Patients with serious injection drug use related infections who experience patient directed discharges on oral antibiotics have high rates of antibiotic adherence but require multidisciplinary outpatient support for retention in care

Background Persons who inject drugs (PWID) are frequently admitted for serious injection related infections (SIRI). Outcomes and adherence to oral antibiotics for PWID with patient directed discharge (PDD) remain understudied. Methods We conducted a prospective multicenter bundled quality improvement project of PWID with SIRI at 3 hospitals in Missouri. All PWID with SIRI were offered multidisciplinary care while inpatient, including the option of addiction medicine consultation and medications for opioid use disorder (MOUD). All patients were offered oral antibiotics in the event of a PDD either at discharge, or immediately after discharge through an ID telemedicine clinic. Additional support services included health coaches, therapist, case manager, free clinic follow up, and medications in an outpatient bridge program. Patient demographics, comorbidities, 90-day readmissions, and substance use disorder clinic follow up were compared between PWID with PDD on oral antibiotics and those that completed IV antibiotics, using an as treated approach. Results Of 166 PWID with SIRI, 61 completed IV antibiotics inpatient (37%) while 105 had a PDD on oral antibiotics (63%). There was no significant difference in 90-day readmission rates between groups (p=0.819). For PWID with a PDD on oral antibiotics, 7.6% had documented non-adherence to antibiotics, 67% had documented adherence and 23% were lost to follow-up. Factors protective against readmission included antibiotic and MOUD adherence, engagement with support team, and clinic follow up. Conclusions PWID with SIRI who experience a PDD should be provided with oral antibiotics. Multidisciplinary outpatient support services are needed for PWID with PDD on oral antibiotics.

Translating Medicaid policy into practice: policy implementation strategies from three US states’ experiences enhancing substance use disorder treatment

Background Despite the important upstream impact policy has on population health outcomes, few studies in implementation science in health have examined implementation processes and strategies used to translate state and federal policies into accessible services in the community. This study examines the policy implementation strategies and experiences of Medicaid programs in three US states that responded to a federal prompt to improve access to evidence-based practice (EBP) substance use disorder (SUD) treatment. Methods Three US state Medicaid programs implementing American Society of Addiction Medicine (ASAM) Criteria-driven SUD services under Section 1115 waiver authority were used as cases. We conducted 44 semi-structured interviews with Medicaid staff, providers and health systems partners in California, Virginia, and West Virginia. Interviews were triangulated with document review of state readiness and implementation plans. The Exploration, Preparation, Implementation, Sustainment Framework (EPIS) guided qualitative theme analysis. The Expert Recommendations for Implementing Change and Specify It criteria were used to create a taxonomy of policy implementation strategies used by policymakers to promote providers’ uptake of statewide EBP SUD care continuums. Results Four themes describe states’ experiences and outcomes implementing a complex EBP SUD treatment policy directive: (1) Medicaid agencies adapted their inner/outer contexts to align with EBPs and adapted EBPs to fit their local context; (2) enhanced financial reimbursement arrangements were inadequate bridging factors to achieve statewide adoption of new SUD services; (3) despite trainings, service providers and managed care organizations demonstrated poor fidelity to the ASAM Criteria; and (4) successful policy adoption at the state level did not guarantee service providers’ uptake of EBPs. States used 29 implementation strategies to implement EBP SUD care continuums. Implementation strategies were used in the Exploration (n=6), Preparation (n=10), Implementation (n=19), and Sustainment (n=6) phases, and primarily focused on developing stakeholder interrelationships, evaluative and iterative approaches, and financing. Conclusions This study enhances our understanding of statewide policy implementation outcomes in low-resource, public healthcare settings. Themes highlight the need for additional pre-implementation and sustainment focused implementation strategies. The taxonomy of detailed policy implementation strategies employed by policymakers across states should be tested in future policy implementation research.

Shifting Pathways of Stimulant Use Among Individuals With Opioid Use Disorder: A Retrospective Analysis of the Last Thirty Years

