Chapter 3F: Medical Management of Patients Taking OUD Medications in Hospital Settings

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Medications for Opioid Use Disorder: For Healthcare and Addiction Professionals, Policymakers, Patients, and Families: Updated 2021 [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2018. (Treatment Improvement Protocol (TIP) Series, No. 63.)

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Medications for Opioid Use Disorder: For Healthcare and Addiction Professionals, Policymakers, Patients, and Families: Updated 2021 [Internet].

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Chapter 3F: Medical Management of Patients Taking OUD Medications in Hospital Settings

Chapter 3F guides the management of patients taking OUD medications in hospital settings. The audience is healthcare professionals in emergency, general medical, surgical, psychiatric, and obstetric units.

Patients with opioid use disorder (OUD) who present to emergency departments (EDs) or are admitted to hospitals for acute medical or psychiatric care can benefit from medication to treat OUD in the hospital setting. During acute medical illness, patients experiencing consequences of opioid use may be motivated to change.³⁹³ Hospital-based providers can take this opportunity to initiate long-term medication maintenance.^394,395

Unfortunately, less than one-quarter of patients with an opioid-related hospitalization are offered Food and Drug Administration-approved medication for OUD within 30 days of discharge.³⁹⁶ Patients who already take OUD medication may also present to the hospital. Thus, a broad understanding of how to manage their OUD medication during hospitalization is necessary.

The keys to effective patient management in general hospital settings are:

•: Balancing medication for OUD with other medical concerns (e.g., surgery, pain management) during hospitalization.
•: Careful management after discharge.
•: Seamless transfer to opioid treatment via an opioid treatment program (OTP) or office-based opioid treatment (OBOT) provider after discharge.

Figure

Hospitalized or ED Patients Taking Medication for OUD

Buprenorphine, methadone, and naltrexone may be ordered in EDs or inpatient hospital units. It's essential for the patient to continue receiving OUD medication while hospitalized.

Pain Management

Pain management for hospitalized patients who take OUD medication is a key element of medical management. Discuss pain management and engage in a shared decision-making process with patients being treated for OUD with buprenorphine, methadone, or naltrexone. Patients may have strong preferences and opinions about pain and use of opioid analgesics for pain treatment. Some patients may want to avoid opioid analgesics. For others, inadequately treated pain may be a trigger for illicit drug use. Involve primary care pain specialists and addiction treatment providers in discussing options for managing OUD medication and pain during patient hospitalization.

Buprenorphine

The hospital team will need to manage buprenorphine for patients who present to the ED or are hospitalized on buprenorphine maintenance. Physicians in inpatient settings can legally order buprenorphine without a waiver if a patient is admitted primarily for other medical reasons.³⁹⁹ Key medication management strategies include:

•

Obtaining written consent to contact the patient's providers, including:

-: Primary care provider.
-: Buprenorphine prescriber.
-: Pharmacy.

•

Confirming the patient's outpatient buprenorphine dose by:

-: Checking prescribing records.
-: Contacting the prescriber or pharmacy.
-: Examining recent prescription bottles.
-: Checking the prescription drug monitoring program database before administering buprenorphine.

•

Providing the usual daily dose to the patient, once that dose is confirmed.

•

Ensuring the patient's outpatient prescriber understands the reason for any missed visits.

•

Informing the patient's outpatient prescriber that the patient may test positive for opioids if treated with opioid analgesics while in the hospital.

•

Maintaining contact with the patient's prescriber, especially when a buprenorphine dose change is considered and in discharge planning.

Patients with pain may continue their buprenorphine while in the hospital. For mild-to-moderate pain, dividing the patient's usual buprenorphine dose three times per day (TID) may provide sufficient pain relief.⁴⁰⁰ In some cases, increased buprenorphine dose may be appropriate. For moderate-to-severe pain, additional analgesia will be necessary. Two approaches to consider:

1.: Continue buprenorphine treatment and use full agonist opioids for added pain relief. Because of the partial blockade caused by buprenorphine, higher-than-usual doses of opioids will probably be required for pain relief. Fentanyl, hydromorphone, and morphine have relatively high binding affinities for the mu-opioid receptor and are most likely to displace buprenorphine from receptors and provide improved analgesia. Once the painful condition has improved, if mild-to-moderate pain persists, buprenorphine can be divided TID to manage residual pain. This approach is usually successful and allows the patient to remain stable on buprenorphine.
2.: Discontinue buprenorphine upon hospitalization and use full agonist opioids to treat pain and prevent withdrawal. This approach avoids the blockade effect of buprenorphine on the mu-opioid receptors but leaves the patient vulnerable to a return to illicit opioid use. It may be useful if the first approach does not achieve adequate pain control.⁴⁰¹ Consider a consult by an addiction medicine, psychiatric, or pain management provider if appropriate and available.

