The number of opioid-related overdose deaths has sharply increased over the past decade, primarily due to the use of synthetic opioids. There were more than 70,000 such deaths in 2023.1 Although opioid-agonist treatment (OAT) is associated with approximately a 50% reduction in all-cause mortality among individuals with opioid use disorder (OUD), only one in four individuals with OUD received recommended OAT in 2022.2,3 Current approved OAT is limited to buprenorphine and methadone.
For methadone treatment, regulatory and logistical challenges limit patients’ access to this life-saving treatment. Restriction of therapy to federally regulated opioid treatment programs (OTPs), limited locations (particularly in rural areas) and dosing hours, and requirements for in-person dosing present unique challenges for this therapy. During transitions of care, these limitations can lead to delays or lapses in treatment. Hospitalists may therefore hesitate to initiate methadone for patients with OUD during hospital admission, resulting in missed opportunities for treatment.
In 2023, the Easy Medication Access and Treatment Act removed the requirement to apply for an exemption to the one-day limitation on methadone dispensing as specified in 21 CFR 1306.07(b) and allowed for the dispensing of up to three days’ methadone for home use.4 However, there is currently no guidance on how to bring this into practice. Delays in accessing methadone can delay patient discharge. As hospital and addiction medicine providers, we developed and implemented standardized procedures to facilitate methadone dispensing upon hospital discharge. This process was piloted in the inpatient setting at two urban Veterans Affairs (VA) Health Care Systems.
Solution Overview
Our efforts have resulted in a process that allows hospitalized patients on methadone therapy, whether newly initiated or continued from prior treatment, to receive a three-day supply of methadone for home use upon discharge. This supply helps to ensure continuity of care, bridging patients to their OTP intake or follow-up appointments without interruption, especially if an OTP visit is not available immediately, such as on weekends or holidays.5
Implementation Process
Both the Seattle and Portland, Ore. VA facilities independently identified the lack of an established process for dispensing methadone to veterans during transitions of care. In 2024, we explored the possibility of providing up to a three-day supply of methadone for home use to “bridge” treatment, preventing delays in discharge, and improving treatment adherence.
Both sites recruited partners representing hospital medicine, the inpatient addiction consult service (ACS), inpatient pharmacy, and the director of their local OTP. As an example, the Seattle VA working group met initially biweekly, and then monthly for a period of six months, to collaboratively draft standard operating procedures (SOPs) for dispensing methadone upon hospital discharge.
These teams first reviewed and compared the implementation of different SOPs from various health care systems, including the University of Washington, Yale New Haven Hospital, the San Francisco and Jesse Owens (Chicago) VA hospitals, as well as published processes from Johns Hopkins Hospital.6 Some systems permit all providers to write for methadone on discharge, while others route these patients through the ACS. Each institution manages the dispensing of methadone on discharge differently. Some permit nursing or pharmacy staff to dispense methadone directly to the patient, while others require physicians to dispense methadone themselves to adhere to a stricter interpretation of the law mandating the “provider to dispense.”7
Next, we designed institution-specific practitioner and pharmacy workflow processes, illustrated in Figures 1 and 2. To avoid inadvertently dispensing methadone to patients while they are still hospitalized, we created a unique inpatient clinic grid that allows providers to prescribe methadone as a clinic order that is not administered during an inpatient stay.
