Inpatient Buprenorphine Guide

For AHS employees, a slide deck on this can be found here

Inpatient Management of Opioid Use Disorder Clinical Practice Guideline

Purpose:

Provide clinical guidelines and recommendations that can be utilized by inpatient hospital services to improve the management of acute care patients with opioid use disorder and co-occurring acute or chronic pain if present.

General Information:

For all patients with suspected opioid use disorder, consult the Substance Use Navigator (SUN).

• Patients with any evidence of non-prescribed opioid use ever (heroin, fentanyl, diverted oxycodone, hydrocodone, etc.)

1. Place an IP Consult to Substance Use Disorders order in Epic

2. Send an Epic Secure Chat to the Substance Use Navigators Group

The SUN will:

1. Engage the patient and provide motivational interviewing, information on treatment options, general support

2. Link the treatment team to Bridge Physician as requested to provide clinical consultation and medication recommendations.

   1. No medication recommendations can be made by the SUN without Bridge Physician consultation.

3. Follow the patient at frequency deemed necessary by Bridge and Primary teams based on availability and resources

For patients with difficult to manage acute or chronic pain conditions who require additional support beyond these guidelines (such as multimodal pain management, procedures such as nerve blocks, etc.), strongly consider also consulting the Pain Consult Service.

Treatment Guidelines

Acute period: The initial period of assessment and treatment where there may be active unstable medical conditions such as sepsis with end-organ injury, active cardiovascular or respiratory emergencies, severe metabolic derangements, severe alterations in level of consciousness, acute injuries, chest tubes, wound vacs, painful dressing changes, and/or surgical interventions.

1. On buprenorphine maintenance prior to admission:

1. Patient report is sufficient confirmation, or CURES report.

2. If no other opioids have been administered yet, continue buprenorphine at maintenance dose, split dosing to q8 hours for improved analgesia

   1. Patients who are strict NPO may still be able to receive buprenorphine sublingually; if sublingual administration is still not possible, use scheduled IV opioids such as hydromorphone or fentanyl titrated to relief of withdrawal and pain

3. For acute pain may add other opioids titrated to pain level: PO route preferred if available, IV for breakthrough, hydromorphone or fentanyl preferred

4. For co-occurring pain, maximize multimodal approach using the CA Bridge Guide to Acute Pain Management for Patients on Buprenorphine.

1. On methadone maintenance prior to admission:

   1. Confirm dose with Opioid Treatment Program (Methadone Clinic)

   2. Continue home dose while inpatient, splitting to q8 hour dosing for improved analgesic effect, EXCEPT IF:

      1. QTc > 500 ms (instead, use Full Agonist Opioid Protocol as below)

      2. Patient is started on new medications that interact with methadone metabolism (follow Epic alerts; contact inpatient pharmacy to adjust dose)

      3. Patient has acute liver failure (discuss dosing with pharmacy)

   3. In patients who are strict NPO may use methadone IV (1:2 IV:PO ratio, split dose q8 hours, discuss with pharmacy) or if methadone not appropriate, use Full Agonist Opioid Protocol below and schedule short-acting IV opioids titrated to relief of withdrawal and pain

   4. If an acute pain condition is present may add additional short-acting opioids as needed per routine approaches (PO route preferred if available, IV for breakthrough)

   5. Maximize multimodal pain management approach as needed

1. No history or uncertain history of treatment with buprenorphine or methadone, or history of treatment with either methadone or buprenorphine but last dose of methadone >72 hours ago or buprenorphine >24 hours ago (any interruption of treatment before or during hospitalization):

   1. Offer buprenorphine.

      1. If patient agrees to buprenorphine, assess for complicating factors:

         1. Inpatient administration of full-agonist opioid within past 6 hours

         2. Methadone use within past 5 days

         3. Chronic daily intentional fentanyl use within 3 days of admission

         4. Altered mental status, delirium, intoxication

         5. Severe acute pain, severe trauma, or planned major surgeries

         6. Organ failure or other severe medical illness

      2. If no complicating factors, use a traditional buprenorphine start as described in the CA Bridge Buprenorphine Start Guide.

