Missed Opportunities for Treatment of Opioid Use Disorder in the Hospital Setting: Updating an Outdated Policy

First, buprenorphine effectively treats withdrawal symptoms. Buprenorphine and methadone are superior to other medications in treating symptoms of withdrawal.⁷ If withdrawal symptoms are treated, patients are less likely to leave against medical advice⁸ and are more likely to complete treatment.

Second, MOUD is the standard of care for treating OUD.⁹ Medications include the full agonist methadone, the partial agonist buprenorphine, and the long-acting antagonist naltrexone. Although all these drugs are effective and legal to initiate for inpatients,⁶ this perspective focuses on buprenorphine in an effort to draw attention to associated policy barriers. Buprenorphine is the only MOUD that can be offered as office-based therapy by providers in the outpatient setting. Meta-analyses show that MOUD is associated with lower rates of mortality, illicit opioid use, HIV transmission, and violent crime and arrest.⁹

Third, MOUD treatment, rather than just referral, leads to higher long-term treatment success.¹⁰ When initiating buprenorphine in the hospital, treatment retention rates at one month were double that of referral alone. Six months after discharge, patients were five times more likely to remain engaged in treatment compared with those who received a detoxification protocol only.

Fourth, buprenorphine is not only effective, but it is also safe and has low risks of misuse. Because buprenorphine is a partial agonist, it has both a ceiling effect on respiratory depression (decreasing potential lethality) and on euphoria (decreasing the likelihood of misuse). Among individuals who took nonprescribed buprenorphine on the street, less than 7% reported taking it for any attempt at euphoria. Instead, people with OUD most often use nonprescribed or diverted buprenorphine to treat withdrawal symptoms.¹¹

Fifth, buprenorphine treatment is associated with fewer hospital readmissions.¹²

Finally, initiating OUD treatment is feasible in the hospital setting. Any hospitalist can legally prescribe buprenorphine to treat opioid withdrawal for hospitalized patients admitted for medical or surgical reasons. A waiver is necessary only for prescribing at the time of hospital discharge for use in non-inpatient settings of care.

The United States Congress passed the Drug Addiction Treatment Act (DATA) of 2000, which codified the X waiver, in response to the growing opioid crisis. Only those providers with the DATA X waiver can write buprenorphine prescriptions to be filled in an outpatient pharmacy. To obtain an X waiver, physicians must complete an 8-hour course, whereas physician assistants and nurse practitioners must complete a 24-hour course. This training far exceeds any required training to prescribe opioids for pain.

Unfortunately, the X waiver requirement obstructs hospitalists from initiating buprenorphine in the inpatient setting in the following ways: (1) hospitalists often choose not to initiate chronic buprenorphine treatment if they lack the X waiver that would allow them to write the discharge prescription and/or (2) they are unable to identify a waivered provider in the community to continue the prescription. Unfortunately, only 6% of all medical practitioners are waivered to prescribe buprenorphine; greater than 40% of US counties are “buprenorphine deserts,” with no providers waivered to prescribe buprenorphine.¹³