Substance Use Disorder

Substance Use Disorder (SUD)– Barrington Hwang, Kristopher Kast

Background

  • SUDs are common, complex, and chronic neuropsychiatric disorders with well-described inherited risk, dysregulated neurophysiology, and multiple effective treatment modalities
  • Pts w/SUD face significant stigma, prior traumatic experiences in healthcare environments
  • Approaching pts respectfully and fostering partnership is important to quality care
  • Using the term “abuse” undermines the disease model of addiction, connoting volitional “bad” behavior driving recurrent substance use
  • Person-centered, specific terminology: “person with opioid and alcohol use disorders”
  • Avoid the qualifier “Polysubstance,” suggests the specific diagnoses are less important data
  • Clarify specific diagnoses for each substance category:
    • Identify the current substance exposures and distinguish use disorder from unhealthy use and episodic use
  • DSM 5 Criteria (same for most substance categories): Requires 2+ criteria met in past year; use must cause clinically significant impairment and/or distress:
    • Loss of control – larger amounts, longer time, ongoing use despite consequences, efforts/desire to reduce use
    • Physiologic changes -- tolerance, withdrawal (these 2 alone do not necessarily imply a disorder if they result from prescribed therapy), craving
    • Consequences – hazardous use, interpersonal problems, medical problems, failed role obligations, lost activities
  • In the general hospital, SUD management first requires identifying and stabilizing withdrawal states to mitigate risks of severe sequelae (seizure, delirium), unintended iatrogenic harm (opioid abstinence leading to lost tolerance and post-discharge overdose), and distress-driven AMA discharge 

 

General Management:

  • Consider Addiction Psychiatry consultation for management of complex withdrawal states, substance use disorders and co-occurring psychiatric diagnoses, assistance with risk stratification for hospital misuse and/or hospital discharge with PICC lines for outpatient antibiotics, and differentiation of pain requiring opioid therapy and opioid use disorder
    • At VUMC: In Epic, “Inpatient Consult to Psychiatry, Addiction Medicine”
    • Team consists of addiction psychiatrists, nurse practitioners, fellows/residents, social workers, and recovery coaches
  • If in the emergency room and not admitted, consult PAS

 

 

 

Opioid Use Disorder – Rita Hurd, David Marcovitz

Background

  • Standard of care is opioid stabilization with buprenorphine or methadone (in OUD) or other full agonist opioids (in chronic opioid therapy)
  • Methadone and buprenorphine can be ordered by any physician for inpatients
  • Maintenance agonist therapy should be offered to every patient, with preference for an “opt-out” approach (even for uninsured patients through state grant funding)

 

Presentation (Withdrawal)

  • Restlessness/psychomotor activation, anxiety, irritability, nausea, abdominal cramping, loose stool, diffuse musculoskeletal pain, chills, Insomnia, yawning
  • Pupillary dilation, piloerection, tearing, nasal congestion, diaphoresis, restless legs

 

Evaluation

  • Clinical Opioid Withdrawal Scale (COWS): quantifies severity of opioid withdrawal and allows for safer buprenorphine inductions
  • Asking about opioid exposure: “You’re uncomfortable. I work with a lot of people in the hospital, and some come with regular exposure to opioids from a lot of different places (their doctors, friends), should we be treating any withdrawal for you?”

 

 

Medications for Opioid Use Disorder (MOUD)

