Trea%ng opioid addic%on in hospitalized medical pa%ents

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Angelina Hudson
8 years ago
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1 Trea%ng opioid addic%on in hospitalized medical pa%ents Miriam Komaromy, MD, FACP Associate Professor of Medicine Associate Director of Project ECHO University of New Mexico Health Sciences Center Tel: Mr. L is a 34 yo man who is admi<ed with suspected endocardi%s. He is an ac%ve injec%on drug user, and was injec%ng heroin just prior to admission. He is alarmed about his medical condi%on, and is ini%ally coopera%ve with treatment. However, a few hours ader admission he begins to become restless and agitated. You prescribe clonidine for suspected opioid withdrawal. At 6 AM the floor nurse calls to tell you that the pa%ent has led the hospital AMA. What op%ons are available to treat impending opioid withdrawal in an inpa%ent? Who can prescribe buprenorphine to a hospitalized pa%ent? Buprenorphine is safe Can prescribe as a taper or maintenance Much more effectve than clonidine for withdrawal Will retain patents in the hospital for treatment of their medical illness Humane, and makes patent management easier Any physician; a buprenorphine waiver is not required when treatng an inpatent SAMHSA website FAQ: h`p://buprenorphine.samhsa.gov/faq.html#a25 Gowing L, Cochrane Database 2009 How should buprenorphine be prescribed to a hospitalized opioid- addicted pa%ent? Write orders to begin treatment with buprenorphine once mild- to- moderate withdrawal symptoms are present Clinical Opiate Withdrawal Score (COWS) can be used to measure this Start patent with a 4 mg test dose, and if it is well tolerated then give additonal 4 mg every 2 hours untl withdrawal symptoms resolve or 12 mg is reached on day 1. Subsequent daily dose can increase to 16 mg/day if needed. ConTnue this dose daily untl discharge (if maintenance can be arranged) or untl 3 days prior to discharge, when dose should be tapered off. Can rx either buprenorphine monoproduct or buprenorphine/naloxone combo (Suboxone) Must be administered sublingually Clinical Opioid Withdrawal Score (COWS) Pulse rate SweaTng Restlessness Pupil size Bone/join aches Runny nose/tearing GI Upset Tremor Yawning Anxiety/irritability Gooseflesh skin Score = mild- to- moderate withdrawal 1

He is alarmed about his medical condi%on, and is ini%ally coopera%ve with treatment. However, a few hours ader admission he begins to become restless and agitated.

2 Caveats Do not initate buprenorphine if the patent has been using methadone within the past week or the UDS is (+) for methadone Do not initate buprenorphine if the patent is not opioid- dependent (in which case, the patent will not develop withdrawal symptoms) Risk of respiratory suppression from buprenorphine is almost non- existent for adults UNLESS high- dose benzos are co- administered, so: Do not use bup in a patent who needs high- dose benzos, eg actve alcohol withdrawal Total daily bup dose can be given as a q day dose, except in patents with pain; divide TID- QID for be`er analgesia Bup interferes with effect of other opiates, but is itself a potent analgesic What about buprenorphine maintenance? Maintenance treatment with buprenorphine is highly effectve at reducing relapse, injecton drug use, HIV and Hep C infecton 1, and death Bup is covered by Medicaid without prior authorizaton Unfortunately, there are far too few bup prescribers in NM, and arranging for a patent to transfer to maintenance therapy is hard ASAP: Socorro Lopez- Mezon RN works to arrange rapid intake into ASAP for patents being discharged from UNM. # First Choice: patents who have primary care at FCCH can usually get bup maintenance there Page K, JAMA Int Med 2014 Trial of buprenorphine 72% of inpa%ents randomized to maintenance buprenorphine with linkage to outpa%ent bup treatment successfully entered maintenance outpa%ent treatment, vs. 12% of inpa%ents randomized to 5 day bup taper. 40 Heroin addicts Buprenorphine 16 mg/day vs taper + placebo All received counseling, groups Followed for 1 year Buprenor -phine Placebo Retained at 1 yr 70% 0 % died 0 20% Kakko et al, Lancet 2003 Liebschutz J, JAMA Int Med 2014 Evidence con6nues to grow showing that buprenorphine saves lives Heroin overdose deaths fell by 2/3 as buprenorphine MAT availability increased in BalTmore Warning: if a pa%ent is tapered off of opioids the pa%ent MUST be warned that their tolerance will be lowered and they can easily overdose and die ader discharge if they resume the same dose of opioids (RR of death 15) Consider dispensing Narcan (naloxone) for overdose preven%on prior to discharge! Schwartz, AJPH, 2012 Ravndal E, Drug Alcohol Depend

