Background: Persons with opioid use disorder (OUD) represent an estimated 4-11% of hospitalized patients and are increasingly admitted for opioid-related complications. In response to the opioid epidemic, national organizations have recommended hospitals develop protocols to engage patients with OUD in opioid agonist treatment (OAT) during hospitalization. Buprenorphine is an effective OAT for OUD that is associated with reductions in substance use and mortality. Prior studies have shown that buprenorphine initiation in the hospital with linkage to outpatient treatment is associated with increased engagement in care and decreased opioid use. However, most hospitals lack an addiction consult service and hospitalized patients with OUD are often not started on OAT prior to discharge.
Purpose: The REACH-IN quality improvement initiative aimed to identify hospitalized patients with OUD, initiate buprenorphine, and facilitate their transition to outpatient care.
Description: Mount Sinai Hospital is a large, urban, tertiary-care hospital without an addiction consult service. To fill this gap, medical students and housestaff collaborated with a hospitalist, a primary care attending, and staff from REACH, a primary care-based program that offers buprenorphine treatment. We identified hospitalized patients with OUD in two ways: 1) we screened a daily electronic report that captured all new admissions or emergency department (ED) visits concerning for recent opioid use and 2) hospital staff directly referred patients. Identified patients were evaluated by an attending for buprenorphine eligibility and appropriate candidates were started on buprenorphine and titrated to a stable dose. Prior to discharge, REACH staff met with patients for a warm hand-off and provided an appointment within one week.
From July 30, 2018 to November 28, 2018, we screened 1158 encounters, 1139 (98.4%) of which were identified via the report, with the remaining 19 (1.6%) via direct referrals from clinicians. 633 patients were discharged from the ED and were not eligible for inpatient assessment. Of the remaining 525 patients, 39 (7.4%) were evaluated, 9 (23.1%) of whom were started on buprenorphine in the hospital. Of the 30 not started on buprenorphine, 21 (70.0%) were referred to REACH or another OAT program; 4 eventually started buprenorphine at REACH. Of those that started buprenorphine in the hospital, 7 (77.8%) attended an initial outpatient visit, with 6 (66.7%), 4 (44.4%), and 4 (44.4%) engaged in treatment at 30, 60, and 90 days respectively; 2 (22.2%) remain hospitalized.
Conclusions: Inpatient hospitalizations are a ‘reachable moment’ for persons with OUD and hospitalists are well positioned to respond to the opioid epidemic. As hospitals see increasing numbers of opioid-related admissions, a hospitalist-led initiative can help identify patients with OUD, initiate buprenorphine, and facilitate linkage to outpatient treatment. These data provide preliminary evidence for the feasibility and effectiveness of this model.