Effect of initiation of medications for opioid use disorder on hospitalization outcomes for endocarditis and osteomyelitis in a large private hospital system in the United States, 2014–18

Abstract

Background and Aims Opioid use disorder (OUD) has led to not only increases in overdose deaths, but also increases in endocarditis and osteomyelitis secondary to injection drug use (IDU). We studied the association between initiation of medications for opioid use disorder (MOUD) and treatment outcomes for people with infectious sequelae of IDU and OUD. Design and setting This is a retrospective cohort study reviewing encounters at 143 HCA Healthcare hospitals across 21 states of the United States from 2014 to 2018. Participants Adults aged 18–65 with the ICD diagnosis code for OUD and endocarditis or osteomyelitis (n = 1407). Measurements Main exposure was the initiation of MOUD, defined as either methadone or buprenorphine at any dosage started during hospitalization. Primary outcomes were defined as patient‐directed discharge (PDD), 30‐day re‐admission and days of intravenous antibiotic treatment. Covariates included biological sex, age, ethnicity, other co‐occurring substance use disorders, and insurance status. Findings MOUD was initiated among 269 (19.1%) patients during hospitalization. Initiation of MOUD was not associated with decreased odds of PDD. Initiation of MOUD did not impact 30‐day re‐admission. Patients who received MOUD, on average, had 5.7 additional days of gold‐standard intravenous antibiotic treatment compared with those who did not [β = 5.678, 95% confidence interval (CI) = 3.563, 7.794), P < 0.05]. Conclusion For people with opioid use disorder hospitalized with endocarditis or osteomyelitis, initiation of methadone or buprenorphine appears to be associated with improved receipt of gold‐standard therapy, as quantified by increased days on intravenous antibiotic treatment.

Clostridium botulinum – like organism bacteremia in a user of black tar heroin

“…Patients with opioid use disorder are at risk for many infectious conditions in addition to Clostridia, such as endocarditis, Hepatitis C, and HIV infection. In studies of endocarditis patients with opioid use disorder, use of medications for opioid use disorder (MOUD) was associated with a higher rate of receiving gold standard therapy for endocarditis [ 19 ], and lower mortality while actually receiving MOUD, though retention in MOUD programs post-discharge was low [ 20 ].…”

Linking opioid use disorder treatment from hospital to community

“…These invasive infections are increasingly common [2][3][4][5][6], and in-hospital initiation of medications for opioid use disorder (MOUD) is both a crucial component of secondary prevention [7][8][9][10][11][12] and the standard of care for treating opioid use disorder [13][14][15][16][17]. While the paper refers to 'initiation of MOUD' having limited effect, the investigators did not actually assess the effect of in-hospital initiation of buprenorphine or methadone maintenance treatment for opioid use disorder; they identified patients receiving either medication for any indication, including for opioid withdrawal [1]. We worry that soft-pedaling this distinction may mislead patients, clinicians and policymakers into thinking that MOUD treatment has relatively little impact in the hospital setting.…”

“…Unfortunately, dosages of methadone and buprenorphine were not reported in the study; these might have been used as a proxy for providers' intentions to continue these medications long-term. Table 2 shows that only 44 patients (3.1% of the total sample and 16.4% of those who received any dose of MOUD) were continued on MOUD at discharge, indicating that most patients only received these medications short-term, probably to relieve symptoms of opioid withdrawal [1]. As the authors note, a randomized controlled trial has shown continuation of MOUD after in-hospital initiation is much more effective at engaging patients in treatment compared to simply outpatient referral after withdrawal management [19].…”

“…We read with interest Jo and colleagues' study of hospitalized patients with injection drug use-associated infective endocarditis and osteomyelitis who received methadone or buprenorphine [1]. These invasive infections are increasingly common [2][3][4][5][6], and in-hospital initiation of medications for opioid use disorder (MOUD) is both a crucial component of secondary prevention [7][8][9][10][11][12] and the standard of care for treating opioid use disorder [13][14][15][16][17].…”

“…Jo and colleagues reported on 1407 patients with opioid use disorder (OUD) hospitalized with endocarditis or osteomyelitis who did not have an active MOUD prescription at the time of admission [1]. They described that '269 (19.1%) patients were initiated on MOUD during their hospitalization', and they defined 'initiation on MOUD' as receipt of any dose of methadone or buprenorphine while hospitalized.…”