New recommendations on managing patients with opioid use disorder from SHM

The Society of Hospital Medicine recently released a consensus statement on the management of opioid use disorder (OUD) and associated conditions among hospitalized adults.

The statement was based on a systematic review of relevant guidelines. A working group drafted the statement, collected feedback, and finalized the 18 recommendations addressing identification and treatment of OUD and opioid withdrawal, perioperative and acute pain management in patients with OUD, and methods to optimize care transitions at hospital discharge. The consensus statement was published by the Journal of Hospital Medicine on July 26.

Some recommendations from the statement include:

• Use nonstigmatizing and person-first language.
• Offer testing for HIV; hepatitis A, B, and C; syphilis; and pregnancy, as well as urine drug analysis.
• Offer buprenorphine or methadone as first-line agents to treat opioid withdrawal and OUD (buprenorphine at 2 to 4 mg, methadone at 20 to 30 mg). Continue buprenorphine or methadone during hospitalization in patients already on these medications.
• Prescribe nonopioid adjunctive medications (e.g., clonidine, loperamide, NSAIDs, acetaminophen, ondansetron, hydroxyzine) as appropriate for opioid withdrawal symptoms.
• Offer intramuscular naltrexone if the patient prefers opioid antagonist treatment to methadone or buprenorphine.
• Assess and treat pain in the setting of OUD.
• Obtain an X waiver to prescribe buprenorphine at hospital discharge.
• Link patients to a buprenorphine prescriber or an opioid treatment program, when desired, as well as to psychosocial support, mental health treatment, mutual support groups, peer recovery support, harm reduction services, and, if appropriate, resources for housing and shelter.
• When patients on medication for OUD require postacute care, discharge patients to facilities that will continue these medications.
• Prescribe naloxone at hospital discharge for all patients with OUD.

The systematic review of relevant guidelines, published with the consensus statement, included 19 guidelines which were released between January 2010 to June 2020 and addressed OUD treatment, opioid withdrawal management, opioid overdose prevention, or care transitions. The review found that most recommendations were based on observational studies or expert consensus. “Future research should systematically study buprenorphine and methadone initiation and titration among people using fentanyl and people with pain, especially during hospitalization,” the review concluded.