Inpatient management of opioid use disorder: A review for hospitalists

The United States is experiencing an epidemic of nonmedical opioid use. A concerted effort to better address pain increased the provision of prescription narcotics in the late 1990s and early 2000s.¹ Since then, there has been significant growth of opioid use and acorresponding increase in overdose-related deaths.^1-3 Public health officials have responded with initiatives to secure the opioid supply and improve outpatient treatment resources. However, the role of hospitalists in addressing opioid use disorder (OUD) is not well established. The inpatient needs for these individuals are complex and require a collaborative approach with input from outpatient clinicians, inpatient clinicians, addiction specialists, social workers, and case managers. Hospitals are often under-resourced to provide such comprehensive services. This frequently results in the hospitalist bearing significant responsibility for inpatient addiction management despite often insufficient addiction education or experience.^4,5

Therefore, there is a need for hospitalists to become leaders in the inpatient management of OUD. In this review, we will discuss the hospitalist’s role in the inpatient management of individuals with OUD.

Opioid use disorder is a medical illness resulting from neurobiological changes that cause drug tolerance, dependence, and cravings.⁶ It should be considered a treatable chronic medical condition, comparable to hypertension or diabetes,⁷ which requires a multifaceted treatment approach, including psychosocial, educational, and medical interventions.

Psychosocial Interventions

Individuals with OUD often have complicated social issues including stigmatization, involvement in the criminal justice system, unemployment, and homelessness,^5,8-10 in addition to frequent comorbid mental health issues.^11,12 Failure to address social or mental health barriers may lead to a lack of engagement in the treatment of OUD. The long-term management of OUD should involve outpatient psychotherapy and may include individual or group therapy, behavioral therapy, family counseling, or support groups.¹³ In the inpatient setting, hospitalists should use a collaborative approach to address psychosocial barriers. The authors recommend social work and case management consultations and consideration of psychiatric consultation when appropriate.

Management of Opioid Withdrawal

The prompt recognition and management of withdrawal is essential in hospitalized patients with OUD. The signs and symptoms of withdrawal can be evaluated by using the Clinical Opiate Withdrawal Scale or the Clinical Institute Narcotics Assessment, and may include lacrimation, rhinorrhea, diaphoresis, yawning, restlessness, insomnia, piloerection, myalgia, arthralgia, abdominal pain, nausea, vomiting, and diarrhea.⁴ Individuals using short-acting opioids, such as oxycodone or heroin, may develop withdrawal symptoms 8 to 12 hours after cessation of the opioid. Symptoms often peak on days 1 to 3 and can last for up to 10 days.¹⁴ Individuals taking long-acting opioids, such as methadone, may experience withdrawal symptoms for up to 21 days.¹⁴

While the goal of withdrawal treatment is to reduce the uncomfortable symptoms of withdrawal, there may be additional benefits. Around 16% of people who inject drugs will misuse drugs during their hospitalization, and 25% to 30% will be discharged against medical advice.^15,16 In hospitalizations when patients are administered methadone for management of withdrawal, there is a significant reduction in discharges against medical advice.¹⁶ This may suggest that treatment of withdrawal has the added benefit of preventing discharges against medical advice, and the authors postulate that treatment may decrease surreptitious drug use during hospitalizations, although this has not been studied.

There are 2 approaches to treating opioid withdrawal—opioid substitution treatment and alpha₂-adrenergic agonist treatment (Table 1).^4,17-20 Of note, opioid substitution treatment, especially when using buprenorphine, should be started only when a patient has at least mild withdrawal symptoms.²⁰

Factors to consider when selecting a withdrawal treatment regimen include comorbidities, anticipated length of stay, anticipated discharge setting, medications, interest in long-term addiction treatment, and other patient-specific factors. In general, treatment with methadone or buprenorphine is preferred, because they are better tolerated and may be more effective than clonidine.^21-24 The selection of methadone or buprenorphine is often based on physician or patient preference, presence of contraindications, or formulary restrictions, as they have similar efficacy in the treatment of opioid withdrawal.²³ In cases where opioid replacement therapy is contraindicated, such as in an individual who has received naltrexone, clonidine should be used.²⁴

Methadone and buprenorphine are controlled substances that can be prescribed only in outpatients by certified clinicians. Therefore, hospitalists are prohibited from prescribing these medications at discharge for the treatment of OUD. However, inpatient clinicians are exempt from these regulations and may provide both medications for maintenance and withdrawal treatment in the inpatient setting.

As such, while a 10 to 14-day taper may be optimal in preventing relapse and minimizing withdrawal, patients are often medically ready to leave the hospital before their taper is completed. In these cases, a rapid taper over 3 to 5 days can be considered. The disadvantage of a rapid taper is the potential for recrudescence of withdrawal symptoms after discharge. Individuals who do not tolerate a rapid taper should be treated with a slower taper, or transitioned to a clonidine taper.

Many hospitals have protocols to help guide the inpatient management of withdrawal, and in many cases, subspecialist consultation is not necessary. However, the authors recommend involvement of an addiction specialist for patients in whom management of withdrawal may be complicated. Further, we strongly encourage hospitalists to be involved in creation and maintenance of withdrawal treatment protocols.