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1 A Multidisciplinary Approach to the Care of the Patient with Endocarditis and Opioid Use Disorder Jennifer Dundon, PA-C Leslie Bosworth, LICSW Christopher Rowley, MD John Whitlock, CNS Lorraine Britting, CNP We have No Conflicts of Interest to Report 1

2 1. Scope of the problem at BIDMC 2. Genesis of the workgroup 3. Patient Case Presentation 4. Resources for patients/families and clinicians Thank you to Elana Rosenthal, MD Infectious Disease Fellow Extraordinaire 2

3 Confirmed Opioid Related Deaths 2015 not available Opioid-Related Deaths, Unintentional/Undetermined Massachusetts: ,400 Confirmed Estimated Number of deaths 1,200 1, ,173 1, BIDMC: Clinical Query to ED: 956 patients Inpatient: 551patients Outpatient: 655 patients 3

4 747 patients with Infectious Endocarditis (IE) 102 patients with associated IDU 130 admission for IE 233 admissions total after initial admission for IDU-IE Race White 75/102 (73.53) Black 12/102 (11.76) Hispanic 6/102 (5.88) Unknown 9/102 (8.82) Sex Male: 56/102 Female: 46/102 OSH transfer Initial admission: 57/102 (55.88) 130 admissions for IE Surgery consulted: 73% Surgery done: 38% Age at Sentinel Admission < >= /14-8/14 4

5 Sentinel IDU-IE Admission, n = 102 Inpatient consults Social Work Consult: 86% Addictions Consult: 24% Psychiatry Consult: 24% Discharge planning Addiction mentioned in the discharge summary plan: 56% Plan for medication assisted therapy (MAT): 8% 6/8 restarting or continuing previous treatment 1/8 discharged on methadone without methadone clinic in place 1/8 pregnant, started on methadone by pain service Discharged with Rx naloxone: 0% Sentinel Admission (102) Readmission (131) IDU Readmission (42) Pts with surgery (48) All Inpatient Consults Social Work 87% 54% 41% 93% 68% Addiction Clinical RN 24% 7% 10% 31% 14% Psychiatry 24% 10% 10% 18% 16% Discharge Planning Discharge Summary 56% 31% 55% 23% 42% Plan for MAT 8% 14% 12% 6% 11% Naloxone Prescription 0% 0% 0% 0% 0% 5

6 Liebschutz JM, Crooks D, Herman D, Anderson B, Tsui J, Meshesha LZ, Dossabhoy S, Stein M. Buprenorphine treatment for hospitalized, opioid dependent patients: a randomized clinical trial. JAMA Intern Med. 2014; 174(8): people were assigned to a detox group detox alone 72 people were assigned to a linkage group started Suboxone in the hospital and continued to be followed in an outpatient primary care clinic that continued the Suboxone. 52 (72.2%) of the linkage group followed up at the PCP Suboxone clinic, whereas only 8 (11.9%) of detox only patients did. After 6 months, 12 (16.7%) of linkage patient were still getting Subxone at the PCP clinic, whereas only 2 (3%) of detox only patients were. Readmissions Death Time from discharge #1 to admission #2 Median = 35.5 days Average = days Time from discharge #1 to readmission for recurrent IE Median = 216 days Average = days 24/102 (23.5%) Time from admission #1 to death Median = 325 days Average = 607 days Age at death Median = years Average = years 6

7 Jennifer Dundon, PA Leslie Bosworth, LICSW John Whitlock, RN, MS, CNS Evolution Pathway Patient and Family resources 7

8 Nurses Social Work Psychiatric CNS Surgery CNS Infectious Disease MD s Hospitalists Cardiothoracic surgeon Pain consult Ethics MD and RN Government affairs liaison Case Management Residents/Fellows NP s and PA s ALCOHOL AND DRUG ABUSE GUIDELINE PLEASE NOTE: The following titles are all weblinks; by pressing Control and clicking a topic, you will be taken directly to that section. If you want to print out only a part of this document, you can print out those pages by specifying them (for example, for the flowsheet, pages 5-6) in the Print Dialogue Box. MANAGEMENT OF ALCOHOL WITHDRAWAL... DIAGNOSIS OF ALCOHOL WITHDRAWAL... HISTORY OF ALCOHOL USE... WITHDRAWAL SYNDROMES... DIFFERENTIAL DIAGNOSIS OF DELIRIUM IN ALCOHOLICS:... MONITORING FOR ALCOHOL WITHDRAWAL... BIDMC ALCOHOL AND BENZODIAZEPINE WITHDRAWAL FLOWSHEET AND CIWA... TREATMENT OF ALCOHOL WITHDRAWAL... MANAGEMENT OF OPIATE WITHDRAWAL... DIAGNOSIS OF OPIATE WITHDRAWAL... HISTORY OF NARCOTIC USE... SIGNS OF OPIATE WITHDRAWAL... SYMPTOMS OF OPIATE WITHDRAWAL... MONITORING FOR NARCOTIC WITHDRAWAL... BIDMC NARCOTIC WITHDRAWAL FLOWSHEET AND CINA... TREATMENT OF NARCOTIC WITHDRAWAL METHADONE MAINTENANCE PATIENTS METHADONE WITHDRAWAL REGIMEN CLONIDINE WITHDRAWAL REGIMEN BUPRENORPHINE WITHDRAWAL REGIMEN ADJUNCTIVE MEDICATIONS... LAST DOSE METHADONE LETTER FOR METHADONE MAINENENCE CLINIC... MANAGEMENT OF OTHER SUBSTANCES OF ABUSE... MANAGEMENT OF UNKNOWN SUBSTANCE WITHDRAWAL... WHOM TO CALL FOR HELP... SELF-HELP FACT SHEET... LOCATING COMMUNITY RESOURCES... REFERENCES AND WEB RESOURCES... 8

