Hospital Policies for Opioid Use Disorder Treatment: A Policy Content Analysis and Environmental Scan Checklist

Abstract

Objective:

Hospital-based delivery of opioid agonist therapy ([OAT]; buprenorphine, methadone) is an often-overlooked component of the opioid use disorder (OUD) care continuum. Hospitals are complex clinical environments and organizational policies may inform access to care. This study aimed to identify and describe OUD-related hospital policies.

Methods:

We obtained policies through a purposive sampling of addiction physicians affiliated with 10 U.S. hospitals. Experts provided 25 documents that we analyzed using a framework analysis. We then assessed policy concordance with national recommendations and conducted a post-hoc synthesis to create an environmental scan checklist.

Results:

We observed two hospital policy domains, with four sub-domains, each: 1) OAT management (a. acute pain and perioperative; b. OAT continuation; c. OAT initiation; d. opioid withdrawal) and 2) security and behavioral management (a. aberrant drug use; b. patient-directed discharge; c. safety protocols; d. peripherally inserted central catheters). OAT policy concordance with national guidance varied by sub-domain. Our post-hoc synthesis resulted in a hospital policy environmental scan checklist.

Conclusions:

Hospital policies are not a singular solution to increasing OAT access, however, in the midst of a worsening drug-related overdose crisis, we observed the divergence of individual policies from federal recommendations. Policies should enhance, rather than deter OAT access.

1. Introduction

The hospital is an important part of the opioid use disorder (OUD) care continuum.¹ During hospitalization, patients with OUD should have access to opioid withdrawal management, opioid agonist therapy ([OAT]; buprenorphine and methadone), patient-centered trauma-informed care, and linkage to treatment upon discharge.² Yet research suggests that first-line OAT, is infrequently administered during^3,4 and after hospitalization.⁵ The persistence of this clinical care deficit in the midst of a public health crisis is not well elucidated, however, a growing literature suggests that causes of sub-optimal care are multifaceted and complex, including the misinterpretation of restrictive OAT polices inside and outside the hospital,^6,7 stigma and discrimination towards patients hospitalized with OUD,^7–10 and provider concerns about safety.¹¹

One approach to counteract this treatment gap is to implement national clinical guidance recommendations in the hospital.^12,13 The Substance Abuse & Mental Health Services Administration’s (SAMHSA) treatment guideline recommends continuing outpatient OAT and providing short-acting non-OAT opioids to manage pain as needed, and initiating OAT when planned linkage to care is available.¹² Further, SAMHSA states: “The TIP [Treatment Improvement Protocol] expert panel urges providers not to force patients to withdraw from opioid agonist treatment in the hospital, especially if they have acute illness, pain, or mental illness.”¹² Moreover, the National Academies of Sciences, Engineering, and Medicine’s Committee on Medication-Assisted Treatment for OUD states that “withholding or failing to have available all classes of FDA [Food and Drug Administration]-approved medications for the treatment of opioid use disorder in any care or criminal justice setting is denying appropriate medical treatment.”¹³

OAT delivery is but one important consideration in the care of patients who are hospitalized with co-occurring OUD. There is, however, less consensus as to which non-OAT related services comprise an appropriate standard of care. Systematic and narrative reviews, clinical checklists, and single-site case studies describe a variety of services to support patients and to enhance systems of care during hospital admission. These interventions may include a) psychosocial modalities^14–17 (e.g., involving social work or case management); b) harm reduction education^14–18 (e.g., providing opioid overdose or safer injection education); and c) systems-related interventions^14,16,18,19 (e.g., establishing addiction consult services [ACS]).

In this study we aimed to identify, describe, and compare the content of hospital policies related to the care of patients with OUD obtained from a small and limited sample of well-resourced U.S. hospitals and health systems. The final study output is a hospital OAT policy environmental scan checklist, which we created through the synthesis of study findings, supported by national guidelines, national policy, and prior research.

2. Methods

2.1. Data Collection

In 2018, we obtained 25 hospital documents through the purposive recruitment of 11 board-certified (n = 10) and board-eligible (n = 1) addiction physicians affiliated with 10 U.S. addiction medicine fellowship programs. These participants were from a study sample of 17 key informants. The other six key informants did not provide hospital guidance documents. Details on study recruitment are published elsewhere.^20,21 This study was reviewed, approved, and designated a minimal risk human subjects study by Oregon Health & Science University’s Institutional Review Board (#18092).

