Managing the Hospitalized Patient with Opioid Use Disorder · 2019. 11. 15. · Walley AY,...
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Managing the Hospitalized Patient with Opioid Use Disorder MARLENE MARTIN ASSISTANT CLINICAL PROFESSOR UNIVERSITY OF CALIFORNIA, SAN FRANCISCO 23RD ANNUAL MANAGEMENT OF THE HOSPITALIZED PATIENT CME COURSE OCTOBER 18, 2019
Transcript of Managing the Hospitalized Patient with Opioid Use Disorder · 2019. 11. 15. · Walley AY,...
ManagingtheHospitalizedPatientwithOpioidUseDisorder
MARLENEMARTINASSISTANTCLINICALPROFESSOR
UNIVERSITYOFCALIFORNIA,SANFRANCISCO
23RDANNUALMANAGEMENTOFTHEHOSPITALIZEDPATIENTCMECOURSEOCTOBER18,2019
35Ymanadmittedovernightwithrightupperextremityerythema,pain,andswelling
● Startedonempirictreatmentforcellulitis● Youaregettingsignoutfromyourovernightcolleaguewhenyougetpaged
thatheiscomplainingofdiarrhea,abdominalpain,headache,andnausea● Youevaluatethepatientandnoteheisyawningandthathispupilsare
dilated.Heendorseslastusingheroinbeforebeingadmitted
Objectives 1. Diagnoseandtreatopioidwithdrawalandopioid
usedisorder(OUD)witheithermethadoneorbuprenorphine
2. Identifyhowtolinkhospitalizedpatientstobuprenorphineormethadonetreatmentondischarge
3. NamethreeoptionsforOUDharmreduction
Outline q Prevalence,demographics,andcharacteristicsofhospitalizedpatientswithOUD
q DiagnosingOUDq Medicationtreatment
q Cases
Source: CDC, 2017
ThreeWavesofOpioidOverdoseDeaths
Source: AHRQ, 2017
OUD-relatedhospitalizationsandEDvisitsalmostdoubledinthelastdecade
SUDamonghospitalizedpatientso Upto25%ofhospitalizedpatientso Morelikelytobeadmittedfromtheemergencydepartment
o Longerlengthsofstay,costlier,higherreadmission
o HighAMArates
o Lowestquartileofincome
o Unconnectedtocare
StatisticalBrief#249.HealthcareCostandUtilizationProject(HCUP).March2019.AgencyforHealthcareResearchandQuality,Rockville,MD.BrownRL,LeonardT,SaundersLAetal.Theprevalenceanddetectionofsubstanceusedisordersamonginpatientsages18to49:anopportunityforprevention.PrevMed1998;27(1):101-10).EnglanderH,WeimerM,SolotaroffRetal.PlanningandDesigningtheImprovingAddictionCareTeam(IMPACT)forHospitalizedAdultswithSubstanceUseDisorder.JHospMed.2017May;12(5):339-342.Spooner,K.K.,Salemi,J.L.,Salihu,H.M.,Zoorob,R.J.,2017.DischargeagainstmedicaladviceintheUnitedStates,2002-2011.MayoClin.Proc.92,525–535.WalleyAY,Paasche-OrlowM,LeeEC,etal.Acutecarehospitalutilizationamongmedicalinpatientsdischargedwithasubstanceusedisorderdiagnosis.JAddictMed.2012Mar;6(1):50-6.RonanMVandHerzigSJ.HospitalizationsRelatedToOpioidAbuse/DependenceAndAssociatedSeriousInfectionsIncreasedSharply,2002-12.HealthAff(Millwood).2016May1;35(5):832-7.
