Acute General Medical and Surgical Admission:

Acute General Medical and Surgical Admission: Managing Substance Use Disorders in Patients Who are Severely Ill Scott Grantham, MD Executive Director, Behavioral Health Saint Francis Health System

By the end of this activity, you will be able to: Describe the process for establishing a diagnosis of opioid use disorder ( OUD ) Discuss the possible co-morbid conditions that may affect the patient with OUD Understand the opportunities for screening and referral to treatment options for hospitalized patients Objectives:

Conflict of Interest Disclosures: None

I. Review of treatment settings II. Diagnosing Opioid Use Disorder III. Treatment of Opioid Use Disorder, Opioid Withdrawal IV. Screening for, and treating, co-morbid conditions V. Transition to outpatient services VI. Other Substance Use Disorder considerations Outline:

1. The shortest duration buprenorphine taper associated with lasting abstinence is: 3 days 1 week 2 weeks 4 weeks 2. Methadone can be used to relieve acute opioid withdrawal symptoms under the: One day rule Three day rule Emergency rule Methadone rule Pre/Post Test:

Medical Treatment Settings

Inpatient Acute med/surg Acute psych Freestanding Imbedded Long-term Acute Care (LTAC) Partial Hospital Program (PHP) Outpatient Emergency Department Observation Skilled Nursing Facility (SNF) Residential Intensive Outpt Program (IOP) Behavioral Health Clinic Primary Care Clinic

Saint Francis Hospital / Saint Francis Hospital South Psychiatry Consult Service ER, Obs, Inpt Assessment, treatment (including buprenorphine initiation), referral Over 3500 assessments completed per year Example:

Saint Francis Hospital Vinita / Saint Francis Hospital Muskogee Imbedded acute psychiatric units Specialized by age (general adult, geriatric) Example (cont d):

Laureate Inpatient General adult acute unit Mood and anxiety disorders acute unit Geriatric acute unit Eating disorders acute unit Laureate Outpatient Chemical Dependency IOP Mental Health IOP Eating Disorders residential, PHP, recovery house Outpatient clinic Buprenorphine therapy Example (cont d):

Diagnosing Opioid Use Disorder

Opioid use disorder is defined as two or more of the following within a 12-month period: Using larger amounts of opioids or over a longer period than was intended Persistent desire to cut down or unsuccessful efforts to control use Great deal of time spent obtaining, using, or recovering from use Craving, or a strong desire or urge to use substance Failure to fulfill major role obligations at work, school, or home due to recurrent opioid use Continued use despite recurrent or persistent social or interpersonal problems caused or exacerbated by opioid use Giving up or reducing social, occupational, or recreational activities due to opioid use Recurrent opioid use in physically hazardous situations Continued opioid use despite physical or psychological problems caused or exacerbated by its use Tolerance (marked increase in amount; marked decrease in effect) Withdrawal syndrome as manifested by cessation of opioids or use of opioids (or a closely related substance) to relieve or avoid withdrawal symptoms. Tolerance and withdrawal criteria are not considered to be met for those taking opioids solely under appropriate medical supervision. Severity of opioid use disorder is categorized as mild (presence of 2-3 symptoms), moderate (4-5 symptoms), or severe (6 or more symptoms). Diagnostic Criteria:

Non-judgmental approach Allow for ambivalence and ambiguity Stress the importance of obtaining the information for the purpose of being able to justify the offering of treatment to address the symptoms that are most important to the patient History Taking:

Collateral information is invaluable Family Friends Medical record Laboratory testing (example: UDS ) Prescription Monitoring Program ( PMP ) Discussion with other providers History Taking (cont d):

Treatment of Opioid Use Disorder, Opioid Withdrawal

Symptomatic : Clonidine Ibuprofen Cyclobenzaprine, methocarbamol Promethazine Loperamide Doxepin, clonazepam, hydroxyzine Medication Assisted Therapy: Buprenorphine OR Methadone Opioid Withdrawal Treatment:

