Abstract
Introduction
Methadone ameliorates opioid withdrawal among hospitalized patients with opioid use disorder (OUD). To continue methadone after hospital discharge, patients must enroll in an opioid treatment program (OTP) per federal regulations. Uncontrolled opioid withdrawal is a barrier to linkage from hospital to OTP.
Aim
Describe a federally compliant In-Hospital Methadone Enrollment Team (IN-MEET) that enrolls hospitalized patients with OUD into an OTP with facilitated hospital to OTP linkage.
Setting
Seven hundred-bed university hospital in Aurora, CO.
Program Description
A physician dually affiliated with a hospital’s addiction consultation service and a community OTP completes an in-hospital, face-to-face medical assessment required by federal law and titrates methadone to comfort. An OTP-affiliated nurse with hospital privileges completes a psychosocial evaluation and provides case management by arranging transportation and providing weekly telephone check-ins.
Program Evaluation Metrics
IN-MEET enrollments completed, hospital to OTP linkage, and descriptive characteristics of patients who completed IN-MEET enrollments compared to patients who completed community OTP enrollments.
Results
Between April 2019 and April 2023, our team completed 165 IN-MEET enrollments. Among a subset of 73 IN-MEET patients, 56 (76.7%) presented to the OTP following hospital discharge. Compared to community OTP enrolled patients (n = 1687), a higher percentage of IN-MEET patients were older (39.7 years, standard deviation [SD] 11.2 years vs. 36.1 years, SD 10.6 years) and were unhoused (n = 43, 58.9% vs. n = 199, 11.8%). Compared to community OTP enrolled patients, a higher percentage of IN-MEET patients reported heroin or fentanyl as their primary substance (n = 53, 72.6% vs. n = 677, 40.1%), reported methamphetamine as their secondary substance (n = 27, 37.0% vs. n = 380, 22.5%), and reported they injected their primary substance (n = 46, 63.0% vs. n = 478, 28.3%).
Conclusion
IN-MEET facilitates hospital to OTP linkage among a vulnerable population. This model has the potential to improve methadone access for hospitalized patients who may not otherwise seek out treatment.
KEY WORDS: addiction consultation service (ACS), methadone, opioid use disorder (OUD), opioid treatment program (OTP), hospitalization
Introduction
Ninety-one percent of the 83,000 opioid involved overdose deaths in the USA in 2022 involved fentanyl.1 Hospitalizations related to opioid use disorder (OUD) are increasing—from 2000 to 2016 hospitalizations related to OUD increased 219%, a threefold increase.2 When patients with OUD are hospitalized, guidelines recommend the use of methadone or buprenorphine to reduce opioid withdrawal and to treat OUD.3, 4 Adequately managed opioid withdrawal reduces patient-directed discharges,5 improves patient and clinician satisfaction,6, 7 reduces rehospitalization, 8–10 and increases OUD treatment linkage.11–13 Hospitalization is a reachable moment to initiate methadone or buprenorphine among out of treatment adults with OUD.14
During hospitalization, there are no legal restrictions on the use of methadone for opioid withdrawal management.15 Methadone can be rapidly titrated in the hospital to reduce severe opioid withdrawal.16 In the outpatient setting in the USA, methadone for the treatment of OUD can only be dispensed from an opioid treatment program (OTP).17 Federal regulations state that patients must undergo a physical evaluation by an OTP-recognized clinician for OTP enrollment.17 Patients who would like to continue in-hospital-initiated methadone following hospital discharge must arrive to a local outpatient OTP within 24 h of hospital discharge to avoid experiencing opioid withdrawal symptoms. Hospital to outpatient OTP linkage can take days to weeks and delays in access to medications for OUD increases the risk of return to illicit opioid use and overdose.18 Reported barriers to outpatient OTP linkage after hospital discharge include uncontrolled opioid withdrawal, pain, lack of transportation or personal identification, unstable housing, unstable medical or mental illness, and stigma.7, 19 The federal requirement that methadone may only be dispensed from an outpatient OTP for OUD treatment is unique to the USA and limits OUD treatment access.20–23 Interventions that reduce barriers to OTP enrollment may improve treatment engagement and retention in OUD care.23
Despite reported barriers to OTP treatment linkage after hospital discharge, patients initiated on methadone during hospitalization are more likely to engage in methadone treatment after hospital discharge compared to patients not initiated on methadone during hospitalization.9, 24 In our hospital, many patients who accept methadone for opioid withdrawal management request methadone for OUD treatment following hospital discharge. To address this need, we developed a federally compliant program to directly enroll hospitalized patients with OUD into an OTP with in-hospital methadone initiation, dose titration, and facilitated hospital to OTP linkage without methadone dose disruption following hospital discharge. Here, we describe a novel in-hospital methadone enrollment program designed to enroll hospitalized patients with OUD into one of three local community OTPs to avoid a period of opioid withdrawal during the hospital to OTP transition. Next, we report descriptive variables including number of OTP enrollments completed during hospitalization, percentage of patients who linked from the hospital to the OTP, and sociodemographic characteristics of patients who completed in-hospital methadone enrollments compared to patients who self-referred to the community OTP. Lastly, we describe lessons learned through the process of offering in-hospital OTP enrollment to hospitalized patients with OUD. Findings will inform a future comparative effectiveness trial of in-hospital OTP enrollment versus usual methadone care versus buprenorphine initiation with a follow-up appointment for hospital to OTP linkage.
