Patients With Opioid Use Disorder More Likely to Discharge Before Medical Advice

In hospitals across the United States, patients with opioid use disorder (OUD) were discharged before medically advised (BMA) more often in 2020 than they were in 2016. This may be due to undertreatment of opioid withdrawal symptoms, according to study findings published in JAMA.

Previous research has shown that patients who discharge BMA compared with patients who discharge as advised are at doubled risk for both death and hospital readmission within 30 days. Since 2014, as unregulated fentanyl has become abundantly available, these outcomes have become especially relevant for patients with OUD. The risks are particularly acute for these patients because withdrawal-related symptoms, including pain, can prompt hospitalized patients to self-discharge.

However, patients admitted to a hospital with opioid-related diagnoses do not routinely receive opioid withdrawal medications, such as buprenorphine and methadone. Many of these patients self-discharge within 3 days of admission, when withdrawal symptoms are most acute.

For the study, the researchers collected retrospective data from 2016 to 2020 from the Nationwide Readmissions Database. Among 64 million unique patients, they identified patients diagnosed with both OUD and an injection-related infection (eg, bacteremia, endocarditis, osteomyelitis). This yielded a cohort who were likely to have relatively severe OUD and were likely to use fentanyl. The team compared discharge BMA rates among these patients with the corresponding rates both in patients with nonopioid-related mental health or substance use diagnoses and in patients with any nonopioid-related diagnosis.

During the 4 years prior to 2020, the researchers found that among all opioid-related admissions, the rate of discharge BMA increased from 7.5% to 11.3% (annual growth rate, 0.7%; P <.001). In the cohort with OUD and injection-related infection, the rate of discharges increased from 9.3% to 17.0% (annual growth rate, 1.8%; P <.001). Lastly, they found that among those in this cohort, individuals discharged BMA before 3 days postadmission also increased, from 42.6% to 48.0% of early discharges (annual growth rate, 1.1%; P < .001). The proportion of BMA within 3 days did not change in patients with other opioid-related diagnoses.

In contrast to these increases, in patients admitted with nonopioid-related mental health or substance use diagnoses (P =.002) and with all nonopioid diagnoses (P <.001), the annual growth rate of patients who discharge BMA was 0.1%.

A key study limitation was potential misclassification in identifying patients with OUD based on their diagnostic codes, which can be ambiguous or inaccurate.

The researchers drew particular attention to the disparate increase in patients who discharge BMA within 3 days and speculated that these patients may not have received treatment for acute withdrawal symptoms while hospitalized. “Future studies should determine whether widespread implementation of evidence-based treatment with methadone and buprenorphine mitigates increasing BMA rates among patients with OUD,” the researchers concluded.