Background: Individuals with opioid use disorder (OUD) commonly face stigma when receiving healthcare. Although experienced stigma of patients with OUD in hospital settings is linked to worse treatment outcomes, less is known about the stigmatizing care practices of hospital-based providers that result in experienced stigma. Objective: This study aimed to explore hospital-based stigma experiences and positive care experiences of people with OUD to identify stigmatizing and nonstigmatizing care practices to inform hospital-based care. Design: This was a qualitative study based on semi-structured, in-person focus groups. Participants: Participants were people who self-identified as being in recovery from opioid use disorder recruited through a community recovery organization in Austin, TX. Approach: Focus groups followed a semi-structured interview guide encouraging discussion of stigmatizing healthcare experiences. We used applied thematic analysis in a systematic, inductive approach to categorize themes around hospital-based care experiences. Key Results: Among participants (n = 18), stigmatizing experiences reflected the following hospital-based care practice themes: using non-person-first language, ignoring pain, labeling as “drug-seeking,” and not valuing the lived expertise of patients. These practices resulted in fear/avoidance of care, distrust of the care team, and internalized stigma. On the other hand, using recovery-oriented language, being polite, and engaging in shared decision making resulted in open communication with providers and trust of the care team. Conclusions: Stigma experienced in hospital settings has significant consequences for patients with OUD. Hospital systems must implement policies that promote patient-centered practices and avoid stigmatizing practices to improve hospital-based care delivery for people with OUD.

Introduction In 2017, we launched the “B-Team” (buprenorphine team), the first hospitalist-led opioid use disorder (OUD) treatment program in Texas. Based on initial success, we obtained funding from Texas Health & Human Services to expand the model to other hospitals in Texas through the Support Hospital Opioid Use Disorder Treatment (SHOUT) Texas program. Methods This is a mixed methods study of the implementation of the SHOUT program, which is an OUD treatment intervention, in different hospitals in Texas. Our implementation approach combined training, tailoring, and technical assistance following the Replicating Effective Programs (REP) strategy with statewide telementoring delivered via Project ECHO. To evaluate the reach, adoption, and impact of SHOUT Texas, we assessed: 1) participating hospitals (adoption); 2) patients screened for OUD (impact); 3) patients started on medications for OUD (impact); 4) patients discharged with coordinated outpatient care (impact); 5) providers and staff trained via ECHO (reach); and 6) satisfaction with ECHO training (impact). Additionally, semi-structured interviews were conducted with key stakeholders at expansion sites to identify strengths and weaknesses of the implementation strategy and supports and barriers to successful implementation. Rapid qualitative analysis was completed by a team of analysts who transcribed and summarized interviews to identify key domains of interest and emergent themes. Results Between 2020 and 2023, the SHOUT Texas program expanded to three additional Texas hospital sites, resulting in 3065 hospitalized adult patients starting treatment for OUD. More than 2500 interprofessional clinicians (physicians, nurses, physician assistants, social workers) received SHOUT training regarding inpatient initiation of OUD treatment, with 241 attending at least one hour-long Project ECHO session. Eight key stakeholders at expansion sites were interviewed. Successful components of the SHOUT program included training resources, in-person launches, and collaboration with specialized addiction treatment subject matter experts. Challenges included identifying outpatient follow-up, pharmacy and medication constraints, and nursing education barriers. Interviews also identified lessons learned, advice to other hospitals, and next steps to build capacity. Conclusions Implementation of the SHOUT Texas model across diverse hospital settings using REP and Project ECHO resulted in significant provider engagement and rapid increase in the number of patients initiating OUD treatment during hospitalization. Lessons learned from this novel approach may be applicable in other states, particularly those that have not expanded Medicaid.

