Treating opioid addiction in hospitalized medical patients

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Treating opioid addiction in hospitalized medical
patients

• Miriam Komaromy, MD, FACP
• Associate Director, ECHO Institute

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Mr. L is a 34 yo man who is admitted with
suspected endocarditis. He is an active
injection drug user, and was injecting heroin
just prior to admission. He is alarmed about his
medical condition, and is initially cooperative
with treatment. However, a few hours after
admission he begins to become restless and
agitated. You prescribe clonidine for suspected
opioid withdrawal. At 6 AM the floor nurse calls
to tell you that the patient has left the
hospital AMA.
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What options are available to treat impending
opioid withdrawal in an inpatient?

• Buprenorphine is safe
• Can prescribe as a taper or maintenance
• Much more effective than clonidine for withdrawal
• Will retain patients in the hospital for
  treatment of their medical illness
• Humane, and makes patient management easier

Gowing L, Cochrane Database 2009
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Who can prescribe buprenorphine to a hospitalized
patient?

• Any physician a buprenorphine waiver is not
  required when treating an inpatient

SAMHSA website FAQ http//buprenorphine.samhsa.go
v/faq.htmlA25
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How should buprenorphine be prescribed to a
hospitalized opioid-addicted patient?

• Write orders to begin treatment with
  buprenorphine once mild-to-moderate withdrawal
  symptoms are present
• Clinical Opiate Withdrawal Score (COWS) can be
  used to measure this
• Start patient with a 4 mg test dose, and if it is
  well tolerated then give additional 4 mg every 2
  hours until withdrawal symptoms resolve or 12 mg
  is reached on day 1. Subsequent daily dose can
  increase to 16 mg/day if needed.
• Continue this dose daily until discharge (if
  maintenance can be arranged) or until 3 days
  prior to discharge, when dose should be tapered
  off.
• Can rx either buprenorphine monoproduct or
  buprenorphine/naloxone combo (Suboxone)
• Must be administered sublingually

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Clinical Opioid Withdrawal Score (COWS)
Pulse rate Sweating Restlessness Pupil
size Bone/join aches Runny nose/tearing GI
Upset Tremor Yawning Anxiety/irritability Goos
eflesh skin
Score 13-24 mild-to-moderate withdrawal
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Caveats

• Do not initiate buprenorphine if the patient has
  been using methadone within the past week or the
  UDS is () for methadone
• Do not initiate buprenorphine if the patient is
  not opioid-dependent (in which case, the patient
  will not develop withdrawal symptoms)
• Risk of respiratory suppression from
  buprenorphine is almost non-existent for adults
  UNLESS high-dose benzos are co-administered, so
• Do not use bup in a patient who needs high-dose
  benzos, eg active alcohol withdrawal
• Total daily bup dose can be given as a q day
  dose, except in patients with pain divide
  TID-QID for better analgesia
• Bup interferes with effect of other opiates, but
  is itself a potent analgesic

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What about buprenorphine maintenance?

• Maintenance treatment with buprenorphine is
  highly effective at reducing relapse, injection
  drug use, HIV and Hep C infection 1, and death
• Bup is covered by Medicaid without prior
  authorization
• Unfortunately, there are far too few bup
  prescribers in NM, and arranging for a patient to
  transfer to maintenance therapy is hard
• ASAP Socorro Lopez-Mezon RN works to arrange
  rapid intake into ASAP for patients being
  discharged from UNM. 994-7980
• First Choice patients who have primary care at
  FCCH can usually get bup maintenance there

Page K, JAMA Int Med 2014
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72 of inpatients randomized to maintenance
buprenorphine with linkage to outpatient bup
treatment successfully entered maintenance
outpatient treatment, vs. 12 of inpatients
randomized to 5 day bup taper.
Liebschutz J, JAMA Int Med 2014
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Trial of buprenorphine

• 40 Heroin addicts
• Buprenorphine 16 mg/day vs
• taper placebo
• All received counseling, groups
• Followed for 1 year

Buprenor-phine Placebo
Retained at 1 yr 70 0
died 0 20
Kakko et al, Lancet 2003
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Evidence continues to grow showing that
buprenorphine saves lives
Heroin overdose deaths fell by 2/3 as
buprenorphine MAT availability increased in
Baltimore
Schwartz, AJPH, 2012
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Warning if a patient is tapered off of opioids
the patient MUST be warned that their tolerance
will be lowered and they can easily overdose and
die after discharge if they resume the same dose
of opioids (RR of death 15)
Ravndal E, Drug Alcohol Depend 2010
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Ms. R is a 42 year-old woman who develops
gall-stone-related pancreatitis. She is
hospitalized for treatment and pain control. On
admission, she reports that she is on maintenance
therapy with Suboxone (buprenorphine/naloxone) 16
mg per day for treatment of Opioid Use Disorder.
UDS () for buprenorphine, (-) for methadone and
benzos. She is having marked abdominal pain.
How would you manage her pain?
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Management of pain in patients treated with
buprenorphine

• Options include
• Managing pain with buprenorphine divide dose
  TID-QID, and increase total dose as needed for
  analgesia up to 32 mg or more per day
• Continuing buprenorphine but overriding it
  Fentanyl has an even higher affinity for the mu
  opioid receptor than bup, so provides effective
  analgesia
• Stopping buprenorphine and beginning pain
  management with other opioids, with plan to
  resume bup prior to discharge
• Make an explicit plan with patients about
  resuming buprenorphine

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Ms S is a 64 year old woman who has been treated
for 5 years with oxycodone for pain from spinal
stenosis. She is hospitalized after being found
unconscious by her husband in what appears to be
an accidental overdose. How would you address her
ongoing pain and also her overdose risk?
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• Buprenorphine can be prescribed off label for
  patients who do not meet DSM criteria for Opioid
  Use Disorder (opioid addiction)
• Useful in patients who have major risks of
  overdose or other complications from standard
  opioids
• Safer, no tolerance, no sedation, and no
  development of opioid-induced hyperalgesia
• Not recommended for use in patients treatment
  with benzodiazepines because of overdose risk

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Mr. J is a 50 year old man who is hospitalized
for pneumonia and alcohol withdrawal. He has a
long history of Alcohol Use Disorder, and has
attempted to stop drinking many times without
prolonged success.After several days of
treatment he is preparing for discharge. What
could you offer to help him to maintain his
sobriety?
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miriamk1_at_salud.unm.edu