(74) An OUD Support Line Improves Opioid Use Disorder Treatment in Hospitalized Patients

Background & Introduction: Inpatient hospitalization presents opportunities and challenges in the care for patients with opioid use disorder (OUD). Because many people with OUD avoid unnecessary interactions with the health care system due to stigma and other barriers, inpatient hospitalization can be a crucial opportunity to engage patients in treatment, including with evidence-based medications for OUD (MOUD).(1) Hospitalization also presents the challenge of untreated or partially treated withdrawal interfering with the completion of recommended inpatient care.

Inpatient initiation of buprenorphine-naloxone to treat OUD results in improved patient outcomes and quality of care, including increased outpatient follow-up, decreased opioid overdose, and decreased hospital length of stay or readmissions.(2,3) Formal addiction consultation services (ACS) improve treatment initiation and post-discharge engagement, (4) however most hospitals do not have access to such services, risking suboptimal care for patients with OUD.(5) Implementation of an ACS may not be feasible for many institutions due to stigma, insufficient funding, lack of expertise, or lack of stakeholder buy-in.(6)

Our institution does not have an ACS. To address common barriers to buprenorphine-naloxone prescribing, namely inexperience and lack of knowledge, we implemented a lower-barrier alternative to an ACS: an OUD support role staffed by outpatient internal medicine faculty with experience in OUD treatment.

Methods: Our hospital uses a two-way secure texting application to facilitate communication for patient care. Messages may be sent to an individual or a “role”, which rotates between individuals who sign-in during their shifts. In February 2023, we created a “role” named Opioid Use Disorder Support with the following description: “Contact this role if considering inpatient initiation of Buprenorphine for patients with Opioid Use Disorder. Mon-Fri 8am-5pm.” We announced its existence during teaching sessions with residents, but no other advertising was performed.

Two internal medicine-trained physicians with knowledge and clinical experience with MOUD rotate shifts on the role.

These physicians prescribe buprenorphine-naloxone for MOUD in the primary care setting. They were also on the committee that wrote our hospital policy and protocols for care of patients with OUD and have created relationships with local opioid treatment programs (OTPs), physicians prescribing buprenorphine-naloxone outside of our organization, and skilled nursing facilities. Any individual working in our hospital can contact the role to ask for advice. The physicians do not see patients themselves; they offer advice and education in a model of “curbside” consultation. No bill is generated for this service; final decisions are made and documentation performed by the patient’s primary team.

Results: From April 2023 to September 2024, the OUD support role was contacted 93 times, an average of 5.2 times per month. Callers included residents/fellows (internal medicine, surgery, obstetrics/gynecology, psychiatry, palliative care, orthopedic surgery, neurosurgery and emergency medicine), nurse practitioners and physician assistants (cardiothoracic surgery, ICU, trauma surgery and internal medicine), attending physicians (surgery, palliative care), pharmacists, and case managers. During the 93 contacts, OUD treatment was discussed 63 times, opioid withdrawal management 14 times, and coordination of care/discharge planning 14 times. Initiation of medications for OUD (MOUD) was planned for 26 patients, with 23 planning for buprenorphine-naloxone and 3 planning for methadone. We do not have data to confirm actual treatment initiation, or whether MOUD was prescribed at the time of discharge for transition to the outpatient setting. Other topics addressed by this role included taking a complete OUD history, pain management in patients with OUD, continuation of MOUD during inpatient admission, MOUD in pregnant patients, and peri-operative management of MOUD, among others.

From May 2023-May 2024, of the 350 inpatients with OUD on their problem list, 94 (26.9%) had at least one order for methadone and 77 (22.0%) had at least one buprenorphine-naloxone order written during hospitalization. This rate of methadone orders is consistent with baseline data in our hospital, and nearly all reflect continuation of outpatient management. This rate of buprenorphine-naloxone orders is a steep increase; in an 8-month period preceding the launch of the OUD support line, a total of 16 buprenorphine-naloxone orders were written in our hospital.

Conclusion & Discussion: The OUD support pager role addressed a clear need, as evidenced by the level of multi-disciplinary engagement. Most calls addressed knowledge gaps or discomfort with buprenorphine-naloxone, known barriers to prescribing MOUD, (6) with many resulting in plans for MOUD initiation. We also improved overall care for patients with OUD, providing education on withdrawal treatment, pain management, inpatient continuation of MOUD, and discharge planning. It is heartening to see that many clinicians in our hospital desire better care for patients with OUD and seek real-time advice to do so.

One limitation to this approach is reliance on the volunteer efforts of addiction medicine “champions”—a model that may prove unsustainable due to the burden of uncompensated labor. Fortunately, our physician champions have academic or research roles which allow them to be flexible and receive calls throughout the workday. We hope that the demonstrated need met by the OUD support role will convince stakeholders to fund this activity or bridge to a more robust ACS.

For institutions unable to implement a formal ACS, an OUD support role is an effective and lower-barrier alternative that can help improve care for patients with OUD and increase MOUD access for those that need it.

References: 1. Englander H, Weimer M, Solotaroff R, Nicolaidis C, Chan B, Velez C, Noice A, Hartnett T, Blackburn E, Barnes P, Korthuis PT. (2017). Planning and Designing the Improving Addiction Care Team (IMPACT) for Hospitalized Adults with Substance Use Disorder. Journal of Hospital Medicine, 12(5). https://doi.org/10.12788/jhm.2736

2. Liebschutz, J. M., Crooks, D., Herman, D., Anderson, B., Tsui, J., Meshesha, L. Z., Dossabhoy, S., & Stein, M. (2014). Buprenorphine treatment for hospitalized, opioid-dependent patients: A randomized clinical trial. JAMA Internal Medicine, 174(8), 1369–1376. https://doi.org/10.1001/jamainternmed.2014.2556

3. Wang, S. J., Wade, E., Towle, J., Hachey, T., Rioux, J., Samuels, O., Bonner, C., Kirkpatrick, C., O’Loughlin, S., & Foster, K. (2020). Effect of Inpatient Medication-Assisted Therapy on Against-Medical-Advice Discharge and Readmission Rates. The American Journal of Medicine, 133(11), 1343–1349. https://doi.org/10.1016/j.amjmed.2020.04.025

4. Englander, H., Dobbertin, K., Lind, B. K., Nicolaidis, C., Graven, P., Dorfman, C., & Korthuis, P. T. (2019). Inpatient Addiction Medicine Consultation and Post-Hospital Substance Use Disorder Treatment Engagement: A Propensity-Matched Analysis. Journal of General Internal Medicine, 34(12), 2796–2803. https://doi.org/10.1007/s11606-019-05251-9

5. Naeger, S., Ali, M. M., Mutter, R., Mark, T. L., & Hughey, L. (2016). Prescriptions Filled Following an Opioid-Related Hospitalization. Psychiatric Services, 67(11), 1262–1264. https://doi.org/10.1176/appi.ps.201500538

6. Priest, K. C., Englander, H., & McCarty, D. (2020). “Now hospital leaders are paying attention”: A qualitative study of internal and external factors influencing addiction consult services. Journal of Substance Abuse Treatment, 110, 59–65. https://doi.org/10.1016/j.jsat.2019.12.003