Group Cognitive Behavioral Therapy for Substance Use Disorders Among Psychiatric Inpatients in a Medically Underserved Area: An Intervention for Opioid Misuse

Abstract

Objectives:

Opioid misuse is a serious public health concern, yet few people seek treatment for this condition. Hospitals may be one opportunity to identify those with opioid misuse and to teach them skills to help manage their opioid misuse upon discharge. We tested the relationship between opioid misuse status and motivation to change substance use among patients admitted with substance misuse to an inpatient psychiatric unit in a medically underserved area in Baton Rouge, Louisiana, who attended at least 1 group session of motivation enhancement therapy combined with cognitive behavioral therapy (MET-CBT) from January 29, 2020, through March 10, 2022.

Methods:

Of the 419 patients in our sample, 86 (20.5%) appeared to misuse opioids (62.5% male; mean age, 35.0 y; 57.7% non-Hispanic/Latin White). At the beginning of each session, patients completed 2 measures of motivation—importance and confidence to change substance use—from 0 (not at all) to 10 (most). At the end of each session, patients rated perceived session helpfulness from 1 (extremely hindering) to 9 (extremely helpful).

Results:

Opioid misuse was associated with greater importance (Cohen d = 0.12) and confidence (Cohen d = 0.13) to change substance use and with attending more MET-CBT sessions (Cohen d = 0.13). Patients with opioid misuse rated sessions as highly helpful (score of 8.3 of 9), and these ratings did not differ from patients who used other substances.

Conclusions:

Inpatient psychiatry hospitalizations may provide an opportunity to identify patients with opioid misuse and introduce these patients to MET-CBT to learn skills to manage opioid misuse upon discharge.

Opioid misuse (ie, heroin use or the use of prescription opioids without a prescription or use that is not as prescribed, such as using more than prescribed) is a major problem in the United States. In 2020, 9.5 million people in the United States misused opioids, and adults used opioids at higher rates than adolescents. ¹ Most opioid misuse involves misuse of prescription pain relievers; in 2020, 8.6 million people indicated prescription opioid misuse without heroin use, and 902 000 people indicated heroin use. ¹ Opioid misuse is especially concerning given the high rates of problems related to misuse. For example, opioid-related overdoses and deaths are at an all-time high, comprising more than 70% of drug overdose deaths in 2020. ² Furthermore, the number of emergency department visits for opioid overdoses increased 10% from 2019 to 2020, ³ and rates of opioid use disorder (OUD; ie, experiencing clinically significant problems related to opioid use) are high; 28.4% of those who misused opioids met criteria for an OUD. ¹

Despite increasing rates of opioid misuse and related problems, including overdose risk, few people who misuse opioids seek treatment to help them manage their use. In 2020, 11% of those with OUD received medication-assisted treatment (MAT), ¹ the combination of medication for opioid misuse with psychotherapy (eg, motivational interviewing strategies, cognitive behavioral therapy [CBT], contingency management) for opioid misuse, which has been found to be beneficial for opioid misuse. ⁴ Taken together, these data highlight a crucial need for interventions for opioid misuse, overdose, and OUD.

Hospital settings are an ideal setting in which to identify and intervene with people who misuse opioids. A large portion of adults who seek treatment—either to reduce substance use or for medical treatment of withdrawal symptoms, injury, or other health problems related to substance use—receive treatment in a hospital setting. ⁵ Furthermore, high rates of medical (eg, hepatitis, pancreatitis, chronic pain) and mental health comorbidities contribute to high rates of health care use among patients who misuse opioids. ⁶ These patients are more likely to present at hospitals for comorbid conditions than for their opioid misuse and, thus, may benefit from hospital-based interventions to explore and resolve ambivalence about changing opioid misuse and to learn skills to manage OUD symptoms.