Pregnant women on buprenorphine can continue buprenorphine through their labor. Labor pain for pregnant patients on buprenorphine can be managed effectively with epidural analgesia or intravenous opioids. Spinal anesthesia is effective in patients on buprenorphine; patients can receive general anesthesia if needed.⁴⁰²

Perioperative pain management of patients on buprenorphine requires further study, but multiple approaches have been found effective. Most patients can continue buprenorphine through the operative period. Treat postoperative pain with regional anesthesia, nonopioid pain management, or full agonist opioids. Remember that higher doses are likely to be necessary. Some data suggest that buprenorphine divided TID may even be as effective as morphine for postoperative pain control.⁴⁰³ Alternatively, buprenorphine can be discontinued 72 hours before a planned surgery and restarted after resolution of acute postoperative pain. The risk of this approach is that it leaves the patient vulnerable to a return to use of illicit opioids.⁴⁰⁴

Methadone

The hospital team will need to manage methadone for patients who present to the ED or are hospitalized on methadone maintenance treatment. This includes pregnant women. Generally, only physicians in OTPs can order methadone to treat OUD. However, physicians in an inpatient setting can legally order methadone administration to patients admitted primarily for other reasons.⁴⁰⁵

Contact the patient's OTP directly to confirm the outpatient methadone dose, the last day of dose administration, and whether the patient was dispensed take-home doses (and how many doses) after the last dose administration at the OTP. This is to avoid double dosing and to avoid providing a full dose to a patient who hasn't been to the OTP for several days. Notify the OTP of the patient's admission and discharge so that OTP staff is aware of:

•: The patient's upcoming missed visits.
•: Medications received during hospitalization.
•: Medications prescribed at discharge.

Patients in pain should receive their full usual daily dose of methadone, barring contraindications. This is their baseline dose and should not be considered a dose for pain management.

The expert panel for this Treatment Improvement Protocol (TIP) recommends restarting buprenorphine before discharge when possible, with a proper handoff between inpatient and outpatient providers.

They'll need pain medication in addition to their usual methadone dose. If their condition is painful enough to require opioids, prescribe short-acting opioids as scheduled, not as-needed, treatment. Because these patients are already opioid tolerant, they'll likely require higher doses of opioids than patients without tolerance.⁴⁰⁶ However, as with any patient, use nonopioid multimodal pain management when possible to minimize reliance on opioids and maximize pain control.⁴⁰⁷

Box

CLINICAL CAUTION.

It is important to tell patients who receive take-home doses that they should not take their own medication while in the hospital. They will receive methadone from the treatment team. Patients can be asked to lock their take-home medications with their other valuables. It is also important to monitor these patients closely after the initial and subsequent methadone administration in the hospital. Some patients who receive take-home doses do not take their entire dose every day, so they may display signs of intoxication or frank overdose if the hospital staff gives them the full dose.

Naltrexone

Patients taking oral naltrexone for OUD treatment may continue naltrexone when admitted to the hospital if they do not have and are not at risk for developing a painful condition requiring opioid analgesia. Oral naltrexone provides full blockade of opioid receptors for up to 72 hours. Extended-release injectable naltrexone (XR-NTX) provides measurable naltrexone levels for 1 month or longer. Thus, managing acute pain in patients taking XR-NTX is complicated.

In patients who have taken naltrexone, manage severe pain intensively via nonopioid approaches, such as regional anesthesia or injected nonsteroidal anti-inflammatory drugs.

Naltrexone blockade can be overcome with very high doses of opioids, but patients must be closely monitored for respiratory depression in a setting with anesthesia services. This is especially true upon discontinuation of oral naltrexone, which dissociates from opioid receptors.

Hospitalized or ED Patients Not Taking Medication for OUD

Patients with OUD who present to the ED or are admitted to the hospital for an acute medical problem may benefit from initiating medications for OUD during their hospitalization. A thoughtful and respectful discussion of treatment options and patient-centered provision of medication can be a critical entry point into care. Research supports the efficacy of initiating either buprenorphine or methadone during acute hospital stays^408,409 and starting patients on buprenorphine in the ED.⁴¹⁰

Buprenorphine Induction in the Hospital Setting

Patients admitted to the hospital for medical conditions incident to OUD can undergo medically supervised withdrawal or receive buprenorphine maintenance treatment during their inpatient stay.⁴¹¹ It is important to adequately address opioid withdrawal because hospital patients may otherwise sign out against medical advice or use illicit opioids in the hospital. Buprenorphine can also be initiated for maintenance treatment if there is a system in place that allows smooth and reliable discharge to an outpatient buprenorphine prescriber. Unlike methadone, a several-day delay between discharge and the first visit to the outpatient provider is acceptable for stable patients, as long as sufficient medication is provided until the patient begins outpatient treatment. The prescription for medication to be taken outside the hospital must be written by a prescriber with a buprenorphine waiver. If there is no prescriber with a waiver, it is possible to have a patient return to the hospital ED or a clinic within the hospital to have the buprenorphine dose administered by a physician (who does not need to be waivered) for up to 3 days.