Methods
Overview
The In-Hospital Methadone Enrollment Team (IN-MEET) enrolls hospitalized patients with OUD into one of three local community OTPs. The IN-MEET team includes an addiction medicine physician dually affiliated with the university hospital’s Addiction Consultation Service (ACS) and the OTP, and an OTP-affiliated nurse with privileges to the university hospital.17 The IN-MEET team began enrolling patients in April 2019. Following IN-MEET’s implementation in our single site, descriptive data were obtained via a retrospective chart review to identify the population IN-MEET reached, to compare sociodemographic characteristics of IN-MEET patients to patients who self-enrolled in our community OTP, and to identify targeted areas for IN-MEET’s improvement. This study was approved by the Colorado Multiple Institutional Review Board.
Settings and Partnerships
IN-MEET is the result of a partnership between a hospitalist-directed addiction consultation service (ACS) in a 700-bed university hospital25 and a community-based substance treatment program with three OTP locations that serves more than 1500 clients annually.26 The ACS provides dedicated addiction care to hospitalized patients with substance use disorders or unhealthy substance use. From August 2022 to August 2023, the ACS completed over 1700 consultations, initiated buprenorphine for OUD over 150 times, prescribed methadone in the hospital to manage opioid withdrawal over 180 times, administered extended-release naltrexone over 100 times for alcohol use disorder, and prescribed oral naltrexone or acamprosate over 450 times for alcohol use disorder.
IN-MEET Enrollment Process
The ACS is typically consulted when a hospitalized patient develops signs or symptoms of opioid withdrawal. An ACS clinician meets with the patient during hospitalization, verifies opioid withdrawal, and offers buprenorphine or methadone to treat opioid withdrawal symptoms. If the patient prefers methadone, the methadone dose is titrated over the first days of hospitalization. If the patient requests methadone continuation following hospital discharge and meets DSM-5 criteria for moderate to severe OUD, the ACS team offers IN-MEET enrollment.
IN-MEET Physician Enrollment
When the patient accepts IN-MEET enrollment, the ACS team contacts the IN-MEET team via email communication for an in-hospital OTP enrollment. The IN-MEET physician meets with the patient in the hospital to complete a face-to-face medical assessment;17, 27 screens for HIV, hepatitis C, syphilis (treponema Ab), and tuberculosis (QuantiFERON Gold); reviews an electrocardiogram for QTc prolongation; and orders a methadone dose titration plan. When patients are hospitalized for more than 1 week, further methadone dose titrations are managed by the ACS clinician (Fig. 1).
Figure 1.
In-hospital methadone enrollment (IN-MEET) with opioid treatment program linkage.
IN-MEET Nurse Enrollment
Next, the IN-MEET nurse completes a psychosocial evaluation and provides case management by securing identification required for OTP enrollment, arranging transportation to the OTP, and providing weekly telephone check-ins to maximize hospital to OTP linkage. When a patient lacks a state issued identification, the IN-MEET nurse enrolls patients into the OTP using their hospital identification bracelet and the patient’s photograph uploaded into the hospital’s electronic health record. When patients need transportation to get to the OTP, the IN-MEET nurse arranges for specific pick-up and drop-off locations for transportation. Most IN-MEET patients are members of the state’s Medicaid program and qualify for non-emergency medical and non-medical transportation through Medicaid (Fig. 1). Upon completion of the methadone enrollment, the IN-MEET team members document patient encounters in both the hospital and OTP electronic health record.
IN-MEET Hospital Discharge Process
At hospital discharge, IN-MEET patients are prescribed naloxone and, when indicated, are referred to infectious disease clinics for treatment of infections, i.e., hepatitis C, HIV, or tuberculosis. Upon OTP linkage, patients continue their methadone without dose disruption, meet with an OTP physician or nurse practitioner for further dose titration, and are assigned a counselor and medical case coordinator who provide case management and assist with Supplemental Nutrition Assistance Program (SNAP) applications, referral to primary care, behavioral health services, and other social support services (Fig. 1).
If a patient desires IN-MEET enrollment but does not live locally and will not follow up at one of the three affiliated OTPs, the ACS care coordinator and the IN-MEET nurse will work together to identify an accepting OTP in another state or region and will transfer the patient’s OTP enrollment paperwork to the external OTP. In this scenario, under the Drug Enforcement Administration’s exception to the 3-day exemption,28 patients receive up to a 3-day supply of methadone to prevent opioid withdrawal during travel time between the hospital and their OTP destination. They are also prescribed naloxone at hospital discharge.
Standard Methadone Hospital Discharge Process
If the patient prefers enrollment to a non-affiliated OTP, the ACS team member provides the patient a list of local OTPs for post discharge, on-site OTP enrollment. They are prescribed naloxone at hospital discharge. This care is standard practice for most hospitalized patients with OUD who prefer methadone following hospital discharge in the USA.17
IN-MEET Funding
Our OTP partners secured grant funding to support a small percentage of clinical time for an IN-MEET physician and a full-time IN-MEET nurse position through a state senate bill29 which funds programs that expand OUD treatment access for Coloradoans. IN-MEET has exceeded metrics for OUD treatment referrals and there are no anticipated future funding gaps for IN-MEET.
Data Source and Measures
We collected data on the total number of IN-MEET enrollments, the number of enrollments completed per patient, and the number of patients who linked from the hospital to the OTP. Patient-reported sociodemographic data, housing status, educational level, insurance status, and details regarding substance use type and route of administration were obtained during the OTP intake using the Global Appraisal of Individual Needs – Initial (GAIN-I),30 a standardized biopsychosocial assessment tool that aims to bridge the gap between clinical research and evidence-based practice, and the Drug/Alcohol Coordinated Data System (DACODS), the primary substance use disorder client level treatment data collection instrument used by the Colorado Behavioral Health Administration.31 Next, we compared patient-reported sociodemographic characteristics between patients who enrolled in IN-MEET to patients who completed community OTP enrollments, i.e., patients who self-enrolled into one of the three community OTPs to which we enrolled IN-MEET patients. All data collected during an IN-MEET enrollment or a community OTP enrollment are stored in the OTP’s electronic health record. All data reported were queried from this source.
Data Analysis
We used a chi-square test or Fisher’s exact test to assess for bivariate associations between IN-MEET and community OTP enrollments. Analyses were performed using R version 3.6.3 (R Core Team, Vienna, Austria).
Results
From April 2019 to April 2023, the IN-MEET team completed 165 methadone enrollments. Among a subset of patients enrolled during April 2019 to February 2022, the IN-MEET team completed 96 enrollments among 73 patients, an average of 1.3 enrollments per patient. Of the 73 patients, 56 (76.7%) presented to the OTP after hospital discharge.
Sociodemographic Characteristics of IN-MEET Patients and Community Enrolled Patients
We compared sociodemographic characteristics of IN-MEET patients (n = 73) and community enrolled patients (n = 1687). Approximately 70% (n = 51) of IN-MEET patients identified as male compared to 56.3% (n = 950) of community enrolled patients. Most IN-MEET patients (n = 64, 87.7%) and community enrolled patients (n = 1337, 79.3%) identified their race as white. Sixty-two percent (n = 45) of IN-MEET patients and 39.7% (n = 670) of community enrolled patients declined to report their ethnicity. Almost half (n = 36, 49.3%) of IN-MEET patients and 55.9% (n = 943) of community enrolled patients reported never being married. More than half (n = 43, 58.9%) of IN-MEET patients reported being homeless. In contrast, 75.6% (n = 1275) of community enrolled patients reported living independently. Most IN-MEET patients reported having a high school degree (n = 29, 39.7%) or having some college or an Associate’s degree (n = 23, 31.5%) and most community enrolled patients reported having a high school degree (n = 724, 42.9%) or having some college or an Associate’s degree (n = 476, 28.2%). Many IN-MEET patients (n = 57, 78.1%) and community enrolled patients had Medicaid as their insurance type (n = 1049, 62.2%) (Table 1).
Table 1.
Baseline Demographics and Treatment Data for IN-MEET Enrolled Patients and Community Enrolled Patients
| IN-MEET enrollment n = 73 | Community enrollment n = 1,687 | P-value | |
|---|---|---|---|
| Patient characteristics | |||
| Age (mean, SD) | 39.7 (11.2) | 36.1 (10.6) | 0.008 |
| Gender (n, %) | 0.03 | ||
| Male | 51 (69.9%) | 950 (56.3%) | |
| Female | 22 (30.1%) | 737 (43.7%) | |
| Race (n, %) | 0.46 | ||
| White | 64 (87.7%) | 1337 (79.3%) | |
| Black or African American | 3 (4.1%) | 167 (9.9%) | |
| American Indian/Alaskan Native | 2 (2.7%) | 34 (2.0%) | |
| Asian | 0 (0.0%) | 8 (0.5%) | |
| Native Hawaiian/Pacific Islander | 0 (0.0%) | 4 (0.2%) | |
| Other/Declined/Unknown | 4 (5.5%) | 137 (8.1%) | |
| Ethnicity (n, %) | < 0.001 | ||
| Non-Hispanic | 13 (17.8%) | 607 (36.0%) | |
| Hispanic | 15 (20.5%) | 410 (24.3%) | |
| Declined/unknown | 45 (61.6%) | 670 (39.7%) | |
| Marital status (n, %) | 0.36 | ||
| Never married | 36 (49.3%) | 943 (55.9%) | |
| Married | 14 (19.2%) | 307 (18.2%) | |
| Widowed | 2 (2.7%) | 40 (2.4%) | |
| Separated | 9 (12.3%) | 101 (6.0%) | |
| Divorced | 11 (15.1%) | 251 (14.9%) | |
| Unknown | 1 (1.4%) | 45 (2.7%) | |
| Housing status (n, %) | < 0.001 | ||
| Correctional facility/jail | 2 (2.7%) | 46 (2.7%) | |
| Dependent living (lives with parents) | 0 (0.0%) | 6 (0.4%) | |
| Halfway house | 0 (0.0%) | 11 (0.7%) | |
| Homeless (no fixed address and includes shelters) | 43 (58.9%) | 199 (11.8%) | |
| Independent living | 25 (34.2%) | 1275 (75.6%) | |
| Inpatient | 0 (0.0%) | 2 (0.1%) | |
| Residential facility/assisted living/group home/nursing home | 0 (0.0%) | 13 (0.8%) | |
| Sober living | 1 (1.4%) | 55 (3.3%) | |
| Supported housing | 1 (1.4%) | 39 (2.3%) | |
| Unknown | 1 (1.4%) | 41 (2.4%) | |
| Highest school grade completed (n, %) | 0.53 | ||
| < 12 years | 10 (13.7%) | 297 (17.6%) | |
| GED or graduated HS | 29 (39.7%) | 724 (42.9%) | |
| Some college/Associate’s degree | 23 (31.5%) | 476 (28.2%) | |
| Bachelor/Master/Doctoral degree | 10 (13.7%) | 147 (8.7%) | |
| Unknown | 1 (1.4%) | 43 (2.5%) | |
| Insurance status (n, %) | < 0.001 | ||
| Medicaid | 57 (78.1%) | 1049 (62.2%) | |
| Medicare | 2 (2.7%) | 17 (1.0%) | |
| Private | 1 (1.4%) | 49 (2.9%) | |
| Self-pay/uninsured | 0 (0.0%) | 249 (14.8%) | |
| Military/government plan (TANF) | 0 (0.0%) | 17 (1.0%) | |
| Other/unknown | 13 (17.8%) | 306 (18.1%) | |
| Substance-related questions | |||
| Primary drug type (n, %) | < 0.001 | ||
| Alcohol | 2 (2.7%) | 244 (14.5%) | |
| Barbiturate/benzodiazepines | 0 (0.0%) | 0 (0.0%) | |
| Cocaine | 0 (0.0%) | 41 (2.4%) | |
| Methamphetamine | 0 (0.0%) | 194 (11.5%) | |
| Heroin/fentanyl | 53 (72.6%) | 677 (40.1%) | |
| Prescription opioids (illicitly used) | 11 (15.1%) | 369 (21.9%) | |
| Cannabis | 0 (0.0%) | 27 (1.6%) | |
| Nicotine | 0 (0.0%) | 0 (0.0%) | |
| Othera | 0 (0.0%) | 12 (0.7%) | |
| None/unknown | 7 (9.6%) | 123 (7.3%) | |
| Secondary drug type (n, %) | 0.05 | ||
| Alcohol | 6 (8.2%) | 99 (5.9%) | |
| Barbiturate/benzodiazepines | 0 (0.0%) | 31 (1.8%) | |
| Cocaine | 5 (6.8%) | 119 (7.1%) | |
| Methamphetamine | 27 (37.0%) | 380 (22.5%) | |
| Heroin/fentanyl | 4 (5.5%) | 57 (3.4%) | |
| Prescription opioids (illicitly used) | 7 (9.6%) | 102 (6.0%) | |
| Cannabis | 5 (6.8%) | 209 (12.4%) | |
| Nicotine | 6 (8.2%) | 148 (8.8%) | |
| Othera | 0 (0.0%) | 11 (0.7%) | |
| None/unknown | 13 (17.8%) | 531 (31.5%) | |
| Usual route of administration during treatment of your primary substance (n, %) | < 0.001 | ||
| Oral (swallow) | 5 (6.8%) | 409 (24.2%) | |
| Smoking (pipe/cigarette) | 14 (19.2%) | 532 (31.5%) | |
| Inhalation (nose/mouth) | 1 (1.4%) | 141 (8.4%) | |
| Injection (IV/IM) | 46 (63.0%) | 478 (28.3%) | |
| Other/unknown | 7 (9.6%) | 127 (7.5%) | |
| Tobacco use (yes) (n, %) | 0.11 | ||
| Current | 55 (75.3%) | 1179 (69.9%) | |
| Former | 9 (12.3%) | 169 (10.0%) | |
| Never | 2 (2.7%) | 201 (11.9%) | |
| Did not answer/unknown | 7 (9.6%) | 138 (8.2%) | |
aIncludes ketamine, LSD, PCP, other amphetamines (e.g., Benzedrine, Dexadrine, Desoxyn), other stimulants (e.g., Ritalin, Sanorex, Adderall), other hallucinogens, gamma-hydroxybutyrate/gamma-butyrolactone (GHB/GBL), methylenedioxymethamphetamine (MDMA/ecstasy), other sedatives/hypnotics (e.g., chloral hydrate, Dalmane), and over the counter drugs
Substance Use Behaviors of IN-MEET Patients and Community Enrolled Patients
A higher percentage of IN-MEET patients (n = 53, 72.6%) reported heroin or fentanyl as their primary substance of use compared to community enrolled patients (n = 677, 40.1%). A higher percentage of IN-MEET patients (n = 27, 37.0%) reported methamphetamine as their secondary substance of use compared to community enrolled patients (n = 380, 22.5%). Sixty-three percent (n = 46) of IN-MEET patients reported injection as their usual route of drug administration compared to 28.3% (n = 478) of community enrolled patients. Many IN-MEET patients (n = 55, 75.3%) and community enrolled patients (n = 1179, 69.9%) reported tobacco use (Table 1).
