In much the same way that staff in an inpatient hospital wouldn't want to discharge a diabetic patient without access to insulin, leaders at Boston Medical Center have worked to initiate patients with opioid use disorders to medication before they exit the door.
The safety-net hospital's Addiction Consult Service, established in July 2015, is staffed by an attending physician who is board-certified in addiction medicine and a nurse with addiction expertise. A study published in the August issue of the Journal of Substance Abuse Treatment helped to bolster the argument that initiating medications in an inpatient setting is a feasible strategy.
Zoe Weinstein, MD, director of the Addiction Consult Service, tells Addiction Professional that hospital leaders were compelled to move in this direction in part because studies that were conducted there had demonstrated that this strategy could be applied broadly. Since the period that was examined in the recently published study, the hospital has worked to give patients more rapid access to ongoing medication treatment in the critical time immediately after discharge.
“Our main discharge clinic for buprenorphine had been open only once a week,” says Weinstein. “Now we have the bridge clinic open Monday through Friday.”
The study examined the initial 26 weeks of the Addiction Consult Service's activity, which consists of diagnosis, brief bedside counseling, initiation of medication treatment, and discharge planning. The outpatient clinical sites for post-discharge linkage included two Boston Medical Center clinics and three local methadone clinics operated by another organization.
Researchers examined patient engagement by calculating the percentage of patients who followed up at their first outpatient appointment after discharge and again at 30, 90 and 180 days post-discharge. A patient was classified as remaining in care if he/she had an active prescription for a medication to treat addiction and/or had notes in the clinic's electronic medical record that indicated ongoing treatment.
The researchers reported that there were 337 consultations for Boston Medical Center patients in the first 26 weeks of the service. A total of 78% of these individuals had an opioid use disorder (by comparison, 37% had an alcohol use disorder and 28% had a cocaine use disorder). Among patients initiated on methadone, 76% visited the methadone clinic post-discharge, and engagement rates at 30, 90 and 180 days were 54%, 39% and 29%, respectively. Among patients initiated on buprenorphine, the corresponding percentages were somewhat lower (49% engagement immediately post discharge, and 39%, 27% and 18% at 30, 90 and 180 days).
Weinstein says there are several possible explanations for why engagement tends to be better among methadone patients, including that this could reflect properties of the drug itself. Selection bias in terms of who gets referred to which treatment also could be in play here, she says. In addition, the more structured setting of a methadone clinic can help to reduce attrition.
Naltrexone also was recommended for some patients, but it often could not be initiated in the hospital setting. One barrier here is that injectable naltrexone for opioid dependence does not tend to be on hospitals' inpatient formularies, and that remains the case at Boston Medical Center, says Weinstein. Also, initiation of naltrexone can be hampered by the requirement that patients be opioid-free for several days before they can start on the antagonist medication.
The study paper concludes that while this research demonstrates the feasibility of inpatient initiation of medication treatment, “Effectively linking to and retaining patients in post-discharge addiction care remains a challenge and warrants further innovation and program development.” The expanded hours of the Boston Medical Center bridge clinic has served as one way to address that.
An advantage that the hospital had in establishing this inpatient service was its history of strong outpatient services. These transitional services are still rare at the inpatient level across the country, partly because of challenges encountered in linking to outpatient care. “You often have to go to an outside source,” Weinstein says.