As a practicing hospitalist in a safety net hospital, I am on the front lines battling the opioid epidemic. In the past five years, I have seen an increase in the number of hospitalized patients with heroin-related medical complications, including abscesses, cellulitis, infective endocarditis and overdose events. My personal experiences reflect national statistics, which reveal a 64% increase in opioid-related emergency department visit and a 100% increase in opioid-related inpatient stays between 2009 to 2014.1 Even more alarming, during 2010 to 2015, the rate of drug overdose deaths in the United States increased in 30 states.2Addressing the management of opioid withdrawal and the treatment of addiction among hospitalized patients is integral to battling this epidemic.
Managing opioid withdrawal in hospitalized patients can be challenging. Heroin is often cut with fentanyl or other opioid derivatives3,4 and cannot be directly converted to morphine equivalents for accurate opioid dosing to stave off withdrawal. When patients experience opioid withdrawal symptoms, including nausea, vomiting, muscle aches, and an impending sense of doom5, they are at increased risk of leaving the hospital Against Medical Advice (AMA).6,7 Physicians, caregivers and other health care experts recommend against AMA discharge due to an increase in mortality risk and rehospitalization.8 Patients experiencing opioid withdrawal may leave the hospital AMA when they feel stigmatized for their addiction or when they feel their symptoms are not adequately being addressed or alleviated. Despite the fact that heroin withdrawal is effectively managed with opioids,9physicians may be reluctant to aggressively treat withdrawal symptoms with opioids due to the fear of being manipulated by “opioid seeking patients”, the concern for causing respiratory depression and the belief they may be contributing to their patient’s addiction.10
Hospitalized patients with opioid-related medical issues often recover. Draining an abscess, treating their infective endocarditis or cellulitis with antibiotics will usually cure their medical issue. Treating their addiction proves to be far more challenging. Many providers feel a sense of inadequacy when treating patients with opioid use disorder. The epidemic is severe and rapidly growing, and the overall training for such treatment in medical school and residency is limited. Most physicians have learned to manage opioid dependent patients “on the job” and addiction-trained physicians, specialists in addiction medicine or addiction psychiatry, are few and far between. Furthermore, treatment resources post hospitalization are limited for patients who are struggling financially.
Here are some facts. In the past two decades, overdose deaths related to opioid medications, both prescribed and obtained illegally, exceeded overdose deaths related to other commonly abused substances, including cocaine and heroin.11 More recently, however, heroin-related overdose deaths are steadily increasing.12,13 This shift may be attributed to the introduction of tamper-resistant opioids14, the increasing street cost of opioid medications15 and the availably of cheap, potent black tar heroin found in many cities across the United States.16 Rates of heroin overdose in younger people now exceed rates of prescription opioid overdose.17 Luckily, there are effective treatment options for what’s known in the medical community as opioid use disorder beyond daily methadone dosing, which can be burdensome for people maintaining a professional, full-time job and family life. But there are new treatments that show promise.
Medication assisted therapy combines behavioral therapy with medications such as buprenorphine to treat opioid use disorders. Buprenorphine is an opioid partial agonist, producing effects such as euphoria or respiratory depression. With buprenorphine, however, these effects are weaker than full agonists such as heroin or methadone. Study after study has shown that increased access to opioid agonist treatment is associated with a reduction in overdose deaths.18-21 A 2014 Cochrane review found that buprenorphine prescribed at fixed doses (above 7 mg per day) was non inferior to methadone prescribed at fixed doses (40 mg or more per day) in retaining people in treatment or in suppression of illicit opioid use.22 In addition, with buprenorphine, the opioid effect levels off with moderate dosing, usually between 12 to 16 mg per day.23
This is called the “ceiling effect”, which has the benefit of lowering the risk of abuse, dependency and side effects. Because buprenorphine is an opioid partial agonist, withdrawal symptoms are kept at bay when taken by a person with opioid dependence.24 Similarly, cravings for heroin or other opioids are diminished. If a person using buprenorphine also uses heroin, or another full opioid agonist, they will not experience additional euphoria nor are they at risk of respiratory depression, because their mu (opioid) receptors are already occupied by buprenorphine. If a person uses heroin and, soon after, takes buprenorphine, they will experience precipitated withdrawal. Precipitated withdrawal occurs when an antagonist (i.e. naloxone) or a partial agonist (buprenorphine) displaces the heroin from the mu receptor. Buprenorphine has a higher affinity for the mu receptor than heroin, but a lower intrinsic activity, which leads to immediate opioid withdrawal symptoms.25
Buprenorphine does produce euphoria in opioid naïve patients and in some with opioid dependence. In order to decrease the likelihood of diversion and misuse of buprenorphine, it is combined with naloxone hydrochloride, which binds to opioid receptors and can reverse and block the effects of other opioids.26 It is highly effective in reversing the effects produced by opioids and saves lives when used to treat respiratory depression from an opioid overdose. Buprenorphine and naloxone products come in many forms, including sublingual tablets, buccal film, and other transmucosal products. When taken orally, the naloxone remains inactive. When injected, the naloxone becomes active and the user will experience opioid withdrawal.
