Published in the December 2008 issue of Today’s Hospitalist
ASK JAMES FRANKO, MD, how frequently he encounters medical patients who also present with drug abuse, and he has a weary answer. “Every day,” says the section chief for hospital medicine at Carilion Clinic in Roanoke, Va. Dr. Franko has treated grandmothers who come through the emergency department with evidence of cocaine use. “And we see many patients who know they’re abusing their prescription opioids.”
Hospitalists everywhere are grappling with the clinical and practical challenges of drug abuse, especially when it comes to withdrawal or pain management. While it’s true that inpatient problems related to alcohol abuse are much more prevalent, “there is an epidemic of misuse or addiction to prescription opioids and heroin nationwide,” says hospitalist Michael Miller, MD, president of the American Society of Addiction Medicine and medical director of the New State Alcohol/Drug Treatment Program at Meriter Hospital in Madison, Wis.
“If you think you don’t have these patients on your panel,” says Emily Robinson, NP, an addiction consult liaison at Faulkner Hospital in Boston, “you’re not looking for them.” While published reports of the prevalence of inpatient drug abuse and dependence put activity at between 8% and 29%, Ms. Robinson suspects that the observed rate would likely tend to the higher end.
“I don’t think we have a good handle on that in part because of coding,” she says. “The primary diagnosis for admission is almost never opiate dependence, and it often doesn’t make it to the secondary one.”
A newly passed mental health and addiction parity act may pave the way for better reimbursement and more comprehensive therapy. For now, however, many hospitalists say they’re at a loss on how to treat patients with opiate dependence. Others say they’re just plain frustrated by patients who take up scarce hospital beds “and even scarcer physician time.
Dealing with withdrawal
A major challenge of treating opiate dependent patients is overcoming the sense of frustration that hospitalists feel caring for this population.
“A lot of physicians don’t have much empathy for those patients or the time to deal with substance-abuse issues, so they focus on their medical problems,” says Susan Lee, DO, an internist and psychiatrist who recently joined Carilion’s 30-member hospitalist group. “They want the psychiatrist to come in and get them out of there.”
When it comes to drug-abusing patients, an obvious concern is withdrawal. Patients withdrawing from cocaine do not face physiologic challenges, Dr. Miller says, in the way that patients in alcohol withdrawal might. But there is a short-term risk of suicide during the first 24 hours of detoxification. “That risk is related not just to psychology,” he says, “but to dopamine depletion.”
With opioid withdrawal, on the other hand, most patients face little physical danger “as long as they are otherwise in good health. But patients can get so distressed and agitated that they become disruptive. When managing opioid withdrawal, experts say physicians have several options.
They can replace and then taper the opioid being abused, or substitute methadone (or the newer agent buprenorphine), then taper. Or physicians can use a non-opioid treatment, clonidine, at 0.1 to 0.2 mg orally every four to six hours. Experts point out, however, that physical and psychological distress can continue with clonidine and affect treatment compliance.
“If a patient says, ‘You have to dose me,’ you can tell him he’s not in danger and that you’ll do your best to make him comfortable,” Dr. Miller advises. With agitated patients, a short course of low-dose benzodiazepines, such as 0.5 mg of lorazepam every four hours for three to five days, “is not inappropriate. Hospitalists don’t have to be afraid to use benzos in a controlled environment for a specific indication like withdrawal.”
The challenge of managing pain in these patients can be less straightforward. Opioid-dependent patients will seldom get significant pain relief from the dose of opioid that they have been abusing, says Faulkner’s Ms. Robinson, who performs about 300 consults a year, primarily on patients managed by hospitalists.
“They’ll need an opioid on top of that,” she explains. “And if we unintentionally make patients feel too good, we can live with in the short-term as long as they don’t experience medically compromising side effects.”
