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Methadone Dose and Patient-Directed Discharge in Hospitalized Patients With Opioid Use Disorder
Rebecca R Meredith1, William M Garneau1, Kenneth A Feder2
1Division of Hospital Medicine, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland.
JAMA Network Open
|March 25, 2026
Summary
Higher doses of methadone for hospitalized patients with opioid use disorder (OUD) within the first 48 hours were linked to lower rates of patient-directed discharge (PDD). Early and sufficient methadone treatment may reduce PDD in this population.
Area of Science:
- Addiction Medicine
- Pharmacology
- Public Health
Background:
- Patient-directed discharge (PDD) is a significant concern for patients with opioid use disorder (OUD), associated with increased morbidity and mortality.
- Understanding risk factors for PDD is crucial for improving care and outcomes for hospitalized individuals with OUD.
- The fentanyl era presents unique challenges in managing OUD and preventing adverse outcomes like PDD.
Purpose of the Study:
- To determine if higher cumulative doses of methadone administered within the initial 24, 48, and 72 hours of emergency department contact reduce the likelihood of PDD in hospitalized patients with OUD.
- To investigate the association between early methadone dosing and PDD rates during the fentanyl era.
Main Methods:
- A retrospective observational cohort study was conducted at a US academic health center.
- Included were hospitalized adults with OUD who received methadone within 72 hours of emergency department presentation.
- Data on cumulative methadone doses at 24, 48, and 72 hours and PDD occurrence were analyzed using adjusted logistic regression.
Main Results:
- Among 325 patients in the 24-hour cohort, higher cumulative methadone doses were associated with significantly lower odds of PDD at 48, 72, 96 hours, and ever.
- Each additional 10 mg of methadone in the first 24 hours reduced PDD odds by approximately 29% (aOR, 0.71).
- Similar protective associations were observed for the 48-hour cohort, though less pronounced, while the 72-hour cohort showed nonsignificant trends.
Conclusions:
- Higher cumulative methadone doses within the first 48 hours of care are associated with substantial reductions in PDD incidence among hospitalized patients with OUD.
- Early and adequate initiation of methadone treatment for withdrawal symptoms may be a key strategy to decrease PDD in this vulnerable population.
- These findings underscore the importance of timely and sufficient methadone administration in managing OUD during hospitalization.
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