This Brief Report includes follow-up data about the sustainability and expansion of the Buprenorphine Team (B-Team), a hospital-based opioid treatment (HBOT) program. Between September 2018 and January 2023, the B-Team started 398 patients with opioid-use disorder (OUD) on buprenorphine therapy and coordinated outpatient care for 353 patients before discharge. Two-hundred and forty-nine of these patients were scheduled for follow-up at our partner addiction treatment clinic. Retention rates at our partner clinic remain relatively high: 73 patients (36% of eligible patients) continued to attend appointments between 6 and 12 months, and 40 of 180 patients (22%) who have been discharged from the hospital for at least 1 year continued to attend appointments. This model has been adopted at three additional Texas hospitals, resulting in rapid growth: 1037 patients were started on buprenorphine across these four sites during 2021-2022. Our longitudinal results support HBOT as an effective model for treating patients with OUD.

Journal of Hospital MedicineEarly View PERSPECTIVES IN HOSPITAL MEDICINE Breaking a cycle of stigma: An interprofessional team approach to building trust for hospitalized patients with substance use disorder Richard Bottner DHA, PA-C, Corresponding Author Richard Bottner DHA, PA-C richard.bottner@austin.utexas.edu orcid.org/0000-0003-4110-1628 @RichBottner Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA Correspondence Richard Bottner, DHA, PA-C, Dell Medical School, The University of Texas at Austin, 1601 Trinity Street, Bldg. B, Stop Z0900, Austin, TX 78712, USA. Email: richard.bottner@austin.utexas.edu; Twitter: @RichBottnerSearch for more papers by this authorAlanna Boulton MSHA, Alanna Boulton MSHA alanna.boulton@austin.utexas.edu Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USASearch for more papers by this authorBlair Walker MD, Blair Walker MD Department of Psychiatry, Dell Medical School at The University of Texas at Austin, Austin, Texas, USASearch for more papers by this authorJananie Ramesh MD, Jananie Ramesh MD Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USASearch for more papers by this authorHemali Patel MD, Hemali Patel MD Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USASearch for more papers by this authorEvan Solice BCC, Evan Solice BCC Department of Chaplain Services, Ascension Texas, Austin, Texas, USASearch for more papers by this authorSlade Skaggs RSPS, Slade Skaggs RSPS Communities for Recovery, Austin, Texas, USASearch for more papers by this authorChristopher Moriates MD, Christopher Moriates MD Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USASearch for more papers by this author Richard Bottner DHA, PA-C, Corresponding Author Richard Bottner DHA, PA-C richard.bottner@austin.utexas.edu orcid.org/0000-0003-4110-1628 @RichBottner Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA Correspondence Richard Bottner, DHA, PA-C, Dell Medical School, The University of Texas at Austin, 1601 Trinity Street, Bldg. B, Stop Z0900, Austin, TX 78712, USA. Email: richard.bottner@austin.utexas.edu; Twitter: @RichBottnerSearch for more papers by this authorAlanna Boulton MSHA, Alanna Boulton MSHA alanna.boulton@austin.utexas.edu Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USASearch for more papers by this authorBlair Walker MD, Blair Walker MD Department of Psychiatry, Dell Medical School at The University of Texas at Austin, Austin, Texas, USASearch for more papers by this authorJananie Ramesh MD, Jananie Ramesh MD Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USASearch for more papers by this authorHemali Patel MD, Hemali Patel MD Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USASearch for more papers by this authorEvan Solice BCC, Evan Solice BCC Department of Chaplain Services, Ascension Texas, Austin, Texas, USASearch for more papers by this authorSlade Skaggs RSPS, Slade Skaggs RSPS Communities for Recovery, Austin, Texas, USASearch for more papers by this authorChristopher Moriates MD, Christopher Moriates MD Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USASearch for more papers by this author First published: 27 March 2022 https://doi.org/10.1002/jhm.12814Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Early ViewOnline Version of Record before inclusion in an issue RelatedInformation