Whereas methadone treatment must be performed in a highly structured clinic, buprenorphine can be prescribed by physicians, nurse practitioners and physician assistants in various settings, including a physician’s office, a hospital, a health department or even in a correctional care facility.27 This means hospital-based providers can prescribe buprenorphine and treat opioid use disorders in the hospital setting with a plan to transition to an office-based buprenorphine prescriber for ongoing medication assisted therapy.
Under the Drug Addiction Treatment Act of 2000 (DATA 2000)28, physicians are required to complete 8 hours of training before applying for a physician waiver prior to prescribing buprenorphine to patients at the time of hospital discharge.29 Nurse practitioners and physician assistants are required to complete 24 hours of training before obtaining a DATA waiver.30 The time it takes to obtain a DATA waiver is negligible to the impact a health care provider could have on people struggling with opioid addiction.
Please consider becoming a buprenorphine prescriber in your hospital.
- Weiss AJ, Elixhauser A, Barrett ML, Steiner CA, Bailey MK, O'Malley L. Opioid-Related Inpatient Stays and Emergency Department Visits by State, 2009-2014: Statistical Brief #219. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006.
- Rudd RA. Increases in drug and opioid-involved overdose deaths—United States, 2010–2015. MMWR Morbidity and mortality weekly report. 2016;65.
- Moore PQ, Weber J, Cina S, Aks S. Syndrome surveillance of fentanyl-laced heroin outbreaks: utilization of EMS, Medical Examiner and Poison Center databases. The American Journal of Emergency Medicine. 2017.
- Macmadu A, Carroll JJ, Hadland SE, Green TC, Marshall BD. Prevalence and correlates of fentanyl-contaminated heroin exposure among young adults who use prescription opioids non-medically. Addictive behaviors. 2017;68:35-38.
- Wesson DR, Ling W. The clinical opiate withdrawal scale (COWS). Journal of psychoactive drugs. 2003;35(2):253-259.
- Chan AC, Palepu A, Guh DP, et al. HIV-positive injection drug users who leave the hospital against medical advice: the mitigating role of methadone and social support. Journal of acquired immune deficiency syndromes (1999). 2004;35(1):56-59.
- Seaborn Moyse H, Osmun WE. Discharges against medical advice: a community hospital's experience. Canadian journal of rural medicine : the official journal of the Society of Rural Physicians of Canada = Journal canadien de la medecine rurale : le journal officiel de la Societe de medecine rurale du Canada. 2004;9(3):148-153.
- Glasgow JM, Vaughn-Sarrazin M, Kaboli PJ. Leaving Against Medical Advice (AMA): Risk of 30-Day Mortality and Hospital Readmission. Journal of General Internal Medicine. 2010;25(9):926-929.
- Donroe JH, Holt SR, Tetrault JM. Caring for patients with opioid use disorder in the hospital. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2016;188(17-18):1232-1239.
- Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Annals of internal medicine. 2006;144(2):127-134.
