(21) Advancing the Evidence on Emergency Department and Hospital Linkage to Methadone Treatment

Background & Introduction: The overdose crisis has reached unprecedented levels in the US, with deaths disproportionately increasing among Black individuals.2 Despite the effectiveness of medications for opioid use disorder (MOUDs) in reducing mortality, few patients receive treatment.3,4 Emergency departments (EDs) are an important touchpoint for people who use drugs (PWUD) who are otherwise disconnected from care.

The Sustaining Peers in Emergency Departments (S-PED) program integrated Peer Recovery Specialists (PRSs) into a community ED and hospital serving a primarily Black population in West Philadelphia. Through this initiative, our team established a novel clinical pathway to connect patients to outpatient methadone treatment via CareConnect, a virtual buprenorphine bridge clinic that offers MOUD initiation and care navigation. While the effectiveness of methadone treatment is well-established, many barriers to treatment access remain, including the daily dosing requirement and other federal regulations that govern opioid treatment programs (OTPs).5 Additionally, Philadelphia’s drug supply has become increasingly dangerous, spurring the need for accessible MOUD pathways.1

By leveraging low-barrier services, like CareConnect, we sought to facilitate the process of coordinating methadone treatment following discharge. Given the limited evidence on feasibility and effectiveness of methadone linkage directly from acute care hospitals, we aimed to evaluate the outcomes of this novel MOUD pathway.

Methods: The methadone linkage pathway included an initial evaluation and dosing during an ED or hospital encounter, followed by next-day intake at a partnering OTP. This pathway facilitated bridge dosing in the ED for patients with anticipated delays in establishing care. To evaluate this pathway, we conducted a retrospective, mixed-methods quantitative and qualitative evaluation of the methadone linkage program between September 2022 and June 2024.

First, we used electronic health record (EHR) data to identify all referrals from the ED or hospital to the methadone pathway including patient-level characteristics. We obtained outcomes data in partnership with the partnering OTP, including primary (OTP intake within 30 days of initial referral) and secondary outcomes (ED methadone bridge dosing, days between referral and intake, and retention in methadone treatment at 30 days).

Then, we conducted semi-structured interviews with participants to examine participants’ experiences with past OUD treatment and the new methadone referral pathway, with an emphasis on barriers and facilitators to accessing treatment following ED or hospital discharge. Interviews were recorded, transcribed verbatim, and double coded by the research team using NVivo 14. We utilized thematic content analysis to identify common themes.

Results: There were a total of 33 participants who were referred to the methadone linkage pathway. The mean age of participants was 43. Participants were 61% white, 24% Black; 6% of patients reported Hispanic ethnicity. Most patients were insured through Medicaid (85%). Roughly 30% of patients reported housing insecurity at the time of the referral.

Patients were referred to outpatient methadone from the ED (n = 30%), hospital (n = 52%), or following a hospital detox stay (n = 18%). Nearly all patients had previously received MOUD in the past, including methadone only (39%), buprenorphine only (9%), or both (49%). Additionally, many patients had co-occurring substance use. Cocaine was the most common co-occurring substance (55%), followed by benzodiazepines (49%) and amphetamines (27%).

Of the 33 participants, 19 (58%) completed intake within 30 days of referral to the partner OTP. 18 (55%) of these patients remained engaged in methadone treatment at 30 days. The mean time from referral-to-intake was 11 days (SD 32). There were 6 (18%) patients who returned to the ED after referral for bridge dosing prior to planned intake at the partnering OTP.

We interviewed 15 patients who were referred to the pathway. Of the 13 patients referred to our partner OTP, 8 (62%) established methadone intake at the OTP within 30 days and 5 (38%) did not. The semi-structured interviews revealed multiple factors that influenced the likelihood of initiating or resuming methadone treatment following discharge from the ED or hospital. We identified five key themes related to patient decision-making as well as barriers and facilitators to accessing treatment. First, participants' past experiences with MOUD strongly influenced their choice of methadone over buprenorphine, with greater perceived effectiveness in addressing opioid withdrawal. Second, we found that patients expressed strong preference for outpatient treatment over detox or inpatient settings given prior treatment experiences as well as life and work obligations. Third, participants highlighted key social needs as barriers in their efforts to access outpatient methadone treatment, including transportation and stable housing. Fourth, peer support was perceived as essential to the outpatient methadone pathway, allowing participants to feel supported in the hospital setting but also facilitating access to care navigation following departure from the hospital. Finally, participants highlighted that ongoing stigma in healthcare settings regarding methadone affected their interactions with healthcare providers and overall care trajectory, despite efforts to normalize this treatment strategy among ED and hospital clinicians.

Conclusion & Discussion: EDs and hospitals serve as primary points of contact for PWUD, providing an opportunity to offer comprehensive care and linkage to longitudinal treatment. Although linkage pathways have traditionally focused on buprenorphine, we found that 58% of patients referred to an outpatient methadone pathway were able to rapidly initiate or resume treatment. Key facilitators for this pathway included strong motivation to start methadone treatment in the outpatient setting based on prior treatment experiences, and peer support during the linkage process. Barriers included social needs, particularly housing and transportation, that limited access to outpatient care, as well as ongoing stigma in the hospital setting. Establishing linkage pathways for methadone may be increasingly important given that patients often opt for this treatment approach but may not require or be willing to utilize traditional pathways to initiating outpatient methadone treatment, including a prolonged inpatient or residential treatment stay.

References: 1. Friedman, J., Montero, F., Bourgois, P., Wahbi, R., Dye, D., Goodman-Meza, D., & Shover, C. (2022). Xylazine spreads across the US: a growing component of the increasingly synthetic and polysubstance overdose crisis. Drug and alcohol dependence, 233, 109380.

2. Gondré-Lewis, M. C., Abijo, T., & Gondré-Lewis, T. A. (2023). The opioid epidemic: a crisis disproportionately impacting Black Americans and urban communities. Journal of racial and ethnic health disparities, 10(4), 2039-2053.

3. Krawczyk, N., Rivera, B. D., Jent, V., Keyes, K. M., Jones, C. M., & Cerdá, M. (2022). Has the treatment gap for opioid use disorder narrowed in the US?: A yearly assessment from 2010 to 2019”. International Journal of Drug Policy, 110, 103786.

4. Saini, J., Johnson, B., & Qato, D. M. (2022). Self-reported treatment need and barriers to care for adults with opioid use disorder: the US national survey on drug use and health, 2015 to 2019. American journal of public health, 112(2), 284-295.

5. Thakrar, A. P., Pytell, J. D., Stoller, K. B., Walters, V., Weiss, R. D., & Chander, G. (2023). Transitioning off methadone: A qualitative study exploring why patients discontinue methadone treatment for opioid use disorder. Journal of Substance Use and Addiction Treatment, 150, 209055.