Strategies to increase medications for opioid use disorder in hospital settings in the USA: protocol for a scoping review

Abstract

Introduction

Opioid use disorder (OUD) remains a serious and life-threatening disease. Medications for opioid use disorder (MOUD) are effective treatments for OUD but a minority of eligible patients receive them. Hospitalisation is an opportune time to increase MOUD use. However, the description of the most successful strategies to implement MOUD is underexplored. This scoping review will methodically review what strategies have been described in the literature to increase MOUD use in hospital settings in the USA.

Methods and analysis

Our scoping review will be completed using methods outlined by the JBI Manual for Evidence Synthesis. English-language studies published after 1 January 2000, and situated in the USA will be included. Studies must explicitly mention an implementation strategy with the aim to increase MOUD initiation in a hospital setting. MOUD will include buprenorphine, methadone and naltrexone. Experimental and observational studies will be included for review. Our search strategy will be guided by an academic librarian to search Ovid-Medline, Embase, CINAHL, APA PsycInfo, Scopus, Web of Science and Sociological Abstracts for peer-reviewed studies from 1 January 2000 to present. Studies will be described by their strategy components, potential mechanisms and outcomes. We will report our findings according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis Extension for Scoping Reviews. Study selection and data extraction will be completed by two reviewers. If disagreements arise, the study will be reviewed and resolved by a third reviewer.

Ethics and dissemination

This study does not involve the collection of new data and therefore does not require approval from an institutional review board. We will submit the results of our review to an academic peer-reviewed journal for publication and to relevant stakeholders.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• We will use theories and frameworks from implementation science to comprehensively describe the components, mechanisms and potential outcomes of implementation strategies designed to increase medications for opioid use disorder use in a hospital setting.

• Eligible studies will be limited to the US healthcare system.

• The grey literature will not be searched.

• As a scoping review, we will not appraise the strength of the evidence nor provide statistical comparisons between the different strategies.

Introduction

Prior literature and studies

Drug overdose remains a significant problem in the USA. While overdose deaths have decreased in the past several years,¹ a substantial number of patients continue to suffer with opioid use disorder (OUD). Fortunately, effective treatments for OUD exist. Buprenorphine and methadone, commonly referred to as medications for opioid use disorder (MOUD), are highly effective in reducing morbidity and mortality.2,4 Unfortunately, less than 25% of patients receive them.^{5 6}

Hospitalisation is an opportunity to increase access to MOUD. A significant portion of hospitalisations are related to substance use disorders or complications of substance use.7,9 Inpatient addiction consult services (ACS) have become widespread in the USA. ACS have been shown to be effective in increasing MOUD use among hospitalised patients with OUD.^{10 11} Yet, ‘hospital-based addictions care cannot depend solely on consult services’.¹² Like many specialty services, the supply of addiction medicine experts is not sufficient to meet the clinical demand of patients in need of OUD treatment. Therefore, identifying the full spectrum of effective strategies to improve MOUD use is necessary.

We can identify and detail these strategies using implementation science (IS). IS is ‘the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice’.¹³ IS seeks to narrow the ‘know-do’ gap between what we know works and what we do in practice. Given that an estimated two-thirds of implementation efforts fail, we risk wasted time, effort and funding if we do not understand what makes strategies successful, how they work and what outcomes they affect.¹⁴ To clarify, an innovation or intervention is the evidence-based practice that an organisation wants to implement. Implementation strategies are ‘methods or techniques used to enhance the adoption, implementation, and sustainability of a clinical program or practice’.¹⁵ For the purpose of this study, the intervention we seek to examine is MOUD in the hospital setting. An example of an implementation strategy used in this setting is ACS.

There has been extensive research on the barriers to treatment of OUD and addiction care in general.¹⁶ Over the past decade, in the context of the worsening opioid epidemic, there have been increasing calls and efforts to improve MOUD delivery.1217,20 A recent scoping review searched for ‘best practices and guidelines for initiating MOUD during hospitalization, and how do these practices contribute to successful care transitions and linkage to ongoing outpatient treatment’.²¹ While this work offered valuable insights, further investigation into the components, mechanisms of action and implementation outcomes of previous strategies is needed. A preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews and JBI Evidence Synthesis was conducted and no current or underway systematic reviews or scoping reviews on the topic were identified.²²

Rationale for this study

We chose to conduct this scoping review to explore what strategies have been used to increase MOUD use in US hospital settings. Compared with other methods of evidence synthesis, we chose a scoping review because we want to explore the literature, summarise the evidence of prior implementation efforts and identify research gaps. By doing so, we hope to provide a toolbox of strategies that readers can consider implementing in their own settings. To help fit low-resource contexts and push the field beyond ACS, we will give special attention to strategies that are distinct from ACS.

A frequent problem in implementation studies is the poor description of what the strategies entail. Among the studies included in this review, we will describe strategy components using the framework described by Proctor et al.¹⁵ When reporting an implementation strategy, it is recommended to name it, define it and specify its components by actor, action, action target, temporality, dose, implementation outcome affected and justification. This helps to (a) clarify the design and execution of the strategies, (b) allow researchers to replicate the strategies in future studies and (c) enable stakeholders at other organisations to adapt the strategies for their specific environment.

Context matters in implementation efforts.²³ Implementing an exact replica of an implementation strategy that has been successful in one context may have drastically different outcomes in another. To improve transferability across different contexts, there have been increasing calls to identify the mechanisms of implementation strategies.²⁴ If we understand how a strategy works, its mechanism of action, then we can understand how barriers interfere with those effects. We will describe strategies using normalisation process theory (NPT) as a mechanistic framework.^{25 26} NPT is a middle-range theory that helps to explain the work people do to maintain or change complex interventions. It consists of four main constructs: (1) coherence, (2) cognitive participation, (3) collective action and (4) reflexive monitoring. We will attempt to classify each implementation strategy and its mechanism(s) according to these NPT constructs.²⁵

Finally, to help select strategies that are feasible and worthwhile, providers, administrators and other stakeholders need to know the impact of these strategies. We will describe the implementation outcomes of each strategy using the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework.²⁷ This commonly used framework is used to plan and evaluate programmes by examining its RE-AIM. By doing so, we will describe how strategies balance effectiveness, feasibility and sustainability.

In summary, our overall goal is to give a broad overview of what strategies have been employed in hospital settings to increase MOUD use and highlight gaps in the literature. We hope these efforts will inform stakeholders and identify research opportunities for future implementation efforts.

Purpose of the study protocol and registration

This purpose of this study protocol is to provide a plan for research team members, establish standardisation in study procedures, communicate our efforts and methods with the scientific community, provide accountability and allow transparency in the study design, execution and funding. We registered the protocol on Open Science Framework Registries: https://doi.org/10.17605/OSF.IO/DQCJZ

Methods and analysis

Overview

The proposed scoping review will be conducted in accordance with the JBI methodology for scoping reviews.^{22 28} We will use the Preferred Reporting Items for Systematic reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-Sc) to guide the design and reporting of review elements.²⁹ The study team will include clinical hospitalists, addiction medicine specialists, a postgraduate research fellow, a medical librarian and experts in dissemination and implementation (D&I) science.

The research question

The research question was selected by discussion with the study team and using the Population–Concept–Context framework (table 1).²⁸ The main question we sought to answer is: ‘What implementation strategies have been described for improving use of MOUD in hospital settings?’ Within this question, we developed the following subquestions: (1) ‘How many of these strategies are distinct from ACS?’, (2) ‘What mechanisms help explain how these implementation strategies achieve their effects?’ and (3) ‘What implementation outcomes were described?’ By answering this question, hospital and clinical leaders will be able to review what strategies have been tried, how they achieve their effects and how effective they have been in their specific contexts.

Table 1. Research question defined by separate PCC components.

Concept	Explanation
P (Population)	Hospitalised adult patients with opioid use disorder (OUD).
C (Concept)	Implementation strategies to increase inpatient use of medications for opioid use disorder (MOUD). MOUD refers to buprenorphine, methadone or naltrexone.
C (Context)	Hospital setting Studies from 2000 to present Studies from the USA Studies in English language

PCC, population–concept–context.

