Inpatient Management of Opioid Use Disorder: Methadone

Transcription

1 Inpatient Management f Opiid Use Disrder: Authrs: Diana Cffa, MD, Kristin Harter, PharmD, Hannah Snyder, MD Advisrs: Jadine Cehand NP, CNS, Curtis Geier, PharmD, Michelle Geier, PharmD, Crinna Gamez, MD, Tamara Lenhff, PharmD, Kelly Pfeiffer, MD, Brad Shapir, MD, Sctt Steiger, MD, Becky Tsui, MD, Sarah Windels, Barry Zevin, MD Disclaimer: These clinical practice guidelines d nt set a standard f care, rather they are an educatinal aid t practice. They d nt set a single best curse f management, nr d they include all available management ptins. They were develped by an interdisciplinary team based n published evidence and expert pinin; as the literature develps best practices may change. They shuld never be used as a substitute fr clinical judgement. Individual prviders are respnsible fr assessing the unique circumstances and needs f each case. Adherence t these guidelines will nt ensure successful treatment in every situatin. This infrmatin is intended fr healthcare prviders and subject matter experts, it is nt intended fr use by patients and the general ppulatin. This guideline applies t patients in inpatient medical settings. If any f the fllwing pints are different fr pregnant patients, it is nted in each segment f the fllwing dcument.

2 Gal f Treatment: COWS (Clinical Opiid Withdrawal Scre See Appendix A) f 5 r less fr a perid f 24 t 36 hurs Eliminatin f drug hunger r cravings N sedatin r respiratry depressin frm medicatin If patient uses illicit piids while n methadne, patient shuld nt feel substantially intxicated Mnitring: COWS scre is used t mnitr a patient s respnse t buprenrphine, it can be dne by a prvider r RN As treatment is initiated, COWS assessments and sedatin assessments shuld be checked at 30 minutes and 4 hurs after each dse fr all inductin patients r fr thse patients wh are being re-titrated t a maintenance dse, and shuld be dcumented in a daily COWS sheet Each COWS must be reprted t a supervising prvider if perfrmed by an RN Based n the COWS, the prvider may decide if there will be a change in mnitring frequency Pregnancy Only: Fetal mnitring beynd what is necessary fr initial fetal evaluatin is nt necessary slely fr methadne administratin unless rdered by the prvider. Patients n utpatient methadne : Prvider MUST cntact patient s utpatient piid treatment prgram (methadne clinic) t cnfirm dsing and last administratin Cntinue the patient s current dse, after checking that inpatient medicatins d nt change metablism r prlng QTC, that the patient is nt sedated, and that they are nt intxicated shuld typically be cntinued during acutely painful events, but methadne alne will nt cntrl severe acute pain see separate acute pain guidelines If the methadne clinic cannt be reached fr any reasn, fllw steps 4-6 belw t cntrl symptms in the interim, starting with 20 mg f methadne fr the first dse If a patient has missed utpatient dsing and unable t speak t a prvider at their methadne clinic, ne apprach is t give full dse if 1-2 days are missed, half dse if 3-4 days are missed, and treat as new start if 5 r mre days are missed. Hwever, we strngly recmmend discussing any missed dse adjustments with the methadne clinic as these are high risk situatins. Nalxne must als be rdered by the prvider as a PRN fr signs f verdse (0.1 mg IV q 1 t 2 minutes PRN RR < 8/min r Ramsey sedatin scale > 4) 12/1/2017 Page 2 f 10

