1. Treating opioid addiction in hospitalized medical patients Miriam Komaromy, MD, FACP Associate Director, ECHO Institute

2. Mr. L is a 34 yo man who is admitted with suspected endocarditis. He is an active injection drug user, and was injecting heroin just prior to admission. He is alarmed about his medical condition, and is initially cooperative with treatment. However, a few hours after admission he begins to become restless and agitated. You prescribe clonidine for suspected opioid withdrawal. At 6 AM the floor nurse calls to tell you that the patient has left the hospital AMA.

3. What options are available to treat impending opioid withdrawal in an inpatient? Buprenorphine is safe Can prescribe as a taper or maintenance Much more effective than clonidine for withdrawal Will retain patients in the hospital for treatment of their medical illness Humane, and makes patient management easier Gowing L, Cochrane Database 2009

4. Who can prescribe buprenorphine to a hospitalized patient? Any physician; a buprenorphine “waiver” is not required when treating an inpatient SAMHSA website FAQ: http://buprenorphine.samhsa.gov/faq.html#A25http://buprenorphine.samhsa.gov/faq.html#A25

5. How should buprenorphine be prescribed to a hospitalized opioid-addicted patient? Write orders to begin treatment with buprenorphine once mild-to-moderate withdrawal symptoms are present Clinical Opiate Withdrawal Score (COWS) can be used to measure this Start patient with a 4 mg test dose, and if it is well tolerated then give additional 4 mg every 2 hours until withdrawal symptoms resolve or 12 mg is reached on day 1. Subsequent daily dose can increase to 16 mg/day if needed. Continue this dose daily until discharge (if maintenance can be arranged) or until 3 days prior to discharge, when dose should be tapered off. Can rx either buprenorphine monoproduct or buprenorphine/naloxone combo (Suboxone) Must be administered sublingually

6. Clinical Opioid Withdrawal Score (COWS) Pulse rateSweating RestlessnessPupil size Bone/join achesRunny nose/tearing GI UpsetTremor YawningAnxiety/irritability Gooseflesh skin Score 13-24 = mild-to-moderate withdrawal

7. Caveats Do not initiate buprenorphine if the patient has been using methadone within the past week or the UDS is (+) for methadone Do not initiate buprenorphine if the patient is not opioid-dependent (in which case, the patient will not develop withdrawal symptoms) Risk of respiratory suppression from buprenorphine is almost non-existent for adults UNLESS high-dose benzos are co-administered, so: Do not use bup in a patient who needs high-dose benzos, eg active alcohol withdrawal Total daily bup dose can be given as a q day dose, except in patients with pain; divide TID-QID for better analgesia Bup interferes with effect of other opiates, but is itself a potent analgesic

8. What about buprenorphine maintenance? Maintenance treatment with buprenorphine is highly effective at reducing relapse, injection drug use, HIV and Hep C infection 1, and death Bup is covered by Medicaid without prior authorization Unfortunately, there are far too few bup prescribers in NM, and arranging for a patient to transfer to maintenance therapy is hard ASAP: Socorro Lopez-Mezon RN works to arrange rapid intake into ASAP for patients being discharged from UNM. # 994-7980 First Choice: patients who have primary care at FCCH can usually get bup maintenance there Page K, JAMA Int Med 2014

9. 72% of inpatients randomized to maintenance buprenorphine with linkage to outpatient bup treatment successfully entered maintenance outpatient treatment, vs. 12% of inpatients randomized to 5 day bup taper. Liebschutz J, JAMA Int Med 2014

10. Buprenor -phine Placebo Retained at 1 yr 70%0 % died 020% Trial of buprenorphine 40 Heroin addicts Buprenorphine 16 mg/day vs taper + placebo All received counseling, groups Followed for 1 year Kakko et al, Lancet 2003

11. Schwartz, AJPH, 2012 Heroin overdose deaths fell by 2/3 as buprenorphine MAT availability increased in Baltimore Evidence continues to grow showing that buprenorphine saves lives…

12. Warning: if a patient is tapered off of opioids the patient MUST be warned that their tolerance will be lowered and they can easily overdose and die after discharge if they resume the same dose of opioids (RR of death 15) Ravndal E, Drug Alcohol Depend 2010

13. Ms. R is a 42 year-old woman who develops gall-stone-related pancreatitis. She is hospitalized for treatment and pain control. On admission, she reports that she is on maintenance therapy with Suboxone (buprenorphine/naloxone) 16 mg per day for treatment of Opioid Use Disorder. UDS (+) for buprenorphine, (-) for methadone and benzos. She is having marked abdominal pain. How would you manage her pain?

14. Management of pain in patients treated with buprenorphine Options include: Managing pain with buprenorphine: divide dose TID-QID, and increase total dose as needed for analgesia up to 32 mg or more per day Continuing buprenorphine but “overriding it”: Fentanyl has an even higher affinity for the mu opioid receptor than bup, so provides effective analgesia Stopping buprenorphine and beginning pain management with other opioids, with plan to resume bup prior to discharge Make an explicit plan with patients about resuming buprenorphine

15. Ms S is a 64 year old woman who has been treated for 5 years with oxycodone for pain from spinal stenosis. She is hospitalized after being found unconscious by her husband in what appears to be an accidental overdose. How would you address her ongoing pain and also her overdose risk?

16. Buprenorphine can be prescribed off label for patients who do not meet DSM criteria for Opioid Use Disorder (opioid addiction) Useful in patients who have major risks of overdose or other complications from standard opioids Safer, no tolerance, no sedation, and no development of opioid-induced hyperalgesia Not recommended for use in patients treatment with benzodiazepines because of overdose risk

17. Mr. J is a 50 year old man who is hospitalized for pneumonia and alcohol withdrawal. He has a long history of Alcohol Use Disorder, and has attempted to stop drinking many times without prolonged success. After several days of treatment he is preparing for discharge. What could you offer to help him to maintain his sobriety?

18. miriamk1@salud.unm.edu