WhytreatOUDinthehospital?o Eliminatewithdrawalandreducecravingso Ifreturntousewhileontreatmentoccurs,less/nohigh
o Maintaintolerance
o RootcauseofEDvisits,admissions,andreadmissions
o Patientsmotivatedtocutbackorstopuse–pivotaltouchpoint
o Whenaddressed:o ImprovedratesofPCPandaddictiontreatmentfollowupo Reducedsubstanceuseafterdischargeo Lower30-dayreadmissionso Improvedpatientandproviderexperiences
VelezCM,NicolaidisC,KorthuisPT,EnglanderH."It'sbeenanExperience,aLifeLearningExperience":AQualitativeStudyofHospitalizedPatientswithSubstanceUseDisorders.JGenInternMed.2017Mar;32(3):296-303.WeiJ,DefriesT,LozadaM,YoungN,HuenW,TulskyJ.Aninpatienttreatmentanddischargeplanningprotocolforalcoholdependence:efficacyinreducing30-dayreadmissionsandemergencydepartmentvisits.JGenInternMed.2015Mar;30(3):365-70.EnglanderH,CollinsD,PerrySPetal."We'veLearnedIt'saMedicalIllness,NotaMoralChoice":QualitativeStudyoftheEffectsofaMulticomponentAddictionInterventiononHospitalProviders'AttitudesandExperiences.JHospMed.2018Nov1;13(11):752-758.EnglanderH,WeimerM,SolotaroffRetal.PlanningandDesigningtheImprovingAddictionCareTeam(IMPACT)forHospitlaizedAdultswithSubstanceUseDisorder.JHospMed.2017May;12(5):339-342.LiebschutzJM,CrooksD,HermanD.Buprenorphinetreatmentforhospitalized,opioid-dependentpatients:arandomizedclinicaltrial.JAMAInternMed.2014Aug;174(8):1369-76.
Outline q Prevalence,demographics,andcharacteristicsofhospitalizedpatientswithOUD
q DiagnosingOUDq Medicationtreatment
q Cases
Symptoms◦ Withdrawal◦ Uncontrolledpain
Diagnoses◦ Skinandsofttissueinfections◦ Endocarditis,osteomyelitis◦ Trauma◦ Overdose
DSMCriteria◦ Chronicpain
NotallwhouseopioidshaveOUD
DiagnosingOUD
Riskofbodilyharm
Withdrawal
Tolerance
Control:Exceededownlimits
Failedattemptstoquit/controluse
Compulsion:Timeusing,getting,recovering
Gaveupothermeaningfulactivities
Consequences:Relationshiptrouble
Physical/psychologicalconsequences
Rolefailure
Craving
ImpairedControl
SocialImpairment
RiskyUse
PharmacologicalCriteria
Outline q Prevalence,demographics,andcharacteristicsofhospitalizedpatientswithOUD
q DiagnosingOUDq Medicationtreatment
q Cases
Opioids: full agonist heroin, oxycodone, fentanyl, etc
Methadone: full agonist Activates receptor
Buprenorphine: partial agonist High affinity, ceiling effect
Extended-release naltrexone, naloxone: Full antagonist, high affinity
Y
Y
Y
Y
ßMu receptor
MedicationsforOUD
MedicationsforOUDMethadone Buprenorphine
Treatmentretention Higherthanbuprenorphine Retentionimprovesatdoses>16mg
Officevisits Dailyvisitstotreatmentprogram Daily-monthly;canalsoprovideasDOTinsomesettings
Whocanprescribeinacutecare?
Anyinpatientproviderduringhospitalization.AnyproviderinED:upto72hoursdosing
Anyinpatientproviderduringhospitalization.AnyproviderinED:upto72hoursdosing
Whocanprescribeatdischarge?
OpiateTreatmentProgram(methadoneclinic) AnyproviderwithDATA2000Xwaiver
Sedation Yesathighdoses,non-tolerantpatientsorslowmetabolizers
Ceilingeffectforrespiratorydepression
Withdrawalwhenstarting Takestimetoreachcomfortabledose Needtobeinwithdrawal
Buprenorphine:precipitatedwithdrawal
o Mustbeinwithdrawalpriortoinduction
o Highaffinity Y Y Heroin
J L
Buprenorphine
0.
10.
20.
30.
40.
Inmethadone Outofmethadone Inbuprenorphine Outofbuprenorphine
Allcausemortalityper1000personyears
Source: Sordo et al, BMJ, 2017
DecreasedMortality
7264
127
0
20
40
60
80
Daysinbupover6months
%Patients
Maintenance Detox
Num
ber o
f Days
80
70
60
50
40
30
20
10
0
Source: Liebschutz et al, JAMA Internal Medicine, 2014
HospitalInitiationofBuprenorphine
%
%
Source:ChutuapeMetal,TheAmericanJournalofDrugandAlcoholAbuse,2001.
