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

Slides
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This SHM Rapid Clinical Update webinar, moderated by Dr. Joseph Sweigart with presenters Dr. Marlene Martín and Dr. Susan Calcaterra, focuses on hospitalist management of opioid use disorder (OUD). It provides practical guidance on diagnosing OUD, initiating evidence-based medication treatment during hospitalization, and ensuring effective linkage to outpatient care at discharge.<br /><br />OUD is prevalent among hospitalized patients, often leading to longer, costlier stays, frequent ED admissions, and high readmission and self-discharge rates. The ongoing COVID-19 pandemic has worsened opioid-related risks by increasing social isolation and disrupting support services. The rise in fentanyl-related deaths highlights the urgency of addressing OUD in hospital settings.<br /><br />The presenters emphasize respectful, person-first language to reduce stigma associated with substance use. They review DSM-5 criteria for OUD diagnosis, identifying key behavioral and physiological signs such as impaired control, craving, tolerance, withdrawal, and social impairment.<br /><br />Hospitalists are encouraged to initiate first-line treatments: buprenorphine (a partial mu-opioid agonist) and methadone (a full agonist). Both reduce mortality and improve treatment retention. Initiation protocols are discussed, including traditional buprenorphine induction—requiring the patient to be in mild withdrawal—and low-dose “microdosing” approaches that avoid precipitated withdrawal, especially useful in fentanyl users or those on long-acting opioids.<br /><br />Methadone can be started safely in-hospital following controlled dosing guidelines despite regulatory misconceptions. Pain management in patients on OUD medications, especially perioperative, requires careful continuation and possible dose adjustments rather than stopping buprenorphine or methadone outright. Multimodal pain control strategies are recommended.<br /><br />For discharge planning, hospitalists should prescribe buprenorphine if waivered or link patients with outpatient programs. Methadone requires partnerships with Opioid Treatment Programs (OTPs). Harm reduction interventions—such as naloxone distribution, syringe services, and infectious disease screening—are crucial components of comprehensive OUD care.<br /><br />The Society of Hospital Medicine advocates for hospitalists to obtain the X-waiver to prescribe buprenorphine and supports improved hospital-based OUD management. Practical steps provided include assessment, treatment initiation, harm reduction, and facilitated care transitions, aiming to reduce stigma and improve outcomes for hospitalized individuals with OUD.
Keywords
Opioid Use Disorder
Hospitalist Management
Buprenorphine Induction
Methadone Treatment
Harm Reduction
COVID-19 Impact
DSM-5 Criteria
OUD Diagnosis
Outpatient Linkage
X-waiver Prescribing