Hospital-Based Addiction Consultation Addresses Gaps, Improves Treatment Rate

Intervention by a hospital-based addiction consultation service improved receipt of evidence-based treatment for patients with opioid use disorder (OUD), according to a study published in JAMA Internal Medicine.¹ The findings suggest hospital-based addiction consultation could help improve rates of treatment for OUD and potentially reduce overdose and mortality.

While medications for OUD (MOUD) are effective, the study authors noted that hospitalized patients with OUD rarely receive MOUD or are linked to treatment following discharge. In the Substance Use Treatment and Recovery Team (START) clinical trial (NCT05086796), patients were randomized to receive either START addiction-focused consultation service or usual care. The main outcomes were receipt of MOUD during hospitalization and successful linkage to treatment for OUD within 30 days of discharge.

OUD-focused discharge plans were significantly more common in the START group vs the usual care group, and START patients were more likely to initiate or continue MOUD following discharge vs usual care. | VILevi - stock.adobe.com

“This opportunity is particularly important for patients who may face barriers to accessing MOUD in the health care system and other community access points due to stigma, unstable housing, costs, logistical issues, lack of knowledge among practitioners, racial and ethnic discrimination, and other social determinants of health,” the authors wrote. “Hospitalization provides a structured, supportive environment where these barriers can be temporarily overcome, allowing for direct engagement with specialized addiction care, treatment initiation, and connection to ongoing support services.”

A total of 325 patients were randomized to receive either START addiction consultation services (n = 164) or usual care (n = 161), with patient characteristics similar at baseline. The START addiction consultation services included an addiction medicine specialist (AMS) and care manager (CM) team providing intervention tailored to each patient based on motivational interviewing and addiction-focused discharge planning.

Usual care varied between institutions—Cedars-Sinai Medical Center had an existing consultation-liaison service with psychiatrists and social workers to discuss opioid use with the patient, and Baystate Medical Center and the University of New Mexico could be treated directly with MOUD and discharge planning by the medical team. START previously served as the AMS at each hospital, but the usual care group did not receive START consultation during the study.

Patients who received START intervention were more likely to initiate MOUD treatment while hospitalized vs the usual care group, with 57.3% vs 26.7% of patients initiating MOUD, respectively. Linkage to OUD care following discharge was also more common among the START consultation group (72%) vs the usual care group (48.1%). The most received MOUD was methadone, with 90 patients in both groups (66%) receiving it while in the hospital. Buprenorphine was given to 36 patients in the START group (38.3%) and 17 in the usual care group (39.5%). Five patients (5.3%) in the START group and 1 (2.3%) in the usual care group received both methadone and buprenorphine. Both methadone and oral naltrexone were given to 2 patients in the START group (1%) and none in the usual care group.

OUD-focused discharge plans were significantly more common in the START group (49.4%) vs the usual care group (27.3%), and START patients were more likely to initiate or continue MOUD following discharge (52.4%) vs usual care (30.8%). The START group was also more likely to see a clinician for OUD following discharge (34.4%) vs usual care (18.3%).

The only independent variable associated with MOUD initiation was length of stay, but there was no difference between groups as far as the effects of length of stay. Every 10 days increased the likelihood of MOUD initiation by 3.8%.

“The undertreatment of OUD continues to present a critical public health challenge. The START ACS model presented in this randomized clinical trial provides a promising solution by addressing key roadblocks that contribute to the undertreatment of OUD in hospital settings and poor linkage to postdischarge care and offers a practical approach to hospital-based care that can significantly improve treatment uptake for individuals with OUD,” the authors concluded. “Moreover, the ACS is a translational model in that it has the potential to be adapted and applied to enhance treatment uptake for people with other substance use disorders and behavioral health problems, offering a comprehensive approach to addressing widespread health care gaps.”

An accompanying editorial called for improvements to usual care for hospitalized patients with OUD.² Authors Susan L. Calcaterra, MD, MPH, MS and Dale Terasaki, MD, MPH, emphasized the importance of linking reimbursement to OUD care quality, noting that the opioid epidemic has been going on for more than 2 decades, and it is unlikely that hospital-based clinicians will organically integrate OUD treatment into practice without support from hospital leadership.

“To motivate hospital leaders to enact these changes, CMS and other insurers should link hospital payments to the quality of OUD care provided, including initiation of MOUD with OUD treatment linkage and naloxone provision,” they wrote. “Similar value-based measures have successfully incentivized hospitals to address health care–associated infections, 30-day readmissions, and patient safety. Medical societies should insist on providing fair reimbursement for the provision of substance use disorder treatment.”

References

1. Ober AJ, Murray-Krezan C, Page K, et al. Hospital addiction consultation service and opioid use disorder treatment: the START randomized clinical trial. JAMA Intern Med. Published online April 7, 2025. doi:10.1001/jamainternmed.2024.8586
2. Calcaterra SL, Terasaki D. When usual care is subpar care for hospitalized patients with opioid use disorder. JAMA Intern Med. Published online April 7, 2025. doi:10.1001/jamainternmed.2025.0001