Started only after the appearance of mild to moderate opioid withdrawal symptoms (or 8-12 hours after last opioid use) Day 1: 4mg x1, then another 4mg x1 after 4 hours Day 2: Maximum of 16mg/day Day 3: Maximum of 24mg/day Buprenorphine Initiation:

Other opioids are largely irrelevant (receptor potency) What if full agonists are needed for treatment of acute pain? What about benzodiazepines? What about concurrent opioid and alcohol/sedative withdrawal? Requires a provider with a DATA 2000 waiver Buprenorphine Initiation (cont d):

Day 1: 15mg x 1, then another 15mg x 1 in 4 hours (maximum 30mg/dose, 40mg/day) Stabilize dose every 2-3 days Caution: respiratory depression may not reach maximum effect until several days after a dosage change Pharmacokinetics affected by genetic differences, active metabolites, and other medications Not recommended for inexperienced clinicians Methadone Therapy:

Established by the Narcotic Addict Treatment Act 1974 Allowed for use of opioid agonist therapy, despite the restrictions contained in the Controlled Substances Act Only exceptions to registration: Three day rule (administer, not prescribe) 72 hour period cannot be renewed or extended Incidental adjunct to medical or surgical conditions other than OUD Methadone Therapy (cont d):

Comorbid Conditions

Chronic pain Insomnia Mood / anxiety disorders Post-Traumatic Stress Disorder Alcohol Use Disorder Sedative Use Disorder Sexually transmitted diseases Bacteremia / endocarditis Pregnancy Other Conditions to Consider:

Pregnancy test HIV test (never had one? today is the day) Syphilis IgG, Hepatitis, other STDs (depending upon circumstances) PHQ-9 Trauma history Substance abuse history Offer an influenza vaccine General Screening:

Blood cultures Echocardiogram MRI Brain with and without contrast Spinal column imaging Lumbar puncture Osteomyelitis workup Buprenorphine screen (urine) When Indicated:

Transition to Outpatient Services

Buprenorphine 4 week taper shown to lead to greater rates of abstinence at 12 weeks (50%), compared to 1 week (20%) and 2 week (16%) tapers Indefinite therapy Medication Assisted Therapy:

Methadone Logistically more challenging Location, cost, daily visits Initiation with buprenorphine followed by transition to methadone is easier than vice versa Medication Assisted Therapy (cont d):

Naltrexone One study demonstrated non-inferiority of naltrexone depot injections, compared to daily buprenorphine/naloxone Medication Assisted Therapy (cont d):

Residential CD-IOP Individual counseling Peer support / 12-step groups Court diversion Professional re-entry Contingency Management Psychosocial Interventions:

Other Substance Use Disorder Considerations

Concurrent opioid withdrawal and alcohol/sedative withdrawal Alcohol/sedative withdrawal prophylaxis and treatment protocols Uncommon withdrawal states GHB Clonidine Uncommon intoxication states Dextromethorphan Synthetic cannabinoids, amphetamine-like chemicals Carfentanil Other Considerations:

1. The shortest duration buprenorphine taper associated with lasting abstinence is: 3 days 1 week 2 weeks 4 weeks 2. Methadone can be used to relieve acute opioid withdrawal symptoms under the: One day rule Three day rule Emergency rule Methadone rule Pre/Post Test:

Questions

1. Modesto-Lowe, V; et al. Methadone Deaths: Risk Factors in Pain and Addicted Populations. J Gen Intern Med, 25(4): 305-309. 2. https://www.samhsa.gov/programscampaigns/medication-assistedtreatment/legislation-regulations-guidelines/special 3. Sigman, SC, et al. A Randomized, Double-blind Evaluation of Buprenorphine Taper Duration in Primary Prescription Opioid Abusers. JAMA Psych, 70(12): 1347-1354. 4. Tanum, L, et al. Effectiveness of Injectable Extended-Release Naltrexone vs Daily Buprenorphine-Naloxone for Opioid Dependence: A Randomized Clinical Noninferiority Trial. JAMA Psych, published online October 18, 2017. References: