Overcoming Legislative and Institutional Barriers to Implementing Methadone Dispensing in a California Health System

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BACKGROUND: Opioid overdose deaths increased markedly during the COVID-19 pandemic, highlighting the need to optimize access to medications for opioid use disorder (MOUD). Hospitalization presents a key opportunity to initiate treatment. However, methadone access is uniquely limited by federal and state regulations requiring dispensing through Opioid Treatment Programs (OTPs). This frequently delays hospital discharge, prolongs inpatient length of stay, or necessitates return emergency department (ED) visits when OTPs are inaccessible. In March 2022, the Drug Enforcement Administration permitted hospitals to dispense up to a 72-h supply of methadone for OUD while arranging OTP care, but unclear state-level authorization limited adoption in our California hospital. METHODS: We describe the multidisciplinary process of implementing hospital-based methadone dispensing under the federal 72-h rule at a California acute care hospital. This included legislative advocacy culminating in passage of Assembly Bill 2115, regulatory and legal review, Board of Pharmacy engagement, development of electronic medical record workflows, pharmacy operations redesign, and anti-stigma education. We also evaluated baseline utilization and costs associated with delayed discharges and ED return visits related to methadone access and reported early post-implementation outcomes. RESULTS: Prior to implementation, methadone-related barriers accounted for 33 excess inpatient days and 15 ED visits in a 7-month period, with an estimated cost of $415 970 annually. In the first 8 months after implementation, 25 patients received dispensed methadone, avoiding at least 40 inpatient days and 12 ED visits, with estimated cost savings of $269 164. Nine patients were newly initiated on methadone during hospitalization. CONCLUSIONS: Hospital-based methadone dispensing under the 72-h rule is feasible, legally permissible in California following AB 2115, and associated with reductions in length of stay, ED utilization, and healthcare costs. This program improves continuity of care, reduces stigma, and expands access to lifesaving MOUD, offering a framework for other institutions and states.

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