Safety and preliminary outcomes of short-acting opioid agonist treatment (sOAT) for hospitalized patients with opioid use disorder

Abstract

Background Patients with opioid use disorder (OUD) frequently leave the hospital as patient directed discharges (PDDs) because of untreated withdrawal and pain. Short-acting opioids can complement methadone, buprenorphine, and non-opioid adjuvants for withdrawal and pain, however little evidence exists for this approach. We described the safety and preliminary outcomes of short-acting opioid agonist treatment (sOAT) for hospitalized patients with OUD at an academic hospital in Philadelphia, PA. Methods From August 2021 to March 2022, a pharmacist guided implementation of a pilot sOAT protocol consisting of escalating doses of oxycodone or oral hydromorphone scheduled every four hours, intravenous hydromorphone as needed, and non-opioid adjuvants for withdrawal and pain. All patients were encouraged to start methadone or buprenorphine treatment for OUD. We abstracted data from the electronic health record into a secure platform. The primary outcome was safety: administration of naloxone, over-sedation, or a fall. Secondary outcomes were PDDs and respective length of stay (LOS), discharges on methadone or buprenorphine, and discharges with naloxone. We compared secondary outcomes to hospitalizations in the 12 months prior to the index hospitalization among the same cohort. Results Of the 23 cases, 13 (56.5%) were female, 19 (82.6%) were 40 years or younger, and 22 (95.7%) identified as White. Twenty-one (91.3%) regularly injected opioids and four (17.3%) were enrolled in methadone or buprenorphine prior to hospitalization. sOAT was administered at median doses of 200–320 morphine milligram equivalents per 24-h period. Naloxone administration was documented once in the operating room, over-sedation was documented once after unsanctioned opioid use, and there were no falls. The PDD rate was 44% with median LOS 5 days (compared to PDD rate 69% with median LOS 3 days for prior admissions), 65% of sOAT cases were discharged on buprenorphine or methadone (compared to 33% for prior admissions), and 65% of sOAT cases were discharged with naloxone (compared to 19% for prior admissions). Conclusions Pilot implementation of sOAT was safe. Compared to prior admissions in the same cohort, the PDD rate was lower, LOS for PDDs was longer, and more patients were discharged on buprenorphine or methadone and with naloxone, however efficacy for these secondary outcomes remains to be established.

Critical care for patients with substance use disorders

“…It is not acceptable to treat the illness sequelae of substance use without addressing the root cause of addiction − this is akin to antibiotics without source control. Effective ICU management of substance withdrawal and pain can prevent delirium, patient-directed discharges, overdoses, and instead prime patients to engage in life-saving hospital-based SUD care [50 ▪ ,82]. Elevating care for our most vulnerable ICU patients requires us to do more than bear witness to their tenuous survival − often at the intersection of addiction, homelessness, structural racism, economic depravity, multimorbidity, mental illness, and frailty.…”

“…toxic leukoencephalopathy [79] Infections Bacteremia [80]; COVID-19 [81]; dental disease [82]; Two recently published cohort studies, enrolling patients in pulmonary hypertension specialty clinics, allude to the significance of this problem, particularly in the western United States [20,21]. However, no studies on this topic have been conducted in ICU/hospitalized patients.…”

ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids

“…In the inpatient setting, clinicians may consider a LDB-OC approach, HDB, and ancillary medications (Table 3). 10,47 Buprenorphine initiation in highly supportive environments, such as hospitals, can improve treatment retention. 25 †LDB-OC = low-dose buprenorphine initiation with opioid continuation (prescribed versus nonprescribed).…”

Better care at the bedside for hospitalized patients with opioid use disorder

“…A methadone dose of 20–30 mg should be administered with objective signs of opioid withdrawal, for example, piloerection, lacrimation, and rhinorrhea, and titrated by 10 mg/day up to 60 mg with ongoing titration by 5–10 mg every 3–5 days until resolution of opioid‐withdrawal symptoms 1,7,8 . Supplemental short‐acting opioids can be administered to reduce severe opioid‐withdrawal symptoms during methadone dose titration 9 . Ensuring patients are directly linked to a buprenorphine prescriber or an Opioid Treatment Program (OTP), that is, a methadone clinic, after discharge will reduce the risk of return to illicit opioid use and overdose 1 .…”

“…Ensuring patients are directly linked to a buprenorphine prescriber or an Opioid Treatment Program (OTP), that is, a methadone clinic, after discharge will reduce the risk of return to illicit opioid use and overdose 1 . When patients decline buprenorphine or methadone, immediate‐release oxycodone or oral hydromorphone can be scheduled three or fourtimes daily coupled with “as needed” short‐acting opioids to reduce opioid‐withdrawal symptoms 9 . Nonopioid adjunctive medications (e.g., clonidine, loperamide, hydroxyzine, etc.)…”