3 Patients wh are cnsidering starting methadne 1. Determine clinical indicatin fr methadne therapy: Indicatin Opiid use disrder, severe, with r withut cmrbid chrnic pain and Desire fr methadne treatment t assist with cessatin r reductin in use Cntraindicatins Allergy t methadne Respiratry depressin Cautin QTc>500 Recent use f benzdiazepines, alchl, r ther sedatives Liver disease Pregnancy nly: inductin may ccur at utpatient clinic r inpatient under bstetric team guidance If the patient falls under the cautin categry, call the UCSF Substance Use Warmline ( r ) r yur lcal addictin specialists. 2. Discuss ptins with patient and btain patient preference fr methadne vs. buprenrphine (see Appendix B Nn-pregnancy Decisin Guide; Pregnancy Only: See Appendix C Pregnancy Only Decisin Guide). In the inpatient setting clinicians can legally rder buprenrphine r methadne if the patient is admitted primarily fr anther 1 medical reasn., 2 Prir t starting methadne, ensure that there is a lcal methadne clinic that will be able t enrll yur patient in their prgram. 3. Prir t inductin: Verify DSM 5 criteria fr piid use disrder Check baseline EKG fr QTc, CURES reprt ( ), urine tx screen, urine pregnancy test Nska A, Mhan A, Wakeman S, Rich J, Butwell A. Managing Opiid Use Disrder During and After Acute Hspitalizatin: A Case-Based Review Clarifying Regulatin fr Acute Care Settings. Jurnal f addictive behavirs, therapy & rehabilitatin. 2015;4(2): /1/2017 Page 3 f 10

4 Pregnancy Only: als check baseline maternal vital signs, NST as indicated, and a urine tx (utx can nly be perfrmed after patient verbal cnsent) If a patient is experienced mixed alchl and piid withdrawal, be very cautius and cnsult with experts t determine which pathlgy predminate as the cmbinatin f benzdiazepines and piids can be high risk Nalxne must als be rdered by the prvider as a PRN fr signs f verdse (0.1 mg IV q 1 t 2 minutes PRN RR < 8/min r Ramsey sedatin scale > 4). Adjunctive Medicatins fr Opiid Withdrawal can be very helpful t safely cntrl symptms and shuld be used rutinely unless there is a cntraindicatin: Diphenhydramine mg, PO three times daily prn insmnia/anxiety Ondansetrn 4 mg PO every 6 hurs PRN nausea Ibuprfen mg, PO fur times daily prn pain (Pregnancy Only : Ibuprfen is cntraindicated) Acetaminphen 650 mg PO 6 fur times daily PRN pain Lperamide 4mg PO x 1 initially, then 2mf prn each additinal lse stl (NTE 16 mg/24 hurs) Clnidine 0.1 mg PO q4 hurs prn w/d symptms (NTE 2 dses/24 hurs and include BP parameter) DO NOT ORDER benzdiazepines as standard PRN adjunctive therapy. 4. dsing cnsideratins: Peak cncentratin f methadne is ~3.5 hurs after dse received and nset f actin is 30 minutes t 1 hur after dse is received, s prvider r RN per prvider rder must evaluate fr sedatin and withdrawal symptms via COWS assessment 30 minutes and 4 hurs after each dse Steady state is reached after ~4.5 days at same dse (levels cntinue t rise fr several days after dse increase) The initial dse depends n patient (standard is 10 t 30 mg), as the severity f withdrawal des nt reliably indicate the level f tlerance. Dsing is at prvider s discretin, but prvider may cntact an expert, such as at the Substance Use Warmline r lcal piid treatment prgram If a patient is uninterested in methadne maintenance therapy and nly wants withdrawal treatment while hspitalized, d nt exceed 40 mg and taper such that patient receives 20 mg r less n day f discharge. Of nte, this is nt recmmended and increases risk f relapse. In patients wh are NPO, methadne can be administered via NG tube, as a sublingual liquid, r IV. Discuss dsing intervals and IV vs PO biavailability with pharmacy prir t use. 12/1/2017 Page 4 f 10

