ManagingtheHospitalizedPatientwithOpioidUseDisorder

MARLENEMARTINASSISTANTCLINICALPROFESSOR

UNIVERSITYOFCALIFORNIA,SANFRANCISCO

23RDANNUALMANAGEMENTOFTHEHOSPITALIZEDPATIENTCMECOURSEOCTOBER18,2019

35Ymanadmittedovernightwithrightupperextremityerythema,pain,andswelling

●  Startedonempirictreatmentforcellulitis●  Youaregettingsignoutfromyourovernightcolleaguewhenyougetpaged

thatheiscomplainingofdiarrhea,abdominalpain,headache,andnausea●  Youevaluatethepatientandnoteheisyawningandthathispupilsare

dilated.Heendorseslastusingheroinbeforebeingadmitted

Objectives 1.  Diagnoseandtreatopioidwithdrawalandopioid

usedisorder(OUD)witheithermethadoneorbuprenorphine

2.  Identifyhowtolinkhospitalizedpatientstobuprenorphineormethadonetreatmentondischarge

3.  NamethreeoptionsforOUDharmreduction

Outline q  Prevalence,demographics,andcharacteristicsofhospitalizedpatientswithOUD

q  DiagnosingOUDq  Medicationtreatment

q  Cases

Source: CDC, 2017

ThreeWavesofOpioidOverdoseDeaths

Source: AHRQ, 2017

OUD-relatedhospitalizationsandEDvisitsalmostdoubledinthelastdecade

SUDamonghospitalizedpatientso  Upto25%ofhospitalizedpatientso  Morelikelytobeadmittedfromtheemergencydepartment

o  Longerlengthsofstay,costlier,higherreadmission

o  HighAMArates

o  Lowestquartileofincome

o  Unconnectedtocare

StatisticalBrief#249.HealthcareCostandUtilizationProject(HCUP).March2019.AgencyforHealthcareResearchandQuality,Rockville,MD.BrownRL,LeonardT,SaundersLAetal.Theprevalenceanddetectionofsubstanceusedisordersamonginpatientsages18to49:anopportunityforprevention.PrevMed1998;27(1):101-10).EnglanderH,WeimerM,SolotaroffRetal.PlanningandDesigningtheImprovingAddictionCareTeam(IMPACT)forHospitalizedAdultswithSubstanceUseDisorder.JHospMed.2017May;12(5):339-342.Spooner,K.K.,Salemi,J.L.,Salihu,H.M.,Zoorob,R.J.,2017.DischargeagainstmedicaladviceintheUnitedStates,2002-2011.MayoClin.Proc.92,525–535.WalleyAY,Paasche-OrlowM,LeeEC,etal.Acutecarehospitalutilizationamongmedicalinpatientsdischargedwithasubstanceusedisorderdiagnosis.JAddictMed.2012Mar;6(1):50-6.RonanMVandHerzigSJ.HospitalizationsRelatedToOpioidAbuse/DependenceAndAssociatedSeriousInfectionsIncreasedSharply,2002-12.HealthAff(Millwood).2016May1;35(5):832-7.

WhytreatOUDinthehospital?o  Eliminatewithdrawalandreducecravingso  Ifreturntousewhileontreatmentoccurs,less/nohigh

o  Maintaintolerance

o  RootcauseofEDvisits,admissions,andreadmissions

o  Patientsmotivatedtocutbackorstopuse–pivotaltouchpoint

o  Whenaddressed:o  ImprovedratesofPCPandaddictiontreatmentfollowupo  Reducedsubstanceuseafterdischargeo  Lower30-dayreadmissionso  Improvedpatientandproviderexperiences

VelezCM,NicolaidisC,KorthuisPT,EnglanderH."It'sbeenanExperience,aLifeLearningExperience":AQualitativeStudyofHospitalizedPatientswithSubstanceUseDisorders.JGenInternMed.2017Mar;32(3):296-303.WeiJ,DefriesT,LozadaM,YoungN,HuenW,TulskyJ.Aninpatienttreatmentanddischargeplanningprotocolforalcoholdependence:efficacyinreducing30-dayreadmissionsandemergencydepartmentvisits.JGenInternMed.2015Mar;30(3):365-70.EnglanderH,CollinsD,PerrySPetal."We'veLearnedIt'saMedicalIllness,NotaMoralChoice":QualitativeStudyoftheEffectsofaMulticomponentAddictionInterventiononHospitalProviders'AttitudesandExperiences.JHospMed.2018Nov1;13(11):752-758.EnglanderH,WeimerM,SolotaroffRetal.PlanningandDesigningtheImprovingAddictionCareTeam(IMPACT)forHospitlaizedAdultswithSubstanceUseDisorder.JHospMed.2017May;12(5):339-342.LiebschutzJM,CrooksD,HermanD.Buprenorphinetreatmentforhospitalized,opioid-dependentpatients:arandomizedclinicaltrial.JAMAInternMed.2014Aug;174(8):1369-76.

