Study finds 1 in 6 patients with opioid use disorder leave the hospital early

The number of patients admitted with opioid use disorder (OUD) and injection-related infections who left the hospital before completing treatment increased significantly between 2016 and 2020 (from 9.3% to 17%), according to analysis from researchers at the Perelman School of Medicine at the University of Pennsylvania. One in six of these patients now leave the hospital before their care team deems them safe to do so.

The findings, published today in JAMA, also reveal that the rate at which patients with any opioid-related issues (patients presenting with other issues but who also exhibit a dependence on opioids) left the hospital before completing treatment increased more than 50% (from 7.5 to 11.3%).

In both of these groups, nearly half of BMA discharges occurred before the third day, when withdrawal symptoms were most severe. Now that fentanyl has become the dominant opioid-causing overdose; the findings illustrate the need for patient-centered care that adequately manages pain and withdrawal symptoms so that patients can complete treatment.

Approximately 500,000 patients are discharged against medical advice or before medically advised (BMA) in the United States annually, and those circumstances are associated with an increased likelihood of death and hospital readmission. Previous research shows that patients with addiction cite withdrawal and pain as their reason for BMA discharge.

"The rapid increase in early discharges is alarming; in 2016, less than one in ten patients admitted for OUD and injection-related infections left the hospital before their care team considered it safe. By 2020, one in six were leaving early," said lead author Ashish Thakrar, MD, an assistant professor of Medicine in the division of Internal Medicine.

"What's more, since the study period ended, the COVID-19 pandemic caused the opioid crisis to escalate, underscoring just how urgent it is to understand how we might be able to reverse this trend and get patients the treatment they need."

Using nationally representative data from the National Readmissions Database, researchers compared the rate of discharge BMA in patients admitted for OUD to the BMA discharge rate for non-opioid admissions. They also evaluated changes in the proportion of BMA discharges before the third admission day, when opioid withdrawal is most severe, and changes in the proportion of discharges BMA in patients with stimulant use disorder.

They identified opioid-related admissions as those with opioid use, dependence, abuse, or overdose. To account for patients who were more likely to have severe OUD and fentanyl use, they also included patients with OUD and injection-related infections, such as bacteremia, endocarditis, or osteomyelitis.

Between 2016 and 2020, they found that the number of patients admitted with OUD and injection-related infections who left the hospital BMA increased by 82%, from 9.3% to 17%. They also found that the discharge BMA rate for all opioid-related admissions increased 50% during this period, from 7.5% to 11.3%. The proportion of BMA discharges occurring before the third day also increased for individuals with OUD and an injection-related infection, from 42.6% to 48%.

In contrast, the BMA rate increased only marginally for non-opioid mental health or substance use admissions and all non-opioid admissions (from 3.1 to 3.5% and 1.1 to 1.5%, respectively).

"These data didn't allow us to discern which type of opioid that individuals were using when admitted for OUD, but we know that fentanyl, an opioid 25 to 50 times more potent than heroin, has spread in unregulated drug supplies and is now involved in 88% of opioid overdoses in the US. Withdrawal symptoms from fentanyl are more difficult to manage than from other opioids like heroin and oxycodone," said Thakrar.

"This study illustrates why we need more research on how to manage individuals withdrawing from fentanyl and other substances in the unregulated drug supply."

"The drugs that individuals are using have changed over the past decade, and how we treat them should change, too," said senior author M. Kit Delgado, MD, MS, an associate professor of Emergency Medicine and Epidemiology and director of the Penn Medicine Nudge Unit. "Health systems can expand the use of interventions that are already proven to treat withdrawal and reduce but not widely used, such as medications like buprenorphine and methadone."

Thakrar and Delgado also suggest that hospitals could be incentivized to reduce discharges of BMA and to support specialty services such as addiction consult services that have been proven to reduce BMA discharges and that can reduce the risks of future readmission or death.