Inpatient Management of Opioid Use Disorder: A Review for Hospitalists

A s a result of the epidemic of opioid use disorder (OUD), there has been a secondary surge in hospitalizations for infectious complications of injection drug use (IDU). 1,2 In the previous 10 years, there have been significant increases in IDU-associated human immunodeficiency virus (HIV) 3 and hepatitis C virus (HCV) 4 infection as well as increased hospitalizations from IDU-associated skin and soft tissue infections, osteomyelitis, septic arthritis, bacteremia, fungemia, and infective endocarditis in the United States. 2,[5][6][7] Patients admitted with IDU-associated infections have long lengths of stay, high rates of leaving against medical advice (AMA), readmission, and mortality. [8][9][10][11][12][13] In a British cohort (median age 36 years), five-year mortality after an episode of IDU-associated endocarditis was 42%. 14 Admissions for IDU-associated infections can be a troubling experience for both patients and providers alike. 15 While management decisions of IDU-associated infectious syndromes have sometimes been based on emotion, dogma, and an often-stigmatizing approach toward people suffering from addiction, 16 with a better understanding of addiction and effective treatments, as well as accumulating data in both addiction and infectious disease fields, it is an appropriate time to reevaluate the approach to treatment.The goal of this review is to examine recent evidence and attempt to answer questions that frequently arise in the management of hospitalized patients with IDU-associated infections. The questions addressed in this review primarily stem from the discussion of Schranz and colleagues in their description of increasing hospitalizations for IDU-associated endocarditis. 7 Additionally, questions were developed from discussions with practicing academic hospitalists. For each question, a review of the published literature was performed, with a focus on articles published between 2014 and 2019. Finally, a framework for how to approach patients with infectious complications of IDU is presented. As a comprehensive review of infectious complications of OUD would be difficult to cover in one review, this review will focus on eight questions that frequently arise in the care of inpatients.

Section: Key Management Questions In the Inpatient Management Of Infementioning

confidence: 99%

Section: Key Management Questions In the Inpatient Management Of Infementioning

confidence: 99%

Section: Key Management Questions In the Inpatient Management Of Infementioning

confidence: 99%

See 1 more Smart Citation

New Answers for Old Questions in the Treatment of Severe Infections from Injection Drug Use

Serota

Vettese

2019

“…Two hospital/acute pain guidelines and 5 chronic pain guidelines also recommend urine drug testing, although differing on when and whom to test, with some favoring universal screening. 11,20,23 Screening hospitalized patients may reveal substances not reported by patients, but medications administered in emergency departments can confound results. Furthermore, the commonly used immunoassay does not distinguish heroin from prescription opioids, nor detect hydrocodone, oxycodone, methadone, buprenorphine, or certain benzodiazepines.…”

Section: Identifying Misuse and Opioid Use Disordersmentioning

confidence: 99%

“…Other authors have recently published narrative reviews on the management of acute pain in hospitalized patients with opioid dependence and the inpatient management of opioid use disorder. 10,11…”

mentioning

confidence: 99%

The Evaluation of Medical Inpatients Who Are Admitted on Long‐Term Opioid Therapy for Chronic Pain

Mosher

Herzig

Danovitch

et al. 2017

Individuals who are on long-term opioid therapy (LTOT) for chronic noncancer pain are frequently admitted to the hospital with acute pain, exacerbations of chronic pain, or comorbidities. Consequently, hospitalists find themselves faced with complex treatment decisions in the context of uncertainty about the effectiveness of LTOT as well as concerns about risks of overdose, opioid use disorders, and adverse events. Our multidisciplinary team sought to synthesize guideline recommendations and primary literature relevant to assessing medical inpatients on LTOT, with the objective of assisting practitioners in balancing effective pain treatment and opioid risk reduction. We identified no primary studies or guidelines specific to assessing medical inpatients on LTOT. Recommendations from outpatient guidelines on LTOT and guidelines on pain management in acute-care settings include the following: evaluate both pain and functional status, differentiate acute from chronic pain, investigate the preadmission course of opioid therapy, obtain a psychosocial history, screen for mental health conditions, screen for substance use disorders, check state prescription drug monitoring databases, order urine drug immunoassays, detect use of sedative-hypnotics, and identify medical conditions associated with increased risk of overdose and adverse events. Although approaches to assessing medical inpatients on LTOT can be extrapolated from related guidelines, observational studies, and small studies in surgical populations, more work is needed to address these critical topics for inpatients on LTOT.

The Core Competencies in Hospital Medicine—Clinical Conditions 2023 Update Methodology

Nichani,

Brooks,

Fitterman

et al. 2023

As hospital medicine continues to evolve, the Society of Hospital Medicine (SHM) recognizes the importance of periodic re-evaluation and adaptation of The Core Competencies in Hospital Medicine to reflect and guide the continual expansion of hospitalists' scope of practice. Since its first publication in 2006, the Core Competencies were last revised in 2017 to reflect existing practice. The Core Competencies were initially developed to describe hospitalists' roles and expectations and identify growth opportunities. As hospital medicine has expanded, SHM seeks to maintain the Core Competencies as a framework to guide curricular development, enhance practice assessment, improve the quality of care, and cultivate systems-based practices. Additionally, it helps elucidate the clinical and systems-based aspects central to the field. Thus, the new chapters in the 2023 clinical conditions update focus on enhancing individual hospitalist practice in evaluating and managing common clinical conditions. The accompanying article describes the chapter review and revision process and the criteria for new chapter selection.