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Background Hospital-based strategies that link persons with infectious complications of opioid use disorder (OUD) to medications for OUD (MOUD) are of great interest. The objective of this study is to determine whether a hospital-based protocol would increase the use of MOUD and to identify barriers to MOUD during admission and at the time of discharge. Methods This study included participants with a documented or suspected history of injection drug usage receiving care for an infection at the University of Alabama at Birmingham Hospital from 2015 to 2018. The protocol, the intravenous antibiotic and addiction team (IVAT), included Addiction Medicine and Infectious Diseases consultation and a 9-item risk assessment. We quantified MOUD use before and after IVAT and used logistic regression to determine factors associated with MOUD. We explored barriers to MOUD uptake using chart review. Results A total of 37 and 98 patients met criteria in the pre- and post-IVAT periods, respectively. With IVAT, the percentage with OUD receiving MOUD significantly increased (29% pre-IVAT and 37% post-IVAT; P = .026) and MOUD use was higher in “high risk” participants (62%). Clinical and sociodemographic factors were not associated with MOUD receipt. Conclusions A hospital-based protocol may increase the use of MOUD; however, the uptake of MOUD remains suboptimal (

Background Hospitalized persons who inject drugs are at a greater risk of adverse hospital outcomes including discharge against medical advice, inpatient illicit drug use, overdose, and death. However, there are limited data on the frequency and outcomes of these events in the United States. Methods This retrospective analysis included patients with injection-related infections receiving a protocol for injection drug use (IDU) at University of Alabama at Birmingham Hospital from 2016 to 2017. In-hospital IDU was suspected or reported drug usage plus confirmatory drug screen, and documented discharges “against medical advice” were deemed patient-directed discharges (PDD). We analyzed the frequency of and associations between in-hospital IDU, PDD, 30-day readmission, and deaths (between 2016 and 2019) using McNemar’s tests. Logistic regression models evaluated the association between PDD, in-hospital IDU, readmission, and death. Results Overall, 83 patients met inclusion criteria: 28 (34%) with in-hospital IDU, 12 (14%) PDD, 9 (11%) died, and 12 (14%) 30-day readmission. In-hospital IDU was significantly associated with PDD (P = .003), 30-day readmission (P = .005), and death (P = .0003). Patient-directed discharges and 30-day readmission were not significantly associated with death nor with each other. Conclusions In a cohort of patients receiving inpatient care for injection-related infections, illicit drug use, PDD, 30-day readmissions, and death were common. Furthermore, patients who use illicit drugs while hospitalized are significantly more likely to leave early, be readmitted, and/or die. We must design models of care that prevent adverse outcomes, including drug use and PDD, to reduce barriers to evidence-based treatment of infections., In hospitalized patients with injection related infections, we found that illicit drug use, premature discharge, readmissions and death were common. Further, those who use illicit drugs while hospitalized are significantly more likely to leave early, be readmitted and die.

A 9-point risk assessment identified persons with a history of injection drug use who were safe for discharge. "Low-risk" patients were discharged with outpatient antibiotics; others continued inpatient treatment. Use of the assessment reduced the mean length of stay by 20 days and total direct cost by 33%, creating capacity for an additional 333 patients.

Several studies have demonstrated the importance of agonist therapies such as methadone and buprenorphine for preventing relapse for individuals being released from jail or prison to the community. No studies have examined the impact of methadone for increasing the completion of community supervision requirements and preventing opioid relapse for individuals under community corrections supervision. This observational study compared the community corrections completion rate and opioid relapse rate of individuals receiving methadone maintenance therapy (MMT) to individuals who did not.Of the 2931 individuals enrolled under criminal justice supervision in the community, Treatment Accountability for Safer Communities (TASC), and who met criteria for opioid dependence, 329 (11%) individuals reported receiving MMT in the community.The majority of participants were White (79.8%) and male (63.5%), with a mean age of 31.33years (SD=9.18), and were under supervision for 10.4months (SD=9.1). MMT participants were less likely to fail out of supervision compared to individuals not in MMT (39.0% vs. 52.9%, p0.001), and had a lower rate of relapse (32.9%) and longer time to relapse (average days=89.7, SD=158.9) compared to the relapse rate (55.9%) and time to relapse (average days=60.5, SD=117.9) of those not on MMT.While the observational nature of this study prevents causal inferences, these results suggest that utilization of MMT in community corrections may increase the likelihood of completing supervision requirements and delay time to opioid relapse. Providing agonist therapies to opioid dependent individuals under supervision appears to be a critical strategy in this important population.

