Inpatient care of OUD with buprenorphine uptitration

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Inpatient care of OUD with buprenorphine uptitration

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Considerations

Patients with OUD admitted to the hospital should have their pain and withdrawal adequately managed regardless of, and prior to deciding, plans to continue treatment after discharge. 

Particular attention to avoiding withdrawal should be paid in pregnant patients, as withdrawal can harm the pregnancy. Agonist MOUD is much safer and more effective than withdrawal management (formerly referred to as "detox") and is recommended by the American College of Obstetricians and Gynecologists (ACOG). 

Starting hydromorphone concurrently with the uptitration of buprenorphine is safe, minimizes the risk for and severity of withdrawal, and treats pain and hyperalgesia associated with withdrawal symptoms. Titrate buprenorphine to therapeutic levels prior to stopping hydromorphone.

Buprenorphine films are easier than tabs for this rapid uptritration schedule.

Potential complicating factors include:

  • Allergy or sensitivity
  • Severe respiratory compromise
  • Chronic use of long acting opioids (e.g., methadone or Oxycontin®)

Consider expert consultation, but prioritize treating symptoms.

Consider screening for HIV, HCV, STIs, and mental health comorbidities. Link to ongoing care as needed.

Protocol

Document icon ScalaNW_Inpatient-Care-OUD Flowchart for Inpatient Care of OUD with Buprenorphine Uptitration

Related Protocols

Additional Clinical Guidance

  • Opioid use disorder (OUD) is a treatable health condition. It is best treated with methadone or buprenorphine.
  • Buprenorphine and methadone are life-saving medications for OUD that reduce the risk of all-cause mortality and overdose death by over 50%.
  • Recovery often requires multiple treatment attempts. A repeat encounter is not a treatment failure, but an opportunity to reinitiate potentially life-saving medication.
  • If patients continue to use other opioids while on methadone or buprenorphine, a higher dose may be needed to manage their symptoms. Therapeutic dosing should be guided by adequate management of withdrawal and cravings.
  • Opioid withdrawal is excruciating. Without swift and adequate intervention, patients may self-direct discharge and be at risk for overdose.
  • Patients with OUD are highly stigmatized. Stigma prevents people from seeking care and worsens health outcomes. Providers should challenge biases to provide compassionate, evidence-based care. 
Document icon ScalaNW_Inpatient-Care-OUD-Guidance

AssessmentAccordion Icon

  • Assess the Clinical Opiate Withdrawal Scale (COWS) score before administering buprenorphine. This initiation approach is appropriate for patients with minimal signs of withdrawal. Patients in moderate withdrawal can follow a higher dose initiation pathway.

LabsAccordion Icon

  • Drug testing is not necessary to initiate treatment for OUD.
  • If drug testing is performed for clinical reasons, obtain informed consent.

PharmacotherapyAccordion Icon

  • This up-titration method for initiating buprenorphine is ideal for inpatient settings. It eliminates the need for withdrawal prior to starting the medication.
  • Low initial doses occupy minimal receptors, allowing full agonists to maintain therapeutic effect and prevent withdrawal.
  • Gradual dose escalation prevents sudden receptor displacement that can cause precipitated withdrawal in other initiation methods.
  • A full agonist (hydromorphone) is continued during the up-titration to create a ramp onto buprenorphine, rather than abrupt receptor activity change.

Special populationsAccordion Icon

This protocol is appropriate for pregnant patients.

Polysubstance useAccordion Icon

Polysubstance use is never a contraindication for initiating buprenorphine or methadone.

AdministrationAccordion Icon

  • Administering buprenorphine:
    • Buprenorphine comes in film and tablet forms, and both must be taken sublingually. The medication is poorly absorbed in the stomach. It must be taken correctly to receive the benefit.
    • The patient should let the medication dissolve fully under their tongue. This typically takes 5-10 minutes, but sometimes longer. Drinking water prior to administration can help it dissolve faster. Many patients find the taste unpleasant. One way to know that the medication is dissolved and absorbed is when the taste subsides.
    • Patients should not eat, drink, or talk while the medication is dissolving.
    • To prevent oral decay, instruct the patient to rinse their mouth with water 30 minutes after administration.

Discharge planningAccordion Icon

  • Help the patient schedule a follow-up appointment. Hospitals enrolled in ScalaNW can call the 24/7 appointment scheduling line and receive a confirmed date, time, and location for MOUD follow up appointment during the 10-minute phone call.
    • For hospitals not enrolled in ScalaNW, the Washington Recovery Helpline MOUD Locator (online or at 1-866-789-1511) is a useful resource for finding OUD treatment in Washington.
  • Provide the patient with a buprenorphine prescription to last until their scheduled outpatient appointment. When possible, prescribe 3 additional days beyond the appointment date to allow for barriers or rescheduling. If no appointment is scheduled, provide at least 7-14 days of medication to give the patient time to secure an appointment.
    • Patients can call the Washington Telebuprenorphine Hotline (206-289-0287) if they run out of medication prior to their follow up appointment.
  • Provide the patient with discharge instructions that include the time of the last dose and when to take the next dose. Ensure the patient understands the importance of taking buprenorphine at around the same time every day.
  • Many patients need adjunct medications to control withdrawal symptoms until they stabilize on buprenorphine. If needed, provide prescriptions for adjunct withdrawal.
  • When possible, connect patients with supports such as social workers, care navigators, or peers to improve patient experience and strengthen linkage to care.