Primary objective

The primary objective of this scoping review is to methodically review what strategies have been described in the scientific literature to increase MOUD use in hospital settings.

Secondary objectives

To complete this primary objective, we propose the following specific aims:

• To identify the components of each implementation strategy, using the framework described by Proctor et al.¹⁵

• To characterise the kinds of implementation strategies that have been employed, using NPT as a framework.^{25 26}

• To explore the implementation outcomes of each strategy, using RE-AIM.²⁷

Inclusion criteria

Population

The population of interest of this review are hospitalised adult (age ≥18 years) patients with OUD. Because OUD has a broad impact across populations, no exclusions will be made on patient gender, race or ethnicity. Likewise, because OUD is clinically relevant to many medical specialties, we will not make any exclusions on specialty population.

Concept

The concept we will explore is what implementation strategies have been used to increase MOUD. Specifically, we want to know what were the components of each strategy and the possible mechanisms that supported those strategies. To capture the full breadth of MOUD implementation, we chose to include all three FDA-approved MOUD agents: buprenorphine, methadone and naltrexone.

Context

Our review will be focused on implementation strategies in the hospital setting. We will exclude studies set in the emergency department, urgent care or ambulatory care settings. We chose to limit our inclusion criteria to those published in the English language and situated in the USA after 1 January 2000. By doing so, we will maintain the temporal relevance and applicability of current implementation strategies. Additionally, limiting our review to English language studies in the USA is important for future implementation efforts, due to the unique epidemiologic, economic and regulatory context of the US healthcare system.

Types of sources

This scoping review will consider both experimental and quasi-experimental study designs including randomised controlled trials, non-randomised controlled trials, before and after studies and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies and case–control studies will be considered for inclusion. This review will also consider descriptive observational study designs including case series and individual case reports for inclusion.²²

Patient and public involvement

Patients and members of the public were not involved in the development of this project.

Search strategy

A medical librarian developed a comprehensive search strategy that included controlled vocabulary terms (eg, MeSH, Emtree) and keyword terms. We used a search validation procedure to confirm the effectiveness of our search strategy. We identified three benchmark articles that were relevant to our research question.^{10 30 31} The preliminary search strategy included the following: MOUD and opiate addiction and implementation and hospitalised patients. The search was executed to see if the benchmark articles were included in the search. If they were not, we adjusted our search terms, Boolean operators and filters as needed until they were retrieved. Ovid-Medline, Embase, CINAHL, APA PsycInfo, Scopus, Web of Science and Sociological Abstracts will be utilised to find relevant studies (see online supplemental appendix 1). We chose not to search the grey literature because we wanted to limit our search to peer-reviewed studies and due to concerns about the reproducibility of a grey-literature search strategy. Results will be limited to English and from 1 January 2000 to present. After the search is completed, all items were imported into Covidence for deduplication, study selection and data extraction. We executed this search on 11 November 2025. If necessary, we will report the date of our most recent search. We do not plan to repeat our search.

Study selection

General inclusion and exclusion criteria are included in table 2. We will pilot test the inclusion and exclusion criteria on a random sample of references obtained from our search. To assess inter-rater reliability between reviewers, two reviewers will independently screen these references based on our inclusion and exclusion criteria. We will test inter-rater reliability using Cohen’s Kappa coefficient.³² We will repeat this process until we achieve a Kappa coefficient of ≥0.8 (ie, strong agreement).

Table 2. Inclusion and exclusion criteria of study selection.