5 DAY 1 Give mg methadne Prvider r RN per prvider rder must evaluate 30 minutes and 4 hurs later fr sedatin via Ramsey AND withdrawal via COWS If withdrawal is present with COWS >8 (see COWS scring belw), may give additinal mg dse Prvider r RN per prvider rder must evaluate 30 minutes and 4 hurs later fr sedatin via Ramsey sedatin scre r withdrawal via COWS Cntinue dsing as abve as needed, but d nt exceed 40 mg methadne in first 24 hurs; fr mst patients lwer dses will be sufficient If at any pint patient experiences sedatin, additinal methadne dses are nt t be rdered and subsequent dses shuld be held r decreased D nt write PRN methadne rders Order adjunctive medicatins as needed t treat withdrawal symptms (see belw) Have Scial Wrk prvide list f Opiate Treatment Prgrams (OTP) and send referral t prgram f patient s chice after cnfirming prgrams capacity fr new patients Pregnancy Only: Nt all prgrams take pregnant patients, please check befre sending referral DAY 2 Evaluate the patient fr sedatin and withdrawal symptms befre am dse If n cmplaints f withdrawal r sedatin, rder methadne daily dse equal t ttal dse f methadne administered n day 1 If withdrawal symptms are present and there is n sedatin, then rder ttal daily dse frm day mg as single daily dse Prvider r RN per prvider rder must evaluate 30 minutes and 4 hurs later fr sedatin via Ramsey AND withdrawal via COWS If withdrawal is present and n sedatin after 4 hurs, prvider may rder anther ne-time 5-10 mg dse as lng as the daily limit f 50 mg fr day t has nt been reached If smnlence r respiratry depressin is present at any pint, hld additinal methadne dses and decrease next day s dse D nt exceed 50 mg n day 2; in mst cases lwer dses shuld be sufficient t cntrl withdrawal and prevent sedatin DAY 3 Evaluate the patient fr sedatin and withdrawal symptms befre am dse If n cmplaints f withdrawal r sedatin, rder methadne daily dse equal t ttal dse f methadne administered n day 2 If withdrawal symptms are present and there is n sedatin, then rder ttal daily dse frm day mg as single daily dse (nt t exceed 60 mg) Prvider r RN per prvider rder must evaluate 30 minutes and 4 hurs later fr sedatin via Ramsey AND withdrawal via COWS If withdrawal is present and n sedatin after 4 hurs, prvider may rder anther ne-time 5-10 mg dse as lng as the daily limit f 60 mg fr day t has nt been reached If smnlence r respiratry depressin is present at any pint, hld additinal methadne dses and decrease next day s dse D nt exceed 60 mg n day 3; in mst cases lwer dses shuld be sufficient t cntrl withdrawal and prevent sedatin 12/1/2017 Page 5 f 10

6 Subsequent hspital days Generally best t hld dse steady fr 5 days befre further increase, due t lng half-life serum levels will cntinue t increase After 5 days at steady dse, titratin at apprximately 10 mg every 5 days can cntinue based n nging cravings r withdrawal Actively reinfrce plans fr maintenance therapy and wrk n discharge plans Prvider r RN per prvider rder shuld mnitr COWS prtcl until cessatin f withdrawal symptms fr 24 t 36 hurs has ccurred (COWS < 5) If any evidence f smnlence r respiratry depressin, cnsult with pharmacy r Substance Use Warmline t determine apprpriate dse decrease hld additinal dsing until this is dne Discharge planning Scial wrk r prvider shuld cnfirm OTP s intake availability and details with their intake crdinatr Sme OTPs require that if patient is t discharge n a weekend r hliday, they will need t be transprted t the clinic n a nn-hliday weekday t cmplete the intake prcess prir t hspital discharge Skilled nursing facilities (SNFs) that are nt classified as hspitals can nly keep patients n methadne if patients are already enrlled in an utpatient methadne prgram discuss these details with the SNF early in the prcess Yu cannt prescribe methadne n discharge. The patient will need t g t the designated OTP, usually early the day after discharge. The OTP will ften request that yu fax a discharge summary prir t the patient s arrival. Prescribe nalxne n discharge as a prn medicatin fr signs/symptms f verdse and als cnsider PREP/PEP if indicated fr HIV preventin Other Dsing Cnsideratins Replacing Vmited Dses: If tablets are used and full dse is visible in emesis, can cnsider replacing 75% f dse If emesis ccurs < 15 minutes after administratin, cnsider replacing 50% f dse If emesis ccurs > 15 minutes after administratin, d NOT replace the dse. Check a COWS 4 hurs after emesis and re-titrate the dse. Prvider may rder a 5-10 mg ne time dse. Prvider r RN per prviders rders shuld check fr sedatin and a COWS assessment 30 minutes and 4 hurs after additinal dse Addressing Overdse: Split Dsing: Overdse is marked by btundatin, apnea, respiratry failure, and hypxia RN t call prvider and start xygen fr RR < 12, O2 saturatin < 95%, and/r change in mental status Administer nalxne per prvider rder fr RR < 8 r sedatin scale > 4 if any f these symptms ccur, hld subsequent dses and cntact the warmline r yur lcal addicitn experts Split dsing may be necessary fr patient with acute r chrnic severe pain. Pregnancy Only: As gestatinal age increases, plasma levels f methadne change secndary t a decrease in half-life and an increase in clearance and vlume f distributin. This generally ccurs during the secnd and third trimester. As such, prvider may strngly cnsider splitting the daily methadne dse t an AM and PM dse if the patient experiences withdrawal symptms r cravings at night. 12/1/2017 Page 6 f 10

