Management of opioid withdrawal and initiation of medications for opioid use disorder in the hospital setting

ABSTRACT

Introduction

Opioid use disorder (OUD) has become increasingly prevalent among hospitalized patients in the United States and globally. As its prevalence increases, this provides a valuable opportunity for clinicians in the hospital setting to engage and initiate management and treatment of OUD.

Purpose

This article aims to provide hospitalists and other clinicians working in the hospital with a narrative review of the management of opioid withdrawal and the initiation of medications for opioid use disorder (MOUD) in the hospital and provide an update on a novel low dose approach to buprenorphine induction (also commonly referred to as the ‘microinduction’ method).

Methods

Authors performed a narrative review of the literature.

Results

Management can initially include treating withdrawal symptoms with opioids as well as with a combination of non-opioid medications such as alpha 2 agonists, benzodiazepines, and/or antiemetics as needed. Besides simply managing withdrawal symptoms, clinicians can further improve the care of patients with OUD through initiating maintenance treatment with MOUD, ideally with opioids used in the initial management of withdrawal. Opioid detoxification is an inferior method of primary treatment and is associated with relapse and poor outcomes. In contrast, treatment with MOUD using methadone or buprenorphine is associated with superior treatment outcomes and reduced relapse compared to detoxification alone. Treatment with MOUD using methadone or buprenorphine can be successfully used in the hospital setting. A novel low dose approach to buprenorphine induction may be useful in minimizing precipitated withdrawals in patients who have recently used or received opioids, which makes this an attractive option in the hospital where patients are frequently on opioids for acutely painful conditions. The hospital setting also provides a valuable opportunity for clinicians to address harm reduction in patients with OUD. Finally, clinicians can improve the long-term outcomes of patients with OUD by ensuring a smooth discharge with adequate and timely follow-up.

Conclusion

Proper management of opioid withdrawal and initiation of MOUD in the hospital can improve outcomes in patients with OUD.

KEYWORDS:

• Addiction
• opioid use disorder
• opioid
• opioid-related disorders
• buprenorphine
• methadone
• inpatient
• microinduction

Declaration of funding

No funding was received for the production of this manuscript.

Disclosure of any financial/other conflicts of interest

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. A peer reviewer on this manuscript discloses following relationships: Consultant/ Speaker, Owner, and Researcher for Spirify, US World Meds, Salix, Enalare, Scilex, Pfizer, Lilly, Teva, Taketa, Regeneron, Grunenthal, Neumentum, BDSI and Bridge Therapeutics. Peer reviewers on this manuscript have no other relevant financial or other relationships to disclose.