(22) Secondary Outcomes from the START RCT to Improve OUD Care for Inpatients

Background & Introduction: Substance use disorders, particularly opioid use disorder (OUD), are prevalent and costly in inpatient settings, yet often go unaddressed during hospitalization. While medications for opioid use disorder (MOUD) are effective, they are seldom initiated in hospitals or continued post-discharge. We assessed secondary outcomes from the Substance Use Treatment and Recovery Team (START) intervention, an inpatient addiction consult service to determine its effectiveness in increasing: 1) OUD specific discharge planning; 2) initiating or continuing MOUD within 30 days after discharge; 3) patient follow-up to any outpatient OUD care after discharge; and 4) post-discharge substance use (increase, no change, or decrease). In-patient addiction consult programs have the potential to improve hospital discharge instructions, increase continuity of care, and improve patient outcomes including substance use following discharge.

Methods: We randomized patients (age  18 years) to receive START or usual care (UC) in three public academic medical hospitals in three U.S. states. Of 442 patients referred by medical teams or identified through an automated electronic medical record report, 325 (73.5%) were eligible and randomized: 164 to START and 161 to UC. Of those, 229 (70.5%) completed a 1-month post-discharge follow-up interview. We report risk ratios (aRR) for secondary outcomes except for discharge planning for which we report an odds ratio (aOR) for the ordinal outcome. All are adjusted for site and any prior buprenorphine treatment.

Results: Participants were 66% male, 48% Hispanic; 39% White, 7% Black, 9% American Indian or Alaska Native, 7% more than one race, 1% Asian, and 38% another race. Median age (Q1, Q3) was 41 years (32, 50). START participants relative to UC participants were significantly more likely to: 1) have an OUD specific discharge plan with follow-up visit date [aOR=2.46, 95% CI=(1.61,3.74)], and (2) to initiate or continue MOUD within the 30 days post-discharge [aRR=1.71, 95% CI: (1.23, 2.39)]. START participants were also more likely to have at least one visit for outpatient OUD care post-discharge [aRR=1.88 95% CI=(1.17, 3.03)]. A majority of participants in both START and UC reported declines in substance use: 64.8% had lower use of pain medication, heroin (79.0%), fentanyl (72.5%), and methamphetamine (81.3%).

Conclusion & Discussion: The START intervention had a significant positive impact on key aspects of OUD care and patient outcomes. START participants showed markedly improved rates of OUD-specific discharge planning, MOUD initiation or continuation, and engagement in outpatient OUD care relative to UC. Reduction in substance use was also reported by a majority of participants in both arms. These findings coupled with our previously reported positive primary outcome results underscore the potential for inpatient addiction consultation services to bridge critical gaps in the care continuum for patients with OUD. By facilitating smoother transitions from inpatient to outpatient settings and promoting sustained engagement in evidence-based treatments, interventions like START can potentially reduce hospital readmissions, lower healthcare costs, and most importantly, improve long-term outcomes for patients struggling with OUD.

References: Ober AJ, Murray-Krezan C, Page K, Friedman PD, Osilla K, Ryzewicz S, Huerta S, Mazer M, Leamon I, Messineo G, Watkins KE, Nuckols T, Danovitch I. The Substance Use Treatment and Recovery Team (START) Study: Protocol for a Multi-site Randomized Controlled Trial Evaluating an Intervention to Improve Initiation of Medication and Linkage to Post-discharge Care for Hospitalized Patients with Opioid Use Disorder. Addiction Science and Clinical Practice 2022; e-pub 28 July; 17(1) 1-6. PMCID: PMC9331017. https://doi.org/10.1186/s13722-022-00320-7.

Ober AJ, Murray-Krezan C, Page K, Friedmann PD, Anderson J, Osilla KC, Ryzewicz S, Huerta S, Nuckols T, Hoskinson R, Garvey R, Peltz A, Watkins KE, Nuckols T, Mariano LT, Danovitch. Substance Use Treatment and Recovery Team (START) Addiction Consultation Service for People Hospitalized People with Opioid Use Disorder: Multisite Randomized Controlled Trial. Under editorial review: JAMA Internal Medicine.