A Healthcare Risk Control (HRC) member recently asked for information to support development of policies for managing patients with opioid use disorder in acute care.
In our response, we note that a major concern in many acute care settings is how frequently patients present because of opioid overdose, undergo reversal (e.g., with naloxone), and are discharged but eventually return because they have overdosed again. Generally, reversing an overdose treats only the overdose; it does not treat the underlying opioid use disorder. Withdrawal management (detoxification) by itself is also not a lasting, effective treatment for opioid use disorder. Patients who are not undergoing treatment for the underlying opioid use disorder are likely to be at risk for poor outcomes, overdoses, and return visits.
Today, opioid use disorder is often treated with medication-assisted treatment (MAT), which combines the use of certain medications, such as methadone or buprenorphine, with behavioral therapies and counseling.
When developing a policy, the organization should consider which services it currently offers to treat opioid use disorder, which services it plans to offer in the future, and for which services it plans to establish effective referral networks. Options range from treatment in an outpatient clinic to partial hospitalization to residential treatment. Health systems can implement creative variations on these themes in a range of settings.
An important issue to consider is the dispensing and administration of medications such as methadone or buprenorphine to hospital patients in various circumstances.
The organization may consider initiating MAT in the hospital or emergency department (ED). The Substance Abuse and Mental Health Services Administration (SAMHSA) notes that MAT professionals may provide treatment and services in a range of settings, including hospitals, through opioid treatment programs that are accredited by SAMHSA-approved accreditation bodies and certified by SAMHSA. There are examples of acute care settings initiating MAT in the ED; through an urgent care center dedicated to opioid use disorder; through an inpatient interdisciplinary consultation service (more information about this example is available in a case study from the American Hospital Association); and through nearby outpatient clinics. The National Council for Behavioral Health offers a slide presentation on organizational considerations for implementing MAT. Legal counsel can help the organization establish policies that comply with applicable laws, such as the federal laws addressing MAT and opioid treatment programs.
Existing policies regarding issues such as searches of patients and their belongings, visitation, discussion of patient information with their loved ones, and drug diversion may also need to be reviewed and revised as needed.
Organizations may consult several guidelines and other resources when developing programs, services, and policies. Guidelines include the U.S. Department of Veterans Affairs/Department of Defense guidelines on managing substance use disorder. Other guidelines and resources that specifically address MAT include the following:
The organization should identify which individuals and groups will need competencies in the medical and behavioral health management of patients with opioid use disorder. Depending on the services offered, some individuals will need competencies in overdose reversal, withdrawal assessment and management, behavioral health services, or MAT.
Even some providers and staff who will not be directly treating the patient's opioid use disorder may need to develop certain competencies in order to safely meet the patient's other needs. For example, prescribers and pharmacists who care for these patients' other acute conditions will likely need competencies in the intricacies of medication management for these patients (or access to consultation with professionals who have such expertise). The Society of Hospital Medicine's toolkit on reducing opioid-related adverse drug events has information on the management of pain in hospital patients, including nonpharmacologic options, nonopioid pain medications, and opioids to treat pain. The toolkit includes a discussion of the use of opioids to treat pain in hospital patients who are opioid tolerant or are on MAT, which can be pharmacologically complex.
Various providers and staff may need skills in spotting signs of opioid use disorder in hospital patients, assessing patients for opioid withdrawal, or managing specific groups of patients with opioid use disorder (e.g., pregnant women).
Some providers may need competencies in the treatment of common medical comorbidities, such as chronic pain, HIV infection, or hepatitis, or common behavioral health comorbidities.
Although many hospitals and EDs that do not themselves provide treatment for opioid use disorder refer patients to treatment, patients may be unlikely to act on referrals if they are presented as just a phone number to call. Hospitals and EDs may wish to investigate ways to engage patients before they leave the hospital.
The models described above facilitate patients' transition to substance use disorder services in various ways. Other examples are available. One medical center has substance use disorder counselors present in the ED, who screen and engage patients through techniques such as motivational interviewing. The counselors then refer patients for substance use disorder treatment; other necessary services such as temporary housing, transportation, and insurance; and health and social services, including primary care.
The recommendations contained in Ask HRC do not constitute legal advice. Facilities should consult legal counsel for specific guidance and develop clinical guidance in consultation with their clinical staff.