Treating Opioid Use Disorder on the Inpatient Psychiatric Unit: A Novel Buprenorphine Consultation Service

Abstract

Background: Opioid Use Disorder (OUD) has claimed the lives of many Americans, with rates of overdose steadily rising over the past decade. Despite having highly effective medications to treat this condition, many providers still hesitate to prescribe them. Psychiatric inpatient facilities have a unique opportunity to engage patients with co-occurring disorders in the treatment of OUD; however, significant barriers exist. This study describes a novel OUD–buprenorphine (BUP) consultation service that provides such care to hospitalized psychiatric patients. Methods: This IRB-approved retrospective study reviewed the medical records of 123 hospitalized psychiatric patients who received consultations from the BUP consultation service. Descriptive and comparative statistics were performed. Results: The sample was predominantly male, with significant unemployment and housing instability. Patients were hospitalized for depressive, bipolar, and schizophrenia spectrum disorders. Over 90% of patients were discharged on buprenorphine, with over 50% being connected to specialized substance use services. No increase in the length of stay was found, and no difference in outcomes was observed based on diagnosis or BUP discharge status. Discussion/Conclusions: This novel service was effective in providing OUD treatment to patients with complex co-occurring psychiatric disorders without significantly increasing their length of stay. Despite acute exacerbations in psychiatric illness, patients were able to engage in discussions regarding BUP. While the study was limited in scope, it underscores the feasibility of integrating OUD treatment in the acute psychiatric inpatient setting.

1. Introduction

The opioid crisis continues to devastate communities across the United States and worldwide, with approximately 82,000 Americans dying of opioid-related overdoses in 2022 [1]. The gold-standard treatment for Opioid Use Disorder (OUD) includes pharmacotherapy with three FDA-approved medications (MOUD): buprenorphine (BUP), methadone, and extended-release naltrexone [2]. Treating patients with MOUD has been found to improve treatment retention and reduce both mortality and burden on the healthcare system [2,3,4]. Psychiatric conditions, including serious mental illness (SMI), are highly comorbid with OUDs, with up to 25% of adults with OUDs having co-occurring SMI [5].

Despite the high comorbidity of OUDs and psychiatric illness, the treatment of OUDs across psychiatric services is often very limited [2,5,6,7]. Recent reports suggest that potentially only one-third of community outpatient mental health facilities and less than half of surveyed psychiatric hospitals provide any sort of MOUD to patients with co-occurring disorders [2,6]. This may be due, in part, to stigma against providing MOUD, a lack of knowledge/training about MOUD, and varying regulations surrounding its provision [6]. When treatment for OUD and psychiatric illness are not provided concurrently, this creates an additional barrier for patients who then have to navigate complex and separate healthcare systems [2].

The present study describes patient characteristics and the buprenorphine/naloxone (BUP) prescribing and discharge outcomes of a specialty BUP consultation program that was instituted at an academic inpatient psychiatric hospital designed to increase access to BUP and other addiction-related services in this population.

2. Materials and Methods

This retrospective study was approved by the Institutional Review Board at New York Medical College and the Clinical Research Institute at Westchester Medical Center Health Network (Protocol 14042). Data were collected from a 96-bed inpatient psychiatric facility serving Westchester County, New York, and the surrounding Metropolitan and Hudson Valley areas. The study period spanned from 1 January 2018 to 15 August 2020 and included all psychiatric inpatients who received a consultation from a specialized BUP consultation service.

This service was led by a geriatric/emergency psychiatrist who received X-waiver training and included residents and medical students. The team was consulted by and worked in close collaboration with the primary inpatient team. In addition to providing consultation for BUP, the service also provided motivational interviewing, assisted in outpatient referrals, and provided bridge prescriptions for BUP after discharge. By initiating BUP while patients were admitted, the team hoped to increase the likelihood of successful treatment retention in outpatient OUD treatment [8].

Variables collected from patients’ electronic medical records included discharge diagnosis, substance use, treatment history, and sociodemographic variables. Descriptive statistics were generated using SPSS Version 30 [9]. Comparative statistics, including chi-square tests for categorical variables and independent t-tests for continuous variables, were also performed. If any variable was not able to be obtained for an individual patient, they were not included in the analysis for that variable.

3. Results

One hundred and twenty-three (123) patients admitted to inpatient psychiatry during this time period received BUP consultations; of these, one hundred and fourteen were initiated on BUP. The sample age was, on average, 37 years, predominately male and predominately White (

Table 1. Sociodemographic characteristics of study sample.

Variable	Frequency
Age in years (Mean (SD))	36.6 (12.1)
Gender Identity N (%)
Male	85 (69.1%)
Female	34 (27.6%)
Transgender or Gender Non-Conforming	4 (3.3%)
Race N (%)
Asian/South Asian	3 (2.4%)
Black	8 (6.5%)
Latinx	9 (7.3%)
White	91 (74.0%)
Other/Unknown	12 (9.8%)
Undomiciled N (%)	37 (30.1%)
Unemployed N (%)	89 (72.4%)

). About one-third were undomiciled, and over 70% were unemployed (Table 1). Individuals had a wide range of psychiatric illnesses, most commonly depression (56.9%), followed by bipolar disorder (30.1%) and schizophrenia spectrum illness (13.0%) (

Table 2. Clinical characteristics of study sample.