         1. Wait until patient develops opioid withdrawal (subjective symptoms and at least one objective sign such as dilated pupils, restlessness, sweating, diarrhea, nausea, tachycardia, piloerection)

            1. Withdrawal typically occurs 6-8 hours from last short-acting opioid use (heroin, morphine IR, oxycodone IR), 12-24 hours after last long-acting opioid use (morphine ER or oxycodone ER), and >48-72 hours from last methadone.

            2. For patients with chronic daily fentanyl use or methadone use prior to admission, recommend Full Opioid Agonist and Buprenorphine Cross-Taper Protocols as below.

         2. When withdrawal develops, administer buprenorphine 8 mg SL x1

            1. If patient feels better, give another 8 mg SL and titrate to 16-32 mg per day to eliminate opioid withdrawal, craving or pain, with dosing schedule based on patient preference; split dosing q6-8 hours if co-occurring pain. 

            2. If patient feels worse within 20 minutes of first buprenorphine 8 mg SL dose, assess for alternative causes and address as described in the CA Bridge Start guide above.

      3. If complicating factors, start the Full Opioid Agonist and Buprenorphine Cross-Taper Protocols as below.

   2. If patient declines buprenorphine, start the Full Opioid Agonist Protocol as below and reassess interest in MOUD when stabilized.

Full Opioid Agonist Protocol

1. Start morphine extended release PO scheduled and include holding parameters for RASS<-1 or RR<12, dosing as below.

   1. Patient reports active illicit opioid use most days in the week prior to admission:

      1. Assume high tolerance, start morphine ER 60 mg po q8 hours plus morphine IR 15-30 mg po q4-6 hours PRN breakthrough withdrawal, cravings or pain

   2. If remote illicit opioid use or uncertain: 

      1. Start morphine ER 30 mg po BID + morphine IR 15 mg po q4-6 hours PRN breakthrough withdrawal, cravings or pain

   3. Titrate doses empirically to resolution of withdrawal, craving, or pain

   4. For patients receiving meds via tube, start equianalgesic morphine IR (tabs or liquid) q4-6 hours scheduled

   5. In patients with renal dysfunction, use equianalgesic hydromorphone instead of morphine (discuss dosing with pharmacy)

      1. Instead of morphine 60 mg ER can use hydromorphone 4-6 mg po q4 hours scheduled

      2. Instead of morphine 30 mg ER can use hydromorphone 2 mg po q4 hours scheduled

   6. In patients who are strict NPO use scheduled equianalgesic IV and PRN IV opioids titrated to relief of withdrawal and pain (discuss dosing with pharmacy)

   7. Titrate additional opioids as needed per routine approaches (PO route preferred if available, IV for breakthrough, PCA if appropriate)

      1. For example, morphine IR 15-30 mg po q4-6 hours PRN as above or equianalgesic hydromorphone if renal dysfunction

Buprenorphine Cross-Taper Protocol

1. If patient expresses interest in buprenorphine while receiving full agonist opioids such as on the Full Agonist Protocol as above, do the following while continuing other opioids:

   1. Day 1: Start Butrans (transdermal buprenorphine) 20 mcg/hour patch place TWO patches on skin and schedule buprenorphine 1 mg SL q6 hours x 4 doses

   2. Day 2: Increase buprenorphine to 1 mg SL q3 hours scheduled x 8 doses

      1. If patient starts to feel worse within 20 minutes after any one dose, PAUSE the next dose and wait 4 hours before resuming 1 mg SL

   3. Day 3: Increase buprenorphine to 8 mg SL q8 hours scheduled (24 mg/day)

      1. Can increase buprenorphine up to 8 mg q6 hours (32 mg/day) for craving, withdrawal, or pain

      2. Taper other opioids as needed

      3. Remove Butrans 20 mcg/hour patches

      4. Discuss with the Bridge Clinic physician next steps

Stabilization: The period after acute assessment and treatment when care is being de-escalated, patients are more stable, and discharge from the hospital is being planned.

