Hospitalization presents a critical juncture to engage patients with opioid use disorder, but safety net hospitals are less likely to offer transitional opioid programs (TOPs), which initiate treatment and connect patients to care after discharge. This study explored determinants of TOP adoption in 4 diverse safety net health systems.
Methods:
We interviewed key participants affiliated with safety net health systems and partner community-based organizations about TOPs within their organization. We used inductive coding informed by grounded theory to identify emerging themes related to TOP implementation and thematic analysis to compare determinants across health systems. A deductive approach was then used to map data that aligned with an existing TOP typology to document the presence of specific programs and promote comparison in implementation progress across sites. Throughout the iterative process, we developed analytic themes related to the extent to which TOPs were integrated into each health system. Finally, determinants were mapped to Consolidated Framework for Implementation Science Research domains.
Results:
Determinants spanned inner and outer setting domains and shaped the presence of TOPs and their integration into routine health system operations. The number and types of care transition models varied across organizations. We grouped health systems into 2 patterns, foundational and embedded, reflecting differences in how their TOPs were organized and supported. Reimbursement rates, inefficient organizational functioning, and stigma hindered TOPs at all phases of implementation, while organizational champions were key facilitators. Foundational programs experienced severe staffing shortages and low organizational support. Embedded programs were distinguished by grant-writing staff and more supportive outer contexts.
Conclusions:
This study highlights the challenges and opportunities faced by safety net health systems in implementing TOPs. The findings emphasize the need for tailored implementation strategies that address the unique barriers and leverage facilitators within resource-constrained settings, particularly at different phases of implementation.
RubinR.As overdoses climb, emergency departments begin treating opioid use disorder. JAMA. 2018;319(21):2158-2160. doi:10.1001/jama.2018.4648
2.
DeoSVRazaSKalraA, et al. Admissions for infective endocarditis in intravenous drug users. J Am Coll Cardiol. 2018;71(14):1596-1597. doi:10.1016/J.JACC.2018.02.011
3.
CollierMGDoshaniMAsherA.Using population based hospitalization data to monitor increases in conditions causing morbidity among persons who inject drugs. J Community Health. 2018;43(3):598-603. doi:10.1007/S10900-017-0458-9
4.
RosenthalESBrokusCSunJ, et al. Undertreatment of opioid use disorder in patients hospitalized with injection drug use-associated infections. AIDS. 2023;37(12):1799. doi:10.1097/QAD.0000000000003629
5.
DunphyCCZhangKXuLGuyGP.Racial-ethnic disparities of buprenorphine and vivitrol receipt in Medicaid. Am J Prev Med. 2022;63(5):717. doi:10.1016/J.AMEPRE.2022.05.006
6.
ChangJEFranzBCroninCELindenfeldZLaiAYPagánJA.Racial/ethnic disparities in the availability of hospital based opioid use disorder treatment. J Subst Abuse Treat. 2022;138:108719. doi:10.1016/j.jsat.2022.108719
7.
GoedelWCShapiroACerdáMTsaiJWHadlandSEMarshallBDL. Association of racial/ethnic segregation with treatment capacity for opioid use disorder in counties in the United States. JAMA Netw Open. 2020;3(4):e203711. doi:10.1001/JAMANETWORKOPEN.2020.3711
8.
ShanahanCWBeersDAlfordDPBrigandiESametJH.A transitional opioid program to engage hospitalized drug users. J Gen Intern Med. 2010;25(8):803. doi:10.1007/S11606-010-1311-3
9.
JamesHMorganJTiLNolanS.Transitions in care between hospital and community settings for individuals with a substance use disorder: a systematic review. Drug Alcohol Depend. 2023;243:109763. doi:10.1016/J.DRUGALCDEP.2023.109763
10.
WeinsteinZMWakemanSENolanS.Inpatient addiction consult service: expertise for hospitalized patients with complex addiction problems. Med Clin North Am. 2018;102(4):587. doi:10.1016/j.mcna.2018.03.001
11.
GryczynskiJNordeckCDWelshCMitchellSGO’GradyKESchwartzRP.Preventing hospital readmission for patients with comorbid substance use disorder: a randomized trial. Ann Intern Med. 2021;174(7):899-909. doi:10.7326/M20-5475/SUPPL_FILE/M20-5475_SUPPLEMENT.PDF
12.
D’OnofrioGO’ConnorPGPantalonMV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644. doi:10.1001/JAMA.2015.3474
13.
WilsonJDAltieri DunnSCRoyPJosephEKlippSLiebschutzJ.Inpatient addiction medicine consultation service impact on post-discharge patient mortality: a propensity-matched analysis. J Gen Intern Med. 2022;37(10):2521. doi:10.1007/S11606-021-07362-8
14.
