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

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 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.

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

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

Where are we?

The Opioid Epidemic An Acute Care Problem

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/

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

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.

Medica<ons for Opioid Use Disorder

Withdrawal Management Symptoma/c treatment/Adjunc/ve meds: • Adjunc0ve medica0ons The following can be prescribed PRN for symptoms of withdrawal • Low dose methadone or • Acetaminophen 650mg PO q6h prn pain buprenorphine taper • Clonidine 0.1-0.3mg PO q6-8 h prn withdrawal symptoms (NTE 1.2mg/day, hold if BP <100/70) • Maintenance • Diphenhydramine 25-50mg PO q8h prn buprenorphine or insomnia/anxiety • Loperamide 4mg PO ini0ally, then 2mg PRN each addi0onal loose stool (NTE 16mg/24h) methadone • 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

Detox Doesn’t Last 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.

Decreased Mortality All cause mortality per 1000 person years 40. 30. 20. 10. 0. In methadone Out of methadone In buprenorphine Out of buprenorphine 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

Treatment Starts Here Acute Care Medica0on Treatment

Why Start in the ED? • Trea0ng emergency of withdrawal • Frequent site of care for pa0ents with OUD • Ojen otherwise not engaged in care • Buprenorphine only

ED Initiation of Buprenorphine % in care at 30 days Days illicit opioid use/week Brief interven0on Brief interven0on Referral Referral Buprenorphine Buprenorphine 0 20 40 60 80 100 0 0.5 1 1.5 2 2.5 3 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.

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

Hospital Initiation of Buprenorphine Linkage Detox 80 80 72 65 70 Number of Days % Patients 60 60 50 40 40 30 20 20 12 7 10 0 0 Received MAT in 6 mo after Days in MAT over 6 months discharge Liebschutz et al. Buprenorphine Treatment for Hospitalized, Opioid-Dependent Pa0ents. JAMA Intern Med. 2014 Aug; 174(8): 1369–1376 .

Making it Happen

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 other 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

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.

What are her treatment op<ons? • What has she tried? • What are her preferences?

Case: Which treatment is best? • She has tried methadone in the past, but did not like that it made her feel “foggy” • She tried buprenorphine/naloxone obtained 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.

www.bridgetotreatment.org

Let’s Start!

Yes, In Acute Opioid Withdrawal

Yes, Withdrawal Symptoms Improved

Stop Overdose Deaths • Universal naloxone prescribing • OUD • Chronic opioids • Any illicit drugs

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.

Percent rate of change for all opioid overdose deaths from 2016-2017 30 25 20 15 % rate of change 10 5 0 White Black Hispanic American Asian/Pacific Indian/Alaska Islander Na0ve hbps://www.cdc.gov/mmwr/volumes/67/wr/mm675152e1.htm?s_cid=mm675152e1_w

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

No, Opioid Withdrawal Symptoms Not Improved

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

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

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?

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

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