SGIM Forum

Best Practices

Fighting another Epidemic: Strategies to Treat Substance Use Disorders

Dr. Hanna (reem.hanna@cuanschutz.edu) is an assistant professor in the Division of Hospital Medicine at the University of Colorado School of Medicine and director of the Hospital Medicine Global Health Scholar Program at the University of Colorado Hospital. Dr. Callister (Catherine.callister@cuanschutz.edu) is an assistant professor in the Division of Hospital Medicine at the University of Colorado School of Medicine.

Introduction

An increase in opioid overdose and alcohol use is a consequence of the COVID-19 pandemic.1,2 Greater isolation, increased unemployment, and decreased access to treatment resources and support groups are likely contributing to these findings. In the face of this pandemic, there are proven tools to help clinicians treat patients with substance use disorders, however many patients hospitalized for overdose are not provided naloxone, offered medication-assisted treatment, or connected with addiction treatment.1 In our role as hospitalists who work on our hospital’s addiction medicine consultation service, we review the following five steps that physicians can take to address opioid, alcohol, and other use disorders in hospitalized patients.

1. Ensure all at risk-patients have a naloxone prescription. Naloxone is an opioid agonist that rapidly reverses the effect of opioid overdose. The CDC recommends naloxone prescription for patients with a history of opioid overdose, any substance use disorder, opioid dosages ≥50 morphine milligram equivalents (MME)/day or concurrent benzodiazepine use.3 The usual dose is 0.4 mg when administered intravenously, intramuscularly, or subcutaneously. We recommend prescribing the naloxone intranasal spray as it is dispensed at a premeasured 4 mg dose of the 4 mg/0.1 mL concentration. Standing-orders for naloxone allow pharmacists to dispense naloxone without a prescription to ensure all patients have access. Education of patients, caregivers, and household members is essential for its success.

2. Review harm reduction practices with patients. Hospitalization is a good opportunity to introduce or review harm reduction practices with patients, including naloxone provision, HIV and hepatitis C screening, pre-exposure prophylaxis (PrEP) discussion and prescription, a review of safe injection practices, and resources for syringe exchange programs.

Test for HIV and Hepatitis C

People who inject drugs should be tested frequently for HIV and Hepatitis C; however, often opportunities for screening are missed.

Prescribe PrEP for People Who Inject Drugs

PrEP significantly reduces the risk of HIV infection in people who inject drugs, and the CDC recommends prescribing PrEP to this population. The hospital stay can be used as a time to educate patients about PrEP, prescribe it, and connect patients with close outpatient follow up.

Review Safe Injection Practices

These include: One shot = one new needle and syringe, avoid sharing needles or other injection equipment, clean skin thoroughly prior to injection, and use with others in case of overdose. For a comprehensive review of safe injection practices we recommend the manual “Getting off right: a safety manual for injection drug users.”3

Provide Information about Local Syringe Exchange Programs

Connecting patients to a needle exchange program enables them to access clean needles, other injection supplies, and, often, fentanyl test strips.

3. Prescribe or connect patients to medication for Opioid Use Disorder (OUD). Like many other chronic diseases, OUD has highly effective medications that are associated with decreased heroin use, treatment retention, and a reduction in all-cause mortality.4 Despite these benefits, many hospitalized patients with OUD do not receive life-saving treatment with buprenorphine or methadone, even following an overdose event.4 A hospital stay is an excellent opportunity to discuss medication options for treatment with patients and to initiate the medication of their choice.

