Caring for patients with opioid use disorder in the hospital

• Published in: Canadian Medical Association journal (CMAJ) 2016-12, Vol.188 (17-18), p.1232-1239
• Main Authors: Donroe, Joseph H, Holt, Stephen R, Tetrault, Jeanette M
• Format: Article
• Language: English
• Subjects: Acute Pain - drug therapy; Addictions; Alcohol; Analgesics, Non-Narcotic - therapeutic use; Analgesics, Opioid - adverse effects; Analgesics, Opioid - poisoning; Analgesics, Opioid - therapeutic use; Buprenorphine - therapeutic use; Buprenorphine, Naloxone Drug Combination - therapeutic use; Care and treatment; Central service department; Chronic illnesses; Drug dosages; Drug overdose; Drug Overdose - therapy; Drug use; Evaluation; Heroin; Hospitalization; Hospitals; Humans; Intubation; Medical referrals; Methadone - therapeutic use; Mortality; Naloxone - therapeutic use; Narcotic Antagonists - therapeutic use; Narcotics; Opiate Substitution Treatment - methods; Opioid-Related Disorders - therapy; Opium habit; Pain management; Practice guidelines (Medicine); Respiration, Artificial; Review; Studies; Substance abuse treatment; Substance Withdrawal Syndrome - etiology; Substance Withdrawal Syndrome - therapy; Systematic review
• ISSN: 0820-3946; 1488-2329
• DOI: 10.1503/cmaj.160290

The goals of treating withdrawal are to alleviate unnecessary distress, maintain the therapeutic alliance between patient and provider, facilitate treatment of the primary reason for admission and increase the patient's engagement in longterm addiction management. According to a 2010 systematic review,21 there was no statistically significant difference in completion of opioid detoxification between the opioid agonists buprenorphine and methadone (odds ratio 1.64, 95% confidence interval [CI] 0.68-3.79). As such, choosing between them should take into account the patient's preference and commitment to longterm addiction treatment, comorbid medical conditions, potential adverse effects (e.g., QTc prolongation), medication interactions (e.g., with some antiretroviral medications) and availability of outpatient providers able to continue the opioid agonist therapy.21 Methadone initiated at 10- 30 mg daily and slowly titrated to a total daily dose of 20-40 mg is usually sufficient to treat withdrawal symptoms.18,20 Alternatively, buprenorphine may be initiated, according to standard protocols, once moderate opioid withdrawal is evident (Figure 1).22 Buprenorphine initiated too early can precipitate withdrawal. Interviews with providers have commonly identified concerns about deception and manipulation on the part of patients with opioid use disorder who report pain.34,35 At the same time, patients with opioid use disorder fear that they will be labelled as "drug seekers," that their pain will go undertreated, that the underlying condition will go undiagnosed or that their opioid agonist therapy will be discontinued.34,36 Elements of an effective initial pain encounter include reviewing both patient and provider expectations regarding pain management, acknowledging prior difficult interactions, reassuring the patient that the pain will be addressed and that opioid agonist therapy will be continued or substituted if necessary, and reviewing the medication schedule. Involving the patient in decisions about pain management is particularly relevant for those with opioid use disorder and may prevent some of the stressful doctor-patient interactions related to opioids that both parties dislike.26,27,37 The analgesic effect of buprenorphine is also shorter than its effects on withdrawal and craving. Given its high affinity for the opioid ì receptor, buprenorphine effectively blocks the actions of most other opioids, thereby complicating acute pain management.41 Severa