Patients who leave hospital against medical advice are more likely to experience a drug overdose

People discharged from hospital early or “before medical advice” (BMA) are ten times more likely to suffer a drug overdose in the following month, according to a new study published in Journal of the Canadian Medical Association.

Patients leave hospital early for a variety of reasons, including improperly managed pain, food cravings, stress exacerbating psychiatric problems, conflict with hospital staff, and restrictions on movement or visitors. Hospital patients who initiate a BMA discharge are up to three times more likely to die in the following year than people who receive a routine doctor-recommended discharge. A discharge “before medical recommendation” is also known as “patient-initiated” or “against medical advice.”

“Doctors and nurses have long wondered whether BMA leakage increases the risk of subsequent overdose,” says Dr. John Staples, lead author of the study and associate professor of clinical medicine at the University of British Columbia in Vancouver, BC.

“For patients with substance use disorders, a long hospital stay can sometimes be a period of drug abstinence, potentially reducing opioid tolerance and limiting access to [addiction] treatments. After these patients leave the hospital, persistent pain and untreated addiction may lead to heavier than usual drug use. All of these factors can increase the risk of subsequent overdose.”

To understand the link between BMA discharge and drug overdose, researchers conducted a study examining health data from 189,808 hospital admissions between 2015 and 2019 in British Columbia, Canada. A total of 6,440 (3.4%) of these admissions ended with patients leaving the hospital against medical advice. They found that patients with a BMA discharge were more likely to be younger men with mental illness, substance use disorders, or a history of illicit drug use.

The rate of fatal or non-fatal illicit drug overdoses in the first 30 days after hospital discharge was 10 times higher after BMA discharge than after discharge on medical orders. Discharge 'before medical orders' was associated with subsequent overdoses, even when other risk factors for overdose were taken into account.

“These findings indicate that patients initiating BMA discharge are at very high risk of overdose, that BMA discharge may be a causal factor for subsequent overdoses, and that patients initiating BMA discharge (particularly those with a history of substance use disorder) should be urgently offered clinical and social supports to reduce overdose-related harm,” the authors write.

They point out that there are opportunities to improve the medical care of these patients.

“Hospitals and health systems should develop evidence-based protocols to prevent discharges due to BMA and should explore new avenues of follow-up care to reduce the risk of drug overdose after hospital discharge,” the authors advise.