Inpatient Management of Opioid Use Disorder-Slides

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This document addresses inpatient management of patients with opioid use disorder (OUD), focusing on initiating buprenorphine treatment, including standard and low-dose (microdosing) protocols, managing precipitated withdrawal, and adapting strategies for illicit fentanyl users. The case study follows a 35-year-old man with untreated OUD and MRSA endocarditis, emphasizing the importance of offering medication for opioid use disorder (MOUD) alongside infection treatment to improve outcomes such as longer antibiotic use and reduced readmissions.<br /><br />Buprenorphine, a partial mu-opioid receptor agonist with a ceiling effect on respiratory depression, is highlighted for OUD treatment. Traditional buprenorphine/naloxone initiation requires patients to be in moderate opioid withdrawal (COWS ≥8). Alternatively, low-dose initiation (microdosing) allows gradual buprenorphine introduction while continuing full opioid agonists, beneficial for patients currently using fentanyl or with pain requiring opioids. Microdosing protocols vary from 3- to 7-day regimens, with dosage escalation while tapering full agonists based on shared decision-making.<br /><br />Precipitated withdrawal, characterized by a sudden increase in withdrawal symptoms after buprenorphine initiation, is managed by reinstating buprenorphine dosing or full opioid agonists along with non-opioid symptom relief (e.g., clonidine, analgesics, antiemetics). Pain management in patients on buprenorphine involves multimodal strategies, including split buprenorphine doses and short-acting opioids when necessary.<br /><br />The document discusses challenges posed by illicit fentanyl—due to its potency and lipophilicity—requiring flexible buprenorphine initiation strategies, and the emerging issue of xylazine, a veterinary sedative adulterant causing sedation, skin ulcers, and withdrawal symptoms without a reversal agent. Harm reduction in hospitalized opioid users includes offering MOUD, screening for infectious diseases, addressing pain and withdrawal adequately, providing naloxone, and counseling patients on safer use practices.<br /><br />Discharge planning should ensure continuation of MOUD with appropriate prescriptions, linkage to outpatient care, and provision of naloxone. Patient engagement and shared decision-making remain central throughout. The case concludes with the patient acknowledging possible ongoing heroin use despite buprenorphine, reinforcing the importance of harm reduction counseling and naloxone access.<br /><br />Overall, this resource promotes evidence-based, patient-centered inpatient approaches to OUD treatment incorporating newer challenges with fentanyl and xylazine, aiming to reduce morbidity and mortality.
Keywords
opioid use disorder
buprenorphine initiation
microdosing protocol
precipitated withdrawal
illicit fentanyl
medication for opioid use disorder (MOUD)
pain management
xylazine adulterant
harm reduction
inpatient treatment