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. Author manuscript; available in PMC: 2021 Mar 1.
Published in final edited form as: J Subst Abuse Treat. 2019 Dec 5;110:59–65. doi: 10.1016/j.jsat.2019.12.003

“Now Hospital Leaders Are Paying Attention”: A Qualitative Study of Internal and External Factors Influencing Addiction Consult Services

Kelsey C Priest 1,2, Honora Englander 3,4, Dennis McCarty 2
PMCID: PMC7181883  NIHMSID: NIHMS1548004  PMID: 31952629

Abstract

Background

Hospitalizations related to opioid use disorder (OUD) are increasing, necessitating an increase in the delivery of opioid agonist therapy (OAT) among hospitalized adults. The addiction consult service (ACS) is a promising organizational intervention to address this growing clinical need. Little is known about the barriers and facilitators of ACS development and operations.

Methods

We completed 17 semi-structured telephone interviews with board-certified or board-eligible addiction physicians across 16 U.S. acute care hospitals. Interviews explored contextual facilitators and barriers for ACS development and operations. We transcribed, coded, and analyzed interviews, and derived final themes using a directed content analysis.

Results

We identified six themes that promoted or inhibited ACS development and operations: 1) stigma and discrimination; 2) internal (e.g., hospital administrators) and external stakeholders (e.g., State Medicaid programs); 3) addiction-informed institutions with addiction-related resources; 4) access to community-based treatment programs (e.g., local opioid treatment programs); 5) restrictive and misinterpreted OAT policies; and 6) service financing. The first theme, stigma and discrimination, is presented as a stand-alone-theme but permeates the five other themes as a broader meta-theme.

Conclusions

As OUD-related hospitalizations increase, and the opioid-related overdose crisis continues, understanding the constraints related to the development and operations of ACSs are important preliminary steps for improving the care of patients hospitalized with OUD. Clinical champions, hospital leaders, and hospital societies could act, through practice and policy initiatives, to support ACS development and increase the delivery of evidence-based services (e.g., OAT) to patients hospitalized with OUD.

Keywords: Opioid use disorder, Opioid agonist therapy, Buprenorphine, Methadone, Addiction consult service, Addiction medicine consult service

1. Introduction

The opioid-related overdose epidemic is increasing demands on acute care delivery systems within the United States (Weiss, Barret, Heslin, & Stocks, 2016). Hospitalization costs related to opioid use disorder (OUD) are rising (Ronan & Herzig, 2016). Attention to strategies to enhance care for hospitalized patients with OUD, however, have been limited. The lack of attention is unexpected in the midst of an opioid-related overdose epidemic (Hedegaard, Miniño, & Warner, 2018) and growing evidence suggesting that hospital-based interventions are possible (Weimer, Morford, & Donroe, 2019) and desired by patients hospitalized with OUD (Nordeck et al., 2018; Velez, Nicolaidis, Korthuis, & Englander, 2017). Opioid agonist therapy ([OAT]: buprenorphine or methadone) is first-line treatment for OUD (Mattick, Breen, Kimber, & Davoli, 2009, 2014). OAT administration is clinically feasible during hospitalization (Suzuki, 2016; Trowbridge et al., 2017) and increases treatment engagement (Englander, Dobbertin, et al., 2019; Liebschutz et al., 2014) and drug-free days upon discharge (Wakeman, Metlay, Chang, Herman, & Rigotti, 2017). However, patients infrequently receive OAT during hospitalization (Rosenthal, Karchmer, Theisen-Toupal, Castillo, & Rowley, 2015) and it is uncommon for patients to receive OAT or behavioral services upon hospital discharge (Naeger, Ali, Mutter, Mark, & Hughey, 2016; Naeger, Mutter, Ali, Mark, & Hughey, 2016).