Given that most people who have opioid misuse do not seek treatment for their opioid misuse but do seek treatment for other comorbid conditions, our study describes efforts at Our Lady of the Lake Regional Medical Center in Baton Rouge, Louisiana, to increase accessibility of motivation enhancement therapy combined with CBT (MET-CBT) for substance misuse by offering this intervention to patients during inpatient psychiatry hospitalization. MET-CBT can be delivered successfully to psychiatry inpatients for substance misuse, ⁷ and MET-CBT administered in outpatient settings can reduce opioid misuse. ⁸ Furthermore, patients with opioid misuse may be more motivated than patients who use other substances (eg, alcohol) to change their opioid use out of fear of exposure to fentanyl-related overdose and a desire to avoid future involvement with the criminal justice system. ⁹ Patients with opioid misuse in an inpatient psychiatry unit may be especially motivated to change their use given that among people seeking outpatient substance use disorder (SUD) treatment, psychiatric symptoms are related to more motivation to change substance use among patients who use opioids but related to less motivation to change the use of other substances (eg, cannabis). ¹⁰

The current study had several objectives. First, we examined whether inpatients with opioid misuse differed from those who used other substances in motivation to change substance misuse. We hypothesized that patients admitted for opioid misuse would be more motivated to change their substance use behaviors than patients admitted with the use of nonopioid substances given the serious risks (eg, overdose) associated with opioid misuse. Second, we tested whether patients with opioid misuse differed from those who use other substances in acceptability and utility of a nonrandomized, open-enrollment MET-CBT group for substance misuse. To assess the impact of opioid use status on acceptability, we hypothesized that patients with opioid misuse would voluntarily attend >1 MET-CBT session. To assess utility, we hypothesized that patients with substance misuse would rate MET-CBT sessions as helpful.

Methods

Participants and Procedures

This study was conducted at a hospital in a medically underserved area in Baton Rouge. Low-income residents are particularly underserved with regard to mental health services, as evidenced by the area’s designation as a Health Professional Shortage Area. ¹¹ Furthermore, this project was conducted in Louisiana, a state with the third largest increase in opioid-related overdoses, with 776 synthetic opioid/heroin-involved deaths reported in 2020 and 1179 synthetic opioid/heroin-involved deaths reported in 2021. ¹² Clinical psychology graduate students extracted demographic, medical, substance use, and MET-CBT group–related data from the electronic medical records of 419 adult patients who were hospitalized on a 21-bed general acute inpatient psychiatric unit in a large regional general medical and surgical hospital and attended at least 1 session of group MET-CBT for substance misuse and/or SUD from January 29, 2020, through March 10, 2022. ¹³ Patients were referred by medical staff to these sessions. Informed consent to participate in this research was not required because data were collected retrospectively, but use of these data for research purposes was approved by the Louisiana State University and the Louisiana State University Health Sciences Center institutional review boards. Consistent with the area’s designation as a medically underserved area, the sample was racially and ethnically diverse with a large representation of patients of low socioeconomic status; most patients (n = 366) were uninsured or received government health insurance (ie, Medicaid, Medicare, Veterans Affairs).

We allocated patients to the opioid misuse group based on 3 metrics: (1) OUD diagnosis was extracted from the patients’ inpatient psychiatry admission note, (2) reason for admission concerned opioid misuse (eg, overdose, heroin use while pregnant), and/or (3) patient report of opioids as their substance of choice at the beginning of their MET-CBT session. Patients who indicated that opioids were a substance of choice were also classified as having opioid misuse. Thus, the final sample of patients in the opioid misuse group was 86, and 333 patients were in the other substance group; their substances of choice included cannabis (n = 195), alcohol (n = 171), cocaine/crack cocaine (n = 68), methamphetamine/crystal meth (n = 71), benzodiazepines (n = 23), nicotine (n = 14), ecstasy (n = 8), synthetic marijuana (n = 11), stimulants (n = 8), hallucinogens (n = 7), and other (n = 2).

