Abstract
In this issue of the Journal of Addiction Medicine, two studies fill an important gap in knowledge by examining predictors of leaving against medical advice (AMA) from inpatient withdrawal management settings. The studies identify important risk factors for leaving AMA and highlight important areas for inpatient withdrawal management, including the use of substance specific standardized protocols and initiation of opioid agonist treatment instead of opioid detoxification given harms associated with opioid withdrawal. Further need for increased training in addiction medicine for primary care physicians, and use of inpatient addiction medicine consult services as part of early intervention for substance withdrawal are also discussed.
Keywords: Substance use disorder, opioid use disorder, gamma-hydroxybutyrate, withdrawal management, leaving against medical advice
Leaving hospital against medical advice (AMA) exposes patients to the harms of inadequately treated medical conditions and up to a threefold increase in one year mortality (Choi et al. 2011, Southern et al. 2012). It also places a strain on the healthcare system, as those with serious illnesses that have not completed treatment prior to discharge often need to be readmitted and may return with a more serious form of illnesses requiring a lengthier stay (Choi et al. 2011). Patients with substance use disorders (SUDs) have an increased likelihood of leaving hospital AMA (Choi et al. 2011), which puts this population that is known to be socially and physically vulnerable, at even higher risk for poor outcomes. Withdrawal management is a key component of managing patients with SUDs and often a first step in engaging individuals in ongoing treatment for addiction; however, if done inadequately, it may lead to poor outcomes including leaving AMA (McNeil et al. 2014).
In this issue of the Journal of Addiction Medicine, two studies fill an important gap in knowledge by examining predictors of leaving AMA from inpatient withdrawal management settings. Ling et al. used a case-control study design to examine frequency and predictors of leaving AMA from an inpatient medical withdrawal unit in Toronto, Canada, equipped to deal with withdrawal from many types of substances. The authors observed increased odds of leaving AMA among patients undergoing withdrawal from gamma-hydroxybutyrate (GHB), those with Axis I psychiatric diagnoses, and those admitted through the emergency department versus a planned admission. They found decreased odds of leaving AMA among those without nicotine dependence and with a longer length of stay. In the second study, Pytell and Rastegar used a retrospective observational study design to examine factors associated with leaving AMA among patients admitted to an inpatient medical withdrawal unit in Baltimore, United States, for alcohol withdrawal, with or without co-morbid opioid use disorder (OUD). The authors found that there were higher odds of leaving AMA among younger patients and among those admitted from the emergency department versus a planned admission, and no difference for those with co-morbid OUD.
Taken together, there appear to be differences in AMA risk by substance. Ling et al. explored AMA rates among patients admitted for withdrawal management for any type of substance, whereas Pytell and Rastegar examined only those withdrawing from alcohol, although the role of concurrent management for OUD was also considered in their study. The finding from Ling et al. that patients admitted for management of GHB withdrawal, compared to alcohol withdrawal, had increased odds of leaving AMA underscores the importance of objective validated measures to assess and effectively manage withdrawal. Tools such as the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) and the Brief Alcohol Withdrawal Scale (BAWS) are widely utilized for alcohol, whereas there is a paucity of assessment tools or standardized treatment approaches for other substances, including the management of GHB withdrawal (von Theobald et al. 2017). Ling et al. used phenobarbital; however, there is no widely accepted evidence-based protocol or clinical guidelines beyond recommendations for use of benzodiazepines for GHB (Kamal et al. 2016). The establishment of evidence-based standardized withdrawal assessment and management approaches that are substance specific may help to optimize symptom control to reduce AMA risk.