Hospital-based clinicians frequently care for patients with opioid withdrawal or opioid use disorder (OUD) and are well-positioned to identify and initiate treatment for these patients. With rising numbers of hospitalizations related to opioid use and opioid-related overdose, the Society of Hospital Medicine convened a working group to develop a Consensus Statement on the management of OUD and associated conditions among hospitalized adults. The guidance statement is intended for clinicians practicing medicine in the inpatient setting (e.g., hospitalists, primary care physicians, family physicians, advanced practice nurses, and physician assistants) and is intended to apply to hospitalized adults at risk for, or diagnosed with, OUD. To develop the Consensus Statement, the working group conducted a systematic review of relevant guidelines and composed a draft statement based on extracted recommendations. Next, the working group obtained feedback on the draft statement from external experts in addiction medicine, SHM members, professional societies, harm reduction organizations and advocacy groups, and peer reviewers. The iterative development process resulted in a final Consensus Statement consisting of 18 recommendations covering the following topics: (1) identification and treatment of OUD and opioid withdrawal, (2) perioperative and acute pain management in patients with OUD, and (3) methods to optimize care transitions at hospital discharge for patients with OUD. Most recommendations in the Consensus Statement were derived from guidelines based on observational studies and expert consensus. Due to the lack of rigorous evidence supporting key aspects of OUD-related care, the working group identified important issues necessitating future research and exploration.

BACKGROUND:Hospitalizations related to the consequences of opioid use are rising. National guidelines directing in-hospital opioid use disorder (OUD) management do not exist. OUD treatment guidelines intended for other treatment settings could inform in-hospital OUD management.OBJECTIVE:Evaluate the quality and content of existing guidelines for OUD treatment and management.DATA SOURCES:OVID MEDLINE, PubMed, Ovid PsychINFO, EBSCOhost CINHAL, ERCI Guidelines Trust, websites of relevant societies and advocacy organizations, and selected international search engines.STUDY SELECTION:Guidelines published between January 2010 to June 2020 addressing OUD treatment, opioid withdrawal management, opioid overdose prevention, and care transitions among adults.DATA EXTRACTION:We assessed quality using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument.DATA SYNTHESIS:Nineteen guidelines met the selection criteria. Most recommendations were based on observational studies or expert consensus. Guidelines recommended the use of nonstigmatizing language among patients with OUD; to assess patients with unhealthy opioid use for OUD using the Diagnostic Statistical Manual of Diseases-5th Edition criteria; use of methadone or buprenorphine to treat OUD and opioid withdrawal; use of multimodal, nonopioid therapy, and when needed, short-acting opioid analgesics in addition to buprenorphine or methadone, for acute pain management; ensuring linkage to ongoing methadone or buprenorphine treatment; referring patients to psychosocial treatment; and ensuring access to naloxone for opioid overdose reversal.CONCLUSIONS:Included guidelines were informed by studies with various levels of rigor and quality. Future research should systematically study buprenorphine and methadone initiation and titration among people using fentanyl and people with pain, especially during hospitalization.

This commentary provides an overview of the Association of Multidisciplinary Education and Research in Substance use and Addiction (AMERSA) 2021 annual conference: Transforming Care Through Evidence and Policy. The topics covered during the conference were especially critical given the unprecedented rise in drug overdose deaths and continued impact of the COVID-19 pandemic on substance use and addiction. The importance of tackling stigma and ensuring that we partner with those with lived experience to have maximal impact was highlighted.

Stigmatization of opioid use constitutes a significant barrier to addressing the opioid crisis. Increasing use of social media by healthcare professionals provides an opportunity to foster destigmatization. However, little is known about stigmatization and destigmatization within healthcare professional social media communities. Accordingly, this study investigates the use of stigmatizing and destigmatizing language in three such communities: Medical Twitter, Public Health Twitter, and Epidemiology Twitter. Using a dataset of 2,319 tweets discussing opioids and associated with these Twitter communities, we analyzed each tweet for evidence of stigmatizing or destigmatizing language based on guidance from the National Institute on Drug Abuse. The results indicate that overall use of both stigmatizing and destigmatizing language is currently low across communities compared to the overall volume of opioid-related content. Additionally, there are measurable changes in stigmatizing and destigmatizing language on quarterly bases between 2012 and 2020. During this time, Public Health Twitter has seen a quarterly 19% reduction in rates of stigmatizing (IRR = 0.81, 95% CI 0.67 to 0.97), and all communities have experienced a quarterly 57% increase in destigmatizing language (IRR = 1.57, 95% CI: 1.33 to 1.85). This study also reveals that tweets containing stigmatizing and destigmatizing language receive minimal user engagement (measured by likes, retweets, quote tweets, and comments). While the longitudinal findings on increasing use of destigmatizing language are promising, they also indicate a need for increased efforts to encourage broader use of destigmatizing language. Leveraging the social learning potentials of Twitter offers one promising pathway for future initiatives.