The limited provision of OAT and other OUD-related services during hospitalization likely has health and care quality implications. Hospitalized patients who inject drugs are more likely to leave hospitals and emergency departments against medical advice (Choi, Krantz, Smith, & Trick, 2015; McNeil, Small, Wood, & Kerr, 2014; Ti et al., 2015). Studies of hospitalized people who inject drugs suggests that they experience insufficient pain control and poor withdrawal management (Biancarelli et al., 2019; McNeil et al., 2014). One of the potential consequences of these ineffective, and potentially harmful health care experiences, is the future avoidance of the acute care delivery system until emergent care is required (Biancarelli et al., 2019; Paquette, Syvertsen, & Pollini, 2018). Moreover, studies suggest that hospitalized patients with OUD want to start treatment during hospitalization (Englander et al., 2017; Velez et al., 2017).

One suspected reason for suboptimal care for patients with OUD is stigma and discrimination. Stigma is defined as: “the complex of attitudes, beliefs, behaviors, and structures that interact at different levels of society (i.e., individuals, groups, organizations, systems) and manifest in prejudicial attitudes about and discriminatory practices against people with mental and substance use disorders” (National Academies of Sciences, Engineering, and Medicine, 2016). Policies may act as “stigmatizing structures of society” and allow for the perpetuation of discriminatory practices, which can promote negative social norms and increase self-stigma for people with mental and substance use disorders (SUDs) (National Academies of Sciences, Engineering, and Medicine, 2016).

Addiction consult services (ACSs) are a promising organizational intervention to not only enhance care, including OAT administration, for patients with OUD and other SUDs during hospitalization (Englander, Priest, et al., 2019), but also to counteract stigmatizing practice (Englander, Collins, et al., 2018). Clinical trials or multisite outcome studies on ACSs have yet to be conducted—one is forthcoming (McNeely et al., 2019)—but several prospective single-site evaluations (Englander, Dobbertin, et al., 2019; Trowbridge et al., 2017; Wakeman et al., 2017), retrospective studies (Englander, Dobbertin, et al., 2019; Nordeck et al., 2018; Suzuki, 2016), and qualitative analyses (Englander, Collins, et al., 2018; Priest, 2019; Velez et al., 2017) support its use. In a study of nine ACS, from a cohort of well-resourced U.S.-based hospitals, services were most often interprofessional, only operated on weekdays, did not provide services in the emergency department, were funded through a patchwork of financial streams, and had three primary domains of responsibility: 1) SUD education and culture change; 2) SUD treatment; and 3) SUD hospital policy development—including OAT-related policies (Priest & McCarty, 2019a). Moreover, clinical champions from this study persuaded hospital administrators to support ACS creation through the development of a “business case”(Priest & McCarty, 2019b). Little is known, however, about the challenges of ACS development and operations. This study extends prior descriptive qualitative analyses of ACS organizational structure (Priest & McCarty, 2019a) and the “business case”(Priest & McCarty, 2019b), to examine specific facilitators and barriers to developing, implementing, and operating ACS in well-resourced U.S. hospitals.

2. Methods

2.1. Study Aim and Conceptual Framework

Based on prior evidence and clinical expertise, we assumed that ACSs were likely an important organizational attribute for hospital OAT delivery; thus, we focused on this specific organizational intervention. The study conceptual framework was based on an interdisciplinary scholarly review of policy, organization, system, and economic theories—including the Health Care Access Framework (Levesque, Harris, & Russell, 2013). Prior research, and the conceptual framework informed the development of the study interview guide and subsequent data analyses (Priest, 2019; Priest & McCarty, 2019a).

2.2. Study Cohort Recruitment

We recruited study participants, through email, using a purposive sampling strategy that began with the Addiction Medicine Foundation’s publicly-available list of accredited fellowship programs (Addiction Medicine Foundation, 2018). This approach was supplemented with respondent-driven and expert recommendations. Participants self-identified as having knowledge of ACS development at their institution, or were identified by others at their institution as addiction experts with direct experience or close-knowledge of ACS development and operations (Priest, 2019; Priest & McCarty, 2019a). The final study cohort included 17 key informants from 16 U.S. hospitals, 14 of which had established (n = 9) or planned (n = 5) ACS.

