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 2
Review a protocol for inpatient initiation of methadone or buprenorphine in patients with opioid use disorder (OUD) Learning Describe outcomes after protocol initiation, including effect on AMA discharges, length of stay Objectives and control of withdrawal symptoms Identify potential areas for improvement to continue enhancing patient care 3
Institution Tertiary, non-profit, community medical center Largest hospital in Alaska 401 beds 62 emergency department beds Level II trauma center 4
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? Pre-Test a) Correct titration of medications b) Use of supportive care medications Assessment c) Social work consult d) Pain management 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 5
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 6
Symptom management Nursing screening of all patients Scheduled medications Gabapentin, clonidine, COWS ordered hydroxyzine, sleep aids OUD Provider paged – discussion PRN Medications of methadone vs. Non-opioid pain control, Treatment buprenorphine/naloxone nausea and vomiting, anti-diarrheal Methadone: 10 mg TID Protocol Social work and case Buprenorphine/naloxone: 4/1 mg PRN COWS > 8 management consult Titration and dose Patients discharged with adjustments to effective dose Narcan kit 7
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) Efficacy Secondary outcomes: Inpatient LOS Objective 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 8
Identity potential areas for protocol implementation improvement and care of these patients. Outcome Measures: Time from baseline COWS score to COWS score < 8 Quality for > 24 hours Improvement Process Measures Initiations of methadone and Objective 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. 9
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 10
Results – Patient Characteristics Pre-Implementation Post-Implementation 203 patients identified 138 patients identified 40 patients excluded for MAT PTA, 16 patients 53 excluded for MAT PTA, 12 patients excluded excluded for other reasons for other reasons 147 patients included in final analysis 73 included in final analysis Average age: 36 Average age: 38 55% female (78/147), 45% male (66/147) 45% female (33/73), 55% male (40/73) Comorbidities: Comorbidities: Other SUD: 97% (142/147) Other SUD: 95% (69/73) Psychiatric: 44% (64/147) Psychiatric: 42% (30/73) Chronic pain: 16% (23/147) Chronic pain: 19% (14/73) Alcohol abuse: 6% (9/147) Alcohol abuse: 3% (2/73) 11
Results – AMA Dispositions Pre-Implementation Post-Implementation AMA rate per total patients: 27.2% (40/147) AMA rate per total patients: 23.3% (17/73) Medications AMAs/MAT Type Medications AMAs/MAT Type Buprenorphine/ 13.3% Buprenorphine/ 33.3% Naloxone Naloxone (2/15) (2/6) Methadone 26.6% Methadone 33.3% (12/45) (18/54) None 23.1% None 23.0% (3/13) (20/87) 12
Results – Length of Stay Total Buprenorphine/ Methadone None naloxone Pre- 12.5 days 16.6 days 14.8 days 10.7 days Implementation (n=147) (n=6) (n=54) (n=87) Post- 10.5 days 4.1 days 12.2 days 11.9 days Implementation (n=73) (n=15) (n=45) (n=13) 13
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) 14
Results – AMA Comparisons Left Methadone PRN Time to Gabapentin Sleep Clonidine AMA Titrated Buprenorphine/ COWS < 8 Ordered Medications Scheduled Appropriately naloxone Ordered for 24 Hrs Scheduled Yes 16.7% (2/12) 50% 2.35 29.4% 5.9% (1/17) 23.5% (1/2) days (5/17) (4/17) No 33% 69.2% 2.43 26.8% 18.9 19.6% (11/33) (9/13) days (15/56) (10/56) (11/56) 15
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 16
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) 17
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 18
Results – Supportive Care Medications Supportive care medication usage Pain Stomach cramp medications 34.2% (25/73) Gabapentin 27.4% (20/73) Diarrhea medications 34.2% (25/73) Muscle cramp medications 30.1% (22/73) Hydroxyzine 41.1% (30/73) NSAIDS 64.4% (47/73) Clonidine 52.1% (38/73) Oral opioids 86.3% (63/73) Sleep medications 65.8% (48/73) APAP 91.8% (67/73) Nausea & vomiting medications 90.4% (66/73) Average pain score reduction from admission to discharge was 0.7 (on a scale of 1-10) 19
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 Conclusion & with buprenorphine/naloxone Discussion Initiations increased by 16.4% for buprenorphine/naloxone and by 24.9% for methadone Treatment protocols for OUD patients may decrease rates of AMA disposition, allowing patients a greater opportunity to receive the medical care that they need 20
1. Which of the following are aspects of the OUD treatment protocol? Post-Test a) TAPS screening b) Social work consult Assessment c) Buprenorphine/naloxone or methadone initiation Questions d) Naloxone kit 21
1. Which of the following are aspects of the OUD treatment protocol? Post-Test a) TAPS screening b) Social work consult Assessment c) Buprenorphine/naloxone or methadone initiation Questions d) Naloxone kit 22
Recommend
More recommend
