Thread by @adfoxMD

Invited as discussant for inpatient medicine case conference.

40yo M w/ persistent asthma & >10 exacerbations past yr

Smoker? No
Environmental exposures? No pests/2nd hand smoke at home
Med adherence? High co-pays, yes

But also resumed intranasal heroin use last yr

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Can intranasal heroin use lead to asthma exacerbations?

Yes.

Mechanism may be histamine release w/i respiratory tract & bronchospasm

ncbi.nlm.nih.gov/m/pubmed/12576…

Inpatient mangement asthma unchanged, but in AM, pt tells team “I’m anxious”

Starting to go into opioid withdrawal.

What should we do?

Usually before fatal opioid overdose, there are multiple “touch points” where med initiation possible @LarochelleMarc

Those starting methadone or bupe after non-fatal overdose much lower mortality (vs. no meds) over next 12 months.

Our job is to identify & treat addiction.

1. Taking a substance use history

Recommend @JonGiftosMD’s harm reduction informed approach to assessment & patient-centered goal setting.

2. Make opioid use disorder diagnosis.

Can look up DSM5 criteria, but remember that addiction is characterized by compulsive use, craving, loss of control & ongoing use despite consequences.

3. Interpretation of urine drug testing.

Residents struggle here (unknowingly)

Heroin tests (+) as opiate, but methadone & fentanyl are synthetic & will appear as opiate (-).

Has this pt used fentanyl? We don’t know.

4. Inpatient initiation of buprenorphine treatment.

@liebschutz et al showed that inpatient bupe initiation & linkage to care post-discharge leads to ⬆️ ppl starting opioid agonist treatment (72% vs. 12% w/ 5-day “detox”).

ncbi.nlm.nih.gov/m/pubmed/25090…

5. Informed consent about treatment.

I usually remind ppl that bupe is an opioid & will maintain physical dependence.

Discuss safe medication storage.

Bupe can be sedating if no tolerance or if combined w/ other sedatives.

6. Assess for bupe contraindications.

Allergy buprenorphine/naloxone ❌

Use caution:
Alcohol use d/o
Benzo use d/o
LFTs 5x ULN

FDA guidance highlights that untreated OUD can carry greater risk than bupe-benzo interaction. Careful med mngmnt best.
fda.gov/Drugs/DrugSafe…

7. Assess withdrawal using COWS scale.

Buprenorphine can induce withdrawal by displacing full opioid agonists from opioid receptors - must be in mild-mod withdrawal (COWS 8-12) before starting meds.

Use caution if pts have been taking methadone.

8. Goal should be to reach a dose that blocks craving.

@liebschutz et al reached 16 mg by day 3.

16 mg more effective than lower dose - often “lower better” mentality driven by stigma

cochrane.org/CD002207/ADDIC…

9. Linkage to care also important.

Hospitals should establish reliable referral site.

Pt previously referred to bupe program requiring daily medication pick up, but couldn’t fit w/ work schedule.

But some may need structured outpatient program.

➡️ shared decision-making

House staff Q’s:

Could starting buprenorphine inpatient worsen things for pt if no follow-up?

Not sure why this always comes up as concern.

Even tapering course of bupe is better than allowing pt to withdraw in hospital & d/c w/ nothing.

Can buprenorphine be started from emergency dept?

Yes, strong rationale & good RCT by D’Onfrio et al demonstrating feasibility & effectivess of starting bupe in ED

ncbi.nlm.nih.gov/pmc/articles/P…

Ultimately, I think we need a medication first option for pts

Agree w/ @rayraywino

Start medication, prevent withdrawal, minimize craving & then can target ongoing needs (depression, trauma, housing instability, etc.)

***pt gave permission for me to discuss case, details changed