2.2. Conceptual Framework and Data Analysis

The study’s conceptual framework^20,21 provided the foundation for study design, analysis, and interpretation of findings. We viewed hospital documents as organizational technologies reflecting the shared beliefs and understandings of people within a respective hospital.^22,23 We analyzed the documents using a framework analysis approach: beginning with an a priori policy framework, then document familiarization, indexing and charting of the policies, policy comparison, and interpretation.²⁴ We started with four a priori policy content categories: 1) OAT continuation, 2) withdrawal management, 3) OAT initiation and 4) acute pain and perioperative management. During the analytic process, we added a fifth category: 5) security and behavioral management. From our initial analysis, we created two umbrella categories and eight policy sub-domains. It was possible for a guidance document to have policy content applicable to more than one policy sub-domain, thus, the unit of analysis was the policy content. We also assessed whether OAT-related policies were concordant with SAMHSA’s recommendations.¹² We excluded details on care for specific patient populations (e.g., pregnant people) from these analyses. Policy summaries, by hospital, are available from the corresponding author. The first (KCP), and senior author (DM) had access to all hospital policies. First author (KCP) conducted the primary analyses, senior author (DM) reviewed policy comparison tables and domains, and second author (HE) reviewed the final analytic output, which led to the development of the Hospital OAT Policy Checklist (Table 3). Checklist creation was informed by study results, national guidance documents, prior literature review, and addiction medicine expertise (HE).

Table 3.

Hospital OAT Policy Checklist

Question	Recommended Practice
⎕ Does your hospital formulary have all classes of FDA-approved OUD treatment—methadone, buprenorphine, buprenorphine/naloxone, and naltrexone?  ⎕ No  ⎕ Yes	All classes of FDA-approved medications for OUD treatment should be available (agonist and antagonist therapy).13
⎕ Does your hospital pharmacy have OAT administration or formulary restrictions?  ⎕ No  ⎕ Yes	As long as the primary reason for admission is not opioid withdrawal, there should be no restrictions on the duration of OAT administration during hospitalization.26 For example, if someone is admitted for a 6-week course of intravenous antibiotics and OAT is started, they should be offered OAT for the duration of their hospitalization, regardless of length of stay, with linkage to care at discharge.
⎕ Does your hospital have an OAT continuation policy? If so, does it align with national standards?  ⎕ No  ⎕ Yes	Do not force patients to withdraw from OAT during hospitalization.12
⎕ Does your hospital have an OAT and perioperative/pain management policies? If so, do they align with national standards?  ⎕ No  ⎕ Yes	For pain management and surgical patients, in most clinical scenarios, hospitals should continue outpatient OAT through the operative period and provide short-acting non-OAT opioids to manage pain.12
⎕ Does your hospital have an OAT initiation hospital policy? If so, does it align with national standards?  ⎕ No  ⎕ Yes	Initiate OAT during hospitalization when there is planned linkage to care12: Buprenorphine: 2 to 4 mg of buprenorphine or 2/0.5 mg to 4/1 mg of buprenorphine/naloxone, with a daily maximum dose of 8 mg for Day 1 and ≤ 16 mg for Day 2. Methadone: 10 to 30 mg for patients with opioid tolerance, and 5 to 10 mg for patients with low opioid tolerance. The total methadone dose on Day 1 should not exceed 40 mg.
⎕ Does your hospital have an opioid withdrawal management policy? If so, does it align with national standards?  ⎕ No  ⎕ Yes	Only provide OAT for withdrawal management per patient preference. Short-term medically supervised withdrawal is not recommended because of its high rates of return to illicit opioid use. OAT is first-line treatment for withdrawal management.12

Table Notes. OAT = opioid agonist therapy

2.3. SAMHSA Recommendations

We assessed policy concordance with national treatment recommendations from SAMHSA’s Treatment Improvement Protocol 63¹² across four dimensions: 1) acute pain and perioperative management, 2) OAT continuation, 3) OAT withdrawal management, and 4) OAT initiation.

Acute pain and perioperative management.

