A first-of-its-kind substance use disorder screening tool is piloted at New Hampshire Hospital
New Hampshire Hospital provides acute, inpatient psychiatric services. (Hadley Barndollar | New Hampshire Bulletin)
A person experiencing a schizophrenic episode is admitted to New Hampshire Hospital, unable to accurately convey information about themselves to doctors. That means weeks might pass before a co-occurring substance use disorder is identified.
Dr. Corneliu Stanciu consistently saw those missed opportunities for intervention, and a failure on the hospital’s part to set individuals up for a successful discharge down the line. If doctors could identify a substance use disorder early on without depending on the patient’s input, how could that influence outcomes?
New Hampshire Hospital is the state’s 202-bed acute psychiatric facility, where most patients are admitted involuntarily. Stanciu, the hospital’s director of addiction services, has designed what is believed to be a first in the medical field: a data-driven substance use disorder screening algorithm for patients with severe mental illness, one that is entirely objective.
Featured in a peer-reviewed study published in The Primary Care Companion for CNS Disorders in May, the screening tool uses data points from available medical and law enforcement records that can indicate the need for an early screening by a psychiatrist who specializes in substance use disorder.
That early intervention, Stanciu said, can increase the likelihood of patient success upon discharge.
“When one is in an acute psychiatric crisis, they’re not always able to accurately and even at all provide the input,” said Stanciu, who is also an assistant professor of psychiatry at Dartmouth Geisel School of Medicine. “They may be so disorganized that we’re not able to have these types of conversations early on in their admission. We’re missing that window of opportunity to intervene right away.”
The Primary Care Companion for CNS Disorders study, which included 302 New Hampshire Hospital patients ages 18 to 65, found the screening tool “holds promise in its ability to improve objective and timely identification of substance use in a seriously mentally ill inpatient population, helping to facilitate treatment.”
Dr. Jeffrey Fetter, chief medical officer at New Hampshire Hospital and a co-author of Stanciu’s study, recalled being told as a medical student that depression needs to be treated before substance use. On a different day, he’d be told substance use needs to be treated before depression.
“But what we’ve learned is it works better if you don’t do that,” he said. “It works better if you treat both things at the same time.”
Screenings of all kinds are common in medicine, particularly for substance use. But existing screenings, which rely heavily on subjective self reporting and are often used in primary care settings, weren’t necessarily feasible for much of the population New Hampshire Hospital serves – individuals with severe mental illness such as schizophrenia, bipolar disorder, and major depressive disorder.
While New Hampshire Hospital is not primarily a substance use disorder treatment facility, mental illness and substance use are common co-occurring diagnoses, meaning many of the individuals admitted are grappling with both.
According to the Substance Abuse and Mental Health Services Administration’s 2021 National Survey on Drug Use and Health, approximately 9.2 million adults in the U.S. had a co-occurring disorder.
Unique about Stanciu’s screening algorithm is that it doesn’t rely on patient input. In fact, the patient doesn’t even need to be there. Doctors instead use best evidence to determine if the person would benefit from an initial substance use disorder consultation.
That includes medical charts and records, such as urine toxicology, blood alcohol level, and prior documentation of substance use; current and past medication regimens; and interactions with law enforcement and the court system.
Between 2019 and 2021, Stanciu and other Dartmouth Health specialists at New Hampshire Hospital collected data necessary to later pilot the algorithm in one general admission unit, resulting in “several hundred patient referrals.” Working with Dartmouth statisticians, they continue to compare how its implementation does versus the current standard of care in the hospital’s other seven units.
Stanciu and Fetter both discussed substance use as a comorbidity, meaning it’s critical to identify as early as possible in a patient’s hospital stay. If it flies under the radar, staff may miss the chance to “coordinate the best possible discharge for that patient.”
“Once you discharge a patient back into the community, if you don’t have a good continuity of care plan, it all didn’t matter,” Fetter said.
Outcomes from the algorithm, Stanciu said, are “looking very good on paper.” But for it to be statistically significant, they’ll need more data and another year or so of observation. The goal is to ultimately see the screening tool generalized and implemented at acute psychiatric hospitals elsewhere.
Stanciu sees the algorithm impacting individuals and public health as a whole. Not adequately tackling substance use within a facility like New Hampshire Hospital, he said, has “significant financial and human costs.”
The need has grown exponentially since the COVID-19 pandemic, and is demonstrated by the hospital’s capacity numbers. As of Oct. 26, the facility did not have a single open bed.
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