7 Drug Interactins Sme cmmn drugs may have pharmackinetic r synergistic interactins with methadne. The methadne dse may require adjustment. Please cnsult with clinical pharmacist fr mre cmplete list f interactins. Drugs that may INCREASE methadne cncentratin r effect (kay t use, but mnitr the patient): azle antifungals, sme SSRI s, tricyclic antidepressants, eryrthrmycin, ciprflxacin, quetiapine Drugs that may DECREASE methadne cncentratin/effect: rifampin, many antiretrvirals, phenytin, carbamezapine ** CAUTION ** c-administratin f CNS depressants such as benzdiazepines may lead t increased sedatin and respiratry depressin, while c-administratin f naltrexne r buprenrphine may lead t precipitated withdrawal Breastfeeding Guidelines: maintenance fr piid use disrder is nt a cntraindicatin fr breastfeeding. Patients taking methadne fr piid use disrder wh are nt currently abusing ther substances and wh wish t breastfeed shuld be encuraged t regardless f the methadne dse. Current evidence shws that breastfeeding while n methadne maintenance is beneficial t nenates with nenatal abstinence syndrme (NAS). Nenates receiving breast milk frm these patients experience lwer NAS scres, require less pharmaclgic treatment such as mrphine, and have shrter lengths f hspital stay. Cnsult Cntacts: UCSF Substance Use Warm-line: r (available M-F, between 10 a.m. and 6 p.m EST) 12/1/2017 Page 7 f 10

8 PATIENT NAME: PATIENT DATE OF BIRTH: DATE OF ASSESSMENT: MEDICAL RECORD NUMBER: Clinical Opiid Withdrawal Scre (COWS) Fr each item, write in the number that best describes the patient s signs r symptm. Rate nly the apparent relatinship t piate withdrawal. Fr example: If heart rate is increased because the patient was jgging just prir t assessment, the increased pulse rate wuld nt add t the scre. Enter scres at time zer, 30 minutes after first dse, 2 hurs after first dse, etc. Time: Time: Time: Time: Resting Pulse Rate : Recrd beats per minute after patient is sitting r lying dwn fr ne minute 0 - pulse rate 80 r belw 1 - pulse rate pulse rate pulse rate greater than 120 Sweating : Over past ½ hur nt accunted fr by rm temperature r activity 0 - n chills r flushing 1 - subjective chills r flushing 2 - flushed r bservable mistness n face Restlessness : Observatin during assessment 0 - able t sit still 1 - reprts difficulty sitting still, but is able t d s Pupil size 0 - pupils pinned r nrmal size fr light 1 - pupils pssibly larger than nrmal fr light 3 - beads f sweat n brw r face 4 - sweat streaming ff face 3 - frequent shifting r extraneus mvement f legs/arms 5 - unable t sit still fr mre than a few secnds 2 - pupils mderately dilated 5 - pupils dilated that nly rim f the iris is visible Bne r jint aches : If patient was having pain previusly, nly the additinal cmpnent attributed t piate withdrawal is scred 0 - nt present 1 - mild/diffuse discmfrt 2 - patient reprts severe diffuse aching f jints/muscles Runny nse r tearing : Nt accunted fr by cld symptms r allergy 0 - nne present 1 - nasal stuffiness r unusually mist eyes GI upset : Over last ½ hur 0 - n GI symptms 1 - stmach cramps Tremr : Observatin f utstretched hands 0 - n tremr 1 - tremr can be felt, but nt bserved Yawning : Observatin during assessment 0 - n yawning 1 - yawning nce r twice during assessment Anxiety r irritability 0 - nne 1 - patient reprts increasing irritability r anxiusness Gseflesh skin 0 - skin is smth 4 - patient is rubbing jints r muscles and is unable t sit still because f discmfrt 2 - nse running r tearing 4 - nse cnstantly running r tears streaming dwn cheeks 2 - nausea r lse stl 3 - vmiting r diarrhea 5 - multiple episdes f diarrhea r vmiting 2 - slight tremr bservable 4 - grss tremr r muscle twitching 2 - yawning three r mre times during assessment 4 - yawning several times/minute 2 - patient bviusly irritable r anxius 4 - patient s irritable r anxius that participatin in the assessment is difficult 3 - pilerrectin f skin can be felt r hairs standing up n arms 5 - prminent pilerrectin 5 12 = mild; = mderate; = mderately severe; > 36 = severe withdrawal TOTAL OBSERVER INITIALS

