Published in the July 2016 issue of Today’s Hospitalist.
AS HOSPITALISTS know full well, an unprecedented number of hospitalized patients suffer from a comorbid opioid use disorder. To care for these patients, one hospitalist recommends a pragmatic approach.
According to Jesse Theisen-Toupal, MD, who spoke at the Society of Hospital Medicine’s annual meeting this spring in San Diego, savvy hospitalists need to incorporate opioid withdrawal treatment into their care plans for these patients. Otherwise, patients with opioid use disorder may not be able to endure their hospitalization to receive the treatment they need for the medical condition that caused them to be admitted in the first place.
Realistic hospitalists can also put patients’ hospital stay to good use by teaching individuals who inject heroin or opioids how to at least be safe if they are going to continue to inject. Hospitalists should promote evidence-based addiction strategies that take patient interest, impediments and preference into account.
“The goal of opioid overdose education and naloxone distribution is to reduce the opioid overdose death rate.”
~ Jesse Theisen-Toupal, MD Washington D.C. Veterans Affairs Medical Center
“Harm reduction is a pragmatic approach and an area where I think hospitalists can improve quite a bit,” said Dr. Theisen-Toupal, who sees patients at the Washington, D.C., Veterans Affairs Medical Center. “Not everyone is ready to abstain from opioid misuse, and even when they are, they sometimes relapse. These strategies are aimed at preventing negative consequences associated with drug use, whether patients are in treatment or not.”
The premise behind teaching safer injection practices (if patients inject) and how to use naloxone to treat opioid overdose is much like the argument for teaching teenagers safe sex to reduce the rates of unwanted pregnancies and sexually transmitted diseases.
“Critics argue that we should be doing an abstinence-only strategy rather than a harm-reduction strategy,” Dr. Theisen-Toupal said. But studies have found benefits in tactics like needle-exchange programs and opioid overdose education and naloxone distribution.
Injecting drugs accounts for between 8% and 15% of new HIV cases and between 60% and 90% of new hepatitis C cases, he explained. “Injection drug use predisposes people to a lot of serious viral, bacterial and fungal infections. The goal of these harm-reduction strategies is to reduce the viral, bacterial and fungal infectious complications of injection drug use.”
Dr. Theisen-Toupal makes it a regular practice to educate all his hospitalized patients who inject about safer injection practices and trains them how to recognize the signs of an overdose and in how to use naloxone. And as part of his discharge package, he gives patients at risk of an opioid overdose a prescription for naloxone—because the time immediately following discharge is a particularly high-risk time for overdose.
“Let’s say individuals are in the hospital for two weeks dealing with an infection. They leave the hospital and use the same amount of heroin they always use, but this time it’s too much because they lost their tolerance, and they overdose,” Dr. Theisen-Toupal said. “The goal of opioid overdose education and naloxone distribution is to reduce the opioid overdose death rate.”
A byproduct of the national opioid epidemic is that hundreds of thousands of inpatients are now regular users of opioid analgesics and heroin.
“As hospitalists, we are seeing these people more and more often,” Dr. Theisen-Toupal said. Hospitalists need to realize that a hospital admission for many of these people means losing access to the opioids they depend on, which in turn means they will suffer withdrawal.
As he put it, “Then they are faced with some hard decisions: Should they stay in the hospital to have their medical condition treated but go through withdrawal? Or should they leave and treat their withdrawal themselves?”
Instead of pushing patients to make that decision, “we need to get these people to a normal state using medications to treat their withdrawal.” To do so, he added, hospitalists need to understand that withdrawal from drugs like heroin and oxycodone will start eight to 12 hours after the drug is stopped, and that symptoms—including tachycardia, sweating, restlessness, dilated pupils, bone and joint aches, runny nose and tearing, gastrointestinal upset, tremor, yawning, anxiety, and gooseflesh skin—will peak in one to three days. Symptoms can last up to 10 days or longer if the patient is on a long-acting opioid like methadone.