All participants were referred to MET-CBT groups because of medical staff concerns about their substance use (eg, positive toxicology screen, report of problems related to substance use). Most of the sample (302 of 333) was diagnosed with at least 1 SUD, and SUD was the primary diagnosis for 148 patients. Suicidal thoughts and behaviors were among the most common reasons noted for hospitalization (n = 162); other reasons for admission included accidental overdose, acute intoxication, psychosis, aggression, physical conditions (eg, motor vehicle accident, gunshot wound), and other psychological conditions (eg, depression, manic episode).

MET-CBT

Group MET-CBT for SUD was implemented in the psychiatry inpatient unit as a component of a Graduate Psychology Education (GPE) program grant (D40HP33350) awarded from the US Department of Health and Human Services to increase training in and access to clinical services for opioid misuse. Prior to this GPE award, no evidence-based psychotherapy was provided in the hospital for SUD; thus, a primary goal of the GPE award was to increase accessibility of psychotherapy to patients with opioid misuse, other SUDs, and related conditions. Sixty-minute group MET-CBT sessions were administered during 3 days per week from January through June 2020 and from October 2021 through March 2022; patient response to the groups was so positive that medical staff encouraged our team to offer sessions on all 5 workdays, which our group leaders had availability to conduct from June 2020 through August 2021.

Session topics were chosen from an MET-CBT for SUD manual ¹⁴ and included goal setting, functional analysis, coping with cravings, managing thoughts about use, refusal skills, and seemingly irrelevant decisions. Goal setting and motivational interviewing techniques (eg, discussing the pros and cons of substance use) were incorporated in all sessions. These topics were presented weekly. Each session was conducted by 2 trained clinical psychology graduate students under the supervision of the first author (J.D.B), a licensed clinical psychologist with >10 years of experience with MET-CBT for SUD. Six graduate students were group leaders (2 per year), all but 1 of whom had a master’s degree in psychology. All graduate students completed didactics in MET-CBT for SUD prior to conducting MET-CBT, and group sessions were reviewed weekly by the first author (J.D.B.) to ensure adherence to the manual.

At the beginning of each session, patients were asked to identify their substance of choice. If participants reported using >1 substance, they were asked to identify which substance they used the most often and/or which substance caused them the most problems. Patients were also asked to complete 2 Readiness-to-Change assessments to assess 2 indices of motivation ¹⁵ : importance to change substance use and confidence to change substance use. These assessments were adapted from Miller and Rollnick ¹⁵ and were rated from 0 (not at all) to 10 (most). Increases in importance and confidence have corresponded with behavioral changes. ¹⁶ At the end of each session, patients completed written assessments of perceived session helpfulness using a 9-item rating, from 1 = extremely hindering to 9 = extremely helpful. ¹⁷

Data Analytic Strategy

First, we tested whether patients with opioid misuse differed from those who used other substances on demographic and other relevant medical data (eg, suicidal ideation and behaviors, length of inpatient admission). We used analysis of variance for continuous variables and χ² analysis for dichotomous variables. Any variable for which patient groups differed was included as a covariate in subsequent analyses. Second, we used analysis of covariance to test whether patients with opioid misuse differed from those who used other substances on indices of motivation to change substance misuse, number of MET-CBT sessions attended, and session helpfulness. We considered P < .05 to be significant. We conducted all analyses using SPSS version 26 (IBM Corp).

Results

Compared with the use of other substances, opioid misuse was associated with a significantly greater likelihood of having government health insurance (Table 1). Opioid misuse was not significantly related to other demographic or substance use variables, psychosis, or suicidal thoughts and behaviors at admission or the number of days in the inpatient unit.

Table 1.