In most clinical scenarios, providers should continue outpatient OAT through the operative period and provide short-acting non-OAT opioids to manage pain as needed.¹² For buprenorphine, SAMHSA outlines two options: 1) continue and provide full agonists, or 2) discontinue and provide full agonists.¹² If providers pursue option 2, they should restart buprenorphine and provide a proper handoff prior to discharge.¹² The guidance states: “Most patients can continue buprenorphine through the operative period.”¹² In contrast, for methadone, patients should receive their daily dose, barring contraindications, and that full agonists—sometimes at higher doses—will likely be required in addition to their daily methadone dose.¹²

OAT continuation.

In most clinical scenarios, providers should continue outpatient OAT throughout hospitalization, the guidance “urges” against forcing withdrawal from OAT during admission.¹² Thus, every effort should be made, in alignment with patient goals to continue OAT throughout hospitalization.¹²

Opioid withdrawal management.

Providers should not use medically induced withdrawal as first line treatment: “The TIP expert panel recommends offering maintenance therapy with medication, not short-term medically supervised withdrawal.”¹² However, if withdrawal is the patient’s preference, an OAT taper is recommended.¹² Clonidine should only be used as monotherapy when OAT is unavailable or if it is patient preference.¹² These recommendations were not specific to hospitalization.¹² SAMHSA does not distinguish between OAT initiation for withdrawal management versus maintenance (e.g., ongoing OAT), thus they provide only one dosing protocol for OAT initiation.¹²

OAT initiation.

SAMHSA states: “Patients with OUD who present to the ED [emergency department] or are admitted to the hospital for an acute medical problem may benefit from initiating medications for OUD during their hospitalization.”¹² SAMHSA’s OAT initiation protocols are not hospital specific. SAMHSA recommends that buprenorphine initiation should begin with 2 to 4 mg of buprenorphine or 2/0.5 mg to 4/1 mg of buprenorphine/naloxone, with a daily maximum dose of 8 mg for Day 1 and ≤ 16 mg for Day 2.¹² Providers should use caution when increasing doses above 24 mg/6 mg, documenting the clinical rationale, risks, and benefits for prescribing beyond the FDA recommended dose.¹² For methadone initiation, SAMHSA recommends generally initiating at 10 to 30 mg for patients with opioid tolerance, and 5 to 10 mg for patients with lower opioid tolerance, with a maximum day 1 dose of 40 mg.¹²

3. Results

3.1. Hospital Document Characteristics

We obtained hospital documents from physicians affiliated with addiction medicine fellowships connected with hospitals and health systems in the Western (n = 2), Midwestern (n = 3), Southern (n = 2), and Northeastern (n = 3) locations of the United States from May to July 2018. One hospital shared their policies with another smaller hospital affiliate discussed in the interview. We obtained 25 OUD-related hospital documents including practice guidelines, policies, tools, order sets, quick reference guides, and protocols. Interviewees provided up to as many as 7 documents and as few as 1. Hospital policy comparative tables with policy content details are provided in the supplemental materials (Appendices A, B, C, D, and E).

3.2. Hospital OAT Management Policies

Hospital documents included recommendations related to four clinical management issues: 1) acute pain and perioperative management; 2) OAT continuation; 3) opioid withdrawal management; and 4) OAT initiation.

3.2.1. Acute Pain & Perioperative Management.

Three hospitals had acute pain and perioperative management policies. Policies were organized by OAT type (buprenorphine vs. methadone), by differing levels of pain (mild, moderate, and severe) and temporality (pre-operative, intra-operative, and post-operative). The documents included recommendations for the use of non-opioid adjuvants, the use of non-OAT opioids, alternative OAT dosing, and discharge planning. All policies recommended the same general practice: OAT continuation for all patients who were previously on outpatient OAT and the use of non-opioid adjuvants to manage pain in the pre-operative and post-operative period, and were concordant with SAMHSA recommendations.¹² See Table 1.

Table 1.

Policy Concordance: Acute Pain & Perioperative Management, OAT Continuation, and Opioid Withdrawal Practices

SAMHSA Recommendation	Hospital3	Policy Concordant	Policy Discordant
Acute Pain & Perioperative Management	A	X	.
Providers should continue outpatient OAT through the operative period and provide short-acting non-OAT opioids to manage pain as needed.	C	X	.
	K	X	.
OAT Continuation	C	X	.
Providers should continue outpatient OAT throughout hospitalization.	D	X	.
	I	X	.
	K	X	.
Opioid Withdrawal1	D	X	.
Providers should not use medically induced withdrawal as first line treatment. If withdrawal is the patient’s preference, an OAT taper is recommended. Clonidine should only be used as monotherapy when OAT is unavailable or if it is patient preference.	F2	X	Intravenous methadone
	H	X	.
	I	X	.
	J	.	Clonidine
	N	.	Clonidine and intramuscular buprenorphine injection

Table Notes. OAT = opioid agonist therapy.

