Sky Lee, MD Assistant Director of Inpa0ent Services This work was - - PowerPoint PPT Presentation

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Sky Lee, MD Assistant Director of Inpa0ent Services This work was - - PowerPoint PPT Presentation

May 28, 2023 255 likes •704 views

Sky Lee, MD Assistant Director of Inpa0ent Services This work was supported in part by the California Health Care Founda0on and the California Department of Health Care Services with funding from the Substance Abuse and Mental Health

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Sky Lee, MD Assistant Director of Inpa0ent Services

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This work was supported in part by the California Health Care Founda0on and the California Department of Health Care Services with funding from the Substance Abuse and Mental Health Administra0on. The ideas and opinions expressed herein are those of the authors and endorsement by the State of California, SAMHSA, UCSF or their contractors and subcontractors is not intended nor should be inferred. I, Sky Lee, hereby declare that the content for this ac0vity, including any presenta0on of therapeu0c op0ons, is well balanced, unbiased, and to the extent possible, evidence- based. My partner/spouse and I have no financial rela0onships with commercial en00es producing, marke0ng, re-selling, or distribu0ng health care goods or services consumed by, or used on, pa0ents relevant to the content I am planning, developing, presen0ng, or evalua0ng.

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Overview

  • The California Bridge Program
  • The Opioid Epidemic in Acute Care
  • Medica0ons for Opiate Use Disorder
  • Inpa0ent Buprenorphine Starts
  • Health Dispari0es
  • Resources
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The California Bridge Program

  • Support exis0ng acute care providers: ED, inpa0ent, OB
  • Treat exis0ng pa0ents with OUD presen0ng for acute care
  • Prevent withdrawal, support recovery via methadone &

buprenorphine Na0onal: webinars, guidelines, order sets, FAQs, monographs

  • California: targeted support for hospitals
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Where are we?

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The Opioid Epidemic

An Acute Care Problem

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California

  • 348,193 individuals with an opioid use disorder (OUD) (2016)
  • 2,196 opioid overdose deaths (2017)
  • ~165K-245K people with OUD without access to opioid agonist treatment (2016)
  • 2.4% of prescribers in the county had a buprenorphine waiver (2016)

hbps://www.urban.org/sites/default/files/es0mates_of_opioid_use_disorder_and_treatment_needs_in _california_0.pdf hbps://discovery.cdph.ca.gov/CDIC/Oddash/

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OUD Impacts Hospitals

hbps://hcup-us.ahrq.gov/reports/statbriefs/sb219-Opioid-Hospital-Stays-ED-Visits-by-State.jsp

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OUD Complicates Inpatient Treatment

  • 25-30% of admibed pa0ents leave AMA
  • Craving
  • Fear of mistreatment
  • Financial and social pressures
  • Withdrawal
  • Reduced adherence
  • Increased readmission
  • Pa0ents with OUD on buprenorphine had reduced 30 and 90 day hospital

readmission rate by 53 and 43%compared to those not on buprenorphine

Lianping Ti et al. Leaving the Hospital Against Medical Advice Among People Who Use Illicit Drugs: A Systema0c Review AJPH, December 2015 Moreno, et al. Predictors for 30 day and 90 day hospital readmission among pa0ents with opioid use disorder. Journal of Addic0on Medicine. 2019.

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Medica<ons for Opioid Use Disorder

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Symptoma/c treatment/Adjunc/ve meds: The following can be prescribed PRN for symptoms of withdrawal

  • Acetaminophen 650mg PO q6h prn pain
  • Clonidine 0.1-0.3mg PO q6-8 h prn

withdrawal symptoms (NTE 1.2mg/day, hold if BP <100/70)

  • Diphenhydramine 25-50mg PO q8h prn

insomnia/anxiety

  • Loperamide 4mg PO ini0ally, then 2mg PRN

each addi0onal loose stool (NTE 16mg/24h)

  • Tizanidine 2-4mg q6h prn muscle spasms
  • Ondansetron 4mg PO q6h prn nausea
  • Trazadone 50mg PO qhs prn insomnia
  • Melatonin 3mg PO qhs prn insomnia
  • Adjunc0ve medica0ons
  • Low dose methadone or

buprenorphine taper

  • Maintenance

buprenorphine or methadone

Withdrawal Management

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Chutuape, M et al. One-, three-, and six-month outcomes ajer brief inpa0ent opioid detoxifica0on. The American Journal of Drug and Alcohol Abuse. Vol 27:1, 2001.

