one of their hospitalization.”

The patients who received MOUD mostly received buprenorphine and naloxone, but a smaller proportion received methadone (17%) and naltrexone (7%), the study authors said. Of the patients who died, 5 were referred for autopsy. The autopsies showed that none had detectable levels of buprenorphine, which the study authors said meant it was either not prescribed or the patient had not been taking it.

“Due to stigma and criminalization of substance use, many do not report their illicit drug use or behaviors like using drugs in the hospital,” Eaton added. “We realize that we were unable to identify some patients with opioid use disorders that are undiagnosed or not disclosed, and those who used illicit drugs in the hospital without exhibiting signs of intoxication, overdose were not captured in this analysis.”

The goal of the study was to encourage all physicians, including infectious disease physicians, to take an active role in treatment to ensure patients receive buprenorphine (or another FDA approved treatment for opioid use disorder), and consulting with addiction medicine and pain experts early in the hospitalization to prevent these high risk behaviors, Eaton explained.

“Treatment of opioid use disorder is prevention—preventing a range of infections and supporting retention in care related to both antibiotics, antivirals and even prevention such as PrEP.”