Improving Hospital Inpatient Management of Opioid Use Disorders

New Hampshire has been devastated by the opioid crisis. Between the years of 2002 and 2014, SAMHSA documented an average of 52,000 people per year reporting misuse of opioids. New Hampshire also ranked fourth in the nation for opioid related deaths according to 2017 data from The National Institute on Drug Abuse.

The effects of opioid use in New Hampshire are only beginning to be addressed by advances in access to care. A critical need still exists in engaging patients with an Opioid Use Disorder (OUD) in the hospital inpatient setting. According to a 2014 study appearing in JAMA, 8 to 29% of hospitalized patients have a non-alcohol substance use disorder.  This same study indicated a 183% increase from 2004-2011, with only 64% of cases detected by treatment teams.

A survey conducted by the Foundation for Healthy Communities in August 2019 revealed that only 9 of the 26 acute care hospitals in the state are currently providing OUD medications for addiction treatment (MAT) in the inpatient setting. Anecdotal reports from hospitals in NH suggest that OUD affected patients in inpatient settings are more likely to leave the hospital against medical advice (AMA). This hypothesis is supported by published findings in December 2015 that cite that 25-30% of hospitalized patients with OUD leave AMA. Anecdotal reports from hospitals also indicate other gaps or lapses in care for inpatients with OUD. Examples include patients with OUD who are inappropriately receiving pain medications, experience disruptions in their previously established MAT care, or who have derailed their own care for the reason they were admitted because their OUD issues went unmanaged.  

These statistics, combined with the incidence of opioid related fatalities, speak to the critical need for hospitals to respond with an improved quality of care that better identifies patients with OUD and enhances access to treatment and/or harm reduction strategies.

Including the Voice of People with Lived Experience

The project seek to address existing gaps in addiction treatment in New Hampshire for hospital inpatient populations, but it will also serve a critical need including people living with or who are in recovery from a substance use disorder in the design, implementation and evaluation of treatment programs, processes, and other services.  Including those with lived experience improves care delivery and builds trust and collaboration between healthcare professionals and patients and families. 

Addressing Stigma as a Barrier to Care

Despite the broad reach of Opioid Use Disorders within New Hampshire’s communities, stigmatization and social isolation remain significant barriers to care for those needing treatment. This breach affects both providers and patients in harmful ways. For providers, bias and misinformation still prevail in many locations in terms of understanding Opioid Use Disorders as a chronic disease of the brain. Provider limited personal understanding, skill sets, and institutional support to effectively engage and treat those with Opioid Use Disorders has the potential to lead to inadequate care delivery and poor patient outcomes as well as provider burnout.  From the patient and family perspective, bias, and internalized stigma of those with OUD can lead to negative treatment experiences and a reluctance to seek treatment in the first place. Fear of mistreatment, according to a 2015 review published in AJPH, was one of the leading factors contributing to patients with an OUD curtailing inpatient care and leaving AMA.

Foundation for Opioid Response Efforts (FORE)

The funder of this project, Foundation for Opioid Response Efforts (FORE), is a private, national organization focused on contributing sustainable and scalable solutions to the opioid crisis, FORE awarded $10.1 million in grants to 19 organizations across the country, supporting projects that address access to opioid use disorder treatment and services in urban, rural, minority, tribal, and low-income communities.   Recognizing the urgency of the crisis, FORE wanted to inspire and accelerate action toward ending the overdose epidemic by convening and supporting stakeholders advancing patient-centered, evidence-based solutions to opioid use disorder and overdose.  

In response to its first request for proposals, FORE received responses from 443 organizations from 46 states. Our project was one of 19 projects selected after rigorous review by a panel of 50 independent experts from across the country. They include several projects that are developing or expanding models to better deliver treatment services to adults, adolescents, pregnant or parenting women, justice-involved persons, and uninsured populations. Other funded projects are addressing payment and regulatory policies to increase access to treatment or provide telehealth, mobile, and rural hospital services.