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Clinical Medicine | November 2, 2022 | FREE
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Owning OUD in the hospital

Less than 15% of patients with opioid use disorder (OUD) receive treatment with buprenorphine or methadone during hospitalization. New recommendations for hospitalists aim to change that.

Every hospitalist is aware of the ever-worsening opioid epidemic. In May, the CDC reported an estimated 107,622 drug overdose deaths in 2021 in the U.S., an increase of nearly 15% from 2020.

But that awareness does not always result in treatment of opioid use disorder (OUD) during hospitalization, according to Shoshana J. Herzig, MD, MPH, FACP, director of hospital medicine research and associate chief of hospital medicine for academic affairs for the division of general medicine at Beth Israel Deaconess Medical Center in Boston.

“Medication treatment of opioid use disorder reduces death by 30% … [yet] prior studies estimate that only about 20% of patients who are hospitalized with opioid use disorder-related complications end up receiving these medications during their hospitalization,” she said. “So there's a huge practice gap.”

To try to close that gap, Dr. Herzig and others with expertise in inpatient management of OUD wrote a consensus statement for the Society of Hospital Medicine on care for hospitalized patients with OUD, which was published in July by the Journal of Hospital Medicine.

Another recent paper noted that this responsibility falls on hospitalists due to the shortage of addiction medicine specialists in this country, particularly in smaller or community-based hospitals. “Given the pervasiveness of the opioid epidemic, hospitalists cannot wait or rely on addiction medicine specialists. We must take ownership of these patients and become part of the solution,” said an Annals for Hospitalists article published in the October Annals of Internal Medicine.

Experts offered a number of ways that hospitalists and hospitals can join the effort to improve care for their patients with OUD.

Improving inpatient OUD care

The consensus statement, which was based on a systematic review of relevant guidelines, includes 18 recommendations on managing OUD and related conditions for clinicians who practice in the hospital. They fall into three main categories: identifying and treating OUD and opioid withdrawal, managing OUD in the setting of acute pain, and optimizing care transitions for patients with OUD at discharge.

The statement recommends that hospitalists offer buprenorphine or methadone as first-line agents to treat opioid withdrawal and OUD and continue these medications during hospitalization in patients already on them. However, research shows that this may not be current practice, with less than 15% of more than 12,000 veterans with OUD receiving these medications during hospitalization in fiscal year 2017, according to results published in April 2020 by the Journal of General Internal Medicine.

Starting medications for OUD in the hospital is lifesaving on multiple levels, said Susan Calcaterra, MD, MPH, MS, lead author of the statement and an associate professor of hospital medicine and director of the Addiction Medicine Consultation Liaison Service at the University of Colorado Hospital in Aurora.

Maintaining patients' opioid tolerance during hospitalization is important because if they lose that tolerance, their risk of overdose is much higher if they return to use after leaving the hospital, she said. The medications also prevent withdrawal symptoms, allowing patients to feel comfortable during their hospital stay so they don't leave before completing medical treatment, for example, antibiotics for endocarditis or osteomyelitis related to injection drug use.

“We know that when that happens, they're more likely to come back to the hospital, so readmissions go up, and they're more likely to die from untreated disease,” Dr. Calcaterra said. “So … there are benefits, certainly to the patient, also to the health care system, to treating patients with these medicines.”

The consensus statement also recommends hospitalists obtain a special waiver through the U.S. Drug Enforcement Agency (DEA), commonly called an “X” waiver, to prescribe buprenorphine at discharge. A historical barrier to getting an X waiver was the required eight hours of training. But as of April 28, 2021, a new exemption allows eligible clinicians to treat up to 30 patients with OUD at one time using buprenorphine without having to meet certain training-related requirements.

That means it's no longer a heavy lift for busy hospitalists to get their X waiver, Dr. Calcaterra said. “The process itself now takes about 10 minutes,” she said. “And then once you complete the process, it takes, from what I'm reading and hearing, about six weeks for the official X waiver to be added to your DEA registration.”

Dr. Herzig obtained her X waiver about three years ago and said she has started several hospitalized patients on buprenorphine. “I think all hospitalists should have their X waiver,” she said. (Read ACP Hospitalist's September 2021 story for more on prescribing buprenorphine as a hospitalist.)

Even without an X waiver, hospitalists can prescribe buprenorphine during hospitalization, noted Dr. Herzig, who is also an associate professor of medicine at Harvard Medical School in Boston. “The only time that the X waiver is required is if you want to discharge a patient with a prescription for buprenorphine,” she said. “So that's where the X waiver comes in handy, because obviously it's hard to start a patient on buprenorphine in the hospital and then not be able to prescribe it on discharge.”

Even if the patient does not have a bridge buprenorphine prescription or linkage to OUD treatment after discharge, “That's not a reason to withhold treatment” with buprenorphine during hospitalization, Dr. Calcaterra added.

Continuing buprenorphine in the hospital can also be an answer to the statement's recommendation to assess and treat pain in the setting of OUD. It should be dosed every six to eight hours in patients with acute pain, in addition to use of short-acting opioids and nonopioid analgesics (usually at two to three times the usual dose), Dr. Calcaterra said.