DetoxDoesn’tLast
Outline q Prevalence,demographics,andcharacteristicsofhospitalizedpatientswithOUD
q DiagnosingOUDq Medicationtreatment
q Cases
Opioid Use Disorder (OUD), Opioid Withdrawal, and Linkage to Treatment Da
y1
MethadoneGuideforOUDTreatmentandWithdrawal
q Utox,pregnancytest,considerQTc,CURES,COWS,confirmOUD
q Give20mgmethadoneq Every4hours->COWS,ifhavingcravingsorwithdrawal,give10mgmore.Donotexceed40mg
Day2
q GivetotalDay1doseinamq Every4hours->COWS,ifhavingcravingsorwithdrawal,give10mgmore.Donotexceed50mg
3 q GivetotalDay2doseinamandfollow
sameprotocol.Donotexceed60mg
Day4
q GiveDay3maxdose.Continueprotocoluntilreaching60mgdaily.Thenholdfor5daysbeforeincreasingby10mgevery5days
Day1
BuprenorphineGuideforOUDTreatmentand*Uncomplicated
Withdrawalq Utox,pregnancytest,CURES,COWS,confirmOUD,considerQTc&LFTs
q Startbuprenorphine(bup)whenmildwithdrawal(COWS>8)ornoopioidsfor5days.Ifreceivedopioids:q Shortactingàwait12hrsq Longactingàwait24-48hrsq Methadoneinlast5daysàrequesthelp
q Give**bup4-8mg(ensuresublingual)q 1hourlateràrecheckCOWS.If≥8give4mgmore
q 6hourslater(soonerifwithdrawing)àrecheckCOWS.If≥8give4mg.Maxdose16mgonDay1
Day2
q GivetotalDay1doseinam.TIDdosingifpatienthaspain
q 1hourlateràifhavingcravings,pain,orwithdrawalincreasetotaldailydoseby4-8mg
q Goaldailydose16-24mg/day.Ifgreater,requesthelp
Adjunctive Support Clonidine 0.1-0.3 mg PO q6-8 hours PRN
(NTE 1.2 mg/day) à Sweating, restlessness, hot flashes, watery eyes, anxiety
Loperamide 4 mg PO x 1, then 2 mg PRN (NTE 16 mg/24 hours) à Loose stools
Zofran 4 mg PO q 6 hours PRN à Nausea Trazodone or Melatonin à Insomnia Diphenhydramine 25-50 mg, PO q 8 hours
PRN à Insomnia or anxiety Tylenol and/or Ibuprofen 650 mg PO q 6
hours PRN à Pain
Bup and Methadone Quick Facts • Inpatient providers can order bup or methadone for OUD, opioid withdrawal, or to continue outpatient tx
• X-waivered providers can prescribe bup on discharge
• Inpatient providers cannot prescribe methadone for OUD on discharge *Uncomplicated = no methadone for 5
days, no acute pain or surgery, not altered, no severe illness
**If concerned for precipitated withdrawal, start with 2mg
Case145-year-oldmanwithahistoryofinjectionheroinuseisadmittedwithcellulitisofhisrightupperextremity.Twohoursafteradmission,hefeelsachyandnauseous.Hispulseis102,heissweating,andmovingfrequentlyinbed.Assumehissepsisisadequatelyaddressed,andhissymptomsarefromopioidwithdrawal.● Whatmedicationswouldyouofferhim?● Howwouldyoudecidewhentostartthesemedications?● Howwouldyoudosethesemedications?● WhatdoyoudowithhisOUDmedicationsatdischarge?
q COWS≥8,Mustbeinwithdrawalpriortoinduction
q Initialdose8-12haftershortacting,24-48hpostlongacting
q Transitioningfrommethadone—askforhelp
Buprenorphine
WithdrawalAssessmentCOWSshortcut:SubjectivesymptomsANDatleast1objectivewithdrawalsign• Subjective:Nausea,abdominalpain,myalgias,chills
• Objective(atleast1):Restlessness,sweating,rhinorrhea,dilatedpupils,wateryeyes,tachycardia,yawning,goosebumps,vomiting,diarrhea,tremor
WhenCOWS≥8,give4-8mg
Maxday1:16mg
Maxday2:24mg
Therapeuticdose16-24mg/day
Increasedose:craving,withdrawal,pain
Decreasedose:insomnia/mania,sedation
Precipitatedwithdrawal:morebuprenorphineORshortactingfullagonist
Buprenorphine
Monitoron60mgdailyfor5daysbeforeincreasingagainby5-10mg,thenholdthatdosefor5days,etc
Targetdailydose80-120mg
Day1
Startwith10-30mg,reassessin3-4hrs,mayadd10mgPRNw/dsx,max40mg
DocumentCOWS,sedationscores@0min,4h.GoalCOWS<5
Day2
TotalDay1+5-10mgPRN,max50mg
Day3
TodayDay2+5-10mgPRN,max60mg
Methadone
Daysatsteadydose
Peak 3-4
hours
Half life: 24-36 hours
Steady state: 3-7 days
Risk of overdose with induction
Methadone
Startmedicationintheacutesettingandcommunicatewith
PCPorOTP!
