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Naren T, MacCartney P, Crawford S, Cook J. People who use drugs in hospital settings: 'Moving towards a person-centred harm reduction model'. Drug Alcohol Rev 2023; 42:1529-1533. [PMID: 37232049 DOI: 10.1111/dar.13692] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 05/07/2023] [Accepted: 05/11/2023] [Indexed: 05/27/2023]
Abstract
People who use drugs often continue to use drugs while in hospital. However, health-care systems often expect abstinence from drugs as a condition of engagement in various services. This commentary piece proposes that this approach is inconsistent with the principles of person-centred care. A harm reduction-based approach in conjunction with collaboration of people who use drugs is proposed as a model for providing person-centred care to people who use drugs during hospital-based treatment.
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Affiliation(s)
| | | | | | - Jon Cook
- Drug Health Services, Western Health, Melbourne, Australia
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2
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Thakrar AP, Uritsky TJ, Christopher C, Winston A, Ronning K, Sigueza AL, Caputo A, McFadden R, Olenik JM, Perrone J, Delgado MK, Lowenstein M, Compton P. Safety and preliminary outcomes of short-acting opioid agonist treatment (sOAT) for hospitalized patients with opioid use disorder. Addict Sci Clin Pract 2023; 18:13. [PMID: 36829242 PMCID: PMC9951406 DOI: 10.1186/s13722-023-00368-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 02/07/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Patients with opioid use disorder (OUD) frequently leave the hospital as patient directed discharges (PDDs) because of untreated withdrawal and pain. Short-acting opioids can complement methadone, buprenorphine, and non-opioid adjuvants for withdrawal and pain, however little evidence exists for this approach. We described the safety and preliminary outcomes of short-acting opioid agonist treatment (sOAT) for hospitalized patients with OUD at an academic hospital in Philadelphia, PA. METHODS From August 2021 to March 2022, a pharmacist guided implementation of a pilot sOAT protocol consisting of escalating doses of oxycodone or oral hydromorphone scheduled every four hours, intravenous hydromorphone as needed, and non-opioid adjuvants for withdrawal and pain. All patients were encouraged to start methadone or buprenorphine treatment for OUD. We abstracted data from the electronic health record into a secure platform. The primary outcome was safety: administration of naloxone, over-sedation, or a fall. Secondary outcomes were PDDs and respective length of stay (LOS), discharges on methadone or buprenorphine, and discharges with naloxone. We compared secondary outcomes to hospitalizations in the 12 months prior to the index hospitalization among the same cohort. RESULTS Of the 23 cases, 13 (56.5%) were female, 19 (82.6%) were 40 years or younger, and 22 (95.7%) identified as White. Twenty-one (91.3%) regularly injected opioids and four (17.3%) were enrolled in methadone or buprenorphine prior to hospitalization. sOAT was administered at median doses of 200-320 morphine milligram equivalents per 24-h period. Naloxone administration was documented once in the operating room, over-sedation was documented once after unsanctioned opioid use, and there were no falls. The PDD rate was 44% with median LOS 5 days (compared to PDD rate 69% with median LOS 3 days for prior admissions), 65% of sOAT cases were discharged on buprenorphine or methadone (compared to 33% for prior admissions), and 65% of sOAT cases were discharged with naloxone (compared to 19% for prior admissions). CONCLUSIONS Pilot implementation of sOAT was safe. Compared to prior admissions in the same cohort, the PDD rate was lower, LOS for PDDs was longer, and more patients were discharged on buprenorphine or methadone and with naloxone, however efficacy for these secondary outcomes remains to be established.
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Affiliation(s)
- Ashish P Thakrar
- National Clinician Scholars Program at the Corporal Michael J. Crescenz Veterans Affairs Medical Center, University of Pennsylvania, Philadelphia, USA.
- Center for Addiction Medicine & Policy, University of Pennsylvania, Philadelphia, USA.
