methadone or buprenorphine in the management of hospitalized - - PowerPoint PPT Presentation

Review of a protocol for methadone or buprenorphine in the management of hospitalized patients with opioid use disorder

Tess Larson, PGY1 Pharmacy Resident Providence Alaska Medical Center IRB Approved 1

Disclosure

 Potential conflicts of interest: None  Sponsorship: None  Proprietary information or results of ongoing research may be subject to different interpretations  Speaker’s presentation is educational in nature and indicates agreement to abide by the non-commercialism guidelines provided

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Learning Objectives

 Review a protocol for inpatient initiation of methadone or buprenorphine in patients with opioid use disorder (OUD)  Describe outcomes after protocol initiation, including effect on AMA discharges, length of stay and control of withdrawal symptoms  Identify potential areas for improvement to continue enhancing patient care

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Institution

 Tertiary, non-profit, community medical center  Largest hospital in Alaska

 401 beds  62 emergency department beds

 Level II trauma center

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Pre-Test Assessment Questions

1. Which of the following are aspects of the OUD treatment protocol? a) TAPS screening b) Social work consult c) Buprenorphine/naloxone or methadone initiation d) Naloxone kit 2. What of the following was not identified as a potential challenge when using the protocol for treating patients with OUD? a) Correct titration of medications b) Use of supportive care medications c) Social work consult d) Pain management 3. What may be a potential benefit identified by initiation of the protocol a) Decreasing AMA dispositions b) Decreasing readmissions c) Improving use of symptom management medications d) Less withdrawal symptoms

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Background

• Individuals with OUD have greater medical service utilization, higher hospitalization and re-

hospitalization rates, lower medical treatment rates and higher rates of leaving against medical advice (AMA)

• Methadone and buprenorphine are guideline recommended therapy options for patients with OUD
• Extensive data has been published on outpatient initiation and treatment of OUD, but little outcome

information is available when treatment is initiated in patients hospitalized for other conditions

• An institutional OUD management protocol was developed and implemented with goals of improving

inpatient care of patients with OUD and to provide a transition to outpatient OUD management

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OUD Treatment Protocol

 Nursing screening of all patients  COWS ordered  Provider paged – discussion

• f methadone vs.

buprenorphine/naloxone

 Methadone: 10 mg TID  Buprenorphine/naloxone: 4/1 mg PRN COWS > 8

 Titration and dose adjustments to effective dose  Symptom management

 Scheduled medications

 Gabapentin, clonidine, hydroxyzine, sleep aids

 PRN Medications

 Non-opioid pain control, nausea and vomiting, anti-diarrheal

 Social work and case management consult  Patients discharged with Narcan kit

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Efficacy Objective

 Evaluate the effectiveness of the protocol to initiate methadone and buprenorphine/naloxone among hospitalized patients with OUD.  Primary outcome: Rate of departures against medical advice (AMA)  Secondary outcomes:

 Inpatient LOS  30-day ED readmissions  30-day hospital readmissions  Comparisons of AMA disposition with buprenorphine/naloxone and methadone dose adjustments, supportive care medications and pain control as defined by pain scale scores in the first 24 hours and the 24 hours prior to discharge

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Quality Improvement Objective

 Identity potential areas for protocol implementation improvement and care of these patients.  Outcome Measures:

 Time from baseline COWS score to COWS score < 8 for > 24 hours

 Process Measures

 Initiations of methadone and buprenorphine/naloxone in patients indicated as having OUD  Compliance with protocol buprenorphine/naloxone and methadone dose adjustments, supportive care medications orders and management of pain as defined by pain scale scores in the first 24 hours and the 24 hours prior to discharge.

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Methods

 Retrospective electronic health record review of patients with opioid use disorder pre- (January 1, 2018 to December 31, 2018) and post- (April 1, 2019 to March 31, 2020) protocol implementation  Patients identified for inclusion via electronic medical records and computer- generated reports based on smart phrases used when patients are screened into the pathway  Inclusion criteria: > 18 years-of-age, hospitalized and identified as having OUD  Exclusion criteria: Pregnant, incarcerated, critically ill, unable to communicate due to dementia or psychosis, suicidal or currently enrolled in formal addiction treatment

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Results – Patient Characteristics

Pre-Implementation

 203 patients identified  40 patients excluded for MAT PTA, 16 patients excluded for other reasons  147 patients included in final analysis  Average age: 36  55% female (78/147), 45% male (66/147)  Comorbidities:  Other SUD: 97% (142/147)  Psychiatric: 44% (64/147)  Chronic pain: 16% (23/147)  Alcohol abuse: 6% (9/147)

Post-Implementation

 138 patients identified  53 excluded for MAT PTA, 12 patients excluded for other reasons  73 included in final analysis  Average age: 38  45% female (33/73), 55% male (40/73)  Comorbidities:  Other SUD: 95% (69/73)  Psychiatric: 42% (30/73)  Chronic pain: 19% (14/73)  Alcohol abuse: 3% (2/73)

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Results – AMA Dispositions

Pre-Implementation  AMA rate per total patients: 27.2% (40/147) Post-Implementation  AMA rate per total patients: 23.3% (17/73) Medications AMAs/MAT Type Buprenorphine/ Naloxone

