This study sought to describe the patient population that has benefitted from AMCS at HSN in Sudbury, Ontario, Canada; to highlight trends in referrals to community-based addiction support services, ED use, and inpatient use before and after the implementation of AMCS; as well as provide some lessons learned from implementing such services in the era of COVID-19.
Drawing on longitudinal data from HSN's EMR, we identified distinct trajectories of referrals to addiction services, with all referrals peaking between August and October 2020. The results also demonstrated no statistically significant effect on ED and inpatient health care trends after implementing AMCS.
Although AMCS remains a developing form of hospital service, several major hospitals have implemented such services in their centers in recent years in response to the growing number of patients with SUD presenting to acute care settings (16). To the best of our knowledge, HSN is the first Northern regional referral hospital in Ontario that serves rural areas to implement an AMCS. St. Paul's hospital in Vancouver has one of the largest and most long-standing AMCS in North America and reported serving a similar patient population, approximately 60% males in similar age categories (16).
Our primary analysis was descriptive in nature and identified that referrals to out-patient addiction supports from AMCS peaked between August and October 2020. The trend observed in this analysis aligns with the timing of the AMCS implementation. The initiative started at HSN prior to the COVID-19 pandemic, with regional COVID-19 pandemic guidelines beginning March 15, 2020. Figure 1 demonstrated that referrals decreased dramatically between March and May 2020, which aligned with public health stay-at-home orders related to COVID-19. COVID-19 disproportionately burdens people with SUDs, making it more critical than ever to ensure patients are getting adequately treated and connected to care. Further consideration should be given to ways AMCS programs can adapt during the COVID-19 pandemic or other public health emergencies (20). For instance, in Vancouver, Canada, Harris et al. (2021) recently published an article highlighting the need for system, treatment, harm reduction, and discharge planning adaptations during a pandemic (33). This included having telephone-based hospital consultations, providing longer buprenorphine bridge prescriptions at discharge with telemedicine follow-up appointments for tapers or alternatives, and increasing discharge outreach for high-risk patients through designated staff and technology.
Our secondary analysis demonstrated no statistically significant effect on ED and inpatient health care use trends after implementing AMCS. These findings can be explained by several factors, including the consideration of societal norms which focus on punitive measures rather than a compassionate understanding of SUDs, the limited hours of operation of the AMCS, the impact of COVID-19, and lastly, the effect of the increase in the availability and toxicity of synthetic opioids and drug combinations in the drug supply during the study period. Previous studies by Morin et al, showed very high rates of mental health problems among people with OUD (34–36). And that these patents benefitted with reduced morbidity and mortality if they received mental health care from a psychiatrist or family physician while receiving addiction treatment (34, 36). One of the roles of AMCS is to facilitate such coordinated care through arranging psychiatric consultation during the inpatient admission if appropriate. Therefore, there is a possibility that inpatient admissions may have also increased because the introduction of the AMCS provided a more patient-centered and caring experience for patients when they required admission. This may mean that patients with SUDs would be more willing to return to hospital as some of the systemic barriers to accessing acute care, when it is required, were reduced by the intervention of the AMCS.
The evidence is clear that during our study period, the era of COVID-19, grief, isolation, income loss and anxiety around the unknown triggered or exacerbated mental health conditions and led to increased levels of alcohol and drug use, insomnia, and anxiety. Additionally, with the reduction of community-based supports for people with mental health and SUDs, hospitals and EDs became the main point of contact. This combined with the reduction of supports in the community for mental health and addictions led to devastating consequences such as increases in drug overdose deaths (10, 37). The implementation of AMCS at HSN in Sudbury may have mitigated some of the high rates of acute care use during this time. Although our study did not show statistically significant reductions in acute care use in the post AMCS period, perhaps without the AMCS, rates of acute care use would have been much higher.
It is essential to consider that hospital policy and importantly, clinician bias, ideologies, attitudes and core beliefs are essential components to developing a successful AMCS (2, 5, 7, 15–17). Due to legacy hospital policies on substance use, clinicians treating patients with SUD can be at odds with their patients' needs. Considering there is a movement towards hospitals adopting socially accountable care, meaning that service provision addresses the priority health concerns of the population served (38), there is a discordance between the societal norms which focus on punitive measures for substance use and the needs of patients who have a physiologic dependence on a given substance (e.g., opioids). Thus, the culture shift within the hospital may be a significant, yet underappreciated, barrier to successfully implementing an AMCS. Therefore, longer-term mixed-methods evaluation is needed to understand culture change and staff buy-in and to evaluate outcomes over a longer period of time.
Currently, the AMCS only operates during weekdays, limiting the capacity to provide the service to those presenting after hours or on weekends. Priest and McCarty (2019) surveyed nine American hospitals with inpatient addiction medicine services. They found that only one service provided weekend consults, and most services did not provide coverage in the ED (7). This is one area that may need to be further explored and developed as the program matures.
Finally, this implementation study took place at a single academic medical center in Northern Ontario, limiting its generalizability. However, to date, most implementation and evaluation studies have taken place at larger academic centres serving a predominantly urban population. HSN is a mid-sized academic centre that serves a large rural catchment area. This study may offer useful information for other mid-sized centres considering initiating an inpatient addictions medicine consult service. The AMCS model was implemented as a regional model at three other hospitals in Northeastern Ontario. Future studies should seek to include these other hospital programs.
Lessons learned
The AMCS at HSN in Sudbury, Canada, was implemented during a time of collective trauma due to COVID-19, high overdose deaths rates and in an era of significant changes in health service delivery (5, 10, 39). Accordingly, several important lessons have been learned.
Most notably, institutional buy-in is a vital component to the successful implementation of the AMCS. AMCS was implemented as a part of HSN’s strategic plan for 2019–2024. Therefore, despite minimal funding, it was prioritized in the organization. The use of an interprofessional team strengthened the opportunities for patient-centred care. Staff, patient and family input was through surveys was also important in shaping shape the service. Engagement with staff also revealed an appetite by clinicians to improve how they care for people with SUD. Additionally, initiating treatment in the form of medications (e.g., methadone, buprenorphine/naloxone) to interested patients was feasible in the inpatient setting. The need for harm reduction and advocating for harm reduction was also highlighted, particularly for those patients who were not ready to engage in treatment discussions. This suggests that building organizational support and developing a supportive harm reduction policy are essential for other organizations. The need for mutual respect between patients and clinicians has also been a key factor in the implementation of AMCS. Commitment to these tenants was crystalized in a Harm Reduction Position Statement in Appendix C, which was adopted by hospital administration and staff in January of 2021 and ongoing education provided throughout the organization surrounding this.