2.3. Data Collection

Participants completed an electronically recorded, semi-structured, 45-to-60-minute telephone interview. Interviews queried participants on their personal demographics (e.g., age), hospital characteristics (e.g., OAT on formulary), explored facilitators and barriers related to ACS formation (e.g., “What sort of elements within your organization supported the start of the consult service?”), and OUD-related services (e.g., “What do you think are some of the organizational barriers to implementing policies and procedures for caring for persons with OUD at your hospital?”). We updated the semi-structured interview guide during the analytic process to reflect emergent findings (Hsieh & Shannon, 2005). Oregon Health & Science University’s Institutional Review Board reviewed and approved this study protocol (Study #18092).

2.4. Analysis

An a priori code book was created prior to data analysis based on the study’s conceptual framework and literature review (Priest, 2019). Transcripts were coded using a directed content analysis (Hsieh & Shannon, 2005) in iterative cycles using Dedoose (SocioCultural Research Consultants LLC, 2016), a qualitative analysis software. A dual-coder approach (KCP, DM) enhanced study validity. Upon primary analysis 13 facilitators and 10 barriers were identified. An addiction medicine expert (HE) guided the final analytic process with input from the rest of the research team (KCP, DM). In the final round of analysis, facilitators and barriers were collapsed into six higher-order themes. Assigned quote attributions include ACS status (Established, Planned, or None) and individual key informant alpha-numeric identifiers (e.g., A1).

3. Results

3.1. Participant and Hospital Characteristics

The study cohort included 17 addiction physicians, board-certified (n = 16) or board-eligible (n = 1), with a mean age of 47 years, who were trained in family medicine, internal medicine, obstetrics and gynecology, pediatrics, and psychiatry specialties. The nine women and eight men were predominantly white (n = 16), non-Hispanic or Latino (n = 15) with more than five years of work or training (n = 13) at their respective hospital. The hospitals in the cohort were located in the West (n = 4), Midwest (n = 4), Northeast (n = 5), and the South (n = 3). Ten of the 16 hospitals had affiliated or onsite addiction related services (e.g., opioid treatment programs [OTP] and detoxification beds) and most hospitals (n = 15) had OAT available for OUD treatment on the hospital formulary. Nine of the 16 hospitals had an ACS, five hospitals planned to start a service, and two hospitals had no service and no future plans for creating one.

3.2. Themes

We identified six themes that influenced the development, implementation and operations of ACSs. These themes centered on: 1) stigma and discrimination; 2) internal and external stakeholders; 3) addiction-informed institutions with addiction-related resources; 4) access to community-based treatment services; 5) restrictive and misinterpreted OAT policies; and 6) service financing. We present the first theme, stigma and discrimination, as a stand-alone-theme, though this construct permeates the five other themes more broadly as a meta-theme. Thus, we include examples of stigma and discrimination throughout.

3.2.1. Pervasive stigma and discrimination influenced ACS development and operations.

Informants frequently described the existence of stigma and discrimination as inhibiting the care of patients with OUD, the delivery of OAT, and the development of their respective ACS. Informants noted persistent stigmatizing perspectives and discriminatory behaviors by physicians and hospital staff:

…in this area of the country there is still the perception, by many people, that addiction is not an illness. It is a spiritual deficit, or a personal or personality deficit. We have a lot of barriers just in terms of educating our staff to not treat these people differently than they would treat an individual who comes in with chest pain. (Planned, M1)

Informants recognized the connection between stigmatizing behaviors and beliefs with training deficits: “Stigma is about lack of education” (Established, P1) and the failures of the medical education system more broadly to train physicians in evidence-based addiction services. An informant shared that many providers at their hospital believed that OAT administration was “substituting one drug for another” (Planned, C1). Further, informants observed that specific groups of physicians—emergency and orthopedic—who interfaced most frequently with SUD patients were uninformed about best-practices for treating opioid withdrawal. An informant described how the orthopedic surgical team had a culture of “just treat ‘em and street ‘em” (Established, H1). In the emergency department, one informant shared how she believed that the emergency department was re-traumatizing SUD patients and that it was a missed opportunity for treatment engagement. Some noted that their hospital administrators contributed to the institutionalization of stigma towards patients with SUDs by not allocating treatment resources:

