(181) Inpatient Order Set Increases Initiation of Medications for Substance Use Disorders

Background &

Introduction: Hospitals serve as a critical point of contact for people who use drugs (PWUD), who experience higher rates of hospitalization than the general population.¹ PWUD are less likely to have an established primary care provider and therefore disproportionately rely on hospital-based services for the management of both acute and chronic medical conditions.² Despite this disproportionate reliance, PWUD have high rates of patient-directed discharge driven in part by inadequate inpatient management of withdrawal and substance use disorders (SUD).³ Therefore, hospitalizations represent an important missed opportunity to initiate evidence-based SUD medications for PWUD and to improve clinical outcomes. Standardized inpatient approaches are necessary to address this gap with the goal of increasing initiation and discharge prescribing of evidence-based SUD medications and improving the care for this high-risk population.

Methods: We implemented an inpatient SUD order set on October, 1 2024 for PWUD admitted to an urban academic tertiary care hospital in San Diego, California. The order set incorporates evidence-based medications for opioid, methamphetamine, and alcohol use disorders for inpatient initiation and outpatient continuation, adjuvant medications for withdrawal management, and routine prescription of naloxone and other harm reduction supplies on hospital discharge. The order set is accessible to all inpatient medical providers and was promoted through system wide emails and house staff trainings. We conducted a retrospective cohort study comparing outcomes during the 12 months before and after order set implementation. Primary outcomes included rates of inpatient initiation and discharge prescribing of medications for SUD, as well as discharge naloxone prescribing. Mood’s median and Chi-squared tests were utilized to assess for statistically significant differences in patient characteristics and health outcomes between those with and without SUD admitted to our hospital and to assess for statistically significant differences in rates of inpatient initiation and hospital discharge prescription of medications for SUD and rates of discharge prescription of naloxone within the 12 month periods before and after order set implementation.

Results: Between October 1, 2023, and September 30, 2025, there were 73,147 admissions to the medical and surgical services at our hospital. Of these, 10.6% of patients had a SUD, defined as having an active diagnosis of opioid, methamphetamine, or alcohol use disorder on the problem list and/or a positive urine drug screen for fentanyl, heroin, or methamphetamine during the study period. Patients with a SUD were more likely to be younger, male sex at birth, American Indian or Alaska Native, Black, or White race, and non-Hispanic ethnicity compared to patients without a SUD. Patients with a SUD had significantly longer lengths of stay and increased rates of patient-directed discharge and 30-day readmission compared to patients without a SUD. There were no differences in hospital unit at admission between patients with and without a SUD (Table 1). Following order set implementation, hospital initiations of buprenorphine, methadone, and acamprosate increased significantly compared to the prior 12 months. Hospital discharge prescriptions of buprenorphine, acamprosate, and naloxone also increased significantly, whereas initiations and discharge prescriptions of naltrexone did not change significantly (Table 2).

Conclusion &

Discussion: Implementation of a standardized inpatient SUD order set was associated with significant increases in hospital initiations and discharge prescriptions of evidence-based medications for SUD including buprenorphine, methadone, acamprosate, and naloxone. These findings highlight the potential of standardized SUD order sets to reduce variability in care, increase access to life-saving treatments, and enhance clinical outcomes for patients with SUD. Ongoing efforts are needed to address persistent gaps, including unchanged naltrexone utilization and increased rates of patient-directed discharge and 30-day readmissions to further optimize equitable, evidence-based inpatient care for this high-risk population.



References: 1. Kendall, C.E., Boucher, L.M., Mark, A.E. et al. A cohort study examining emergency department visits and hospital admissions among people who use drugs in Ottawa, Canada. Harm Reduct J 14, 16 (2017). https://doi.org/10.1186/s12954-017-0143-4. 2. Artenie, A.A., Jutras-Aswad, D., Roy, É., Zang, G., Bamvita, J.-.-M., Lévesque, A. and Bruneau, J. (2015), Visits to primary care physicians among persons who inject drugs at high risk of hepatitis C virus infection: room for improvement. J Viral Hepat, 22: 792-799. https://doi.org/10.1111/jvh.12393. 3. Lianping Ti and Lianlian Ti: Leaving the Hospital Against Medical Advice Among People Who Use Illicit Drugs: A Systematic Review. American Journal of Public Health, 105,e53_e59, https://doi.org/10.2105/AJPH.2015.302885.