First Advisor

Dennis McCarty

Date of Publication

Winter 3-18-2019

Document Type


Degree Name

Doctor of Philosophy (Ph.D.) in Health Systems and Policy


OHSU-PSU School of Public Health




Opioid abuse -- Treatment, Hospital care, Buprenorphine -- Therapeutic use



Physical Description

1 online resource (xiv, 381 pages)


The United States (U.S.) is in the midst of an opioid overdose epidemic. In the U.S., overdose deaths related to opioid exposure are the leading cause of accidental death, yet life-saving treatments, such as methadone or buprenorphine (opioid agonist therapy [OAT]), are underused. OAT underused is due, in part, to complex regulatory and health services delivery environments. Public health officials and policymakers have focused on expanding OAT access in the community (e.g. office-based buprenorphine treatment, and opioid treatment programs); however, an often-overlooked component of the treatment pathway is the acute care delivery setting, in particular hospitals.

Opioid use disorder (OUD)-related hospitalizations are increasing, and incurring significant costs; care delivered in this setting is likely sub-optimal. This study examined hospital-based services for OUD using a conceptual framework based on an interdisciplinary review of policy, organizational behavior, systems science, economics, and health services delivery scholarship. The study's primary research question was: How do supply-side attributes influence hospital OAT delivery, health outcomes, and health services utilization for persons hospitalized with OUD? Supply-side attributes refer to the contextual elements inside and outside of a hospital that may be associated with hospital OAT delivery performance, such as social structures (e.g., hospital standards of care, societal values) and resources and technologies (e.g., hospital staffing, federal treatment policies).

A mixed methods study described, explored, and identified how patients with OUD are cared for in the hospital and the barriers and facilitators to delivering OAT during hospitalization. The sequential mixed methods approach (i.e., qualitative followed by quantitative analyses) included analysis of 17 key informant interviews with addiction medicine physicians from 16 non-federal U.S. hospitals, 25 hospital guidance documents from 10 non-federal U.S. hospitals, and administrative data from 12,407 OUD-related hospital admissions from the Veterans Health Administration (VHA) health system.

The findings from the study's three aims and 16 research sub-questions were integrated to reach seven conclusions: 1) OAT is underused in the hospital; 2) OAT delivery varies within and across hospitals; 3) OAT is used ineffectively; 4) non-OAT modalities are inappropriately used during and after hospitalization; 5) supply-side attributes inside and outside the hospital facilitate and impede hospital OAT delivery; 6) demand-side attributes facilitate and impede hospital OAT delivery; and 7) the hospital is an important service delivery mechanism in the OUD care continuum.

The study's findings could be extrapolated to improve policy and practice by implementing education and health service delivery interventions through regulatory and allocative policy mechanisms focused on physicians, medical trainees, and hospital and health system administrators. Understanding how OAT delivery may be improved within the acute care delivery system is an important element to support efforts to curb the ongoing drug poisoning crisis.


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