Vancouver IM LMR

Thanks to Dr Azar and Dr Sutherland for sharing your expertise! Just a reminder to the group that CPAS wants to fill an educational role for CTU learners and they are interested in connecting with you if you have questions about the management of Addiction Medicine issues, making sense of OAT dosing decisions, etc. These issues are common and relevant to GIM practice in Vancouver, so I’d encourage everyone to work towards gaining some familiarity with navigating basic Addiction Medicine problems. See below the summary notes from this session:

Human impact

6 people per day in BC are dying of drug overdose (avg. 2000/year) so harm reduction (withdrawal management in hospital to allow for adequate medical treatment of acute issues) and opioid agonist therapy are important tools for us to become comfortable using.

In-hospital management of OUD

Issues to be addressed in hospital:

1. Ensure no overdose
2. Treat opioid withdrawal
3. Address pain management in the context of opioid tolerance
4. Long-term goal management, including harm reduction/safer use (use with company, Take Home Naloxone, apps eg deadman switch alarms, safe injection sites), reduction or cessation – opioid agonist therapy

Pain Management in OUD

• Common source of pain: cellulitis, spinal abscesses, OM
• Prefer non-opiate adjuncts and don’t forget antiemetics
  • Ibuprofen 400-800 mg qh6 po prn
  • Ketorolac 15 mg q8h IV x 48 hours (consider GFR, bleeding risk)
  • Diclofenac topical (can get up to 10% in hospital) tid
  • Acetaminophen 650 q6h (or 975 mg qid) scheduled (<4grams from all sources/daily, <2grams if cirrhosis)
  • Ketamine infusion 15 mg/h (ED)
  • Nabilone 1 mg bid (synethetic cannabinoid)
  • Sativex spray 1-2 sprays q3h prn (can be useful in someone who uses cannabis heavily)

Clinical assessment

• Symptoms/signs of opioid withdrawal: Rhinorrhea, lacrimation, sweating, piloerection, yawning, vomiting, diarrhea, rebound pain +/- tremor (related to agitation)
• Opioid history: Route, time of last use, dose, using additional substances (+seeking out contaminated drugs eg with benzos), previous overdoses, circumstances around use (alone, at harm reduction sites), (Narcan kit, access to “cleans”)
  • Quantity – 1-1.5 “ball” (=3.5 grams/ball) considered significant use, could use financial cost as a very rough estimate (eg $30-40 quite light use, up to $200 daily more common)
• Objective evidence: Looking for track marks (trend to non-IV administration for perceived safety). Urine drug screen a helpful tool to look for recent use of fentanyl.
• Keep in mind relative potency: Fentanyl 100x morphine, carfentanil 100x fentanyl

Approach to withdrawal management

• Temporize with PRN HM
  • Hydromorphone po – 8-16 mg q1h prn (esp if tolerant, could start with range up to 32mg with closed loop communication with ED RN)
  • Hydromorphone sc/iv – 4-8 mg q1h prn (2x potency of PO route)
  • Choose a starting dose, then reassess overnight and uptitrate if needed.
  • Holding instructions: Hold if RR < 9, pinpoint pupils, drowsy, unable to swallow, cannot rouse
    • Add naloxone PRN (naloxone 0.1-0.2 mg IV/intranasal/IM q5min PRN for opioid intoxication)
• Manage symptoms of withdrawal
  • Vomiting -> antiemetics (watch QTc)
  • Tylenol/toradol (opioid sparing analgesia)

• The newer case of opioid/benzo coingestion
  • Recent benzo contamination in unregulated supply – no guidelines governing management, but CPAS approach has been use of CIWA with diazepam PRNs to avoid BZ withdrawal
  • Generally benzos more long acting agents and less likely to cause you trouble overnight. 
  • How to tell what the predominant withdrawal syndrome is/if your CIWA score will be wrong: Unfortunately lots of overlap symptoms (tachycardia, sweating, can have mild “tremor” in agitation of opioid w/d). A prominent tremor more in keeping with benzo withdrawal. Generally guided by reassessment after initial treatment – eg if withdrawal not managed with opioids, may need to address possible benzo w/d

In-hospital management of opioid agonist therapy (OAT) 

• Can we prescribe OAT? SPH – no. VGH – yes.
• Methadone (24 hour drug)
  • Questions to ask to help you decide if you can restart
    • Did they take their last regular dose, and did they miss doses?
      • Ask patient, check PharmaNet (can be inaccurate for the day they are in hospital, may be a few hours delay for missed doses to be reversed in PharmaNet) – better option is to call the Pharmacy if open. 
    • Are they alert enough to take methadone?
  • Protocol:
    • 1-2 days missed: No change
    • 3-4 days: Reduce by 50% or go to starting dose (40 mg) – whichever is higher
    • 5+ days: New start (at 40 mg)
  • For new starts (for CTU, needs CPAS involvement): Guidelines recommend starting at 40 mg daily if patient using fentanyl, otherwise 20 mg in fentanyl-naive patients and 30 mg if unknown. Increase by 10 mg per 5 days (half life about a day but widely variable). Target dose if >100 mg for fentanyl, if using 10+ pts of fentanyl, usually >200mg daily.
  • Safety:
    • decreased LOC -> reduce dose
    • QTc prolongation -> reduce dose
    • Respiratory drive issues -> splitting dose
    • Liver failure -> reduce/stop
    • Renal impairment -> continue
• Buprenorphine (Suboxone = buprenorphine-naloxone)
  • Partial agonist. Does not need daily witness (no street value). Does not decrease respiratory drive and low risk of overdose. Sublingual medication – dissolve under the tongue within 5 minutes (instructions to patient: In that 5 minutes – no eating, no drinking, no talking, don’t swallow the dose)
  • Issue with use is precipitated withdrawal (in active opioid use, a consequence of going from full agonist to partial agonist, wait until they are in withdrawal to start ie COWS >10)
  • Previous strategy with buprenorphine starts would be waiting for withdrawal, then starting med. Recently practice has changed to suboxone microinduction strategy – rapid uptitration of low doses to full dose within a few days.
  • Cerner powerplan (SUS Buprenorphine Naloxone Low Dose Induction): Three day microinduction. Once on full daily dose, stop their previous HM PRNs and go to suboxone PRNs. Every day after that, you can consolidate their suboxone PRNs and add to their suboxone scheduled daily dose
  • Product monograph gives max suboxone dose of 32 mg daily. Most patients are comfortable between 16-24mg.
  • CPAS working on new protocol: Replacing suboxone sl formulation with patches.
  • For continuation in hospital
    • Missed over 5 doses: New start
    • Under 5 doses: Can typically start their usual dose. 
    • “If you’ve missed doses you need to tell me or you will go into precipitated withdrawal if I start suboxone”
• Kadian (slow release oral morphone)
  • Similar to methadone, BUT renally cleared (watch in kidney injury).
  • Guidelines recommend 200 mg daily initial dose, can go up by 100 mg/day (+consolidate the Kadian PRNs)
  • Instructions: “Capsule opened into apple sauce/pudding. Daily witnessed ingestion”