Case Presentation: AS is 36-year-old woman with methamphetamine and opioid use disorder (OUD) hospitalized with endocarditis who is evaluated by the Addiction Consult Service (ACS), and started on sublingual Buprenorphine/naloxone (Bup/nx) for treatment of OUD. Urine drug screens continue to be inappropriately positive for methamphetamine inpatient. Extended Release Buprenorphine (Bup-XR) is discussed and with her agreement administered prior to discharge to increase buprenorphine adherence, reduce risk of overdose from contaminated stimulants, and avoid bup/nx diversion. She continues outpatient treatment with Bup-XR for OUD and counseling for stimulant use disorder. LS is a 47-year-old man with OUD hospitalized with endocarditis and started on sublingual Bup/nx. Patient is administered Bup-XR prior to discharge as his goal is recovery without medication for opioid use disorder (MOUD). Bup-XR does not require daily medication doses and once patient transitions off of MOUD, withdrawal will presumably be milder and slower. CW is a 30 year old female with OUD who presents to the hospital from jail in active opioid withdrawal, requesting treatment for OUD. She is started on sublingual Bup/nx. As most jails in KY do not provide medications for OUD (MODU), she receives Bup-XR on day of discharge. CW follows up 35 days after Bup-XR as an outpatient after release from jail. CW reports no illicit opioid use or opioid withdrawal, and is administered a second dose of Bup-XR. Her OUD is in early remission.
Discussion: According to the Substance Abuse and Mental Health Service Administration (SAMHSA) 2018 data, 2 million Americans have OUD, a chronic medical disease. Yet less than 20% of patients are prescribed MOUD, the standard of care for treatment and recovery. Per to the CDC, almost 80,000 Americans died from an opioid overdose in 2019, and overdose deaths have decreased the overall life expectancy in the United States. Hospitalists frequently provide care for patients with severe infections secondary to intravenous drug use. When OUD is the underlying cause of the infection, hospitalists should be providing MOUD in the inpatient setting and facilitating linkage to ongoing treatment. Bup-XR is a monthly subcutaneous injection with little to no diversion risk and is administered by an X-waivered provider. It is beneficial treatment option for patients with OUD who do not readily have access to MOUD (i.e. if experiencing incarceration, have transportation barriers, or live far from an MOUD provider), or for patients with comorbid non-opioid substance use disorder when diversion is a concern. Buprenorphine decreases mortality in OUD, and Bup-XR demonstrates non-inferior retention in treatment rates compared to sublingual Bup/nx. Bup-XR is well tolerated with a low side effect profile and should be utilized more at time of discharge to facilitate continued outpatient OUD treatment. Patients can return to the sublingual product outpatient if they so choose without negative side effects.
Conclusions: The opioid epidemic continues to affect millions of Americans. Hospitalists are in a unique position to provide treatment for infections related to intravenous drug use while also addressing the underlying root cause, OUD. Hospitalists need to be X-waivered so they can prescribe lifesaving medication for opioid use disorder. Bup-XR is a medication option that may decrease barriers to MOUD for patients.