Addiction Experts Develop Best Practices for Treating Opioid Use Disorder in the Hospital

A new study published in JAMA Network Open on May 7 engaged 42 national experts in hospital-based addiction treatment in a consensus-building process to develop best practices for hospital-initiated medications for opioid use disorder (MOUD).

Hospitalization offers a critical opportunity for individuals with opioid use disorder (OUD) to begin treatment with evidence-based medications, such as buprenorphine and methadone. However, clinicians have faced challenges initiating treatment with these medications in patients who are using fentanyl and other high-potency synthetic opioids (HPSOs).

“Fentanyl and other HPSOs are different from other opioids in the drug supply. They're orders of magnitude more potent, which not only contributes to the overdose crisis and more severe withdrawal we're seeing clinically, but they can complicate treatment because of the other properties they contain. Hospital-based addiction medicine clinicians have often led the way in adapting to changes in the drug supply and helping improve care for people with opioid use disorder,” explains Shawn Cohen, MD, assistant professor of medicine (general medicine) at Yale School of Medicine (YSM) and lead author of the study.

Clinicians across the country are implementing novel initiation strategies and other measures to improve patient experience and outcomes, but often with limited evidence at their disposal. Most large-scale randomized controlled trials evaluating initiation of these medications pre-date the emergence of HPSOs in the unregulated opioid supply, as do available professional society guidelines.

In this study, the group aimed to identify best practices for MOUD initiation in the hospital via a consensus-building process called the Delphi method. They reviewed adaptations in how clinicians are starting methadone and buprenorphine, as well as utilization of other medications, including other opioids, to treat withdrawal.

The study specifically sought to distill expert consensus around the use of emerging rapid methadone initiation, high-dose, and low-dose buprenorphine initiation protocols, adjunctive strategies for managing opioid withdrawal, and integration of long-acting injectable formulations.

In a multi-round survey, the researchers presented participants—physicians and advanced practice providers regularly treating patients with OUD in hospital settings—with hypothetical patient cases where starting MOUD may be indicated. Participants were asked to rate the appropriateness of specific clinical practices on a scale ranging from very appropriate to very inappropriate, taking into consideration the relative prevalence of each practice in the field currently and summary data on the anonymized responses of their peers.

Broad consensus was achieved on the appropriateness of several adaptations in the treatment of patients using HPSOs, signaling practice changes that are actively becoming standard of care as the unregulated opioid supply continues to evolve, despite the availability of rigorous evidence.

“The consensus that these adaptations are appropriate really highlights that experts believe the adaptations work and improve care for hospitalized patients with OUD,” says Cohen.

While clinicians continue to innovate at the bedside to deliver the best possible care for their patients, researchers have an opportunity to strengthen the supporting science.

“The evidence supporting these newer hospital-based opioid withdrawal and OUD treatment innovations is still developing. Studies like this one show clinical consensus among experts in the field of addiction medicine and serve as an important call for more research,” explains Melissa Weimer, DO, MCR, associate professor of medicine at YSM and of public health at Yale School of Public Health, and co-author of the study.

In addition to further study of the safety and effectiveness of practice adaptations emerging in response to HPSOs, the authors call for clear communication and shared decision making with patients, as well as further investment in community-based participatory research centering the perspectives of people who use drugs on how best to meet the challenges posed by HPSOs.

“We hope this consensus-backed guidance can help improve MOUD initiation practices in the hospital and highlight areas where more research is needed to clarify the benefits of certain adaptive practices. As the drug supply continues to change, such as with the recent emergence of newer adulterants like medetomidine, people who use drugs are feeling the brunt of the impact. We need to continue to find ways to adapt our care rapidly using the best evidence and knowledge we can,” shares Cohen.

Other authors of the study are: Elana Straus, BA; David A. Fiellin, MD; Jamie L. Pomeranz, PhD; Joji Suzuki, MD; Jeanette M. Tetrault, MD; E. Jennifer Edelman, MD, MHS; and Paul J. Joudrey, MD, MPH.

The research reported in this news article was supported by the National Institutes of Health (award UL1TROO1863) and Yale University. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.