Outline q  Prevalence,demographics,andcharacteristicsofhospitalizedpatientswithOUD

q  DiagnosingOUDq  Medicationtreatment

q  Cases

  Symptoms◦  Withdrawal◦  Uncontrolledpain

  Diagnoses◦  Skinandsofttissueinfections◦  Endocarditis,osteomyelitis◦  Trauma◦  Overdose

  DSMCriteria◦  Chronicpain

  NotallwhouseopioidshaveOUD

DiagnosingOUD

Riskofbodilyharm

Withdrawal

Tolerance

Control:Exceededownlimits

Failedattemptstoquit/controluse

Compulsion:Timeusing,getting,recovering

Gaveupothermeaningfulactivities

Consequences:Relationshiptrouble

Physical/psychologicalconsequences

Rolefailure

Craving

ImpairedControl

SocialImpairment

RiskyUse

PharmacologicalCriteria

Outline q  Prevalence,demographics,andcharacteristicsofhospitalizedpatientswithOUD

q  DiagnosingOUDq  Medicationtreatment

q  Cases

Opioids: full agonist heroin, oxycodone, fentanyl, etc

Methadone: full agonist Activates receptor

Buprenorphine: partial agonist High affinity, ceiling effect

Extended-release naltrexone, naloxone: Full antagonist, high affinity

Y

Y

Y

Y

ßMu receptor

MedicationsforOUD

MedicationsforOUDMethadone Buprenorphine

Treatmentretention Higherthanbuprenorphine Retentionimprovesatdoses>16mg

Officevisits Dailyvisitstotreatmentprogram Daily-monthly;canalsoprovideasDOTinsomesettings

Whocanprescribeinacutecare?

Anyinpatientproviderduringhospitalization.AnyproviderinED:upto72hoursdosing

Anyinpatientproviderduringhospitalization.AnyproviderinED:upto72hoursdosing

Whocanprescribeatdischarge?

OpiateTreatmentProgram(methadoneclinic) AnyproviderwithDATA2000Xwaiver

Sedation Yesathighdoses,non-tolerantpatientsorslowmetabolizers

Ceilingeffectforrespiratorydepression

Withdrawalwhenstarting Takestimetoreachcomfortabledose Needtobeinwithdrawal

Buprenorphine:precipitatedwithdrawal

o  Mustbeinwithdrawalpriortoinduction

o  Highaffinity Y Y Heroin

J L

Buprenorphine

0.

10.

20.

30.

40.

Inmethadone Outofmethadone Inbuprenorphine Outofbuprenorphine

Allcausemortalityper1000personyears

Source: Sordo et al, BMJ, 2017

DecreasedMortality

7264

127

0

20

40

60

80

Daysinbupover6months

%Patients

Maintenance Detox

Num

ber o

f Days

80

70

60

50

40

30

20

10

0

Source: Liebschutz et al, JAMA Internal Medicine, 2014

HospitalInitiationofBuprenorphine

%

%

Source:ChutuapeMetal,TheAmericanJournalofDrugandAlcoholAbuse,2001.

DetoxDoesn’tLast

Outline q  Prevalence,demographics,andcharacteristicsofhospitalizedpatientswithOUD

q  DiagnosingOUDq  Medicationtreatment

q  Cases

Opioid Use Disorder (OUD), Opioid Withdrawal, and Linkage to Treatment Da

y1

MethadoneGuideforOUDTreatmentandWithdrawal

q Utox,pregnancytest,considerQTc,CURES,COWS,confirmOUD

q Give20mgmethadoneq Every4hours->COWS,ifhavingcravingsorwithdrawal,give10mgmore.Donotexceed40mg

Day2

q GivetotalDay1doseinamq Every4hours->COWS,ifhavingcravingsorwithdrawal,give10mgmore.Donotexceed50mg

