Improving Care for Hospitalized, Opioid-Dependent Patients: A Promising Start

In the United States, an estimated 2 million people are addicted to heroin or opioid analgesics, 80%ofwhomare not in treatment.1 Rates of addiction have increased during the past 20 years, following increased misuse of prescription opioid analgesics, resulting in large increases in opioid-related emergency department visits, hospitalizations, and overdose deaths.2 There are 2 evidence-based treatments for opioid addiction:methadoneandbuprenorphine.Bothof theseopioidagonists have been reported to markedly reduce morbidity and mortality.3 The requirement thatmethadone be dispensed in hospitals or certified methadone clinics has limited its availability, created a stigma for patients, and separated the treatmentofopioidaddiction fromgeneralmedical care.4TheDrug Addiction Treatment Act of 2000 allowed physicians, on completion of a short training course, to prescribe buprenorphine for the treatment of opioid use disorders.1 By creating an avenue for office-based opioid treatment, the Drug Addiction Treatment Act allowed for the expansion of opioid agonist therapy (OAT)andthe integrationofopioidaddiction treatment into primary care. For patients, this has the benefit of increasingaccessandreducing thestigmaassociatedwithOAT. Buprenorphine enables primary care physicians to manageopioid addictionas a chronicdisease. In a consensus statement, theAmericanSociety ofAddictionMedicine stated that the “optimumdurationofmaintenance is unclear, butmay involve lifelong use...similar to other chronic diseases such as diabetes or hypertension.”1(p256) The full potential of engaging individualswho strugglewith opioid abuse disorders into treatment has not been realized. There are multiple structural barriers to engaging thosewhowant it into treatment, including a reluctance of physicians to become buprenorphine prescribers, lackofcounseling resources, financialbarriers, and regulations for physicians, including additional training requirements and limits on the numbers of patients for whom physicians canprescribe buprenorphine.4,5 In addition, there are many wasted opportunities to engage those who need it inOAT.Wehave learned fromother health behaviors, such as tobacco use and risky drinking, that health care professionals’provisionof routinescreeningandreferral to treatmentcan reduceuseand improveoutcomes.Notusingeveryhealthcare encounter to intervenewith opioid addiction, considering its morbidity and the existence of effective treatment, represents a lost opportunity. In this issue of JAMA Internal Medicine, Liebschutz et al6 describe the results of a randomized clinical trial that examined theeffectsofbuprenorphineadministrationduringmedical hospitalization (detoxification group)with linkage to outpatient treatment (linkage group) on illicit drug use and engagement in OAT 6 months after the hospitalization. Hospitalization represents an important opportunity to intervene inopioidaddiction.Althoughmany individualswithopioid abuse disorders are not engaged in primary care, they frequently use emergency departments and inpatient settings. Hospitalization provides an opportunity to engage the patient inmotivational interviewingandplanning for theposthospitalization period. Despite this, health care professionals havenot takenadvantageof this opportunity. Instead, routine practice is to prescribe an inpatient methadone or buprenorphinewith a tapering plan,without providing treatmentduring theposthospitalizationperiod.Thestigmaof substance use, lack of training in substance use treatment for inpatient health care professionals, and a lack of resources available to patients once discharged have created a culture in which it is the norm to not offer posthospitalization treatment for opioid use disorders. However, a more recent focus on reducing readmissions may lead to health systems adopting a variety of strategies to more closely link patients to primary care and community-based services. The studybyLiebschutz et al6 provides evidence of the value of linking hospitalized individualswithopioidabusedisorderswithposthospitalization buprenorphine treatment. Although the studyhad somepromising results, it also revealed the challenges. The study found a much higher proportionofpatientsenrolled inOATafterhospitalizationamong those in the linkage group (52 [72.2%]) than in the detoxification group (8 [11.9%]). Although the linkage group had higher rates of continued engagement with OAT at 6 months compared with the detoxification group (12 [16.7%] vs 2 [3.0%]), the proportionswere small in both groups. The linkage group remained engaged in treatment at less than half the rate of those found in outpatient studies of buprenorphine therapy. This finding is likely because those who enroll in outpatient treatment are preselected for motivation. The barriers to enrolling in outpatient therapy are high enough that individuals who do engage are likely to be more motivated and more socially stable than those enrolled during a hospital stay. The findingsof this studywill not beeasily replicatedwith existing services in most places. The study used a dedicated nursewith addiction trainingwho engaged individuals. Linkage group participants had access to outpatient treatment within 7 days of discharge; participants were given a supply of medication to bridge them to that appointment. These resourceswouldhave tobedeveloped in settings seeking to replicate this study.Evenwith these resources, only 139of the630 individuals approached (22.1%) enrolled in the study.Most of thosenotenrolledhadcontraindications tobuprenorphineuse or were uninterested in participating, making clear the multiple barriers to effectiveness. Evenwith these limitations, the Related article page 1369 Buprenorphine Treatment for Opioid Dependence Original Investigation Research