From access to attrition : exploring the role of hospitals in a longitudinal continuum of care for substance use disorder

Background: Hospitals are an important setting to engage individuals with a substance use disorder (SUD) in evidence-based treatment. However, challenges to engagement exist, including: few patients receiving addiction treatment in hospital, frequent discharges against medical advice, and high rates of attrition from hospital-initiated treatment following discharge. The overall aim of this thesis is to explore factors shaping access to, and strategies to prevent attrition from, ongoing addiction treatment for individuals with a SUD assessed in hospital. Methods: This thesis conducts a systematic review of the existing literature on hospital-based interventions for individuals with a SUD which aim to ensure ongoing care following discharge from hospital. Drawing from a cohort study of individuals with a SUD assessed for hospital-based addiction care, the thesis characterizes this population an explores factors associated with linkage to primary care services among those assessed in an inpatient setting compared to individuals in a hospital-based outpatient addiction clinic. Results: Studies in the systematic review included: 8 randomized controlled trials (31%) and 18 quasi- experimental, observational, and pre-post designs (67%). Included studies summarize pharmacological (27%) and non-pharmacological interventions (73%). The second chapter in this thesis showed that of the 536 included study participants, almost one-third (31%) were between the ages of 30 and 39 years, almost two-thirds (63%) identified as being White, and almost three-quarters (74%) reported male sex at birth. Almost half of participants reported either homelessness or living in a single room occupancy (20% for both). Frequent health care access was also common. Finally, the third chapter found that age (per year older) was positively associated with increased primary care access for both those assessed in inpatient and outpatient settings, while income assistance was positively associated in only the outpatient group. Daily alcohol use and unstable housing were negatively associated with access to primary care services among the inpatient and outpatient groups, respectively. Conclusion: Overall, the results of this thesis indicated that to ensure long-term success with addiction treatment initiated in hospital settings, patients need to be supported at discharge from hospital and when re-established in the community by primary care providers.Medicine, Faculty ofExperimental Medicine, Division ofGraduat