Despite evidence that medications for patients with opioid use disorder (OUD) reduce mortality and improve engagement in outpatient addiction treatment, these life-saving medications are underutilized in the hospital setting. This study reports the outcomes of the B-Team (Buprenorphine-Team), a hospitalist-led interprofessional program created to identify hospitalized patients with OUD, initiate buprenorphine in the inpatient setting, and provide bridge prescription and access to outpatient treatment programs. During the first 2 years of the program, the B-Team administered buprenorphine therapy to 132 patients in the inpatient setting; 110 (83%) of these patients were bridged to an outpatient program. Of these patients, 65 patients (59%) were seen at their first outpatient appointment; 42 (38%) attended at least one subsequent appointment 1 to 3 months after discharge from the hospital; 29 (26%) attended at least one subsequent appointment between 3 and 6 months after discharge; and 24 (22%) attended at least one subsequent appointment after 6 months. This model is potentially replicable at other hospitals because it does not require dedicated addiction medicine expertise.

The week of February 14, 2021, will be forever ingrained in the memories of Central Texas residents. Winter Storm Uri blanketed the region in ice and snow, leading to devastating and unprecedented circumstances. Most residents lost electricity, and the water infrastructure in Austin and other cities collapsed. As roads became impassable, private and public […]

Richard Bottner, DHA, PA-C, Dell Medical School at The University of Texas at Austin; Jeffrey Bratberg, PharmD, FAPhA, University of Rhode Island College of Pharmacy; Marlene Martin, MD, University of California, San Francisco and San Francisco General Hospital; Melissa B. Weimer, DO, MCR, FASAM, Yale University; Ayana Jordan, MD, PhD Yale University; and Matthew Tierney, MS, NP, FAAN, University of California, San Francisco

OBJECTIVE:This study compared opioid utilization and clinical outcomes in surgical patients receiving maintenance buprenorphine therapy who discontinued versus those who continued buprenorphine treatment perioperatively. Lack of high-quality evidence, conflicting results in previous studies, and the possible need for reinduction after discontinuing therapy present clinicians with the complicated dilemma of choosing the best strategy to control post-operative pain in patients receiving buprenorphine.DESIGN:A multicenter, retrospective cohort study.PARTICIPANTS:Hospitalized patients between January 1, 2017 and December 12, 2019 who underwent any type of surgery, had a documentation of an outpatient buprenorphine prescription or inpatient order, and received buprenorphine for 5 or more days prior to the procedure were included.MAIN OUTCOME MEASURE(S):The primary objective was to compare mean 24-hour morphine milligram equivalent (MME) utilization post-operatively between patients who discontinued buprenorphine preoperatively versus those who continued therapy throughout the perioperative period.RESULTS:Fifty-one patients met the inclusion criteria for this study. Of these, 42 patients were continued on buprenorphine through surgery, while nine patients had a documentation of discontinuation preoperatively. The 24-hour post-operative MME utilization (interquartile range) was 58.8 (18-100.8) in patients who continued therapy through surgery versus 152.6 (114.5-236) in patients who discontinued therapy preoperatively (p = 0.005). There were no significant differences in post-operative pain scores or length of stay between groups.CONCLUSION:Post-operative opioid use was significantly lower in patients who continued buprenorphine compared with those who discontinued buprenorphine preoperatively.