Associations Between IN-MEET and Community Enrolled Patients
IN-MEET patients were older (39.7 years, standard deviation [SD] 11.2 years) compared to community enrolled patients (36.1 years, SD 10.6 years, p < 0.05). The two groups had significant differences in self-reported ethnicity (p < 0.001), housing status (< 0.001), insurance status (< 0.001), primary substance use (< 0.001), and in their usual route of drug administration (p < 0.001) (Table 1).
Discussion
Over a 3-year period, which coincided with the COVID-19 pandemic, the IN-MEET team completed 165 methadone enrollments for medically ill, hospitalized patients, many of whom used multiple substances. Two-thirds of IN-MEET patients presented to the OTP following hospital discharge despite high rates of homelessness among this group of patients. IN-MEET provides low barrier in-hospital methadone enrollment to medically ill, hospitalized patients with OUD to facilitate methadone treatment continuation after hospital discharge.
In a subset of 73 IN-MEET patients, 76.7% linked from the hospital to the OTP after discharge. This linkage rate is slightly higher than those reported with in-hospital methadone initiation and OTP referrals (reported linkage rates of 40 to 76%)9, 24 and is higher than linkage rates for hospitalized patients initiated on buprenorphine with OUD treatment referral (reported linkage rates of 40 to 72%).9, 25, 32, 33 Our findings suggest that patients with OUD who receive methadone during hospitalization with dose titration to relieve opioid withdrawal symptoms, and who complete an in-hospital methadone enrollment, are equally likely, or may be more likely, to follow-up at an OTP after hospital discharge compared to hospitalized patients initiated on buprenorphine with a scheduled buprenorphine follow-up appointment. We attribute our higher OTP linkage rate for IN-MEET patients, compared to other reported studies, to a variety of factors. First, IN-MEET patients receive case management support including clear instructions about where and when they should go to follow-up at the OTP after discharge. Next, if a patient lacks transportation, our IN-MEET nurse schedules transportation for pick-up and drop-off locations to and from the OTP utilizing a state Medicaid transportation benefit. If a patient has not presented to the OTP within 24 h of hospital discharge, our IN-MEET nurse will call the patient to check-in on them to and support their follow-up to the OTP. Finally, we ensure our patients are aware that their methadone dose will be continued without disruption upon arriving at the OTP. Future work will systematically study the effectiveness of IN-MEET on OTP treatment linkage to better understand what factors are associated with increased treatment linkage and continued treatment engagement among hospitalized patients with OUD following hospital discharge.
Compared to patients who completed community OTP enrollment, a higher percentage of IN-MEET patients were unhoused, injected their primary substance of use, and used methamphetamine as their secondary substance of use. Hospitalizations among people who are unhoused are increasing with many hospitalizations attributed to substance use or mental health disorders.34 Increasingly, people who use drugs report co-use of opioids and methamphetamine, which is associated with unstable housing and injection.35–37 Co-use of opioids and methamphetamine increases the risk of overdose beyond that of opioid use alone.36 Reported reasons for co-use of opioids and methamphetamine include management of opioid withdrawal symptoms,38 a strategy to stay awake for personal protection from physical or sexual attack when unhoused,39 and to balance out the sedating effect of opioid or the hypervigilance and agitation experienced with methamphetamine.40 Our findings suggest that people who co-use opioids and methamphetamine desire methadone treatment despite limited treatment options for methamphetamine and despite a lack of stable housing or social support. Offering low barrier, in-hospital methadone enrollment may improve OTP treatment engagement, and thereby may support OUD recovery among a socially vulnerable population.