| | - Tanya J Uritsky
- Center for Addiction Medicine & Policy, University of Pennsylvania, Philadelphia, USA
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Cara Christopher
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Anna Winston
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Kaitlin Ronning
- School of Nursing, University of Pennsylvania, Philadelphia, USA
| | - Anna Lee Sigueza
- School of Nursing, University of Pennsylvania, Philadelphia, USA
| | - Anne Caputo
- School of Nursing, University of Pennsylvania, Philadelphia, USA
| | - Rachel McFadden
- Center for Addiction Medicine & Policy, University of Pennsylvania, Philadelphia, USA
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Jennifer M Olenik
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Jeanmarie Perrone
- Center for Addiction Medicine & Policy, University of Pennsylvania, Philadelphia, USA
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - M Kit Delgado
- Center for Addiction Medicine & Policy, University of Pennsylvania, Philadelphia, USA
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Margaret Lowenstein
- Center for Addiction Medicine & Policy, University of Pennsylvania, Philadelphia, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Peggy Compton
- Center for Addiction Medicine & Policy, University of Pennsylvania, Philadelphia, USA
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA
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Azar P, Westenberg JN, Ignaszewski MJ, Wong JSH, Isac G, Mathew N, Krausz RM. Case report: acute care management of severe opioid withdrawal with IV fentanyl. Addict Sci Clin Pract 2022; 17:22. [PMID: 35382882 PMCID: PMC8980769 DOI: 10.1186/s13722-022-00305-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 03/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An increasing number of individuals who use drugs in North America are preferentially consuming fentanyl over other opioids. This has significant consequences on the treatment and management of opioid use disorder (OUD) and its concurrent disorders, especially in acute care if opioid requirements are not met. CASE PRESENTATION We present a patient with severe OUD and daily injection of fentanyl, admitted to hospital for management of acute physical health issues. Due to high opioid requirements and history of patient-initiated discharge, intravenous fentanyl was administered for treatment of opioid withdrawal, and management of pain, which supported continued hospitalization for acute care treatment and aligned with substance use treatment goals. CONCLUSION This case demonstrates that intravenous fentanyl for management of OUD in hospital can be a feasible approach to meet opioid requirements and avoid fentanyl withdrawal among patients with severe OUD and daily fentanyl use, thereby promoting adherence to medical treatment and reducing the risk of patient-initiated discharge. There is an urgent need to tailor current treatment strategies for individuals who primarily use fentanyl. Carefully designed research is needed to further explore the use of IV fentanyl for acute care management of severe opioid withdrawal in a hospital setting.
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Affiliation(s)
- Pouya Azar
- Complex Pain and Addiction Service, Vancouver General Hospital, DHCC, Floor 8-2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada. .,Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
| | - Jean N Westenberg
- Complex Pain and Addiction Service, Vancouver General Hospital, DHCC, Floor 8-2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.,Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Martha J Ignaszewski
- Complex Pain and Addiction Service, Vancouver General Hospital, DHCC, Floor 8-2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.,Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,BC Children's Hospital, Vancouver, BC, Canada
| | - James S H Wong
- Complex Pain and Addiction Service, Vancouver General Hospital, DHCC, Floor 8-2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.,Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - George Isac
- Division of Critical Care Medicine and Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Nickie Mathew
- Complex Pain and Addiction Service, Vancouver General Hospital, DHCC, Floor 8-2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.,Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,BC Mental Health & Substance Use Services, Provincial Health Services Authority, Vancouver, BC, Canada
| | - R Michael Krausz
- Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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Labonté LE, Young S. High-dose intravenous hydromorphone for patients who use opioids in the hospital setting: time to reduce the barriers. Harm Reduct J 2021; 18:87. [PMID: 34389007 PMCID: PMC8361239 DOI: 10.1186/s12954-021-00533-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 08/05/2021] [Indexed: 11/10/2022] Open
Abstract
Individuals who use opioids have higher rates of hospitalization compared to the general population. Insufficiently treated withdrawal and pain are major factors contributing to high rates of self-initiated hospital discharges (also referred to as leaving against medical advice) in this population. While injectable opioid agonist therapy is limited or unavailable in the majority of Canadian communities, intravenous hydromorphone (IV HM) is widely available in the hospital setting and high-dose IV HM may be a useful treatment adjunct to improve comfort and engagement in inpatient care for some individuals who use opioids. However, major barriers to its use exist including lack of comfort amongst healthcare providers and hospital policies restricting administration. In this commentary, we highlight the potential usefulness of high-dose IV HM as a treatment adjunct for individuals who use opioids in the hospital setting and advocate for expanded hospital policies to facilitate its use.
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Affiliation(s)
- Laura E Labonté
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Samantha Young
- Interdepartmental Division of Addiction Medicine, St. Paul's Hospital, Vancouver, BC, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Division of General Internal Medicine, Department of Medicine, St. Michael's Hospital, Unity Health, 30 Bond Street, Toronto, ON, Canada
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Hospital Initiated Injectable Opioid Agonist Therapy for the Treatment of Severe Opioid Use Disorder: A Case Series. J Addict Med 2021; 15:163-166. [PMID: 32769776 DOI: 10.1097/adm.0000000000000713] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Across North America, there is an unprecedented opioid overdose epidemic. Approximately 15% of individuals with severe opioid use disorder (OUD) do not benefit from opioid agonist therapy (OAT) such as buprenorphine/naloxone or methadone and are considered treatment refractory. Of those who inject, injectable OAT (iOAT), with hydromorphone or diacetylmorphine, offered in community settings has demonstrated improved retention to treatment and decreased nonprescription opioid use. This case series seeks to describe iOAT initiation and titration in a hospital setting for treatment refractory individuals with OUD and examine impacts of iOAT on leaving hospital against medical advice (AMA). METHODS A retrospective chart review of 4 patients initiated on iOAT during hospitalization at St. Paul's Hospital in Vancouver, BC was completed between July 2017 to May 2018. Outcomes of interest included: (1) dose titration schedules of hydromorphone; and (2) reports of leaving hospital AMA; and (3) continuation of iOAT in community postdischarge. RESULTS Of the 4 participants, 2 were female and the mean age was 42 years. Despite a history of AMA, all participants stayed until the recommended the discharge after iOAT initiation. The average total doses of intravenous hydromorphone used during titration were: day 1: 100 mg and days 2 to 3: 200 mg. All continued iOAT in the community and one participant was readmitted within 30 days postdischarge. INTERPRETATION This case series describes a novel approach to the management of treatment refractory individuals with severe OUD during hospitalization. Prescribing iOAT in acute care settings is feasible and may reduce rates of leaving hospital AMA.
