Opioid Use Disorder Medications After Hospitalization—Rethinking Engagement in Care

Abstract

Increasingly, health systems are recognizing hospitals as a critical touchpoint in the opioid use disorder (OUD) care continuum. Rapidly emerging evidence from observational studies show that interprofessional hospital-based addiction consultation services (ACS) c an mitigate stigma toward people who use drugs, increase patients' trust in hospital clinicians, increase in-hospital use of methadone and buprenorphine, reduce patient-directed discharges, educate a hospital workforce, transform health systems, and reduce mortality after hospital discharge. 1 Hospitalized people with OUD experience disproportionately high morbidity and mortality. 2 Methadone and buprenorphine are lifesaving and the most effective treatment for OUD, yet most hospitalized patients who need them do not access them. 3 This real-world, step-wedge cluster randomized clinical trial by McNeely and colleagues 4 compares outcomes in 6 New York City hospitals during a period of treatment as usual with a period when the hospitals provided interprofessional ACS intended to facilitate posthospital treatment initiation and engagement with medication for OUD (MOUD), including methadone, buprenorphine, and extended-release naltrexone, for patients with OUD. The authors found that admission to a hospital with an ACS was associated with 8-fold higher odds of MOUD initiation in the 14 days after discharge and almost 7-fold higher odds of engagement in the subsequent 30 days. This study is the most rigorous evaluation of interprofessional ACS to date and provides more compelling evidence for hospitals, health systems, and payers to adopt and expand ACS.While the relative odds of initiating and engaging in MOUD after discharge between hospitals with ACS are impressive, the absolute effect size was modest; even in hospitals with ACS, only 11% of people not taking MOUD at admission initiated MOUD after discharge, and 7.4% sustained engagement in the subsequent 30 days. This raises important questions. It is possible that in New York City, with a relatively high density of available treatment, patients who want MOUD are already taking it. In the study by McNeely et al, 4 42% of otherwise eligible patients were excluded because they had received MOUD in the 30 days before admission; among patients not taking MOUD, 6.7% of people admitted to hospitals without ACS initiated MOUD. This differs greatly from previous estimates in other regions;