Patient-Directed Discharge Among Hospitalized Persons With Opioid Use Disorder in the Fentanyl Era: A Scoping Review

Background: Patient-directed discharge (PDD), also known as discharge against medical advice, is associated with poor outcomes, such as increased hospital readmission and mortality. PDD is 10-20 times more common among persons with opioid use disorder (OUD). This scoping review sought to describe the reported incidence in the fentanyl era and characterize relevant patient level, clinical care level and systems level risk factors that may contribute to this phenomenon. Methods: A comprehensive assessment of the literature was conducted across 4 electronic databases: PubMed, CINAHL, Cochrane Library and Embase. The search strategy was designed to identify articles reporting PDD incidence and OUD in the era of fentanyl and other highly-potent synthetic opioids. Results: PDD incidence varies significantly by population; many studies report PDD rate in 10%-20% range and the incidence rate appears to be increasing over time. Younger patients with co-occurring stimulant use and OUD carry the highest rates of PDD. Studies examining the association between medications for OUD (MOUD) and decreased PDD report mixed findings, which likely reflects the impact of variability in medication selection and timing of administration. Consultation with addiction consult service (ACS) was not consistently associated with decreased PDD. Conclusions: Overall, there is increased rate of PDD in fentanyl era. More work is needed to characterize the relationship between MOUD provision and ACS with incidence of PDD.