“The reason for that is we know that if we stop buprenorphine in the perioperative period, we're creating an opioid deficit, so people not only are having pain but now they're having opioid withdrawal,” she said, adding that it can also be challenging to restart buprenorphine once it's stopped.

Historically, it was common to hold buprenorphine perioperatively. In a study of 183 veterans who were on buprenorphine prior to inpatient surgery in 2018, 66% experienced a perioperative buprenorphine dose hold, according to results published in September 2021 by the Journal of General Internal Medicine. “The authors reported that buprenorphine discontinuation persisted in the postoperative period, which could put patients at risk of return to use and overdose death,” Dr. Calcaterra said.

Another way to reduce the risk of overdose is prescribing naloxone at discharge for all patients with OUD, a practice the statement recommends. “We know that opioids are contaminating all of our [illicit] drug supply,” Dr. Calcaterra said. “We've certainly seen an increase in overdose deaths among people that are primarily users of methamphetamine or cocaine, and it's probably because their drug supply has been contaminated by fentanyl.”

Another recommendation (that was placed first in the statement) is that hospitalists should use nonstigmatizing and person-first language. Doing this in conversations and documentation can make the hospital a more welcoming place for patients with substance use disorders, said Marlene Martin, MD, a coauthor of the statement and a hospitalist and director of the Addiction Care Team at San Francisco General Hospital.

“We wanted to make sure that we include the importance of our role in reducing stigma because people who use substances often avoid coming to the hospital,” she said. “It's something my patients have shared with me so many times. They were so afraid they were going to be in withdrawal, their pain was going to be undertreated, that they were going to be judged.” (A recent ACP Internist article looked at the issue of stigma in substance use disorder treatment.)

Systemic solutions

Unfortunately, the COVID-19 pandemic stalled progress that was being made in expanding access to addiction treatment, noted Dr. Calcaterra. “People were told to isolate, and I think we saw a lot of people relapsing to substance use or suffering … [and] hospitalist groups had to quickly pivot to develop inpatient pathways to treat COVID, so a lot of attention was focused on treating COVID,” she said.

Now that hospitalists are able to become less laser-focused on COVID-19, Dr. Calcaterra hopes they can put these OUD management principles into practice.

“It helps when there is a hospitalist advocate who works to incorporate OUD treatment algorithms into their group's workflow and who will educate colleagues on OUD disorder treatment for hospitalized patients,” she said, noting that CA Bridge, a program from the state of California, provides easy-to-follow inpatient care pathways for substance use disorders.

While individual hospitalists can't fix all the addiction treatment gaps, their savviness about hospital operations and quality improvement can make a difference, said Dr. Martin, who is also an associate professor of clinical medicine at the University of California, San Francisco.

“Hospitalists are so good at being systems leaders and working in interprofessional settings and can build order sets that can help initiate opioid use disorder treatment,” she said. “We can partner with our social work colleagues who work with our community collaborators. … It doesn't have to all rely on one person.”

OUD also needs to be a larger, organizational priority, Dr. Calcaterra added. “I don't think that it's going to happen 100% organically,” she said. “There's going to need to be a push, either from hospital administration or some sort of financial incentive, for hospitalists to do this.”

Emergency medicine has moved in this direction, with EDs across the country now treating OUD as part of standard practice, Dr. Calcaterra noted. “We need to see hospital medicine do the same thing, because the ED is very different than the hospital,” she said.

Hospitals can follow any of at least six addiction care models, according to a narrative review published in May by the Journal of General Internal Medicine: interprofessional addiction consult services, psychiatry consult liaison services, individual consultant models, hospital-based opioid treatment, hospital-based alcohol treatment, and community-based in-reach, in which community clinicians deliver care.

“I think that this framework helps solve some of the puzzle of how hospitals and hospitalists should be thinking about improvement” of inpatient addiction care, said lead author Honora Englander, MD, another coauthor of the consensus statement and a professor of medicine and director of the Improving Addiction Care Team at Oregon Health & Science University in Portland.

Although there are no comparative studies of the different models, addiction consult services are the most comprehensive and are by far the most rigorously studied, she noted. “Interprofessional addiction consult services provide essential, transformative services and should be broadly expanded, supported, and studied,” said Dr. Englander. “But the message, from my perspective, isn't necessarily that every U.S. hospital should have an addiction consult service; the message is that every hospital should have evidence-based, patient-centered, and trauma-informed ways of caring for people with substance use disorder.”

Ultimately, hospitals and health systems should reframe their approach to OUD treatment, according to Dr. Englander, who also led a Perspective on hospital standards of care for people with substance use disorder, published Aug. 25 by the New England Journal of Medicine.

“In any hospital across the U.S., you can walk into the hospital and expect that a doctor can have a conversation with you about your goals of care and your code status. And the same should be true for our approach to opioid use disorder [management],” she said. “We are far from that right now. It's where we need to go, and it's where we need to go quickly, given the crisis in the United States.”