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Opioid Use Disorder

Rita Hurd, David Marcovitz

Background

  • Standard of care is opioid stabilization with buprenorphine or methadone (in OUD) or other full agonist opioids (in chronic opioid therapy)

  • Methadone and buprenorphine can be ordered by any physician for inpatients

  • 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)

  • Restlessness/psychomotor activation, anxiety, irritability, nausea, abdominal cramping, loose stool, diffuse musculoskeletal pain, chills, insomnia, yawning

  • Pupillary dilation, piloerection, tearing, nasal congestion, diaphoresis, restless legs

Evaluation

  • Clinical Opioid Withdrawal Scale (COWS): quantifies severity of opioid withdrawal and allows for safer buprenorphine inductions

  • 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

  • Partial agonist at the mu opioid receptor with high binding affinity

  • Long half-life (24-36 hours) allows for daily dosing

  • TID dosing is more effective for acute pain (as the analgesic effect is shorter-lived)

  • OK to use in renal failure/HD; may reduce dose in hepatic injury

  • All non-pregnant pts should receive buprenorphine-naloxone (e.g. Suboxone) formulations to mitigate risk of diversion/injection

  • Induction:

  • 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;

  • 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

  • Typical starting dose: 12-16 mg/day

  • Maintenance: 4-32 mg daily; 16mg and above to suppress opioid use

  • Requires waivered-provider

  • Acute Pain Management in pts using Buprenorphine:

  • 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

  • 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

  • Post-operatively: reduce opioid requirements and increase buprenorphine to home dose

    • If buprenorphine was discontinued, will require induction procedure

Methadone

  • Full mu opioid agonist with additional NMDA-receptor activity

  • Better option for individuals who cannot tolerate the buprenorphine induction procedure, with significant chronic or escalating pain

  • Long t½: 12-36 hrs; max 10 mg/d q7d, to prevent dose-stacking and delayed overdose

  • Safe in renal failure; dose reduction for hepatic injury

  • Potential for QT prolongation at higher doses, warrants QTc monitoring

  • Induction:

  • 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

  • Limit 40 mg in first 24 hours; then titrate 5 mg/d q3d while admitted

  • Maintenance:

  • 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)

  • After confirming home dose, continue as single daily dose

Naltrexone

  • Mu opioid antagonist; Half-life oral ~4 hours but clinically active ~24 hrs

  • IM maintains clinically effective levels up to 30 days

  • High affinity for mu receptor --> CAN precipitate withdrawal requiring 7-10 days opioid abstinence prior to initiation

  • If due for monthly injection while admitted, may substitute oral formulation until discharged to outpatient provider to receive injection

Additional Information

  • Psychosocial Interventions that complement MOUD:

  • Consider referral to SUD counseling, mutual help (self-help, 12-step, AA), intensive outpatient, and short- or long-term residential treatment

  • Use of other drugs NOT a contraindication to MOUD, however should encourage abstinence from other drugs during therapy (especially benzodiazepines)

  • Prescribe intranasal naloxone for overdose prevention to all OUD patients discharging from hospital, regardless of MOUD status

Last update: 2022-06-26 15:50:43