PriestKCEnglanderHMcCartyD.“Now hospital leaders are paying attention”: a qualitative study of internal and external factors influencing addiction consult services. J Subst Abuse Treat. 2019;110:59. doi:10.1016/j.jsat.2019.12.003
15.
ShearerRHagedornHEnglanderH, et al. Barriers and facilitators to implementing treatment for opioid use disorder in community hospitals. J Subst Use Addict Treat. 2024;167:209520. doi:10.1016/j.josat.2024.209520
16.
BuntingAMFawoleAFernandoJ, et al. Staff perspectives of barriers and facilitators to implementation of the Consult for Addiction Treatment and Care in Hospitals (CATCH) program in New York City safety net hospitals. J Subst Use Addict Treat. 2025;168:209560. doi:10.1016/j.josat.2024.209560
17.
O’GradyMAElkingtonKSRobsonG, et al. Referral to and engagement in substance use disorder treatment within opioid intervention courts in New York: a qualitative study of implementation barriers and facilitators. Subst Abuse Treat Prev Policy. 2024;19(1):12. doi:10.1186/s13011-024-00593-y
18.
MurphyMKChabonBDelgadoANewvilleHNicolsonSE.Development of a substance abuse consultation and referral service in an academic medical center: challenges, achievements and dissemination. J Clin Psychol Med Settings. 2009;16(1):77-86. doi:10.1007/S10880-009-9149-8
19.
FranzBCroninCELindenfeldZ, et al. Rural-urban disparities in the availability of hospital-based screening, medications for opioid use disorder, and addiction consult services. J Subst Use Addict Treat. 2023;160:209280. doi:10.1016/j.josat.2023.209280
20.
ChokshiDAChangJEWilsonRM.Health reform and the changing safety net in the United States. N Engl J Med. 2016;375(18):1790-1796. doi:10.1056/NEJMHPR1608578
21.
CrableELBiancarelliDWalkeyAJDrainoniML.Barriers and facilitators to implementing priority inpatient initiatives in the safety net setting. Implement Sci Commun. 2020;1(1):35. doi:10.1186/S43058-020-00024-6
22.
HawkKFD’OnofrioGChawarskiMC, et al. Barriers and facilitators to clinician readiness to provide emergency department-initiated buprenorphine. JAMA Netw Open. 2020;3(5):e204561. doi:10.1001/JAMANETWORKOPEN.2020.4561
23.
FarhoudianARazaghiEHooshyariZ, et al. Barriers and facilitators to substance use disorder treatment: an overview of systematic reviews. Subst Abuse. 2022;16:11782218221118462. doi:10.1177/11782218221118462
24.
MackeyKVeazieSAndersonJBourneDPetersonK.Barriers and facilitators to the use of medications for opioid use disorder: a rapid review. J Gen Intern Med. 2020;35(suppl 3):954-963. doi:10.1007/S11606-020-06257-4
25.
BrothersTDFraserJMacAdamE, et al. Implementation and evaluation of a novel, unofficial, trainee-organized hospital addiction medicine consultation service. Subst Abus. 2021;42(4):433-437. doi:10.1080/08897077.2020.1856291
26.
PopescuIFingarKRCutlerEGuoJJiangHJ.Comparison of 3 safety-net hospital definitions and association with hospital characteristics. JAMA Netw Open. 2019;2(8):e198577. doi:10.1001/JAMANETWORKOPEN.2019.8577
27.
MartinMSnyderHRCoffaD, et al. Time to ACT: launching an Addiction Care Team (ACT) in an urban safety-net health system. BMJ Open Qual. 2021;10(1):e001111. doi:10.1136/BMJOQ-2020-001111
28.
ChatterjeePSommersBDJoynt MaddoxKE.Essential but undefined – reimagining how policymakers identify safety-net hospitals. N Engl J Med. 2020;383(27):2593-2595. doi:10.1056/NEJMP2030228
29.
AmiriSMcDonellMGDenneyJTBuchwaldDAmramO.Disparities in access to opioid treatment programs and office-based buprenorphine treatment across the rural-urban and area deprivation continua: a US nationwide small area analysis. Value Health. 2021;24(2):188-195. doi:10.1016/j.jval.2020.08.2098
30.
ConwayKPKhouryDHilscherRAldridgeAPParkerSJZarkinGA.Rural and urban differences in undersupply of buprenorphine provider availability in the United States, 2018. Addict Sci Clin Pract. 2022;17(1):1-5. doi:10.1186/S13722-021-00282-2/TABLES/1
31.
LangabeerJRGourishankarAChambersKAGiriSMaduRChampagne-LangabeerT.Disparities between US opioid overdose deaths and treatment capacity: a geospatial and descriptive analysis. J Addict Med. 2019;13(6):476-482. doi:10.1097/ADM.0000000000000523
32.