They start with all the reasons it can’t be done and stop there… people don’t want to say out loud things like ‘well we don’t to be known for that kind of thing.’ … [they] don’t want to draw attention to that [they] would rather draw attention to our new cardiology center…so its prejudiced. (None, G1)

An informant perceived the existence of a double-standard of how hospital leadership holds their ACS to a higher productivity standard than other services:

I think there is still a lot of embedded stigma. It is structural. To assume that there is a good reason for why the addiction consult service is held to a different standard than established consult services. [This is the] number one public health issue that the community is facing. Ebola didn’t generate a lot of revenue but it cost a shit load for the hospital even though we didn’t have one single patient. (Established, K1)

In one community, inpatient providers were reluctant to discharge patients to a specific OTP because it routinely discharged patients with positive urine drug screens for methamphetamine, limiting the community-based treatment options available for referring patients. Finally, the beliefs of local political leaders created barriers to OAT delivery in the hospital setting, as political leaders had uninformed and discriminatory opinions about OAT:

People who are on methadone have to pay private facilities cash in order to get methadone…I can speculate but I think it is political. There is this stigma. They think these people are enjoying themselves on methadone. They do not see it as therapeutic. (Planned, N1).

Participants noted that stigma and discrimination imposed structural barriers to community-based treatment, contributed to restrictive OAT policies, and underpinned many financing challenges (Sections 3.2.4, 3.2.5, and 3.2.6).

3.2.2. Internal and external stakeholders—including themselves or other addiction experts—influenced hospital readiness for ACS development and implementation.

Informants identified a variety of key internal stakeholders who contributed to service development. Informants observed that the dedication of local addiction clinical champions (including themselves), guided by their personal and professional values for the ethical treatment of people with SUDs, was a core driver of service creation. Other supportive stakeholders included members of the pharmacy and therapeutics committee (P&T), nursing staff, hospital security, other physician-led consultation services (psychiatry, pain, and cardiovascular surgical services), and hospital administrators. Compelling fiscal arguments (i.e., “the business case” described in section 3.2.6) and persistent local and national media coverage of the opioid overdose crisis influenced hospitals to act: “But what really opened up the door was the opioid epidemic. Now hospital leaders are paying attention” (Planned, E1) and “Honestly, I think it has been all the attention on the opioid crisis has been getting in popular media and dollars are starting to be direct[ed] to that [OUD services]” (Established, J1). Informants also believed that the media influenced hospital providers: “I think all of the news media coverage of the opioid epidemic. Our providers seeing the reality of that on the streets of our city has been hugely helpful” (Planned, C1).

Supportive external stakeholders, identified by informants, included local city officials, the Association of American Medical Colleges (through the medical school pledge), other nearby hospitals (local competition), the Office of National Drug Control Policy, and state Medicaid programs. In some jurisdictions, direct requests from external stakeholders prompted hospital administrators to act: “The health commissioner here has encouraged hospitals to get more involved” (Established, D1). In a different community, city health department leadership scaled up a city-wide hospital opioid overdose prevention programs and provided funding for hospital-based naloxone distribution.

Some participants described resistance from hospital personnel as a barrier to ACS formation. One such challenge was tension over who best to deliver addiction consults, an issue that arose in some instances with psychiatry consult liaison services: “People get their thing going at a hospital and they see other services as competition” (Planned, E1). This competition was described as a “turf war” (Planned, E1 and M1). Some participants described that hospital administrators impeded ACS establishment by not prioritizing or financing addiction-related issues. An informant, from a hospital without a service, described how their leaders had “no foresight” (None, G1) when it came to addiction-related issues. The informant believed that unless outside forces intervened, like an external mandate requiring OAT delivery or reimbursement incentives, hospital leaders would never provide the necessary resources to improve care for hospitalized patients with OUD.

3.2.3. Addiction-informed institutions with prior or current treatment, training, and research related-resources enhanced hospital readiness for ACS development.

