Jump into an episode dedicated to hospital based addiction medicine, as we cover common scenarios hospitalists encounter. In this episode we talk to Dr. Melissa Weimer @DrMelissaWeimer (Yale) about inpatient management of patients with substance use disorders. Dr. Weimer is board certified in Internal Medicine and Addiction Medicine. She is the Medical Director of the Yale Addiction Medicine Consult Service and is a passionate clinician educator. We discuss a wide range of topics this episode including the management of polysubstance withdrawal, approaching acute pain management for a person with opioid use disorder, and inpatient harm reduction strategies. After this episode listeners will gain new tools to help them best care for hospitalized patients with substance use disorders.
Written and Produced by: Carolyn Chan MD and Nora Taranto MD
Show Notes and CME questions by: Deborah J. Gorth ScM
Cover Art and Infographics by: Carolyn Chan, MD
Hosts: Stuart Brigham MD; Paul Williams MD, FACP; Carolyn Chan MD
Editor: Emi Okamoto MD (written materials); Clair Morgan of nodderly.com
Guest: Dr. Melissa Weimer
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Consider a urine toxicology screen the EKG for addiction medicine. Dr. Weiner suggests one be ordered for any patient presenting with the complications of substance use disorder (SUD), and as part of the medical work-up to obtain a diagnosis in many patient care scenarios. “What you test is important” – Dr. Weimer. Fentanyl should be included in this screen due to its pervasiveness, and remember this is often an add-on test. Additionally, an alcohol panel and alcohol level can provide important information about the possibility of alcohol withdrawal.
If there is a concern that the patient is not providing all the history that you need, one can utilize the results of the urine drug screen. Consider asking a probing question such as: “Your urine drug test showed benzodiazepines, can you tell me more about that?”. Be open, honest, and non-judgemental when having these conversations. Expert Tip: “Sometimes the issues that come up, can be our own baggage with how comfortable we feel talking to patients.” Make the conversation normative, a patient may not feel comfortable talking about substance use if you do not feel comfortable.
The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) is a validated tool to gain a better understanding of the severity of alcohol withdrawal, and the Clinical Opioid Withdrawal Scale (COWS) is used for opioid withdrawal. While there is overlap between these two scales the CIWA-Ar includes evaluations of both tremulousness and hallucinations while COWS includes questions about pupillary dilation, goose flesh and joint aches. These scales are not interchangeable, so be sure that you are using the correct tool. CIWA-B, is a validated tool (Busto, et al, A Clinical Scale to Assess Benzodiazepine Withdrawal) to assess benzodiazepine withdrawal.
Treating benzodiazepine and alcohol withdrawal should be a clinical priority. Withdrawal from either substance can be fatal.
The gold standard for alcohol withdrawal treatment is a long acting benzodiazepine (ASAM 2020, Clinical Practice Guidelines on Alcohol Withdrawal Management), although phenobarbital is also an option. If there is liver dysfunction, it is recommended to avoid benzos that are metabolized through the liver. In patients with liver disease, consider the use of benzos that are metabolized by the kidneys. A helpful mnemonic is “LOT” – these are benzos that are NOT metabolized by the liver – lorazepam, oxazepam, temazepam. If there are minimal concerns about liver function or a patient has close monitoring, diazepam is an effective longer acting benzodiazepine (metabolized by the liver). Due to the prevalence of nutritional deficiencies in this patient population, it may also be necessary to replete vitamins and minerals.
In the setting of polysubstance use disorder, buprenorphine treatment can be started or continued during alcohol withdrawal. One additional consideration for polysubstance use disorder is that naltrexone cannot be used with buprenorphine to mitigate alcohol cravings, so consider using acamprosate or disulfiram to further address alcohol related cravings.
Adjunctive therapy with hydroxyzine, or clonidine, can be used to manage anxiety if vital signs are stable in these withdrawal scenarios. If withdrawal is not being adequately managed, consider transfer to ICU for medications such as dexmedetomidine.
Fixed tapers are standard for treating individuals with benzodiazepine use disorders (Longo, Treatment of Benzodiazepine Dependence). Duration is based both on the dose the patient was previously taking and time available to treat the patient, Dr. Weimer recommends reducing the dose by 20-30% per-day. Tapers can last 2-4 weeks, depending on follow-up and the prior starting dose. If discharging the patient on taper, partner with family to ensure safety and have a comprehensive followup plan. Ideally a patient would be discharged with close outpatient follow-up to assist with managing the taper.
Dr. Weimer recommends Oregon’s Pain Guidance: Opioid and Benzodiazepine Tapers as a resource for tapering these medications safely.
Treat the OUD first, then the acute pain – or treat them together, but you have to treat opioid withdrawal effectively in order to get pain under control. – Dr. Weimer
Pain management in a patient with opioid use disorder (OUD) is a complex clinical scenario; both OUD and pain must be addressed together. Patients with OUD have significant opioid tolerance complicating the use of traditional inpatient pain treatments. It is necessary to treat opioid use disorder before being able to begin treating pain (Alford, 2006). When possible, discuss the options for treatment of OUD, BEFORE the surgery. Plan to utilize multi-modal treatments such as gabapentin, scheduled tylenol, NSAIDs, ketamine, a nerve block if appropriate to manage the acute pain.
