The toll that opioid addiction has taken in the United States is staggering, said Jesse Theisen-Toupal, MD, from the Veterans Administration Medical Center in Washington, DC.
“In 2000, there were 4400 opioid overdose-related deaths,” he reported here at the Society of Hospital Medicine 2016 Annual Meeting. “In 2013, there were 16,000.”
Despite this crisis, some hospitalists are not comfortable talking about safer ways to inject drugs with patients who come to the hospital with opioid addiction, Dr Theisen-Toupal explained.
But they need to come to terms with the fact that many people are not ready to stop opiate misuse, he pointed out. These people need to know how to safely share needles, how to sterilize surfaces, and that sterile water, or at least tap water, should be used to dissolve the drugs.
“I’ve had patients use pond water. I’ve had patients use toilet-bowl water. I had a patient actually use water from a puddle on the side of the road,” he said.
Hospitalists are seeing more patients with opioid addiction. In 2011, there were more than 750,000 emergency department visits by people with opioid addiction, and about a quarter of those patients were admitted, Dr Theisen-Toupal reported.
More Addicted Patients Admitted
When addicted patients are admitted to the hospital for another condition, they have two choices: get medical treatment but suffer withdrawal, or leave the hospital before getting medical treatment to resume opioid use.
He advocates treating these patients for opiate withdrawal in the hospital so they can be also be treated for their other conditions.
The two main treatment options are methadone, an opiate replacement, or clonidine, a nonopiate treatment.
Methadone is effective and well tolerated, said Dr Theisen-Toupal, but you can’t prescribe it to outpatients because of the potential for misuse.
Clonidine is great when opioids are contraindicated, he said, and it can be prescribed to outpatients. However, it is often not well tolerated and can mask other withdrawal symptoms. For example, if someone has an alcohol-use disorder on top of an opioid-use disorder, clonidine could mask the alcohol withdrawal, resulting in serious consequences, he explained.
To achieve sustained success with treatment, you also have to deal with psychosocial barriers, Dr Theisen-Toupal pointed out. People with opiate-use disorder suffer from stigmatization, and rates of unemployment, homelessness, and criminal activity are high in this population.
“I give everyone with opiate-use disorder a social work consultation, and I try to take care of whatever we can in the hospital. If there are issues, I get psychiatry involved,” he explained. If possible, this occurs on an inpatient basis; if not, patients are seen as outpatients.
Opioid abuse has caused confusion in the insurance industry. Some payers are of the opinion that withdrawal treatment does not require a hospital stay, said Michael Miller, MD, medical director of the Herrington Recovery Center at Rogers Memorial Hospital in Oconomowoc, Wisconsin, and former president of the American Society of Addiction Medicine.
“But if a patient doesn’t come in, they can never turn the corner with their disease,” Dr Miller told Medscape Medical News.
This puts the hospitalists in the middle, trying to make the case for admitting the patient. Unfortunately, when it comes to addiction management, there are few specialists to consult.
The biggest problems are the stigmatization of the disease and the deficiencies in medical education on how to manage addiction and withdrawal, Dr Miller explained.
“When patients come in, they are scorned. There’s still the idea that you did this to yourself and no one should be taking burdens off your shoulders,” he said.
Because the relapse rate for opioid abuse is so high, it is important for hospitals to coordinate outpatient care, said Akikur Mohammad, MD, an addiction psychiatrist in Malibu, California, who wrote the book The Anatomy of Addiction.
“This is a serious condition, and hospitals need more addiction specialists on board,” he told Medscape Medical News. People with an opiate addiction are often hospitalized for something else, so checks for opioid use should be part of routine screening, he said.
Surgeon General on What Doctors Can Do
In his opening plenary at the conference, Vivek Murthy, MD, Surgeon General of the United States, offered advice for hospitalists fighting opioid addiction.
He urged the use of opioid alternatives for the treatment of pain, such as physical therapy and nonopioid medications.
“If we have to prescribe opioids,” he said, “we can prescribe them for the shortest possible duration at the lowest possible dose.”
Programs that monitor the use of prescription drugs can alert prescribers to opiate medications the patient has received at another facility. Although such programs are becoming more widespread, many are out of date and need to be better integrated into electronic health records, he acknowledged.
Dr Murthy said that his office “will work directly with physicians and with nurse practitioners, who comprise the bulk of prescribers, to see how we can build momentum in medicine to reduce and reverse opioid addiction.”
Society of Hospital Medicine 2016 Annual Meeting. Presented March 9, 2016.