Incidentally Identified Opioid Misuse and Opioid Use Disorder While Inpatient

Abstract

The opioid epidemic is a major public health challenge and physicians in medical settings must be equipped to identify and manage opioid use disorder (OUD). Nearly 20% of hospitalized patients have a substance use disorder (SUD) and it’s estimated that 44% of illicit drug users may actively continue to use substances while admitted. Unidentified and untreated substance use in hospitalized patients can result in overdose, withdrawal, other negative medical sequelae, and is linked to patients leaving against medical advice. Patients may not disclose substance use to clinicians due to fear of stigmatization or negative unforeseen consequences. Clinicians must screen all admitted patients for SUD with a comprehensive history, physical examination, and appropriate laboratory tests and urine toxicology when indicated. Repeat urine toxicology and clinical assessments may be needed throughout hospitalization in cases where there is ongoing substance use. Differentiating between various substance intoxication and withdrawal presentations is important to avert potential negative medical outcomes. Opioid overdose requires acute medical intervention and these individuals are high risk for repeat overdose and should be started on MOUD when feasible prior to discharge from the inpatient setting. Acute opioid withdrawal should be managed using clinical assessment tools and medications including opioid agonists, alpha-2 adrenergic agonists, and other supportive medications. Management of opioid withdrawal alone is not treatment for individuals with OUD and patients should be started on MOUD and linked with outpatient treatment. New rapid-induction protocols for buprenorphine and naltrexone are becoming more established and feasible in inpatient settings. Methadone can also be started while inpatient although availability of outpatient treatment at a federally certified opioid treatment program may be limited. All individuals with OUD or other SUDs should receive a naloxone kit and linked with outpatient treatment prior to discharge from the inpatient setting. Early identification and management of OUD and other SUDs during acute hospitalization improves medical outcomes and reduces overdose deaths.