Managing Opioid Use Disorder During and After Acute Hospitalization: A Case-Based Review Clarifying Methadone Regulation for Acute Care Settings

Abstract

Objective Treatment with an opioid agonist such as methadone or buprenorphine is the standard of care for opioid use disorder. Persons with opioid use disorder are frequently hospitalized, and may be undertreated due to provider misinformation regarding the legality of prescribing methadone for inpatients. Using a case-based review, this article aims to describe effective management of active opioid withdrawal and ongoing opioid use disorder using methadone or buprenorphine among acutely ill, hospitalized patients. Methods We reviewed pertinent medical and legal literature and consulted with national legal experts regarding methadone for opioid withdrawal and opioid maintenance therapy in hospitalized, general medical and surgical patients, and describe a real-life example of successful implementation of inpatient methadone for these purposes. Results Patients with opioid use disorders can be effectively and legally initiated on methadone maintenance therapy or buprenorphine during an inpatient hospitalization by clinical providers and successfully transitioned to an outpatient methadone maintenance or buprenorphine clinic after discharge for ongoing treatment. Conclusions Inpatient methadone or buprenorphine prescribing is safe and evidence-based, and can be used to effectively treat opioid withdrawal and also serves as a bridge to outpatient treatment of opioid use disorders.

Role of the Hospital in the 21st Century Opioid Overdose Epidemic: The Addiction Medicine Consult Service

“…Today, there is a renewed interest in treating OUD, moving beyond withdrawal management, during acute hospitalization. Over the last decade, the primary literature base for the treatment of OUD and SUD includes care delivery reviews and checklists (Noska, Mohan, Wakeman, Rich, & Boutwell, 2015;Sharma, Lamba, Cauderella, Guimond, & Bayoumi, 2017;Thakarar, Weinstein, & Walley, 2016;Theisen-Toupal, Ronan, Moore, & Rosenthal, 2017;Weinstein, Wakeman, & Nolan, 2018), an implementation case study (Englander et al, 2017), retrospective cohort studies (Nordeck et al, 2018;Suzuki et al, 2015), single-site prospective evaluations (Trowbridge et al, 2017;Wakeman, Metlay, Chang, Herman, & Rigotti, 2017) and one clinical trial (Liebschutz et al, 2014). The literature suggests that care delivery for patients with SUDs in the acute care context is needed, possible, and effective.…”

“…Weinstein et al (2018), for example, recommended that an addiction medicine consultation should include five elements: 1) the history; 2) the physical examination and laboratory tests; 3) withdrawal management; 4) referral and linkage; and 5) long-term medication titration. Other checklists encourage the use of psychosocial interventions, the management of opioid withdrawal, and initiation of opioid agonist therapy (OAT) during hospitalization (Noska et al, 2015;Theisen-Toupal et al, 2017).…”

Identification, Management, and Transition of Care for Patients With Opioid Use Disorder in the Emergency Department

“…Even when the severity of concurrent medical conditions necessitates inpatient admission, patients experiencing acute opioid withdrawal may choose to leave against medical advice if they believe there is no prospect of pain relief. 31 Symptomatic management of acute opioid withdrawal can improve compliance with necessary treatment of concurrent medical or surgical conditions and therefore improve health outcomes. 32,33 Managing patient symptoms, along with expectations, is key to caring for patients with acute opioid withdrawal.…”

Expanding Treatment Opportunities for Hospitalized Patients with Opioid Use Disorders

“…The application of this time limit to hospitalized patients has not been supported by communication from the Drug Enforcement Agency. 24 There is no case law or other regulation requiring an opioid regimen to be time limited for patients during medical hospitalization, and hospital policies need not place undue constraints on the ability of clinicians to stabilize patients on maintenance therapy and transition them to outpatient treatment.…”