9 Appendix B Nn-Pregnancy Decisin Guide Buprenrphine Mechanism Full piid agnist Partial piid agnist, usually paired with nalxne (piid antagnist) Patients fr whm shuld use cautin r avid Risk f withdrawal when starting medicatin Allergy, severe liver disease, QTc prlngatin, drug-drug interactins, high risk jb Nne Allergy, severe liver disease, heavy EtOH r benz, need fr acute piids, recent methadne Sme, if nt in withdrawal prir t starting may have precipitated withdrawal Side effects/risks Hypgnadism, Trsades, cnstipatin, sweating GI upset, cnstipatin, headache, insmnia Sedatin/respiratry depressin Overdse risk frm piid replacement Retentin in treatment Visit frequency Diversin ptential Wh can prescribe after discharge? Mrtality At high dses in nn-tlerant patients r slw metablizers has ptential fr sedatin, wrse in cmbinatin with sme medicatins Lw-mderate, higher when initiating treatment r in cmb with ther medicatins 1 Higher in methadne, with pssible cntributin frm increased structure f prgrams Daily visits t maintenance treatment prgram, take-hmes may be allwed if stable fr lng term. This structure helps sme patients, sme dislike it. Lw fr directly bserved therapy (DOT), high fr take hme Opiid treatment prgram nly Bth ptins substantially decrease all-cause mrtality ver n treatment, 2 methadne may have higher mrtality but may be cnfunded Ceiling effect fr respiratry depressin therefre less risky (unless cncurrent use f sedating drugs, e.g., alchl/benzdiazepines) Lw, increased by cncurrent sedating medicatins May be slightly lwer than methadne, retentin imprves at dses ver 16mg Can range frm daily t mnthly depending n patient treatment needs, may be prvided in primary care setting. Als available in sme methadne clinics, increasing structure and decreasing diversin risk. Lw fr DOT, mderate fr take-hmes, reduced by c-frmulatin with nalxne Any physician, NP, r PA wh has been trained and pssesses DATA2000 waivers (aka X-number) Bth ptins substantially decrease all-cause mrtality ver n treatment, buprenrphine may have lwer mrtality but may be cnfunded Sme patients may decline buprenrphine r methadne, but still be interested in medicatin assisted treatment. In these cases, ne ptin is naltrexne, hwever it has been shwn t 3 have very high drp-ut rates s is nt cnsidered first line. Naltrexne can nly be started after a patient has cmpletely withdrawn frm piids rughly 5-7 day fr shrt acting and 7-10 days fr lng acting. One ptin is t give nalxne as a trial befre administering naltrexne, t make sure the patient desn t experience precipitated withdrawal. Dsing usually begins with 25mg n the first day, and is then increased t 50 mg daily. Fr IM frmulatin, the dse is usually 380 mg q4 weeks. The mst cmmn side effects are nausea, vmiting, and headache 1 McLellan A, Arndt I, Metzger D, Wdy G, O Brien C. Treatment Retentin amng Patients Randmized t Buprenrphine/Nalxne Cmpared t in a Multi-Site Trial. Addictin. 2014; 109(1): Srd L, Barri G, Brav M, Indave B, Degenhardt L, Wiessig L, Ferri M, Pastr-Barrius R. Mrtality risk during and after piid substitutin treatment: systematic review and meta-analysis f chrt studies. BMJ. 2017:357:j Minzzi S, Amat Le Vecchi S, Davli M, Kirchmayer, U, Verster A. Oral naltrexne maintenance treatment fr piid dependence. Cchrane Database f Systematic Reviews: Reviews

