Opioid Use Disorder¶
Rita Hurd, David Marcovitz
Background¶
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Standard of care is opioid stabilization with buprenorphine or methadone (in OUD) or other full agonist opioids (in chronic opioid therapy)
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Methadone and buprenorphine can be ordered by any physician for inpatients
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Maintenance agonist therapy should be offered to every patient, with preference for an “opt-out” approach (even for uninsured patients through state grant funding)
Presentation (Withdrawal)¶
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Restlessness/psychomotor activation, anxiety, irritability, nausea, abdominal cramping, loose stool, diffuse musculoskeletal pain, chills, insomnia, yawning
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Pupillary dilation, piloerection, tearing, nasal congestion, diaphoresis, restless legs
Evaluation¶
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Clinical Opioid Withdrawal Scale (COWS): quantifies severity of opioid withdrawal and allows for safer buprenorphine inductions
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Asking about opioid exposure: “You’re uncomfortable. I work with a lot of people in the hospital, and some come with regular exposure to opioids from a lot of different places (their doctors, friends), should we be treating any withdrawal for you?”
Medications for Opioid Use Disorder (MOUD)¶
Buprenorphine¶
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Partial agonist at the mu opioid receptor with high binding affinity
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Long half-life (24-36 hours) allows for daily dosing
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TID dosing is more effective for acute pain (as the analgesic effect is shorter-lived)
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OK to use in renal failure/HD; may reduce dose in hepatic injury
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All non-pregnant pts should receive buprenorphine-naloxone (e.g. Suboxone) formulations to mitigate risk of diversion/injection
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Induction:
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Hold all opioid medication 12+ hours prior to first buprenorphine dose (typically, this opioid-free period is overnight from 9 PM to 9 AM), with a recorded COWS score >8-10;
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4 mg is given SL, monitoring for oversedation; additional 4 mg is given in 1 hour, and final 4 mg at 4 hours (total of 12 mg in first day)
- Only sedation or hypopnea should prevent a full 12 mg dose
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Typical starting dose: 12-16 mg/day
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Maintenance: 4-32 mg daily; 16mg and above to suppress opioid use
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Requires waivered-provider
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Acute Pain Management in pts using Buprenorphine:
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There is no contraindication to full-agonist opioid analgesia for breakthrough pain
- If the etiology of pts pain would require opioid therapy in a non-OUD patient, do not avoid opioids; these may be used safely in the hospital
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Peri-operative pain management: continue buprenorphine at reduced and split doses (4 mg BID or TID); will prevent withdrawal and cravings, but NOT manage new pain
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Post-operatively: reduce opioid requirements and increase buprenorphine to home dose
- If buprenorphine was discontinued, will require induction procedure
Methadone¶
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Full mu opioid agonist with additional NMDA-receptor activity
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Better option for individuals who cannot tolerate the buprenorphine induction procedure, with significant chronic or escalating pain
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Long t½: 12-36 hrs; max 10 mg/d q7d, to prevent dose-stacking and delayed overdose
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Safe in renal failure; dose reduction for hepatic injury
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Potential for QT prolongation at higher doses, warrants QTc monitoring
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Induction:
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In the hospital, start at 10 mg TID, holding doses for sedation or hypopnea; lower doses if concerned for respiratory compromise or concurrent CNS depressant therapy
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Limit 40 mg in first 24 hours; then titrate 5 mg/d q3d while admitted
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Maintenance:
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Must confirm dose with methadone clinic before restarting outpatient dose; until then, do not give more than initial doses (30 mg in single dose, 40 mg in first 24 hours)
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After confirming home dose, continue as single daily dose
Naltrexone¶
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Mu opioid antagonist; Half-life oral ~4 hours but clinically active ~24 hrs
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IM maintains clinically effective levels up to 30 days
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High affinity for mu receptor --> CAN precipitate withdrawal requiring 7-10 days opioid abstinence prior to initiation
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If due for monthly injection while admitted, may substitute oral formulation until discharged to outpatient provider to receive injection
Additional Information¶
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Psychosocial Interventions that complement MOUD:
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Consider referral to SUD counseling, mutual help (self-help, 12-step, AA), intensive outpatient, and short- or long-term residential treatment
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Use of other drugs NOT a contraindication to MOUD, however should encourage abstinence from other drugs during therapy (especially benzodiazepines)
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Prescribe intranasal naloxone for overdose prevention to all OUD patients discharging from hospital, regardless of MOUD status