Leslie W. Suen

Background: Methadone is effective for treating opioid use disorder (OUD) but must be accessed through federally regulated opioid treatment programs (OTPs). Geographic scarcity, waitlists, and limited intake schedules can delay OTP enrollment, causing patients to miss treatment opportunities. Regulations permit non-OTP practitioners to provide up to three days of methadone to bridge patients to OTP enrollment. This study evaluates the rates of linkage to and early retention in an OTP after initiation of three-day methadone at a Bridge Clinic. Methods: We conducted a retrospective case series of all patients who initiated methadone under the three-day rule at the San Francisco General Hospital Bridge Clinic between June 2024 and July 2025. The hospital also houses an OTP in the same building, which referred patients to Bridge who were unable to complete an intake at the OTP. Outcomes included linkage to OTP care within seven days and retention at 30 days. Safety monitoring included review of all urine drug screens that were either positive for methadone or negative for non-prescribed opioids, emergency department visits, hospitalizations within seven days, and Medical Examiner overdose reports. Multivariable logistic regression examined the association between referral from an OTP to Bridge Clinic and 30-day retention. Results: Among 166 unique patients who received at least one dose of three-day methadone, 63% percent (104/166) linked to an OTP within seven days. Among patients who linked within seven days, 62% (64/104) were retained at 30 days. Referral from the OTP to Bridge clinic was associated with 3.1-fold increased odds of 30-day retention. No methadone-related emergency department visits, hospitalizations, or deaths within 30 days of receipt of methadone were observed. Medical record review of unexpected urine drug screen results revealed that one patient was already enrolled in methadone treatment prior to receiving a dose. Conclusions: Initiating methadone in a low-threshold Bridge Clinic is feasible for engaging patients in OTP care. Referral from OTP to Bridge Clinic was associated with improved treatment retention. Trial registration: Not applicable.

Objectives: To understand patient and staff experiences with in-hospital substance use (IHSU) and develop recommendations to better support patients and staff navigating IHSU. Methods: Semi-structured qualitative interviews with patients engaging in and hospital staff responding to IHSU in the past year at a safety-net hospital in San Francisco, California, from July 2024 to August 2025. We used iterative thematic analysis to identify major themes. Results: Patients (n=19) were recruited from the community (84.2%) and hospital (15.8%). Most identified as men (73.7%), White (63.2%), and unhoused (57.9%); most used fentanyl during hospitalization (57.9%). Staff (n=21) included clinicians (28.6%), nurses (28.6%), nurse leaders (19.0%), administrators (14.3%), and other staff members (9.5%); primary work areas were administration (23.8%), the addiction consult team (19.0%), and medical-surgical departments (19.0%). We identified seven themes regarding patient and staff experiences: (1) IHSU helped patients endure hospitalization; (2) punitive responses exacerbated patient experiences of mistrust, stigma, and distress; (3) patient-centered responses improved patient and staff experiences; (4) staff were concerned for patient and staff safety; (5) nurses were concerned about personal liability; (6) nurses felt unheard in concerns; and (7) staff felt underprepared to respond to IHSU. Conclusions: IHSU helped patients avoid patient-directed discharge but distressed staff—especially nurses—due to a lack of training and support. To improve patient and staff experiences, hospitals can implement standardized addiction medicine training, proactive evidence-based inpatient addiction treatment, trauma-informed IHSU responses, and evidence-based patient-centered policies for responding to IHSU that support patients and staff.