Informants described how prior and current clinical practice, an addiction-related research portfolio, and addiction trained physicians facilitated service formation. Participants described the existence of three clinical practices that preceded consult formation: 1) ad hoc consultations, 2) “curbside consults” (Planned, M1), and 3) phone consultations. Ad hoc consultations occurred when addiction physicians provided either an informal addiction consult directly to a colleague as a favor or provided a consult for another consultation service (“curbside consult”). Prior to ACS formation, one hospital used a paging system to connect providers with addiction experts to support buprenorphine management for non-addiction trained physicians across their hospital.

Normative hospital care standards, specifically the ongoing delivery of evidence-based SUD services, contributed to a supportive environment for ACS development. One informant noted that there was a hospital-wide expectation to deliver OAT: “… [all providers from all services] provide methadone maintenance. It is just routine standard of care, including our surgical services” (Planned, C1). At another hospital, this expectation was a trainee requirement: “We require that all our incoming interns…during new intern orientation [to] get buprenorphine waived” (Planned, O1).

Informants described how the existence of addiction-related resources (i.e., research, clinical programs, physician experts, and fellowship programs) facilitated ACS formation. One informant commented that their institution’s robust addiction research portfolio bolstered service development because institutional leaders viewed the topic with familiarity and positivity. For hospitals, and health systems already operating other addiction-related clinical services (e.g., outpatient services), addiction leaders argued to administrators that ACS creation filled a gap in the care continuum. Participants also felt that addiction trained physicians were critical assets. While some hospitals had existing expertise, others recruited addiction trained physicians to create an ACS or to start an addiction medicine fellowship program. The financial connection between the service and the fellowship was explicit in hospitals where funded fellowship slots supported ACS staffing. In contrast, limited resources, specifically few addiction-trained staff were a common barrier to service development: “We haven’t had enough qualified faculty to be able to do that [start the service] until recently” (Planned, N1). For the two hospitals without plans to start an ACS, an informant lamented: “Manpower is number one” (None, G1) and “It is mostly been for lack of personnel… [to] have the bandwidth to do it” (None, B1). Finally, institutional bureaucratic processes also created barriers to ACS development and implementation:

[when starting a program] …you got to get it cleared by a million different people…it is like dealing with the federal government…you can’t just get everyone in a room really quick and [say] ‘here’s what we are going to do.’ Our size works against us. (Established, H1)

3.2.4. Access to community-based treatment programs upon discharge was a key element for ACS development and operations.

Partnerships with community-based programs were essential to ACS establishment because referral upon discharge was a primary responsibility of the service: “There is no doubt that without pathways to [addiction] treatment in the community we would be hamstrung” (Established, A2). Most informants lamented on the dearth of treatment availability in their network. A few informants, however, perceived their local networks as readily accessible for discharging patients, and thus, this supported service establishment and OAT delivery for hospitalized patients with OUD: “They [community-based treatment programs] were very helpful to us because they offered us [a] pipeline, [a] warm hand off [after consultation] …” (Established, L1). Conversely, informants reported that a limited community treatment resource network diminished ACS creation because of ethical and referral related concerns. Some hospital administrators believed it was unethical to start hospital-based OAT if there was no clear outpatient provider.

Participants noted that post-hospital treatment linkages were often challenging due to: 1) the geographic location of the program in relation to the patient’s residence; 2) the capacity of the treatment programs (e.g., number of beds, number buprenorphine providers, number of clinicians); 3) insurance barriers (e.g. programs not accepting Medicaid); 4) a limited range of programs with the appropriate intensity of services; and 5) discriminatory organizational practices. Informants observed skilled nursing facilities and social service and housing programs deny admission to patients discharged from the hospital on OAT. One informant shared that a particular skilled nursing facility in her community was always full whenever their team tried to discharge a patient there with a history of injection drug use. Another informant observed that outpatient addiction treatment programs were unwilling to invest in resources to care for persons with intravenous antibiotic needs, resulting in: “[patients] sitting here in the hospital for 6 weeks because no treatment center is able to take someone with a PICC line...” (Established, I1).

