(28) Inpatient Discharge Prescribing and Early Engagement Predict Buprenorphine Continuation

Background & Introduction: Opioid use disorder (OUD) continues to drive hospitalizations, particularly in the era of fentanyl.2 Hospitalization represents a touchpoint to initiate treatment, and addiction consultation services have shown to increase initiation of medications for opioid use disorder (MOUD) and improve post-discharge engagement.5 While inpatient buprenorphine initiation is common, fentanyl’s potency raises concerns about precipitated withdrawal, and traditional induction strategies may be inadequate.2 Inpatient addiction consult services employ alternative approaches, including low-dose and high-dose protocols. A systematic review found that these strategies can achieve high transition success, though data remains limited. ¹ However, data examining how hospital-based buprenorphine induction strategies and discharge practices influence post-discharge continuation remain limited.

Because follow-up after hospitalization can be difficult to capture, prescription drug monitoring program (PDMP) data has been used as a surrogate for treatment engagement. PDMP analyses provide insight into whether patients fill buprenorphine prescriptions after discharge — identifying predictors of long-term retention.4 In July 2024, the University of New Mexico Hospital launched CAMINOS (Coordinating Addiction Medicine with Inpatient and Outpatient Services), an inpatient addiction medicine consult service. We evaluated the first year of hospital-initiated buprenorphine, examining associations between induction modality, discharge prescribing practices, and post-discharge treatment continuation.

Methods: We conducted a retrospective case series of adult inpatients evaluated by CAMINOS between July 1, 2024, and June 30, 2025, who were initiated on buprenorphine during hospitalization. Of 255 encounters, exclusions were applied per protocol (incarcerated at discharge, death during hospitalization, methadone initiation or switch, or self-discontinuation), yielding a final analytic cohort of 180 encounters. Exposures included induction modality (low-dose < 2 mg, standard-dose 4–8 mg, high-dose ≥8 mg), discharge buprenorphine dose and duration, and new initiation versus prior buprenorphine exposure. Encounters with zero discharge dose and/or zero days’ supply were classified as hospital initiation without a discharge prescription.

The primary outcome was any buprenorphine prescription fill within 30–90 days after discharge using New Mexico PDMP data; secondary outcomes included sustained continuation at 30, 60, and 90 days. Analyses were primarily descriptive with exploratory, hypothesis-generating inferential testing and logistic regression. Prescription fills were used as a proxy for engagement and may misclassify true medication use.

Results: Among 180 patients, 109 (60.6%) filled buprenorphine within 90 days after discharge. Attrition occurred primarily early: 98 (54.4%) filled within 30 days, 69 (38.3%) within 60 days, and 58 (32.2%) demonstrated sustained continuation at 30/60/90 days.

Prior buprenorphine exposure was associated with higher continuation than new initiation (75.4% vs 52.2%, p=0.0037). Early engagement strongly predicted retention (30-day fill → 90-day continuation OR 6.1, p< 0.001). In exploratory multivariable models, receipt of a discharge buprenorphine prescription remained independently associated with continuation (OR 2.84, p=0.0046), while documented fentanyl use was associated with lower odds (OR 0.38, p=0.034); new initiation showed a trend toward lower continuation (OR 0.49, p=0.059). Post-discharge continuation did not differ by induction modality (χ² p=0.18) or by rural versus urban residence.

One in four patients (27.8%) left the hospital without a discharge buprenorphine prescription; among these, 36.0% had a patient-directed discharge, while most were non–patient-directed discharges. Patients without a discharge prescription had significantly lower continuation than those discharged with buprenorphine (42.0% vs 67.7%, p=0.0028), with differences persisting for sustained retention (20.0% vs 36.9%, p=0.046). In sensitivity analyses restricted to patients discharged with buprenorphine (n=130), induction modality, discharge dose, and discharge duration remained unassociated with retention, while early engagement continued to strongly predict 90-day continuation.

Conclusion & Discussion: In this first-year evaluation of an inpatient addiction medicine consult service, hospitalized patients with opioid use disorder initiated on buprenorphine demonstrated measurable linkage to ongoing treatment, as assessed by PDMP prescription fills at 30, 60, and 90 days post-discharge. Contrary to our hypothesis, buprenorphine induction modality—including low-dose and high-dose strategies designed to mitigate fentanyl-related barriers—was not associated with improved linkage to care or sustained treatment retention. Instead, discharge prescribing and early post-discharge engagement emerged as the strongest predictors of continuation, alongside patient- and prescribing-level factors such as prior buprenorphine exposure. Similar linkage outcomes among rural and urban patients suggest that hospital initiation paired with effective discharge bridging may help attenuate early geographic barriers to care. While these findings were limited by a small sample size and difficulty fully capturing post-discharge follow-up, collectively, these findings indicate that systems-level practices—particularly ensuring a discharge buprenorphine prescription and facilitating early follow-up—may be more impactful for post-hospital MOUD continuity than induction strategy alone in the fentanyl era.

References: Adams, K. K., Waters, K., & Sobieraj, D. M. (2025). Initiating buprenorphine to treat opioid use disorder without prerequisite withdrawal: an updated systematic review. Addiction science & clinical practice, 20(1), 19. https://doi.org/10.1186/s13722-025-00548-z

Englander, H., Thakrar, A. P., Bagley, S. M., Rolley, T., Dong, K., & Hyshka, E. (2024). Caring for Hospitalized Adults With Opioid Use Disorder in the Era of Fentanyl: A Review. JAMA internal medicine, 184(6), 691–701. https://doi.org/10.1001/jamainternmed.2023.7282

Hallowell, B. D., Chambers, L. C., Samuels, E. A., Bratberg, J., McDonald, J., Nitenson, A., Onyejekwe, C., & Beaudoin, F. L. (2022). Sociodemographic and prescribing characteristics that impact long-term retention in buprenorphine treatment for opioid use disorder among a statewide population. Drug and alcohol dependence, 241, 109680. https://doi.org/10.1016/j.drugalcdep.2022.109680

Hooker, S. A., Starkey, C., Bart, G., Rossom, R. C., Kane, S., & Olson, A. W. (2024). Predicting buprenorphine adherence among patients with opioid use disorder in primary care settings. BMC primary care, 25(1), 361. https://doi.org/10.1186/s12875-024-02609-9

McNeely, J., Wang, S. S., Rostam Abadi, Y., Barron, C., Billings, J., Tarpey, T., Fernando, J., Appleton, N., Fawole, A., Mazumdar, M., Weinstein, Z. M., Kalyanaraman Marcello, R., Dolle, J., Cooke, C., Siddiqui, S., & King, C. (2024). Addiction Consultation Services for Opioid Use Disorder Treatment Initiation and Engagement: A Randomized Clinical Trial. JAMA internal medicine, 184(9), 1106–1115. https://doi.org/10.1001/jamainternmed.2024.3422