Inclusion	Exclusion
Adult (≥18 years old) patients with OUD	Patients<18 years old
Hospital, inpatient setting	Emergency room, urgent care, ambulatory settings
Buprenorphine, methadone or naltrexone as MOUD	Other medications as MOUD
Explicitly describe strategies used to increase MOUD use and report MOUD receipt as a primary or secondary outcome	Do not include: (1) strategies of MOUD use or (2) report MOUD receipt as a primary or secondary outcome
Randomised controlled trials, quasi-experimental, pre–post, cluster randomised controlled trials, prospective or retrospective cohorts, case–control, mixed methods, descriptive case reports	Cross-sectional, ecological, opinion/editorials
Published after 1 January 2000	Published before 1 January 2000
Conducted in USA	Conducted outside of USA
Full text articles in English language	Abstracts, conference presentations, theses, dissertations, textbooks

MOUD, medications for opioid use disorder; OUD, opioid use disorder.

Next, studies will be selected in a two-step manner. First, studies will be screened at the title and abstract level. Two research team members will independently review each reference for inclusion or exclusion. We will provide written instructions for reviewers at both the title/abstract and full-text steps. Reviewers will label each reference with a ‘Yes’, ‘Maybe’ or ‘No’. To proceed to the next step, each reference will need approval from two reviewers. If there is disagreement between reviewers, an independent third reviewer will examine the study and provide the tie-breaking decision. This third reviewer will be a senior member of the research team.

Second, studies will be screened at the full-text level for inclusion or exclusion. Again, studies will be reviewed by two reviewers, who will label each reference with a ‘Yes’ or ‘No’ according to the inclusion and exclusion criteria. If disagreements arise, the study will be reviewed by the team, and the conflict will be resolved by a senior member of the research team. The reason for exclusion at the full-text level will be reported in the scoping review. A preliminary list of reasons for exclusion includes non-hospital setting, non-MOUD intervention, non-implementation strategy, wrong study design, conducted outside of USA, non-English publication, no full text available and published prior to 1 January 2000. On completion of the second step, a PRISMA flow diagram will be presented to describe the results of the study selection process.²⁹

Data extraction

We will complete data extraction in three stages: (1) training, (2) execution and (3) verification. Data will be extracted from papers included in the scoping review by at least two independent reviewers using a data extraction tool developed by our study team. We will provide written instructions for reviewers with all extraction stages. The data extracted will include study characteristics (such as author, publication year, publishing journal, etc), specific details about the participants, concept, context, study methods and key findings relevant to the review questions. Data will be charted using Covidence. A draft extraction form is provided (see online supplemental appendix 2).

In the training stage, the data extraction tool will be pilot tested, modified and revised as necessary. Modifications will be detailed in the scoping review. After the training stage, we will proceed with the execution stage and extract data from all included sources. After initial data extraction, authors of papers will be contacted to request missing or additional data, if required.²² We will initially contact authors via email with a brief introduction, explanation of the study’s purpose and request the data needed for our analysis. If we do not receive a response within 2 weeks, we will send a follow-up email as a gentle reminder. We will report how many authors we contacted, how many responded and how many provided the data we requested. If we do not receive a response from the study authors, we will simply report the data as missing.

Finally, in the verification phase, any disagreements that arise between the reviewers will be resolved with additional reviewer(s) or through consensus. Throughout all stages, senior team members will oversee the data extraction process to provide guidance.

Data analysis and presentation

We will report the results using the PRISMA-ScR guidelines for scoping reviews (online supplemental appendix 3).²⁹ We will use descriptive statistics from the charted data and organise the results by (1) study characteristics, (2) strategy components as described by Proctor et al,¹⁵ (3) strategy mechanisms according to NPT^{25 26} and (4) implementation outcomes classified by RE-AIM.²⁷ By doing so, we will accomplish our objective to review and describe the implementation strategies that have been used to increase MOUD in hospital settings. We plan to end our study by 1 August 2026.

Protocol amendments

If we need to make amendments to this protocol, we will do so using the AHRQ process for protocol amendments.³³ We will not incorporate changes into the protocol itself. Instead, we will document amendments with the date, section, description of the original protocol language, description of the protocol change and provide rationale for the change.

Ethics and dissemination

As the study does not involve collection of new data, including protected health information, ethics approval by an institutional review board is not required. We will submit the results of our scoping review to a peer-reviewed academic journal for publication. We may also share our results at national conferences, local seminars and on social media.