3.2.5. Restrictive and misinterpreted OAT policies were a common barrier to ACS operations.

Informants described how the existence of and interpretation of OAT-related policies dictated ACS operations. Informants observed widespread confusion about OAT regulations among staff, including the misunderstanding that hospital providers need a special license to administer methadone or a federal buprenorphine waiver to administer buprenorphine for hospitalized patients. One informant reported that misperceptions regarding methadone administration were perpetuated by in-house legal counsel: “…Our legal department is very conservative when it comes to things like that [administration of methadone]” (None, B1). In some instances, inpatient pharmacists incorrectly applied outpatient federal OAT policies to inpatient administration, not allowing for the administration of buprenorphine or methadone, and calling it “illegal” (Established, J1). Sometimes these misconceptions were codified in hospital policies. Informants described formulary and prescribing restrictions, including hospital-imposed limitations on when providers could administer OAT. One hospital, for example, only allowed methadone for OUD as a continued outpatient medication, and required hospital providers who were administering buprenorphine to have a federal buprenorphine waiver. Notably, this hospital did not have an ACS or plans to start one.

In addition to hospital OAT-related policy barriers, external policies impacted ACS operations. State-mandated, time-intensive clinical assessments prior to OTP admission impeded an ACS’s ability to link patients to an OTP post-hospital discharge. Further, many informants were frustrated with federally mandated buprenorphine patient panel limits, OAT regulations imposed by local pharmacy boards, and the Drug Enforcement Administration. OAT pharmacy benefit management strategies were another source of deep frustration:

…if we induce them in the hospital…it is always unclear to me if the insurance company is going to approve the films or the tablets? Are they going to approve the tablet size? Are they going to have a problem with that? I end up re-writing prescriptions quite a bit in the hospital just to get the prior authorization approved for a couple of days.(Established, I1)

Although external policies and regulations were mostly described as impeding care for patients hospitalized with OUD, informants noted some external policies and regulations that supported OAT delivery. Examples included the American College of Surgeons’ trauma level certification (e.g., requires that all patients with trauma be screened for alcohol use disorder); Medicaid expansion (e.g., increasing access to medical care for patients with SUDs); changing telehealth laws (e.g., increasing access to SUD-related care in the rural communities); and Medicaid coverage for drug use disorder treatments.

3.2.6. Addressing financial issues was critical to ACS development and operations.

Respondents from two hospitals shared how their hospital leadership shut-down previously established ACSs because of a lack of sustainable funding. Informants noted financial challenges related to reimbursement (the lack thereof) and securing and sustaining internal financing, which was described as the “the biggest barrier” (Established, A1) and “the hardest thing” (Planned, M1) for ACS formation:

I think really the biggest obstacle [to ACS establishment] is the money. You just got to follow the money…I think people, culturally, are willing to accept that addiction is a disease and to treat it as such. But they aren’t going to do it out of the goodness of their heart. You have to find a way to pay them (Planned, E1).

Like many other hospital services, informants described how their respective ACSs operated from a cost savings model versus a revenue-generating model. The cost-savings model made it challenging for informants to articulate fiscal value to hospital administrators: “No matter what…we operate at a loss…there is not enough billing, our billing does not support the breadth of our team” (Established, A2). In some cases, hospital administrators were compelled to use their institutional power and ability to allocate resources for the ACS based on the “business case” (Established, A2). Addiction trained physicians were the primary champions who developed and presented the business case, which was a revenue and cost analysis, to justify ACS creation at their respective hospital.

Outside the hospital, informants identified third-party payer issues related to ACS service development and operations: a) lack of reimbursement for interprofessional teams; b) prioritization of detoxification beds versus linkage to care; c) reimbursement limitations (e.g., diagnostic related grouping); d) prior authorization and utilization review; and e) limited financial incentives for delivering evidence-based care: “The hospital is not going to turn off that revenue stream [for detox beds] just because they don’t think it is the best idea for the patient” (Established, H1).

4. Discussion

From a purposive sample of 16 well-resourced acute care hospitals we identified six themes, inside and outside the hospital, pertinent to ACS development and operations. These themes included: pervasive stigma and discrimination towards patients with OUD; the influence of key stakeholders (in particular the informants themselves or other addiction experts); addiction-informed institutions with clinical, educational, and research-related resources; local access to community-based addictions treatment; restrictive and misinterpreted OAT policies; and financial issues.