¹SAMHSA does not recommend medically induced withdrawal as first line treatment.

²Hospital F recommended intravenous methadone, which is not in concordance with SAMHSA recommendations, however, they also provided recommendations for oral/sublingual OAT in accordance with SAMHSA guidelines.

³Seven hospitals had an addiction consult service (Hospitals A, D, F, H, I, J, and K), two planned to start a consult service (Hospital C and N), and one heath system had no consult service or plans to start one (Hospital B). Four hospitals had affiliated opioid treatment programs (Hospitals C, D, H, and I) and four had an affiliated inpatient “detox” (Hospitals B, D, H, and N).

3.2.2. OAT Continuation.

Four hospitals had OAT continuation policies. The policies were organized by OAT type (buprenorphine vs. methadone) and included information on formulation, dose verification, missed dosing, pain management, linkage to care, and legal reminders. All of the policies recommended OAT continuation, which is concordant with SAMHSA recommendations,¹² and consultation with hospital addiction experts as needed. For buprenorphine and methadone, hospitals either required or recommended dose verification from outside sources. Policies were inconsistent with how they recommended handling missed doses, linkage to care, legal reminders, and naloxone orders. Additionally, one hospital recommended the use of intramuscular methadone for patients unable to take medication by mouth. See Table 1.

3.2.3. Opioid Withdrawal.

Six hospitals had withdrawal management policies (medically supervised withdrawal or “detox”). The policies were structured around the hospital’s identified first-line withdrawal medication. Three hospitals had OAT recommendations concordant with national recommendations, and in contrast, three hospitals were discordant, specifically, by including recommendations for: 1) clonidine monotherapy; 2) clonidine and intramuscular buprenorphine injection; 3) and intravenous (IV) methadone, in addition to SAMHSA recommended OAT formulations.¹² The policies also included recommendations on protocol initiation thresholds, starting dose, and 24-hour maximum dose. Each policy recommended a different Clinical Opiate Withdrawal Scale (COWS) threshold for protocol initiation (5 to 13). COWS is a tool for assessing the severity of withdrawal symptoms (e.g., tachycardia, perspiration) using an 11-item assessment administered in the outpatient or inpatient setting.²⁵ All of the protocols were designed for tapering, except one, which indicated that the recommendations could be used for tapering/withdrawal management or OAT initiation. Notably, the policies varied in dosing recommendations, often recommending a lower dose than national guidance.¹² We could not assess for policy concordance for 24-hour methadone maximum as titration is a highly individualized process, as outlined in the SAMHSA recommendations.¹² See Table 1.

3.2.4. OAT Initiation.

Two hospitals had OAT initiation guidance documents. The policies were structured by OAT type (methadone vs. buprenorphine) and one of the policies specified whether the patient was abstinent or not from opioids. For buprenorphine initiation, the two policies had few shared recommendations. Observed differences included first day dosing protocols (e.g., how to dose), COWS thresholds for protocol initiation, and daily dosing maximums. For day 1 buprenorphine dosing, both policies were discordant with national recommendations¹²; higher than recommended. For daily maximum dosing, one hospital was concordant with national guidance and the other had a lower dose than recommendations.¹²

For methadone initiation, maximum day 1 dose was the same between the two policies and concordant with SAMHSA recommendations.¹² There were, however, differences in recommendations between the two policies for the first day dosing protocol, the COWS protocol initiation threshold (not described vs. 5), and maximum daily dose outside of day 1 (60 vs. 40 mg). Finally, we could not assess for policy concordance for maximum daily dose of methadone beyond day 1 as titration of methadone is a highly individualized process, as outlined in the SAMHSA recommendations.¹² See Table 2.

Table 2.