We learned important lessons during the development and implementation of IN-MEET. First, some patients preferred to enroll in non-affiliated, local OTPs for greater convenience or because they were familiar with other clinics. Due to federal regulations for OTP enrollments, we were not able to enroll patients into non-affiliated OTPs. In these situations, the ACS team members provided the patient information on OTP hours and locations to facilitate OTP linkage. If patients were discharged from the hospital over the weekend, we dispensed up to three take-home methadone doses to facilitate linkage to an OTP on a Monday, when most clinics accept walk-in appointments for methadone enrollments.28
When patients did not live locally and required a prolonged hospitalization, we completed an IN-MEET enrollment, and, at the time of hospital discharge, the IN-MEET team directly transferred care to the patient’s local OTP to facilitate treatment continuation with no lapse in methadone dosing.
Lastly, we discovered that once a patient requested methadone enrollment, the IN-MEET team needed to act quickly to complete the enrollment before the medical team discharged the patient. This was challenging for the IN-MEET physician who had other clinical responsibilities. To meet the increasing demand for in-hospital methadone enrollments and to ensure the enrollment process does not prolong hospitalizations, our ACS physicians and advanced practice providers became OTP-credentialed to complete federally compliant OTP enrollments. This change ensures that IN-MEET is more sustainable over time by not being dependent on one OTP-affiliated physician to complete the in-hospital enrollments.
Limitations
This study has important limitations. IN-MEET was the result of a collaboration between a hospital-based ACS and a community OTP. This partnership may be challenging to reproduce in hospitals that lack an ACS or in areas where OTP access is limited. IN-MEET enrollments occurred at a single hospital and results may not be generalizable to other institutions. IN-MEET was designed to fill a hospital to OTP linkage gap for our patients and we offered IN-MEET to any patient who requested in-hospital methadone enrollment. As such, we did not measure the effectiveness of IN-MEET vs. usual care on treatment linkage or ongoing treatment engagement. Due to limited research staffing and funding, we were only able to analyze a subset of IN-MEET patients, instead of the complete cohort of IN-MEET patients. In the future, we aim to study the effectiveness of IN-MEET versus usual care. Lastly, under the Affordable Care Act, Colorado expanded Medicaid coverage to many previously uninsured people which covers the cost of OTP treatment services. Service reimbursement, medication coverage, and ongoing treatment following hospital discharge are dependent upon a reliable payor source for medical cost coverage.
Conclusion
In-hospital methadone enrollment for OUD treatment linkage resulted in a high percentage of OTP linkage for patients who were older and more vulnerable compared to patients who self-referred to a community OTP. This model has potential to improve methadone access to patients who are medically ill and who may not otherwise seek out treatment.
Funding:
Dr. Calcaterra is supported by the National Institute on Drug Abuse (NIDA), National Institutions of Health, grant award number K08DA049905. The content is solely the responsibility of the authors and does not necessarily reflect the official views of the National Institutes of Health. IN-MEET is funded by Colorado State Bill 16-202, “Increasing Access Effective Substance Use Services”.
National Institute on Drug Abuse,K08DA049905,Susan Calcaterra
Data Availability
Data are available upon request.
Declarations
Conflict of Interest
The authors have no conflicts of interest to report.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Ahmad FB CJ, Rossen LM, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics. 2023. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. Accessed 21 Aug 2023.