Characteristics of psychiatry inpatients who attended at least 1 session of motivation enhancement therapy combined with cognitive behavioral therapy (MET-CBT) for substance misuse, by opioid misuse status, Louisiana, January 29, 2020, through March 10, 2022

Variable	Opioid misuse (n = 86)	Other substance misuse (n = 333)	F or χ2 (df) [P value] a	Cohen’s d or Cramer’s V
Age, mean (SD), y	35.0 (10.7)	35.0 (11.6)	0.002 (1, 418) [.96]	0.01
Female sex, %	34.1	38.4	0.52 (1, 416) [.47]	0.04
Non-Hispanic/Latin White, %	36.5	43.8	1.49 (1, 416) [.22]	0.06
Government health insurance, %	78.3	89.9	8.15 (1, 401) [.004]	0.14
Positive toxicology screen for nonopioid substance, %	75.0	77.9	0.31 (1, 419) [.58]	0.03
Reasons for admission included suicidal thoughts and behaviors, %	52.3	47.7	0.57 (1, 419) [.45]	0.04
Reasons for admission included psychosis, %	22.1	21.6	0.01 (1, 419) [.93]	0.01
Likelihood of attending >1 MET-CBT session, %	66.3	34.8	27.88 (1, 419) [<.001]	0.26

^aP < .05 was considered significant.

Participants attended 1-8 MET-CBT for SUD sessions (mean [SD] = 1.7 [1.1]), with 173 of 419 participants attending >1 session. Of 419 participants, 246 (58.7%) attended only 1 session, 100 (23.9%) attended 2 sessions, 41 (9.8%) attended 3 sessions, 17 (4.1%) attended 4 sessions, 10 (2.4%) attended 5 sessions, 3 (0.7%) attended 6 sessions, and 2 (0.5%) attended 8 sessions; no participants attended 7 sessions. Reasons for not attending additional groups included being unavailable during group time (eg, attending other medical appointments, family visits), too tired, not feeling well, not interested, or having been discharged.

Motivation to Change Substance Use

After controlling for government health insurance status, patients with opioid misuse reported greater importance to change substance use than patients who used other substances (mean [SD] rating = 9.5 [1.3] vs 8.9 [2.1]); F_1,374 = 5.15, P = .02, d = 0.12) and greater confidence to change substance use (mean [SD] rating = 9.1 [1.3] vs 8.6 [2.1]; F_1,374 = 4.27, P = .04, d = 0.13).

Acceptability and Utility of MET-CBT for Substance Misuse

Compared with patients who used other substances, patients with opioid misuse had a greater likelihood of attending >1 MET-CBT session (Table 1). After controlling for government health insurance status, patients with opioid misuse attended significantly more MET-CBT sessions than patients who used other substances (mean [SD] sessions = 2.4 [1.5] vs 1.6 [1.0]); F_1,401 = 34.08, P < .001, d = .13). Patients with opioid misuse reported that MET-CBT sessions were helpful regardless of session topic, and ratings of session helpfulness did not differ significantly from patients who used other substances (Table 2).

Table 2.

Ratings of session helpfulness among psychiatry inpatients who attended at least 1 session of motivation enhancement therapy combined with cognitive behavioral therapy (MET-CBT) for substance misuse, by opioid misuse status, Louisiana, January 29, 2020, through March 10, 2022 ^a

Helpfulness	Opioid misuse, mean (SD) rating	Other substance misuse, mean (SD) rating	F (df) [P value] b	Cohen’s d
Mean of all sessions	8.3 (1.4)	8.5 (1.1)	1.43 (1, 320) [.23]	0.17
Functional analysis	8.4 (1.5)	8.3 (1.2)	0.04 (1, 171) [.84]	0.18
Coping with craving	8.5 (1.2)	8.2 (1.2)	0.88 (1, 145) [.35]	0.22
Seemingly irrelevant decisions	8.1 (1.5)	8.5 (1.1)	0.76 (1, 102) [.39]	0.37
Refusal skills	8.3 (1.1)	8.5 (0.8)	0.51 (1, 43) [.48]	0.27
Managing thoughts related to use	8.4 (1.0)	8.4 (1.2)	0 (1, 71) [.95]	0.38

^aAnalyses controlled for variance attributable to government health insurance status. Patients rated perceived session helpfulness using a 9-item rating, from 1 = extremely hindering to 9 = extremely helpful.