Background We implemented an Intravenous Antibiotics and Addiction Team (IVAT) intervention to identify hospitalized persons with a history of injection drug use (IDU) that are safe for discharge with IV antibiotics based on a 9-point risk assessment. IVAT has been shown to reduce average length of stay (ALOS) without increasing readmissions. We analyzed the cost savings of the IVAT to the health system. Methods PWID at the University of Alabama at Birmingham (UAB) hospital with indications for prolonged IV antibiotics received IVAT to determine risk of continued IDU. “Low-risk” patients were discharged for outpatient antibiotics and addiction care; others continued inpatient antibiotics, group therapy, opioid agonist therapy (if applicable), and weekly assessment for discharge readiness. Cost of care was defined by direct costs and was obtained by querying financial accounts. Results A total of 37 pre-IVAT and 111 post-IVAT admissions (including 25 “low risk”) met study criteria. IVAT reduced ALOS by 20 days. Total direct costs per admission in the post-IVAT period were 33% lower: $26,014 versus $38,716 (Table 1). Because ALOS at UAB for all patients is 6.58 days, a 20-day ALOS reduction following IVAT creates capacity for an additional 333 patients (n = 20/6.58 × 111). Conclusion IVAT for PWID allows health systems to focus inpatient resources on those at greatest risk of ongoing IVDU, creates additional inpatient capacity, and may cut hospital direct costs by one-third. Table 1: Hospital Utilization Before and After IVAT Implementation Inpatient Costs Pre-Intervention January 2015–February 2016 Post-Intervention October 2016–January 2018 Number of admissions N = 37 N = 111 Risk group Low N/A 25 (27%) Medium 56 (61%) High 56 (61%) 11 (12%) Total direct costs $1,432,497 $2,887,515 Average LOS 42 22 Uninsured patients 20 (54%) 53 (48%) Medicaid beneficiaries 13 (35%) 31 (28%) Medicare beneficiaries 3 (8%) 9 (8%) Commercially insured patients 1 (3%) 18 (16%) Inpatient costs per admission Total direct costs $38,716 $26,014 Direct costs/day $922 $1,182 Inpatient costs per admission categorized by service Nursing costs $16,305 $9,139 Pharmacy costs $8,829 $5,720 Surgery costs $4,986 $3,474 ICU costs $2,568 $2,081 Disclosures J. M. Rodriguez, finch: Research Contractor, Research support. seres: Research Contractor, Research support.

Aims This project sought to demonstrate the feasibility and acceptability of providing on-site buprenorphine treatment to individuals under community corrections supervision. Methods Seventeen women and 13 men were enrolled on-site over a 2-week period at a community corrections location. Study participants received open-label study medication dispensed weekly over 12 weeks, weekly medication management therapy, and returned for a 1-month follow-up. Results Participants were predominantly female (56%) and white (90%) with an average age of 31.7 ± 7.4 years. More than half (53%) had hepatitis C virus infection and 75.9% reported intravenous use of opioids in the 30 days before treatment. Rates of illicit substance use was high, as 37.9% of urines were positive for benzodiazepines, 31.7% were positive for cocaine, and 13.7% were positive for alcohol across the time in the study. Although rates of positive urines for opiate use and sex with multiple partners did not change during treatment, rates of injection drug use significantly decreased during treatment. Overall, 86.7% of participants were retained through the 1-month follow-up with low rates of adverse events. Conclusions Acceptability and feasibility of this approach were demonstrated by the ability to enroll and randomize the target sample of participants over 2 weeks with high retention and low rates of adverse events through 1-month follow-up. This pilot study demonstrated that this population could be successfully engaged in treatment and show reductions in risky behaviors. However, more intensive interventions may be needed to reduce opiate use to reach this vulnerable population at their point of contact with the criminal justice system.