Two options to discuss with hospitalized patients for acute pain for management and OUD are buprenorphine and methadone. If neither of these two are options for a patient, consider other long-acting opioid medications.
If a patient is already on buprenorphine-naloxone, continue this treatment in the perioperative setting (Lembke, et al, 2019). Make sure to communicate that the patient is on this medication with anesthesia to ensure the use of high-affinity agents (hydromorphone and fentanyl) for pain management during their surgery. . Expert Opinion: Continue the patient on their home dose of buprenorphine, this can include doses up to 16mg or 24 mg a day. Then add hydromorphone, or fentanyl for further pain management, these agents are preferred for their high-affinity receptor properties. Consider split dosing the buprenorphine to maximize its analgesic properties.
Avoid starting buprenorphine if a patient is already receiving opioids for pain treatment as this may acutely precipitate withdrawal. In the post-op setting, if a patient is interested in starting on buprenorphine, yet still on opioids consider starting an extremely low dose buprenorphine (microdosing) while the patient is using a full-agonist may be a method to mitigate withdrawal (Rozylo et al 2020).
Methadone can be prescribed by any physician in the hospital setting to manage opioid withdrawal or pain (Noska, 2015; Dale, 2019). Due to its long half-life, it is important to carefully titrate up the methadone dose to avoid sedation.
If the patient is already on methadone therapy, full opiate agonists can be used on top of methadone to treat acute pain (Alford, 2006). Split dosing for methadone can add additional analgesic benefit – make sure to discuss this option with the patient. Remember any physician can adjust a methadone dose in the hospital without special training. Consider a multimodal pain treatment approach with NSAIDs, nerve blocks, ketamine, acetaminophen, and gabapentin.
Post-Op Pain and OUD
When the acute pain has been stabilized start discussing further treatment options for OUD. One can offer them methadone in the meantime, and then consider switching to buprenorphine at a later time. Dr. Weimer recommends: Framing the discussion – would you like to transition to buprenorphine“quickly” with a time gap of 8-12 hours without exposure to an opioid. During that time we can provide support with medications such as, clonidine, hydroxyzine, NSAIDs, and acetaminophen. Or would you like this to be a more gradual process? Patients will tell you which they prefer for care planning.
Regardless of the approach, it should be developed in partnership with the patient.
Drug use in the hospital is a sign that a patient’s concern is not being adequately addressed. Talk to the patient and assess for possible triggers for in hospital non-prescribed opioid use such as: strong opioid craving, unmanaged pain, or stress. “Even if you don’t like the behavior, you still need to support the patient. It is a sign that something is going on and you can talk to the patient, get their story, be non-judgemental, and offer help”.
Addiction is a disease with numerous triggers for exacerbations, and the healthcare provider should work as an advocate for the patient. An agreement between the patient and care team can be a useful tool to articulate patient concerns and arrange for solutions.
For patients who require intravenous antibiotics, consider utilizing the 9-Point Risk Assessment tool, (Eaton, et al, 2018), to risk stratify which patients may be safe for discharge home with a PICC line. Consider oral, intramuscular, and infusion centers as other delivery options.
Like drug use in the hospital, a patient requesting to leave before the completion of their inpatient treatment plan is a sign that the patient has an unmet concern. ( Paul’s shout out to “Things We Do for No Reason – Against Medical Advice”. ) Sit with patients to understand their motivation for leaving. If the patient is determined to leave, talk about harm reduction. Focus on how to keep the patient safe including access to clean water, clean needles, alcohol swabs, and naloxone. Point the patient in the direction of local harm reduction resources. Every interaction with the medical community colors how people with the substance use disorder see the medical community.
Typically QT prolongation due to methadone is dose dependent (Krantz, et al, 2003). When QT prolongation presents in a patient on methadone, look for reversible causes of QT prolongation: electrolyte abnormalities, a new liver abnormality, or drug-drug interactions. Make sure to recheck the QT after addressing these other causes.. If it remains prolonged, discuss the risk and benefit of reducing methadone; a reduced methadone dose increases the risk of opioid use and its associated morbidity, but a prolonged QT could lead to torsades and sudden cardiac death. Partner with the patient and specialists to make informed changes.
Initiate addiction treatment in the hospital whenever able. It is a reachable moment for patients who are struggling with substance use.
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Listeners will discuss management of common inpatient addiction medicine scenarios.
After listening to this episode listeners will…
Dr Melissa Weimer reports working with Path, an addiction medicine treatment company. No trade names were used and that a balance range of therapeutic options were included in the discussion. The Curbsiders report no relevant financial disclosures.
Weimer MB, Chan CA, Taranto NT, Gorth DJ, Williams PN, Brigham SK, Okamoto E, Watto MF. “#224 Hospital Addiction Medicine”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Original Air Date July 13, 2020.
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