^bP < .05 was considered significant.

Discussion

To our knowledge, this is the first test of the role of opioid misuse status on acceptability and utility of group MET-CBT for SUD sessions for patients with opioid misuse in an acute psychiatric inpatient setting. MET-CBT for SUD was implemented in the psychiatry inpatient unit in an attempt to increase access to therapeutic services for opioid misuse in a medically underserved area. Results indicate that inpatient psychiatry units can play an important role in identifying patients with opioid misuse and starting psychotherapy to teach skills they may use to help manage opioid misuse upon discharge. Although all ratings were high, patients with opioid misuse rated their motivation (importance and confidence to change substance use) significantly higher than patients who used other substances, indicating that these patients may be especially motivated to learn skills to manage their use during their inpatient hospitalization. This finding is especially important given that, consistent with the extant literature, ⁵ most of these patients did not seek treatment for substance use but presented for other reasons (eg, suicidal thoughts and behaviors, psychosis, overdose, medical conditions). Furthermore, patients rated sessions as helpful overall and by each CBT skill.

Our findings indicate that group MET-CBT for SUD sessions may be a useful tool for bolstering motivation (especially importance and confidence) to change risky substance use behavior among patients with opioid misuse. Our data indicate that these group sessions are well received by psychiatry inpatients and may provide a positive introduction to MET-CBT for individuals with opioid misuse. These data are especially promising given that MET-CBT is associated with decreases in opioid misuse. ⁸ These data are also important in light of data indicating that MET-based interventions administered in hospital settings (eg, emergency departments, primary care settings) that usually do not teach CBT skills to manage substance use do not appear effective for reducing opioid use. ¹⁸

Limitations

This study had several limitations. First, data on motivation to change were collected as part of clinical services during MET-CBT sessions; thus, we did not have data on indices of motivation to change among patients who opted not to attend any MET-CBT sessions during their psychiatric inpatient hospitalization. Future work assessing motivation to change and investigating whether brief motivational interventions ¹⁸ geared toward increasing motivation among patients with lower motivation to attend MET-CBT sessions will be an important next step. Second, participants in our MET-CBT group were at various stages of treatment (eg, number of days hospitalized at time of MET-CBT session attendance), which may have affected their motivation to change or willingness to attend MET-CBT sessions for substance misuse. Third, we did not collect any follow-up data on opioid use or seeking of MAT, MET-CBT, or other opioid-related treatment services. Studies with such long-term outcomes will be an important next step. Fourth, we did not assess reasons to change substance use; thus, future work is necessary to determine whether patients with opioid misuse are more motivated to change their use because of the severity of risks associated with opioid misuse (eg, overdose) or whether other factors (eg, pregnancy risk, providing peer support to others, decreasing legal problems, improving relationships) affect their motivation to change.^19,20 Fifth, this study was not a randomized clinical trial, and patients were not randomly assigned to MET-CBT or a control condition. Although our study design strengthened external validity, it limited confidence in concluding that results were specific to MET-CBT. A randomized controlled trial testing the efficacy of MET-CBT for opioid misuse in an inpatient psychiatry setting will be an important next step.

Conclusions

The results of our study indicate that inpatient psychiatry units may be a promising setting in which to intervene with patients with opioid misuse. These patients reported high levels of motivation to change and found group sessions of MET-CBT for substance misuse helpful. As such, group MET-CBT sessions provided in psychiatric inpatient settings may be one opportunity to teach patients skills to manage opioid misuse upon discharge and serve as a positive introduction to MET-CBT for these patients to encourage additional treatment-seeking upon discharge. MET-CBT provided during inpatient psychiatry hospitalization may help decrease the suffering associated with the current opioid crisis.