However, inpatient supervised withdrawal management is not always necessary or appropriate, particularly in the case of opioids. The management of OUD in these inpatient settings were notably different between the two studies. In Pytell and Rastegar, patients with OUD were maintained on opioid agonist treatment (OAT) only if they were prescribed it prior to admission to the unit, while those not previously on OAT were initiated on a buprenorphine taper to manage symptoms of opioid withdrawal. In the study by Ling et al., all patients with OUD were initiated on OAT in lieu of opioid tapers, an approach that is recommended as standard of care for treatment of OUD in Canadian guidelines (Bruneau et al. 2018). Unsurprisingly, OUD was not associated with AMA rates in either study, likely because many patients were initiated or maintained on OAT and opioid tapers can be effective for symptom control in the short term. However, it has been well demonstrated that withdrawal management alone is associated with very low rates of illicit opioid cessation (Nosyk et al. 2012) and increased overall risk of death due to overdose post discharge (Darke and Hall 2003). Therefore, opioid tapers should not be done in withdrawal management settings, and patients with OUD should be offered initiation onto OAT, preferably in an outpatient setting unless withdrawal management for co-morbid substance use is required (Bruneau et al. 2018). Regardless of setting, providing education on harm reduction resources such as overdose education and take-home naloxone kit distribution early on during initiation of OAT remains an essential component of early OUD care.
A key factor for leaving AMA in both studies was admission from the emergency department (ED) instead of a planned admission to an inpatient withdrawal unit. There are several potential reasons for this, including that patients presenting to the emergency department are more likely to be in acute distress from withdrawal symptoms and may have less readiness to enter an inpatient environment. Previous studies have found that, compared to the general population, individuals with SUDs have higher rates of ED utilization and admission to hospital and are more likely to have socio-structural barriers including homelessness and unemployment (Nambiar et al. 2018). Given the unique needs of individuals presenting to the ED, mitigating risk via inpatient services such as addiction medicine consult teams may serve to intervene early on in admission to prevent AMA discharges. Integration of addiction medicine services in hospital improves the quality of medical care, abstinence rates and linkage to primary care (Druss and von Esenwein 2006). Further, despite SUDs being a prevalent and treatable disease, many physicians feel unprepared in the management of these disorders (Wakeman et al. 2016). To relieve the burdens on the ED and to improve the care of patients with SUDs in the community, there is a critical need to better equip primary care doctors with addiction medicine skills and knowledge. This can be done by increasing time dedicated to teaching about SUDs during medical school and residency training programs and expanding access to addiction medicine continuing medical education (Saitz and Daaleman 2017).
While the two papers in the current edition shed light on risk factors associated with leaving AMA, there are several important factors that were not considered. The most pertinent factor for further consideration in future studies is whether connecting patients to ongoing SUD services from withdrawal management facilities impacts AMA risk. There is a currently a fragmented system that exists between withdrawal management and long-term addiction treatment (Socías et al. 2016). It is possible that patients may leave these facilities AMA if they do not have a reliable next step in addiction care arranged. Withdrawal management stabilizes patients in the acute period but, given that SUDs are a chronic disease, should serve as a bridge to ongoing care (Saitz et al. 2008). Future studies need to consider how well withdrawal management environments link into ongoing addiction care and their impact on treatment outcomes. Key socio-structural variables that impact an individuals’ ability to continue to engage in ongoing SUD treatment, such as housing and ability to pay for addiction services, should necessarily be accounted for (Appel et al. 2004).
Patients with SUDs continue to have an increased risk of leaving AMA and the studies by Ling et al. and Pytell and Rastegar in this issue shed light on risk factors for AMA discharges from withdrawal management facilities. Withdrawal management services are a crucial beginning step in engaging patients with SUDs in addiction care and recovery. It is critical to optimize care in these settings to prevent AMA in order to successfully retain patients in treatment.
Acknowledgments
The authors wish to thank Chiarine Hsu for her administrative assistance. We would also like to express our sincere thanks to the reviewers of our paper for their thoughtful suggestions. Dr. Lail is supported by the US National Institutes of Health (R25DA037756) Canadian Addiction Medicine Research Fellowship. Dr. Nadia Fairbairn is supported by a Michael Smith Foundation for Health Research/St. Paul’s Foundation Scholar Award. Funding agencies had no role in the research, design, or writing of the manuscript, nor did they have a role in the decision to submit the paper for publication.
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