Team-Based Care Solves Safety Problem of Discharging OUD Patient With PICC

To mark Mental Health Awareness Month, I wanted to reflect on a particularly challenging patient case I had as an intern. It highlights the need for psychiatric expertise in hospital leadership and for the creation of integrated care models for the inpatient setting.

My patient was a 30-year-old male with a medical history of opioid use disorder and fistulizing Crohn’s disease complicated by multiple prior surgeries. He was admitted to the general medicine team for yet another Crohn’s flare. Unfortunately for my patient, the gastroenterology consulting team recommended complete gut rest indefinitely due to the severity of his disease, requiring placement of a peripherally inserted central catheter (PICC) line for administration of total parenteral nutrition (TPN). In light of his history of IV drug use and lack of current engagement in addiction treatment, there was significant disagreement among the attending physicians involved in his care regarding discharge.

As an intern during my first months of training, I recall feeling caught up in the push and pull between what other providers and my patient thought was best. My internal medicine attendings understandably felt uncomfortable with discharging the patient with a PICC given concerns about the inappropriate use of the line for injecting drugs and the associated risks of re-infection and/or death from overdose.

My patient said that he felt his autonomy was in jeopardy with any further extension of what had already been a nearly two-week hospital stay, especially since he had a young child at home. During one of the many discussions we had, he asked me, “Do ya’ll treat all patients like this?” It was apparent that the barrage of questions regarding his substance use by multiple providers was stigmatizing; how could it not be seen and felt as such from his perspective?

Challenged by his question, I turned to the literature, and although there are limited data regarding best practices for discharging patients requiring a PICC for TPN administration, an emerging body of literature suggests this practice can be safe among a similar patient population—patients who inject drugs and require outpatient antibiotic therapy. Evidence suggests that patients who inject drugs can be safely discharged on antibiotic therapy and have similar rates of mortality, completion of antibiotic therapy, and line-related complications, but they experience higher rehospitalization rates compared with patients who do not inject drugs, according to Suzuki and colleagues in the Open Forum Infectious Diseases. When medications for opioid use disorder (MOUD) are prescribed for OUD patients who inject drugs, they have better outcomes including improved adherence to antibiotic therapy, decreased risk of re-infection, and reduced overdose mortality. Despite these optimistic findings, less than 20% of patients with OUD received MOUD, per Price et al. in the Journal of Infectious Diseases. I was not surprised that my patient encountered many of the barriers described by Calcaterra et al. in the Journal of Hospital Medicine, as reasons for this low prescription rate, including a lack of clear guidelines, sparse experience and education in prescribing MOUD and caring for patients with substance use disorders among nonpsychiatrists, and stigma.

Mental health awareness starts with us as psychiatrists; we must be the leaders to bring this awareness to physicians in other specialties. We have the privilege of being the experts in harm reduction and caring for patients with substance use disorders and can lend this expertise to our nonpsychiatrist colleagues in the inpatient setting through the use of integrated care models. We have seen great results in improving health care outcomes, lowering costs, and reducing disparities with Collaborative Care models in the outpatient setting.

However, there are fewer models, other than the consultant model, that I have seen in the hospital. A major limitation of the consultant model is that the onus of initiating a consultation is on the primary team, who may lack the knowledge to recognize the need for, or benefits of, a consultation. Use of clinical decision support tools, systems-wide order sets, greater collaboration between psychiatrists and physicians in other specialties, and automatic consults for certain clinical scenarios are some ideas that could improve psychiatrists’ involvement in caring for the needs of complex hospitalized patients.

Thankfully, the collective anxiety my team felt was relieved following collaboration with the addiction psychiatry team. Together, we were able to come up with an evidence-based plan grounded in the principles of harm reduction that both the patient and other providers agreed to, which involved initiation of buprenorphine, connection with outpatient substance use treatment, and discharge home with a PICC.

Mental health awareness must start but cannot end with psychiatrists; our leadership and expertise are needed by both our health care systems and patients in developing and running integrated care models within the inpatient setting. ■