Impact of Time to Buprenorphine Initiation on Patient-Directed Discharge in Concurrent Alcohol and Opioid Withdrawal

BACKGROUND: Treatment for alcohol and opioid withdrawal when managed independently is well-established; however, specific guidance on their concurrent management is lacking. This review evaluated the relationship between buprenorphine initiation and time to initiation on key substance use disorder outcomes for inpatients at risk for both alcohol and opioid withdrawal. METHODS: This single-center retrospective cohort study included patients admitted to the acute psychiatry unit from January 1, 2019 through September 30, 2023 and at risk for concurrent opioid and alcohol withdrawal. Patients were divided into 4 cohorts depending on time to buprenorphine initiation from admission: 0 to 24 hours (n = 85), 24 to 72 hours (n = 44), >72 hours (n = 16), and those who did not receive buprenorphine (n = 187). The primary outcome compared the patient-directed discharge (PDD) rate among the 4 cohorts. Secondary outcomes compared the overall length of stay, inpatient readmission rates at 30 and 90 days, and buprenorphine medication retention at 90 days. Descriptive statistics were used for analysis. RESULTS: Of all psychiatric admissions meeting inclusion criteria (N = 332), 43.7% (n = 145) received buprenorphine. PDD rates were higher in those who did not receive buprenorphine compared to those who did (15.5% [n = 29] vs 6.9% [n = 10]) and in those who initiated buprenorphine between 24 and 72 hours versus 0 to 24 hours of admission (11.4% [n = 5] vs 5.9% [n = 5]). Absence of buprenorphine initiation also resulted in higher inpatient readmission rates at both 30 (25.1% [n = 47] vs 11.0% [n = 16]) and 90 days (46% [n = 86] vs 24.1% [n = 35]). CONCLUSIONS: Patients who did not receive buprenorphine had the highest rate of PDD and readmission. Buprenorphine initiation within 24 hours of admission was associated with a lower rate of PDD. Results highlight the importance of the timely initiation of evidence-based medications for opioid use disorder in patients with concurrent alcohol withdrawal, leading to more favorable outcomes for patients and the facility.