Rapid Clinical Updates: Hospitalist Management of Opioid Use Disorder-Handout

Handout
Pdf Summary
Opioid Use Disorder (OUD) presents a major public health crisis, with over two-thirds of drug overdoses involving opioids, primarily driven by rising synthetic opioids like fentanyl despite a decrease in heroin use. OUD leads to frequent hospital admissions, longer hospital stays, poorer outcomes, and an estimated annual cost of $13 billion. Hospitalization serves as a critical intervention point, prompting the Society of Hospital Medicine (SHM) to recommend that hospitalists obtain X-waivers to prescribe buprenorphine and routinely provide naloxone.<br /><br />Buprenorphine, a partial mu-opioid receptor agonist, offers a safer alternative to opioid detoxification with a ceiling effect that limits respiratory depression. Inpatient initiation typically requires the patient to be in mild withdrawal (COWS score ≥8), starting with 2-8 mg and titrating up to 16 mg on day 1 and 24 mg on day 2. Microdosing protocols can initiate treatment without withdrawal symptoms, especially useful for patients regularly using fentanyl or long-acting opioids.<br /><br />Methadone, with higher treatment retention than buprenorphine, is heavily regulated and requires daily dispensing through opioid treatment programs. Though its analgesic peak is within hours, steady-state dosing needs several days. Methadone cannot be prescribed for OUD at discharge but remains valuable for intractable pain. Typical starting doses range from 10-30 mg daily.<br /><br />Regarding acute and perioperative pain, continued use of buprenorphine and methadone during hospitalization is now considered safe and effective, countering previous practice of discontinuation. Splitting doses to twice or thrice daily and increasing doses as needed can improve analgesia.<br /><br />In summary, optimizing inpatient management of OUD with buprenorphine and methadone, along with harm reduction strategies like naloxone prescribing, can improve outcomes in hospitalized patients.
Keywords
Opioid Use Disorder
OUD
buprenorphine
methadone
naloxone
hospitalization
fentanyl
X-waiver
microdosing
harm reduction