Steve Stelovich, MD, co-director of addiction medicine at Faulkner Hospital, likewise advises hospitalists to focus on clinical response, not doses, and to set aside concerns about making a patient’s dependence or addiction worse. “Even if you sense you are being gamed a little bit,” he says, “practice medically on the conservative side and make sure you have the pain under control.”
Ms. Robinson has come up with a script for patients who ask for higher doses of pain medicine. She tells them that because of their dependence or addiction, they’re “probably not the best judge” of how much medication they need for pain control, and that she will let their response guide dosing.
“I tell them, ‘If you are awake and alert, breathing at 18 breaths a minute and talking about your pain, we will be able to give you more opiates.” She makes it clear, however, that if patients are nodding out with decreased respiration and slurred speech, ” ‘and you’re telling me you’re still in pain, it’s not that I don’t believe you. It’s just that I can’t safely treat that pain with opioids anymore because you’re showing signs of intoxication.’ ”
The problem of chronic pain
Chronic-pain patients add an entirely different dimension to the challenge of detecting and managing drug abuse. Studies have found rates of opioid addiction among patients with chronic pain that range from 4% to 19%. Survey data suggest that 22% of primary care patients have chronic pain.
Patients with chronic pain who have managed on steady or slightly increasing opiate doses over several years “aren’t the ones hospitalists need to worry about,” Dr. Stelovich says. Instead, it is in those patients who present with a concomitant addiction where physicians face “a big problem.”
Prior to acute hospitalization, such patients generally have already manifested rapidly escalating drug use to “control” pain, he explains. “In these cases, hospitalists are well advised to consult with the patient’s primary care physician, or pain or substance abuse specialists.”
Addiction medicine specialists have high hopes in the wake of the passage of the federal mental health parity and addiction equity act this October. The bill requires group insurers to cover mental illness and substance abuse disorders on the same terms as other illnesses, starting January 2010. Experts say that hospitalists should start seeing more outpatient and inpatient resources “as well as increased reimbursement.
For now, however, the reality is that many of those patients who want help will fall through the cracks if there’s no treatment plan or nowhere to send them for continuing care. That’s the observation of David Frenz, MD, a family physician who is medical director for addiction medicine for the HealthEast Care System in St. Paul, Minn.
“Patients are often discharged to a primary care provider with the delusional belief that they’ll somehow get plugged into a pain clinic without further delay,” Dr. Frenz observes. “But there’s a two-month wait in my community for pain clinics, so that patient will invariably bounce back if there’s no treatment plan.”
Bonnie Darves is a freelance health care writer based in Lake Oswego, Ore.
Diagnosis: the big stumbling block
HOW DO YOU GET PATIENTS to be real about opiate dependence or other substance issues?
At Carilion Clinic in Roanoke, Va., hospitalists may at least get a heads-up on patients who present to the ED complaining of chest pain. Because many of those patients undergo a urine drug screen, doctors can use those results to make a case for full disclosure, says James Franko, MD, Carilion’s section chief for hospital medicine.
Take a recent patient with acute coronary syndrome, for whom a beta-blocker would have been the standard of care. “If people are intoxicated with cocaine, the beta-blocker could worsen their condition. So I end up saying, ‘I can’t find any reason for your chest pain other than you’re using cocaine,’ ” Dr. Franko says.
When patients remain anxious and close-mouthed, Dr. Franko proceeds with a script he has fine-tuned. “I open up my white coat and say, ‘I don’t have a badge, and I’m not from the police.’ I let them know there’s no risk of me reporting them to anyone.”
Behavioral health hospitalist David Frenz, MD, medical director for addiction medicine for the HealthEast Care System in St. Paul, Minn., takes a straightforward approach when he suspects that patients have a drug dependence or addiction.
He asks them three questions: What happens if they don’t use the drug he thinks they abuse? How much do they use now compared to six months ago? And have they tried quitting on their own? Often, patients’ answers indicate tolerance, withdrawal or impaired control.