- Calcaterra S, Glanz J, Binswanger IA. National trends in pharmaceutical opioid related overdose deaths compared to other substance related overdose deaths: 1999-2009. Drug and alcohol dependence. 2013;131(3):263-270.
- Dasgupta N, Creppage K, Austin A, Ringwalt C, Sanford C, Proescholdbell SK. Observed transition from opioid analgesic deaths toward heroin. Drug and alcohol dependence. 2014;145:238-241.
- Rudd RA, Paulozzi LJ, Bauer MJ, et al. Increases in heroin overdose deaths—28 States, 2010 to 2012. MMWR Morb Mortal Wkly Rep. 2014;63(39):849-854.
- Cicero TJ, Ellis MS. Abuse-deterrent formulations and the prescription opioid abuse epidemic in the United States: lessons learned from OxyContin. JAMA psychiatry. 2015;72(5):424-430.
- Surrat H, Kurtz SP, Cicero TJ, Dart RC. Street prices of prescription opioids diverted to the illicit market. Paper presented at: 74th Annual Meeting College of Problems of Drug Dependence (CPDD). Palm Springs, CA2012.
- Mars SG, Bourgois P, Karandinos G, Montero F, Ciccarone D. “Every ‘never’I ever said came true”: transitions from opioid pills to heroin injecting. International Journal of Drug Policy. 2014;25(2):257-266.
- Meiman J, Tomasallo C, Paulozzi L. Trends and characteristics of heroin overdoses in Wisconsin, 2003-2012. Drug and alcohol dependence. 2015;152:177-184.
- Schwartz RP, Gryczynski J, O’Grady KE, et al. Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995–2009. American journal of public health. 2013;103(5):917-922.
- Degenhardt L, Larney S, Kimber J, et al. The impact of opioid substitution therapy on mortality post‐release from prison: retrospective data linkage study. Addiction. 2014;109(8):1306-1317.
- Dolan KA, Shearer J, White B, Zhou J, Kaldor J, Wodak AD. Four‐year follow‐up of imprisoned male heroin users and methadone treatment: mortality, re‐incarceration and hepatitis C infection. Addiction. 2005;100(6):820-828.
- Clausen T, Waal H, Thoresen M, Gossop M. Mortality among opiate users: opioid maintenance therapy, age and causes of death. Addiction. 2009;104(8):1356-1362.
- Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. The Cochrane database of systematic reviews. 2014(2):Cd002207.
- Walsh SL, Preston KL, Stitzer ML, Cone EJ, Bigelow GE. Clinical pharmacology of buprenorphine: ceiling effects at high doses. Clinical pharmacology and therapeutics. 1994;55(5):569-580.
- (SAMHSA) SAaMHSA. Buprenorphine. https://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine. Accessed 6/9/2017, 2017.
- Treatment TNAoAfB. What is Precipitated withdrawal? 2017; https://www.naabt.org/faq_answers.cfm?ID=70. Accessed 6/9/2017, 2017.
- Abuse NIoD. Opioid Overdose Reversal with Naloxone (Narcan, Evzio). 2016; https://www.drugabuse.gov/related-topics/opioid-overdose-reversal-naloxone-narcan-evzio. Accessed 6/9/2017, 2017.
- Stock C, Shum JH. Bupreorphine:a new pharmacotherapy for opioid addictions treatment. Journal of pain & palliative care pharmacotherapy. 2004;18(3):35-54.
- Division UDoJDDC. DEA Requirements for DATA Waived Physicians (DWPs). 2016; https://www.deadiversion.usdoj.gov/pubs/docs/dwp_buprenorphine.htm. Accessed 6/9/2017, 2017.
- Administration SAaMHS. Buprenorphine Waiver Management. 2017; https://www.samhsa.gov/medication-assisted-treatment/buprenorphine-waiver-management. Accessed 06/9/2017, 2017.
- Administration SAaMHS. Qualify for Nurse Practitioners (NPs) and Physician Assistants (PAs) Waiver. 2016; https://www.samhsa.gov/medication-assisted-treatment/qualify-nps-pas-waivers. Accessed 6/9/2017, 2017.