Buprenorphine

  • Partial agonist at the mu opioid receptor with high binding affinity
  • Long half-life (24-36 hours) allows for daily dosing
  • TID dosing is more effective for acute pain (as the analgesic effect is shorter-lived)
  • OK to use in renal failure/HD; may reduce dose in hepatic injury
  • All non-pregnant pts should receive buprenorphine-naloxone (e.g. Suboxone) formulations to mitigate risk of diversion/injection
  • Induction:
    • Hold all opioid medication 12+ hours prior to first buprenorphine dose (typically, this opioid-free period is overnight from 9 PM to 9 AM), with a recorded COWS score >8-10;
    • 4 mg is given SL, monitoring for oversedation; additional 4 mg is given in 1 hour, and final 4 mg at 4 hours (total of 12 mg in first day)
      • Only sedation or hypopnea should prevent a full 12 mg dose
    • Typical starting dose: 12-16 mg/day
  • Maintenance: 4-32 mg daily; 16mg and above to suppress opioid use
    • Requires waivered-provider
  • Acute Pain Management in pts using Buprenorphine:
    • There is no contraindication to full-agonist opioid analgesia for breakthrough pain
      • If the etiology of pts pain would require opioid therapy in a non-OUD patient, do not avoid opioids; these may be used safely in the hospital
    • Peri-operative pain management: continue buprenorphine at reduced and split doses (4 mg BID or TID); will prevent withdrawal and cravings, but NOT manage new pain
    • Post-operatively: reduce opioid requirements and increase buprenorphine to home dose
      • If buprenorphine was discontinued, will require induction procedure

 

 

Methadone

  • Full mu opioid agonist with additional NMDA-receptor activity
  • FDA-approved for OUD when dispensed from a licensed opioid treatment program
  • Better option for individuals who cannot tolerate the buprenorphine induction procedure, with significant chronic or escalating pain
    • Long t1/2: 12-36 hrs; max 10 mg/d q7d, to prevent dose-stacking and delayed overdose
  • Safe in renal failure; dose reduction for hepatic injury
  • Potential for QT prolongation at higher doses, warrants QTc monitoring
  • Induction:
    • In the hospital, start at 10 mg TID, holding doses for sedation or hypopnea; lower doses if concerned for respiratory compromise or concurrent CNS depressant therapy
    • Limit 40 mg in first 24 hours; then titrate 5 mg/d q3d while admitted
  • Maintenance:
    • Must confirm dose with methadone clinic before restarting outpatient dose; until then, do not give more than initial doses (30 mg in single dose, 40 mg in first 24 hours)
    • After confirming home dose, continue as single daily dose

 

Naltrexone

  • Mu opioid antagonist; Half-life oral ~4 hours but clinically active ~24 hrs
  • IM maintains clinically effective levels up to 30 days
  • High affinity for mu receptor --> CAN precipitate withdrawal requiring 7-10 days opioid abstinence prior to initiation
  • If due for monthly injection while admitted, may substitute oral formulation until discharged to outpatient provider to receive injection

 

Additional Information

  • Psychosocial Interventions that complement MOUD:
    • Consider referral to SUD counseling, mutual help (self-help, 12-step, AA), intensive outpatient, and short- or long-term residential treatment
    • Use of other drugs NOT a contraindication to MOUD, however should encourage abstinence from other drugs during therapy (especially benzodiazepines)
  • Prescribe intranasal naloxone for overdose prevention to all OUD patients discharging from hospital, regardless of MOUD status

 

 

Alcohol Use Disorder – Barrington Hwang , Kristopher Kast

Background

  • 50% of hospitalized pts drink alcohol; at-risk alcohol use is >14 drinks/week or >5 drinks in a sitting (for men; for women and men >65, 7 per week, >4 per sitting)
  • Alcohol withdrawal onset occurs 6-12 hours after last drink, with 90% having non-severe course; CIWA score <10 at 24-48 hours indicates low risk of worsening symptoms
  • Risk of seizures greatest at 12-24 hrs, occurring in ~3% of pts; risk of delirium greatest at 48-72 hrs, occurring in ~5%
  • Risk assessment
    • RF: prior seizures/delirium, co-substance use (especially benzodiazepines), no abstinent days in past month, presenting BAL >200, dysautonomia
    • CIWA symptom-triggered protocol appropriate for pts at low risk of severe withdrawal
    • For non-low risk pts, consider benzodiazepine/barbiturate load and standing taper;
  • Indications for admission: prior severe withdrawal (withdrawal seizures or delirium), comorbidities (medical and psychiatric illness), pregnancy, significant impairment in social/occupational functioning, communication barriers, social barriers

 