At both facilities, the ACS evaluates all patients admitted with opioid withdrawal who express a desire to start methadone. ACS then counsels the patient, assesses their eligibility to receive methadone on discharge, recommends an initial dose of methadone, documents a risk-benefit discussion and patient consent, and makes follow-up arrangements at an OTP. Eligible patients must agree to have a follow-up appointment at an OTP. Additionally, at Portland VA, ACS conducts the initial evaluation for their VA-affiliated OTP, thereby streamlining the lengthy OTP intake process. While any provider at the Portland VA can order methadone for home use, only ACS providers at the Seattle VA are allowed to place methadone orders at discharge as a clinic medication. A methadone bridge-to-care supply of up to three days is ordered in 5- to 10-mg increments. Each methadone order includes the following comment:
“NOT FOR INPATIENT USE/ADMINISTRATION. DISPENSED DIRECTLY TO PATIENT BY PROVIDER FOR OUTPATIENT USE ON ___ (INSERT DATE) WITH TOTAL OF ___ DAYS SUPPLY (INSERT DAYS SUPPLY, MAX 3 DAYS)”
Pharmacy champions at both sites designed the pharmacy workflow as shown in Figure 2. Once methadone is ordered for dispensing on discharge, the pharmacy verifies that it does not exceed a three-day supply. The ordered methadone supply is then taken from the inpatient Omnicell, and each day’s supply is placed in an individual child-proof vial labeled with the comment above. At the Portland VA, the pharmacist dispenses methadone to the patient, who then signs a chain of custody form acknowledging receipt of the medication. At Seattle VA, the provider collects the methadone supply and dispenses it to the patient. The provider and patient sign the chain of custody form, which is returned to the inpatient pharmacy. Subsequently, the pharmacy notifies the VA-affiliated OTP of the dispensed doses. In cases where the patient is referred to a non-VA OTP, the ACS informs the receiving OTP of the dispensed doses.
These workflow processes, as outlined in our local VA SOPs, were forwarded to the pharmacy and therapeutics committee and executive leadership for approval.
Outcomes and Impact
Since the program’s implementation 10 months ago, the Portland VA team has enrolled six patients with OUD, three of whom were newly initiated on methadone.
The first of these patients newly initiated on methadone had a history of alcohol and methamphetamine use and OUD, and was admitted to Portland VA with a right-sided empyema. This patient had been hospitalized for encephalopathy and acute hypoxic respiratory failure after fentanyl overdose six months prior. During that hospitalization, he was started on buprenorphine-naloxone; however, he later transitioned to a non-VA OTP for methadone treatment, which he unfortunately discontinued three months prior to presenting to us; he had since resumed smoking fentanyl. The patient shared with us that methadone was, “the only thing that keeps me from doing heroin or fentanyl,” and expressed his interest in restarting treatment. To facilitate a timely discharge and enrollment in the VA-affiliated OTP, we conducted the OTP intake evaluation and discharged him with a three-day supply of methadone for home use. Six months later, he remains on OAT with methadone.
The second patient had a history of housing instability, stimulant use, and OUD. He was living in a hotel and using fentanyl. He had previously received methadone from two non-VA OTPs but was no longer enrolled in either. During his hospitalization for influenza A, we performed an OTP intake evaluation. Several days into his hospitalization, the patient needed to leave after his mother was diagnosed with pneumonia following a fall. He was discharged with a two-day supply of methadone. Despite the disruption in his care, he presented to the VA-affiliated OTP appointment to continue the enrollment process. Unfortunately, he subsequently could not be reached despite multiple outreach attempts and has not re-engaged in care within the VA system.
The third patient with OUD was admitted for acute decompensated heart failure. His hospitalization was complicated by cecal volvulus for which he required emergent surgical intervention. Despite hydromorphone, oxycodone, and ketamine use, the patient had inadequate postoperative pain control and continued to experience opioid withdrawal symptoms, which were subsequently successfully managed with initiation of methadone. Because he lived far from the Portland VA, the ACS coordinated a referral to a non-VA OTP closer to his home and discharged him with a one-day supply of methadone to bridge him to his OTP intake appointment. A follow-up call to the patient from the VA-affiliated OTP to ensure a smooth transition revealed the Veteran’s enthusiasm as he stated he was, “ecstatic to be clean…it feels great.”
For the remaining three patients who were already on methadone prior to admission, the ACS helped the inpatient team develop a plan for methadone dosing until OTP follow-up. Each patient was provided with one- or two-day supplies of methadone for home to bridge them to their outpatient OTP appointments, which presumably contributed to shorter lengths of hospital stay.
Lessons Learned
Development of these processes benefited from the involvement of an addiction specialist, with the goal of empowering all providers to provide methadone treatment when indicated. For the initiation of new methadone therapy, it remains best practice to involve an addiction specialist for evaluation at the outset. While our institutions rely on local ACS, this role can also be fulfilled via virtual consultations or by outpatient OTP providers on a case-by-case basis. For cases involving continuation of methadone for OUD with no or minimal titration of therapy, any discharging provider could dispense methadone without an addiction specialist. The overall goal is to lower barriers to timely OAT.