Our findings contribute to a growing literature-base on care for patients with OUD and other drug use disorders during hospitalization. Our meta-theme on stigma and discrimination during hospitalization is well supported by prior research, which suggests that patients hospitalized with OUD and other drug use disorders commonly face stigma and discrimination perpetuated by hospital staff (Biancarelli et al., 2019; Horner et al., 2019; McNeil et al., 2014; Simon, Snow, & Wakeman, 2019). Reassuringly, however, earlier work shows that ACSs can contribute to hospital culture change by reframing addiction as a treatable chronic disease (Englander, Collins, et al., 2018; Priest & McCarty, 2019b). Additionally, prior scholarship describes how structuralized stigma likely creates barriers to OUD treatment through the enactment of health care financing and treatment policies, exclusionary zoning practices, and the criminalization of drug possession: “These types of policies and related decision-making not only reinforce the ways in which people with OUDs are treated separately from others but also implicitly classify people with OUDs as being unworthy of investment and undeserving of treatment” (Tsai et al., 2019, p. 5).

Our findings on stakeholder engagement, complement previously described efforts of a single-site program, in which ACS champions articulated the importance and value of internal and external stakeholder engagement for developing their consult service (Englander et al., 2017). Moreover, other researchers have also identified the importance of a community-based treatment network, and potential programmatic solutions for transitioning hospitalized patients with injection drug use upon discharge, such as medically enhanced residential treatment (Englander, Wilson, et al., 2018) or bridge clinics (Snow et al., 2019). Additionally, our findings on the importance of addiction-informed institutions, and financial resources, are supported by organizational behavior scholarship which asserts that the development of organizational technologies, such as a consult service, are informed by the local and external environment, and social structures, goals, and participants within an organization (Scott, 2003). Finally, the misinterpretation of restrictive OAT policies were a commonly cited barrier to ACS operations, a phenomena which is not well described in the literature, yet persists despite reassurances from the federal government that the delivery of OAT is indeed an allowable practice during hospital admission (Nagel, 2002).

4.1. Study Limitations

There are several study limitations. Study results are from a small sample, of well-resourced and academically-affiliated hospitals; findings may not be transferable to smaller or rural hospitals with less resources. It is possible that the challenges faced by lower-resourced hospitals or hospitals without addiction expertise are different, and alternatively, it may not be possible or sustainable to have an ACS in those contexts. Another study limitation was the variation in key informant involvement with establishing or running their respective ACS—some informants were observers, some were creators, and some worked on the service. This exploratory analysis, however, provides insights into areas for future exploration in subsequent studies.

4.2. Study Implications & Action

Due to the complex interacting and contributory elements identified in this study, individual, institutional, and system-wide action is likely needed to support hospital ACS development and operations (e.g., OAT delivery) (Englander, Priest, et al., 2019). Our study findings support nine practice or policy action elements, which are summarized in Table 1. To address stigma and discrimination, all stakeholders (clinical champions, hospital leaders, hospital societies) could participate in, support, and spread education to eliminate harmful language and stereotypes related to OUD and OAT (Health in Justice Action Lab: Changing the Narrative Initiative, 2019). Moreover, legal experts could be consulted if there is concern that community-based treatment programs are discriminating against patients with OUD and preventing medically necessary placement upon discharge. For example, in May 2018, a U.S. Department of Justice settlement found that a Massachusetts skilled nursing facility violated the Americans with Disabilities Act by excluding a patient who was on OAT for their OUD (Legal Action Center, 2018).

Table 1.

