Uptake of slow‐release oral morphine as opioid agonist treatment among hospitalised patients with opioid use disorder

Abstract

Introduction. Buprenorphine and methadone are highly effective first-line medications for opioid agonist treatment (OAT) but are not acceptable to all patients. We aimed to assess the uptake of slow-release oral morphine (SROM) as second-line OAT among medically ill, hospitalised patients with opioid use disorder who declined buprenorphine and methadone. Methods. This study included consecutive hospitalised patients with untreated moderate-to-severe opioid use disorder referred to an inpatient addiction medicine consultation service, between June 2018 and September 2019, in Nova Scotia, Canada. We assessed the proportion of patients initiating first-line OAT (buprenorphine or methadone) in-hospital, and the proportion initiating SROM after declining first-line OAT. We compared rates of outpatient OAT continuation (i.e., filling outpatient OAT prescription or attending first outpatient OAT clinic visit) by medication type, and compared OAT selection between patients with and without chronic pain, using χ 2 tests. Results. Thirty-four patients were offered OAT initiation in-hospital; six patients (18%) also had chronic pain. Twenty-one patients (62%) initiated first-line OAT with buprenorphine or methadone. Of the 13 patients who declined first-line OAT, seven (54%) initiated second-line OAT with SROM in-hospital. Rates of outpatient OAT continuation after hospital discharge were high (>80%) and did not differ between medications (P = 0.4). Patients with co-existing chronic pain were more likely to choose SROM over buprenorphine or methadone (P = 0.005). Discussion and Conclusions. The ability to offer SROM (in addition to buprenorphine or methadone) increased rates of OAT initiation among hospitalised patients. Increasing access to SROM would help narrow the opioid use disorder treatment gap of unmet need.[Brothers TD, Fraser J, MacAdam E, Morgan B, Webster D. Uptake of slow-release oral morphine as opioid agonist treatment among hospitalised patients with opioid use disorder.

Unequal access to opioid agonist treatment and sterile injecting equipment among hospitalized patients with injection drug use-associated infective endocarditis

“…We assessed how often these patients with IDU-IE and untreated opioid use disorder were (a) offered initiation of OAT (i.e., methadone, buprenorphine-naloxone, or 24-hour slow-release morphine) in hospital; (b) successfully started OAT in hospital; and (c) were provided with a prescription to continue OAT on discharge from hospital. These categories are consistent with prior work on the “cascade of care” for opioid use disorder among hospitalized patients [ 27 , 31 ].…”

“…Specialized addiction medicine consultation services can help close this gap, by providing diagnostic and treatment expertise, increasing uptake of these interventions, and assisting in linking hospitalized patients to outpatient addiction treatment [ 25 , 26 , 34 , 44 – 46 ]. In response to identified gaps in care (informed by the present study), hospital-based resident physicians at the Halifax site partnered with community-based addiction physicians to provide an informal (unfunded) addiction medicine consultation service [ 27 , 31 ]. Clinicians have also begun to call for incorporation of addiction medicine specialists into multidisciplinary endocarditis care teams [ 8 , 47 , 48 ].…”

“…Clinicians have also begun to call for incorporation of addiction medicine specialists into multidisciplinary endocarditis care teams [ 8 , 47 , 48 ]. Improving access to OAT in general medical settings requires changes in several areas, including improved education for health professionals, prioritizing access to medications on-demand, enabling multiple medication treatment options, and decreasing patients’ out-of-pocket costs [ 31 , 49 ]. Many patients at both hospital sites also reported injecting stimulants; managing stimulant use disorder requires other addiction treatment and harm reduction strategies beyond OAT, including psychosocial interventions and access to sterile injecting equipment [ 7 , 11 ], which could also be facilitated by specialized inpatient addiction medicine consultation services.…”

Evaluation of an emergency safe supply drugs and managed alcohol program in COVID-19 isolation hotel shelters for people experiencing homelessness

“…The prescribing practices described in this evaluation – safe supply medications and managed alcohol, for unwitnessed consumption – are a recent development. While the relative safety of medications and alcohol dispensed for unwitnessed consumption has not been previously well-described in the literature, the practice is an extension of the evidence from witnessed consumption settings ( Bonn et al, 2021 , Hales et al, 2020 , Tyndall, 2020 , Brothers et al, 2022 , Bonn et al, Submitted , Bonn et al, 2021 ). Witnessed injectable OAT (iOAT) with liquid hydromorphone or diacetylmorphine (Heroin) has a robust evidence-based and has been incorporated into Canadian clinical practice guidelines for opioid use disorder ( Oviedo-Joekes et al, 2016 , Fairbairn et al, 2019 ).…”

“…Compared to Nova Scotia, British Columbia has much higher rates of illicitly manufactured fentanyl, fentanyl analogues, novel benzodiazepines, and methamphetamine availability and use ( Biggar et al, 2021 ). People who use drugs in Nova Scotia most often use hydromorphone tablets (immediate release or extended release) and cocaine, though rates of illicitly manufactured fentanyl use are increasing ( Brothers et al, 2022 , Brothers et al, 2021 , Brothers et al, 2022 , 2022 ). Largely due to these regional differences in the illicit drug supply, British Columbia experienced a rate of opioid poisoning deaths (39.4 per 100,000 people) eight times higher than Nova Scotia (4.9 per 100,000) from January to June, 2021 ( Special Advisory Committee on the Epidemic of Opioid Overdoses 2022 ).…”