3 q GivetotalDay2doseinamandfollow

sameprotocol.Donotexceed60mg

Day4

q GiveDay3maxdose.Continueprotocoluntilreaching60mgdaily.Thenholdfor5daysbeforeincreasingby10mgevery5days

Day1

BuprenorphineGuideforOUDTreatmentand*Uncomplicated

Withdrawalq Utox,pregnancytest,CURES,COWS,confirmOUD,considerQTc&LFTs

q Startbuprenorphine(bup)whenmildwithdrawal(COWS>8)ornoopioidsfor5days.Ifreceivedopioids:q Shortactingàwait12hrsq Longactingàwait24-48hrsq Methadoneinlast5daysàrequesthelp

q Give**bup4-8mg(ensuresublingual)q 1hourlateràrecheckCOWS.If≥8give4mgmore

q 6hourslater(soonerifwithdrawing)àrecheckCOWS.If≥8give4mg.Maxdose16mgonDay1

Day2

q GivetotalDay1doseinam.TIDdosingifpatienthaspain

q 1hourlateràifhavingcravings,pain,orwithdrawalincreasetotaldailydoseby4-8mg

q Goaldailydose16-24mg/day.Ifgreater,requesthelp

Adjunctive Support Clonidine 0.1-0.3 mg PO q6-8 hours PRN

(NTE 1.2 mg/day) à Sweating, restlessness, hot flashes, watery eyes, anxiety

Loperamide 4 mg PO x 1, then 2 mg PRN (NTE 16 mg/24 hours) à Loose stools

Zofran 4 mg PO q 6 hours PRN à Nausea Trazodone or Melatonin à Insomnia Diphenhydramine 25-50 mg, PO q 8 hours

PRN à Insomnia or anxiety Tylenol and/or Ibuprofen 650 mg PO q 6

hours PRN à Pain

Bup and Methadone Quick Facts • Inpatient providers can order bup or methadone for OUD, opioid withdrawal, or to continue outpatient tx

• X-waivered providers can prescribe bup on discharge

•  Inpatient providers cannot prescribe methadone for OUD on discharge *Uncomplicated = no methadone for 5

days, no acute pain or surgery, not altered, no severe illness

**If concerned for precipitated withdrawal, start with 2mg

Case145-year-oldmanwithahistoryofinjectionheroinuseisadmittedwithcellulitisofhisrightupperextremity.Twohoursafteradmission,hefeelsachyandnauseous.Hispulseis102,heissweating,andmovingfrequentlyinbed.Assumehissepsisisadequatelyaddressed,andhissymptomsarefromopioidwithdrawal.●  Whatmedicationswouldyouofferhim?●  Howwouldyoudecidewhentostartthesemedications?●  Howwouldyoudosethesemedications?●  WhatdoyoudowithhisOUDmedicationsatdischarge?

q  COWS≥8,Mustbeinwithdrawalpriortoinduction

q  Initialdose8-12haftershortacting,24-48hpostlongacting

q  Transitioningfrommethadone—askforhelp

Buprenorphine

WithdrawalAssessmentCOWSshortcut:SubjectivesymptomsANDatleast1objectivewithdrawalsign• Subjective:Nausea,abdominalpain,myalgias,chills

• Objective(atleast1):Restlessness,sweating,rhinorrhea,dilatedpupils,wateryeyes,tachycardia,yawning,goosebumps,vomiting,diarrhea,tremor

 WhenCOWS≥8,give4-8mg

 Maxday1:16mg

 Maxday2:24mg

 Therapeuticdose16-24mg/day

 Increasedose:craving,withdrawal,pain

 Decreasedose:insomnia/mania,sedation

 Precipitatedwithdrawal:morebuprenorphineORshortactingfullagonist

Buprenorphine

 Monitoron60mgdailyfor5daysbeforeincreasingagainby5-10mg,thenholdthatdosefor5days,etc

 Targetdailydose80-120mg

Day1

Startwith10-30mg,reassessin3-4hrs,mayadd10mgPRNw/dsx,max40mg

DocumentCOWS,sedationscores@0min,4h.GoalCOWS<5

Day2

TotalDay1+5-10mgPRN,max50mg

Day3

TodayDay2+5-10mgPRN,max60mg

Methadone

Daysatsteadydose

Peak 3-4

hours

Half life: 24-36 hours

Steady state: 3-7 days

Risk of overdose with induction

Methadone

Startmedicationintheacutesettingandcommunicatewith

PCPorOTP!