We also recommend designating a pharmacy champion, as the inpatient pharmacy assumes a significant burden to fill and document methadone dispensing. Inpatient pharmacies are not typically accustomed to packaging medications for outpatient use. At the Portland VA, a single pharmacist facilitated about half of the discharges, as he was recognized as a local expert by his colleagues.
Maintaining chain of custody is a critical obligation for facilities. At Portland VA, it was noted that methadone could be handed to the patient while they are still admitted, and if the discharge is cancelled at the last minute, there is no clear protocol for retrieving the dispensed methadone. Additionally, discharging teams may not always be familiar with the time-consuming process of dispensing methadone. While pharmacists are committed to providing necessary patient care, it is not always practical for them to be pulled to a single task.
Finally, we found that bridge-to-care methadone for home use does not appear on the VA prescription drug monitoring program. This makes the closed-loop communication with receiving OTPs essential for ensuring a safe and successful transition of care.
Future Directions
As we gain more experience from our inpatient bridge-to-care programs, we hope to implement similar processes in our emergency departments (EDs) to facilitate new methadone initiation and improve transitions to OTPs. However, some ED clinicians are concerned that the risks of administering methadone outweigh the benefits.8 As a full opioid agonist, methadone carries risk of overdose, particularly in patients who continue to use other opioids or have comorbidities. In addition, since methadone is dispensed from OTPs, it is sometimes difficult to verify a patient’s last dosage amount and time when OTPs are closed. Nonetheless, with approximately one in eighty ED visits associated with an opioid related diagnosis, hesitation to offer methadone can lead to missed, life-saving treatment opportunities.9 Additionally, VA EDs hold a unique advantage. They can ensure continuity of care through VA-affiliated OTPs, where patients can easily enroll or continue therapy without interruption. However, implementing such a process would necessitate a significant shift from current ED practices and would require the support and agreement of local ED providers. To ensure the program’s success, it is crucial to have an ED champion who can educate providers on dispensing methadone for home use and streamline the workflow within the ED. Ultimately, coordinated efforts between inpatient and ED teams to provide bridge-to-care methadone to patients with OUD have the potential to reduce hospital admissions and, more importantly, decrease mortality rates.
Dr. Shah
Dr. Kahn
Dr. Sears
Dr. Khalighi
Dr. Shah is a hospitalist focused on quality improvement in substance use care at VA Puget Sound Health Care System and a clinical assistant professor of medicine in the division of general internal medicine at the University of Washington, both in Seattle. Dr. Kahn is a hospitalist, addiction medicine specialist, a member of the addiction consult team at the VA Portland health care system, and assistant professor of medicine in the division of hospital medicine at Oregon Health & Science University, both in Portland, Ore. Dr. Sears is a hospitalist, addiction medicine specialist and a member of the addiction consult team at the VA Portland health care system, and an assistant professor of medicine in the division of hospital medicine at Oregon Health & Science University, both in Portland, Ore. Dr. Khalighi is the director of the preoperative medicine clinic at the VA Puget Sound health care system and professor of clinical practice in the division of general internal medicine at the University of Washington, both in Seattle.
References
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- Santo T Jr, et al. Association of opioid agonist treatment with all-cause mortality and specific causes of death among people with opioid dependence: a systematic review and meta-analysis. JAMA Psychiatry. 2021;78(9):979-993. doi:10.1001/jamapsychiatry.2021.0976.
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- American Society of Addiction Medicine. Select federal policies governing methadone and buprenorphine for opioid use disorder. ASAM website. https://www.asam.org/advocacy/practice-resources/regulatory-resources/select-federal-policies-addiction-medications. Accessed July 6, 2026.
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- Brinks S, et al. Dispensing of narcotic drugs to relieve acute withdrawal symptoms of opioid use disorder. Federal Register website. https://www.federalregister.gov/documents/2023/08/08/2023-16892/dispensing-of-narcotic-drugs-to-relieve-acute-withdrawal-symptoms-of-opioid-use-disorder. Published August 8, 2023. Accessed July 6, 2026.
- Strayer RJ, et al. Management of opioid use disorder in the emergency department: a white paper prepared for the American Academy of Emergency Medicine. J Emerg Med. 2020;58(3):522-546. doi:10.1016/j.jemermed.2019.12.034.
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