Background: People who use illicit opioids are more likely to be admitted to hospital than people of the same age in the general population. Many admissions end in discharge against medical advice, which is associated with readmission and all-cause mortality. Opioid withdrawal contributes to premature discharge. We sought to understand the barriers to timely provision of opioid substitution therapy (OST), which helps to prevent opioid withdrawal, in acute hospitals in England. Methods: We requested policies on substance dependence management from 135 National Health Service trusts, which manage acute hospitals in England, and conducted a document content analysis. Additionally, we reviewed an Omitted and Delayed Medicines Tool (ODMT), one resource used to inform critical medicine categorisation in England. We worked closely with people with lived experience of OST and/or illicit opioid use, informed by principles of community-based participatory research. Results: Eighty-six (64%) trusts provided 101 relevant policies. An additional 44 (33%) responded but could not provide relevant policies, and five (4%) did not send a definitive response. Policies illustrate procedural barriers to OST provision, including inconsistent application of national guidelines across trusts. Continuing community OST prescriptions for people admitted in the evening, night-time, or weekend was often precluded by requirements to confirm doses with organisations that were closed during these hours. 42/101 trusts (42%) required or recommended a urine drug test positive for OST medications or opioids prior to OST prescription. The language used in many policies was stigmatising and characterised people who use drugs as untrustworthy. OST was not specifically mentioned in the reviewed ODMT, with ‘drugs used in substance dependence’ collectively categorised as posing low risk if delayed and moderate risk if omitted. Conclusions: Many hospitals in England have policies that likely prevent timely and effective OST. This was underpinned by the ‘low-risk’ categorisation of OST delay in the ODMT. Delays to continuity of OST between community and hospital settings may contribute to inpatient opioid withdrawal and increase the risk of discharge against medical advice. Acute hospitals in England require standardised best practice policies that account for the needs of this patient group.
Bibliographical noteFunding Information:
MH is funded by a National Institute of Health Research Career Development Fellowship [CDF-2016-09-014] for the Care & Prevent Research Project. DL is funded by a National Institute for Health Research (NIHR) Doctoral Research Fellowship [DRF-2018-11-ST2-016]. JS is funded by a substantive academic contract and has research funding from EPSRC and Somerset County Council. The views expressed are those of the authors and not necessarily those of their employing organisations, the NHS, the NIHR or the Department of Health and Social Care. The researchers undertook the study independently of the funders, who did not play a role in the study design, data collection, analysis, interpretation, writing or the decision to submit the article for publication.
We would like to thank the Specialist Pharmacy Service for their responsiveness to revising the ODMT, the administrative staff in participating trusts who cooperated with the freedom of information requests, Maria Measham and Laura Garius at Release for collating policies for the preliminary analysis, the members of the public receiving OST who commented on policies during the meeting conducted by Release, attendees of the Medication Safety Officers and Scottish Drug Forum webinars and the Drug and Alcohol Problems in Primary Care Conference 2020 who commented on the exploratory analysis, Rosalind Gittins for her input when developing the study framework matrix, and the participants of the Care and Prevent study undertaken by MH, whose honest insights prompted this research. We dedicate this paper to the memory of Anthea Martin and Gary Sutton, both instrumental in informing this study.
© 2022, The Author(s).
- Community-based participatory research
- Discharge against medical advice
- Document analysis
- Hospital policy
- Opioid dependence
- Opioid overdose
- Opioid substitution therapy
- Opioid withdrawal
- People who use drugs