9 Safer injection practices for people who inject drugs Remember! Because it is so difficult to stop using, it s important to know Stay as safe as you can while you are still using. how to keep yourself as safe as possible until you are ready to quit. Follow these tips when injecting drugs. Don t stop trying to quit. Hardly anyone quits without Wash your hands with soap and water first. many failures. Keep Needle/syringe trying. o Do not share needles and syringes. HIV, hepatitis C, and other infections can be spread this way. For immediate help, call your doctor or go to your o Always try to use a new needle/syringe for each local emergency room. injection. This is how a needle looks under a microscope after it is used. If you don t have bleach, use o If youare re-using a needle, it must be cleaned one of these: before you use it. If you use it over and over, hydrogen peroxide rubbing alcohol clean it every time. To clean: high-proof drinking alcohol 1. Draw cold water into the syringe several (vodka, rum) times to rinse the syringe (see information below about safe water to use). 2. Draw household bleach into the syringe. Keep it there for at least two minutes. Rinse out all the bleach with clean, cold water. Cookers and spoons o These should be cleaned before each use. Clean first with water, then with bleach. Leave the bleach on the surfaces for at least two minutes, then rinse completely. o Do not share cookers and spoons. HIV, hepatitis C, and other infections can spread this way. Dissolving solids o If using an acid, use Vitamin C powder. o Do not use lemon juice or vinegar. o Do not crush pills in the mouth or teeth. Water for dissolving drugs and cleaning equipment o The safest water is sterile water that you buy at the drug store. (Do not buy sterile saline, or salt water; your drugs may not dissolve completely.) Over o If you don t have sterile water, use water that you ve boiled for at least 10 minutes. Boil just before using, allowing a short time to cool. o If you don t have either of these, use tap water. o It is not a good idea to use toilet water. However, if you do, use water from the tank in the back of the toilet. Do not use water from the bowl where you go to the bathroom. Cottons/filters o Use clean, 100% cotton from a dental pellet, Q-tip, or cotton ball. If you don t have these, filter paper or tampons may work. Do not use cigarette filters. They have small bits of glass. Also, if the cigarette has been smoked, the filter will have harmful substances that should not be injected. o Clean hands before handling the cotton. o Do not share or re-use cotton. HIV, hepatitis C, and other infections can be spread this way. Do not try to get drugs from your used cotton. The used cotton contains harmful bacteria and fungi. Skin o Clean skin with alcohol before injection. o Do not lick skin or needle. This increases the risk of infection. For more information Harm Reduction Coalition, Getting Off Right Safety Manual o Needle Exchange Programs. You can get clean needles through the following programs: Boston Needle Exchange/AHOPE Albany Street, Boston The Needle Exchange at Green Street/AIDS Action Committee 359 Green Street, Cambridge, MA Phone: The Needle Exchange at Amory Street 75 Amory Street, Jamaica Plain, MA Phone: The AIDS Project, Worcester 85 Green Street, Worcester, MA Tapestry Health Needle Exchange, Northhampton 16 Center Street, Suite 423, Northampton MA Tapestry Health Needle Exchange, Holyoke 15A Main Street, Holyoke, MA This material was prepared by clinicians from nursing and infectious diseases at Beth Israel Deaconess Medical Center. It is produced and distributed by the Beth Israel Deaconess Learning Center. 2015, Beth Israel Deaconess Medical Center, All rights reserved. LC /

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12 List of pharmacies with standing orders who can dispense without prescription to any person or family member Naloxone prescribing laws in MA How to prescribe naloxone MA approved training resouces. 1. Hospital wide Opioid Task Force started 2. Continue to spread the word about our resources 3. Use social work and nursing to lead usage of resources for specific patients 12

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