1. On buprenorphine or methadone maintenance already: continue treatment as described above.

1. On Full Opioid Agonist Protocol:

   1. Offer buprenorphine. If agrees, start the Buprenorphine Cross-Taper Protocol as above.

   2. If declines buprenorphine, offer methadone. If agrees to methadone, use the CA Bridge Methadone Start Guide. 

      1. Assess for contraindications and follow the same precautions as described under Methadone Maintenance section above.

      2. Day 1: Start methadone 10 mg po q8 hours and add an extra 10 mg if needed for breakthrough craving or withdrawal to a maximum of 40 mg on Day 1.

      3. Day 2: If no sedation can titrate to max dose of 50 mg on Day 2.

      4. Day 3: Can continue titration as needed to max dose of 60 mg/day.

      5. Day 4 and beyond: Continue same dose as Day 3 for 5 days before increasing further, after which can increase dose by 10 mg q5 days

         1. Typically 30-45 mg methadone will relieve acute withdrawal, but >60 mg is needed to relieve opioid cravings.

      6. When methadone is initiated, the Full Opioid Agonist Protocol should be discontinued. 

         1. Short-acting opioids may be cautiously added as a PRN if needed for breakthrough craving, withdrawal or pain as methadone dose is up titrate as above.

   3. If declines both buprenorphine and methadone or there are contraindications to either, continue the Full Opioid Agonist Protocol and reassess daily.

1. If not on any opioid treatment mid-hospitalization:

   1. Offer buprenorphine. If agrees, start using the CA Bridge Buprenorphine Start Guide as described in the Acute Phase section above.

   2. If declines buprenorphine, offer methadone. If agrees to methadone, use the CA Bridge Methadone Start Guide as described above.

   3. If declines both buprenorphine and methadone or there are contraindications to either, start the Full Opioid Agonist Protocol and reassess daily.

Discharge Planning

1. For patients started or continued on buprenorphine while inpatient:

   1. Ensure patient discharges from hospital with a supply of buprenorphine in-hand from the discharge pharmacy, regardless of destination. 

      1. Ensure SUN/Bridge Team is contacted to facilitate discharge prescription if discharging provider does not have an X-waiver DEA License

      2. If patient discharged to SNF or ARU, a discharge supply of buprenorphine in hand from the HGH Pharmacy is especially required

   2. May still prescribe other opioids for acute pain as appropriate; do not withhold opioid discharge prescription if appropriate for acute pain.

   3. Before discharge, SUN team will provide patient and primary team with appointment date for outpatient follow-up with Bridge Clinic within one week of hospital discharge.

1. For patients started or continued on methadone while inpatient:

   1. As early as possible before discharge, enlist support of inpatient social work team to offer patient linkage to outpatient Opioid Treatment Program (methadone clinic) where methadone maintenance can be continued, regardless of destination.

      1. If discharged to home, do not prescribe methadone at discharge.

      2. If discharged to SNF or ARU, a discharge prescription of methadone may be written by the discharging physician for a diagnosis of pain. 

         1. If no pain diagnosis is present, social work can help coordinate with Opioid Treatment Program to provide methadone to SNF for administration to patient while there.

   2. May still prescribe other opioids at discharge for acute pain as appropriate; do not withhold opioid discharge prescription if appropriate for acute pain.

1. For patients not started on buprenorphine or methadone during hospital stay:

   1. Still offer a discharge prescription of buprenorphine if patient wishes to start after discharge.

   2. SUN team can still offer patient harm reduction services (naloxone kit, syringe kit, clean smoke kit) and outpatient linkage to buprenorphine or methadone treatment.

   3. May still prescribe other opioids at discharge for acute pain as appropriate; do not withhold opioid discharge prescription if appropriate for acute pain.