Tuesday, February 1, 2022

Should Short-Acting Opioids Be Used to Manage Hospitalized Patients With OUD?

Untreated pain, withdrawal, and opioid craving are known to drive people with opioid use disorder (OUD) to delay care despite serious illness, use illicit opioids while hospitalized, and/or leave the hospital early. Such actions can have life-threatening consequences, writes Ashish P. Thakrar, M.D., of the University of Pennsylvania in a Viewpoint article published yesterday in JAMA Internal Medicine.

“[A]s we enter the third decade of a worsening overdose crisis and face an increasingly contaminated supply of illicit opioids, it may be time to consider that adequate doses of short-acting opioids can serve as one component of compassionate, effective care of hospitalized patients with OUD,” Thakrar proposes. “Given their addictive risk, this is not a call to be cavalier with opioids in general. But for patients who already have active OUD, the risk of developing addiction is no longer germane.”

Thakrar cites American Society of Addiction Medicine guidelines that recommend hospitalized patients with OUD be treated with nonopioid medications, buprenorphine, or methadone but notes that these medications may be insufficient to initially manage some patients’ symptoms. For instance, he writes that methadone can take four hours to reach a peak effect and more than a week of daily dosing to achieve a steady state that is therapeutic for withdrawal and craving.

Thakrar describes several scenarios in which short-acting opioids might be used to treat acute pain and withdrawal in hospitalized patients with OUD, including those patients who choose to initiate or decline treatment with methadone or buprenorphine. “This last scenario, admittedly the most controversial, acknowledges that some patients are unable or unwilling to stop using short-acting opioids, even when offered treatment. We can accept this, offer a safer alternative to illicit opioids, and still treat the conditions that require hospitalization,” Thakrar writes.

“Although it may seem radical to some, this approach could quickly and effectively alleviate pain, withdrawal, and opioid craving, thereby facilitating treatment of the medical and surgical complications of addiction and of OUD itself,” he continues.

In an accompanying editorial, Nathaniel P. Morris, M.D., an assistant professor of clinical psychiatry at the University of California, San Francisco, acknowledges the profound impacts that undertreated pain can have on hospitalized patients with OUD.

“Health professionals must do more to provide humane and evidence-based care in these situations, and short-acting opioids may be one tool in the clinician’s comprehensive pain management toolbox, which should include nonpharmacologic strategies and nonopioid medications as well,” he writes. “More data collection surrounding these practices and development of evidence-based protocols can assist inpatient clinicians who are working to address the overwhelming morbidity and mortality associated with OUD. In developing these protocols, researchers and clinicians must also consider the ways in which social determinants of health, such as poverty, homelessness, criminal legal involvement, racism, and unemployment, shape the care of inpatients with OUD and associated health-related outcomes.”

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