Background: Stimulant use among individuals with opioid use disorder has recently increased, driven by changes in drug distribution channels. However, our understanding of polysubstance use is often limited by a need to provide targeted treatment to a primary drug of addiction. Yet there is a crucial need to better understand pathways to addiction, and how the use of multiple substances may differ between populations, as well as time periods.Methods: Using a national opioid surveillance system, we analyzed survey data from new entrants to 124 opioid use disorder treatment centers from 2017 to 2020. Age of first use was collected for prescription opioids, illicit opioids, prescription stimulants, crack/cocaine, and methamphetamines. Year of initial use of an opioid or stimulant was calculated and grouped by 5 year blocs, inclusive of initial use starting from 1991 and ending in 2020 (n = 6,048).Results: Lifetime exposure to stimulants was 82.5% among individuals with opioid use disorder. Mean age of initiation increased for all drugs in 2016–2020, in particular prescription opioids (22.3 to 31.8). Stimulants were initiating drugs for a substantial proportion of individuals with opioid use throughout the analyzed time period. Those initiating opioid/stimulant use from 1991 to 1995 had a mean average of 6.8 years between first and second drug exposure, which steadily decreased to 1.5 years between exposures in 2016–2020. Sankey plots depict significantly more drug transitions in those initiating use from 1991 to 2000 (65.1% had at least two drug transitions) compared to 2010–2020 (16.0%). Opioid-stimulant use increased over time among racial/ethnic minorities, sexual minorities, and those with an educational attainment of high school or less.Conclusion: These data highlight not only the substantial prevalence of stimulant use among individuals who develop opioid use disorder, but also the variability through which pathways of use occur. Prevention and intervention efforts need to take into account increasing ages of initial drug exposures, demographic shifts in stimulant-using populations, and more rapid drug transitions between opioid and stimulants. But at a broader level, prevention, harm reduction ideology, and addiction medicine needs to take into account the ubiquity of polysubstance use among individuals with substance use disorders.

Assessing Knowledge, Attitude, and Practices of Hand Hygiene among Health Care Workers in Eradah Complex in Jeddah

Background: Most of the persons thought that nosocomial infection is spread from the hands of health care workers. The main aim of hand washing is to be aware for all to know that this is a myth that nosocomial infection is spread from hand. Methods: This cross-sectional study was conducted in Eradah Complex in Jeddah. The Saudi Commission for Health Specialties (SCFHS) has accredited Eradah Complex for Mental Health- Jeddah, as a training center for addiction medicine fellowship program. An observation is done by providing a Google form to the health care workers of the Eradah complex in Jeddah. This is to observe the views of the health care workers on the issue of practices of hand hygiene. Results: There were a total of 178 study participants (111 male and 67 participants). Age groups demonstrate that 34.27% of participants belong to the age group of 36 to 45 years. 32.02% of the participants belong to the age group of 26 to 35 years of age group. Moreover, the graph has shown that 14.04% of participants belong to the age group of 18 to 25 years. It has been seen that the number of female workers bearing the position of Nurse is less than those of males. It is important to have more respondents being nurses as the nurses usually communicate directly with the patients. There is a doctor too, but they are less interaction directly with the patient. Therefore, overall graph shows that only 6.18% participants prefer other professions whereas among other percentages, 7.30% participants are pharmacists, 25.28% people are nurses, and 18.54% participants are doctors. Conclusion: The present study has discussed that maintenance of hand hygiene in the hospitals and clinics are of sheer importance. The research methodology that is incorporated in the present study has been helpful for the researchers in understanding the perception of the healthcare workers what they think about the aspect of washing hands primarily after the pandemic. Therefore, it has been seen that most of the participative healthcare workers primarily males do not find the aspect hand hygiene much important and so they rarely use soap for hand wash. On the contrary, the female workers understand the importance of hand wash more and thus, they support the thought of hand hygiene at the workplace.

Dying with dignity: the challenges of end-of-life care in patients with substance use disorders

Substance use disorder is a chronic disease carrying a high risk of morbidity and mortality. We report a case of a patient on long-term opioid agonist treatment who was diagnosed with metastatic cholangiocarcinoma and was referred to palliative care services almost contemporaneously with this diagnosis. In this report, we explore the challenges posed in offering holistic care during the end of life of a patient with a history of opioid dependence. A coordinated approach by addiction medicine and palliative care teams can allow patients from this complex cohort to ultimately die with dignity.