Background: Patients with substance use disorders (SUD) face several challenges when hospitalized, including stigma, undertreated withdrawal and pain, and higher rates of self-directed discharge. Hospital-based harm reduction services can support patients with SUD, increase engagement, build trust, and catalyze culture change. Our hospital’s Addiction Consult Team implemented a harm reduction program to provide education and substance use equipment to hospitalized patients whose SUD goals did not include abstinence. We conducted a qualitative evaluation of our harm reduction program to identify implementation and sustainability themes for long-term success. Methods: This qualitative study consisted of semi-structured interviews conducted between October 2022 and March 2023 with hospitalized patients receiving harm reduction services and hospital staff at an urban safety-net hospital in San Francisco, California. Interviews were audio-recorded and transcribed with informed participant consent. Transcripts were deductively and inductively coded through an iterative process, and we used thematic analysis to identify themes. Results: We interviewed 20 patients and 20 staff participants with interviews ranging from 30–45 min. We identified three themes related to implementation and three related to sustainability. Implementation themes were: (1) Operational barriers, including time constraints, lack of clearly defined roles, and competing demands, challenged delivery of harm reduction kits; (2) Tension between generalized versus specialized harm reduction program ownership limited impact; and (3) Educational gaps impeded broader harm reduction uptake and reinforced stigma. Sustainability themes were: (1) Experiential learning reinforced harm reduction practice and culture change; (2) Interprofessional collaboration, especially involving SUD champions, supported the program; and (3) Sharing patient success stories helped overcome stigma and burnout and highlighted harm reduction effectiveness. Conclusion: Harm reduction program implementation was challenged by resource constraints, complexity of program ownership, and lack of SUD knowledge. In contrast, experiential learning, interprofessional collaboration, and sharing patient successes sustained harm reduction efforts. Based on these findings, we recommend the following for long-term harm reduction program success: operationalize harm reduction workflow via hospital-wide interprofessional efforts; incorporate continuous, multimodal substance use training with all staff to ensure a baseline knowledge and drive culture change; and create feedback processes to share patient outcomes and narratives with staff.

Background: Buprenorphine is an effective treatment for opioid use disorder, but it can be challenging to avoid withdrawal in the process of buprenorphine initiation. After the recent FDA approval of 7-day long-acting injectable buprenorphine, some clinicians have used this formulation to start patients on buprenorphine without a prior sublingual “test dose.” Very little is known about the feasibility of this practice in an outpatient setting. Cases: In this case series, we conducted a retrospective chart review of electronic health record data for all patients who were ordered 7-day long-acting injectable buprenorphine for a “direct-to-inject” initiation within a single public health system from January 1, 2024 to November 15, 2024. We excluded patients who received a cumulative dose of 4 mg or more of sublingual buprenorphine in the 24 hours before injection. We reported on chart-documented patient experiences after injection, whether patients returned to care, and retention on buprenorphine at 7- and 30-days post-injection. We identified 21 unique patients who received direct-to-inject buprenorphine in 22 attempts. In 17 (77%) attempts, the patient received no buprenorphine in the preceding 24 hours. In 5 (23%) attempts, patients received some buprenorphine in the preceding 24 hours (<4 mg) and/or had evidence of buprenorphine in a same-day urine drug screen. Patient experiences post-injection fit into 1 of 3 themes: “It felt fine” (n = 6), “I felt unwell but okay” (n = 13), and “It felt very rough” (n = 3). Most attempts resulted in buprenorphine treatment retention at 7 days (n = 17, 77%) and 30 days (n = 16, 73%) after injection. Discussion: Direct-to-inject buprenorphine was generally well tolerated, with excellent retention on buprenorphine at 7- and 30 days post-injection. Further research is needed to evaluate the correlation between preinjection patient characteristics (time since last use, level of withdrawal) and post-injection patient experience of withdrawal.

Stimulant use disorder (StUD) is a rapidly growing concern in the United States, with escalating rates of death attributed to amphetamines and cocaine. No medications are currently approved for StUD treatment, leaving clinicians to navigate off-label medication options. Recent studies suggest that controlled prescription psychostimulants such as dextroamphetamine, methylphenidate, and modafinil are associated with reductions in self-reported stimulant use, craving, and depressive symptoms. Despite this positive initial evidence, prescribing rates of these medications for StUD treatment remain low, possibly because some clinicians believe that they are subject to the restrictions federal law imposes on medications for opioid use disorder. This is not the case. Rather, at the federal level, these medications are subject only to the general requirement that prescriptions be issued for a legitimate medical purpose within the usual course of professional practice, criteria that are buttressed by recent national guidelines that include controlled prescription psychostimulants as an option within a comprehensive treatment plan for StUD. In this commentary, we review the federal legal landscape regarding the prescription of psychostimulants for StUD and recommend strategies for increasing the utilization of this promising approach. Professional organizations, addiction clinicians, and researchers can reinforce this practice through publishing expert recommendations, developing clinician education materials, and disseminating their real-world experiences and well-documented treatment plans.