(78) Methadone Dose and Patient-Directed Discharge in Persons with Prior Methadone Enrollment

Background & Introduction: In the setting of the ongoing opioid epidemic in the United States, there has been an increase in hospital-based care devoted to caring for persons with opioid use disorder (OUD).[1] However, 10-20% of hospitalizations for patients with OUD end in patient-directed discharge (PDD) which interferes with longitudinal management and is associated with increased 30-day readmission and one-year mortality.[2–4] Stigma, undertreatment of pain, and withdrawal are common reasons for PDD.[5] This phenomenon is exacerbated by prevalence of high-potency synthetic opioids (HPSO) such as fentanyl in the illicit drug supply which further complicates management. We hypothesized that PDD may be due to untreated opioid withdrawal and may be inversely related to dosage and timing of medications for opioid use disorder (MOUD). We specifically focused on patients reporting prior home treatment with methadone as patients currently enrolled in an opioid treatment program (OTP) can receive higher doses within the first 24 hours of hospitalization and may also be more engaged in OUD treatment.

Methods: We performed a retrospective observational study of adult patients (age >18) hospitalized at Johns Hopkins Hospital between July 1, 2019 – June 30, 2022 with an ICD-10-CM diagnosis of OUD in the electronic medical record and methadone listed on the prior to admission medication list. For patients with more than hospitalization, only the most recent hospitalization was included in the analysis. Patients who lacked birthdate, MOUD administration information or invalid COWS scores were excluded. Patients who received intravenous methadone were not included. Patient-level demographics, prior medication list, hospitalization characteristics, clinical details including time of initial emergency department triage, OUD treatment dosage and timing and discharge disposition were extracted by automated query from EMR. The exposure of interest was timing and dose of methadone following first contact with emergency department. The primary outcome of interest was patient-directed discharge, which was defined as any discharge categorized as “Against Medical Advice” or “AWOL (Absent Without Leave).” Secondary outcomes included length of stay and all-cause 30-day hospital readmission to Johns Hopkins Health System. The relationship between PDD and continuous variables and categorical were assessed using the Kruskal-Wallis test and Pearson’s χ2 as appropriate.

Results: 4,308 hospitalizations with OUD were identified, of which 1,280 patients had documented prior methadone treatment and met inclusion criteria (Figure 1). Demographic characteristics included median age 31 years (IQR 21), 55.3% Male, 54.2% Black, 98.5% Non-Hispanic. The most common insurance was Medicaid (70.5%) and the primary service was medicine (80.4%) followed by surgery (11.3%). Slightly over three-quarters (76.8%) of patients were treated with methadone during hospitalization while a minority received buprenorphine (7.3%). Ninety-nine encounters ended in PDD (7.7%). The median length of time prior to administration of methadone was 17 hours in the PDD group and 21 hours in the non-PDD group (p =0.007). For the first 24 hours, the median methadone dose between the PDD and non-PDD group was 30 mg vs. 64.1 mg (p value= 0.1); for first 48 hours the median dose was 62.5 mg vs. 90 mg (p value= 0.025), and for the first 72 hours the median dose was 70 mg vs. 140 mg (p value= < 0.001). The median length of stay was 2 days in the PDD group vs. 5 days in the non-PDD group (p value < 0.001). 30-day all cause hospital readmission rate was 24.2% vs. 11.3% in the PDD group and non-PDD group respectively (p value < 0.001).

Conclusion & Discussion: In this study of hospitalized patients with OUD previously treated with methadone, higher methadone doses at 48 and 72 hours were associated with decreased risk of PDD. These results highlight the role that early and adequate methadone management may lead to decreased level of PDD and decrease subsequent 30-day hospital readmissions. Limitations of this work include the absence of controlling for administered opioid medications other than methadone. Additionally, the use of methadone on the prior to admission medication list does not perfectly reflect confirmed prior methadone program or time of last dose. The cohort likely includes some patients enrolled in OTP with missed doses and no missed doses, and some persons who were not actively enrolled in OTP at time of admission. While prior studies have shown improved outcomes of starting methadone for hospitalized patients, this is the first work to our knowledge that explores the quantitative relationship of dosage of methadone over time and subsequent PDD. More work and larger studies are needed to further assess practice patterns and safety outcomes for more agree methadone initiation and re-initiation, as well as causes of delays to first methadone dose for patients with OUD presenting to acute care settings.

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