Presentation

  • Acute intoxication: disinhibition, slurred speech, ataxia, nystagmus
  • Acute Withdrawal:  nausea, vomiting, anxiety, agitation, audio-visual and tacticle hallucinations, headache, diaphoresis, fine motor tremor while arms and fingers outstretched, autonomic hyperactivity
  • Chronic heavy use:
    • Sequelae of chronic liver disease & malnutrition, including thiamine deficiency
  • Caine criteria for Wernicke’s encephalopathy:
    • 2 or more: (1) malnutrition, (2) ataxia, (3) oculomotor abnormalities, (4) AMS

 

Evaluation

  • Identify last use, quantity per day/week, other sedative-hypnotic use, history of withdrawal, social/occupational dysfunction, other toxic forms of alcohol compounds including methanol, ethylene glycol
  • Acute Alcohol Withdrawal
    • Labs: Blood alcohol level, urine toxicology (+/- ethyl glucuronide to detect use in prior 3 days), BMP, CBC, HFTs (AST:ALT elevation 2:1), CK and β - hCG
  • CIWA score quantifies severity, though subject to inflation by subjective symptoms
  • Objective Alcohol Withdrawal Scale (OAWS) is an alternative for pts at risk of over-reporting symptoms

 

Management

Acute Alcohol Withdrawal

  • Most patients are appropriate for diazepam-based protocols:
    • CIWA-based symptom-triggered for low-risk patients
    • Diazepam load + standing taper for non-low risk patients
  • Substitute lorazepam for pts with hepatic impairment (risk of long acting accumulation)
  • Benzodiazepine resistance: likely due to poor cross-tolerance, these pts  require phenobarbital load ( 8-12 mg/kg (up to 15 mg/kg) divided into 3 doses 3 hours apart)
  • Add folate, multivitamin, and electrolyte repletion
  • If >2 Caine criteria, treat empirically for Wernicke’s encephalopathy with high-dose IV thiamine (500 mg TID IV x 3-5 days)

-      Consider Addiction Psychiatry consultation for complex presentations

 

Alcohol Use Disorder

  • After withdrawal stabilization, engage pt in discussion around use and educate on connection between use and presenting medical problems
  • All patients with AUD should be initiated on pharmacotherapy (MAUD) prior to discharge to mitigate risk of relapse, if consistent with patient’s goals
  • Additional psychosocial treatments effective for AUD include motivational interviewing, 12-step groups (AA, SMART Recovery), cognitive behavioral therapy, sober living facilities, family therapy, contingency management, and IOP/residential facilities
  • If patient does not have abstinence goal, reduced or controlled drinking may allow for harm reduction; naltrexone and topiramate have evidence for non-abstinence outcomes
  • Pharmacologic Interventions:
    • Naltrexone (cannot be on opioid agonist):
      • Need 7-10 days since last opioid before starting
      • 25 mg x1 day, then titrate up to 50 mg daily; also available in q30d IM
      • Monitor liver enzymes; AST/ALT must be < 3-5x ULN
    • Acamprosate (cannot be used in severe renal impairment)
      • Head-to-head, inferior to naltrexone (see COMBINE trial)
      • 333 mg TID, titrating to 666 mg TID dosing
      • Difficult TID dosing may be helpful if framed as commitment/mindfulness practice
    • Disulfiram
      • Infrequently used outside of extreme motivation (e.g. professional under monitoring); would not use outside specialist care
      • Must abstain from alcohol ~2 weeks after last dose, given risk of disulfiram-ethanol reaction (DER), which can be fatal depending upon disulfiram and ethanol doses
    • Topiramate
      • Not FDA-approved for AUD, but has significant supporting evidence
      • Useful for individuals without abstinence goal
      • Titrate slowly over 8 weeks to 200-300 mg/d
    • Gabapentin:
      • Not FDA-approved for AUD, but with some evidence
      • Useful for post-acute withdrawal anxiety, insomnia, or co-occurring neuropathy
      • Titrate to 900-1800 mg/d divided into TID dosing, monitoring for sedation
      • Risk of sedation/apnea if concomitant alcohol use; ensure pt educated about risk