To provide continuity of care at discharge, use these strategies:

•: Develop and maintain a network of local buprenorphine prescribers and other drug treatment providers.
•: Discharge patients directly to a specific outpatient prescriber for stabilization and maintenance after inpatient buprenorphine induction.
•: Send discharge information directly to the outpatient prescriber, including treatment course, medications administered, and medications prescribed.

To initiate buprenorphine during hospitalization:

•: Confirm that there are no contraindications to buprenorphine before initiation.
•: Discontinue opioids for pain management only when no longer needed and the patient is stable enough to tolerate withdrawal.
•: Wait for patients to develop opioid withdrawal symptoms.
•: Initiate buprenorphine treatment.
•: Individualize buprenorphine dosing.
•: Follow the dosing guidance found in Chapter 3D of this TIP.

A clinical trial found that starting buprenorphine in the ED to treat OUD was more effective in linking patients to buprenorphine treatment in the community than were two other approaches without medication.⁴¹² When patients presented in opioid withdrawal, they received 8 mg of buprenorphine in the ED. Patients who were not in withdrawal received a detailed self-medication guide and were provided buprenorphine for an unobserved home induction. In both cases, patients were given sufficient buprenorphine to take 16 mg per day at home until they could see an outpatient prescriber within 72 hours. Close follow-up with an outpatient buprenorphine prescriber was critical for dose stabilization and ongoing medication management.

Methadone Induction in the Hospital Setting

Offer to treat hospitalized patients in opioid withdrawal with methadone (or buprenorphine) maintenance if they can continue the medication in an OTP seamlessly after discharge. Do not start patients on methadone maintenance in the hospital without a clear follow-up plan. Form relationships with local OTPs that allow discharging of patients directly into methadone maintenance treatment.

Box

RESOURCE ALERT.

The TIP expert panel urges providers not to force patients to withdraw from opioid agonist treatment in the hospital, especially if they have acute illness, pain, or a mental illness.

Inpatient methadone inductions should follow the same “start low, go slow” principles that outpatient inductions do (see Chapter 3B of this TIP). The initial dose should be from 10 mg to 20 mg per day. Increase slowly by 5 mg every few days in response to symptoms of opioid withdrawal and level of sedation at the peak plasma level 2 to 4 hours after dosing.

Naltrexone Induction in the Hospital Setting

Consider XR-NTX initiation for patients who complete withdrawal in the hospital and are opioid free for 7 days (short acting) and up to 14 days (long acting). Only do so if:

•: There are no contraindications (such as the need for opioid analgesia).
•: The patient prefers it after a risk/benefit discussion that covers alternative treatments.
•: There are available follow-up opportunities for ongoing medication maintenance upon discharge.

No published data indicate this approach's effectiveness.

If a patient desires and gives informed consent for medically supervised withdrawal and XR-NTX initiation while in the hospital, a first dose of naltrexone can be given before discharge. As with other medications for OUD, discharge coordination is critical. Hospitals that develop XR-NTX induction protocols need to have a clear discharge plan in place for patients who will then need to continue treatment in the outpatient setting. Patients should be advised about the risk of overdose if return to opioid use occurs after discontinuing treatment.

Medical Management Plan

The key to effective treatment is to involve patients and all treating healthcare professionals in developing a comprehensive plan for managing treatment with OUD medication during and after hospitalization. This plan should include:

•: Strategies for pain management (if required).
•: In-hospital dosing procedures.
•: Postdischarge coordination of care with outpatient programs and outpatient providers.

This plan ensures effective pain relief as well as continuity of ongoing care for patients taking medication for OUD.⁴¹³

Notes

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Medications for Opioid Use Disorder: For Healthcare and Addiction Professionals, Policymakers, Patients, and Families: Updated 2021 [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2018. (Treatment Improvement Protocol (TIP) Series, No. 63.) Chapter 3F: Medical Management of Patients Taking OUD Medications in Hospital Settings.
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Medications for Opioid Use Disorder: For Healthcare and Addiction Professionals, Policymakers, Patients, and Families: Updated 2021 [Internet].

Chapter 3F: Medical Management of Patients Taking OUD Medications in Hospital Settings

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Hospitalized or ED Patients Taking Medication for OUD

Pain Management

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Naltrexone

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Buprenorphine Induction in the Hospital Setting

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