A recent Viewpoint argued for a more collaborative and dignifying approach to hospital discharge in patients with opioid use disorder, particularly when they leave prior to treatment completion.
Drawing on a clinical case of a patient hospitalized with Staphylococcus aureus bacteremia, the Viewpoint authors described how stigma, limited family access, and the strain of hospitalization contributed to the patient’s desire to leave early. In response, the care team developed a collaborative discharge plan that included long-acting dalbavancin, oral antibiotics, buprenorphine, naloxone, and follow-up in a substance use disorder clinic.
The authors situated this approach within harm-reduction principles, emphasizing the need to anticipate and treat withdrawal, maintain trust, and plan proactively for an early discharge rather than the one preferred by the clinicians. They pointed to prior research showing that among patients with opioid use disorder (OUD) hospitalized with invasive S aureus infections who had patient-directed discharges, more than 50% of postdischarge deaths were attributed to overdose, while 0% of them were attributed to the infection itself.
They also noted growing evidence supporting the safety and efficacy of oral antibiotic strategies in selected patients with barriers to prolonged intravenous therapy, reinforcing the importance of flexible, patient-centered treatment planning.
Beyond clinical logistics, the Viewpoint authors highlighted the role of language and clinician posture. “We elected to avoid using the term ‘Against Medical Advice’ in our documentation,” wrote lead Viewpoint author Laura Elaine Pax Massarelli, MD, of the Department of Medicine at the Emory University School of Medicine, and colleagues, arguing that the label can stigmatize patients and undermine ongoing care. They added that the term “Against Medical Advice” may also distance clinicians from the act of caring itself following discharge.
The Viewpoint authors acknowledged there may be “no perfect solution” within a fragmented health care system that often lacks support for intensive wraparound services. Their proposal was therefore pragmatic: when treatment cannot proceed as originally planned, clinicians should still organize a medically sound, harm-reducing alternative rather than defaulting to disengagement.
The practical takeaway included treating withdrawal, avoiding stigmatizing language, clearly documenting barriers, and ensuring medications and follow-up are arranged prior to discharge. Even when patients leave early, care can remain intentional, structured, and dignifying.
The authors declared having no competing interests.