Facilitating In-Hospital Opioid Treatment Program Intakes to Support Hospital to OTP Linkage among Hospitalized Patients with Opioid Use Disorder: An Implementation Trial in Four Hospitals

About This Grant

PROJECT SUMMARY / ABSTRACT Methadone is a highly effective medication for opioid use disorder (OUD) treatment. When taken regularly, it is associated with a 50% mortality reduction. Unfortunately, less than 5% of the estimated 7.6 million individuals with OUD receive methadone treatment. Hospitalization is a touch point to initiate methadone for out-of- treatment adults with OUD. While there are no federal restrictions on in-hospital methadone use for OUD, until recently, federal rules required that patients present to an Opioid Treatment Program (OTP) to complete a methadone intake before receiving methadone treatment in the outpatient setting. Current usual care for hospital to OTP linkage includes a referral to an OTP at hospital discharge. At best, only 40% of patients referred to an OTP at hospital discharge link to an OTP. Patient-reported barriers to hospital-to-OTP linkage include opioid withdrawal, lack of transportation, uncontrolled medical and mental health conditions, and stigma. Recent federal regulations governing OTPs relaxed methadone intake rules now allow non-OTP affiliated clinicians to compete the medical evaluation required for a federally compliant OTP intake. In one study, 77% of patients who completed an in-hospital OTP intake linked to an OTP after hospital discharge. Federal regulatory changes and the expanding workforce of hospital-based addiction clinicians provide a unique opportunity to expand in-hospital OTP intakes. Using a novel staircase cluster randomized design with a hybrid type 2 approach, sites will be randomly assigned a time when the study team implements a series of core activities encompassed in “implementation facilitation” (IF). These core IF activities support uptake of clinical activities by hospital-based addiction clinicians and facilitate completion of a federally compliant in-hospital OTP intake. Guided by the Practical, Robust Implementation and Sustainability Model (PRISM), we will begin by identifying site-specific contextual factors important to the implementation of core IF activities including collection of quantitative and qualitative data to inform tailoring of IF activities to account for the local needs and resources at diverse study sites. Next, we will implement IF across study sites based on their randomly assigned start date to cross over from usual care to IF. We will test the effectiveness of IF on hospital-to-OTP linkage by comparing linkage rates during the usual care phase versus the post IF evaluation phase. Implementation outcomes are informed by PRISM's Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework, and include measuring implementation fidelity to use of the core IF activities, adoption of the clinical activities required to complete an in-hospital OTP intake, measuring IF implementation costs, and measuring the proportion and characteristics of patients who did and did not link to the OTP. This study aims to measure the effectiveness of IF on hospital-to-OTP treatment linkage while also obtaining important implementation data for scaling to other treatment sites with an ultimate goal of expanding lifesaving OUD treatment to a vulnerable population.