A harm-reduction approach to hospitalized patients with opioid use disorder

Initiating inpatient treatment is a prime opportunity to elicit insight from patients about their drug use.

It's indisputable that hospitalists are caring for more patients with opioid use disorder (OUD) now than when the term “hospitalist” was coined in 1996. As a hospitalist working at the county hospital in Oakland, Calif., some weeks I treat two patients with infective endocarditis and another 10 patients with OUD at a time, on a service of 17 patients total.

My experience reflects national statistics. Admissions for OUD increased fourfold between 1993 and 2016. In 2012, the rate of OUD-related hospital admissions was 300 per 100,000 U.S. adults, according to data from the Agency for Healthcare Research and Quality. A February 2019 study published in February 2019 in the Journal of the American College of Cardiology using the U.S. National Readmissions Database found 27,432 hospitalizations for IV drug use-associated endocarditis between 2010 and 2015, representing an increase from about 15% of admissions for infective endocarditis in 2010 to 29% in 2015.

I suspect that the high prevalence of infective endocarditis and other OUD-associated conditions, including bacteremia and skin and soft-tissue infections, that I see now will become only more common in hospitals across the country as we attempt to stem the growth of the opioid epidemic. We need an innovative, harm-reduction-based approach to better care for these patients.

The main challenge of these hospitalizations is convincing patients with OUD to remain in the hospital, especially if they need weeks of antibiotics. Patients who use IV drugs are more likely to leave against medical advice than other patients, often prior to completing antibiotics. Some studies have found this to occur up to 50% of the time. Leaving against medical advice is associated with increased mortality, a very real concern I've had when a patient with a 2-cm tricuspid vegetation from Pseudomonas vanished from the hospital and couldn't be reached by phone.

Treating an infection caused by OUD while ignoring the OUD itself is unacceptable, like failing to address smoking cessation after a myocardial infarction. Yet it is still the culture at many hospitalist programs to label patients who use IV drugs as “drug seeking.” Perhaps that explains why, in the past two decades, only 2% of discharged patients with OUD have received counseling or pharmacotherapy, according to a study published in the August 2019 Journal of Substance Abuse Treatment. The majority of patients who could benefit from OUD treatment aren't getting it on the outpatient side either. Only 17% of patients with an opioid-related hospitalization participated in treatment for substance use disorder within a month of discharge, according to a study published in the same journal in October 2016.

Initiating inpatient OUD treatment, including counseling and pharmacologic therapy, is a prime opportunity to elicit insight from patients about their drug use and help them develop resilience to avoid the behaviors that led them to develop infective endocarditis or other complications in the first place. A Canadian study of HIV-positive patients who used IV drugs, published in the Jan. 1, 2004, Journal of Acquired Immune Deficiency Syndrome, found a 50% reduction in the number of patients leaving against medical advice when methadone was started during an inpatient stay.

Inpatient harm reduction for patients with OUD means treatment of withdrawal symptoms, balanced with careful management of OUD and/or chronic pain. Addressing OUD and opioid withdrawal promptly shows the patient that the physician is hearing and addressing what is often the patient's main priority: not to be penalized by the health care system for “being an addict” by being forced to “detox” in the hospital.

When I first started working with my current patient population, I was sometimes uncomfortable giving opiates to my patients with OUD. Doesn't that make us the drug dealers ourselves now? Are we, the clinicians who promised to do no harm, simply enabling a dangerous behavior? However, a harm-reduction approach recognizes that our patients with OUD are already in harm's way and will likely use opioids with or without us. If we inadequately treat opioid withdrawal in the hospital, our patients are more likely to mistrust us and leave against medical advice, which doesn't help treat their OUD or their OUD-related condition. Failing to address the OUD is a lost opportunity to build trust with a patient and initiate medication-assisted treatment.

Pharmacologic options to treat withdrawal include buprenorphine and methadone. They can also include narcotics titrated to relief of withdrawal symptoms, if buprenorphine or methadone is unavailable or the patient is unwilling to try these drugs initially. At discharge, a bridging prescription for buprenorphine can be written by a qualified physician with an X waiver from the Drug Enforcement Administration, whereas continued methadone treatment requires linkage to a methadone clinic.*

It is important to set boundaries up front about the goals of starting OUD therapy in the hospital. The goal is to keep the patient comfortable, while being realistic about the risks of oversedation and recognizing that chronic pain can only be managed, not obliterated. Involving a pain or addiction specialist, if available, may be useful as an additional resource for the patient and ourselves.

As hospitalists, we must embrace a harm-reduction approach and treat patients with OUD for their OUD, not just the sequelae.