Improving Hospital Inpatient Management of Opioid Use Disorders


Why is the Foundation focusing on this work?

Impact of opioid use in New Hampshire

New Hampshire has been devastated by the opioid crisis in the United States. Between the years of 2002 and 2014, SAMHSA documented an average of 52,000 people per year reporting misuse of opioids (1). New Hampshire also ranked fourth in the nation for opioid related deaths according to 2017 data from The National Institute on Drug Abuse (2).

The effects of opioid use in New Hampshire (NH) 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 (3).  This same study indicated a 183% increase from 2004-2011, with only 64% of cases detected by treatment teams.

These statistics, combined with the incidence of opioid related fatalities, speak to the dire need for hospitals to respond with an improved quality of care that does a better job of not only identifying patients with OUD, but provides access to treatment and/or harm reduction strategies.

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 (4). 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 (5). 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’ve derailed their own care for the reason they were admitted because their OUD issues went unmanaged.  


Including the Voice of People with Lived Experience

Not only will this 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 (6).

This project seeks to combat these challenges through provider education and training as well as through developing patient-informed care and engagement strategies. Effective provider education will reduce bias, increase understanding of OUD as a chronic disease of the brain. Effective education will also combat compassion fatigue by better equipping providers with knowledge and skills of clinical treatment strategies and enlarging goals of care to include harm reduction.  Engaging patients and families in designing and evaluating clinical and behavioral treatment strategies will more effectively include an often disregarded and marginalized population. In engaging patients and families as partners of healthcare organizations this project will provide a model for future patient and family engagement and facilitate shift in attitudes towards this patient population.