Patient-Directed Discharge Among Hospitalized Persons With Opioid Use Disorder in the Fentanyl Era: A Scoping Review

Area of Science:

• Addiction Medicine
• Public Health
• Health Services Research

Background:

• Patient-directed discharge (PDD), also known as discharge against medical advice, is linked to adverse outcomes like increased readmission and mortality.
• PDD is notably more prevalent, 10-20 times higher, among individuals with opioid use disorder (OUD).

Purpose of the Study:

• To review the incidence of PDD in the fentanyl era.
• To identify patient, clinical care, and system-level risk factors contributing to PDD in patients with OUD.

Main Methods:

• A systematic literature review was performed across PubMed, CINAHL, Cochrane Library, and Embase.
• Search terms focused on PDD incidence and OUD within the context of fentanyl and other potent synthetic opioids.

Main Results:

• PDD incidence rates vary, with many studies reporting 10%-20%, and an increasing trend over time.
• Younger patients with co-occurring stimulant use and OUD exhibit the highest PDD rates.
• Findings on the association between medications for OUD (MOUD) and PDD are mixed, potentially due to variations in medication and administration timing. Consultation with addiction consult services (ACS) did not consistently reduce PDD.

Conclusions:

• The rate of PDD has increased during the fentanyl era.
• Further research is required to clarify the relationship between MOUD provision, ACS, and PDD incidence.