Literature Collection

BACKGROUND: Substance use is prevalent in Canada, yet treatment is inaccessible. The Rapid Access to Addiction Medicine (RAAM) clinic opened at the University Health Network (UHN) in January 2018 as part of a larger network of addictions clinics in Toronto, Ontario, to enable timely, low barrier access to medical treatment for substance use disorder (SUD). Patients attend on a walk-in basis without requiring an appointment or referral. We describe the RAAM clinic model, including referral patterns, patient demographics and substance use patterns. Secondary outcomes include retention in treatment and changes in both self-reported and objective substance use. METHODS: The Electronic Medical Record at the clinic was reviewed for the first 26 weeks of the clinic's operation. We identified SUD diagnoses, referral source, medications prescribed, retention in care and self-reported substance use. RESULTS: The clinic saw 64 unique patients: 66% had alcohol use disorder (AUD), 39% had opiate use disorder (OUD) and 20% had stimulant use disorder. Fifty-five percent of patients were referred from primary care providers, 30% from the emergency department and 11% from withdrawal management services. Forty-two percent remained on-going patients, 23% were discharged to other care and 34% were lost to follow-up. Gabapentin (39%), naltrexone (39%), and acamprosate (15%) were most frequently prescribed for AUD. Patients with AUD reported a significant decrease in alcohol consumption at their most recent visit. Most patients (65%) with OUD were prescribed buprenorphine, and most patients with OUD (65%) had a negative urine screen at their most recent visit. CONCLUSION: The RAAM model provides low-barrier, accessible outpatient care for patients with substance use disorder and facilitates the prescription of evidence-based pharmacotherapy for AUD and OUD. Patients referred by their primary care physician and the emergency department demonstrated a reduction in median alcohol consumption and high rates of opioid abstinence.

BACKGROUND: Various programs aimed at fostering the resilience of students have been implemented into healthcare undergraduate and postgraduate educational courses and degree programs. Which of these increase their participants' resilience under which circumstances, for whom and why remains uncertain. METHODS: A realist review of articles reporting program outcomes as measures of resilience through the use of via validated psychometric surveys was conducted to investigate which contexts favour the development of resilience of healthcare and health sciences students and which mechanisms have to be activated to achieve this outcome. RESULTS: Thirteen Context-Mechanism-Outcome Configurations were synthesised from data presented in 43 articles. These were combined with theories explaining the theoretical and psychological frameworks underpinning programs to develop a program theory of how and why resilience fostering programs work. Contexts which favour the development of resilience were the use of validated psychological frameworks as program foundation, e.g. Cognitive Behavioural Therapy, mindfulness-based training. Expert facilitation, longitudinal integration into curricula, flexible and multi-modal design and delivery, and opportunities for students to apply and practice resilience-building strategies also created favourable contexts. Meeting students' or practitioners' needs activated mechanisms of trust, engagement and recognition of a program's value and real-world benefits. An increase in resilience was achieved by students developing reflective skills, metacognitive awareness and positive habits of mind. CONCLUSION: The program theory established via a realist review provides guidance on how the individual resilience of healthcare students can be fostered throughout their undergraduate, postgraduate degrees and early practice, potentially supporting them to flourish and remain long-term in their chosen professional roles.

OBJECTIVE: To examine how clinical care navigation-assistance in accessing healthcare and social services-relates to mental healthcare utilization and clinical outcomes, and whether effects are consistent for people of color. METHODS: This retrospective cohort study included participants using a digital mental health benefit (Spring Health), sponsored by 2,045 US employers from 2018-2023. Participants had access to therapists and Care Navigators, clinicians who help select treatment options and schedule appointments. Primary measures were care utilization (conversion to care, multiple-session attendance) and clinical effectiveness (treatment duration, PHQ-9 depression scale, GAD-7 anxiety scale). RESULTS: 36,964 participants had at least 1 mental health assessment and complete demographic information. 13,122 participants who used care navigation were matched to 23,842 participants who did not with 1:2 propensity score matching using demographic and clinical characteristics. Care navigation was associated with increased therapy utilization (OR, 7.10; 95% CI, 3.36-15.00, P < 0.001), multiple-session attendance (OR, 1.57; 95% CI, 1.46-1.69, P < 0.001), number of treatment sessions (IRR, 1.36; 95% CI, 1.33-1.39, P < 0.001), additional clinical improvement (depression: 0.93 points, 95% CI, 0.11-1.75; anxiety: 0.87 points, 95% CI, 0.12-1.62) compared to therapy alone for participants with severe baseline symptoms. White participants and participants of color had similar outcomes. CONCLUSIONS: Participants using care navigation had improved mental healthcare utilization, retention, and reduced depression and anxiety, which was consistent for people of color. Clinical implementation of care navigation may be associated with greater engagement in care, a key requisite for improving treatment outcomes.

BACKGROUND: Hospitalized patients with opioid use disorder (OUD) are rarely started on buprenorphine or methadone maintenance despite evidence that these medications reduce all-cause mortality, overdoses, and hospital readmissions. OBJECTIVE: To assess whether clinician education and a team of residents and hospitalist attendings waivered to prescribe buprenorphine increased the rate of starting patients with OUD on buprenorphine maintenance. DESIGN, SETTING, AND PARTICIPANTS: Quality improvement study conducted at a large, urban, academic hospital in Maryland involving hospitalized patients with OUD on internal medicine resident services. INTERVENTION: We developed a protocol for initiating buprenorphine maintenance, presented an educational conference, and started the resident-led Buprenorphine Bridge Team of residents and attendings waivered to prescribe buprenorphine to bridge patients from discharge to follow-up. MEASUREMENTS: The percent of eligible inpatients with OUD initiated on buprenorphine maintenance, 24 weeks before and after the intervention; engagement in treatment after discharge; and resident knowledge and comfort with buprenorphine. RESULTS: The rate of starting buprenorphine maintenance increased from 10% (30 of 305 eligible patients) to 24% (64 of 270 eligible patients) after the intervention, with interrupted time series analysis showing a significant increase in rate (14.4%; 95% CI, 3.6%-25.3%; P = .02). Engagement in treatment after discharge was unchanged (40%-46% engaged 30 days after discharge). Of 156 internal medicine residents, 89 (57%) completed the baseline survey and 66 (42%) completed the follow-up survey. Responses demonstrated improved resident knowledge and comfort with buprenorphine. CONCLUSION: Internal medicine resident teams were more likely to start patients on buprenorphine maintenance after clinician education and implementation of a Buprenorphine Bridge Team.