(123) Barriers to Inpatient Use of Opioid-Agonist Therapies

Background & Introduction: Medications for opioid use disorder (MOUD), including buprenorphine and methadone, are highly effective in reducing overdose deaths and improving outcomes for patients with opioid use disorder (OUD). Opioid-agonists have a growing role in both acute and chronic pain management, and there are specific contexts in which their use is appropriate. These medications are often managed by specialists in pain or addiction medicine, the inpatient setting can require physicians outside of these specialties to directly prescribe opioid agonists. Transitions of care with these medications to and from inpatient settings is particularly important as inappropriate discontinuation can lead to increased morbidity, loss of treatment engagement, and discharges against medical advice. While initiation of MOUD in emergency or inpatient settings has been previously studied, little is known about hospital-based physicians’ knowledge, comfort, and barriers to maintaining these medications during hospitalization, continuing them upon discharge, or prescribing them for pain management. This study aims to evaluate physician perspectives and barriers regarding the inpatient management and continuation of opioid agonists for treatment of OUD and for pain. Results from this study are intended to inform educational or institutional interventions, so providers across inpatient specialties can feel appropriately equipped to manage these medications when necessary.

Methods: This study was conducted via an anonymous survey of attending physicians at a large academic-affiliated county hospital. The questionnaire was developed based on a review of published survey-based studies related to initiation of MOUD in hospital settings. The survey included multiple-choice and Likert-style questions, and assessed domains such as physician comfort, knowledge, clinical constraints, and educational interest related to opioid agonists for the treatment of OUD or pain. Free-text questions were included to provide respondents an opportunity to describe individual concerns or perspectives. Surveys were distributed via email to faculty physicians on inpatient/admitting services in a variety of departments, including internal medicine, surgery, obstetrics and gynecology, and psychiatry. Qualtrics was used for data collection and analysis.

This study was reviewed by the IRB at UT Health San Antonio and was approved under exempt determination as no identifiable data was collected.

Results: Survey data was collected from July to December 2025. 35 total responses were collected from multiple departments, with 16 responses from internal medicine, 12 from surgical sub-specialists, 6 from obstetrics and gynecology, and 1 from psychiatry. 82.9% of responding physicians reported taking care of patients with an opioid use disorder somewhat or very often. When comparing methadone to buprenorphine, a higher proportion reported familiarity with methadone’s mechanism of action (74.3% versus 60%), indications and contraindications (74.3% versus 37.1%), and dosing and hospital protocols (57.1% versus 31.4%).

Regarding management, 60% of respondents expressed a lack of familiarity with guidelines for managing MOUD. 88.6% of respondents had initiated MOUD inpatient. 88.6% reported that they had continued MOUD inpatient for patients who were previously being treated outpatient. 45.7% reported that they never prescribe MOUD on discharge, and 45.7% reported that they rarely do so.

41.2% of surveyed physicians reported that they felt comfortable managing the risks associated with initiating MOUD and with co-administering MOUD with opioid pain management. A greater proportion (61.7%) reported comfort with continuing MOUD in the hospital for patients already receiving outpatient treatment. However, only 17.7% felt comfortable providing these medications on discharge. The main considerations reported that would prevent respondents from prescribing MOUD were a lack of familiarity with dosing and guidelines (63%), lack of appropriate training (50%), and concerns about liability (50%). 5 of 8 free-text responses expressed concerns regarding follow-up or the transition to outpatient care when managing MOUD.

Regarding the use of opioid-agonist medications for pain management, 54.9% reported that they believed methadone was safe and effective for treating pain, versus 25.8% for buprenorphine. 45.2% would consider using methadone in the hospital for pain management, and 22.6% would do the same for buprenorphine. 29% would prescribe methadone on discharge for short-term pain management and 16.1% would do so for buprenorphine. Primary reported concerns regarding the use of methadone for pain management were a lack of familiarity with dosing and guidelines (56%) and concerns regarding liability (52%). For buprenorphine in pain management, the most selected concerns were unfamiliarity with dosing and guidelines (70%), unfamiliarity with indications for use (56.7%), and lack of appropriate training (50%).

A majority of participants (74.2%) expressed an interest in learning more about MOUD and the use of opioid-agonist medications in pain management. The most popular methods of education deliver requested were online module (75%) and virtual lecture or grand rounds presentation (64.3%).

Conclusion & Discussion: Hospitalization presents a critical opportunity to support patients with opioid use disorder, yet institutional and educational barriers may continue to limit effective management of opioid-agonists in inpatient settings. Given the concerns reported in our survey around routes to establishing follow-up as well as lack of appropriate training and knowledge, physicians may require further educational or structural support to feel comfortable with prescribing opioid-agonists that are not already being managed by an outpatient specialist.

The physicians who were surveyed also reported limited familiarity and comfort regarding opioid-agonist therapies for pain management, especially the use of buprenorphine for this purpose. Educational interventions could help clarify indications, guidelines, and protocols for their use.

As this is a small study at one center, its results cannot be effectively generalized to all inpatient providers. To improve the response rate, free-text responses were not required. Future studies using qualitative methods would allow for greater exploration of individual perceptions, attitudes, and concerns around management of opioid-agonists that cannot be captured fully in multiple choice or Likert-style responses. This approach would be especially important for quality-improvement and institution-specific interventions.

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