Rapid Rise in Premature Hospital Discharges for OUD

One in six inpatients with opioid use disorder (OUD) leave the hospital before completing treatment, possibly due to untreated withdrawal symptoms, a new study shows.

Investigators found that between 2016 and 2020, the number of before medically advised (BMA) discharges nearly doubled. In addition, BMA discharges in patients with OUD and an injection site-related infection, a cohort more likely to have severe OUD and fentanyl use, increased 82%. The increase in BMAs with any opioid-related use increased by 50%.

Furthermore, nearly half of BMA discharges occurred before the third day of hospitalization, leading investigators to speculate that untreated withdrawal may be one reason patients check out early.

“The rapid increase in early discharges is alarming: in 2016, less than 1 in 10 patients admitted for OUD and injection-related infections left the hospital before their care team considered it safe. By 2020, one in six were leaving early,” lead investigator Ashish Thakrar, MD, an assistant professor of medicine at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, said in a press release.

The findings were published online December 4 in a research letter in the Journal of the American Medical Association.

Increased Mortality Risk

Research suggests BMA discharges are associated with a significant increase in all-cause mortality and hospital readmission within 30 days. But current data on BMA discharge trends were lacking.

The investigators used the Nationwide Readmissions Database, which aggregates and weights information from more than 30 states to produce nationally representative data.

They identified patients with ICD-10 codes related to opioid use, dependence, abuse, or overdose, adding comorbid injection site-related infection to capture more severe OUD cases. They then compared annual changes in the BMA discharge rates for OUD patients to those for non-opioid admissions.

From 2016-2020, the annual BMA rate for patients with OUD and an injection site-related infection increased from 9.3% to 17%, an annual growth rate of 1.8% (P <.001 admissions="" all="" an="" annual="" bma="" for="" from="" growth="" increased="" of="" opioid-related="" rate="" the="" to="">P <.001>

During the same time span, the number of BMA discharges for non-opioid mental health or substance use admissions and all non-opioid admissions increased only slightly, with an annual growth rate of just 0.1% for each.

OUD Meds Underutilized

Investigators also detected an increase in BMA discharges before the third day of treatment for OUD admissions with an injection-related infection, from 42.6% in 2016 to 48% in 2020 (P

The rising number of patients leaving treatment less than 3 days into treatment — when opioid withdrawal symptoms are most severe — suggests “untreated withdrawal might contribute to increasing BMA discharges in this cohort,” the authors write.

Investigators note that prior studies have cited untreated withdrawal and pain as primary reasons for BMA discharge. Although methadone and buprenorphine treat opioid withdrawal and are effective for OUD, research suggests they are widely underutilized.

“Since the study period ended, the COVID-19 pandemic caused the opioid crisis to escalate, underscoring just how urgent it is to understand how we might be able to reverse this trend and get patients the treatment they need,” Thakrar said.

Study limitations include that there was no diagnosis code for OUD and that diagnosis codes could be inaccurate. The study also did not include information on the types of opioids patients had used.

The study was supported by the National Clinician Scholars Program and the Corporal Michael J. Crescenz VA Medical Center, the National Institute on Drug Abuse, the Patient-Centered Outcomes Research Institute, the Food and Drug Administration, the National Institutes of Health, and the Abramson Family Foundation. The authors report no relevant financial relationships.