To date, there is a lack of long-term safety and efficacy data for iron chelation therapy in transfusion-dependent patients with sickle cell disease (SCD). To evaluate the long-term safety and efficacy of deferasirox (a once-daily oral iron chelator), patients with SCD completing a 1-year, Phase II, randomized, deferoxamine (DFO)-controlled study entered a 4-year extension, continuing to receive deferasirox, or switching from DFO to deferasirox. Average actual deferasirox dose was 19·4 ± 6·3 mg/kg per d. Of 185 patients who received at least one deferasirox dose, 33·5% completed the 5-year study. The most common reasons for discontinuation were withdrawal of consent (23·8%), lost to follow-up (9·2%) and adverse events (AEs) (7·6%). Investigator-assessed drug-related AEs were predominantly gastrointestinal [including nausea (14·6%), diarrhoea (10·8%)], mild-to-moderate and transient in nature. Creatinine clearance remained within the normal range throughout the study. Despite conservative initial dosing, serum ferritin levels in patients with ≥ 4 years deferasirox exposure significantly decreased by -591 μg/l (95% confidence intervals, -1411, -280 μg/l; P = 0·027; n = 67). Long-term deferasirox treatment for up to 5 years had a clinically acceptable safety profile, including maintenance of normal renal function, in patients with SCD. Iron burden was substantially reduced with appropriate dosing in patients treated for at least 4 years.

Background Injection drug use (IDU) is a growing epidemic, and persons who inject drugs (PWID) are at high risk for infection. IDU is a barrier to outpatient parenteral antimicrobial therapy (OPAT) and provider experience and knowledge may lead to variation in patient care. Recognizing this problem, a multi-disciplinary team implemented a protocol for management of PWID requiring IV antibiotics. The main goals were to standardize the evaluation and risk assessment of PWID with infections and to provide substance abuse counseling and treatment in order to decrease length of stay (LOS). Methods A protocol was developed outlining the evaluation, diagnosis, risk-assessment, treatment, maintenance, and follow up of PWID requiring prolonged IV antibiotics (Figure 1). Patients meeting inclusion criteria were identified and the multidisciplinary team assessed the patient. ID confirmed the diagnosis and outlined the treatment plan, and addiction medicine performed a 9-point risk assessment. Low-risk patients were discharged to complete OPAT. Medium risk and high-risk patients remained hospitalized and were offered group therapy, opioid replacement therapy if applicable, and were reassessed weekly for discharge. These patients were compared with previously identified PWID requiring antibiotics prior to the protocol implementation. Results 37 patients pre-protocol were compared with 34 patients following implementation. Demographics were similar except 56% of the post-implementation group were diagnosed with a concomitant psychiatric disorder vs. 27% in the pre-implementation group (P = 0.01). There was no statistical difference between the number of patients who left AMA in either group (13.5 % pre; 23.5% post; p 0.28) or the number of readmissions (51.4% pre; 32.4% post; P = 0.10). However, the median LOS was significantly reduced in the post implementation group (18. days vs. 42 days; P Conclusion Implementation of a standardized protocol with a multidisciplinary team and risk stratification to determine appropriate patients for discharge has led to improvement in LOS as well as improved addiction care for hospitalized PWID requiring long-term antibiotics. Disclosures All authors: No reported disclosures.