MethadoneCannotprescribeondischargeforOUD

OpioidTreatmentProgramPartnerwithlocalmethadone

clinic

BuprenorphinePrescribeatd/cifwaiveredandbridgetooutpatientplan

Telemedicine BridgeClinic

PrimaryCare(SAMHSAwebsitelistswaiveredproviders)OTP

(Somecarrybup)

MedicationCareTransition

Case260-year-oldwomanwithahistoryoftricuspidvalveendocarditisandanxietyisadmittedforacuteencephalopathy.Urinetoxicologyshowsmorphine,alprazolam,andcocaine.Shortlyafteradmission,shewakesupsweating,tremulous,agitated,andvomitingandisaskingtoleave.Assumehersymptomsarefromopioidwithdrawal.●  Whatmedicationswouldyouofferforherwithdrawalifshedoes

notwanttocontinueOUDtreatmentafterdischarge?●  Whatharmreductionmeasureswouldyouprovideifsheis

interestedintreatingtheOUDbutnotstoppingbenzosorcocaine?●  Whatbloodworkcouldyouobtaintolookforcomplicationsof

OUD?

Opioid Use Disorder (OUD), Opioid Withdrawal, and Linkage to Treatment Da

y1

MethadoneGuideforOUDTreatmentandWithdrawal

q Utox,pregnancytest,considerQTc,CURES,COWS,confirmOUD

q Give20mgmethadoneq Every4hours->COWS,ifhavingcravingsorwithdrawal,give10mgmore.Donotexceed40mg

Day2

q GivetotalDay1doseinamq Every4hours->COWS,ifhavingcravingsorwithdrawal,give10mgmore.Donotexceed50mg

3 q GivetotalDay2doseinamandfollow

sameprotocol.Donotexceed60mg

Day4

q GiveDay3maxdose.Continueprotocoluntilreaching60mgdaily.Thenholdfor5daysbeforeincreasingby10mgevery5days

Day1

BuprenorphineGuideforOUDTreatmentand*Uncomplicated

Withdrawalq Utox,pregnancytest,CURES,COWS,confirmOUD,considerQTc&LFTs

q Startbuprenorphine(bup)whenmildwithdrawal(COWS>8)ornoopioidsfor5days.Ifreceivedopioids:q Shortactingàwait12hrsq Longactingàwait24-48hrsq Methadoneinlast5daysàrequesthelp

q Give**bup4-8mg(ensuresublingual)q 1hourlateràrecheckCOWS.If≥8give4mgmore

q 6hourslater(soonerifwithdrawing)àrecheckCOWS.If≥8give4mg.Maxdose16mgonDay1

Day2

q GivetotalDay1doseinam.TIDdosingifpatienthaspain

q 1hourlateràifhavingcravings,pain,orwithdrawalincreasetotaldailydoseby4-8mg

q Goaldailydose16-24mg/day.Ifgreater,requesthelp

Adjunctive Support Clonidine 0.1-0.3 mg PO q6-8 hours PRN

(NTE 1.2 mg/day) à Sweating, restlessness, hot flashes, watery eyes, anxiety

Loperamide 4 mg PO x 1, then 2 mg PRN (NTE 16 mg/24 hours) à Loose stools

Zofran 4 mg PO q 6 hours PRN à Nausea Trazodone or Melatonin à Insomnia Diphenhydramine 25-50 mg, PO q 8 hours

PRN à Insomnia or anxiety Tylenol and/or Ibuprofen 650 mg PO q 6

hours PRN à Pain

Bup and Methadone Quick Facts • Inpatient providers can order bup or methadone for OUD, opioid withdrawal, or to continue outpatient tx

• X-waivered providers can prescribe bup on discharge

•  Inpatient providers cannot prescribe methadone for OUD on discharge *Uncomplicated = no methadone for 5

days, no acute pain or surgery, not altered, no severe illness

**If concerned for precipitated withdrawal, start with 2mg

HarmReduction Buprenorphineormethadone

 Needleexchangeprograms

 Reviewinjectionpractices Supervisedinjectionfacilities Buddysystem

 HCVandHIVeducation,screening,andtreatment

 HAV,HBV,&TDaPvaccinesprn Naloxone

StopOverdoseDeaths  Universalnaloxoneprescribing

◦ OUD◦ Opioids◦ Anydruguse

Bupren

orph

ine

PostDischargeLinkage

q PrimaryCareifPCPisXwaivered.Ifnot,check*SAMHSAtofindbupprovider.Giveenoughbuptobridgetoappointment.Communicated/cplanwithPCP.