Variable	Frequency
Psychiatric Diagnosis N (%)
Depressive Disorder	70 (56.9%)
Bipolar Spectrum Disorder	37 (30.1%)
Schizophrenia Spectrum Disorder	16 (13.0%)
Co-occurring Substance Use N (%)
Cannabis	39 (31.7%)
Stimulants (Non-prescribed)	52 (42.3%)
Benzodiazepines (Non-prescribed)	20 (16.3%)
Number of prior admissions to detoxification/rehabilitation program (Mean (SD))	2.6 (4.2)
Length of OUD * in years (Mean (SD))	8.6 (8.2)
History of BUP (N (%))	81 (65.9%)
Length of stay (days) (Mean (SD))	11.1 (8.6)
Discharged on BUP (N (%))	114 (92.7%)
Discharge BUP dose * in mg (Mean (SD))	13.5 (7.2)
Discharge Level of Care (N (%))
Inpatient Rehabilitation	38 (30.9%)
Outpatient Rehabilitation	33 (26.8%)
Outpatient Psychiatry	48 (39.0%)
Assertive Community Treatment team	1 (0.8%)
Other Inpatient Service	3 (2.4%)

* Length of OUD: N = 49. Discharge BUP dose: N = 114.

). Many had co-occurring substance use disorders (in addition to OUD), primarily stimulant (42.3%) and cannabis (31.7%) use disorders (Table 2). Nearly two-thirds had received prior BUP treatment in the past but had become non-adherent, with the rest undergoing BUP initiation for the first time. Many patients had a history of prior inpatient substance use treatment, with an average of 2.6 prior detoxification/rehabilitation admissions (Table 2).

Over 90% of patients were discharged on BUP, with an average dose of 13.5 mg, and this was almost entirely in formulations combined with naloxone. At discharge, over 50% were connected with specialized inpatient and outpatient substance use rehabilitation services (Table 2). When comparing patients’ OUD outcomes (the acceptance of BUP, dose, referral status, etc.) across diagnoses, there were no statistical differences. When comparing patients discharged on BUP to those who were not, there were no differences in length of stay (t(121) = −1.17, p = 0.25). Additionally, the length of stay in this population is consistent with the average based on internal metrics from our institution.

4. Discussion

Our findings indicated promising results from the novel BUP consultation service. The context of this study is important, particularly considering that this study took place while the X-waiver requirements from the Drug Enforcement Administration were still in place (which were initially relaxed in April 2021 and then formally removed in December 2022) [10]. During this time, the majority of inpatient psychiatrists at our facility did not have X-waiver training, and those that did had restrictions on the number of patients to whom they were permitted to prescribe BUP under X-waiver restrictions. This service aided in addressing X-waiver restrictions and also added an additional level of clinical support to patients with complex co-occurring disorders.

One potential concern that might preclude providers from providing MOUD on inpatient psychiatric units may be related to fears of increasing the length of stay in order to be able to complete BUP induction [11]. However, these results suggest that the program effectively provided OUD treatment to patients across a wide range of acute mood and psychotic illnesses without any significant increase in their length of stay. Our findings are consistent with what has been previously found in inpatient medical units using addiction medicine consultation services; however, our study is the first to our knowledge to employ a similar approach in the inpatient psychiatric setting [12].

Some providers may be hesitant to initiate BUP during acute exacerbations of psychiatric illness, particularly SMI, due to concerns for increasingly complex medication regimens and risks for polypharmacy or concerns that such acute patients may be unwilling or unable to engage in discussions regarding treating their OUD. This service, however, found that patients were able to engage in motivational counseling despite their acute mental health symptoms, even those with acute psychosis. The types of motivational counseling employed included brief motivational interviewing techniques, which focused on enhancing patients’ intrinsic motivation to change by exploring and resolving ambivalence. These sessions were adapted to the patient’s cognitive and emotional states by using simplified language, focusing on immediate concerns, and incorporating frequent reality testing. Additionally, the counseling sessions were conducted in a supportive environment that prioritized establishing trust and rapport and facilitated patient engagement. Most patients were more than willing to initiate BUP while concurrently receiving treatment for their co-occurring psychiatric disorders. Qualitatively, many experienced improvements in their psychiatric symptoms with BUP induction, and the majority were connected with specialized dual diagnosis aftercare services [13,14].

There are limitations to this study, including the small sample size, lack of a comparison group, and the retrospective nature of the study. This population was predominately White, which is consistent with known racial disparities in the treatment of OUD and with the general population of the geographic area [15]. Additionally, information about previous enrollments in methadone maintenance treatment was not available. However, we believe these findings are important to highlight the feasibility and importance of addressing co-occurring disorders in the acute inpatient psychiatric setting. Future studies exploring the integration of genetic screening with traditional assessment methods could provide insights into individual variations in treatment response, thereby enhancing the personalization of therapeutic strategies. While not directly examined in this study, such approaches could contribute to the development of more tailored interventions in the context of personalized medicine.