Background The use of heroin and prescription opioids has increased over the past decade. The concurrent use of opioids with other depressants such as benzodiazepines increases the risk of overdose death compared with use of either drug alone. This study examined factors associated with concurrent use of opioids and benzodiazepines in a criminal justice sample in the state of Alabama. Methods The Addiction Severity Index (ASI) and urine drug screen results from 28,570 individuals who were under community corrections supervision from 2002–2012 were examined for independent or concurrent opioid and benzodiazepine use. Multinomial logistic regression analyses were conducted to determine associations between socio-demographic characteristics and drug use. Results Concurrent use was detected in 11.5% of the sample. Concurrent use of opioids and benzodiazepines or use of either drug alone was associated with being White, female, married, prescribed psychiatric medications, having seen a physician in the past two years, cannabis use, and having a drug-related offense. Concurrent users were more likely to be unemployed or disabled and have received counseling, and less likely to have completed college, live with relatives or friends, have a history of hallucinations, or have an offense against a person relative to nonusers. Discussion While significant overlap of risk factors exists between individuals with concurrent use versus sole use of opioids or benzodiazepines, individuals with concurrent use generally have more social dysfunction than individuals who tested for either substance alone. Concurrent users may need more psychosocial resources and intensive treatments to promote recovery.

Opiate overdose is an increasingly common cause of death, yet could be easily treated with available opioid antagonists. Opiate use is very common in criminal justice populations, and individuals recently released from prisons or jails are an especially vulnerable group for both overdose and death, particularly in the immediate postrelease period. Participants (N =478) were individuals under community corrections supervision who were surveyed about their opioid use, overdose history, medical history, and demographics. Most participants were male (67.4 percent) and either African American (52.4 percent) or Caucasian (44.2 percent) with an average age of 35 years (SD = 11.1). Two hundred twenty participants (46 percent) reported lifetime use of opioids, whereas 88 (40 percent) reported experiencing an opioid-related overdose. Relative to those with no history of opioid overdose or lifetime opioid use, participants with a history of opioid overdose were more likely to be Caucasian, female, and report higher educational attainment; more likely to be willing to receive additional training about overdose; and reported double to triple the rates of witnessing an overdose or knowing someone who had died from overdose —78 percent and 69 percent, respectively. The rates of actions taken when witnessing overdose were relatively low: 59 percent had called 911, 33 percent had taken someone to a hospital with 23 percent providing no intervention, and only 4 percent having used an opioid antagonist, naloxone. These findings suggest that while opioid overdose is a significant problem in the criminal justice population, affected individuals are open to instruction in effective strategies, such as naloxone training, to prevent fatal opioid overdose.

Recent studies have demonstrated the efficacy of both methadone and buprenorphine when used with opioid dependent men transitioning from prison to the community, but no studies have been conducted with women in the criminal justice (CJ) system. The aim of this study was to determine the efficacy of buprenorphine for relapse prevention among opioid dependent women in the CJ system transitioning back to the community.36 women under CJ supervision were recruited from an inpatient drug treatment facility that treats CJ individuals returning back to the community. Nine were enrolled in an open label buprenorphine arm then 27 were randomized to buprenorphine (n=15) or placebo (n=12; double-blind). All women completed baseline measures and started study medication prior to release. Participants were followed weekly, provided urine drug screens (UDS), received study medication for 12 weeks, and returned for a 3-month follow-up. Intent-to-treat analyses were performed for all time points through 3 month follow-up.The majority of participants were Caucasian (88.9%), young (M±SD=31.8±8.4 years), divorced/separated (59.2%) women with at least a high school/GED education (M±SD=12±1.7 years). GEE analyses showed that buprenorphine was efficacious in maintaining abstinence across time compared to placebo. At end of treatment, 92% of placebo and 33% of active medication participants were positive for opiates on urine drug screen (Chi-Square=10.9, df=1; p0.001). However, by the three month follow-up point, no differences were found between the two groups, with 83% of participants at follow-up positive for opiates.Women in the CJ system who received buprenorphine prior to release from a treatment facility had fewer opiate positive UDS through the 12 weeks of treatment compared to women receiving placebo. Initiating buprenorphine in a controlled environment prior to release appears to be a viable strategy to reduce opiate use when transitioning back to the community.