Policy Concordance: Withdrawal Management & OAT Initiation Dosing Recommendations

SAMHSA Recommendation	Hospital1	Policy Concordant	Policy Discordant
Buprenorphine
Withdrawal: Day 1 Maximum Dose	D	.	↓ (4 mg)
8 mg/2 mg	F	.	↓ (4 mg)
	H	.	↓ (4 mg)
Withdrawal: 24-Hour Maximum Dose	F	.	↓ (8 mg)
24 mg/6 mg	H	.	↓ (10 mg)
Initiation: Day 1 Maximum Dose	C	.	↑ (12 mg)
8 mg/2 mg	K	.	↑ (16 mg)
Initiation: 24-Hour Maximum Dose	C	X	.
24 mg/6 mg	K	.	↓ (16 mg)
Methadone
Withdrawal: Day 1 Maximum Doses5	F	.	↓ (5 to 10 mg)
10 to 30 mg	I	.	↓ (5 to 10 mg)
	H	.	↓ (15 mg)
Initiation: Day 1 Maximum Dose	C	X	.
40 mg	K	X	.

Table Notes. OAT = opioid agonist therapy; ↑ = indicates above the dosing recommendation; ↓ = indicates below the dosing recommendation; X = indicates policy concordance.

¹Seven hospitals had an addiction consult service (Hospitals A, D, F, H, I, J, and K), two planned to start a consult service (Hospital C and N), and one heath system had no consult service or plans to start one (Hospital B). Four hospitals had affiliated opioid treatment programs (Hospitals C, D, H, and I) and four had an affiliated inpatient “detox” (Hospitals B, D, H, and N).

⁵Hospital F used intravenous methadone which is not in concordance with SAMHSA recommendations

3.3. Security and Behavior Management Policies

Four hospitals had policies addressing security and behavior management that emerged as four policy sub-domains: 1) aberrant drug use; 2) decision-making around peripherally inserted central catheter (PICC) lines; 3) patient-directed discharge (i.e., leaving “against medical advice” [AMA]); and 4) patient safety and security assessments. The aberrant drug use sub-domain was the only category with policy content from more than one hospital, thus, it was not possible to compare the other three policy sub-domains. The comparative policy table for aberrant drug use is available in the supplemental materials (Appendix E), in addition to the summaries of the polices from the other three sub-domains (Appendix F).

3.3.1. Aberrant Drug Use.

Two hospitals had policies addressing aberrant drug use. One hospital structured their policy around two categories of intervention (primary vs. secondary)—primary interventions were to occur when there was a high suspicion of potential aberrant behaviors or other factors (e.g., report of controlled substance use inconsistent with the prescription drug monitoring program), and secondary interventions recommended for patients with documented diversion attempts, “medication abuse”, or other factors (e.g., documented tampering with needle box). The other guidance document was organized around “levels of concern” (moderate, high, and confirmed use). Both policies recommended conducting a risk assessment for aberrant drug use, documenting behavior and interventions, guidance on medication administration (e.g., convert pills to liquid form), interventions for securing the environment, behavioral requirements for patients leaving the unit and for patient visitors, the use of urine drug screens, the use of patient sitters, and hospital security involvement. SAMHSA’s treatment recommendations did not discuss aberrant drug use; thus, an assessment of national policy concordance was not possible.

3.4. Hospital OAT Policy Checklist

Study findings underscored the need for a practical tool to support hospital champions seeking to better understand their internal hospital policy landscape. A guide for an internal hospital policy review to ensure that policy content aligns with federal rules,²⁶ is concordant with national recommendations,^12,13 and is not creating additional barriers to OAT.⁷ The six-question checklist, Table 3, addresses questions related to a hospital’s formulary, hospital pharmacy restrictions, and the existence and content of hospital policies related to OAT delivery during admission.

4. Discussion

From a purposive sample of informants from 10 addiction medicine fellowship programs affiliated with well-resourced hospitals and health systems, we identified, and categorized, OUD-related hospital policy content within two umbrella policy domains (OAT management and security and behavioral management) and eight policy sub-domains. Many of the policies analyzed in our study differed in content, structure, and focus. Concordance with SAMHSA recommendations varied depending on the policy domain. Collectively, policies were concordant with SAMHSA standards for acute pain and perioperative management and OAT continuation. In contrast, three out of six hospitals were discordant with SAMHSA practice recommendations for opioid withdrawal management. Additionally, several policies had OAT dosing thresholds below the upper limit recommended by SAMHSA. Our analysis of the security and behavioral management policy domain was limited to only one of the four sub-domains (aberrant drug use) due to the paucity of the primary data collection and there was content consistency between the two policies. The most common policies in the sample were opioid withdrawal (n = 6) and OAT continuation (n = 4).