Study Findings and Potential Interventions to Support ACS Development and Operations

Theme Responsible Party Practice or Policy Action
Stigma and Discrimination
Pervasive stigma and discrimination influenced ACS service development and operations 		Clinical Champion AND Hospital Leaders AND Hospital Societies • Normalize addiction-related treatment as part of usual hospital care

• Participate in, support, and spread education related to eliminating harmful language and stereotypes related to OUD and OAT

• Consult with civil rights and disability lawyers for determination of discrimination in community-based treatment settings
Stakeholders
Internal and external stakeholders influenced hospital readiness for ACS development and implementation 		Hospital Leaders • Identify or hire a clinical champion with addiction expertise
Internal Resources
Addiction-informed institutions with clinical, educational, and research related-resources enhanced hospital readiness for ACS development 		Clinical Champions • Draw upon existing expertise and internal resources across the institution to enhance programming
Community-Based Treatment
Access to community-based addictions treatment was a key element for ACS development, implementation, and operations 		Clinical Champions AND Hospital Leaders • Build relationships with community-based treatment partners to ensure patients have appropriate linkages to care upon discharge for addiction and medical-related needs
Treatment Policies
Restrictive and misinterpreted OAT policies were a common barrier to ACS operations 		Clinical Champions ANDHospital Leaders

Hospital Leaders AND Hospital Societies		 • Reach out to internal stakeholders to identify local policy levers for improvement, including reviewing internal policies to ensure alignment with national recommendations

• 1Advocate for the elimination of restrictive OAT policies inside and outside the hospital
Financing
Addressing financial issues was critical to ACS service development and operations 		Clinical Champions AND Hospital Leaders AND Hospital Societies • Negotiate with third-party payers to reimburse for ACS services and OAT delivery
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Table Notes. ACS = addiction consult service; OAT = opioid agonist therapy

1

Also a potential action to address structural stigma.

To initiate ACS development efforts, hospitals should perform an assessment of their existing strengths, gaps, and resources, and identify or hire a clinical champion—a clinician with addiction expertise. In our study, it was the dedication and efforts of clinical addiction experts who championed ACS development at their respective institutions. Clinical champions could draw upon the existing expertise across their institution. This expertise may exist in outpatient care delivery, research departments, or within the educational missions. To ensure patient linkage to care upon discharge, hospital leaders, and clinical champions could build relationships with community-based addiction and medical treatment partners. To improve internal care processes clinical champions and hospital leaders could reach out to internal stakeholders to identify local policy levers. They could specifically request that the hospital P&T committee review their internal OAT policies, in partnership with the inpatient pharmacy, and internal legal departments to ensure that hospital policies match what is allowed by federal law and what is recommend by national experts. More broadly, clinical champions, hospital leaders, and hospital societies could advocate for the elimination of restrictive treatment policies inside and outside the hospital, such as abolishing the x-waiver (Fiscella, Wakeman, & Beletsky, 2019; Frank, Wakeman, & Gordon, 2018), and to create policies that encourage ACS development and the delivery of evidence-based services. Finally, to address issues related to ACS financing, clinical champions, hospital leadership, and hospital societies could negotiate with third-party payers to reimburse for consults from the ACS, and for OAT delivery specifically. Future research could more explicitly define the economic drivers and outcomes of delivering hospital-based addictions care.

The order of these various actions could be tailored to the opportunities and needs of each institution. For example, at some hospitals, there may be enthusiastic clinical champions who may want pilot consult services and collect data on feasibility, acceptability, and preliminary outcomes, even in the absence of institutional funding. This may pave the way for future growth. At other hospitals, hiring a clinical champion may be critical to galvanizing a team, in which case hospital leaders would need to offer up-front financial and resource investments.

5. Conclusion

This study provides preliminary insight on the challenges of ACS development and operations in a cohort of well-resourced hospitals, and suggests that a complex array of interacting elements were influential. Our findings may be useful as hospitals and health systems work to increase the spread of evidence-informed addictions care and OAT delivery across hospitals.

Highlights.

  • Six themes influenced addiction consult service development and operations

  • Stigma and discrimination towards hospitalized patients were pervasive

  • Stakeholders, community treatment access, and financing were influential

  • Addiction-related institutional experience was key

  • Misinterpreted and restrictive OAT policies impeded service operations

Acknowledgements

We thank Dr. Priest’s dissertation committee for their support of her doctoral studies and study participants for their time and contributions.

Sources of Support

This work was supported by the National Institute on Drug Abuse (F30 DA044700, R33 DA035640, UG1 DA015815) and the Greenlick Family Scholarship.

Footnotes

Conflict of Interest

Authors have no competing interests to declare.

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