SAN DIEGO – Hospitalists have a lot to learn about providing care for the growing number of their patients addicted to opioids.
“By and large, we’re just addressing the medical problems that brought them in,” said Dr. Jesse Theisen-Toupal, an addiction researcher and hospitalist at the Veterans Affairs Medical Center in Washington, D.C. “But whether it’s because of our lack of education, or lack of adequate resources in hospitals, we’re not really [treating] their addiction.”
That’s a real problem that can cause addicted patients harm, and may bring them right back into the hospital.
Dr. Theisen-Toupal, who treated many patients with addiction over the 6-year period when he was a resident and attending physician at Beth Israel Deaconess Medical Center in Boston, discussed these concerns at the Society of Hospital Medicine annual meeting, and in a follow-up phone interview.
While President Obama’s recently announced $1.1 billion program to improve access to treatment for addiction will help, as will lifting the ban on the use of federal funds for syringe exchange programs, those efforts are largely aimed at managing outpatients.
“They may not change the way hospitalists manage an admitted patient with opioid addiction,” Dr. Theisen-Toupal said. “Hospitalists have access to a group of people who are not plugged into outpatient providers, and have a great opportunity to engage them into treatment.” Hospitalists must do much more for these patients than they currently are, he noted, in four key areas.
Pain Management
First, hospitalists must do a better job treating the pain that sometimes comes with an acute medical problem, like appendicitis or infective endocarditis. “We still need to treat them humanely,” Dr. Theisen-Toupal said. “But we’re very hesitant to give into somebody’s addiction, so we often don’t give appropriate doses [of pain medication].”
Better care may mean giving drug-addicted patients higher doses than nonaddicted patients who have lower tolerance thresholds, so long as physicians give the lowest amount that’s adequate for the shortest duration. “And if you can get away with it, use Tylenol or NSAIDs,” Dr. Theisen-Toupal said. “Just treat the pain.”
Withdrawal
Second, hospitalists often overlook the fact that opioid-using patients may go into withdrawal during their stay, a condition the hospitalist should be treating simultaneously.
“The classic teaching is that you can’t die from opioid withdrawal, but you can be really, really miserable,” Dr. Theisen-Toupal said. Without withdrawal treatment, the patient is forced to decide whether to leave the hospital to find and take more drugs, foregoing needed medical care, “or to suffer through the hospital stay.” Many choose the first option.
Thoughtful doses of methadone, buprenorphine, or clonidine can “take that hard decision off the table,” he said. Currently, common practice is to treat obvious symptoms piecemeal, for example, treating diarrhea with an antimotility agent, but that’s not effective at managing withdrawal.
Dr. Theisen-Toupal said detox and treatment centers treat withdrawal, but that knowledge “hasn’t necessarily made its way to the internal medicine and hospitalist community,” nor is it usually part of medical education.
Outpatient Referrals
Third, hospitalists should help connect addicted patients with appropriate outpatient specialists in substance abuse/disorder. “We need to create these connections,” Dr. Theisen-Toupal said. Referral discussions “only take a minute or two.”
Harm Reduction
Fourth, hospitalists must teach addicted patients harm-reduction strategies, such as safer injection practices that won’t bring them back to the hospital. This is “a real opportunity to prevent future harm,” Dr. Theisen-Toupal said.
For example, one-third of injection drug users “will lick the needle before they inject. That’s terrible because there’s bacteria and other nonsterile things in the mouth that they’re then injecting into the body,” leading to infections, he said. He’s also had patients who used roadside puddle water or toilet bowl water to dissolve heroin.
Harm-reduction education “can be just a 2-minute intervention, but it can have a big future payoff to prevent serious infections,” he said.
One easy harm-reduction strategy is to prophylactically prescribe naloxone, which reduces respiratory depression and sedation, in case of an overdose after discharge, and works much like an EpiPen. Dr. Theisen-Toupal said the hospitalist can make sure the patient’s family and friends know how to recognize an overdose and promptly use naloxone correctly. They should then be taught to “call EMS immediately, begin rescue breathing or CPR, and administer naloxone, and stay with the patient until they arrive.”
Dr. Theisen-Toupal acknowledged that some critics argue such policies could encourage drug use. “That is an argument, but when you look at some of the studies, it doesn’t hold much water,” he said. One such study , published in the British Medical Journal in 2013, compared areas with no naloxone education or distribution, some education or distribution, and an extensive amount of education or distribution. In the latter, he said, “there was actually a reduction in the opioid overdose death rate of 46%,” compared with the area that had no naloxone intervention.