Hospital-Based Methadone and Buprenorphine Initiation Practices by Addiction Consult Services

The emergence of fentanyl and other high-potency synthetic opioids (HPSOs) has not only been underlying overdose deaths, but has complicated initiation of methadone and buprenorphine for opioid use disorder (OUD) treatment, including in the hospital. In response, clinicians with addiction expertise have developed novel initiation practices, yet no studies have characterized initiation practices nationally.

To assess the use of novel hospital-based practices for initiating methadone and buprenorphine.

This cross-sectional survey study of directors of hospital-based addiction consult services (ACS) associated with addiction medicine and addiction psychiatry fellowships in hospitals in the US was conducted using a REDcap anonymous survey from October 2023 to April 2024.

Predefined methadone and buprenorphine initiation practices. Standard methadone initiation was defined as 40 mg oral maximum on day 1 with up-titration of 5 to 10 mg every 3 days. Rapid methadone initiation was defined as any initiation regimen more rapid than standard. Buprenorphine initiation practices included low dose, high dose, traditional, and rescue.

The primary outcome was the proportion of ACS directors using predefined methadone and buprenorphine initiation practices. Perceived impact of the drug supply on methadone and buprenorphine initiation was assessed through a 5-point Likert scale ranging from strongly disagree to strongly agree. Typical selection of buprenorphine initiation practices was assessed using 7 case-based scenarios intended to represent common hospital scenarios.

Among 80 consult services, 58 directors (72.5%; median [IQR] age, 41 [38-50] years; 27 of 57 [47.3%] women) completed surveys, one of which was partially completed. Of 57 ACS directors, specialties included addiction medicine (41 respondents [71.9%]), addiction psychiatry (11 respondents [19.3%]), general or consult liaison psychiatry (11 respondents [19.3%]), and toxicology (2 respondents [3.5%]). Among those who reported initiating methadone (47 of 58 respondents [81.0%]), 33 (70.2%) agreed that HPSOs changed their methadone initiation practices. Of 46 respondents, 40 (87.0%) reported rapid initiation of methadone, and of those, 26 (65.0%) reported using rapid initiation for more than 50% of initiations. Full-agonist opioids were used by 31 of 46 ACS directors (67.4%) to treat withdrawal during methadone initiation. Of 58 respondents, 54 (93.1%) agreed that HPSOs changed their buprenorphine initiation practices. All 58 ACS directors reported that their initiation practices offered buprenorphine initiation, including 53 of 57 (92.9%) offering low dose, 50 of 57 (87.7%) offering traditional, 43 of 57 (75.4%) offering high dose , and 20 of 57 (35.1%) offering rescue. For 7 clinical cases provided, low-dose initiation was the most commonly endorsed method of buprenorphine initiation, except in the case of a person presenting in significant withdrawal 2 days after last fentanyl use.

The findings of this survey study of hospital-based academic ACS directors suggest that methadone and buprenorphine initiation has adapted to a shifting opioid supply, often outpacing research and changes in clinical guidelines.