New Answers for Old Questions in the Treatment of Severe Infections from Injection Drug Use

Who Can Prescribe Medications for Treatment of OUD in Hospitalized Patients?

Although buprenorphine prescribing in the outpatient setting requires certification, inpatient physicians are exempt from these requirements and can prescribe buprenorphine or methadone in the hospital setting.²⁰ In the outpatient setting, buprenorphine prescription is restricted to providers with a Drug Addiction Treatment Act of 2000 (DATA 2000) waiver, also known as an “X-waiver”. X-waiver training is eight hours, and free web-based training is available.²³ At the time of discharge, non-X-waivered physicians can prescribe up to 72 hours of buprenorphine as a bridge to follow-up with outpatient addiction services.²⁴ In the outpatient setting, methadone can only be obtained through approved methadone maintenance programs (MMP); however, many such programs are often willing to do intakes on the same day or next day following hospital discharge. For patients already taking methadone at the time of admission, their MMP should be contacted during business hours to confirm the patient-reported dose. If the MMP cannot be contacted on the day of admission, the starting dose of methadone indicated in Figure 1 is sufficient to prevent precipitation of acute withdrawal. The decision of whether to initiate buprenorphine, methadone, or extended-release naltrexone for the treatment of OUD is nuanced and includes consideration of local resources, patient preference, comorbidities, and hospital policy. Successful initiation of inpatient MOUD requires knowledge of local addiction treatment resources. Social workers and case managers can be used to identify outpatient providers willing to continue MOUD. If no plans or desire for outpatient addiction treatment exist, methadone and buprenorphine can be tapered during the last week of hospitalization.

Is It Safe to Place a Peripherally Inserted Central Catheter in a Patient Who Injects Drugs?

Many practitioners believe that IDU is an absolute contraindication to the use of peripherally inserted central catheters (PICC) for administration of antimicrobials; however, evidence of harm is lacking.^25,26 In a review of outpatient parenteral antimicrobial therapy (OPAT) in patients with IDU, there were low overall rates of line-related adverse events and no significant difference in complications between IDU and non-IDU patients receiving OPAT.²⁷ As with any medical intervention, risks and benefits must be balanced. Aside from patient comfort, a PICC allows patients to receive intravenous (IV) antimicrobials in a nonhospital setting, which may be more therapeutic for their addiction. Peripheral venous access can be difficult in patients with IDU who often have atrophic superficial veins. While often cited as a reason to avoid PICCs, there is no empirical evidence that PICC placement leads to increased drug use among people with OUD. Similarly, depriving a patient of a PICC does not prevent drug use, but it may prevent patients from completing infection treatment in a more acceptable setting. The most serious concern with a PICC is that if a patient injects drugs, transient bacteremia/fungemia could seed this prosthetic material and lead to worsening infection. Providers should employ a risk-based approach to the use of PICCs considering patient preferences, addiction disease activity, and stability of home environment weighed against the potential risks of prolonged hospitalization, clinic-based antibiotic infusions through a peripheral IV, or possibly suboptimal oral antimicrobial treatment.