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Quick recognition, treatment critical in substance use disorder withdrawal
NATIONAL HARBOR, Md. — Hospitalization provides an opportunity to positively impact the opioid crisis, as well as treat other substance use disorders, Keri Holmes-Maybank, MD, assistant professor at the Medical University of South Carolina, said during her presentation at Hospital Medicine 2019.
Benzodiazepine withdrawal
“Benzodiazepine withdrawal can be life threatening and really challenging to treat,” she said.
The occurrence and severity of benzodiazepine withdrawal is predicted by the dose and duration of use, according to Holmes-Maybank.
“All patients who are on benzodiazepines for a long period of time are at risk for kindling, which are the changes that occur in the brain that can lead to more severe withdrawal and seizures,” she said.
Prior to initiating treatment for benzodiazepine withdrawal, talk with the patient, as well as their friends and family; check the prescription drug monitoring program; order a urine drug test; and look at their medical chart, she advised.
Hospitalists should monitor the severity of withdrawal to determine the effectiveness of detox using the Clinical Institute Withdrawal Assessment Scale-Benzodiazepines, or CIWA-B, which rates 19 different symptoms, such as irritability, fatigue and insomnia, according to Holmes-Maybank.
Using either symptom-triggered or scheduled benzodiazepines is recommended to treat benzodiazepine withdrawal, she said. When using scheduled benzodiazepines, it is important to determine what the patient was taking each day as their benzodiazepine and translate that to a long-acting scheduled benzodiazepine and then add symptom-triggered benzodiazepines and taper when appropriate, she said.
Trazodone can help with craving, insomnia and anxiety and is associated with higher rates of abstinence when used outside of the hospital setting, according to Holmes-Maybank.
Scheduled benzodiazepines are recommended to initiate prophylaxis if a patient has been continually using benzodiazepines at a high dose for 2 months or a low dose for 4 months or long-acting or high-potency benzodiazepines, she said.
Opioid withdrawal
About 21% to 29% of patients prescribed opioids for chronic pain, or approximately 4.3 million Americans, misuse them, resulting in costs of $79 billion a year, she said.
“Oftentimes, prescribers are directly or indirectly the source of misused opioids,” she said.
Patients must have three criteria from DSM-5 to be diagnosed with opioid withdrawal, such as dysphoric mood, muscle aches and diarrhea, Holmes-Maybank said.
Similar to benzodiazepines, determining the severity of opioid withdrawal depends on the dose and duration, she said. But unlike benzodiazepine withdrawal, opioid withdrawal is not life-threatening.
However, the level of discomfort from opioid withdrawal is severe and patients that are not treated are more likely to use opioids to try to treat the symptoms themselves, so it is important to address it, she said.
Potential medications include clonidine, methadone and buprenorphine, according to Holmes-Maybank.
There are no real options for opioid withdrawal prophylaxis — it is mostly symptom control, she said.
What hospitalists can do
“Hospitalists can have a role on curbing the opioid epidemic,” Holmes-Maybank said.
Important steps that hospitalists can take to help combat the opioid crisis include:
- employing the CDC guidelines for chronic pain and safe opioid prescribing;
- maximizing the use of nonpharmacologic and nonopioid pharmacologic alternatives;
- educating patients about appropriate expectations and risks of opioid use;
- prescribing no more than 7 days of opioids;
- joining or creating a hospital opioid committee;
- using alternatives to opioid therapy such as physical therapy, meditation or art therapy; and
- being aware of and forming relationships with medication-assisted treatment providers for opioid use disorder.
“Hospitalization is a reachable moment for inpatients,” she said. “Many patients are coming in with a complication that is secondary to opioid use disorder. If we can start opioid use disorder treatment or get them connected with someone who can start that treatment, they will have a greater chance to recover.” – by Alaina Tedesco
Reference:
Holmes-Maybank K. Substance use disorders in hospitalized patients. Presented at: Hospital Medicine 2019. March 25-27; National Harbor, Md.
Disclosure: Holmes-Maybank reports no relevant financial disclosures.