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Treating opioid use disorder in the hospital

Are you comfortable initiating opioid agonist therapy?

May 2018
Getty Images; Sudok1

WHEN HANNAH SNYDER, MD, began working on Project Support for Opioid Use Treatment (SHOUT), the initiative was a state effort. But while it was designed to help hospitalists in California reduce the high mortality and readmission rates they see among patients with opioid use disorder, the project very quickly morphed into a national effort.

“We had a target goal of finding and engaging with about 25 hospitals,” says Dr. Snyder, an addiction medicine fellow at Zuckerberg San Francisco General Hospital. But when the project, which is funded by the California Health Care Foundation, kicked off a series of Webinars last fall, it drew nearly 200 participants in 19 states.

SHOUT leaders do provide intensive interventions in California hospitals with onsite visits, grand rounds and coaching calls. But physicians and hospitals around the country are invited to access the projects webinars, educational material and guidelines. (SHOUT leaders are also collaborating with a sister project—MAT ED—designed for clinicians starting opioid agonist therapy in EDs.)

“In many cases, a hospitalist is better positioned than an outpatient provider to really intervene.”

~ Hannah Snyder, MD
Zuckerberg San Francisco General Hospital

Dr. Snyder is very clear about SHOUT’s aim: to help inpatient clinicians become comfortable initiating methadone or buprenorphine in the hospital, therapies that she sees as the best option for most patients with opioid use disorders.

“Our goal is to keep patients on maintenance treatment and not to do this as a detox or taper protocol,” she says. Patients who decide instead to tough out withdrawal in the hospital “often leave against medical advice. Or if they do a taper or a medically-assisted withdrawal through detox, eight or nine out of 10 of them will relapse.”

Dr. Snyder knows that opioid agonist therapy won’t be a silver bullet for all patients. “But we also know that patients benefit from even a short course of treatment,” she says. “Every time they go through the process of trying to quit opioids and enter a period of non-use, they improve their future chances of sustaining sobriety.”

Plus, patients maintained on a medication maintain their tolerance. “So if they do relapse, we think—although this has not been studied—that they should have a lower overdose risk.” Dr. Snyder spoke to Today’s Hospitalist.

What’s the No. 1 pushback you get 
on implementing inpatient treatment?
That opioid use disorder is an outpatient issue, an opinion I really like to challenge. Often, these are patients who do not touch the health care system routinely or have an established primary doctor. But they do present to the hospital very frequently, often with something related to that disorder: endocarditis, osteomyelitis or cellulitis.

They’re so uncomfortable that it can be a moment of change. A study in the May 2017 issue of the Journal of Hospital Medicine found that 54% of patients with moderate- or high-opioid use were interested in medication for addiction treatment. So it’s an ideal time for clinicians to step forward and say, “Hey, we have something that can help you, and we can get you connected to treatment.” In many cases, a hospitalist is better positioned than an outpatient provider to really intervene and make a change.

More people died from drug overdoses in 2016 than in the entire Vietnam War. So we need the entire health care system to address this issue.

What concerns do hospitalists have
 about initiating treatment?
Many have the misconception that it is illegal for them to prescribe buprenorphine or methadone in the hospital without special certification. While regulations limit these as outpatient therapies, those do not apply in the hospital. The DEA has specifically made allowances to use opioids for inpatient opioid-withdrawal treatment.

Federal regulations state that patients admitted for any reason other than their opioid use disorder can be treated with any medication. The regulations go even further to say that emergency rooms or urgent care centers can dose patients for up to 72 hours with observed dosing to allow patients to be bridged into treatment after discharge.

What are barriers to hospitalists 
inducing treatment?
First and foremost, limited time, so we really work with people to streamline the induction process and make it as simple as possible. We’ve developed algorithmic guidelines that let you check off boxes, and we’re working with hospitals on order sets.

Scarce outpatient resources are also a huge barrier, so one of our webinars focuses on telemedicine solutions. We work with telehealth organizations that provide expertise for inpatient starts and then connect patients to outpatient care.

We never want to start someone on methadone or buprenorphine and send that person out without clear follow-up. So we work with hospitals to identify community resources they can refer patients to or to train community providers to feel comfortable prescribing buprenorphine. We also try to pair hospitals with methadone clinics.

The guidelines we’ve developed are designed to make sure that patients being induced with buprenorphine don’t have precipitated withdrawal. When patients are already stabilized on a buprenorphine dose at discharge, many more primary care providers are willing to take them on.

What concerns do patients have about 
starting treatment in the hospital?

A lot of people have strong opinions that using medications is not true abstinence. But I see substance abuse disorders as chronic diseases of the brain. With diabetes patients, I know that many of them are going to end up needing chronic medications. I think about methadone and buprenorphine the same way, and the mortality decreases with these drugs are staggering. For me, this is not substituting one drug for another, but initiating a life-saving intervention.

Working at a major teaching hospital, you must 
have resources not available to others—like
 an addiction service.
Actually, UCSF doesn’t have an addiction service. We do have some onsite addiction specialists, and we can certainly help troubleshoot questions. But the SHOUT guidelines, and we use those ourselves, are designed so inpatient providers can do the induction. All our hospital services feel quite comfortable with methadone starts and more are becoming comfortable starting buprenorphine as well.

And across all hospitals, hospital pharmacists are very strong advocates and allies. They understand the pharmacology, and they know these medications decrease illicit drug use and infectious disease transmission and improve outcomes.

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

Published in the May 2018 issue of Today’s Hospitalist
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