MethadoneCannotprescribeondischargeforOUD
OpioidTreatmentProgramPartnerwithlocalmethadone
clinic
BuprenorphinePrescribeatd/cifwaiveredandbridgetooutpatientplan
Telemedicine BridgeClinic
PrimaryCare(SAMHSAwebsitelistswaiveredproviders)OTP
(Somecarrybup)
MedicationCareTransition
Case260-year-oldwomanwithahistoryoftricuspidvalveendocarditisandanxietyisadmittedforacuteencephalopathy.Urinetoxicologyshowsmorphine,alprazolam,andcocaine.Shortlyafteradmission,shewakesupsweating,tremulous,agitated,andvomitingandisaskingtoleave.Assumehersymptomsarefromopioidwithdrawal.● Whatmedicationswouldyouofferforherwithdrawalifshedoes
notwanttocontinueOUDtreatmentafterdischarge?● Whatharmreductionmeasureswouldyouprovideifsheis
interestedintreatingtheOUDbutnotstoppingbenzosorcocaine?● Whatbloodworkcouldyouobtaintolookforcomplicationsof
OUD?
Opioid Use Disorder (OUD), Opioid Withdrawal, and Linkage to Treatment Da
y1
MethadoneGuideforOUDTreatmentandWithdrawal
q Utox,pregnancytest,considerQTc,CURES,COWS,confirmOUD
q Give20mgmethadoneq Every4hours->COWS,ifhavingcravingsorwithdrawal,give10mgmore.Donotexceed40mg
Day2
q GivetotalDay1doseinamq Every4hours->COWS,ifhavingcravingsorwithdrawal,give10mgmore.Donotexceed50mg
3 q GivetotalDay2doseinamandfollow
sameprotocol.Donotexceed60mg
Day4
q GiveDay3maxdose.Continueprotocoluntilreaching60mgdaily.Thenholdfor5daysbeforeincreasingby10mgevery5days
Day1
BuprenorphineGuideforOUDTreatmentand*Uncomplicated
Withdrawalq Utox,pregnancytest,CURES,COWS,confirmOUD,considerQTc&LFTs
q Startbuprenorphine(bup)whenmildwithdrawal(COWS>8)ornoopioidsfor5days.Ifreceivedopioids:q Shortactingàwait12hrsq Longactingàwait24-48hrsq Methadoneinlast5daysàrequesthelp
q Give**bup4-8mg(ensuresublingual)q 1hourlateràrecheckCOWS.If≥8give4mgmore
q 6hourslater(soonerifwithdrawing)àrecheckCOWS.If≥8give4mg.Maxdose16mgonDay1
Day2
q GivetotalDay1doseinam.TIDdosingifpatienthaspain
q 1hourlateràifhavingcravings,pain,orwithdrawalincreasetotaldailydoseby4-8mg
q Goaldailydose16-24mg/day.Ifgreater,requesthelp
Adjunctive Support Clonidine 0.1-0.3 mg PO q6-8 hours PRN
(NTE 1.2 mg/day) à Sweating, restlessness, hot flashes, watery eyes, anxiety
Loperamide 4 mg PO x 1, then 2 mg PRN (NTE 16 mg/24 hours) à Loose stools
Zofran 4 mg PO q 6 hours PRN à Nausea Trazodone or Melatonin à Insomnia Diphenhydramine 25-50 mg, PO q 8 hours
PRN à Insomnia or anxiety Tylenol and/or Ibuprofen 650 mg PO q 6
hours PRN à Pain
Bup and Methadone Quick Facts • Inpatient providers can order bup or methadone for OUD, opioid withdrawal, or to continue outpatient tx
• X-waivered providers can prescribe bup on discharge
• Inpatient providers cannot prescribe methadone for OUD on discharge *Uncomplicated = no methadone for 5
days, no acute pain or surgery, not altered, no severe illness
**If concerned for precipitated withdrawal, start with 2mg
HarmReduction Buprenorphineormethadone
Needleexchangeprograms
Reviewinjectionpractices Supervisedinjectionfacilities Buddysystem
HCVandHIVeducation,screening,andtreatment
HAV,HBV,&TDaPvaccinesprn Naloxone
StopOverdoseDeaths Universalnaloxoneprescribing
◦ OUD◦ Opioids◦ Anydruguse
Bupren
orph
ine
PostDischargeLinkage
q PrimaryCareifPCPisXwaivered.Ifnot,check*SAMHSAtofindbupprovider.Giveenoughbuptobridgetoappointment.Communicated/cplanwithPCP.
