Published in the September 2014 issue of Today’s Hospitalist
ACCORDING TO addiction medicine specialists, federal legislation may soon be introduced that, if passed, could remove some barriers to outpatient buprenorphine treatment for patients addicted to opiates. Among other provisions, the bill may allow some outpatient physicians “who must be licensed to prescribe buprenorphine “to treat more than 100 patients with the drug, the current federal limit.
That’s great news, according to Jane Liebschutz, MD, MPH, associate chief of general internal medicine at Boston Medical Center. Dr. Liebschutz was the lead author of a study published in the August issue of JAMA Internal Medicine that tested the effectiveness of linking hospitalized patients who have opiate disorders directly to outpatient buprenorphine treatment.
In the trial, researchers randomized patients to one of two groups. Patients in the detox group received a five-day tapering course of buprenorphine detox and a referral to outpatient treatment. Patients in the linkage group, however, received buprenorphine maintenance induction with bridging doses at discharge and a transition to outpatient therapy in the hospital’s primary care clinic. In the hospital, an addiction nurse specialist screened all admissions for opioid use and interviewed all potential participants.
“Addiction is no different from other areas—like heart failure—where people are trying to improve transitions in care.”
~ Jane Liebschutz, MD, MPH Boston Medical Center
When first enrolled in the trial, none of the patients were actively seeking treatment. After following both groups, researchers found that more than 70% of patients in the linkage group entered outpatient buprenorphine treatment at some point within six months vs. only 12% in the detox group. And while not all of those patients stuck with outpatient treatment, participants in the linkage group did report 40% less illicit drug use post-discharge than those in the detox arm.
An accompanying editorial claimed the study outlined “a roadmap for a new course of treatment.” But the editorial also noted that even the trial’s modest success might be tough to replicate, given the lack of both dedicated nurses with addiction training in hospitals and the shortage of certified primary care doctors willing to prescribe buprenorphine.
Then there’s the question of who should initiate treatment in the hospital, according to the editorial: Should every hospital-based physician be trained, or should buprenorphine therapy be handled only by specialists?
Still, the study was one of only a very few to find some success by intervening in the hospital with a challenging group of patients. “If you catch people in the hospital who need treatment, and try to start it and link them to continuing treatment,” says Dr. Liebschutz, “you have a shot at helping them.”
She spoke to Today’s Hospitalist about the study.
Is the usual standard of care in hospitals the same as for the control group in your study: five days of buprenorphine detox?
There is no widely-accepted standard of care, so hospital treatment of patients with opioid disorders is highly variable. In some places, it’s great, but in others it’s highly inadequate. In general, providers are afraid of this population, and these patients are misunderstood and poorly managed.
The key, of course, is in the transition of care. Addiction is no different from other areas “like heart failure “where many people are trying to improve transitions in care. The core issue for many of these hospitalizations is addiction, whether it is related to patients’ medical problems or their lack of self-care.
In the study, 90% of the patients enrolled were injection drug users, and as many as 45% of their hospital admissions were related directly to injection, with abscesses or endocarditis. Rather than just treating patients’ medical problems, we’re trying to get at the underlying addiction and prevent hospitalizations.
Did you track the differences between the two groups in terms of readmissions or ED visits?
We did, although we haven’t published those data yet. While we saw some trends, there was no statistical difference between the two.
Sometimes when patients with opioid disorders get help, they start using more services. Patients may have previously needed treatment for hepatitis C or mental health issues, for example, but never pursued it. Now, they begin taking care of themselves.
Even if you’re not reducing utilization, you’re still saving lives. People not in treatment die of overdoses, while people in treatment don’t.
You write that the outpatient retention rate of treatment for those in the linkage group was “concerning.” After six months, only 17% were still in treatment.
That’s obviously a huge challenge: how to get patients, once they are discharged, over that hump so they’ll stay in treatment. That will be the focus of our next work.
We need to figure out how to motivate patients. In our clinic, for instance, 51% of patients who actively seek buprenorphine treatment “so these are not the patients enrolled in this study “are still receiving treatment at 12 months.
Part of it is helping patients with the structure of going from a drug-using lifestyle to a non-drug-using lifestyle. Studies have looked at counseling given in addition to medication and have not shown it to be any better than just receiving medication. We may need to design a more intensive and structured outpatient treatment program to keep patients engaged in the early months of treatment.
Another option would be giving patients higher maintenance doses than the 16 mg we were giving them. Studies have looked at both methadone and buprenorphine and found that people on higher doses do better.
You write that hospitals would need to implement certain policies to intervene with these patients. They’d have to be able to systematically identify drug users and have discharge planners maintaining an active network of buprenorphine prescribers, and they would need a dedicated substance use team for both initial and bridging treatment in the hospital.
Which of those components is most important?
The key piece is having the personnel, and having an addiction consulting team would be ideal. Members from that team can identify patients in the hospital, work with discharge planning and help with medications.
Another successful hospital model is using a consult liaison psychiatrist. You need someone onsite who is an expert.
Since the study, has your center continued to intervene with hospitalized patients and link them to your outpatient program?
It has not. It costs money to support having a nurse talk to patients and link them to outpatient treatment, and the hospital right now has not funded that position.
But we are talking to administrators, who are interested, and we are hopeful that we will get a package deal. We don’t have this program in place now, but we’re making a business case for it.
Phyllis Maguire is Executive Editor of Today’s Hospitalist.
