Scheduled, short-acting, full agonist opioids reduces rates of in-hospital illicit opioid use and overdose
Background: People with opioid use disorder frequently engage in in-hospital illicit substance use due to untreated pain and withdrawal and leave the hospital as patient-directed discharges (or against medical advice). We developed a protocol to incorporate scheduled, short-acting, full agonist opioids into our practice with the goal of reducing rates of in-hospital illicit substance use and overdose.
Methods: All patients seen by an inpatient addiction medicine consult service at UPMC Presbyterian Hospital in Pittsburgh, PA, deemed to be at high risk of overdose from illicit opioids post-hospitalization were offered the intervention. We provided scheduled short-acting, full agonist opioids and reassessed the patient to determine if dose escalation was required based on subjective report. We offered to initiate methadone or buprenorphine per patient preference through accelerated titration (methadone) and microinduction (buprenorphine). Once on a therapeutic dose of methadone or buprenorphine, we discontinued or tapered short-acting, full agonist opioids. Patients also received opioid analgesia for acute pain, if indicated; this was scheduled as needed. Outcomes included number of patients started on the intervention and number of episodes of in-hospital illicit substance use and overdose, stratified by receipt of intervention at the time of in-hospital illicit substance use.
Results: Eighty-two patients were started on scheduled short-acting, full agonist opioids for opioid withdrawal; 79 received oxycodone and 3 received hydromorphone. Typical starting dose of oxycodone was 20mg oral every four hours (total morphine milligram equivalence [MME] = 180) at the start of our intervention period; one year later, typical starting dose was 40mg every four hours (MME = 360) with a maximum of 70mg every four hours (MME = 630) offered to one patient. Six episodes of in-hospital illicit substance use occurred among people who received short-acting, full agonist opioids for opioid withdrawal; there were no overdoses. Thirteen episodes of IHSU occurred among people who were not initiated on the protocol, with three overdoses. A total of 40 patients were initiated on buprenorphine and 32 on methadone at hospital discharge. No episodes of opioid overdose were related to initiation of short-acting, full agonist opioids.
Conclusions: Aggressively managing opioid withdrawal with scheduled, short-acting, full agonist opioids in the hospital is safe and has promise to reduce rates of in-hospital substance use and overdose.