TrowbridgePWeinsteinZMKerenskyT, et al. Addiction consultation services – linking hospitalized patients to outpatient addiction treatment. J Subst Abuse Treat. 2017;79:1-5. doi:10.1016/J.JSAT.2017.05.007
33.
AaronsGAHurlburtMHorwitzSMC. Advancing a conceptual model of evidence-based practice implementation in public service sectors. Adm Policy Ment Health. 2011;38(1):4. doi:10.1007/S10488-010-0327-7
34.
DamschroderLJReardonCMWiderquistMAOLoweryJ.The updated Consolidated Framework for Implementation Research based on user feedback. Implement Sci. 2022;17(1):1-16. doi:10.1186/S13012-022-01245-0
35.
McneillECroninCPuroNFranzBSilverDChangJ.Variance of US hospital characteristics by safety-net definition. JAMA Netw Open. 2023;6(9):e2332392. doi:10.1001/jamanetworkopen.2023.32392
PalinkasLAHorwitzSMGreenCAWisdomJPDuanNHoagwoodK.Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Adm Policy Ment Health. 2015;42(5):533. doi:10.1007/S10488-013-0528-Y
40.
GoodmanLA.Snowball sampling. Ann Math Stat. 1961;32(1):148-170. doi:10.1214/AOMS/1177705148
41.
ChangJEFranzBPagánJALindenfeldZCroninCE.Substance use disorder program availability in safety-net and non-safety-net hospitals in the US. JAMA Netw Open. 2023;6(8):e2331243. doi:10.1001/JAMANETWORKOPEN.2023.31243
HooverKLockhartSCallisterCHoltropJSCalcaterraSL.Experiences of stigma in hospitals with addiction consultation services: a qualitative analysis of patients’ and hospital-based providers’ perspectives. J Subst Abuse Treat. 2022;138:108708. doi:10.1016/j.jsat.2021.108708
46.
HodgkinDThomasCPDavisMT, et al. The financial sustainability of programs to initiate medications for opioid use disorder in emergency department settings. Acad Emerg Med. 2025;33(2):e70185. doi:10.1111/acem.70185
47.
EnglanderHWeimerMSolotaroffR, et al. Planning and designing the Improving Addiction Care Team (IMPACT) for hospitalized adults with substance use disorder. J Hosp Med. 2017;12(5):339-342. doi:10.12788/JHM.2736
48.
PriestKCMccartyD.Role of the hospital in the 21st century opioid overdose epidemic: the addiction medicine consult service. J Addict Med. 2019;13(2):104-112. doi:10.1097/ADM.0000000000000496
49.
GlasgowREHardenSMGaglioB, et al. RE-AIM planning and evaluation framework: adapting to new science and practice with a 20-year review. Front Public Health. 2019;7:64. doi:10.3389/FPUBH.2019.00064
GaffneyLKMichelsonKA.Analysis of hospital operating margins and provision of safety net services. JAMA Netw Open. 2023;6(4):e238785. doi:10.1001/JAMANETWORKOPEN.2023.8785
52.
Clemans-CopeLLynchVPaytonMAaronsJ.Medicaid professional fees for treatment of opioid use disorder varied widely across states and were substantially below fees paid by Medicare in 2021. Subst Abuse Treat Prev Policy. 2022;17(1):1-12. doi:10.1186/S13011-022-00478-Y/TABLES/3
53.
KatzRFisherTSinger-ClarkT, et al. Creation of a telehealth addiction consultation service at a rural hospital: a case study. Addict Sci Clin Prac. 2025;20(1):76. doi:10.1186/s13722-025-00596-5
54.
EnglanderHJonesAKrawczykN, et al. A taxonomy of hospital-based addiction care models: a scoping review and key informant interviews. J Gen Intern Med. 2022;37(11):2821-2833. doi:10.1007/S11606-022-07618-X
55.
CalcaterraSLMartinMBottnerR, et al. Management of opioid use disorder and associated conditions among hospitalized adults: a consensus statement from the Society of Hospital Medicine. J Hosp Med. 2022;17(9):744-756. doi:10.1002/JHM.12893
56.
EnglanderHPattenALockardRMullerMGreggJ.Spreading addictions care across Oregon’s rural and community hospitals: mixed-methods evaluation of an interprofessional telementoring ECHO program. J Gen Intern Med. 2021;36(1):100. doi:10.1007/S11606-020-06175-5
57.
HerscherMFineMNavalurkarRHirtLWangL.Diagnosis and management of opioid use disorder in hospitalized patients. Med Clin North Am. 2020;104(4):695-708. doi:10.1016/J.MCNA.2020.03.003
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