Buprenorphine

Buprenorphine is a partial opioid agonist with a high affinity for the opioid receptor. If started in the presence of full-dose opioids, buprenorphine will precipitate withdrawal symptoms. Once patients are exhibiting symptoms of withdrawal, as measured by the Clinical Opioid Withdrawal Scale >8 (COWS), buprenorphine/naltrexone 4 mg can be started, followed by additional doses of 4 mg buprenorphine for continued symptoms of withdrawal. For an excellent stepwise protocol of how to initiate buprenorphine or methadone in the hospital, we recommend Project SHOUT’s: Inpatient Management of Opioid Use Disorder: Buprenorphine.5

Methadone

In our practice, we usually administer 20-30 mg of methadone as the first dose with a maximum of 40 mg on the first day and while the patient is in the hospital. Though methadone for OUD treatment is typically administered in opioid treatment programs (OTP), it can be used in the inpatient setting for the prevention of opioid withdrawal. If you are prescribing methadone to prevent withdrawal during a hospital stay, you cannot prescribe methadone at discharge. In the outpatient setting, methadone that is being used to treat opioid use disorder must be prescribed by a SAMHSA approved Opioid Treatment Program (OTP). Ideally, a hospital stay is an opportunity to engage patients in treatment with linkage to an OTP where they can continue to receive care as an outpatient.

4. Offer treatment for alcohol use disorder. While alcohol use disorder causes severe morbidity and early mortality, it remains widely untreated. Naltrexone and acamprosate are two medications used for alcohol use disorder and have been strongly supported by placebo-controlled clinical trials.6 Oral naltrexone is one pill daily and extended release naltrexone is one injection monthly as compared to acamprosate’s two pills three times a day. Thus, naltrexone, as a daily and monthly formation, promotes adherence.6 In rare cases, and at high doses (>50 mg daily), naltrexone has been associated with hepatotoxicity; thus, we suggest acamprosate rather than naltrexone if patient has acute hepatitis, liver enzymes ≥3 to 5 times normal, or liver failure. If a patient is taking prescribed opioid medication, we suggest prescribing acamprosate rather than naltrexone as naltrexone is an opioid antagonist.

5. Connect patients to community resources. In addition to medication-assisted treatment, connecting patients to available community resources is essential for their success. During the COVID-19 pandemic, most treatment programs are continuing their services, but many have moved to an online or phone-based format. Another valuable resource is peer support programs, including the 12-step facilitation which introduces patients to the 12-step philosophy and encourages 12-step engagement. We recommend utilizing social workers and other ancillary resources to assist patients in navigating the various community resources and their availability based on location, insurance, and cost.

As more patients present with substance use disorders in the setting of the COVID-19 pandemic, these 5 steps will help clinicians to provide appropriate treatment and connect their patients to community resources. One specific and important way that physicians can be prepared to treat patients with OUD is to complete their X-waiver training and then prescribe buprenorphine as appropriate in their practice. To develop familiarity and experience with these modalities, physicians should seek out additional information via the buprenorphine waiver training and various educational opportunities at the Substance Abuse and Mental Health Services Administration (SAMHSA).

References

  1. Ochalek TA, Cumpston KL, Wills BK, et al. Nonfatal opioid overdoses at an urban emergency department during the COVID-19 Pandemic. JAMA. 2020;324(16):1673–1674.

  2. Pollard MS, Tucker JS, Green HD. Changes in adult alcohol use and consequences during the COVID-19 pandemic in the US. JAMA. Network Open, 2020. 3(9): p. e2022942-e2022942.

  3. Coalition, N.H.R. Getting off right : A safety manual for Injection Drug Users. 2020 [cited 2020 Nov 20]; Available from: https://harmreduction.org/issues/safer-drug-use/injection-safety-manual/.

  4. Sordo L, Barrio G, Bravo M, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. BMJ. 2017. 357: p. j1550.

  5. Coffa D, Harter K, Lee S, et al. Inpatient management of opioid use disorder: Buprenorphine. CHCF. https://www.chcf.org/wp-content/uploads/2018/03SHOUTGuidelinesInpatientOpioidTreatmentBuprenorphine.pdf. Published December 1, 2017. Accessed December 15, 2020.

  6. Jonas DE, Amick HR, Feltner C, et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 2014 May 14;311(18):1889-900.


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