Background: Opioid substitution therapy (also known as 'opioid agonist therapy' or 'medication treatment of opioid use disorder') is associated with improved health and social outcomes for people who use heroin and other illicit opioids. It is typically managed in the community and is not always continued when people are admitted to hospital. This causes opioid withdrawal, patient-directed discharge, and increased costs. We are establishing a project called iHOST (improving hospital opioid substitution therapy) to address these problems. This is an applied health research project in which we will develop and evaluate an intervention that aims to improve opioid substitution therapy in three acute hospitals in England. The intervention was developed in collaboration with stakeholders including people who use opioids, hospital staff, and other professionals who work with this group. It includes five components: (1) a card that patients can use to help hospital clinicians confirm their opioid substitution therapy, (2) a helpline for patients and staff, (3) an online training module for staff, (4) a clinical guideline for managing opioid withdrawal in hospital, and (5) 'champion' roles at each hospital.
Methods: We will do a mixed-methods study including a quasi-experimental quantitative study and a qualitative process evaluation. The primary outcomes for the quantitative study are patient-directed discharge and emergency readmission within 28 days. We will do a difference-in-difference analysis comparing changes in these outcomes for patients at iHOST sites with changes for patients at control hospitals. The process evaluation will use in-depth interviews, focus groups, and site observations with people who use opioids and staff. We will assess acceptability of the intervention, barriers and facilitators to implementation, and contextual factors impacting outcomes.
Impact: We anticipate that iHOST will improve care for hospital patients who use illicit opioids and/or are receiving community-based opioid substitution therapy. Depending on the results, we will promote the intervention at hospitals across the UK. Dissemination, including through publication, will inform hospital-based services for people who use drugs both in the UK and other countries.
Keywords: Buprenorphine; Heroin Dependence; Hospitals; Methadone; Opiate Substitution Treatment; Opioid-Related Disorders; Staff Development; Substance-Related Disorders.
People who use heroin and other illegal opioids can be supported with medically prescribed opioids. These legal medicines, like methadone and buprenorphine, can reduce the need for illegal opioids and improve overall wellbeing. Normally, these treatments are managed in community clinics. They can be provided at stable doses for long periods, sometimes decades. However, when people are admitted to hospital for treatment of medical problems, they don’t always continue receiving these crucial treatments. This happens for various reasons – sometimes hospital staff do not fully understand how the medicines work, or the hospital might have overly strict rules that restrict their use. As a result, patients can experience opioid withdrawal and pain, which can lead them to leave hospital to buy illegal opioids. It might also cause arguments between staff and patients. Hospitals often focus too much on potential risks associated with these medicines, and sometimes forget the needs of patients who depend on them. We are addressing these issues in three hospitals in England. Our project consists of five components: (1) a patient card with information about their opioid treatment to speed up prescriptions; (2) a helpline for patients and hospital staff to seek support; (3) an online training module for hospital staff; (4) clinical guidelines for managing opioid withdrawal in hospitals; (5) named ‘champions’ in each hospital to raise the profile of these resources. These components have been developed together with people who use heroin and hospital staff. We will study the effect of the project using a combination of quantitative and qualitative methods. The quantitative aspect will assess how the project affects the number of patients leaving against medical advice or returning to hospital in emergencies. The qualitative aspect will involve interviews and focus groups to understand how patients and staff perceive the project.
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