Detox Doesn’t Last

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0. 10. 20. 30. 40.

In methadone Out of methadone In buprenorphine Out of buprenorphine

All cause mortality per 1000 person years

Sordo Luis, Barrio Gregorio, Bravo Maria J, Indave B Iciar, Degenhardt Louisa, Wiessing Lucas et al. Mortality risk during and ajer opioid subs0tu0on treatment: systema0c review and meta-analysis of cohort studies BMJ 2017; 357 :j1550

Decreased Mortality

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Treatment Starts Here

Acute Care Medica0on Treatment

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  • Trea0ng emergency of

withdrawal

  • Frequent site of care for

pa0ents with OUD

  • Ojen otherwise not

engaged in care

  • Buprenorphine only

Why Start in the ED?

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ED Initiation of Buprenorphine

20 40 60 80 100

Buprenorphine Referral Brief interven0on

% in care at 30 days

0.5 1 1.5 2 2.5 3

Buprenorphine Referral Brief interven0on

Days illicit opioid use/week

D’Onofrio et al. Emergency department-ini0ated buprenorphine/naloxone treatment for opioid depedence: a randomied clinical trial. JAMA. 2015 Apr 28;313(16):1636-44. doi: 10.1001/jama.2015.3474.

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Why Start in the Hospital?

  • 67% of hospitalized people who use drugs state that

they would like to cut back or quit

  • Fear of bad outcomes
  • Forced abs0nence allows 0me for thinking
  • Respect and kindness from providers
  • Increased support
  • Treat withdrawal, prevent AMA, linking to care
  • Methadone or buprenorphine

Englander et al. J Hosp Med. 2017 May; 12(5): 339–342

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72 65 12 7 20 40 60 80 Received MAT in 6 mo after discharge Days in MAT over 6 months

% Patients

Linkage Detox Number of Days 80 70 60 50 40 30 20 10

Liebschutz et al. Buprenorphine Treatment for Hospitalized, Opioid-Dependent Pa0ents. JAMA Intern Med. 2014 Aug; 174(8): 1369–1376.

Hospital Initiation of Buprenorphine

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Making it Happen

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DEA Regulations

  • If the pa0ent presents to ED or urgent care in

withdrawal:

  • Legal to administer 72 hours of methadone or

buprenorphine to treat withdrawal

  • If pa0ent is admibed for a medical or surgical reason
  • ther than opioid dependency:
  • Methadone and buprenorphine can be administered

to maintain or detoxify

  • Including new starts
  • On discharge, regular rules apply

Drug Enforcement Administra0on/Department of Jus0ce, 2017, §1306.07

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Case

  • June is a 50 yo F with history of hypertension and hyperlipidemia who

presented with sepsis from pyelonephri0s.

  • You see from her chart that she has been either seen in the

emergency department or admibed for celluli0s several 0mes. Upon further discussion, she men0ons that she uses heroin and is nervous about staying in the hospital as she will go into withdrawal.

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What are her treatment op<ons?

  • What has she tried?
  • What are her preferences?
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  • She has tried methadone in the

past, but did not like that it made her feel “foggy”

  • She tried buprenorphine/naloxone
  • btained from a friend and she had

a posi0ve response to it

  • Ajer a discussion of her op0ons,

June states she would like to start buprenorphine/naloxone.

Case: Which treatment is best?

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www.bridgetotreatment.org

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Let’s Start!

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Yes, In Acute Opioid Withdrawal

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Yes, Withdrawal Symptoms Improved

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Stop Overdose Deaths

  • Universal naloxone prescribing
  • OUD
  • Chronic opioids
  • Any illicit drugs
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Health Dispari<es

  • Non-white minori0es less likely to receive treatment (an0dote therapy

for acute overdose, prescrip0on opioids, etc)

  • Increasing rates of opioid mortality in non-white minority popula0on
  • Be cognizant of our implicit bias and systemic injus0ces

Wilder ME, Richardson LD, Hoffman RS, et al. Racial dispari0es in the treatment of acute overdose in the emergency department. 2018. Clinical Toxicology 56:12; 1173-1178 Santoro TN, Santoro JD. Racial bias in the US opioid epidemic: A review of the history of systemic bias and implica0ons for care. 2018. Cureus 10(12);e3733 Alexander MJ, Kiang MV, Barbien M. Trends in black and white opioid mortality in the United States 1979-2015. Epidemiology. 2018. 29(5); 707-715.

