TL;DR:
- Hospital admission is a critical “reachable moment” to engage patients with Opioid Use Disorder (OUD) in life-saving Opioid Agonist Treatment (OAT).
- Initiating OAT in-hospital manages withdrawal, improves patient comfort, reduces the likelihood of leaving Against Medical Advice (AMA), and serves as a powerful bridge to long-term care.
- The protocol is straightforward: start with a low, safe dose of methadone or buprenorphine and titrate cautiously while the patient is an inpatient.
- A successful discharge requires a warm hand-off. Arrow Medical’s walk-in model eliminates barriers, requiring no formal referral—simply ensure the patient knows to come to our clinic the day after discharge.
Initiating Opioid Agonist Treatment (OAT) during their hospital stay is a high-impact intervention. It does more than just manage their withdrawal symptoms. It demonstrates that the healthcare system can respond to their needs with compassion and effective medical treatment, which builds trust and dramatically increases the likelihood they will engage in long-term care upon discharge.
Who is a Candidate for Inpatient OAT Initiation?
Any patient admitted with a known or suspected OUD who is not currently on OAT is a potential candidate. This is especially true for patients who are:
- Expressing a desire to stop or reduce their use.
- At high risk of leaving Against Medical Advice (AMA) due to untreated withdrawal.
- Admitted following a non-fatal overdose.
- Experiencing significant pain and discomfort from withdrawal that is complicating their primary medical care.
Starting OAT is a clinical decision that can transform a patient’s hospital course and their long-term health trajectory.
The Inpatient OAT Initiation Protocol
The goal of inpatient initiation is to safely start the patient on medication to relieve withdrawal symptoms and begin stabilization.
1. Assessment and Choice of Medication:
- Discuss treatment options with the patient. Both methadone and buprenorphine are excellent choices.
- Methadone: A good option for patients with high opioid tolerance or when there is uncertainty about recent opioid use.
- Buprenorphine (Suboxone): An excellent option, but can require the patient to be in moderate withdrawal to avoid precipitated withdrawal. The COWS (Clinical Opiate Withdrawal Scale) score should be used to guide initiation. Other protocols exist for starting buprenorphine in the inpatient setting. Please refer to the MetaPHI website for more information.
2. Safe Starting Doses:
- Methadone: Initial dose is dependent on a number of factors, such as current opioid tolerance, comorbidities, and previous methadone prescriptions in the community. Initial doses of up to 40mg can be started, with lower doses utilized for patients with questionable tolerance or multiple comorbidities. A supplemental dose can be given several hours later if withdrawal symptoms persist.
- Buprenorphine: After the patient is in moderate withdrawal (COWS > 12), start with a small initial dose (e.g., 2-4mg) and titrate upwards every 1-2 hours based on their response. An alternative approach is a buprenorphine macroinduction, an off-label patient-centred approach aimed to reach therapeutic doses faster in patients with known high tolerance to opioids.
3. Titration During Admission:
- The patient’s dose can be gradually increased daily while they are an inpatient, with the goal of reaching a dose that comfortably manages their withdrawal for 24 hours.
The Critical Step: The Warm Hand-off on Discharge
A successful inpatient start can be completely undone by a failed transition to an outpatient clinic. A warm hand-off is essential. This is where Arrow Medical’s model excels.
- No Formal Referral Needed: Our walk-in model eliminates the need for faxed forms, phone calls, or appointments. The biggest barrier for patients is administrative complexity; we remove it.
- Plan the First Outpatient Dose: The patient’s first dose at our clinic should be scheduled for the day after discharge. Provide their last inpatient dose on the morning of discharge.
- Provide Clear Instructions: Give the patient the name, address, and hours of the nearest Arrow Medical clinic (we have locations in Toronto, Barrie, Bancroft, and Crystal Beach).
- Communicate Clearly: Tell the patient, “Go to this clinic tomorrow morning. They are expecting you. You will see a doctor and get your medication.”
- Send Discharge Summary: Please send a copy of the discharge summary to our clinic so our physicians have the clinical context.
Frequently Asked Questions for Hospital Teams
Q: What if the patient leaves AMA before we can arrange follow-up?
Even one or two days of OAT can be beneficial. It can plant a seed and show the patient that treatment is tolerable. Still, provide them with our clinic information. Many patients who leave AMA will present to our clinics days or weeks later because of the positive experience they had in the hospital.
Q: How is buprenorphine initiated if the patient is receiving short-acting opioids for pain?
This is a complex clinical scenario that requires careful planning. It often involves stopping the short-acting opioid and allowing the patient to go into withdrawal before starting buprenorphine, or an off-label technique called a microinduction. Please refer to the MetaPHI website for more information on these techniques.
Q: What about patients with polysubstance use (e.g., benzodiazepines, alcohol)?
These patients can still be safely started on OAT. In fact, stabilizing their OUD is often the first step in being able to address their other substance use. Co-morbidities should be managed concurrently.
Hospital admission is a unique opportunity to change a patient’s life. By initiating OAT and partnering with Arrow Medical for a seamless discharge, you provide a powerful bridge from acute crisis to long-term recovery. Please call us to coordinate care.