Implementation insights: Hospitalization is a reachable moment to address opioid and other substance use disorders. This includes initiation of pharmacotherapy such as buprenorphine, which is the standard of care but not frequently offered. Initiating pharmacotherapy for interested patients with opioid use disorder (OUD) during hospitalization does not require a formal addiction consultation service and can be accomplished by any in-hospital prescriber, aided by interprofessional and multidisciplinary teams with support from senior leadership. Barriers to widespread adoption include lack of education; stigma towards people with substance use disorders; inadequate outpatient capacity to address OUD; regulatory requirements; and challenges to modifying electronic health record algorithms, clinical workflows, and institutional policies.

•Diagnose opioid use disorder and discuss the use of medications for opioid use disorder.•Describe the key components needed to start a medications-for-opioid-use-disorder treatment program.•Review the unique competencies of palliative care providers that make them ideal to be first responders to the opioid epidemic. The United States continues to face a public heatlh crisis of epic proportion, with over 500,000 deaths from opioid overdoses since 2000. Medications for opioid use disorder, like buprenorphine, offer patients an effective approach to cessation. Unfortunately many barriers to use of medications for opioid use disorder exist, including insufficient number of programs offering medications for opioid use disorder, inadequate number of addiction specialists to provide these medications, and stigma surrouding patients with opioid use disorders and the medications used to treat them. Palliative care providers are in a unique position to be first responders to this health crisis by providing medications for opioid use disorder. Many palliative providers are comfortable and competent in the pharmacology and clinical use of buprenorphine and methadone as analgesics, both of which have been shown to reduce mortality in the setting of opioid use disorder. In addition, palliative providers are trained in advanced communication skills and must be open to working with vulnerable patient populations, such as patients with opioid use disorders. This presentation will focus on the use of buprenorphine in patients with opioid use disorders, including a review of the pharmacokinetic properties of buprenorphine in patients with opioid use disroders, guidance on avoiding preciptated withdrawal during induction, and management of acute and chronic pain with opioid use disorder. Through audience polling, didactics, and case review, partipants will be given the building blocks to consider induction of buprenorphine in the hospital and transition to care in the outpatient setting. We will highlight two programs, an inpatient burprenorphine induction program at Dell Seton Medical Center University of Texas at Austin, and an outpatient palliative program offering medications for opioid use at Dartmouth Hitchcock Medical Center.

•Compare and contrast different types of palliative care simulation described in the literature.•Identify opportunities within one’s own institution to develop similar coursework.•Create learning outcomes for the use of simulation in palliative care education. Simulation has become a common education modality across most health professions but is not widely adopted in palliative care education. In a recent review, Smith et al. (2018) found several examples in the literature of end-of-life communication training for nurses and nursing students. However, less than 25% of the thirty articles reviewed included team-based simulation encompassing nursing, social work, and medical students. Simulation provides students a tangible experience in interprofessional palliative care prior to workforce entry. The Foundation for Interprofessional Collaborative Practice course incorporates learners from the UT Austin Schools of Pharmacy, Medicine, Nursing, and Social Work and would be appropriate for additional disciplines including psychology and chaplaincy. This two-semester experience places students in small interprofessional teams which meet monthly. In the first part of the palliative care module, learners participate in a three-hour large group session with small group breakouts based on materials adapted from the iCOPE curriculum (Head, et al. 2014). In the second part of the module, the focus of our Interactive Educational Exchange, students participate in a twenty-minute goals-of-care conversation in a standardized patient lab utilizing trained patient actors. The group facilitator observes the interaction remotely and then provides direct feedback. This portion of the module is based on original content created by our steering committee. Over 500 learners have participated and report increased comfort with palliative care communication and interprofessional teamwork. Introduction to palliative care is an important opportunity for interprofessional learners. Many students have little previous knowledge of palliative care and end-of-life issues. This course allows students to explore these concepts in a safe environment while being positively exposed to the field. We plan to evaluate whether interprofessional communication training influences learner comfort with difficult conversations in future clinical practice.