JAMA Network Open: 42 Hospital-Addiction Experts Set Consensus on When and How to Start MOUD During an Admission

What landed

A peer-reviewed Delphi consensus paper, led by Yale School of Medicine and published in JAMA Network Open on May 7, brought together 42 national hospital-based addiction-medicine specialists to do something the field has needed for years: a single, authoritative document covering when and how to initiate medications for opioid use disorder (MOUD) during a hospital admission.

The consensus covers four specific clinical scenarios: rapid methadone initiation in patients in withdrawal; low-dose (“micro-induction”) buprenorphine for patients who can’t tolerate traditional inductions; high-dose buprenorphine inductions for patients who can; and the use of long-acting injectable buprenorphine to bridge from inpatient to community. It also addresses adjunctive medications for withdrawal symptom management — clonidine, ondansetron, loperamide — and explicit guidance on how to coordinate the inpatient start with an outpatient methadone clinic or community bupe prescriber.

Why it matters

Hospitals are one of the highest-leverage points in the recovery system. Per the CDC’s MOUD study tracker, patients who start MOUD during a hospitalization have meaningfully better 30- and 90-day retention than those who are referred at discharge without a medication start. The problem has been that individual hospitals — even those with addiction-medicine consult services — have been working from competing internal protocols built around outdated assumptions about precipitated withdrawal.

For Arizona specifically, this is a usable input. The AHCCCS-supported addiction-medicine consult services in Phoenix-area health systems can adopt or cite this consensus directly. It lowers the activation energy for emergency departments and inpatient teams that want to start MOUD but have not had a defensible written protocol to point to. We will update our hospital-based MOUD cluster to reflect the new consensus this week.