Trends in Buprenorphine and Methadone Initiation for Opioid Use Disorder Among Patients Using Fentanyl: A Mixed-methods Analysis From an Inpatient Addiction Consult Service.

Abstract

To analyze trends in initiation of medications for opioid use disorder (MOUD) among hospitalized patients with opioid use disorder (OUD) and explore patient-reported factors underlying medication selection amid widespread fentanyl prevalence. This retrospective mixed-methods study included adult patients with OUD hospitalized at an urban academic hospital between January 2018 and December 2022. Eligible patients were not on MOUD before admission and were seen by the addiction consult service. We evaluated trends in MOUD (buprenorphine, methadone and no MOUD) selection and performed multivariable logistic regression to examine the association between admission year and methadone initiation. In addition, we performed an in-depth review of 100 medical records (10 per MOUD type per year) to examine patient perspectives on prior MOUD experiences and potential challenges influencing selection. Among 1034 patients, methadone selection increased from 14.6% in 2018 to 41.4% in 2022, while buprenorphine was not significantly different (34.6%-37.9%). Selection of no MOUD decreased from 50.8% to 20.7%. Later admission year was associated with a higher likelihood of methadone selection compared with no MOUD, highest in 2021 (aRRR: 9.29, 95% CI: 4.98-17.33) compared with 2018. In qualitative review, most patients (70%) were afraid of fentanyl contamination; 90% had prior MOUD experience, primarily positive; 38% (23/61) expressed fear of precipitated withdrawal, and 63% (33/52) were concerned about slow methadone titration. Methadone selection increased during the study period. Early initiation challenges were the primary patient-reported barriers. These findings underscore evolving challenges related to fentanyl and need to optimize MOUD stabilization strategies.