Inpatient Opioid Withdrawal Guidelines Improve Management, Not AMA or Readmissions

Introduction: Inpatient hospitalizations for medical conditions related to injecting drugs have skyrocketed with the growing epidemic of opioid use disorder (OUD) (1). These patients frequently leave the hospital before being deemed medically stable, being discharged “against medical advice” (AMA) (2). This creates a driving clinical need to improve care for these patients. Uncontrolled withdrawal is an important driver of AMA discharge (3), and medications for OUD (MOUD) should be offered to all patients (4). Addiction medicine consult services (AMCS) have been described as the gold standard (5), but our hospital lacks this resource. However, despite our lack of AMCS, in 2018, our large urban academic medical center developed guidelines for managing opioid withdrawal with a goal of facilitating proactive, coordinated, and generalist-driven care of inpatients with OUD. Internal medicine and family physicians were educated on these guidelines. The goal of this study was to determine if these new guidelines regulating MOUD improved patient outcomes such as AMA and readmission.

Methods: We studied 1821 admissions representing 1326 unique patients with an OUD-related ICD-10 code billed during the admission. Patients were discharged before (July 1, 2017 – March 31, 2018) or after (January 1, 2019 – July 31, 2019) the guideline was published and publicized. Data from the hospital electronic health record and Vizient database were analyzed with SPSS and R. Parametric and nonparametric tests (including chi square and analysis of variance) were used to determine statistical significance. We aimed to measure changes in MOUD use as well as changes in the rates of AMA discharge and readmission within 30 days.

Results: Methadone use doubled during the intervention period (23% to 52%, p<0.001). Buprenorphine use was negligible prior to the intervention; after, 13.6% of admissions involved buprenorphine. 64.8% of admissions involved some form of MOUD post-intervention, from 23% before (p < 0.001). Psychiatry consultation decreased from 34% pre-intervention to 22% after (p < 0.001). AMA discharge was unchanged before and after the intervention (14%). Readmissions increased from 12% to 16% (p=0.045) during the study period.

Conclusions: Generalist-driven withdrawal guidelines improved the proportion of patients with OUD treated with MOUD, with less reliance on psychiatry. This did not impact AMA discharge, and was associated with an increase in readmissions. Readmissions, though often considered a negative quality marker, may in fact be evidence of subjectively improved care leading patients to return more readily to have their serious medical illness addressed. Though hospitals frequently use readmissions as an outcome, AMA discharge may be a more useful outcome to assess care quality in patients with OUD. MOUD may be a marker of disease severity in this observational study, confounding attempts to describe its impact on outcomes. A generalist driven model can improve use of MOUD and should be considered by institutions lacking resources for an AMCS.

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