Our findings contribute to a growing literature base on hospital-based management of OUD. Studies suggest patients with OUD infrequently receive OAT during hospitalization⁴ or upon discharge^5,27; although, hospitalized patients would like to be offered OAT.²⁸ Moreover, there is research documenting how hospitals are risk environments for people who use drugs due to contextual forces within hospitals.⁸ Specifically, patients’ have unmet clinical needs such as withdrawal,²⁹ untreated pain,²⁹ and experience stigmatizing and discriminatory behaviors from hospital providers and staff,³⁰ such as increased interactions with hospital security³¹ and room searches.⁸ These experiences can lead patients to leave the hospital against medical advice⁸ and to seek out alternatives to relieve their discomfort (e.g., using non-prescribed substances during admission).²⁹ Use of non-prescribed substances during admission may be common. In a cohort of people who use drugs in Vancouver, Canada, 44% of patients reported using non-prescribed drugs while hospitalized.³² Similarly, in a cohort of patients with injection related infections admitted to a single hospital in Alabama, more than a third had in-hospital drug use based on suspected or reported illicit drug use and a positive urine drug screen.³³

Although there is a scant literature base on hospital policies for OUD management^7,34,35 research suggests opportunities for policies and standardization. In a study of 26 health care providers in Toronto and Ottawa, Canada, researchers observed that few health care providers could identify hospital policies specific to substance use.²⁹ Instead, health care providers reported that their personal beliefs about addiction guided their clinical and behavioral management decision making (e.g., ignoring the behavior, increased surveillance, loss of privileges, threats of discharge, substitution dosing of medication).²⁹

4.2. Policy & Practice Implications

Hospitals may respond to clinical management complexity through the creation of policies, as we observed in our study. Hospital policies may aid in facilitating adherence with recognized professional practices, reducing practice variation, and serving as an educational resource. Hospital policies may also propagate outdated or non-evidenced informed clinical practices. Thus, policies should not be a static technology, policy content should continuously evolve to meet clinical needs. There are decades of evidence supporting the use of OAT as first line treatment, yet the exact dosing strategies may vary over time due to an evolving unregulated drug supply. Hospital policies should be systematically reviewed and updated to reflect current clinical practice. For example, increasingly, hospital providers use buprenorphine patches and buprenorphine micro-dosing to allow patients to remain on full agonist opioids and avoid experiencing withdrawal that accompanies typical OAT initiation protocols.^36,37 Further, in an era of increasing fentanyl contamination in the illicit drug supply,^38,39 lower doses of methadone (10 mg) may be insufficient to inhibit acute opioid withdrawal and cravings. The existing SAMHSA guidelines recommend a range of 10 to 30 mg with a max of 40 mg on day 1 for methadone, and 8 mg/ 2mg for buprenorphine, which may not be sufficient for some patients. Underdosing of methadone,⁴⁰ which can impact retention in care, is common in the outpatient setting.

As we observed in our study, it is likely that some hospital policies propagate non-evidence-based practices, such as underdosing of OAT, not using OAT for withdrawal management (e.g., clonidine only protocols), using alternative forms of OAT (e.g., intravenous methadone, intramuscular buprenorphine), and focusing on tapering/withdrawal management versus OAT initiation with linkage to care. Hospital policymakers (e.g., hospital administrators, legal counsel, pharmacy leaders, the pharmacy & therapeutics committee, and clinical champions) can use the Hospital OAT Policy Checklist to counteract these aforementioned policy deficits to ensure that the policies reflect SAMHSA recommendations, an evolving clinical practice, and do not impose additional barriers to care.

Although not described in the literature, it is likely that hospital policies are created with the intention of diminishing hospital liability, do not include input from people with lived experience, and are not trauma-informed. Thus, when creating and updating OUD-related treatment policies, hospital policymakers should consider how stigma⁴¹ and other oppressive elements (e.g., racism, classism, sexism) are structuralized through policy.⁴² Moreover, hospital policymaking is an opportunity to be informed by the patient and family experience.⁴³ Hospital policymakers should also consider the principles of trauma-informed care, which is an organizational structure and therapeutic framework to help understand, recognize, and respond to trauma that individuals have experienced. One of SAMHSA’s 10 implementation domains for creating a trauma-informed organization is organizational policy.⁴⁴ People with OUD, unlike many other hospitalized patients, may be unjustly viewed through a criminal lens. Thus, it is possible that hospital policies focused on controlling visitors and conducting room searches may disproportionately burden this patient population,⁸ which in turn, could further reinforce negative provider cognitive biases about substance use disorders.⁴⁵