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5 10 15 20 25 30 White Black Hispanic American Indian/Alaska Na0ve Asian/Pacific Islander

Percent rate of change for all opioid overdose deaths from 2016-2017

% rate of change hbps://www.cdc.gov/mmwr/volumes/67/wr/mm675152e1.htm?s_cid=mm675152e1_w

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What If Withdrawal Symptoms Are Not Improved APer Ini<al Dose of Bup?

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No, Opioid Withdrawal Symptoms Not Improved

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How To Start Bup If Out of Acute Withdrawal Window

  • Typically >72 hours ajer short ac0ng opioids
  • Start Bup 8mg SL bid
  • Titrate up prn cravings
  • Can adjust to qday vs split dosing
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But…What About Pregnancy?

  • Buprenorphine is SAFE in pregnancy & breasxeeding
  • Bup monoproduct and Bup/Nx combina0on product both OK to use
  • Split dosing and an0cipate increasing dose in later trimesters
  • Bup start alone does not require fetal monitoring or inpa0ent

admission

  • Decreases NAS compared to methadone
  • Gradual postpartum reduc0on of Bup dose per pa0ent craving
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Case: Time for Discharge

Ajer 3 days, June has improved clinically. She has been transi0oned to PO an0bio0cs for her pyelonephri0s and her current dose of buprenorphine/naloxone is 16/4mg. She states she feels well enough to go home and you agree.

  • How will you write her buprenorphine prescrip0on on discharge?
  • Where does she go from here?
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How do I find an X-waivered provider?

  • SAMHSA Buprenorphine Provider Lookup

hbps://www.samhsa.gov/medica0on-assisted-treatment/physician- program-data/treatment-physician-locator

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Many Models For Outpa<ent Treatment

  • Connect with X-waivered PCP
  • Outpa0ent Buprenorphine Clinic
  • Bridge Clinics
  • Connect with the Community
  • Counseling while valuable should not be mandatory
  • Medica0on First model allows for engagement
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Worst Case Scenario

Return to use

  • Death rate is likely reduced because tolerance has not been lost
  • Prior quit abempts predict future success
  • Posi0ve experience with the health care system—connec0ons

maber

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What about buprenorphine and acute pain?

  • June was connected back to her PCP. A year later, she comes back to

the hospital for a scheduled right knee replacement. She has been stable on buprenorphine/naloxone.

  • What do you do for her buprenorphine/naloxone?
  • What about pain control ajer

the surgery?

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Keep the buprenorphine!

  • Con0nue home dose of buprenorphine/naloxone
  • Stopping buprenorphine prior to surgery is not necessary and

increases risk of relapse

  • Consider around the clock acetaminophen and other non-opioid

analgesics

  • If needed, ok to add on short ac0ng opioids to help control acute pain
  • An0cipate needing higher doses of opioids
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You are NOT alone!

  • California Bridge Program
  • Guidelines, toolkits, webinars
  • hbps://www.bridgetotreatment.org
  • Substance Use Warmline at the Clinician Consulta0on Center
  • hbp://nccc.ucsf.edu/clinical-resources/substance-use-resources/
  • 1(855) 300-3595
  • SAMHSA Buprenorphine Provider Lookup
  • hbps://www.samhsa.gov/medica0on-assisted-treatment/physician-program-data/

treatment-physician-locator

  • Includes link to Buprenorphine training course for DATA 2000 waiver
  • PCSS MAT Mentoring program
  • pcssmat.org
  • Includes link to Buprenorphine training course for DATA 2000 waiver
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Take Home Points

  • Pa0ents in the hospital already have OUD—now we need

to treat them

  • Buprenorphine and methadone treat withdrawal, save

lives

  • Acute care ini0a0on is straighxorward and within scope
  • Just treat it!
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Office Hours: hW hWps:/ s://ed ed-b

  • brid

ridge. e.or

  • rg/offic

ffice-hours/ Email: sky@bridgetotreatment.org