10 Appendix C Pregnancy Decisin Guide Buprenrphine Mechanism Full piid agnist Partial piid agnist, usually paired with nalxne (piid antagnist) Patients fr whm shuld use cautin r avid Risk f withdrawal when starting medicatin Allergy, severe liver disease, QTc prlngatin, drug-drug interactins, high risk jb Nne Allergy, severe liver disease, heavy EtOH r benz, need fr acute piids, recent methadne Sme, if nt in withdrawal prir t starting may have precipitated withdrawal Side effects/risks Hypgnadism, Trsades, cnstipatin, sweating GI upset, cnstipatin, headache, insmnia Sedatin/respiratry depressin Overdse risk frm piid replacement At high dses in nn-tlerant patients r slw metablizers has ptential fr sedatin, wrse in cmbinatin with sme medicatins Lw-mderate, higher when initiating treatment r in cmb with ther medicatins 4 Higher in methadne (88% in the MOTHER study), with pssible Retentin in treatment cntributin frm increased structure f prgrams Visit frequency Diversin ptential Wh can prescribe after discharge? Mrtality Daily visits t maintenance treatment prgram, take-hmes may be allwed if stable fr lng term. This structure helps sme patients, sme dislike it. Lw fr directly bserved therapy (DOT), high fr take hme Opiid treatment prgram nly Bth ptins substantially decrease all-cause mrtality ver n treatment, methadne may have higher mrtality but may be cnfunded 5 Reduced preterm birth and lw birth weight rates Nenatal Outcmes 6 Higher dses d NOT crrelate with mre NAS NAS is 75% - in MOTHER study: 17.5 day average length f hspitalizatin 10.4 mg mrphine required during hspitalizatin Naltrexne is nt a gd ptin in pregnancy due t safety cncerns Ceiling effect fr respiratry depressin therefre less risky (unless cncurrent use f sedating drugs, e.g., alchl/benzdiazepines) Lw, increased by cncurrent sedating medicatins Slightly lwer than methadne (67% in the MOTHER study, with mst drp uts during inductin) Can range frm daily t mnthly depending n patient treatment needs, may be prvided in primary care setting. Als available in sme methadne clinics, increasing structure and decreasing diversin risk. Lw fr DOT, mderate fr take-hmes, reduced by c-frmulatin with nalxne Any physician, NP, r PA wh has been trained and pssesses DATA2000 waivers (aka X-number) Bth ptins substantially decrease all-cause mrtality ver n treatment, buprenrphine may have lwer mrtality but may be cnfunded Reduced preterm birth and lw birth weight rates Later average gestatinal age and higher average birth weight than methadne Higher dses d NOT crrelate with mre NAS NAS less severe than fr methadne in MOTHER study: 10 day average length f hspitalizatin 1.1 mg mrphine required during hspitalizatin 4 Jnes HE, Kaltenbach K, Heil SH, et al. Nenatal abstinence syndrme after methadne r buprenrphine expsure. N Engl J Med. 2010;363(24): Sr d L, Barri G, Brav M, Indave B, Degenhardt L, Wiessig L, Ferri M, Pastr-Barrius R. Mrtality risk during and after piid substitutin treatment: systematic review and meta-analysis f chrt studies. BMJ. 2017:357:j Jnes HE, Kaltenbach K, Heil SH, et al. Nenatal abstinence syndrme after methadne r buprenrphine expsure. N Engl J Med. 2010;363(24):