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Best Practices for Hospital-Based Initiation of Medications for Opioid Use Disorder: A Consensus Statement
Shawn M Cohen1,2, Elana Straus3, David A Fiellin1,3,4,5
1Program in Addiction Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, Connecticut.
JAMA Network Open
|May 7, 2026
Summary
Hospital clinicians reached consensus on best practices for initiating medication for opioid use disorder (MOUD) in patients with opioid use disorder (OUD) using high-potency synthetic opioids. These guidelines address methadone and buprenorphine initiation and opioid withdrawal management.
Area of Science:
- Addiction Medicine
- Clinical Practice Guidelines
- Pharmacology
Background:
- High-potency synthetic opioids complicate medication for opioid use disorder (MOUD) initiation for hospitalized patients.
- Hospital-based addiction clinicians require evidence-based guidance for MOUD initiation in this population.
- Existing evidence is limited, necessitating expert consensus on best practices.
Purpose of the Study:
- To establish expert consensus on optimal practices for hospital-initiated MOUD among patients with opioid use disorder (OUD) exposed to high-potency synthetic opioids.
- To guide clinical decision-making in managing OUD in hospitalized patients receiving MOUD.
- To inform the development of evidence-based protocols for MOUD initiation in acute care settings.
Main Methods:
- A 2-round Delphi survey process was conducted with national experts in hospital-based addiction medicine.
- Experts included physicians and advanced practice clinicians with extensive experience in treating hospitalized patients with OUD.
- Consensus on practice appropriateness was determined using the RAND/UCLA appropriateness method.
Main Results:
- Consensus affirmed the appropriateness of initiating both buprenorphine and methadone, including rapid methadone initiation.
- Expert consensus deemed high- and low-dose buprenorphine initiation appropriate, while traditional initiation was uncertain and rescue initiation inappropriate.
- The use of non-MOUD full agonist opioids was considered appropriate for managing opioid withdrawal during MOUD initiation or for patients declining MOUD.
Conclusions:
- This study established expert consensus on key aspects of hospital-initiated MOUD and opioid withdrawal management for patients with OUD.
- The derived best practices offer valuable guidance for clinicians adapting to the challenges posed by high-potency synthetic opioids.
- Further research is needed to evaluate the effectiveness and safety of these consensus-based practices.
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