q SUDBridgeClinicifavailableq SomeOTPshaveDOTforbupq Telemedicineq Emergencyadministration(ieinED)forupto72hours
q Someavailableformulations:q Bup-naloxoneSLfilmsq Bup-naloxoneSLtabsq Buprenorphinetabs
Metha
done
q OTP(methadoneclinic)->refertooneinyourcommunity.Establishpartnershipstoeasetransitions.Greatforpatientswhoneedmorestructure.
HarmReductionChecklistq HIVandHCVtestingandtreatmentq HAV,HBV,&TDaPvaccinesprnq Reviewsafeinjectionpractices
q Don'tusealoneq Cleaninjectionsiteq Injectslowlyorusetestshotq Usecleanneedleandothersupplies("works")
q Don'tshareneedlesorworksq Needleexchangeprogramsq Bupormethadoneasharmreductionq Naloxoneforeverypatientq PrEP/PEPq Treatwithdrawalevenifpatientisambivalentormaynotwantbupormethadoneafterdischarge
Other Resources • UCSF Substance Use Warmline: Call
855-300-3595, weekdays PST 6 am-5 pm for Addiction MD, RN, or pharmacist
• ED-Bridge: Detailed resources at: https://ed-bridge.org • SAMHSA: Find waivered providers at: https://www.samhsa.gov
Withdrawal Assessment COWS shortcut: Subjective symptoms AND at least 1 objective withdrawal sign • Subjective: Nausea, abdominal pain,
myalgias, chills, runny nose • Objective (at least 1): Restlessness,
sweating, rhinorrhea, dilated pupils, watery eyes, tachycardia, yawning, goose bumps, vomiting, diarrhea, tremor
Diagnosing OUD 1. Does the patient use heroin and have
signs and symptoms of withdrawal? If YES -> OUD.
2. If unsure OR no signs of withdrawal OR patient using prescription drugs, refer to DSM criteria below
DSMCriteria
Riskofbodilyharm ExceedsownlimitsRolefailure RelationshiptroubleUnabletocutdownTimespentgettingUsingdespitehealthGivesupactivitiesCravingToleranceWithdrawal
For patients with acute pain and OUD • DO treat acute pain on top of OUD
• PRN opioids work even if on bup • Split bup into TID or QID dosing to treat acute or
chronic pain • DO continue methadone or bup dosing before
and after surgery • DO use adjunctive medications, regional,
ketamine, etc This Toolkit Belongs To:
Case340-year-oldmanwithahistoryofOUDinrecoveryx2monthsonbuprenorphine16mgdailyisadmittedafteramotorvehicleaccidentandfoundtohavemultiplefracturesrequiringoperativerepair.● Whatdoyoudowithhisbuprenorphinebeforesurgery?Whatif
hewasonmethadone?● Whatdoyoudowithhisbuprenorphineafterthesurgeryto
managehispain?Whatifhewasonmethadone?
Whatcanyoudoatyourinstitution?Ø DispensenaloxoneforallpatientswhouseopioidsordrugsØ Ensurebuprenorphineandmethadoneareonformulary,continuedduring
hospitalization/surgery
Ø CreatehospitalordersetorguidelinefornewstartsØ PartnerwithstakeholdersØ Startprescribing!Ø Disseminateyourknowledgewithcolleagues
Objectives 1. Diagnoseandtreatopioidwithdrawalandopioid
usedisorder(OUD)witheithermethadoneorbuprenorphine
2. Identifyhowtolinkhospitalizedpatientstobuprenorphineormethadonetreatmentondischarge
3. NamethreeoptionsforOUDharmreduction
ReflectionsTake1minutetowritedown(ortweet):● Whatconceptortoolyouaretakingawayfromthis
workshop?
● WhatisoneaspectofOUDorharmreductionthatyoucanspeaktoprovidersatyourhomeinstitutionabouttoraiseawareness?
Thankyou!
Email me at [email protected]
Additional Resources: UCSF Substance use warmline: (855) 300-3595, 6am-5pm PT
SAMHSA, TIP 63: Medications for OUD www.ed-bridge.org