q SUDBridgeClinicifavailableq SomeOTPshaveDOTforbupq Telemedicineq Emergencyadministration(ieinED)forupto72hours

q Someavailableformulations:q Bup-naloxoneSLfilmsq Bup-naloxoneSLtabsq Buprenorphinetabs

Metha

done

q OTP(methadoneclinic)->refertooneinyourcommunity.Establishpartnershipstoeasetransitions.Greatforpatientswhoneedmorestructure.

HarmReductionChecklistq HIVandHCVtestingandtreatmentq HAV,HBV,&TDaPvaccinesprnq Reviewsafeinjectionpractices

q Don'tusealoneq Cleaninjectionsiteq Injectslowlyorusetestshotq Usecleanneedleandothersupplies("works")

q Don'tshareneedlesorworksq Needleexchangeprogramsq Bupormethadoneasharmreductionq Naloxoneforeverypatientq PrEP/PEPq Treatwithdrawalevenifpatientisambivalentormaynotwantbupormethadoneafterdischarge

Other Resources • UCSF Substance Use Warmline: Call

855-300-3595, weekdays PST 6 am-5 pm for Addiction MD, RN, or pharmacist

• ED-Bridge: Detailed resources at: https://ed-bridge.org • SAMHSA: Find waivered providers at: https://www.samhsa.gov

Withdrawal Assessment COWS shortcut: Subjective symptoms AND at least 1 objective withdrawal sign • Subjective: Nausea, abdominal pain,

myalgias, chills, runny nose • Objective (at least 1): Restlessness,

sweating, rhinorrhea, dilated pupils, watery eyes, tachycardia, yawning, goose bumps, vomiting, diarrhea, tremor

Diagnosing OUD 1. Does the patient use heroin and have

signs and symptoms of withdrawal? If YES -> OUD.

2. If unsure OR no signs of withdrawal OR patient using prescription drugs, refer to DSM criteria below

DSMCriteria

Riskofbodilyharm ExceedsownlimitsRolefailure RelationshiptroubleUnabletocutdownTimespentgettingUsingdespitehealthGivesupactivitiesCravingToleranceWithdrawal

For patients with acute pain and OUD •  DO treat acute pain on top of OUD

• PRN opioids work even if on bup • Split bup into TID or QID dosing to treat acute or

chronic pain •  DO continue methadone or bup dosing before

and after surgery •  DO use adjunctive medications, regional,

ketamine, etc This Toolkit Belongs To:

Case340-year-oldmanwithahistoryofOUDinrecoveryx2monthsonbuprenorphine16mgdailyisadmittedafteramotorvehicleaccidentandfoundtohavemultiplefracturesrequiringoperativerepair.●  Whatdoyoudowithhisbuprenorphinebeforesurgery?Whatif

hewasonmethadone?●  Whatdoyoudowithhisbuprenorphineafterthesurgeryto

managehispain?Whatifhewasonmethadone?

Whatcanyoudoatyourinstitution?Ø  DispensenaloxoneforallpatientswhouseopioidsordrugsØ  Ensurebuprenorphineandmethadoneareonformulary,continuedduring

hospitalization/surgery

Ø  CreatehospitalordersetorguidelinefornewstartsØ  PartnerwithstakeholdersØ  Startprescribing!Ø  Disseminateyourknowledgewithcolleagues

Objectives 1.  Diagnoseandtreatopioidwithdrawalandopioid

usedisorder(OUD)witheithermethadoneorbuprenorphine

2.  Identifyhowtolinkhospitalizedpatientstobuprenorphineormethadonetreatmentondischarge

3.  NamethreeoptionsforOUDharmreduction

ReflectionsTake1minutetowritedown(ortweet):●  Whatconceptortoolyouaretakingawayfromthis

workshop?

●  WhatisoneaspectofOUDorharmreductionthatyoucanspeaktoprovidersatyourhomeinstitutionabouttoraiseawareness?

Thankyou!

Email me at Marlene.Martin@ucsf.edu

Additional Resources: UCSF Substance use warmline: (855) 300-3595, 6am-5pm PT

SAMHSA, TIP 63: Medications for OUD www.ed-bridge.org