868. HIV, Opioid Use Disorder, and Injection related Infections: Clinical Outcomes in 4 Academic Hospitals

Background Because hospitals are a safety net for persons with injection drug use (IDU), they play a valuable role towards ending the HIV epidemic. The objective of this study is to evaluate the hospital outcomes of persons with HIV (PWH) and opioid use disorder (OUD). Methods CHOICE is a retrospective review of hospitalized persons with an infectious complication of OUD and IDU at University of Maryland, George Washington University, University of Alabama at Birmingham, and Grady Memorial Hospital. Participants were hospitalized between 1/2/2018-12/21/2018, had ICD9/10 diagnosis codes consistent with OUD and acute bacterial/fungal infection, and verification of OUD-associated infection. HIV was defined by chart review. We explored HIV viral load (VL), antiretroviral therapy (ART) and medications for opioid use disorder (MOUD) on admission, discharge, consultation, and community care. Overall CHOICE Study Enrollment Results Overall, 287 were admitted with OUD and infections over the study period; 22 had HIV of whom 3 (14%) were diagnosed during the admission. Of the HIV negative, 1 was discharged on PrEP. Of PWH, most were Black (55%), male (68%), and Medicaid recipients (77%); median age was 48. Median length of stay was 10 days. Common bacterial infections were skin/soft tissue (55%), Bacteremia (41%), and Osteomyelitis (18%). On admission, few were on antiretroviral therapy (ART; 32%) or MOUD (23%). Of the 13 with a VL during admission, 100% had viremia (median VL 6,226 copies/mL). During the admission, 81% were evaluated by Infectious Diseases consultant and 50% by Addiction Medicine. At discharge, 11 and 6 had documentation of an ART plan and MOUD receipt, respectively. In the year following the admission, of 21 with follow up data, a majority were evaluated in the emergency department (68%) and readmitted (57%). HIV Outcomes for Hospitalized Persons with Injection Related Bacterial Infections Conclusion For patients with IDU, hospitalization is a missed opportunity to address HIV treatment and prevention through PrEP, VL surveillance, and ART linkage. Because addiction treatment improves HIV outcomes, Addiction consultation should be standard of care but was under-utilized. Subsequent ED visits and readmissions suggest that hospitals provide continuity of care for patients with IDU who would benefit from HIV, HCV, and other services in acute settings. Disclosures Greer A. Burkholder, MD, MSPH, Eli Lilly (Grant/Research Support) Elana S. Rosenthal, MD, Gilead Sciences (Research Grant or Support)Merck (Research Grant or Support) Ellen Eaton, MD , Gilead (Grant/Research Support) Ellen Eaton, MD , Gilead (Individual(s) Involved: Self): Research Grant or Support

The Second Heart Program—A multidisciplinary team supporting people who inject drugs with infective endocarditis: Protocol of a feasibility study

Introduction Infective endocarditis (IE) is a severe and highly prevalent infection among people who inject drugs (PWID). While short-term (30-day) outcomes are similar between PWID and non-PWID, the long-term outcomes among PWID after IE are poor, with 1-year mortality rates in excess of 25%. Novel clinical interventions are needed to address the unique needs of PWID with IE, including increasing access to substance use treatment and addressing structural barriers and social determinants of health. Methods and analysis PWID with IE will be connected to a multidisciplinary team that will transition with them from hospital to the community. The six components of the Second Heart Team are: (1) peer support worker with lived experience, (2) systems navigator, (3) addiction medicine physician, (4) primary care physician, (5) infectious diseases specialist, (6) cardiovascular surgeon. A convergent mixed-methods study design will be used to test the feasibility of this intervention. We will concurrently collect quantitative and qualitative data and ‘mix’ at the interpretation stage of the study to answer our research questions. Ethics and dissemination This study has been approved by the Hamilton Integrated Research Ethics Board (Project No. 7012). Results will be presented at national and international conferences and submitted for publication in a scientific journal. Clinical trail registrarion Trial registration number: ISRCTN14968657 https://www.isrctn.com/ISRCTN14968657.

The Birth of Naloxone: An Intellectual History of an Ambivalent Opioid

Naloxone, which reverses the effects of opioids, was synthesized in 1960, though the hunt for opioid antagonists began a half-century earlier. The history of this quest reveals how cultural and medical attitudes toward opioids have been marked by a polarization of discourse that belies a keen ambivalence. From 1915 to 1960, researchers were stymied in seeking a “pure” antidote to opioids, discovering instead numerous opioid molecules of mixed or paradoxical properties. At the same time, the quest for a dominant explanatory and therapeutic model for addiction was likewise unsettled. After naloxone’s discovery, new dichotomizing language arose in the “War on Drugs,” in increasingly divergent views between addiction medicine and palliative care, and in public debates about layperson naloxone access. Naloxone, one of the emblematic drugs of our time, highlights the ambivalence latent in public and biomedical discussions of opioids as agents of risk and relief.

Development of a virtual reality simulation for exposure based addiction therapy

After the success of virtual reality (VR) applications in supporting exposure-based and psychoeducational cognitive behavioural therapy for various mental illnesses, the technology is also gaining traction in addiction medicine. This paper will describe the concept behind a custom-developed VR simulation for this application with a particular emphasis on alcohol-related addictive disorders. Using Unreal Engine 4, an exposure simulation and a scenario for learning and applying coping strategies were developed for the Oculus Quest. Because of the common association of supermarkets with the procurement of alcohol among addicts, a small shop was implemented as initial scenario. Since the feeling of presence is an important parameter in the quality assessment of a simulation, the degree of immersion was evaluated in initial practical tests after development. In surveys with ten healthy testers, the majority showed a feeling of immersion. Cybersickness and unrealistic collision physics were identified as disruptive factors to the extent of immersion. This work provides the basis for a novel concept for addiction therapy which focusses on a fusion of playful psychoeducation, adjustable exposure, and the internalization of coping strategies with the help of multisensory biofeedback as well as the documentation of the objective physiological measurements for assessment of therapy success. The aim is to best possible address the specific requirements for clinical and home use in terms of self-containment, immersion, and ease of use. To evaluate and exploit the scientific potential of this concept scientific studies and technical improvements to both simulation and hardware are required.