Because few hospitalizations last this long, patients will continue to suffer from withdrawal after they leave the hospital. “That can be enough to cause someone to relapse,” he said.
Complicating withdrawal treatment is the fact that the most effective, well-tolerated and straightforward strategy, which uses methadone, depends on the patient remaining in the hospital. Methadone can’t be prescribed for outpatients for the purpose of opioid use disorder, and the recommended way to order it is to give 10 mg oral or IM doses every couple of hours up to a maximum of 40 mg to treat withdrawal symptoms. Patients must then taper the methadone off slowly—usually by a decrease of 5 mg a day.
“Our patients aren’t typically in the hospital for 10 to 14 days,” said Dr. Theisen-Toupal, so doctors can try a shorter taper duration of three to five days.
That should get patients through the really bad period, although they may still have some withdrawal symptoms at discharge. “Those should be more mild, but they still can be enough to cause someone to relapse.”
An alternative approach to withdrawal treatment involves a clonidine taper, he added. This medication can be prescribed at discharge, which is a major advantage. However, many patients will develop side effects, such has hypotension or bradycardia, which may limit its use in many patients.
“Detoxification is not a cure for addiction,” Dr. Theisen-Toupal reminded hospitalists. About one-third of patients are likely to relapse within three days and 50% within 14 days. Because treating withdrawal is not the same as treating substance use disorder, he orders a social-work consult for all patients and considers a psychiatry consult for anyone with a comorbid mental illness.
His motto, he said, is first things first. “We have to treat the barriers to patients’ care or they are not going to succeed in treating their addiction,” he pointed out. That starts with psychosocial issues such as homelessness, reduced employment, alcohol use disorder or psychiatric comorbidities.
Furthermore, he talks to everyone about getting medication-assisted treatment—methadone, buprenorphine or naltrexone—and refers anyone he can to an opioid use disorder treatment specialist.
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
What to teach patients
HOW CAN HOSPITALISTS help keep patients who abuse opioids out of the hospital? Jesse Theisen-Toupal, MD, assistant professor of medicine at George Washington University School of Medicine and Health Sciences, says it is critical to teach them how to avoid infections that can stem from injection drug use.
Here are tips Dr. Theisen-Toupal offers his patients.
Use sterile water. If that’s not an option, boil water for 10 minutes before use. If that’s not available, use bottled water. And if that’s not an option, use tap water. “The key is never to use stagnant water,” Dr. Theisen-Toupal said. “I have had patients who use pond water, toilet-bowl water, puddles at the side of the road. This can lead to nasty infections, and you need to tell people that because many don’t realize how important that is.”
Never use lemon or lime juice when dissolving heroin because candida will grow in lemons or limes. Instead, patients can use vitamin C or ascorbic acid.
Don’t use cigarette filters instead of cotton pellets. Cigarette filters include glass particulates, “so when filling the syringe with heroin, patients are also filling it with glass particulates,” which can cause many problems. Reusing a cotton pellet or touching it raises the risks of infection as well.
Never lick the needle or the injection site. “This seems like common sense,” Dr. Theisen-Toupal says, “but about one-third of drug users will lick the needle before they inject. This is something you have to discuss.” In addition, individuals should always clean the injection site with an alcohol swab prior to injecting.
Use sterile equipment and never share equipment. If you can’t use a sterile needle and syringe, clean them both before and after use with bleach and water. However, it is best to use new and sterile supplies each time. In some regions, these supplies can be obtained (and used supplies can be disposed of properly) through syringe exchange programs where patients can also receive additional education and services.
Unfortunately, Dr. Theisen-Toupal said, large parts of the country are unserved by such programs. Moreover, while there are 90 safe injection sites around the world, the U.S. doesn’t have a single one. In Canada, on the other hand, Vancouver has two, and Toronto, Montreal and Ottawa are in the process of setting them up.
Dr. Theisen-Toupal said he recommends that hospitalists create a patient information sheet that outlines safer injection practices and lists needle exchange programs in their area. They can give these sheets to patients who inject drugs and to family members at discharge.