That sequence of questions ” which are based on the classic CAGE questions for alcohol abuse ” works well when patients are ready for change, Dr. Frenz adds. When patients are in denial, however, the questions are useless. Hospitalists and community physicians often ask him to consult on patients taking opioids for ill-defined chronic pain syndromes.
“I ask the patient what happens if he doesn’t take his OxyContin for a day or two,” he explains. “If he looks at me and says ‘nothing,’ I’m dead in the water.”
To tease information out of those patients, Susan Lee, DO, an internist and psychiatrist who recently joined Carilion’s hospitalist group, turns to motivational interviewing techniques.
“The premise is that you’re assessing ambivalence,” says Dr. Lee. “There has to be a certain amount of that for you to make a dent.”
She starts by saying, “Tell me what you understand about what brought you here today.” If patients say something to the effect that they need to end their drug dependence, Dr. Lee proceeds to have them talk about how the abuse is hurting them. That helps reinforce changes a patient may want to make.
The approach works best, she adds, when the hospitalist sits in a chair, rather than standing in the doorway, and makes some physical contact with the patient. She sometimes kneels at the bedside.
“That shows a collaborative approach,” Dr. Lee says. “You can actually make a connection in just a few minutes.”
Addiction medicine becomes another hospitalist “specialty”
IN 2005, the HealthEast Care System, which operates three acute hospitals in St. Paul, Minn., began devoting hospitalists specifically to its behavioral health units. Today, eight of the 23 hospitalists at HealthEast’s St. Joseph’s Hospital work exclusively in that arena, providing medical consultations on an adult psychiatry unit and staffing an inpatient chemical dependency unit.
That unit has 28 beds and is designed specifically for higher-acuity patients who also have substance use disorders. That population isn’t well served in the traditional inpatient care model, according to David Frenz, MD, the unit’s medical director.
“This arm of our service came about to keep the acute-care guys on track,” Dr. Frenz says. “These patients can be time consuming and require a very specific skill set related to mental health and addiction.”
The new specialization “was a business gambit that worked for us,” he adds. “There’s a lot of substance abuse treatment out there, but it tends to be low acuity. We deliberately said we will treat people who are sick and also happen to have drug and alcohol problems, like the injection drug user with endocarditis who needs several weeks of IV antibiotics in a controlled environment. They have nowhere else to go.”
HealthEast’s targeted approach has addressed a number of needs. For one, acute-care hospitalists and primary care physicians who need help managing substance-related disorders now have access to timely consultations. They also have a place to transfer patients who decide they’re ready for substance abuse treatment. Some payers allow direct transfer to the unit, while others require the patient to be discharged and readmitted.
According to Dr. Frenz, a hospital should consider such a unit (or dedicated beds) if substance use disorders are prevalent among medical inpatients. At the very least, the hospital needs a solid addiction medicine consultative service.
Such units not only give patients somewhere to go but improve throughput hospital-wide. Dr. Frenz cites the example of the opioid dependent patient who ends up in the ED so frequently that someone, out of frustration, finally caves in.
“There’s something crazy about all these ED visits at $1,000 a pop, so you just admit them,” he says. “Then it’s hard to discharge them, and you know they’ll come back. If you ask your length-of-stay people at most hospitals to identify their biggest LOS problems, these patients will be a big chunk of them. They’re just languishing for a lack of a better plan.”
Besides lowering the rate of ED “bounce-backs,” Dr. Frenz’s group reduces costs by taking the primary role in managing chemically dependent patients, with psychiatrists serving as consultants. Inverting that relationship, he says, has leveraged scarce psychiatry resources and reduced laboratory and imaging costs.
Check out the Today’s Hospitalist section on Clinical Protocols for "Addiction: a brief primer." This discussion of differential diagnoses and treatment approaches has been prepared by David Frenz, MD, a hospitalist and addiction medicine specialist at St. Joseph’s Hospital in St. Paul, Minn.