- 2.Singh JA, Cleveland JD. National U.S. time-trends in opioid use disorder hospitalizations and associated healthcare utilization and mortality. PLoS ONE. 2020;15(2):e0229174. 10.1371/journal.pone.0229174. [DOI] [PMC free article] [PubMed]
- 3.Calcaterra SL, Martin M, Bottner R, et al. Management of opioid use disorder and associated conditions among hospitalized adults: A Consensus Statement from the Society of Hospital Medicine. J Hosp Med. 2022;17(9):744-756. 10.1002/jhm.12893. [DOI] [PMC free article] [PubMed]
- 4.Calcaterra SL, Bottner R, Martin M, et al. Management of opioid use disorder, opioid withdrawal, and opioid overdose prevention in hospitalized adults: A systematic review of existing guidelines. J Hosp Med. 2022;17(9):679-692. [DOI] [PMC free article] [PubMed]
- 5.Alrawashdeh M, Rhee C, Klompas M, et al. Association of early opioid withdrawal treatment strategy and patient-directed discharge among hospitalized patients with opioid use disorder. J Gen Intern Med. 2023. 10.1007/s11606-023-08059-w. [DOI] [PMC free article] [PubMed]
- 6.Bredenberg E, Tietbohl C, Dafoe A, Thurman L, Calcaterra S. Identifying factors that contribute to burnout and resilience among hospital-based addiction medicine providers: A qualitative study. J Subst Abuse Treat. 2023;144:108924. 10.1016/j.jsat.2022.108924. [DOI] [PubMed]
- 7.Calcaterra SL, Lockhart S, Callister C, Hoover K, Binswanger IA. Opioid use disorder treatment initiation and continuation: a qualitative study of patients who received addiction consultation and hospital-based providers. J Gen Intern Med. 2022. 10.1007/s11606-021-07305-3. [DOI] [PMC free article] [PubMed]
- 8.Englander H, Dobbertin K, Lind BK, et al. Inpatient addiction medicine consultation and post-hospital substance use disorder treatment engagement: a propensity-matched analysis. J Gen Intern Med. 2019;34(12):2796–2803. 10.1007/s11606-019-05251-9. [DOI] [PMC free article] [PubMed]
- 9.Trowbridge P, Weinstein ZM, Kerensky T, et al. Addiction consultation services - Linking hospitalized patients to outpatient addiction treatment. J Subst Abuse Treat. 2017;79:1-5. 10.1016/j.jsat.2017.05.007. [DOI] [PMC free article] [PubMed]
- 10.Wakeman SE, Larochelle MR, Ameli O, et al. Comparative effectiveness of different treatment pathways for opioid use disorder. JAMA Netw Open. 2020;3(2):e1920622-e1920622. 10.1001/jamanetworkopen.2019.20622. [DOI] [PMC free article] [PubMed]
- 11.Tierney HR, Rowe CL, Coffa DA, Sarnaik S, Coffin PO, Snyder HR. Inpatient opioid use disorder treatment by generalists is associated with linkage to opioid treatment programs after discharge. J Addict Med. 2022;16(2):169-176. [DOI] [PMC free article] [PubMed]
- 12.Christian N, Bottner R, Baysinger A, et al. Hospital buprenorphine program for opioid use disorder is associated with increased inpatient and outpatient addiction treatment. J Hosp Med. 2021;16(6):345-348. [DOI] [PMC free article] [PubMed]
- 13.D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. Jama. 2015;313(16):1636-44. 10.1001/jama.2015.3474. [DOI] [PMC free article] [PubMed]
- 14.Englander H, Priest KC, Snyder H, Martin M, Calcaterra S, Gregg J. A call to action: hospitalists’ role in addressing substance use disorder. J Hosp Med. 2020;15(3):184-187. 10.12788/jhm.3311. [DOI] [PMC free article] [PubMed]
- 15.U.S. Department of Justice DEA, Diversion Control Division. Title 21 Code of Federal Regulations 1306.07: Administering or dispensing of narcotic drugs. United States Drug Enforcement Administration. July 29, 2022. Updated 2020. https://www.govinfo.gov/content/pkg/CFR-1998-title21-vol9/xml/CFR-1998-title21-vol9-sec1306-07.xml. Accessed 8 Aug 2023.
- 16.Martin M, Englander H, Calcaterra SL. Things We Do for No Reason™: Avoiding methadone for opioid withdrawal. J Hosp Med. 2023. 10.1002/jhm.13138. [DOI] [PMC free article] [PubMed]
- 17.Substance Abuse and Mental Health Services Administration. Federal Guidelines for Opioid Treatment Programs. HHS Publication No. (SMA) XX-XXXX. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015.
- 18.Larochelle MR, Bernson D, Land T, et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: a cohort study. Ann Intern Med. 2018;169(3):137-145. 10.7326/m17-3107. [DOI] [PMC free article] [PubMed]
- 19.Hoover K, Lockhart S, Callister C, Holtrop JS, Calcaterra SL. Experiences of stigma in hospitals with addiction consultation services: A qualitative analysis of patients’ and hospital-based providers’ perspectives. J Subst Abuse Treat. 2022;138:108708. 10.1016/j.jsat.2021.108708. [DOI] [PMC free article] [PubMed]
- 20.Calcaterra S, Bach P, Chadi A, et al. Methadone matters: what the United States can learn from the global effort to treat opioid addiction. J Gen Intern Med. 2019;34(6):1039-1042. [DOI] [PMC free article] [PubMed]
- 21.Joudrey PJ, Chadi N, Roy P, et al. Pharmacy-based methadone dispensing and drive time to methadone treatment in five states within the United States: A cross-sectional study. Drug Alcohol Depend. 2020;211:107968. 10.1016/j.drugalcdep.2020.107968. [DOI] [PMC free article] [PubMed]
- 22.Joudrey PJ, Edelman EJ, Wang EA. Drive times to opioid treatment programs in urban and rural counties in 5 US States. JAMA. 2019;322(13):1310-1312. 10.1001/jama.2019.12562. [DOI] [PMC free article] [PubMed]
- 23.Davis CS, Carr DH. Legal and policy changes urgently needed to increase access to opioid agonist therapy in the United States. Int J Drug Policy. 2019;73:42-48. 10.1016/j.drugpo.2019.07.006. [DOI] [PubMed]
- 24.Tierney HR, Takimoto SW, Azari S, Steiger S, Martin M. Predictors of Linkage to an opioid treatment program and methadone treatment retention following hospital discharge in a safety-net setting. Subst Use Misuse. 2023;58(9):1172-1176. 10.1080/10826084.2023.2212070. [DOI] [PubMed]
- 25.Calcaterra SL, McBeth L, Keniston AM, Burden M. The development and implementation of a hospitalist-directed addiction medicine consultation service to address a treatment gap. J Gen Intern Med. 2022;37(5):1065-1072. 10.1007/s11606-021-06849-8. [DOI] [PMC free article] [PubMed]
- 26.University of Colorado SoM, Department of Psychiatry. Addiction Research and Treatment Services (ARTS). 2022. https://www.artstreatment.com/. Accessed 8 Aug 2023.
