The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence. 1.Opioid-related disorders-drug therapy. 2.Opioid-related disorders-psychology. 3.Substance abuse-prevention and control. 4.

https://www.zora.uzh.ch/id/eprint/17408/1/opioid_dependence_guidelines.pdf

Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence

ContextThe prevalence of medical disorders is high among substance abuse patients,
yet medical services are seldom provided in coordination with substance abuse
treatmentObjectiveTo examine differences in treatment outcomes and costs between integrated
and independent models of medical and substance abuse care as well as the
effect of integrated care in a subgroup of patients with substance abuse–related
medical conditions (SAMCs)DesignRandomized controlled trial conducted between April 1997 and December
1998Setting and PatientsAdult men and women (n = 592) who were admitted to a large health maintenance
organization chemical dependency program in Sacramento, CalifInterventionsPatients were randomly assigned to receive treatment through an integrated
model, in which primary health care was included within the addiction treatment
program (n = 285), or an independent treatment-as-usual model, in which primary
care and substance abuse treatment were provided separately (n = 307) Both
programs were group based and lasted 8 weeks, with 10 months of aftercare
availableMain Outcome MeasuresAbstinence outcomes, treatment utilization, and costs 6 months after
randomizationResultsBoth groups showed improvement on all drug and alcohol measures Overall,
there were no differences in total abstinence rates between the integrated
care and independent care groups (68% vs 63%, P =
18) For patients without SAMCs, there were also no differences in abstinence
rates (integrated care, 66% vs independent care, 73%; P = 23) and there was a slight but nonsignificant trend of higher costs
for the integrated care group ($36796 vs $32409, P
= 19) However, patients with SAMCs (n = 341) were more likely to be abstinent
in the integrated care group than the independent care group (69% vs 55%, P = 006; odds ratio [OR], 190; 95% confidence interval
[CI], 122-297) This was true for both those with medical (OR, 338; 95%
CI, 168-680) and psychiatric (OR, 210; 95% CI, 104-425) SAMCs Patients
with SAMCs had a slight but nonsignificant trend of higher costs in the integrated
care group ($47081 vs $42795, P = 14) The incremental
cost-effectiveness ratio per additional abstinent patient with an SAMC in
the integrated care group was $1581ConclusionsIndividuals with SAMCs benefit from integrated medical and substance
abuse treatment, and such an approach can be cost-effective These findings
are relevant given the high prevalence and cost of medical conditions among
substance abuse patients, new developments in medications for addiction, and
recent legislation on parity of substance abuse with other medical benefits

/pdf/integrating-primary-medical-care-with-addiction-treatment-a-4sgg9n1p3a.pdf

Integrating primary medical care with addiction treatment: a randomized controlled trial.

https://www.ph.ucla.edu/epi/faculty/detels/DrugAlcDep_Sorensen.pdf

Drug abuse treatment as an HIV prevention strategy: a review

Background: Many injection drug users (IDUs) seek care at emergency departments and some require hospital admission because of late presentation in the course of their illness. We determined the predictors of frequent emergency department visits and hospital admissions among community-based IDUs and estimated the incremental hospital utilization costs incurred by IDUs with early HIV infection relative to costs incurred by HIV-negative IDUs. Methods: The Vancouver Injection Drug User Study (VIDUS) is a prospective cohort study involving IDUs that began in 1996. Our analyses were restricted to the 598 participants who gave informed consent for our study. We used the participants’ responses to the baseline VIDUS questionnaire and, from medical records at St. Paul’s Hospital, Vancouver, we collected detailed information about the frequency of emergency department visits, hospital admissions and the primary diagnosis for all visits or hospital stays between May 1, 1996, and Aug. 31, 1999. The incremental difference in hospital utilization costs by HIV status was estimated, based on 105 admissions in a subgroup of 64 participants. Results: A total of 440 (73.6%) of the 598 IDUs made 2763 visits to the emergency department at St. Paul’s Hospital during the study period. Of these 440, 265 (60.2%) made frequent visits (3 or more). The following factors were associated with frequent use: HIV-positive status (seroprevalent: adjusted odds ratio [OR] 1.7, 95% confidence interval [CI] 1.2–2.6; seroconverted during study period: adjusted OR 3.0, 95% CI 1.6–5.7); more than 4 injections daily (adjusted OR 1.5, 95% CI 1.1–2.1); cocaine use more frequent than use of other drugs (adjusted OR 2.0, 95% CI 1.2–3.6); and unstable housing (adjusted OR 1.5, 95% CI 1.1–2.2). During the study period 210 of the participants were admitted to hospital 495 times; 118 (56.2%) of them were admitted frequently (2 or more admissions). The 2 most common reasons for admission were pneumonia (132 admissions among 79 patients) and soft-tissue infections (cellulitis and skin abscess) (90 admissions among 59 patients). The following factors were independently associated with frequent hospital admissions: HIV-positive status (seroprevalent: adjusted OR 5.4, 95% CI 3.4–8.6; seroconverted during study period: adjusted OR 2.9, 95% CI 1.4–6.0); and female sex (adjusted OR 1.8, 95% CI 1.1–3.1). The incremental hospital utilization costs incurred by HIV-positive IDUs relative to the costs incurred by HIV-negative IDUs were $1752 per year. Interpretation: Hospital utilization was significantly higher among communitybased IDUs with early HIV disease than among those who were HIV negative. Much of the hospital use was related to complications of injection drug use and may be reduced with the establishment of programs that integrate harm reduction strategies with primary care and addiction treatment.

/pdf/hospital-utilization-and-costs-in-a-cohort-of-injection-drug-21gqwdp8bc.pdf

Hospital utilization and costs in a cohort of injection drug users

Individuals with alcohol and drug use problems may receive health care from medical, mental health, and substance abuse providers, or a combination of all three. Systems of care are often distinct and separate, and substantial opportunities for benefit to patient, provider, and payer are missed. In this article, we outline (1) the possible benefits of linking primary care, mental health, and substance abuse services from the perspective of the major stakeholders-medical and mental health providers, addiction clinicians, patients, and society-and (2) reasons for suboptimal linkage and opportunities for improving linkage within the current health care system. We also review published models of linked medical and substance abuse services. Given the potential benefits of creating tangible systems in which primary care, mental health, and substance abuse services are meaningfully linked, efforts to implement, examine, and measure the real impact should be a high priority.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/646882/ioi00065.pdf

Benefits of Linking Primary Medical Care and Substance Abuse Services: Patient, Provider, and Societal Perspectives

OBJECTIVES. Intravenous drug users are at high risk for medical illness, yet many are medically underserved. Most methadone treatment programs have insufficient resources to provide medical care. The purpose of this study was to test the efficacy of providing medical care at a methadone clinic site vs referral to another site. METHODS. Patients with any of four target medical conditions were randomized into an on-site group offered medical care at the methadone treatment clinic and a referred group offered medical care at a nearby clinic. Entry to treatment and use of medical services were analyzed. RESULTS. Of 161 intravenous drug users evaluated, 75 (47%) had one or more of the target medical conditions. Fifty-one were randomized. In the on-site group (n = 25), 92% received medical treatment; in the referred group (n = 26), only 35% received treatment. CONCLUSIONS. Providing medical care at a methadone treatment program site is more effective than the usual referral procedure and is a valuable public he...

K. M. Pabst

Papers

Providing medical care to methadone clinic patients: Referral vs on-site care

Providing medical care to methadone clinic patients: A controlled study of referral versus on-site care