(38) Getting Well: Expanding Tools to Treat Opioid Use Disorder In the Hospital

Background & Introduction: Qualitative studies have shown that, amidst myriad other reasons, patients with opioid use disorder (OUD) often leave the hospital prior to completion of medical therapy due to inadequate treatment of withdrawal and pain. Current guidance for the inpatient medical management of both opioid withdrawal and, more broadly, OUD consist of treatment with methadone or buprenorphine. While both medications are highly effective for reducing opioid use and decreasing mortality, we have observed that, with highly potent synthetic opioids including fentanyl now dominating the illicit opioid market, these medications can be less effective in stabilizing pain and withdrawal symptoms during the critical early period of hospitalization. This is in addition to unique medical and legal challenges that make initiation and continuation in the hospital complex. One approach to address this issue is expanding the array of opioid medications available to hospitalized patients with opioid withdrawal, to include both long and short-acting formulations. The advantage is the ability to start at high and therapeutic doses to rapidly control withdrawal symptoms, which is often avoided with methadone due to risk of arrhythmia. Preliminary studies demonstrated that this is safe but there is limited data on the patient-reported outcomes and perspectives of such an approach.

Methods: To investigate the impact of this approach, we conducted semi-structured interviews with 15 English-speaking patients hospitalized with OUD at a tertiary care hospital. Requirements were that patients be treated by an addiction medicine consultation team with long-acting opioids for at least three days. Interviews were transcribed, coded in NVivo 12 by the primary investigator, and analyzed for themes.

Results: Consistent with previous literature, a majority of participants related a pattern of hospital avoidance related to concerns about withdrawal: both delaying necessary care and leaving the hospital prematurely. One participant described this feeling as “I know I gotta go but I'm scared because I don't want to feel sicker than I already do.” To prepare for the likely scenario that their withdrawal would not be managed while in the hospital, participants frequently reported saving up a supply of opioids to bring with them to the hospital in order to “self-medicate”. Statements like “I brought in [stuff] with me. And then I had someone bring me stuff… You know, I just took care of myself. And I knew they weren't really gonna do much for me.” reveal how feeling compelled to use while admitted to the hospital in the past led participants to feel uncared for, or as if they had to care for themselves. In contrast, addressing withdrawal via basal-bolus dosing with oxycodone extended-release and as needed short acting formulations was correlated with more comfortable inpatient admissions that facilitated active engagement in medical treatment. “Yeah, and it honestly helped me, like, where I can not keep my mind on it too much where I can focus on actually, like, you know, my body healing from, the other stuff that I've done to it.”
Providers and participants were able to work together to rapidly uptitrate scheduled doses of opioids when necessary, which is an advantage over methadone given its limitations on the speed of titration. This was viewed favorably by participants, “I was always comfortable… When I wasn't, they raised whatever they needed to raise right away, gave me like a dose of something immediately.” which kept communication open and honest and demonstrated the medical team's commitment to the patient’s wellbeing. “And immediately, they made sure I was comfortable. Before we even went on to go and see what was wrong with me. And that, that actually means a lot. A lot.”

Conclusion & Discussion: The current standards of care for hospitalized patients with OUD are inadequate, resulting in brief and inefficient inpatient admissions. Our existing tools, buprenorphine and methadone, are safe and highly effective, but with the rising potency of opioids patients can benefit from supplementation with higher dose long and short acting opioid agonist medications in the early period of hospitalization. This approach serves to stabilize acute withdrawal symptoms, facilitate continued hospitalization as indicated, and ultimately function as a bridge to evidence-based MOUD. This expansion of the toolbox to treat patients with OUD gives providers the flexibility to respond to patient needs, promoting patient-centered care and minimizing barriers to effective hospital-based care.

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