so: Do not use bup in a patent who needs high- dose benzos, eg actve alcohol withdrawal Total daily bup dose can be given as a q day dose, except in patents with pain; divide TID- QID for be`er

3 Ms. R is a 42 year- old woman who develops gall- stone- related pancrea%%s. She is hospitalized for treatment and pain control. On admission, she reports that she is on maintenance therapy with Suboxone (buprenorphine/naloxone) 16 mg per day for treatment of Opioid Use Disorder. UDS (+) for buprenorphine, (- ) for methadone and benzos. She is having marked abdominal pain. How would you manage her pain? Management of pain in pa%ents treated with buprenorphine OpTons include: Managing pain with buprenorphine: divide dose TID- QID, and increase total dose as needed for analgesia up to 32 mg or more per day ConTnuing buprenorphine but overriding it : Fentanyl has an even higher affinity for the mu opioid receptor than bup, so provides effectve analgesia Stopping buprenorphine and beginning pain management with other opioids, with plan to resume bup prior to discharge Make an explicit plan with patents about resuming buprenorphine Ms S is a 64 year old woman who has been treated for 5 years with oxycodone for pain from spinal stenosis. She is hospitalized ader being found unconscious by her husband in what appears to be an accidental overdose. How would you address her ongoing pain and also her overdose risk? Buprenorphine/naloxone can be prescribed off label for patents who do not meet DSM criteria for Opioid Use Disorder (opioid addicton) Buprenorphine transdermal patch is FDA approved for treatment of pain Useful in patents who have major risks of overdose or other complicatons from standard opioids Safer, no tolerance, no sedaton, and no development of opioid- induced hyperalgesia Not recommended for use in patents treatmed with benzodiazepines because of overdose risk Project ECHO Extension for Community Health Outcomes NEJM : 364: 23, June , Arora S, Thornton K, Murata G 3

UDS (+) for buprenorphine, (- ) for methadone and benzos. She is having marked abdominal pain. How would you manage her pain?

4 Methods Use Technology to leverage scare resources Sharing best practces Case- based learning Web- based database to monitor outcomes Arora S, Geppert CM, Kalishman S, et al: Acad Med Feb;82(2): Arora S, Kalishman S, Thornton K, Dion D et al: Hepatology Sept;52(3): Treatment Outcomes Outcome ECHO UNMH P- value SVR* (Cure) Genotype 1 SVR* (Cure) Genotype 2/3 N=261 N=146 50% 46% NS 70% 71% NS Minority 68% 49% P<0.01 *SVR=sustained viral response NEJM : 364: 23, June , Arora S, Thornton K, Murata G 4

2010 Sept;52(3):1124-33 Treatment Outcomes Outcome ECHO UNMH P- value SVR* (Cure) Genotype 1 SVR* (Cure) Genotype 2/3 N=261 N=146 50%

5 Please visit our website, echo.unm.edu or contact me if you would like to par%cipate in ECHO. We love pharmacists! 5

The path forward: How can we develop a rational system for addressing Opioid Use Disorder?

The path forward: How can we develop a rational system for addressing Opioid Use Disorder? Miriam Komaromy, MD, FACP Associate Director, ECHO Institute University of New Mexico Bernalillo County Opioid