(39) Linking Hospitalized People with OUD to Treatment: Findings from a Multisite RCT

Background & Introduction: Despite being in the midst of an opioid epidemic, an unacceptably small minority of hospitalized patients with opioid use disorder (OUD) are linked to follow-up care for OUD. Addiction consultation services (ACS) have been established as a model of care to initiate treatment and connect patients to aftercare. Studies suggest that ACS are feasible, that the inpatient hospitalization is a teachable moment, and that patients are willing to engage with treatment both in the hospital and after discharge. However, there have been no RCTs demonstrating the effectiveness of ACS. Robust evidence is needed to establish ACS as a standard of care and to make the case for broader adoption.

To address this gap, we conducted a multi-site RCT testing the effectiveness of a hospital-based ACS (the Substance Use and Recovery Team (START)). The START intervention consists of an addiction medicine specialist and care manager team, delivering motivational counseling and interactive discharge planning and one month of follow up telephone calls after discharge from the hospital. In this poster, we present findings of an interim analysis testing the effects of the START on linkage to OUD care 30 days after discharge from hospital.

Methods: We conducted a multi-site RCT in three diverse hospitals to evaluate whether the START increases linkage to care after discharge among patients with OUD. Linkage to care was defined as receiving a medication for opioid use disorder (MOUD) or at least one visit for psychosocial treatment for OUD, obtained through patient self-report in a one-month follow-up interview. We randomized patients from Cedars Sinai Medical Center in Los Angeles, the University of New Mexico Medical Center in Albuquerque, and Baystate Health in Springfield Massachusetts to receive either the START or usual care, stratifying by site and prior MOUD exposure. We fit a logistic regression model to the data, with linkage to care within 30 days after discharge (yes vs. no) as the dependent variable and treatment arm as the independent variable. We included adjustment for site and prior MOUD exposure (yes vs. no), as well as key covariates -- age, sex, and ethnicity (Hispanic vs. not Hispanic). We conducted an interim analysis to assess effects of the intervention on linkage to OUD care after discharge. We hypothesized that, compared to patients who received UC, patients who received the START intervention would be more likely to receive linkage to post-discharge OUD care.

Results: Participants (n=291) were age 42.9 on average (SD 13.1), with 64% male, and 48% Hispanic. Self-reported race included 7% American Indian or Alaska Native, 1% Asian, 7% Black or African American, 40% White or Caucasian, 7% More than 1 race, and 38% some other race. Unhoused participants made up 31% of the sample. Sixty seven percent of participants had a probable OUD related to heroin use, and 75% had a probable OUD related to prescription pain medication use. Seventy nine percent of participants reported having ever used MOUD prior to the study. Nearly half of participants had a co-occurring serious mental illness, with 39% reporting a bi-polar disorder diagnosis and 17% reporting a schizophrenia diagnosis.

Participants in the START intervention arm were nearly three times as likely to link to MOUD care following hospital discharge than participants in the UC arm (OR = 2.82, 95% CI: (1.58, 5.01), p = 0.0004). None of the other independent variables were significantly related to linkage to care.

Findings from our RCT testing the effects of an ACS called the START on linking patients with OUD to treatment within 30 days after discharge from the hospital are clinically and statically significant. That is, hospitalized patients receiving the START, consisting of an addiction medicine specialist and care manager team using a manualized intervention, are more likely than usual care patients to start treatment for OUD after discharge from the hospital.

Conclusion & Discussion: Our findings are the first to offer evidence from a large rigorous RCT that ACS – the START in particular – can effectively link hospitalized patients with OUD to post-discharge treatment. The inpatient setting presents a critical window of opportunity where patients may be more receptive to discussing AUD and planning for treatment because of an illness or injury related to their OUD. A model of care that leverages hospital resources (i.e., a physician and a care manager) a is a realistic, sustainable model for intervention that could have broad public health impacts, even in hospitals with limited resources. Moreover, an intervention designed specifically for the inpatient setting, where the average length of stay is 6 days, and immediately after discharge, offers patients the opportunity to engage with the START over the course of the hospital stay and to be provided with much needed support after leaving the hospital. Next steps are to test the effects of START on initiation of medications for opioid use disorder in the hospital and on substance use and hospital readmissions after discharge, and to examine how ACS like the START can be implemented and sustained beyond the research study.

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*This study was supported by the National Center for Advancing Translational Sciences, and National Institute on Drug Abuse. Grant # 1U01TR002756-01A1. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.