Patient EducationAccordion Icon

Educate the patient about:

  • Buprenorphine administration
    • Must be administered under the tongue for proper absorption.
    • It can take 5-10 minutes for the medication to fully absorb. Avoid eating, drinking, smoking, or talking during this time.
    • Drinking water prior to administration can help it dissolve faster.
    • To prevent oral decay, rinse mouth with water 30 minutes after administration.
  • The risks of combining sedatives with buprenorphine, which can cause respiratory depression.
  • The importance of avoiding driving or operating machinery until accustomed to the medication. Provide work notes if needed.
  • Overdose prevention strategies. Ensure the patient and their support system understand when and how to use naloxone.
  • The risks of change in use patterns, which can alter tolerance and increase risk of opioid overdose.

Discharge Instructions

Information about buprenorphine

  • Buprenorphine is a safe and effective medication used to treat opioid use disorder (OUD).
  • Buprenorphine helps people with OUD break the cycle of use and withdrawal, feel more stable, and focus on other parts of their lives so they can recover.
  • When used as prescribed, buprenorphine significantly lowers the risk of opioid overdose if you take other opioids.
  • There are two kinds of buprenorphine. Buprenorphine-naloxone also contains naloxone. Naloxone is not absorbed when the medication is taken as directed (under the tongue). If the medication is injected, however, the naloxone will be absorbed and can cause severe opioid withdrawal.
  • There is no limit to how long a person can take buprenorphine. It is recommended that most people be on the medication long-term.
  • Side effects may occur and are typically mild and improve over time. These can include constipation, sweating, headache, dizziness, trouble sleeping, nausea, and sleepiness. If these occur, notify your health care provider, nurse, or pharmacist.
  • Over time, your body will adjust to buprenorphine. If you stop taking it suddenly, you will feel withdrawal symptoms within a few days.
  • A common side effect of buprenorphine and other opioid medications is constipation. To prevent constipation: stay hydrated, eat plenty of fiber, and start taking an over-the-counter stool softener. If you do not have a bowel movement in over 24-48 hours, try an over-the-counter laxative. Talk to the pharmacist to help choose the best one for you.

How to take buprenorphine

  • You will receive buprenorphine in either film or tablet form.
  • Do not swallow the medicine. It will not work if swallowed.
  • Place the medication under your tongue and allow it to fully dissolve. This can take 5-15 minutes.
    • Drinking water before taking buprenorphine may help it dissolve faster.
    • Do not drink water while the medication is under your tongue.
  • Do not eat, drink, talk, or smoke while the medication is dissolving.
  • After the medication has dissolved, do not smoke, eat, or drink for at least 15 minutes.
  • To prevent tooth decay, rinse your mouth with water 30 minutes after taking the medication.

CAUTION

  • Continue taking your regular buprenorphine dose, even if you feel better. Stopping may cause withdrawal and cravings. Your risk of overdose will be much higher if you use opioids without being on this medication.
  • Do not start taking or increase your use of other sedative medications like benzodiazepines. The combination of buprenorphine and other sedatives could make you so sleepy that you may stop breathing.
  • Do not drink more than your usual amount of alcohol while starting buprenorphine.
  • Do not drive when you first start buprenorphine because it may slow your reaction time. Wait until you know how it affects you.
  • Remember that changes in opioid use patterns can alter your tolerance and increase your risk of opioid overdose. If you use other opioids, take steps to lower the risk—carry naloxone, never use alone, or call the Never Use Alone lifeline (877-696-1996).

Buprenorphine dose and time taken

________mg @___:____

Overdose Prevention

  • Using drugs is risky. If you use drugs, lower your risk of dying from an opioid overdose with the following strategies:
  • Naloxone
    • Today you received naloxone or a prescription for naloxone. This is an opioid overdose reversal medication. It is safe to use on anyone you suspect is experiencing an opioid overdose.
    • Visit stopoverdose.org or talk to your provider, nurse, or pharmacist to learn more.
  • Try not to use alone
    • If you are not with other people, connect with a confidential service like neverusealone.com. This peer-led service will send someone to help if you stop responding during a chat or phone call.
  • Start low & go slow
    • You can't know the full contents or strength of drugs. If you use, start with a very small amount to see how it affects you.
    • Be extra cautious if you have low tolerance (for example, after not using for awhile). If you decide to use more, slowly increase in small amounts.
  • Watch and wait before next person uses
    • If you’re with a group of people, take turns to see how the drug is affecting people. Someone needs to be able to ask for help.
  • Avoid mixing drugs
    • Mixing drugs increases your risk. If you use multiple drugs, try to use one at a time and use less of each.
    • Know the signs of opioid overdose and how to respond.
    • If someone is unresponsive or has unusual or no breathing, call 911 and give them naloxone and rescue breaths.
  • Always have naloxone
    • Tell others you have it, where it is, and when to use it.
  • Treatment with methadone or buprenorphine
    • These medications, if taken as directed, lower the risk of death by over 50%.
    • If you need help finding a treatment provider, call the Washington Recovery Helpline at 866-789-1511 or go to warecoveryhelpline.org. 
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References

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