Given the high rates of hospitalization among individuals with OUD, inpatient settings present a significant opportunity to engage individuals in evidence-based OUD care and promote harm reduction. However, as summarized below, there is currently a limited body of research evaluating OAT initiation in inpatient settings.
Two RCTs published in 2014 and 2019 used similar protocols to randomize participants into a 5-day buprenorphine/naloxone taper over group or a buprenorphine/naloxone OAT initiation group with inpatient dose stabilization and linkage to an affiliated OAT or primary care program.240 The 2019 RCT (N=115) found that linkage participants (n=56) had lower rates of unregulated opioid use at days 12 (b=-6.81, 95% CI: 9.69; -3.92, p<0.001), 35 (b=-8.55, 95% CI: 11.63; -5.47, p<0.001), 95 (b=-7.34, 95% CI: 10.59; -4.11, p<0.001), and 185 (b=-3.52, 95% CI: 7.07; 0.27, p=0.052).240 Linkage participants also had higher prescription buprenorphine use rates at all assessments (p<.001) than taper participants (n=59).240 The 2014 RCT (N=139) similarly found that linkage participants (n=72) were more likely than those in the taper group to enter OAT (n=67; 72.2% vs. 11.9%; p<.001) and receive buprenorphine-based OAT at 6 months (16.7% vs. 3.0%; p=.007), and reported lower rates of previous-month opioid use at 6 months (incidence rate ratio: 0.60; 95% CI: 0.46–0.73; p<.01).241 These findings accord with a 2015 retrospective case series (N=47) that found that just under half of the patients (n=22; 46.8%) initiated on buprenorphine successfully initiated office-based treatment within 2 months of being discharged from the hospital.242
The literature on inpatient methadone initiation is also scant. One 2022 retrospective cohort analysis of patients who received a medical consult and community care transition services for OUD (N=152) compared methadone to buprenorphine/naloxone for inpatient OAT initiation in terms of the duration of community-based treatment retention post-discharge.243 Post-discharge treatment retention rate among patients who chose buprenorphine (n=106) was 37% at 2 weeks, 26% at 30 days, and 13% at 12 weeks; the retention rates for the same respective follow up times among patients who selected methadone (n=46) was 43%, 39%, and 35%. Methadone was associated with increased probability of retention in outpatient treatment as compared to buprenorphine (P<0.01). While acknowledging the limitations of this retrospective study and calling for experimental research to establish the effectiveness of inpatient methadone initiation, the authors concluded that this medication can be effectively initiated in hospital and may have a higher probability of treatment retention. 243
Other investigations of methadone initiation in inpatient settings include a 2019 retrospective chart review from an acute pain service initiating methadone treatment in hospitalized patients with acute pain244 and a 2019 case study from Vancouver, BC, in which a patient at St. Paul’s Hospital was successfully rapidly titrated onto methadone (see Rapid Titration in Monitored Settings for more information on the protocol used).245
Barring specific contraindications or concerns, both traditional induction and rapid titration protocols may be used for inpatient inductions (see Appendix 3).