{
  "abstract": "Background Delayed provision of opioid substitution therapy (OST) in acute hospitals contributes to patient distress, opioid withdrawal and discharge against medical advice (DAMA). We aimed to improve access to opioid substitution therapy (OST) for hospital inpatients, using the iHOST (‘improving hospital opioid substitution therapy’) clinical guidelines, developed through a deliberative consensus process in partnership with clinical, academic and peer experts with professional body oversight.Methods This pre–post quality improvement study evaluates implementation of the iHOST guideline at a tertiary hospital serving inner city London, UK between 2021 and 2023. Clinical records of all patients administered OST in the 12 months before and 11 months after the policy’s introduction were evaluated for measures of process (reducing urine drug screening, improving time-to-administration), balancing (avoiding emergency naloxone administration, avoiding increased mortality) and outcome (discharge against medical advice).Results Among 259 patients pre-policy and 194 post-policy, the median time to first methadone dose fell from 18.1 hours to 14.8 hours and the proportion of patients waiting more than 24 hours reduced from 32% to 21% (OR 0.57, 95% CI 0.37 to 0.88). Urine drug screening was one-sixth as likely to be performed on admission. There was no change in the likelihood of discharge against medical advice, which occurred for 24% of admissions during both periods (p=0.96). Naloxone was required for only 2% of admissions (five pre-policy, four times post p=1.00), indicating no compromise of patient safety.Conclusions Implementing the iHOST guideline successfully reduced unnecessary delays to methadone administration without increasing the risk of opioid toxicity. While high rates of DAMA, even after improving access to OST, point to an ongoing need for patient-centred engagement strategies, successful implementation of the iHOST guideline supports its wider use: it is now under evaluation in two additional hospitals, after which it will be optimised to assess its utility for nation-wide practice.",
  "authors": [
    {
      "affiliations": [
        "University College London Hospitals NHS Foundation Trust, London, UK"
      ],
      "name": "Michael Trent Herdman"
    },
    {
      "affiliations": [
        "University College London Hospitals NHS Foundation Trust, London, UK"
      ],
      "name": "Brihitejas Patel"
    },
    {
      "affiliations": [
        "University College London Hospitals NHS Foundation Trust, London, UK",
        "University College London Medical School, London, UK"
      ],
      "name": "Poppy Pierce"
    },
    {
      "affiliations": [
        "University College London Hospitals NHS Foundation Trust, London, UK",
        "University College London Medical School, London, UK"
      ],
      "name": "Vedika Apte"
    },
    {
      "affiliations": [
        "University College London Hospitals NHS Foundation Trust, London, UK",
        "University College London Medical School, London, UK"
      ],
      "name": "Zainab Mashal Hussain Wasti"
    },
    {
      "affiliations": [
        "University College London Hospitals NHS Foundation Trust, London, UK"
      ],
      "name": "James Norman"
    },
    {
      "affiliations": [
        "University College London Hospitals NHS Foundation Trust, London, UK"
      ],
      "name": "Agnes Niemet"
    },
    {
      "affiliations": [
        "University College London Hospitals NHS Foundation Trust, London, UK",
        "Central and Northwest London Hospitals NHS Foundation Trust, London, UK"
      ],
      "name": "Kate Robinson"
    },
    {
      "affiliations": [
        "University College London Hospitals NHS Foundation Trust, London, UK",
        "Central and Northwest London Hospitals NHS Foundation Trust, London, UK"
      ],
      "name": "Iona Martin"
    },
    {
      "affiliations": [
        "London School of Hygiene and Tropical Medicine, London, UK"
      ],
      "name": "Marisha Wickremsinhe"
    },
    {
      "affiliations": [
        "London School of Hygiene and Tropical Medicine, London, UK"
      ],
      "name": "Nerissa Tilouche"
    },
    {
      "affiliations": [
        "University College London Hospitals NHS Foundation Trust, London, UK"
      ],
      "name": "Adrian 'Bean’ Noctor"
    },
    {
      "affiliations": [
        "University of Bristol Centre for Academic Primary Care, Bristol, UK"
      ],
      "name": "Jennifer Scott"
    },
    {
      "affiliations": [
        "Bradford Teaching Hospitals NHS Foundation Trust, Bradford Institute for Health Research, Bradford, UK"
      ],
      "name": "Dan Lewer"
    },
    {
      "affiliations": [
        "University of Bristol School of Psychological Science, Bristol, UK",
        "School of Population Health Sciences, University of Bristol Medical School, Bristol, UK"
      ],
      "name": "Adam Holland"
    },
    {
      "affiliations": [
        "London School of Hygiene and Tropical Medicine, London, UK"
      ],
      "name": "Magdalena Harris"
    },
    {
      "affiliations": [
        "University College London Hospitals NHS Foundation Trust, London, UK",
        "London School of Hygiene and Tropical Medicine, London, UK"
      ],
      "name": "Michael Brown"
    }
  ],
  "title": "Improving opioid substitution therapy in the acute hospital setting: implementation of a best practice guideline",
  "uid": "535610ab-f510-5dbb-ab9a-bbffa3e11431"
}