It is unlikely that hospitals will create and implement evidence-informed policies without regulatory requirements or financial benefit,⁴⁶ thus, implementation is likely to be limited to the innovators and early adopters.⁴⁷ External levers will be needed to encourage change. This may come in the form of hospital accreditation requirements, leadership from the American Hospital Association, payer policies, or state legislatures.⁴⁸

Future research should expand upon the second policy domain, as providers have articulated discomfort when discharging patients who inject drugs with PICC lines for fear of tampering⁴⁹ and concerns about how to manage patient requests to leave the ward.¹¹ Moreover, future research should investigate the existence of other hospital policy domains not identified in this study. Notably absent in this sample, yet widely acknowledged as a key component of the OUD care continuum is harm reduction.^15,18 The minimal presence of harm reduction principles and guidance documents may reflect hospital culture, beliefs, and education related to harm reduction in this cohort of hospitals. Moreover, harm reduction policies may explicitly describe harm reduction practices (e.g., naloxone, syringe distribution) or may reflect broader harm reduction practices (e.g., smoking policies).

Another policy domain, not described in this study, is surgical. Specifically, policies and practices related to heart-valve replacement such as the use of drug use contracts^50–52 and organ transplant policies. Standardization of practice, through polices or protocols, may be warranted as evidence by a recent clinical decision-making survey of U.S.-based cardiac surgeons.⁵³ In this survey study, hypothetical care of infective endocarditis deviated significantly between patients with and without injection drug use.⁵³ Researchers observed that the majority of surgeons (93%) would operate on patients with recurrent non-injection drug use endocarditis versus 26% of patients with recurrent injection drug use related endocarditis.⁵³ Most surgeons in the sample reported they would not impose limits on the number of operations for patients with recurrent non-injection drug use endocarditis (73%), in contrast, the majority would limit the number of surgeries for patients with injection drug use related endocarditis (84%).⁵³ Concerningly, over half (64%) of surgeons reported having declined to operate on patient’s injection drug use related infective endocarditis.⁵³

4.3. Study Limitations

This study has several significant limitations. First, importantly, hospital policies do not necessarily reflect practice, instead, policies may reflect hospital-wide recommendations or idealized versions of care. Second, the study sample draws from a small subset of well-resourced hospitals, which could influence the content of the policies (e.g., access to addiction expertise) and subsequent implementation (e.g., person-power). Third, the findings from this study are primarily descriptive. We cannot make recommendations on what the content of hospital policies should include, what hospital policies should exist, or how to implement them. We instead identified hospital policy domains, described the content of the policies, noted concordance with national recommendations, and created an internal organizational environmental scan in the form of a policy checklist. Fourth, the interpretation of study findings is constrained by the study cohort, other policy domains likely exist but were not observed within this sample. Fifth, this policy analysis was cross-sectional. A single time-point assessment of policies and guidelines is limited by the durability and strength of the evidence that informs the guidance documents at that time. The national guidance document used to compare standards of care was published and modified after the creation of the policies. However, emerging literature of practice barriers to MOUD implementation supports the premise that hospital policies remain a barrier to evidence-based treatment for OUD.^6,7 Finally, we do not know how these policies were developed, who was involved, and the process for implementing and disseminating these policies across these hospitals and health systems.

5. Conclusions

Hospital policies are not a singular intervention to improve OUD-related care, however, in the midst of a worsening drug-related overdose crisis hospital leaders should act to ensure that their internal organizational policy climate aligns with national recommendations and enhances rather than deters access to first-line therapies for patients with OUD. Hospital policymakers, and clinical champions, have the power to change, improve, and create new organizational policies that most effectively serve patients with OUD. Our hospital policy environmental scan checklist may assist clinical leaders in reviewing their institutional policies to ensure that their respective policies do not create barriers to care. Finally, we observed that many hospitals, even those with addiction expertise, are not always aligned with national recommendations, this is an area for ongoing improvement.

Highlights.

• Hospital policies focus on opioid agonist therapy and security/behavioral management

• Hospitals polices may not be concordant with national treatment guidance

• Our findings guided the creation of a hospital policy environmental scan checklist

• It is possible that hospital policies recommend outdated or non-evidence-based care

• Hospital policies may inform care for patients with opioid use disorder