33.3% (2/6)

Methadone

33.3% (18/54)

None

23.0% (20/87)

Medications AMAs/MAT Type Buprenorphine/ Naloxone

13.3% (2/15)

Methadone

26.6% (12/45)

None

23.1% (3/13)

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Results – Length of Stay

Total Buprenorphine/ naloxone Methadone None Pre- Implementation

12.5 days (n=147) 16.6 days (n=6) 14.8 days (n=54) 10.7 days (n=87)

Post- Implementation

10.5 days (n=73) 4.1 days (n=15) 12.2 days (n=45) 11.9 days (n=13)

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Results – 30 Day Readmissions

Pre-Implementation Post-Implementation

Total Readmissions

24.5% (36/147) 34.2% (25/73)

ED Readmissions

17.0% (25/147) 24.7% (18/73)

Inpatient Readmissions

6.8% (10/147) 9.6% (7/73)

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Results – AMA Comparisons

Left AMA Methadone Titrated Appropriately PRN Buprenorphine/ naloxone Ordered Time to COWS < 8 for 24 Hrs Gabapentin Ordered Sleep Medications Scheduled Clonidine Scheduled

Yes 16.7% (2/12) 50% (1/2) 2.35 days 29.4% (5/17) 5.9% (1/17) 23.5% (4/17) No 33% (11/33) 69.2% (9/13) 2.43 days 26.8% (15/56) 18.9 (10/56) 19.6% (11/56)

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Results – COWS Control

 Average Time to COWS < 8 for 24 hours from baseline COWS:  2.43 Days  Average Time to COWS < 8 for 24 by OUD medication used:  Buprenorphine/Naloxone: 1.6 days  Methadone 2.3 days  None: 4.1 days

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Results – Buprenorphine/Naloxone

 Total initiations

 Pre: 4.1% of all OUD patients (6/147)  Post: 20.5% of all OUD patients (15/73)

 66.6% of patients (10/15) had a PRN dose ordered  Titrations

 Day 1: 46.7% (7/15) of dose titrations done correctly  Day 2: 25% (3/12) of dose titrations done correctly  Day 3: 12.5% (1/8) of dose titrations done correctly  Day 4 and beyond: 0% (0/8) of dose titrations done correctly

 60% (9/15) of patients received PO opioids (non-hydromorphone), and 26.6% (4/15) received IV opioids (non-hydromorphone)

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Results – Methadone

 Total initiations

 Pre: 36.7 % of all OUD patients (54/147)  Post: 61.6% of all OUD patients (45/73)

 Correct titrations occurred in 29.5% of patients (13/45)  PRN oxycodone given in 45% of opportunities where COWS > 8 (42/93)  64.4% of patients (29/45) had > 3 sedating drug-drug interactions

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Results – Supportive Care Medications

 Pain  Gabapentin 27.4% (20/73)  Muscle cramp medications 30.1% (22/73)  NSAIDS 64.4% (47/73)  Oral opioids 86.3% (63/73)  APAP 91.8% (67/73)  Stomach cramp medications 34.2% (25/73)  Diarrhea medications 34.2% (25/73)  Hydroxyzine 41.1% (30/73)  Clonidine 52.1% (38/73)  Sleep medications 65.8% (48/73)  Nausea & vomiting medications 90.4% (66/73)

Average pain score reduction from admission to discharge was 0.7 (on a scale

• f 1-10)

Supportive care medication usage

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Conclusion & Discussion

 Trend towards reduction in AMA disposition rates , however, significance not known  Average time to COWS < 8 for 24 hours was decreased from 4.3 days (no MAT) to 2.3 days with methadone and 1.6 days with buprenorphine/naloxone  Initiations increased by 16.4% for buprenorphine/naloxone and by 24.9% for methadone  Treatment protocols for OUD patients may decrease rates

• f AMA disposition, allowing patients a greater opportunity

to receive the medical care that they need

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Post-Test Assessment Questions

1. Which of the following are aspects of the OUD treatment protocol? a) TAPS screening b) Social work consult c) Buprenorphine/naloxone or methadone initiation d) Naloxone kit

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Post-Test Assessment Questions

1. Which of the following are aspects of the OUD treatment protocol? a) TAPS screening b) Social work consult c) Buprenorphine/naloxone or methadone initiation d) Naloxone kit

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Post-Test Assessment Questions

2. What of the following was not identified as a potential challenge when using the protocol for treating patients with OUD? a) Correct titration of medications b) Use of supportive care medications c) Social work consult d) Pain management

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Post-Test Assessment Questions

2. What of the following was not identified as a potential challenge when using the protocol for treating patients with OUD? a) Correct titration of medications b) Use of supportive care medications c) Social work consult d) Pain management

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Post-Test Assessment Questions

3. What may be a potential benefit identified by initiation of the protocol a) Decreasing AMA dispositions b) Decreasing readmissions c) Improving use of symptom management medications d) Less withdrawal symptoms

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Post-Test Assessment Questions

3. What may be a potential benefit identified by initiation of the protocol a) Decreasing AMA dispositions b) Decreasing readmissions c) Improving use of symptom management medications d) Less withdrawal symptoms

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