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Lewer D, Jones NR, Hickman M, Larney S, Ezard N, Nielsen S, Degenhardt L. Risk of discharge against medical advice among hospital inpatients with a history of opioid agonist therapy in New South Wales, Australia: A cohort study and nested crossover-cohort analysis. Drug Alcohol Depend 2020; 217:108343. [PMID: 33122155 PMCID: PMC7736124 DOI: 10.1016/j.drugalcdep.2020.108343] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/09/2020] [Accepted: 09/28/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND People who use illicit opioids have high rates of hospital admission. We aimed to measure the risk of discharge against medical advice among inpatients with a history of opioid agonist therapy (OAT), and test whether OAT is associated with lower risk of discharge against medical advice. METHODS We conducted a cohort study of patients admitted to hospital in an emergency between 1 August 2001 and 30 April 2018 in New South Wales, Australia. All patients had a previous episode of OAT in the community. The main outcome was discharge against medical advice, and the main exposure was whether patients had an active OAT permit at the time of admission. RESULTS 14,035/116,957 admissions (12 %) ended in discharge against medical advice. Admissions during periods of OAT had 0.79 (0.76-0.83; p < 0.001) times the risk of discharge against medical advice, corresponding to an absolute risk reduction of 3.0 percentage points. Risk of discharge against medical advice was higher among patients who were younger, male, identified as Aboriginal and/or Torres Strait Islander, and those admitted for accidents, drug-related reasons, or injecting-related injuries (such as cutaneous abscesses). In a subsample of 7793 patients included in a crossover-cohort analysis, OAT was associated with 0.84 (95 % CI 0.76-0.93; p < 0.001) times the risk of discharge against medical advice. CONCLUSIONS Among patients with a history of OAT, one in eight emergency hospital admissions ends in discharge against medical advice. OAT enrolment at the time of admission is associated with a reduction of this risk.
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Affiliation(s)
- Dan Lewer
- National Drug and Alcohol Research Centre, 22-32 King St, Randwick NSW 2031, Australia; Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 7HB, UK.
| | - Nicola R Jones
- National Drug and Alcohol Research Centre, 22-32 King St, Randwick NSW 2031, Australia
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol BS2 8DZ, UK
| | - Sarah Larney
- National Drug and Alcohol Research Centre, 22-32 King St, Randwick NSW 2031, Australia; University of Montreal, 2900 Edouard Montpetit Blvd, Montreal, Quebec H3T 1J4, Canada; Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Université de Montréal, Canada
| | - Nadine Ezard
- National Drug and Alcohol Research Centre, 22-32 King St, Randwick NSW 2031, Australia; Alcohol and Drug Service, St Vincent's Hospital, Sydney, NSW, Australia; National Centre for Clinical Research in Emerging Drugs, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre and Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, 22-32 King St, Randwick NSW 2031, Australia
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Vaid P, Wilson P, Abelseth G, Monty Ghosh S, Zaganelli C, Klemann J. Case report: perioperative pain management in a patient on injectable opioid agonist treatment undergoing total knee arthroplasty. Can J Anaesth 2020; 67:1682-1684. [PMID: 32720254 DOI: 10.1007/s12630-020-01765-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/24/2020] [Accepted: 06/30/2020] [Indexed: 11/27/2022] Open
Affiliation(s)
- Patrycja Vaid
- Acute Pain Service (APS), Department of Anesthesia, Alberta Health Services (AHS), Calgary, AB, Canada.
| | - Patty Wilson
- Calgary Injectable Opioid Agonist Therapy (iOAT) Program, AHS, Calgary, AB, Canada
| | - Gregory Abelseth
- Section of Orthopaedics, Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - S Monty Ghosh
- University of Calgary, AHS, Calgary, AB, Canada.,University of Alberta, AHS, Edmonton, AB, Canada
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