Hospitalized patients with opioid use disorder present unique clinical challenges, including higher rates of patient-directed discharge (PDD), incomplete treatment courses, and frequent readmissions. To compare outcomes in hospitalized patient encounters involving OUD and bacteremia that were ordered medications for opioid use disorder versus high-dose opioid agonist therapy (HDOAT) alone. This single-center, retrospective study included 268 OUD patients, 383 encounters, and 303 cases of bacteremia admitted to Temple University Hospital from Jan 1, 2020 through Dec 31, 2022. Outcomes of interest included PDD, 7 and 30-day readmission, inpatient mortality, length of stay (LOS), one year mortality and antibiotic completion. Bacteremia is a serious illness and requires long term treatment, thus it is an optimal model for this work. Of 383 encounters, 234 involved MOUD, and 149 involved HDOAT alone. Among the HDOAT group, doses were up to 2,070 MMEs/day. MOUD included buprenorphine and methadone. HDOAT included non-MOUD full agonist such as oxycodone and/or hydromorphone. For case-level outcomes, MOUD was associated with higher antibiotic completion (35.0% vs 23.3%, OR 1.77, p < 0.05). For encounter-level outcomes, MOUD was associated with lower PDD rates (38.5% vs 69.8%, OR 0.27, p < 0.0001) and longer LOS (8d vs 3d), seven-days readmission and inpatient mortality rates were similar between groups. However, 30-day readmission rate was lower in the MOUD group (32.9% vs 43.0%, OR 0.65, p < 0.05). PDD, readmission and mortality were similar regardless of timing of MOUD initiation (<72 h vs > 72h) or severity of opioid dependence. Notably, 23% of HDOAT cases successfully completed antibiotics, often across multiple encounters. MOUD initiation was associated with lower PDD and higher antibiotic completion rates. Timing of MOUD initiation did not affect outcomes. HDOAT may serve as a second-line approach to support continuity of care in patients declining MOUD.
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