- 27.Davis CS, Carr DH. Legal and policy changes urgently needed to increase access to opioid agonist therapy in the United States. Int J Drug Policy. 2019/11/01/ 2019;73:42–48. 10.1016/j.drugpo.2019.07.006. [DOI] [PubMed]
- 28.Request for Exception to Limitations on Dispensing for OUD (2023). https://www.deadiversion.usdoj.gov/drugreg/Instructions-to-request-exception-to-21-CFR%201306.07(b)-3-day-rule-(EO-DEA248R1).pdf.
- 29.Steadman PYD. SB16-202: Increasing Access Effective Substance Use Services. In: 73rd General Assembly CGA, editor. SB16-202. Denver, Colorado, 2016. p. 5. https://leg.colorado.gov/bills/sb16-202.
- 30.Dennis M. The Global Appraisal of Individual Needs (GAIN) Progressive Approach to Assessment. https://gaincc.org/about/. Accessed 31 May 2023.
- 31.DACODS User Manual (Drug and Alcohol Coordinated Data System) (2022). https://adad.cdhs.state.co.us/Training/DACODS%20User%20Manual,%20revised%2012222009.pdf.
- 32.Liebschutz JM, Crooks D, Herman D, et al. Buprenorphine treatment for hospitalized, opioid-dependent patients: a randomized clinical trial. JAMA Intern Med. 2014;174(8):1369-76. 10.1001/jamainternmed.2014.2556. [DOI] [PMC free article] [PubMed]
- 33.Christian N, Bottner R, Baysinger A, et al. Hospital buprenorphine program for opioid use disorder is associated with increased inpatient and outpatient addiction treatment. J Hosp Med. 2021;16(6):345-348. 10.12788/jhm.3591. [DOI] [PMC free article] [PubMed]
- 34.Wadhera RK, Choi E, Shen C, Yeh RW, Joynt Maddox KE. Trends, causes, and outcomes of hospitalizations for homeless individuals: a retrospective cohort study. Med Care. 2019;57(1):21-27. 10.1097/mlr.0000000000001015. [DOI] [PMC free article] [PubMed]
- 35.Glick SN, Klein KS, Tinsley J, Golden MR. Increasing heroin-methamphetamine (goofball) use and related morbidity among seattle area people who inject drugs. Am J Addict. 2021;30(2):183-191. 10.1111/ajad.13115. [DOI] [PMC free article] [PubMed]
- 36.Korthuis PT, Cook RR, Foot CA, et al. Association of methamphetamine and opioid use with nonfatal overdose in rural communities. JAMA Network Open. 2022;5(8):e2226544-e2226544. 10.1001/jamanetworkopen.2022.26544. [DOI] [PMC free article] [PubMed]
- 37.Han B, Compton WM, Jones CM, Einstein EB, Volkow ND. Methamphetamine use, methamphetamine use disorder, and associated overdose deaths among US adults. JAMA Psychiatry. 2021;78(12):1329-1342. 10.1001/jamapsychiatry.2021.2588. [DOI] [PMC free article] [PubMed]
- 38.Silverstein SM, Daniulaityte R, Getz K, Zule W. “It’s crazy what meth can help you do”: lay beliefs, practices, and experiences of using methamphetamine to self-treat symptoms of opioid withdrawal. Subst Use Misuse. 2021;56(11):1687-1696. 10.1080/10826084.2021.1949612. [DOI] [PubMed]
- 39.Bungay V, Malchy L, Buxton JA, Johnson J, MacPherson D, Rosenfeld T. Life with jib: A snapshot of street youth’s use of crystal methamphetamine. Addict Res Theory. 2006;14(3):235–251. 10.1080/16066350500270901.
- 40.Ivsins A, Fleming T, Barker A, et al. The practice and embodiment of “goofballs”: A qualitative study exploring the co-injection of methamphetamines and opioids. Int J Drug Policy. 2022;107:103791. 10.1016/j.drugpo.2022.103791. [DOI] [PMC free article] [PubMed]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data are available upon request.