The complex management of the opioid-addicted patient admitted to hospital

Abstract

In the real world the clinician can meet two kinds of opioidaddicted patient (OAP), the first is represented by a patient with opioid use disorder (OUD), as diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and the second kind is a patient who became addicted to prescription opioid pain relievers. This last figure is increasing in the last years in western countries. Opioids are strong pain medications, but they are usually not the best way to treat long-term (chronic) pain not caused by cancer, such as in arthritis, low back pain, or frequent headaches. Long-term treatment with opioids (> 8 weeks) for chronic pain presents substantial public health risks [1]. In fact, the risks of overdose and addiction can increase due to medication-related factors such as higher daily doses (> 100 MME, Morphine Milligram Equivalents), longer duration of prescribing and perhaps the use of long-acting opioids, and patient-related factors: age > 65 yr, renal or hepatic impairment, sleep-disorders, depression, substance-use disorder, history of overdose and adolescence. In the last years we are assisting to a rise in opioid-related mortality [2], especially in USA and Europe. The crisis, described as a “triple wave epidemic” of deaths, arises from the increase in mortality attributable to three classes of opioids: prescription opioid pills, heroin and synthetic opioids (fentanyl, its analogs and other illicit synthetic opioids) [3]. Moreover, considerable mortality also arises directly from polydrug use, such as the combination of heroin or other opioids, including medications for opioid use disorder (MOUD), with alcohol or benzodiazepines, and indirectly from drug use associated to blood-borne infections, trauma and violence, and various chronic underlying diseases. The last causes could be involved in an under-estimation of opioid-related mortality. Diagnosing opioid addiction requires a thorough evaluation, which include the results of urine drug testing and prescription drug monitoring. The clinician has to know that different OAP exist on a continuum of severity (mild, moderate and severe) and that severity distinction has different treatments. The hospital, therefore, in many cases represents the favorite place for the screening, engagement and initiation of treatment for the OAP. Usually, in Italy and in other western countries, the OAP is admitted to hospital after a first evaluation and treatment in Emergency Department. Clinical problems related to the OAP are not only the overdose and the withdrawal syndromes, but also a variety of medical and surgical complaints (i.e., intravenous-drug associated infections, asthma, diabetes, etc.). So, the equation “one disease one cure” does not fit to appropriately take care of the OAP. Together with the diagnosis of medical and surgical conditions, the clinician has to determine the severity of opioid use on the patient’s physical and psychological functioning, the outcomes of post treatment episodes, the risk factors for overdose and concurrent illicit or licit drug use. While the OAP is hospitalized, adverse drug events derived from drug-drug interactions (DDI), inappropriate drug dosage and administration must be avoided. Moreover, a complete psychiatric evaluation to reveal pre-existent pathologies or to explore the patient’s psychosocial condition is needed. During the hospital stay the clinician should approach the OAP using communication strategies to stop the opiate use and before the discharge to refer the patient to appropriate settings, i.e. detoxification centers where medication-assisted treatment (MAT) is considered a good option for OUD as a part of a comprehensive treatment plan. MAT provides the use of one of three medications, each one with some anticraving activity: methadone, buprenorphine or naltrexone, in combination with psychosocial and/or behavioral therapy. * Enrica Cecchi [email protected]; [email protected]